Soarian Clinicals Service Provider Workspace

Transcription

1 Soarian Clinicals Service Provider Workspace Participant Guide

2 Table of Contents 1. Welcome!... 6 Course Description... 6 Learning Objectives... 6 What to Expect... 6 Evaluation... 6 Agenda Getting Started... 8 Soarian Clinical Goals Train/Test Domain Overview... 9 Log On to the TRAIN/TEST Domain... 9 Information and Security... 9 Help Desk Service Provider Workspace Learning Objectives Setting Preferences to use the Service Provider Workspace Service Provider Workspace Filters Managing Orders Order Status Indicator Order Details Chart Ordered Assessments Access Charting Takeaways Allergies Learning Objectives View Allergy Status Allergy Status Table Allergies in Charting How to Reassess Allergies Chart New Allergies Results not found - Free Text Allergies Revise Allergies View Allergies Takeaways Place Orders Learning Objectives Navigate to Orders Select Orders and Session Details Order Sources Session Defaults Apply to Unsigned Orders Search for Orders Place Orders Page 3 of 63

3 Visit Selection Options Order Detail Forms Opening Order Detail Form from Add Orders Section Unsigned Orders Current Orders Order Conflicts Recurring Order Enter Charges on Orders Takeaways Assessments and Documentation Learning Objectives Access Charting - Documentation Assessment Browser Begin New Assessment- Overview Assessment Charting Icons Charting an Assessment Assessment Statuses Takeaways Patient Record Learning Objectives Access Patient Record Patient Record Settings Select Data in the Patient Record Takeaways Clinical Summary Learning Objectives Access Clinical Summary Clinical Summary Screen Edit Assessment Information in the Clinical Summary Takeaways The Soarian/Census Worklist Learning Objectives Census/Worklist Screen Select Nurse Station/Unit Census/Worklist Screen Components Takeaways Overview Activity Course Wrap Up Summary of Learning / Objectives review Thank You Course Evaluation Appendix Glossary of Terms Page 4 of 63

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5 1. Welcome! Welcome to the Soarian Service Provider Workspace Training Course. Thank you for taking the time to join us; we hope that you find your time in this course truly beneficial. Course Description This course covers the functionality of the Soarian solution. It is intended for users who will be using the Soarian applications in their daily workflow. The purpose of this course is to teach you to use the Soarian solutions in your department. During this course, you will view several demonstrations and practice different activities that simulate your day-to-day tasks. Participants are expected to fully participate in activities and will be given the opportunity to demonstrate skills during the sessions. Learning Objectives By the end of this course, you will be able to do the following: Use Soarian Clinicals to manage a patient census Use and manage the Service Provider Workspace(SPW) Chart patient clinical information View and edit patient information Enter and maintain patient orders Enter Charges from Service Provider Workspace(SPW) What to Expect This learning event is based on the principle of learn-by-doing. This performance-based approach acknowledges that you are responsible for your own learning and that practicing the tasks you need to learn is more effective than listening to a lecture or watching a demonstration. For this approach to be successful, however, you must understand and involve yourself in the learning process. You will be guided to think and reason through situations that might be new to you. Use the resources that are available to you and ask your instructor for assistance or clarification when you need it. Evaluation In this performance-based learning event, your instructor will evaluate your work and provide feedback as you proceed to ensure that you learn from each activity. Agenda This agenda is intended to provide a general view of the planned topics for each day. Each class will progress at different rates. Page 6 of 63

6 Agenda Logon to Soarian Clinicals Access the Service Provider Workspace (SPW) Set Preferences Identify the components of the Service Provider Workspace screen Use the SPW filters Chart Allergies View and manage orders Chart Assessments from within the SPW View information in the Patient Record View Information in the Clinical Summary Page 7 of 63

7 2. Getting Started Soarian Clinical Goals Soarian is a range and variety of applications designed to improve quality of care and patient safety in Winthrop. Soarian Clinicals is one application in the Soarian suite. Soarian Clinicals will be used by clinicians to chart patient allergies, home medications, assessments, place orders and document care plans. This creates an electronic patient record throughout the patient stay. Soarian: Enables Winthrop to move toward a full electronic medical record Helps Winthrop manage care processes across multiple facilities, disciplines and departments Provides the care team with easy access to the information they need, when they need it Promotes consistent processes to hand-off tasks between caregivers, helping to reduce the human element in delays and errors Page 8 of 63

