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EMR Training Manual

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1. History Source of Historical Info Dose Administration Date fo Free H BR History Location Personi Oh eS 4 Choose the vaccines from the list multiple vaccines can be chosen at once Then click add 5 Next complete all the details that are known and click chart 3 Gl ete el a ipia pler smi haere bag brenge H LL visare har b corage PRPS vk kagezgb u b corake PAP T u D e la KEE 99 DRH Clinical Transformation 33 Pamela Haddox RN BSN May 2009 Inmumizatean Details Hishorical Entry a re D c meni Immuniration Administration Weieen E dl o To arene AH Hian Location Paar LG L J munization W5 Date Vecrer fo D kte Grau Fee g el Lie Moschee Log Meni Daie SS Se eg tamrin Typa N Excection Euin e Esseg Taimi igang notes ES Gen nem If more than one vaccine is chosen highlight each one in your list and complete the details before clicking chart The information entered will now display in the previous immunizations colum Menu q Immunization Schedule Prin PPPOE Adult Immunizations 65 yr 65 yr 2 minutes ago Overview Results Review Immunization Schedule PowerOrders SP add Clin Doc Forms Tasks Pt Info Fuurt Immunization Schedule Yacc Uontraindicated Status Due Date Sc 1 02 04 2009 Adult Immuniz Previous Immunizations Hide Uncharted Records Patient Schedule Vac
2. 02 09 2009 Ooo T O DRH Clinical Transformation 32 Pamela Haddox RN BSN May 2009 Immunization Schedule Documenting vaccines given at the DMC is done through the scanning process on the eMAR Once the vaccine 1s scanned required fields will display to enter the lot number expiration date info sheet given and any state programs used for pediatric patients Once the process is completed all vaccines will display on the immunization schedule section of the chart 1 To document a vaccine that was given outside the DMC first click on the immunization schedule section of the menu bar 2 Next click on the word history at the bottom 3 Next click add to selections Immunization Details Historical Entry Selected Immunizations Ready Immunization Site Product Menu 8 Immunization Schedule A Print 2 0 minutes ago Overview Adult Immunizations 24 Hour Summary Results Review 65 yr PFY Dose 1 Immunization Schedule PowerOrders SP add Clin Doc Forms Tasks Pt Info Patient Schedule Allergies SF add Problems and Diagnoses Previous Immunizations IT Hide Uncharted R Vacc Contraindic Future Immunization Schedule Vacc Contraindicated Status Due Date Sc 1 02 04 2009 Adult Immuniz l Chart Modi Adhoc FaceSheet LOS List View Medication List zb add Reference Text Browser 9 Ise Document Immunization Administration
3. Communication Bo Aeria Four ician name TA A efTime a Bebe ti Dee e e After clicking on the first intervention a communication box will appear You must enter the name of the provider In this case it would be Healthcare Provider since this is a nursing order The communication type should be entered as RN Plan of Care Then click OK and continue selecting the rest of your interventions When finished selecting the interventions click OK at the bottom Next the add orders screen will display again If there are no more orders to enter click done Find i Search Starts with Type Ch Inpatient D EZ ol LajF Search within au x At location DRHUHC Folders Sm AP Actiyity Intolerance Sm AP Anxiety S 4P Ansiety Related to Insufficient Kn al amp P Comfort Impaired Sl amp P Fetal Surveillance sl amp P Nausea Sl amp P Potential Complication Hypo Hy sl amp P Potential Complication Preclampsia m amp P Potential Complication Pre term L S8 4P Potential Complication Premature Sl amp P Potential Complication Sickling Cr Sap espiratory Function Altered Rel ISelap p espiratory Function Risk for Alt S1 BH Alteration in Mood Anxiety BH Alteration in Mood Depression BH Alteration in Mood Fear Phobia u BH Alteration in Mood Mania S1 EH Alteration in Sleep Appetite Ener u BH Alteration of Thought S1 BH Psychiatrc Core
4. You are now able to search using acronyms DRH Clinical Transformation 30 Pamela Haddox RN BSN May 2009 Adding Past Procedures To add past procedures or surgeries first click on the histories section of the menu bar and select the procedure tab Histories Active o R Click the icon Next type the procedure in the yellow procedure field and click the binoculars Histories Jonken WI e m RE E Rr E E WI Now select the appropriate option from the list and click OK NM Procedure Search WS xi fonsteciory Sismi wan eminem z 5 hi IA Adva CH ed 0 oo is yi Ki Tonsillectomy and adenoidectomy age 42921 CPT4 Procedure Tonsillectomy and adenoidectomy und 42820 Tonsillectomy primary or secondary ag 42826 Tonsillectomy primary or secondary un 42825 DRH Clinical Transformation Pamela Haddox RN BSN May 2009 31 Next complete any details known about the procedure gi B TEE heri ii wm IT Tonsillectomy Tonsillectomy and adenoidectomy age 12 or over adenoidectomy age 12 or over Tonsillectomy and adenoidectomy age 12 or over v at r W iT OK OK amp Add New When finished click OK amp Add New to add another procedure or click OK if all procedures have been entered The procedures will now appear on the procedure tab in the history section for all to view Histories Active 2 Tonsillectomy and adencide
5. DONE at the bottom of the screen DRH Clinical Transformation 26 Pamela Haddox RN BSN May 2009 The next step is to complete any details that are not already appropriate to the patient Then compliance must be completed for each medication The compliance indicates whether or not the patient 1s still taking the medication as prescribed Medication History F Add J No Known Home Medications T Unable To Obtain Information N Document Medication by Hx D Order Name Status Detalles Last Occurred Information Source Complianc C Documented Medications by Hx d aspirin Document Patient Still taking 4 furosemide Lasix Document gt w Details for aspirin Details Vis Order Comments Compliance Status Information source Last dose date time Still taking as prescribed z Patient ees EIB B Comment Document History Cancel When compliance is completed for every medication click document history at the bottom right corner If there are previous medications in this section the nurse is responsible for completing compliance for those meds as well To do this right click on the medication and select Add Modify compliance Documented Medications by Hx F simvastatin Zocor ZU mg Documented 1 Tab By Mouth UH oral tablet Modity lansoprazole Prevacid 15 Documented 1 Cap By Mouth Daily Suspend mg oral enteric coated c Complete
6. DRH Clinical Transformation Pamela Haddox RN BSN May 2009 Orders For Signature 53 Entering Orders Click on the Power Orders section of the menu bar Click the add order icon PowerOrders Print 2 0 minutes ago Add a Document Medication by Hx Orders Medication List WM Display fal Active Orders DI B Customize View LTP Been ae Orders For Signature a o Orders Yitals Patient Care lt A ADT Condition Code Statt E EA Vital Signs per Protocol Ordered 02 12 09 10 44 00 CONTINUOUS Ba iii 3 Restraint Ordered 02 11 09 10 09 00 02H Next type what you are looking for in the find box and choose the appropriate option from the list Clinical Dx Code S lincalDe ode l Teee CBC Ditf Diagnosis Problem being Addressed this Visit Find cbe Seago Starts with Y Type Ch Inpatient D a Add Convert Display fan E Gil E ei Search within fan D At location ORHUHC i Convert Display Lat D Name of Problem D RHEUMATOID ARTHRINIS 240 O Dj RHEUMATDIDARTARINS 2140 TEST PATIENT D 838068947 Done Then the ordering physician box will appear Type in the physician name If the display reads multiple matches click the binoculars and make your selection from the list This box will only appear for the first order entered Ordering Physician Ei Physician name DAHPhysician MDU E Order Date Time jozizr200g ils HN Plan of Care Per Prot
7. OK Cancel Preview Verify you have the correct person by checking the birth date and other demographic information Then select the encounter and click OK Recent t 7 shows the last nine charts the user has opened Use the drop down arrow and select the patient s chart you wish to open Dy Recent MRN Burnside Rhonda Duck Daffy Duck Donald Pan Peter Sailorman Popeye Bunny Bugs Simpson Homer Hook Captain VD OM d Dy A A P Fudd Elmer DRH Clinical Transformation Pamela Haddox RN BSN May 2009 11 Patient Access List PAL The Patient Access List PAL is a list of patients assigned to a caregiver that contains key information associated with each patient including location allergies attending physician pharmacy orders overdue tasks and many other pieces of information Accessing the PAL Tab 1 In PowerChart click the Patient Access List PAL on the toolbar E Patient List S Multi Patient Task List Patient Access List T Shift Assignment A 2 The timeframe selection window will open Select the appropriate shift by highlighting the row and click OK Timeframe Selection x Afternoon 4 Hours 1500 1900 Afternoon 8 Hours 1500 2300 Day 10 Hours 400 1400 Day 12 Hours 700 1900 Day 4 Hours 1100 1500 Day 8 Hours 700 1500 b Geleh a Time Range From Pap HE TC Fy ro ep Se ml A 3 Next the e
8. 4 Medications are divided into four categories Scheduled A medication order that has fixed dose times e Unscheduled A medication that does not have a scheduled time It is always displayed as available to administer at the current time PRN Medications that are not scheduled but should be carried out in specific circumstances or on an as needed basis Continuous infusions A continuous infusion order displays as pending so additional infusions can be added at any time DRH Clinical Transformation 64 Pamela Haddox RN BSN May 2009 Medication Column Indicators Administration events are designated by a color under the appropriate date and time column e Yellow represents the current date time column e Teal represents current or future medication e Red represents past due or STAT medication e Gray represents canceled voided and discontinued medications MAR Icons 3 Pharmacy needs to verify the medication order a Pharmacy rejected the medication order Pharmacy comment has been entered Right click on the medication details and select Order Info then select the Comments tab to view the comment Administrative note will display a nurse to nurse communication Right click on the medication details and select Create Admin Note or View Admin Note Only one Admin Note icon will display on the MAR but multiple entries can be displayed on the same note e Needs Nurse to Review Review Note orders from the O
9. Chart Close Plan of care will be demonstrated in daily documentation section Patient education will be demonstrated in daily documentation section After selecting these forms click chart at the bottom The forms will come up one at a time to be completed DRH Clinical Transformation 19 Pamela Haddox RN BSN May 2009 Admission Assessment When completing the admission assessment use the navigator bar on the left to move from one section to the next until every necessary section has been completed Adult Admission Assessment Burnside Rhonda l oj sl wv Me ele OF 02 03 2009 FSi w ff 1551 By DRHNurse RN15 Female Repre ee Rec Vital Signs Detailed Musculoskele MS Detailed Oral eg Tympanic Degl Pain Score g N A Rest Neurological Neuro Detale Rectal Degl Axillary Degl Pain Score P N A Seizures COEN Sleep Rest AR Bia Gara Mia Pain Scale Integumentar 0 10Pain Scale Ow ntegumentar Deeg gt PABS NIPS FL Temporal Degl RN Notified of P Yes O N PASS Oo NM Pain Score D gt Infiltration Ph b Glasgow Com Systolic mmHg H mmHg Mean Arterial Apical Heart bpm Fetal Heart Diastolic BP Pressure Rate Rate L Schmid s Fall Functional As location of BP Arm right O Thigh right O Wrist Right Peripheral bpm e Collection Arm left O Thigh left Wrist Left pulse Rate Functional As gt Belongings
10. ei furosemide Lasik AU mg Documented 40 mg 2 Tab By Mouth Daily a oral tablet void sl aspirin aspirin 325 mg oral Documented 1 Tab By Mouth Daily 4ddiModify Compliance tablet a Order Information a foLlC acid folic acid 1 mg Documented 1 Tab By Mouth Daily peda izi oral tablet Comments Reference Information Enable Edit on the Line DRH Clinical Transformation 27 Pamela Haddox RN BSN May 2009 Past Medical History 1 To enter the patient s past medical history first click on the histories section of the menu bar Then choose the past medical tab Histories Active and Resolved 7 2 Click the Add icon 3 Type the disease condition in the search box and click the bineculars Histories REN O eo ime vec oT are HE z DRH Clinical Transformation 28 Pamela Haddox RN BSN May 2009 4 Choose the appropriate option from the list and click O x Search asthma d Starts with DI Within Terminology DI gt Show Advanced Options SW View Synonym E Concept Family Li Multi Axial ES Cross Mapping Asthma ee 301485011 SNOMED CT Finding ASTHMA 493 ICD 9 CM Diseases amp i Asthma cardiac 1495417010 SNOMED CT Finding Asthma currently active 456163018 SNOMED CT Finding Asthma currently dormant 456164012 SNOMED CT i Finding Asthma annual rev
11. 09 17 09 Medications H WS BUER SO E4 Scheduled Scheduled Unscheduled ee lisinopril Start 09 16 09 9 00 00 Routine 10 mg By Mouth Tab Daily 10 mg 10 mg Systolic Blood Pressure Diastolic Blood Pressure FOE d ranitidine Zantac Start 09 16 09 11 00 00 Routine 150 mg By Mouth Tab BID Tab ine Zoloft Start 09 16 09 11 00 00 Routine 25 ma By Mouth Tab D aily 150 mg 150 mg 150 mg Enter the any details required for the medication Then entered the name of the nurse who administered the medication and the date time reflected on the paper MAR sign the documentation Performed by DRHNurse RN15 ranitidine f 50 mg Diluent knone gt DI ml Route By Mouth sl Site T Not Given Reason X Comment DRH Clinical Transformation 79 Pamela Haddox RN BSN May 2009 What s Next At the DMC we are committed to improving our technology to ensure patient safety support clinical judgment and achieve excellent outcomes for our patients One of the ways in which we do that is by listening to those individuals taking care of the patients at the bedside If you have an idea that would support our goals then we want to hear from you Please find a super user and submit your idea for the quarterly EMR awards If you need further assistance understanding any portion of the material covered in this manual please contact your site clinical transformation team at 313 745 7796 f
12. Additional Dosage Digoxin is a cardiac digitalis glycoside derived from the plant Digitalis lanata Digoxin reversibly inhibits sodium potassium ATPase which enhances sodtum calcium exchange Additional calcium is available to activate the actin myosin contractile complex resulting in increased myocardial contractile force Digoxin also has indirect action on the cardiovascular system including depression of the sinoatrial SA and atrioventricular AV nodes and restoration of carotid sinus baroreceptor activity via effects on the autonomic nervous system Like other digitalis glycosides digoxin has a mild diuretic effect that is independent of changes in glomerular filtration rate and renal blood flow Clinically digoxin increases myocardial contractility and is most useful in patients with systolic dysfunction By depressing the conduction system in the heart ventricular rate responses may be decreased allowing for more diastolic filling time and cardiac output This may be particularly useful in certain supraventricular tachycardias Digoxin is FDA approved for treatment of congestive heart failure cardiogenic shock and paroxysmal supraventricular tachycardia and for reduction of ventricular rate in atrial fibrillation and atrial flutter It has limited value in patients with isolated right heart failure due to anemia arteriovenous fistulae beriberi or thyrotoxicosis A cohort study has shown that long term use of digoxin is an independe
