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EmpowerSystems Electronic Health Record User Guide

1. 38 Chapter 8 Medical Records and Health Information Security s scscsececeeseceeseeeeceeeeeeeteaeeesseeteneeeeeeseeeeeneas 4l 2 empowerlnpatient Ambulatory Image File Empower PDF Chart 35 m d p ei ea creverit ete eed sapo Ver OE YER dosdecksvetdcctaseseeaiaaedeiaseeestess 41 PDF Storage Document Management SYSteM csccccesssesssseesssesssecessseessesessecstssessecessecenssessuesessecesesesssecssesensseentess 42 Security for Personal Health Information eese sii ieseseeee esee enean nennen tina nasse asia tassa assess saa asas aas s asas a 43 Chapter 9 Reporting and Data Mining ete i 46 Empower Report Alert Writer irte cr t xi rp eu e v pe CNN ERE EUR ET RR YE RYE E RRe ARN LET V EYE A RAY YAN E YR ORT R 48 I umseesteeet cud 51 Getting Started with Standard Reports cccsceesssscccccesseesnscecccessnessuscescessseensseeseceseeeessssaeseeseseessaaeeeeceseeeasseeessesens 52 Meaning ful Use ReDOFLS oes ee rte ii e negar ti cue FR EE YYR YR Ro ERE RE CERE E E eE EEO Ea a VER aud ne Phor fee pes R Eu Mae RERE 60 Chapter 10 General User Mantab sissioni dcaa adaa aet aaaea delicia des aa cusa ostio bein nde lor casu ae iacu ssp dece 61 Chapter 11 Nurse Medical Assistant User Manual eere eene ee eene nennen ananas tn tn sns ne esee sn nennen 69 Chapter 12 Provider U
2. st ChampusSt on ChampsSevie oo o ChampusRankGrade ChampusStats ChampusRetreDate Champus Non Avail Cert on File Baby Coverage Combine Baby Bill Blood Deductible Special Coverage Approval Name Special Coverage Approval Title p ers CENE LM p i VENE Non Covered Insurance Code Po Payor ID C Payor Subscriber ID Po Eligibility Source Po Room Coverage Type Amount ee Policy Type Amount Po Daily Deductible Po Living Dependency Po Ambulatory Status Po Citizenship _ o Primary Language Po Living Arrangement Po O Protection Indicator Po Student Indicator Po Religion _ Mother s Maiden Name Po Nationality _ o Ethnic Group SO Marital Status Po oo LM EE MM L MR p PERENNEM SSS _ a E HE _ Publicity Indicator i p L EY Y nsured s Employment Start Date nsured s Employment Stop Date m E __ Job Title Job Code Class _ Job Status Employer Contact Person Name Employer Contact Person Phone No Employer Contact Reason nsured s Contact Person s Name nsured s Contact Person Phone No EUN 12 13 14 15 16 18 19 20 21 22 23 24 25 26 28 29 30 31 32 33 34 35 36 38 39 40 Al 42 43 ES 45 46 48 49 50 51 52 53 122 empowerlnpa
3. 31 May hg 10 58 Empower Test Client Open Medium Clinical Issue 7 Back Home View Tickets Submit a Ticket Knowledgebase News empowersustems 04 Jun 12 Support Center Ticket List 14652 gt Need Assi on Submitting a Non Emergent Ticket My Account Logout Logged In Empower Test Client p Ticket Details amp My Account 1 Ticket ID 14652 Department Technical Issue Bj Change Password Status Work in Progress Priority Low Search Created On 31 May 2012 12 26 PM Last Update 31 May 2012 12 26 PM f Search Edit Properties E s Entire Support Site xl Status Work in Progress z Priority Low g 7 update L p Support Patient Name Type None if applicable n a Account n a Medical Records Number n a 7 upsate post repy Conversation Empower Test Client Posted On 31 May 2012 12 26 PM usen 2 Hello Can you please provide me with a Quick Start Guide to using the Empower Client Support system 1 Sincerely 1 Test User 1 Back Home View Tickets Submit a Ticket Knowledgebase News EU TTE English U S From here you can add an update ask another question provide necessary information change the status or the priority and post the reply The reply will go to the appropriate Empower team member 166 empower
4. tblluTriageTransportMode This table list the options in the triage history for the patient mode of arrival in the ED 146 empowerlnpatient Ambulatory Appendix 13A Workflow Procedure for CPOE Interface Post Go Live The following is the recommended workflow procedure to implement during and post Go Live for Empower CPOE Interface Reason Even though the Empower CPOE Interface is working sometimes and by accident the wrong mnemonic was provided by the hospital mapped incorrectly or an unexpected question was not answered correctly or deactivated In either case when Empower passes the Hospital s Health Information System HIS this incorrect or missing information that is required to order the diagnostic study the CPOE will fail for this particular order This procedure is implemented to immediately identify any failed CPOE orders correct and to fine tune the interface Furthermore this procedure is designed to prevent any delays in the medical evaluation of ED patients that require diagnostic studies Procedure 1 After the physician orders diagnostic studies with the Empower CPOE interface a printed hard copy of the diagnostic studies will be generated placed on a clip board and submitted to the Unit Clerk 2 The Unit Clerk will open the diagnostic portion of the patient s account in the Hospital s Health Information System HIS 3 The Unit Clerk will compare the Diagnostic Orders generated in
5. Choose File no file selected r Recipients 1 You can specify custom recipients in the field below multiple e mail addresses can be seperated using empty space or comma The added recipients will only receive updates sent by our agents ec N Back B Home View Tickets Submit a Ticket Knowledgebase News FUTT English U S Knowledgebase From this example you can see that our new knowledge base will try to recognize as you type in the body of the ticket and suggest articles from our knowledge base This is a work in progress and will improve as time goes on and more articles are added to the knowledge base Upload File s You can upload files to the ticket by browsing your computer to the file you would like to upload Add Recipients You can add recipients who are not currently in the system to the ticket in the space provided and they will then be copied on all replies for that ticket only 164 empowerlnpatient Ambulatory See Example below of required fields and completed content similar to an email The site will show you the information once the ticket is entered empowersustems 31 May 12 Support Center Submit a Ticket Technical Issue mit a My Account Logout Your ticket has been submitted to our department successfully One of our support agents will get back to you with more information shortly 7 Logged In Empower Tes
6. um 557g 175 260 EN Room 4S0 421 01 ADLs Nursing Serial SHIFT HYGIENE ADL rev 05 05 11 White RN Carina CASE MANAGER ASSESSMENT WOUNDS NURSING NURSING TURN FREQUENCY At this time repositioned to left side padding placed between bony prominences ORAL CARE Assist PERI CARE Assist FOLEY CARE Complete SKIN CARE Assist with skin cleaning and moisturizing ACTIVITY Up in chair FEEDING Set up and assist COUGH AND DEEP BREATHING EXERCISES Done every 2 hours while awake EQUIPMENT Incentive spirometry Done every one hour while awake EQUIPMENT VTE Venous Thromboembolism Prophylaxis SCD s in place and functioning LIST VTE PROPHYLAXIS CONTRAINDICATION if applicable N A TRACH CARE none SITZ BATH N A Case Management PROGRESS NOTE Blazek RN Patricia Marie Intensity of service dobutamine drip Discharge plan home Comments chf syncope 97 4 69 16 119 74 atr fib Dobutamine drip lasix increased to 100 mg iv q 8 d50 iv x 2 for ac 64 153 24 u a cr clearance pending Nursing Serial SHIFT NURSING ASSESSMENT rev 11 04 10 White RN Carina Transmission Precautions Standard O2 Type Liter Flow Nasal Cannula Rhythm Strip Interpretation Paced Rhythm LOC Drowsy Affect Calm and cooperative Eye Opening 3 to voice Verbal Response 4 Confused or disoriented Motor Response 4 flexion withdrawal Pupil right 2mm Pupil left 2mm Pupils equal and reactive Ability to Move right arm moderate
7. Prone Relationship Social Security Employer Business Phone Occupation S Address 1 Address 2 cy MEN State JIL Zip 60406 Next Of Kin Data Name Relationship Phone Business Phone Address 1 Address 2 City State Zip Phone 1of 2 Business Phone Patient Demographics Name Relationship Address 1 Address 2 City State Zip Phone EN Business Phone 2of 2 Metro South Medical Center 12935 South Gregory Street Blue Island IL 60406 2428 708 597 2000 Admitting Admitting Patient Name Age DOB Gender Race Insurance Weight Height Medical Record Account EN NENNEN 0 9 WELLCARE 857kg 1752600 M Allergies nka Room 450 421 01 Admission Assessment Weight 85 7kg Height 75 26cm BMI 27 9 Past Medical History Social History cardiomyopathy Lives at home with Family Hypercholesterolemia Smoker Former diabetes Alcohol use 10 years ago refuse flu shot pneumovax Todd 773 552 3246 Bronchitis Congestive Heart Failure Hypertension DC AICD MEDTRONIC MAY 13 2010 Family History Allergies Unknown family history nka Home Medications Admission Aspirin 32
8. 3 Registration Emergency Department Registration Tracker MAMES H Patient Name Account Age MD RN txamRm mer Reg Admitted Admit To Disposition E provee PERS ero gp pM 1 epo wr 38 7 L EN SEES E772 EXE 7 NECI i eT Security Minimize Emergency Department Security Tracker H Patient Name ExamRm AdmitBed Age MD RN intr Reg Admit To Disposition PD 600 o 1055 LLL c ERE A Te 6 a MEN a 63 empowerlnpatient Ambulatory For Administrative and Clinical users the tracker will have active control buttons to launch different aspects of the program These grey control buttons at the bottom of the screen are user specific and are determined by the system administrator They allow users to perform various tasks such as to adding or deleting patients adding or deleting staff changing passwords accessing old records or many other desired functions Examples of these functions include e Add Patient allows patients to be added to Empower It also bypasses the live system interface so patients can be added during system down time and test patients can be added for educational or demonstration purposes e Admin Tools provides administrators access to specific non clinical functions e Change Password allows a user to change their password at any time Every user is expected to understand that their password is their electronic signature and must be protected at all e Log Out should be used whenever the documentation
9. In addition to Empower s multilingual Discharge Instruction content our partnership with ExitCare provides clients with access to robust discharge instructions in English and Spanish Additional languages are available from ExitCare for an annual fee based upon hospital volume ExitCare is an industry leader in providing comprehensive user friendly visually engaging content to ED Inpatient and Ambulatory environments Prescription Writer amp e Prescribing Empower has a one click prescription writer which lists the name dosage and route of the medication from one single database in order to expedite documentation of the prescription The database used is nationally recognized as an industry leader If a medication is not listed in the prescription writer simply contact your Project Manager and the new medication can 25 empowerlnpatient Ambulatory quickly and easily be added The prescription writer can also be used to send prescriptions electronically to the pharmacy The prescriptions are sent via fax numbers that can be added at anytime by the clinic or by your Empower representative Bed Control Notification of Admission and Transfers Empower can also automatically notify Bed Control about all hospital admissions done through the emergency department and all transfers within the hospital There are three notifications that can be transmitted to Bed Control 1 Automatic page providing the following informatio
10. L Use of N A L Free text guidelines Diagnoses Reviewing the chart L Coding impact Review Triage 3 screens L Chief complaint as default first diagnosis View Old Records L Required second diagnosis View Nurses Notes and Repeat Vital signs Discharge Instructions Responses to Medical Interventions LJ Additional Information D mia mia mia m Scanned documents L Prescription Writer Physical Exam Q Work and School Release L Left side is normal statements Set Chart Ready to Print L Right side is more options L Smart Technology L Repeat Physical Exams L Scoring Chart Diagnostics L Medical Decision Making Check boxes Chart Addendums Nonstandard Tests Q Culture Rad Other follow up Reviewing Results with amp without Interface Return Patient to Tracker Print Nurses Orders Consider CPOE Document in Repeat Physical Exam 0 D oO D 0 Only able to choose from lists Remove from tracker and PDF is updated Transcription guidelines Table Edits per hospital designee Report Writer 00 D D D D 0 Chart Audits by Super users 136 empowerlnpatient Ambulatory Appendix 3D Physician Electronic Signature Empower will automatically sign the ED chart and prescriptions if allowed by your state pharmacy board for the physician First Middle Last Name Credentials P
11. ipi are required to perform a pain reassesment no RN Initials for the disposition 84 empowerlnpatient Ambulatory MD Screens This screen allows the user to view the practitioner s overview and review notes These notes will be from the hospital consultants and the practitioner Discharge Instructions A i 5 N Patient Discha rge Patient Name Gender Race Insurance Weight Medical Record Acct Number I t ti Empower Test 11 06 1953 F i 12312312 nstructions Allergies IVP dye Shrimp Erythromycin Acetominpohen w Cadiene Morphine Food allergy specify Discharge Diagnosis Diet Instructions Activity Instructions Advanced Age Pregnant Clear Liquid Diet Touch Down Weight bearing with Crutches Additional Instructions Prewritten Discharge Instructions Click here to add instructions Congestive Heart Failure come back if symptoms worsen Laceration After Care Warm Water soapy baths 2x day for 20 min Breast Cancer General Information Vaccine Tetanus and Diphtheria Td CDC Follow Up List Language z Follow Up Date Time Practitioner Name Clinic Name Address State Zip Phone Comments Huffman Miranda 12246 S Pulaski Discharge Instructions In this area practitioners nurses and medical assistants will select information to give to the patient as they leave the office Discharge Diagnosis This is determined by the practitioner as is read only Diet Instructions Double click in the box to op
12. 4 or less STANDARD FALL RISK INTERVENTIONS AS NOTED BELOW Standard precautions initiated Includes initial and ongoing fall risk education safe room set up including call light in reach and not dangling moving furniture on non exit side of bed side rails up x2 bed locked and low adequate lighting and room is clear of clutter If high risk additional interventions below High risk precautions initiated N A Metro South Medical Center Patient Name Age DOB Admitting Admitting 12935 South Gregory Street Blue Island IL 60406 2428 708 597 2000 Gender Race Insurance Weight Height Medical Record Account E pe 85 7kg 175 26cm NIE Allergies nka 05 24 2011 20 00 05 24 2011 20 00 05 24 2011 20 00 05 24 2011 20 00 05 24 2011 20 45 05 24 2011 22 11 05 24 2011 23 00 05 25 2011 0 00 05 25 2011 3 16 05 25 2011 3 20 05 25 2011 4 15 05 25 2011 6 12 05 25 2011 7 30 ADLs VASCULAR ACCESS WOUNDS ASSESSMENT NURSING NURSING NURSING NURSING NURSING NURSING NURSING NURSING NURSING Room 4S0 421 01 Nursing Serial SHIFT HYGIENE ADL rev 05 05 11 TURN FREQUENCY Patient able to reposition self frequently in bed ACTIVITY Bedrest with BSC Nursing Serial SHIFT MULTIPLE LINE ASSESSMENT rev 12 21 09 PIVL Site 1 Location Left AC Fossa PIVL Site 1 dressing label Date Time placed lac 20 5 23 PIVL Site 1 Inspection Site is clean and dry without redness drainage or swelling Patie
13. 5 History of hypertension in the past PLAN As above Thank you I will follow with you APPROVED ELECTRONICALLY BY Salvatore C Ventura M D ON Wed May 25 15 55 44 CDT 2011 SALVATORE VENTURA M D cc AHMED ZAFAR Metro South Medical Center 12935 South Gregory Street Blue Island IL 60406 2428 708 597 2000 Admitting Admitting Patient Name Age DOB Gender Race Insurance Weight Height Medical Record Account ae le gem 00 557g 175 25m NENNEN ENENN Allergies nka Room 4S0 421 01 VENTURA SALVATORE MT V DV MST13 DD 05 24 2011 11 27 AM DT 05 24 2011 09 25 PM ID 1231869 JOB 97262 Page of Exam Objective Assessment Plan Problem List Electronically signed and authenticated by the Following Physicians SALVATORE C VENTURA Specialty Nephrology Metro South Medical Center 12935 South Gregory Street Blue Island IL 60406 2428 708 597 2000 Admitting Admitting Patient Name Age DOB Gender Race Insurance Weight Height Medical Record Account e el ll 857 15260 NN Allergies nka Room 4S0 421 01 MD Name VENTURA SALVATORE C Date of Note 05 25 2011 6 03 Note Type PROGRESS NOTE History Subjective HPI Paragraph Patient with Evaluation of renal failure Other Notes Urine output is good by foley Mild SOB at rest No chest pain No N amp V abdominal pain Exam Objective Date Time of Exam May 25 2011 6 03AM GA Sitting upright in no distress She is tachypneic Lung
14. R insurancePianiD 3 z50 C R Y insuranceCompanyID 4 250 XON Y insurance CompanyName 5 250 XAD Y insurance CompanyAddress 6 250 XPN Y insurance Co Contact Persen CS 7 250 XIN Y imsuenceCoPhoneNumer s u si Goo 6 9 i XoN v GmwNme 30 i2 cx Y insured sGroup mp ID Cii 250 XoN Y insured sGroupEmp Name aa 8 r PenHfecweDse O as 8 DT _ Planxpiration Date SSS Caa 250 CM Authorization information ras 3 is Penne O Tooo 16 250 XN Y Nameofinsured SS SSCS a7 2 s insureds Relationship to Paten rae Ts insured sDateofBith SS E Insured s Address 120 IN2 empowerlnpatient Ambulatory SEQ LEN DT OPT RP ELEMENT NAME NOTES 20 2 S Assignment of Benefits TOO a 2 is CormtonofBenfis a2 2 st Coord of Ben Priory 33 2 Notice of AdmissionFlag S 24 8 DT Notice of AdmissionDate CS as a D jRewerof igblyFlag 36 8 DT ReportofligibiityDate 27 2 i Release information Code 38 1s ST Preadmitcerpac 39 26 Ts _ Verification DateTime 30 250 XN Verification By SSCS 31 2 1S TypeofAgreementCode raz 2s Billngstatus SSCS
15. User Issues Unable to type numbers using the numeric keys The screen is black unable to enter anything Forgotten Password or new user without a log in or password Document scanned into incorrect chart Unable to close print a chart due to abnormal or repeat vital signs Unable to close print a chart due to request for Trauma Notification Request to merge charts for patients entered twice New PCP to add to the system Request for Discharge Solution Make sure the Num Lock is on Check all connections and make sure the computer is plugged in Make sure the computer is turned on If it is just one computer this is an issue for your internal IT Department If it is all computers consult your internal IT Department before calling EmpowerSystems Contact internal Account Administrator who has the ability to Add Edit Staff A scan entered into the wrong patient can be deleted using the Delete Scan button and scanned into the correct chart Abnormal Vital Signs allows the user to Override and print close the chart It is a gray button at the bottom center Repeat Vital Signs are required for certain chief complaints The override button does not appear You must enter a repeat set of VS If this is not possible document NA in all VS fields NA NA for BP You can type See NN in the Pain field and make an explanation of why in the NN This will come back as an abnormal Vital Sign and the user can O
16. Y PlannedPatientTransportComment OBX SEQ LEN DT OPT RP ELEMENT NAME NOTES 1 10 st JStID OX 0 2 2 ID R Vauetype o 3 590 CE R Observation Identifier 4 20 ST C jObsevationSubld o 5 65536 C Y ObservationValue J 6 6 CE Uit 0 0 7 10 ST __ ReferencesRange J 0 8 5 jY SjAbnrmaltyFags J o o 9 5 NM Probability S 10 5 ID Y jNetweofAbnomalTest 11 1 ID R jObsevatonResultSttus 12 26 Ts __ DatelastObs NormalValues 13 20 ST QUserDefinedAcessCheks 14 26 Ts __ Date Time ofthe Observation 15 60 CE jPrdwersld 16 80 XCN ResponsibleObserver 00 00 000 17 60 CE Y ObservationMethod AL1 SEQ LEN DT OPT RP ELEMENT NAME NOTES Pata ls r seta a 2 5 Allerytye 3 eo ce R Allergy Code Mnemonic Description va 2 is Allereyseverity SCS s as st Almyfexton Identification Date NTE SEQ LEN DT OPT RP ELEMENT NAME NOTES SetID NTE 000 G j SowceofComment J Y Comment 0 0 O a ja ja 2 8 p 3 64k FT 125 FT1 empowerlnpatient Ambulatory SEQ LEN DT OPT RP ELEMENT NAME NOTES pa tats fse 5 85 j 2 12 st Transaction 3 1
17. empowersystems ONC Certified Comprehensive EHR Advanced Core HIS Implementation Support Manual empowerlnpatienttAmbulatory This manual in its entirety is proprietary material and is not to be disseminated to other hospitals or IT companies Drummond Drummonc gt gt gt certified gt gt gt certified e COMPLETE EHR T COMPLETE EHR AME This complete EHR is 2011 2012 compliant and has been certified by an ONC ATCB in accordance with the applicable certification citeria adopted by the Secretary of Health and Human Services This certification does not represent an endorsement by the U S Department of Health and Human Services or guarantee the receipt of incentive payments empowersystems Certified on 9 30 lO empowersystems Inpatient 2 10012010 3716 1 empowersystems Ambulatory 09302010 688 1 2012 2013 empowersystems All Rights Reserved empowerlnpatient Ambulatory i 5 Chapter T implementation OVerVIGW dixerit iniii an xolg dE s X PRSE DX EX XR EHE a x dx PRSE EX LOK RU Eu cUr 6 PHASE I Project Kickoff amp Assessment o cccccccesssssccscccsessssnsceseccceseeesceeesceesecsnsuseesscesseessseeeseeceseessssaeseccesseessaseseeeesns 6 PHASE II Application D VCIOPIMent cccccccscsssssssccccsssssssnsscsccesssssnsssscecssssessanssaeesessuaanssssasesssenaaasasceesessua
18. 05 25 11 09 Secretary Completed LUCIANO Phone order written repeated verified per FOCHESATTOFILLHO LUCIANO SHIN HENRY 05 25 2011 11 28 appears euvolemic Change dose of enalapril 10mg po White RN Carina 05 25 12 08 Secretary Completed bid SHIN HENRY 05 25 2011 11 28 OK to DC home from cardiac standpoint F U with Dr White RN Carina 05 25 12 08 Secretary Completed Erickson in 1 week coumadin clinic in 1 week SHIN HENRY 05 25 2011 11 28 1 2liter day fluid restriction at home White RN Carina 05 25 12 08 Secretary Completed SHIN HENRY 05 25 2011 11 33 Kdur 40MEq po x 1 now then 20mEq po daily White RN Carina 05 25 12 08 Secretary Completed SHIN HENRY 05 25 2011 11 34 chem 6 in 1 week White RN Carina 05 25 12 08 Secretary Completed SHIN HENRY 05 25 2011 11 34 D C dobutamine White RN Carina 05 25 12 08 Secretary Completed FOCHESATTOFILLHO 05 25 2011 12 13 d c foley Phone order written repeated verified per White RN Carina 05 25 12 13 Secretary Completed LUCIANO FOCHESATTOFILLHO LUCIANO VENTURA SALVATORE 05 25 2011 18 30 foley CATH for 24 hour urine collection Phone order White RN Carina 05 25 18 30 Secretary Completed C written repeated verified per VENTURA SALVATORE C VENTURA SALVATORE 05 26 2011 6 29 Remove patient name from Dr Ventura s list White RN Carina 05 26 8 18 Secretary Completed C Milenkovic Steven 05 26 2011 9 15 Chem 6 and BNP in am White RN Carina 05 26 9 16 Secretary Completed Robert Milenkovic Steve
19. 05 26 2011 11 02 Age DOB Admitting Admitting Gender Race Insurance Weight Height Medical Record Account EN MM e WELLCARE 85 7kg 175 26cm MEN a ADLs VASCULAR ACCESS ASSESSMENT WOUNDS NURSING RESPIRATORY PHYSICAL THERAPY Room 4S0 421 01 Nursing Serial SHIFT HYGIENE ADL rev 05 05 11 Yang PCP Hai L TURN FREQUENCY Patient able to reposition self frequently in bed ORAL CARE Self PERI CARE Self FOLEY CARE N A SKIN CARE Assist with skin cleaning and moisturizing ACTIVITY Bedrest FEEDING Self COUGH AND DEEP BREATHING EXERCISES N A EQUIPMENT Incentive spirometry N A EQUIPMENT VTE Venous Thromboembolism Prophylaxis N A Nursing Serial SHIFT MULTIPLE LINE ASSESSMENT rev 12 21 09 White RN Carina PIVL Site 1 Location Right Forearm PIVL Site 1 dressing label Date Time placed PIVL Site 1 Inspection Site is clean and dry without redness drainage or swelling Nursing Serial SHIFT NURSING ASSESSMENT rev 11 04 10 White RN Carina Transmission Precautions Standard O2 Type Liter Flow Room Air Rhythm Strip Interpretation Atrial Fib LOC Awake Alert and Oriented x 3 Affect Calm and cooperative Eye Opening 4 spontaneous Verbal Response 5 Alert and Oriented X 3 Motor Response 6 obeys commands Pupil right 2mm Pupil left 2mm Pupils equal and reactive Ability to Move right arm moderate Ability to Move right leg moderate Ability to Move left leg moderate Ability to
20. AMA e Total transfers e EDstays greater than 12 hours e Total city ambulance runs e Total private ambulance runs 46 empowerlnpatient Ambulatory ED Log e Triage time e Patient name e Gender e Physician e Nurse e Diagnosis e Medical record number e Account number e Disposition e Disposition time Using the complex report writer specialized ED logs with any desired information such as patient contact information or insurance information can also be generated Naturally the accuracy of any report is dependent on the quality of the documentation input to Empower Education regarding both the data elements required and the reporting methods used in order to generate complex reports will be provided during the GoLive and Post GoLive phases of the Empower implementation In addition chart audits will provide education and feedback to the front end users about the quality of the documentation which will further enhance the accuracy of Empower reporting 47 empowerlnpatient Ambulatory Empower Report Alert Writer Perspective Goals As the technological advancements of Empower s ONC Certified EHR continue to evolve our remains delivering user friendly technology that allows our Inpatient Ambulatory and ED clients to be self sufficient and independent in as many aspects of EHR administration as possible Medical Order Sets Hospital Forms and Formulary Management are several of the core elements unde
21. IL 60406 2428 Admitting Admitting Weight 708 597 2000 Medical Record Account 05 23 18 48 05 23 18 49 05 24 8 15 05 24 8 36 05 24 8 36 05 24 8 36 05 24 10 23 05 24 10 22 05 24 10 03 05 24 10 03 05 24 12 15 05 24 11 41 05 24 12 15 05 24 11 40 05 24 11 40 05 24 11 40 05 24 12 15 05 24 12 15 05 24 11 40 05 24 11 40 05 24 12 14 05 24 13 55 05 24 22 11 05 25 6 51 05 25 6 51 05 25 6 51 05 25 6 51 05 25 6 50 05 25 6 51 05 25 6 34 Room 4S0 421 01 Secretary Completed Secretary Completed Secretary Completed Secretary Completed Secretary Completed Secretary Completed Secretary Completed Secretary Completed RN Completed Secretary Completed Secretary Completed Secretary Completed Secretary Completed Secretary Completed Secretary Completed Secretary Completed Secretary Completed Secretary Completed Secretary Completed Secretary Completed Secretary Completed Secretary Completed RN Completed Secretary Completed Secretary Completed Secretary Completed Secretary Completed Secretary Completed Secretary Completed Secretary Completed Metro South Medical Center 12935 South Gregory Street Blue Island IL 60406 2428 Admitting Admitting 708 597 2000 Patient Name Age DOB Gender Race Insurance Weight Height Medical Record Account EARS Em EN um 557g 175 26cm EN INI Allergies nka Room 4S0 421 01 FOCHESATTO
22. NO Chronic physical pain distress NO Recent unemployment NO Recent loss of loved one NO Symptoms or diagnosis Post Partum depression No further screening needed 12935 South Gregory Street Blue Island IL 60406 2428 708 597 2000 Admitting Admitting Insurance Weight Height Medical Record Account O X X ee 080 85 7kg ro EINEN Room 45S0 421 01 3 Multiple attempts but successful TOTAL SCORE 5 or more HIGH FALL RISK PATIENT Skin Integrity 4 Sensory no limits 3 Skin occasionally moist 4 Skin rarely moist 3 Walks occasionally 3 Slight limit mobility 2 Inadequate nutrition 3 No apparent problem NO RISK score 19 or more VTE DVT Patient is on maintenance anticoagulation no further assessment needed at this time Metro South Medical Center 12935 South Gregory Street Blue Island IL 60406 2428 708 597 2000 Admitting Admitting Patient Name Age DOB Gender Race Insurance Weight Height Medical Record Account C x EN MM e WELLCARE 85 7kg 175 26cm MEN x e Allergies nka Room 4S0 421 01 MD Notes MD Name AHMED ZAFAR Date of Note 05 23 2011 18 25 Note Type HISTORY AND PHYSICAL History Subjective HPI Paragraph Patient with 62 year old lady was admitted to hospital from my office because of multiple problems She has been having weight gain and increasew in abdominal girth She was very short of breath exertional and progressively worsening functional status At office she had blood gluco
23. RN Carina White RN Carina White RN Carina White RN Carina White RN Carina White RN Carina White RN Carina Yang PCP Hai L Staff McCabe RN Janet Gender Race FUROSEMIDE ENALAPRIL MALEATE PO Fluids POTASSIUM CHLORIDE ENALAPRIL MALEATE FAMOTIDINE METOCLOPRAMIDE HCL CARVEDILOL FUROSEMIDE ASPIRIN FUROSEMIDE PO Fluids Output Type Urine Output Shatteen PCP Angie E Urine Output Garza PCP Ana Urine Output Garza PCP Ana Urine Output 100 MG 10 MG 20 MEQ 10 MG 20 MG 10 MG 25 MG 80 MG 325 MG 100 MG Height INTRAVENOU S HELD DOSE PO Fluids ORAL ORAL ORAL ORAL ORAL HELD DOSE ORAL INTRAVENOU S PO Fluids Amount ml Comments up to bathroom voided and had stool pt flushed before rn saw results 0 200 150 brpx foley foley 3 12935 South Gregory Street Blue Island IL 60406 2428 Admitting Admitting Weight 85 7kg 10 ML 0 ML 360 ML 1 Tablet 1 Tablet 1 Tablet 1 Tablet 1 Tablet 0 ML 1 Tablet 0 ML 360 ML 708 597 2000 Medical Record Account ro NEIN 4SO 421 01 Vitals Time 05 25 21 00 BP NA NA Pulse NA Respiration N error in documentatior was not giver breakfast 100 Vitals Time 05 26 08 35 BP 107 74 Pulse 75 Respiration 1 Vitals Time 05 26 08 35 BP 107 74 Pulse 75 Respiration 1 Vitals T
24. SHORTNESS OF BREATH 786 05 Likely secondary to CHF r out MI check BNP and Cardioplogy evaluation Weakness Nos 780 79 Weakness and Fatigue likely from advanced Cardiomyopathy has EF of 10 Needs PT OT Hypoglycemia in diabetic unspecified 250 80 Check Glucose monitor off Insulin and oral agents Other Medical Orders Additional Comments Home Med Recon Continue Aspirin 325 mg Tab Daily Home Med Recon Continue Chlordiazepoxide 25 mg Cap At Bedtime as needed Home Med Recon Continue Colace 100 mg Cap Twice Daily as needed Home Med Recon Continue Colchicine 0 6 mg Tab Twice A Day Home Med Recon Continue Coreg 25 mg Tab Twice A Day Metro South Medical Center 12935 South Gregory Street Blue Island IL 60406 2428 708 597 2000 Admitting Admitting Patient Name Age DOB Gender Race Insurance Weight Height Medical Record Account ae m ee eum 557g 175 25m NENNEN ENENN Allergies nka Room 4S0 421 01 Home Med Recon Continue Glipizide 10 mg Tab Twice A Day Home Med Recon Continue Lasix 80 mg Tab Twice A Day Home Med Recon Continue Pepcid 20 mg Tab Twice A Day Home Med Recon Continue Reglan 10 mg Tab Three Times A Day Home Med Recon Continue Simvastatin 40 mg Tab Daily Home Med Recon Continue Warfarin 5 mg Tab Daily Electronically signed and authenticated by the Following Physicians AHMED ZAFAR Specialty Internal Medicine Metro South Medical Center 12935 South Gregory Street Blue Island IL
25. Skin No pallor rashes warm amp moist HEENT PERRL EOMI Moist Mucous Membranes No Icterus Neck NT Full ROM No JVD Lung Chest Wall Lungs Lungs CTA No Ret Chest Wall Chest Wall NT Cardio Vascular RRR No M Abdomen Palpation Tenderness None BS BS NL No Bruits Abd Appearance slightly distended Neuro Motor Major Muscle Groups 5 5 Sensory Gross Sensory Intact Coordination Extremity Location Low Ext Bilateral Pain Tenderness None Sub Location Appearance No Edema ROM Pulses CBR lt 2 sec Repeat Additional Exams May 24 2011 9 53AM HARRIS RICHARD G Reviewed pertinent diagnostic tests vital signs and clinical notes Assessment Plan Problem List Acute on Chronic Systolic Heart Failure with Severe Cardiomyopathy EF 10 N A continue IV Lasix May need Dobutamine HCCI consult bmp in am Weakness Nos 780 79 PT and OT ordered Hypoglycemia in diabetic unspecified 250 80 remains hypoglycemic IVF D5 0 9NS with 10meq kcl at 70cc hr Acute Renal Failure N A suspect due to prerenal azotemia diuretic medications May need nephrology consultation consult Dr Ventura SYNCOPE AND COLLAPSE 780 2 Likely from Cardio myopathy vs low glucose needs Pacemaker check Electronically signed and authenticated by the Following Physicians HARRIS RICHARD G Specialty Internal Medicine Metro South Medical Center 12935 South Gregory Street Blue Island IL 60406 2428 708 597 2000 Admitting Admitting Patient Name Age DOB Gend
26. enter the name birth date age will automatically populate and gender Click Save and Record and Empower will generate a new Medical Record After Clicking Save and Record the staff member will be taken to the Demographics section in Empower Old Records On the Patient Tracker screen click Old Records Type in a patient name or portion of the name or a MR number and click Search Click on the desired name visit date and on the bottom click View PDF Chart to view a chart Click View Patient s Empower Chart to view the Empower record Return to Tracker can be clicked if the patient was inadvertently removed Addendums can be made to the chart in View Chart by the Nurse in the Nurses Notes or the Physician in the Repeat Exams at any time After any changes are made the electronic PDF chart will need to be regenerated by highlighting the patient record in Old Records and click the box to regenerate the PDF which is the official patient medical record Addendums to any other area of the chart must go through administration or medical records so the chart can be opened unlocked If this is deemed necessary Empower will contact and coordinate and provide step by step instructions to complete this 74 empowerlnpatient Ambulatory Administrative Tools The use of these tools is designed for the clinics Empower administrators and designees for data collection and will be taught in detai
27. sdsas Cancelled MAJUMDAR 06 22 13 40 MAHFUZUL tetanus vaccine Entering Medical Orders Click in the white box to open a pop up form for entering orders The user can enter orders by clicking the box and using the drop down menu or free text The Diagnostic Order drop down includes all of the commonly ordered radiology tests Pharmacy Orders drop down includes common medication Other Medical Orders and Comments drop down is an area for orders not previously used or free text lt is necessary to choose a practitioner to assign the order If a diagnostic test is ordered by selecting from the lists in Medical Orders it will flow to the Diagnostics Screen where the results will interface and populate the result fields RN Add Order Date 7 1 2010 Add Save And Close Another Plan Scan Documents To scan or view scanned documents click Scan Documents To scan place the document in the scanner choose a scan type and click Scan To view other scanned documents the Previous Button will scroll through individual scans or there is the ability to filter through the 82 empowerlnpatient Ambulatory drop down menu Documents can be viewed on any computer but scanning can only be done at the computer directly connected to the scanner Time Scanned 6 23 2010 1 56 23 PM Filter by scan type x Choose a scan type before scanning Outside Labs hA BCBS of Illinois a Store F
28. 0 10 05 24 2011 1 30 05 24 2011 1 40 Age DOB Admitting Admitting Gender Race Insurance Weight Height Medical Record Account EN MM e WELLCARE 85 7kg 175 26cm B a FALL RISK ADLs VASCULAR ACCESS ASSESSMENT NURSING NURSING NURSING Room 4S0 421 01 Nursing Serial SHIFT FALL RISK ASSESSMENT INTERVENTIONS rev 12 10 10 McCabe RN Janet Currently History of Confusion Disorientation Impulsivisity Yes 4 HX Depression with active symptoms at present No 0 Altered elimination Frequency Urgency Incontinence Diuretics Yes 1 Currently History of Dizziness Vertigo Yes 1 Male Gender No 0 Currently taking anticonvulsants check MAR No 0 Currently taking benzodiazepines check MAR No 0 Mobility assessment reveals Get up and Go Test Patient needs to push up but successful in 1 attempt 1 TOTAL SCORE 5 or more STANDARD AND HIGH RISK INTERVENTIONS AS NOTED BELOW Standard precautions initiated Includes initial and ongoing fall risk education safe room set up including call light in reach and not dangling moving furniture on non exit side of bed side rails up x2 bed locked and low adequate lighting and room is clear of clutter If high risk additional interventions below High risk precautions initiated Includes Appropriate signage posted in room chart labels on Fall risk ID band applied red slippers provided hourly rounding done proactive bladder program established and exit alarm
29. 07 59 BP 119 74 Pulse 69 Respiration 1 Vitals Time 05 25 07 59 BP 119 74 Pulse 69 Respiration 1 Vitals Time 05 25 07 59 BP 119 74 Pulse 69 Respiration 1 Vitals Time 05 25 07 59 BP 119 74 Pulse 69 Respiration 1 Metro South Medical Center Patient Name Allergies nka 05 25 9 28 05 25 9 28 05 25 9 28 05 25 9 29 05 25 16 00 05 25 16 20 05 25 16 28 05 25 17 00 05 25 18 01 05 25 18 45 05 25 21 00 05 25 21 00 05 25 21 00 05 25 21 00 Age DOB i eum 0 White RN Carina White RN Carina White RN Carina White RN Carina White RN Carina White RN Carina White RN Carina White RN Carina White RN Carina White RN Carina Bahena RN Cecilia Bahena RN Cecilia Bahena RN Cecilia Bahena RN Cecilia Gender Race FUROSEMIDE FUROSEMIDE FUROSEMIDE ASPIRIN POTASSIUM CHLORIDE METOCLOPRAMIDE HCL WARFARIN PHARMACY DOSING FUROSEMIDE FUROSEMIDE ENALAPRIL MALEATE CARVEDILOL FAMOTIDINE METOCLOPRAMIDE HCL SIMVASTATIN 80 MG 80 MG 80 MG 325 MG 40 MEQ 10 MG 80 MG 80 MG 10 MG 25 MG 20 MG 10 MG 40 MG Height PO Fluids IV Push IV Push ORAL ORAL ORAL HELD DOSE IV Push IV Push ORAL ORAL ORAL ORAL ORAL 12935 South Gregory Street Blue Island IL 60406 2428 Admitting Admitting Weight 85 7kg 0 ML 0
30. 3 times a day DISCONTINUE DISCHARGE HOSPITAL MEDS POTASSIUM CHLORIDE 20 MEQ ORAL daily DISCONTINUE DISCHARGE HOSPITAL MEDS SIMVASTATIN 40 MG ORAL at bedtime DISCONTINUE DISCHARGE HOSPITAL MEDS WARFARIN PHARMACY DOSING 1 ORAL daily DISCONTINUE DISCHARGE HOSPITAL MEDS ZALEPLON 10 MG ORAL at bedtime as need DISCONTINUE DISCHARGE HOSPITAL MEDS ACETAMINOPHEN 650 MG ORAL every 6hr as needed DISCONTINUE DISCHARGE HOSPITAL MEDS ALUM MAG HYDROXIDE SIMETHICONE 30 ML ORAL AS needed DISCONTINUE DISCHARGE HOSPITAL MEDS ATROPINE SULFATE 1 MG INTRAVENOUS AS needed DISCONTINUE DISCHARGE HOSPITAL MEDS MAGNESIUM HYDROXIDE 1596 10 ML ORAL AS needed DISCONTINUE DISCHARGE HOSPITAL MEDS NITROGLYCERIN 0 4 MG SUBLINGUAL AS needed DISCONTINUE DISCHARGE HOSPITAL MEDS TRIMETHOBENZAMIDE HCL 200 MG INTRAMUSCULAR every 6hr as needed DISCONTINUE empowerlnpatient Ambulatory Empower Inpatient Summary Chart for Faxing 232 empowerlnpatient Ambulatory Patient Name Date of Birth Gender ID Number ID Number Type Address E lee Medical Record Number Physician Name Date of Visit Guterman Seth J 10 29 2012 10 17 00 eae CHICAGO IL 60643 Problem List MD Name Type ICD 9 Code Patient Problem Diagnosed Guterman Seth J 716 90 Arthritis 10 29 2012 DIAGNOSIS 719 46 Knee Pain 10 29 2012 Medication List Rx Norm Code Product Generic Name Brand Name Strength Dose Frequency Date Started Status 256217 Medication ibuprofen i
31. 33 a NM _ Lifetime ReserveDays 34 1 NM DelayBeforeLR Day 35 8 is CompanyPlancode 3e a5 sr PolicyNumber 37 i2 ce PeyDedutble 38 iz CP Policytimit amount 39 4 NM _ Policytimit pays 40 iz CP RoomRate SemiPrivate rar az cp RoomRate Private 42 250 ce insureds EmploymentStatus as a is Jmwessk 44 2150 XAD Y ImsuedstmploerAddes ras 2 st Verification status ras 8 iS PriorinsurancePlaniD a s S CoverageType SS ras 2s hoep 49 2350 x Y mmwedsibNumber SEQ LEN DT OPT RP ELEMENT NAME NOTES 1 250 CX Y Insured stmployeeIO o 2 11 ST insured sssn 3 250 XCN Y Insured sEmployerName 4 1 15 EmployerInformationData 5 1 15 Y gMalCamPaty 6 15 ST Medicare Health Ins Card No 7 250 XPN Y Medicaid Case Name o 8 15 ST Medicaid Case Number 9 250 XPN Y ChampusSponsorName 00000 10 20 ST jChampsiDNumber 121 empowerlnpatient Ambulatory SEQ LEN DT OPT RP ELEMENT NAME NOTES 250 CE DependentofChampusRecipent ST _ Champus Organization
32. 60406 2428 708 597 2000 Admitting Admitting Patient Name Age DOB Gender Race Insurance Weight Height Medical Record Account e el oc geeXkXew 00 857 15260 NNI Allergies nka Room 4S0 421 01 MD Name KASON THOMAS T Date of Note 05 24 2011 8 11 Note Type CONSULTATION History Subjective HPI Paragraph Patient with Pt c o CHF Sx PND DOE baseline SOB leg edema No recent syncope No ICD shocks No palps No chest pain Had cath in 2000 SFH normal corns LVEF 596 Had ICD generator changed May 2010 Sees Dr Tierney Other Notes ECG 100 electronic vent pacing Exam Objective Date Time of Exam May 24 2011 8 11AM GA Awake A amp Ox3 Skin No pallor rashes warm amp moist HEENT PERRL EOMI Moist Mucous Membranes No Icterus Neck JVD Mild Lung Chest Wall Lungs crackles L R at bases Chest Wall Chest Wall NT Cardio Vascular RRR No M Abdomen Palpation Tenderness None BS BS NL No Bruits Abd Appearance No Pulsating Masses Extremity Location Low Ext Bilateral Pain Tenderness None Sub Location Appearance Edema Mild ROM Pulses CBR 2 Sec Repeat Additional Exams May 24 2011 8 11AM KASON THOMAS T Reviewed pertinent diagnostic tests vital signs and clinical notes Assessment Plan Problem List CHF Acute on Chronic Systolic N A Needs IV diuresis Would like to add an ACEI or ARB but her Cr is increasing Need to watch CMP in AM Continue coreg BP too low 90 70 for hydralazine or imdur IC
33. Awake A amp Ox3 Skin No pallor rashes warm amp moist HEENT PERRL EOMI Moist Mucous Membranes No Icterus Neck NT Full ROM No JVD Lung Chest Wall Lungs Crackles bibasilar Chest Wall Chest Wall NT Cardio Vascular RRR 3 6 HSM Abdomen Palpation Tenderness None BS BS NL No Bruits Abd Appearance No Pulsating Masses Neuro Motor Major Muscle Groups 5 5 Sensory Gross Sensory Intact Coordination Extremity Location Low Ext Bilateral Pain Tenderness None Sub Location Appearance No Edema ROM Pulses CBR 2 sec Repeat Additional Exams May 26 2011 9 10AM Milenkovic Steven Robert Reviewed with Physician Assistant Agree with HPI PE Assessment and Plan Assessment Plan Problem List CHF Acute on Chronic Systolic N A Would like to add an ACEI or ARB but her Cr is increasing Continue coreg BP too low 90 70 for hydralazine or imdur IV Lasix per Nephrology Chem 6 and BNP in am D C IV Lasix after pm dose and restart 80mg po BID in am of 5 27 Normal Corns via Cath 00 N A DIABETES 648 03 management per PCP Severe MR N A Not a surgical candidate due to extremely low LVEF HTN 401 9 continue home meds Hyperlipidemia 272 4 home meds ICD N A Mgmt by Dr Tierney Agree with interrogation Syncopal episode one week ago does not sound cardiac but interrogation will tell if VT or VF involved Chronic kidney disease N A Staging currently in progress Electronically signed and authenticated by the Follow
34. Back Home View Tickets Submit a Ticket Knowledgebase News Language English U S empowersustems 31 May 12 Support Center Submit a Ticket Submit a Ticket P4 My Account Logout If you can t find a so TT TET P oblem in our knowledgebase you can submit a ticket by selecting the appropriate ticket type below Logged In Empower Test Client amp My Account Ticket Type r 8 Change Password Clinical Issue Billing and Coding gt Search 1 O Technical Issue Search 1 Interface Issue Entire Support Site 9 Report Request O Sales 3 Back Home View Tickets Submit a Ticket Knowledgebase News FLU English U S Select the appropriate Ticket Type for the issue you want to submit Clinical Issue Any issues of a clinical nature where clinical workflow terminology or resources are involved Billing Coding Any issues for review by our Coding Billing team can be posted here Technical Issue Any issues of a technical nature where programmers would most like need to be involved Interface Issues Any issues involving interfaces between your Empower system and your HIS Ancillary systems Devices Sales Any question you would like relayed to our sales team can be posted here 163 empowerlnpatient Ambulatory Report Request Any Report related request or inquiry You must fill in the requir
35. Center 12935 South Gregory Street Blue Island IL 60406 2428 708 597 2000 Admitting Admitting Patient Name Age DOB Gender Race Insurance Weight Height Medical Record Account el oc geum 09 857 175260 NN Allergies nka Room 4S0 421 01 05 24 2011 8 00 ASSESSMENT Nursing Serial SHIFT NURSING ASSESSMENT rev 11 04 10 Bayless RN Michel Transmission Precautions Standard O2 Type Liter Flow Room Air Rhythm Strip Interpretation Paced Rhythm LOC Awake but confused Affect Calm and cooperative Eye Opening 4 spontaneous Verbal Response 4 Confused or disoriented Motor Response 6 obeys commands Pupils equal and reactive Ability to Move right arm moderate Ability to Move right leg moderate Ability to Move left leg moderate Ability to Move left arm moderate Skin Color Normal Skin Temperature cool Skin Moisture Moist Skin turgor non tenting Respirations Even and unlabored Breath Sounds Right Diminished Breath Sounds Left Diminished Retractions No retractions noted Abdomen Round firm Bowel Sounds Active x 4 quadrants Pedal Edema Right 2 plus Moderate 1 2 inch Pedal Edema Left 2 plus Moderate 1 2 inch Pedal Pulses Right 1 plus Barely palpable Pedal Pulses Left 1 plus Barely palpable 05 24 2011 8 00 WOUNDS Nursing Serial SHIFT WOUND ASSESSMENT rev 05 06 10 Bayless RN Michel WOUND ASSESSMENT No wounds at this time no further assessment needed TOTAL NUMBER OF WOUNDS N A no wounds present up
36. Chest Wall Lungs Diminished with crackles at both bases Cardio Vascular Paced S1 S2 No rub Abdomen Palpation Soft BS Good Abd Appearance Flank fullness Neuro Motor No asterixis Extremity Location Legs Appearance Edematous Repeat Additional Exams May 25 2011 6 03AM VENTURA SALVATORE C Reviewed pertinent diagnostic tests vital signs and clinical notes Assessment Plan Problem List Non Oliguric ARF 2nd Ischemic ATN N A Most likely has chronic ischemic nephropathy 2nd to cardiomyopathy Urine analysis 30 mg dl protein Urine Culture pending Renal Ultrasound negative Creatinine improved on dobutamine drip Will stage the CKD with a 24 hour urine collection She may need hemodialysis for fluid management patient is aware Start 24 hour urine for creatinine clearance and protein Chem 7 at 5 PM today Renal panel tomorrow AM LVEF 10 ICD Parox A Fib MR N A Very volume overloaded pleural effusions ascites and peripheral edema Stop IV fluids if OK with Dr Harris Double concentrate IV Dobutamine Increase Lasix to 100 mg IV Q 8 hours NIDDM Hyperlipidemia N A Per PMD Electronically signed and authenticated by the Following Physicians VENTURA SALVATORE C Specialty Nephrology Metro South Medical Center 12935 South Gregory Street Blue Island IL 60406 2428 708 597 2000 Admitting Admitting Patient Name Age DOB Gender Race Insurance Weight Height Medical Record Account C el oc geX xeuw 009 857
37. Comfort measures provided include quiet environment warm blankets and distraction Does patient use any alternative therapies N A PHYSICAL ASSESSMENT was completed as noted below Mental status Awake but disoriented describe Skin Pink warm and dry capillary refill is brisk Oral Mucosa Lips and tongue are moist Neck Trachea is midline no JVD is noted Lung sounds Clear to ascultation bilaterally Retractions No retractions are noted Nasal flaring is not present Stridor No stridor is heard Abdomen is hard distended and non tender Bowel sounds Quiet bowel sound are heard x 4 quadrants Lower extremities bilaterally 2 edema is noted Pedal pulses are strong bilaterally Pupils Equal and reactive Hand grasps Strong and equal bilaterally Ability to Move right arm strong Ability to Move left arm strong Ability to Move right leg moderate Ability to Move left leg moderate Tubes Drains Ostomy Trach None of these devices are present Venous access device None present on admission 05 23 2011 19 03 SHIFT NARRATIVE Nursing Serial SHIFT END NOTE new 4 19 11 Burge RN Patricia Medical Orders review I have reviewed and as appropriate carried out all medical orders during my shift except those orders endorsed to the oncoming RN and or are scheduled in the future Diagnostic test review I have reviewed all pertinent diagnostic data as available and appropriate during my shift Patient report given and patient care endo
38. Empower InpatienttAmbulatory Practitioners will select which medication is to be prescribed These medications populate the Selected Meds field Use the drop down menu Fax Locations to select the pharmacy The Fax Meds button will place the prescription in the Fax Queue When finished the Close button will end e prescribing This is also the area that Medication Reconciliation will be completed Discharge Med Recon Patient Name Age DOB Gender Race Insurance Weight Medical Record Acct Number Empower Test ES Years 11 06 1953 Female BLACK AFRICA MEDICARE 4 43kg D00632325TEST 910600154 Allergies Dilaudid HOME meds will be displayed on the patient s HOME medication list If a medication has a Rx value of Yes then a prescription will be generated for that particular mediation ror Start Stop Category Medication Rate Frequency Duration Quantity Refill Status Date Date OP L T FT I r fReular 0 5 Eye Drops i l months p active l Yes Gindamycin Phosphate Topical 1 l l p eene l Yes flindamycin Phosphate Topical 1 eme F pF p pmwe Jd vs Dlacor xR 120 mgj2 hr Cap rtebiet Daily l po powe Yes Click on a Hospital medication to add that medication to the HOME medication list above Category Medication HOSPITAL CARVEDILOL 12 5 MG Twice Daily HOSPITAL ELNDAMmYCIN PHOSPHATE 900 MG 100 ML HRevery 8 hrs HOSPITAL FUROSEMIDE 20
39. Glucose monitor Glucose monitor CKMB HEMOGLOBIN A1C Admitting Admitting Weight Height 85 7kg Gender Race Insurance History Progressively worsening functional status of syncope 1 week ago weakness fatigue H o aicd cardiomyopathy hypercholeserolemia diabetes bronchitis chf htn Technique Axial images from a CT study of the brain were performed without IV contrast No prior study Findings Mild age related cerebral and cerebellar atrophy Minor chronic small vessel ischemic disease in the periventricular white matter Bilateral basal ganglia calcifications No acute intracranial hemorrhage No mass effect midline shift or sulcal effacement Ventricular system and cisternal spaces are unremarkable Imaged mastoid air cells and paranasal sinuses are clear No acute calvarial fracture Impression Atrophy and chronic small vessel ischemic disease changes as outlined above No acute intracranial hemorrhage No CT evidence of acute ischemic change CK1 133 BNP 2444 NA 145 K 4 1 CL 107 CO2 27 BUN 51 CREAT 1 88 GLUCOSE 7 3 CA 9 1 ALT 18 AST 41 ALKPHOS 55 GFR 34 9 TBILI 1 5 FOLATE 14 6 B12 1894 BGM 71 BGM 68 BGM 54 BGM 70 MBINDEX 4 5 CKMB 6 HA1C 7 1 12935 South Gregory Street Blue Island IL 60406 2428 episode 708 597 2000 Medical Record Account ro NEN Room 4S0 421 01 McCabe RN 05 24 1 41 Janet KASON 05 24 8 12 THOMAS T KASON 05 24 8 12 THOMAS T Cr
