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EMRDoc Version 2.9.5 User Manual

1. Abdominal Pain In Pregnancy Easyto Read Abdominal Pain Child Abdominal Pain Easyto Read Abdominal Pain Women C Recurrent Abdominal Pain Syndrome In Children E o y Preview Edit Remove selected selected Physician Practice all Abraham Michael IT EPOWERdoc Ball Eye MD ENT Bogart Jama NP Bogart Jama NP Brewster Sam Brewster Joseph MD Bates County Memorial Hospital Preview Edit Brewster Joseph MD Bates County Memorial Hospital Ha a Search by Impression i Select Impression from drop down box will produce list of instruction titles according to selected impression ii Select set of instructions from list will populate in box on the right iii To preview edit or remove selected instructions highlight instruction in box then select desired action NOTE editing instructions does not allow saving for future use b Select Follow up Provider i If PCP chosen from database and documented in chart provider will auto populate for follow up ii Otherwise select follow up physician using categories search bar or scroll bar iii Physician will populate in box on the right iv To preview edit or remove selected physician highlight listing the box and choose desired action v Add new provider if needed does not allow saving for future use 54 Page 2 c Select Follow up Time
2. regarding a particular patient 3 Can be added and deleted at any time during patient s stay 4 Examples include DNR D C after sober pt combative sister has POA etc 5 Create notes to keep in database for future use or free text in bottom box Q UC 1 Designed for Unit Clerks to keep up with orders placed into EPD 2 Number will appear in cell to represent new orders 3 Click on cell to clear number OR 4 Open chart to Orders tab and place note for each order number on tracking board will decrease by number of orders with notes placed R Reg 1 Denotes patients who have been partially or fully registered 2 Must change manually by clicking on cell 3 1 click produces Q 2 click produces F 3 click clears cell Inside Patient Chart Open chart via chief complaint on TB 1 Chart Header This shows no matter where you are inside the patient s chart EPOWERdoc 2 9 TucSDAY SARAH PCP Ball Eye MD 21Yr F 10 a oN Allergies Pain 4 10 02 Sat 100 on 2L min v NC Code FULL A Left side of chart header 1 Patient s Name a Shows name age gender b Clicking on name produces view print screen or patient menu 2 HA MRN AT non functional tabs a Hospital account number b Medical record number c Arrival Time time patient was registered into the system 3 Room a If patient in room clicking Room produces Bed Management window b If empty room clicking Roo
3. e If Meds Allergies and or Medical Problems box gray they were imported via chief complaint selection OR there were none documented in prior visit K Select Import History L NOTE This function to be used BEFORE you begin documenting If you import history AFTER you ve already documented meds allergies PMH the import will REPLACE your documentation Previewing final chart ip E Click icon on chief complaint bar F Current view defaults to RN chart top left if logged in as RN G May select different view types from drop down box top left H Chart view defaults can be individualized for each user Administrative task The sections in the History tab are as follows A Current Medications click Add Edit Current Medication button or select None or Unknown Current Medications for MUDDY WATERS Medication Dose Route Search E Drug Name Begins With Drug Name Contains BOGOR OOReEooo sree 12 Hr Decongestant ER Tab 12 Hr Nasal Spray 12Hr Nasal Spray 12 Hr Nasal Spray 12 Hr No Drip Nasal Spray 12 Hr Sinus Nasal Spray 12 Hr Sinus Relief Nasal Spray 29G 1 2in Pen Needle 29G 1 2in Pen Tip Needle 29G 1 2in Unifine Pentips 29G 1 2in Unifine Pentips 31G 1 4in Pen Needle 31G 1 4in Pen Tip Needle 31G 1 4in Unifine Pentips 31G 1 4in Unifine Pentips 31G 5 16in Pen Needle 31G 5 16in Pen Needle 31G 5 16in Pen Tip Needle y Dose 1 tablet
4. to next section b Select appropriate options below each vital sign 2 UTO Unable to obtain i e pt combative restless refuses etc 3 Time Obtained a Defaults to current time b Click in box to change to actual time c OR click Prior to arrival if applicable 4 Notes allows addition of free text notes to specific set of vital signs i e BP elevated because patient won t sit down or temp inaccurate due to patient drinking hot coffee 5 Visual Acuity enter appropriate information and click Record 6 Glasgow enter appropriate information OR click All Normal and click Record 7 Developmental for infants head circumference measurements 8 After entering all desired vital signs click Record This clears the entries but does not exit out of the screen allowing more vital signs entries 9 View History allows user to view all vital signs recorded on patient See screenshot below a May also edit vital signs by right clicking on specific vital sign which will produce free text box b May delete vital sign entry by clicking x located to the right of the line 16 Page c USERS CAN ONLY EDIT DELETE THEIR OWN VITAL SIGN ENTRIES d EDITING GCS VISUAL ACUITY single left click on the entry then edit and record Cannot delete GCS or visual acuity entries at this time e May also view vital signs history by clicking vital sign letter in patient s chart header 10 To ex
5. box some order sets may be linked to particular chief complaints B Orders in set automatically populate Order sheet C Must cancel order from set if not needed Order Sets Set up by facility A Selection of order set produces window containing orders to choose from B Select desired orders and Add to Order Sheet C Record via normal ordering process Cancelling Orders May NOT cancel order already placed in progress or recorded from pending orders In Orders tab select order to be cancelled Click Cancel Order Click Yes or No in warning box Enter reason for cancellation in free text box then click Record nmo gt Order will be removed from Pending Orders section AND will appear in Messages queue as order cancelled G If need to cancel order after already initiated 1 In Course tab under Pending Orders select order that was initiated in progress and click Note 2 In Orders tab enter Free text order 3 Type cancellation and reason click OK 4 Record new free text order 5 Order for cancellation will appear in Pending Orders in Course tab 6 Select order in Pending Orders and click Noted View Print order sheet by clicking Print button OR Order Sheet button 34 Page 6 Time Finished Function should be not be used to complete an order Orders must be addressed through Pending Orders Messages 1 If Messages button is red A Orders Messages exist
6. 14 14 1 144 177 A Most procedures linked to an order allowing this step to be skipped if procedure is recorded via pending orders section Click Record nmoupnowyw Click to view additional related procedures Select desired procedure s Change date time or use default G Procedure note will also be added to Nursing Notes section If further documentation necessary for particular procedure a template will be produced specific to recorded procedure example shown below 64 Page Orders History Pending Orders Nursing notes 12 20 2011 12 25 12 20 2011 12 25 Sarah RN Procedures IV Placement with fluids Time fluids initiated By ThisED EMS Another hospital Solution NS LR W2NS W4NS D51 2NS D5W DIOW Amount mi 50 100 250 500 1000 or Rate Bolus KVO 20 ml hr KVO30mV hr 125 ml hr 250 ml hr 500 mil hr 1000 ml hr or Physical Procedures Results IV placement with fluids Time stopped Additive mi mihr via W pump Site R L Antecubital Forearm Wrist Hand Finger Thumb Bicep Externaljugular Scalp Shoulder Foot Other Cathetersize 12 14 16 18 20 22 24 Butterfly or Double lumen 18 20 20 22 20 24 Attempts 1 2 3 4 5 gt 5 Difficult IV procedure Complications None Infiltration Inability to aspirate blood Unsuccessful Notes 5 Quick Notes Notes Interventions THANKGODITS FRIDAY Time Time F All Notes M Triage I Interven
7. Long C MD Miller 3 L DO Morris J Clark C AMS Claypool K CDR Cole D HIM Cook D IT Randy K DO Resident R MD Richard E MD Cook M IT Dains K RN Dizney B PRM Richard R MD Stein test A J MD Taylor T MD Unknown D MD Donnohue A RN Draper D RN Eastland K AMS Eaton A Vitt P C MD Wirkkula J Erickson R PRM Flater D RN Forkner A RN Foster C AMS Friederich J W Gaylord K HIM USERNAME PASSWORD Backspace Admitting Team and Consultants Utilities Administration Ancillary Personne Login Change My Profile Retrieve Password TrackingOnly Paper Templates Reset Password EPOW doc EMERGENCY DEPARTMENT DOCUMENTATION SYSTEMS This product i This produc that have infringement of permitted by program Please call 17 5588 for information on you are an authorized user pursuant to a current signed ag Copyright 2009 EPOWERdoc Inc All rights reserved with EPOWERdoc Inc 1 Select user name from one of the provider columns cted by copyright laws and intemational copyright treaties as well as other intellectual property laws and treaties censed not sold This product and all information accessible from it is distributed for limited use only to authorized users red into a license agreement with EPOWERdoc Inc Unauthorized installation use copying distribution or other OWERdoc s copyright an
8. POWERdoc User Manual Version 2 9 5 2012 This manual contains instructions for the use of EPowerdoc It includes general system information for all users as well as specific documentation for nurses physicians techs EMT s and unit clerks Table of Contents Logging IM cid E E E T EEE EEE 4 Tracking Doard TUNCIONS iii is 5 Patient chart UNC Sari ia 10 Adding a PAI cuca adria 6 Bed MNAE EMENE coin di da e ad dia 8 13 Viewing Printing Chart cccccccccsssssssscsssssssssesssecsessssessescoesesacscercassnssesesecaesesasatenseeseees 8 13 15 36 38 60 68 Viewing Entering vital SIgns cccccccsecsssssesceecsesessessssseesesscsesecarseseesceecaesesacscsecarsnseeseetcaees 13 15 38 60 62 Nursing Documentation Initiating Patient Chart Selecting a Chief Complaint ccccccsscscssssescsecsessssescssssssesacsceecseessescaecaescseeeeseenees 14 MA VS Cie A O O 15 Assessment aiii ia 21 A tiDn a A a E a E E aay 23 DISPOSITION taD kieten e a se EE E aae eE e teats audi deeds Beers 30 Ordes e Aia 33 MESSABES coco A A A A A Ad 35 Addendums Call Backs ccccsccccssssccsssscscssssssscscsccceecsessecssscscescssssccssseccesesececcesssaceseacecssescsscacscesesecsessescesseesens 36 Endler SHiTt process A ee 37 Physician Documentation History ti A A A eave 39 AaOr E o aaa diet 45 A E 45 a teaieaieiaescpeceaterteg eneeeneaee 48 PEOCOQULES Taiana airis 52 Results tapin enla 52 DIE oiea T o E EEEE T S AE EEE ER
9. change title as necessary and click Record to save changes v Delete Indication Select indication click Delete selected indication then click Record to save changes 5 Medications 6 a b c d Search for and select medication Select dose route and any other information will show in special instructions column in Orders tab Click Add to List Click Record THIS DOES NOT RECORD THE ORDER it ONLY adds the order to the order sheet Free text order any additional order not found in the above categories a b Be aware Free text orders are NOT interfaced meaning will not cross to HIS will only appear in RN Pending Orders section Do not use this function as a quicker ordering method 49 Page G To remove order from list BEFORE recording 1 Use Select All checkbox to deselect all orders 2 Select order to be removed 3 Click Cancel Order 4 Click Yes Once all desired orders appear in Orders tab click Record 1 Order sheet may automatically pop up to print or view depending on Facility Settings 2 Orders will appear in Pending Orders section of Course tab AND in Messages for RN to view and document 3 Red carat will appear by patient s name on tracking board to alert staff of orders messages on patient Facility Orders Set up by facility A Select desired order set may need to click View All box some order sets may be linked to part
10. number of items resulted Will turn green upon return of first result 3 3 value number of results review by physician practitioner 4 The general orders include nursing tech orders 5 Click on cell to open EKG 1 Shows Ordered when done so via Orders tab 2 Click on cell to open 3 Manually change to Completed by clicking in the cell Stage of Care Shows stage of patient visit 1 Populates automatically majority of stages are linked to particular parts of the chart 2 May be changed manually to reflect a particular stage of care that the system does not automatically recognize i e pt to xray surgical consult ambulance en route etc 3 Click on cell to open ISO Isolation 1 Populates automatically when documented in chart 2 Click on cell to open 3 If selected from tracking board will populate chart 4 Colored pink if isolation selected Plan Disposition admit plan 1 Click on cell to open 2 Options customizable per facility Alerts 1 Populates automatically when documented in chart 2 Click on cell to open 3 Options customizable per facility Info Permission to release information 1 Populates automatically when documented in chart 2 If No is selected it is colored orange 3 Click on cell to open 4 If selected from tracking board will populate chart 9 Page P Comments NOT PART OF LEGAL CHART 1 Click on cell to open Comments window 2 May be used as an FY