13. Consults BP Cuff Size Infant Orange cuff some are White Size 9 0 14 8 cm Method of BP Auscultated cuff O Thigh cuff Palpated Pediatric Green cuff Size 13 8 21 5 cm Collection Automated cuff Arterial Line DC Needs Small Adult Royal Blue cuff Size 20 5 28 5 cm gt Drains Tubes O Adult Navy Blue cuff Size 27 5 36 5 cm Large Adult Burgundy cuff Size 31 40 cm NIH Stroke Safety Care K Braden Gi E Y 4 gt There are three areas of the navigator bar that are required fields They are marked with E Those items are the Schmidt Fall Risk Functional Assessment and the Braden Score When the form is completed use the green checkmark a at the top left corner to sign your documentation or the floppy ei disk icon to save if you need to return to it later DRH Clinical Transformation 20 Pamela Haddox RN BSN May 2009 Pressure lcers Documenting that a pressure ulcer is present will place Impaired tissue integrity on the problem list An auto alert discern will fire alerting the RN to order the pressure ulcer management orderset and a task will be placed on the PAL Discern Notification Message x Subject Discem Alert Impaired Tissue Integrity ed Priority Status High Priority Value Event Date Time 05704 2009 8 16 27 Message class subclass APPLICATION DISCERN EU EICH LCE Does Patient have a Pressure Ulcer Yes as of May 04 2009 08 15 00 E
14. Do not leave the computer while still signed on Do not access any charts that do not apply to your current job and caseload Help Desk To get help for any issue with EMR please call the Help Desk at 313 966 2400 DRH Clinical Transformation 5 Pamela Haddox RN BSN May 2009 10 11 12 13 14 Definition of Terms Ad hoc file cabinet for blank forms Alerts warnings pop ups on screen to inform the users of possible adverse events Demographic bar pink bar across top of chart displaying patient info such as name birth date allergies sex etc Discern alert an automatic alert informing users to perform a function based on assessment criteria that has been entered Drop down arrow downward pointing arrow at the end of an entry box that when clicked displays entry options Encounter a specific patient visit Favorites a folder in which users can store frequently used items for easy recall at a later time Filter a method of arranging data to view only what the user wants to view FIN number financial information number used for billing purposes and separates visits Icon a symbol Medication wizard the screen from which medications are scanned and administrated marked with a barcode icon Menu bar a list containing the sections of the chart Navigator bar a list of areas within a section of the chart or power form clicking on an item in the list will bring that area to the top of t
15. Neurontin Details E Order Comments 7 Diagnosis Remaining Administrations Unknown Stop Unknown lt gt rder details 0 n Detail values gi B Start Date Time O Missing Required Details Dy Table Orders for Nurse Review Sign When the details are completed click Sign Remember to refresh the screen to change the order status from processing to ordered DRH Clinical Transformation Pamela Haddox RN BSN May 2009 Voiding Orders Use the void order option when the order that was entered and signed was done so in error or on the wrong patient Itis meant to completely cancel the original order Only orders that have not been acted upon can be voided orders with status of Ordered or Pending Orders with a status of Completed can not be voided To void an order right click on the order and select Void PowerOrders ea A Print 2 1 minutes Modify Copy Kancel Reorder Spend Add Document Medication ky Hx Orders Medication List ld N isplay La Active Orders DI B ActYyate Customize Vie ew O Complete Orders for Signature D e Order Name Status Cancel 3 rders ON f RA 6d gabapentin Neurontin Ordered Void ine 300 mg By Mouth il ADT Condition Code Statu 9 B acetaminophen hydrocod Ordered ine 1 Tab By Mouth e j A By Mouth ii Activity one Norco 325 mg 10 Reschedule Task Times _ til Nutrition Services
16. low Low dose correction dose BG 120 200 give 0 Units BG 201 2 6 02 16 09 17 00 metoprolol Start 02 16 09 17 00 00 25 mg By Mouth Tab vi D Ki D PRN acetaminophen Start 02716709 9 56 00 Routine 1000 mg By Mo acetaminophen 1 000 mg By Mouth Pain acetaminophen Tylenol Pain Scale Score 9 Ready to Scan When all medications have been scanned and all required fields and values have been entered click Sign 2 of 2 Back DRH Clinical Transformation Pamela Haddox RN BSN May 2009 Notice how the given medications display on the MAR They will display in a column marked with the actual time it was scanned and will be listed beneath the teal line E Print 2 0 minutes ago 15 February 20054 6 04 17 February 4009 16 04 Clinical Range e 6703 02 16 09 D 02 16 09 17 00 Se YY eee y metoprolol Start 01 26 09 17 00 00 Routine 25 mg By 25 mg Mouth Tab BID 25 ma By Mout 185 mmHa Auth 96 mmHa Auth 102 Auth verifie G ranitidine Start 01 26 09 17 00 00 Routine 150 mg By Mouth Tab BID KE lt 9 P 3 r en Ty nol N outh Tab 06 PRN P Pain i 1 000 ma By W Pain Scale Score 9 Auth Verified a4 Continuous Infusions Not Given Patie The PRN medications that are given are listed the same as other medications However they are also still listed in the current date time column and ready to be given again This column will list the last ti
17. 2 Encounter Date Fiedy DRHNurse RM15 Rl Encounter Form Allergies Problems and Diagnoses FaceSheet LOS Lisk Wier Medication List Reference Text Browser uth verifiedy DRHNurse RMS Ey thursday February 05 27009 Hos 27 Plan of Care Guth Verified Multi Contributors been las 24 Patient Education 4uth verifizd Multi Contributors Ep wednesday January 28 2000 fee B 10 52 Adult Admission Assessment Guth Verified DRHNurse HNZ0 NE 40 Acht Admission History Tn Error Multi Contributors DRH Clinical Transformation 43 Pamela Haddox RN BSN May 2009 Form Icons con colors are used to represent whether or not all of the required fields have been completed on a form A blue icon indicates the required documentation is complete a red icon indicates required documentation has not been completed and a yellow icon indicates an Uncharted form Red Incomplete Bort by Date D IS Sal Forms H Thursday December 15 2005 46 EM 5LF Evaluation Auth verified Z7ORDER POE NURSING Blue Complete i Je 1 46 PM Physical Therapy Daily Notes Auth iere ZZORDER POE NURSING L Bi 20pwM Gr Daily Note Auth Verified ZZORDER POE NURSING IS Kiwednesdae December 14 7005 L aen neen Therapy In Error ZZORDER POE PHYSICIAN E Tuesday December 13 2005 11 46 AM Cast Application Auth Verified ZZORDER POE PHYSICIAN F Monday December 05 2005 r 5 58 PM RT B
18. Activity O Nutrition Services Wi Vitals Patient Care ii Medications ig IV Infusions i Laboratory Services ii Radiology Services ii Consults D Pulmonary Services ii Cardiology Cardiovascular ii Therapy Services LJ Communication EJ Miscellaneous Fa Z Details Displayed All Active Orders Diagnoses amp Problems Pislabed amd Mu Tahlia I Nedara Far hhi vr D est imr I The options of No known home medications and Unable to obtain information are available if applicable ishory o Known Home Medications ATnable To Obtain Information M Document Meditnaten by Hs To begin adding a medication to the list click ee Next type the medication name into the find box and select the item with the correct detail An order sentence box will display The RN is only concerned with the details of how the med is taken This will not place a prescription in the file Choosing 30 tab or 90 tab will have no effect in this area Click OK Find lasix Search Starts with DI Type a Document Medication by Hx Lasix Lasix 10 mg ml injectable solution Lasix 10 mg ml oral liquid x Lasix 10 mg ml oral solution Lasix 20 mg oral tablet Lasix 40 mg oral tablet Lasix 80 mg oral tablet 1 Tab By Mouth Tab Dalu 20 Tab 1 Tab Bu Mouth Tab Daily 90 T ab Order Sentences for furosemide Lasix 20 mg oral tablet Cancel Burnside Rhonda D 84107 Done When all medications have been entered click
19. Click in the red line The medication administration details form will display If the warning 1s dose related the dose number field will be highlighted indicating that field needs to be corrected Change the amount to be administered and click OK ve metoprolol Start 02 18 09 9 00 00 25 mg By Mouth Tab Performed date time 02 18 2003 Hoan E Performed by DRHNurse RN15 EI Systolic Blood Pressure fi 86 mmHg Diastolic Blood Pressure ES mmHg Monitored HA 102 Ei ma DI Diluent lt none gt DI ml Route By Mouth DI Site v I Not Given Reason e Comment ee Caution Icon The Caution icon ik will display if the scanned medication dosage is less than what was ordered If two Tabs of the medication were ordered and only one Tab was scanned then the Caution icon ES display ga Scheduled BA KN SN I 08 Jun 2006 09 00 moxifloxacin 400 mg 1 Tab Tab By Mouth Other Reason in comme 08 Jun 2006 17 00 ampicillin irst Dose 06 08 06 E 00 0 00 A gm gt A mL Mi PB 0 Stable Shrs Ref e 72hrs 09 Jun 2006 01 00 ampicillin 09 Jun 2006 09 00 ampicillin Firs t Dose 06 09 06 9 00 0 00 1 gm WV RT Stable 8 Bhs Refrigerated stable 72hrs 09 Jun 2006 09 00 micafungin 150 mg 15 mL IVPB Other Reason in comments Rx to micafungin Sodium Chloride 0 9 100 mL 09 Jun 2006 09 00 moxifloxacin 400 ma 1 Tab Tab By Mouth Other Reason in comme D 09 Jun 20
20. Discharge T B OT Initial Evaluation T B OT Initial Evaluation Acute Care TD EN OT Swallow Charges Patient Education gl El Patient Education IT E Patient Rights T E Perinatal Admission Assessment TD Esch De De DE De De Ce DE DE OE OE DME B Chart Close Kducation Individuals Barriers to Teaching Learning Comment Taught Learning Method Response Teaching Evaluation lt Multi lpha gt lt Multi lpha gt lt Multidipha gt lt Multi lpha gt lt Multi lpha gt lt Multi lpha gt lt Multi lpha gt v in the top left corner to sign the form or use the ei to save it if you DRH Clinical Transformation Pamela Haddox RN BSN May 2009 38 Nursing Plan Of Care To begin documenting plan of care first click on the E AdHoc icon on the toolbar Next select EMR forms and select the plan of care form Charting O B Neurological ICU Assessment T B Perinatal Ongoing Assessment IT D KS EMR Forms T B Neurovascular Assessment Lower Extrehity DO E Perinatal Triage DE Assessment C B Neurovascular Assessment Upper Extrem 7 E Pharmacy Clinical Interventions IT D O Emergency Service T E NIH Stroke Scale E Pin wire Care CB C Critical Care C EB Observation Patient Assessment MV SE Plan of Care DE ni Gei T EB Orientation ICU IT E Point of Care Testing IT D m Ae gt Gas T EB Orientation Med Surg T E Po
21. Ordered 01 26 09 9 28 35 One Time Only l EENS Ordered via Discern Expert Admission Assessment Hu beli Therapy Services z LJ Communication 2 i Miscellaneous 2 E Order Sets 4 o i 2 Equipment Supplies Medications B aone Noro AR mp 10 x LA N di acetaminophen hydrocod Ordeged Start 01 28 09 14 31 00 Routine 1 Tab By Mouth IL Ta E z Dil 1 All Active Dn 5 3 Show More Orders ly Table Orders for Nurse Review Orders For Signature The navigator bar on the left helps move through the orders profile with little scrolling The bolded sections contain orders Clicking on a section will bring it to the top of the profile Columns of the orders profile window 1 S Indicates the order has an active status 2 Indicator column The Mortar and Pestle indicates the order requires pharmacy verification The Caduceus Physician Cosign indicates the order requires a physician s co signature The Eyeglass Icon indicates the order requires nurse review electronic notation H The Decision Support icon indicates that reference information decision support 1s associated with the order These icons only display if they apply to the order A Order name Displays orders that were placed below each clinical category 4 Order status Displays order status For example Ordered Discontinued Transfer Canceled Pending and Complete 5 Order details Displays the details
22. Problems and Diagnoses FaceSheet LOS List View Medication List Reference Text Browser Histories Lieu Flowsheet DRH Clinical Transformation 24 Pamela Haddox RN BSN May 2009 Menu Bar The menu bar located on the left side of the patients chart can be hidden to allow a larger viewing area Click on the pushpin icon M located on the top right of the menu bar Menu q DEP YIEE 24 Hour Summary Results Review N MAR Immunization Schedule PowerOrders SF add Clin Doc Forms Tasks Pt Info Patient Schedule Allergies SF add Problems and Diagnoses FaceSheet Los List View Medication List SF Add Reference Text Browser Histories I View Flowsheet If menu bar is already hidden hover mouse over the small tab on left that reads menu click on the pushpin to leave menu bar displayed Overview 24 Hour Summary Results Review d s MAR Immunization Schedule PowerQrders ate Add Fia Mas DRH Clinical Transformation Pamela Haddox RN BSN May 2009 Medication List To enter the list of medications first go to the medication list on the menu bar and click Document by History Medication List s Addl Document Medication by Hx Orders Medication List 4 Display All Active Medications DI ei AT Pesen Bas No orders currently meet the specified filter criteria View Orders For Signature 8 Medication List ii ADT Condition Code Statu O
23. dose correction dose BG 120 200 give 0 Units BG 201 K 02 16 0917 00 metoprolol Start 02 16 09 17 00 00 25 mg By Mouth Tab vi Ze RK PRN acetaminophen Start 02 16 09 9 56 00 Routine 1000 mg By Mo acetaminophen 1 000 mg By Mouth Pain acetaminophen Tylenol The bly circle 4 indicates there are required fields to be completed before signing the medication The D indicates there 1s additional information to be entered The information 1s as follows For blood pressure medication you must enter a blood pressure and heart rate e For insulin you must enter a blood glucose level CBG e For pain medications you must enter a pain score e For any injections or infusions you must enter the site it was given To enter these values click on the icon For the site use the dropdown arrow For all others enter the values in the labeled fields metoprolol IMMEDIATE re ease 25 mg tab Davis Virginia 3 Cer 4 metoprolol furosemide 40mg 4ml Davis Yirginia EE E Start 02 16 09 9 00 50 25 mg By Mouth Tab Perfoyyf d date time 02 16 2003 Hil 1622 E Start 02 16 09 9 00 00 40 mg MW PUSH Injection sumed by DRHNurse RN15 E a e Aa Performed date time 02 16 2009 ilkez E 2 Systolic Blood Pressure 185 mmHg Performed by DRHNurse RN15 EI EE Diastolic Blood Pressure ES mmHg Monitored HR fi od furosemide D ma DI ac Diluent lt none gt DI m
24. maintained To Unchart results that were entered in error complete the following steps 1 Select a form 2 Right click on the form and select Unchart to open a comments dialog box all Forms E monday February 09 2009 Eis 28 Vital Signs Auth Verified DRHNurse RN15 15 28 Incision Wound Care Auth Verified DPHhlumge e 3 Thursday February 05 2009 view e 09 27 Plan of Care Auth Verified Multi Contribute Modify Boa z3 Patient Education Auth Verified Multi Contr E E wednesday January 28 2009 Print 10 52 Adult Admission Assessment Auth Verified 1 History O E HOH Adult Admission History In Error Multi Contrit Change Date Time 3 Type an explanation in the comments box below describing why you are uncharting the form Incision Wound Care Unchart Burnside Rhonda x v Gg rsrformed on Enn 1528 By DRHNurze RH15 Comment charted on ocorrect patient 4 Click the Sign Form icon to unchart the information Notice that the form is displayed as In Error DRH Clinical Transformation 45 Pamela Haddox RN BSN May 2009 Intake and Output Intake and output is an important element of patient care I O should be documented for every patient as the incident occurs or as ordered by the physician To begin documenting I O click on the I O section of the menu bar Notice that the clinical range or timeframe begins on the previo
25. minutes ago Patient ccess List Me 7 N e zz DRHEMR Shift 20 January 2009 07 00 20 January 2009 15 00 Tasks Results Section Section Notifications Section Demographic Section Name Section Name section displays patient s name Demographic section displays info such as age sex rm number etc Notification section displays new orders as soon as they are signed by provider Also displays new lab and radiology reports Tasks section Displays tasks that are due at a given time for a patient Results section displays last entered vital signs DRH Clinical Transformation Pamela Haddox RN BSN May 2009 13 PAL Icons Icons displayed on your PAL were specifically chosen to give you a good idea of the type of activity they represent All icons on the PAL provide access to additional patient information You must double click on the icons for access A single click only changes the patient you are focused on There are three icons that will display your patient s Allergy status in the demographics section No Known Allergies Known Documented Allergy DN Allergies not Recorded In the Notification section order or result notifications can appear as a clipboard or an eyeglass icon fl The Clipboard icon indicates a new result Double click to view details Click Apply to acknowledge that the results have been reviewed ed The Eyeglass icon indicates an order that needs to reviewed note