40. MD documents the physical exam to the point that the MD sets the patient s disposition e MDFinish_HrsMins The average length of time from the point that the MD documents the physical exam to the point that the MD sets the chart ready to print e Print HrsMins The average length of time from the point that the MD sets the chart ready to print to the point that the chart gets printed e 2SD columns These are the second standard deviations of the raw average based on all data not excluded Empower recalculates the average excluding any value that lies outside of the second standard deviation value Those outside of the two standard deviations are flagged as outliers in the Disposition Data section Disposition Data e Outlier This result will be either NO or will have one or more codes indicating what indicator lies outside of the two standard deviations such as ER which would indicate ExamRoom DMD which would indicate DoorToMD TR which would indicate Triage or LOV which would indicate Length of Visit e Exclusion Yes or Y if the record is excluded for any reason otherwise N for No This makes it easy to locate the specific records using a single filter e Negative Time Yes or No If a time calculation results in a value that is lt 15 minutes the record is marked as an exclusion e Triage Acuity The triage level of urgency e TriageAcuityValue The numerical equivalent of the triage assessment ranging from high to low
41. MG twice daily HOSPITAL influenza Vaccine 0 5 mlIM one time HOSPITAL influenza Yaccine 0 5 mlIM one time HOSPITAL INSULIN 70 30 DAILY CHG 50 U Once Daily 86 empowerlnpatient Ambulatory Print Orders Click Print Orders to print a hard copy of the Medical and Diagnostic orders for pharmacy for the nurse to use when multiple orders need to be carried out and to verify patient identity at the bedside Tips e Left click on the Disposition field for a patient will bring up a red screen asking if you wish to remove the patient from the screen You can click Yes No The patient record is always stored in Old Records e To switch between Empower and another program open the other program first and then Empower Use ALT TAB to switch between the two programs e Throughout Empower Inpatient Ambulatory there are message boxes and labels to instruct a user on how to use particular section or provide the correct documentation e To access a particular field and document information simply left click with the mouse e Review your entries and always click the Save button when it appears as long as the correct information has been entered e Certain fields are required fields The computer will prompt with a message box and by highlighting the required field in red if you have forgotten to enter required information e f you are uncertain of what to do or have selected the wrong patient you can always cli
42. ML 0 ML 1 Tablet 2 Tablet 1 Tablet 0 ML 0 ML 0 ML 1 Supp 0 ML 0 ML 0 ML 0 ML 708 597 2000 Medical Record Account roo NEEIENI 4S0 421 01 Vitals Time 05 25 07 59 BP 119 74 Pulse 69 Respiration 1 Vitals Time 05 25 15 16 BP 111 79 Pulse 70 Respiration 1i Vitals Time 05 25 16 30 BP NA NA Pulse NA Respiration N Vitals Time 05 25 07 59 BP 119 74 Pulse 69 Respiration 1 Vitals Time 05 25 16 30 BP NA NA Pulse NA Respiration N Vitals Time 05 25 15 16 BP 111 79 Pulse 70 Respiration 1i Vitals Time 05 25 15 16 BP 111 79 Pulse 70 Respiration 1i inr 3 19 Vitals Time 05 25 16 30 BP NA NA Pulse NA Respiration N Vitals Time 05 25 16 30 BP NA NA Pulse NA Respiration N Vitals Time 05 25 15 16 BP 111 79 Pulse 70 Respiration 1i Vitals Time 05 25 21 00 BP NA NA Pulse NA Respiration N Vitals Time 05 25 21 00 BP NA NA Pulse NA Respiration N Metro South Medical Center Patient Name Allergies nka 05 26 1 03 05 26 1 09 05 26 8 24 05 26 9 17 05 26 9 17 05 26 9 17 05 26 9 17 05 26 9 17 05 26 9 17 05 26 9 18 05 26 11 50 05 26 12 30 Output Date Time 05 24 2011 2 00 05 24 2011 6 02 05 24 2011 16 00 05 24 2011 18 01 Age DOB am um a 50 Bahena RN Cecilia Bahena RN Cecilia Yang PCP Hai L White RN Carina White
43. Moisture Dry Skin turgor non tenting Respirations Unlabored Breath Sounds Right Clear Breath Sounds Left Clear Retractions No retractions noted Abdomen Distended Bowel Sounds Active x 4 quadrants Pedal Edema Right 1 plus Mild 0 1 4 inch Pedal Edema Left 1 plus Mild 0 1 4 inch Pedal Pulses Right 2 plus Palpable Disappears with Pressure Pedal Pulses Left 2 plus Palpable Disappears with Pressure Nursing Serial SHIFT NARRATIVE NOTE new 6 29 10 restart 24 hour urine agiain pt forgetting to urinate in the hat explain needed for test of the kidney for tom Ana pcp aware pt need protein and creat clearance 24 hour restart again Cont to monior Nursing Serial SHIFT NARRATIVE NOTE new 6 29 10 please monitor pt 24 hour collection keep foley intact to help collect uinre Pt forget to save urine otherwise per Dr Venture Nursing Serial SHIFT END NOTE new 4 19 11 Medical Orders review I have reviewed and as appropriate carried out all medical orders during my shift except those orders endorsed to the oncoming RN and or are scheduled in the future Additional shift end comments pt in bed alert and oriented forgetful at time to save urine although hat bathroon for her collected 24 hour urine Pt dobutamne discontinue pvil in left arm pvil in place Pt pain free And new foley to help collect urine Rn to bedside No foley noted Patient refusing foley insertion Patient explained importance of foley and md recomm
44. Move left arm moderate Skin Color Normal Skin Temperature cool Skin Moisture Moist Skin turgor non tenting Respirations Unlabored Breath Sounds Right Clear Breath Sounds Left Clear Retractions No retractions noted Abdomen Soft Bowel Sounds Active x 4 quadrants Pedal Edema Right No edema noted Pedal Edema Left No edema noted Pedal Pulses Right 2 plus Palpable Disappears with Pressure Pedal Pulses Left 2 plus Palpable Disappears with Pressure Nursing Serial SHIFT WOUND ASSESSMENT rev 05 06 10 White RN Carina WOUND ASSESSMENT No wounds at this time no further assessment needed TOTAL NUMBER OF WOUNDS N A no wounds present upon assessment EQUIPMENT Pressure relief mattress WOUND ASSOCIATED PAIN N A WOUND TREATMENT N A Nursing Serial SHIFT NARRATIVE NOTE new 6 29 10 pt sister loretta at bed side will White RN Carina like POT paper sign today if chaplin available Respiratory Assessment Plan of Care Kennerson RT Carol Oxygen nc on sb Attempted to see pt in the AM for therapy although she adamantly refused as she is scheduled Bohanek MPT Amy for d c to home later today Will monitor Metro South Medical Center DOB aay EE NEM c uum 00 Patient Name Allergies nka 05 26 2011 11 30 05 26 2011 11 30 05 26 2011 11 59 05 26 2011 12 33 05 26 2011 15 22 05 26 2011 15 24 05 26 2011 15 43 Age VASCULAR ACCESS NURSING PHARMACY SPIRITUAL CARE NURSING NURS
45. Powered by EMPOW Depending on the level of access less buttons will be available Current User This displays the current person logged into the system Add a Patient Patient Information Date Time Entered 04 08 11 1 34 Last Name Middle Name First Name Date of Birth Age Gender xxIxxixxxx you dont have to enter the Master MRN Patient Type Save Clear Reco Form Cancel Patient Search Result Click on a patient to auto populate the Form above 73 empowerlnpatient Ambulatory In the Live environment the patient names will be entered into the hospital core HIS system or Practice Management software using a short registration which will flow via the interface into the Empower Patent Roster If the interface is not Live or there is a core HIS downtime this method can also be used For education and in the Test environment users can enter patients using the Add a Patient button in the lower left of the Patient Tracker screen Click the Add a Patient button and enter the name birth date age will automatically populate and gender If the patient has previously been in the hospital system their demographic information will already be in the database Click Save Record and the Triage screen will open The Medical Record Number can be added later and is a required field to close the chart If the patient cannot be found this is a new patient to the database For new patients
46. Rectal Examination is deferred Extremities Both lower extremities are edematous to the knees The sacrum is edematous Neurologic Examination is remarkable for the absence of asterixis LABORATORY TESTS White blood count is 5 4 hemoglobin 14 7 potassium is 3 9 and albumin is 3 5 IMPRESSION 1 BEN has nonoliguric acute renal failure that is most Page of MetroSouth Medical Center 12935 South Gregroy Street Blue Island Illinois 60406 CONSULTATION a MR NN ACCT likely secondary to ischemia induced acute tubular necrosis Causes of renal ischemia include hypotension and cardiomyopathy I recommend dobutamine therapy if acceptable with Cardiology consultant The patient also has a component of chronic ischemic nephropathy related to her heart disease A workup to evaluate for possible diabetic nephropathy will be initiated I recommend a Foley catheter urinalysis and urine culture renal ultrasound and serum immunoelectrophoresis Chemistries will be monitored No acute indications for dialysis 2 Nonischemic dilated cardiomyopathy status post implantable cardioverter defibrillator implant paroxysmal atrial fibrillation and mitral regurgitation are being managed by HCCI As discussed above dobutamine therapy is suggested 3 Hypoglycemia superimposed on history of non insulin dependent diabetes mellitus and hyperlipidemia is being managed by primary care physician I recommend discontinuation of glipizide Glucotrol
47. SALVATORE C VENTURA SALVATORE C VENTURA SALVATORE C VENTURA SALVATORE C VENTURA SALVATORE C VENTURA SALVATORE C VENTURA SALVATORE C VENTURA SALVATORE C KASON THOMAS T HARRIS RICHARD G AMIN PARAG K VENTURA SALVATORE C VENTURA SALVATORE C VENTURA SALVATORE C VENTURA SALVATORE C VENTURA SALVATORE C VENTURA SALVATORE C FOCHESATTOFILLHO LUCIANO Age DOB am umo uum 00 Gender Race 85 7kg 05 23 2011 18 43 Home Med Recon Continue Warfarin 5 mg Tab Daily Bayless RN Michel 05 23 2011 18 46 05 24 2011 7 45 05 24 2011 8 19 05 24 2011 8 20 05 24 2011 8 20 05 24 2011 9 55 05 24 2011 9 55 05 24 2011 9 57 05 24 2011 9 58 05 24 2011 11 16 05 24 2011 11 16 05 24 2011 11 16 05 24 2011 11 17 05 24 2011 11 17 05 24 2011 11 17 05 24 2011 11 18 05 24 2011 11 18 05 24 2011 11 25 05 24 2011 11 26 05 24 2011 12 14 05 24 2011 13 55 05 24 2011 22 11 05 25 2011 6 07 05 25 2011 6 07 05 25 2011 6 07 05 25 2011 6 08 05 25 2011 6 09 05 25 2011 6 09 05 25 2011 6 34 PT INR stat and at AM bnp level now Lasix 80mg IVP bid 2 Day s Hold PO lasix we will use IV lasix AM labs CMP HCCI consult bmp in am consult Dr Ventura IVF D5 0 9NS with 10meq kcl at 70cc hr Insert Foley Urine analysis and urine culture STAT Renal Ultrasound Serum immunoelectrophoresis Chem 7 at 6 PM today Renal Panel tomorrow
48. User pee pertinent diagnostic tests vital signs and clinical notes 08 06 12 11 Ecps Tech User The following Life or Limb Threatening Differential Diagnosis were considered Myocardial Infarction CAD Thoracic 09 08 14 40 Aorta Dissection TAD Pneumothorax Myocarditis Pericarditis Pneumonia Mediastinitis Ecos Tech User Not Ill Appearing Radial Pulses Bilaterally Femoral Pulses Bilaterally 09 08 14 40 The Second Section History of Pertinent Negatives High Cholesterol Smoking HTN Connective Tissue Coag D O Back Pain This area documents negative history of the patient If the patient does have a history of these issues clicking on that one will remove it from documentation in the History Subjective Section in Patient Family Denies Please note Fx CAD Aortic Dissection PE SLE and Diabetes have been removed Please Note once removed this negative history must be manually entered Patient Family Denies High Cholesterol Smoking HTN Connective Tissue Coag D O Back Pain 97 empowerlnpatient Ambulatory The Third Section Physical Exam Pertinent Negatives Not Ill Appearing Radial Pulses Bilaterally Femoral Pulses Bilaterally This area documents a Normal Physical Exam If there are abnormalities that conflict with these statements they should be removed The history left will populate to the Physical Objective Section Red Arrow above Please Note once removed these history must
49. Ww N x xX X X X X X X X X X xXx x x XxX X X X X X X X X X X X X xXx xXx x x IV Insertion IV Medicine x xX X 0X 0X 0X 0X 0X 0X 0X 0X 0X X X X X X X X X X X X x HL x xX X X 0X KR 0X 0X 0X 0X 0X 0X 0X 0X 0X 0X 0X 0X X X X X X X X X X X X X x Admission Transfer General Medical Floor Admission Transfer Tele CCU ICU empowerlnpatient Ambulatory Physician LOS Calculation Levels of service are determined based on three factors e History o HPl History of present illness o PFSH Past medical family and social history o ROS Review of systems e Examination e Medical Decision Making o Number of diagnosis or management options o Amount or complexity of data to review o Risk of complication or death if condition goes untreated Empower draws this information from structured fields within the system and then determines a suggested level of service Levels of service should be audited or reviewed by a certified medical professional The method Empower uses in determining medical decision making is based on CPT guidelines and the Marshfield Rules as suggested by CMS Empower breaks down the medical decision making in the following manner Number of Dx s and Management options No diagnostic tests One Diagnostic test Two or more diagnostic tests Amount and or Complexity of Data Reviewed Additional hx from PD FD Family NH Friend 2pts Risk of Complications Morbidity and or Mortali
50. ago Pmh cardiomyopathy dm chf htn aicd Bun 49 cr 1 8 gluc 44 ct brain neg for acute changes cxr bibasilar pleural effusions congetive changes 97 8 70 20 122 79 100 ra Paced rhythm Admit orders standing orders card consult ac qid lasix 80 iv bid Per pmd syncope chf Per card chf no acei or arb d t cr 5 24 bnp 2444 gluc 54 bun 51 cr 1 88 renal consult Renal us pending 94 2ax 69 20 118 83 95 2 nc Paced rhythm Lasix iv bid dobutamine drip Dcp home f u d c needs as pt progresses Nursing Serial SHIFT NARRATIVE NOTE new 6 29 10 foley inserted 100cc clear dark yellow urine out upon insertion Ua and urcl sent to lab CHF CONSULT CHF teaching done brochure provided Neice was present for teaching states pt was admitted for edema sob and altered mental status Has been living with husband and using canned and processed foods Heart failure overview discussed along with 2 gm sodium 64 oz fluid restrictive diet medication excersise weight monitoring recording symptom recognition when to notify physician Page 7 of carepath was provided Sodium monitoring and recording was established as discharge goal A follow up call will be made post discharge Neice is a nurse and was very recptive to information discussed Pt is verbally responsive but confused Bohanek MPT Amy Bayless RN Michel Bayless RN Michel Blazek RN Patricia Marie Blazek RN Patricia Marie Bayless RN Michel Hack
51. all common IV therapies e O2 This drop down menu includes all common methods of oxygen delivery Standard Order Sets Open the Medical Orders field by clicking on the white box The standard order sets are in the bottom field Clicking on this box opens a drop down menu that contains all of the order sets for the institution Add Order Date 2 9 2008 ED Guidelines Abdorninal Pain Upper Female ED Guidelines Abdorninal Pain Upper Male Save And d ED Guidelines Admission Close o ED Guidelines Alcohol Intoxication ED Guidelines Allergic Reaction Mild ED Guidelines Allergic Reaction Severe After selecting an order set it can be adjusted by clicking on items are not needed and then selecting Add to Chart 101 empowerlnpatient Ambulatory ED Guidelines Chest pain Cardiac Monitor Continuous Pulse Ox 2 Liters Nasal Cannula Continuous Pulse Ox Titrate greater than 95 W Saline Lock EKG ASA 325mg PO NTG 1 150 Sub Lingual Hold if SBP less than 100mm Hg NitroPaste 1 Inch Chest Wall CBC BMP Chem7 Cardiac Markers PCXR CXR PA amp Lateral Lopressor 5mg slow IVP Old Medical Records Heplock Admitting Orders Optional If the Emergency Department physicians write the admitting orders then this feature can be used It functions the same as Medical Orders when selecting Standard Order Sets If additional orders are needed then click Add Another Plan and add any other necessary
52. and paroxysmal nocturnal dyspnea She becomes short of breath easily upon exertion She denies nausea vomiting loss of appetite abdominal pain change in bowel habits melena or passage of blood per rectum GU system is as described above She complains of leg swelling PHYSICAL EXAMINATION General The patient is alert cooperative in no distress and sitting upright Vital Signs She weighs 85 9 kg temperature is 97 4 pulse is 72 blood pressure is 110 83 and respiratory rate is 24 HEENT Head is normocephalic Both pupils are round and reactive to light Extraocular movements are intact Conjunctivae are pink Mucous membranes of the oropharynx are moist Neck Supple Adenopathy is absent Carotid pulses are weak but symmetrical Bruits are absent Chest Lung fields are remarkable for diminished air entry in both lower lobes Heart Exam reveals S1 S2 and a 2 6 systolic murmur at the left sternal border Pericardial rub is absent Breast Examination is deferred Abdomen Slightly distended and slight fullness is evident Bowel sounds are present The abdomen is soft and nontender I do not Metro South Medical Center 12935 South Gregory Street Blue Island IL 60406 2428 708 597 2000 Admitting Admitting Patient Name Age DOB Gender Race Insurance Weight Height Medical Record Account mmo mm e guum c0 57e 17526m MENNE ENENIN Allergies nka Room 4S0 421 01 feel masses GU Examination is deferred
53. any way it simply instruct the program to omit or include that particular piece of information when calculating the statistics e Comments This is a place for a reviewer to make any comments about a particular chart These comments will be viewable and editable by other users but the comments cannot be seen outside of the application The field can contain up to approx 4000 characters of information ED Hourly Statistics Report The hourly statistics report shows the patient population for each hour of the day within any given date range This provides a means of examining patient flow during the day The report consists of a data grid with each row in the grid corresponding to a single day and each cell in the row corresponding to an hour within that day There are two buttons located about the data grid One button is the Census View which shows the total number of patients in the ED for each hour of the day The other button is the In amp Out view which consists of an upper grid with the number of patients entering the ED during each hour and a bottom grid with the number of patients leaving the ED during each hour 56 empowerlnpatient Ambulatory Log The Log is a listing of all of the patients that were seen in the ED during a specified time Some definitions associated with this report include e Room The exam room in which the patient was placed after triage In some cases rather than a room number the symbol WR is displ
54. be made using a different format For example the medical records department may require that a file is named one way while the billing department may require it named another In these cases two sets of the patients charts are created and the copies can be directed anywhere that the Empower server has write access to the directory and the format options are the same options listed above The local network administrator can determine the file location Once exported to the network the PDF chart is available for the hospital to import into any hospital document management system 42 empowerlnpatient Ambulatory Security for Personal Health Information Per ONC ATCB EHR Certification requirements Empower provides client administrators with a variety of tools to configure security settings per their institution s security policy for personal health information Please refer to the following examples Password Length Can require users to select an 8 character minimum requirement JAE uM oo 1 d CO 23 TEES d Ci 325 es dH oe I di UXLZLLZUN even E uj IISIIZLuEl 2 CZLCONNNEE Gd CC uud AS dd ILONNNNN uud a eS Ls ad a 1 d CILILCNNNN 7 NIXLILLNNNE ud E 2 PATIENT aoe ae assword complex er tabled Description This tabte lists 74 ECDS Fabie b ApplicatonSettings Allow Update Truo Allow New True Allow Delete True Record 10 72 gt y i MZomitereadi Search ET 43 empowerl
55. desired Acuity is based on the Emergency Severity Index ESI 5 level system Empower also has customizable tables for hospitals that use a different system The ESI 5 level is assigned in Triage ESI Level CATEGORY eje Ke 1 jResusitation RED Emergent GREEN GREEN 1 RENNES RED 3 Urgent YELLOW 4 E 73 Patient Name appears on the tracker when entered by the ADT interface or the Add a Patient button Age appears on the tracker when the date of birth is entered by the ADT interface or the Add a Patient button Chief Complaint is initially populated with the complaint entered by the ADT It is updated by the chief complaint from the Triage Clinical Note and finally replaced by the chief complaint on the physicians note MD Name identifies the doctor caring for the patient with the physicians initials RN Name identifies the primary nurse caring for the patient By double clicking in this box a pop up screen will appear with the list of nurses names Clicking on the appropriate name will set the corresponding initials to appear in the box The initials will also populate any orders or notes entered This field should be updated when the primary nurse is changed 89 empowerlnpatient Ambulatory Disposition is entered by the doctor or nurse on the discharge screen and populated into this field Exam Room is populated with the room number from the triage clinical note unless another room nu
56. down by zone 59 empowerlnpatient Ambulatory Meaningful Use Reports As the Government is attempting reform the health care system a set of standards has been established for Electronic Healthcare Medical Records EHR EMR The Office of the National Coordinator for Health Information Technology ONC enforces these standards Empower has been Comprehensively Certified for its EHR Inpatient Ambulatory ED by the Drummond Group since 2010 Using Empower s ONC Certified EHR allows users to be eligible for stimulus funds and incentive payments provided that Meaningful Use can be demonstrated To monitor Meaningful Use Empower has developed a real time tool to measure and report Meaningful Use at different locations and settings When the Meaningful Use threshold is met for a specific target the report and generated numerical fields have a Green background When a threshold is not met the corresponding field is Red MU Threshold Inpatient Report Name Meets Performance Instances Eligible Instances Performance Rate Threshold a o o a ho 1 G o MUAM Inpatient Active medication lit da 1 255 1 80 MUAM Inpatient Advanced Directives td MH MUAM Inpatient CPOE 8H MUAM Inpatient Discharge Instructions 25 td MH MUAM Inpatient Electronic copy of patients record 3 business days Odo 0 0 0 0 89 MUAM Inpatient Lab Results O O A 0 0 21 1 Jo 4 MUAM Inpatie
57. e splint applied discussion f Order Entry g Interface Impact on Job Descriptions 5 Disposition Determined by Physician a No disposition can be done until the chart is finalized by a physician b Discharge Instructions driven by physician nurse can add information c Physician can print many parts of the chart 22 empowerlnpatient Ambulatory 6 Chart Completion by Nurse MA a Consider Complete entire chart print entire chart and disposition patient b Consider For discharged patient print discharge instructions return and complete documentation and print entire chart 7 Bed Management a Bed Manager Feature Who is responsible Charge Nurse Floor ED Nurse Tech Secretary Patient brought to exam room from waiting room Who is responsible Tech MA Triage RN Primary RN other Inpatient ED room changes Who is responsible 23 empowerlnpatient Ambulatory Chapter 5 General Clinical Documentation Physicians Nurses and Staff Documentation The transition from paper to computer Empower documentation is immediate Physicians and nurses will enter all clinical documentation on computers at the time of Go Live The clinical information includes the physician and nursing notes diagnostic and medical orders vital signs discharge instructions and prescriptions The initial workflow and communication of information will remain unchanged A clipboard or binder can still be the center of communi
58. e Operational Efficiency Reports e Disease Management Reports e Documentation Reports for Coding and Billing e Meaningful Use Reports and Compliance e Physicians Productivity Reports e Hospital Staff Productivity Examples of Alerts e Myocardial Management Compliance and Contraindications Alerts Beta Blocker Door to Balloon Time etc e Congestive Heart Failure Management Compliance and Contraindications Alerts Ace Inhibitor etc e Pneumonia Management Compliance and Contraindications Alerts Appropriate Antibiotics e Stroke Management Compliance and Contraindications Alerts etc e Surgical Care Improvement Project SCIP Management Compliance and Contraindications Alerts e Disease Management Compliance and Contraindications Alerts Diabetes HbA1C Tracking etc Setting Expectations Each hospital and their staff will have different levels of proficiency with the Report Alert Writer based upon familiarity of SOL functionality hospital unit specific clinical documentation methods specialized clinical workflow and related communication systems hospital forms medical order sets etc 49 empowerlnpatient Ambulatory A realistic expectation is that hospital staff that are proficient with Empower EHR clinical documentation front end and database back end will be able to efficiently create a vast array of Reports and Alerts Examples may include the following e Patient Lists with Medical Disease
59. entered by the ADT interface or the Add a Patient button Age appears on the tracker when the date of birth is entered by the ADT interface or the Add a Patient button Chief Complaint is initially populated with the complaint entered by the ADT It is updated by the chief complaint from the Triage Clinical Note and fianlly replaced by the chief complaint on the physicians note MD Name identifies the doctor caring for the patient with the physicians initials RN Name identifies the primary nurse caring for the patient By double clicking in this box a pop up screen will appear with the list of nurses names Clicking on the appropriate name will set the corresponding initials to appear in the box The initials will also populate any orders or notes entered This field should be updated when the primary nurse is changed 70 empowerlnpatient Ambulatory Disposition is entered by the doctor or nurse on the discharge screen and populated into this field Exam Room is populated with the room number from the triage clinical note unless another room number is entered by clicking on the box and selecting a room Bed Assignment provides an area to enter the inpatient room number where appropriate It also functions as a sticky note by clicking on the box a pop up field appears that allows 18 characters of free text which will also appear on the tracker This can be used to notify of ISOL or other information Time in ER in Hou
60. for risk management safeguards and correct physician billing Acronyms used are common and include e PMHx Past Medical History e SoHx Social History e FmHx Family History Admission Assessment Nurses The nursing staff documents the above listed histories and also the patient s allergies current and previous medications skin integrity nutrition status advance directives and fall DVT and self harm risk assessment in this area The language of documentation can be customized to suit Joint Commission terminology and any particular preferences of the patient care setting Exam Objective Provider This area documents the patient s physical exam There are check boxes that allow the physician to enter a normal exam statement multi select fields that provide pre written abnormal findings and areas for free text entry Repeat Exams are required prior to completing a chart Lacerations Procedures Provider Laceration repair and other procedures are documented by the physician in this area in language appropriate for coding Free text entry is again permitted Diagnostic Results Provider and Nurse This screen contains diagnostic laboratory results and it also contains a link to the PACS radiology system Results will auto populate into the field when the laboratory interface is active Some of the fields have a diagnostic interpretation area for the physician to complete as such completion is sometimes required for correct ph
61. in the ED s statistics To correct the demographics in case the original clinical chart was in error go to the Patient Demographics screen in Empower and enter the correct Account Number If Empower has received an interface message with the same account number you will receive a message similar to the following Patient Information Date Time Entered lo2 09 08713 Last Name First Name Age Gender impowER Manud es 2 Years Male HIS Patient Record Found 1253 9876243 Patient Name EmpowER Manual Medical Record 1000456 Date of Birth Email Date of Birth 10 5 1942 10 05 1942 SmdeM Import interFace values and continue Save c Record bra No Medical Record Number Acct Number The Import Update Demographics function can be used on any active patient in Empower Open the Patient Chart Click on the Patient Name and the chart will open to the Medical Orders screen Gray Control Buttons At the bottom of each screen you will see gray buttons Click on these buttons to move through the various portions of the chart Each one acts as a Save button from the current screen Vital Signs Intake Fluids Clinical Notes Patient List Admission 4 Diagnostic Medical Scan A Patient Discharge Assessment Demographics Results Orders Documents Locals Reports Instructions Vital Signs Admitting Weight and Height This is the weight of the patient on their initial visit Click the box to enter infor
62. is completed or the workstation is not in use e Old Records allows previous charts to be viewed Users can search by a patients name or partial name or their medical record number e The Current User is displayed at the bottom left corner of the tracking board Documentation Methods The four types of fields used for Empower documentation are e Drop down Boxes that allow users easily to scroll through tables by typing the first few characters of the desired word If a particular word is not found information can be free texted e Multi select Boxes function like a drop down box but also allow words to be strung together e Check Boxes simply let the user check a prewritten statement or field e Free Text Fields allow information to be manually entered via keyboard or voice recognition technology The system automatically populates all time fields with the time that the data was entered The time fields can be changed to reflect different times by clicking in the time field and entering the corrected time using military or twenty four hour format Physician Note This page contains the current physician note consults latest vital signs and other information There is also a Physician Note List that lists all previous SOAP notes This area can also be filtered 64 empowerlnpatient Ambulatory History Subjective Provider The fields in this area that are highlighted in blue are required to be complete by government agencies
63. order 23 from Mar Phone order written repeated verified per REYNOLDS ALBERT no coumadin today Phone order written repeated verified per FOCHESATTOFILLHO LUCIANO AICD check Home Med Recon Continue Aspirin 325 mg Tab Daily Home Med Recon Continue Chlordiazepoxide 25 mg Cap At Bedtime as needed Home Med Recon Continue Colace 100 mg Cap Twice Daily as needed Home Med Recon Continue Colchicine 0 6 mg Tab Twice A Day Home Med Recon Continue Coreg 25 mg Tab Twice A Day Home Med Recon Continue Glipizide 10 mg Tab Twice A Day Home Med Recon Continue Lasix 80 mg Tab Twice A Day Home Med Recon Continue Pepcid 20 mg Tab Twice A Day Home Med Recon Continue Reglan 10 mg Tab Three Times A Day Home Med Recon Continue Simvastatin 40 mg Tab Daily Weight 85 7kg Height Bayless RN Michel Bayless RN Michel Bayless RN Michel Bayless RN Michel Bayless RN Michel Bayless RN Michel Bayless RN Michel Bayless RN Michel Bayless RN Michel Bayless RN Michel Bayless RN Michel Burge RN Patricia Burge RN Patricia Burge RN Patricia Critchett RN Daisyrenee Bahena RN Cecilia Kane Rph Richard Bayless RN Michel Bayless RN Michel Bayless RN Michel Bayless RN Michel Bayless RN Michel Bayless RN Michel Bayless RN Michel Bayless RN Michel Bayless RN Michel Bayless RN Michel Bayless RN Michel 12935 South Gregory Stre
64. process it is necessary to identify all key individuals to ensure proper communication To this end please complete Appendix 1A and return to your Empower Project Manager within 1 week of the agreement Empower Implementation Team Contact Information The Empower personnel assigned to your facility during the implementation process are available and can be contacted at any time if questions or issues arise All communication should include your assigned project manager as they are responsible for the coordination and completion of your Empower InpatienttAmbulatory implementation and they have a team of resources available to meet your needs Your designated Empower Project Manager will also 6 empowerlnpatient Ambulatory provide you with a list of contacts should there come a time that you need to contact another individual for a specific issue Creating an Implementation Timeline and Project Strategy The first priority in the implementation process is to create an action plan and timeline Please familiarize yourself with the sample timeline Appendix 1B to ensure that we are coordinated with all steps of the Implementation process Your Empower Project Manager will work with your identified Project Manager to review this document to both create deadlines and identify resources Schedule the First Meeting Introduce leadership discuss resources and detail a preferred time frame for implementation Computer Hardware and Supp
65. products 5 My Account Located on the right task bar Change your account settings and password here Reset Your Password Click on the change password button in the My Account section My Account Logged In Empower Test Client amp My Account 8 Change Password Entire Support Site l Enter your old and new passwords and click Submit 31 May 12 Support Center Change Password Change Password My Account Logout You can change your password by entering your old and new passwords below Logged In Empower Test Client 8 My Account Change Password Old Password n Bj Change Password New Password oue Search 1 New Password Confirm SS Search lt Entire Support Site I 5 Back Home View Tickets Submit a Ticket Knowledgebase News PT English U S 162 empowerlnpatient Ambulatory By clicking on My Account you can change your email and name settings empowersustems K 04 Jun 12 Support Center My Account 4 My Account My Account You can update your account details by editing the form below If you wish to change your account password click here Ew Logged In Empower Test Client My Account My Account Gg aem Change Password Primary E mail greenerdoc ecds md Full Name Empower Test Client Search Entire Support Site zl 99
66. pt intructed to use bathroon and void in hat provided NUTRITION CHF Diet Instruction completed Pt up in chair on RD visit CHF Resource DI noted and reinforced to pt RD reviewed 2gm Na diet 64ounce Fluid Restriction and Wt Monitoring Educational materials including Sample Menu and RD phone number provided Advised pt to have husband or daughter who shops and preps meals to review and contact RD w any questions or concerns Currently pt tolerating Diabetic diet w good appetite intake RD to follow up low risk per protocol Pharmacy Coumadin Dosing Note New Dose Coumadin consult was received on a Female 62 years old INR 3 19 Hgb Hct 14 7 44 8 Platelets 182 Coumadin Dose No coumadin today We will continue to follow and adjust therapy as needed for an INR goal of 2 3 Nursing Serial SHIFT NARRATIVE NOTE new 6 29 10 Pt aunt Inez and Loretta into see pt called to stated she will need a ride home pt has no order from primary for discharge on cardiologist Pt w ill probably be discharge tommorw Spoke with her aunts pt is forgetful at time almost pull out foley Spoke with Dr lucanio keep to until tommorrow monito in place Calll liight near pt encouraged to use calll light if needing assistance Pt bed lock and low postion for safety cont to monil Nursing Serial SHIFT MULTIPLE LINE ASSESSMENT rev 12 21 09 PIVL Site 1 Location Right Forearm PIVL Site 1 dressing label Date Time placed 5 23 PIVL Site 1 Inspect
67. rates and other issues that can occur when information is manually entered 108 empowerlnpatient Ambulatory The Empower Implementation team will discuss these options with the hospital team in order to assist in determining which registration interface is best Diagnostic Results Empower is a clinical documentation tool intended to replace the clinician s pen and paper and not the official laboratory record The hospital is to provide the laboratory dictionary mnemonics codes messages etc from the Health Information System which is then mapped by Empower Empower working as the clinician s pen affords the clinical administrator the discretion to identify which tests or components are clinically significant and are to be included as part of the Empower order process Empower references the provided Abnormal Critical flags from the host interface so that any site specific variations will be identified and highlighted Each individual physician should still look at each laboratory value rather than rely exclusively on the systems prompts Order Entry CPOE Automated Unit Secretary The Empower order entry interface is designed so that instead of the unit secretary manually ordering diagnostic tests from the hospital menus Empower electronically orders the same diagnostic tests Unlike other systems that require specific ancillary questions to be answered prior to accepting an order Empower provides 3 options for satisfying s
68. systems tblluGenPlace This table list options for the triage injury location field tblluGenTimeUnits This table list options for physician HPI onset of symptoms tblluGroups Allows EmpowerSystems to assign role base options tblluHospital This table contains the on and off switch for certain hospital specific features in EmpowerSystems tblluLabResultsABG This table contains the different types of result interpretations for the diagnostic study ABG tblluLabResultsAmylaseLipase This table contains the different types of result interpretations for the diagnostic study Amylase amp Lipase tblluLabResultsBloodCulture This table contains the different types of result interpretations for the diagnostic study Blood Culter tblluLabResultsBMPChem7 This table contains the different types of result interpretations for the diagnostic study Basic Metabolic Panel Chem7 Asterix tblluLabResultsCardiacMarkers This table contains the different types of result interpretations for the diagnostic study Cardiac Markers tblluLabResultsCBC This table contains the different types of result interpretations for the diagnostic study CBC 142 empowerlnpatient Ambulatory tblluLabResultsCTScan This table contains the different types of result interpretations for the diagnostic study Advance Radiology Studies tblluLabResultsEKG This table contains the different t
69. the name this is where the patient s Address and Employer is entered 79 empowerlnpatient Ambulatory Insurance Clicking on the open spot will open a second window where the patient s Insurance information is entered For patients with multiple insurances Add Another Repeat Exam is used to add until complete Click Save and Record when completed Person to Notify This tab is used to enter Power of Attorney information Next of Kin This tab is used to enter Next of Kin as sometimes it is not the same as Power of Attorney Individual clinics will determine which will be used if it is the same Guarantor This information is usually reserved for Pediatric patients or Workman s Compensation Diagnostic Results Diagnostics are those tests done to determine what is wrong with the patient These tests results will either come from the hospital scans or entered in the office Use the PACS button to connect to the hospital to review the actual image To view a result single click on that result To enter a result click on the 1 line empty A second window will open up The nurse has the option of free texting or choosing the Diagnostic Name from the drop down menu The result can also be entered in the Diagnostic Interpretation via free text or the drop down menu Results can be filtered using the drop down menu Keep in mind that if a test was not performed it will not be in the drop down PHARMACY RN T
70. to a PDF file with a naming convention chosen by the hospital see Chapter 8 This chart image file can then be imported into the hospital document management system The Empower chart does not need to be scanned as it is part of the hospital database and therefore the hospital document management system Certain clinical information however is generated and captured outside of the Empower documentation system e g ambulance run sheet nursing home transfer sheet insurance and patient identification card etc Empower recommends this information be scanned at the point of care and this scanned information will then be included in the PDF chart Alternatively through HL 7 and integration much of this information can be transferred to a patient s chart electronically Abbreviations Empower has all appropriate Joint Commission compliant abbreviations Certain hospitals have created documentation policies that go beyond Joint Commission abbreviations as there may be the potential for confusion between physicians and hospital staff using a handwritten 27 empowerlnpatient Ambulatory medical record Empower believes that some of these policies are outdated and when applying abbreviations to the printed document we recommend that the hospital review the Empower abbreviations and if the hospital concludes that the abbreviations are acceptable then the hospital should change the policy on documentation to include the Empower abbrevi
71. 0 ST _ TransactionBatchID J o o 4 26 TS R TransactionDate oo 5 26 TS __ Transaction Posting Date 6 8 Is R Transactiontype J o S 7 80 cE R Transactioncode 8 40 ST B TransactionDescription 9 40 ST B Transaction Description Alt 10 6 NM __ TransactionQuantity 11 12 cP __ TransactionAmount Extended 0 12 12 CP __ TransactionAmount Unit 13 60 cE DepartmentCode J 0 14 60 cE ImsurancePlanID 15 2 CP InswaneAmout 16 80 PL __ Assigned Patient Location 17 1 is Ffeeschedule 0 18 2 IS JPeietTyp 0 19 60 CE Y DiagnosisCode 20 120 XCN __ PerformedByCode J 0 21 120 XCN OrderedByCode 00000 22 12 CP J UntCot 0 00 0 23 22 E FillerOrderNumber 000000 24 120 XCN EnteredByCode 0 0 eje T ee m 126 empowerlnpatient Ambulatory Appendix 1A Hospital Staff Contact Information Identifying hospital leadership and the implementation team whose resources will be impacted by Empower is essential to its success Please complete the table below within one week of contract signing and email it to the Empower Project Manager assigned to your hospital Title Name Phone Email Administration CEO CFO C
72. 011 14 46 Note Type PROGRESS NOTE History Subjective HPI Paragraph Patient with Chart Review Other Notes Exam Objective Assessment Plan Problem List Non Oliguric ARF 2nd Ischemic ATN N A Most likely has chronic ischemic nephropathy 2nd to cardiomyopathy Urine Culture pending Creatinine improved Await staging LVEF 10 ICD Parox A Fib MR N A NIDDM Hyperlipidemia N A Electronically signed and authenticated by the Following Physicians VENTURA SALVATORE C Specialty Nephrology Metro South Medical Center 12935 South Gregory Street Blue Island IL 60406 2428 708 597 2000 Admitting Admitting Patient Name Age DOB Gender Race Insurance Weight Height Medical Record Account e el oc geXu no 00 857 15260 NNI Allergies nka Room 4S0 421 01 MD Name VENTURA SALVATORE C Date of Note 05 26 2011 6 20 Note Type PROGRESS NOTE History Subjective HPI Paragraph Patient with Evaluation of renal failure Other Notes Urine output is good in response to IV lasix Patient is incontinent of urine at times She denies SOB but still has increased abdominal girth discomfort She has severe leg swelling No chest pain nor N amp V Exam Objective Date Time of Exam May 26 2011 6 20AM GA Supine no distress Lung Chest Wall Lungs Diminished at bases Cardio Vascular Paced S1 S2 No rub Abdomen Palpation Soft nontender BS Good Abd Appearance Distended flank fullness Neuro Motor No aste
73. 15260 NNI Allergies nka Room 4S0 421 01 MD Name FOCHESATTOFILLHO LUCIANO Date of Note 05 25 2011 8 38 Note Type PROGRESS NOTE History Subjective HPI Paragraph Patient with no New Complaints alert and awake this am having hypogycemic episodes still Other Notes Review of Systems NOT Covered in HPI All other systems reviewed and negative ENT Neg Heart Neg Resp Neg GI Neg GU Neg Skin Neg Neuro Neg Psych Neg Musculoskeletal Neg Endocrine Neg Hematologic Lymphatic Neg Allergic Immunologic Neg Constitutional Sxs Neg Eyes Neg Exam Objective Date Time of Exam May 25 2011 8 38AM GA Awake A amp Ox3 Skin No pallor rashes warm amp moist HEENT PERRL EOMI Moist Mucous Membranes No Icterus Neck NT Full ROM ve JVD Lung Chest Wall Lungs coarse w decreased sounds bil in the lower fields Chest Wall Chest Wall NT Cardio Vascular RRR No M S3 S4 Rub Abdomen Palpation Tenderness None BS BS NL No Bruits Abd Appearance No Pulsating Masses distended w clear signs of ascites Neuro Motor Major Muscle Groups 5 5 Sensory Gross Sensory Intact Coordination Extremity Location Low Ext Bilateral Pain Tenderness None Sub Location Appearance No Edema ROM Pulses CBR 2 sec Repeat Additional Exams May 25 2011 8 38AM FOCHESATTOFILLHO LUCIANO Reviewed pertinent diagnostic tests vital signs and clinical notes Assessment Plan Problem List Acute on Chronic Systolic Heart Failure with Severe Cardi
74. 2 25 BUN 49 CREAT 1 75 GLUCOSE 57 AGAP 11 BUNCR 28 CA 9 3 PHOS 5 4 ALB 3 5 GFR 37 9 VENTURA SALVATORE C 05 25 6 03 BGM 64 BGM 153 BGM 117 IFEINT CANCELED SPEINTERPT CANCELED IGM CANCELED IGA CANCELED IG G CANCELED GAMMA CANCELED BETA CANCELED ALPHA2 CANCELED ALPHA1 CANCELED ALB CANCELED TPROT CANCELED BGM 68 BGM 140 NA 146 K 3 6 CL 108 CO2 25 BUN 47 CREAT 1 67 GLUCOSE METABOLIC PANEL 99 AGAP 13 AG RATIO 1 0 BUNCR 28 GLOBTOT 3 6 ALB 3 6 TPROT PHOSPHOROUS EKG Preliminary RENAL FUNCTION PANEL PT 7 2 CA 9 1 ALT 21 AST 35 ALKPHOS 64 GFR 40 0 TBILI 1 5 PHOS 5 0 INT 3 19 PT 36 1 Metro South Medical Center Patient Name Pe EH E 7006 WELLCARE Allergies nka VENTURA SALVATORE C VENTURA SALVATORE C AHMED ZAFAR AHMED ZAFAR AHMED ZAFAR FOCHESATTOFIL LHO LUCIANO FOCHESATTOFIL LHO LUCIANO FOCHESATTOFIL LHO LUCIANO HCCI CARDIOLOGISTS FOCHESATTOFIL LHO LUCIANO FOCHESATTOFIL LHO LUCIANO VENTURA SALVATORE C AHMED ZAFAR MILENKOVIC STEVEN MILENKOVIC STEVEN MILENKOVIC STEVEN MILENKOVIC STEVEN FOCHESATTOFIL LHO LUCIANO Age 05 25 7 31 05 25 17 00 05 25 11 06 05 25 16 29 05 25 21 09 05 26 5 00 05 26 5 00 05 26 5 00 05 26 5 00 05 26 5 00 05 26 5 00 05 24 14 04 05 26 11 24 05 27 5 00 05 27 5 00 05 27 5 00 05 27 5 00 05 27 5 00 DOB IFE PANEL BASIC METABOLIC PNL CA TOTAL Glucose mo
75. 5 06 2011 Harry R Platt M D APPROVED ELECTRONICALLY BY Harry R Platt M D ON Tue May 24 13 04 14 CDT 2011 cc AHMED ZAFAR PLATT HARRY MT ASR DD 05 24 2011 08 17 AM DT 05 24 2011 09 54 AM ID 1231783 JOB 1231783 Metro South Medical Center Patient Name Allergies nka AHMED ZAFAR AHMED ZAFAR VENTURA SALVATORE C AHMED ZAFAR AHMED ZAFAR Age 05 23 19 01 CT BRAIN W O IV 05 24 5 03 05 24 14 04 05 24 14 42 05 24 16 05 DOB CONTRAST Glucose monitor URINALYSIS ROUTINE AUTO Glucose monitor Glucose monitor 12935 South Gregory Street Blue Island IL 60406 2428 708 597 2000 Admitting Admitting Gender Race Insurance Weight Height Medical Record Account Female WELLCARE 85 7kg 175 2600 AEN wa Room 4S0 421 01 McCabe RN 05 24 1 41 CT SCAN OF THE BRAIN WITHOUT IV CONTRAST Janet ACCESSION 0142077 CLINICAL INDICATION Shortness of breath Syncope Worsening functional status for 1 week Weakness and fatigue Cardiomyopathy ICD Diabetes Bronchitis Congestive failure Hypertension FINDINGS Mild prominence of the cortical sulci are noted There are physiologic calcifications in the basal ganglia Mild low attenuation white matter changes suggest minimal small vessel white matter chronic ischemia including the basal ganglia regions There are calcifications in the carotid siphons and vertebral arteries Bone window settings appear normal IMPR
76. 5 23 2011 18 42 05 23 2011 18 42 05 23 2011 18 42 05 23 2011 18 42 05 23 2011 18 42 05 23 2011 18 42 05 23 2011 18 43 05 23 2011 18 43 05 23 2011 18 43 05 23 2011 18 43 cbc cmp tsh ua urcl trop cpk STAT Phone order written repeated verified per AHMED ZAFAR HGB A1C VIT B12 FOLIC CBC CMP IN AM Phone order written repeated verified per AHMED ZAFAR CPK AND TROP Q8HRS Phone order written repeated verified per AHMED ZAFAR Brain CT WITHOUT contrast STAT Phone order written repeated verified per AHMED ZAFAR Chest X ray PA lateral STAT Phone order written repeated verified per AHMED ZAFAR PT OT TO CONSULT WHEN CLEARED BY CARDIOLOGY Phone order written repeated verified per AHMED ZAFAR HOLD ALL DIABETIC MEDICATIONS UNTIL NOTIFIED BY Z AHMED Phone order written repeated verified per AHMED ZAFAR HOLD LOW DOSE SLIDING SCALE UNTIL PATIENTS BLOOD SUGAR IS GREATER THAN 150 Phone order written repeated verified per AHMED ZAFAR Renal Diet Phone order written repeated verified per AHMED ZAFAR CONSULT Dr IAFFALDANO Phone order written repeated verified per AHMED ZAFAR Acc Check QID Phone order written repeated verified per AHMED ZAFAR Admit to Telemetry Unit per AHMED ZAFAR MD Initiate MICU order set per AHMED ZAFAR MD Initiate electrolyte replacement order set per AHMED ZAFAR MD Change diet from renall to diabetic Phone order written repeated verified per AHMED ZAFAR dc iv fliuds
77. 5 mg Tab Daily Chlordiazepoxide 25 mg Cap At Bedtime as needed Colace 100 mg Cap Twice Daily as needed Colchicine 0 6 mg Tab Twice A Day Coreg 25 mg Tab Twice A Day Digoxin 0 25mg PO Daily Enalapril 20mg PO 1 tablet Twice A Day Glipizide 10 mg Tab Twice A Day HUMALOG 6units After Meals Subcutaneous 6 UNITS Three times daily AFTER Meals Insulin Detemir SubQ 20 units At Bedtime Lasix 80 mg Tab Twice A Day Pepcid 20 mg Tab Twice A Day Reglan 10 mg Tab Three Times A Day Simvastatin 40 mg Tab Daily Warfarin 5 mg Tab Daily Zithromax 250mg PO Daily Advance Directives Fall Risk No living will 4 YES Current Historical No existing POA healthcare Confusion disorientation Impulsivisity No organ and tissue donor 0 NO Current Historical Symptomatic Depression 0 NO Altered elimination 0 NO Dizziness vertigo 0 NO Male gender 0 NO Anti epileptics taken 0 NO Benzodiazepines taken Metro South Medical Center Patient Name Age DOB Gender Race Allergies nka Nutrition No Poor appetite more than 5 days Yes Less than 50 usual intake past 7 days No Recent unintentional weight loss more than 10 Ibs past month No Diarrhea vomiting Hyperemesis more than 7 days No Receives nutrition via feeding tube or IV No Open draining wounds or pressure ulcers No New onset diabetes No dietary consult indicated at present Suicide Self Harm Risk NO Previous psychiatric DX NO Prior thoughts self harm