11. Allergies l 2011 11 29 P ba Sarah M Johnson BSN Orders History Physical Procedures Results Disposition Chief Complaint EXTREMITY PROBLEM O 90000 i Cardiopulmonary Labs Radiology Medications O 1 Edit Sets _ Facility Orders My Orders Order Sets Record Order for Thane F Labs test Shortness of Breath Order Sheet Test Med set Selected O 1 Order Notes Place a note regarding a specific order A B e D Click on the box in Notes column next to desired order Select desired comment from pop up window OR Free text note in white box Click Record 2 Cancelling Orders A Sop E An order CANNOT be canceled once already set in progress or completed via RN Pending Orders section In Orders tab select order to be cancelled Click Cancel Order button on the right Warning box will appear click Yes or No A reason for cancellation box will appear type reason and click Record 3 View Print order sheet Clicking Print button OR Order Sheet button on the right 69 Page
12. Page G A a Chart Signed by statement with user date time placed on chart 2 Transfer button a b c d e f g h Used to transfer care of patient to another nurse reporting off Warning box appears all are soft stops user should address the warnings pertaining to parts of the chart that the transferring user was responsible for Once warnings addressed click Yes to proceed with transfer Select the nurse you are reporting off to Click Record A Report given to statement will appear with user date time Chart signed by statement will appear with user date time If erroneous transfer click Undo Transfer button 3 Remove button Allows removal of user s name from chart Printing button Produces Print View screen allowing user to view print certain aspects of chart See General Info section of manual for further instructions 9 Close Lock Chart Locks and releases chart to medical records Facility dependent After user has completed charting AND signed off 1 Click Lock and Release to Medical Records 2 Select OK The chart will gray out disallowing any further charting RN may UNLOCK chart but ONLY for 2 hours after locking Chart can ONLY be locked and unlocked by the primary RN see admin manual for further information on locking unlocking charts Privilege dependent Facility may have auto lock process i
13. Soln for Inj I Epinephrine 1 10 000 for Inj J Epinephrine 1 1000 for Inj T Furosemide 10mg ml for Inj I Glucagon Emergency Kit Img I Hydrocodone APAP 10 325mg Tab T Hydrocodone APAP 7 5 500mg Tab I Hydrocodone APAP 7 5 750mg Tab 7 Ipratrop Albut 0 5 3mg 3ml Inh I Lidocaine 0 5 Soln for Inj a Select appropriate medication or free text in Other box b Enter known details i e dose site etc on the line provided c Click Record J Triage Assessment details of patient s complaint 1 If multiple chief complaints each complaint will have its own triage assessment template to address individually K Nursing Notes used for any interventions done in triage Details to be discussed in Course section L Triage Acuity 1 Select appropriate acuity level 2 Will automatically populate on tracking board M Triage Disposition 1 Click on the line to produce bed management screen 2 Select appropriate area and desired bed for patient 3 Click Assign bed to 4 Click Time to Room use default or select actual time 5 If patient was added directly to room via the tracking board room number will appear Sign Triage Once signed user CANNOT edit tab will be LOCKED grayed out O Free Text Note remains functional after Triage tab is locked if any additional charting is needed zZ 22 Page Assessment 1 Triage information crosses over IF entered in Triage tab 2 Any triage information
14. Text Note A Click button to open free text window B Click Record after note entry 4 Procedure Notes RN Procedures THANKGODITS FRIDAY x ABG I Gastric lavage I Pelvic exam Airway GU TT Paracentesis asst Blood obtained T Incision and Drainage I Peritoneal lavage asst Blood transfusion initial T Incontinence care Rectal Blood transfusionrecheck I Intraosseous access Rescusitation Breathing treatments iv I Restraints Bum care Labs Safety Capillary Blood Glucose T Lumbar puncture Samples obtained Cardioversion I Moderate sedation I Sexual assault exam Central line asst Monitoring Suction Chest tube asst T Needle decompression T Swallow Screen Critical lab value NG Tube Tests Dislocation reduction Nutrition I Thoracentesis asst Dressing 08 Tracheostomy Education Ortho Transport EENT Ortho Immobilization Wound EKG performed I Oxygen therapy Gtube Pacemaker i 1101171717111110 4 1 a A Most procedures linked to an order allowing this step to be skipped if procedure is recorded via pending orders section Click to view additional related procedures Select desired procedure s Click Record Change date time or use default mmom If further documentation necessary for particular procedure a template will be produced specific to recorded procedure example shown below G Procedure note will also be added to Nursing Notes section 27 Page Physic
15. aia Whit Loss of conscious 1 Tracking Board Header Na E ZrO0Werndoc 2 9 All Patients All Beds My Patients To Be Seen Incomplete Pa de A 7 AN ADD Patient Active Patients etn Se mo anar Total RECENT Patients Waiting Room To Be Seen OLD Patients Waiting Admission Call Backs Total Incomplete w Sarah M Johny _A 5 Page A Tabs at the top of the Tracking Board header Will display no matter where you are in the system 1 All Patients displays every patient currently registered in the ED this is the default tab when entering the system 2 All Beds displays every bed in the ED both occupied and empty 3 My Patients displays existing ED patients assigned to you as the primary provider 4 To Be Seen displays only the patients who have not yet been documented on by the physician or nurse 5 Incomplete displays charts from the recent patients list that the logged in user as the primary provider has NOT SIGNED B Tabs on left side of Tracking Board header 1 Add Patient Use this function to manually add patient into EROWERdoc if gt Patient has not been registered through hospital system and provider s needs to begin documentation gt Interfaces down and provider s needs to begin documentation gt Registration is backed up and providers need to begin documentation gt The minimum patient info needed for this function is first and last name DOB and gen
16. b Select Yes or No from the warning box C Order Sets Authorized users only Process same as above may add reference material if warranted Procedures Chief Complaint Procedures Phys 91 20 NA Results ALCOHOL INTOXICATION I Anoscopy I Arterial line T Arterial puncture I Arthrocentesis T Blood transfusion T Burn debridement I Cardioversion T Central line I Chest tube T Cricothyroidotomy FT Critical care procedures EKG interpretation Feeding tube Foley catheter placement FB or rust ring removal eye FB removal orifice FB removal soft tissue Generic Procedure Hydration therapy 13 D Bartholin cyst abscess 13 D General 18 D Paronychia Intubation CIC CIA ICAA Sign after completed Physical I Laceration repair Laryngoscopy Lumbar puncture Nail procedures Nasal cautery and pack Nerve block NG OG tube and or gastric lavage Osteopathic manipulation therapy Paracentesis Pericardiocentesis Peritoneal lavage Reduction general Reduction radial head subluxation Reduction shoulder Results Sedation IV IM Spinal clearance Splinting Stroke Scale Stroke thrombolysis Suture Staple removal O Thoracotomy emergent I Thoracentesis E m m m mm et m m e m m m m m m l a Select one or multiple procedure s from list Complete additional documentation as necessary If procedure was added in error click Remove Procedures Results Dispositi
17. of vital signs i e BP elevated because patient won t sit down or temp inaccurate due to patient drinking hot coffee 5 Visual Acuity enter appropriate information and click Record 6 Glasgow enter appropriate information OR click All Normal and click Record 7 Developmental for infants head circumference measurements 61 Page 8 After entering all desired vital signs click Record This clears the screen but does not close it allowing additional vital signs entries 9 View History allows user to view all vital signs documented on patient See screenshot below A Edit vital signs by right clicking on specific vital sign which will produce free text box B Delete vital sign entry by clicking x located to the right of the line C EDITING GCS VISUAL ACUITY single left click on the entry then edit and record Cannot delete GCS or visual acuity entries at this time D USERS CAN ONLY EDIT DELETE THEIR OWN VITAL SIGN ENTRIES E Vital signs history can also be viewed by clicking on vital sign letter in patient s chart header 10 To exit out of vitals history OR input screen click Exit Vital Signs Histo OY Bi Positio t Position Sarah 140 70 sitting awake repeated per physician request 14 15 Sarah 135 72 sitting awake pt refused repeat temperature 14 00 Sarah 165 70 itti 2 Fe sitting awake 14 50 Sarah L 20 20 R 20 25 Both 20 25 Notes Procedures All patient care intervent
18. on a patient that the logged in user is assigned to as primary provider May include 1 New patient assignments and or patient dispositions when selected by physician 2 An internal email message 3 An order cancellation B Click button to view address messages Messages From j Message Status Sent Order FRIDAY SARAH Out IV Fluid Therapy SOLUTION NS AMOUNT 500ml RATE 125 Order FRIDAY SARAH Out Amylase Serum Verbal from D Duck MD Order FRIDAY SARAH Out Lipase Serum Verbal from D Duck MD Order FRIDAY SARAH Out Basic Metabolic Profile Verbal from D Duck MD 1281201 4 07 00 PM Order FRIDAY SARAH Out HCG Qualitative Serum HCG Verbal from D Duck MD 12 9 2011 4 07 00 PM GoTo 0 PM 12 9 2011 4 07 00 PM GoTo 12 9 2011 4 07 00 PM GoTo 12 9 2011 4 07 00 PM GoTo Order FRIDAY SARAH Out Urinalysis Microscopic if indicated Verbal from D Duck MD 12 9 2011 4 07 00 PM GoTo Order FRIDAY SARAH Out Hepatic Function Panel Verbal from D Duck MD 12 9 2011 4 07 00 PM GoTo Order WEDNESDAY SARAH Out EKG Verbal from D Duck MD 12 14 2011 3 56 00 PM GoTo Order FRIDAY THANKGODITS Out EKG E 12 16 2011 11 30 00 GoTo Order FRIDAY THANKGODITS Out Morphine 10mg mi Soin for inj 5 mg IVP Verbal from D Erns 12 16 2011 4 07 00 PM GoTo 12 19 2011 12 GoTo 12 19 2011 12 32 0 GoTo 12 19 2011 12 33 00 GoTo Assign Patient FRIDAY THANKGODIT
19. s Route Orally Frequency Every day Last Taken This moming 1 Enter Medication Name multiple ways to select medication a Use search box to type the first letter or whole name b Click alphabet buttons 40 Page c d Use scroll bar Manually enter medication in top white box may be used for meds not listed in the database 2 Enter Medication details a b c d e Enter dose route frequency last time taken OR click Unknown at the bottom of each column Click Add To List This DOES NOT RECORD the medication allows user to enter multiple medications without exiting the screen OR select the med and Remove from List if desired button not functional after meds are recorded Click Record screen will close and page will refresh 3 Edit Remove Medication once already recorded a b c d e J Click Add Edit Current Medication Highlight med to edit remove discontinue checkmarks are for verification of meds not for selection Click Modify Change Status or Modify dose Edit dose route frequency as desired or select status from drop down box Click Record B Allergies click Add Edit Allergies button or select None or Unknown see screenshot below May also add edit remove allergies by clicking on Allergies in the patient s chart header Allergies for MUDDY WATERS x Filter By Categories Common C AllAllergens Categories Medications Current Allergi
20. 2 20 2 2 200 20 2 20 2 1 10 300 30 3 300 30 3 303 3 300 30 3 30 3 2110 40 4 40 4 40 4 4 40 4 40 4 3 10 co 50 5 50 5 50 5 5 50 5 50 5 a0 60 6 60 6 60 6 6 60 6 60 6 5 10 70 7 70 7 A 70 7 70 7 6 10 e 80 8 80 8 80 8 8 80 8 80 8 7 10 o 909 0 909 90 9 9 o 909 o 909 sno Y Sitting Awake 9 10 Left Arm ral Rectal L Standing Standing Asleep 10 10 Y Right Thigh Supine Axillary Tympanic supine Oww Manuab By Palpation Doppler Temporal Doppler Weight UTO Height I UTO p Pulse Oximetry F UTO Time I Actual stated SA02 On Via Time Obtained EAN isd EE _S a J 12 15 2011 14 26 100 10 1 1 100 10 1 100 10 1 10 1 1 2 RA NC T Priorto amival 200 90 2 2 200 20 2 20 2 20 2 L M Mask TUTO Al 300 30 3 3 30 3 30 3 30 3 02 NRB mask i WATERS 400 40 4 4 40 4 404 40 4 BVM keaton a 500 50 5 5 50 5 50 5 50 5 BIPAP 600 60 6 6 60 6 60 6 60 6 CPAP o ee bee o 80 8 8 80 8 80 8 80 8 ETT Ventilator Notes 90 9 9 90 9 0 90 9 90 9 Tracheostomy EE Z 1 Entering Vital Signs A Click number options OR free text and tab to next section B Select appropriate options below each vital sign 2 UTO Unable to obtain i e pt combative restless refuses etc 3 Time Obtained A Defaults to current time B Click in box to change to actual time C OR click Prior to arriva if applicable 4 Notes allows addition of free text notes to specific set
