EDM Training Manual. EDM Tracker/Worklist/Documentation 2. Temporary Status 14. Reception/Triage 15. Departing/Discharging 24.

Transcription

1 EDM Training Manual EDM Tracker/Worklist/Documentation 2 Temporary Status 14 Reception/Triage 15 Ordering Medications 18 Medication Reconciliation 22 Departing/Discharging 24 Admit Request 27 On Call List (ED HUC only) 30 Page 1

2 EDM Tracker/Worklist/Documentation Pathway: EDM Clinical Emergency Department Tracker Purpose: The EDM Tracker provides a starting point to all the screens and functions needed to view, edit and document patient information. The EDM Tracker displays pertinent information about your patient divided into various columns. This screen is interactive; you have the ability to change some information directly by double clicking on the specific column. The Folder Icon can click in this column to open chart of highlighted patient Completed Results Indicator field ED Room, BED Triage/Priority Score Name/Chief Complaint Orders-type will be indicated. Time Status Event These buttons allow you to manage your patient list. Tracker/Status Board ED Room/Bed/ED Priority: Assign a patient a room, assign multiple patients to one room using the Bed or middle section, and ED Priority allows user to assign a triage/priority classification to the patient. Page 2

3 Name/Chief Complaint: Same Names will appear highlighted in Yellow. Unable to change the name field from the tracker. Can add or change the chief complaint from the tracker. Orders: This field will show order indicators when new orders are placed on the patient. Able to view these by clicking directly on the icon which takes you into the orders screen to review the new orders placed. Results: When new results are completed the appropriate indicator will appear in this field. Directly review the result when clicking on the label. Patient Status/Time: This column gives the user the ability to track and record the patient flow thru the department. Clicking on this allows the user to change what is happening to the patient during their visit and record the length of time of each status. When clicking on the Current Status, a lookup will appear to all Status Events. The most common next status will be highlighted, if applicable, simply click or enter and the patient s status will be updated. RN/ERP: Assign or change a RN or MD providing care for the highlighted patient. Visit Time/Reg Status: This column indicates the length of stay in the department and registration status. Right Verb Strip (right side of the screen) Lists: Can access different locations, Pods, find accounts. Tracker: Returns you to the EDM Tracker. On Call Staff: Use this screen to view a list of staff members currently on call. Assignments: Use this screen to change your patient assignments. Clinical Data: Use this routine to enter, edit, or view information for a highlighted account. This is where you will document home medications and allergies. Reassign ED Staff: Menu key to change multiple patients over to a different provider all at once either as a physician or nurse. Manage Orders: Use this screen to view, enter, and edit acute care orders, medications, and order sets. We will not train to this functionality for nursing staff. Patient Reports: Use this function to print patient reports for one or more patients. (patient snapshot, complete record (legal record)). Location Reports: Manager s view of reports. Will be taught to leadership. Calls: Use this functionality to enter or edit information about calls to and from your department. Reception: Menu key to receive new patients into the department. Triage: Menu key to enter triage documentation Patient Snapshot: Able to view quick synopsis of patient data. Formally known as MD ED Summary. Page 3

4 Admit: Menu key to request admit of ED patients to your facility. This function allows you to go to the admissions application. (BCH nursing staff-will utilize admit as inpatient and obs). Sign Up: Will sign user up when clicking on this button as pt care provider Open/Close Chart: Opens and Closes the highlighted patient s chart Ready for Discharge: updates patient status Ready to Discharge. Management: Statistical graphs/logs related to care in the ED. Preferences: Use this screen to define your Status Board/EDM Tracker preferences. Main: Facility, regular type of patients, can remove patients from list in pre-determined amount of time. Status Board/Tracker: Defines what is accessible in lists menu key Chart/Plan of Care: Default page when opening patients chartexpanded/contracted.. Worklist: Determines Interventions or Medications to view in your worklist. Outcomes do not apply to ED. Medications: Display MAR preferences. Preview-preview display preferences. Footer Buttons Refresh: Allows user to manually refresh the tracker. Add to My List: Allows user to customize your own tracker by highlighting a specific patient and clicking the footer button. Close All Charts: Allows user to close all charts if multiple charts are open at a specific time. Edit Coverage: Kootenai ED Only: Gives you the option of customizing the tracker to a specific area directly. Minus/Plus: Clicking these allows expanding or contracting the amount of lines visible per patient. (tracker is set to 3 lines) Show Empty Stations: Clicking this button allows user to show or hide empty rooms on the tracker. Question symbol: Help function key World symbol: Reference/Lookup function, possible link to reference websites. Printer symbol: Printer function Lock symbol: Suspend function Mail symbol: possible future link to system Page 4