78. 6 29 10 pt telemonitor remvoed Pivl cover with 2x2 to stop bleeding Pt explain about meds and discharge instruction regarding CHF fluid restriction at home 1 2 ml Nursing Serial SHIFT NARRATIVE NOTE new 6 29 10 request wheelchair for discharge cf 19641 response time 16 minutes Nursing Focused DISCHARGE NOTE rev 12 10 10 Patient is aware of the plan of care to discharge Patient was made aware of plan of care to discharge and verbalized understanding Vascular access device s PIVL D C d with catheter intact dressing applied to site no bleeding Indwelling drains None Belongings induding any home meds if applicable Were gathered and packed by family inventory verified and signature obtained General Discharge Instructions Patient not able to receive instructions After care instructions relayed to care provider who verbalized goo understanding had no questions unanswered agrees to comply Special Discharge Instructions CHF Discharge instructions Patient was given instruction on diet exercise weight monitoring activity level follow up and what to do if symptoms worsen Transportation arrangements Patient going home with family Patient was discharged to Home with family Patient left unit Accompanied by transporter via wheelchair Notifications By RN Num MD Notified Paqe Time Pages Harris Richard G 05 24 9 45 1 M D Ventura Salvatore C 05 24 10 02 M D White RN Carina White RN Carina Kane Rp
79. 8 708 597 2000 Admitting Admitting Metro South Medical Center Patient Name Age DOB Gender Race Insurance Weight Height Medical Record Account ae mmm uem o 557g 7520 NENNEN EEEEENN Allergies nka Room 4S0 421 01 05 25 10 32 White RN 68 16 127 87 95 Denies pain dobutamine di Carina 12 8 mg hour 05 25 11 08 Garza PCP 69 18 127 87 98 PCP entry 115 acc Ana 05 25 15 16 Garza PCP R95 5 70 18 111 79 PCP entry Ana 05 25 16 30 Garza PCP PCP entry 291 acc Ana 05 25 20 21 Bahena RN Oral 97 7 69 20 123 86 Denies pain afib ra Cecilia 05 25 21 00 Fontillas PCP PCP entry Accu check Arthur 193 05 26 1 00 Fontillas PCP PCP entry Accu check Arthur 211 05 26 1 05 Fontillas PCP Oral 97 8 69 22 130 90 9996 PCP entry 88 2 1 6 Room Air Arthur 05 26 5 00 Fontillas PCP PCP entry Accu check Arthur 153 05 26 8 35 White RN Oral 97 9 75 16 107 74 96 Denies pain pt is on rroom Carina Oral 97 4 69 20 130 91 95 PCP entry accucheck 18 05 26 11 40 Yang PCP Hai L Metro South Medical Center 12935 South Gregory Street Blue Island IL 60406 2428 708 597 2000 Admitting Admitting Patient Name Age DOB Gender Race Insurance Weight Height Medical Record Account aa mm mmm oc guum 0 87 175260 EN NN Allergies nka Room 4S0 421 01 Clinical InterDisciplinary Notes Date Time Note Type Clinical Note Staff 05 23 2011 16 42 ADMISSION Nursing Admission CORE MEASURES ASSESSMENT Rev 01 06 11 Burge RN Patri
80. 93 Cecilia 05 24 18 52 Critchett RN 72 129 87 Daisyrenee 05 24 18 52 Bahena RN 72 129 87 Cecilia 05 24 19 35 Bahena RN 76 103 68 Cecilia 05 24 19 52 Bahena RN 75 110 78 Cecilia 05 24 20 14 Bahena RN Oral 97 6 76 20 103 68 Denies pain paced Cecilia 05 24 20 49 Wylie PCP PCP entry accu 64 rn Elana notified 05 24 20 52 Bahena RN 69 116 86 Cecilia 05 24 21 59 Bahena RN 72 107 78 Cecilia 05 24 22 01 Bahena RN Denies pain accucheck 68 Cecilia after apple jui with 2 sugars and cheese crackers 05 24 22 51 Bahena RN 69 132 94 Cecilia 05 24 22 55 Bahena RN 69 119 89 Cecilia 05 24 22 59 Wylie PCP PCP entry repeat accu 1 Elana 05 24 23 31 Wylie PCP Oral 97 5 69 18 119 89 PCP entry unable to obte Elana 02 rn notified 05 24 23 56 Bahena RN 69 115 90 Cecilia 05 25 0 51 Bahena RN 69 134 90 Cecilia 05 25 1 51 Bahena RN 72 129 93 Cecilia 05 25 2 51 Bahena RN 69 142 89 Cecilia 05 25 3 16 Bahena RN Denies pain Accucheck 15 Cecilia 05 25 3 52 Bahena RN 69 109 81 Cecilia 05 25 4 52 Bahena RN 69 112 91 Cecilia 05 25 5 23 Wylie PCP PCP entry 86 6 0 7 Elana 05 25 5 52 Bahena RN 72 139 91 Cecilia 05 25 6 32 Wylie PCP PCP entry accu 117 Elana 05 25 6 52 Bahena RN 69 119 84 Cecilia 05 25 7 59 White RN Oral 97 4 69 16 119 74 Denies pain pt in bed roon Carina air Dobutamir infusing at 5mcg kg 12935 South Gregory Street Blue Island IL 60406 242
81. A no wounds present upon admission SECOND TIER WOUND ASSESSMENT CONDUCTED BY Second RN Name Michele EQUIPMENT Pressure relief cushion WOUND ASSOCIATED PAIN N A WOUND TREATMENT N A Metro South Medical Center 12935 South Gregory Street Blue Island IL 60406 2428 708 597 2000 Admitting Admitting Patient Name Age DOB Gender Race Insurance Weight Height Medical Record Account Em NEM oo gem 009 857 15260 NNI Allergies nka Room 4S0 421 01 05 23 2011 16 44 ADMISSION Nursing Admission RISK ASSESSMENT SCREENS Burge RN Patricia FUNCTIONAL SCREENING Completed as follows PT Transferring Requires assistance person PT Ambulation Completely independent OT Bathing Requires assistance person OT Dressing Requires assistance person OT Toileting Requires assistance person OT Feeding Completely independent SP Communication Effective SP Swallowing Effective SPIRITUAL CULTURAL NEEDS completed as follows Religious beliefs Baptist Is your faith spirituality an important part of your life No Will being in the hospital interfere with any religious or cultural practices No Do you have any specific requests to meet your spiritual Cultural needs during hospitilization No PSYCHOSOCIAL NEEDS assessed as follows Are there any special difficulties produced by this hospitalization No EDUCATIONAL NEEDS assessed as follows Current Illness chf htn Treatment plan meds Medications No needs Pain manageme
82. AM Start Dobutamine if OK with Dr Kason Do renal ultrasound at bedside due to hypoglycemia Stop Glipizide Hold colchicine notify Dr Harris OK to start Dobutamine at 5mcg kg min Phone order written repeated verified per KASON THOMAS T Inpatient status from the start Phone order written repeated verified per HARRIS RICHARD G D50 ivp x1 stat Phone order written repeated verified per AMIN PARAG K Start 24 hour urine for creatinine clearance and protein Chem 7 at 5 PM today Renal panel tomorrow AM Stop IV fluids if OK with Dr Harris Double concentrate IV Dobutamine Increase Lasix to 100 mg IV Q 8 hours change accucheck Q4hours Phone order written repeated verified per FOCHESATTOFILLHO LUCIANO Bayless RN Michel Bayless RN Michel Bayless RN Michel Bayless RN Michel Bayless RN Michel Critchett RN Daisyrenee Bayless RN Michel Critchett RN Daisyrenee Critchett RN Daisyrenee Bayless RN Michel Bayless RN Michel Bayless RN Michel Bayless RN Michel Bayless RN Michel Bayless RN Michel Bayless RN Michel Bayless RN Michel Bayless RN Michel Bayless RN Michel Critchett RN Daisyrenee Blazek RN Patricia Marie Bahena RN Cecilia Bahena RN Cecilia Bahena RN Cecilia Bahena RN Cecilia Bahena RN Cecilia Bahena RN Cecilia Bahena RN Cecilia Bahena RN Cecilia Height 175 26cm NENNEN NEN 12935 South Gregory Street Blue Island
83. Ability to Move right leg moderate Ability to Move left leg moderate Ability to Move left arm moderate Skin Color Normal Skin Temperature warm Skin Moisture Dry Skin turgor tenting Respirations Unlabored Breath Sounds Right Diminished Breath Sounds Left Diminished Retractions No retractions noted Abdomen Distended Bowel Sounds Active x 4 quadrants Pedal Edema Right 1 plus Mild 0 1 4 inch Pedal Edema Left 1 plus Mild 0 1 4 inch Pedal Pulses Right 2 plus Palpable Disappears with Pressure Pedal Pulses Left 2 plus Palpable Disappears with Pressure Nursing Serial SHIFT WOUND ASSESSMENT rev 05 06 10 White RN Carina WOUND ASSESSMENT No wounds at this time no further assessment needed TOTAL NUMBER OF WOUNDS N A no wounds present upon assessment EQUIPMENT Pressure relief mattress WOUND ASSOCIATED PAIN Patient has pain see clinical notes and or vitals table for pain assessment WOUND TREATMENT N A Nursing Serial SHIFT NARRATIVE NOTE new 6 29 10 24 hour urine for protein and White RN Carina creat foley on ice Nursing Serial SHIFT NARRATIVE NOTE new 6 29 10 pt up in the chair warm fingertips White RN Carina pulse ox placed on middle finger right hand Metro South Medical Center Patient Name Allergies nka 05 25 2011 9 50 05 25 2011 9 52 05 25 2011 9 57 05 25 2011 10 00 05 25 2011 10 54 05 25 2011 11 09 05 25 2011 12 34 05 25 2011 16 30 12935 South Gregory Street
84. Ambulatory Program e Click on the EmpowerSystems icon on the desktop e Log In with the ID provided by your system administrator 61 empowerlnpatient Ambulatory Patient Tracking Board Universal View The opening screen is the Patient Tracker which lists all of the active patients This tracker can be configured to meet the needs of nearly any department It can list the patient s name room number the treating or primary physician the primary nurse the disposition the number of hours that patient has been in the hospital or many other pieces of data It also contains indicators that detail the registration diagnostic and order status The initials of the physician and primary nurse caring for the patient are displayed alongside the name of each patient The tracker provides a conduit to a nearly any location in the patient s chart and can be customized or modified as the need arises Examples of Trackers Radiology Emergency Department Radiology Tracker gt on Exam Patient Name b EIL UHCG Test Name Reason for Exam Dispo Room 68 Years Female z pang INXA JUS ABDOMEN LIMITED Abdominal ISNO Pain Nausea Hypo 515 58 Years Male 000000703 INXA TELEPHONE left knee 3S0 ASSESSMENT epo ment HINA 328 LE 68 Years Male 000641075 ara N A CT PELVIS W O IV Doreniasive Co 4S0 ICONTRAST Iornity 430 Provider Efficiency MetroSouth MEDICAL CENTER BLUE ISLAND IL Wait Time to See a Physici
85. BHCG ETOH Blood Culture Adult zi Dose or Fluid Rate Frequency r H H Pharmacy Instructions i Cancel Common Diagnostic Tests Orders are entered by clicking the appropriate box and then selecting from the drop down menu The menu can be customized to the institution If the appropriate test is not found then free texting can be used Diagnostic Order This drop down menu contains the most commonly ordered laboratory and radiology tests Pharmacy Orders This drop down menu contains the most commonly used medications This field is locked to the Empower Smart Technology medication database to ensure that Drug Drug Interactions and Potential Allergy Alerts are active 100 empowerlnpatient Ambulatory Allergy Alert You re attempting to order NTG 10mcg min titrate CP The patient is allergic to NTG 10mcg min titrate CP Do you still want to order this medicine When a weight based medication dose is selected from the list the dosage will be automatically calculated by Empower Other Medical Orders and Comments This is an area for orders not found elsewhere Orders can be free texted in this area However when orders are free texted the results do not flow back to the diagnostics screen It is recommended that free texting is avoided where possible as it can impact data capture and reporting Contact your system administrator if any additions to the lists are required e IVF This drop down menu lists of
86. Blue Island IL 60406 2428 Admitting Admitting 708 597 2000 Age DOB Gender Race Insurance Weight Height Medical Record Account m u um 557g 175 25m NENNEN EEEENN Room 4S0 421 01 ADLs NURSING PHYSICAL THERAPY NURSING NUTRITION PHARMACY NURSING VASCULAR ACCESS Nursing Serial SHIFT HYGIENE ADL rev 05 05 11 TURN FREQUENCY Patient able to reposition self frequently in bed ORAL CARE Self SKIN CARE Self ACTIVITY Up in chair brp FEEDING Self Nursing Serial SHIFT NARRATIVE NOTE new 6 29 10 pt pulse ox is 97 98 after 15 minutes of monitor continously S Pt was resting in supine upon entry Stated she felt better today O Pt was able to perform bed mobility tasks with SBA using the rail She stood with CGA and ambulated x 15 no device with CGA She then requested to use the bathroom and was assisted there with CGA Left pt on the toilet as she needed to have a BM RN aware A Pt had 2 LOB during short distance ambulation today but continues to refuse PT suggestion regarding the use of an assistive device to improve dynamic balance and safety She is a high fall risk and would benefit from continued skilled PT to achieve more safe amp Ind functioning P Continue POC Treatment time 10 minutes func ther ex Nursing Serial SHIFT NARRATIVE NOTE new 6 29 10 Dr Shin in to see pt discontinue Dobutamine Drip and pt pull foley no tramua noted to vagina area order to discontinue foley
87. CPU Speed MHx 2 Quad Core CPU or higher RAM 64 GB or Higher Hard Drive Space 200GB Local Server RAID partitioned with 30GB for Op Sys Partition remainder in Data Partition Optical Drive DVD RW Drive empowerlnpatient Ambulatory Monitor 17 Flat Screen or other functional equivalents Uninterruptible Power Supply UPS dedicated to TS in case of brown out APC 1500 or higher Ethernet Card TCP IP SERVER SUPPORT SOFTWARE Live SQL Windows Server 2008 R2 x64 or newer SQL Server 2008 or newer with Windows SQL licenses for needed computers or Terminal Service Licenses with SQL Studio manager and all client workstation tools installed Microsoft Office 2007 ONLY not newer Professional with Access 2007 full version installed NOTES Configuration Benefits Virtual Machine configuration of supporting servers will incur licensing costs but yield Requirements substantial savings and offer increased flexibility in the long term Empower supports virtual servers however we do not recommend a virtual machine for the LIVE SQL environment The Test Application Interface PDF generator server s could be Support VMs if the client so desires SERVER HARDWARE Live SQL Enhanced Capacity Recommended for 100 Bed Facilities 2 Clustered Servers for Redundancy of LIVE System Attached to SANS with sufficient Se
88. Client E My Account amp Change Password HL7 Interfaces 2 7 Report requests 1 Technical Support 0 Search Entire Support Site 23 FLUTE English U S You are now ready to submit track and monitor Non Emergent tickets for your facility We hope this guide will serve you well as you familiarize yourself with this user friendly resource As always your Empower project manager is available to discuss more specifics surrounding your Non Emergent issues 167 empowerlnpatient Ambulatory Empower Inpatient Sample Chart 168 Patient Demographics Admission Data Account Number Medical Record Admit Date Admit Time EMR MD Primary Care MD Admit Clerk Reason For Visit Other Doctors Comments Patient Data Patient Name aes 5 23 2011 15 33 45380 AHMED ZAFAR 45380 AHMED ZAFAR SHORTNESS OF BREATH MN Visit Dx AHMED ZAFAR Date of Birth Social Security Race Sex Religion Marital Maiden Name Patient Email Address 1 Address 2 EE NENNEN es BAP M cy MEN UNEMPLOYED Employer State JIL Zip 60406 Phone Occupation UNEMPLOYED Address 1 Addres
89. D N A Mgmt by Dr Tierney Agree with interrogation Syncopal episode one week ago does not sound cardiac but interrogation will tell if VT or VF involved Chronic coumadin use N A Interrogation confirms Afib and no shocks So syncopal episode one week ago probably related to blood sugar NIDCM N A Normal corns by cath 2000 but LVEF 5 at that time Has ICD DIABETES 648 03 management per PCP MITRAL VALVE DISORDER 424 0 Moderate MR Not a surgical candidate due to extremely low LVEF tricuspid regurg N A Mod to severe Again not an operative candidate HTN 401 9 continue home meds Hyperlipidemia 272 4 home meds Other Medical Orders Additional Comments Lasix 80mg IVP bid 2 Day s Hold PO lasix we will use IV lasix Metro South Medical Center 12935 South Gregory Street Blue Island IL 60406 2428 708 597 2000 Admitting Admitting Patient Name Age DOB Gender Race Insurance Weight Height Medical Record Account x 8l E MS na WELLCARE 85 7kg 1752600 EN Ir Allergies nka Room 4S0 421 01 AM labs CMP Electronically signed and authenticated by the Following Physicians KASON THOMAS T Specialty Cardiology MD Name HARRIS RICHARD G Date of Note 05 24 2011 9 53 Note Type PROGRESS NOTE History Subjective HPI Paragraph Patient with remains hypoglycemic Feels better though and denies any current SOB Other Notes Exam Objective Date Time of Exam May 24 2011 9 53AM GA Awake A amp Ox3
90. ENT rev 11 04 10 Transmission Precautions Standard O2 Type Liter Flow Nasal Cannula 2L Rhythm Strip Interpretation Paced Rhythm LOC Awake but confused Affect Calm but uncooperative Eye Opening 4 spontaneous Verbal Response 4 Confused or disoriented Motor Response 6 obeys commands Pupils equal and reactive Ability to Move right arm moderate Ability to Move right leg moderate Ability to Move left leg moderate Ability to Move left arm moderate Skin Color Normal Skin Temperature cool Skin Moisture Moist Skin turgor non tenting Respirations Even and unlabored Breath Sounds Right Diminished Breath Sounds Left Diminished Retractions No retractions noted Abdomen Soft and non tender Bowel Sounds Active x 4 quadrants Pedal Edema Right 2 plus Moderate 1 2 inch Pedal Edema Left 2 plus Moderate 1 2 inch Pedal Pulses Right 1 plus Barely palpable Pedal Pulses Left 1 plus Barely palpable Nursing Serial SHIFT NARRATIVE NOTE new 6 29 10 sent Dr Harris an Empower message regarding the D C of the Colchicine Case Management INITIAL ASSESSMENT Severity of illness chf on imaging Intensity of service dobutamine drip Comments meets inpt criteria CLINICALS FAXED TO WELLCARE 877 844 8538 REF 8876538 NOT EQ HEALTH SOLUTIONS CALL FOR ADMIT DX 786 05 Direct admit tele from pmd office with sob wt gain and increase in abd girth In office bg 23 improved to 47 after glucose tab Also relates hx syncope 1 wk
91. ESSION MINIMAL SMALL VESSEL WHITE MATTER CHRONIC ISCHEMIC CHANGE NO HEMORRHAGE OR OTHER FOCAL INTRACRANIAL LESIONS SEEN OTHERWISE PORI CT WITHIN 24 HOURS OF PRESENTATION NO HEMORRHAGE ACUTE INFARCTION OR ABNORMAL MASS ON THIS STUDY Harry R Platt M D APPROVED ELECTRONICALLY BY Harry R Platt M D ON Tue May 24 13 08 54 CDT 2011 CC AHMED ZAFAR PLATT HARRY MT ASR DD 05 24 2011 08 58 AM DT 05 24 2011 10 02 AM ID 1231794 JOB 1231794 BGM 62 HYALINE 21 50 MUCUSURINE OCCASSIONAL EPITHLIAL 11 20 WBC Bayless RN 05 24 15 06 0 3 RBC 0 3 LEUKOURINE NEG UROBILURINE NORMAL NITRITE Michel NEG UBLD TRACE BILIURINE NEG KETURINE NEG UGLUC NEG PROTEINUA 30 PHURINE 5 0 SPCGRAVITY 1 007 CHARACTER CLEAR COLORURINE YELLOW BGM 107 BGM 108 Metro South Medical Center Patient Name Pe EH E 7006 O WELLCARE Allergies nka VENTURA SALVATORE C AHMED ZAFAR VENTURA SALVATORE C AHMED ZAFAR AHMED ZAFAR AHMED ZAFAR HCCI CARDIOLOGISTS VENTURA SALVATORE C VENTURA SALVATORE C AHMED ZAFAR AHMED ZAFAR HCCI CARDIOLOGISTS VENTURA SALVATORE C VENTURA SALVATORE C FOCHESATTOFIL LHO LUCIANO Age 05 24 11 23 05 24 18 52 05 24 18 00 05 24 20 44 05 25 3 16 05 25 5 33 05 25 5 00 05 25 5 00 05 25 5 00 05 24 22 02 05 24 22 59 05 25 7 30 05 25 7 30 05 25 9 10 05 26 5 00 05 25 9 48 DOB US RETROPERI KIDNEY BLADDER ULTRASOUND OF THE RETR
92. FILLHO 05 25 2011 6 39 give one amp of d50 ivp now Phone order Bahena RN Cecilia 05 25 6 39 Secretary Completed LUCIANO written repeated verified per FOCHESATTOFILLHO LUCIANO FOCHESATTOFILLHO 05 25 2011 6 39 stop iv fluids Phone order written repeated verified Bahena RN Cecilia 05 25 6 39 Secretary Completed LUCIANO per FOCHESATTOFILLHO LUCIANO FOCHESATTOFILLHO 05 25 2011 6 40 call for blood sugar below 80 Phone order Bahena RN Cecilia 05 25 6 40 Secretary Completed LUCIANO written repeated verified per FOCHESATTOFILLHO LUCIANO FOCHESATTOFILLHO 05 25 2011 8 46 accu Checks q 4 hrs White RN Carina 05 25 8 55 Secretary Completed LUCIANO FOCHESATTOFILLHO 05 25 2011 8 55 Nursing staff to assist pt w feeding White RN Carina 05 25 8 55 Secretary Completed LUCIANO FOCHESATTOFILLHO 05 25 2011 9 02 cbc cmp magnesium pt ptt inr in am White RN Carina 05 25 9 26 Secretary Completed LUCIANO FOCHESATTOFILLHO 05 25 2011 9 03 warfarin pharmacy to dose N A White RN Carina 05 25 9 26 Secretary Completed LUCIANO Milenkovic Steven 05 25 20119 15 BNP in am White RN Carina 05 25 9 26 Secretary Completed Robert FOCHESATTOFILLHO 05 25 2011 9 30 Pt INR now amp daily am while on coumadin per Kannankeril Jaya J 05 25 9 30 Secretary Completed LUCIANO coumadin phcy protocol Phone order written repeated verified per FOCHESATTOFILLHO LUCIANO FOCHESATTOFILLHO 05 25 2011 11 09 No COUMADIN today per coumadin phcy protocol Kannankeril Jaya J
93. HMED ZAFAR 05 24 5 00 PT INT 2 60 PT 29 3 AHMED ZAFAR 05 24 5 00 COMPREHENSIVE NA CANCELED K CANCELED L CANCELED CO2 CANCELED BUN METABOLIC PANEL CANCELED CREAT CANCELED GLUCOSE CANCELED AGAP CANCELED AG RATIO CANCELED BUNCR CANCELED GLOBTOT CANCELED ALB CANCELED TPROT CANCELED CA CANCELED ALT CANCELED AST CANCELED ALKPHOS CANCELED GFR CANCELED TBILI CANCELED AHMED ZAFAR 05 24 5 00 VITAMIN B12 KASON 05 24 8 12 FOLATE THOMAS T AHMED ZAFAR 05 24 5 00 CBC W AUTO DIFF WBC 5 4 RBC 5 26 HGB 14 7 HCT 44 8 PLTCT 182 MCV 85 1 MCHC 32 7 RBCMORPH Few Anisocytosis Slight Poikilocytosis Ovalocytes Target Cells Burr Cells MONOS 14 LYMPHS 15 BANDS 2 SEGS 69 MANDIFFDONE Man Diff Done MPV 9 5 RDW 21 2 MCH 27 9 AHMED ZAFAR 05 23 18 51 TSH TSH 2 078 Blazek RN 05 24 13 51 Patricia Marie Metro South Medical Center Patient Name Le EH feral WELLCARE Allergies nka UNKNOWN PHYSICIAN AHMED ZAFAR HARRIS RICHARD G AHMED ZAFAR AHMED ZAFAR AHMED ZAFAR AHMED ZAFAR AHMED ZAFAR AHMED ZAFAR AHMED ZAFAR AHMED ZAFAR Age DOB 05 23 20 17 VIRTUAL 05 24 10 52 05 24 7 48 05 24 6 31 05 24 6 32 05 24 1 21 05 24 5 47 05 24 9 42 05 24 11 18 05 24 10 18 05 24 5 00 RADIOLOGIC PRELIM REPO CK CKMB B TYPE NATRIURETIC PEPTIDE COMPREHENSIVE METABOLIC PANEL 53 AGAP 11 AG RATIO 0 9 BUNCR 27 GLOBTOT 3 9 ALB 3 4 TPROT VITAMIN B12 FOLATE Glucose monitor Glucose monitor
94. History of Confusion Disorientation Impulsivisity Yes 4 HX Depression with active symptoms at present No 0 Altered elimination Frequency Urgency Incontinence Diuretics Yes 1 Currently History of Dizziness Vertigo No 0 Male Gender No 0 Currently taking anticonvulsants check MAR No 0 Currently taking benzodiazepines check MAR No 0 Mobility assessment reveals Get up and Go Test Patient needs to push up but successful in 1 attempt 1 TOTAL SCORE 5 or more STANDARD AND HIGH RISK INTERVENTIONS AS NOTED BELOW Standard precautions initiated Includes initial and ongoing fall risk education safe room set up including call light in reach and not dangling moving furniture on non exit side of bed side rails up x2 bed locked and low adequate lighting and room is clear of clutter If high risk additional interventions below High risk precautions initiated Includes Appropriate signage posted in room chart labels on Fall risk ID band applied red slippers provided hourly rounding done proactive bladder program established and exit alarms are in place and active Nursing Serial SHIFT MULTIPLE LINE ASSESSMENT rev 12 21 09 Bayless RN Michel PIVL Site 1 Location Left AC Fossa PIVL Site 1 dressing label Date Time placed 20g 5 23 PIVL Site 1 Inspection Site is clean and dry without redness drainage or swelling Patient s central venous access device continues to be necessary due to N A Metro South Medical
95. ID jComtycode S S 18 6 ID Y 3 Character Set 19 60 CE Principal Language of Message EVN SEQ LEN DT OPT RP ELEMENT NAME NOTES Event type code Duplicatedin MSH Date Timeofevent Date Timeplaneedeven amp ventreaoncode jOperatorlD 0 0 0 amp ventOcumed X PID SEQ LEN DT OPT RP ELEMENT NAME NOTES EN E o0 RCM Patient 1D External bu CY Paientib nemal a Ov AlternatePatient ID EN Y PHemName re Mother sMaidenName Useof th O S o Ce oo RN Ov PatintAias 0 e LY Pet po E EN ERR 0 EE Pati 0 RR Dp C O E C lt 18 Xx e oO o0 o 116 empowerlnpatient Ambulatory SEQ LEN DT OPT RP ELEMENT NAME NOTES 19 a6 ST SSN Number Patient 20 35 DIN _ Driver stic Num Patient C1 20 cK Mothersidentifier S mj s t5 HmcGmp o 3 0 ST BnhPee 4 2 D MutpleBihindesor 735 2 NM BinhOrder 735 a i y oesi 3 60 c _ Veterans MiltaryStatus 3 8 c Neony 29 26 T PatenDesthDsteandTime 30 1 ib jPaenDeshindetor PV1 SEQ LEN DT OPT RP ELEMENT NAME NOTES p12 4 st Setid PatientVisit o 2 4 i R PatientClass 3 80 PL Assig
96. ING DISCHARGE Notifications By MD No Notification Documentation 12935 South Gregory Street Blue Island IL 60406 2428 Admitting Admitting 708 597 2000 Gender Race Insurance Weight Height Medical Record Account 857 175260 ANN NNI Room 4S0 421 01 Nursing Serial SHIFT MULTIPLE LINE ASSESSMENT rev 12 21 09 PIVL Site 1 Location Right Forearm PIVL Site 1 dressing label Date Time placed PIVL Site 1 Inspection Site is clean and dry without redness drainage or swelling Patient s central venous access device continues to be necessary due to N A Nursing Serial SHIFT NARRATIVE NOTE new 6 29 10 pt resting in chair sister loretta call for pickup discharge home per md s Pt is stable pain free and accucheck with normal liimits Pharmacy COUMADIN NOTE FOLLOW UP DOSING The patient chart and current labs have been reviewed INR level 3 30 Pharmacy plan Hold Coumadin dose for today and repeat INR in AM We will continue to follow and adjust as needed for an INR goal of 2 5 3 5 At bedside with pt Introduced myself to pt as Chaplain Chapman and explained the purpose of my visit That a family member has called this chaplain and said she wanted Power of Attorney Health Care done for pt Pt stating she already has a Power of Attorney Health Care Pt states she does not need Power of Attorney Health Care Pt states she does not want Power of Attorney Health Care Nursing Serial SHIFT NARRATIVE NOTE new
97. IO CNO COO Directors Managers Billing ED Medical Director ED Nurse Manager Information Systems Laboratory Marketing Public Relations Medical Records Pharmacy Quality Assurance Radiology Registration Risk Management Other Key Project Resources Clinical Analyst Hardware Specialist Interface Resource or LIS Analyst Network Administrator Project Manager SQL Database Admin Systems Analyst Unit Clerk s 127 empowerlnpatient Ambulatory Appendix 1B Implementation Project Timeline Check List Phase Project Kickoff Assessment introductory cal Project Team Agenda to include Empowersystems COO i lent potential weeRy phone conference Empowersysteme _ Project Packet C meemewstonMama a a LL emadetecipt PF review races P Fst enpectationsandidentity resources PM EmpowerSystems IT Conference Call Hosp IT EmpowerSystems Hardware Hosp IT m EmpowerSystems Connectivity Hosp IT EmpowerSystems Security Hosp IT EmpowerSystems Interfaces Hosp IT ae EmpowerSystems Timeline Hosp IT EmpowerSystems Specs Hosp IT Purchase Hardware Hom Tem Conference cal Aematomdude feon pf ety reaistration interface capabiines fenone yy E Choose EmpowerSystems Kick Of
98. Kurt W M D 2338 New Street NULL Blue Island IL 60406 708 824 1114 12 00 00 AM IN 2 WEEKS Patient Medication List Aspirin 325 mg Tab 1 tablet Daily Colace 100 mg Cap 1 tablet Twice Daily as needed Coreg 25 mg Tab 1 tablet Twice A Day DOCUSATE SODIUM 100 MG 2x a day as needed Enalapril 10mg PO 1 tablet Twice A Day starting taking in 1 week FAMOTIDINE 20 MG 2 times a day 0900 2100 HUMALOG 6units After Meals Subcutaneous 6 UNITS Three times daily AFTER Meals Insulin Detemir SubQ 20 units At Bedtime Lasix Oral 100 mg Twice A Day Potassium Chloride 20meq PO 1 tablet Daily Reglan 10 mg Tab Three Times A Day Simvastatin 40 mg Tab Daily Metro South Medical Center 12935 South Gregory Street Blue Island IL 60406 2428 708 597 2000 Admitting Admitting Patient Name Age DOB Gender Race Insurance Weight Height Medical Record Account m O X ee 080 55 175265 i NENEIENI Allergies nka Room 4S0 421 01 Warfarin 5 mg Tab Daily ZALEPLON 10 MG at bedtime as need 2100 Exam Objective Assessment Plan Problem List Electronically signed and authenticated by the Following Physicians FOCHESATTOFILLHO LUCIANO Specialty Internal Medicine Admitting Admitting Patient Name Age DOB Gender Race Insurance Weight Height Medical Record Account um mm o5 umo 557g 1752600 ENEEN NNI Allergies nka Room 4S0 421 01 Diagnostic Results Ordering Date Time Diagnostic Reviewed D
99. Left Lower Extremity RUE Right Upper Extremity LUE Left Upper Extremity BLE Bilateral Upper Extremity 2pt Two point discrimination PP Pin Prick Prop Proprioception NL Normal SLR Straight Leg Raise XSLR Cross Straight Leg Raise F N intact Finger to Nose Intact H S Heel Shin Intact GSS intact Gross Sensory System Intact Miscellaneous CM Cardiac Monitor Exp Explored 141 empowerlnpatient Ambulatory Appendix 9A Empower Table Names and Descriptions The Empower look up tables are listed below These tables are pre populated with the common clinical terminology used by physician and nurses when documenting on the chart In addition some tables are used by the smart technology built into Empower The hospital will have an Empower table editor only to those tables not affected by the smart technology Each field on an Empower form is connected to a look up table The hospital can identify the look up table that is connected to a field on the form by reading the table description and then finding it on the Empower forms Empower recommends only populating tables and not deleting tables tblluALDrugs This table contains drug allergy and classification tblluApplicationSettings This table contains the on and off switch for certain hospital specific features in EmpowerSystems tblluBelongDiagnostic This table Check Boxes on the physician diagnostic form with specific tests tblluDiagMapping T
100. MISSION HOME MEDS Aspirin 325 mg Tab Daily CONTINUE ADMISSION HOME MEDS Chlordiazepoxide 25 mg Cap At Bedtime as needed CONTINUE ADMISSION HOME MEDS Colace 100 mg Cap Twice Daily as needed CONTINUE ADMISSION HOME MEDS Colchicine 0 6 mg Tab Twice A Day CONTINUE ADMISSION HOME MEDS Coreg 25 mg Tab Twice A Day CONTINUE ADMISSION HOME MEDS Digoxin 0 25mg PO Daily CONTINUE ADMISSION HOME MEDS Enalapril 20mg PO 1 tablet Twice A Day CONTINUE ADMISSION HOME MEDS Glipizide 10 mg Tab Twice A Day CONTINUE ADMISSION HOME MEDS HUMALOG 6units After Meals Subcutaneous 6 UNITS Three times daily AFTER Meals CONTINUE ADMISSION HOME MEDS Insulin Detemir SubQ 20 units At Bedtime CONTINUE ADMISSION HOME MEDS Lasix 80 mg Tab Twice A Day CONTINUE ADMISSION HOME MEDS Pepcid 20 mg Tab Twice A Day CONTINUE ADMISSION HOME MEDS Reglan 10 mg Tab Three Times A Day CONTINUE ADMISSION HOME MEDS Simvastatin 40 mg Tab Daily CONTINUE ADMISSION HOME MEDS Warfarin 5 mg Tab Daily CONTINUE ADMISSION HOME MEDS Zithromax 250mg PO Daily CONTINUE DISCHARGE HOME MEDS Aspirin 325 mg Tab 1 tablet Daily CONTINUE DISCHARGE HOME MEDS Colace 100 mg Cap 1 tablet Twice Daily as needed CONTINUE DISCHARGE HOME MEDS Coreg 25 mg Tab 1 tablet Twice A Day CONTINUE DISCHARGE HOME MEDS diagnostic test to be completed One Time CONTINUE DISCHARGE HOME MEDS DOCUSATE SODIUM 100 MG 2x a day as needed CONTINUE DISCHARGE HOME MEDS Enalapril Maleate Oral 2 5 mg Twice A Day CONTINUE DISCHA
101. Need Treatment Plan Readiness to Learn Accepting Attentive Teaching Method Activity Based Response to Teaching Acknowledges understanding Patient Family taught the following Compensatory strategies Metro South Medical Center Patient Name Allergies nka 05 24 2011 8 46 05 24 2011 9 45 12935 South Gregory Street Blue Island IL 60406 2428 708 597 2000 Admitting Admitting Age DOB Gender Race Insurance Weight Height Medical Record Account um mmm oo ee 557g 1752600 EN NN Room 4S0 421 01 PLAN OF CARE Occupational Therapy Interdisciplinary Plan of Care Barder OT Jennifer INTERVENTIONS Assess functional skills performance OUTCOMES Maximize independence in daily living skills EP LAB Nursing Focused EP LAB DEVICE INTERROGATION rev 5 13 11 Bartkus RN Carol A CURRENT DEVICE FUNCTION Normal ICD Function COMPANY Medtronic DEVICE STORED EVENTS NOTES No stored events DATE OF IMPLANT May 13 2010 MODE VVIR UPPER RATE 120 LOWER RATE 70 ICD CURRENT PARAMETERS VT OFF ICD CURRENT PARAMETERS VF 200 BPM ICD CHARGE TIME seconds 9 1 SECS BATTERY CHARGE volts 3 13V UNDERLYING RHYTHM Other DEPENDANT ATRIAL SENSING AMPLITUDE mv 0 4mv VENTRICULAR SENSING AMPLITUDE mv unable to obtain LV SENSING AMPLITUDE mv na ATRIAL IMPEDENCE ohms 703 OHMS VENTRICULAR IMPEDENCE ohms 323 OHMS LV IMPEDENCE ohms NA RV SHOCK IMPEDENCE ohms 42 OHMS SVC SHOCK IMPEDENCE ohms 58 OHMS ATRIAL THRESHOLD vol
102. OPERITONEUM KIDNEY BLADDER CK CKMB RENAL FUNCTION PANEL Glucose monitor Glucose monitor Glucose monitor COMPREHENSIVE METABOLIC PANEL PHOSPHOROUS IFE PANEL Glucose monitor Glucose monitor COMPREHENSIVE 12935 South Gregory Street Blue Island IL 60406 2428 Admitting Admitting Weight Height Medical Record Account 85 7kg 1 NN 4S0 421 01 05 24 18 58 708 597 2000 Gender Race Insurance Room Critchett RN Daisyrenee ACCESSION 0142219 HISTORY BUN 51 creatinine 1 88 COMPARISON STUDY None FINDINGS The right kidney measures around 10 5 cm in length x 4 6 x 4 3 cm in diameter The left kidney measures around 10 0 cm in length x 4 8 x 4 1 cm in diameter There is no hydronephrosis or mass of either kidney Renal parenchyma is preserved There is free fluid in the abdomen Foley catheter is present in the bladder which cannot be otherwise evaluated IMPRESSION 1 NO MASS OR HYDRONEPHROSIS OF EITHER KIDNEY NO ACUTE RENAL ABNORMALITIES ASSESSMENT OF PARENCHYMAL ECHOGENICITY IS SOMEWHAT LIMITED ON THE RIGHT WITH QUESTION OF SLIGHT INCREASED ECHOGENICITY THE LEFT RENAL ECHOGENICITY APPEARS NORMAL 2 ASCITES IN FOUR QUADRANTS Liisa L Laakso D O APPROVED ELECTRONICALLY BY Liisa L Laakso D O ON Tue May 24 17 40 40 CDT 2011 cc LAAKSO LIISA MT ASR DD 05 24 2011 04 20 PM DT 05 24 2011 05 24 PM ID 1232037 JOB 1232037 CK1 121 NA 144 K 3 9 CL 108 CO
103. OUND ASSESSMENT rev 05 06 10 WOUND ASSESSMENT No Bahena RN Cecilia wounds at this time no further assessment needed TOTAL NUMBER OF WOUNDS N A no wounds present upon assessment EQUIPMENT Pressure relief mattress WOUND ASSOCIATED PAIN N A WOUND TREATMENT N A 05 25 2011 20 00 ASSESSMENT Nursing Serial SHIFT NURSING ASSESSMENT rev 11 04 10 Bahena RN Cecilia Transmission Precautions Standard O2 Type Liter Flow Room Air Rhythm Strip Interpretation Atrial Fib LOC Awake Alert and Oriented x 3 and forgetful Affect Calm and cooperative Eye Opening 4 spontaneous Verbal Response 5 Alert and Oriented X 3 Motor Response 6 obeys commands Pupils equal and reactive Ability to Move right arm strong Ability to Move right leg strong Ability to Move left leg strong Ability to Move left arm strong Skin Color Normal Skin Temperature warm Skin Moisture Dry Skin turgor non tenting Respirations Even and unlabored Breath Sounds Right Clear Breath Sounds Left Clear Retractions No retractions noted Abdomen Soft and non tender Bowel Sounds Active x 4 quadrants Pedal Edema Right 1 plus Mild 0 1 4 inch Pedal Edema Left 1 plus Mild 0 1 4 inch Pedal Pulses Right 1 plus Barely palpable Pedal Pulses Left 1 plus Barely palpable 05 25 2011 21 00 NURSING Due to patient s previous hypoglycemic events will hold insulin coverage Bahena RN Cecilia 05 26 2011 0 00 NURSING Medication Administration Record Reconciled and Verifie
104. RGE HOME MEDS FAMOTIDINE 20 MG 2 times a day 0900 2100 CONTINUE DISCHARGE HOME MEDS HUMALOG 6units After Meals Subcutaneous 6 UNITS Three times daily AFTER Meals CONTINUE DISCHARGE HOME MEDS Insulin Detemir SubQ 10 units At Bedtime CONTINUE DISCHARGE HOME MEDS Lasix Oral 100 mg Twice A Day CONTINUE DISCHARGE HOME MEDS Potassium Chloride 20meq PO 1 tablet Daily CONTINUE DISCHARGE HOME MEDS Simvastatin 40 mg Tab Daily CONTINUE DISCHARGE HOME MEDS Warfarin 5 mg Tab Daily CONTINUE DISCHARGE HOME MEDS ZALEPLON 10 MG at bedtime as need 2100 CONTINUE DISCHARGE HOSPITAL MEDS ASPIRIN 325 MG ORAL daily DISCONTINUE DISCHARGE HOSPITAL MEDS CARVEDILOL 25 MG ORAL 2 times a day DISCONTINUE DISCHARGE HOSPITAL MEDS CHLORDIAZEPOXIDE HCL 25 MG ORAL at bedtime as need DISCONTINUE DISCHARGE HOSPITAL MEDS DOCUSATE SODIUM 100 MG ORAL 2x a day as needed DISCONTINUE DISCHARGE HOSPITAL MEDS ENALAPRIL MALEATE 10 MG ORAL 2 times a day DISCONTINUE DISCHARGE HOSPITAL MEDS FAMOTIDINE 20 MG ORAL 2 times a day DISCONTINUE 12935 South Gregory Street Blue Island IL 60406 2428 708 597 2000 Metro South Medical Center Ee fu Admitting Admitting Patient Name Age DOB Gender Race Insurance Weight Height Medical Record Account Eee EN E 570096 WELLCARE 85 7kg 175 26cm MEN s Allergies nka Room 4S0 421 01 DISCHARGE HOSPITAL MEDS FUROSEMIDE 100 MG INTRAVENOUS every 8 hrs DISCONTINUE DISCHARGE HOSPITAL MEDS METOCLOPRAMIDE HCL 10 MG ORAL
105. Sensory Coordination Neuro py D a a Lymphatics pE The Date Time of the exam will default to the time of documentation If this differs from the actual time of the exam it can be entered if different by clicking in the time box and entering the time in military time with no punctuation e g 2 00 PM is entered as 1400 Repeat or Additional Notes Check boxes are available for required EMTALA discharge statements transfers AMA and LWBS Click in the white box to free text a repeat exam or provide additional information regarding the physical exam Phrases can also be selected from the drop down box Laceration Procedures Laceration details such as location length shape depth wound exploration and procedure must be selected from the drop down lists to provide the required documentation for appropriate reimbursement The additional comments allows free texting of additional details Other Procedures Procedures must be selected from the list and free text is not permitted due to coding regulations Free texting may be done in the Additional Comments section 95 empowerlnpatient Ambulatory High Risk Chief Complaints Empower can improve Clinical Documentation with certain Chief Complaints These High Risk Chief Complaints are identified in the Subjective box of the History Subjective portion of the Emergency Note Once the Chief Complain is entered a Pop up window opens and the Practitioner is able to do
106. Standard Foreign Order Number Strategy Default This strategy sets the Empower placer number to the same value as the ID of the record in the Empower database table i e 12345 System Specific Foreign Order Number Strategy This strategy sets the Empower placer number to EMPOWER plus the value of the ID of the record in the Empower database table i e EMPOWER 12345 112 empowerlnpatient Ambulatory Creation of New Order by Empower The Empower placer number is created for the new order The ancillary system should fill in this placer number in the placer field for all subsequent messages about this order Order Status Change Status changes are usually only sent by the ancillary system These should be sent with an order control code of SC Currently the inbound interface supports transitions to in progress and completed Order Cancellation Cancellations are a special kind of status change They should be sent as an order message with a CA order control code Outbound Orders The Outbound Orders interface will send HL7 2 2 The Outbound Orders interface will send the following message trigger events Trigger Events O01 General Order Message Supported Order Control Codes NW New Order NA Number Assign CA Cancel Order Request SC Status Changed Although the Outbound Orders interface is HL7 2 2 compliant some segments and fields will not be used for this interface implementation Listed bel
107. T OPT RP ELEMENT NAME NOTES elejo JjswDte OOO o s or emoe 1 aoj eo sr ere o ra 20 sce bCdedas raz 20 amp employeeNumber 3 eo XoN OrganizationName GT1 SEQ LEN DT OPT RP ELEMENT NAME NOTES pa ats R JStlD f 2 250 CX GuarantorNumber 3 250 XPN R jGueanorName S 4 250 XPN Guarantor Spouse Name 00 5 250 XAD GuarantorAddress o 6 250 xTN GuarantorPhNum Home 7 250 xTN GueantorPhNum Busness 8 26 TS Guarantor Date Time of Birth 9 4 is jGuratorSex 10 2 IS jGuratorlype 11 250 CE Guarantor Relationship 12 12 st GuarantorssN S 13 8 DT GuarantorDate Begin 14 8 DT GuarantorDate End S 15 2 NM GuarantorPriority o 16 250 XPN Guarantor Employer Name 17 250 XAD Guarantor Employer Address 18 250 XTN Guarantor Emp Phone Number 19 250 CX Guarantor Employee ID Number 20 2 IS Guarantor Employment Status 21 250 XON Guarantor Organization Name 22 1 ID Guarantor Billing HoldingFlas 23 250 CE Guarantor Credit Rating Code 24 26 TS Guarantor Death Date And Time 25 1 ID Gu
108. THOD DEFINITION UPDATES ESCALATION RESOLUTION System Completely Down Issue Affecting Entire System Sulagaane Emergent Physicians Cannot Call Line Document at All on Any Patients Continuous as Within 2 Hours from 4 Hours from Initial Information Initial Contact Contact Becomes Available Management Attention Required Main Empower Server Failure System Up with Degraded Functionality Critical Emergent Entire Interface Every 2 Hours Until Within 4 Hours from 6 Hours from Initial Call Line Functionality Down Resolved Initial Contact Contact for All Patients Interface Server Failures 157 empowerlnpatient Ambulatory Empower Non Emergent Support Matrix oaa METHOD DEFINITION UPDATES ESCALATION RESOLUTION Online Ticketing System System Operational with Minor Functionality Loss Minor Subsystem Functionality Failures Limited Data Entry Access Issues General High Impact Bug Fixes Peripheral Application Server Failures Upon Resolution or Weekly Until Resolved Within 24 Business Hours from Contact 32 Business Hours Depending Upon Scope and Complexity Online Ticketing System Medium Minor Operational Issues Without Immediate Patient Documentation Impact Report Requests Enhancement Requests Upon Resolution or Weekly Until Resolved Within 36 Business Hours from Contact 40 Business Hours Depending Upon Scop
109. This field will have an X if there is a Physical Exam time in the patient s chart It does not mean that there is a Repeat Exam Any records on this report will meet the definition of an LWBS 57 empowerlnpatient Ambulatory Narcotics Report The Narcotics Report lists all of the narcotic orders in the ED There is also a report for narcotic prescriptions The report gives the patients name the date of the visit the medication given the ordering physician the dispensing nurse and the order location or where injection was given It also lists whether the order was cancelled or refused along with any nursing comments Non Finalized Chart Report Non Finalized charts are inactive charts that are no longer on the patient tracking screen but were never printed Other non finalized charts include e Improper assignment of LWBS or a LWCT patient As mentioned earlier the database makes certain assumptions about LWBS charts Charts with the LWBS disposition and a repeat exam will flag the chart as a problem In this case charts should be set either LWCT Left Without Completing Treatment Eloped Left Without Notifying ED Staff Left AMA or anything else that indicates that the MD did in fact see the patient e Discharged patients on which charts were not printed One common nursing practice is to print the patient s discharge instructions discharge the patient and then return later to complete the chart This increases the possibil
110. Timeliness Summary Chart Arrival To Exam Room by Hour Arrival To Exam Room by Hour Chart Arrival to Full Registration Arrival to Full Registration Chart Select a report from the drop down menu on the left specify a start and end date then select the Run button located to the right Results are then displayed in a panel below Multi Facility If the facility has multiple sites then a report can be generated which contains an additional field located below the date range that will list the names of all of the facilities It cannot be left blank 52 empowerlnpatient Ambulatory Reports The standard reports are generally complex queries involving multiple tables frequently containing many nested subqueries and multiple search criteria The listing of reports presented in this overview reflects what is available as of this writing but there are always more reports being developed and added In general new reports are created in order to address a generally accepted need among clients Reports based on data in structured fields are more likely to be developed and implemented sooner than reports based on free text fields There are over one hundred different reports as sample of which is listed below Standard Report Name 72 Hour Returns LWBS All PCP Log Admit Transfer Statistics LWBS Call Back Pharmacy Usage Ambulance Patients LWBS Insurance Pneumonia Antibiotic Timeliness ASA Beta Blockers LWBS Peds Press Ganey Provider Dispos
111. ZAFAR MD Institute ACLS Protocols for sustained symptomatic Bayless RN Michel 05 23 18 37 Secretary Completed arrhythmias per AHMED ZAFAR MD Notify physician of all arrhythmia events actions and Bayless RN Michel 05 23 18 37 Secretary Completed current status as soon as possible per AHMED ZAFAR MD Initiate Potassium and Magnesium replacement Bayless RN Michel 05 23 18 37 Secretary Completed protocols as needed per AHMED ZAFAR MD DIET per AHMED ZAFAR MD Bayless RN Michel 05 23 18 37 Secretary Completed DIAGNOSTIC TESTING per AHMED ZAFAR MD Bayless RN Michel 05 23 18 37 Secretary Completed Repeat Troponin level 8 hours after first draw x 1 per Bayless RN Michel 05 23 18 37 Secretary Completed AHMED ZAFAR MD Repeat CK MB level every 8 hours after first draw x2 Bayless RN Michel 05 23 18 37 Secretary Completed per AHMED ZAFAR MD PCXR STAT if not done in ED per AHMED ZAFAR MD Bayless RN Michel 05 23 18 37 Secretary Completed 12 lead EKG STAT if not done in ED per AHMED Bayless RN Michel 05 23 18 37 Secretary Completed ZAFAR MD 12 lead EKG daily x 2 per AHMED ZAFAR MD Bayless RN Michel 05 23 18 37 Secretary Completed Metro South Medical Center Patient Name Age DOB Gender Race Insurance eo Allergies nka AHMED ZAFAR AHMED ZAFAR AHMED ZAFAR AHMED ZAFAR AHMED ZAFAR AHMED ZAFAR AHMED ZAFAR AHMED ZAFAR AHMED ZAFAR AHMED ZAFAR AHMED ZAFAR 05 23 2011 18 40 0
112. a White RN Carina White RN Carina White RN Carina PO Fluids CARVEDILOL FAMOTIDINE METOCLOPRAMIDE HCL SIMVASTATIN IV Fluids DOBUTAMINE 500MG 250 D5W 250 ML INTRAVENOUS AS needed DOBUTAMINE 500MG 250ML D5W KASON THOMAS T POTASSIUM CHLORIDE FUROSEMIDE FAMOTIDINE METOCLOPRAMIDE HCL CARVEDILOL 5 MG 80 MG 25 MG 20 MG 10 MG 40 MG 20 MEQ 100 MG 20 MG 10 MG 25 MG Height 12935 South Gregory Street Blue Island IL 60406 2428 Admitting Admitting Weight 85 7kg ORAL INTRAVENOU S PO Fluids HELD DOSE ORAL ORAL ORAL IV IV ORAL INTRAVENOU S ORAL ORAL ORAL Room 1 Tablet 8ML 120 ML 0 ML 0 ML 0 ML 0 ML 840 ML 152 5 ML 1 Tablet 0 ML 1 ML 1 Tablet 1 Tablet 708 597 2000 Medical Record Account 175 26cm M NEEEEN 4S0 421 01 Vitals Time 05 24 17 41 BP NA NA Pulse NA Respiration N Vitals Time 05 24 17 41 BP NA NA Pulse NA Respiration N no appetite Vitals Time 05 24 20 49 BP NA NA Pulse NA Respiration N Vitals Time 05 24 20 49 BP NA NA Pulse NA Respiration N Vitals Time 05 24 20 49 BP NA NA Pulse NA Respiration N Vitals Time 05 24 20 49 BP NA NA Pulse NA Respiration N 12 hour night shift 12 hour nights Vitals Time 05 25 16 30 BP NA NA Pulse NA Respiration N Vitals Time 05 25
113. a custom or special project then a written request must be communicated to Empower that includes the scope of the project and any deliverables Empower will then provide a Statement of Work SOW and timeline estimate for testing and delivering the project Supplemental Services Empower is available to complete custom development requests which are supplemental to the standard licensing and maintenance services as stipulated in the client contract Based on a client request Empower will assess the scope of work involved and develop a Statement of Work SOW including relevant development costs and associated maintenance fees Your Empower project manager can provide you with a full list of supplemental services offered 30 empowerlnpatient Ambulatory Chapter 7 Coding and Billing The Empower InpatienttAmbulatory system can code the physician professional Level of Service E amp M Evaluation and Management with accuracy if the clinicians provide the appropriate documentation In addition Empower can also assign ICD 9 and CPT codes to diagnoses and procedures if the correct documentation is provided It has been Empower s experience that certain physicians and physician groups prefer to use certain ICD 9 and CPT codes whereas other coders at different facilities and or physician groups may prefer other codes Empower has been designed to customize the ICD 9 and CPT codes to the preference of the individual coders at the facility ho
114. aboratory results If the laboratory result interface is not active then the provider will need to interpret enter all results For certain diagnostics such as the EKG or radiological studies the provider will need to provide their own interpretation Drop down statements or free text may be used e To view results click into Result Interpretation Once in this screen results can be trended e Clicking on any diagnostic or medical intervention U B E R M will navigate to the appropriate diagnostic or medical Intervention screen Assessment Plan Medical Orders Staff Name Assessment Diagnosis Problem List Filter By Start Date Priority Status Medical Orders mer c MD Name __ MD Time Medical Orders and comments Filter By I Clinical Staff _Staff Time _ Status Guterman Seth J 04 08 11 16 Cardiac Monitor Guterman Seth J 04 08 11 16 Continuous Pulse Ox e The initial Assessment Diagnosis is taken from the initial Subjective complaint It can be changed at any time and additional Assessments can be added as needed e Each Assessment has a section for comments start date priority and status 99 empowerlnpatient Ambulatory Medical Orders Click on the white box to open Medical Orders MD Add Order Cardiac Monitor Continuous Pulse Ox Pulse Ox Glucose Scan normal range 7 Quick HemoGlobin Urine Dip Urinalysis Urine Culture Urine HCG Urine Tox Quantitative
115. an Wait Time to See a Nurse Wait Time to Exam Room 5 Min 0 Min 0 Min Bed Assignment Time Nurse Transfer Time 0 Min 0 Min These wait times reflect the approximate time to see a Physician at MetroSouth Medical Center Times are updated frequently as conditions change Please note patients with the most serious illnesses injuries are given priority Wait times may be affected by the number of patients in the ED and severity of their conditions MD Name MD Evaluation Current Time Patients Per Hr Penn Mark 3 HR 04 07 2011 15 06 25 NUSSBAUM ERIC 2 HR 04 07 2011 15 06 25 Tu 62 InpatienttAmbulatory Waiting Room Patients Waiting in Exam Room for MD Evaluation Acuity Patient Name Age Gender Chief Complaint Exam Rm Time Elaspeq po 0 Years Female Falling 2B 00 27 ICU nPatient Tracker Medical Order Abnormal Value MetroSouth Medical Center init Clerk liti InPatient Tracker pcut Future Last Name First Name Exam Rm MD RN Days Disposition Future Bed Bed Status C M A 451 4801 01 FREDRICK Jr EARL IfGuerrero RN Cora 6 480631 Ea o fesreereor jrocnesarrorminofwood RN Karen MY 26 soz ac NICU TIT MetroSouth Medical Center InPatient Tracker Future Last Name SR Name Exam Rm MD Days Disposition Future Bed Bed Status C M A pany Dssosor forare KiMoeDroasch tN Cow LPT ic ee eee MI HAIAT GULAMA JAdamstinds PO a 1 pev fanv s902 01 JLINDSAY CATHERIN ot a
