Electronic Charting for the IDT Staff

Transcription

1 Electronic Charting for the IDT Staff Hi-Tech Menu System... 2 Update Memo Alert... 2 Log In to the HTS System... 3 Create or Change a Password... 3 Electronic Signatures... 4 Notes... 5 Edit Notes Library... 5 Edit Notes... 7 Clinical Assessments... 9 Edit Assessment Scoring Complete and Lock an Assessment Buttons at Bottom of Screen Edit MDS Activities Section F Section V. CAA Summary Edit CAA Resources Print CAA Resources Edit Care Plans Other Electronic Charting Learn More in our August Webinars: G:\HITECH\Webinars\Webinar Docs\ElectronicChartingIDTStaff.docx Page 1 of 25

2 Hi-Tech Menu System HTS Login Menu The Login Menu is the first screen that displays when you click the HTS icon on your desktop. This menu displays all HTS applications. After you log in, you can access the applications used at your facility, based on menu security. Update Memo Alert After an update is installed, when you log in, the Master Menu will display the Review Program Update Changes message (on right). Click the following: View Memo Now to display/print the memo. Remind Me Later to display the Alert again in 24 hours for this User ID. Don t Remind Me Again to stop the display of this Alert for this User ID. The Alert will be displayed for up to 30 days until the user clicks View Memo Now or Don t Remind Me Again G:\HITECH\Webinars\Webinar Docs\ElectronicChartingIDTStaff.docx Page 2 of 25

3 Log In to the HTS System You must log in before you can use any programs. Security can be added to a User ID to limit program choices. NOTE: Your System Administrator (SA) must create a User ID for anyone who wants to log in to the Hi- Tech System. User ID: (1-10 alpha-numeric characters) Enter your User ID. Press the [Enter] key or click in the Password field. Password: Enter your Password (1-10 alpha-numeric characters). Press the [Enter] key. If you enter the wrong User ID or Password, the screen will display: Invalid User ID/Password. Click OK and try again. When you enter a valid User ID and Password: Your Home Menu will display all applications authorized for your User ID. Within those applications, if your User ID does not have access to a program, that menu option will be displayed in non-bold italics. The Password field is a blind field. As you enter your codes, only bullets ( ) will be displayed. Someone watching cannot see what you enter. Keep your Password secret. If someone uses your User ID and Password, any changes they make or records viewed will be logged under your User ID. IMPORTANT: Once you have logged into the HTS System, do not leave your computer unattended. Another person could access data, and this action would be logged under your User ID. If you leave your system, exit the program. Create or Change a Password From the Log In or Home screens, enter your User ID then click the Change Password icon. Edit User ID Records screen will be displayed with your User ID. Old Password: If you are setting up the first password, leave this field blank. Press the [Enter] key. Enter New Password (1-10 alpha-numeric characters). Verify Password: Enter the same new password. It must match the New Password entry or when you click Ok, the screen will display: New Passwords do not Match. G:\HITECH\Webinars\Webinar Docs\ElectronicChartingIDTStaff.docx Page 3 of 25

4 Electronic Signatures As you move towards more electronic documentation and signature in Hi-Tech, be sure that each staff person s User ID record also includes credentials that should be included with the electronic signature. Your System Administrator can access to these records through Utilities > System Structure > Maintenance > User/Security. In the Full Name field, add the credentials after the last name, as shown on the right. In the IMAR Electronic Medication Administration System, enter the credentials in the Title field, as shown below: G:\HITECH\Webinars\Webinar Docs\ElectronicChartingIDTStaff.docx Page 4 of 25