8 3. Train/Test Domain Overview The TRAIN/TEST domain is a safe environment where you will have the opportunity to practice using Cerner Soarian applications in a system that replicates the live system. You will be working through several independent activities in the TRAIN domain. This environment is to be used only during class and practice times and is a safe place for you to learn. Log On to the TRAIN/TEST Domain Log on to the TRAIN/TEST domain by following the steps given to you by your instructor. The steps you use to log into the training domain may vary from the steps you will use to log into the production or live domain. 1. Double-click Soarian icon located on your desktop. 2. Enter the user name and password given to you by your instructor. 3. Click OK or press ENTER. Information and Security Specific confidentiality and security issues must be followed to protect the patient when dealing with computerized healthcare records. There are also increasing Health Insurance Portability and Accountability Act (HIPAA) and Joint Commission on Accreditation of Healthcare Organizations (JCAHO) regulations that dictate how these records are handled. Do not select anything obvious, such as your birth date, Social Security number, or child's name when selecting a password. Do not tell anyone your password. Your system may require you to change your password at regular intervals. 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. Not every employee will be allowed to see or perform every activity on the computer. For example, a laboratory technician will be able to see and do more in the laboratory application than a nurse will. 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 Whenever you run into an issue with Cerner Soarian or are trying to work with a process that may have changed, ask your local super user or administrator for help. If you are not getting a satisfactory answer, call the Help Desk. Page 9 of 63

9 4. Service Provider Workspace The Service Provider Workspace (SPW) provides an internal clinical workflow where you have a patient census based on orders that need to be completed. In addition to viewing a patient census based on orders, you can also complete orders, view order details, and enter charges directly within the Workspace. You can also navigate to other patient specific areas to perform clinical tasks for your patient such as charting assessments, entering orders and viewing results. Learning Objectives By the end of this course, you will be able to do the following: Access the Service Provider Workspace (SPW) Set Preferences to filter the census to see patients just for your department Identify the components of the Service Provider Workspace screen Use the SPW filters View and manage orders based upon order date and status Chart Assessments from within the SPW order Enter charges from within the SPW order Navigate to other screens in Soarian from SPW. Search for a Patient. Setting Preferences to use the Service Provider Workspace The first time you use the Service Provider Workspace you need to set Preferences so that you see a list of patients with only those orders for which your department is responsible. Click the Tools icon and then select Preferences Page 10 of 63

10 Select the Service Provider category on the left. The list of available departments display on the left. Click the see sub-departments. to expand the department and Check the department name and or sub departments and then click the selection to the right. Click Save. The workspace will then display the orders for your selected department. to move your You only have to do this step the first time you log on to use the Service Provider Workspace. The system will remember your settings. Patient Information that displays on the SPW includes the following: name, age, gender, medical record number, patient location, order status, order name, priority, and scheduled time for order completion. Links to Orders and Charting also display. Clicking the patient name provides a link to the Patient Record, where you can view patient results as well as other clinical information. Clicking the order name opens the order details. Some orders have assessments which can be charted right from the Order details form. Charges can be added from the Order details form where appropriate. Page 11 of 63

11 You may need to scroll to see all the patients. Also, there may be multiple pages Use the paging arrows to view additional pages. Service Provider Workspace Filters The SPW can be customized to filter for Available Location, Status, Dates and Primary & Secondary Sorts. Click on the locations down arrow to filter the list of patients by nurse station. The list will display only nurse stations with patients who have orders for your department. Select the nurse stations you will be responsible for covering The worklist will then only display patients on the nurse stations selected. Select if no change is to be made. Click on the status down arrow to filter the list of patients by the status of their orders. Page 12 of 63

12 Click on the dates down arrow to filter your census according to the order date and also amount of time each day. The Next day s range has a maximum of 3 days. You will only be able to see orders 3 days in advance. Click on Sorting down arrow to select a primary and secondary sort for the workspace. You may want to sort by priority, patient, location, status, service (order name), schedule date/time, or requesting unit. Managing Orders As you provide care to your patients, you will update the order statuses in the SPW. 1. To update the order status, check the box next to the patient s name, then click the order status. The order status will then be updated. Page 13 of 63

13 2. Click the appropriate order status. 3. Use an order status of In-Progress for orders you have started but are unable to complete at this time. 4. Use an order status of Discontinue to cancel an order. 5. You will be prompted to select a reason for discontinuing the order. The reason may be selected from a list or you can free text a reason. 6. A stop sign symbol displays next to the discontinued order. 7. Click Complete to complete an order. This completes the order with the current date and time. Page 14 of 63

14 8. Click the dropdown arrow next to Complete to complete the order and select a Date and Time as to when it was completed Order Status Indicator Order Status Active In Progress Complete Discontinued Status Indicator Description An active order. The order has been started but not completed. The order is completed The order is discontinued. Order Details Click on the Service (Order Name) to launch the Order Detail form. Enter Assessment and Charges as appropriate. Page 15 of 63

15 The Order Detail tab displays the order detail form that was completed at the time the order was placed. Based on the order selected, Assessment tab may display to allow user to enter required documentation related to the order Page 16 of 63

16 Based on the order selected, Charges tab may display to allow user to enter charges for the service. Chart Ordered Assessments Some orders require assessment data to be charted prior to completion. You must complete the charted data prior to completing the order. If you try to complete an order and assessment data is required you will get a message. Page 17 of 63