5 On Call Staff Click on On Call Staff this will bring user to the on call list for that present day. This will take the place of the current Mox on call list and is available to all nursing staff via status boards or trackers. To return to On Call list click on Back tab and it will bring user back to the main On Call Staff list. Printing/Viewing Patient Reports To print or view patient reports From tracker choose Patient Reports tab from Right side of screen. Select patient/patients by putting a check in the box. The Report button at the bottom of the screen will highlight. This will allow the user to select the type of chart to print or view. Page 5

6 After making the selection click on Ok the user will have a prompt come up to select whether the user wants to: View, Print, Download, or Mail. Selecting View brings up the patient summary on the computer screen. Selecting Print and this will print out the complete patient report that has been selected. After the user has viewed or printed the report it will bring the user back out to the current tracker. Management Menu Key Manual Management Allows you to access graphs regarding the Census and statistics. Click on the management on the right verb strip. Once a specific graph is chosen, there are function keys at the bottom of each graph that allow you to view daily, weekly, or monthly statistics. Types of Graphs Available: Current Status: Use this graph to view the current number and location of Emergency Department patients. Arrivals: This reflects the new arrivals to the Department Historical Status Count: Use this graph to view a patient status history. Average Length of Stay: Use this graph to view length of stay statistics. Average Time in Status: Use this graph to view patient status progression Page 6

7 Open Chart Worklist Purpose: The worklist is used to document on assessments and interventions you have for your patient. To access the worklist go to your tracker and highlight your patient. Click on the Open Chart tab on the right of your tracker. Once you open the chart click on the worklist tab on the right side of your screen. The 1st column tells if it is and A-Assessment or T-Treatment. The 2 nd column gives the name of the Care Item to be done The 3rd column (with the clipboard) is the frequency to be done. Edit frequency by clicking on the empty space, a time lookup is provided. The 4th column lets you know there is additional data associated with that item. Clicking on the [?] will give you definition for the icon listed. P=protocol, I=Item detail (detailed information associated with intervention). The 5th column is the time the activity was last completed. The 6th column indicates when this intervention is due. Red indicates time intervention is overdue. Page 7

8 The 7th column is Document NOW. ED Visit Data: Looks to Current data, patient demographics, mini audit trail Mar: Medication Administration Record. Write Note: Able to write free text note. TAR: Transfusion Administration Record-for administration of blood. Discharge: Discharge occurs within a patients open chart. Will learn this functionality during section C. Documenting in EDM Documenting an Intervention: To Document: Click in the appropriate cell (NOW) and a check mark will appear. User can check off as many cells across and down as needed. Once items are checked, the Document button will be high lit at the bottom of the screen. Clicking on document will launch the screens checked off on the worklist. Assessments and treatments will populate into worklist based on chief complaint. Contracting and Expanding: Contracting or expanding documentation may be done by clicking the + or buttons to the left of the Assessment or Treatment, such as Social History and Functional above. See blue arrow on screen shot below. Assessment/Treatment: Point and Click Functionality. Page 8

9 Question Types Questions requiring dates or time Can use drop down arrow or type in date, time or N for now. Free text, comment or text boxes. Square answers: can choose more than 1. Circle answers: can only choose 1. Instance Types: allows the user to choose a body part location or time to document on, such as a left wrist. The documentation field remains collapsed until the body location is filled in. There are different instance types: time, body part, location, can ad lib free text. See example below. Page 9

10 Adding Assessments/Treatments: To add an assessment or intervention not present on the worklist, click the add button at the bottom of the page. Click on Treatments or Assessments on the menu to the right, and choose from the Items listed on the page. If the choice is not showing, the Prior and Next buttons at the bottom may be used to change pages. Multiple choices may be made at one time if need. The selected items will be highlighted at the bottom of the page. If your highlighted choice is correct, click Save in the bottom right corner. If the highlighted choice is incorrect, click on the highlighted item again and the checkmark to the left of the item will be removed. Adding a Note to the Assessment or Treatment A free text note may be added to any assessment by clicking on the Add Note button at the bottom of the documentation screen. This note will stay with the documentation section it is attached to in the Electronic Medical Record (EMR). Page 10