26. z z Cardiovascular Burnside Rhonda x O sm a Cardiovascular Assessment Heart Rhythm Nail Bed Color Edema AC Pink O Pale C None C Fitting Irregular Dusky Other C Generalized C Other t Antiembolism Device Left Antiembolism Device Right L Foot pumps C Foot pumps L Graduated compression stockings knee high C Graduated compression stockings knee high C Graduated compression stockings thigh high C Graduated compression stockings thigh high L Sequential compression device knee high C Sequential compression device knee high L Sequential compression device thigh high C Sequential compression device thigh high C Other C Other Pulses Absent Doppler Comment Dorsalis Pedis Pulse Left Dorsalis Pedis Pulse Right Radial Pulse Left Radial Pulse Right U _ Capillary Refill Greater than 3 seconds Lessthan3seconds 3 seconds Capillary Refill Site C Left hand Left foot Other Cardiovascular O Yes JO Right hand Right foot Detailed Assessment f fe The bottom right corner of each system assessment contains an option for a detailed assessment If what you need to document is not found on the first page then choose the detailed assessment option When finished documenting on the page use the blue curved arrow 0 called the circle back button located in the upper left corner to return
27. 02 11 09 10 09 00 GZH Next enter the order in the find box and choose the appropriate option from the list Find social Search Starts with Type p Inpatient DI EN fad ve Gal Folder earch within fan Di At location ORHUHC 7 Social Isolation B Social Work Consult Social Work Consult Jones Leroy D 841078459 Done DRH Clinical Transformation Pamela Haddox RN BSN May 2009 57 Next the physician name box will display For nursing orders the physician name is entered as Healthcare Provider Drdering Physician Order Date Time pazzo ils The communication type for most nursing orders should be per protocol since policy allows nurses to enter the orders When entering an order for a social work consult the decision support box will appear Deci ton Support eppes Piiz Felu SClatup annin iome Heath Care a Balic sipimi D of pandit by he Garg Marya Epelisin Please place a Care Management Spectallst Referral oder noze services e h sded This box is giving you information to help you make a decision lt is letting you know what things reguire a social work consult and which would require a CMS consult since they are often confused After reading the information click OK If you have entered the wrong consult by mistake you can remove it from the scratchpad DRH Clinical Transformation 58 Pamela Haddox RN BSN May 2009 Now you are returned to your order wi
28. 06 10 24 ranitidine First Dose 06 09 06 10 24 00 75 mg By Mouth Pi PRN acetaminophen First Dose 06 09 06 10 23 00 Routine 650 mg acetaminophen 325 mg B Ready to Scan Sign Scan the additional dose s to get the ordered dosage The caution icon will disappear when the scanned amount matches the ordered amount Then click Sign DRH Clinical Transformation 69 Pamela Haddox RN BSN May 2009 Unchart a Medication To unchart a medication that has been charted right click in the cell containing the charted medication and select unchart MAR A Print 2 0 minutes ago 17 February 2009 07 41 19 February 2009 0X 41 Clinical Range SS Er vs Scheduled digoxin Start 01 27 09 9 00 00 Rouime 0 125 mg By Mouth Tab Daily a 4 02 18 09 08 00 digoxin ON digoxin View Details E View Gommenis view Order Info Start 01 27 09 9 00 00 Routine 25 ma B y Add Comment Mouth Tab Daily hydrochlorothiazide Systolic Blood Pressure Niastalir Blood Preece Modify Unchart 25 maByh Enter a reason for uncharting in the comment box Ol A Performed or MARAT EI ET By DRHNurse RN15 Comment dropped on floor Then click the green checkmark y to sign the form DRH Clinical Transformation Pamela Haddox RN BSN May 2009 70 Modify a Medication A charted medication can be modified to make corrections To modify a charted dose right cl
29. 09 16 46 Constant Indicator o Li Activity Extrernities l kl T Monitor weight Trends Processing 02 09 09 16 46 E T Teach Diet Restrictions Processing 02 09 09 16 46 H Bi Medications S CH Iv Infusions LI Teach Factors to Increase Processing 02 09 09 16 46 z Laboratory Services Circulation O Radiology Services wi Activate Pressure Ulcer Ordered 01 28 09 10 57 17 H E Consults Prevent Orderset Ordered by Discern Expert j B Pulmonary Services ba O Cardiology Cardiovascular z O Therapy Services L E Cammi nication Ordered 01 28709 10 57 16 Ordered by Discern Expert Activate Pressure Ulcer Manage Orderset The orders are now in the processing status You must now click the refresh icon iz to complete the order signature process DRH Clinical Transformation 42 Pamela Haddox RN BSN May 2009 Forms Completed Forms may be viewed modified or uncharted from the Forms section of the menu bar The options available to you will vary according to your needs For example you may be able to modify forms for which you are the author but not forms with another person as the author You are only allowed the option to view documents completed by someone else Whenever a form is modified or uncharted the system tracks the care provider and the changes they make in the system This ensures accurate documentation It is important that you do not complete the documentation for care you did not perform since the system will always a
30. 13 00 Start 02 12 09 13 00 Routine 300 Laboratory Services b Complete Blood Count Order 02 12 2009 11 52 02 12 09 11 52 Routine 1 One Ti BF with Differential CBC Di Collect One lavender top tube On AE Complete Blood Count Orde 02 12 2009 a 12 12 03 11 54 Routine 1 One T with Differential CBC Di Remove collect One lavender top tube Or Ordering Physician Ekle EMR NA gt K Details for Complete Blood Count with Di 010 Information Details A Order Comments i Add To Favorites Enable Edit on the Line Detail values aas S IS BA z O Missing Required Details Dy Table Orders for Nurse Review Sign Order details Priority Routinel If an unwanted order is on the scratchpad it can be removed by right clicking on the order and selecting remove When all the information has been verified and is correct click Sign eF Add 4 Document Medication by Hx Orders Medication List 5 minutes Customize Vie MM Display fan Active Orders D WS Se for Signature af OrderName Status Details S Orders Medications j O ADT Condition Code Stat ul gabapentin Neurontin Processing Start 02 12 09 13 00 Routine 300 ma By Mouth Cz H dee wi D acetaminophen hydrocod Ordered Start 01 28 09 12 31 00 Rotine 1 Tab By Mouth GE Nutrition Services one Norco 325 mg 10 M Vitals Patient Care E E L Med
31. Active Orders an Show More Orders Again the physician name box will appear Enter the physician s name that authorized the discontinuation Drdering Physician x Physician name DRHFhysician MDOT E Order Date Time jozn2r200g l HN Plan of Care Per Protocol OF Cancel Enter the appropriate communication type and click OK The order will display with lines through it and the status will read discontinue n Mion J SH M 0rdername status Detais Vitals Patient Care Vital Signs per Protocol Ordered 02 12 09 10 44 00 CONTINUOUS Restraint Monitoring Ordered 02 11 09 10 03 00 CONTINUOUS wi Adult Admission History Ordered 01 26 09 9 28 36 One Time Only Ordered via Discern Expert Admission Assessment Ru A ICL dmissinn Ordered 11 76209 9 28 36 One Time Onlu by naa e Kb w Details for Restraint Assessment Med Surg Details U Order Comments N Diagnosis x a Order details 5 ln Detail values Discontinue Date and Time 02 12 09 1 Displayed All Active Orders Show More Orders a Dx Table Orders for Nurse Review Orders For Signature Click the orders for signat re button at the bottom DRH Clinical Transformation Pamela Haddox RN BSN May 2009 60 by Hx WM Orders for Signature DR 4R 4R03 A FIN 685304784 Yitals Patient Care D Jia Details O Missing Required Details Dy Table Orders for Aurse Re
32. DT our documentation has indicated this patient has an active or probable ww ulcer he problem Impaired tissue integrity has been added to the Problem List If he Pressure Ulcer Management Orderset is not in place please add it to the patient s overall plan of care RN Responsibility 1 Complete all assessment and documentation requirements of the wound Pressure Ulcer Care Pre Pressure Present on Location Description Length Width Depth Drainage Ulcer Ste Stage Ulcer Status admission cm cm cm KAlpha gt lt Muli lpha gt lt lpha gt lt Multi lpha gt lt Multi lpha gt lt Multi lpha gt lt Muli lpha gt lt lpha gt lt Multi lpha gt lt Multi lpha gt lt Multi lpha gt lt Multdlipha gt lt Alpha gt lt MultidIpha gt lt Multilpha gt lt MultidIpha gt EEN lt Multi lpha gt lt lpha gt lt Multi lpha gt lt Multilpha gt lt Multi lpha gt Pressure Ulcer 5 lt Multi lpha gt lt Alpha gt lt Multi lpha gt o lt Multilpha gt lt Multi lpha gt lt Multidlipha gt lt Alpha gt lt MultidIpha gt lt Multilpha gt lt MultidIpha gt lt Multidipha gt lt Alpha gt lt MultidIpha gt lt Multilpha gt lt MultidIpha gt 2 Goto the Power Orders section of the chart and place the pressure ulcer management orderset Menu a Overview E 24 Hour Summary ski Pressure Dressing yo Pressu
33. Diffe 02 04 09 16 13 00 Routine 1 One Time Only 1 Oapfs Blood Mur Ordered Collect One lavender top tube Order not more than one within a 24 Deselect AU Select All Apply 2 Click on the word apply This will display the order in more detail L Burnside Rhonda Actions Requiring Review JD x Action Action Date Time EnteredBy De tals SCH DRHPhysician Complete Blood Count with Differential Order 02 04 09 16 13 58 MDOT CBC Diff per protocol M SelectAll Burnside Rhonda Review Bierger 3 After reviewing the details of the order click on the word review The icon and the order are now removed from the PAL list The order can still be viewed from the orders section of the chart DRH Clinical Transformation Pamela Haddox RN BSN May 2009 Admission Documentation When a patient is admitted an icon will appear on the PAL list that will contain the forms to be completed Patient Access List Burnside Rhonda G Print 2 minutes ago Shift 03 February 2009 07 00 03 February 2009 19 00 N15 00 15 17 00 17 If there is no icon double click on the patient s name to open the chart The forms can be found by clicking the ad hoc icon on the toolbar E Tear oft Z ch ae Charges BP charge Entry Ml ext Calculator aco Medication Administration a FM Conversation A Report dt Next click EMR forms and select the needed forms by clic
34. EMR Training Manual Nurse DMG DETROIT MEDICAL CENTER Table of Contents Coarne EN G Vi e ye ba E Ba kd EEN 3 Kb ELE O a il n a e E il ni a ini e milini E geli e s 4 Information SecurityandConfidentality gt ie or Ke a PAP ME PE RM EE e ER e EY EYE 6 pet Ee En a m ny le e ii e le li GL dene eli 8 Toolbars Te EE 10 Patient Access ISU Als sr a in gl rini g le aa rn la de m lde la 12 E ee E 14 Creating your own assignment list EE 15 CMa ae TOn eege 16 TRAST AMO EE 17 Orders Tor tee 18 Admission Documentation EEN 19 Admission Assessment EE 20 Pes G e lt A PR ETE 21 E ES E E a EE P E E A E A E Mr e 23 Ee We m 6 p Lisl ME ME EE EN PE PE EY E 26 Ee eege 28 EE TCA SE el l EE EE 30 VOCS Past Procedir S ee 31 Immunization e Ne EE 33 Ee 35 Daily Documentation ongoing asgesgment 0 cece cece eee eee eee e eee e ee eee ee eee eee eee Eee EEE EEES 36 Patent Ee tee EE 38 LELE PO EE 39 EE 43 leie a Where dE 45 e vE EE A YE EE EEE MY eae sas 46 FRG UT e bea i gee di eme a ip an elle en ai mi iin ama eki ge en me inan se een 49 Sen TEE 52 Nora O CN 57 eege 60 ANIC CTs COORG CE e MEYE RE EE EEE EE Ee 61 EE 63 Medication b A EETA EEREN 64 Nieman WE MT E 70 Te a e Te E EE 71 Re schedule Ee e E T2 e WEE e EE 73 Reference ManualandEducatlonleatlets Ge 74 er IRCS PONG EEE E EMEN PE PENN EN PEN A PA SEY PE YE EE YE PE 79 HandoffCommunlc
35. Laboratory Services Order Information Ef Vitals Patient Care E Medications Complete Blood Count Ordered O Comments One Time Only 1 De with Differential CBC Di Results Order not more than 3 Iv Infusions i ef Laboratory Services vg SZ Troponin Ordered Print One Time Only 1 De f il Radiology Services Reference Information Lithium Heparin SST Consults Consults Advanced Filters p Pulmonary services E WW Social Work Consult Ordered Enable Edit on the Line zommu nity Resources i z EJ Cardiology Cardiovascular B Therapy Services DHUIE For stat CONSUNS page designated do we sic D Carcial Work Dans db Ordered N7 177N9117 R 7 0N Rantina Camm mihi Basa ireas The orders profile will display the order status as Void with a line through the order aay os es sere J San LTR nerme Taas Dos Laboratory Services CH KSM Complete Blood Count Org red with Differential CBC Di wv RA Troponin Ordered Consults OETH SW ec 02 12 09 11 52 00 Routine 1 One Time Only 1 De Collect One lavender top tube Order not more than 01 28 09 12 39 00 Routine 1 One Time Only 1 De Tube Type and Volume Green Lithium Heparin SST Gocial ark Cons it Ordered 2212709 11 5700 Do fire Cammini Descmres 7 b f w Details for Social Work Consult Details Gel Order Comments N Diagnosis Oder details e lin Detail values Void Date and Tim
36. Mouth Tab 6 PAN Pain 7 000 ma By W Pain Scale Score 10 Auth Mee Next enter the patient s pain level after receiving the medication E Pain Response Davis irginia C si VHO S B air T O2 16 2009 feio By DAHNurse RH15 elses Intervention Info acetaminophen Performed by ORANurse RATS on 027 N09 12 07 00 acetaminophen 1000mg By Mou Fain Pain Score after Pain Medication is given Then click the green checkmark to sign the form OO emm DRH Clinical Transformation 75 Pamela Haddox RN BSN May 2009 Handoff Communication When giving or receiving report the nurse must use the information in the EMR Using the EMR gives the nurse the opportunity to ask questions as well as making sure all tasks have been completed before transfer of care During handoff communication several of the tabs within the EMR are utilized There is also a flowsheet available to aid in the process To access the flowsheet first click on the results review section of the menu bar From the all results tab click the dropdown arrow Menu a africa tayfa Overview d En YS 24 Hour Summary E an All Results 748 hr Summary Lab Radiology Vitals UO MAR Flowsheet P Results Flowsheet v eH All Results Flowsheet Immunization Schedule All Activity Flowsheet 709 11 46 PowerOrders zb add Emergency Emergency Physician Clin Doc o Health Histor sult
37. Set S1 BH Self harm Potential for Sul BH Sensor Perceptual 5u BH Violence Risk For u Cv Cardioyascular Nursing Int 8 F4 Functional Ability M obility Nursing m GD Failure to Thrive Adult u Gi Bowel Elimination Impaired a Gl Tissue Perfusion Ineffective Gl u GU Tissue Perfusion Ineffective Re al GU Urinar Elimination Ineffective el Dral Mucous Membrane Impaired S IN Tissue Integrity Impaired S IN Tissue Perfusion Ineffective Renal m P Acute Pain Labor P Ansiety Related to Insufficient Kno Sa IP Ansiety Related to Labor and Birth Isi Feta Surveillance TESTDRH TESTO1 D 841000017 I P Girieving Anticipatory P Potential Complication Premature Sli P Potential Complication Sickling Cris elt Respiratory Function Altered Rel al M Metabolic Nursing Interventions u NCC Acute Care Core Set m NCC Critical Care Core Set S NCP Autonomic Dysreflekia NCP Communication Impaired u NCP Confusion u NCP Disturbed Sensory Perception m NCP Knowledge Deficit Sm NCP Memory Impaired gt m NCP Pain Acute gt m NCP Pain Chronic m NCP Tissue Perfusion Ineffective C u NCP Stroke Su P Chemotherapy Side Effects Eu P Discomfort Abdominal Done DRH Clinical Transformation Pamela Haddox RN BSN May 2009 4 Next the orders will display on the scratchpad for you to view before signing This 1s
