EMR DOCUMENTATION FOR ED PROVIDERS ```

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1 EMR DOCUMENTATION FOR ED PROVIDERS ```

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3 /EMR Documentation for ED Providers TABLE OF CONTENTS INFORMATION SECURITY AND CONFIDENTIALITY SECURITY MEASURES INTRODUCTION SECURITY MEASURES LEARNING OBJECTIVES MANUAL LAYOUT BENEFITS OF COMPUTERIZED PHYSICIAN ORDER ENTRY (CPOE) AND ELECTRONIC DOCUMENTATION LOGGING IN TO FIRSTNET CHECKING IN AS AN AVAILABLE PROVIDER ASSIGNING YOURSELF TO A PATIENT FIRSTNET ORGANIZER TOUR OF FIRSTNET ENHANCED PROVIDER TOOLBAR UNDERSTANDING FIRSTNET TRACKING BOARD COLUMNS Cosigning Orders VIEWING ORDERS & EVENTS FROM THE TRACKING BOARD QUICK FLOWSHEETS AND PT SUMMARY To mark a result as reviewed: POWERCHART OVERVIEW Title Bar Menu Bar Organizer Bar Action Bar Print and Refresh Bar Patient Defining Area Toolbar PATIENT CHART OVERVIEW OPENING A PATIENT S CHART PATIENT CHART LAYOUT

4 /EMR Documentation for ED Providers (Rev 6/27/2012) Patient Toolbar The Status Bar MENU COMPONENTS Menu Pin and Unpin PATIENT DEMOGRAPHIC BAR MENU COMPONENT DEFINITIONS VIEWING RESULTS REVIEW Examples of Results Things You Should Know View Result Legend Customize Results Review for Easier Viewing Filter and Find Data Filter by Navigator Filter or Search Viewing Results Using the Navigator Using the Results Display Changing the Clinical Date Range MAR SUMMARY HOW TO ACCESS THE MAR SUMMARY WORKSPACE OVERVIEW USING THE MAR SUMMARY APPLYING FILTERS THROUGH NAVIGATION BUTTON APPLYING FILTERS THROUGH SHOW VIEWS BUTTON ALLERGY REVIEW AND MANAGEMENT ALLERGY WORKSPACE LAYOUT Things You Should Know DOCUMENT NO KNOWN ALLERGIES (NKA) MODIFY AN ALLERGY DOCUMENTING AN ADVERSE REACTION CANCEL AN ALLERGY MARKING ALLERGIES AS REVIEWED PERFORM REVERSE ALLERGY CHECK

5 /EMR Documentation for ED Providers MEDICATION LIST MEDICATION HISTORY WORKSPACE OVERVIEW Terminology Display Icons in Medication List MEDICATION HISTORY/EXTERNAL PRESCRIPTION HISTORY REVIEW AND MANAGEMENT DOCUMENTING MEDICATION HISTORY Document a Home Medication Document a Medication with Different Daily Doses Document Rainbow Coverage Medication Document a Miscellaneous Medication Process for Inpatient Admission Modifying Home Medications Complete a Home or Prescription Medication Void a Medication REVIEWING EXTERNAL MEDICATION HISTORY Verifying External Plan Pulling in External Prescription History PATIENT INFORMATION VIEWING PATIENT INFORMATION Patient Demographics VISIT LIST PATIENT PROVIDER RELATIONSHIP SUMMARY PATIENT SUMMARIES VIEWING PATIENT SUMMARIES Patient Care Summary Chart Summary Screen Viewing the Pregnancy/Prenatal Summary Screens FORM BROWSER FORM BROWSER OVERVIEW CLINICAL FOLDERS CLINICAL FOLDERS OVERVIEW Document Viewing IMMUNIZATION SCHEDULE