116. and Specific Diagnosis MRSA VRE Positive Patients e Patient Lists with Medical Disease Management Compliance e Doctors Lists with Medical Disease Management Compliance e Hospital Staff Lists with compliance of completing hospital forms e Diagnostic Test Lists of Abnormal Tests e Hospital Forms Lists Completed Forms Restrains Care Plan etc e Hospital Order Sets List based on Diagnosis Management and Compliance e Alerts for Abnormal Vital Signs e Alerts for Correct Antibiotics based on Diagnosis e Alerts for Abnormal Diagnostic Test e Alerts for Documenting Correct Coding Information e Alerts for SCIP Compliance based on Type of Surgery For hospital clinical and IT staff with minimal knowledge in SQL Clinical Documentation Workflow and Database Structure requiring the following types of highly complex reports the hospital may prefer to engage the Empower reporting team e Calculation Reports i e reports involving time e Complex Clinical Documentation Reports e Complex Workflow Reports e Complex Communication Reports e Category Reports Medications e Printing Reports Faxing Reports Email Reports 50 empowerlnpatient Ambulatory Recommended Knowledge Foundations Empower s ONC Certified EHR participates in the practice of medicine between doctors and hospital staff by providing comprehensive clinical documentation services complicated communication notifications and supporting complex workflow systems Emp
117. apter 3 It is recommended that a computer lab be set up for the training of SuperUsers After scheduling both the Go Live and the training sessions these dates cannot be changed without incurring a significant charge by the hospital PHASE IV Go Live The Empower Go Live will occur on a Tuesday morning after nurse shift change On the day of Go Live an Empower team representative will inspect the computer server and work stations as well as the printers tracking systems and all relevant areas During implementation workflow and methods of communication will not change but the transition from paper to computer Empower documentation will be immediate The physician and nurses will enter all clinical documentation including physician and nurse notes diagnostic and medical orders diagnostic results vital signs discharge instructions and prescriptions on computers at the time of Go Live PHASE V Post Go Live Assessment amp Transition The Empower Go Live team will be onsite in the inpatient ambulatory setting around the clock until a time that users are deemed comfortable with the software The Empower team will assist the physicians nurses and staff with documentation and navigation of the system After the Empower team departs Empower will still be on site at the hospital but in a remote virtual environment Empower provides technical support both by phone and via remote connectivity in order to respond to questions f
118. arantor Death Flas 26 250 CE Guarantor Charge Adj Code 27 10 CP Guarantor Household Income 28 3 NM Guarantor Household Size 29 250 CX Guarantor Employer ID Num 30 250 CE Guarantor Marital Status Code 31 8 DT Guarantor Hire Eff Date 32 8 DT EmplymentStpDate 33 2 IS ivngDepndeny 34 2 IS jAmbultorSttus 119 IN1 empowerlnpatient Ambulatory SEQ LEN DT OPT RP ELEMENT NAME NOTES 35 250 ct Citizenship 36 250 ct Primarylanguage S 37 2 i living Arrangement TCS 38 250 ce Publictycode 39 1 n Protectionindicator 40 2 is Studentindicator aso c Rigo 42 250 xPN MotersMsdenName as 250 c Nationality aa aso c EmkGou as 250 XPN Contact Person sName 46 250 XIN Contact Person s Telephone Num ap 250 c CotetReson CS ras 2 t Contact Relationship 49 39 s Pome S 4 so so xc obcas 51 250 XON Guarantor Employer s Org Name sa 2s Handicap PSS sa 2 8 Posas SST sa so FC Guarantorfinancial Class 55 250 cE Guarantorrae S SEQ LEN DT OPT RP ELEMENT NAME NOTES afafa R e M 2 s0o ce
119. arrow until you see these numbers Apply and Save Contact a super user or Internal IT if you need assistance Plasma Screen blank or a E Check connections make sure it is turned on Reboot the computer displays incorrect information mM attached to this Try all of this prior to calling the help line or lacks information Log out of EmpowerSystems and right click on the time display and Time incorrect on the j change to the correct time Contact internal IT if unable to change computer the time All lab diagnostics must be selected from the drop down tables if entered in Medical Interventions If a blood test shows on the Lab Results not crossing to Medical Interventions screen it was free texted and that text is not EmpowerSystems or crossing mapped Cancel the incorrect and re enter appropriately slowly If the test does appear in diagnostics contact the lab and then call the help line regarding this interface issue Patients not crossing to Contact your IT department with patient examples and if they 154 empowerlnpatient Ambulatory EmpowerSystems via the determine it is not an internal problem they should contact ADT interface or crossing EmpowerSystems Technical Support slowly 155 empowerlnpatient Ambulatory Technical Support Guidelines In an effort to allow Emergent calls to take precedence over Non Emergent calls and provide more appropriate and efficien
120. artment as this is unlikely to be a result of Empower e Interface Orders or Results on an Individual Patient Unless this issue applies to multiple patients open a Non Emergent ticket on our support site and include specific examples to include MRH Account Date of Service Test Examples and what should have crossed e Physician Signatures As of v1 7 5 Empower provided your hospital with the ability to capture and manage all signatures via tablet PC If you have not already done so please make arrangements to acquire a tablet PC for this purpose as we will no longer be accepting faxed signatures for processing e PDF Generation Empower employs notification technology to let us know when if our PDF process is interrupted This can naturally occur due to network errors and will be corrected quickly during normal business hours By calling the Emergent Emergent Support Line 877 222 3237 selecting the correct option and leaving a voice message will notify the technician on duty 24 7 This automated process takes approximately 15 20 minutes to receive a response Again our Non Emergent ticket system is always available by visiting www empower md and choosing Support in the top right corner of the web page Additional details are on the proceeding pages Please contact your Empower Project Manager if your team is unsure of the login and password 156 empowerlnpatient Ambulatory Empower Emergent Support Matrix dle ME
121. ask Select desired medication If not an IV or Liquid medicine enter O in the amount field Ensure all other information is correct Date Time Route Save work using appropriate tab For Medications that have to be double signed ex Heparin or Insulin document the name of the Nurse who also signed in the Comments Field The Filters at the top can filter by Time Route Drug Name or Type To verify that Medications have been charted go to the Intake Screen The Medication entered from the Pharmacy RN Task should be listed If it is not on the Intake Screen enter per Intake Instructions Discontinued medications will be highlighted in Orange at the bottom of the screen 80 empowerlnpatient Ambulatory Patient Name Age DOB Gender Race Insurance Weight Medical Record Acct Number Pharmacy RN Tasks FLEMING JAMES 51 Years 03 02 1958 Male wHITE CAUCA UNITED HC SELECT PB 2 kg 000541438 0921000083 Allergies NKDA Drug Name Filter Time Interventions LP s8i v Filter By Order Type PHARMACY M s Order Status Clinical Notes Nurses Notes In this area Nurses and Medical Assistants will document their own assessments and observations Single click on the 1 row to open a large pop up form with several options for documenting On the right is large white box where the user can free text any type of note In the upper left corner is a drop down table Templates and phrases can be selected from th
122. ate Time Staff Resulted Name Result Interpretation By Reviewed AHMED ZAFAR 05 23 16 28 Glucose monitor BGM 194 AHMED ZAFAR 05 23 19 01 XR CHEST ONE VIEW PORTABLE AHMED ZAFAR 05 24 5 00 VITAMIN B12 AHMED ZAFAR 05 24 5 00 FOLATE AHMED ZAFAR 05 23 18 51 CBC W AUTO DIFF KASON 05 24 8 18 THOMAS T AHMED ZAFAR 05 23 18 51 PT INT 2 80 PT 31 6 McCabe RN 05 23 21 54 Janet AHMED ZAFAR 05 23 18 51 COMPREHENSIVE NA 144 K 3 9 CL 108 CO2 23 BUN 49 CREAT 1 80 GLUCOSE KASON 05 24 8 22 METABOLIC PANEL 44 AGAP 13 AG RATIO 0 9 BUNCR 27 GLOBTOT 4 1 ALB 3 5 TPROT THOMAS T 7 6 CA 9 4 ALT lt 16 AST 40 ALKPHOS 57 GFR 36 7 TBILI 1 6 AHMED ZAFAR 05 23 18 52 CK CKMB CK1 147 McCabe RN 05 23 21 46 Janet AHMED ZAFAR 05 23 19 10 CKMB MBINDEX 4 1 CKMB 6 McCabe RN 05 23 21 46 Janet AHMED ZAFAR 05 23 18 52 TROPONIN I TROPU 0 10 McCabe RN 05 23 21 46 Janet AHMED ZAFAR 05 23 19 26 CBC W AUTO DIFF WBC 5 5 RBC 5 63 HGB 15 9 HCT 48 5 PLTCT 183 MCV 86 2 MCHC Critchett RN 05 24 8 26 32 7 RBCMORPH Slight Anisocytosis Microcytosis Macrocytosis Daisyrenee Poikilocytosis Target Cells MANDIFFDONE Man diff not indicated BASOS 0 3 E0 0 9 MONOS1 9 4 LYMPH 18 9 NEUTRO 70 5 MPV 9 1 RDW 21 3 MCH 28 2 05 23 22 46 EKG Preliminary AHMED ZAFAR 05 23 21 07 Glucose monitor BGM 94 AHMED ZAFAR 05 24 2 52 CK CKMB CK1 164 AHMED ZAFAR 05 24 3 06 CKMB MBINDEX 4 3 CKMB 7 AHMED ZAFAR 05 24 2 52 TROPONIN I TROPU 0 10 KASON 05 24 8 00 THOMAS T A
123. atements for a work or school release can be added using the Table Editor Discharge Med Recon Patient Name Age DOB Gender Race Insurance Weight Medical Record Acct Number Empower Test 55 Years 11 06 1953 Female IBLACK AFRICA MEDICARE I54 43kg 000632325TEST 910600154 Allergies Dilaudid HOME meds will be displayed on the patient s HOME medication list IF a medication has a Rx value of Yes then a prescription will be generated For that particular mediation Fluid Start Stop Category Medication Rate Frequency Duration Quantity Refill Status Date Date Rx l O LJ Acular 0 5 Eye Drops jad fi month p ACTIVE ves Avage 0 1 Topical Cream I 1 LT FL kw v flindamycin Phosphate Topica 1 feme PF FF P Disormizmgz4rem e p Click on a Hospital medication to add that medication to the HOME medication list above Category Medication HOSPITAL FARVEDILOL 12 5 MG Twice Daily HOSPITAL cLINDAMYCIN PHOSPHATE 900 MG 100 ML HRevery 8 hrs HOSPITAL FUROSEMIDE 20 MG twice daily HOSPITAL influenza Vaccine O 5 mlIM one time HOSPITAL influenza Vaccine 0 5 mlIM one time HOSPITAL INSULIN 70 30 DAILY CHG 50 U Once Daily 104 empowerlnpatient Ambulatory Ready to Print When the visit is complete the provider can complete the chart by clinking Finalize Chart Clicking this button will initiate Empower s Smart Technology an
124. ation process This manual begins with an overview of the implementation process and is then divided into specific chapters that address the various aspects of the Inpatient Ambulatory setting The Empower InpatienttAmbulatory implementation process is designed to be a seamless and expedient approach to transitioning physicians nurses and staff from a handwritten and or dictation based environment to the Empower chart This project will involve various hospital clinic departments and personnel throughout the stages in the implementation process A description of the five phases of the Empower InpatienttAmbulatory implementation process is included in Appendix 1B It is important that the project teams of both Empower and the host hospital maintain clear lines of communication at all times EmpowerSystems commits to a successful implementation having been through this process many times This manual addresses both the common processes that all settings share as well as the unique variances in workflow processes Inpatient Ambulatory initiatives and policies and procedures specific to any one institution In addition to this manual the Empower Inpatient Ambulatory process requires conveniently scheduled meetings or calls between all parties involved in the implementation PHASE I Project Kickoff amp Assessment Identifying the Inpatient Ambulatory Resources and Contact Information In order for Empower to execute the implementation
125. ations for computer generated charts Although not all physicians practicing at the hospital are hospital employees the hospital would still retain control of certain aspects of the program as the servers are housed at the hospital If the hospital still opts not to utilize Empower abbreviations then the hospital can designate a resource to use the table editor to change the abbreviations or instruct hospital employees to only use approved abbreviations Empower employs smart technology to secure information related to risk management government compliance and coding Modifying or deleting information in the Empower tables could cause certain features to malfunction or system errors could arise A list of the Empower abbreviations is available in Appendix 4A Table Editor Empower is installed with pre populated lookup tables that contain the common clinical terminology used by physician and nurses Each field on an Empower form has a lookup table The internal table editor allows the Super User physicians nurses and designees to customize these tables to reflect the clinical words and statements most commonly used in that institution or office The table editor is a very powerful tool as it affords the administrators of the system immediate change capabilities in the database For this reason Empower recommends formal discussions and training prior to a user making any changes to the system The Empower table editor does not provide access to anyth
126. atures are not uploaded to the system charts will print without physician signatures It is advisable that the hospital provide this form to the Medical Staff Office so that they can include the collection of this information in the physician credentialing process Ongoing Training The hospital must identify a resource Empower SuperUser to be responsible for training of new physicians nurses and ancillary staff after the initial Empower training and Go Live have been completed This individual will be responsible for all additional clinical staff training Empower has provided the following skills verification templates for documentation of education records For User Specific Manuals please see Chapters 10 12 Appendix 3A Empower MA RN Skills Verification Appendix 3B Empower Registration Skills Verification Appendix 3C Empower Provider Skills Verification 20 empowerlnpatient Ambulatory Chapter 4 Inpatient Ambulatory Workflow Perspectives The inpatient and ambulatory workflow is affected by many internal registration medical assistants etc and external laboratory radiology medical records coding insurance companies billing etc factors There are many different types of workflow e Clinical evaluation of the patient medical assistants nurses physicians e Clinical documentation medical assistants triage nurses physicians e Clinical communication medical assistants triage nurses physicians unit c
127. ayed indicating that the patient was sent back to the waiting room after triage e MOA Mode of Arrival The method ambulance police walk in etc in which the patient arrived at the ER e Triage Nurse Triage nurse initials e Care Nurse Primary nurse initials e First Nursing Note Time ofthe first nursing note for the patient e First Phys Exam Time that the MD performed the physical exam e LWBSAII and LWBS Peds Report The LWBS All report lists all patients with a disposition of LWBS or Left Without Being Seen within a specified time frame The LWBS Peds report does likewise for pediatric patients What qualifies as an LWBS Patients who were entered into the system but left before they were seen by an MD may be legitimately tagged as LWBS If a patients get to an exam room and then leaves an MD may see the patients name listed in the exam room and believing that a patient is there waiting to be seen enter the patient s chart to look at the triage note This will generate physician documentation for the patient despite the fact that the patient left and was never seen At this point the MD should simply set the disposition to LWBS and remove the patient from the tracker MDs should not enter a repeat exam for these patients A chart with both a LWBS disposition and a repeat exam is a documentation inconsistency that will cause the chart to be placed on the Non Finalized report for review by administration MD Documentation
128. b qid eto Gn p UD UEM pedi 137 Appendix 4A Computer Documentation Abbreviations eese esee eene eerte testen te toto tn snam ennnen 138 Appendix 9A Empower Table Names and Descriptions eerie esee retener nennt tnn anansnenon 142 Appendix 13A Workflow Procedure for CPOE Interface Post GO Live ssssssesssssssssssssseessessssssssesseraeeeseses 147 Appendix 13B Hospital Order Entry Problem Log Sheet essent 148 Appendix 13C Diagnostic Results Interface Workflow Post Go Live csssssssssesesssssseseecsesseesesessessararaceees 150 empowerlnpatient Ambulatory Appendix 13D Hospital Diagnostic Results Problem Log Sheet cssssssesesesssccsesseesessssesessscaeseseneseeeseeataceeeess 151 Technical Support G uidelllies iiseicin cater or DER Erb Face HP OA UE D da o obl d dE OR AER UA DA EA Rd pud 156 Client Support Quick Start Guiden riter rh chant nh Ph kn ee E EXER Pee de RP EY arre v ea rd Ra eo Fr o EET RR pae 160 Empower Inpatient Sample Chal iie ee i aes eee aceon 168 Empower Inpatient Summary Chart for FaxinnG csscccscsecesessesesesseeeesesesesseseseeseaeeeseeeeseseatensseeteseaeensseeneneaeas 232 empowerlnpatient Ambulatory Notes empowerlnpatient Ambulatory Chapter 1 Implementation Overview The Empower Inpatient Ambulatory Implementation Manual will guide your facility through the EmpowerSystems Empower implement
129. be manually entered The Fourth Section Consider Diagnostic Studies and Interventions Cardiac Markers amp Repeat in 4 ats mmm ECG Chest X Ray Chest CT Bilateral BP TransEsophageal Echo D Dimer Pulse Ox ABG V Q Scan ASA NitroGlycerin AntiCoagulation AntiBiotics Unlike the other Sections this is for display as is Read Only These orders will NOT be placed nor will there be any documentation of these orders in the chart The bottom of the pop up has two buttons Ignore Add To Patient Chart Ignore will not import any documentation into the chart Add To Patient Chart will import the Documentation to the areas specified above The High Risk Chief Complaints are editable Edits can be made to age gender Chief Complaint and any of the Sections In addition new High Risk Chief Complaints can be added Please contact your Empower Support Personnel to learn more 98 empowerlnpatient Ambulatory Diagnostic Results Abnormal Values past 24Hr MCH 31 5 GLUCOSE 134 TPROT 8 4 ALKPHOS 143 GLOBTOT 3 7 CKMB lt 1 TROPU lt 0 01 a J nd Time Ordered Diagnostic Name Result Interpretation Filter By Diagnostic Type T Status 30 40 0409 11 TROPONIN I 8 53 411 EK G Scanned 345 00711 EKG INo Acute Changes 8 45 04 08 11 Cardiac Monitor Normal Sinus Rhythm e Abnormal Values will appear in red on the top of the screen e The interface will populate all l
130. buprofen 200mg 2 4 times per day ACTIVE tablet 40 0 MG Medication Allergy List Date Type Code Medication Agent Reaction Status Recorded Drug Allergy 0 Denies allergies ACTIVE 10 29 2012 Diagnostic Test Results Date Type LOINC Code Test Name Performed RADIOLOGY 73562 XR KNEE AP LATERAL 10 29 2012 W OBLIQUE S 233 empowerlnpatient Ambulatory Admitting Admitting Patient Name Age DOB Gender Race Insurance Weight Height Medical Record Account 2 sea 28 ys Male NEN 0000805 0UD 703 192 88cm MEN EE Allergies Denies allergies Room ED FT22 Discharge Home Instructions Discharge Diagnosis Knee Pain Arthritis Discharge Activity Discharge Diet Discharge Instructions Work note Discharge Prewritten Instructions Knee Wear and Tear Disorders Follow Up Date Time Practitioner Name Clinic Name Address i State Zip Phone Khan Humaira M D MetroSouth Health 12246 S Pulaski IL 60803 708 385 5601 Comments Prescriptions Rx If prof n 2009rig Tab Patient Vistruttidns take 24dbl 400 MG py P R RIB QO P falroutent times per day Pharmacy nstructions as needed forpa gy 20 Rx Work NOP NO prolshy staring Sr WalkingFot Vek O P VOID VOIDR RNB QO P VOID VOID VOID VOID VOID VOID VOID VOID VOID VOID VOID VOID QE D 0 Print Date Time 10 30 2012 9 37 06 AM Received transitional record Diagnosis Diagnostic Results Procedures Follow up Patient Instructions and Home Medication List Discharge Dat
131. c medical record The Empower chart reflects the company s philosophy of One Patient One Chart One Database There is no need to collate several separate charts or pieces of charts into one record at the end of the patient encounter Empower Inpatient Ambulatory provides all the tools necessary in order to document the patient s clinical information while simultaneously caring for the patient The software is written such that it follows the patient stepwise through the healthcare system beginning with the registration process and ending with the discharge instructions Starting the Program Cu e Click on the Empower icon on the desktop e Loginis provided by your system administrator e Initial password is welcome e When you log in with this password you will be prompted that your password has expired e Click yes and enter your new password e Write down this log in and password 88 empowerlnpatient Ambulatory Empower Inpatient and Empower ED Patient Roster Patient Roster i Patient s Last Name to access Patients s Chart Patient s First Name to remove the patient Exam Rm Lace Search MD Search Disposition Filter Filter Chief Complaint Exam Bed Length Acuity Datient Name Age Assessment Dx MD Attending Disposition Room Assign of Stay To 3 f7 Y fLeg Pain WATSON n R Discharge Home ED Hall 15 fis 03 27 E E c Vicki The following columns appear on the tracker and can be modified as
132. cation between physicians and nurses until a comfort level is established with documenting in and communicating with computers After the nurse completes the triage for a patient a printed hard copy of the triage note will be placed on the clipboard or binder which is then given to the physician or put in the chart rack The same will be true for physicians when documenting diagnostic and medical orders a printed hard copy will be placed on the chart and given to the nurse or unit clerk to execute When lab results are printed they will be collated on the ED clipboard or binder for the physician to review As the CPOE Computer Physician Order Entry and diagnostic interfaces go live this workflow will change this will be addressed in Chapter 13 As the patient is dispositioned a printed chart of the entire patient encounter will be sent to medical records or if the patient is being admitted with the chart to the floor After the hospital reaches a certain comfort level with the Empower printed chart the hospital can reassess the current workflow and start moving towards a completely paperless environment Point of Care Diagnostic Testing Empower captures all clinical information in the Inpatient and Ambulatory settings including point of care testing glucose scan urine pregnancy quick hemoglobin etc ordered by physicians and nurses Nurses and staff should document the point of care tests in the Diagnostic Results or Nursing Notes sect
133. charge Disposition 37 35 CM __ Dischargedto Location S SCS 3s 2 5 Dette 1 39 2 1s _ Servicngraciity rao a i e jBdsmws o rar 2 is jAcwtsus a2 go PL Pendinglocation 43 s0 PL ProrTempraloton A 26 T5 AdmitDatefime TCS as 26 I5 DischneDate Tme S SSCS ras iz NM _ Current Patient Balance S ar az nm Totalcharges S as az NM _ TotarAdustments S 49 iz NM _ TotalPayments S 50 20 x AtmaeVstih csi a is Visitndicator S 52 60 XN Y OtherHealthcare Provider MRG SEQ LEN DT OPT RP ELEMENT NAME NOTES 1 20 CX R Y PriorPatientID Internal 2 20 cx Y PriorAlternatePatient ID S 3 20 CX __ Prior Patient Account Number 4 20 CX jProrPatentID Exeral o 5 20 CX jProrVisitNumbr J o 6 20 CX jProrAtemateVisitID J S 7 48 XPN jProrPaientNam o oo NK1 SEQ LEN DT OPT RP ELEMENT NAME NOTES jafs Rs 2 4a xp JName 00 3 60 CE Relationship 4 100 XAD jAddes 0 0 000 5 40 XN PhoneNumber J o 6 40 xTN jBusinesPhoneNumbr 0 0 7 60 cE jConztRode O 118 empowerlnpatient Ambulatory SEQ LEN D
134. cia Have you had a flu shot this season List date or answer no No refuses Have you had the pneumonia vaccine Pneumovax in the past 10 years List date or answer no No refuses Do you smoke Not anymore If reformed smoker how long ago did you quit N A Does anyone at home smoke No Patient and family were directed to smoking cessation information anyway 05 23 2011 16 42 ADMISSION Nursing Admission DVT VTE PROPHYLAXIS SCREENING Rev 1 7 10 Burge RN Patricia Is the patient on maintenance anticoagulation warfarin heparin or fondaparinux Yes No further assessment needed at this point Order baseline INR if takes Warafin and not already done The baseline INR No baseline INR done order placed See diagnostics will monitor 05 23 2011 16 43 ADMISSION Nursing Admission FALL RISK ADMISSION INTERVENTIONS Burge RN Patricia TOTAL SCORE from admission assessment 5 or more STANDARD AND HIGH RISK INTERVENTIONS AS NOTED BELOW Standard precautions initiated Includes initial and ongoing fall risk education safe room set up including call light in reach and not dangling moving furniture on non exit side of bed side rails up x2 bed locked and low adequate lighting and room is clear of clutter 05 23 2011 16 43 WOUNDS Nursing Admission FIRST WOUND ASSESSMENT rev 11 04 10 Burge RN Patricia WOUND ASSESSMENT No wounds at this time no further assessment needed TOTAL NUMBER OF WOUNDS NOTED UPON ADMISSION N
135. ck the Patient List button to return to the Patient Roster 87 empowerlnpatient Ambulatory Chapter 12 Provider User Manual Introduction The Empower InpatienttAmbulatory computer documentation system was created by clinically experienced physicians and nurses The program merges technological information with medical information to create a real time documentation system that improves communication and enhances patient flow EmpowerSystems has been recognized in the past as a success story and role model by the Joint Commission and we continually monitor and adopt the changing Joint Commission standards in order to ensure continuing compliance The system also ensures compliance by prompting the physician or nurse at various HCFA mandated junctions electronically applying the physicians signature and ensuring follow up by faxing the chart to the primary care provider or specialists office The program is dynamic and flexible and can be customized to the needs of various physicians nurses and inpatient ambulatory settings Empower Inpatient Ambulatory is also an inexpensive alternative to costly transcription or verbal documentation This program unlike others is not template based but rather is based on a single free formed chart that is populated by the physician s or nurse s description of the patient s history physical exam diagnostic tests medical orders and clinical summary to provide an accurate EMR or electroni
136. ck to bed Speech clearer now Pt states she feels better requesting and given graham crackers Sitting up in bed watching tv No major changes from previous assessment patient remains neurologically and McCabe RN Janet hemodynamically stable Accucheck 62 pt took rest of oj with sugar and then another 120ml of orange juice Speech McCabe RN Janet not slurred now pt warmer and dry Drinking readily with the straw Accucheck rechecked 68 Pt warm and dry speech clear initiating conversation Denies pain McCabe RN Janet Watching tv Nursing Serial SHIFT END NOTE new 4 19 11 McCabe RN Janet Medical Orders review I have reviewed and as appropriate carried out all medical orders during my shift except those orders endorsed to the oncoming RN and or are scheduled in the future Diagnostic test review I have reviewed all pertinent diagnostic data as available and appropriate during my shift Patient report given and patient care endorsed to Daisy RN Nursing Serial DAILY BRADEN SKIN ASSESSMENT Bayless RN Michel Sensory Perception 3 Slightly Limited Moisture 3 Occasionally moist Activity 3 Walks Occasionally Mobility 3 Slightly Limited Nutrition 3 Adequate Friction and Shear 3 No apparent problem Total Score 19 or more No interventions needed at present continue to monitor Nursing Serial SHIFT FALL RISK ASSESSMENT INTERVENTIONS rev 12 10 10 Bayless RN Michel Currently
137. closure 159 empowerlnpatient Ambulatory Client Support Quick Start Guide Empower s Non Emergent Support System is a web based portal that can be reached by selecting the Support button atop any page of the website or simply Click Here and bookmark the URL Locating the Support System empowersystems Products Compliance empowersystems About Contact Forum ONC Certified Comprehensive EHR Advanced Core HIS empowerED The fully comprehensive Emergency Department Information System EDIS developed by physicians nurses and technical experts in a live Emergency Department Empower ED is the only EDIS acclaimed by the Joint Commission as a success story and role model in ED documentation Empower ED delivers the functionality and user friendliness needed to ensure 100 6 User Acceptance and successful Meaningful Use compliance Learn More empowerlnpatient The ONC ATCB Certified Comprehensive Electronic Health Record EHR assures 100 Physician Acceptance full Meaningful Use Compliance and the most User Friendly architecture available today Empower s One Patient One Chart One Database philosophy translates to a true Continuum of Care across all hospital departments and physicians offices while seamlessly integrating with ANY Core Hospital Information System HIS Learn More 160 empowerHIS Empower HIS is built upon cutting edge system architecture and offers both local and
138. cloud based options The feature rich technologies include ADT Patient Registration System Hospital Scheduling System Lab Information System Radiology Information System Pharmacy Management System Surgical Suite Management Coding Billing Management System Insurance Contract Management System and more Learn More empowerlnpatient Ambulatory empouJercsusterns Support Center t News b gt Log in Lost Password H View news articles and manage subscriptions P4 7 E E mail E3 greenerdoc ecds md Password Latest News B May 31 Empower Systems is a Proud Sponsor of 22nd Annual Fairway to Health Golf Tournament May 31 Empower Systems to Exhibit at 2nd Annual Southeast Regional CAH Conference May 31 Empower Systems Exhibiting at Healthcare Trade Faire amp Regional Conference May 31 Wireless Technology Prevents Medical Errors May 31 Studies Tout Benefits of Electronic Prescribing But Adoption Is Slow Home News Language Each User at the hospital will have his own login and password Use your email address as your login Your initial password will be welcome Select Remember Me and Click the Log in button Please reset your password immediately upon first entry For quick reference please bookmark the login page in your web browser Support Center empowersystems Support Cente
139. counts on the workstation When the users log in again it will use the default profile s setup certificate L For workstations requiring PDF Browser and or Custom Reporter locate the PDF Browser link and or the Empower Reporter on the server within the ECDS shared directory and copy this link shortcut to the local workstation All Users desktop L Install NET 1 1 or newer This is not required for workstations that are going to run the Empower Inpatient program alone L Empower Inpatient references the Windows default printer for non specialized printing Please be certain that the default printer is defined Maintenance of Hardware amp Support Software If any additional computers need to be loaded with the Empower Inpatient Ambulatory software simply follow the initial setup checklist of the Empower client computers and both hardware and software specifications Empower Ambulatory Workstation Setup The hospital will provide a terminal remote desktop server L Open Remote Desktop Connection and enter the Computer and Username supplied by the hospital Please enter a password if needed L For ease of access a shortcut may be saved on the desktop 19 empowerlnpatient Ambulatory Chapter 3 Training of Physicians Nurses and Support Staff Empower is designed to be both comprehensive and user friendly Most physicians and nurses who are comfortable emailing or surfing the Web require very little traini
140. cument statements to manage and decrease risk in the Emergency Note High Risk Chief Complaint Risk Management Myocardial Infarction CAD Pulmonary Embolus Thoracic Aorta Dissection TAD Pneumothorax AAA Myocarditis Pericarditis Pericardial Effusion Pneumonia High Cholesterol Smoking HTN Connective Tissue Coag D O FHx CAD Aortic Dissection PE Back Pain Looks Comfortable Not Ill Appearing Radial Pulses Bilaterally Femoral Pulses Bilaterally Cardiac Markers amp Repeat in 4 hrs ECG Chest X Ray Chest CT Bilateral BP TransEsophageal Echo D Dimer Pulse Ox ABG V Q Scan ASA NitroGlycerin AntiCoagulation AntiBiotics Add To Patient Chart 96 empowerlnpatient Ambulatory The First Section Differential Diagnosis Myocardial Infarction CAD Thoracic Aorta Dissection TAD Pneumothorax Myocarditis Pericarditis Pneumonia Mediastinitis This area is the medical problems considered with the Chief Complaint Clicking on one of the problems removes it from the list and therefore documentation Please note the general pop up screen shot compared to the one above Pulmonary Embolus AAA Myocarditis and Pericardial Effusion have all been removed The rest of the problems left populate to the Physical Objective Section Blue Arrow Please Note once removed these problems must be manually entered Repeat Exam MD Additional Clinical Information and or Exam Notes Date Time Ecs Tech
141. d Bahena RN Cecilia 05 26 2011 0 00 NURSING Nursing Serial SHIFT NURSING ASSESSMENT rev 11 04 10 Transmission Precautions Bahena RN Cecilia Standard O2 Type Liter Flow Room Air Rhythm Strip Interpretation Atrial Fib LOC Awake Alert and Oriented x 3 and forgetful Affect Calm and cooperative Eye Opening 4 spontaneous Verbal Response 5 Alert and Oriented X 3 Motor Response 6 obeys commands Pupils equal and reactive Ability to Move right arm strong Ability to Move right leg strong Ability to Move left leg strong Ability to Move left arm strong Skin Color Normal Skin Temperature warm Skin Moisture Dry Skin turgor non tenting Respirations Even and unlabored Breath Sounds Right Clear Breath Sounds Left Clear Retractions No retractions noted Abdomen Soft and non tender Bowel Sounds Active x 4 quadrants Pedal Edema Right 1 plus Mild 0 1 4 inch Pedal Edema Left 1 plus Mild 0 1 4 inch Pedal Pulses Right 1 plus Barely palpable Pedal Pulses Left 1 plus Barely palpable 05 26 2011 1 00 NURSING Due to patient s hypogylcemic events will hold coverage will recheck blood sugar in am Bahena RN Cecilia Admitting Admitting Patient Name Age DOB Gender Race Insurance Weight Height Medical Record Account Eee EN E e pr WELLCARE 85 7kg 175 26cm MEN a Allergies nka Room 4S0 421 01 05 26 2011 5 00 NURSING blood sugar 153 will monitor Bahena RN Cecilia 05 26 2011 5 53 NURSING Patient noted incontinent of urine 24 hour urine incomplete and
142. d and supervised by a consulting company that is certified by both AHIMA and CCS P Furthermore it has been Empower experience in working with physician and facility coders around the country that there are gray areas and black and white areas with respect to coding Coding the gray areas of the chart includes three types of human coders conservative middle of the road and aggressive Empower takes the position that aggressive coding is ideal as long as it is supported by clinical documentation Empower recognizes that certain coders who code the physician and coder billers might not agree with Empower coding at times 31 empowerlnpatient Ambulatory Empower Inpatient Ambulatory Calculation of RN Level of Service LOS CMS does not currently outline a specific method of assigning nursing levels of service LOS as they do with physician LOS Under the current arrangement CMS allows individual facilities to implement their own methods of determining LOS provided all 6 levels are identified 99281 99282 99283 99284 99285 and 99291 It is expected that all charts are consistently evaluated using the hospital s approved methodology Empower has a method built in that provides a suggested nursing LOS as designed by our expert coding resources Empower also includes customizable features to allow individual facilities to adjust the calculation to their approved standards These customizable features are further detailed below and a
143. d fields and when a user attempts to close the chart the computer will guide them with a message and red highlight to the required area of documentation Gray Control Buttons At the bottom of each screen are grey buttons which serve to move through the various portions of the chart The current screen is automatically saved when moving from one screen to the next Physician History Exam Diagnostic Assessment Plan Nursing Discharge Patient List Notes List Subjective Objective Results Medical Orders Screens Instructions SEDET Demographic pecie Rhia d Patient Reports rnare 93 empowerlnpatient Ambulatory Subjective Patient Name Age DOB Gender Race Insurance Weight Medical Record Acct Number a gt 1 Years 02 12 2010 Male IBLACK AFRICA 11 79 kg 000722364 1109800129 Allergies Denies allergies Latest Vital Signs If unable to get History then document in Assoc Sxs Pertinent Hx Hx unobtainable due at a Note Type _ Date of Progress Note Temp Pulse Resp B P Pulse OH BMI WT kg HT cm Pain Scale LMP fo Ti urgency or poor hR mmm 04 08 2011 9 02 E pe 18 J ps 7 1 79 kc 66 04 cm o Subjective _ Location Congestion Il J Paye SC J JAcute J Quality Episode Frequency Episode Duration Radiations constant a I z Exacerbating Factors Symptoms Improve with AssociSts PettinentiHii Cough rever Patient Family Denies on ROS Symptoms and Signs not covered in th
144. d will prompt the user for any missing documentation When this is complete it will be illustrated on the tracker that the chart has been closed The nurse then completes the printing process Missing Documentation Message You haven t detailed the patient s condition No Dis position and Condition found for patient Recommended Finalize Chart Cancel 105 empowerlnpatient Ambulatory Complete the information required and click Finalize again Continue this process until you reach the following screen Compare the Level indicators The lowest value is the MAXIMUM possible billing level for this chart The Medical Decision Making level should ALWAYS be lower than or equal to the History and Physical Exam levels Values highlighted in red indicate inadequate documentation for the relevant column If you are admitting this patient and the Medical Decision Making level is not IV or V you should review those areas of the chart that pertain to Medical Decision Making Diagnostics check for uninterpreted diagnostic tests Medical Orders and Notifications Also if you reviewed an old medical record for this patient including old EKGs or recieved additional information from CPD CFD a nursing home or relatives of the patient be sure to note this using the check boxes on the History form since these items contribute significantly to the Medical Decision Making level This screen allows you to return to HPI or Phy
145. domen distended firm non tender Bowel Sounds Active x 4 quadrants Pedal Edema Right 2 plus Moderate 1 2 inch Pedal Edema Left 2 plus Moderate 1 2 inch Pedal Pulses Right 1 plus Barely palpable Pedal Pulses Left 1 plus Barely palpable Medication Administration Record Reconciled and Verified McCabe RN Janet Found pt sitting on side of bed states I want to go to the bathroom Skin cool dry Speech McCabe RN Janet somewhat slurred Hand grasps equal moderate strength Accucheck done 71 B p 97 89 hr 72 Pt denies pain Pt placed on bedpan pt did not appear strong enough to walk to bathroom Bladder scan done 409ml in bladder Pt able to drink about 1 3 glass OJ with a packet of sugar unable to void on bedpan removed McCabe RN Janet Metro South Medical Center Patient Name Allergies nka 05 24 2011 2 00 05 24 2011 4 00 05 24 2011 5 05 05 24 2011 5 48 05 24 2011 6 45 05 24 2011 8 00 05 24 2011 8 00 05 24 2011 8 00 Age DOB i umm 00 NURSING NURSING NURSING NURSING SHIFT NARRATIVE SKIN ASSESSMENT FALL RISK VASCULAR ACCESS 12935 South Gregory Street Blue Island IL 60406 2428 Admitting Admitting Weight Height Medical Record Account 85 7kg 15 NNI Room 4S0 421 01 McCabe RN Janet 708 597 2000 Gender Race Insurance Found pt standing at foot of bed on way to bathroom assisted to bathroom with 2 RN s Pt voided and had bm flushed before rn could see results Walked ba
146. domiciled No New joint replacement Amputee Fracture No New HIV diagnosis No HX mental retardation No Suspected abuse neglect No New Head Spinal cord injury No Single parent under age 17 or adoption request No Pregnancy High risk Complicated pregnancy No Domestic abuse suspected or confirmed No New ostomy No PEG tube insertion No Terminal illness No New dialysis patient No Admitting Admitting Patient Name Age DOB Gender Race Insurance Weight Height Medical Record Account Em NEN oc gexum c0 857 175260 NEN Allergies nka Room 4S0 421 01 05 23 2011 16 49 ADMISSION Nursing Admission PATIENT ASSESSMENT rev 11 04 10 Burge RN Patricia Patient arrived on unit via Wheelchair Admit Source Direct Admission Transmission precautions indicated upon admission Standard precautions indicated and followed ORIENTATION TO ROOM UNIT Patient significant other oriented to room and unit including the intial plan of care call light and bed TV controls Bathroom and emergency call light phone and was provided with an admission packet BELONGINGS were inventoried and documented on belongings form patient family signature obtained Previous Hospitalizations MSMC CHIEF COMPLAINT chf SUMMARY OF HISTORY OF PRESENT ILLNESS chf htn dm Summary of prior treatment for present illness meds PAIN ASSESSMENT Patient denies pain now Patient personal acceptable level of pain is N A Location of pain N A Type of discomfort N A
147. e drop down and they flow to the white box on the right It is possible to use a combination of drop down phrases and free text NursingPhrase 2 Liters NC Advanced Directive Information has been provided Patient Family have been instructed such information will be honored Time Note Entered 10 11 Date Note Entered I 02 09 2008 Save and Add Return Additional Medical Orders Medical Orders are those interventions that make the patient feel better This is an interactive screen which allows nursing to enter any Intervention or any Diagnostic Test To sign medical orders single click on Clinical Staff or Clinical Staff Time A new pop up window will open up and the option to sign on one order or all orders is available The time can be modified if needed In the Order Status area a new window will pop up to document completion refusal or cancellation 81 empowerlnpatient Ambulatory Patient Name Gender Race Insurance Weight Medical Record Acct Number Empower Test i 12312312 Allergies IVP dye Shrimp Erythromycin Acetominpohen w Codiene Morphine Food allergy specify Filter By X a O Abdominal Pain Lower ED Guidelines Verbal Read Back per zzDUBOIS THIERRY MD Dubois Thierry J ee lzzDLIBOIS 07 01 12 11 antus SUBCUTANEOUS units 10 Every evening Dubois Thierry J 07 01 22 22 RN Completed THIERRY EDUBOTS 7 01 12 08 Order Cancelled Dubois Thierry J 7 1 2010 10 23 17 PM
148. e HPI V All ROS Negative GU Neq Musculoskeletal ea ENT Neq J Skin Nea I Endocrine ea Heart Nea I Neuro Nea I Hematologic Lymphatic Nea I Resp Neg 1 Psych Mea Allergic Immunologic Nea lt amp wea Eyes Mea I Constitutional Sxs Nea Past Medical History Social History Allergies Home Medication redcoon iss VELUM have een discontinued Denies Past Medical History Denies significant social history Denies allergies Albuterol Ampules 1 every 4 hours as nee ACTIVE Azithromycin 100mg 5ml Sml x 1 day th ACTIVE Benadryl 12 5 mg 5 mL Elixir ACTIVE Ibuprofen 100mg 5ml Sml by mouth 3 ti ACTIVE Nebulizer amp Compressor For Neb ACTIVE Nebulizer Accessories Kit ACTIVE No Home Medication ACTIVE older sis sick as well Family History Subjective This is the chief complaint and is a required field It can be selected from the list for easier coding or manually entered If uncertain of the chief complaint select Waiting Evaluation as a temporary complaint and return to the field at a later time Also in the interest of time this can be entered and then the user can move on to Diagnostic and Medical Orders and return to complete the Subjective and Physical Exam when time permits If a history is not attainable due to the patients condition select the phrase Hx unattainable due to Tx urgency or poor historian in Assoc Sxs Pertinent Hx This phrase will effect coding to a Level 5 in the ED wit
149. e Time 10 29 2012 12 07 00 PM Attending Physician Guterman Seth J All patients must follow up with a doctor within 48 hours if there are still medical symptoms or problems Nurse Signature Patient Signature 234
150. e a LOS 5 This becomes your recommended Empower RN LOS that appears on the EmpowerSystems chart Figure1 Metro South Medical Center Patient Name Age DO Gender Race Insurance Weight Height Medical Recor Acct Number MN gt 24 0110 1 Female BLACK UNITED HC CHO i70 MEE Allergies Toradol Zosyn Room Number ED 2B Recommended MD Level Of Service 4 Recommended Evaluation and Management Code 99284 Recommended Facility RN Level Of Service 4 Recommended Evaluation and Management Code 612 Discharge Diagnosis Summary boils Consultants Specialty DUBOIS THIERRY Family Medicine Follow Up MDs Jablonska Urszula Metro South Health Center 401 East 162nd Street South Holland 60473 708 210 2001 Mar 29 2011 12 00AM Patient Medication List Dilaudid 4 mg Tab 1 tablet every 4 6 hours O Vancomycin IV Solution Daily O Electronically signed and authenticated by the Following Physicians DUBOIS THIERRY Specialty Family Medicine 34 empowerlnpatient Ambulatory Nursing Level of Service The Nursing Level of Service LOS reflects the patient s acuity and the amount of nursing time and skill level that is required to manage the patient in the emergency department RN LOS 1 reflects nursing skill level to manage a non urgent patient This is represented when no diagnostic or medical orders are executed RN LOS 2 reflects nursing skill level to manage a low acuity patient The nursing intervention and skills are only r
151. e and Complexity Online Ticketing System General Assistance Information Training and Other Service Requests Upon Resolution or Weekly Until Resolved Within 48 Business Hours from contact 80 Business Hours Depending Upon Scope and Complexity 158 empowerlnpatient Ambulatory Empower Escalation Notification Matrix ACTION RESPONSIBILITY RESPONSE TIME Identify Escalation Level Site Support Rep owner Immediate VP of Project Management First level Support Team Notified Site Support Rep owner 30 minutes after escalation Notification Sent to Various Levels of Mgt Site Support Rep owner 30 minutes after escalation Customer Informed of Escalation Status Site Support Rep owner 30 60 minutes after escalation Second Level Support Team Notified and Activated VP of Project Management 4 hrs after escalation Notification Sent to Operations and Various Levels of Mgt VP of Project Management Every 2hrs and with issue updates Executive Mgt Notification VP of Project Management 6 hrs after escalation VP of Project Mgt Executive Mgt Contacts the Client VP Proj Mgt Exec Mgt 24 hrs after escalation Scheduled Issue Status Conference Call Empower and Client Technical and Project Mgt Teams As needed Post Mortem amp Follow Up Site Support Rep VP of Project Met 1 week after issue
152. e chart for storage in an electronic format which can also be uploaded into a hospital document imaging and management system Each chart is an individual file that is labeled with the patient s name and account number so that the image file can be imported directly into the patient s electronic health record Additionally as the chart is an image file it does not need to be scanned into the hospital document imaging and management system instead it is automatically imported into the Empower EHR Image File Empower PDF Chart As it is much easier to hack into a database and alter information than it is to modify a paper document or image file Empower believes that the security of the clinical information is better preserved when the information is stored as a hard copy document or image file as opposed to discrete data stored in a database Because clinical information is dynamic Empower allows clinicians to update or modify certain clinical information until the chart is locked and the patient has been dispositioned In order for Empower smart technology to work correctly the patient record must contain current and accurate information At this time Empower does not track edits or updated information unless it is documented in Additional Clinical Information and or Exam Notes section of the physicians chart or in the Clinical Notes section of nursing chart If the hospital wants to be aware of all edited or updated information th
153. e staff should document all new information in the Repeat Exam or Nursing Notes sections Empower can also lock the entire chart after a certain period of time has passed since the patient has been dispositioned from the ED and the chart has been printed It can also configure different lockout times for each Inpatient ED and Ambulatory 41 empowerlnpatient Ambulatory module If this feature is desired simply notify the Empower Project Manager and Empower will be configured for this task PDF Storage Document Management System After a patient is dispositioned the chart is converted into an Adobe PDF file and sent to a network location dictated by the hospital The location is configurable and it can be anywhere on the hospital s network where the Empower server has write access to the directory The PDF file name can be formatted in 1 of 6 different ways Naming Convention Example lt account number gt pdf 123456789 pdf patient id gt pdf Empower unique ID JD 1 18 2008 15 6 pdf lastname firstname pdf doejohn pdf account number gt lt patient name pdf 123456789doejohn pdf lt lastname gt lt firstname gt lt accountnumber gt pdf Doejohn123456789 pdf lt medical record gt _ lt account number gt pdf MR9999 123456789 pdf note the underscore The format must apply to all PDFs and cannot be changed There cannot be different formats for different patients However additional copies can
154. ect prescription medications by clicking on an empty box in the Home Medication section Typing at least two characters into the pop up box will prompt Empower to access the medication database and as more characters are typed the program will drill 67 empowerlnpatient Ambulatory down to more specific options Selected prescriptions print with an electronic signature when the nurse prints the chart Prescriptions can also be faxed or E Prescribed Finalize Chart Physician When the disposition is complete the physician can select the Finalize Chart button This prompts the risk management features to scan the chart for incomplete documentation and allows the physician to view the estimated level of service assigned to the chart The physician can then review the documentation and make any required additions or corrections prior to completion of the chart Print Nurse After the physician finalizes the chart the nurse can print the entire chart by clicking the Print Menu button and then selecting the Print All button All previously printed or temporary hard copies of the chart should be discarded in accordance with Medical Records policies The nurse can also print the Clinical Summary or Medication Reconciliation page for the patient to keep in accordance with Meaningful Use guidelines 68 empowerlnpatient Ambulatory Chapter 11 Nurse Medical Assistant User Manual The Empower InpatienttAmbulatory computer d