21. 53 Addendum SCA BaO S cai ida 58 EGO SITE DIOCOSS oiire e oea ito 59 Tech EMT Paramedic Documentation Vital SENS 61 Notes Procure E E A 62 Unit Clerks A ec seceeesnesntsnstennneiiieniiinnninnnniiiintinintisttinnenitenteentn 68 Ordesa a ss ola 69 3 Page General System Info for ALL Users gt EPD isa single left click system Only double click required when opening program from the desktop gt Follow the Red Road All pop up windows include a red button being the next required action to take in order to save documentation NOT clicking the red button may result in lost documentation gt Saving Refreshing Aside from pop up windows mentioned above EPD saves charted information automatically and refreshes every 30 60 seconds customizable per facility gt Date Time boxes Add edit dates and or times anywhere there is a date time line in the program gt Calendars Select arrows to change months click on month line to select year Click month line again to select year ranges Login EPOWERdoc PHYSICIANS Akkulugari S MD Arst H MD NURSES STAFF Adams P AMS Arnold A RN Assistant P PA Bixler D MD Brown K MD Chisum D DO Barth S AMS Bean S PRM Bearce B AMS Belloit W RN Ernst D MD Galvin W DO Holcomb M S MD Johnston R MD Boin S RN Brockman M RN Burch J RN Camerer R HIM Kellenberger R DO
22. EPD On gt This is the 2 of two methods of importing Click Prior Visits Choose visit from list current visit red prior visits black Select items to import bottom left e If Meds Allergies and or Medical Problems box es are inactive those items were imported via chief complaint selection OR there were none documented in prior visit Select Import History NOTE This function to be used BEFORE you begin documenting If you import history AFTER you ve already documented meds allergies PMH the import will REPLACE your documentation 7 Previewing final chart A B D Click icon on chief complaint bar Current view defaults to RN chart top left if logged in as RN May select different view types from drop down box top left Chart view defaults can be individualized for each user Administrative task 8 Triage sections described below A C Arrival and triage times Automatically populate but can be changed manually to reflect actual times 1 Alerts when alert selected will populate corresponding column of tracking board Facility dependent General Info 1 First use of 3 click function 2 Isolation Status when item is selected patient s name on tracking board will be pink Vital signs Add Edit Vital Signs button located in every tab See screenshot below This is the vital signs entry screen May also get this screen by clicking on the Ht or Wt i
23. Enter free text note d If desired make note public using checkbox Allows other physicians to view note e Click Record to add to Quick Notes database this does not add note to chart f Select note and click Add to List g Choose additional notes and or click Record to add to chart 46 Page Categories Show All Notes Only Public Only Private Both Assessment Disposition General My Notes Add a new Note lx New Note e New Note Category Course E ME Note Call placed to Consultant Lh Qos nee nase GD Close C Reassessment Allows for a quick patient reassessment 3 Consultation s A Select Provider 1 Select from provider list using one of the 3 search tools or add new provider as discussed in History tab 2 Choose from one of three consult options on bottom right of the window 3 Click Record 4 Fill out appropriate information including date times 47 Page Orders EPOWERdoc 2 9 All Patients All Beds My Patients To Be Seen Incomplete FRIDAY THANKGODITS 12 20 2011 20 54 PCP 67 BP 110 85 T 6 Allergies MRN Roo AT 12 20 2011 11 29 Phys NP NPPA NPPA 7 Code Levek 0 Sarah M Johnson BSN S History Physical Procedures Results Disposition 4 Chief Complai EXTREMITY PROBLEM EE 0 9900 nara New gffers N P acord Order Cardiopulmonary Thankgodil TSE i Labs Meds Medications hrer Cancel Order Free text order O Task list testin
24. In calendar i Use arrows to select monthd ii Click on month title bar to select year iii Click on year title bar to select year range iv If exact month day not known just select year and click OK e Add additional problems as applicable f Click Record 2 Editing Removing Medical Problems a Click Medical Problems button b Highlight problem to edit remove Checkbox used for verification purposes not for problem selection c Select Change Status d Click Inactive or Remove e Click Save Changes and Record 20 Page G Medication Reconciliation 1 This button used ONLY after RN has verified all home medications allergies and medical problems 2 Allows other users to know the medication reconciliation process has been completed for this visit 3 Adds statement to the chart including user date time H PCP click on the Add Edit Primary Care Provider button or select None out of town or doesn t know name May also do this by clicking on PCP in the patient s chart header Primary Care Providers blank Family Practice blank Abraham Michael IT EPOWERdoc Ball Eye MD Bogart Jama NP Bogart Jama NP Bogart Jama NP Brewster Joseph MD Bates County Memorial Hospital Brewster Sam Brewster Joseph MD Bates County Memorial Hospital Brewster Joseph MD Bates County Memorial Hospital Brewster Sam Brewster Joseph MD Bates County Memorial Hospital Brewster Sam Brewster Joseph MD Bate
25. ORD the allergy allows user to enter multiple allergies without exiting the screen d You can also Remove From List as needed button is only active before recording allergy e Click Record 3 Editing Removing Allergies a Click Add Edit Allergies b Highlight allergy checkbox is for verification purposes only not for selecting med c Select Change Status and choose item as necessary d Click Save Changes or ignore if applicable e Click Record 19 Page F Medical Problems Click Medical Problems button or select None or Unknown Medical Problems for MUDDY WATERS x Problems Show All Show Active Show Inactive 050 0 Variola major 050 1 Alastrim 050 2 Modified smallpox 051 2 Contagious pustular dermatitis 051 9 Paravaccinia unspecified 052 Chickenpox 052 0 Postvaricella encephalitis 052 1 Varicella hemorhagic pneumonitis 052 7 With other specified complications 052 8 With unspecified complication 052 9 Varicella without mention of complication 053 Herpes zoster 053 0 With meningitis 053 1 With other nervous system complications 053 10 With unspecified nervous system compli 053 11 Geniculate herpes zoster 053 12 Postherpetic trigeminal neuralgia 053 13 Postherpetic polyneuropathy zi 1 Entering Medical Problems a Search by description or ICD9 code b Enter part of or entire problem in Search For box c Select problem and click Add to List d
26. Quick Note Create user specific notes for future use d Choose Spanish if applicable e May add edit prescriptions excuses from D C Instructions window see instructions below f Click Record if not ready to print OR click Record and Print g DC Release select appropriate choice Ready for D C Changes stage of care on tracking board to Waiting Discharge DC pending L XR If RN to discharge patient AFTER labs xrays are done Changes stage of care to Hold and places notification in RN Disposition tab DC pending orders If RN to discharge patient AFTER carrying out particular orders Changes stage of care to Hold and places notification in RN Disposition tab h Click Release Discharge Hold button if set as mentioned above when patient ready for DC Changes stage of care from Hold to selected dispostion Prescriptions Excuses a PRESCRIPTIONS a honap f Click Prescriptions Excuses button in Disposition section OR click Add Edit Rx Excuses button from within DC Instructions window Review and fill out medication reconciliation if window appears facility dependent By prescribing these medications button will produce statement in the chart In Rx window select medication using search box alphabet or scroll bar Fill out prescription pad as necessary using keyboard OR number pad Choose Dispense as Written as applicable leaving checkbox blank will show Generic Allow
27. S Out FRIDAY THANKGODITS in room no WR 1 has been assigned Assign Patient FRIDAY THANKGODITS Out FRIDAY THANKGODITS in room no WR 1 has been assigned Assign Patient FRIDAY THANKGODITS Out FRIDAY THANKGODITS in room no WR 1 has been assigned secre 1 Orders noted or recorded from Pending Orders section automatically removed from Messages queue 2 To address document an order from Messages window click directly on patient s name OR click GoTo 3 Click on message to open it 4 To remove a message select checkbox and click Note OR click directly on Message and click Delete C Send a New Message 1 Use for communication purposes 2 May link message to particular patient 3 Click inside To box to produce list of providers for selection 4 Select one or multiple groups OR select customized group from drop down box click OK 35 Page 5 Enter other desired info click Send D Print Messages a hard copy may be printed as needed 2 A red carat will appear next to patient s name on tracking board when messages orders exist on that patient A By clicking patient s name you may view messages ONLY for that patient B Inthe view print window select Messages then click View C ANYONE can view messages for a patient by clicking the name even if logged in user is NOT the primary provider 3 View Print messages May also view messages by clicking on patient s name while inside pa
28. TRIC ABDOMINAL TENDERNESS GENERALIZED ABDOMINAL TENDERNESS LEFT LOWER QUADRANT ABDOMINAL TENDERNESS LEFT UPPER QUADRANT ABDOMINAL TENDERNESS PERIUMBILICAL ABDOMINAL TENDERNESS RIGHT LOWER QUADRANT ABDOMINAL TENDERNESS RIGHT UPPER QUADRANT ABDOMINAL TRAUMA ABNORMAL ACID PHOSPHATASE LEVEL ABNORMAL ALKALINE PHOSPHATASE LEVEL ABNORMAL AMYLASE LEVEL ABNORMAL ARTERIAL BLOOD GASES ase TRE ABNORMAL BOWEL SOUNDS y ance eco A Select desired impression using search box or scroll bar B Click Add to Final Impressions to populate list on the right C If desired impression not listed in database type it in the Search box 1 For one time use click Add to Final Impressions 2 To save to database click Add to Final Impressions and Save for future Searches D Once all desired impressions listed may use Move Up and Move Down buttons to place in specific order 53 Page E Use the Remove Selected button if needed F Click Record 2 Disposition Phys A Discharge Instructions Prescriptions and Excuses listed under DISCHARGE disposition B Select appropriate disposition for patient each will populate a specific template accordingly C Time of Disposition Must be documented in order to sign off chart Changes stage of care on tracking board to Waiting selected disposition D Discharge 1 Discharge Instructions Discharge Instructions TST EDS
29. VING user should have NO patients listed under a My Patients tab b Incompletes tab or c top half of slide out tool 37 Page Physician Documentation Quick Highlights General Info o Single click system no double clicking to select and item o Follow the red road o No need to save refresh while charting except in pop up windows o Blank lines free text box or time box Documentation o Click on Chief Complaint to open patient chart o Chart initially opens to History tab then will always open to last place most recent user left off within chart o 3 click function 1st click circles prompt 2nd click either un circles prompt OR where appropriate places red slash making it a pertinent negative 3 click removes slash o Physicians may view all nursing documentation but not able to document on RN tabs o Orders tab shared between RN s and Physicians Viewing Printing Chart o Through View Print screen 1 Click patient s name on Tracking Board 2 Click patient s name in chart header while inside patient s chart 3 Click Printing button in the Disposition tab o Through Preview button on Chief Complaint Bar while inside patient s chart Viewing Entering Vital Signs o Enter vitals via Vital Signs entry screen 1 Click Add Edit Vital Signs button within RN chart tabs 2 Click on V in vital signs colum on tracking board next to patients name o E
30. al Procedures Results Orders History Nursing notes 12 20 2011 12 25 12 20 2011 12 25 Sarah IV placement with fluids RN Procedures IV Placement with fluids Time fluids initiated By ThisED EMS Another hospital Solution NS LR 1 2NS 14NS D51 2NS D5W DIOW Amount mi 50 100 250 500 1000 or mi Rate Bolus KVO20ml hr KVO30mV hr 125 ml hr 250ml hr 500 ml hr 1000 ml hr or Site R L Antecubital Forearm Wrist Hand Finger Thumb Bicep Externaljugular Scalp Shoulder Other 12 14 16 18 20 22 24 Butterfly or Double lumen 181 20 20 22 20 24 Attempts 1 2 3 4 5 gt 5 Difficult IV procedure Complications None Infiltration Inability to aspirate blood Unsuccessful Notes Time stopped Additive mihr via W pump Foot Catheter size 5 Medications A All medications should be documented via Pending Orders section B If need to document medication not listed in pending orders click Medications button C Search for specific medication using one of multiple search functions D Fill out sections as appropriate E Click Add To List then Record F OR select med and Remove From List if erroneous 6 Quick Notes Notes Interventions THANKGODITS FRIDAY K F All Notes cd rn si M Triage I Interventions I Tests I Comfort Safety I Monitoring I Patient Interaction I Patient Tracking I Resuscitation I Trauma I Techs Il Respiratory Therapy I Transporters Free tex