38. a decreased Date Oates Alpha gt Excess e When choosing goals for your care plan keep in mind that these must be evaluated and a resolution applied to them Please be sure that if you choose more than one goal per plan that these goals will always be met at the same time If not you will need to list them on separate lines DRH Clinical Transformation Pamela Haddox RN BSN May 2009 The comment section allows for free text and it should contain assessment data to aid n the evaluation of the care plan Please see example below Plan of Care AduftMedical Rehab Plan of Care Problem Plan of Care Goals Plan of Care Expected Res Plan of Care Comments Category Initiated Resolution Date gt Cardiovascular DM Dw Fluid Volume Cu Edema decreased 0270909 0212 09 2 9 2 pitting edema DL E Excess The care plan will be continued and updated daily by each nurse until the goals are met or the patient is discharged When finished with the form use the in the top left corner to sign the form or use the mi to save it if you need to return to it later Nursing Interventions After initiating a care plan you must order nursing interventions These only need to be ordered one time and will remain on the orders profile for all to see until discontinued To order nursing interventions first click on the Powerorders section of the menu bar and click the P Add icon Next click on the folder icon below the find box Diagnos
39. associated with the order DRH Clinical Transformation 52 Pamela Haddox RN BSN May 2009 The orders profile contains a filter to enable the user to see different views of the orders profile PowerOrders E Print 1 minutes ago s Add a Document Medication by Hx Orders Medication List lq Display Jal Active Orders DI B All Active Orders a ig All Active Orders 24 Hours Back Details Orders for Signature amp Orders CH All Medications All Statuses D 7 All Non Medications All Stak Z ADT Condition Code Stat m aseene 2 12 09 10 44 00 CONTINUOUS Nutrition Services Completed Drd j m m M SAF Restraint Monitoring Ordered 02 11 09 10 09 00 CONTINUOUS B Medications z E IV Infusions B Laboratory Services be HI Rarlinlnnv Servires o ICT Adrnissian Ordered MA 296 09 9 79 38 Nna Time Onlu Click the dropdown arr w and choose the selection you wish to see gt Adult Admission History Ordered 01 26 09 9 28 36 One Time Only Ordered via Discern Expert Admission Assessment Ru Customize view a If orders are not reviewed from the PAL list they will display in a section of the orders profile PowerOrders A Print 2 0 minutes ago a Add 7 Document Medication by Hx Orders Medication List tegen Ri AJ Y denme Taas Details Vitals Patient Care p Orders For Signature 5 Orders ii ADT Condition Code Stat wi S 60 Vital Si
40. atlon eee 76 Downtime documentation Gene TI DRH Clinical Transformation Pamela Haddox RN BSN May 2009 Course Objectives By the end of this presentation the student will 1 Have an increased knowledge of the principles that drive Clinical Transformation 2 Understand how the DMC integrates technology to support patient safety and clinical judgment and achieve excellent outcomes for patients 3 Understand basic EMR functionality DRH Clinical Transformation Pamela Haddox RN BSN May 2009 Introduction When the DMC began its EMR journey in 2006 it made history We became the first system across the country to implement EMR across all DMC facilities in 13 months During the implementation of the EMR it was apparent that the DMC was not only implementing technology but the DMC was Transforming the way Patients Receive Care We did this because at the DMC we intend for our care to be safer and better than any other system While this video is to teach you how to use the system its overriding purpose is the message that EMR at the DMC is really about excellence for our clinicians and our patients Clinical Transformation was created during our EMR implementation process It became obvious during our planning that EMR was not a project but an approach to excellent outcomes for our patients Although our class today is going to provide you with education around using EMR and its functionality our overall
41. cine Contraindic Admin Date F Add 10 16 2008 Allergies Problems and Diagnoses FaceSheet The immunization schedule also displays the CDC schedule for immunizations for pediatric patients DRH Clinical Transformation 34 Pamela Haddox RN BSN May 2009 Entering Allergies To begin entering allergies for a patient first click on the allergies section on the menu bar Mem 4 Allergies Overview 24 Hour Summary Mark Alas Reviewed Results Review Hoo 7 SEN 2 active S Immunization Schedule re EI PowerOrders Clin Doc Forms Tasks Pt Info Patient Schedule Allergies Problems and Diagnoses 2 Next click the add icon 3 Then type the name of the allergen into the search field and click search Ea 5cope Sally MRN D 841078462 Add Allergy Adverse Effect aspin pseudoeph MUL DA 03291 aspirin codeine MUL DR Reason aspirin hydrocodone MUL DR ETE aspirin oxycodone MUL DR SE aspirin meprobam MUL DR md entered gt wi aspirin caffeine MUL DR aspirin phenyltalox MUL DR SS md entered gt mg M SS aspirin methocarb MUL DR aspirin carisoprodol MUL DR mf EE aspirin pentazocine MUL DR SE Anacin P M spiri MUL DR SC Bayer Aspirin PM MUL DR SS EE Congespirin Asp MUL DR Bayer Aspirin MUL DR St Jose
42. d Double click to review Click Apply to acknowledge that the orders have been reviewed noted A Red icon indicates a STAT order or a result that is out of the normal range Double click to view Click Apply button to acknowledge that they have been reviewed Icons that appear in the Task section provide an indication of the type of activity that needs to be done S Medications Medication PRN Response Activity Activity Hygiene Nursing Assessments Treatments Admitting Audiology Care Management Communication Orders Patient Assessment Monitoring Procedures Discharge Vital Signs Respiratory Nursing Tasks Respiratory Respiratory Assessment Respiratory Treatments Pulmonary Diagnostics D IV s IV Parenteral Therapy Interventions Unit Based Tests Interventions Dressings Wound Skin Care Education Tubes Drains Fluid Elim Patterns Safety Measures Precautions Nurse Blood Draw All blood draw orders where the nurse is indicated to draw the blood EN Unscheduled Task This activity can be from any of the other types but is unscheduled el Communications Communication Orders Order Notification Spiritual Care Consults DRH Clinical Transformation 14 Pamela Haddox RN BSN May 2009 Creating your own assignment list for your PAL Each individual must create an assignment list 1f his her area is using the Shift assignment function This list will automatically contain any patients assigned using the shift a
43. d cuff C Diastolic BP Collection Arm left O Wrist Right Collection Automated cuff C Thigh right O wrist Left O Thigh cuff gt A Mean Arteria Pressure Weight kg kg Calculated Ibs Enter only one 2 Click on the Results Information icon ei Result Information X Performed by hAHNurse AN15 Date Time ogi6 2009 Lilli E Modify Date Time of Curent Documentation Orly Modify Date Time of Previous and Current Documentation Comment Cancel 3 Type in the name of the person you are transcribing for and change the date time field to reflect the date time the documentation was completed on paper and click OK After completing the form sign the documentation DRH Clinical Transformation 78 Pamela Haddox RN BSN May 2009 Documenting Medications By Proxy Prior to downtime pharmacy will print paper MAR for all patients Medication administration will be documented on the paper forms during downtime When the system is back up the medications from the paper MAR must be documented on eMAR If you are documenting medications that you administered then you will enter the medications manually without scanning If you are entering medications that were administered by another nurse then they are being entered by proxy To begin click on the dose you wish to document 15 August 2009 10 86 17 September 2009 10 26 Clinical Range pee 09 16 09 09 16 09
44. d for you however your exact location will be bookmarked The next time you sign on to Citrix from any DMC computer within four hours you will be returned to the exact place you were before you clicked Suspend amp Log Off Click the Log Off button on your taskbar tray when you are leaving at the end of your shift This will close all your applications and log you out of the system entirely When you return for your next shift you will need to log in to any applications you wish to use Log Off and Suspend are located in the lower right corner of your screen above the clock DRH Clinical Transformation Pamela Haddox RN BSN May 2009 Tool Bars and Icons Toolbars can be customized to user preference Click and hold on the four vertical dots in front of the toolbar A four point arrow will appear n Patient List A Multi Patient Task List 7 Patient Access List ei Shift PEDINA WD Lawson 4MIEDICA DMC Policy and Procedures E Tear G R Attach ag Charges DP Charge Entry Hl Egt 2 Calculator i dir MI Medication Administration a PM Conversation gt OO menune ge Lippincott sM g While still holding the mouse button down drag the toolbar where desired and release the mouse button This will allow you to view all icons If the toolbars are not showing all icons you will have to use the dropdown arrow at the end to view hidden icons H Diech mst Charges Bi halas Entr al Exit El Calcula
45. der other than the order details the provider or covering service provider will be contacted to change the order Fax Order An order that is received via facsimile machine to the clinician site from another health care provider The faxed order must have a physician provider signature date and time If there are more orders from the same physician you can enter them now When entering a medication order an order sentence box will appear Select the appropriate details from the list and click OK Search PJstats with zl Type Eh inpatient zl Search within fan DI At location DRHUHC Neurontin Neurontin Leve L Order Sentences Order Sentences for gabapentin Neurontin 300 ma By Mouth Capsule TIC 200 mg By Mouth Capsule 4 tim a day 400 mg By Mouth Capsule 4 times day 600 mg By Mouth Capsule TID 800 mg By Mouth Capsule TID When all orders have been entered click Done DRH Clinical Transformation 55 Pamela Haddox RN BSN May 2009 Next the scratchpad will display the orders you have entered Here you have a chance to review the orders and make corrections before signing them Complete any details that are missing by highlighting the order and then completing the information at the bottom by ml 4 Orders for Signature Y Order Name Status Stat eta DR 4R 4R03 FIN 685304784 Medications p gabapentin Neurontin Order 02 12 2009
46. e 02712709 16 03 ii o Displayed All Active Orders Show More Orders Z Dy Table Orders for Nurse Review Orders For Signature DH AH ARA A FIR BELA eles U MIRSA komme Leta rderi be Hui pa Le Sign the order and refresh the screen DRH Clinical Transformation Pamela Haddox RN BSN May 2009 Medication Administration Medications are viewable from the electronic medication administration record or MAR section of the chart as soon as the orders are entered Medication administration is charted on the MAR by using the scanning process The scanning process must be used to ensure patient safety Benefits of the scanning process include oh tg MA Improves patient safety through reduction of human errors in the patient care process Automates positive patient identification Verifies the five rights through barcode technology Eliminates illegible notations Automates the documentation of medication administration Automates the documentation of tasks at the point of care related to specific physician and or nursing orders R Overview A Print lt 2 0 minutes ago 15 February 2009 09 54 17 February 2009 09 54 Clinical R a 02 15 09 02 16 aaa E or eer insulin aspart E Er metoprolol Ke Start 01 26 09 17 00 00 Routine e 25 mg Mo uth Tab BID Diastolic Blood Pressure Monitored HR 150 mg 150 mg geelaminonhen Pain Scale Score
47. e the task is completed it must be tasked off Patient Access List Eb print g 1 minutes ago Shift 03 February 2009 07 00 03 February 2009 19 00 First double click on the icon to determine what needs to be completed x Tasks appearing in this window are accurate as of 027 0372009 15 08 Please select the refresh button to update he Refresh display Status Pl 02 03 03 15 04 Collect Complete Blood 02 03 09 15 04 00 Routine 1 One Time Only 1 Da Pending Complete Blood Count Collect One lavender top tube Order not more than gt Quick Chart Chart After completing the task click chart never click quick chart at the bottom of the box This will remove the task from all areas of the chart DRH Clinical Transformation Pamela Haddox RN BSN May 2009 Orders For Nurse Review As soon as an order is signed in the EMR an eyeglasses icon sa will appear in the notification section of the PAL This alerts the nurse that there 1s a new order and it must be reviewed by the nurse eh Print ka 0 minutes ago Patient Access List Shift 04 February 2009 07 00 04 February 2009 19 00 Davis Virginia Scope Sally Johnson Paul Burnside Rhonda 1 To review the order double click on the eyeglasses This will display the order x E Drders 3 ge Dn ll N 1 C Order Description Order Display o ooo o o od E f Ffa Complete Blood Count with
48. ed gt d f 0 125 mg al gt 5 09 9 00 00 Routine 0 125 mag By Mouth Tab Daily Monitored HR Order Info Task Info m Chart Details TER H Quick Ghart Start 09 9 00 00 Routine 25 mg By Chart Done Mouth Tab Daily Chart Not Done hydrochlorothiazide Unchart Systolic Blood Pressure TART This Dose Diastolic Blood Pressure Enter the new date and time for the medication Reschedule digoxin for x Currently scheduled date and time ozn 5 09 09 00 Rescheduled date and time ez le ro E Rescheduling reason lt none gt b Cancel Then click OK wm DRH Clinical Transformation Pamela Haddox RN BSN May 2009 Reguesting a Medication If a medication is missing or another dose is needed it can be requested from pharmacy through the electronic MAR To request a medication right click on the medication details and select med request Print 2 2 minutes ago ebruary 2009 07 41 19 February 2009 07 41 Clinical Range Kat 02 18 09 02 18 09 Medications 07 48 08 00 Order Info Sta 27 09 9 00 00 Routine 0 125 mg Event Task Summary Continuous Infusions Mouth E Reference Manual _Oontinuous Usions digoxin Med Request Monitored HR D A 02718709 09 00 0 125 mg Scheduled e Reschedule Admin Times Additional Dose Start 01 27 09 9 00 00 R
49. ential for sl H Senson Perceptual ml EH wiolence Risk For kel Cardhovascular Nursing Intervent 8 FA Functional Ability Mobility Mursin ba G0 Failure t lt a GI E owel Elirimation Impared a Gl Tissue Perfusion Ineffective Gl lt a GU Tissue Perfusion Ineffective A ka GU Urinary Elimination Ineffective Gel Dral Mucous Membrane Impaired LalIN Tissue Integrity Impaired Kell Tissue Perfusion Ineffective Re Sellp Acute Pain Labor a P Ansiety Related to Insufficient Er Sa IP Ansiety Related ta Labor and Birt Sa P Fetal Surveillance Now choose the category that matches your plan of care Dcw Cardiovascular Nursing Interventions NLP Search within A At location DRHUHE D IF Potential Complication Prematur Kellp Poterpel Complication Sickling Cri os Respiratory Function Altered He 58 M Metabolic Nursing Interventions Kelt Acute Care Core Set NCC Critical Care Core Set omic Dysreflesia Communication Impaired Sm NCF Confusion Sa NCP Disturbed Sensor Perception ba NCF Knowledge Deficit SelNCPMemon Impaired ba NCF Pain Acute m HCF Pain Chronic el NCF T issue Perfusion Ineffective C Sa NCF Stroke m F Chemotherapy Side Effects D PDDiscomtort Abdominal Le Anticipatory DN Each green line represents a goal for that problem Find the goal s you selected and choose the appropriate interventions listed beneath the goal
