User Guide for Evolve Simulation Learning System: Electronic Medical Record (Fundamentals)

Transcription

1 User Guide for Evolve Simulation Learning System: Electronic Medical Record (Fundamentals)

2 Introduction The Simulation Learning System s Electronic Medical Record (EMR) allows you to document the treatment of your simulation patient. You can order and administer medications, review medical history and lab reports, document patient teaching, and many other functions provided by standard electronic medical record systems. The EMR is divided into 17 tabs. Like a standard electronic medical record, some of these tabs can be edited while others can only be reviewed: Edit Review Identification x Flow Sheets x x Medication Records x x Nurses Notes x x Orders x x Physician s Progress Notes x Laboratory Reports x x Diagnostic Reports x Consults/Procedures x History and Physical x x Nursing Admission x x Surgical Reports x Emergency Department x x Patient Education x x Demographics x Consents x Signatures x The functions of each tab are explained later in this guide. As you complete your documentation, you can save your progress and resume at a later time, save your work as a PDF, and submit the EMR to your instructor for review. Please review this guide before beginning work with the EMR, and save it for reference as you complete your documentation.

3 Technical Requirements The EMR is accessed through the Evolve Learning Management System. There is no software to download or install: the EMR runs within your internet browser, using a popup window. In addition, the EMR requires the following technical specifications: Broadband connection (DSL or cable) 1024 x 768 screen resolution Firefox 2 or Internet Explorer 7 and higher NOTE: Pop-up blocking software/settings must be disabled. Adobe Acrobat Reader (to view PDF) Keep in Mind As you work with the EMR, please keep the following in mind: The EMR will only function while you are logged on to Evolve. If you are logged out of your course or otherwise disconnected, you must login again before accessing or using the EMR. Save your progress often by clicking Save from the menu in the top-right corner of the EMR. Your EMR data cannot be changed after you enter your initials into a record, or once you submit the EMR to your instructor. Depending upon your internet connection, the EMR may take from a few to many seconds to load or save data. This is especially true when submitting the EMR to your instructor. In general, you can add records to the EMR by entering data into text fields, and then clicking the green plus symbol ( ) beneath or next to the dataentry fields. NOTE: After adding a record or data, be sure to click Save from the menu in the topright corner of the EMR.

4 Access The Post-simulation Learning Resources folder of each scenario contains a link to the EMR for that scenario. Access to this link is controlled by your instructor, who will notify you when the link is available: NOTE: Pop-up blocking software/settings must be disabled to access the EMR.

5 Login You will be presented with a login screen each time you access the EMR. This login is only a simulation, and no username or password are required. These fields will be prefilled using information from your Evolve account. Simply click Sign In to begin using the EMR. NOTE: When you first access a scenario s EMR, you may be asked to enter different Initials. This is because you share the same initials with either a nurse or physician of that scenario s EMR. You may use any initials you wish.

6 Identification The Identification tab contains basic information about your patient, including name, primary and secondary diagnoses, height and weight. Much of this information is also displayed at the top of the EMR across all tabs. This tab cannot be edited.

7 Flow Sheets The Flow Sheets tab contains the lab results and vital statistics for your patient, and is divided into several sections. Click the title of a flow sheet to review its data, and to enter your own records: To add your own record, select a Day and Time for the new column using the drop-down menus. After you ve entered the statistics for the new column, enter your initials and click the green plus symbol ( ) at the bottom of the flow sheet: Be sure to click Save at the top of the EMR after you add a column, and before accessing other flow sheets or EMR tabs.

8 Medication Records The Medication Records (MAR) tab lists the medications and administration history for your patient. You may also use this tab to order new medications and enter administration data for existing medications. The MAR is divided into 3 sections, based on medication type: STAT, Scheduled, and PRN. Click a section to view the medications for that type: Administration days and times are listed in columns to the right of each medication. Click any time highlighted in blue to view the adminstration details for that time. The formatting of each time indicates the medication s administration history: crossed out = administered circled = held none = pending Medications with gray backgrounds have been discontinued.

9 Medication Records: Administering Medications To Administer, Hold, or Discontinue an existing medication, click the appropriate button to the left of the medication. A pop-up window will open in which you can enter the administration details: Select the Day and Time from the drop-down menus. You may specify a pending time or enter a new day and time. When you ve completed the details, enter your initials and click Administer, Hold, or Discontinue. The new administration will appear next to the medication.

10 Medication Records: Adding a Medication To add a new STAT, Scheduled, or PRN medication, select the appropriate section and click Add a New Medication button: A pop-up window will open in which you can enter the medication details: NOTE: Though you can specify any Day for the medication times, only times with days included in the MAR will appear. For example, if the MAR has columns for Tuesday and Wednesday, and you order a medication for Thursday, that pending administration time will not appear. After you ve completed the medication details, enter your initials and click Add Medication to save the record. The new medication will appear at the bottom of the list, at which point you can Administer, Hold, or Discontinue.