31. ation 1 Macro button usage Y a Click button to select all normal prompts within section then button will turn green J b System Macros Precede individual systems l e ENT Skin etc c May still change prompts after clicking macro button d Click green button to remove all the normal prompts e Another method Document all abnormals first THEN click Macro button to select all other normals 2 Click PE Complete upon completion 3 Coding tool in chart header will populate as applicable 4 Coding level total will then calculate automatically Course 1 Diagnostic Considerations for A Medical Decision Making required B Specific to each chief complaint C Circle one or multiple prompts AND OR use free text line if needed 2 Notes Course A Fill out as appropriate B Quick Notes see screenshots below 1 Select existing note a Use Show All checkbox OR b Select category c Choose Public Private or Both d Click on desired note e Click Add to List f Select additional notes and or click Record to add to chart 45 Page EPOWERdoc 2 9 All Patients My Patients To Be Seen Incomplete PCP Allergies Close C Only Public Only Private Both Call placed to Consultant New Note Edit Close Selected Notes 2 To create New Note a Click New Note button b Select existing category from drop down box or free text new category c
32. by facility 2 Green V normal vitals 3 No V no vitals entered on that patient 4 Clicking on V opens vital signs entry screen Acuity Levels customized per facility 1 Populates when assigned through triage note 2 May be assigned changed manually by clicking on cell to open Acuity box this will NOT change original Triage acuity LOS Length of stay 1 Clock starts when the patient is first entered into system 2 Clock stops when pt is discharged Time of Departure is selected in RN Disposition tab 3 Clock does NOT restart when patient is moved from room to room 4 Carat colors yellow gt 2 hrs orange gt 4 hrs red gt 6 hrs CHIEF COMPLAINT THIS IS THE PORTAL INTO THE PATIENT S CHART 1 Assigned by nurse when chart is initiated i e if no chief complaint listed patient has not been triaged 2 Click on cell to open 8 Page 3 Click on chief complaint to document on patient chart RN Prov1 1 Nurse assigned to patient as Primary 2 May pre assign by clicking on room number 3 Automatically populates when RN begins documenting in Assessment tab 4 May have second RN column for LPN s and or Paramedics 5 Click on cell to open PHYS PA 1 PHYS Populates when physician begins documenting 2 PA Used for secondary provider 3 Click on cell to open Orders Shows the progress of any orders placed into EPD Labs Rad General 1 1 value number of items ordered 2 2 value
33. chart ii Hard Stops blue gt Items must be completed in order to sign chart but CAN be overridden in particular instances gt Click directly on warning to go to part of chart requiring completion gt OR click Override and select or free text reason for override gt After completion return to Disposition tab to sign chart iii Soft Stops black gt Served mostly reminders or warnings in the patient record i e abnormal vital signs labs not reviewed by physician etc gt Not required to address or override c Once warnings addressed click Yes to sign off d Chart Signed by statement with user date time placed on chart 2 Transfer button a Used to transfer care of patient to another physician reporting off b Warning box appears all are soft stops user should address warnings pertaining to parts of chart that the transferring user was responsible for c Once warnings addressed click Yes to proceed with transfer d Select Physician PA NP to transfer to e Click Record f A Report given to statement will appear with user date time g Chart signed by statement will appear with user date time h If erroneous transfer click Undo Transfer button 3 Remove button Allows removal of user s name from chart G Printing button Produces Print View screen allowing user to view print certain aspects of chart See General Info section of manual for fur
34. cting desired items to view i e admitted patients patients with orders placed awaiting discharge etc 2 Tracking Board Body Active Patient Area Tracking board views may differ depending on the View ID number in the provider settings and facility customizations Acuity VS LOS Chief Complaint RN1 Physi Phys2 Stage of EKG LAB RAD GEN ISO Plan In Comments Chart Care fo Y EDSEL T 24YrM Abdominal pain B 41 Yr F Abdominal pain 47 Yr Mm Allergic reaction 25 Yr M 2 Back or flank pain 33 Yr F ee 43 YrM Extremity swellin Allergic reaction A Room ED layout customized by facility 1 Bed Management a Moving patient to a room Click on room number and select desired area and room number then Assign pt b Select Triage disposition at bottom of Triage or Assessment tab to assign pt to room 2 Reserve a bed a Click room number b Click Reserved then click Record c Type reason for reserved then click Record 3 Block assigning May pre assign nurses using this function ONLY IF ROOM IS EMPTY a Click room number b Click Ready or Reserved if reserving an ambulance also c Click Assign RN select RN name and click Record d To UN assign click room number se
35. d or intellectual property rights by persons or firms will be prosecuted to the fullest extent f you do not have a current license agreement with EPOWERdoc Inc you are prohibited from installing or using this 7 mms and conditions Continuing with installation or use indicates that Version 2 9 4 Page A Physicians secondary providers on left nurses and ancillary staff on right B Numeric user ID will populate May type the number for quicker access C May also type last name i e Johnson 2 Password If 1 time entering the system password is 1 You will then be asked to set new password 3 Click Login User button or hit Enter This opens the main screen tracking board TB Other functions on login screen may be selected BEFORE HITTING ENTER but are for authorized users only Main Screen Tracking Board TB Functions explained below EPOWERdoc 2 9 ADD Patient Active Patients Bates County Memorial Hospital Total 10 RECENT Patients Waiting Room d OLD Patients Tonea A Be S Waiting Admission 0 Call Backs Total Incomplete Acuity VS LOS Chief Complaint a Phys2 Stage of Chart Care A EDSEL T Abdominal pain B Nabdominal pain aaa va Back or flank pain vob or substa Extremity swellin Allergic reaction Tube replacement gt
36. der a Click Add Patient b Fill in known patient info c Click on Register d On the next screen click Information Confirmed e The patient will now show on the TB name will be blue and may be charted on until registration finishes the full registration process f NOTE IF ORDERS ARE PLACED ON A BLUE PT the orders will not go through until the patient is reconciled merged by registration g Registration must complete the reconciliation process on any blue patient 2 Recent Patients Will display all inactive ED patients in alphabetical order within the last 48 hours 3 Old Patients Used to search for inactive ED patients of more than 48 hours ago 4 Call Backs Patients who the ED physician or nurse has set to be followed up on i e to check pain level give radiology results make sure wound is healing well etc Further discussed in Documentation C Tabs on right side of Tracking Board header This area never changes regardless of where user is in the system 1 Minimize Screen 2 Logout of EPD 3 Resources Lists all physicians including specialties referrals etc 4 Messages a Turns red when logged in user has messages b Messages include orders for a patient assigned to user patient assignments and dispositions and or email messages if created in EPD c Ared carat also appears next to patient s name if order s exist for that patient 6 Page 5 Filter View Allows user to change view of tracking board by sele
37. details a Enter dose route frequency last time taken b OR click Unknown at the bottom of each column c Click Add To List This DOES NOT RECORD the medication allows user to enter multiple medications without exiting the screen d OR select the med and Remove from List if desired button not functional after meds are recorded e Click Record screen will close and page will refresh 3 Edit Remove Medication once already recorded a Click Add Edit Current Medication b Highlight med to edit remove discontinue checkmarks are for verification of meds not for selection c Click Modify d Change Status or Modify dose e Edit dose route frequency as desired or select status from drop down box f Click Record to add to the list then click Record again to add to the chart 18 Page E Allergies click Add Edit Allergies button or select None or Unknown see screenshot below May also add edit remove allergies by clicking on Allergies in the patient s chart header Allergies for MUDDY WATERS IK 1 Entering Allergies multiple ways to select an allergy a Filter by category b Use search box c Use scroll bar d Add unlisted or free text allergy in the Other allergy box at the bottom 2 Entering Reactions a Select appropriate reaction s b OR add unlisted or free text reaction in the Other reaction box at the bottom c Add To List This DOES NOT REC
38. dit vitals or View History 1 Click directly on one of the vital signs acronyms in patient chart header 2 Click View History button within vital signs entry screen 3 RIGHT CLICK on vital sign to edit 4 LEFT CLICK on GCS Visual Acuity to edit Signing Off Locking Charts May not be required to lock Determined by facility o All primary users responsible for signing AND or locking charts before end of each shift o In EPD user is considered primary provider if 1 User name displayed in 1 MD provider column on tracking board 2 Checkmark appears by user s name in Sign Off section of Disposition tab o Logged in user s charts located in My Patients tab slide out tool and or Incompletes tab o See End of Shift Process at the end of Physician Documentation portion of the manual Coding Assist Tool o Located in the upper right hand corner of patient chart header left of user information area o After completing each of the sections designated by the 4 acronyms will turn from orange to white and will automatically calculate coding level o Clicking on each acronym will bring you to the place in the chart where that section is located 38 Page History 1 Enter patient s chart through Chief Complaint on tracking board 2 11 time in patient s chart opens to History tab 3 The green dash in every section allows user to minimize collapse section the red allows user to re open section 4 Most triage information fo
39. e 7 Click Record Time of Departure 1 To be addressed when patient PHYSICALLY LEAVES department 2 Must be addressed before signing off the chart Disposition Signature 1 Release Bed Assignment CLICKING THIS BUTTON REMOVES PATIENT FROM ACTIVE TRACKING BOARD 1 Use ONLY when patient PHYSICALLY LEAVES ED 2 Once released patient removes from active tracking board and is placed in Recent Patients 3 The patient will also appear in slide out tool in Recent Patients 4 User may still document and or sign off chart after bed is released 30 Page 4 Call Backs A B C Used for multiple purposes 1 Lab Condition recheck 2 Patients who Elope LWBS Some facilities require this 3 Change in radiology report If set by RN or Phys chart will appear in Call Backs top left queue on main Tracking Board To complete a callback 1 Click patient s name in Call Back list 2 Select RN Chart click View 3 Click RN Addendum on bottom left 4 Document appropriate information and click Record 5 land O Totals automatically populate Notifications If anyone has been notified regarding this patient 7 Notes A If alternate forms used i e blood transfusion restraints OR forms sedation etc B Critical care time Fill in as appropriate if applicable to facility Not usually for RN use 8 Sign Off A Places final signature on chart B Primary provider is denoted with a check bo
40. e database a Bottom of right column click New Provider b Fill in known information 43 Page c Click Record if only recording it to patient s chart for this visit OR click Record and Save to save added physician to the database for future use 3 Edit Provider Info a Select provider to edit b Click Edit button on far right c Edit necessary information d Click Record E Prehospital Populated from triage 1 Add Edit Prehospital Medications Includes meds given by EMS EMS Medications I Adenosine 3mg ml Soln for Inj T Magnesium Sulf 50 for Inj J Albuterol 0 5 Soln for Inh J Midazolam mg ml Soln for Inj J Albuterol 9Omcg act Inhaler J Morphine 2m9 ml Soln for Inj J Amiodarone 50ma ml for Inj J Naloxone 0 4mg ml Soln for Inj T Aspirin 81mg Chew Tab T Nitroglycerin 0 4mg SL Tab I Atropine 0 4m9 ml Soln for Inj I Sodium Bicarbonate 5 for Inj I Benadryl 50ma ml Soln for Inj I Dextrose 25 Soln for Inj I Diazepam 5mg ml Soln for Inj J Epinephrine 1 10 000 for Inj I Epinephrine 1 1000 for Inj I Furosemide 10m9 ml for Inj I Glucagon Emergency Kit Img I Hydrocodone APAP 10 325mg Tab I Hydrocodone APAP 7 5 500mg Tab I Hydrocodone APAP 7 5 750mg Tab I Tetanus dTAP Pediatric T Ipratrop Albut 0 5 3mg 3ml Inh T Tetanus Immune Globulin Adults T Lidocaine 0 5 Soln for Inj J Tetanus Immune Globulin Pediatric a Select the appropriate medication b Enter any kn
41. ed on script Click Create Prescription will populate in the list below Repeat steps c g as necessary Once all desired prescriptions listed i Move on to create excuses see below 2c ii Save them as a prescription set for future use by clicking Save as New Rx Set See below 2b iii If no excuses desired click Record if not ready to print OR click Record and Print b MANAGING PRESCRIPTION SETS user specific a b Select create set of prescriptions as desired for specific diagnoses Click Manage my Rx sets 55 Page Manage My Rx Sets Create New Set My Rx Sets ccoo Bd Prescription for Drugs for Rx Set c 3 Call Back Dispense amount Dispense unit Sig Unit Freq Additional instructions Refills p T Dispense as written c Click Create New Set d Free text set name and Record e Click Add Drugs f Select desired medication and Record then highlight medication and fill out prescription pad as necessary DO NOT click Save until all desired prescriptions added g Repeat adding drugs then click Save h Edit or Delete sets by selecting the set from the My Rx Sets drop down box within Manage My Rx Sets window Add edit remove sets and or medications EXCUSES j Click Prescriptions Excuses OR click Add Edit Rx Excuses button from within DC Instructions window OR click Create Excuse button from within Rx window i Selec