6 /EMR Documentation for ED Providers (Rev 6/27/2012) IMMUNIZATION WORKSPACE LAYOUT Terminology: Viewing Previous Immunizations Modifying an Immunization/Vaccine Things to Know Before Beginning INTERDISCIPLINARY SUMMARY PROBLEMS AND DIAGNOSES PROBLEMS AND DIAGNOSES OVERVIEW CONVERTING A PROBLEM TO A DIAGNOSIS PATIENT HISTORIES HISTORIES OVERVIEW History Types ADDING PAST MEDICAL HISTORY Modifying Past Medical History ADDING PROCEDURE HISTORY Modify Procedure History ADDING FAMILY HISTORY Modifying Family History ADDING SOCIAL HISTORY Modify Social History VIEWING PREGNANCY HISTORY REFERENCE TEXT BROWSER REFERENCE TEXT BROWSER Using the Reference Text Browser To print the reference material: INTERACTIVE VIEW/I&O IView Workspace Layout Navigator: View Window Changing Bands Filter/Seeker Window: GRAPHING REVIEW VIEWING THE PREGNANCY/PRENATAL SUMMARY SCREENS

7 /EMR Documentation for ED Providers ED SUMMARY PAGE Tips for Using the ED Summary ORDER ENTRY (BASICS) ACCESSING ORDERS WORKSPACE ORDERS WORKSPACE LAYOUT Customizing the Orders Workspace ADD ORDER WINDOW ADDING ORDERS PLACING ORDERS ADDING ORDER SETS SUB-PHASE (NESTED) ORDER SETS SAVE ORDER SET ELEMENTS AS FAVORITES ORGANIZE FAVORITES Delete Order from Favorites MERGE VIEW VIEWING AND SELECTING EXCLUDED COMPONENTS MEDICATION ORDER ENTRY-DOSE CALCULATOR COMPLEX MEDICATION ORDER ENTRY ORDER INFORMATION CLINICAL DECISION SUPPORT: ORDER-RELATED ALERTS/WARNINGS Patient Level Alerts Order Level Alerts Duplicate Order Alert Discern Alerts Decision Support Alerts Drug-Allergy Alert Overriding an Order Related Alert ORDER ACTIONS ADDING AN ORDER TO AN ORDER SET (ADD TO PHASE) MODIFYING ORDERS DISCONTINUING ORDERS DISCONTINUING AN ORDER SET VOIDING ORDER SETS

8 /EMR Documentation for ED Providers (Rev 6/27/2012) VOIDING SINGLE ORDERS CANCEL AND REORDER CANCEL/DISCONTINUE MEDICATION RECONCILIATION HOW TO ACCESS COMMON TERMS ADMISSION RECONCILIATION ACTIONS MODIFY AND CONTINUE AN ACTIVE MEDICATION HOLD/DO NOT CONTINUE MEDICATION ADD A NEW INPATIENT ADMISSION MEDICATION ORDER DISCHARGE RECONCILIATION OVERVIEW RENEWING ORDERS DISCHARGE RECONCILIATION PROCESS DISCHARGE RECONCILIATION ACTIONS CREATE NEW RX FOR A NON FORMULARY MEDICATION CONTINUE AFTER DISCHARGE DO NOT CONTINUE AFTER DISCHARGE VIEW OF RECONCILIATION HISTORY FROM NAVIGATOR POWERNOTE OVERVIEW ACCESSING POWERNOTE ED DOCUMENTS ICONS AND SYMBOLS NAVIGATING POWERNOTE PowerNote Navigator POWERNOTE DOCUMENTATION AREA SELECT BY ENCOUNTER PATHWAY AUTO POPULATE A POWERNOTE VIEW SENTENCES IN POWERNOTE SELECT BY FAVORITE POWERNOTE SHOW/HIDE STRUCTURE USE MOUSE FOR DATA ENTRY IN POWERNOTE INSERT/REPEAT A SENTENCE PRECOMPLETED NOTES Create a Precompleted Note