11 Choose the type of note to be documented on and click on it. This will bring up a free text screen to type in. When complete click on OK to save this will bring the user back to the documentation currently being utilized. A clipboard will appear at the top of assessment when note attached. Saving: To save all documentation click Save in the bottom right corner. This will return you to the worklist. Page 11

12 Done will appear in the NOW column showing that documentation has been completed. The Last Done column will show the number of minutes the assessment or intervention was last documented on. Documenting Detail I did it Treatment Type : An I did it type of Treatment has preset documentation attached to allow the user to simply say they did the Treatment. An example of an I did it Treatment is the FAST Exam shown below. Page 12

13 To document from the worklist click on the treatment in the NOW box, which will highlight the Treatment in green. To view or edit the I did it Treatment documentation click on the I in the box in the highlighted line. The documentation is in the green highlighted box and may be edited to suit the patient. To edit the text in the Item Detail box click the Edit button in blue next to the Text box. This document edit text is available with all assessments/treatments. Page 13

14 The user is now able to remove documentation or add observations, when documentation is complete click the Save button. To complete this type of documentation, simply click the Save button again at the bottom. Viewing and Editing Existing Documentation To view documentation previously done select the Assessment or Treatment, then click the View/Edit button at the bottom of the page. Previous documentation may now be viewed. If edits need to be made, click the Edit button at the bottom of the page. Click Save when edits are complete. Recalling Previous Documentation to New Documentation To recall documentation previously done, click the Recall button at the bottom of the screen. Diamonds will appear to the right of each question, and may be clicked on to pull previous documentation into the current Assessment or Treatment. If the previous documentation is not correct, the provider may enter the new information instead. Click Save when complete to return to the Worklist. See example below. Changing the ModeTo change the Mode the provider views and enters information, click the Mode button at the bottom of the Assessment. Page 14

15 The Mode of documentation is a provider preference and may be changed at any time. To document in this Mode the provider must click on the down arrow to make a choice then OK. Hiding Text: The Hide/Show Text button will allow the provider to remove instruction type text from the Assessment or Treatment screen, such as the WNL statements. Temporary Status Purpose: ANY INPATIENT needing to be seen by ED Physician for issues that attending MD cannot care for at any time during In patient visit. (including youth: acute/residential and adult psych for KMC) ADM will relocate patient back on ER tracker using Clinical Data: Additional tab and changing temp location status, updating patient room assignment at this time. ER RN will Triage patient following normal procedures once patient is temp located by ADM Staff. Continue care of patient thru rest of visit as ER Patient, there are some differences to consider. Status event of Temporary Status when first placed on tracker by ADM can be updated to reflect patient flow thru the department. Nursing: Triage/Discharge Assessments will not show under Page 15

16 Triage/Discharge Routine. These will have to be documented from the worklist, each assessment will have to be added to the worklist. From Triage Routine, Triaged At (time field)/time Seen by provider (time field) Cannot be updated to reflect the new triage time, please bypass these fields. Orders from floor will show on main tracker under orders column and also under current orders in Orders tab. emar will also reflect all inpatient medication orders. MD: In discharge routine prior Clinical impressions should not be deleted, please add new impressions to these. Discharge date and time Not able to change this information. Use status event of Admitted when Patient ready to go back to floor. This will remove patient off tracker. For patient that needs a higher level of care or needs transfer to another facility after evaluated in ED this patient treated like an inpatient needing transfer and is done through the attending physician. Reception Purpose: Use this function to receive a new patient into the Emergency Department. RECEPTION : (note Ambulance symbol for quick access to this menu button) The screen below will appear, input patient name. The more information in the fields the greater likelihood of the exact patient displaying. Function button: Select the appropriate function button on the bottom of the screen. Search: Use this function button initially for all patients, this will assist you in choosing the correct patient account if the patient has had a prior visit. Find More: Select this function key if there are multiple people with similar identify characteristics chosen and you do not see the correct patient. New Patient: Select this function key if you are unable to find your Page 16

17 patient using the above keys. Cancel: Select this function key if you need to cancel the new reception or you have entered information in error and do not want to save it Choose patient from list, verify birth date! If there is any doubt have registration receive patient. Once a patient has been chosen the following screen will appear. If patient has been in the system before the header and demographic section will auto fill. All questions with asterisks are required before filing (arrows). Page 17