42. edited in this tab will not flow backwards to Triage tab 3 Macro button Y Si A Click button to select all normal prompts within section then button will turn green System Macros Precede individual systems l e ENT Skin etc May still change prompts after clicking macro button Click green button to remove all the normal prompts Another method Document all abnormals first THEN click Macro button to select all other mon y normals 4 Adding additional Chief Complaint click on Chief Complaint Bar produces Chief Complaint Selection screen for add edit removal of CC authorized users only Chief Complaint KIDNEY STONE EE 9900 5 SEE TRIAGE INSTRUCTIONS FOR CURRENT MEDS ALLERGIES MEDICAL PROBLEMS AND PCP 6 Other sections within this tab are as follows A General Assessment General appearance of the patient B Nursing Assessment Details of patient s complaint entered in Triage tab will populate User may edit as necessary This will NOT change information entered in Triage tab C Nursing Exam User s physical examination documentation D Past Medical Family Social History 1 Click No significant or Unknown if warranted 2 Information will transfer to physician s History tab E Patient Safety Screening 1 Click the Macro button if you want to select all normal prompts 2 Click Unable to Assess or Unable Unwilling to answer if necessary 3 You MUST s
43. elect an option for each individual screening F You may assign acuity level and room if not done in the Triage tab G Sign Assessment Places signature on the chart for nursing assessment documentation H Sign Triage If triage was completed in Assessment tab still must Sign Triage Course 1 Majority of patient care documented in this tab 2 Vital Signs see Triage section in manual 3 Pending Orders A ANY orders placed in Orders tab B May select individual order or use Select All box when necessary 1 Noted Simply acknowledges the order a Recommended use only for orders the user will not be doing anything with such as radiology tests b Select order s 23 Page a e f Click Noted Order is removed from Pending Orders section and placed in Nursing Notes section as Order Noted order name with user name date time both functions facility dependent The Noted column in the Orders tab automatically populates with the appropriate time Order is also removed from Messages queue 2 In Progress Places an order in progress making other users aware the order is being carried out to avoid duplicate actions a b c d e f g Select order s Click In Progress Order remains in Pending Orders and turns red until further recorded The Noted and Initiated columns in Orders tab automatically populate with appropriate time Order also shows as in p
44. es Show All Show Active Show Inactive 1 Entering Allergies multiple ways to select an allergy a Filter by category 41 Page b c d Use search box Use scroll bar Add unlisted or free text allergy in the Other allergy box at the bottom 2 Entering Reactions a b c d e Select appropriate reaction s OR add unlisted or free text reaction in the Other reaction box at the bottom Add To List This DOES NOT RECORD the allergy allows user to enter multiple allergies without exiting the screen You can also Remove From List as needed button is only active before recording allergy Click Record 3 Editing Removing Allergies a b c d e Click Add Edit Allergies Highlight allergy checkbox is for verification purposes only not for selecting med Select Change Status and choose item as necessary Click Save Changes or ignore if applicable Click Record C Medical Problems Click Medical Problems button or select None or Unknown Medical Problems for MUDDY WATERS x Problems Show All Show Active Show Inactive Change Status Remove from List 1 Entering Medical Problems a b Search by description or ICD9 code Enter part of or entire problem in Search For box 42 Page c Select problem and click Add to List d In calendar v Use arrows to select monthd vi Click on month title bar to select year vii C
45. ew Print order sheet by clicking Print button OR Order Sheet button 1 Order Sets NOT user specific may pertain to quality indicators or standards of care See 7C for additions and editing a b c Click the desired pre constructed order set In the Protocol Order Set screen select desired orders noting reference material in the right column Select Mode of Transportation if applicable then Add to order sheet and Record as previously instructed 7 Editing Order Sets Bottom left of Orders tab Can be done while inside any patient chart A Facility Orders Authorized users only B My Orders Individual physicians secondary providers 1 Click My Orders Manage My Orders Xx O A ooo kS TEE Categories for Set xyz 2 To Add a Click Add New Set b Enter set title in free text box and click Save c Choose desired orders from categories on the right d Once added may link set to a chief complaint by clicking Link Sets to CC and choosing from the selection menu e Click Save and Close 3 To Edit a Select desired set name orders in set will appear in Orders column b Edit name of set click Edit Set Name c Edit set contents select order on the right and click Remove From Set OR add order by choosing from category d Click Save and Close 51 Page 4 To Remove a Select set to be deleted then click Remove Set
46. g AAA C Trauma Major Print one 1 Placing new orders Orders on left actions on right A Select desired orders from categories on left category descriptions listed below B Within each window use search box OR scroll bar C Select one or multiple orders D Certain orders may require further information if so pop up box will appear when order is selected Click Add to Order Sheet F Continue steps A E as needed 1 General Contains nursing tech orders and interventions i e IV restraints ice chips etc 2 Cardiopulmonary contains Cardiology and RT orders 3 Labs contains point of care testing quick lists and all other labs as provided by facility 4 Radiology includes xray CT scans MRI Ultrasounds Nuc Med etc a Select Mode of Transporation on the bottom right required field b Requires Indications box will appear after Recording orders i Default list is Suggested List for given chief complaint OR click Show all indications to view entire list 48 Page ii Add edit delete indication from list by clicking Edit Indications Edit Indication List Ix Add New Indication Bu Pal Carbon monoxide 5 Record CarboxyHemoglobin iii Click Add New Indication Use free text box click Record to add it to list Close Edit Indications window find newly added indication select it and click Record iv Edit Indication Select indication to edit
47. ic Flushed Jaundiced Mottled Pale Normal Tugor Decreased Normal Mental status Awake Alert Oriented to Person Place Time Notoriented Noresponse Unable to assess M OOD gt Change date time or use default Select Reassessment type produces specific template for further charting Fill out as necessary Use Notes line for additional free text if applicable Click Record Reassessment note will populate in Nursing Notes section 29 Page Disposition 1 Add Edit Vital Signs as in previous sections 2 Final Diagnosis Impression automatically populates from physician Disposition tab 3 Disposition A If physician has selected disposition will auto populate in RN Disposition tab B If physician created D C Instructions Rx and or excuses will appear at bottom of RN Disposition section C Add Edit Rx and Excuses RN s can only add or edit excuses NOT prescriptions 1 Click the Add Edit Rx and Excuses button 2 X out of Medication Reconciliation window 3 In Prescriptions screen click Create Excuses at the bottom 4 If excuse previously created Excuses window will show information Excuses Ix Select Time Frame Nowork from _________ Retumon _________ Imstmuctionss ___ Light work from Retum on Instructions No school from Retum on Instructions No Phys Ed from Retum on Instructions O Ua I Note for Treatment in the ED 5 Add edit desired information 6 Click Create Excus
48. icular chief complaints B Orders in set automatically populate Order sheet C Must cancel order if not needed My Orders User specific order sets created by the individual physician See 7B for additions and editing A For adding edit removing sets see 7B below B Select desired order set C Orders in set automatically populate Order sheet D Must cancel order if not needed Order Sets Set up by facility not user specific A Selection of order set produces window containing orders to choose from B Select desired orders and Add to Order Sheet C Record via normal ordering process Cancelling Orders A May NOT cancel order already placed in progress or recorded from pending orders B In Orders tab select order to be cancelled C Click Cancel Order D Click Yes or No in warning box E Enter reason for cancellation in free text box then click Record F Order will be removed from Pending Orders section AND will appear in Messages queue as order cancelled G If need to cancel order after already initiated 1 In Course tab under Pending Orders select order that was initiated in progress and click Note 2 In Orders tab enter Free text order 3 Type cancellation and reason click OK 4 Record new free text order 5 Order for cancellation will appear in Pending Orders in Course tab 6 Select order in Pending Orders and click Noted 50 Page 6 Vi
49. ient chart o Due to privileges ward clerks can only view document on certain parts of chart discussed later Viewing Printing the Chart o Through View Print screen 1 Click patient s name on Tracking Board 2 Click patient s name in chart header while inside patient s chart 3 Click Printing button in the Disposition tab o Through Preview button on Chief Complaint Bar while inside patient s chart Viewing Vital Signs o View History click on the V in vital signs column on tracking board e Privilege setting may NOT allow this function o OR click on patient s name on tracking board to view RN chart as discussed above Orders Results o To view manage orders i Click in Orders column next to patient s name this will open to Orders tab ii OR click on chief complaint to open patient s chart then go to Orders tab o To view results 1 Click in Orders column next to patient s name this will open to Orders tab 2 OR click on chief complaint to open patient s chart then go to Results tab on Physician side Rec Printing o To print a requisition for any order 1 In Orders tab check the box next to desired order 2 Click Print on bottom right of tab 68 Page Orders Unit Clerks functions designated by facility EPOWERdoc 2 9 All Patients All Beds My Patients To Be Seen Incomplete FRIDAY THANKG Phys NP NPPA NPPA wt UNI 12 20 2011 20 54 PCP 7 BP 110 85 7
50. ions and or procedures are documented in RN Course tab 1 Pending Orders A ANY orders placed in Orders tab B May select individual order or use Select All box when necessary 1 Noted Simply acknowledges the order 62 Page a b c d e 1 Recommended use only for orders the user will not be doing anything with such as radiology tests Select order s Click Noted Order is removed from Pending Orders section and placed in Nursing Notes section as Order Noted order name with user name date time both functions facility dependent The Noted column in the Orders tab automatically populates with the appropriate time Order is also removed from Messages queue 2 In Progress Places an order in progress making other users aware order is being carried out to avoid duplicate actions a b c d e f g Select order s Click In Progress Order remains in Pending Orders and turns red until further recorded The Noted and Initiated columns in Orders tab automatically populate with appropriate time Order also shows as in progress in Messages queue NOTE Orders CANNOT be cancelled after placed in progress To cancel order after in progress e Select order in Pending Orders and Note it e Place Free Text Order in Orders tab Order cancelled reason e Go back to Course tab and Record free text order 3 Record Order Used for completion o
51. it out of the vitals history OR the input screen click Exit Vital Signs History Time Deny 14 45 Sarah 140 70 repeated per physician request 14 15 Sarah 135 72 pt refused repeat temperature 14 00 Sarah 165 70 14 50 Sarah L 20 20 R 20 25 Both 20 25 17 Page D Current Medications click Add Edit Current Medication button or select None or Unknown Current Medications for MUDDY WATERS Drug Name Begins With Drug Name Contains lafe Jo fo fe fe fo fu fr fo Pu fo fm 0000 A 0 ES Ka ES 12 Hr Decongestant ER Tab E 12 Hr Nasal Spray 12Hr Nasal Spray 12 Hr Nasal Spray 12 Hr No Drip Nasal Spray 12 Hr Sinus Nasal Spray 12 Hr Sinus Relief Nasal Spray 29G 1 2in Pen Needle 29G 1 2in Pen Tip Needle 29G 1 2in Unifine Pentips 29G 1 2in Unifine Pentips 31G 1 4in Pen Needle 31G 1 4in Pen Tip Needle 31G 1 4in Unifine Pentips 31G 1 4in Unifine Pentips 31G 5 16in Pen Needle 31G 5 16in Pen Needle 31G 5 16in Pen Tip Needle hu Dose 1 tablet s Route Orally Frequency Every day Last Taken This moming x Frequency Last Taken 1 Enter Medication Name multiple ways to select medication a Use search box to type the first letter or whole name b Click alphabet buttons c Use scroll bar d Manually enter medication in top white box may be used for meds not listed in the database 2 Enter Medication
