If your looking for PT/OT/ST documentation, try these sections of the Menu: Results Review Clin Docs (PowerForms Textual Rendition)

Transcription

1 Locating Chart Documentation If your looking for PT/OT/ST documentation, try these sections of the Menu: Results Review Clin Docs (PowerForms Textual Rendition) If you re looking for a Physician documentation, try this section of the Menu: Clin Docs (ex. Physician Progress Notes) If you re looking for Nursing documentation, try these sections of the Menu: Results Review (look in appropriate sections) I&O (ex. Intake and Output) Forms (sort by Form, example Admission History form) Clin Docs (ex. PowerForm Textual Rendition) MAR Summary (ex. Medications)

2 How to Place Orders 1. Go to Menu and click on the + sign to the right of Orders 2. Write the name of the order you are entering in the find field. Consider changing starts with to contains if you are unsure of the exact name of the order. 3. Enter the physicians name that you received the order from 4. Select the correct communication type 5. Select Done to close the smaller initial order window. 6. Enter the required fields for the order. Required fields will be blue or yellow highlighted areas. Add any special instructions. DME and HHC orders should be specific as this is the actual order for the agency to follow. For example, a DME order should include the patient s height and weight. 7. Complete the order by clicking the sign button 8. Refresh the screen by using the minutes ago button. Remember to enter a Hospice Provider Information order when a patient is placed in a hospice contract bed. Communication Types: Telephone: select when an order has been communicated to you over the phone will initiate cosign process the MD will receive a notification to co-sign the order Previous CPOE (Computerized Physician Order Entry): select when a physician entered an order, but the order needs to be updated or enhanced. Example MD orders home health care; use the previous CPOE to update to home health care for nursing, PT/OT and medication management. Protocol/No Cosign Reqd: select when entering an order that is a part of an approved protocol Written/Fax: recognized by the EMR when a physician enters orders. This should not be used by Social Service staff members. Verbal: selected when entering a verbal order this order type should be used rarely and only in an emergency when the MD is present and cannot enter him/herself. Unlikely to be used by social services.

3 Completing a Patient Discharge Depart Process 1. The Depart icon is located on the Action Tool Bar. (Remember, if you don t see the Depart icon, you can use the button bar on the far right of the screen to access a pull down menu) 2. Click on the Follow Up notepad with pencil 3. Select free text to input information (most likely a provider s name & phone number). Remember this section can only hold a small amount of text. Once free text is entered, click Add button and the comment area will become available for entering more information. 4. The comment area is used to provide the patient/family with details of what the patient will need to do after discharge. 5. Repeat steps 2 4 to add any additional information you wish to share with the patient. Remember the Depart process is used to communicate information directly to the patient/family not to the multidisciplinary team.

4 Downtime Instructions EMR Downtime Instructions: If the EMR is down for maintenance or for other issues you will need to: 1. Print your notes from Canopy and place them in the patient s folder. 2. Communicate any essential information to the patient s nurse. On each unit, one computer has been designated as the PCLA/Downtime Computer. It is most likely the HUC s computer and should be labeled PCLA. This computer will be backed up routinely (hourly) by IS. You will be able to access patient specific information from this computer during downtime.

5 How to Re-set MPTL MPTL Re-setting You will need to re-set your Multi-Patient Task List (MPTL) the first time you access the EMR after Go-Live Here is the information you will need: 1. Right click on the far right of the blue bar and select Change Time Frame Criteria 2. Then the Task List Properties box will open. On the Time Frames tab click Current and select the timeframe you want your MPTL set for. (Most will choose Defined Time Frame and then the shift they normally work, or they may use 24 Hr Day to see across shifts.) 3. Next, click on the Patient List tab. You may only see Departmental View, or if you have other patient lists defined, you will see those as well. Place a check mark beside Choose a Patient List and click on Departmental View. and click OK.