17 Click on the Service (Order Name) to chart data. Use the Assessment tab to chart the assessment associated with the order. Complete all appropriate chapters and fields. Update the assessment Status to Complete then Save. The order status updates to Complete. Page 18 of 63

18 Access Charting From the SPW you can access Charting, where you can chart assessments, complete any in progress assessments and update Allergies by clicking on the Charting icon. See the Assessment and Documentation Chapter for more information on charting an assessment. You may access Orders from the SPW also. The Menu Bar Search Use the Search tool to find patients not on your census. You will be able to navigate directly to the various workflow screens, view the Face Sheet, or add them to your census. 1. Click Search from the Menu Bar. You can search by patient name, by identifier or by unit (location of the patient). Page 19 of 63

19 2. Click the appropriate search tab: By Name, By ID, By Unit or Advanced. 3. Enter search criteria: e.g. enter the Last Name of the patient for a By Name search. Note Bold Fields in the search criteria denote required information. 4. Enter as much information that you know to filter your search. 5. Click the Search button; a list of patients that match your search criteria displays below. 6. Click to view the patients Facesheet. 7. Click to highlight the appropriate patient. 8. Click on the Patient Record dropdown to select and navigate to another workflow, such as Clinical Summary, or Charting. 9. Click the Add to Census button to add the patient to your personal Census. Note Any patient added to a census in this manner will remain on your census until they are manually removed. The Remove Patient from Your Census link appears on all manually added patients. Click on the icon. An informational message displays indicating the patient has been removed from your Census. Activity Access the Service Provider Workspace to manage your orders. You are working on the XXX unit today and need to see patients there that have orders for you to complete. Log into Soarian using the information given to you by your instructor. 1. Click the Service Provider icon to access the Service Provider Workspace. 2. Click the icon from the menu. 3. Select Preferences then click on Service Provider on the right column. 4. Under Available select your department and click the arrow to move it to the Selected column. Click Save and Close to return to the Service Provider Workspace. 5. Click Refresh to view orders on the SPW. 6. Since you are working on XXX for just today use your filters to limit the patients on the SPW. 7. Click on Dates and select orders for just Today. Click OK. 8. Click on the Location and limit the orders to just the nurse station given to you by your instructor. 9. Find your patient s orders. If any orders require data to be charted, click on the order name and complete the data. Click Save. You return the SPW and the order is Complete. 10. You completed an order 30 minutes ago. Click the checkbox next to your patient and an order that needs to be completed. Page 20 of 63

20 11. Click the Complete drop down arrow and select Use this date/time. Populate today s date and a time reflecting 30 minutes ago. Click OK. The physician canceled an order. Click the checkbox next to your patient and click Discontinued. 12. The reason is already selected click OK. The order is removed for the SPW. 13. Click on a completed order name from the SPW. Notice the Charges tab displays to allow you enter charges associated with the completed order. Takeaways You are responsible for the activity performed under your Username. Set Preferences for SPW the first time you log in to Soarian. Subsequently, the system will remember your selections. SPW will display all patients with orders that are expected to be completed. You can individualize your display to reflect your assignment by filtering for Location, Status, Dates and Sorting. Navigate to other sections of the system to chart assessments, view results and enter orders. Page 21 of 63

21 5. Allergies Allergies must be entered before any orders can be placed for a patient. Order entry may be restricted until Allergies are charted. The nurse is responsible to ensure that Allergies are completed accurately and in a timely manner. Learning Objectives By the end of this course, you will be able to do the following: Navigate to Charting Review the Patient Header Chart Allergies Revise Allergies View Allergy Status Patient allergy information is displayed on all main screens in Soarian in the Allergies hyperlink in the patient header. From the Patient Census click the patient name then click on the Allergies hyperlink to open a dialog box. Page 22 of 63

22 The Allergy display dialog is view only; Users are not able to add or make changes from this screen. The dialog displays the Allergy Name, Reaction, and Severity The Allergies hyperlink is also available on the patient header. The Patient Header is viewable on all screens in Soarian such as the Patient Record, Clinical Summary, Charting, Plan of Care, Orders and Visit. Click Allergies hyperlink to view the patient s allergies. Click the Close button after you have finished viewing the allergies. A patient may have different allergy statuses at various times. Page 23 of 63

23 Allergy Status Table Allergy Status Description Latex and Contrast charting is not required and no allergies have been charted yet. Latex and Contrast charting is required and no allergies have been charted yet. Or with a new patient, the Reassess screen was bypassed with No Change or Postpone. Allergies for the patient must be reviewed. This occurs If a patient s record has been merged. If this is a new visit, new location, or a specific timeframe has been met. No Known Allergies No Known Drug Allergies No Known Food Allergies The numeric value is the number of allergies charted for the patient. Click on this hyperlink to view a list of the patient s active allergies, reactions, and their severity. The red highlighted triangle indicates that at least one or more of the charted allergies has a severe reaction. Click on this hyperlink to view a list of the patient s active allergies, reactions and their severity. The display of multiple for a patient with more than one allergy is a preference setting. Allergies in Charting You can view allergy information, chart new allergies, modify allergy information, reassess allergies, verify allergies, and view allergy history from the Charting screen. 1. Navigate to Charting from the Service Provider Workspace. Page 24 of 63