155. ed by clicking in the white box They can be selected from the drop down menu or manually entered e Empower offers pre printed instruction sheets for most common diagnoses using a quick pick list or a drop down menu that has several thousand options Double clicking on the desired instructions moves the topic to the box on the opposite side After all of the appropriate instructions have been selected click Save and Close e ExitCare discharge instruction content English amp Spanish is integrated within this view Additional ExitCare languages are available at an annual fee based on hospital volume Other Discharge Instructions To add a Discharge Instruction double click on any item in the Common Instructions to move it to the Selected Instructions To remove a Discharge Instruction double click on any item in the Selected Instructions To add a Discharge Instruction from the All Instructions drop down box select an item and click the add button Common Instructions Abdominal Pain Appendectomy Laparoscopic Care After Surgery Arterial Hypertension High Blood Pressure amp Dangers Asthma Acute Bronchospasm Atrial Fibrillation Bladder Cancer Breast Cancer General Information CABG Coronary Artery Bypass Grafting Care After Surgery Cancer General Information Cancer of the Colon Treatment by Resection Cardiac Arrhythmia Irregular Heart Rate Cellulitis Chest Pain Non Cardiac Chest Pain Non Specif
156. ed fields with and then fill out the body of the ticket with whatever specifics apply empowersyustems 31 May 12 Support Center Submit a Ticket Technical Issue Submit a Ticket If you can t find a solution to your problem in our knowledgebase you can fill in the fields below with as much detailed information as possible and send it to our agents Logged In Empower Test Client I B My Account General Information 1 Priority m 7 amp Change Password 5 ir Support d Patient Name Type None if applicable n a Search d Account k A 4 Entire Support Site FIN n a XN z Medical Records Number nja 1 Message Details Subject 4 I Need Assistance on Submitting a Non Emergent Ticket Hello M Can you please provide me with a Quick Start Guide to using the Empower Client Support system a Sincerely Test User Knowledgebase suggestions 7 The following articles from our knowledgoBeemmmemetelevant to what you re looking for Please take the time to read them before submitting your ticket 3 HL7Connect Checklist Prior to Shutting Down any of the EmpowER servers Relevance 48 0396 3 Requesting Empower Reports Relevance 47 1796 r Upload File s SS 3 Choose File no file selected FoU Choose File no file selected E SN Choose File no file selected
157. ed when date of birth entered by the ADT interface or by using Add a Patient Gender as entered by the ADT interface or by using Add a Patient New Established is populated by clicking on the box once Who will do this will be determined by your workflow Exam Room is populated by clicking in the box once Who will do this will be determined by your workflow Appointment Time Appointment Status entered by the ADT interface or by clicking in the box Appointment Status only Time in Office is calculated in minutes when the patient is placed on the Roster 72 empowerlnpatient Ambulatory Triage is answered by clicking the box and choosing the correct answer This can be used to communicate with the practitioner that the patient is ready to be seen Complaint Message is populated by clicking on the box once This area is free text MD Name column identifies the doctor taking care of the patient by their name via dropdown menu Disposition is entered by the doctor on another screen Orders When new orders are entered an Orange box with an N is displayed When the order has been noted Complete the box turns Purple with an E to reflect the order has been executed Filtering Sorting the Tracker Filters can be applied to show a Patient Name who has been put on the Patient Roster Empower Patent Roster Buttons Document Dubois Thierry J Imaging Add Patient Edit Staff Form Builder Change Apaseord
158. edical interventions for intravenous fluids tblluPhysLacerationDepth This table lists the options in the laceration note for laceration depth tblluPhysLacerationExploration This table lists the options in the laceration note for laceration exploration tblluPhysLacerationLength This table list the options in the laceration note for laceration length tblluPhysLacerationLocation This table list the options in the laceration note for laceration location tblluPhysLacerationProcedure This table lists the options in the laceration note for laceration procedure tblluPhysLacerationShape This table lists the options in the laceration note for laceration description tblluPhysLocation This table list the options in the history for location of symptoms tblluPhysLungs This table list the options in the physical exam for lung auscultation tblluPhysLymphatics This table lists the options in the physical exam for lymphatic system tblluPhysNeck This table lists the options in the physical exam for the neck tblluPhysNeuroCoordination This table lists the options in the physical exam for coordination tblluPhysNeuroMotor This table lists the options in the physical exam for nerve motor skills tblluPhysNeuroSensory This table list the options in the physical exam for the nerve sensory evaluation tblluPhysOnset This table list the options in the history for on
159. en up the options Users can select from options or free text and save Double click on a selected item to delete or add text Activity Instructions Double click in the box to open up the options Users can select from options or free text and save Double click on a selected item to delete or add text Prewritten Discharge Instructions Double click in the box to open up the options Users can select from options by double clicking from the list If instructions are not in the list use the drop down box for other options Once the proper instructions are found use the Add to List Button Once all the instructions needed are selected use the Save and Close Button 85 empowerlnpatient Ambulatory Language This drop down menu will select the language the instructions are printed out English is the default Follow Up List In this area follow up appointments and referrals to certain providers can be given to patients Click on the first open the input box Using the drop down box a pre populated list of physicians with demographic information will fill the rest of the fields Users can also free text in any field if a practitioner is not in the list Follow Up MD Follow Up List Follow Up Date Time Practitioner Name Clinic Name Address i State Zip Phone L Add Another Delete Cancel Discharge Rx In the bottom right hand corner is a button labeled Discharge Rx This will open the e prescribing feature of
160. ending foley Patient continues to refuses and states it hurts Dr Ventura notified of patient refusing foley and informed Rn if possible to place foley and attempt to collect 24 hour urine with or without foley Rn informed if 24 hour urine unable to be collected secondary to patient s confusion Dr Ventura stated will address with patient and primary md in am Nursing Serial SHIFT NARRATIVE NOTE new 6 29 10 Patient received alert and oriented X3 Pt denies cp and sob Pt is sr See assessment area Refer to carenotes for assessment patient reinstructed on saving urine Nursing Serial DAILY BRADEN SKIN ASSESSMENT Sensory Perception 4 No impairment Moisture 4 Rarely Moist Activity 3 Walks Occasionally Mobility 3 Slightly Limited Nutrition 3 Adequate Friction and Shear 3 No Apparent Problem Total Score 19 or more No interventions needed at present continue to monitor 708 597 2000 Medical Record Account 4SO 421 01 White RN Carina White RN Carina White RN Carina White RN Carina Bahena RN Cecilia Bahena RN Cecilia Bahena RN Cecilia Bahena RN Cecilia Admitting Admitting Patient Name Age DOB Gender Race Insurance Weight Height Medical Record Account Em NEN oo ili 857 15260 NNI Allergies nka Room 4S0 421 01 05 25 2011 20 00 NURSING Nursing Serial SHIFT FALL RISK ASSESSMENT INTERVENTIONS rev Bahena RN Cecilia 12 10 10 Currently History of Confusion Diso
161. enses CALs for Windows Server for workstations requiring access to server SERVER SUPPORT SOFTWARE Terminal Server Terminal Server Windows Server 2008 R2 x64 Microsoft Office 2007 Professional with Access 2007 full version installed and Adobe Acrobat Software for PC Access Remote Desktop Terminal services enabled for remote access Remote Desktop licenses are required for every computer used in Inpatient Ambulatory and ED units Hospital Administration etc Virus Software Anti Virus Software hospital standard Additional Software Microsoft Office 2007 Professional for Word and Access Additional Licenses Microsoft SQL Server Enterprise or Standard Edition and Client Access Licenses CALs for Windows Server for workstations requiring access to server empowerlnpatient Ambulatory WORKSTATION HARDWARE Machine CPU Speed MHz 1 Dual core CPU or higher RAM 1GB minimum Hard Drive Space 40GB 7200RPM IDE HD Monitor 17 or larger flat screen for desktop space efficiency 1024x768 recommended resolution for appropriate Empower viewing Mouse Keyboard USB optical or laser mouse and keyboard Ethernet Card TCP IP Scanner required Cannon DR 2010C DR 2510C DR 3010C Flatbed 101 Add On Tablet PC for Signature Capture required Panasonic CF H1 with Cradle CF VEBH11 WORKSTATION SUPPORT SOFTWARE O
162. equired for a single diagnostic order specimen collection or medical interventions RN LOS 3 reflects nursing skill level to manage a semi urgent patient The nurse must intervene and execute skills that require multiple Diagnostic Orders Specimen Collections and or Medical Interventions RN LOS 4 reflects nursing skill level to manage an urgent patient The nurse must intervene and execute skills that require multiple Diagnostic Orders Specimen Collections and or Medical Interventions with IV Insertion or extensive documentation such as Psychiatry or Detox Admissions RN LOS 5 reflects nursing skill level to manage an emergent patient The nurse must intervene and execute skills that require multiple Diagnostic Orders Specimen Collections and or Medical Interventions with IV Insertion and extensive documentation for a general hospital admission RN LOS 6 reflects nursing skill level to manage a potentially critical or critical patient The nurse must intervene and execute skills that require multiple Diagnostic Orders Specimen Collections and or Medical Interventions with IV Insertion an extensive cardiac monitoring or Intensive Care Unit level of management The EmpowerSystems RN LOS coding is accurate if the nurse documents all nursing procedures medications and hospital supplies in the medical intervention section of Empower ED The EmpowerSystems RN LOS will be down coded if the Nurse documents any nursing procedures medicati
163. er Race Insurance Weight Height Medical Record Account e el i 857 15260 NNI Allergies nka Room 4S0 421 01 MD Name VENTURA SALVATORE C Date of Note 05 24 2011 11 15 Note Type CONSULTATION History Subjective HPI Paragraph Patient with Consult Dictated Other Notes Exam Objective Assessment Plan Problem List Non Oliguric Acute Renal Failure N A 2nd to ischemic ATN probably has chronic ischemic nephropathy R O diabetic nephropathy Suggest dobutamine Rx No indications for dialysis at this time Insert Foley Urine analysis and urine culture STAT Renal Ultrasound Serum immunoelectrophoresis Chem 7 at 6 PM today Renal Panel tomorrow AM Do renal ultrasound at bedside due to hypoglycemia Hold colchicine notify Dr Harris NIDCM ICD Parox A Fib MR N A Start Dobutamine if OK with Dr Kason Hypoglycemia NIDDM Hyperlipidemia N A Stop Glipizide H O Hypertension N A Electronically signed and authenticated by the Following Physicians VENTURA SALVATORE C Specialty Nephrology Metro South Medical Center 12935 South Gregory Street Blue Island IL 60406 2428 708 597 2000 Admitting Admitting Patient Name Age DOB Gender Race Insurance Weight Height Medical Record Account 2 4 E H i gm WELLCARE 85 7kg 175 26cm B EU Allergies nka Room 4S0 421 01 MD Name SALVATORE C VENTURA Date of Note 05 24 2011 11 27 Note Type CONSULTATION History Subjective CONSULTATION Other Notes Metr
164. ertinent diagnostic data as available and appropriate during my shift Patient report given and patient care endorsed to CeCe RN 05 24 2011 20 00 NURSING Nursing Serial SHIFT NARRATIVE NOTE new 6 29 10 patient received aler and Bahena RN Cecilia orientedx3 Pt denies cp and sob Pt is paced See assessment area d5 9ns with 20kcl 70cc hr Dobutamine 12 7 hr infusing without complications to lac iv site Blood return noted to LAC Iv site Will monitor 05 24 2011 20 00 SKIN ASSESSMENT Nursing Serial DAILY BRADEN SKIN ASSESSMENT Bahena RN Cecilia Sensory Perception 4 No impairment Moisture 4 Rarely Moist Activity 3 Walks Occasionally Mobility 3 Slightly Limited Nutrition 3 Adequate Friction and Shear 3 No Apparent Problem Total Score 19 or more No interventions needed at present continue to monitor 05 24 2011 20 00 FALL RISK Nursing Serial SHIFT FALL RISK ASSESSMENT INTERVENTIONS rev 12 10 10 Bahena RN Cecilia Currently History of Confusion Disorientation Impulsivisity No 0 HX Depression with active symptoms at present No 0 Altered elimination Frequency Urgency Incontinence Diuretics Yes 1 Currently History of Dizziness Vertigo No 0 Male Gender No 0 Currently taking anticonvulsants check MAR No 0 Currently taking benzodiazepines check MAR No 0 Mobility assessment reveals Get up and Go Test Patient needs to push up but successful in 1 attempt 1 TOTAL SCORE
165. ervention Exception Within the Medical Orders Intervention table allows for hospital defined entries which may not warrant inclusion in the RN LOS calculation It is for this reason there is an exclusion column to identify interventions the hospital would like to individually omit from this calculation when chosen from the list Admission Exception The RN LOS can be calculated secondarily by the type of unit the patient is admitted to or if IV interventions take place tblluRNLOSExceptions vchCriteria This exception table is also customizable for the client The names of the units can be changed added or omitted as well as the levels of service indicated for admission to a specific unit Currently there are two exceptions that could alter the RN LOS e vchType A stands for Admit or Transfer to these units For example a patient that is admitted to Psych or Detox would be coded to LOS 4 in this area 33 empowerlnpatient Ambulatory e vchType I stands for IV interventions For example if a patient receives IV medications the chart would be coded to LOS of 4 in this area Final Exception and Calculation of RN LOS Empower takes the Preliminary RN LOS and compares it to the Exceptions for RN LOS as described above and suggests the level that is the greater of the two Finally in the case of an admitted or transferred patient to a general medical floor or any unit other than those in the above exception table will receiv
166. ess days of training at eight 8 hours per day Web Based Sessions If on site training is not preferred due to staff s schedule limitations or a desire to invest in training over a longer period of time intensive web based training sessions are offered Trainees benefit from the same Empower team of Clinical physician nurse and IT experts but in a remote setting accomplished by Hamachi VPN connection and Glance interactive web software In addition web sessions will be recorded and provided to clients so they can refer 51 empowerlnpatient Ambulatory back to key portions as needed The cost for this training option is 225 hour and schedule options are very flexible Delegated Option While the Report Alert Writer is an exciting tool for our clients some may prefer to have Empower design highly complex reports for them For this option the standard rate of 225 hour applies Getting Started with Standard Reports When administrative access is given a Report Writer button will appear on the patient roster screen When this program is launched a list of reports will appear with their corresponding descriptions listed to the right as shown below Report List View M Description Antibiotics Administered before Blood Culture Report List 3 dmi fore Blood Culture Antibiotics Administered before Blood Culture Date Range antibiotics Administered before Blood Culture Chart Antibiotics Timeliness Summary Antibiotics
167. essssssssracacenscsesesssesraranes 21 Chapter 5 General Clinical Documentation ceeesseseseseesessseaseseseessseseecaeseseeseseaeaeaeseseeecstotatacaesseseseaeacaeseseneseears 24 Physicians Nurses and Staff Documentation cccccccccceesssscccccesseessnscesccessessssceseceseeensasaeseeceseeessaeeeeseseesssseseseesees 24 Discharge Instructions Pre Writt n cccccccccsssscccesssscceessscceesssccsenssscesessscesessseccesssseceessesceeessecceesssecsesseeecessseseessaeas 25 Prescription Writer amp e Prescribing visiseseciessccicatscveaveesscascetvessseseasceausdsaceaeacunauvedtecavasdeedanessdvedeseovedeeasseedavochesdeaacdd3 eaves 25 Drug to Drug Interaction and Allergy Detection essssisissseeeese eese ernannt risusa ss essa aaa asas ss sso 27 FODIC ECILOM gm EE ia 28 Automatic PAGING eiue SER 28 Medication Reconciliation HistOry ccccsscceessssessceesseeessceesscsesssensecessceesesecsssesstesesseeestesesssecssesesseeesssseassecatesensseentess 29 Chapter 6 Personalization Policy and Procedures e e eseeenenenentntntntnte tente 30 Supplemental ServiGes uci err et eit ETRE E EN th WATER PME ERN Ve EXER FMe Ear Re e RR VR uev Kan ap Pe Nono cie ANATAET 30 Chapter 7 Coding and BIA isse isi tiim Cte s td eL arene ere Dd Ld dE 3l Empower InpatienttAmbulatory Calculation of RN Level of Service LOS esses 32 Physician LOS CQIGUIATION M
168. et Blue Island IL 60406 2428 708 597 2000 Patient Name Allergies nka 05 25 2011 7 30 05 25 2011 8 01 05 25 2011 8 05 05 25 2011 8 06 05 25 2011 8 27 05 25 2011 8 32 05 25 2011 8 33 Age DOB Admitting Admitting Gender Race Insurance Weight Height Medical Record Account EN MM e WELLCARE 85 7kg 175 26cm MEN EET SHIFT NARRATIVE NURSING SKIN ASSESSMENT PLAN OF CARE PLAN OF CARE FALL RISK VASCULAR ACCESS Room 4S0 421 01 Nursing Serial SHIFT END NOTE new 4 19 11 Bahena RN Cecilia Medical Orders review I have reviewed and as appropriate carried out all medical orders during my shift except those orders endorsed to the oncoming RN and or are scheduled in the future Diagnostic test review I have reviewed all pertinent diagnostic data as available and appropriate during my shift Patient report given and patient care endorsed to Carina Rn Additional shift end comments Carina Rn aware to start 24 urine stop iv fluids give amp of d50 initiate new double concentration dobutamine initiate new lasix dosage Nursing Serial SHIFT NARRATIVE NOTE new 6 29 10 pt in bed drowsy awaken with White RN Carina verbal stimuli oriented x 2 3 forgetful Pt has Dobuatime 5mcg kg min 12 8 ml hr infusing via pump into right forearm pvil site patent and intact Pt foley to gravity draining clear amber urine Pt has trace edema mild discoloration Pt abd distended bowel sound patent Pt oriented to use ca
169. et Blue Island IL 60406 2428 Admitting Admitting 708 597 2000 Medical Record Account 05 23 18 39 05 23 18 41 05 23 18 42 05 23 18 42 05 23 18 42 05 23 18 43 05 23 18 43 05 23 18 44 05 23 18 44 05 23 18 45 05 23 18 47 05 23 19 03 05 23 19 03 05 23 19 03 05 24 7 07 05 26 3 52 05 26 11 59 05 23 18 58 05 23 18 49 05 23 18 49 05 23 18 48 05 23 18 49 05 23 18 49 05 23 18 49 05 23 18 49 05 23 18 48 05 23 18 49 05 23 18 48 175 26cm NENNEN NEIN 4SO 421 01 Secretary Completed Room Secretary Completed Secretary Completed Secretary Completed Secretary Completed Secretary Completed Secretary Completed Secretary Completed Secretary Completed Secretary Completed Secretary Completed Secretary Completed Secretary Completed Secretary Completed Secretary Completed Secretary Completed Secretary Completed Secretary Completed Secretary Completed Secretary Completed Secretary Completed Secretary Completed Secretary Completed Secretary Completed Secretary Completed Secretary Completed Secretary Completed Secretary Completed Metro South Medical Center Patient Name Allergies nka AHMED ZAFAR AHMED ZAFAR HARRIS RICHARD G KASON THOMAS T KASON THOMAS T KASON THOMAS T HARRIS RICHARD G HARRIS RICHARD G HARRIS RICHARD G HARRIS RICHARD G VENTURA SALVATORE C VENTURA SALVATORE C VENTURA
170. et upon expiration of the user account 45 empowerlnpatient Ambulatory Chapter 9 Reporting and Data Mining Empower Administrative Tools or Admin Tools provides a snapshot of the more common statistics Designated Super Users can be provided with access to the Administrative Tools These tools can assist administrators in identifying data that may need further analysis through other reports available via the Report Alert Writer Custom reports can provide answers to virtually any data driven question and can be created by your Super Users or requested through your Project Manager if the complexity is outside the normal scope Empower Admin Tools track the following information keeping in mind that all time flow studies are dependent on the accuracy of the entered data Operation Performance Index OPI Studies e Daily Census e Average Length of Stay of discharged patients e Average Length of Stay of admitted patients e Average time to triage patients e Average time from waiting room to exam room e Average time for a physician into an exam room e Average time for a nurse to execute a diagnostic or medical order Inpatient ED Statistics Total discharges e Total admissions e Total admissions to Telemetry e Total admissions to ICU e Total admissions to Pediatrics e Total admissions to Psychiatry e Total admissions to General Medical floors e Total left without being seen LWBS e Total left Against Medical Advice
171. ett RN Ginny Admitting Admitting Patient Name Age DOB Gender Race Insurance Weight Height Medical Record Account Em NEN oo peus 009 857 175260 NN Allergies nka Room 4S0 421 01 05 24 2011 17 25 ASSESSMENT Nursing Serial SHIFT NURSING ASSESSMENT rev 11 04 10 Bayless RN Michel Transmission Precautions Standard O2 Type Liter Flow Room Air Rhythm Strip Interpretation Paced Rhythm LOC Drowsy Affect Calm Eye Opening 4 spontaneous Verbal Response 5 Alert and Oriented X 3 Motor Response 6 obeys commands Ability to Move right arm strong Ability to Move right leg moderate Ability to Move left leg moderate Ability to Move left arm strong Skin Color Normal Skin Temperature cool Skin Moisture Moist Skin turgor non tenting Respirations Even and unlabored Breath Sounds Right Diminished Breath Sounds Left Diminished Retractions No retractions noted Abdomen Round firm Bowel Sounds Active x 4 quadrants Pedal Edema Right 2 plus Moderate 1 2 inch Pedal Edema Left 2 plus Moderate 1 2 inch Pedal Pulses Right 1 plus Barely palpable Pedal Pulses Left 1 plus Barely palpable 05 24 2011 19 18 SHIFT NARRATIVE Nursing Serial SHIFT END NOTE new 4 19 11 Bayless RN Michel Medical Orders review I have reviewed and as appropriate carried out all medical orders during my shift except those orders endorsed to the oncoming RN and or are scheduled in the future Diagnostic test review I have reviewed all p
172. f Meeting Phase ll Data Collection and Application Development 128 empowerlnpatient Ambulatory ED Charges Nursing Inventions Procedures and RN LOS bs Hospital Dictionary Question and Responses Laboratory Hospital Question and Responses Radiology Hospital Number and secure Email addresses Entry Identification Number List of Triage Categories Operating System and Support Software Installation NEN Do ee Nm user to prevent PDF Generator Shut Down Hospital Confirms MS Operating System Password Never Changes to prevent PDF Generator Shut Down EE EmpowerSystems submits Scanner DLL for Hospital Hospital Installs MS Internet Information Services IIS amp Optional open SMTP Ports or provide Email Exchange Server and Hospital Provide SMTP Address Hospital Installs Scanner DLL and Tests Scanning into EmpowerSystems EmpowerSystems Hosp IT Hospital Installs EmpowerSystems Launcher on every Client Computer from the ECDS Shared Folder Hospital Installs Support Software on Server for MS Operating System 2000 must install Microsoft Data Access Components MDAC 2 8 and also install Dot Net Hospital Framework 1 1 or greater XP OS already has these tools Hospital Sets the Display Screen on Computer Monitor Hospital 1024x768 resolution Hospital Provides High Speed Internet Access VPN Only Hospital ospita MS Virtual or Cisco VPN with Logins and Passwords j Hospital Provides High Speed I
173. f the patient encounter Empower provides all the tools necessary in order to document the patient s clinical information while simultaneously caring for the patient The software is written such that it follows the patient stepwise through the healthcare system beginning with the registration process and ending with the discharge instructions Empower Inpatient Ambulatory Nursing MA Documentation Starting the Program exp e Click on the Empower icon on the desktop e Loginis provided by your system administrator e The Patient Tracker will appear as the opening screen 69 empowerlnpatient Ambulatory Empower Inpatient Patient Roster Patient Roster in Patient s Last Name to access Patient t s First Name to re Loc Chief Complaint Bed Length i Chart Acuity Patient Name Age Assessment Dx MD Attending RN Disposition Room Assign of Stay Status RDC XU 3 67 Y i WATSON 2 wn R i 03 27 E BG See 1 a imma Ochargetone peas e eet re A LE oo LEN aids a aa U The following columns appear on the tracker and can be modified as desired Acuity is based on the Emergency Severity Index ESI 5 level system Empower also has customizable tables for hospitals that use a different system The ESI 5 level is assigned in Triage ESI Level CATEGORY COLOR Resuscitation RED Emergent GREEN uc RED 3 Urgent YELLOW 4 5 Referred GREEN Patient Name appears on the tracker when
174. g Joint Commission standards in order to ensure continuing compliance The system also ensures compliance by prompting the physician or nurse at various HCFA mandated junctions electronically applying the physicians signature and ensuring follow up by faxing the chart to the primary care provider or specialists office The program is dynamic and flexible and can be customized to the needs of various physicians nurses and inpatient ambulatory settings Empower is also an inexpensive alternative to costly transcription or verbal documentation This program unlike others is not template based but rather is based on a single free formed chart that is populated by the physician s or nurse s description of the patient s history physical exam diagnostic tests medical orders and clinical summary to provide an accurate EMR or electronic medical record The Empower chart reflects the company s philosophy of One patient One Chart One Database There is no need to collate several separate charts or pieces of charts into one record at the end of the patient encounter Empower provides all the tools necessary in order to document the patient s clinical information while simultaneously caring for the patient The software is written such that it follows the patient stepwise through the healthcare system beginning with the registration process and ending with the discharge instructions Navigation d5 Starting the Empower Inpatient
175. gine Database Billing System The Outbound Charges interface will send the following message trigger events Trigger Events P03 Post Detail Financial Transactions Although the Outbound Charges interface is HL7 2 2 compliant some segments and fields will not be used for this interface implementation Listed below are the various triggering events and segments that include data that will be sent from Empower InpatienttAmbulatory This subset of HL7 segments is offered only to show which segments are important for this implementation Message Definitions Post Detail Financial Transactions MSH Message Header OEY EVN Event Type PID Patient Identification FT1 Financial Transaction Segment Definitions MSH SEQ LEN DT OPT RP ELEMENT NAME Receiving application Receiving facility 2j 12j s R 2 4 ST R 3 180 HD Sendi 4 180 HD Sending facility 5 180 HD Recei 6 180 HD Recei 26 T5 jDate Timeofmessage 115 empowerlnpatient Ambulatory SEQ LEN DT OPT RP ELEMENT NAME NOTES 8 40st sewty 9 7 t M R mesae 10 20 sr R MessagecontroliD a s r R Procesio a s R Vo 1 13 I5 NM jSeqeneenumber S 14 180 ST Continuationpointer J 15 2 ID __ Acceptacknowledgementtype 16 2 ID __ Application acknowledgementtype 17 2
176. h Richard Chapman Leland N White RN Carina White RN Carina White RN Carina Response Time Metro South Medical Center Patient Name Allergies nka Intake Start Time End Time 05 23 21 41 05 23 21 41 05 23 21 41 05 23 21 42 05 23 21 42 05 23 21 42 05 23 21 43 05 24 9 40 05 24 9 40 05 24 9 40 05 24 9 40 05 24 9 40 05 24 10 00 05 24 10 10 05 24 14 00 05 24 15 44 Age DOB Staff McCabe RN Janet McCabe RN Janet McCabe RN Janet McCabe RN Janet McCabe RN Janet McCabe RN Janet McCabe RN Janet Bayless RN Michel Bayless RN Michel Bayless RN Michel Bayless RN Michel Bayless RN Michel Critchett RN Daisyrenee Bayless RN Michel Bayless RN Michel Bayless RN Michel Gender Race Medicine Device Type COLCHICINE CARVEDILOL GLIPIZIDE FUROSEMIDE FAMOTIDINE METOCLOPRAMIDE HCL SIMVASTATIN FAMOTIDINE METOCLOPRAMIDE HCL COLCHICINE CARVEDILOL FUROSEMIDE POTASSIUM CHLORIDE D5W 0 9 NACL D5W 0 996 NACL DOBUTAMINE 500MG 250 D5BW METOCLOPRAMIDE HCL Insurance am umm coc auum 0 12935 South Gregory Street Blue Island IL 60406 2428 708 597 2000 Admitting Admitting Weight Height Medical Record Account 85 7kg 175 26cm MEN NNI Room 4S0 421 01 Dosage Route Rate Site Amt Residual Comments 0 6 MG ORAL 5 ML 25 MG ORAL 5ML 10 MG HELD DOSE 0ML as ordered until
177. he options for prewritten phrases in the Nursing Note tblluOrderLocation This table lists the options in the medical order section for Location Response Quantity field tblluPEDefaults This defines the default normal physical exam physician and nurse based on patient age tblluPhysAbdAppearance This table lists the options in the physical exam for abdominal appearance tblluPhysAbdBowelSounds This table lists the options in the physical exam for abdominal auscultation tblluPhysAbdTenderness This table lists the options in the physical exam during abdominal palpation tblluPhysBack This table lists the options in the physical exam during of the back tblluPhysCardiac This table list the options in the physical exam for cardiac auscultation tblluPhysChest2 This table list the options in the physical exam for lung auscultation tblluPhysChestWall This table list the options in the physical exam for chest wall palpation 143 empowerlnpatient Ambulatory tblluPhysChiefComplaintAsx This table lists the options in the Triage and Physician for chief complaint tblluPhysCondition This table lists the options in the physical exam for condition on disposition tblluPhysDiagnosis This table list the options in the for diagnosis tblluPhysDisposition This table list the options in the medical intervention for disposition tblluPhysDurati
178. his report can sometimes be skewed by the actions of the first responders who often administer these medications prior to arrival without subsequently entering that information properly into Empower This can be corrected using manual overrides that reconcile the information without having to modify any patient data While most of the fields in this report are self explanatory items such as name age and gender other report fields include e In Time The time that the patient was added to Empower e Medical Record Number The hospital s medical record number e Account Number The hospital s account number e ASA Given Yes or No e Beta Blockers Given Yes or No e Include and Exclude This will allow the user to record whether the patient was give aspirin beta blockers or both This does not alter the record in any way it simply instruct the program to omit or include that particular piece of information when calculating the statistics Calculations Total MI Cases refers to the total number of patients diagnosed with acute myocardial infarction Both the ASA and the Beta Blocker columns contain two numbers The first number is the total number of patients with acute myocardial infarction treated with the medication the second number is the percentage of patients with acute myocardial infarction treated with the medication Disposition Statistics Report The Disposition Statistics Report analyses the patient disposition data duri
179. his table groups certain diagnostic studies in order for smart technology to functions tblluDIRx This is table contains the physician prescriptions tblluDIRxRefills This table documents the number of default refills tblluDischInstAddComments This table conditions prewritten statements for the additional comments on the discharge form tblluDischInstrFollowUpOther This table contains prewritten discharge instructions name and maps it to the hospital preferred name tblluDischInstWorkSchool This table contains information on when to return to work or school tblluDischInstWorkSchoolRestriction This table contains information on any work or school restrictions or limitations tblluDrug2Drug This table contains drug to drug information and group classifications tblluERSort This table allows areas in the emergency department to be designated and sort on the tracking system tblluExamRoom This table lists all exam rooms in the emergency department tblluGenGender This table lists the patient gender options tblluGenLanguage This table lists different languages a patient might speak tblluGenLivesWith This table list the different types of living arrangements tblluGenLowMedHigh This table lists the options for the assessing the Patient s Parent or Child readiness to learn tblluGenNegPos This table contains the yes or no options for physician review of
180. hout requiring the completion of all of the fields Review of Systems These can be entered individually or the All Systems Negative box can be checked and then the individual positive items can be detailed separately There is also a free text box for additional comments Additional Comments This area can be used for more detailed histories or physician templates Past Medical History This area auto populates with the information obtained in the Admission Assessment area Additional information can be added by checking the appropriate boxes or clicking in the white box and free texting under Other PMHx 94 empowerlnpatient Ambulatory Social and Family History Check appropriate boxes or click in the white boxes labeled Other to add more information Smoking status is required to meet Meaningful Use Physical Exam To document the Physical Exam check the box on the left to populate a normal statement for that system Clinking on the arrow to the right or beginning to free text causes drop down tables appear If an appropriate exam is not found in the drop down list the physical findings can be free texted Exam Date Time 05 30 2007 10 46 SIG Gen Appearance V lawke AROXG on m ST Skin Rr HEENT f Neck amp NT Full ROM No JVD Chest E JVD Mild JVD Mod JVD Severe Abdomen E JVD GU m Babu Back pm LAD Diffuse NT LAD Diffuse Tender Mobile Ue Exeniy ET aI aI zii a Neuro Motor
181. hysician will immediately update the Diagnostic results in the chart in the diagnostic studies section of Empower 3 The physician will also keep a Log of any missing or incorrect diagnostic results identified from the Diagnostic Results Interface 4 The Diagnostic Results interface Log will track the Patient s Name and the Diagnostic Results Name 5 The clinical administration will fax the log to Empower at 312 276 8116 or via email at contact empower md so that the discrepancies can be corrected for future diagnostic results that are acquired through the interface thereby fine tuning the Empower Diagnostic Results interface 6 The Diagnostic Results Interface Log will track the Patient s Name Empower Diagnostic Study Name and the Hospitals Diagnostic Results Mnemonic code The procedure can be terminated after 90 days or until resolution of all discrepancies between the Diagnostic Results Interface into Empower and the Printed Diagnostic Results from the Hospital s Health Information System HIS 150 empowerlnpatienttAmbulatory Appendix 13D Hospital Diagnostic Results Problem Log Sheet Document all interfaced orders that do not pass through the Order Entry interface between Empower and Health Information System Please complete each row Patient Name Account Number Empower Order Name Hospital Code 151 empowerlnpatienttAmbulatory 152 empowerlnpatient Ambulatory Empower User Troubleshooting Guide
182. ial X mimi mo 2m r 1 2 2 22 3 22 4 22 5 2 6 1 7 200 8 200 9 26 10 120 11 120 12 120 13 80 14 40 15 26 16 200 _17 60 18 60 19 120 123 OBR empowerlnpatient Ambulatory SEQ LEN DT OPT C C RP ELEMENT NAME Set ID OBR NOTES 75 75 Placer Order Number CE TS TS TS Q C C C C N Collection Volume Collection Identifier 2 Specimen Action Code Danger Code Relevant Clinical Info oio m C o Specimen Received Date Time x sS Ordering Provider x Order Callback Phone Number n Placer Field 1 o Placer Field 2 Filler Field 1 Filler Field 2 NIV A4 C Y v Principal Result Interpreter 33 200 CM Y Assistant Result Interpreter S 34 200 CM Y Technician 200 CM Y Transcriptionist 36 26 TS Scheduled Date Time J 37 4 NM Number of Sample Containers 38 60 CE Y Transport Logistics of Coll Sample 39 200 CE Y j Colecto sComment o o 40 60 CE _ Transport Arrange Responsibility 124 C o Y 2 5 x o o o fe p e 2 empowerlnpatient Ambulatory SEQ LEN DT OPT RP ELEMENT NAME NOTES 41 30 ID TransportArranged 42 1 ID EscortRequired 43 200 CE
183. ic Cholecystectomy Adult Care After Surgery Chronic Obstructive Pulmonary Disease COPD Colonoscopy Care After Surgery Congestive Heart Failure Diabetes Mellitus Diverticulosis and Diverticulitis Care After Surgery Esophagitis Heartburn EI Kidney Failure EI Kidney Stones Ureteral Lithiasis Knee Arthroscopic Procedure Lung Cancer Metastatic Cancer Q amp A Myocardial Infarction Heart Attack Ovarian Cancer Palpitations Irregular Heart Beat Pneumonia Prostate Cancer Shoulder firthrnccany All Instructions Selected Instructions Eye Cataract Risks Congestive Heart Failure Diet Iron Rich Stroke Cerebrovascular Accident Transient Ischemic Attack TIA Uterine Artery Embolization For Fibroids CABG Coronary Artery Bypass Grafting Care After Surgery Cholecystectomy Adult Care After Surgery z i d Add to List Cancel 103 empowerlnpatient Ambulatory Prescription Writer Click the gray box for Discharge Rx which brings up the Prescription Writer screen It also includes the Drug to Drug Interaction Alert and the Potential Allergy Alert Select a prescription from the list The prescription writer can also be used to document work or school releases The prescription writer is the ideal software to function in this dual manner because it automatically lists the name of the patient and the date that the medical care was provided along with the physician s signature Typical st
184. ility assessment reveals Get up and Go Test Patient makes multiple attempts but is successful 3 TOTAL SCORE 4 or less STANDARD FALL RISK INTERVENTIONS AS NOTED BELOW Standard precautions initiated Includes initial and ongoing fall risk education safe room set up including call light in reach and not dangling moving furniture on non exit side of bed side rails up x2 bed locked and low adequate lighting and room is clear of clutter If high risk additional interventions below High risk precautions initiated Includes Appropriate signage posted in room chart labels on Fall risk ID band applied red slippers provided hourly rounding done proactive bladder program established and exit alarms are in place and active Nursing Serial SHIFT MULTIPLE LINE ASSESSMENT rev 12 21 09 White RN Carina PIVL Site 1 Location Right Forearm PIVL Site 1 dressing label Date Time placed 5 23 PIVL Site 1 Inspection Site is clean and dry without redness drainage or swelling Patient s central venous access device continues to be necessary due to Multiple IV drug and or fluid therapy requiring central venous access Metro South Medical Center 12935 South Gregory Street Blue Island IL 60406 2428 708 597 2000 Patient Name Allergies nka 05 25 2011 8 33 05 25 2011 8 49 05 25 2011 8 59 05 25 2011 9 01 05 25 2011 9 02 05 25 2011 9 06 Admitting Admitting Age DOB Gender Race Insurance Weight Height Medical Record Account m u
185. ime 05 26 08 35 BP 107 74 Pulse 75 Respiration 1 Vitals Time 05 26 08 35 BP 107 74 Pulse 75 Respiration 1 Vitals Time 05 26 08 35 BP 107 74 Pulse 75 Respiration 1 Vitals Time 05 26 08 35 BP 107 74 Pulse 75 Respiration 1 start in am Vitals Time 05 26 08 35 BP 107 74 Pulse 75 Respiration 1 Vitals Time 05 26 11 40 BP 130 91 Pulse 69 Respiration 2 lunch 100 Metro South Medical Center Patient Name Allergies nka 05 25 2011 5 23 05 25 2011 11 00 05 25 2011 22 02 05 26 2011 0 30 05 26 2011 3 00 05 26 2011 5 00 05 26 2011 14 19 Age DOB Gender Race 12935 South Gregory Street Blue Island IL 60406 2428 Insurance am umo uum 00 Wylie PCP Elana White RN Carina Fontillas PCP Arthur Fontillas PCP Arthur Bahena RN Cecilia Fontillas PCP Arthur Yang PCP Hai L Urine Output Urine Output Stool Urine Output Urine Output Urine Output Urine Output 650 240 350 300 708 597 2000 Admitting Admitting Weight 85 7kg Height Medical Record Account 1752600 EN ECT Room 450 421 01 foley d c foley soft brown yellow urine commode yellow urine bsc BRP didn t save urine brp Admitting Admitting Patient Name Age DOB Gender Race Insurance Weight Height Medical Record Account Em NEN i 857 15260 NNI Allergies nka Room 4S0 421 01 Medication Reconciliation Med Recon Type Med Type Medication Status AD
186. implement redundant mirror computer servers for data backup Although this increases hardware costs it essentially guarantees that the Empower servers will never be down due to a hard drive issue Software Updates amp Patches Empower deploys the software system updates and patches when the system is approved The hospital then has 14 days to test the software and accept all Empower updates and software patches If the hospital refuses the patches or updates then the Empower software live database deployment may be delayed for as long as six to even twelve months The Project Manager will coordinate with the hospital to ensure that this 14 day period will have the highest probability of success Health Insurance Portability and Accountability Act HIPPA Empower is compliant with HIPAA Health Insurance Portability and Accountability Act of 1996 Empower requires a user login ID and password for access and in addition the passwords can be set to require changing at pre set time intervals Empower tracks all users names and the dates and the times that they access any clinical information Empower also has an automatic log off that also can be set to particular time interval For additional security related logistics please refer to Chapter 8 The hospital must sign a Business Associate Agreement with Empower in order to be HIPAA compliant The hospital should provide Empower with this before the Go Live The clinic may also use the Busi
187. inder Print Results for your CVS Store CVS pharmacy Online http www cvs com CVSApp store storefinderresultsprint jsp storeln Conditions of Admiss Conditions of Admiss Medicare Rights NEW DOC 204224 j NIH Scale Page 1 NIH Scale Page 2 Note To Requestor o Patient Rights Privac Patient Self Determir Y Questions Call 888 607 4287 or emall customercare cvs com Copyright 1999 2010 CVS com Patient List This button will return the user to the Patient Roster Print The Print button will open a window to give the different options to print There is one Default printer assigned during set up but there are other options if multiple printers have been installed In addition a dedicated prescription printer can be added Patient Reports Information from visits and anticipatory guidance reports are generated from this button Please see Chapter 9 Vitals Reassessment Empower has the ability to prompt the RN to obtain another set of Vital Signs with certain Chief Complaints The Chief Complaints are chosen by the site administrator using the Table Editor Choosing Chief Complaint and Associated Symptoms in the Table List or tblluPhysChiefComplaintAsx in Table Information displays the correct Table Setting the column booRepeatVitals to True for the specific complaint will trigger the prompt 83 empowerlnpatient Ambulatory EmpowER Table Editor Chief Complaint and Associated Symptoms vchPhysChiefComplaintAsx
188. ing Serial SHIFT NURSING ASSESSMENT rev 11 04 10 Transmission Precautions Standard O2 Type Liter Flow Room Air Rhythm Strip Interpretation Atrial Fib LOC Awake Alert and Oriented x 3 Affect Calm and cooperative Eye Opening 4 spontaneous Verbal Response 5 Alert and Oriented X 3 Motor Response 6 obeys commands Pupils equal and reactive Ability to Move right arm strong Ability to Move right leg strong Ability to Move left leg strong Ability to Move left arm strong Skin Color Normal Skin Temperature warm Skin Moisture Dry Skin turgor non tenting Respirations Even and unlabored Breath Sounds Right Clear Breath Sounds Left Clear Retractions Intercostal Abdomen Round soft ascites Bowel Sounds Active x 4 quadrants Pedal Edema Right 1 plus Mild 0 1 4 inch Pedal Edema Left 1 plus Mild 0 1 4 inch Pedal Pulses Right 1 plus Barely palpable Pedal Pulses Left 1 plus Barely palpable Accucheck 153 Iv noted leaking left arm iv dc d After 5 unsuccessfuls attempt by Rey Rn 22g placed to rfa by Stacey Rn from Er Weight 85 4 dobutamine 5mcg kg min 12 8cc hr Medication Administration Record Reconciled and Verified Bahena RN Cecilia Bahena RN Cecilia Bahena RN Cecilia Bahena RN Cecilia Bahena RN Cecilia Bahena RN Cecilia Bahena RN Cecilia Bahena RN Cecilia Bahena RN Cecilia Bahena RN Cecilia Bahena RN Cecilia Bahena RN Cecilia Bahena RN Cecilia Metro South Medical Center 12935 South Gregory Stre
189. ing static Fair Balance Standing dynamic Fair Fair Bed Mobility Supine lt gt Sit Not assessed as pt was already up in the bathroom Ind upon entry Transfers Sit Stand CGA Transfers Bed lt gt Chair CGA Gait Device Used HHA Assist Needed CGA Distance 25 Gait Analysis Unsteady Although pt refused to use an assistive device Decreased cadence and step length Endurance Fair Pt reported SOB with activity Unable to get an accurate O2 sat as her hands were too cold Instructions provided on fall safety Yes Verbal ASSESSMENT Pt required encouragement to participate in the PT Eval and responses were delayed at times She presented with general deconditioning and impaired gait but was reluctant to use an assistive device despite PT suggestion She would benefit from continued skilled PT to improve general strength endurance and balance needed for more safe amp Ind functioning Goals Time Frame 3 5 days Improve bed mobility to Sup A Goals Time Frame 3 5 days Improve transfers to Sup A Goals Time Frame 3 5 days Increase ambulation to Sup A x 150 with or without device and O2 sats 9096 on RA Potential for Physical Therapy Fair Discharge Recommendations Home with possible Home PT Pt may need an assistive device for home use Treatment goals and plan were discussed and developed with patient and or family Yes INTERVENTIONS PLANNED Bed Mobility gt Range of Motion Exercise gt Transfer Training g
190. ing Physicians Milenkovic Steven Robert KASON THOMAS T Specialty Cardiology Metro South Medical Center 12935 South Gregory Street Blue Island IL 60406 2428 708 597 2000 Admitting Admitting Patient Name Age DOB Gender Race Insurance Weight Height Medical Record Account e Em NEM Oo ge eus 009 857 15260 NN Allergies nka Room 4S0 421 01 MD Name FOCHESATTOFILLHO LUCIANO Date of Note 05 26 2011 9 25 Note Type DISCHARGE History Subjective DISCHARGE SUMMARY Other Notes Admit Date 5 23 2011 3 33 00 PM Discharge Date Patient Not Yet Discharged Discharge Diagnosis Acute on Chronic Systolic Heart Failure with Severe Cardiomyopathy EF 10 AICD in place PAF ECHO EF 10 and severe MR ARF CKD Cr at discharge 1 55 HTN Hypercholesterolemia DM Hypoglycemia in diabetic unspecified Procedures Consultants Specialty VENTURA SALVATORE C Nephrology AHMED ZAFAR Internal Medicine KASON THOMAS T Cardiology HARRIS RICHARD G Internal Medicine Milenkovic Steven Robert Cardiology FOCHESATTOFILLHO LUCIANO Internal Medicine Discharge Diet Cardiac Diet Renal Diet 1800 Calorie ADA Diet Dicharge Activity Activity As Tolerated Additional Discharge Instructions Click here to add instructions CHF Patient was given instruction on diet exercise weight monitoring activity level follow up and what to do if symptoms worsen Follow Up MDs AHMED ZAFAR NULL 12 00 00 AM IN 1 WEEK Erickson
191. ing that would potentially affect the systems smart technology Empower recommends populating but not deleting tables If there are any questions please contact Empower support or your project manager Automatic Paging System Empower has a paging system that will automatically page hospital staff technicians bed control physicians respiratory therapy and any others And as the patient leaves the ED and is transported to the floor a page can automatically be transmitted to a nurse supervisor or resident physician with all pertinent patient information 28 empowerlnpatient Ambulatory Medication Reconciliation History Empower is a Comprehensive ONC Certified Product and uses an active medication list and true medication reconciliation in accordance with Joint Commission requirements for NPSG 8B The medication reconciliation report can accurately and completely provide a complete list of the patients medications for both hospital admissions and hospital discharges provided the information is properly entered into the Empower Inpatient system The report contains the home medications as entered into Empower Medication Table and prescription medication also as entered Active and inactive medications are also listed as required as are all medications dispensed in the hospital On discharge the home medication table will clearly display all active medications 29 empowerlnpatient Ambulatory Chapter 6 Personalization Po
192. ion Site is clean and dry without redness drainage or swelling Patient s central venous access device continues to be necessary due to Multiple IV drug and or fluid therapy requiring central venous access Garza PCP Ana White RN Carina Bohanek MPT Amy White RN Carina Burke RD LDN Paula Kannankeril Jaya J White RN Carina White RN Carina Metro South Medical Center DOB ae EH ENEEEHH D 7006 WELLCARE Patient Name Allergies nka 05 25 2011 16 30 05 25 2011 16 32 05 25 2011 18 31 05 25 2011 18 32 05 25 2011 19 45 05 25 2011 19 51 05 25 2011 20 00 05 25 2011 20 00 Age ASSESSMENT NURSING NURSING SHIFT NARRATIVE NURSING NURSING NURSING NURSING 12935 South Gregory Street Blue Island IL 60406 2428 Admitting Admitting Weight Height 85 7kg 17520600 EN Gender Race Insurance Room Nursing Serial SHIFT NURSING ASSESSMENT rev 11 04 10 Transmission Precautions Standard O2 Type Liter Flow Room Air Rhythm Strip Interpretation Normal Sinus Rhythm LOC Awake Alert and Oriented x 3 Affect Calm Eye Opening 3 to voice Verbal Response 5 Alert and Oriented X 3 Motor Response 6 obeys commands Pupil right 2mm Pupil left 2mm Pupils equal and reactive Ability to Move right arm moderate Ability to Move right leg moderate Ability to Move left leg moderate Ability to Move left arm moderate Skin Color Normal Skin Temperature cool Skin