52. l Signs o Enter vitals via the Vital Signs entry screen 1 Click the Add Edit Vital Signs button within RN chart tabs 2 Click the V on tracking board next to patient s name o Edit vitals or View History 1 Click directly on one of the vital signs acronyms in the patient chart header 2 Click the View History button within the vital signs entry screen 3 RIGHT CLICK on vital sign to edit Patient Care Orders o In RN Course tab 1 Pending Orders use In Progress ONLY if you will be performing order 2 Click Record Order ONLY if order has been completed 3 If order is linked to a procedure fill in appropriate documentation as applicable 4 If order is not linked to a procedure and further documentation is desired required click Procedures button to document procedure as necessary 5 May also use Free text Notes and or Quick Notes as desired 60 Page Vital Signs Add Edit Vital Signs button located in every tab See screenshot below This is the vital signs entry screen May also get this screen by clicking on the Ht or Wt in the patient s chart header OR click on the V on tracking board Vital Signs UDDY WATERS B aes T UTO gt y Temperature TUTO T UTO Respiratory Rate UTO p Pain f UTO 100 10 1 100 10 1 100 10 1 1 100 10 1 100 10 1 vo 8 200 20 2 200 20
53. laint or 1 few letters in search box OR C Use scroll bar on the right Select desired chief complaint it will appear in Selected CC box Add optional text at the bottom if needed by clicking on selected chief complaint Click Record Importing Prior Visits via CC A IF patient has prior visits IN EPD does not include visits prior to EPD implementation Import S ont History box will appear after clicking Record B This is one of two ways to import See Prior Visits below C May import Current Medications Allergies and or Medical Problems 14 Page D If selection s is are gray these were not documented on prior visit 6 The screen will take a few seconds to refresh and will open directly to the Triage tab Triage 1 Can be done from Triage OR Assessment tab If primary nurse will be triaging the patient begin 2 Triage performed within Nursing Assessment if bypassing Triage tab and starting in Assessment tab 3 The green dash in every section allows user to minimize collapse section the red allows user to re open section Most triage information forwards to Assessment tab AND to physician s History tab 5 Adding an additional Chief Complaint click on the Chief Complaint Bar produces Chief Complaint Selection screen for add edit removal of CC authorized users only Chief Complaint KIDNEY STONE Ea O 9900 Ml morts patient history If red patient has prior visit IN
54. lect any radio dial then click Record e NOTE If RN is pre assigned that RN will remain assigned to that room when patient is gone If RN assigned through the chart RN name will be removed from room when patient is gone B Name pt s name age and gender 1 Blue name patient has been manually added into EPD and must be merged by registration 2 Green name patient has been registered via hospital registration system and correctly crossed into EPD but chart not yet initiated i e patient signed in and waiting to be triaged 7 Page 3 Black name patient has been merged AND chart has been initiated All patient names eventually need to be black NOTE Orders will not cross interface if patient s name is blue 4 Click on patient s name Produces view print screen or patient menu See below Select to view and or print any part of the patient s chart EMRdoc Ix MONDAY MANIC O Previous Records Not printed O Insurance Not printed E A WA E mio naped View Print O RAN Chat Not printed E Se R Screen O Discharge Instructions Not printed O RX O Excuses Not printed i u I Meds Reconciliation Not printed Patient O Order Sheet Not printed O Complete Legal Log O Changes Legal Log O HIPAA Log O Transfer Form Not printed O Admission Form Not printed Ol Messages Not printed MA EE E a VS Vital Signs 1 Red V abnormal vitals parameters set
55. lick Printing button in the Disposition tab 58 Page End of Shift Process At the end of every shift ALL primary and or tracking board providers are responsible for making certain their charts are completed signed off and or locked Process and requirements determined by facility and discussed during Education 1 Sign Off on Active patients those still in ED A From active tracking board click on My Patients tab or slide out tool B Once report has been given on existing patients transfer care of patients to oncoming physician or nurse C Open patient chart From slide out tool click on patient s name unsigned charts appear on top half 1 2 3 4 5 6 7 In Sign Off section of Disposition tab checkmark should appear by logged in user s name if primary provider Click Transfer Address any warnings pertaining to parts of chart you were responsible for Select name of receiving RN then click Record Checkmark will move to receiving RN s name designating him her as new primary provider for patient Report given to AND Chart signed by statement placed in chart Patient removed from My Patients AND transferred to bottom half of slide out tool 2 Sign off on Inactive patients those no longer in the ED A Click Incompletes tab OR click slide out tool while on Recent Patients tracking board B Open patient chart From slide out tool click on patien
56. lick on year title bar to select year range viii If exact month day not known just select year and click OK e Add additional problems as applicable f Click Record 2 Editing Removing Medical Problems a Click Medical Problems button b Highlight problem to edit remove Checkbox used for verification purposes not for problem selection c Select Change Status d Click Inactive or Remove e Click Save Changes and Record D PCP click on the Add Edit Primary Care Provider button or select None out of town or doesn t know name May also do this by clicking on PCP in the patient s chart header Primary Care Providers blank blank Abraham Michael IT EPOWERdoc Ball Eye MD Bogart Jama NP Bogart Jama NP Bogart Jama NP Brewster Joseph MD Bates County Memorial Hospital Brewster Sam Brewster Joseph MD Bates County Memorial Hospital Brewster Joseph MD Bates County Memorial Hospital Brewster Sam Brewster Joseph MD Bates County Memorial Hospital Brewster Sam Brewster Joseph MD Bates County Memorial Hospital Brewster Joseph MD Bates County Memorial Hospital MANUAL U Primary Care Doctors a 1 Entering PCP multiple ways to select PCP a Enter part of PCP s last name in Search for box in all section b Search by specialty in left column c Usethe scroll bar d Once you select PCP click Record 2 Add New Provider for physicians NOT listed in th
57. m allows insertion of new patient see Add a Patient 4 Phys a Physician provider assigned to patient b Clicking Phys produces physician assignment window c Automatically populates with physician name when user begins documenting in History tab 10 Page 5 Wt Ht a Populate automatically when entered in vital signs screen discussed later b Clicking directly on Wt or Ht produces vital signs entry screen Middle of chart header 1 Vital signs history a Shows most recent set of vital signs recorded to the chart b Click any of the titles BP T P R Pain O2 Sat to produce the vital signs history screen 2 PCP Allergies Code a Populate automatically when entered in Triage Assessment tabs b Click directly on title in header to add edit remove information authorized users only Right side of the chart header 1 HPI ROS PFSH PE Physician coding tool a When physician has completed these sections within patient chart header will display number and acronyms turn from orange to white b May click directly on acronym to go to that part of the chart 2 Chief Complaint Bar Click directly on bar to add edit remove chief complaint as necessary Authorized users only Chief Complaint ABDOMINAL PAIN NN 00900 A Prior Visits 1 Turns red if patient has prior visits in EPOWERdoc system 2 Allows user to import patient s history from selected prior visit into the current visit Discus
58. n place so users do not lock their own charts 32 Page Orders nurses place verbal orders only EPOWERdoc 2 9 All Patients All Beds My Patients To Be Seen Incomplete 12 20 2011 20 54 PCP E Allergies MRN E AT 12 20 R Phys NP NPPA NPPA Pain a 3 Ht Code Levet 0 Sarah M Johnson BSN Z History Physical Procedures Results Disposition Chief Complaint EXTREMITY PROBLEM EE 990060 CTA E AAA Por N General Facility Orders T View All My Orders T View all Order Sets T View All a z MMMM Record Order for pil amaia Y O Abdominal Pain Female Adult O headache migraine Thankgodits F Ci Data set Oz ga O Meds Medications Order Sheet Cancel Order Free text order O Task list testing Edit Se C Trauma Major Facility Orders My Orders Time Finished l an NG ca 1 Placing new orders Orders on the left actions on the right A Select desired orders from the categories on the left category descriptions listed below B Within each window use search box OR scroll bar C Select one or multiple orders D Certain orders may require further information if so pop up box will appear when order is selected Click Add to Order Sheet Continue steps A E as needed 1 General Contains nursing tech orders and interventions i e IV restraints ice chips etc 2 Cardiopulmonary contains Cardiology and RT orders 3 Labs contains point of care testing
59. n the patient s chart header OR click on the V on tracking board 15 Page Vital Signs AUDDY WATERS M Blood Pressure T UTO gt y Temperature T uTO Heart Rate TUTO Respiratory Rate UTO p Pain UTO Systolic Diastolic Eiza ESTA EA E HA A 100 10 1 100 10 1 100 10 1 1 100 10 1 100 10 1 oto 8 200 20 2 200 20 2 20 2 2 200 20 2 20 2 1 10 300 30 3 300 30 3 303 3 300 30 3 30 3 2110 40 4 40 4 40 4 4 40 4 40 4 3 10 co 50 5 50 5 50 5 5 50 5 50 5 ano 60 6 60 6 60 6 6 60 6 60 6 5 10 70 7 70 7 70 7 7 70 7 70 7 510 80 8 80 8 80 8 8 80 8 80 8 7 10 o 909 o 99 90 9 9 o 909 o 909 so Y Sitting 9 10 E Am standing Ora Rectal Standing Asleep 10 10 Right aca Supine Axillary Tympanic ET ear anuab By Palpation Doppler Temporal Doppler Weight UTO Height FT uto Pulse Oximetry T UTO y Time I Actual V Stated SA02 On Via Time Obtained SSS z 7 12 15 2011 14 26 100 10 1 1 100 10 1 100 10 1 10 1 1 2 RA NC T P orto anival 200 20 2 2 200 20 2 20 2 20 2 LM Mask l UTA 300 30 3 3 30 3 30 3 30 3 02 NRB mask ds 400 40 4 4 40 4 40 4 40 4 BVM MUDDY 500 50 5 5 50 5 s0 5 50 5 BIPAP 600 60 6 6 60 6 60 6 60 6 cpap 700 70 7 7 70 7 707 707 ETT Bagged 80 8 8 80 8 80 8 80 8 ETT Ventilator Notes 90 9 9 90 9 0 90 9 90 9 Tracheostomy ED Klos GBD om a 1 Entering Vital Signs a Click number options OR free text and tab
60. number 2 Select desired area and room number then click Assign bed to 1 OR select Triage disposition at bottom of Triage tab or Room Assignment at bottom of Assessment tab to assign pt to room o Reserve a bed 1 Click room number 2 Click Reserved then click Record 3 Type reason for reserved then click Record o Block assigning May pre assign nurses using this function 1 Click room number 2 Click Ready or Reserved if reserving an ambulance also 3 Click Assign RN select RN name and click Record 4 To UN assign click room number select any radio dial then click Record 5 NOTE If RN is pre assigned that RN will remain when patient is gone If RN assigned through the chart RN name will be removed when patient is gone Viewing Printing the Chart o Through View Print screen 1 Click patient s name on Tracking Board 2 Click patient s name in chart header while inside patient s chart 3 Click Printing button in the Disposition tab o Through Preview button on Chief Complaint Bar while inside patient s chart Viewing Entering Vital Signs o Enter vitals via the Vital Signs entry screen 1 Click the Add Edit Vital Signs button within RN chart tabs 2 Click the V on tracking board next to patient s name o Edit vitals or View History 1 Click directly on one of the vital signs acronyms in the patient chart header 2 Click the View History bu
61. on 0000 Fr Thrombolysis MI or PE E Trigger point injection Ultrasound Abdomen Non trauma Ultrasound Abdomen Trauma Ultrasound Aorta Ultrasound Cardiac Non trauma Ultrasound Cardiac Trauma Ultrasound DVT Ultrasound General multipurpose Ultrasound Miscellaneous Ultrasound Ocular Ultrasound Pelvis Pregnant Ultrasound Pelvis Non pregnant Ultrasound Renal Bladder Ultrasound Soft tissue Ultrasound Testes Duplex scan o US guided peripheral vascular access I Vaginal delivery z i A a T Venous access I X RAY abdomen I X RAY bonelsoft tissue I X RAY chest Add Procedures to Chart Click Add Procedures to Chart a template specific to each procedure will populate below list 1 All lab rad cardiopulmonary orders placed in Orders tab will appear in Results tab 2 Lab and radiology results will populate IF interfaced and dependent upon facility 3 Once results are reviewed take one of the following actions A Laboratorial Studies 1 WNL Places statement for result within normal limits along with user date time stamp 2 ABN Places statement for abnormal result along with user date time stamp 3 ACK Places statement for acknowledgement of result 52 Page 4 Pend Places statement that result is pending 5 Clear Clears statement from above action B Radiological Studies 1 Same as above 2 Allows for selection of interpreted and o