24 Patient Allergies are listed in the following order: Latex and/or IV Contrast Allergies Active Drug Allergies (sorted by Severity) All other active Allergies (sorted by Severity) Inactive Allergies The Allergy Name, Reaction, Severity and Allergy Type are visible. Sometimes allergies may be listed twice, as is the Strawberry allergy example above, even though you have charted the allergy only once. This occurs when the allergy exists as more than one type of allergy. For example, Strawberry is defined as a Food as well as a Drug allergy. The number in the parentheses of the Allergies hyperlink reflects a count of both types of the allergy. The symbol to the right of an allergy indicates that there are comments entered regarding the allergy. Click on the allergy name to view the associated comments. The symbol will display next to allergies that have a Type of Drug. Hover the cursor over the symbol to view the components or ingredients of the drug. This is helpful when you wish to quickly view the components for multi-ingredient drugs. How to Reassess Allergies Allergies are charted via Charting, Allergies. Allergies need to be charted before orders can be placed on the patient. Allergies must be charted on new patients and at every new visit. Page 25 of 63

25 1. The Reassess Allergies dialog box displays for all new patients and at every new visit. 2. Click Update to add new patient allergies, update current allergies, or add details about an allergy. 3. Click No Change if you have questioned the patient and no new allergies or details need to be added. 4. Click Postpone if you wish to navigate to a different Assessment on the Charting Screen. Note If you click Postpone, Soarian reminds you to reassess allergies every five minutes when the Allergies chart displays. You cannot add allergies or Orders until you click No Change or Update. 5. The Allergy Visit Dialog Box displays. 6. Populate the appropriate checkboxes. You must select Yes or No to Latex and IV Contrast. 7. Select Unable to Assess if you are unable to determine the patient allergies. You will be prompted to enter a reason for this Allergy Status. Selecting Unable to Assess allows Order Entry to occur. Chart New Allergies Page 26 of 63

26 1. Type in the first few characters of the allergy in the New Allergy field. The more common allergies display in the dropdown for ease of selection. 2. Use the single form of names when searching for non-drug allergies, for example EGG rather than EGGS. 3. Click Search if there is not a match in the drop down. A dialog box will display results based on your search criteria. 4. Click on the desired allergy name to select it. 5. Click the arrow to move the allergy to the Selected Results section. 6. Repeat to add additional allergies. 7. Every effort should be made to find the correct allergy, especially when entering medication allergies. Check the spelling of the allergy; use generic instead of brand name of medications; or use a % sign as a wildcard to obtain additional results. 8. Click Add once all allergies are in the Selected Results section. 9. You will be prompted to add at least one reaction for each allergy added. Page 27 of 63

27 10. Use the Reaction and Severity drop down menus. 11. Reaction is required. You can have multiple reactions if needed. 12. Common Reactions are listed but a reaction may be entered in free-text. 13. Severity is recommended. The choices are limited to Mild, Moderate and Severe. 14. Onset of allergy is not required. 15. Some reactions have a pre-selected severity, such as Severe for Anaphylaxis. 16. Click Save. Results not found - Free Text Allergies If you do not find the allergy, try your search again with a different name. Winthrop does not permit free text allergies. If you cannot find a specific allergy, please call the pharmacy for advice on how to document the allergy. Page 28 of 63

28 Revise Allergies 1. Click on the allergy name to revise the allergy information. Page 29 of 63

29 2. Change the Status to not active if the patient no longer has the allergy. 3. Change the Status to marked in error if you charted the incorrect allergy for the patient, or entered it on an incorrect patient. 4. Use the Reactions and Severity dropdowns to modify the allergy information if needed. 5. Click the to remove the Reaction. 6. You are prompted to enter a Reason for the allergy revision after you save your changes. 7. Enter a reason and click OK. View Allergies The Allergies hyperlink displays on the Patient Header. The Allergies hyperlink updates based on allergy information. Use your mouse to hover over the link to view the allergies, or click the Allergies hyperlink to view allergy details. Page 30 of 63

30 Activity Your shift just started and you need to chart allergies for your patient as soon as possible so the physician can place orders. Your patient is allergic to peanuts with a moderate reaction of nausea/vomiting and Amoxicillin with a severe reaction of hives. The patient denies any other allergies. 1. Navigate to Charting. 2. Click Update to enter allergy information. Value the fields based on the patient allergies. 3. Notice the Patient Header allergies hyperlink is updated Takeaways Patients must have allergies charted before orders can be entered. The Patient Header and Patient Specific Information display patient allergy information. You chart, view and revise allergies from the Charting screen. Allergies can be revised by clicking on the name of the allergy. Allergies can be edited to change, add or remove reactions. Allergy statuses can be changed to not active or erroneous. Reactions/Severity can be removed with the minus button. You can have multiple reactions for one allergy. Use singular forms of names when searching for non-drug allergies, e.g. EGG and peanut. Page 31 of 63