9 /EMR Documentation for ED Providers AUTO TEXT Creating an Auto Text Entry CREATING AND SAVING A MACRO INSERTING A MACRO SPECIFIC MACROS MODIFYING A MACRO DELETING A MACRO MODIFYING A MACRO POWERNOTE ED BASICS HANDS ON EXERCISES EXERCISE 1: PRE-ARRIVE A PATIENT EXERCISE 2: MODIFY A PATIENT S PRE-ARRIVAL INFORMATION EXERCISE 3: ATTACH /DETACH PRE-ARRIVAL INFORMATION Detaching Pre-Arrival Information EXERCISE 4: ADDING A NEW POWERNOTE EXERCISE 5: ADDING A PROCEDURE OR ADDITIONAL RFV NOTE EXERCISE 6: DEPART PROCESS; BEGINNING WITHIN PNED EXERCISE 7: DEPART PROCESS; PATIENT DISCHARGE DISCHARGE RECONCILIATION PROCESS DISCHARGE RECONCILIATION ACTIONS MESSAGE CENTER DOCUMENTS ADDITIONAL FUNCTIONALITY HIM QUERY/DEFICIENCY RENEWAL ORDERS COSIGNING ORDERS REFUSE ORDERS FOR CO-SIGNATURE GRANTING PROXIES POWERNOTE ED INDEPENDENT EXERCISE Physical Exam Section: Medical Decision Making Impression and Plan Section REQUEST ENDORSEMENT Sign a Note

10 /EMR Documentation for ED Providers (Rev 6/27/2012) PROVIDER CHECK OUT LOGGING OUT OF FIRSTNET APPENDIX ORDER NAMING CONVENTION FREQUENCY MEANINGS AND TIMES ORDERS ICONS AND INDICATORS MAR SUMMARY ICONS AND DEFINITIONS SLIDING SCALE ORDERS TAPER DOSING ORDERS TAPER DETAILS PLANNED REGIMEN AND ORDER DETAILS MODIFYING TAPERS DISPLAY FILTERS DISCERN ALERTS WITH TAPERS MULTUM INTERACTION CHECKING AND TAPERS ADMISSION RECONCILIATION IN ERROR REPORT

11 Information Security and Confidentiality INFORMATION SECURITY AND CONFIDENTIALITY When dealing with computerized health care records, specific confidentiality and security issues must be followed to protect the patient. There are increasing HIPAA and DNV regulations that dictate how these records are handled. When signing on to FirstNet, use your own User Name and Password, do not share. When you open a chart for the first time, you will be asked to identify your relationship to the patient, for example primary RN, consulting physician, etc. The application keeps an audit trail, or record, of who enters each chart and when. FirstNet records who signed into the chart and who documented each piece of information in the chart. Do not leave the computer while still signed on. Do not access any charts that do not apply to your current job and case load. SECURITY MEASURES Note: To safe guard patient Information, you should never walk away from the computer and leave your FirstNet session open. Leaving it open will allow anyone to access patient charts and other private information. Leaving your session open will also put you at risk because anyone can attach your electronic signature to the actions they performed in the system. 11

12 Introduction INTRODUCTION Topics in this Unit: Security Measures Learning Objectives Manual layout Benefits of CPOE and EMR Logging-in/out Checking In As Available Provider Assigning yourself to a patient FirstNet Organizer Tour Of FirstNet Enhanced Provider Toolbar Understanding the FirstNet tracking board Viewing orders and events from the tracking board Quick FlowSheet and PT Summary Computerized Provider Order Entry (CPOE) is supported by the Electronic Medical Record (EMR) used by Kaleida Health at all Emergency Departments. It is an enterprisewide record combining clinical and financial operations and enabling, physicians, nurses, pharmacists and other authorized caregivers to view patient status, consider evidence, enter orders and document their actions, as well as share information in a single, easy-to-use patient record. 12