193. ion name in the below field press search button Click Home Medications on the correct Medication tc add to the fist Medication Name Doxage Frequency can alzo be free text in the same field In both c always press the Save or Add Med Button to add the Medication Name Dosage Frequency to the Triage Medication Lisst Medication Name Dosage Frequency Route es as el Save And Add Another Dez 1 Return Med ec Cancel Start typing the Medication Name after two characters a drop down menu will appear The more characters types the more specific the options become This will give a list of the medications in our databank with different dosages Choose the medication dosage and route most appropriate by single click The boxes with an error require a choice from a pre populated list 78 empowerlnpatient Ambulatory When satisfied click Save and Return to return to Home Medication or click Add Another Medication to do so In the Home Medication Window push the Save Button to return to the Admission Assessment page Allergies Medications It is imperative to select the from the drop down list as the Empower Smart Technology features include allergy detection and cross reactivity Although free text is allowed for the rare medications substances not included in the tables Empower may not identify potential allergies or Drug to Drug Interactions Intake Fluids In this area anything given to the patient is documented To e
194. ional information from CPD CFD a nursing home or relatives of the patient be sure to note this using the check boxes on the History form since these items contribute significantly to the Medical Decision Making level The example above identifies this chart could have been coded a Level IV based on Medical Decision Making However it would be down coded to a Level if the physician does not review and provide additional documentation of History and Physical Exam to support the MDM Every physician sees this screen when they Set Ready to Print It offers the provider the opportunity to complete any documentation that may have been overlooked initially 40 empowerlnpatient Ambulatory Chapter 8 Medical Records and Health Information Security According to hospital policy and procedures the hospital Medical Records department is responsible for the security and storage and of the medical record Although Empower is not responsible for this security it still provides a moderate to high level of HIPAA compliant security For additional security the Empower chart can be locked for any period of time that the hospital may require Although Empower is not responsible for medical record storage it can still provide a very accurate back up copy and can also provide the hospital with a hard copy of the chart should Medical Records prefer the traditional paper chart Additionally Empower will provide an electronic PDF image of th
195. ions Test name and result should be documented in the diagnostic form for physician review 24 empowerlnpatient Ambulatory Demographics Printout Empower has the ability to automatically print demographics Information which can serve as a notification to the registration clerk providing them with the patient s name date of birth exam room number and other clinical information Discharge Instructions Clinical Summary and Physician Follow Up The staff using Empower also can provide patients with information about the follow up physician upon discharge The staff can document the PCP or specialist s name office address and office phone number in Empower The hospital or clinic must provide Empower with contact information for the physicians and specialists in an electronic format Other physicians and clinics can always be added as needed via the Empower Table Editor or the Discharge Page Empower also has the capability to automatically fax and or email the entire note to the referred physician regardless of whether that physician in an Empower user Discharge Instructions Pre Written When a patient is discharged Empower can print pre written diagnosis specific discharge instructions prescriptions and a clinical summary of their care in if needed a variety of different languages For those facilities that develop their own custom discharge instructions Empower can add content as provided in a Microsoft Word document
196. ire storage for Scans PDFs Size of SANS dependent on amount of scanning and uaru Inpatient Ambulatory Volume Recommend at least 2TB with expansion for future growth Machine CPU Speed MHx 2x Intel Xeon E7 4830 2 13 GHz 24M 6 4 GT s QPI Turbo HT 8C RAM 128 GB or Higher Hard Drive Space 200GB Local Server RAID partitioned with 30GB for Op Sys Partition remainder in Data Partition Optical Drive DVD RW Drive Monitor 17 Flat Screen Uninterruptible Power Supply UPS sufficient for both clustered servers in case of brown out APC 1500 or higher Ethernet Card TCP IP Recommendation for 100 Beds 2x Intel Xeon E7 4870 2 40 GHz 30M Cache 6 4 GT s QPI Turbo HT 10C 13 empowerlnpatient Ambulatory SERVER SUPPORT SOFTWARE Test Application Interface Servers TEST APPS Server Terminal Server Windows Server 2008 R2 x64 SQL Server 2008 with SQL Studio manager and all client workstation tools installed PDF Generator Adobe Acrobat Standard version 7 or newer installed Microsoft Office 2007 Professional with Access 2007 full version installed Software for PC Access Remote desktop Terminal services enabled for remote access Virus Software Anti Virus Software hospital standard Additional Software Microsoft Office 2007 Professional for Word and Access Additional Licenses Microsoft SQL Server Enterprise or Standard Edition and Client Access Lic
197. iskDiagStudies This table lists the options in the High Risk Chief Complaints for diagnostic studies and medical interventions tblluRiskDiffDx This table list the options in the High Risk Chief Complaints for differential diagnosis tblluRiskPertHxNeg This table lists the options in the High Risk Chief Complaints for pertinent negatives in history tblluRiskPertPhysNeg This table list the options in the High Risk Chief Complaints for pertinent negatives in physical exam tblluRNCharges This table lists the mapping of the facility charges to the core HIS tblluRNLOSCoding This table list the options for setting the criteria to calculate the RN level of Service tblluRNLOSExceptions This table lists the options to set the exceptions when calculating the RN level of Service tblluRoleGroup This table lists which groups are role based tblluRoles This table lists what roles have been set for the group tblluSecondaryDiagnosis This table lists secondary diagnosis and ICD9 that will print on ED chart tblluSecondaryDiagnosisMap This table maps the check boxes in past medical history to a secondary diagnosis tblluStandardOrders This table lists the items which will display in the diagnostic and medical order sets tblluTriageAgelncrements This table lists the options in the triage history for duration of symptoms tblluTriageAllergies This table list the
198. itchett RN 05 24 15 26 Daisyrenee KASON 05 24 8 12 THOMAS T Metro South Medical Center 12935 South Gregory Street Blue Island IL 60406 2428 708 597 2000 Patient Name Age DOB Allergies nka AHMED ZAFAR 05 23 19 01 XR CHEST 2 VIEWS Admitting Admitting Gender Race Insurance Weight Height Medical Record Account Female WELLCARE 85 7kg 175 2600 B IEEE Room 4S0 421 01 HARRIS 05 24 9 53 CHEST TWO VIEWS RICHARD G ACCESSION 0142076 CLINICAL INDICATION Shortness of breath Congestive failure COMPARISON One view chest 05 06 2011 TECHNIQUE AP and lateral upright two view chest 1955 hours 05 23 2011 FINDINGS Heart size is moderately increased with multichamber enlargement The aorta is tortuous and calcified A left ICD seen with right atrial and right ventricular leads Heart size is moderately increased Hazy opacity at the right costophrenic angle and at the left base as well as blunting of the posterior left costophrenic angle indicates bilateral pleural effusions with subjacent airspace disease such as atelectasis infiltrate or basilar congestive change Left hemidiaphragm is indistinct on the lateral and frontal view The mid and upper lungs are essentially clear IMPRESSION BIBASILAR PLEURAL EFFUSIONS AND SUBJACENT ATELECTASIS OR INFILTRATE OR BASILAR CONGESTIVE CHANGE MODERATE CARDIOMEGALY LEFT ICD WITH RIGHT ATRIAL AND RIGHT VENTRICULAR LEADS APPEARANCE IS SIMILAR TO THE PREVIOUS EXAMINATION OF 0
199. itions Audit Utilities LWCT Conscious Sedation Provider Efficiency Business Reports Messages QA Conscious Sedation Call Backs Narcotics QA Ortho Conscious Sedation LWCT AMA Narcotics Rx QA Restraints Disposition Statistics Non Finalized Registration Report Disposition Statistics Peds Non Registered Summary Statistics Fast Track Notifications Time To MD Summary Hourly Statistics Nurse Efficiency Triage Acuity Summary Log Nurse Patients Zone Statistics Ambulance Patient Report The Ambulance Patient Report identifies all of the patients brought in by ambulance within a given time frame It contains the following fields e Service Date Date and time that the patient s record was started in Empower e Squad Ambulance EMS The name of the ambulance provider that transported the patient e DOB Date of Birth e Age Patient s Age e vchPatientID This field contains either the Empower generated patient ID or a number provided by the hospital s ADT system e MR Facility s medical record number e Chief Complaint This is the chief complaint as entered by the MD rather than from Triage e SSH Social Security number e Dx allofthe diagnoses the MD makes on this visit e Insurance Name all of the insurance companies that cover the patient 53 empowerlnpatient Ambulatory ASA Beta Blockers Report This reports the compliance with the aspirin and beta blocker protocol for acute myocardial infarction The results of t
200. ity that charts will get removed from the patient tracking system without ever being printed They will then show up on the Non Finalized report e Inactive non printed charts with repeat exams If a repeat exam is performed the chart should then be printed or reprinted Otherwise it will appear on the Non Finalized report Nurse Patients Report The Nurse Patients Report identifies all of the nurses that documented on patient chart during a certain timeframe Likewise it can report all of the patients one which a single nurse documented during a certain timeframe There are 3 possible roles a nurse might fill with a patient in the ED e Primary The nurse recorded as the primary care nurse for the patient e Auxiliary A nurse that documented on the chart other than the primary care nurse such as charge nurses or float nurses e Triage A nurse whose only documentation on the record is related to triage A nurse could conceivably be counted as both primary and triage or auxiliary and triage The primary and auxiliary roles take precedence over the triage role A nurse will be listed only once for each patient and in the highest role applicable 58 empowerlnpatient Ambulatory Pneumonia Antibiotics Timeliness Report This report analyses compliance with the Pneumonia Antibiotics Protocol The report analyses patients who were admitted to the hospital with a diagnosis of pneumonia detailing the length of time from the patient arri
201. l by Empower Training Specialists during Go Live Edit Staff This button is used by administrators to add new associates or change the level of access for current associates For deleting associates please make them Inactive Form Builder This button is used to build forms for Clinical Notes These are the forms and templates available in Clinic Notes Nursing Notes section Super Users will have training on this feature prior to Go Live Table Editor This button is used to manipulate certain tables add or delete items Please see Appendix 9A for the list of tables Messaging Empower has an internal email system used to communicate to other Empower users The Messages button gives the user access to this function The recipient must acknowledge that they have READ ALL MESSAGES immediately when they first login prior to taking care of patients This ensures that every user must read and acknowledge all policy and procedure changes and will not be able to use the system until they have Instructions for an admin user to send a message are as follows 75 empowerlnpatient Ambulatory e Click on MESSAGES e Select the Nurse or Doctor from the drop down list OR select ALL e Click in the white box and compose your message e Click SEND e f you have a MESSAGE this screen will be the first to appear after you log in An audit of these Messages is available in the Empower Report Writer for reference Note This message func
202. l policy Document individual medical orders interventions and use of standard order sets Document verbal orders per hospital policy Document response cancel refused to medical orders interventions Document nursing note change time change date Document nursing diagnosis expected outcome goal achieved and rationale Document consulting physician notifications View scan and delete scanned documents View physician assessments and old records View modify discharge instructions and check prescriptions Print all temporary triage and respond to prompts print chart Understands safety prompts are built into the print menu Understands the prompt for abnormal VS and appropriate use of override Print copies of orders for ancillary RN and ED use med pharmacy orders Medication Reconciliation process in EmpowerSystems Demonstrates use of bed manager Edit ED Staff Super User 134 empowerlnpatient Ambulatory Appendix 3B Empower Tech Skills Verification Trainee Name Date Training verified by General OOOOO D OD Log In and Change Password Add Patient ex John Doe Modify patient tracker by nurse by room number change from alphabetical order to room number order how to change initials from one primary RN to another put multiple patients in one room change room number Enter Repeat Vital Signs noting ability to change time and date Note diagnostic orders within the scope of job description and h
203. l regurgitation 7 Nonischemic dilated cardiomyopathy complicated by congestive heart failure Metro South Medical Center 12935 South Gregory Street Blue Island IL 60406 2428 708 597 2000 Admitting Admitting Patient Name Age DOB Gender Race Insurance Weight Height Medical Record Account e Em NEN oc gem 000 857 15260 NNI Allergies nka Room 4S0 421 01 MEDICATIONS Lasix 80 mg IV b i d Librium 25 p o q h s colchicine 0 6 mg p o b i d Coreg 25 mg p o b i d Glucotrol 10 mg p o b i d Pepcid 20 mg p o b i d Reglan 10 mg p o t i d Zocor 40 mg p o q h s Colace 100 mg p o b i d aspirin 325 mg p o daily and Coumadin dose daily Page of MetroSouth Medical Center 12935 South Gregroy Street Blue Island Illinois 60406 CONSULTATION DEAE MR NNG ACCT ALLERGIES None SOCIAL HISTORY The patient is married without children The patient has a history of smoking cigarettes at a rate of one package per day between 14 and 52 years of age She also reports drinking alcohol excessively between her teen years and 52 years of age She does not abuse drugs FAMILY HISTORY Mother is living and well Father died of unknown cause Two brothers and two sisters are living and well REVIEW OF SYSTEMS The patient denies headache recent acute change in vision or hearing She reports slurred speech during hypoglycemic episodes She denies chest pain chest pressure or cough but does complain of orthopnea
204. lease Print Legibly ex John Q Medicine DO DEA Number __ If preferred to be electronically included on Rx User ID Usually same as host HIS system Start Date Physician Signature s Please sign your name below exactly as you would like it to appear as this will be digitized and imported into the system Please avoid writing on the lines Additional boxes are just in case if used identify preferred signature 137 empowerlnpatient Ambulatory Appendix 4A Computer Documentation Abbreviations Abbreviation Interpretation History HA GU a ENT CAD HTN CHF CVA L R B XRT LNMP PVD SLE HD MWF HDT Th iD iD SOB DOE PND FB c s RLE LLE RUE LUE BLE ur LMF LRF LPF RIF RMF RRF RPF 138 empowerlnpatient Ambulatory Abbreviation Interpretation Non Applicable Associated Symptoms Bilateral Lower Extremity Abbreviation Interpretation Physical Exam General Appearance A o Ox1 Ox2 Ox3 Skin No Abbreviations aes HEENT HEENT FB L R d c MMM DMM PERRL EOMI NT Neck ROM TMG sa Cardiac DEM SEM RRR IRR Irregular Rate Rhythm Lung BS Breath Sounds CTA Ret Poor AM e 139 empowerlnpatient Ambulatory Abbreviation Interpretation Chest Wall LLSB Left Lower Sternal Border RLSB Right Lower Sternal Border BLSB Bilateral Lower Sternal Border Abdomen BS Bowel Sounds WNL Within Normal Limits RLQ Right Lower Quadrant LLQ Left Lo
205. lerks ancillary staff e Registration e Order entry e Diagnostic results e Collating and distributing the chart to medical records e Collating and distributing the notes to inpatient units and attending physicians e Collating and distributing the notes to hospital and physician coders and or billers Empower takes a phased approach to implementing the Inpatient and Ambulatory systems in order to minimize the impact on all departments During the Empower Go Live the greatest impact will be on the physician and nursing documentation All other aspects of the Inpatient and Ambulatory workflow will remain virtually the same The workflow process related to collating and distributing the chart will remain unchanged as the current handwritten chart will simply be replaced with a computer generated chart Registration workflow process will be impacted depending on the type of interface design that is articulated in Chapter 13 CPOE will change the unit clerk s workflow and responsibilities as their role changes from entering data orders into the inpatient ordering system to simply auditing confirming the order when received electronically in the inpatient information system The diagnostic results workflow process for laboratory and possibly radiology should continue as usual Please review the Diagnostic Results section also in Chapter 13 The collation and distribution of the inpatient chart will initially occur with a printed hard copy The inpa
206. licy and Procedures Although the Empower personalization policy does not allow the deletion of any items from the lookup tables it does allow unlimited additions which provides the inpatient and ambulatory setting with maximum benefit while at the same time retaining the user friendliness the risk management features and the single database features of Empower During the Data Collection amp Application Development phase of the implementation Empower will populate the tables and generate templates with the information provided by the physicians and staff prior to the Go Live Once the Empower table editor is available to selected Super User staff and administration Empower will provide them with instruction to manage the lookup tables Empower retains the right to limit or expand the availability of certain tables and your Empower Project Manager is always available to discuss any adjustments to the table editor Any request for customization that requires changes to the Empower Source Code is considered a Supplemental Services project Examples of such projects may include additions alterations or deletions to the following Screen Print Layout e Labels fields or check boxes e Functionality such as logic reminders or required fields driven by individual clinic policies or mandates If a user request is in alignment with a documented government compliance mandate then there is no fee for the service If however it is considered
207. ll light sr x 2 up bed locked and low position for safety Cont to monitor Nursing Serial DAILY BRADEN SKIN ASSESSMENT White RN Carina Sensory Perception 4 No impairment Moisture 4 Rarely Moist Activity 1 Bedfast Mobility 3 Slightly Limited Nutrition 2 Probably Inadequate Friction and Shear 3 No Apparent Problem Total Score 15 18 Mild risk Initiated at risk interventions White RN Carina Nursing Serial DAILY INTERDISCIPLINARY POC White RN Carina Care Plan per Care Path Protocol gt 24 hour urine dobutamine drip and monitor io KNOWLEDGE INT See Interdisciplinary Patient Family Instruction Form gt DISCHARGE PLANNING INT gt pending SKIN INT Monitor skin integrity gt dry and intact PAIN INT Monitor pain using pain scale gt denies at this time O2 therapy gt room air Elevate HOB gt 30 degree Assess mobility gt up as with assistance Assess transfers gt assistance x 1 2 Assess gait gt slightly unsteady need assistance x 1 Nursing Serial SHIFT FALL RISK ASSESSMENT INTERVENTIONS rev 12 10 10 White RN Carina Currently History of Confusion Disorientation Impulsivisity No 0 HX Depression with active symptoms at present No 0 Altered elimination Frequency Urgency Incontinence Diuretics Yes 1 Currently History of Dizziness Vertigo No 0 Male Gender No 0 Currently taking anticonvulsants check MAR No 0 Currently taking benzodiazepines check MAR No 0 Mob
208. lnpatient Ambulatory Knowledgebase If you go back to the main support page you can also access the Knowledgebase by clicking the link for knowledge base Support Center E 4 A Knowledgebase sm Search support articles and find answers to frequently asked questions View Tickets Submit new tickets view existing tickets or create new replies Submit a Ticket Submit a new ticket u News View news articles and manage subscriptions You will be directed to the Knowledgebase which will show categories for articles that pertain to Empower functionality and technical issues From here you can select the article you are interested in You may also be directed to the article when you are submitting a ticket as explained previously empouuersusterns 31 May 12 Support Center Knowledgebase es Knowledgebase Categories 4 Knowledgebase articles are categoriz PPP Which category you would like to browse You can also search the knowledgebase using the search field beside this text O Report requests 1 E Requesting Empower Reports CJHL7 Interfaces 2 B HL7Connect backup for all EmpowER Clients P HL7Connect Checklist Prior to Shutting Down any of the EmpowER servers 7 more topics more topics Cj Technical Support 0 J Articles E Test Video Dewak Back Home View Tickets Submit a Ticket Knowledgebase News a My Account mem Logged In Empower Test
209. lowing Physicians FOCHESATTOFILLHO LUCIANO Specialty Internal Medicine Metro South Medical Center 12935 South Gregory Street Blue Island IL 60406 2428 708 597 2000 Admitting Admitting Patient Name Age DOB Gender Race Insurance Weight Height Medical Record Account e um m s 857g 1752600 EN NNI Allergies nka Room 4S0 421 01 MD Name Milenkovic Steven Robert KASON THOMAS T Date of Note 05 25 2011 9 13 Note Type PROGRESS NOTE History Subjective HPI Paragraph Patient with Mildly sob just with conversation States that she slept flat with 2 pillow last evening and woke up once with PND Other Notes Exam Objective Date Time of Exam May 25 2011 9 13AM GA Awake A amp Ox3 Skin No pallor rashes warm amp moist HEENT PERRL EOMI Moist Mucous Membranes No Icterus Neck NT Full ROM 4 JVD Lung Chest Wall Lungs Diminished bibasilar Chest Wall Chest Wall NT Cardio Vascular RRR 4 6 HSM Abdomen Palpation Tenderness None BS BS NL No Bruits Abd Appearance Distended Neuro Motor Major Muscle Groups 5 5 Sensory Gross Sensory Intact Coordination Extremity Location Low Ext Bilateral Pain Tenderness None Sub Location Appearance 4 Edema ROM Pulses CBR 2 sec Repeat Additional Exams May 25 2011 9 13AM Milenkovic Steven Robert Reviewed with Physician Assistant Agree with HPI PE Assessment and Plan Assessment Plan Problem List CHF Acute on Chronic Systolic N A Would like to add a
210. lysis This table contains the different types of result interpretations for the diagnostic study urinalysis tblluLabResultsUrineCulture This table contains the different types of result interpretations for the diagnostic study Urine Culture tblluLabResultsUrineDip This table contains the different types of result interpretations for the diagnostic study Point of Care Urine Dip Stick tblluLabResultsUrineTox This table contains the different types of result interpretations for the diagnostic study urine Toxicology tblluLabResultsUSNucScan This table contains the different types of result interpretations for the diagnostic study tblluLabResultsXRay This table contains the different types of result interpretations for the diagnostic study ABG tblluLabTestsGeneral This table contains the different types non standard diagnostic tests tblluLabTestsRadStudies This table contains the different types advanced radiology tests tblluLabTestXRay This table contains the different types plain x rays tblluMap2Map This table maps hospital dictionary to the physician dictionary for diagnostic results tblluMediMap This table maps hospital dictionary to the physician dictionary for diagnostic orders tblluNursingDx This table lists the options for Nursing Diagnosis tblluNursingOutcome This table lists the options for Nursing Outcomes tblluNursingPhrase This table lists t
211. mation Information can be entered in kilograms or pounds Visit Vital Signs are entered by single clicking the any box in the empty row 1 A new Vital Sign box will open and information is entered by clicking in the specific box or using the tab button to progress to the next box 77 empowerlnpatient Ambulatory Admission Assessment Admission Assessment fest Exam 35 Years M Allergies Patient denies allergies Past Medical History Social History Allergies Home Medication Asthma No Significant Social History Patient denies allergies ALBUTEROL O 09MG INH Four Times a Day INHALAT Hx of twins Family History This includes all pertinent information to begin care of the patient Fill in all pertinent fields by double clicking on the specific box Past Medical History Social History Family History and Allergies are added by single clicking on them from the list on the left The box on the bottom can be used as a drop down table or free text Information required for Meaningful Use is also required in Empower Selected situations can be commented changed or deleted by double clicking on the text After information is satisfactorily completed click on the Save button Home Medication Clicking on this field will open a Home Medication window Clicking on the first empty row will open the Add a Medication Window ES Add Home Medications i i Search a Medication Name Dosage Frequency by typing 3 letters of the medicat
212. mber is entered by clicking on the box and selecting a room Bed Assignment provides an area to enter the inpatient room number where appropriate It also functions as a sticky note By clicking on the box a pop up field appears that allows 18 characters of free text This note will appear on the tracker and can be used for ISOL or other information Time in ER in hours and minutes The box appears Green for patients who have been in the department for less than three hours Yellow for patients who have been in the department for more than three but less than five hours and Red for patients who have been in the department for more than five hours Diagnostic and Medical Orders section has five columns each with one of the following designations e U Urine e B Blood e E EKG and other diagnostics like Pulse Ox amp Peak Flow e R Radiology e M Medical Interventions like an IV or medication When orders are entered an Orange box with the letter N for New is displayed in the box When an order has been completed the box turns Purple and displays the letter E to reflect that the order has been executed The R D C X U columns are interface columns that reflect the following e R Registration this box will display green when the full registration process is complete e D Diagnostics this box will display yellow when all diagnostic tests are complete e C Critical Values this box will display a red C to notify clinician
213. mmend an antivirus software vendor or provide antivirus software for the product Hospital is responsible for the purchase installation and maintenance of the antivirus software Scanner amp Tablet PC Requirements For all Inpatient and Ambulatory units Empower Systems requires specific scanner models Cannon DR 2010C DR 2510C DR 3010C Flatbed 101 Add On for general use and Tablet PC Panasonic CF H1 with Cradle CF VEBH11 for signature capture If a hospital or unit within the hospital decides to utilize an alternate Scanner or Tablet PC there will be 225 hour fee for Empower Systems to configure the unapproved device on the hospital network Database Backup Options The hospital is responsible for all software backup and for all recovery of clinical data in the Empower software system Empower utilizes Microsoft SQL Server software for management and storage of clinical data which allows several options for data storage Empower s Microsoft SQL Server backup includes gt Tape cassette Local hard drive directory Network hard drive directory required gt RAID hard drives required The frequency of data backup can be adjusted depending on the speed and quality of the hospital computer server hardware The data back up intervals include gt 1hour gt 6hours gt 12 hours gt 24 hours gt Microsoft SQL software replication real time 16 empowerlnpatient Ambulatory The hospital can also
214. mmunication that might occur in the early phases of the interfaces development and deployment The following appendixes are provided to identify and communicate any problems with the interfaces during and after the Go Live Appendix 13A Workflow Procedure for CPOE Interface Post Go Live Appendix 13B Hospital Order Entry Problem Log Sheet Appendix 13C Diagnostic Results Interface Workflow Post Go Live Appendix 13D Hospital Diagnostic Results Problem Log Empower PDF Chart Export As mentioned in Chapter 8 the Empower final chart is formatted in an Adobe PDF file This file is generated from the Empower App Server and stored on the network drive provided The file is then available for the hospital to import to their document management system This task may be contracted with Empower please refer to the signed contract for clarification 110 empowerlnpatient Ambulatory Empower HL7 Orders and Results Interface Specifications Subject to change during development Order Result Processing Understanding order and result identification and the stages of the order life cycle is crucial to ensure the proper implementation of the orders and results interfaces Orders in Empower are identified by the order number The outbound interface identifies the order with a placer order number that can be generated at the time a new order is created by the outbound interface Ancillary systems use their own schemes to generate fille
215. n Wireless Access Point 2 TWAIN Compliant Required for Wireless Scanners mm uA Plasma LCD Screen s See HW Specs Wireless Laptops Optional d lt NM 2 lt p Desktop Workstations See Specs wrecue Servers Network mma tee imc ae feed seein Software VPN Network Printer Prescription Printer Empower Remote for Empower Technical Support empowerlnpatient Ambulatory Below is the typical Empower Ambulatory architecture design and network configuration Scanner i Physician preme Office Printer Remote Connection v Empower Office Server N Remote Connection Scanner Physician E A Office Printer Network Specifications The Empower InpatienttAmbulatory software system can function in any network environment e g Star Configuration Cluster Citrix however Empower performs maximally in a Star network configuration In more complex hospital networks although there is greater risk that there might be unforeseen software glitches Empower is committed to resolving any issue that impedes physician and nursing documentation Remote Connectivity The Empower InpatienttAmbulatory software system requires high speed internet connections to the server and remote software connectivity either Microsoft Remote Desktop Terminal Services or PC Anywhere to each client computer The Empower Inpatient Ambula
216. n patient name gender diagnosis bed assignment and admitting physician 2 Electronic notification over the hospital network printing the following information patient name gender diagnosis bed assignment and admitting physician 3 An Empower tracking board can be placed in Bed Control displaying the following information patient name gender diagnosis bed assignment and admitting physician Order Sets Guidelines Protocols etc Empower has both Diagnostic and Medical Order sets that can be customized to each hospital and physician office Empower will automatically check off diagnostic tests on the diagnostic and medical order forms when choosing these order sets from the medical order section To view the current default diagnostic and medical order sets in Empower go to the medical order section and choose from Standard Order Set Modifications or additions to the order sets can be done by a Super User or by an Empower Project Manager Admission Orders and Clinical Pathways Empower allows the physician to enter admission orders or hospital specific clinical pathways The Admission Orders functionality is similar to the Standard Order Sets listed above This is an optional feature Please communicate with your Empower Project Manager regarding activation de activation of this feature The following clinical pathways currently are deployed to all hospitals These are fully customizable and can be expanded or deleted Congesti
217. n 05 26 2011 9 15 D C IV Lasix after pm dose and restart 80mg po BID White RN Carina 05 26 9 16 Secretary Completed Robert in am of 5 27 FOCHESATTOFILLHO 05 26 2011 9 26 Discharge Home White RN Carina 05 26 10 43 Secretary Completed LUCIANO FOCHESATTOFILLHO 05 26 2011 9 33 pt s bp gt 100 of systolic White RN Carina 05 26 10 43 Secretary Completed LUCIANO FOCHESATTOFILLHO 05 26 2011 9 33 going home on low dose ACEI and BB White RN Carina 05 26 10 43 Secretary Completed LUCIANO Admit to MD MD Time RN RN Time Disposition Condition Admitting Admitting Patient Name Age DOB Gender Race Insurance Weight Height Medical Record Account ae le gem 00 557g 75260 NENNEN EN Allergies nka Room 4S0 421 01 Vitals Head Pulse Pain Wt Wt Ht e LMP Taken at Taken by Temp Pulse Resp BP Ox Scale kg Chg cm BMI EGA USEGA LMP Status Comments 05 23 17 24 Burge RN Oral 97 8 70 20 122 79 100 Denies pain pt on roomair Patricia 05 23 17 25 Burge RN Oral 97 8 69 20 124 91 98 Denies pain pt on roomair Patricia 05 23 19 45 McCabe RN Oral95 1 68 24 132 70 Denies pain Vpacing Room Janet Air 05 23 21 19 Shatteen PCP PCP entry ACCU Angie E CHECK 2100 94 05 23 23 22 Shatteen PCP Oral97 4 71 20 102 77 94 PCP entry Angie E 05 24 0 00 McCabe RN Denies pain Vpacing Room Janet Air 05 24 1 30 McCabe RN 72 24 97 89 Denies pain Paced Room A Janet 05 24 6 01 Shatteen PCP PCP entry 85 9 0 accu Angie E check 0500 62 05 24 6 01 Sha
218. n ACEI or ARB but her Cr is increasing Continue coreg BP too low 90 70 for hydralazine or imdur Would continue inotropic rx for another 24 48hrs IV Lasix per Nephrology BNP in am appears euvolemic Change dose of enalapril 10mg po bid OK to DC home from cardiac standpoint F U with Dr Erickson in 1 week coumadin clinic in 1 week 1 2liter day fluid restriction at home Normal Corns via Cath 00 N A Severe MR N A Not a surgical candidate due to extremely low LVEF DIABETES 648 03 management per PCP HTN 401 9 continue home meds Hyperlipidemia 272 4 home meds ICD N A Mgmt by Dr Tierney Agree with interrogation Syncopal episode one week ago does not sound cardiac but interrogation will tell if VT or VF involved Chronic kidney disease N A Staging currently in progress Other Medical Orders Additional Comments Kdur 40MEq po x 1 now then 20mEq po daily chem 6 in 1 week D C dobutamine Metro South Medical Center 12935 South Gregory Street Blue Island IL 60406 2428 708 597 2000 Admitting Admitting Patient Name Age DOB Gender Race Insurance Weight Height Medical Record Account a mum neuem ee 557g 175 25m ENS Allergies nka Room 4S0 421 01 Prescriptions Provided to Patient Potassium Chloride 20meq PO 1 tablet Daily 306 Electronically signed and authenticated by the Following Physicians Milenkovic Steven Robert KASON THOMAS T Specialty Cardiology MD Name VENTURA SALVATORE C Date of Note 05 25 2
219. n regarding the patient condition prior to discharge Intake Nurse enters Provider Views These values can be filtered and totaled during different time frames Output Nurse enters Provider Views These values can be filtered and totaled during different time frames Scan View Scan Physician and Nurse Previous scans can be viewed from any computer and those computers directly connected to scanners can also scan documents into the system Pharmacy RN Tasks Physician and Nurse Medications ordered and dispensed are documented and displayed in this area If a pharmacy interface is used this information can be auto populated Print Orders Physician and Nurse Prints a hard copy of all diagnostic and medical orders This can be used at the bedside to verify a patient identity by unit secretaries to enter orders or transmit orders to ancillary departments Notifications Physician and Nurse The physician or nurse can document the notification of other physicians consultants or other agencies Response time can also be documented Discharge Instructions Physician and Nurse Discharge Diagnosis is imported to this screen from the provider s assessment Diet activity and any other instruction are also chosen The patients follow up physicians complete with address and phone numbers are also assigned All instructions are available in different languages Discharge RX Prescriptions Physician The physician can sel
220. naaseeeesesns 8 PHASE III Testing Training amp Technical Readiness sssscccccccsssesssscscceceseeesssssesecesseesssseesceceseessssseseesesssensaseeseeesens 8 PHASE IV GO LIV m 9 PHASE V Post Go Live Assessment amp Transition cccccccsseccceeeeeeeneneceeeeeeeeeeeaaaeeeeeeeseseaaaeeeeeeseneeaaaeeeeeeseeeeesaaeeeeeeenegs 9 Chapter 2 System Technological Requirements and Specifications s 1O Basi Architectural DeSIQM RE ERE M 10 Hardware amp Support Software Specifications ccccccccccsseessscccccsssescsssceesccceseessseeseceseseeenseeesecseseeensaseeeecesseeasseeeesesens 12 Health Insurance Portability and Accountability Act HIPPA Y sees 17 Empower Inpatient Workstation Setup cscccscccccccseessssccsccessesssaseesccessesssseeseceseseessaaeeeeseseeessaeeeeceseeenaaseseeeesens 18 Empower Ambulatory Workstation SCtup ccscccccccccssssssssscccccssessssscesccessecsaseeseccsseeeensaaesecseseeensaseseecesseeasseeeeeesens 19 Chapter 3 Training of Physicians Nurses and Support StafF cscsssssssssessssssessscsssessssssessssesescscsesesesesererars 20 Ongoing Trainin Gosses eaa ethic lead eveedesdleeedadesass sabes latssscodase ieee A Eaa aai EEE aE EEEa NEERA EA KEREKERE EE 20 Chapter 4 Inpatient Ambulatory Workflow Perspectives 2 ssscsscssesssssssssssssscessescscess
221. natures Empower Launcher Shortcut o Locate the Empower Launcher link on the server within the ECDS shared directory o Copy this link shortcut to the local workstation into the All Users desktop By using this shortcut the most current version of Empower software will be automatically updated Empower Certificate o Locate the file Empower Certificate spc on the server within the ECDS shared directory Right click on Empower Certificate spc and choose INSTALL Choose NEXT Click Place all certificates in the following store Choose Trusted Root Certification Authorities Click OK NEXT and FINISH O O 0 0 0 L When the Empower software is run for the first time it will ask about the security certificate Please select the check box to install the certificate It will never ask again for that workstation 18 empowerlnpatient Ambulatory The certificate is a security feature for any software that runs VBA code in order to insure that the code is from a secure source and has not been modified by a virus or other source If the inpatient users all have unique network logins then installation of the certificate to all users at once is more challenging The simplest method to accomplish the installation is to install the certificate and all other settings described above for a default user profile Then copy the entire profile including all associated files to the default profile then delete the user ac
222. ned Patient Location 4 2 is Admissiontype 000 5 20 CX jPradmtNumber 0000 6 80 PL PriorPatient Location 7 60 xcN Y Attending Doctor S 8 60 xcN Y ReferringDoctor 9 60 XN Y ConsultingDoctor 10 3 IS Hospitalsevice o 11 80 PL Temporary Location 12 2 IS jPreadmitTesindiato 13 2 IS jReadmisinindiatr 14 3 IS AdmitSource S 15 2 IS Y Ambulatorystatus 16 2 IS VIPindicator S S 17 60 XcN Y Admitting Doctor J S 18 2 IS jPaien yp 0 19 20 CX jViitNumbr o 20 50 FC Y FiandalCass 21 2 IS Charge Price Indicator 22 2 IS CourtesyCode S 23 2 IS CreditRating o 24 2 IS Y Contractcode 0 0 25 8 DT Y Contract Effective Date o 26 12 AM Y ContractAmount S 27 3 NM Y ContractPeriod o 28 2 IS interestcode 0 117 empowerlnpatient Ambulatory SEQ LEN DT OPT RP ELEMENT NAME NOTES 33 1 S T Transfer to Bad Debt Code 30 8 bT _ TransfertoBadDebtbate CS 31 10 ts BeDekAgnyCode 32 az NM _ BadDebr Transfer Amount 33 i2 NM _ BadDebtRecovery Amount sa a s Delete Accountindicator S 35 8 br De eteAcoutDte S 36 s s _ Dis
223. ness Associate Agreement in Appendix 2A The hospital should provide Ambulatory users with a business agreement also 17 empowerlnpatient Ambulatory Empower Inpatient Workstation Setup Windows XP Workstations vs Windows 2000 Windows 2000 requires MDAC 2 8 or newer to be installed whereas Windows XP has this built in by default Note The local workstation must have read write modify access to a C Empower folder The launcher will create and use this as long as the logged in user has permissions to create write to that directory Please complete the following while logged in as an administrator m Access 2003 or 2007 Runtime or Access 2003 or 2007 and no other installed version of Access which is available on the original full Office 2003 CD in the directory cdrom FILES ACCRT ACCESSRT MSI Adobe Acrobat Reader for printing pre printed discharge instructions only o Immediately after installation please launch the Adobe Reader This will prompt the license screen for acceptance Please click accept If the Accept button is not clicked then in the future the license pop up will not be visible behind the Empower Inpatient Ambulatory program and hence it will appear as though the system is not responding when in fact the system is waiting for a response to the pop up All client workstations must have MS Paint installed or some graphics program that is considered an OLE Server in order to print sig
224. ng Agency or temporary staff needs only a brief 15 30 minute in service Empower provides on site training for SuperUsers These administrative users then train all nursing and ancillary staff Physician training is provided by Empower via web based sessions in an effort to accommodate physicians limited schedule availability Physicians can join their scheduled session from any location with internet access and a phone connection The hospital is responsible for scheduling physician training segmented in 90 minute sessions While more than one physician can be trained at once we recommend no more than a 4 1 ratio On site SuperUser training will be scheduled during the implementation process and is coordinated between the project managers It is recommended that a training environment computer lab is available with a maximum computer to trainee ration of 1 2 After scheduling the Empower Go Live and training sessions these dates cannot be altered without the hospital incurring a significant expense SuperUsers will be identified and instructed on the process of maintaining and creating new user accounts in Empower These SuperUsers should be able to capture physician signatures via Tablet PC for input to Empower If the hospital would prefer Empower to load all physician signatures this can be accommodated at a standard billable rate provided a completed Physician Electronic Signature Form Appendix 3D accompanies the request If physician sign
225. ng a specified date time range Dispositions could include main ED discharges and admissions and other areas such as fast track discharges and admissions Performance statistics can be calculated for each category with the exception of Left Without Being Seen Registration Error and No Disposition 54 empowerlnpatient Ambulatory Disposition Aggregates e DispoType The disposition category such as admit discharge or transfer e DispoTypeCount The total number of patients counted in that category e Exclusions The total number of patients whose data was not considered due to either manual exclusion or automatic exclusions e LengthOfStay HrsMins The average length of stay for patients in a specific category expressed in hours and minutes e Triage HrsMins The average length of time from the point that the Empower chart was started to the point that the triage note was started expressed in hours and minutes e ExamRoom HrsMins The average length of time from the point that the Empower chart was started to the point that the patient was assigned to an exam room e DoorToMD HrsMins The average length of time from the point that the Empower chart was started to the point that the MD begins the patient assessment e MDToExamRoom The average length of time from the point that the patient is placed in the exam room to the point that the MD begins the physical exam e Dispo HrsMins The average length of time from the point that the
226. nitor Glucose monitor Glucose monitor MAGNESIUM PHOSPHOROUS COMPREHENSIVE METABOLIC PANEL B TYPE NATRIURETIC PEPTIDE PT PTT CBC W AUTO DIFF CULTURE URINE Glucose monitor BUN LYTES NA K CL CO2 B TYPE NATRIURETIC PEPTIDE CREATININE PT 12935 South Gregory Street Blue Island IL 60406 2428 Admitting Admitting Weight Height 85 7kg Gender Race Insurance PATHREVIEW Reviewed and approved by Dr A Handelsman Pathologist IFEINT No monoclonal proteins identified SPEINTERPT Serum Protein Electrophoresis shows an essentially normal electophoretic pattern IGM 63 IGA 262 IG G 1810 GAMMA 1 65 BETA 0 82 ALPHA2 0 73 ALPHA1 0 27 ALB 3 33 TPROT 6 8 NA 142 K 4 1 CL 107 CO2 25 BUN 48 CREAT 1 62 GLUCOSE 189 GFR 41 4 AGAP 10 BUNCR 30 CA 8 7 BGM 115 BGM 291 BGM 193 MAG 1 5 PHOS 4 3 NA 146 K 4 1 CL 109 CO2 24 BUN 46 CREAT 1 55 GLUCOSE 131 AGAP 13 AG RATIO 0 9 BUNCR 30 GLOBTOT 3 6 ALB 3 1 TPROT 6 7 CA 8 8 ALT 18 AST 33 ALKPHOS 54 GFR 43 6 TBILI 1 4 BNP 1429 PTT 42 0 INT 3 30 PT 37 8 WBC 4 7 RBC 5 24 HGB 15 0 HCT 45 3 PLTCT 146 MCV 86 5 MCHC 33 1 COMMENT10 slt enlarged plt RBCMORPH Slight Anisocytosis Polychromasia Poikilocytosis Burr Cells Spherocyte Target Cells Schistocytes MANDIFFDONE Man diff not indicated BASOS 0 3 E0 2 4 MONOS1 10 3 LYMPH 20 1 NEUTRO 66 9 MPV 9 5 RDW 21 8 MCH 28 6 Specimen Urine Cath Collected 05 24 2011 14 00 Status Final Last Updated 05 26 2011 11 33 C
227. npatient Ambulatory gums old eel 1 Ml LL 39 a aM A i5 1 dd Ce 2523 a Le 2 em O Pasman J ail A 5 nt KE pev penati a remise SSE ILGNNEE 24 NEAN Pep E Save PS di Ce oso NN d B LIZLGLNENNS ui Se E CCLXLILLGUN dd CONWHRRHM JIIINNNNS di oo NICE ud icAGCULZN Bows PP ESV LLL BL QOEZZZNNE i ZLIIIZIZNI S FRE ES d LO aaa JEE d i i35 CS dH IOCLONNNNMSO a dil A 5 Eeron E ouneoreeon cs pea a Gd CC uua SL dd INNNNNENN uuu KE ud IILILILIUNN E d or 1 d co A ull Se Maximum Number of Passwords Kept Able to store 5 total or for a 12 month period whichever occurs first Click in Pabent s Last Name to access Patient s Chart Asy Patient Name MD Attending RN Disposition a E ci CS SS ICIICNNEE GNI NN a dA C RM T OCIZONNEN d a i P CLLLNNEN P MATCHER PHYLLIS a dication Reachon 7 LINE u A d SDIDONNNN E ai Pourvess creme IS ab Se E PE SS dd CS Ss d ILLLLXLCONE Force Password Change Based on Time Parameters Can require users to update their password every 180 days 44 empowerlnpatient Ambulatory Maximum Number of Login Attempts Before Access Blocked Can set this to 5 attempts El Enipont Table tator thiluApplicationSettings Wehcaegoy vchSelingName v SY FRONTEND X sccountLockAttempte number of failed Auto Lock Account after Predetermined Time Period For example 15 minutes Require User to Change Password Upon Resets This can be s
228. nt Moisture 4 Rarely Moist Activity 2 Chairfast Mobility 4 No Limitations Nutrition 3 Adequate Friction and Shear 3 No Apparent Problem Total Score 19 or more No interventions needed at present continue to monitor 05 26 2011 8 21 PLAN OF CARE Nursing Serial DAILY INTERDISC PATIENT FAMILY EDUCATION POC White RN Carina Special Learning Needs No special learning needs identified Educational Need Medications Readiness to Learn Accepting Attentive Teaching Method Explanation Discussion Response to Teaching Follow up needed plan Patient Family taught the following discuss filuid restriction upon discharge monitor kidneys and blood count for coumadin 05 26 2011 8 24 PLAN OF CARE Nursing Serial DAILY INTERDISCIPLINARY POC White RN Carina Care Plan per Care Path Protocol gt possible discharge in today KNOWLEDGE INT See Interdisciplinary Patient Family Instruction Form gt DISCHARGE PLANNING INT gt pending for today SKIN INT Monitor skin integrity gt dry and intact PAIN INT Monitor pain using pain scale gt denies O2 therapy gt roomair Elevate HOB gt 30degree Assess mobility gt u p as lib chair Assess transfers can transfer self Assess gait gt steady Metro South Medical Center 12935 South Gregory Street Blue Island IL 60406 2428 708 597 2000 Patient Name Allergies nka 05 26 2011 8 25 05 26 2011 8 27 05 26 2011 8 28 05 26 2011 8 35 05 26 2011 9 50 05 26 2011 10 43
229. nt MedRecon 23 1 1 5 1 0 9 s MUAM Inpatient Patient specific education OWM o 2 1 4 6 MUAM Inpatient Patient summary record 25 tO MH MUAM Inpatient Record Demographics Oa MH MUAM Inpatient Smoking status 22 1 1 OBa se amp b y o MUAM Inpatient Uptodateproblemlist 24 1 1 1 1 2 1 se 1 Jg MUAM Inpatient Vitals BMI Growth Chats o 24 1 1 1 1 12 1 e A MU Threshold Ambulatory Report Name Eligible Instances Meets Performance Instances Performance Rate 60 empowerlnpatient Ambulatory Chapter 10 General User Manual This is an overview of how information is captured within Empower Inpatient Ambulatory in order to provide perspective to users whose primary purpose is acquiring information from rather than entering information into the Empower system INTRODUCTION The Empower InpatienttAmbulatory computer documentation system was created by clinically experienced physicians and nurses The program merges technological information with medical information to create a real time documentation system that improves communication and enhances patient flow Empower has been recognized in the past as a success story and role model by the Joint Commission and we continually monitor and adopt the changin