31 6. Place Orders Allergy documentation must occur for the patient before Orders can be placed; this is a safety feature of Soarian. No one can place orders without allergy documentation. The physician will be placing the majority of patient orders in Soarian, however there may be times when the clinician will need to place orders for the physician; for example, if the physician cannot access a computer to place orders and phones the nurse. The physician indicates the order(s) to be placed and stays on the phone while the clinician places the order(s). Once the orders are selected, the system performs clinical checking, such as allergies to medications. The recommended practice is for the physician to remain on the phone until the order process is completed and all clinical checks have been resolved. There may be times when the physician will give the clinician Verbal orders. Verbal orders should be used only in emergency situations. Learning Objectives By the end of this course, you will be able to do the following: Search for Orders Place Telephone and Verbal Orders Populate Order Detail Forms Select Orders from Lists Enter Charges from SPW Resolve Order Conflicts Navigate to Orders 1. Click on Orders from the SPW. Select Orders and Session Details The Orders screen allows you view, revise and place orders for patients. It is divided into three (3) panes; Current Orders, Add Orders, and Unsigned Orders. Page 32 of 63

32 Current Orders and Add Orders sections are both expanded. Unsigned Orders is collapsed on the right hand side. Panels can be opened or closed by using the icon at the top right of each panel. Session Defaults can be opened or closed by clicking on the icon. Populate the Session Defaults section before placing orders. Select the Ordered By and Order Source. Note These fields are required for every order. Page 33 of 63

33 The Ordered By drop down list contains the patient s physician. Select the ellipsis button to search for a different physician. Order Sources Order Source defines the type of order. It is important that you select the correct source: Verbal Order - The physician asks the Clinician to place an order on their behalf. Verbal orders should be used only in emergency situations. Telephone Order with Read Back the physician cannot access a computer to place orders and phones the Clinician to place the orders. Nutritional Standard Dietary needs Session Defaults Apply to Unsigned Orders The Default Session values will be applied to all orders if none of the orders are selected in the Unsigned Order pane. Page 34 of 63

34 You may change the Session Defaults for the Orders on the Unsigned Orders Pane. The changes can apply to all orders or the orders you select. Make your changes to the Session Defaults, such as changing the Priority from Routine to Stat. Click on the Apply to Unsigned button. The values of the session defaults will be applied to orders in the unsigned order session. The session default values will revert back to the default values after the orders are signed. This also applies to Pending Activation check box on the session details. The order(s) would be placed as pending active on the selected visit. Search for Orders Order categories are listed under the Lists section. 1. Click on an order category to view the common orders and make a selection. The Search field is used to perform a character search for orders. It may be used if you are unable to find the order under Lists. Page 35 of 63

35 2. Click one of the following radio buttons before you begin your search: All searches across all orders Meds searches for medications only Lab searches for Lab orders only Set searches for Order Sets 3. Enter at least 3 characters to search for an individual order. Place Orders 4. Click the order category to view the orders from the Add Orders pane. 5. Click on the plus sign to expand and view the orders in the category. Note You will see this message next to the Category Name, if you click on the Category Name by mistake, instead of the plus sign. Click the Category Name again or click an order from the category list to remove the message. Page 36 of 63

36 6. Select the order to be placed for the patient. Note Notice the Unsigned Orders pane opens when the Add button is selected. 7. A count will display on the bottom of the screen indicating the number of items selected. 8. Click Add & Close to close the Add Orders pane when all orders are selected. Visit Selection Options You may place orders on a different visit for the patient by clicking on the drop down next to Selected Visit Click on the Other Visit radio button to view other visits. Select the appropriate Visit from the drop down. The visit will display on the header. Order Detail Forms Page 37 of 63

37 An Order Detail form displays for an order that requires additional information. Order Detail forms are configured relevant to the departmental ordering needs. The Order Type displays in the session details section. The Order Name displays with additional fields that may be filled out. The red Exclamation mark signifies there are required fields that need to be completed. Fields with bold labeling are required fields, such as Specimen Source. Populate other fields as needed. Some fields may pre-populate with carry-forward information, such as Height and Weight. Fields in grey cannot be changed. Use the Start, Repeat, Every, and Stop fields to define recurring orders. Use a priority of Routine and change the Start On time for Lab orders with specific start times. Click Order & Finish to continue. Click the Next button if there is more than one Order Detail form to complete. Opening Order Detail Form from Add Orders Section The Order Detail Form may be opened from the Add Orders pane. The Order Detail Form icon displays when you hover on an order item. A tooltip displays when you hover over the icon. Click on the icon to view the Order Detail Form for the order. Unsigned Orders Page 38 of 63