13 Introduction LEARNING OBJECTIVES At the end of this course, you will be able to perform the following tasks: Log on/off the application Access and navigate through the appropriate application Locate and open a patient chart Understand and use the various sections in the patient chart View results associated with the patient View clinical notes Add problems and diagnoses to the patient s chart Add allergies to a patient s chart Complete full orders management steps Medication reconciliation admission and discharge Fully understand PowerNote Complete the Depart Process View, sign, review, forward, and refuse documents and orders in Message Center as well as create proxies and messages MANUAL LAYOUT The items that will be discussed are listed below. The features of each topic are covered in the Summary section followed by a detailed discussion of the functionality. Results Review MAR Summary Allergy Review and Management Medication History/ External Rx History Review and Management Order Entry (Basics) Order-related Alerts Order Management Medication Reconciliation Problems and Diagnoses Interactive View/I&O Advanced Graphing Medication Reconciliation Overview and Process Message Center Overview and Process 13

14 Introduction BENEFITS OF COMPUTERIZED PHYSICIAN ORDER ENTRY (CPOE) AND ELECTRONIC DOCUMENTATION Elimination of handwriting interpretation errors. Reduction of transcription errors. Reduction of medication errors and adverse drug events. Improved accuracy and timeliness of communication between all departments and individuals who work with the EMR at Kaleida Health. On-line validation of medication orders by pharmacists, which improves medication management and delivery. Easily accessible electronic medical records for our patients. Achievement of regulatory compliance and Meaningful Use requirements. Elimination of duplicative processes by sharing information across caregivers. Clinicians are able to deliver care from anywhere, anytime. Clinical decision support in the form of rules and alerts can be delivered directly to the ordering provider. Help Desk For Technical Assistance, call

15 Introduction LOGGING IN TO FIRSTNET Objective: This exercise will provide you with the steps necessary to Locate and sign on to the FirstNet Application. 1. Click the Citrix icon from the lower-right corner of your computer taskbar. 2. Select Applications from the shortcut menu that displays. 3. Then select Cerner-SCTRAIN Environment>FirstNet SCTRAIN. 4. The Cerner Millennium log in window displays. The Domain field is set to SCTRN. 5. Type the User ID from your Training Card in the User Name field. Press the Tab key to advance. 6. Type the Password from your Training Card in the Password field. Press the Enter key or Click the OK button. The Announcement screen may display. This screen displays system-wide messages pertaining to FirstNet. You can prevent this from displaying each time by selecting Don t show again until new information has been posted. 7. Click OK to close the new information window. 15

16 Introduction CHECKING IN AS AN AVAILABLE PROVIDER Objective: This exercise will provide you with the steps necessary to make yourself available as a Provider in the ED. The first time you log into FirstNet at the beginning of your shift, a dialog box will appear asking if you want to be checked in as an available provider. 1. If you would to like to be listed as an available provider, click Yes. The Provider Check-In window displays. If you do not automatically Check-In, you will be asked if you want to check-in each time you log in to FirstNet. 2. To check in manually, click on the Check-In icon on the toolbar. 3. The system displays the Provider Check-In/Out window. Verify your name displays in the Provider field. 4. Modify the name in the Display Name field to the way you want it to display on the tracking lists. 5. Select your Provider Role. 6. Set the default relationship to your Provider role. 7. Check the Available Provider and the Available Reviewer checkboxes at the bottom of the window. 8. Check the box next to All Providers. 9. Click OK to apply your changes. The Provider Check-In/Out window will close and you will be listed as an available provider on the ED Staff tracking list. ASSIGNING YOURSELF TO A PATIENT Objective: This exercise will show you how to assign a patient to your care. Note: The Doctor tracking list tab is designed to assist the physician in prioritizing the patients that need to be seen. If the patient s To Do column contains a caduceus icon that means the patient has not been seen by a physician. 1. Click on the Doctor Tracking tab and make sure that your filter is set to <None> 2. Using your sign-on card with your patient information, highlight your patient s row. 16