5 Notes Libraries > Face Sheet > Edit Notes Library NR49 You can write Face Sheet, Nursing and Progress Notes through Edit Medical Record > Notes or through Documentation > Notes > Edit Notes. Hi-Tech recommends that you build a Notes Library of frequently used Notes text or formats. You can copy these items into individual resident s records and edit the text to suit that resident. Spend time deciding what kind of notes you ll record in your notes library. A well-designed library will make it easier to write and manage notes. Here are some suggestions: 1. Begin with the items that will be common to many residents. Set these up in the order that you would like to see them on a printed record in the chart. 2. Don't put highly individualized items in the library. Enter these in residents' notes as needed. Discipline code is optional. You can assign a code for the staff discipline that will use this kind of note, or you can select FS (Face Sheet) if the note will be selected for Face Sheet notes in Edit Notes. Using the AC (Activities) discipline code will allow you to sort and view all Activities Notes. If the code you want to use does not appear in the Inquiry list of codes, add it to the System through Libraries > Face Sheet > Disciplines. Library #: Enter a number that will identify this note. Hi-Tech recommends that you begin with the number 2 or 5 and then number the items by 2s (002, 004, 006, 008) or 5s (005, 010, 015, 020). This leaves space between records so you can insert new records between existing items, keeping related items together. The sample on the right is a note template record that you can select and use to document residents emergency room visits. In Edit Notes, pull this template into a resident s notes records and then complete the required information. See an Activity note template on the next page. G:\HITECH\Webinars\Webinar Docs\ElectronicChartingIDTStaff.docx Page 5 of 25

6 When you are satisfied with the content of the note record, click Ok. Click Print Report button to print the Note Library G:\HITECH\Webinars\Webinar Docs\ElectronicChartingIDTStaff.docx Page 6 of 25

7 Documentation > Notes Edit Notes NR32 IMPORTANT: You cannot delete notes, but you can inactive them through Inactivate Notes. Use this program to enter and edit the following types of notes on residents conditions, activities, behavior, etc. Face Sheet Notes (previously recorded on Edit Face Sheet > Notes screen). Nursing and Progress Notes, and other types of notes that you define in the Note Library. Secure Notes (i.e. Complete Notes). View MDS 3.0 and CAA Notes recorded through MDS / Care Plans > MDS > Edit MDS. Choose Note Type Select standardized text from library Add new notes here Click binoculars to display Note Inquiry. See next page. View All or select a Type of Note. Use scroll bar on right to scan through Notes. When you select a Resident, if the resident has existing notes, the first note of the selected type will display at Existing Notes. At the bottom of the screen, Source: will identify the program from which you chose to edit notes, i.e. Edit Notes (from menu), Face Sheets, CAA Notes. (Existing notes converted from previous notes: CV-Notes.) G:\HITECH\Webinars\Webinar Docs\ElectronicChartingIDTStaff.docx Page 7 of 25

8 To select a note, click the binoculars to display the Note Inquiry screen (on right). On this screen you select Progress, Face Sheet, CAA or MDS to list just that type of note. Selected Note displays in text box below. To edit the note, click OK to display note at Modify Note (next screen). Select a note to display the full note in the text area at the bottom of the Inquiry screen. If you want to edit this note, click OK and it will be displayed at Modify Note on the Edit Resident Notes screen (below). NOTE: You cannot edit RAP or CAA notes. Check Note Complete (Locked) and save the note so you can no longer edit the note. See the next page. The User ID assigned to a note is the only User ID that can edit, lock or inactivate the note. Copy Text: On the Note Inquiry screen (top right) select and display the note to be copied. Click the Copy Text button. The text will be copied to Add Note as a new note that you can edit. You can also copy text from each page of a multi-page note. Display the Note Inquiry screen (below). Each page of the note will be listed. Check the box of the note that you want to copy. It will be displayed. Click the Copy button to copy the text of that note to the Add Note area as a new note that you can edit and save. G:\HITECH\Webinars\Webinar Docs\ElectronicChartingIDTStaff.docx Page 8 of 25