230. nt No needs Medical equipment No needs Nutrition Diet No needs Rehabilitative techniques No needs Community resources No needs Personal hygiene grooming No needs ASSETS BARRIERS TO PLAN OF CARE assessed as follows Does patient have previous experience or knowledge related to reason for this hospitalization Asset Good knowledge base on diagnosis Patient emotional relational support system Asset Good support system in place with family friends Hearing Asset Normal hearing or corrected with hearing aides Vision Asset Has normal vision or has corrected vision Language Asset Speaks and understands English Physical Asset Describe Cognition Mental status Barrier Describe aox2 Cultural Religious No barrier Does patients appearance demonstrate poor hygiene malnutrition and or dehydration No Does patient appear frightened or intimidated in the presence of caregiver No Does the patient have unexplained bruises lacerations abrasions burns head injuries sprains or fractures No 05 23 2011 16 47 ADMISSION Nursing Admission REFERRAL ASSESSMENT Burge RN Patricia Lives alone or with non capable caregiver and needs post acute care No Currently uses home care devices No Lives in a nursing home or imtermediate care facility No New CVA diagnosis No New CABBG dignosis No Patient in foster care system No Active substance abuse confirmed by tox screen No Drug overdose Attempted suicide No Unidentified patient No Un
231. nt s central venous access device continues to be necessary due to N A Nursing Serial SHIFT WOUND ASSESSMENT rev 05 06 10 WOUND ASSESSMENT No wounds at this time no further assessment needed TOTAL NUMBER OF WOUNDS N A no wounds present upon assessment EQUIPMENT Pressure relief mattress WOUND ASSOCIATED PAIN N A WOUND TREATMENT N A Nursing Serial SHIFT NURSING ASSESSMENT rev 11 04 10 Transmission Precautions Standard O2 Type Liter Flow Room Air Rhythm Strip Interpretation Atrial Fib LOC Awake Alert and Oriented x 3 Affect Calm and cooperative Eye Opening 4 spontaneous Verbal Response 5 Alert and Oriented X 3 Motor Response 6 obeys commands Pupils equal and reactive Ability to Move right arm strong Ability to Move right leg strong Ability to Move left leg strong Ability to Move left arm strong Skin Color Normal Skin Temperature warm Skin Moisture Dry Skin turgor non tenting Respirations Even and unlabored Breath Sounds Right Clear Breath Sounds Left Clear Retractions Intercostal Abdomen Round soft ascites Bowel Sounds Active x 4 quadrants Pedal Edema Right 1 plus Mild 0 1 4 inch Pedal Edema Left 1 plus Mild 0 1 4 inch Pedal Pulses Right 1 plus Barely palpable Pedal Pulses Left 1 plus Barely palpable blood sugar 64 Patient asymptomatic Patient given apple juice with sugar and sandwich Will monitor Dr Amin notified of accucheck Orders received and initiated Accucheck 140 Nurs
232. nter medication single click on the first empty row The new window called Intake Documentation opens Empower will automatically time stamp but this can be changed if needed by clicking in the box The Medicine Device Type is the name of what is given This is a dropdown menu with no free text Dosage Rate is for infusion therapy IV Route Site is how the medicine is given Amount is free text with the unit type after Residual is any amount wasted The comments section is the area where site lot number and expiration can be documented Demographics This button will open a window with different tabs If the ADT Interface is active it should be populated The information can be entered manually Demographics Demog ra ph ics Patient Name Age Gender Race Insurance Weight Medical Record Acct Number Blue Cross Blue Shielc 11 06 1953 100 KG kg 000632325 12312312 Allergies IVP dye Shrimp Erythromycin Acetominpohen w Codiene Morphine Food allergy specify Admission Patient information Insurance Person To Notify Next Of Kin Guarantor Account Number Medical Record Admit Date Admit Time EMR MD Primary Care MD Admit Staff po0632325 Jenson amp 28 emn OO 1 guwemensehRN Reason For Visit MN Visit Dx Eough Other Doctors Leedy Steve Comments Admissions This tab will give information about PCP Consults and reason for the visit Patient Information As noted by
233. nternet Access Remote Software connection Only MS Remote Desktop or PC Hospital Anywhere and with Logins and Passwords Status ME E MEE un mE REM s E NEN p E p NE p EmpowerSystems Software Installation Test and Live Install EmpowerSystems EmpowerSystems 129 empowerlnpatient Ambulatory P sta mpowersystems Table ecitor OO Empowersystems sst mpowersystems Complex Report Writer Empowersystems Install and Tests Emailing Software to PCP Email Optional EmpowerSystems Accounts Pe Test Automatic EmpowerSystems Pager EmpowerSystems EmpowerSystems Table Building EmpowerSystems will Order Diagnostic Tests using CPOE Charge Capture EmpowerSystems hospitals mnemonics EmpowerSystems will identify the correct Diagnostic Diagnostic Results Table EmpowerSystems Results using the hospitals mnemonics Phase Ill Testing Training and Technical Readiness EmpowerSystems i EmpowerSystems Discuss Workflow Issues on Site Evaluation SF 2 EmpowerSystems Determine Nurse Onsite Training Dates SE Send Nurses Training Power Point Presentation Starter EmpowerSystems Kit SF 2 D EmpowerSystems Choose Physician Internet Training Dates SE Send Physician Training Power Point Presentation Starter EmpowerSystems Kit SF Training Nurses Hospital Coordinate and schedule Nurse EmpowerSystems Training SF T
234. oSouth Medical Center 12935 South Gregory Street Blue Island Illinois 60406 CONSULTATION MR NN ACCT DATE OF BIRTH DISCH HEN PT ADMIT DATE 05 23 2011 CONSULTANT SALVATORE VENTURA M D ATTENDING ZAFAR AHMED M D DATE OF CONSULTATION 05 24 2011 REASON FOR CONSULTATION I am asked to see this patient by Dr Harris for evaluation of elevated creatinine concentration HISTORY M oe TTT woman with long standing nonischemic dilated cardiomyopathy She was admitted to MetroSouth Medical Center Hospital for evaluation of increasing abdominal girth increasing leg swelling and shortness of breath Her symptoms were complicated by one episode of syncope one week prior to the admission Upon admission she was found to have severe hypoglycemia and this is being corrected with adjustment of her diabetic medications and with administration of IV sugar BE denies prior history of renal disease or nephrolithiasis She does not have flank pain gross hematuria dysuria nor urinary incontinence However review of computer records indicates that her creatine concentration measured between 1 3 and 1 5 mg dL during the last year It measured 1 33 mg dL on 05 05 2011 Today it measures 1 8 mg dL PAST MEDICAL HISTORY 1 Hypertension for 10 years 2 Non insulin dependent diabetes mellitus for one year 3 Hyperlipidemia 4 ICD implant in 2000 replacement on 05 13 2010 5 Paroxysmal atrial fibrillation 6 Mitra
235. ocumentation system was created by clinically experienced physicians and nurses The program merges technological information with medical information to create a real time documentation system that improves communication and enhances patient flow Empower has been recognized in the past as a success story and role model by the Joint Commission and we continually monitor and adopt the changing Joint Commission standards in order to ensure continuing compliance The system also ensures compliance by prompting the physician or nurse at various HCFA mandated junctions electronically applying the physician s signature and ensuring follow up by faxing the chart to the primary care provider or specialist s office The program is dynamic and flexible and can be customized to the needs of various physicians nurses and inpatient ambulatory settings Empower is also an inexpensive alternative to costly transcription or verbal documentation This program unlike others is not template based but rather is based on a single free formed chart that is populated by the physician s or nurse s description of the patient s history physical exam diagnostic tests medical orders and clinical summary to provide an accurate EMR or electronic medical record The Empower chart reflects the company s philosophy of One Patient One Chart One Database There is no need to collate several separate charts or pieces of charts into one record at the end o
236. omyopathy EF 10 N A HCCI and renal on the case Severly depressed EF w massive vol overload On dobutamine dose changed noted Lasix increased by Dr Ventura d c IV fluids switch D5 to D50 prn Possible paracentesis therapeutic if discomfort increases even with appropriate diuresis which I don t expect to have a significant effect on her ascites volume Possibility of HD there as raised by Dr Ventura Acute Renal Failure N A previous Cr 1 2 1 38 US noted Some kind of underlying CKD w superimposed ATN sec to extremely depressed EF likely CKD w u by renal noted SYNCOPE AND COLLAPSE 780 2 symptomatic hypoglycemia Cont to have sugar issues D50 prn as above accuchecks q 4 hrs Awaiting interrogation to r o ventricular event HCCI on the case Hypoglycemia in diabetic unspecified 250 80 as above plus PO intake encouraged Nursing staff to assist pt w feeding HTN 401 9 Hypercholesterolemia 272 0 DM N A Weakness Nos 780 79 PT OT Other Medical Orders Additional Comments accu Checks q 4 hrs Nursing staff to assist pt w feeding Metro South Medical Center 12935 South Gregory Street Blue Island IL 60406 2428 708 597 2000 Admitting Admitting Patient Name Age DOB Gender Race Insurance Weight Height Medical Record Account i u 080 85 7kg 175 260 i NEIN Allergies nka Room 4S0 421 01 cbc cmp magnesium pt ptt inr in am warfarin pharmacy to dose N A Electronically signed and authenticated by the Fol
237. on This table lists the options in the history for duration of symptoms tblluPhysExacerbatingFactors This table list the options in the in history for symptoms exacerbation and improving factors tblluPhysExtrAppearance This table lists the options in the physical exam for extremity appearance tblluPhysExtremityLocation This table lists the options in the physical exam for identifying a particular area on the extremity tblluPhysExtremityPulses This table lists the options in the physical exam for extremity circulation tblluPhysExtremityROM This table lists the options in the physical exam for extremity range of motion tblluPhysExtrPain This table lists the options in the physical exam for extremity during palpation tblluPhysExtrSubLocation This table list the options in the physical exam for identifying a specific area on the extremity tblluPhysFrequency This table lists the options in the in history for symptom frequency tblluPhysGeneralAppearance This table lists the options in the physical exam for general appearance tblluPhysGU This table lists the options in the physical exam for genital area tblluPhysHEENT This table lists the options in the physical exam for Head Eyes Ears Nose and Throat tblluPhysInterventions This table lists the options in medical interventions for medical orders tblluPhysIVF This table lists the options in m
238. on assessment EQUIPMENT Pressure relief mattress on bed WOUND ASSOCIATED PAIN N A WOUND TREATMENT N A Admitting Admitting Patient Name Age DOB Gender Race Insurance Weight Height Medical Record Account a mm umm oc eum 0 857 1752600 M IN Allergies nka Room 4S0 421 01 05 24 2011 8 38 OCCUPATIONAL Occupational Therapy Inpatient Evaluation Barder OT Jennifer THERAPY Compensatory strategies for safety practiced in ADL activity Yes Reason for referral Weakness PRIOR LEVEL OF FUNCTION Independent ADL s prior to admission pt lives with husband Precautions cardiac safety Subjective I feel unsteady OBJECTIVE ADL Feeding Modified independent Toileting Standby assist UE Dressing Standby assist LE Dressing Standby assist UE Bathing Standby assist LE Bathing Standby assist Grooming Standby assist Functional Communication Able to communicate needs Splinting Adapted Equipment Per pt she was not using a device PTA Recommend a tub transfer bench with back rest for home use Assessment This 62 y o female presents with general weakness decreased ADL skills decreased BUE strength decreased balance with transfers and mild decrease in endurance Pt was cooperative during initial eval and would benefit from OT to improve overall strength and ADL skills Goals 1 Pt will practice gentle AROM exs for ADL needs 2 Pt will demonstrate clothing retrieval from closet 3 Pt will demonstrate energy conservation techniq
239. ons and hospital supplies in the primary nursing note The RN LOS can be adjusted to reflect a hospital s approach to coding conservative middle of the road or aggressive In all approaches to coding the documentation will support the RN LOS CD 9 Codes will be applied to all Diagnosis when the physician chooses directly from the EmpowerSystems look up tables If the physician enters a diagnosis by free texting in the field then no ICD 9 code will be applied 35 empowerlnpatient Ambulatory Clinical Examples of Nursing LOS with Automated Coding 24 year old male presents for medical clearance after MVA Patient has no complaints Patient is triaged and there are no other nursing interventions Patient is discharged home e55 year old male has pain on urination Patient is triaged urine collected and sent to the laboratory Patient is discharged home with a prescription and diagnosis of Urinary Tact Infection 17 year old female presents with ankle pain after a fall RN Intervention Urine Collection for Pregnancy Test X Ray Short Leg Post Mold and Crutches Patient is discharged home with a prescription for pain medication with a diagnosis of Ankle Avulsion Fracture 4 month old boy presents with fever of 104 RN Intervention IV Insertion Blood Collection Urine Collection and Anti Pyretic PO Patient is discharged home with a prescription for fever with a diagnosis of Viral Syndrome 55 year old male Diabe
240. ons in the triage I history for the immunization history tblluTriagelnfectious This table list the options in the triage history for the patient infectious disease assessment tblluTriagelntervention This table lists the options in the triage Ill for the patient fall assessment 145 empowerlnpatient Ambulatory tblluTriageLivingConditions This table lists the options in the triage III for assessment of how the patient lives tblluTriageMedDetaillnfo This table list the options in the triage history for how the medications arrived at the hospital tblluTriageMeds This table lists the options in the triage history for home medication tblluTriageNutrition This table lists the options in the triage Il physical exam for nutritional assessment tblluTriageOBLabel This table list the options in the triage history for pregnancy assessment tblluTriagePainScale This table list the options in the triage I history for pain assessment tblluTriagePlan This table lists the options in the triage III for the disposition plan tblluTriagePsychStatus This table lists the options in the triage Il physical exam for general appearance tblluTriageSkinColor This table lists the options in the triage II physical exam for skin color tblluTriageStaffStatus This table list the options in the triage history for the physician assessment on the medical staff
241. options in the triage history for allergy to medication animals etc tblluTriageArrivalMode This table list the options in the triage history for the patient mode of arrival to the hospital tblluTriageAssesment This table list the options in the triage history for the patient assessment and acuity tblluTriageAssessedDisability This table lists the options in the triage Ill assessment of disability tblluTriageComaEye This table lists the options in the triage Il physical exam Glasgow coma sale eye opening tblluTriageComaMotor This table lists the options in the triage Il physical exam Glasgow coma sale motor function tblluTriageComaVerbal This table lists the options in the triage Il physical exam Glasgow coma sale verbal function tblluTriageDailyLiving This table lists the options in the triage Ill for assessment of daily living needs tblluTriageExtrPulses This table lists the options in the triage II physical exam for extremity circulation tblluTriageExtrROM This table lists the options in the triage II physical exam for extremity range of motion tblluTriageGoingHomeWith This table lists the options in the triage Ill for assessment of the patient transportation home tblluTriageHistorian This table list the options in the triage history for the person providing the medical information on the patient tblluTriagelmmUTD This table list the opti
242. or of 22nd Annual Fairway to Health Golf Tournament May 31 Empower Systems to Exhibit at 2nd Annual Southeast Regional CAH Conference May 31 Empower Systems d Exhibiting at Healthcare Trade Faire amp Regional Conference May 31 Wireless Technology Prevents Medical Errors May 31 Studies Tout Benefits of Electronic Prescribing But Adoption Is Slow E Home View Tickets Submit a Ticket Knowledgebase News EL LEE English U S You will be taken to a page with a list of all the tickets that you have submitted If you are an Empower support administrator which most users are you will see all tickets submitted from your hospital 165 empowerlnpatient Ambulatory You can click on the ticket number to open the text of a particular ticket You can also click on the headings at the top last update last replier status priority department to sort by that field empowersyustems 31 May 12 1 Support Center Ticket List 7 M ea gt My Account Logout Listed below are the tickets you ve submitted in the past Click on a ticket s subject to view the ticket and its history Logged In Empower Test Client 8 My Account By Change Password i Search Entire Support Site Die 2 14652 I Need Assistance on Submitting a Non Emergent Ticket 31 May 2012 12 26 PM Empower Test Client 1 14651 my computer is slow
243. or vice versa depending on preference 55 empowerlnpatient Ambulatory e Disposition The disposition type that the record was assigned based on the actual disposition e LengthOfStay The length of time from the point that the chart was started to the point that the chart was printed expressed in hours and minutes e Triage HrsMins The length of time from the point that the chart was started to the point that the patient was triaged expressed in hours and minutes e ExamRoom HrsMins The length of time from the point that the chart was started to the point that the patient was placed in an exam room e DoorToMD HrsMins The length of time from the point that the chart was started to the point that the MD documented the patient s physical exam e MDsStart HrsMins The length of time from the point that the patient was placed in an exam room to the point that the MD documented the physical exam e Dispo HrsMins The length of time from the point that the MD documented the physical exam to the point that the MD documented the disposition e MDkFinish HrsMins The length of time from the point that time the MD documented the physical exam and the point that the MD sets the chart ready to print e Print HrsMins The length of time time from the point that the MD set the chart ready to print to the point that the chart is actually printed e Include and Exclude Data can be manually included or excluded This does not alter the record in
244. order to identify any gaps in the documentation This is because the charges are identified by the documentation of items and procedures using the Empower lookup tables and if documentation of these items in the tables is poor then the cost benefit ratio of the automated charge capture may be determined by the hospital to be too low to justify its use Empower requires that the Registration Diagnostic Results and Order Entry interfaces to be built prior to Go Live Registration ADT There are three options for the registration interface each of which has a different impact on the registration and triage workflow Registration Interface design and workflow options are listed below in order of recommendation 1 A short registration is completed in the hospital registration software which creates an Empower chart through the interface which is then followed up with full registration 2 All patients are registered with a short form in Empower and the interface passes that information to the hospital registration software and assigns an account number 3 Patients are registered separately in Empower and hospital registration software Empower provides a unique patient identifier The Registration Clerks then enters that unique patient identifier in a designated field on the patient chart which allows the interface to synchronize the Empower patient record with the hospital registration software This is not recommended due to the high failure
245. orders or order sets When all desired Diagnostic and Medical Orders have been added click Save and Close If the hospital does not have an order interface the designated staff will then enter those diagnostics into the core system Disposition This is found on the Assessment Plan Medical Orders screen at the bottom Disposition and Condition must be selected from the drop down box For admissions enter the name of the admitting physician which can be selected from the list Notifications This is also found on the Assessment Plan Medical Orders screen Click the gray button to bring up the Notifications screen and select a doctor from the list or free text the name of the admitting physician This will auto populate a statement regarding the notification of admission discharge or referral si Poe MD John Discussed Relevant Hx Exam Diagnostic Evaluation amp Disposition Agrees c Plan 6 8 2007 12 58 00 PM 102 empowerlnpatient Ambulatory Discharge Instructions e Discharge Instructions can be accessed from any screen The practitioner is required to select an Assessment Diagnosis The initial Subjective complaint appears as the initial diagnosis but the physician must then choose a diagnosis that reflects the results of the diagnostics e The follow up physician can be selected from the list or alternatively the Add Edit can be used to enter a physician that is not on the list e Additional instructions can be add
246. ort Software Purchasing This is a time intensive task which can delay the entire implementation if not undertaken early so we recommend that this step occur on a parallel path with other Empower timelines If the Inpatient Ambulatory Departments are unable to purchase these items the Empower Project Manager may purchase and install these items with payment terms detailed at that time Inpatient Ambulatory IT Responsibilities Empower software can be connected and configured in about 1 week once provided with high speed internet access After this the hospital IT staff copies the Empower software the Empower launcher onto each client computer The Empower Inpatient Ambulatory software will reside in a shared folder on the hospital network Each client computer must be configured to login to the hospital network and to print the chart on a laser printer in the appropriate work station empowerlnpatient Ambulatory Establish a Go Live Date The Empower Go Live date a k a First Product Usage or FPU serves as a rallying point for all parties involved to establish both milestones and deadlines Once a Go Live date is designated it should not be changed Hence it is crucial that all parties adhere to the timeline PHASE II Application Development Hardware and Software Configuration Setup The hospital IT staff is responsible for operating system and support software installation and system connectivity Once Empower has been pro
247. ory Patient Roster Patient Roster Click in Patient s Last Name to access Patients s Chart Click in Patient s First Name to remove the patient Name Search MD Search ee Exam Appointment Time Time In Complaint New je xecuted New LastName FirstName Age Gender Established Room Appointment Status Office Messages MD Name Disposition Orders HIBBETT BABY ue F 08 27 2010 LATE 6420 01 Well Baby Check Rube Steven H E 8 00 N Patient Name appears on the tracker when generated by the ADT interface or by using Add a Patient Age as entered when date of birth entered by the ADT interface or by using Add a Patient Gender as entered by the ADT interface or by using Add a Patient New Established is populated by clicking on the box once Exam Room is populated by clicking in the box once Appointment Time Appointment Status is entered by the ADT interface or by clicking in the box Appointment Status only Time in Office is calculated in minutes from the time that the patient is placed on the Roster 91 empowerlnpatient Ambulatory Complaint Message is free texted by clicking on the box MD Name uses a dropdown menu to identify the name of the doctor caring for the patient Disposition is entered by the doctor on their documentation screen and crosses over to the tracking board Orders displays an orange box with a letter N when new orders are entered When the order has been comple
248. ospital policy For UC ED Tech see hospital policy to be determined Document nursing note change time change date add note in Nurses Notes within scope of job description Document consulting physician notifications View scan and delete scanned documents View physician assessments and old records Print copies of orders for ancillary RN and ED use med pharmacy orders Demonstrates use of bed manager 135 empowerlnpatient Ambulatory Appendix 3C Empower MD Skills Verification Trainee Name Training verified by Date Login amp Tracking Board Medical Interventions L Log In and Change Password L Standard Order Sets L Name appears in lower left corner L Ordering Diagnostics in Medical Interventions Review Tracking Board Verbal orders Orders entered by nursing Gray buttons L Coding impact Room number sort QO L Adding initials L Avoid free text if able L Sort by initials 0 Acknowledging verbal nursing orders L Sort by Exam Room L Print Nurses Orders Consider CPOE L Nand E for UBERM L Medication Allergy Alert U R DandC LL Medication Interaction Alert L Viewing Labs Lacerations and Other Procedures QO QO L IV infusion time Select Patient 0 Choosing from lists only L Chief Complaint must select from the list Notifications L Social History L Trauma requirement L Use of lists the art of scrolling
249. ow are the various triggering events and segments that include data that will be sent from Empower This subset of HL7 segments is offered only to show which segments are important for this implementation 113 empowerlnpatient Ambulatory Message Definitions General Order Message MSH Message Header PID Patient Identification ena PV1 Patient Visit L1 g i Inbound Results The Inbound Results interface will receive HL7 2 2 or 2 3 ORU messages from the Interface Engine and will store clinical data necessary to perform the Results Viewing functions of Empower The Inbound Results interface will accept the following message trigger events Trigger Events RO1 Unsolicited Transmission of an Observation Although the Inbound Results interface is HL7 2 3 compliant some segments and fields will not be used for this interface implementation Listed below are the various triggering events and segments that include data that will be stored in Empower This subset of HL7 segments is offered only to show which segments are important for this implementation The Inbound Results interface can accept messages that contain any segment listed in the HL7 2 3 standard Message Definitions Unsolicited Transmission of An Observation MSH Message Header ub 114 empowerlnpatient Ambulatory Outbound Charges The outbound charges interface sends real time charges information to a Billing System Empower SQL Server Interface En
250. ower recommends each hospital clinical unit ICU Telemetry Labor amp Delivery Emergency Department Pediatrics etc designates a clinical administrator and an IT database expert to attend on site training for the Empower Report Alert Writer This combination of clinical and technological expertise will assist both parties in mastering program functionality In order to be proficient with the Report Alert Writer the hospital staff will need a basic foundation of SQL Server names and functions as well as Empower s database table structure The SQL or Structured Query Language has a special purpose in programming language designed for managing and displaying data in relational database management systems Prior to receiving web based or on site training we recommend attendees read the publication Teach Yourself SQL in 10 Minutes 3rd Edition Training Options Standard Introduction Each Empower hospital receives 1 hour of complimentary web based product demonstration and general training Additional training is recommended in order to maximize use of the Report Alert Writer On Site Sessions Hospitals can purchase on site training sessions for 5 person groups of clinical administrators and IT staff led by Empower Report Alert experts On site training delivers impactful results as clients receive hands on experience with the product and detailed guidance by our experts The 12 500 fee for this option includes five 5 busin
251. per Bayless RN Michel 05 23 18 37 Secretary Completed AHMED ZAFAR MD Nitroglycerin gr1 150 sublingual as needed may Bayless RN Michel 05 23 18 37 Secretary Completed repeat x 3 every 5 minutes if systolic BP more than 90 per AHMED ZAFAR MD Sonata 10mg oral as needed at bedtime for sleep if Bayless RN Michel 05 23 18 37 Secretary Completed under age 65 and over 50kg reduce dose to 5mg if over 65 or under 50kg per AHMED ZAFAR MD Tigan 200mg Intramuscular every 6 hours as needed Bayless RN Michel 05 23 18 37 Secretary Completed for nausea per AHMED ZAFAR MD GENERAL NURSING ORDERS per AHMED ZAFAR MD Bayless RN Michel 05 23 18 37 Secretary Completed Obtain vascular access with PIVL and flush per Bayless RN Michel 05 23 18 37 Secretary Completed protocol per AHMED ZAFAR MD Daily weight every morning and record per AHMED Bayless RN Michel 05 23 18 37 Secretary Completed ZAFAR MD Oxygen at 2l minute titrate as needed per AHMED Bayless RN Michel 05 23 18 37 Secretary Completed ZAFAR MD Record Intake and output every shift per AHMED Bayless RN Michel 05 23 18 37 Secretary Completed ZAFAR MD Bedrest with BRP per AHMED ZAFAR MD Bayless RN Michel 05 23 18 37 Secretary Completed Continuous Cardiac Monitor per AHMED ZAFAR MD Bayless RN Michel 05 23 18 37 Secretary Completed Notify Physician if no relief after first 2 doses of NTG Bayless RN Michel 05 23 18 37 Secretary Completed for acute chest pain per AHMED
252. perating Systems Software Windows XP SP2 with Windows Paint installed so graphic filters are functional on workstation for viewing scanned documents Additional Software Microsoft Access 2007 Runtime free This can be modified based on Terminal Server infrastructure as chosen by client Additional Software Adobe Acrobat Reader version 7 or newer free Virus Software Anti Virus Software hospital standard The majority are basic recommendations Requirements are noted as such Empower supports a large variety of hardware software configurations and hospital office size and volume may dictate changes needed in specifications Hardware amp Third Party Software Empower Systems does not recommend a hardware vendor or provide hardware to Hospital Hospital is responsible for the purchase installation and maintenance of any hardware required for the product Empower Systems does not recommend any third party software except for software listed on Hardware amp Support Software Specifications above empowerlnpatient Ambulatory Backup amp Anti Virus Software Empower Systems does not recommend a backup vendor or provide backup software to Hospital Hospital is responsible for the proper backup of critical dictionaries files and point to point interfaces Hospital is responsible for properly restoring backup files in case of a system error or crash Empower Systems does not reco
253. r 4 E View Tickets E Submit new tickets view existing tickets or create new replies Knowledgebase awe amp Change Password J Search support arcas and find anewersto frequently asked questions Qo subscriptions amp 3 E Search Latest Knowledgebase Articles Date Added Entire Support Site Bin 1 B Test Video Dewak 20 Oct 2011 01 59 PM Ra J Sumi e ty Accent 0073 E Sube wm new ticket logged Im Empower Test Client B My Account May 31 Empower Systems is a Proud Sponsor of 22nd Annual Fairway to Health Golf Tournament May 31 Empower Systems to Exhibit at 2nd Annual Southeast Regional CAH Conference May 31 Empower Systems s Exhibiting at Healthcare Trade Faire amp Regional Conference 7 May 31 Wireless Technology Prevents Medical Errors May 31 Studies Tout Benefits of Electronic Prescribing But Adoption Is Slow E Home View Tickets Submit a Ticket Knowledgebase News 161 empowerlnpatient Ambulatory Upon Login you will see the Support Center page From here you have these options 1 View Tickets Here you can View your existing Tickets 2 Submit a Ticket Submit a new support ticket here 3 Knowledgebase Access the empower Knowledge base here this will also interact with you automatically during a new ticket creation process 4 News News releases about the Empower and its
254. r numbers which are sent to the inbound Results interface Both of these numbers are associated through a translation table to the Empower order number The Orders interface is able to send both full orders with order placer number and order requests without the placer number In the case of an interface to a single lab system full orders will be sent out with a generated placer number and results from the lab system will be processed CPOE Interface to Lab System Ne i Orders ORM O01 i 8H d4 B cy o Results ORU RO1 o Empower SQL Server Interface Engine Lab Systems Database When interfacing to an Order Master System which handles the generation of order numbers for multiple lab systems Empower will send out order requests without a placer number The Order Master System will then send back an Order Confirmation message with the generated order number and forward the original order to the appropriate system The Lab System will then send the results directly to Empower which will be associated with the order number received by the Order Confirmation message 111 empowerlnpatient Ambulatory CPOE Interfaces to Order Master System SQL Server Database Lab Systems Order Master System Order Identification The value of the ancillary systems filler number is determined entirely by the ancillary system The value of the placer number can be generated by one of the following strategies
255. r the direct control of you the Super User In keeping with this philosophy Empower is proud to announce that with respect to report and alert writing aka Clinical Decision Support Rule our clients can now design their own reports and alerts in an autonomous fashion The goal is to minimize and possibly eliminate costs to the hospital for custom report and alert development The end result of this initiative is to enable our clients to become self sufficient and to avoid the added expense of external report writing software and 3e party data mining services Convenient Accessibility The Empower Report Alert Writer is an integrated tool built on SQL Server Best Practices with a user friendly front end allowing Clinical and IT leadership to write limitless reports and alerts without the need for in depth programming knowledge Once reports are written they can be run once or saved as recurring reports for future convenience The Empower Report Alert Writer is a role based tool which can be launched from within Empower by simply clicking the Report Writer button The user will then choose either of the following options to launch whichever tool is desired 1 Report Writer 2 Alert Writer Powerful Functionality Hospital staff with the designated Empower administrative rights can write any report or alert in real time 48 empowerlnpatient Ambulatory Examples of Reports e Quality Reports e Government Compliance Reports
256. raining Physicians Hospital Coordinate and schedule EmpowerSystems Physician Training SF o EmpowerSystems Deadline for Front end user training SF Meet to discuss EmpowerSystems impacts EmpowerSystems Meeting departments EmpowerSystems meets and presents EmpowerSystems EmpowerSystems to Hospital Coders EmpowerSystems meets and presents EmpowerSystems EmpowerSystems to Laboratory Director EmpowerSystems meets and presents EmpowerSystems EmpowerSystems to Radiology Director NE as EmpowerSystems meets and presents EmpowerSystems 130 empowerlnpatient Ambulatory EmpowerSystems to Pharmacy Director EmpowerSystems meets and presents EmpowerSystems EmpowerSystems to HIM EmpowerSystems meets and presents EmpowerSystems EmpowerSystems to QA and Risk Management EmpowerSystems meets and presents EmpowerSystems EmpowerSystems to Registration and Unit Clerks Hospital imports ED PDF Chart using Hospital Document Bath o Imaging amp Management System Registration Interface Building and Testing Interface Team EmpowerSystems Portion Registration Interface Building and Testing Hospital PM Interface Team i Diagnostic Results interface Building and Testing Interface Team EmpowerSystems Portion Diagnostic Results interface Building and Testing Interface Team Hospital Portion CPOE Charge Capture Interface testing Al
257. re preceded by an asterisk Preliminary RN LOS Calculation DiagScore i e Diagnostics see Figure 1 this score is determined by the total number of diagnostics ordered for the patient Any diagnostics that are indicated as cancelled or refused are EXCLUDED from this total IntScore i e Medical Orders see Figure 1 this score comes from how many interventions are ordered for the patient Any interventions that are cancelled or refused are EXCLUDED from this total Example DiagScore IntScore Total Score RN LOS Ce EM B z 6 Diagnostic 7 Medical 13 Total Score 5 Tests Interventions 1 o o Total Score 13 Which falls between 10 amp 16 RN LOS 5 32 empowerlnpatient Ambulatory Every hospital has the table above available to them for adjustment of the Low High ranges to determine the LOS If you are inclined to alter this table please use caution and remain cognizant of the systems logic Please note the overlapping of numbers to be inclusive of the end result e g If you change the 11 to 13 you would need to change the number 10 to 12 If you have questions or concerns regarding the editing of this or any other table in Empower please contact your Empower Project Manager Exceptions for RN LOS Once Empower calculates the preliminary RN LOS the level of service is still subject to the exception list as detailed below Int
258. rientation Impulsivisity No 0 HX Depression with active symptoms at present No 0 Altered elimination Frequency Urgency Incontinence Diuretics Yes 1 Currently History of Dizziness Vertigo No 0 Male Gender No 0 Currently taking anticonvulsants check MAR No 0 Currently taking benzodiazepines check MAR No 0 Mobility assessment reveals Get up and Go Test Patient needs to push up but successful in 1 attempt 1 TOTAL SCORE 4 or less STANDARD FALL RISK INTERVENTIONS AS NOTED BELOW Standard precautions initiated Includes initial and ongoing fall risk education safe room set up including call light in reach and not dangling moving furniture on non exit side of bed side rails up x2 bed locked and low adequate lighting and room is clear of clutter If high risk additional interventions below High risk precautions initiated N A 05 25 2011 20 00 NURSING Nursing Serial SHIFT HYGIENE ADL rev 05 05 11 TURN FREQUENCY Patient able to Bahena RN Cecilia reposition self frequently in bed ACTIVITY Bedrest with BSC 05 25 2011 20 00 VASCULAR ACCESS Nursing Serial SHIFT MULTIPLE LINE ASSESSMENT rev 12 21 09 Bahena RN Cecilia PIVL Site 1 Location Right Forearm PIVL Site 1 dressing label Date Time placed 5 25 22g PIVL Site 1 Inspection Site is clean and dry without redness drainage or swelling Patient s central venous access device continues to be necessary due to N A 05 25 2011 20 00 NURSING Nursing Serial SHIFT W
259. rixis Extremity Location Legs Appearance Edematous Repeat Additional Exams May 26 2011 6 20AM VENTURA SALVATORE C Reviewed pertinent diagnostic tests vital signs and clinical notes Assessment Plan Problem List Non Oliguric ARF CKD 2nd Ischemic Nephropathy N A Creatinine improved to 1 62 mg dl with supportive care Patient refuses foley and she is incontinent of urine unable to stage her CKD Dialysis for Rx of cardiomyopathy complicated by renal failure and refractory severe fluid retention was discussed with patient She does not wish to consider dialysis as a treatment option at this time I will sign off case Remove patient name from Dr Ventura s list LVEF 10 ICD Parox A Fib MR N A Medical managment per HCCI NIDDM Hyperlipidemia N A Per PMD Electronically signed and authenticated by the Following Physicians VENTURA SALVATORE C Specialty Nephrology Metro South Medical Center 12935 South Gregory Street Blue Island IL 60406 2428 708 597 2000 Admitting Admitting Patient Name Age DOB Gender Race Insurance Weight Height Medical Record Account e i s 857g 175260 M NEN Allergies nka Room 4S0 421 01 MD Name Milenkovic Steven Robert KASON THOMAS T Date of Note 05 26 2011 9 10 Note Type PROGRESS NOTE History Subjective HPI Paragraph Patient with Still looks volume overloaded but denies sob orthopnea Other Notes Exam Objective Date Time of Exam May 26 2011 9 10AM GA
260. rom front end users There are many advanced methods to fully maximize the systems functionality and Empower wants to be certain that the Inpatient Ambulatory setting takes full advantage of all of the operational efficiencies including Meaningful Use that are built into the system However this process takes time and may not all occur during the Go Live week The Empower team will assign a project account manager as the long term resource for questions and needs regarding Empower Empower senior management also visits its partner hospitals on a regular basis to assist the hospital with not only any issues that may have developed but also with leveraging many of the new and advanced features of Empower software empowerlnpatient Ambulatory Chapter 2 System Technological Requirements and Specifications The hospital should provide all of the computer hardware and support software detailed in this chapter Please forward any questions regarding the following to Empower prior to installation No software substitutions can be made Hardware requirements provided below are the minimum for small Inpatient Ambulatory settings Mid to large sized facilities generally require a more substantial configuration Clients should consider increasing the devices performance features if additional software is to be used concurrently with Empower Basic Architectural Design Below is the typical Empower Inpatient architecture design and network configuratio
261. rs and Minutes The box appears Green for patients who have been in the department less than three hours Yellow for patients who have been in the department for more than three but less than five hours and Red for patients who have been in the department for more than five hours Diagnostic and Medical Orders has five columns each with one of the following designations e U Urine e B Blood e E EKG and other diagnostics like Pulse Ox amp Peak Flow e R Radiology e M Medical Interventions like an IV or medication When orders are entered an Orange box with the letter N for New is displayed in the box When the order has been completed the box turns Purple and displays the letter E to reflect that the order has been executed The R D C X U columns are interface columns and reflect the following chart status issues e R Registration this box will display green when the full registration process is complete e D Diagnostics this box will display yellow when all diagnostic tests are complete e C Critical Values this box will display a red C to notify clinicians of critical abnormal lab values e X Radiology Results box will display yellow when a radiologic study is completed and uploaded into the PACS system e U Unit Clerk when the Unit Secretary signs off on orders that have been entered in the Core system CPOE is not active or checks to make sure orders cross into the Core system Admit To displays the name of
262. rsed to Janet RN 05 23 2011 19 45 NURSING Nursing Serial SHIFT NARRATIVE NOTE new 6 29 10 Recvd pt awake alert oriented to McCabe RN Janet place and person questionable on time Denies pain Vpacing on monitor 05 23 2011 19 45 ADLs Nursing Serial SHIFT HYGIENE ADL rev 05 05 11 McCabe RN Janet TURN FREQUENCY Patient able to reposition self frequently in bed ACTIVITY Bedrest with BRP FEEDING Self COUGH AND DEEP BREATHING EXERCISES Done every 2 hours while awake EQUIPMENT VTE Venous Thromboembolism Prophylaxis N A LIST VTE PROPHYLAXIS CONTRAINDICATION if applicable N A 05 23 2011 19 45 VASCULAR ACCESS Nursing Serial SHIFT MULTIPLE LINE ASSESSMENT rev 12 21 09 McCabe RN Janet PIVL Site 1 Location Left AC Fossa pivl PIVL Site 1 dressing label date Time placed 20g 5 23 PIVL Site 1 Inspection Site is clean and dry without redness drainage or swelling Patient s central venous access device continues to be necessary due to N A Metro South Medical Center Ee fu Admitting Admitting Patient Name Age DOB Gender Race Insurance Weight Height m O X e ee 080 85 7kg Allergies nka 05 23 2011 19 45 ASSESSMENT Nursing Serial SHIFT NURSING ASSESSMENT rev 11 04 10 Transmission Precautions Standard O2 Type Liter Flow Room Air Rhythm Strip Interpretation Paced Rhythm LOC Awake Alert and Oriented x 2 Affect Calm Eye Opening 4 spontaneous Verbal Response 5 Alert and Oriented X 2 Motor Respon
263. s 2 City State Zip Insurance Data Insurance Name Subscriber Phone Subscr ber Relationship Policy Number Group Number Fin Class Auth Number WELLCARE Address 1 P O BOX 31372 13 Address 2 CLAIMS City TAMPA State F L Zip 336313372 Insurance Name Subscriber Phon Subscr ber Relationship Policy Number Group Number Fin Class Auth Number MEDICAID ILLINOIS Address 1 CLAIMS DEPT NNNEENS 13 Address 2 PO BOX 19132 City SPRINGFIELD State IL Zip 62794 Person To Notify Data Name Relationship Phone Address 1 Address 2 City State Zip Name Relationship M Phone EN Business Phone Address 1 Address 2 City State Zip Guarantor Data Name Phone EN Relationship Social Security Employer Business Phone Occupation Address 1 Address 2 o Pe ia cy MEN Name State IL Zip
264. s are in place and active Nursing Serial SHIFT HYGIENE ADL rev 05 05 11 McCabe RN Janet TURN FREQUENCY Patient able to reposition self frequently in bed ACTIVITY Bedrest with BRP FEEDING Self COUGH AND DEEP BREATHING EXERCISES Done every 2 hours while awake EQUIPMENT VTE Venous Thromboembolism Prophylaxis N A LIST VTE PROPHYLAXIS CONTRAINDICATION if applicable N A Nursing Serial SHIFT MULTIPLE LINE ASSESSMENT rev 12 21 09 McCabe RN Janet PIVL Site 1 Location left upper arm pivl PIVL Site 1 dressing label date Time placed 2 23 20g PIVL Site 1 Inspection Site is clean and dry without redness drainage or swelling Patient s central venous access device continues to be necessary due to N A Nursing Serial SHIFT NURSING ASSESSMENT rev 11 04 10 McCabe RN Janet Transmission Precautions Standard O2 Type Liter Flow Room Air Rhythm Strip Interpretation Paced Rhythm LOC awake alert oriented to person always unsure of time and place intermittently Affect Calm Eye Opening 4 spontaneous Verbal Response see above Motor Response 6 obeys commands Pupils reacts Ability to Move right arm moderate Ability to Move right leg moderate Ability to Move left leg moderate Ability to Move left arm moderate Skin Color Normal Skin Temperature warm Skin Moisture Dry Skin turgor non tenting Respirations Unlabored Breath Sounds Right Clear Breath Sounds Left Clear Retractions No retractions noted Ab
265. s of critical abnormal lab values e X Radiology Results box will display yellow when a radiologic study is completed and uploaded into the PACS system e U Unit Clerk when the Unit Secretary signs off on orders that have been entered in the Core system CPOE is not active or for those with direct order entry checks to make sure that orders have crossed into the Core system 90 empowerlnpatient Ambulatory Admit To displays the name of the doctor to whom the patient is admitted Chart Status appears red until the chart is complete When the chart is ready for disposition it appears green When the ED physician finalizes the chart the Empower ED risk management program scans the chart for incomplete documentation and then guides the physician through the completion of all necessary documentation Completing the documentation will change the status box color to green and the word Ready will appear within the box The nurse can then print and close the chart and is likewise prompted to complete any required documentation Filtering Sorting the Tracker Filters can be applied to limit the patients displayed by selecting from the drop down fields Name Search Location Search MD Search Disposition or Exam Room To remove the filters select All from the drop down fields Sorting can be done on any column by right clicking on the column heading and choosing a sort option Empower Ambulat
266. se 6 obeys commands Pupils reacts Ability to Move right arm moderate Ability to Move right leg moderate Ability to Move left leg moderate Ability to Move left arm moderate Skin Color Normal Skin Temperature cool Skin Moisture Dry Skin turgor non tenting Respirations Unlabored Breath Sounds Right Clear Breath Sounds Left Clear Retractions No retractions noted Abdomen distended firm non tender Bowel Sounds Active x 4 quadrants Pedal Edema Right 2 plus Moderate 1 2 inch Pedal Edema Left 2 plus Moderate 1 2 inch Pedal Pulses Right 1 plus Barely palpable Pedal Pulses Left 1 plus Barely palpable 05 23 2011 19 45 Nursing Serial SHIFT WOUND ASSESSMENT rev 05 06 10 WOUNDS WOUND ASSESSMENT No wounds at this time no further assessment needed TOTAL NUMBER OF WOUNDS wounds 0 EQUIPMENT Pressure relief mattress on bed WOUND ASSOCIATED PAIN N A WOUND TREATMENT N A 05 23 2011 19 45 Nursing Focused IV START NOTE new 12 21 09 VASCULAR ACCESS Peripherally Inserted Vascular Lock was established as follows Site used for start Left AC Fossa Device Type Size Other 20g butterfly Lock attached secured with tape line flushed easily after insertion Bioocclusive dressing applied site was labelled with device type size start time date and initials Patient tolerance Patient tolerated procedure well 05 23 2011 19 50 05 23 2011 19 52 NURSING SPIRITUAL CARE Pt to CT scan with RN monitor per w c also