17 Introduction FIRSTNET ORGANIZER Objective: This exercise will introduce you to the Organizer s tracking list, tabs and toolbar locations. The Organizer is the main workspace within FirstNet. The Organizer is divided into four different sections based upon the image shown below. A. Organizer Toolbar, contains Enhanced Tracking Lists and Multi-patient task list buttons B. Tracking list tabs will display according to sign on. C. Tracking census and events: all patients, site specific tabs to navigate through the variety of patient care areas. D. FirstNet Toolbar: This can be found just above the Tracking Board. E 1 E 2 Message Center Button: One of two (2) ways to access the Message Center. Message Center Icon: One of two (2) ways to access the Message Center. 17

18 Introduction TOUR OF FIRSTNET ENHANCED PROVIDER TOOLBAR Objective: This exercise will introduce you to the FirstNet Enhanced Toolbar. The FirstNet Provider toolbar sits just above the tracking lists and provides easy access to commonly used FirstNet functions. Starting from the left of the toolbar, the button (icon) definitions are listed as follows: UNDERSTANDING FIRSTNET TRACKING BOARD TABS Objective: There are many different tracking lists that are a part of your FirstNet Organizer. This exercise will introduce you to tracking lists and how to best use them. Depending on your position in the department, only the tabs that pertain to you will be viewable from your sign-on. To view a specific list, Click once on the tab name. If you cannot see what you need to see, you may need to change the FILTER you have chosen. All Beds: Contains a list of all the beds in your department and will show if the bed is occupied or available, dirty or do not use. Triage/WR: Displays patients that are in the waiting room and are awaiting triage. Doctor List: Shows all patients. The physician can use the My Patients or the My Patients and Unassigned options from the Quick Filter drop-down to show their patients and what patients need to be seen next. This tracking list is designed to assist the physician with their provider assignments by organizing the patients according to acuity and length of stay. 18

19 Introduction Staff List: Displays a list of all of the providers/nurse that has checked in to FirstNet for the last 24 hours. It also shows the provider s availability, number of assigned patients, and the provider/nurse s role. Check out: Shows all patients placed in the check out location. When you place a patient in check out you cause their length of stay to stop incrementing. If a patient is placed in check out by mistake you have the ability to place the patient back onto the tracking list. Any time lost will be automatically added to the length of stay. Main: Displays as only patients housed in the main ED. Observation: Displays as only patients housed in the observation unit. Look-up: allows the user to 'look-up' a patient that had been seen in the ED for the past. You can filter by 36, 60 or 72 hours as well as 'My Patients'. Post D/C 14 days: Displays all discharged patients that have pending lab results or lab results that require review. GVI CTs Pending: Patient s located at the GVI that need CT results. Urgent care (BGH)/Kids express (WCHOB): All fast track patients. Behavioral Health (BGH): list of patients located within the Behavioral Health unit. Neuro Step-Down Unit (MFG): list of patients that are located in the Neuro Step-down unit. Transfers: list of patients that are being transferred from one Kaleida facility to another Kaleida facility. UNDERSTANDING FIRSTNET TRACKING BOARD COLUMNS Make sure you are on the Doctor tab. 1. Bed Double-Clicking in this column allows you to select and display the bed number for the associated patient. It is also used to check out the patient, by selecting the Checkout option. In the selection window, the number (i.e. (3) or (0)) displayed indicates the amount of patients already in that bed. 2. LOS 3. VI 4. Pre The moment the KH ED Sign in was complete; this is the amount of time that has elapsed since the patient has been in the ED. Visitor Information: Security, privacy, visitors not allowed. Pre-arrival form can be viewed if populated from the Track Board. 19