9 Clinical Assessments Clinical: Nursing Care or Clinical: Res Care / Asstd Living > Documentation > Clinical Assessments Edit and create Assessment templates: Libraries > Documentation > Clinical Asmnt Library Hi-Tech has defined and provided the following Clinical Assessment templates in the Clinical Assessments Library. You can edit and add your own assessments through Libraries > Documentation > Clinical Asmnt Library. Risk for Falls Risk for Dehydration BIMS Brief Interview Mental Status Bowel & Bladder Training Nutritional Risk PHQ-9 Mood Interview Contracture Risk Skin Risk AIMS (Abnormal Involuntary Movement Scale) G:\HITECH\Webinars\Webinar Docs\ElectronicChartingIDTStaff.docx Page 9 of 25

10 Documentation > Clinical Assessments Edit Assessment NRE6 IMPORTANT: At User, if this is not your User ID, log out and log back in under your User ID. The User ID is attached to the Assessment record. An assessment created by one User cannot be edited by another user. You cannot change the User ID from this program. NOTE: After you enter the Resident ID, click View Assessments on File to list the assessments (sample below) that have already been entered for this resident. Select the assessment that you want to edit. See more on Locked Assessments on Page 15. G:\HITECH\Webinars\Webinar Docs\ElectronicChartingIDTStaff.docx Page 10 of 25

11 1. Enter or select the Resident ID 2. Enter the Assessment reference number. Click the binoculars icon to list and select an Assessment (shown on right). 3. Sort By: Reference Number or Assessment Title. 4. Status: F = Favorites I = Inactive 5. Select Display Favorites Only to display the Assessments flagged as Favorites in the library. 6. The screen below displays Assessment 001: Risk for Falls: Acuity range defined for this assessment in the assessment library. Compare to Total Score on a Complete Assessment. Questions defined for this assessment in the library. G:\HITECH\Webinars\Webinar Docs\ElectronicChartingIDTStaff.docx Page 11 of 25

12 Date: Enter or select the date for a new assessment or existing assessment that is not yet Complete. Click View History to list and select existing assessment. NOTE: You can create multiple assessments on the same date. You can edit assessments until they have been Locked. You can view but not change Locked assessments. View History will display assessments entered by all Users. You can view the answers of another User s assessment, but you cannot edit or lock another User s assessment. 7. After you enter or select a Date, the screen will display each Assessment Question (Q) so you can select the one you want to answer or edit (sample on the right). 8. Checkmark the Answer to that Question. NOTE: In the library you can set up Questions to allow for multiple Answers (shown on right). The screens below show selected Question, Answer and Comment. Assessment Question 9. Enter a Comment if necessary. Answers defined for this Question and the acuity score for each answer Enter comments related to Question and/or Answer NOTE: If the library template includes Help text, you can click the Help button to display that text. G:\HITECH\Webinars\Webinar Docs\ElectronicChartingIDTStaff.docx Page 12 of 25

13 10. Click Ok to save the entries. The Question, Answer, Score and Comment will be displayed: (Q) = Question (A) = Answer (C) = Comment 11. New Assessments will be in Add* mode and the program will automatically display the next Question that has been defined for the Assessment. For example, after you click Ok to save the Cognitive Status Question, the screen displays 02 General Health (shown below). You can continue through the entire assessment this way, selecting Answers to each Question, or you can click the Cancel button to exit the question on display and then manually select the questions you want to add to the assessment. *Add: The program is in Add mode when you start a new assessment. The word Add displays in lower left corner). If you return to edit an existing assessment Modify will display at the lower left. G:\HITECH\Webinars\Webinar Docs\ElectronicChartingIDTStaff.docx Page 13 of 25