267. se of 23 which inmproved to 47 upon use of a Sugar tablet She had an episode of syncope a week ago Other Notes Review of Systems NOT Covered in HPI ENT Neg Heart Pos Resp Pos GI Neg GU Neg Skin Neg Neuro Pos Psych Neg Musculoskeletal Neg Endocrine Pos Hematologic Lymphatic Neg Allergic Immunologic Neg Constitutional Sxs Neg Eyes Neg Exam Objective Date Time of Exam May 23 2011 6 25PM GA Knows month and day not date or year knows the name of President knows that she s in the office Skin No pallor rashes warm amp moist HEENT PERRL EOMI Moist Mucous Membranes No Icterus Neck NT Full ROM No JVD Lung Chest Wall Lungs Lungs CTA No Ret Chest Wall Chest Wall NT AICD in place Cardio Vascular RRR No M Abdomen Palpation Tenderness None BS BS NL No Bruits Abd Appearance No Pulsating Masses Neuro Motor Major Muscle Groups 5 5 Sensory Gross Sensory Intact Coordination Back NT no CVAT GU Normal Extremity Location Low Ext Bilateral Pain Tenderness None Sub Location Appearance No Edema ROM Pulses CBR 2 sec Lymphatics No LAD Repeat Additional Exams May 23 2011 6 25PM AHMED ZAFAR Reviewed pertinent diagnostic tests vital signs and clinical notes Assessment Plan Problem List SYNCOPE AND COLLAPSE 780 2 Likely from Cardio myopathy vs low glucose needs Pacemaker check AICD check Congestive Heart Failure 428 0 Acutre Systolic follow up chest X ray and BNP PT INR stat and at AM
268. seen by Dr Ahmed rescheduled due to tests 80 MG ORAL 5 ML 20 MG ORAL 5 ML 10 MG ORAL 5 ML 40 MG ORAL 5 ML 20 MG ORAL 1 Tablet Vitals Time 05 24 09 57 BP 110 83 Pulse NA Respiration N 10 MG ORAL 1 Tablet Vitals Time 05 24 09 57 BP 110 83 Pulse NA Respiration N 0 6 MG ORAL 1 Tablet Vitals Time 05 24 09 57 BP 110 83 Pulse NA Respiration N 25 MG ORAL 1 Tablet Vitals Time 05 24 09 57 BP 110 83 Pulse NA Respiration N 80 MG IV Push 8 ML Vitals Time 05 24 09 57 BP 110 83 Pulse NA Respiration N INTRAVENOU 0 ML 1000 Vitals Time S 05 24 14 48 BP NA NA Pulse NA Respiration N 70 ml hr 70ml hr IV 0ML 500 Vitals Time 05 24 09 57 BP 110 83 Pulse NA Respiration N 250 ML INTRAVENOU 0 ML 250 S 10 MG ORAL 1 Tablet Vitals Time 05 24 15 00 BP 121 89 Pulse 69 Respiration 2 Metro South Medical Center Patient Name Allergies nka 05 24 18 01 05 24 18 02 05 24 18 17 05 24 21 11 05 24 21 11 05 24 21 11 05 24 21 11 05 25 7 00 05 25 7 00 05 25 9 25 05 25 9 27 05 25 9 27 05 25 9 28 05 25 9 28 Age DOB am EE oc ee Bayless RN Michel WARFARIN SODIUM Gender Bayless RN Michel FUROSEMIDE Garza PCP Ana Bahena RN Cecilia Bahena RN Cecilia Bahena RN Cecilia Bahena RN Cecilia Bahena RN Cecilia Bahena RN Cecilia White RN Carina White RN Carin
269. ser Manius itio eie a cosas eso uc Reo d seio DER lea cciees 88 Ghapter 13 InterfatES mme 108 Registration ADT EP 108 Diagnostic Results e e E dvasadeveadbelecbadsdeveasacdceniasesbawasvedsapeeaanayaese Gko Guo PR R ERR SHR EN TENERE FERE Ni 109 Order Entry CPOE Automated Unit SCCretary ccccccssscessssessscesssseesscesseccesscecsesecsecesseseesececsssessesesssseesesecstsessacensts 109 Diagnostic Results amp Order Entry TCSting cccsssccsccccsssesssccscccseeesssssescccsesessaseseeceeseeesasessecesseessseeeceeseesnsaaeesscesees 109 Empower HL7 Orders and Results Interface Specifications cssssecccccseseesscesceccessnsssuseeeccessesnaseeeceesseetsaseesseeeess 111 Appendix 1A Hospital Staff Contact Information sssssssssssssesssssssssessessssscscscsesesesesesseacaeacecaescseeseessesrsraranacssses 127 Appendix 1B Implementation Project Timeline ChecR List eese rete enne reete tnam nne 128 Appendix 2A Business Agreement iii eiscea ceste ice dic eson saca aue anse pies caca ca E Sede a canis n Es pe E UE Rn Duca Sede DR RsaDaaD pue 133 Appendix 3A Empower RN Skills Verification eere eere eeecen ense tenete sesenta aan an arse se setate sa sassn soin snis 134 Appendix 3C Empower MD Shills Verification eere eee eeeeeseee setenta tate tn tnra an aman setate setate sensn sr sEseaa 136 Appendix SD Physician Electronic Signatile inr ee DU E
270. set of symptoms tblluPhysOxygen This table list the options in medical interventions for oxygen requirements tblluPhysPharmacyOrders This table list the options in admission orders for medication tblluPhysPMHx This table lists the options in the history for other past medical history tblluPhysProcedures This table list the options in the laceration note for physician procedures tblluPhysQuality This table lists the options in the history for quality of the symptoms tblluPhysRadiations This table lists the options in the history for radiation of the symptoms tblluPhysSkin This table lists the options in the physical exam for the skin tblluPulseLabel This table lists the options Vital Section Heart Rate for the location of 144 empowerlnpatient Ambulatory a specific pulse tblluQuestionResponse This table lists the mapping of the question and responses to the core HIS tblluQuestions This table list the options in the Diagnostic Order Entry for questions that are requested by the core HIS tblluRepeatExamPhrases This table lists the options in the physical exam for prewritten repeat physician examinations tblluResponses This table list the options in the Diagnostic Order Entry for answers that are requested by the core HIS tblluRiskCC This table lists the options in the High Risk Chief Complaints for symptoms tblluR
271. sical Exam and will highlight identified deficiencies History of Present Illness Patient Name Age History EMD EmpowER Manual 65 Ye Symptoms and Signs not covered in the HPI AlROSNegative GU i Musculoskeletal Mei ENT i Skin Endocrine BI Heart NNI Neuro Hematologic Lymphatic NI Resp WI Psych Bf Allergic Immunologic x a eves Constitutional sxs 106 empowerlnpatient Ambulatory Choose Review MDM if you are interested in the systems calculation for MDM Once you have successfully set the chart Ready to Print nursing will see the Chart Status on the Tracker and disposition the patient Congratulations You have now completed the Empower chart 107 empowerlnpatient Ambulatory Chapter 13 Interfaces Empower interfaces to the hospital s core HIS using an HL7 engine or Scripting interface The HL7 interface has been the most reliable and least expensive to maintain and the Empower HL7 interface engine can be modified to any specifications set forth by the hospital Empower can also build interfaces through other methods such as Scripting The following interfaces are included with the purchase of the Empower system e Registration ADT e Diagnostic Results e CPOE Computer Physician Order Entry e Empower PDF Chart Export e Charge capture The charge capture interface is usually not executed until a thorough chart review process has been completed in
272. spital or within the physicians group The Empower table editor allows the facility hospital and physicians group coders to modify the ICD 9 and CPT codes that are ultimately assigned to the patient s chart This allows the human coder to become more familiar or comfortable with Empower because they can assign their preferred codes In addition Empower provides a secondary diagnosis The secondary diagnosis is based on provider input or past medical history The secondary diagnoses sometimes are not very specific i e cancer psychiatric etc because the patient is unable to give specific details about a medical problem Certain secondary diagnoses are more specific hypertension asthma etc that are documented in the chart These secondary diagnoses are listed in Past Medical History but can be labeled inactive chronic or resolved Many times the physician might treat the patient for chronic medical problem exacerbation high blood pressure etc but not document hypertension as a primary diagnosis It can be added in Assessments as a secondary tertiary etc diagnosis This approach allows the facility coders to capture hypertension as a diagnosis If the hospital coders do not agree with this approach then just instruct the physicians not to use additional assessments The physician LOS is based on the algorithm point system created by CMS Center for Medicaid and Medicare The Empower algorithm for coding the physician LOS was create
273. t Endurance Training gt Gait Training gt Balance Exercises gt Treatment Frequency 3 5 X per week Total TX Time 38 52 minutes 05 24 2011 10 09 PLAN OF CARE Physical Therapy INTERDISCIPLINARY PATIENT FAMILY EDUCATION PLAN OF CARE Bohanek MPT Amy Special Learning Needs No special learning needs identified Educational Need Rehabilitation Techniques Readiness to Learn Accepting Attentive Teaching Method Explanation Discussion Response to Teaching Follow up needed plan Patient Family taught the following Fall prevention tips physical therapy plan of care and home exercise program Metro South Medical Center Patient Name Allergies nka 05 24 2011 10 10 05 24 2011 11 49 05 24 2011 12 17 05 24 2011 13 55 05 24 2011 13 56 05 24 2011 14 03 05 24 2011 14 25 Age DOB PLAN OF CARE ASSESSMENT NURSING CASE MANAGER CASE MANAGER NURSING CHF RESOURCE NURSE Admitting Admitting 12935 South Gregory Street Blue Island IL 60406 2428 708 597 2000 Gender Race Insurance Weight Height Medical Record Account E BE 00086 WELLCARE 857kg 1752605 ME Room 4S0 421 01 Physical Therapy Interdisciplinary Plan of Care PHYSICAL THERAPY Assess transfers gt Assess bed mobility gt Assess gait gt Instruct in home exercise program gt OUTCOME Increase exercise independence gt Increase independence of mobility gt Increase safety gt Nursing Serial SHIFT NURSING ASSESSM
274. t Client 1 Ticket Information r Laid Ticket ID 14652 amp Change Password Department Technical Issue Search z Full Name Empower Test Client Search ll E mail greenerdoc ecds md E B Entire Support Site Bis Priority Low ir Support Patient Name Type None if applicable n a Account n a Medical Records Number n a I Need Assistance on Submitting a Non Emergent Ticket Hello 1 Can you please provide me with a Quick Start Guide to using the Empower Client Support system Sincerely Test User Recipients 7 Back Home View Tickets Submit a Ticket Knowledgebase News T English U S Select the view tickets option f th in client t fter ing i elec e view tickets option trom e main client support page atter logging In empowersystems E 31 May 12 Support Center View Tickets 7 Submit a Ticket My Account Logout E Submit new tickets Vessels Or create new replies Submit a new ticket E w Logged In Empower Test Client 3 gt amp My Account E B Change Password E s Knowledgebase News Y Search support articles and find answers to frequently asked questions View news articles and manage subscriptions E TS gt Search Date Added Entire Support Site j 20 Oct 2011 01 59PM FGA J Latest Knowledgebase Articles E Test Video Dewak May 31 Empower Systems is a Proud Spons
275. t Number Empower Order Name Hospital Code 148 empowerlnpatienttAmbulatory 149 empowerlnpatient Ambulatory Appendix 13C Diagnostic Results Interface Workflow Post Go Live The following is the recommended workflow procedure to implement after the Go Live Date for Empower Diagnostic Results Interface Reason Even though the Empower Diagnostic Results Interface is working sometimes and by accident the wrong diagnostic mnemonic or result was provided by the hospital In either case when Empower receives the diagnostic mnemonic and or results from the Hospital s Health Information System HIS this incorrect or missing information will prevent Empower from displaying the correct diagnostic mnemonic or results to the physician This procedure is implemented to immediately identify any failed or incorrect diagnostic mnemonic or results correct and to fine tune the Diagnostic Results Interface Furthermore this procedure is designed to prevent any delays in the delivering the diagnostic results information to the physician in order to expedite the clinical evaluation and the patient s disposition Procedure 1 The physician will compare the Diagnostic Results generated off the printer from the Hospital s Health Information System HIS with the Diagnostic Results that are placed into Empower by the Hospital s Health Information System HIS 2 If the physician identifies missing or incorrect diagnostic results the p
276. t customer service our Emergency phone support is an automated system monitored by our technical support staff Callers will be routed through a call script to ascertain if the issue is a true emergency and if the appropriate troubleshooting by hospital IT has been completed prior to selecting the option to leave an Emergent message for our team to respond to The Emergent Emergent Support Line 877 222 3237 is intended only to be available to hospital IT departments or designated EmpowerSystems clinical administrators so that appropriate on site troubleshooting is completed prior to contacting EmpowerSystems The IT team should rule out network outages hardware resources availability and integration prior to contacting EmpowerSystems on an emergent basis to avoid financial penalties Empower Definition of an Emergency Clinicians in the ED unable to document on one or more patients currently active in the ED or complete integration failure between Empower and your Core Hospital Information System ex ADT failure Orders or Results not crossing for multiple patients Examples NOT Considered Emergencies e Forgotten Passwords or New User Setup Your hospital system administrator has been provided training to manage user accounts in Empower e Printing Problems Empower has been set up at each site to work to the specifications identified during implementation Any issues concerning printing should be managed through your IT dep
277. tails of these procedures The nurse is prompted for certain required information such as the IV completion time before closing the chart Only a nurse or Unit Secretary can document cancelled or refused medical orders by clicking on the respective medical order status field If an order is placed by a nurse she must also assign a provider to this order The provider will then be prompted to sign these orders prior to completing the chart Clinical Notes Nurse Enters MD Views This is divided into two sub forms l Clinical Notes a personalized form that includes Chief Complaint History Limited Nurse Physical Exam and Government Agency and JCAHO required documentation ll Vital signs Nurses notes are displayed in chronological order Documentation is completed by using either site specific phrases or free text entry The institution can also create forms for documentation which can also replace pre printed paper forms and protocols currently in use Vital Signs Nurse Enters MD Views By clicking on the vital signs and the pop up box vital signs can be viewed and entered These can also be trended A patient monitor interface can be used and the latest vital signs from the monitor will be displayed for viewing and any needed correction prior to saving The nurse is 66 empowerlnpatient Ambulatory alerted to any abnormal vital signs and returned to this screen allowing the nurse to repeat the vital signs or consult the physicia
278. ted the box turns purple with a letter E to reflect that the order has been executed Open the Patient Chart Clicking on a patients name open the patients chart and navigate to the opening screen the subjective part of the patient encounter Data Entry and Navigation Drop Down Boxes Clicking on the small arrow on the right side of the scroll box will open the drop down menu Typing the first few letters begins the auto fill process and the list scrolls to area of the menu that most closely matches the typed entry Weakness Weakness Arm Weakness Diffuse Weakness Face L Weakness Face R Weakness Face Weakness Foot L Weakness Foot R 92 empowerlnpatient Ambulatory Pop Up Forms If a white box with no arrow appears click in the white space and a pop up form appears This provides a Drop Down list and a blank area to free text Associated Symptom Pertinent Hx Cough Moderate Myalgias Fever Patient states Cough I cough so hard I vomit Cough Barky Cough Mild Cough Moderate Cough Severe Cough c sputum Blood Cough c sputum Clear Cough c sputum Green Check Boxes These allow the user to click a small box to acknowledge a prewritten statement Tab and Enter Keys Using Tab or Enter on the keyboard will move the cursor from one field to the next Fields can also be navigated by left clicking the mouse in the appropriate box Required Fields Empower has certain require
279. terminated Will inform Dr Bahena RN Cecilia Ventura when he rounds 05 26 2011 6 14 NURSING Dr Ventura aware of 24hour urine incomplete and terminated Bahena RN Cecilia 05 26 2011 6 43 SHIFT NARRATIVE Nursing Serial SHIFT END NOTE new 4 19 11 Bahena RN Cecilia Medical Orders review I have reviewed and as appropriate carried out all medical orders during my shift except those orders endorsed to the oncoming RN and or are scheduled in the future Diagnostic test review I have reviewed all pertinent diagnostic data as available and appropriate during my shift Patient report given and patient care endorsed to Carina Rn 05 26 2011 6 45 ADLs Nursing Serial SHIFT HYGIENE ADL rev 05 05 11 Fontillas PCP Arthur TURN FREQUENCY Patient able to reposition self frequently in bed ORAL CARE Self PERI CARE Self FOLEY CARE N A SKIN CARE Self ACTIVITY Assist BRP FEEDING Self 05 26 2011 8 18 NURSING Nursing Serial SHIFT NARRATIVE NOTE new 6 29 10 I want to go today pt stated Pt White RN Carina refused foley and up in the chair Alert and oriented x3 pt void per brp pivil right arm patent and intact flushes well Pt denies any pain and in no distress Pt understand about monitor her input and output when she return home on fluid restriction Call light tray table and phone near bedside 05 26 2011 8 20 SKIN ASSESSMENT Nursing Serial DAILY BRADEN SKIN ASSESSMENT White RN Carina Sensory Perception 4 No impairme
280. the Hospital s Health Information System HIS by the CPOE interface against the printed Hard Copy of the Diagnostic Orders generated by the physician 4 If the Unit Clerk identifies missing or incorrect diagnostic studies the unit clerk will immediately update the Diagnostic Orders in the diagnostic studies portion of the patient s account in the Hospital s Health Information System HIS 5 The Unit Clerk will also keep a log of any missing or incorrect diagnostic studies ordered through the CPOE Interface 6 The CPOE Interface Log will track the Patient s Name Empower Diagnostic Study Name and the Hospitals Mnemonic Message 7 The clinical administration will fax the log to Empower at 312 276 8116 or email to contact empower md so that the discrepancies can be corrected when future diagnostic studies are ordered through the interface thereby fine tuning the Empower CPOE interface The hospital will also have to assign a resource that EnpowerSystems can train how to update the Empower Order Entry Tables The procedure can be terminated after 90 days or until resolution of all discrepancies between the CPOE interface and the Printed Diagnostic Physician Orders 147 empowerlnpatienttAmbulatory Appendix 13B Hospital Order Entry Problem Log Sheet Document all interfaced orders that do not pass through the Order Entry interface between Empower and Health Information System Please complete each row Patient Name Accoun
281. the doctor to whom the patient is admitted 71 empowerlnpatient Ambulatory Chart Status appears Red while the chart is incomplete or Green when ready for disposition When the physician finalizes the chart Empower s risk management functionality scans the chart and provides prompts for the physician to complete all necessary documentation Doing so will change the status box to Green and the word ready will appear inside of the box after which the nurse can Print and close the chart The nurse is likewise prompted to complete any required documentation prior to completing the chart Filtering Sorting the Tracker Filters can be applied to limit the patients displayed selecting from the drop down fields Name Search Location Search MD Search Disposition or Exam Room To remove any of the filters select All from the drop down fields Sorting can be done on any column by right clicking and choosing a sort option Patient Roster Click in Patient s Last Name to access Patients s Chart Click in Patient s First Name to remove the patient Name Search Appointment Time Time In Complaint LastName FirstName Age Appointment Status Office Messages MD Name Disposition Orders HIBBETT BABY Rire 08 27 2010 LATE 6420 01 WellBabyCheck Rube Steven H 1 8 00 N Patient Name appears on the tracker when generated by the ADT interface or by using Add a Patient Age as enter
282. tic presents with fever and leg redness RN IV Insertion Blood Collection Urine Collection Antibiotics infused and patient is admitted to general medical floor of the hospital with a diagnosis of Cellulitis 78 year old female with Coronary Artery Disease presents with Chest Pain RN Intervention IV Insertion Blood Collection ECG Chest X Ray Sublingual Nitroglycerin Nitroglycerin Drip Aspirin and Heparin Infusion Patient admitted to the ICU with a diagnosis of Unstable Angina 36 empowerlnpatient Ambulatory Coding Grid of Common ED Diagnoses RN Work Load Diagnosis High BP Transient Medical Clearance Otitis Media w o fever Tactile Fever Wound Check Contusion Otitis Media with fever Pharyngitis Strain Toothache URI UTI Asthma Mild Conjunctivitis DUB Laceration Migrane VagBleeding w o Pregnancy Abdominal Pain Asthma Mod Asthma Mod Severe Dehydration Kidney Stone VagBleeding w Pregnancy CVA Hip Fracture Hyperglycemia Incomplete AB Pneumonia PyleoNephritis Threatened AB Angina Chest Pain CHF Intracranial Bleed Sepsis Syncope x K K KX 0X 0X 0X 0X KR KR 0X 0X 0X X X 0X 0X X X 0X 0X X X X X X X X X X K x No Intervention XO 0X 0X 0X 0X 0X 0X K 0X X 0X 0X X X 0X 0X X X X X X X X x x Single Intervention Multiple Interventions X 0X X X X X X X X X xXx x RN LOS 3 RN LOS 3 RN LOS 3 RN LOS 3 RN LOS 3 RN LOS 3 x 0X 0X 0X X KX 0X 0X X X 0X X X X X X X X x
283. tient Ambulatory SEQ LEN DT OPT RP ELEMENT NAME NOTES 2 IS Y Insured sContactPersonReason 8 DT __ Relationship to the Patient Start Date 8 DT Y Relationship to the Patient Stop Date 2 IS InsuranceCo Contact Reason 250 XIN Insurance Co Contact Phone No 2 is PolicyScope 2 I PolicySource 250 CX __ PatientMemberNumber 2 IS __ Guarantor Relationship to Insured 250 XIN Y jInsured sTelephoneNo Home 250 XIN Y jIsured sTelephoneNo Bus 250 CE Military Handicapped Program 2 ID jSupendHag 2 0 a 2 ID __ StoplosstimitFlag 250 XON Y jInsuredOrganzation Nameand ID 250 XON Y Insured Employer Org Nameand iD 250 CE Y Rae 250 CE HCFAPatRelationshiptolnsured p Po _ w Copaytimitrlag w _ i xon v xon N NIN o ul N e oO N N ORC SEQ LEN DT OPT RP ELEMENT NAME NOTES Order control O O O O O o0 Placer Order Number Filler OrderNumber SSS Placer Group Number Orderstatus Ooo Response oS y Quantity ae 7 yO Date Time of Transation eedBy S ES NN NN NN EE Co oS pem RE po x Xx fo 4 Verified By Ordering Provider Enterer s Location X eo 2 va olola
284. tient chart will also be converted to an image file PDF which will be electronically stored on the inpatient network If the hospital has a document imaging system Care Center Chart Script etc then the hospital could work with that vendor to import the Empower PDF so that it can be accessed throughout the Inpatient setting 21 empowerlnpatient Ambulatory The Empower Project Manager assigned to your site will help assess and decide the best way to integrate Empower into your workflow process Because Empower can function in many different workflow scenarios it will take some time to see which workflow processes work best for your institution The following agenda should be reviewed with your Empower team 1 Registration Quick Reg Full Reg a Role of Greeter b Role of Registration c Role of Triage Nurse Medical Assistant d Full Registration 2 Paper Chart Clipboard a Temporary Triage Emergency Department b Other documents signatures results 3 Primary Nursing Documentation a Use of Empower Response column in Medical Interventions b Use of Empower Clinical Notes assessments social information repeat assessments c Repeat Vital Signs interface option to consider Frequent Vital Signs Print strips mount and scan OR nurse enters Scanning 4 Tech MA Unit Secretary a Vital Signs b Point of Care EKG Glucose Check Urine Dips and Blood draws c Notifications d Bed Assignments e Nurses Notes i
285. tionality is designed for internal policy communications and will not function or connect to any other email system Duplicate Patients Inevitably for whatever reason there will be a duplicate patient record There are two major concerns to be acknowledged and one way for them to be expeditiously addressed in Empower 1 Orders with an erroneous account number will fail to interface 2 Empower does not and will not provide merge functionality for clinical data The following process will quickly and easily remove the erroneous account so clinical data is ONLY entered on the one record and provide a solution to correct update demographics Below is an example of a duplicate patient Empower Manual It is easy to identify the top chart is in error by the amount of time on the Roster and the lack of information Patient Tracking System r Y 5 1 A n iti Exam Bed Time n Chart ient Name Age Chief Complaint MD RN Disposition Roan AE ER Admit To Staus RP E 3akagain Shesa o3 Ls prz Tele12 0 Upon this discovery immediately click in the Disposition column to remove the erroneous chart from the tracker You are about to remove EmpowER Manual from the patient roster Are you sure you want to continue IV Duplicate Patient Registration Error Remove c Patient ibis 76 empowerlnpatient Ambulatory Checking off Duplicate Patient Registration Error will prevent this record from being included
286. tment Empower agrees to the following e To treat patient healthcare information as confidential e To use the information only for the purpose of providing the service for which ECDS is under contract with the hospital e To disclose the information only to the business business associate s employees who need access to the information in order to provide the services under the contract and who have signed an agreement requiring those employees to keep the information in confidence e To return the information in usable form upon request or upon completion of the work contract SIGNATURES Hospital Representative Date Empower Representative Date 133 empowerlnpatient Ambulatory Appendix 3A Empower RN Skills Verification Trainee Name Date Training verified by General DOCDODCODCDDODDODDODDODCDOLUO Log In and Change Password Add Patient ex John Doe Modify patient tracker by nurse by room number change from alphabetical order to room number order how to change initials from one primary RN to another put multiple patients in one room change room number Enter information in Triage to expedite care of critical patient PCP unk Chief Complaint Unk or i e Chest Pain Infection Control Unk Allergies Unk Return to Patient Tracking Complete Triage I Il and IIl Understands JCAHO requirements and rationale Note diagnostic orders within the scope of job description and hospita
287. to care for self Blood Urine EKG Radiology Test Level 4 Exceptions 2 or more Diagnostic Panels e g CBC Chem7 Liver Profile 1 or more CAT scans MRI Ultrasound or Nuclear Medicine diagnostics ordered 1 or more IV IVP or IVPB ordered 3 or more Standard Tests 2 or more Albuterol Txordered 1 hour or longer Albuterol Txordered Chem20 Trauma panel MI Panel CVA Panel CMP or Comprehensive Metabolic Panel ICU CCU Panel Chest Pain Panel or Abdominal Pain Panel ordered 39 empowerlnpatient Ambulatory Level 3 Exceptions 1 or more IM PO SQ orders 1 or more Prescriptions given at discharge Discharge Instructions include pre written instruction for Head Injury Admission for Detox 1 Diagnostic Panel e g CBC Chem 7 Liver Profile Crisis Evaluation Psychiatric Evaluation Compare the Level indicators The lowest value is the MAXIMUM possible billing level for this chart The Medical Decision Making level should ALWAYS be lower than or equal to the History and Physical Exam levels Values highlighted in red indicate inadequate documentation for the relevant column If you are admitting this patient and the Medical Decision Making level is not IV or V you should review those areas of the chart that pertain to Medical Decision Making Diagnostics check for uninterpreted diagnostic tests Medical Orders and Notifications Also if you reviewed an old medical record for this patient including old EKGs or recieved addit
288. tory software system utilizes only software based but not hardware based VPN products 11 empowerlnpatient Ambulatory Hardware amp Support Software Specifications The hospital will need and should provide the following computer hardware and support software SERVER HARDWARE Live SQL Structure 2 Clustered Servers for Redundancy of LIVE System Attached to SANS with sufficient storage for Scans PDFs Size of SANS dependent on amount of scanning and patient Volume Recommend at least 2TB with expansion for future growth Machine CPU Speed MHx 2 Quad Core CPU or higher RAM 64 GB or Higher Hard Drive Space 200GB Local Server RAID partitioned with 30GB for Op Sys Partition remainder in Data Partition Optical Drive DVD RW Drive Monitor 17 Flat Screen Uninterruptible Power Supply UPS sufficient for both clustered servers in case of brown out APC 1500 or higher Ethernet Card TCP IP Recommendation for 100 Beds 2x Intel Xeon E7 4870 2 40 GHz 30M Cache 6 4 GT s QPI Turbo HT 10C SERVER HARDWARE Test Application and Interface Servers Virtual Machines Machine CPU Speed MHx 2 Quad Core CPU RAM 16 GB or Higher except Terminal Server need 64GB Hard Drive Space 200GB Local Server RAID partitioned with 30GB for Op Sys Partition remainder in Data Partition SERVER HARDWARE Terminal Server VM Machine
289. ts unobtainable VENTRICULAR THRESHOLD volts 0 5V 0 40ms LV THRESHOLD volts NA ATRIAL 96 PACED 0 VENTRICULAR PACED 97 3 96 LV PACED NA PROGRAMMING CHANGES Program changes made RA UNDERSENSING ADDITIONAL COMMENTS INCREASED SENSITIVITY TO 0 15mv Metro South Medical Center 12935 South Gregory Street Blue Island IL 60406 2428 708 597 2000 Admitting Admitting Patient Name Age DOB Gender Race Insurance Weight Height Medical Record Account a m ee o5 umo 857 1752600 M EN Allergies nka Room 4S0 421 01 05 24 2011 9 56 PHYSICAL THERAPY Physical Therapy Inpatient Evaluation Bohanek MPT Amy Reason for Referral Weakness gait training and prevent deconditioning PRECAUTIONS High fall risk precautions Prior Level of Function Per pt she was Ind with all mobility tasks and ADLs PTA without a device Social History from Home with Husband who also has medical issues Ambulation devices None Level of Orientation A O x 3 Responses delayed at times Observation Telemetry IV Stairs Yes SUBJECTIVE Pt reported This water just got in my legs overnight Stated she had SOB with activity Present Pain Level 0 Range of Motion Limited B shoudlers and slightly in B LE due to edema Otherwise WFL Strength Approx 3 5 to 3 5 grossly Sensation Proprioception She denied any numbness tingling Coordination Fair Fair Balance Sitting static Good Fair Balance Sitting dynamic Good Fair Balance Stand
290. tteen PCP PCP entry accu Angie E check 0600 68 05 24 9 42 Critchett RN 0 accucheck 54 Daisyrenee Notified Dr Harris 05 24 9 57 Bayless RN 110 83 95 Denies pain 2L nasal cannt Michel 05 24 11 00 Garza PCP Ax 94 2 69 20 118 83 PCP entry Ana 05 24 11 20 Garza PCP PCP entry 70acc Ana 05 24 13 45 Bayless RN 69 109 85 Denies pain Michel 05 24 14 00 Bayless RN 69 134 91 Denies pain Michel 05 24 14 32 Critchett RN 69 128 92 Daisyrenee 05 24 14 36 Critchett RN 73 124 89 Daisyrenee 05 24 14 48 Bayless RN Denies pain acc 107 Michel 05 24 14 51 Critchett RN 71 137 97 Daisyrenee 05 24 15 00 Garza PCP Ax 94 5 69 20 121 89 PCP entry Ana 05 24 15 36 Critchett RN 69 134 96 Daisyrenee 05 24 16 08 Garza PCP PCP entry 108 acc Ana 05 24 16 21 Critchett RN 69 131 93 Daisyrenee 05 24 17 07 Critchett RN 71 140 97 Daisyrenee 05 24 17 38 Critchett RN 70 110 79 Daisyrenee 05 24 17 41 Bayless RN R 96 9 Denies pain paced Michel 05 24 17 52 Critchett RN 71 123 88 Daisyrenee Metro South Medical Center 12935 South Gregory Street Blue Island IL 60406 2428 708 597 2000 Admitting Admitting Patient Name Age DOB Gender Race Insurance Weight Height Medical Record Account ee pe 79 075265 M NENNEN Allergies nka Room 4S0 421 01 05 24 18 07 Critchett RN 69 118 90 Daisyrenee 05 24 18 23 Critchett RN 69 109 88 Daisyrenee 05 24 18 37 Critchett RN 71 126 93 Daisyrenee 05 24 18 37 Bahena RN 71 126
291. ty Diagnostictests i x x x OY Medicalintervention x x x x Admission or transfer to Gen Med Floor x Admission or transfer to Tele ICU or Surgery x tt n m m w Y 38 empowerlnpatient Ambulatory Empower then uses this formula to determine the preliminary suggested physician LOS Number of Dx and Management mgmt options Amount and or Complexity of data reviewed Risk of Complications Morbidity and or Mortality Total divided by 3 i e averaged Preliminary suggested Level of service For example Number of dx and mgmt options level3 Amount and or complexity of data reviewed levld Risk of Complications Morbidity and or Mortality levl2 3 4 2 9 divided by 3 averaged 3 or preliminary suggested level 3 In addition to this formula Empower compares the preliminary suggested level of service to the exception list seen below and determines a secondary suggested level of service The higher of these two levels is the one that is used for the final suggested level of service provided HPI history of present illness ROS Review of Systems PFSH Past medical Family and Social history and Examination are documented appropriately to support the suggested level per the 1995 CMS guidelines Empower Exceptions Level 5 Exceptions Admission for Psych if documented Suicidal Homicidal or unable
292. uch requirements 1 Empower can automatically answer relevant clinical information if the information is already documented in Empower for example whether the patient is pregnant or taking coumadin 2 Empower can provide default responses to standard questions for example a question such as how the patient is transported may always be answered as portable 3 The clinician and manually enter the answers to the questions Diagnostic Results amp Order Entry Testing Empower has successfully implemented a multitude of interfaces with numerous systems Experienced Empower clinicians reference the dictionaries provided and match them with the tables in Empower to complete the mapping process The hospital team will also be provided with a spreadsheet of this mapping to review This will not only reduce any translation errors but also expedite the testing process Even with this process however there is always the chance that there may still be unintentional errors created in the interfaces between the clinicians language and the hospital dictionaries Empower policies which should be 109 empowerlnpatient Ambulatory implemented at the interface Go Live assist in identifying any errors that may occur when linking the names for specific diagnostic orders and results in Empower with the analogous names in the hospital dictionary The hospital should implement these policies and procedures in order to prevent any delays or misco
293. ues for daily living Potential for reaching These Goals Excellent DISCHARGE RECOMMENDATIONS Home with HHC OT Treatment Plan ADL s ROM Strengthening Treatment Plan discussed with Patient Treatment frequency 3 5 times weekly UE PROM WFL UE AROM 3 4 ROM at Bilateral shldrs otherwise WFL Hand function Functional for feeding LUE strength 3 5 RUE strength 3 5 Muscle Tone Hypertonic Sensation Functional for ADL s PAIN present level Denies pain Left UE Fine Motor Coordination Opposes all digits Right UE Fine Motor Coordination Opposes all digits Balance sitting static Good Balance sitting dynamic fair Balance standing static Fair Balance standing dynamic Standby assist minimal assist Sitting tolerance Greater than 60 minutes Standing tolerance Approximately 1 minute with unilateral hold Endurance Fair for function COGNITION Oriented X 3 STM Intact LTM Intact Problem solving fair Judgement Safety fair PERCEPTION Visual tracking Intact Neglect none Body image scheme intact Spatial relationships Reads clock R L discrimination intact BED MOBILITY TRANSFERS Rolling Standby assist Supine Sit Standby assist Toilet transfer Standby assist minimal assist Sit lt gt Stand Standby assist Time 45 min 05 24 2011 8 46 PLAN OF CARE Occupational Therapy INTERDISCIPLINARY PATIENT FAMILY EDUCATION PLAN OF CARE Barder OT Jennifer Special Learning Needs No special learning needs identified Educational
294. ulture Result Final Colony Count 10 000 COL ML Isolate 1 Final Streptococcus agalactiae Group B BGM 186 INT CANCELED PT CANCELED 708 597 2000 Medical Record Account ro NEIN Room 4S0 421 01 Blazek RN 05 26 8 50 Patricia Marie Milenkovic 05 26 9 04 Steven Robert Blazek RN 05 26 8 50 Patricia Marie Admitting Admitting Patient Name Age DOB Gender Race Insurance Weight Height Medical Record Account e Em NEN oo geuum o9 857 15260 NNI Allergies nka Room 4S0 421 01 Medical Orders Clinical Staff MD Name MD Time Medical Orders Clinical Staff Time Order Status micu standing orders Phone order Bayless RN Michel 05 23 18 31 Secretary Completed written repeated verified per AHMED ZAFAR CRITICAL CARE TELEMETRY ADMISSION ORDER SET Bayless RN Michel 05 23 18 37 Secretary Completed per AHMED ZAFAR MD MEDICATION ORDERS per AHMED ZAFAR MD Bayless RN Michel 05 23 18 37 Secretary Completed Acetaminophen 650mg oral every 4 hours as needed Bayless RN Michel 05 23 18 37 Secretary Completed for fever more than 101 degrees F or pain notify physician if no relief in 1 hour per AHMED ZAFAR MD Colace 100mg oral as needed at bedtime for Bayless RN Michel 05 23 18 37 Secretary Completed constipation per AHMED ZAFAR MD Milk of magnesia 30ml oral as needed for constipation Bayless RN Michel 05 23 18 37 Secretary Completed per AHMED ZAFAR MD Mylanta 30ml oral as needed for indigestion
295. val to the administration of the first dose of antibiotics Therefore the nurse must diligently document the time that the antibiotics were given rather than the time that they were signed off on the chart If antibiotics were given within 4 hours the 4 hours column will say Yes If antibiotics were first given later than four hours the 4 hours column will say No If antibiotics were not given the 4 hours column will remain blank Provider Efficiency Report The Provider Efficiency Report looks at specific points in the patient flow for either physicians or midlevel providers All of the fields in this report are identical to the fields with the same names in the Disposition Statistics Report but are calculated on a per provider basis rather than a per disposition basis Summary Statistics Report The Summary Statistics Report is a collection of printable reports The Summary of Operational Statistics Report presents the aggregate data from the Disposition Statistics Non Finalized LWBS and Pneumonia Antibiotics Timeliness reports in a printable format Similarly the Zone Statistics Report and Provider Efficiency Reports are printable versions of the aggregate data in the electronic reports of the same names Zone Statistics Report The Zone Statistics report is designed for emergency department that are divided into zones This report presents the same data as the Disposition Statistics Report but breaks that data
296. vchCode SooRepeatVitals vy tblluTableEditor ERa T Application Settings Assessments Ab pief Rash B True iet Complaint an ed Symp Abdomen Rash L s Common Advance Directives Abdomen Rash R i Common Discharge Activity Abdominal Breathing amma poring xm Abdominal Cramping Diffuse Common FMHx Abdominal Cramping Local Common Nutrition Abdominal Cramps mes Miriigily Abdominal Cramps Lacrimation Rhinnorhea True Common SoHx Abdominal Distention True Common Suicide Abdominal Girth Decreasing True Common VTE DVT Abdominal Girth Increasing True condition Abdominal Mass True Abdominal Pain True Table Information Abdominal Pain Cramps True Abdominal Pain Epigastri 789 06 T rc ominal Pain ed TES This table lists the chief complaint in History Abdominal Pain Lower True Abdominal Pain Upper True Abdominal Pain only c coughing 789 00 True Abdominal Pain only c Diarrhea True Abdominal Pain Diarrhea 789 00 m Abdominal Pain Dysuria Abdominal pain Weakness Dizziness Abdominal Swelling Abdominal Swelling L 789 30 i ECDS Table tbluphysChiefComplaintAsx Abdominal Swelling R Allow Update True Abdominal Wall Abrasion 911 0 Allow New True pal Alall Rloadina 458 0 Allow Delete True lof2758 gt M be a lt No Filter Search Upon Print All for that Chief Complaint a message will appear to prompt for another set of Vital Signs Message Missing Documentation Required
297. ve Heart Failure Hyperglycemia Chest Pain Pnemonia Hypoglycemia Stroke 26 empowerlnpatient Ambulatory Drug to Drug Interaction and Allergy Detection The Smart Technology in Empower employs drug to drug interaction and allergy detection for the patient s home medications medications administered in the office and the medication given as a prescription This Smart Technology however only works if the nurses and physicians use the correct information and spelling Our large medicine database also includes hyper allergenic substances We encourage users to use this list When writing orders or prescriptions physicians have the ability to override both the drug to drug interaction and the allergy detection alerts if necessary The Empower database although not all inclusive will still identify the vast majority of most drug to drug interactions These drug to drug interaction and allergy detection prompts are not meant to replace a physician s clinical judgment The hospital pharmacy is responsible for maintaining and updating the information in the Empower database and the pharmacy staff can be provided with access to the Empower table editor for system maintenance Scanning Procedure and Outside Information Empower charts can be imported into the hospital document imaging system PCI Care Center etc without having to scan the chart As the patient is dispositioned from either the ED or Inpatient setting the chart is converted
298. verride and print close the chart The user should document NA in the notification screen for the simple trauma diagnosis that does not require a notification EmpowerSystems does not merge charts This is a user issue Those involved must manually remove documentation from the incorrect chart and re enter into the correct chart This can be done using copy and paste The incorrect chart can be removed from the Tracker by clicking on the Disposition field This can be done on the Discharge Instruction page Add Edit New Provider This is also managed by the internal Account Administrator via table editing The option for Discharge Instructions only opens when the disposition 153 empowerlnpatient Ambulatory User Issues Solution instructions for a patient being of Discharge is selected by the ED physician Transferred The hospital has designated staff to do these edits Write request in Table edits and additions the EmpowerSystems notebook for consideration The additions edits will be done internally You will need to change the Display Settings on that computer Log out of EmpowerSystems and click Start in the lower left corner e Click Settings e Click Control Panel EmpowerSystems screen too small or too large you can t Click Settings see all the fields or unable to e Click Settings tab at top click some of the gray buttons Set resolution to 1024x768 by moving your mouse on the little
299. vided remote access to the hospital system the Empower Inpatient Ambulatory system setup will proceed Provide Hospital Data During Phase I your Project Manager will provide samples of required data to that can be used to customize Empower InpatienttAmbulatory system to your sites needs Empower will complete this customization and configure the server to prepare for system testing and use Interface Development and Go Live Preparation Interface development and testing should occur parallel to Empower training sessions and implementation This process can start after Empower has been provided with a high speed internet connection available to the computer servers and after the hospital has deployed the client computers with Empower to the training room and the respective clinical departments For more information on interfaces see Chapter 13 PHASE III Testing Training amp Technical Readiness Empower trains all physicians nurses and staff members on the system in accord with the hospital workflow policies and procedures See Chapter 4 Empower provides on site training for SuperUsers over a period of several days during which trainees will be provided with lectures discussion and practice on the Empower Inpatient Ambulatory system Empower physician training is web based in order to accommodate their potential schedule limitations empowerlnpatient Ambulatory Full details on training parameters can be found in Ch
300. ways Last Interface to be Built amp Tested EmpowerSystems Interface Team Portion CPOE Charge Capture Interface testing Always Last Interface Team Interface to be Built amp Tested Hospital Portion Go Live Countdown Monday Walk Through EmpowerSystems Pre Go Live task list PPM Arrange for office near or a computer in ED with remote software connection to EmpowerSystems Server for Hospital IT support Tracking Systems Installation for other ED areas and EmpowerSystems Departments During Go Live Week EmpowerSystems Go Live EmpowerSystems Go Live EmpowerSystems Install EmpowerSystems Table Editor on assigned f EmpowerSystems Hospital Employee Computers During Go Live Week Train Hospital Employee on EmpowerSystems Table TBD Editor During Go Live Week Optional Configure BioAlert If requested EmpowerSystems Phase V Post GoLive Assessment and Transition EmpowerSystems Senior i EmpowerSystems Go Live Evaluation and Review Checkout meeting During Go Admin Hosp Exec 131 empowerlnpatient Ambulatory CPOE Charge Capture Interface Go Live See EmpowerSystems Implementation Manual 132 empowerlnpatient Ambulatory Appendix 2A Business Agreement This agreement is between EmpowerSystems Empower and the hospital Empower will be accessing confidential healthcare information on the medical evaluation and treatment of patients in the Emergency Depar
301. went to chest xray Spiritual Care Assessment Religious affiliation Christian Interventions Prayer scripture pt received pryer and encouragement appreciated the visit 05 23 2011 19 53 PLAN OF CARE Spiritual Care Interdisciplinary Plan of Care INTERVENTION Spiritual care assessment completed and emotional needs identified OUTCOME Accepts spiritual interventions and counseling 05 23 2011 20 15 05 23 2011 21 20 05 23 2011 22 30 05 24 2011 0 00 NURSING NURSING NURSING SKIN ASSESSMENT Returned from CT Scan per w c assisted back to bed Accucheck 94 no coverage ordered Dr Cusick called with consult no new orders received Nursing Serial DAILY BRADEN SKIN ASSESSMENT Sensory Perception 4 No impairment Moisture 4 Rarely Moist Activity 3 Walks Occasionally Mobility 3 Slightly Limited Nutrition 4 Excellent Friction and Shear 3 No apparent problem Total Score 19 or more No interventions needed at present continue to monitor 12935 South Gregory Street Blue Island IL 60406 2428 708 597 2000 Medical Record Account ro NEEEENM Room 4S0 421 01 McCabe RN Janet McCabe RN Janet McCabe RN Janet McCabe RN Janet Carney PhD Phillita T Carney PhD Phillita T McCabe RN Janet McCabe RN Janet McCabe RN Janet McCabe RN Janet Patient Name Allergies nka 05 24 2011 0 00 05 24 2011 0 00 05 24 2011 0 00 05 24 2011 0 00 05 24 2011
302. wer Quadrant RUQ Right Upper Quadrant LUQ Left Upper Quadrant BUQ Bilateral Upper Quadrant BLQ Bilateral Lower Quadrant PS Peritoneal Signs c With S Without Dist Distention Genital Exam Cx Cervix CMT Cervical Motion Tenderness Ut Uterus Adx Adnexa 4 Positive id Negative CxOs Cervical Os Extremities BLE Bilateral Lower Extremity RLE Right Lower Extremity LLE Left Lower Extremity RUE Right Upper Extremity LUE Left Upper Extremity BLE Bilateral Upper Extremity LIF Left Index Finger LMF Left Middle Finger LRF Left Ring Finger LPF Left Pinky Finger RIF Right Index Finger RMF Right Middle Finger RRF Right Ring Finger RPF Right Pinky Finger AC Joint Acromio Clavicular Joint DIP Distal Inter Phalanges PIP Proximal Inter Phalanges 140 empowerlnpatient Ambulatory Abbreviation Interpretation IP Inter Phalanges MCP Meta Carpal Phalanges DIPJ Distal Inter Phalanges Joint PIPJ Proximal Inter Phalanges Joint IPJ Inter Phalanges Joint MCPJ Meta Carpal Phalanges Joint MTP Meta Tarsal Phalanges MTPJ Meta Tarsal Phalanges Joint BP Brachial Pulse RP Radial Pulse FP Femoral Pulse PP Popliteal Pulse DP Dorsal is Pedis Pulse PT Posterior Tibialis Pulse AROM Active Range of Motion PROM Partial Range of Motion CBR Capillary Blood Refill Neuro MMG Major Muscle Groups Ext Extremity MAE B Moves All Extremities Equal Bilaterally BLE Bilateral Lower Extremity RLE Right Lower Extremity LLE
303. ypes of result interpretations for the diagnostic study EKG tblluLabResultsETOH This table contains the different types of result interpretations for the diagnostic study ETOH tblluLabResultsGeneral This table contains the different types of result interpretations for the diagnostic study non standard studies tblluLabResultsGlucoseScan This table contains the different types of result interpretations for the diagnostic study point of care glucose scan tblluLabResultsHgB This table contains the different types of result interpretations for the diagnostic study point of care hemoglobin tblluLabResultsLiverProfile This table contains the different types of result interpretations for the diagnostic study Liver Function Studies tblluLabResultsPeakFlow This table contains the different types of result interpretations for the diagnostic study Peak Flow tblluLabResultsPTPTT This table contains the different types of result interpretations for the diagnostic study Pt amp PTT tblluLabResultsPulseOximetry This table contains the different types of result interpretations for the diagnostic study Pulse Ox tblluLabResultsQuantBHCG This table contains the different types of result interpretations for the diagnostic study quantitative BHCG tblluLabResultsURHCG This table contains the different types of result interpretations for the diagnostic study urine pregnancy tblluLabResultsUrina
304. ysician billing The auto populated results will not overwrite the provider s interpretation The results can be filtered and in addition to the results this screen also lists both the time that the specimen was collected by the staff and the time that the specimen was received by the laboratory 65 empowerlnpatient Ambulatory Assessment Plan Medical Orders Provider and Nurse The first patient assessment will come from the subjective section of the patients chart Subsequent assessments can be entered by the providers When the assessment is selected from the list the site defined codes will also be included in the PDF Chart Common diagnostic orders are placed by checking the box near the name of the test Less common studies are ordered from the Diagnostic Orders drop down box and pharmacy orders are also selected from the corresponding drop down box Non standard orders can also be selected or free texted in the Other Medical Orders and Comments Standard Order Sets are specific sets of diagnostics and in some cases treatments that can be ordered with a single check box These sets are hospital specific and can also be selected from a drop down list In addition if the physician chooses to admit the patient the admission orders can also be selected individually or in order sets Location and Response of IV Insertion or Insertion of Drains on the Input Form Output Form or Nursing Notes allows the nurse an area to document the de

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