50. focus 1s to provide the safest care to our patients using current evidence that is available to the clinicians All disciplines can see the story unfold and use the information to make decisions about patient care and treatment As a clinician you will always rely on your clinical judgment and use the information gathered in the EMR to make clinical decisions that are best for your patient DRH Clinical Transformation 4 Pamela Haddox RN BSN May 2009 Information Security and Confidentiality When dealing with computerized health care records specific confidentiality and security issues must be followed to protect the patient Also there are increasing HIPAA and JCAHO regulations that dictate how these records are handled When selecting a password do not choose anything obvious such as your birth date social security number or spouse and children s names Do not tell anyone your password The DMC system requires you to change your password every 90 days When you open a chart you will be asked to identify your relationship to the patient for example Staff Nurse or Chart Review The system keeps an audit trail or record of who enters each chart and when It records who read the chart and who recorded each piece of information in the chart Every employee will not be allowed to see or perform every activity on the computer For example a lab technician will be able to see and do more in the lab application than a nurse will
51. geguired Details Dy Table Orders for Nurse Review Click on the required field on the left side and then select the appropriate details from the list n the right Sign When all the required fields and details are completed click Sign Remember to refresh in order to change the order status from proce sing to ordered Display All Active Orders E prenne 3 az Consults O D Social work Consult Processing 02 72 09 1455 Routine Community Resources NOTE For stat consults page designated Social Worker or call c Sprint a Customize view DRH Clinical Transformation Pamela Haddox RN BSN May 2009 59 Discontinuing Orders To cancel an order that is no longer needed right click on the order and select Cancel DC Glas Details ad Order Name itals Patient Care Vital Signs per Drago Ordered 02 12 09 10 44 00 CONTINUOUS at EES g Ordered 02 1109 10 09 00 02H sment Med Surg Renew SS g Restraint Monitoring Or Modify A Gg Es wi Adult Admission Histon Or Copy Cancel Reorder on Assessment Ru ei ICU Admission Or Suspend Assessment Activate on Assessment Au wi Initiate Plan of Care Or Soules Cancel Dic on Assessment Au Medications void w By Sg gabapentin Neurontin Ur Beschedule Task Times 300 mg By Mouth nat in E ee e a i i Mr N J Gosign iho Dose Range checking S f ES GE Order Information N Comments z Displayed All
52. gns per Protocol Ordered 02 12 09 10 44 00 CONTINUOUS vid Activity MS adr Restraint Ordered 02 11 09 10 09 00 Q2H LA Nutrition Services Assessment Med Surg e itals Patient Care z Medications l IV Infusions el z Laboratory Services li Radiology Services Ei ICU Admission Ordered 01 26 09 9 28 36 One Time Only Consults Assessment i Ell Pulmonary Services x Initiate Plan of Care Ordered 01 26 09 9 28 35 One Time Only l Cardiology Cardiovascular l Therapy Services J Communication EA So Restraint Monitoring Ordered 02 11 09 10 09 00 CONTINUOUS Adult Admission History Ordered 01 26 09 9 28 36 One Time Only Medications Customize View a Ordered via Discem Expert Admission Assessment Ru Ordered via Discern Expert Admission Assessment Ru Ordered via Discern Expert Admission Assessment Ru i Miscellaneous Ei EA bo acetaminophen hydrocod Ordered Start 01 28 09 12 31 00 Routine 1 Tab By Mouth d A nne Naren 325 mp 1N x 7 LJ Order Sets 4 gt D Equipment Supplies i oces c a Details Displayed All Active Orders Show More Orders E Dy Table rders for Nurse Review Arin Antion Date Time Freed n Order Dear DAHHwse ANTS Vitel Signs pet Probocol zen TS Rs TOT OHHH wc ANT Reslard Mortari TUUU CONTINL 1 71 DAHNwse ANTS Restraint AssezapertMedifann Select gil og gt After reviewing the orders click the review button at the bottom
53. h for disease conditions using acronyms such as COPD or AFIB you must first add the SNOMED database This must only be completed one time per username 1 To begin click on the histories section of the menu bar and click the past medical tab 2 Click the EEN icon 3 Next click on the binoculars Histories G Print Bo minut Family Past Medical ProcedNre Past Medical Name of Problem Last Agviewed Age at Onset OnsetDate Age at Resolved Condition Responsible Provider Comments BATE Free Tent 7 Display s At Age Onset Date ee ee Mpe CT Confirmation Classification Resolved At Age Resolved Date Confirmed Medical 7 D E EIB sl Status Cancel Reason Resolved DI 4 Click on show advanced options Problem Search 7 x G Starts with within Terminology D Search Show Advanced Options aa VIEW Synonym RE Concept Family LE Mun Axial ww Cross Mapping Terminology Asis 5 Next click on the ellipsis icon Problem Search Search d Starts with e Within Terminology DI v Hide Advanced Options Search by Name Ode Terminology fICD SCM SNOMED ET J Terminology Axis lt All terminology axes gt S Si View Synonym E Concept Family SR Multi Axial vw Cross Mapping Terminology x Erminoloay Axis Ce reg ee SNOMED CT Cancel 6 Place a checkmark in the box in front of SNOMED CT and click OK
54. he screen Overdue a task that has not been completed in the allotted timeframe DRH Clinical Transformation 6 Pamela Haddox RN BSN May 2009 15 16 17 18 19 20 GAR 22 25 24 25 Patient access list PAL a list of patients assigned to the caregiver that contains key information associated with each patient Power chart the electronic medical record Power form an electronic form in the medical record Power orders electronic order entry Refresh updating the current screen Scratch pad the orders for signature window Suspend a way of logging off for a short time while holding your place in the chart Tab a section or heading in the chart Tasks patient care items to be carried out for the patient Time frame the date and time being viewed Toolbar the bar at the top of the screen containing icons and charting options DRH Clinical Transformation Pamela Haddox RN BSN May 2009 Logging in to CIS Powerchart 1 On your desktop double click the DMC Citrix Desk POF ef OME irri 2 Enter your DMC Enterprise User ID and Password DMC Citrix Desktop Login Desktop H otli ht on the DMC Citri e DMC Portal Pointers Instructions e Enter your DMC Enterprise DMC NT Network User ID and Password This is the one you use for E Mail VPN NetLearning for Physicians or remote access to the DMC Intraweb If you don t have an NT Network User ID Password yo
55. ications aboratory Services LI Complete Blood Coun Processing 02 12 09 11 52 Routine ft One Time Only 1 Dayls with Differential DREF DI Collect One lavender topftube Order not more than Ei EA Troponi Ordered 01 28 09 12 39 00 Rofttine 1 One Time Only 1 De Tube Type and Yolum Green Lithium Heparin SST z E Iv Infusions z Laboratory Services gt ii Radiology Services i Consults u D Pulmonary Services The orders are now in a processing status Click the refresh icon di to place the orders in an ordered and active status DRH Clinical Transformation Pamela Haddox RN BSN May 2009 56 Nursing Orders Some orders can be placed by the nurse They include L mi de Social work consult CMS consult wound care nurse consult nutrition consult nurse to nurse psych consult immunizations initial restraint orders can not order restraint renewal nursing interventions includes pressure ulcer ordersets supply orders To enter a nursing order click the power orders section of the menu bar then click ADD PowerOrders Sh Print 2 0 minutes ago ee Add a Document Medication by Hy Orders Medication List lq Display AI Active Orders Pi Customize view Orders for Signature aj E OrderName Status Details o Orders Vitals Patrent Care in E ADtiCondtoniCode State sw SZ Vital Signe per Protocol Ordered 02 12 09 10 44 00 CONTINUOUS p p E Activity we Bali Ordered
56. ick in the cell containing the charted medication and select modify A Print 2 0 minutes ago 17 February 2009 07 41 19 February 2009 07 41 Clini al Range D I naki 02 18 09 718709 02718709 Medications S E Scheduled digoxin Start 01 27 09 9 00 00 Routine 0 125 mg By Mouth Tab Daily i hoo S hydrochlorothiazide l Start 01 27 09 9 00 00 Routine 25 mg By Mouth Tab Daily i Systolic Blood Pressure view Details Diastolic Blood Pressure View Gomments View Order Info insulin aspart insulin aspart correction Add Comment dose low Star t 02 16 09 12 00 00 Routine 0 5 Units Unchart T ow dose correction dose BG 120 200 give a Enter the necessary changes 8 Berg hydrochlorothiazide Start 02 18 09 9 00 00 25 mag By Mouth Tab Systolic Blood Pressure mmHg Diastolic Blood Pressure mmHg hydrochlorothiazide 25 mg DI Diluent lt none gt DI ml Route By Mouth DI Site 7 Not Given Reason 7 Comment Then click the green checkmark to sign the form DRH Clinical Transformation Pamela Haddox RN BSN May 2009 Reschedule a Medication To reschedule a medication dose right click on the cell containing the dose to be rescheduled and select reschedule this dose MAR A Print lt 2 0 minutes ago e ol 17 February 2009 07 41 19 February 2009 07 41 Clinical Range ze 02 18 09 02 18 09 02 18 09 ZS A Schedui
57. iew 1488421017 SNOMED CT Procedure Asthma attack 396119015 SNOMED CT _ Finding Asthma care 2163236010 SNOMED CT Procedure Asthma causes daytime symptoms 1 to 1208954011 SNOMED CT Finding Asthma causes daytime symptoms 1 to 1208955012 SNOMED CT Finding Asthma causes daytime symptoms most 1208956013 SNOMED CT Finding Asthma causes night symptoms 1 to 2 ti 1208957016 SNOMED CT Finding Asthma causing night waking 264541013 SNOMED CT Finding Asthma clinical management plan 2474332015 SNOMED CT Duett value Asthma confirmed 1780388018 SNOMED CT Contgxt dep Asthma control step 0 282488010 SNOMED CT Progedure Asthma control step 1 282489019 SNOMED CT Prgcedure Asthma control step 2 282490011 SNOMED CT Pgcedure Asthma control step 3 282491010 SNOMED CT Tocedure Asthma control step 4 282492015 SNOMED CT Procedure Asthma control step 5 282493013 SNOMED CT Procedure xl Add to Favorites Cancel 5 Next complete any of the details that are known and click OK 1f finished or click OK amp add new if there is more history to add Responsible Provider Condition Comments al Free Text EI Display As At Age Onset Date asthma der Dis Confirmation Confirmed Medical Classification Cancel Reason Resolved At Age arr EE Resolved Date DRH Clinical Transformation Pamela Haddox RN BSN May 2009 OK Cancel 29 Adding SNOMED Database To be able to searc
58. il metoprolol 25 ma zl Diluent DI Route fiv PUSH DI Site D O Meni j N Antecubital Fossa Left al Route By Mouth DI Site z Not Given Antecubital Fossa Right Arm Left Lower Not Given Reason Arm Left Mid Arm Left Upper Reesor Ej Arm Right Lower Arm Right Mid Comment Arm Right Upper Comment Ca lick OK when done DRH Clinical Transformation 66 Pamela Haddox RN BSN May 2009 To chart a medication was not taken click on the blue checkmark Scheduled Mnemonic d dl MV v DI 36 PRN 02 16 03 09 00 digoxin 02 16 09 09 00 furosemide f e 02 16 09 09 00 metoprolol 02 16 09 09 00 fanitidine 02 16 0912 00 insulin aspart Start 02 16 09 9 00 00 0 125 mag By Mouth Tab Start 02716709 9 00 00 40 mg I PUSH Injection furosemide 40 mg IV PUSH 02716 0300 hydrochlorothiazide Start 02 16 09 9 00 00 25 mg By Mouth Tab Start 02 16 09 9 00 00 25 mg By Mouth Tab metoprolol 25 mg By Mouth Systolic Blood Pressure 185 mmHg Diasto Start 02716709 9 00 00 150 mg By Mouth Tab Start 02 16 09 12 00 00 0 5 Units Subcutaneous Injection insulin aspart insulin aspart correction dose low Low dose correction dose BG 120 200 give 0 Units BG 201 02 16 09 17 00 insulin aspart Start 02 16 09 17 00 00 0 5 Units Subcutaneous Injection insulin aspart insulin aspart correcti
59. ill print to the local default printer NOTE PCLA ts a View Only application No changes can be made mor orders entered mio CIS The bread e ents E ders i appear in alphabetzal order and the list cannot lf you encounter any probem please call the Help Desk at 3i 3 066 2400 Make sure to mention in the help desk ticket that you are using PCLA to expedite your DRH Clinical Transformation 77 Pamela Haddox RN BSN May 2009 Transcribing Documentation By Proxy If you are completing your own documentation you would complete the items as you would normally Only the date time section would need to be changed If the downtime crosses shifts you may have to enter the documentation for someone else This is called entering information by proxy You will be entering only the information that has been documented on paper 1 Open the form from ad hoc or from the PAL as appropriate do Hes Performed on By DRHNurse RN15 Vital Signs Vital Signs Oral Degl Tympanic Degl Pain Score Rest P N A N Pain Score Activity P N A Rectal Degl Axillary Degl Pain Scale o VAS O PABS Peripheral bpm Apical Heart bpm coat Pulse Rate Rate nmHg Pain Scale O 0 10 Pain Scale OPS Fetal Heart Pediatric O Wong Baker O N PASS Rate OUCHER O NIPS RN Notified of P Wen FLACC S Pain Score Systolic mmHg mmHg Location of BP O Arm right O Thigh left Method of DD O Auscultate
60. ion if needed The PowerChart local Access PCLA application provides access to view patient results for different categories e labs medications radiology etc during downtime PCLA is strictly a view only application It does not allow for any changes such as changing the clinical date range entering orders and sorting patient results Each designated computer will have a card displayed next to it with the instructions for logging m to the system In the event this happens all documentation must be entered into the computer when the system is back up PCLA Monitor Card Please find the monitor card on PCLA device for instructions to login into PELA Instruction for PowerChart Local Access PELA for Downtime Only Username Password How to Access PELA Double click on the DT Viewer icon on the fe Desktop The PowerChart LA Login dialog box will appear Enter the Username and Password written above then click OR Click on the patent s name from the list on the left to view a snapshot of the patents Medical Electronic Record Enter your CIS Powerlhart Username and a reason for wewing the patient s chart ihen click OR Results wall appear on the right Step 3 Click on the desired hyperlink at the top to view different categones i e Labs Meds Rads etc How to Print from PELA Step 1 Select File menu in the menu bar at the top lett comer then select Print Step 2 Click on the Print button and the results w
61. is Problem being Addressed this Vizit Find Search Starts with si Type Z de Add Convert Display LA fai Pl ra 7 Folders Search within Jal 21 Clinicals ode Clinical Ds SE Children s Hospital of Michigan gL etot Recerving Hospital CC qHarper Hutzel Hospital Huron Yalley Sinal Hospital Karmanos Cancer Center Michigan Orthopaedic Specialty Hos Rehabilitation Institute of Michigan Rose Diagnostic Imaging Center Sinal Grace Hospital Problems e of Care ae Add Convert Display All z Now select plan of care from the list DRH Clinical Transformation 40 Pamela Haddox RN BSN May 2009 Erd I search Starts with Type di Inpatient E ei izl ki La Folder Folders ea AP Activity Intolerance La 4P Ansiety Km AP Ansiety Related to Insufficient K Sa 4P Comfort Impaired lt a 4P Fetal Surveillance elap Hauses ml P Potential Complication Hypo Hy ml amp P Potential Complication Preclampsia Complication Pre term Se AP Potential Complication Prematur sml amp P Potential Complication Sickling L sml A P A espiratory Function Altered A m A P A espiratory Function Risk for Alt ml EH Aterzbon in Mood Ansiety KelDH Akerapon in Mood Depression ml EH Alterzbon in Mood Fear Phobia KelDH Akerapon in Mood Mania ml EH Alteratlar in Sleep Appetite Ene m EH Alteratior of Thought ml EH Psychiatrc Core Set eml EH Seli harm Pot
62. isk for skin breakdown The problem At risk for impaired tissue integrity has been added to the Problem List If the Pressure Ulcer Prevention Orderset is not in place please add it to the patient s overall plan of care RN Responsibility 1 Go to the Power Orders section of the chart and place the pressure ulcer prevention orderset Menu q Overview E 24 Hour Summary Pressure D essing Results Review Pressure Garment Measure Fit I O Pressure Infusion Bag MAR Pressure Paley Neuropathy Immunization Schedule Sm Pressure Ulcer Management gt amp s Pressure Ulcer Prevention Clin Doc m Pressure Ulcer Treatment LIP and 2 Forms Pressure Wound Protocol Tasks Pressure Close Pt Info Pressure Opening 2 Complete the task on the PAL Tasks appearing in this window are accurate as of 5 4 2009 08 21 Please select the refresh button to update the Refresh display _ Date and Time Task tals Status O 5 4 2009 08 16 Goto Orders Pressure 05 04 09 8 16 28 Pending Go to Orders Press Ule Ordered by Discem Expert Quick Chart e 3 Initiate Risk for impaired tissue integrity care plan See page 39 of this manual for explanation 4 Complete patient education see page 38 of this manual for explanation DRH Clinical Transformation 29 Pamela Haddox RN BSN May 2009 Admission History Again use the navigator bar on the left to complete each section Be sure to complete