14 Scoring Acuity range As you select Answers for Assessment Questions, the program displays the score for each answer in the Score column. The sum of the answer scores are displayed at Total Score (right side of the screen). Score for each Answer Score for entire assessment You can compare the Total Score to the Acuity Ranges listed at the top-right corner of the screen. For example: The Total Score of 10 displayed on the right would fall into the high-risk range. Score Override: Select this item if you want to change the score assigned by the program. Provide a Reason. For example: When you do a BIMS or PHQ-9 assessment, the resident might give you four or more nonsensical answers. You can enter 99 as the Override Score to reflect the nature of those responses and to reflect the scoring you have also used on the MDS. NOTE: Define acuity Ranges in the Assessment Library > Assessment ID > Scoring Ranges. In the library, you can also designate non-scored assessments and non-scored questions within a scored assessment. G:\HITECH\Webinars\Webinar Docs\ElectronicChartingIDTStaff.docx Page 14 of 25

15 Complete and Lock an Assessment If you have decided an assessment is complete, checkmark Assessment Complete (Locked). or Assessment Complete (Locked & Signed) if you allow electronic signatures and this resident has permission. If all Questions are not answered, and you select Assessment Complete (Locked), or Locked & Signed, the screen will display: Not all questions have been answered Continue? Click Yes to Continue. The screen will display the message: Completing this Assessment will Lock It OK? If you click Yes, you will not be able to change this assessment. You will be able to view and print it. If you discover errors in a locked assessment, you can Inactivate it. If you click Yes, the program will allow you to schedule the next assessment of this type and it will be added to the resident s calendar. You should understand how to use the Hi-Tech Clinical Calendar if you plan to use this feature. Buttons at Bottom of Screen Cancel: Do not save any of the choices or changes. (Add mode only.) Ok: Save all entries on the screen. Return to Resident ID for next entry. NOTE: If the assessment does not have any answered questions, it will not be saved. End: Save all entries on the screen and return to the menu. Print: Launch Print Assessment. The displayed resident and assessment will be selected for printing. Notes: Launch Edit Notes for this resident to enter a Progress Note related to this assessment. TIP: To help you organize Assessment Progress Notes, you can add the notes under specific Discipline codes. Please see instructions in the Clinical Records System User Instruction Manual > Section A > Documentation > Edit Notes. G:\HITECH\Webinars\Webinar Docs\ElectronicChartingIDTStaff.docx Page 15 of 25

16 Clinical Records System for Nursing Care MDS/Care Plans > MDS Edit MDS Select the assessment. Click Ok. Select Section F Preferences for Customary Routines and Activities. G:\HITECH\Webinars\Webinar Docs\ElectronicChartingIDTStaff.docx Page 16 of 25

17 MDS / Care Plans > MDS > Edit MDS Activities Section F Dietary Section K G:\HITECH\Webinars\Webinar Docs\ElectronicChartingIDTStaff.docx Page 17 of 25

18 Section V. CAA Summary The program will calculate all the triggered CAAs from MDS responses. If the Activities CAA is triggered, you must process the CAA Resource worksheet and decide if you will care plan Activities for the resident. See Edit CAA Resources on the next page. Print the CAA Trigger Test to understand why a care area was triggered for this MDS G:\HITECH\Webinars\Webinar Docs\ElectronicChartingIDTStaff.docx Page 18 of 25

19 MDS / Care Plans > MDS Edit CAA Resources After you complete and print the MDS, you can edit and print a CAA Resource Worksheet for Activities. Select the resident and the ARD (below) to display the list of triggered CAAs (on right). You can deselect triggered CAAs and choose to complete just the Activities CAA. Click Edit. This will display the CAA Resources edit screen (below). Complete the screen as instructed to complete the CAA Resource Worksheet in the RAI manual (Chapter 4 and Appendix C). Screen 1 of 4: G:\HITECH\Webinars\Webinar Docs\ElectronicChartingIDTStaff.docx Page 19 of 25

20 Print CAA Resources To print a completed CAA Resource Worksheet, select the resident, ARD and Activities. You can also print blank worksheets. Sample: Page 1 of 4: G:\HITECH\Webinars\Webinar Docs\ElectronicChartingIDTStaff.docx Page 20 of 25