18 Verify DOB: re-enter in Date of birth to verify information. Stated Complaint: free text area. This is displayed on the triage tracker. Status: Pending triage defaults in. Can change by typing in field or using drop down arrow. Registration not required to complete.. Arrived At: Self populates to date and time when patient entered into system. Arrived By: You can begin typing or use the drop down arrow to choose from a list of modes of arrival for patient. Priority: This is the triage classification of the patient based on the five level triage classification system. You can begin typing or use the drop down arrow to choose your triage class. Registration not required to fill this out. Condition: This field does not need to be filled in, Registration and/or RN do not need to assign a patient condition. Triaged At: Time of beginning default in. Able to type in n/n to populate the time now, you can also choose the drop down arrow to enter a different time if need. ED Location: Emergency Department defaults. Can change to correct pod. Registration not required to complete. Area: Lobby defaults can change room according to pod. Registration not required to complete. PCP: Can assign PCP using drop down arrow or start typing. Nursing not required to complete. Page 18

19 Save: At this time you will be prompted if any asterick (required) are left blank. Once saved the following print face sheets, armbands menu will automatically appear. Click ok to print the necessary forms. Triage Purpose: Triage can be completed from reception using the triage assessment section or from triage tab (right verb strip). They are the same assessments in both fields, same screen design as reception. Chief Complaint: This is a look up to chief complaints existing in the system. You can begin typing your complaint into this area and it will automatically populate into the field or you can use the drop down arrow at the side to look to all the chief complaints to choose from. (Using the space titled Other, can add in multiple additional chief complaints if appropriate. ED Provider: Assign ED physician by typing in provider name or use the drop down arrow, ED Nurse: Assign Nurse by typing in name or using the drop down arrow. ED Location: Change location to correct pod or leave in KMC ED. Area: Change to correct room or leave lobby if going back to lobby. Status: In triage will default once triage assessments are completed. Change by typing in field or using drop down arrow. Triage Assessments: Check the assessments and document. The triage list will be different based on variations in patient ages. This list can include: ED Triage Assessment (Chief complaint, Vaccination, Social and Functional History, Tobacco Usage, and Advanced Directive) Admission History or Pediatric Admission History Page 19

20 Vital Signs Pain Assessment Height and Weight Fall Assessment Tool (over age 60). Triage information other then assessments is saved at time that a field is completed. Allergies/medications: Click on the tab at the top. Choose the edit button, you are able to add new or edit existing allergies or meds at this time. Required information has an asterisk. Click Save at the right hand when completed. You have the ability to print a home medication list. Order Management Medications Purpose: to order ED physician RBVO or written ED orders. Open patient tracker to view patients to start your order process. Click on patient name to select and highlight patient to open the chart. After highlighted click on Open Chart it will then open to the Order Management Screen. At the top of the page displayed a Current Orders tab and a History tab. Page 20

21 The Current Orders tab will automatically open and display active orders. Orders are broken down into categories such as Medications, Radiology, etc. The History tab when clicked on will display all orders placed on the patient including canceled and discontinued orders. Please see order management manual for non medication orders. On the Order Management screen the Function buttons are at the bottom of the screen (New Orders, New Meds, New Sets and Restorable). To place a new Medication order, select the New Meds button at bottom of screen. The New Meds button will open up a new screen which gives the option to search by favorites, Category group, or specific name. Defaults to favorites if exists. Nurses will be prompted to enter physician and order source. Read Back Verbal Order will send the order to the providers esign queue. See screen shot below. Once selected click ok. Page 21

22 To select a medication click on name or string below which bring up page of associated strings. Click in box to choose appropriate medication. Notice blue edit box, if starred edit is required if not, can click ok. Page 22

23 Starred edit cannot enter past without editing medication string. Click on Edit tab. items need completed before filin g. Page 23

24 Complete the required information before filing. Once complete the Edit button will no longer have a *. Click OK which will bring up the final editable order review before orders are saved. If conflicts exist the conflicts page will appear prior to the final editable order review. See screen shot below, the user must manage these conflicts before orders can be saved. May override, replace, or erase order. If override a reason list will appear to indicate reason why override is occurring. Page 24