63. isplay at the bottom of the screen to show the intake and output balance for the patient 170 Print 2 0 minutes ago 09 February 2009 07 00 12 February 2002 06 59 Clinical Range Pg FLUID BALANCE Intake Output EN Oral OTHER IN Urine Stool OTHER 0 Urine Formed 02 10 09 07 00 200 02 10 09 08 00 0 02 10 09 10 00 I 0 02 10 09 11 00 I 0 02 10 09 12 00 I 0 02 10 09 13 00 0 0 02 10 09 14 00 I 0 Day Shift Totals 02 10 09 07 00 I 02710709 15 00 I 0 02 10 09 16 00 I 0 02 10 09 17 00 If the patient has other sources of intake or output that are not listed in the I O section those columns can be added by clicking the display hidden category icon d t x Select the categories you wish to add Intake Categories Output Categories n Chest Tube Drainage 3 0 Chest Tube Drainage 4 je C Gastric Tube CI GI Stoma o Hermovac 1 C Hemovac z jee T Hemovac 3 Double click on the folder to display the items Next select the appropriate options and click OK These columns will now display on the I O section DRH Clinical Transformation Pamela Haddox RN BSN May 2009 47 Modify Unchart Results Previously charted results can be modified by doing the following 1 Right click on the result to be modified 2 Select modify 3 Enter the corrected value 4 Enter a comment in the comments field 5 Click OK Oral 09 February 2009 07 00 12 February 2009 06 59 Clinic
64. king in the box to the left of them L Ad Hoc Charting Burnside Rhonda E EM R Forms EI Adult Admission Assessment Assessment C EB Adult Admission History C Emergency Service T D Adult Nutritional Intake Critical Care T D Adult Ongoing Assessment D PCA Forms T D Adult Pain Assessment m z Se Vitals Pain GCS Advance Directive E EMA rome ER E Clinics C DI Antepartum Assessment amp ED C B Arterial Blood Gas Analysis by Respiratory Pharmacy E Asthma Assessment Outpatient Pharmacy E Behavioral Health Admission Assessment EH Archive Folder C E Behavioral Health Admission History Ca All ltems T amp Behavioral Health Ongoing Assessment D E Blood Gas Draw C E Braden Assessment C B Burn Injury Nutritional Tracking T E Burns The necessary forms include Admission assessment Admission history T B Cardiovascular Adult Assessment T B Cardiovascular ICU Assessment C DI Cast Application C B Continuous Passive Motion D EI ED Treatments and Procedures T DCD Triage and Assessment Adult DAH IT D ED Triage and Assessment Pediatric T E Education Wound Care IT B Fim IT B Gastrointestinal Adult Assessment IT B Gastrointestinal ICU Assessment C E Genitourinary Adult Assessment T D Genitourinary Dialysis Assessment Detailed C DI Genitourinary Dialysis Assessment Simple IT EB Genitourinary ICU Assessment DC B Glascow Coma Scale C E Home Health Disposition T D HtAwt llergies T E Hygiene
65. lood Gas Result Entry Auth Yerifiedi Z7ORDER POE NURSING Yellow In Error uncharted Modify Forms Depending upon your security you may be able to modify forms from the Forms tab Modify a form by completing the following steps 1 Select a form 2 Right click the form and select Modify Fall Forms E EMonday February 09 2009 ie H15 26 Vital Signs Auth Verified DRHNurse HNTS 15 28 Incision Wound Care Auth Verified DF HM unggahi o 3 thursday February 05 2009 E Ge 09 27 Plan of Care auth verifizd Multi Contribute Modify Se 09 24 Patient Education Auth Verified Multi Contr Hnchart Si wednesday January 28 2009 Print 10 52 Adult Admission Assessment auth Verified 1 History NE BH adult Admission Histery In Error Multi Contrt Change DakejTime 3 Make the necessary changes When you are finished click the Sign Form icon to chart the information Find the form you just modified in Forms Notice that the status is displayed at the end of the form in parentheses If the form was saved and not signed the status will display as In Progress If the form was signed the status will display as modified DRH Clinical Transformation 44 Pamela Haddox RN BSN May 2009 Unchart Results Results that were entered in error such as charted to the wrong patient can be uncharted from the original form An audit trail tracking who uncharted it and why is
66. me the PRN medication was given The RN must read the medication details to determine if it is time for another dose before administering The computer will not stop you from giving the medication sooner than what the order states because it is ordered as a PRN Warnings and Cautions The Warning icon will display if the medication scanned e Has a dose greater overdose than what has been ordered Dosage sent needs to be divided ex give half tab e Is from a multi dose container the total container dosage is scanned therefore not the dosage that is ordered ex insulin e sina different form liquid vs tablet than what has been ordered medication needs to be reordered in correct form The scanned line will be highlighted in RED A pop up warning message will display the reason for the warning The Sign button will not be active i T a Scheduled ee CC Se EE i d 08Jun 2 moxifloxacin 40 10 mg 1 T a J ab By y Mo uth Other Reason in c zommenis r 03 Jun 2006 01 00 5 ranitidine 150 mg is not the correct dose as indicated on the order profile 09 Jun 2006 09 00 The correct ordered dosage is 75 mg aa 09 Jun 2006 09 00 imments Aix to ca CN 03 Jun 2006 09 00 BAR EE 3 SOY in comments amp y PRN acetaminophen First Dose 06 09 06 10 23 00 Routine 650 mg By Mouth T 4 b Ready to Scan Back Sign Click OK on the warning page DRH Clinical Transformation 68 Pamela Haddox RN BSN May 2009
67. mplaints Pain not present Reports feeling rested Genitourinary J R i j Cardiovascular System C WDL s O Exception Unable to Assess WDL s Heart rhythm regular Capillary refill less GU Detailed than 3 seconds No edema present Genitourinary Reproductive Respiratory System O WDL s Exception Unable to Assess Female Repre WODL s Respirations regular and unlabored Breath sounds clear Airway patent Patient on room air Seed Gastrointestinal System O WDL s Exception Unable to Assess WDL s Mucous membranes moist pink and Musculoskele intact Abdomen non tender and non distended Bowel sounds present BEE By DRHNurse RN15 Integumentar ntegumentar Genitourinary System O WDL s Exception Unable to Assess WDL s Voiding clear yellow to amber urine No D Braden flank pain ell gt in Progress DRH Clinical Transformation 36 Pamela Haddox RN BSN May 2009 The ongoing assessment is charted by exception This means only variances are documented in detail Ifa particular system does not have any variances then the WDL within defined limits option is selected The limits are defined in the blue lettering to the right of the row Se Respiratory System C wDL s Exception Unable to Assess WL s Respirations regular and unlabored Breath sounds clear Airway patent Patient on room air Clicking the exception option will open another page for you to document the findings
68. ndow Find I Search Starts with DI Type Ch Inpatient DI EN Gi iz bd Cal Folder Search within fan DI At location ORHUHC d Social Isolation B Social Work Consult Jones Leroy D 841078459 Enter any other nursing orders when finished click Done Done Next complete the necessary details from the scratchpad The x indicates there are required details that must be completed before signing the order PowerOrders ee Add d i Document Medication by Hx Orders Medication List WM Orders for Signature gt Orders for Signature B Orders i ii ADT Condition Code Statu i Activity Gigi Nutrition Services e itals Patient Care m Medications e Infusions bM Laboratory Services i Radiology Services E Consults H Pulmonary Services Xx Details for Social Work Consult D Cardiology Cardiovascular i Therapy Services ESS Details 43 Order Comments N Diagnosis Li Communication DR AR 4R03 Fin 685304784 4 H D Miscellaneous Order details B lin Detail values GR Order eg eene leet Detail Mi X e Social Work Consult Order 02 12 2009 11 57 BH Print ZZ 1 minutes ago 02 12 09 11 57 Routine NOTE For stat consults page d aoe Reason for Consult ry Adiust Wat Ges i i D justment to llness Tx Dx i ke Equipment Supplies Special Instruction a tegen zi Ei 4 gt Diagnoses amp Problems 1 Missin
69. nt nsk factor for death in patients with atrial fibrillation AF without congestive heart failure CHF but there does not appear to be excess risk in those with AF and CHF Pharmacokinetics Digoxin is available for intravenous and oral administration Bioavailability of orally administered digoxin depends on the digoxin preparations The mean bioavailability of digoxin tablets ranges from 48 to 80 digoxin capsules bioavailability ranges from 70 to 100 and the mean bioavailability of digoxin elour ranges from 70 to 89 Food delays the absorption but does not significantly affect the peak plasma concentrations of orally administered digoxin Following oral tahlet administration neak senim concentrations nf donn nrcur at 1 ta 2 hore Th some nafhiente oral administered dignyin is converted tn imartiye redhurhon E To print the information for the patient right click any where in the window The only option available is print DRH Clinical Transformation Pamela Haddox RN BSN May 2009 74 Pain Response After giving any pain medication the patient s pain must be reassessed to determine if the current interventions are controlling the pain The electronic MAR will aid the nurse in this process by sending a task to the MAR and the PAL list To complete the pain response from the MAR click on the cell labeled pain response Monitored HA acetaminophen Tylenol We Start 02716709 9 56 00 Routine 1000 mg By ain Respons
70. ocol OF Cancel DRH Clinical Transformation 54 Pamela Haddox RN BSN May 2009 Next choose a communication type rom the list and click OK Communication types l 2 Written Order An order that is written by a physician provider Per Protocol An order that is based on DMC policy protocol and or falls within a clinician s scope of practice per licensure and policy Order Clarification An order that clarifies an existing diagnostic test procedure or intervention order placed by a provider RN Plan of Care An order placed by a Registered Nurse for interventions to support the nursing plan of care Verbal Order An order that is given to a clinician verbally by a physician provider who has the authority to give a verbal order per CEN 045A Verbal and Telephone Orders EMR This communication must be face to face Phone Order An order that is communicated to a clinician via the telephone Only clinicians eligible to receive verbal orders per 1 CEN 045A Verbal and Telephone Orders EMR accept this order communication type Supply Order An order for patient care supplies Order Clarification An order that clarifies an existing diagnostic test procedure or intervention order placed by a provider Order Clarification is used to change order sentence details only and not the original order e g changing RN Draw to Lab to Draw for a laboratory specimen order If changes need to be made to the original or
71. olumn will indicate a scheduled task that is currently overdue e PRN Continuous An icon in this column indicates a PRN or continuous treatment or medication 1s ordered for the patient e Current An icon in the Current column indicates a task is due at the current time The type of icon in the column will indicate which type of task is due e Individual timeframes Columns are created to indicate specific times in your shift that treatments or medications are due These columns are based on the frequency selected when the order was entered To access tasks for charting double click the task icon in the appropriate column For example i Vital signs are charted from the PAL by double clicking on the icon in the PRN Cont section Click in the box for vital signs per protocol then click Chart at the bottom B Date andTime Lis Lea Continuous Vital Signs per Protocol 01 13 09 7 48 00 CONTINUOUS CIS ed PRN acetaminophen Start 01 13 09 7 50 00 Routine 1000 mg By acetaminophen Tyle Pending Pending Quick Chart Chart This will bring up the vital signs form After completing use the green checkmark to sign the form or the floppy disk to save it if you need to return to it later DRH Clinical Transformation 16 Pamela Haddox RN BSN May 2009 Tasking Off As tasks become due for a patient an icon will display in the tasks section of the PAL These are reminders for the care provider Onc
72. on dose low Low dose conection dose BG 120 200 give 0 Units BG 201 02 16 0917 00 metoprolol Start 02 16 09 17 00 00 25 mg By Mouth Tab acetaminophen Start 02716709 9 56 00 Routine 1000 mg By Mo acetaminophen 1 000 mg By Mouth Pain acetaminophen Tylenol Pain Scale Score 9 ranitidine Start 02 16 09 9 00 00 150 mg By Mouth Tab MW Not iven Patient NPO No Blood Retum Comment Order Being Clarified Order Changed Patient nauseated Patient Not Available Patient Refused Patient Sedated Scheduled Mnemonic Result A7 Row 02 16 09 09 00 digoxin Start 02 16 09 9 00 00 0 125 mg By Mouth Tab kv dd 02 16 09 09 00 furosemide Start 02716709 9 00 00 40 mg I PUSH Injection furosemide 40 mg IV PUSH furosemide Lasix RF amp Edi 02 16 03 09 00 hydrochlorothiazide Start 02 16 09 9 00 00 25 mg By Mouth Tab Y A ki g 02 16 09 09 00 metoprolol Start 02716709 9 00 00 25 mg By Mouth Tab metoprolol 25 mg By Mouth Systolic Blood Pressure 185 mmHg Diasto Vi D 02 16 09 09 00 fanitidine Start 02 16 09 9 00 00 150 mg By Mouth Tab BF o oa 02 16 09 12X00 insulin aspart Start 02 16 09 12 00 00 0 5 Units Subcutaneous Injection insulin aspart insulin aspart correction dose low Low dose correction dose BG 120 200 give 0 Units BG 201 D eu 02 16 0917 00 insulin aspart Start 02 16 09 17 00 00 0 5 Units Subcutaneous Injection insulin aspart insulin aspart correction dose
73. or other resources that may be available DRH Clinical Transformation 80 Pamela Haddox RN BSN May 2009
74. outine 25 mg By Create Admin Note Mouth Tab Daily Alert History Select a reason for the request from the list e Medication Request x DAG SOT r Mone Dose Missing Dropped Medication Medication Last Request Extra Dose Weasted Admin Wasted Prep Cancel Then click OK DRH Clinical Transformation Pamela Haddox RN BSN May 2009 73 Reference Manual and Education Leaflets The electronic MAR also serves as a reference guide for medications To access the reference manual right click on the medication details and select reference manual lt Print minutes agc air E 17 Fekruary 2009 11 46 19 February 2009 11 46 Clinical Range ZE 02 18 09 02 18 09 6 09 02 18 09 07 41 07 48 09 00 Scheduled gigi Order Info 0 125 mg Event Task Summary Reference Manual Med Request Reschedule Admin Times ore Routine 25 ma By Additional Dose ial ee ail ea ai Create Admin Note Alert History Guctolic Aland Pracciura The first to display will be information for the healthcare provider After reading the information click OK to return to the MAR The information can also be displayed in terminology appropriate for the patient by clicking the tab labeled education leaflet Drug Reference Education Leaflet Reference e Search a Pharma ology Warnings Pregnancy Lactation Side Effects IV Compatibilty Dosage
75. ow Low dose correction dose BG 120 200 give 0 Units BG 201 u Deia 02 16 0917 00 insulin aspart Start 02 16 09 17 00 00 0 5 Units Subcutaneous Injection insulin aspart insulin aspart correction dose low Low dose correction dose BG 120 200 give 0 Units BG 201 C ga l 02 16 0917 00 metoprolol Start 02 16 09 17 00 00 25 mg By Mouth Tab E 9 erl PRN acetaminophen Start 02 16 09 9 56 00 Routine 1000 mg By Mouth Tab 0 acetaminophen Tylenol Next scan the medications to be given As you scan you will notice several icons appearing on the screen Scheduled Mnemonic A Nd 02 16 0909 00 digoxin Start 02 16 09 9 00 00 0 125 mg By Mouth Tab OO A 02 16 09 09 00 furosemide Start 02 16 09 9 00 00 40 mg IV PUSH Injection ewe EE furosemide Lasix TEN Ed LS 02 16 09 09 00 hydrochlorothiazide Start 02 16 09 9 00 00 25 ma By Mouth Tab YM2 boi LS 02 16 03 09 00 metoprolol Start 02716709 9 00 00 25 mg By Mouth Tab metoprolol 25 mg By Mouth Vi el 02 16 09 09 00 ranitidine Start 02716709 9 00 00 150 mg By Mouth Tab ranitidine 150 mg By Mouth RF Sei 02 16709 12 00 insulin aspart Start 02 16 09 12 00 00 0 5 Units Subcutaneous Injection insulin aspart insulin aspart correction dose low Low dose conection dose BG 120 200 give 0 Units BG 201 6 027 16 09 17 00 insulin aspart Start 02 16 09 17 00 00 0 5 Units Subcutaneous Injection insulin aspart insulin aspart correction dose low Low