11 Nurses Notes The Nurses Notes tab contains the notes of the attending nurses of your patient. Use this section to record your own notes. To enter a new record, select a Day and Time from the drop-down menus, and enter your notes and signature. If your notes are related to a specific form available in the patient s record, you can link that form to your note by using the Linked Forms button available beneath your note:

12 Forms may be available within the Diagnostic Reports, Consultations, Surgical Reports, and Consents tabs. A tab with available forms will have an arrow to the immediate left of its checkbox. Click the arrow to expand the list of available forms, and check the box of the form(s) you wish to associate with your note. Click Associate to link the form(s); a link to the form will appear beneath your note: When finished, click the green plus symbol ( Save after adding a record. ) to add your record. Be sure to click

13 Orders The Orders tab contains the past medical orders of the attending physicians of your patient. Use this section to record new medical orders. To enter a new record, select a Day and Time from the drop-down menus. Enter the Order Type and Orders, then click the green plus symbol ( ) to add the record. NOTE: As only those with authority may sign these records you ll receive the alert below when attempting to sign your record. This alert is intentional, and will not prevent adding or saving orders. Be sure to click Save after adding a record.

14 Physician s Progress Notes The Physician s Progress Notes tab contains notes from the attending physicians about the history and condition of your patient. This tab cannot be edited.

15 Laboratory Reports The Laboratory Reports tab contains the history and results of laboratory tests for your patient. Laboratory tests are organized by type, and values are listed by day and time. This tab cannot be edited.

16 Diagnostic Reports, Consults/Procedures, Demographics, and Consents This series of tabs contains signed and scanned documents relating to the care and treatment of your patient. Access these tabs to view and review these documents. NOTE: Not all patients will have associated documentation. Depending upon the scenario, a patient may have all, some, or none of this documentation. These forms may also be available via links in the Nurses Notes, Orders, and Physician s Progress Notes tabs. You can also create links to these forms in the Nurses Notes tab. This tab cannot be edited.

17 History and Physical The History and Physical tab contains the medical history of your patient, and the results of his or her initial physical exam. This tab cannot be edited. Click a section title at the top of the tab to skip to that section.

18 Nursing Admission The Nursing Admission tab contains the data collected during your patient s admission. Depending upon the scenario, this tab may or may not be edited. If you must complete this tab as part of your simulation scenario, enter data into the available text fields as you have done for previous EMR tabs. Some sections contain only text fields, while others (e.g., Current Medications) require that you click the green plus symbol ( ) to add data. When you have completed the form, enter your name as the Signature, the Day and Time, and click the blue Save button at the bottom of the form.

19 Emergency Department The Emergency Department tab contains data gathered during your patient s visit to the emergency department. Depending upon the scenario, this tab may or may not be edited. If you must complete this tab as part of your simulation scenario, enter data into the available text fields as you have done for previous EMR tabs. Some sections contain only text fields, while others (e.g., Allergies) require that you click the green plus symbol ( ) to add data. When you have completed the form, enter your name as the Signature, the Day and Time, and click the blue Save button at the bottom of the form.

20 Patient Education The Patient Education tab contains the goals and educational interventions for your patient. Patient goals are listed in the top-half of the tab, and the interventions are listed in the bottom-half. Add new patient goals and interventions by completing the available text fields and clicking the green plus symbol ( ). You may also update the Current Teaching data of existing interventions. Be sure to click Save after adding goals and interventions.

21 Signatures The Signatures tab contains the electronic signatures of health care providers who have previously recorded data on the medical record. This tab cannot be edited.

22 Restarting Your EMR If, for some reason, you need to clear your EMR and begin again, simply click Restart from the menu in the top-right corner of the EMR. You can restart your EMR at any point before submitting your EMR to the instructor. You will not be able to restart your EMR once you submit your work to the instructor. NOTE: Restarting the EMR deletes all your entered data. Be absolutely sure you wish to delete your data before clicking the Restart button. After you have submitted your EMR for review, your instructor can either Restart the EMR, or Unlock the EMR for further editing. Please contact your instructor for further information.

23 Submitting Your EMR for Review When you ve completed your patient s EMR, submit your work to Evolve for review by clicking Submit from the menu in the top-right corner of the EMR. NOTE: Submitting your EMR for instructor review will lock the EMR, and you will no longer be able to make or save further changes. After successfully submitting your EMR, the Save, Submit, and Restart functions will no longer be available. You can review your EMR work in Evolve by selecting Documentation (EMR) from the Post-simulation Learning Resources folder of the appropriate scenario: Your submission will appear below the link to the EMR. Though you can no longer edit your EMR, you can review the data you entered during simulation. In all tabs, your data will be highlighted in yellow. You may also download a PDF of your data by clicking Print or Download from the menu in the top-right corner of the EMR. This file can be saved to your computer for later reference.

24 Troubleshooting The Electronic Medical Record is an internet-based application, which means that it is vulnerable to the same limitations as any other website. Please review the following common problems and solutions before contacting support: Q: The EMR link is not visible in the Post-simulation Learning Resources folder. A: The EMR link needs to be enabled by your instructor. If the link is not available, please contact your instructor for access. Q: Nothing happens when I click the EMR link. A: The EMR opens in a pop-up window. Please be sure that pop-ups are enabled for your browser and any security software you may have installed. Q: The EMR is taking too long to load, or isn t loading at all. A: Like any website, the performance of the EMR is dependent upon the speed of your computer and internet connection. Q: My data isn t being saved. A: Clicking the green plus symbol only adds a record to the EMR, it does not save your data. Click Save from the menu in the top-right corner of the EMR to save your progress. Q: I received an error when I tried to Save or Submit my EMR. A: Before reporting this issue, please close the EMR, logout of Evolve, and close all open browsers. Login to Evolve and the EMR, and try submitting your data again. If the error persists, please contact Evolve Support with your name, Evolve ID, and name of your institution. Please be prepared to also share your operating system, browser, versions, and any errors you experienced. Live support is also available 24/7 by calling