38 Orders displayed in Unsigned Orders are not active until reviewed and signed. Verify the order(s) with the ordering physician. Hover the mouse over the order to see order information. Click on the order if you need to make any additional changes. The order detail form opens. Click on the Select All checkbox to remove all orders from the Order Session. The Add Order pane is collapsed. Click on the Add Orders blind to expand the pane if needed. Click Sign to place the order(s) for the patient. Reauthenticate to complete the order session. Page 39 of 63

39 Current Orders The Add Order pane expands and the Unsigned Orders pane is collapsed. Orders display in the Current orders pane and are now active. 1. Click on the button to collapse the pane. 2. Click on the button to expand the pane. 3. Hover your mouse over the order to view order status. 4. Orders in bold italics indicate that the order needs to be co-signed by the physician and acknowledged by the nurse. 5. Click the Select All checkbox to Discontinue, Resume, or Renew. Order Conflicts There are order conflicts, such as medication and allergy checking that display on the Unsigned Orders pane. The physician will need to address any order conflicts that arise before you can place the order. Page 40 of 63

40 This is an example of a Duplicate Order alert. Conflicts appear in red font. This order is the new order being placed. Duplicates refers to the active order on Current Orders pane that conflicts with the new order being placed for the patient. Select either keep or revoke for each order. You may be required to enter a reason in the Comment field if the physician chooses to keep both orders. Click Accept to complete. Recurring Order Orders may be placed as a onetime only order or may be placed as a recurring order so that multiple occurrences of the order will be generated. Page 41 of 63

41 Populate the Order Detail form to define how the order should reoccur. Use the Start, Repeat and Stop sections to indicate when the order should start, repeat and end. The system will automatically calculate the stop date. Click Order & Finish and complete the ordering process. View the Stop Date and Time by hovering over the order on the Unsigned Orders pane. Enter Charges on Orders Some orders will automatically generate charges. Other charges will be entered manually. 1. Click the Order name. 2. Click the Charges Tab. 3. Click the Picklist button to select charges from your department s charging Picklist. Page 42 of 63

42 4. Click the appropriate Charge Activity Category. 5. Click the Picklist name to view charges. Page 43 of 63

43 6. Select charges by entering the quantity and then click Add. Note: More than one charge may be selected at a time. 7. Charges display on Unsigned Charges for you to review. 8. Review the charges, check the Charging Complete field and then click Sign. 9. Click Close to return to the Service Provider Workspace. 10. The charging complete indictor icon will display on the SPW as an indicator that the charging is complete for this order. Activity Page 44 of 63

44 The patient s physician calls you as he is driving to the airport and needs you to place some orders for his patient: (place orders that are common for your discipline) 1. Navigate to Orders. 2. Populate the Ordered By and Order Source fields. 3. Use the Lists or Search field to search for orders. 4. Select the orders and click Add 5. Populate Order Detail forms as needed. 6. Review the orders on the Unsigned Orders. 7. Verify with the physician that the orders are correct on the Unsigned Orders. 8. Click Sign to place the orders. Takeaways Populate the Ordering Physician and Order Source fields on the Session Defaults before you search and place any orders. Use Lists to find common orders. Prior to using the Search field, select All, Meds, Labs or Set button to limit the search. Search for Orders by typing at least 3 characters. Select the orders and click the Add button. All Order Conflicts must be communicated to the physician, so they can determine the appropriate action. Verify the orders with the physician from the Unsigned Order pane to allow for any necessary changes. Keep the physician on the phone until all orders are placed and verified Page 45 of 63

45 7. Assessments and Documentation The Assessments or Documentation function is used to record clinical observations and detailed information regarding a patient s medical condition.. The structured assessments are designed as single columns of information, a single page of information, or chapters of information. Learning Objectives By the end of this course, you will be able to do the following: Navigate to Charting Understand icons and fields on Assessments Chart an Assessment Access Charting - Documentation 1. Navigate to Charting from the Service Provider Workspace. 2. Select Documentation from the list on the left hand side to open the Assessment browser. Page 46 of 63

46 Assessment Browser The Assessment Browser screen has two main sections: Scheduled/Incomplete Assessment on the left side will list Scheduled (assessments ordered by a physician) and Incomplete Assessments (assessments that were started by a clinician and not completed). Begin New Assessments on the right side where you select a new assessment from the Filtered list or from All Tab of the assessments in Winthrop s portfolio. Begin New Assessment- Overview The Filtered tab displays the most commonly used assessments in alphabetical order. The list is filtered by the Patient (age, gender, location), and role of the user. The All tab displays all the available assessments in folder hierarchy. 1. Click on a folder to see an alphabetical list of assessments in the Portfolio. 2. Click on the name to open the assessment. Page 47 of 63