21 Complete the resident s CAA and return to Edit MDS to complete Section V100 and V200. Sign the MDS in Section Z. Print the MDS. G:\HITECH\Webinars\Webinar Docs\ElectronicChartingIDTStaff.docx Page 21 of 25

22 MDS / Care Plans > Care Plans Edit Care Plans Select the resident. Enter the Care Plan Date. Select Edit Care Plan and Auto RAP/CAA Driven This will display all the triggered CAs selected for Care Planning. You can deselect all the triggered CAAs except Activities: G:\HITECH\Webinars\Webinar Docs\ElectronicChartingIDTStaff.docx Page 22 of 25

23 This will display the Select Problems to Edit screen for the Activities CAA. These problems have been linked to this CA via Libraries > MDS / Care Plans > Link CAs to Problems. Select the problems you want to add to the resident s care plan to address the Activities CA. Click OK. On the Edit Resident Care Plan screen, edit the Problem text if necessary. Select or enter Goals and Approaches for the Problem. If you have selected multiple problems from the Select Problems to Edit screen, after you finish editing the final approach, the next problem will be displayed for editing. G:\HITECH\Webinars\Webinar Docs\ElectronicChartingIDTStaff.docx Page 23 of 25

24 Hi-Tech will present August Webinars on the following Electronic Charting Features: Other Electronic Charting Use Activities to record items such as bingo, birthday party, music hour, etc. Use Events* to record health-related items such as ER visits, falls, infection, flu, etc. Use Vitals to record residents vitals and weights. *NOTE: Assign security to limit access to the more confidential, health-related Events records. For example, allow only Nursing and Administration to access Events, while all clinical staff can access Activities. Select these items from Edit Medical Record, by clicking the button on the right side of the screen (see sample on right) Or select the items from the Documentation Menu: See August Webinar descriptions on the next page. G:\HITECH\Webinars\Webinar Docs\ElectronicChartingIDTStaff.docx Page 24 of 25

25 Learn More in our August Webinars: Activities and Electronic Charting Friday, August 2 11 am-12 noon Please join this Webinar to see how easy it is to record and report on residents' Activities and move your activities department to electronic documentation. Ask your Activities staff to join you to see the benefits of electronically tracking your residents' Activities in the Hi-Tech Clinical Records System. For Nursing Facilities, we will demonstrate the completion of specific sections of the MDS 3.0, as well as the CAA-driven Care Plan for Care Area 10 Activities. The Webinar will focus on how your Activities staff can use the Clinical Records System to: Document participation in activities. Write electronic Summary Notes about a resident s activity participation, abilities, interest. Complete the Activities section of the MDS 3.0. Transfer paper Care Plans into an electronic format that can be easily maintained. Complete an Activities assessment electronically thru Clinical Assessments. Set up user security that allows staff members to view and/or access Activities The Dietary Staff and Electronic Charting Wednesday, August am-12 noon Does your Dietary Staff maintain your resident information electronically? Join this webinar to learn how to track Resident weights, and Dietary Notes and Clinical Assessments electronically. Please join this Webinar to see how easy it is to record and report on residents' Dietary information and move your Dietary staff to electronic documentation. Ask your Dietary staff to join you to see the benefits of electronically tracking residents' weights in the Hi-Tech Clinical Records System, allowing you to report on weight gains and losses. For Nursing Facilities, we will demonstrate the completion of specific sections of the MDS 3.0, as well as the CAA-driven Care Plan for Care Areas 12 Nutritional Status, 13 Feeding Tubes and 14 Dehydration/Fluid Maintenance. The Webinar will focus on how your Dietary staff can use the Clinical Records System to: Document resident weight and diet. Write electronic Summary Notes about a resident s dietary needs. Complete the Dietary section of the MDS 3.0. Transfer paper Care Plans into an electronic format that can be easily maintained. Complete an electronic Dietary and Food Preferences assessment thru Clinical Assessments. G:\HITECH\Webinars\Webinar Docs\ElectronicChartingIDTStaff.docx Page 25 of 25