62. own details i e dose site etc on the line provided c Any medication NOT listed in the database can be added into the Other box d Click Record F Mode of Arrival Populated from triage G Source H HPI Each chief complaint will have unique HPI 1 Assessment time defaults to current time or change to actual assessment time 2 Option to give reason for inability to complete any of the sections tied to sign off warnings at the end If reason is selected not required to complete HPI ROS or PMFSH 3 Click HPI Complete upon completion of section 4 Coding tool in chart header will populate as applicable I ROS 1 Some prompts may already be selected from HPI to prevent double documentation 44 Page 2 Comprehensive ROS produces a more detailed review of systems 3 All other systems negative Automatically selects None for all systems except prompts specifically clicked May still change selected prompts after button is clicked 4 Click ROS Complete upon completion of section 5 Coding tool in chart header will populate as applicable J Past Medical Family Social History already populated from triage 1 May change documentation as needed This WILL NOT change the nurse s chart 2 Click PFSH Complete after reviewing and documenting as necessary The coding tool for PFSH will turn from orange to white Physical 1 There are only two sections in this tab A Add Edit Vital Signs B Physical Examin
63. perative Attentive Inattentive Appropriate Inappropriate Calm Anxious Speech Coherent Slurred Jumbled Foreign language No speech Skin Temperature Warm Hot Cool Cold Moisture Dry Moist Clammy Diaphoretic Color Ashen Cyanotic Flushed Jaundiced Mottled Pale Normal Tugor Decreased Normal Mental status Awake Alert Oriented to Person Place Time Notoriented No response Unable to assess Change date time or use default Select Reassessment type produces specific template for further charting Fill out as necessary Use Notes line for additional free text if applicable Click Record Reassessment note will populate in Nursing Notes section nmo gt 66 Page Reassessment aa Polos No deficits Srono Bouin Decreased oct 1 In Reassessment window click Time Performed to record actual time patient was reassessed 2 Select Reassessment type each type produces specific template for further charting 3 After completion click Record 4 Reassessment note will populate in Nursing Notes section 67 Page Ward Clerks Quick Highlights General Info o Single click system no double clicking to select and item o Follow the red road o No need to save refresh while charting except in pop up windows o Blank lines free text box or time box Tracking Board o Click on patient s name to open View Print screen o Click on Chief Complaint to open pat
64. quick lists and all other labs 4 Radiology includes xray CT scans MRI Ultrasounds Nuc Med etc a Select Mode of Transporation on the bottom right this is a required field 5 Medications a Search for and select medication b Select dose route and any other information will show in special instructions column in Orders tab c Click Add to List 33 Page 5 d Click Record THIS DOES NOT RECORD THE ORDER it ONLY adds the order to the order sheet 6 Free text order any additional order not found in the above categories a Be aware Free text orders are NOT interfaced meaning will not cross to HIS will only appear in RN Pending Orders section b Do not use this function as a quicker ordering method G If needing to remove an order BEFORE recording 1 Use Select All checkbox to deselect all orders 2 Select order needing to remove 3 Click Cancel Order 4 Click Yes H Once all desired orders appear in Orders tab click Record Choose physician from verbal order pop up box and click Record 1 Order sheet may automatically pop up to print or view depending on Facility Settings 2 Verbal orders are now placed will appear in Pending Orders section of Course tab AND in Messages 3 Red carat will appear by patient s name on tracking board to alert staff of orders messages on patient Facility Orders Set up by facility A Select desired order set may need to click View All
65. r viewed by radiologist and or ED physician 3 Interpretation Allows ED Physician to document his her own interpretation a Clicking Interpretation button brings user to Procedures tab and automatically produces template specific for radiology study to be interpreted b Fill out the documentation as necessary and Sign c Interpretation button in Results tab will then read View Interp clicking this button again will bring user back to Procedures tab to view documented interpretation C Cardiopulmonary 1 EKG Interpretation button will appear if EKG ordered 2 See steps above to interpret Disposition 1 Impression s Requirement for chart sign off Impressions TST EDS x Type to search peo Search mode Search by Contains Begins With Diagnosis ICD9 Add to Final Impressions o ie gt Search Results Final Impressions AAA RUPTURED ABDOMEN INJURY 1 Move Up ABDOMINAL AORTIC ANEURYSM NOT RUPTURED ABDOMINAL AORTIC ANEURYSM RUPTURED 2 ABDOMINAL AORTIC INJURY Move Down ABDOMINAL PAIN OF UNCERTAIN ETIOLOGY 4 ABDOMINAL PAIN EPIGASTRIC ABDOMINAL PAIN GENERALIZED 5 ABDOMINAL PAIN LEFT LOWER QUADRANT ABDOMINAL PAIN LEFT UPPER QUADRANT 6 ABDOMINAL PAIN PERIUMBILICAL ABDOMINAL PAIN RIGHT LOWER QUADRANT J ABDOMINAL PAIN RIGHT UPPER QUADRANT ABDOMINAL RIGIDITY 8 Remove selected ABDOMINAL SWELLING ABDOMINAL TENDERNESS ABDOMINAL TENDERNESS EPIGAS
66. r performance of an order a b c d e g Nursing Notes Select an order s Click Record Order Select actual time order was completed Order is removed from Pending Orders section and placed in Nursing Notes section as Order Performed order name with user name date time Completed column in Orders tab automatically populates with appropriate time Order also removed from Messages queue If order is linked to a procedure in the Procedures button requiring further documentation it will add template in Procedures section for user to fill in accordingly 1 Edit Time Performed A Click directly on date time to edit B User can edit time ONLY for his her own nursing note C Cannot edit Time Recorded 2 Edit Nursing note A Click directly on note to edit B User can only edit his her own nursing note C If note entered by another user only an amendment to the note is allowed 63 Page 3 Free Text Note A Click button to open free text window B Click Record after note entry 4 Procedure Notes RN Procedures THANKGODITS FRIDAY ABG Airway Blood obtained Blood transfusion initial Blood transfusionrecheck Breathing treatments Bum care Capillary Blood Glucose Central line asst Chest tube asst Critical lab value Dislocation reduction EENT EKG performed Gtube i 1111117171111141 t itte tt 1 1144 7905044 Pacemaker
67. rogress in Messages queue NOTE Orders CANNOT be cancelled after placed in progress To cancel order after in progress e Select order in Pending Orders and Note it e Place Free Text Order in Orders tab Order cancelled reason e Go back to Course tab and Record free text order 3 Record Order This function used for completion or performance of an order a b c d e f g Select an order s Click Record Order Select actual time order was completed Order is removed from Pending Orders section and placed in Nursing Notes section as Order Performed order name with user name date time Completed column in Orders tab automatically populates with appropriate time Order also removed from Messages queue If order is linked to a procedure in the Procedures button requiring further documentation it will add template in Procedures section for user to fill in accordingly Medication Documentation From Pending Orders section Pending Orders SelectAll Record Order M 08 18 2011 14 30 Sarah Valium 5ma ml Sol for Inj IVP Verbal from D Duck MD 08 18 2011 14 30 Sarah Toradol 30mg ml Soln for Inj 60 mq IM Verbal from D Duck MD MINE Select one or multiple medications Click Record Order Change date time or use default In Medication Procedures window A Select highlight medication gt Particular details from original order
68. rwards to Assessment tab AND to physician s History tab A Adding an additional Chief Complaint click on the Chief Complaint Line and the Chief Complaint Selection screen will pop up See screenshot below Chief Complaint KIDNEY STONE Ea O 9900 Chief Complaint Selection CARDIOVASCULAR M Earache CONSTITUTIONAL O Foreign body ENDOCRINE O Foreign body ear ENVIRONMENTAL O Influenza lke illness adult GASTROINTESTINAL O Laceration Nose HEMATOLOGIC O Nose injury MISCELLANEOUS O Nosebleed MUSCULOSKELETAL O Sore throat NEUROLOGIC Cl OB GYN O Tooth problem OPHTHALMOLOGIC PSYCHIATRIC RESPIRATORY SKIN SOFT TISSUE TOXICOLOGIC TRAUMA UROLOGIC MANUAL USER M B Select category in the left hand column OR C Type complaint or 1 few letters in search box OR D Use scroll bar on the right 39 Page 8 Select desired chief complaint it will appear in Selected CC box Add optional text at the bottom if needed by clicking on selected chief complaint Click Record The screen will take a few seconds to refresh and will open directly to the Triage tab PAGINE m porting patient history If red patient has prior visit IN EPD TIO mm G This is the 2 of two methods of importing H Click Prior Visits Choose visit from list current visit red prior visits black J Select items to import bottom left
69. s County Memorial Hospital Brewster Joseph MD Bates County Memorial Hospital MANUAL U Primary Care Doctors 1 Entering PCP multiple ways to select PCP a Enter part of PCP s last name in Search for box in all section b Search by specialty in left column c Use the scroll bar d Once you select PCP click Record 2 Add New Provider for physicians NOT listed in the database a Bottom of right column click New Provider b Fill in known information c Click Record if only recording it to patient s chart for this visit OR click Record and Save to save added physician to the database for future use 3 Edit Provider Info a Select provider to edit b Click Edit button on far right c Edit necessary information d Click Record Prehospital includes ANY prehospital care the patient received not limited to EMS 1 Enter necessary information or click No Prehospital Care 21 Page 2 Add Edit Prehospital Medications EMS Medications I Adenosine 3mg ml Soln for Inj T Albuterol 0 5 Soln for Inh J Albuterol 9Omcg act Inhaler I Amiodarone 50mg ml for Inj T Aspirin 81mg Chew Tab T Atropine 0 4m9 ml Soln for Inj J Magnesium Sulf 50 for Inj J Midazolam mg ml Soln for Inj J Morphine 2mg ml Soln for Inj I Naloxone 0 4mg ml Soln for Inj I Nitroglycerin 0 4mg SL Tab T Sodium Bicarbonate 5 for Inj I Benadryl 50mg ml Soln for Inj I Dextrose 25 Soln for Inj T Diazepam 5mg ml
70. sed further in Documentation section of the manual p Preview 1 Preview print chart 2 Select desired view and or chart i e Prose Template views RN Phys chart Up Down Arrows 1 Double arrows top bottom of tab 2 Single arrows scroll up down 3 Chart tabs Assessment Course Disposition Wot Ee History Procedures Results Disposition A RN tabs B 1 Left side 2 Nurses may view physician tabs but information will be grayed out which disallows charting Physician tabs 1 Right side 2 Physicians may view nurse tabs but information will be grayed out which disallows charting Shared Orders tab 1 Nurses and Physicians share this tab 11 Page 4 D Slide out tool El 1 Click directly on arrow Produces a box showing all patients for whom the logged in user is primary provider a Top half Charts not signed b Bottom half Charts signed c Red charts Signed AND locked 2 May flip between charts by clicking on patient name while inside chart or tracking board 3 On active tracking board slide out tool holds user s active patients 4 In Recent Patients slide out tool holds user s inactive patients 5 See End of Shift Process section of manual for further discussion regarding use of slide out tool 12 Page Nursing Documentation Quick Highlights Bed Management o Moving patient from one room to another 1 Click on room
71. t s name unsigned charts appear on top half 1 In Sign Off section of Dispostion tab checkmark should appear by logged in user s name if primary provider 2 Click Sign Off button 3 Address warnings as required See RN Disposition section of manual 8 F 1 b 4 Click Yes to sign off 5 Chart signed by statement placed in chart 6 Patient removed from Incompletes tab AND transferred to bottom half of slide out tool BEFORE LEAVING user should have NO patients listed under a My Patients tab b Incompletes tab or c top half of slide out tool 59 Page Tech EMT RT Documentation Quick Highlights General Info o Single click system no double clicking to select an item o Follow the red road o No need to save refresh while charting except in pop up windows o Blank lines free text box or date time box Documenting in the chart o Click on Chief Complaint to enter patient s chart o Chart opens to last place the last user left off o Documentation for Techs EMT s LPN s based on user privileges set by administration Viewing Printing the Chart o Through View Print screen 1 Click patient s name on Tracking Board 2 Click patient s name in chart header while inside patient s chart 3 Click Printing button in the Disposition tab o Through Preview button on Chief Complaint Bar while inside patient s chart Viewing Entering Vita