47 Assessment Charting Icons The icons on the right hand side of the screen allow you to perform additional functions for the opened assessment. You can hover your mouse over the icon for a description of its function. A grey icon indicates it is disabled or unavailable. Icons Name Description Back to Assessment Browser Returns to the Assessment Browser without saving information that was entered on View Previous Assessments Revert Add a Note Revision History Save the assessment Allows you to view and edit information on previously charted assessments of the same type Resets the information on the assessment to its last saved state The note will be saved when the user saves the assessment. The Note is not attached to the assessment but will be viewed separately in the Patient Record, Clinical Summary, and Clinical Notes. The assessment name and date/time the assessment was collected will automatically display with the Note Displays changes made to the assessment; with the date, time and name of the user who made the change Signs the assessment and saves the information Page 48 of 63

48 Charting an Assessment The Wound Treatment Assessment is an example of a chapter assessment. Click on each chapter on the left to chart a page of the assessment. Ostomy Assessment is an example of a single page Assessment. Page 49 of 63

49 Chemotherapy and Radiation Therapy Assessment is an example of a columnar assessment. Use the various fields to populate the assessment. Bold fields are required. You will not be able to save the assessment as Complete until all required fields are valued. Some fields will carry forward information from visit to visit or from another assessment. For example, if the patient s Weight was charted on the Vital Signs assessment, the Weight will display on the RT Initial Assessment as well. Review all carry forward data to make sure the information is correct. The scroll bar is used to view additional data. Use the Back to Assessment Browser when you need to leave an unfinished assessment and perform another function. Save the assessment In progress first. If you opened the assessment by mistake use the Back to Assessment Browser icon before you chart and save any information. This returns you to where you can select another assessment. Assessment Statuses Draft Use to save information as you are charting the assessment but have not completed it. It is important to note that no other users will be able to see your assessment until it is saved as Complete. Complete Select when you have finished charting the assessment. Activity Navigate to Charting and select an assessment of your discipline. 1. From the SPW, click the Charting icon on the far left for your patient. 2. Click Documentation, under the Filtered click on an assessment in your discipline to chart. 3. Be sure to chart all required fields. 4. Save the Assessment as Complete. Page 50 of 63

50 Takeaways Bold chapters indicate the chapter has required fields to be completed. A red triangle on the chapter signifies required information is missing on the assessment. Use the Back to Assessment Browser icon when you save the assessment In progress, and need to leave the charting Screen for this patient or when you opened an assessment by mistake. Save the assessment as Draft as you chart. Save the assessment as Complete when you are finished entering all possible information. You will return to the Assessment Browser. Page 51 of 63

51 8. Patient Record The Patient Record provides an easy way to view comprehensive information on your patient across visits. You can view diagnostic results, orders, clinical documentation, and other clinical information for your patients. The Patient Record can also be used to edited information from assessments. Edits may be time-restricted by Winthrop. Learning Objectives By the end of this course, you will be able to do the following: Access Patient Record Set Date and Time options in the Patient Record View Information in the Patient Record Access Patient Record Click the Patient Name from the Service Provider Workspace Menu Bar. Alternately, click on Patient Record in the Patient Header. Patient Record Settings The Patient Record displays patient information across a time period or occurrences. The dropdown on the left lists categories of information, such as Laboratory and Radiology. Click the dropdown and select the category of information to view. Page 52 of 63

52 Use the, and dropdowns to define the time frame or number of occurrences to view the information. Select Data in the Patient Record The date and time in the banner across the top reflects the collected date and time of the result or assessment. Click on a result to view more information. Select the Details tab to information. Other tabs may be available depending on the result. Activity You need to correct some charting you previously entered. 1. Navigate to the Patient Record. 2. Click the drop down and select Documentation. 3. Find the assessment that you charted and click on the assessment icon. 4. View information. 5. Click Close. Takeaways View Assessments in the Patient Record. Use the Occurrence, Timeframe or Calendar controls to sort and filter information in the Patient Record. Select Documentation from the drop down in the Patient Record to view assessments. The Collected date and time is sorted in reverse chronological order in the Patient Record and Clinical Summary. The date/time reflects when the assessment was initially started in Charting. Page 53 of 63

53 9. Clinical Summary The Clinical Summary provides a quick view the patient s current clinical information. The Clinical Summary gathers information from all areas of Soarian into one view. You can view information and make changes as needed. Learning Objectives By the end of this course, you will be able to do the following: Access Clinical Summary Overview of the Clinical Summary View Information in the Clinical Summary Revise assessment information in the Clinical Summary Access Clinical Summary 1. Click on patient name from Service Provider Workspace screen. 2. Click on in the Patient Header. Clinical Summary Screen The Clinical Summary displays a snapshot view of patient information. Click on a category from the Navigator on the left to view information in the container on the right. Information may be viewed in one or more containers, depending on the selection made from the Navigator. Click on the Occurrence icon to change the time frame. Graph or trend numerical data by clicking on the Graph/Trend icons. Hover the cursor over the Plus Sign icon to display a tooltip describing the action that will occur when selected. Page 54 of 63