76. ph Aspirin MUL DR St Joseph Aspirin MUL DR Bayer Childrens A MUL DR MML DP LZ LDL LL LL DC CL 5 Complete all information known about the allergy and click k when finished or apply to add another allergy DRH Clinical Transformation Pamela Haddox RN BSN May 2009 Daily Documentation Ongoing assessment Nursing documentation is a three part process to be completed each shift The parts include the ongoing assessment plan of care and patient education To begin click the ad hoc icon on the toolbar Ze oft Z ch ae Charges BP charge Entry Ml Ek Calculator Buer Medication Administration a FM Conversation MA Report Builder Next click EMR forms Ad Hoc Charting Burnside Rhonda Charting T B Activity E EMR Forms T D Adult Admission Assessment Assessment T D Adult Admission History D Emergency Service T D Adult Nutritional Intake C Critical Care T B Adult Ongoing Assessment D PCA Forms IT B Adult Pain Assessment D Rehab Services JC D Adult Vitals Pain GCS m e Mel C B Advance Directive C D Aldrete EMR Forms Peds Nec e Clinics C D Antepartum Assessment amp ED C B Arterial Blood Gas Analysis by Respiratory Pharmacy E Asthma Assessment Outpatient Pharmacy C E Behavioral Health Admission Assessment Archive Folder C E Behavioral Health Admission History Ca Allltems T DI Behavioral Health Ongoing Assessment D EB Blood Gas Draw C E B
77. raden Assessment DC B Burn Injury Nutritional Tracking T EB Burns Select the forms needed ongoing assessment plan of care patient education Then click chart T B Cardiovascular Adult Assessment D B Cardiovascular ICU Assessment C B Cast Application C B Continuous Passive Motion IT B ED Treatments and Procedures T B ED Triage and Assessment Adult DAH IT B ED Triage and Assessment Pediatric T amp Education Wound Care IT B Fim IT E Gastrointestinal Adult Assessment IT EB Gastrointestinal ICU Assessment IT B Genitourinary Adult Assessment T D Genitourinary Dialysis Assessment Detailed LC DI Genitourinary Dialysis Assessment Simple IT B Genitourinary ICU Assessment DC EI Glascow Coma Scale C E Home Health Disposition IT B HWwt llergies T E Hygiene The first form to display is the ongoing assessment amp Adult Ongoing Assessment Burnside Rhonda WE wv Me les OE eL e 02 05 2009 Leed X Review Adu Psychosocial Soe Pregnancy Status Primary Pain Additional Pai Pain Assessrr Cardiovascul Lactation U Li Pregnancy Lactation Status Assessment Review CV Detailed Respiratory Resp Detailec Gastrointestin GI Detailed Subjective O WDL s Exception Unable to Assess Psychosocial O WDL s Exception Unable to Assess Nutrition WDL s Responds to care Able to participate in care Makes decisions and suggestions about care WDL s No subjective co
78. rders section or the PAL Medication Scanning To begin medication administration first review the MAR and collect the medications needed Proceed to the patient s room with scanning device in tow Perform the Five Rights From the toolbar click on the a l calculator HR AdHoc IM Medication Administration d PM Conversat Next a screen will display telling you to scan the patient s armband Pinger sean Ihe prienna withand Albernatiyely aclect the patient pacts manually bp clicking the Hent battog DRH Clinical Transformation 65 Pamela Haddox RN BSN May 2009 Now all medications that can be given will display Medications can be given up to one hour before the scheduled time Medications that are overdue and have not been charted will also display They will not drop off the list until they are charted Scheduled Mnemonic Details Result C 4 del 02 1609 09 00 digoxin Start 02 16 09 9 00 00 0 125 mg By Mouth Tab To e A 6S LS 02 16 09 09 00 furosemide Start 02 16 09 9 00 00 40 mg MW PUSH Injection furosemide Lasix Ter i E 02 16 09 03 00 hedrochlorothiazide Start 02 16 09 9 00 00 25 mg By Mouth Tab t 2 d l 02 16 09 09 00 metoprolol Start 02 16 09 9 00 00 25 mg By Mouth Tab T A del 02 16 0909 00 ranitidine Start 02 16 03 9 00 00 150 ma By Mouth Tab C A9 i 02 16 0912 00 insulin aspart Start 02 16 09 12 00 00 0 5 Units Subcutaneous Injection insulin aspart insulin aspart correction dose l
79. re Garment Measure Fit Pressure Infusion Bag er aai Pressure Palsy Neuropathy Immunization Schedule baj Pressure Ulcer Management gt SE Ulcer Prevention Clin Doc ba Fressure Ulcer Treatment LIP and a 1 Pressure Wound Protocol Taie Pressure Close Pressure Opening Pt Info 3 Complete the task on the PAL Tasks appearing in this window are accurate as of 5 4 2009 08 21 Please select the refresh button to update the Refresh display _ Date and Time Details 5 4 2009 08 16 Go to Orders Pressure 05 04 09 8 16 28 Pending Go to Orders Press Ule Ordered by Discem Expert Quick Chat Chat 1 4 Initiate impaired tissue integrity care plan See page 39 of this manual for explanation Complete patient education See page 38 of this manual for explanation DRH Clinical Transformation 21 Pamela Haddox RN BSN May 2009 Documenting a Braden score lt 18 will place risk for impaired tissue integrity on the problem list An auto alert discern will fire alerting the RN to order the pressure ulcer prevention orderset and a task will be placed on the PAL Discern Notification Message j x Subject Discem Alert At Risk for Impaired Tissue Integrity Priority Status High Priority Value fi oo Event Date Time 05704 2009 8 25 34 Message class subclass APPLI CATION DISCERN EIST ECO A m TEE Braden Score 16 as of May 04 2009 08 24 00 EDT he Braden Score value indicates a r
80. ree part process which includes 1 Restraint Assessment 2 Restraint Monitoring 3 Restraint Education Restraint Assessment Restraint assessments are completed every two hours and are tasked off from the PAL list The RN must go in and check the patient every two hours checking for the following things e Skin integrity Repositioning Nutrition Circulation Hygiene Toileting Reassessing the need for continued restraint use An icon Se will appear on the PAL list every two hours 10 00 10 12 00 12 14 00 14 Double click on the icon Be sure the box in front 1s checked and click Chart Tasks appearing in this window are accurate as of 02 11 2003 10 11 Please select the refresh button to update the Refresh display Refresh Date and Time Details Eles 02 11703 10 05 Restraint Assessment 02711709 10 09 00 Status Fending Quick Chart Chart The item will be removed from all areas of the chart and your name will be attached to the documentation as having completed your restraint assessment DRH Clinical Transformation 49 Pamela Haddox RN BSN May 2009 Restraint Monitoring The restraint monitoring form should be completed every shift The RN must assess the need for continued restraint use and record the findings on the restraint monitoring form The form can be completed from the prn cont section of the PAL Double click on the icon e La Sch Be Beie SS L bu bw WM Be
81. s Ca Assessment Ca Critical Care Ea PLA Forms Ea Rehab Services T Ei ICU Admission Assessment IT E ICU Ongoing Assessment IT E Immunization History Refusal Ca Emergency Service IC E Incentive Spirometry IT E Incision ound Care D E Integumentary Adult Assessment Ci Respiratory Service w l Clinics EL Pharmacy DDDDDD All tem No education data available lt Alpha gt lt Alpha gt The comment box allows free text and should be used to provide some specifics about what was taught When finished with the form use the need to return to it later Outpatient Pharmacy CH Archive Folder EMA Forme Adult EMA Forme PedsNec IT E Kardes Update D EI Integumentary ICU Assessment D EI Moderate Sedation Monitoring IT E MAI Safety Screening Form D EI Neonatal Admission Assessment IT EI Neonatal Admission History D E Neonatal Ongoing Assessment IT E Neonatal Nutrition D E Neonatal Visual Assessment D E Neonatal Intermittent Assessment D E Neurological Adult Assessment D E Neurological Checks ak D Neurological ICU Assessment DE D E Neurovascular Assessment Lower Extremity 7 E E Neurovascular Assessment Upper Extremity D E T EV NIH Stroke Scale IT Observation Patient Assessment TD IT EI Orientation ICU D Orientation Med Surg D EI Orientation Rehab D Orthopedic Device Care Ey IT E Orthostatics T E Ot Daily Note T OT Dail Note Acute Care CT T OT
82. s Forms Tasks d Pressure Pt Info bd Pressu Patient Schedule EE See E easure Allergies Add be Hate Problems and Diagnoses FaceSheet BMT Pheresis Collection Se BMT Follow Up Tests Oral BMT Common Labs y List view OB Summary D Istrip Medication List Add ProFile Documents Reference Text Brows Transplant Surgery Transplant Surgery Clinic Histories Online Forms Rest I view FlowgMeet ctivity Gen Radiolog Select handoff from the list ir Bav All Results 48 hr Summary Lab Radiology Vitals Flowsheet Wand D Eil Level Hand Oft DI Table Group List ne 17 February 2009 11 46 19 February 2009 11 46 Clinical Range ne Navigator x Hand 02 18 09 02 18 09 02 18 09 aren 12 29 12 25 07 41 Vital Signs Vital Signs L Systolic Blood Pressure 136 L Diastolic Blood Pressure 78 85 16 LI Temperature Oral 37 0 LI Pulse Oximetry 100 ap Room air Peripheral I s L Pain Score Rest Pain Score Activity Integumentary INCISION WOUND CARE GRID Incision W ound Peripheral IVs PERIPHERAL I ASSESS INTERVENTION GRI Peripheral Iv As The handoff flowsheet will display information that was recorded from nursing assessments DRH Clinical Transformation 76 Pamela Haddox RN BSN May 2009 Downtime Documentation Occasionally the system needs to be taken down temporarily to be updated During this time there 1s one computer on each unit that is available for viewing patient informat
83. s you must complete the discontinuation section of this form DRH Clinical Transformation Pamela Haddox RN BSN May 2009 50 Restraint Educatlon The restraint education 1s completed from the same form wv RM ZE aa miz Performed on Out dE E e 1223 Monitoring Discontinuatio Y Education Education Topics Individuals Taught Barriers to Learning C Hospital policy regarding use C Patient C Legal Guardian C None C Financial concerns C Reason for restraint C Caregiverls C Parent C Acuity of illness C Hearing deficit C Release criteria C Daughter s C Sonis C Awareness of deficits Language barrier C Other C Friend C Spouse C Cognitive deficit C Learning disabled C Foster Parentis C Step parent s Grandehildiren L Other Sxandparent s C Cultural barrier C Literacy C Desire Motivation C Religious C Emotional state C Speech barrier Teaching Method Teaching Evaluation C Printed materials m C Class C Telephone C Follow SpNeeded C Computer assisted C Verbal C Teaching Ondsiag C Demonstration C Video E ducational TY C Teaching Deferred C Explanation C written Handouts C Other C Interactive internet C Vendor Support Practice C Other Each day a patient is in restraints they must be educated on the reason for restraint use and the release criteria These can both be selected at the same time After completing all necessar
84. ssignment function 1 From the PAL right click on the green bar containing the unit name Options Patientfist Help ny Shift Assignment z EN E Tear Off Q MEDLINE Avs G Lippincott QQ sam B 3 Calculator a AdHoc Il Medication Administration Mf it amp PM Conversation BP Charge Entry w charges ata Attach Tea Z Pharmacy WIND CIS Intraweb 4MEDICA Z DMC Policy and Procedures Lawson E gt Recent gt MRN d G Print 2B 4 minutes ago Task Edit View Patient Chart Links A Patient List GA Multi Patient Task List 2 Patient Access Lis Patient Access List Shift 20 January 2009 07 00 20 January 2009 15 00 Overdue PRN Conti Current Change Patient List Change Timeframe 2 Click on change patient list 3 Choose New at the bottom 4 Click on assignment at the top Patient Lis Type Select a patient list type Assignment Ancillary CareTeam Custom Lifetime Relationship Location Location Group Medical Service Provider Group Query Visit Relationship Finish Cancel 5 Type the name of your list in the box and click Finish DRH Clinical Transformation Pamela Haddox RN BSN May 2009 15 Charting From the PAL The tasks section of the PAL includes multiple sub columns for indicating different types of tasks as well as times that tasks are due including e Overdue An icon in the Overdue c
85. ssociate it with you Note To complete Patient Admission Assessment History forms if started by another nurse you must open up a new form and complete the required information Do not open and modify another nurse s form View Documents in the Forms section The Forms section within a patient s chart lists all of the forms started or completed for that patient They are displayed ina tree format with folders grouping forms by similar criteria Double click or right click and select View to view the details on a form Sort by Date E Monday February 09 2000 m H15 26 vital Signs Auth Verified DRHNurse RAS 5 26 Incision wound Care 4uth Verified DRHNurse RAILS ER Ep Thursday February 05 2000 a Hos 27 Plan of Care Auth Verified Multi Contributors b a ae 24 Patient Education 4uth verified Multi Contributors Si Ewednesday January 78 2000 b Al n 52 Adult Admission Assessment Auth verified DRHNurse RNZ0 B40 H Adult Admission History In Error Multi Contributors Sort Forms 1 From within your patient s chart click on the Forms section of the menu bar 2 Review the different sort options by clicking the sort drop down box Notice how the display changes as you try each option Menu q DEF WIE 24 Hour Summary Results Review LO MAR Immunization Schedule PowerOrders Clin Doc Farms Tasks PE Info Patient Schedule Sort by Date
86. st Intervention Assessment IT D amp EMR Ge a a T E Orientation Rehab IT B Postpartum Assessment E T EB Orthopedic Device Care T E Postprocedure Assessment Adult IT D EMR Forms Peds Nec Ga Clinics T B Otthostatics T E Postprocedure Education IT D CO ED T B OT Daily Note T D PPD Reading BIE Pharmacy T B OT Daily Note Acute Care C D Preprocedure Assessment Adult TD Outpatient Pharmacy C E OT Discharge B Preprocedure Checklist CE Archive Folder T B OT Initial Evaluation T E Preprocedure Education IT Allltems B OT Initial Evaluation Acute Care T EB Primary Contact WS C B OT Swallow Charges C E Procedural Sedation IT D T EB Patient Education T E Projected Target Length of Stay IT T B Patient Rights IT B PT Daily Note E T E Perinatal Admission Assessment T D PT Daily Note Acute Care TD 4 ils gt Chart Close Next click chart To begin click in the category field and make your selection Plan of Care Adult Medical Rehab Plan of Care Problem Plan of Care Goals Plan of Care Expected Resolution Plan of Care Comments Category Initiated Resolution Date Next choose your problem and goals Be sure that the suffix in the category field matches the prefixes of the other fields Plarrof Care Adult Medical Rehak Plan of Care Problem Plan of Care Goals Plan of Care Expected Resolution Plan of Care Comments Category Initiated Resolution Date Cardiovascular CV Fluid Volume CV Edem
87. stablish relationship box will appear Establish Relationship Ioj x Select an appropriate relationship Patients without relationships Mouse Minnie Simpson Bart Simpson Lisa Coyote Wile E Jetson Elroy Rubble Barney Fudd Elmer Flintstone Fred Hook Captain Oil Olive Simpson Homer Pan Peter Duck Donald Rubble Betty Bunny Bugs Flintstone Wilma Duck Daffy x Jetson George dee 4 Uncheck any patients you are not assigned to by clicking in the box in front of their name DRH Clinical Transformation 12 Pamela Haddox RN BSN May 2009 5 Use the drop down arrow to select your relationship Establish Relationship BR D x Select an appropriate relationship Chart Review Clinical Nurse Specialist Coordinator Flintstone Fred Hook Captain Dil Olive Simpson Homer Pan Peter Duck Donald Rubble Bethy Bunny Bugs Flintstone Wilma Duck O atty Simpson Marge Jetson George The sections of the PAL are as shown Task Edit View Patient Chart Links Options PatientList Help A Patient List GA Multi Patient Task List Patient Access List oY Shift Assignment g E Calculator HR AdHoc Wil Medication Administration Af Exit amp PM Conversation BP Charge Entry aa Charges 4 Attach 8 Tear off Q meone Avis G Lippincott Q sam g T Pharmacy wno cs Intraweb 4MEDICA Ame Policy and Procedures Z Lawson B A Recent MRN dh g Print Z 4