72. t appropriate excuse s and time frames ii Free text Special Instructions or click Quick Note to create edit remove customized special instructions for future use iii When finished click Create Excuse iv Click Record if not ready to print or click Record and Print A Use to call patient after discharge for lab rad results and or condition check B If call back set chart placed in Call Back queue button on left of main tracking board header C See Call Backs section below for call back documentation instructions 4 Sign Off 902 gt Places final signature on chart Primary provider is denoted with a check box Facility determines requirement for other users to sign chart Checkmark does NOT have to appear in front of user s name in order to sign off 56 Page E If user s name NOT checked but logged in user IS primary provider simply check the box in front of user s name F EVERY chart MUST be signed off by primary provider using one of the following functions 1 Sign Off button a Select Sign off button if chart is completed and patient has been dispositioned b Warning box will appear denoting any applicable stops to be addressed prior to signing off on chart i Critical Stops red gt Items must be completed in order to sign chart gt Cannot be overridden gt Click directly on warning to go to part of chart requiring completion gt After completion return to Dispostion tab to sign
73. t note 12 20 2011 12 35 12 20 2011 12 35 Medication given Ace wrap applied Backboard Spinal Immobilization BP monitor applied Cardiac monitor C collar Dressing applied Elevation of extremity Fetal heart tones attempted Gastroccult performed Glucometer performed Hemoccult performed Ice applied Knee immobilizer placed Labs drawn Nasal clip applied Nasal pressure applied Oral airway inserted 28 Page OTmMOnN gt Select category on the left or select All Notes and scroll through Notes listed alphabetically Click directly on the note to select may choose multiple user name date time will populate Type additional information as needed in free text line adjacent to note Use free text box at the bottom if necessary Click Record Notes will populate in Nursing Notes section Reassessment Used to reassess patient as needed Use in place of Assessment tab which is for initial primary assessment only j H Reassessment x Time performed 12 20 2011 12 42 Performed by Sarah Reassessment type General Pain Neuro Cardiovascular Respiratory Gl GU Musculoskeletal Behavioral Waiting Room General Distress Nome Mild Moderate Severe Psychosocial Cooperative Uncooperative Attentive Inattentive Appropriate Inappropriate Calm Anxious Speech Coherent Slurred Jumbled Foreign language No speech Skin Temperature Warm Hot Cool Cold Moisture Dry Moist Clammy Diaphoretic Color Ashen Cyanot
74. ther instructions 5 Close Lock Chart Locks and releases chart to medical records Facility dependent A After user has completed charting AND signed off 1 Click Lock and Release to Medical Records 2 Select OK B The chart will gray out disallowing any further charting User may UNLOCK chart but ONLY for 2 hours after locking 57 Page D Chart can ONLY be locked and unlocked by the primary RN see admin manual for further information on locking unlocking charts Privilege dependent E Facility may have auto lock process in place in which case users not required to lock their own charts Addendums 1 Use when need to add edit chart after it has been closed locked 2 Open View Print screen by clicking on patient name 3 Select RN Chart and click View 4 Click RN Chart addendum button bottom left 5 Document necessary information and click Record 6 Addendum will appear at the end of the RN chart but user must exit the chart preview screen and re enter in order to re fresh the document Call Backs 1 Can be set by physician and or RN in Dispostion tab 2 Once set chart will appear in Call Backs queue on left of tracking board header 3 Call backs are documented using Call Back button located within final chart preview A To obtain View Print screen 1 Click on patient s name from tracking board 2 Click on patient s name in chart header from within patient chart 3 C
75. tient s chart The View Print screen will appear Select Messages and choose to View or Print Addendums 1 Use when need to add edit chart after it has been closed locked Open View Print screen by clicking on patient name Select RN Chart and click View Click RN Chart addendum button bottom left Document necessary information and click Record Addendum will appear at the end of the RN chart but user must exit the chart preview screen and O 91 Bw 05 re enter in order to re fresh the document Call Backs 1 Can be set by physician and or RN in Dispostion tab 2 Once set chart will appear in Call Backs queue on left of tracking board header 3 Call backs are documented using Call Back button located within final chart preview A To obtain View Print screen 1 Click on patient s name from tracking board 2 Click on patient s name in chart header from within patient chart 3 Click Printing button in the Disposition tab 36 Page End of Shift Process At the end of every shift ALL primary and or tracking board providers are responsible for making certain their charts are completed signed off and or locked Process and requirements determined by facility and discussed during Education 1 Sign Off on Active patients those still in ED A From active tracking board click on My Patients tab or slide out tool B Once report has been gi
76. tion Date ee o me A Fill out information modifications as applicable B Click Record C Modify button can ONLY be used once Use Free Text button for any additional modifications 25 Page 2 Reassess Medication Reassessment px Toradol 30mg ml Soln for Inj 60 mg IM Result Effective Partially effective Not effective Pan EZ AAA BO A Time Checked 08 18 2011 14 42 A Select desired information B Change date time if necessary C Click Record 3 IV Stop Time A Change date time or use default 4 Titrate Titrate Medication Ik Toradol 30mg ml Soln for Inj 60mg IM Titrate Dose ____ mcg mg G ml mEq Units per Kg perminute perhour Rate mi nr Additional Note o ooo O OO ES A Select desired information Change date time if necessary Click Record 5 Cosign A Cosigning RN to log in under his her name o gt B Select medication to cosign C Click Cosign button 6 Free Text A Use for any additional modifications notes etc B Click Record C Close Medication Notes box Nursing Notes 1 Edit Time Performed A Click directly on date time to edit B User can edit time ONLY for his her own nursing note C Cannot edit Time Recorded 26 Page 2 Edit Nursing note A Click directly on note to edit B User can only edit his her own nursing note C If note entered by another user only an amendment to the note is allowed 3 Free
77. tions I Tests I Comfort Safety I Monitoring I Patient Interaction 12 20 2011 12 35 12 20 2011 12 35 I Patient Tracking TF Resuscitation FT Trauma I Techs I Respiratory Therapy I Transporters Free text note Notes listed alphabetically 2 A AE Click Record Use free text box at the bottom if necessary Medication given Ace wrap applied Backboard Spinal Immobilization BP monitor applied Cardiac monitor C collar Dressing applied Elevation of extremity Fetal heart tones attempted Gastroccult performed Glucometer performed Hemoccult performed Ice applied Knee immobilizer placed Labs drawn Nasal clip applied Nasal pressure applied Oral airway inserted Select category on the left or select All Notes and scroll through Click directly on the note to select may choose multiple user name date time will populate Type additional information as needed in free text line adjacent to note 65 Page 6 N Notes will populate in Nursing Notes section Reassessment Used to reassess patient as needed Use in place of Assessment tab which is for initial primary assessment only j H Reassessment x Time performed 12 20 201112 42 _ _ Performed by Sarah ___ _ Reassessment type General Pain Neuro Cardiovascular Respiratory Gl GU Musculoskeletal Behavioral Waiting Room General Distress None Mild Moderate Severe Psychosocial Cooperative Uncoo
78. tton within the vital signs entry screen 3 RIGHT CLICK on vital sign to edit 4 LEFT CLICK on GCS Visual Acuity to edit Signing Off Locking Charts May not be required to lock Determined by facility o All primary users responsible for signing AND or locking charts before end of each shift o In EPD user is considered primary provider if 1 User name is displayed under the 1 RN provider column of the tracking board 2 There is a checkmark by user s name in the Disposition tab gt Sign Off section o YOUR primary user charts located in My Patients tab slide out tool and Incomplete tab o See End of Shift Process at the end of the Nurse Documentation portion of the manual 13 Page Initiating Patient Chart assign a chief complaint 1 Click Initiate Chart in the chief complaint cell next to patient s name See screenshot below Chief Complaint Selection Filter by Category CARDIOVASCULAR CONSTITUTIONAL ENDOCRINE ENVIRONMENTAL GASTROINTESTINAL HEMATOLOGIC C MISCELLANEOUS MUSCULOSKELETAL NEUROLOGIC OB GYN OPHTHALMOLOGIC M Earache O Foreign body O Foreign body ear O Influenza lke illness adult O Laceration Nose O Nose injury O Nosebleed O Sore throat O Thrush O Tooth problem PSYCHIATRIC RESPIRATORY SKIN SOFT TISSUE TOXICOLOGIC TRAUMA UROLOGIC MANUAL USER M A Select category in the left hand column OR B Type comp
79. ven on existing patients transfer care of patients to oncoming physician or nurse C Open patient chart From slide out tool click on patient s name unsigned charts appear on top half 1 In Sign Off section of Disposition tab checkmark should appear by logged in user s name if primary provider 2 Click Transfer 3 Address any warnings pertaining to parts of chart you were responsible for See RN Disposition section of manual 8 F 1 b 4 Select name of receiving RN then click Record 5 Checkmark will move to receiving RN s name designating him her as new primary provider for patient 6 Report given to AND Chart signed by statement placed in chart 7 Patient removed from My Patients AND transferred to bottom half of slide out tool 2 Sign off on Inactive patients those no longer in the ED A Click Incompletes tab OR click slide out tool while on Recent Patients tracking board B Open patient chart From slide out tool click on patient s name unsigned charts appear on top half 1 In Sign Off section of Dispostion tab checkmark should appear by logged in user s name if primary provider 2 Click Sign Off button 3 Address warnings as required See RN Disposition section of manual 8 F 1 b 4 Click Yes to sign off 5 Chart signed by statement placed in chart 6 Patient removed from Incompletes tab AND transferred to bottom half of slide out tool BEFORE LEA
80. will automatically populate on the right side B Add change any further desired information if applicable 24 Page C Add to List D Repeat steps a c if multiple meds E Record Medication Actions Notes From Nursing Notes section Nursing notes Ferner Photo Record Procedure Notes Quick Notes Recorded Performed By ecm 8 18 2011 14 35 8 18 2011 14 35 Sarah Valium 5mq ml Sol for Inj _IVP_ em 8 18 2011 14 35 8 18 2011 14 35 Sarah Torado 30ma ml Soln for Inj 60 IM Click directly on documented medication to add notes Select desired action from Medication Notes box Medication Notes Valium 5mg ml Sol for Inj IVP Valium 5mg ml Sol for Inj K Valium 5mg ml Sol for Inj IVP Time Given Intiated 08 18 2011 14 35 Amount Dose Site f applicable mcg mg gams mi unit s unitdose puff s drop s R L Jugular Scalp Deltoid Bicep Antecubtal Forearm tablet s capsule s tsp tbsp inch es Wrst Hand Finger Thumb Foot Thigh Gluteal PerKg Perhour Perminute Per Protocol Si Notes MIV Saline Flush Im 3m 5m 10m m Route Rate PO M SL SubQ inhaled Rectal Topical Result Ocular Otic Opthalmic Nasal Transdemal Feeding Tube Effective Partially effective Not effective NGTube Gtube Additional Route s Pain 0 12345 678 9 10 VP IVPB Bolus Infusion No reaction Reaction P Additional Note over minutes or mi hr A EA Dilutent NS D amp W Loti Manufactor Espira
81. x C Facility determines requirement for other users to sign chart D Checkmark does NOT have to appear in front of user s name in order to sign off E If user s name NOT checked but IS primary provider simply check the box in front of user s name F EVERY chart MUST be signed off by primary provider using one of the following functions 1 Sign Off button a Select Sign off button if chart is completed and patient has been dispositioned b Warning box will appear denoting any applicable stops to be addressed prior to signing off on chart i Critical Stops red gt Items must be completed in order to sign chart gt Cannot be overridden gt Click directly on warning to go to part of chart requiring completion gt After completion return to Dispostion tab to sign chart ii Hard Stops blue gt Items must be completed in order to sign chart but CAN be overridden in particular instances gt Click directly on warning to go to part of chart requiring completion gt OR click Override and select or free text reason for override gt After completion return to Disposition tab to sign chart iii Soft Stops black gt Served mostly reminders or warnings in the patient record i e abnormal vital signs labs not reviewed by physician etc gt Not required to address or override gt Your signature will appear stating you have signed off on the chart c Once warnings addressed click Yes to sign off 31

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