54 Click the Refresh icon in the upper right corner of the Containers to refresh the information. Click on Sort Options to select a different sequence or format of information. Edit Assessment Information in the Clinical Summary 1. Select Wound/Ostomy from the navigator. 2. Click on the value link to edit the assessment information. 3. Click Edit to modify the assessment. 4. Change any information as needed. 5. Change the Status to Erroneous if the assessment was charted on the wrong patient. Page 55 of 63

55 6. A Reason for Revision is required if you make any changes to the assessment. 7. Chapters that have not been opened have an icon. 8. Use the History tab to view any changes on the assessment and who made them. The History tab displays the Revision Date, Changed By, and Reason for the changes. Activity You want to view the patients most recent assessments based on your discipline. 1. Navigate to the Clinical Summary. 2. Select an assessment from the navigator. 3. Click on a field to view additional information. Takeaways The Clinical Summary is a snapshot view of the patient s current information. In the Clinical Summary you can view and edit information. Click on the Navigator or Tabs to view information. Use the Refresh button to update current information. Use the duration icon to see past information. Use the Plus Sign to chart additional information when available. Winthrop will place a time restriction for editing Assessments. A Reason for Revision is required for any changes to documentation. Page 56 of 63

56 10. The Soarian/Census Worklist This is where you can define the patients you will be taking care of during your shift. You can access and view patient information from the Census/Worklist. It is the gateway to perform clinical tasks for your patients, such as maintaining allergies and reviewing/editing charting assessments. Note You are responsible for the activity recorded under your username. Learning Objectives By the end of this course, you will be able to do the following: Log into Soarian Clinicals Select a Nurse Station Identify the components of the Soarian Census/Worklist screen Census/Worklist Screen Soarian will remember the last nurse station selected. Nurse Station selected drives the list of patients that displays on the census. Select Nurse Station/Unit 1. Click the underlined blue hyperlink to select a different nurse station or location. Page 57 of 63

57 2. You must click on the blue door next to Nurse Stations to view all the nurse stations in Winthrop. 3. Click on the unit where you are working. 4. The patients assigned to a bed on the selected unit will now display on your census. Page 58 of 63

58 Census/Worklist Screen Components The Census/Worklist screen has two main sections: the right is the patient census and the left contains worklists. The Worklist displays tasks or information relevant to your patients that need attention. Hover the mouse pointer over a worklist item to display a tooltip. This shows if the count is by item or by patient. The Alerts worklist will alert you of important items for all patients, such as an incomplete Admission Assessment for a patient in a specific amount of time. Use the Menu items to perform the following: Service Provider Workspace Opens the Service Provider Workspace Search Links Print Help used to find patients to add to your census or to access patient information. access other applications such as DM Full. print context-sensitive reports. context-sensitive Soarian specific help. Tools provides access to common functions defined by Winthrop, such as Preferences, Text Block Editor, Charge Viewer, etc. Logoff exit Soarian Clinicals. Page 59 of 63

59 Patient Specific Information Click on a patient s name to view the Patient Specific Information or PSI. Click the Navigation Icons for access to the patient Facesheet, or navigate to the Patient Record, Clinical Summary, Clinical Flowsheet, Charting, Plans of Care, Orders, and Visit screens. The Care Team link displays the clinicians (Nurse, CNAs, etc.) associated with the patient. This includes the nurse assigned to the patient. The Physicians link displays a list of physicians with a relationship to the patient. The Allergies link reveals the patient s current active allergies or if there is a need to assess/ reassess allergies. Current Results displays on the right. The Add Patient to Census link allows you to view the patient in your census. This patient will remain on your census until manually removed. Activity You are ready to log into Soarian Clinicals. You will select your nurse station. Search and add a patient to your census as assigned by your instructor. 1. Log into Soarian using the information given to you by your instructor. 2. Select your Nurse Station. 3. Click on your assigned patient to view Patient Specific Information 4. Click the Search from the menu bar and add patient assigned by your instructor. Takeaways The Census displays patients assigned to a bed on the nurse station displayed next to the user s name. The Worklists display tasks that need attention for your assigned patients. Click on the patient name in the Census to view the Patient Specific Information. Page 60 of 63

60 Use patient specific information to view more detailed information regarding your patient and to access the navigation icons. 11. Overview Activity A Provider calls and asks you to place orders appropriate to your discipline. Place the orders for your patient. You have completed the services for your patient. Complete the orders and chart data as needed. 12. Course Wrap Up Summary of Learning / Objectives review During this course you received a general understanding of the functionality of the Soarian solution and how Soarian supports your daily workflow. This course also included demonstration and activities to practice the tasks such as creating an assignment, charting allergies, and assessments, in addition to entering and maintaining patient orders. Thank You This concludes the Soarian Clinicals Serive Provider Training course. Please take a few minutes and complete the course evaluation. Your feedback is valuable and helps us continuously refine this course. Thank you for attending. 13. Course Evaluation Page 61 of 63