25 Once conflicts are resolved then the review order page will appear for final edits prior to saving. Page 25

26 Medication Reconciliation Home Medications: Nurse updates home medications in Triage Physician Reconcile: Physician responsible for reconciling medications through Order management. Home Meds: Discharge: After the physician completes the reconcile process in orders and ambulatory orders, the nurse reviews the home med list for the correct medications as outlined in physician prescription/discharge instructions and updates accordingly. Then nurse updates the last dose/time taken. Then nurse prints the home medication list after these updates via the discharge functionality it is also set to print with the discharge packet. Page 26

27 Discharging/Departing a Patient From EDM Purpose: To depart a patient from the ED (admits and discharges). Page 27

28 The patient status cannot be in a READY TO DISCHARGE status unless REG ER admission status occurs. Can still enter information but cannot Discharge off the tracker. Discharge Plans Tab: This will bring you to the screen, noted with the button at the top. To enter the discharge information, use the drop down arrows to the right and make a selection from the menu. Instructions: Not utilized at this time, will have to input free text which instructions are given. Stand alone forms: Release from school, PE, etc. Prescriptions: For physician use only. Forms: all forms created as stand alone. Referrals: Looks to referral lookup. Additional Free text: opens to word document. Can use canned text (if created) or free text. Physicians should record instructions given here. Can click in item detail section to give patient further instructions (see green arrow) Page 28

29 Discharge Data Tab Provider: will default in. Status: will default in from current status on tracker, or when RDC button is clicked. Time Seen by Provider: Time stamp from the ERP in Room Status Event or can be manually entered. Triaged at: defaults in based on when triage occurred. Other ED Providers: can assign more then one ED provider. Clinical Impressions: Medical findings by the physician. Discharge Disposition: To be completed by physician. Condition: patient condition recorded by provider. Discharge comment: Free text box. Discharge date and time: Documenting in this field will take a patient off the tracker. It will be grayed out until REG status occurs. This field is to be used for all patients whether admitted or discharged from the ED. Discharge Interventions: Can associate required or recommended assessments. Can add from here using + at bottom. To document, check the assessments and click document. Warning can occur based on facility decision which assessments are required upon discharge. Once discharge data and plan have been completed may print packet or each form separately. Page 29

30 Printing Packet: To print the patient s discharge packet, click the Print Packet button at the bottom of the screen. Can print by type instead (discharge reports). Information previously entered in the Discharge screen will now print. Admit Request Select patient that is to be admitted by highlighting. Then go to the menu buttons on the right of the screen, and choose Admit. Choose Admit request. Page 30

31 Bed request: Request service required to complete the admit request form which will be presented upon choosing a location for admit. Do not fill out any other questions in the bed request section. Page 31

32 Choose location for admit. The following Fields are required: Registration Type: Inpatient defaults but it can be changed to observation or outpatient. Request Accommodation: Choose a service level. Request Admitting Doctor: Use the drop down menu to select a physician. Request Attending Doctor: Use the drop down menu to select a physician. Request Reason: Allows the user to select from Inpatient, Observation, or Outpatient. Request Time: Select time of request Request Date: Select date of request Page 32

33 Room Assignment: Select a room number from the drop down menu. Primary Diagnosis: Free Text Secondary Diagnosis: Free Text When complete with the information select the Save and it will send the message to Admitting and Registration. The patient status will change automatically to pending admission on the tracker. Page 33

34 Click on Triage Click on reprint admission forms Reprint Admission Forms/Labels Choose forms to reprint Page 34

35 Building the Physician On Call List Purpose: To build a view list of on call physicians. Pathway: Clinical Emergency Dept EDM On Call In the upper left corner of the screen you are given a Service scroll box that will allow the user to choose a specific specialty group. Below that is Page 35

36 the Date of call and Slot which allows user to pick a group (On Call, No Call, and Specific Providers office names etc.). To the right of the date and slot box is the Provider box, which allows the user to choose the provider for the group of Physicians on call. We will not be instructing or teaching to adding a comment for the end user to view. Page 36

37 After complete with On Call list the user may also view by clicking on the Editable Preview tab at top of page. This will bring up the Dates, Service/Slot and list of Providers. On this screen the user can preview the information that was selected and make edits as need by clicking on slot or provider the Slot or Provider that needs to be edited and/or updated. Page 37

38 To edit highlight the Provider s name and choose the x this will allow the user to remove the item and insert the correct Provider. This function works the same for when user chooses On Call, etc. When user has finished with previewing and editing choose the Save button at the bottom of the screen and this will save all changes made by the user. Page 38