Physician/Provider EMR Guidance Packet

Transcription

1 Electronic Medical Record (EMR) Access 1. While at the center, we recommend that you ask the center for a computer tablet or Net PC for your use in the EMR applications. 2. If the preference is to use your own hardware device, please be aware that Internet Explorer is the approved browser for PointClickCare (PCC). The web address is: 3. Other browsers such as Mozilla, Safari (ipad) and Chrome will run PointClickCare but are not officially approved by PCC to run all functionality. PCC Access Access to PCC: You will be given a username and password to log in to PCC (referred to as your GSDS username and password). *Note: Please contact the Center For Solutions (CFS) at if needing assistance with username and password. 1. From the EMR Tablet Start page, click the Medical Record icon. Revised 1/22/2016 Page 1

2 2. Enter your GSDS user name and password and click Login. Note: your username will have a prefix of gss. Revised 1/22/2016 Page 2

3 PCC Navigation Once logged into PCC, you will see the following Home Page. Please note the Clinical tab is where you will be working within the residents medical records. You may navigate forward and backwards using arrows within PCC (as displayed below) Revised 1/22/2016 Page 3

4 1. PCC Clinical Resident s legal medical record components/modules that may be helpful with your visit are listed as follows (as displayed below): Profile (may view/display Admission Record - Face Sheet) Medical Diagnosis Allergies Immunizations Orders Weights/Vitals MDS (Minimum Data Set) Assessments (User Defined Assessments- UDAs) which include data collection and assessments such as: Pain, Falls, Wound, Nursing Admit, Nutritional, etc.) Progress Notes (may be run by Progress Note Type such as: Communication/Visit with physician; Mood/Behavior, Health Status, etc.) PCC- Clinical Reports General Progress Notes- may filter by date range and by type: e.g to , Type- Health Status, Communication/Visit with physician- Run report- report will display Care Plan PCC- Clinical- Resident s name Care Plan tab the print link next to the active care plan will display the current comprehensive care plan to view Tasks (Point of Care documentation) Note: Point of Care (POC) is an area in the PCC application where direct caregivers (e.g. C.N.A s, Activity staff, Dietary staff) document responses and outcomes to cares delivered. 2. The Dashboard (Dash) within each resident s record in PCC offers the following information panes that may be helpful to your visit: Most recent weights and vitals High risk progress notes (which include incidents, infection, mood/behavior, and vital signs significant changes) Advance Directive Current diet Current medications ordered Active medical diagnosis Revised 1/22/2016 Page 4

5 3. PCC Reports within PCC hover over Clinical > Other > Reports that may be helpful with your visit include the following: General i. Progress Notes by Type, such as Mood & Behavior, Communication/Visit with Physician, health status, resident/family education, eadmin Notes (will note responses, for example, to PRN medication administration); ii. MD/Nurse Communication this report may be helpful in viewing the resident s current weights/vitals, diagnoses, progress notes within a date range, etc. Point of Care i. Document Survey Report- includes tasks and responses to interventions/tasks (Point of Care - POC Documentation) as in: Bowel & bladder documentation, food and fluid intake, mood & behavior, activities, ADLs, etc. ii. Nutrition Report this report looks at a week ending by date selected; displays decreased intake, average meal intake % over past 4 weeks and any weight change Weights and Vitals i. Weights/Vitals Summary - includes: weight, height, blood pressure, temperature, pulse, respirations, oxygen saturation, blood sugar Orders - i. Order Summary or Medication Review Report: to review current consolidated orders. These reports include active medical diagnosis, active orders (medications/treatments/other), active Advance Directive, active Diet order, etc. ii. Administration Records (Medication, Treatment, Enteral Feed) iii. Diet Type Report iv. Order Listing Report ability to display a report of orders based on selected criteria. For example, for a resident by a specific medication class, such as antidepressants or anticoagulants. Revised 1/22/2016 Page 5

6 4. Access to Resident Spaces: You will be given a username and password to log in to Resident Spaces (referred to as your GSDS username and password). You may access Resident Spaces through the Our Resident Spaces icon OR through the Home > External Links within PointClickCare. OR Revised 1/22/2016 Page 6

7 Login to Resident Spaces using your GSDS user name and password. 5. Resident Spaces: The repository of scanned clinical documents that are part of the legal medical record for each resident. Search Options in Resident Spaces that may assist with your visits are as follows: Resident last name, Resident first name Date range Categories: i. Advance Directives ii. Assessment/Data Collection iii. Flowsheet iv. History & Physical v. Hospice vi. Hospital/Other Providers vii. Lab/Radiology Reports viii. Miscellaneous ix. Orders x. Progress Notes xi. Release/Authorization xii. Therapy xiii. Transfer/Discharge Revised 1/22/2016 Page 7

8 You may click on the search options as applicable and then click on the Search button. This will display the requested clinical documents. You may then right-click anywhere on the listed document, click view to view the image. NOTE: You may have the PCC application and Resident Spaces environment open simultaneously. At this time, these applications are not fully integrated, but you may toggle between the two as needed. Revised 1/22/2016 Page 8

9 6. Remote Access: Allows access to PCC and Resident Spaces outside of the center (office or home) Website for remote access: i. Hint: do not enter www. Enter your Good Sam user name and password (GSDS). i. First time users will be prompted to enroll in Password Self Service. ii. First time users are encouraged to change their temporary passwords. iii. First time users will be prompted to download the Citrix client. You will be directed to the Citrix Receiver web page where you can select to login to PointClickCare or Resident Spaces. Reminder: when logging into PCC your user name is prefaced by gss i.e. gss.jdoe To close the Citrix Receiver page click your name in upper right corner and select Log Off. Detailed instructions and frequently asked questions document may be obtained from the center staff or from this site: 7. Practitioner Engagement: Ability for physicians to electronically sign telephone and verbal orders either remotely or at the center. Check with your center to verify this functionality is available. Revised 1/22/2016 Page 9