88. sure the box in front 1s checked and click Chart Date and Time Status LI Ki cos acetaminoapher hydroc Start 01 2689 12 31 00 Routine 1 Tab Du Mouth Pendine acetaminophen hydrac Fle Continuous Restraint Monitorning Di 02711709 10 05 00 SONTINUOUS Pendinic Restraint Monitoring Duck Chart Chart Next complete the sections of the form to show the methods used before applying restraints wv Ne pes el Seema o2 11 2009 kilo E Monitoring S Basic Interventions For Patient In Restraints Discontinuation Education Verbal Reminders Exercise Ambulation Repositioning Patients allowed to make choices eorientation Consider relocation of patient Sensory Aids Glasses Hearing Aids Patient Specific Interventions RN documenta jon of additional interventions initiated check all that apply Treatment Comfort M wrap hide V sites C Provide familiar items from home C Limit access to tubes and drains C Reduce stimulizintrusions promote rest C Alter placement cover lines tubes C Position patient for comfort C IV pole pump tubes out of visual field C Tuck gown in pant bottoms to hide tubes Diversional Other C Include in activities e g ADL s C Repetitive activities C Music television C Give items to hold C Encourage family involvement diversion Plan Of Care P Continue Restraint Use C Discontinue Restraint Use If you choose to discontinue the restraint
89. the reguired fields that are marked with Ma die T LEE 7 d Adi t admiron History ES TUR TES pui do sis mA Pec med up Jeu R D UE Oy LAD DOS DN FAHELA Ei Chaar Be T r oi Aurel op Lt Patient Liri iigiin bry Fuer M t m PI et Pari Medical De L Patient Firari CC fakslar TC echu O Siler Husing Fanti Arkueee Darrin Vaccine Screening Every patient at the DMC will be screened for the flu vaccine from October to March and every patient over the age of 65 will be screened for the pneumonia vaccine all year To complete the screening process select the influenza or pneumococcal assessment from the navigator bar KA General Info ee Influenza Vaccination A Influenza Assess Prosthetics Impl E Vaccination Date of last flu shot Allergy bes do E SS BR TB Screen K Pneumococcal 4 Disease Exposu By Nutrition Eating Disorder Home Environme Social Habits Family Social Coping amp Stres ENEE Administer vaccine GO for coagulopathy deficiencies or severe Thrombocytopenia platelets lt 20 000 If the patient meets criteria select the administer option This will automatically place an order for the vaccine DRH Clinical Transformation 23 Pamela Haddox RN BSN May 2009 As a part of the admission process every patient is screened and offered smoking cessation if appropriate To begin the process select the social habits section from the na
90. to the previous page Braden Braden Proto Subjective WDL s Exception Unable to Assess IM Iniiration Fh Cardiovascular System O WDL s Exception Unable to Assess Drains T ube Neurological Neuro Detaile Respiratory System WDL s Exception Unable to Assess Trial of Water Seizures i Gastrointestinal System WDL s Exception Unable to Assess Glasgow Corr Schmid s Fall The left side of the ongoing assessment is the navigator bar This contains sections that may need to be documented based on the patient condition It also contains two required fields that are marked by a blue circle containing a white X H These items are the Braden Scale and the Schmidt Fall Risk When the form is completed use the green checkmark in the top left corner to sign the documentation or use the floppy disk icon A to save the form if you need to return to it later DRH Clinical Transformation 37 Pamela Haddox RN BSN May 2009 Patient education is an important part of caring for the patient Education should be completed every shift for every patient Patient Education To begin documenting education first click on the E AdHoc icon on the toolbar Next select EMR forms and select the patient education form E Ad Hoc Charting Johnson Georgia a 5 Then click chart To complete the form click on the term alpha in each box and complete the appropriate details Charting f EMR Form
91. tor S AdHoc WN Medication Administration oa DM Conversation Report Builder 4dd or Remove Buttons ae Patient List S Multi Patient Tas d TR a o r lil atk To customize the icons within the toolbar right click any where on the toolbar and choose customize t my Shift Assignment Customize wall eS le e ee TT The customize box will appear Customize Tool Bars x To rearrange the order of the icons within a toolbar click on the icon you wish to move and drag it into the desired position Icons may not be moved between toolbars GE eS Se a e a O D KAR A Mu Custom Links Click and hold on the icon you wish to move While holding the button down drag the icon to the new location and release Icons can only be moved within the same toolbar When finished close the box DRH Clinical Transformation Pamela Haddox RN BSN May 2009 10 Patient Search 1 Click on the binoculars icon P located to the right of the screen 2 Enter the patient s FIN number and click search To practice use 613392984 a Patient Search 2 x mg FIN ID Card FAF weight Name EU ND 1 Gender Birth D Ier 3392984 g 0 00 TEST PATIENT 11081868 D 8380689 Female 03 04 ReaD ate AN Last Name First Name Gender z b SSN El MRN ei 3392984 Emergency Active Emergency Medicine DRHUHC EMBDDR PTID Search Reset gt
92. u can obtain one by clicking here or contact the Help Desk at 313 966 2400 3 On your DMC Citrix Desktop double click the Start Cla 4 Enter your User Name and Password and click OK gt CERNER I MILLENNIUM Password Domain Cem a cones atio This pr ogr sed u Mom Gan em Sarpo ation of Kansas apene ssou erg memeli m use reproduction distributio retin onion of thie ioe a a ins ivil and criminal p aoe Fa rd n be found in n Help About Closing CIS and Citrix You should always close confidential information before walking away from the PC However you don t want to close everything you re working on log out of Citrix and CIS and then have to re open it all again later in your shift repeating the process every time you step away to care for a patient That s why you have several options for closing your work one for only closing PowerChart one for logging off Citrix completely and one for holding your place in all open applications until you return el Exit When you are finished in CIS but wish to leave your Citrix desktop open click on the Exit button on the PowerChart toolbar CIS PowerChart closes completely and returns you to your Citrix Desktop DRH Clinical Transformation Pamela Haddox RN BSN May 2009 LI Suspend When you need to walk away for a short time click the Suspend button in your taskbar tray Your Citrix session CIS and any other applications you have open will be close
93. us day Scroll down to find the yellow highlighted row The highlighted yellow row line serves as your place holder to help keep you on the right date and time Charting can take place on any row before the yellow row Charting can not take place after the yellow row UO Print 2 0 minutes age lt de EI EE EE m US February 2009 07 00 12 February 2009 06 59 Clinical Range Alt a u FLUID BALANCE Intake Output EN Oral OTHER IN Urine Stool OTHEF 0 02 10 09 07 00 02 10 09 08 00 02 10 09 10 00 02 10 09 11 00 02 10 09 12 00 02 10 09 13 00 02 10 09 14 00 Day Shift Totals 02710709 07 00 02 10 09 15 00 02 10 09 16 00 02 10 09 17 00 First click on the start charting icon E Now click in the field and enter the values UO A Print 2 1 minutes ago Av i S N 09 February 2009 07 00 12 February 2009 06 59 Clinical Range T E Intake Output a Oral OTHER IN Urine Stoo OTHER 0 Urine For Other 02710709 07 00 0 200 02 10 09 08 00 0 02 10 09 10 00 I 02710709 11 00 U 02 10 09 12 00 U 02 10 09 13 00 U 02 10 09 14 00 U Day Shift Totals 02 10 09 07 00 U U S 0 0 0 02 10 09 15 00 02 10 09 16 00 02 10 09 17 00 0 I When finished entering all the values click the green checkmark to sign the documentation DRH Clinical Transformation 46 Pamela Haddox RN BSN May 2009 Notice that the values are added together in the row titled shift totals There is also a graph that will d
94. view Next click Sign Remember to refresh The order will now display as discontinued in the orders profile Cancel Reorder The cancel reorder option should be used when you would like to keep the same order but change some of the order details This option is available so that you don t have to cancel the order and then completely re enter the same order To cancel reorder right click on the order and select Cancel Reorder a ES E e A noen n Dog G ns gabapentin Neurontin Order 7 ma ma By Mouth enew wv EA DB acetaminophen hydrocod Orden ab By Mouth Modify one Norco 325 mg 10 e Copy Laboratory Services EEN Ei F 60 Complete Blood Count Orden Suspend ime Only 1 De with Differential CBC Di epes not more than chivate Ei T Troponin Orden Gomplete ime Only 1 De Cancel DC m Heparin SST Consults void SS ep Social Work Consult Orden SS oe D Social Work Consult Orden Reschedule Administration Times Medication Request Gosign No Dose Range Ghecking Advanced Filters Enable Edit on the Line ity Resources ted Social Work ity Resources ted Social Work Order Information 4 Comments of la Deals Resuls Displayed All Active Orders Pill ow More Orders S Dy Table Orders for Nurse Review EE ers For Signature ary 2009 15 22 DRH Clinical Transformation Pamela Haddox RN BSN May 2009 Ol The ordering physician box
95. vigator bar of the admission history form Smoking Status Tobacco use in last year Smoking cessation material support offered Ig Patient Accepte C Patient Refuses Ci Yes No Unable to obtain Exposure to Tobacco Smoke Parent Smokes If patient smokes or parent smokes is selected C Lives with someone who smokes provide smoking cessation information Patient smokes d Answering YES to tobacco use in the last year will require you to offer smoking cessation material support to the patient The box to the right becomes yellow and is a required field Answering patient accepts the smoking cessation material will automatically place an order for a smoking cessation consult The consult is performed by respiratory and should not be completed by nursing When the form is completed use the green checkmark a at the top left corner to sign your documentation or the floppy ei disk icon to save it if you need to return to it later Once the admission history form is completed the nurse must collect information about the patient s past medical history and medications taken at home These items are documented from the menu bar inside the patient s chart To open the patient s chart double click on their name Menu q A A Results Review UO MAR Immunization Schedule PowerOrders zb add Clin Doc Forms Tasks Pt Info Patient Schedule Allergies zb add
96. will appear Enter the name of the physician whom asked for the changes Ordering Physician Ei Physician name JDRHPhysician MDOT E Order Date Time 0271272009 Hi DN Plan of Care Per Protocol UK ncel Enter the appropriate communication type and click OK The orders profile will display the order to be discontinued and the new order JL Te er ame ae Detais r Medications LJ gabapentin Neurontin Order Start 02 12 09 17 00 Routine 300 mg By Mouth C wi LA D acetaminophen hydrocod Ordered Start 01 28 09 12 31 00 Routine 1 Tab By Mouth one Norco 325 mg 10 ZS Laboratory Services yi Sd Complete Blood Count Ordered 02 12 09 11 52 00 Routine 1 One Time Only 1 De with Differential CBC Di Collect One lavender top tube Order not more than 4 b w Details for gabapentin Neurontin G Order Comments N Diagnosis a Remaining Administrations Unknown Stop Unknown Ce Order details t Lo lin Detail values Displayed All Active Orders Show More Orders Dy Table Orders for Nurse Review Orders For Signature Click the Orders for signature button at the bottom Next the scratchpad will display This is where you can make the changes to the order ers for Signature GOV OrderName Status Start Details DR AR 4RO3 A FIN 685304784 Order Start 02 12 09 17 00 Bo WM Ord gabapentin Neurontin w Details for gabapentin
97. y sections of the form click the green checkmark in the top left corner DRH Clinical Transformation 51 Pamela Haddox RN BSN May 2009 PowerOrders The orders section of the patient s electronic medical record allows physicians and clinicians to place medication continuous infusion consults lab radiology and care orders In addition to placing orders on a patient power orders contains a display that shows all existing orders that were placed on the patient during a specific encounter Power orders also enables designated clinicians the ability to review cancel discontinue cancel reorder and void existing orders a Add F Document Medication by Hx rders Medication List WM Display 4 E orders eal Customize view Vitals Patient Care E ge Vital Signe per Protocol Ordered 02 12 09 10 44 00 CONTINUOUS SG Order ADT Condition Code State pay Meo Restraint Ordered 02 11 09 10 09 00 02H 5 Bi Nutrition Services Assessment Med Surg Si Vitals Patient C Re Seegen sf Sc Restraint Monitoring Ordered 02 11 09 10 09 00 CONTINUOUS ie E IY Infusions wi Adult Admission History Ordered 017 26 09 9 28 36 One Time Only LB Laboratory Services Ordered via Discern Expert Admission Assessment Au 3 Radiology Services E ICU Admission Ordered 01 26 09 9 28 36 One Time Only ei Consults Assessment Ordered via Discern Expert Admission Assessment Hu YA ni E Initiate Plan of Care
98. your chance to correct any mistakes before signing the orders ele Add d i Document Medication by Hx Orders Medication List 4 Orders for Signature OJ e Wielen Joas Stat Boa DR 4R 4R05 A FIN 685304768 R Vitals Patient Care gt Orders for Signature B Orders D ADT Condition Code Stat Activity p Monitor Weight Trends Order 02 09 2009 16 46 02 09 09 16 46 Li Nutrition Services b EI Elevate Edematous rder 02 09 2009 16 46 02 09 09 16 46 Constant Indicator me Vitals Patient Care Extremities f Medications Eh Teach Diet Restrictions Order 02 09 2009 16 46 02 09 09 16 46 r H TY Infusions Ep E Teach Factors to Increase Order 02 09 2009 16 46 02 09 09 16 46 B Laboratory Services Circulation 2 Radiology Services E Consults ef Pulmonary Services l Cardiology Cardiovascular Therapy Services l Communication l Miscellaneous gt Details O Missing Required Details Dy Table Orders for Nurse Review Sign Diagnoses amp Problems If the orders are correct click sign at the bottom right corner ae Add cat Document Medication by Hx Orders Medication List Display AI Active Orders B E J rdeNeme Status Desk O e Customize view Orders For Signature a d 5 Orders Vitals Patient Care p O ADT Condition Code Statt L Elevate Edematous Processing 02 09
99. zad mL FLUID BALANCE Intake Oral Tube OTHER IH Iw re Feeding Feeding Flush Day Total 02 09 09 07 00 02 10 09 i 0 0 0 06 59 02 10 09 07 00 02 10 09 08 00 02 10 09 09 00 View Details 02 10 09 10 00 Wen Comments 02 10 09 11 00 Add Comment 02 10 09 17 00 Modify 02 10 09 13 00 Unchart 02 10 09 14 00 Change Date Time canoe Day Shift Totals 02 10 09 07 00 4dd Additional Result Comments The unchart function should be used when results have been charted in error Results can be uncharted by doing the following 1 Right click on the result to be uncharted 2 Select unchart 3 Enter a comment in the comments field 4 Click OK Result Uncharting Jones Leroy D 841078459 Ka 09 February 2009 07 00 12 February 4009 06 59 Clinica Oral FLUID BALANCE Intake Oral Tube OTHER IW Bi reste eae a Feeding Feeding Flush Day Total 02 09 09 07 00 02 10 09 0 0 0 0 06 59 02 10 09 07 00 02 10 09 08 00 AN View Details i 02 10 09 11 00 ME Eomments 02 10 09 12 00 Add Comment 02 10 09 13 00 Modify 02 10 09 14 00 Day Shift Totals 02 10 09 07 00 Change Date Time i STEE ddd Additional Result Cancel Comments DRH Clinical Transformation 48 Pamela Haddox RN BSN May 2009 Restraints Restraints should always be used as a last resort after all other measures have been exhausted If restraints are needed the documentation is a th

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