20 Introduction 5. A This column displays the documented Acuity for the patient by depicting it in a colored number. The patient s name may also have a colored background which also represents the patient s acuity. Color is removed once the provider is signed up for the patient. The options are: 6. Name 7. Age Patient Name This is the age in years, months, weeks or days of the patient. 8. Allergy The Allergy column displays the status of allergy documentation, depicted by three different types of icons: No Allergy Information Documented Allergies Documented (Hover your mouse to view allergy in tooltip form) Allergies Documented 9. Reason for Visit This field is populated by an RN on the Tracking Board from the Triage form. This displays the ED common Reason for Visit into Tracking Board. 10. MD 11. CS This is the display name of the Kaleida Health Staff Provider. Cosign - This column will be populated if there are any verbal orders to cosign. COSIGNING ORDERS Cosign orders are orders placed by non-physician users, such as RNs require co-signature from a physician. The order types that require co-signature are predefined by your site, and the provider who is to receive the cosign request is specified in the order. To sign a Cosign Order, complete the following steps: 1. Open the Cosign Order. The Order Information window opens. 2. Click Approve or Refuse or modify the details of the order. If approved, a statement is added to the patient's chart, stating you cosigned the order, and the Order Information window closes. 20

21 Introduction 3. Click OK or OK & Next. Refusing to cosign an order that is not a med student order does not stop or cancel it. 1. Open the Cosign Order. The Order Information window opens. 2. Select Refuse and select a reason for your refusal. A statement is added to the patient's chart, stating you refused to cosign the order. 3. Click OK or OK & Next. 12. RES Resident/PA/NP/MS (Medical Student) 13. Kg 14. RN This displays the patient s weight in kilograms. Double-clicking in this field will display the patient s quick FlowSheet. Nurse 15. To Do This is displays Events and/or Interventions to be carried out. 16. Orders 17. Sign Placed by any clinician or approved personnel to carry out interventions on a patient. Provider (MD Resident Midlevel) notifies Provider status of PNED. 18. Meds 19. ECG Reflects the number of meds that are due/remaining to be administered by the RN. The number of ECG s ordered will be displayed whenever an ECG 12-Lead order has been placed. The icon only displays when all orders that were placed have been also been completed. On the other hand the numbers, when displayed represent how many ECG 12 Leads were ordered and how many have been acquired as denoted in this format: ordered/acquired (i.e. 1/0). Right-Clicking the ECG column displays additional information regarding the Order status of the ECG. Double-Clicking on the ECG column displays the latest ECG 12 Lead Order Status on the Quick FlowSheet. The actual ECG may be viewed by double-clicking this link in the quick FlowSheet. 21

22 Introduction 20. Lab Similar to the ECG field, this column will display an icon or numbers in this field. The icon denotes that all orders have been completed, and the data can be viewed when hovering over the icon as in the image below. When numbers display, they indicate the number of tests orders and the number of tests completed and it is in this format: # test ordered/# tests completed. 21. Rad The Rad column displays the same icon if all orders have been completed. 1 / 0 / 0 = Ordered / Complete / Official by a KH Radiologist This displays all radiology orders. 22. Comments For patients who have been placed in a bed, this is a drop-down field which contains prebuilt comments to select from (i.e. Abscond) or it will also allows freetext commenting by double-clicking in the cell (i.e. ICU 107 ). 23. PCP This is the display name of the Primary Care Physician. VIEWING ORDERS & EVENTS FROM THE TRACKING BOARD Objective: This exercise will demonstrate how you can, at a glance, see the orders on the Tracking Board. 1. Hover over the ECG/Lab/Rad column to see a list of orders that have been placed and their status. Instructor Demo 22

23 Introduction QUICK FLOWSHEETS AND PT SUMMARY Objective: The Quick FlowSheet provides a condensed view of the patient s vital signs, pain assessment, lab results, and radiology results. In this exercise, we will review the functions of the FlowSheet and the ED Summary screens. 1. Double-click the TO DO column to access the ED Quick Flowsheet. 2. Click on the Assessment tab. 3. Double- click an individual result, event set, individual orderable, or order activity type column cell to access a Quick Flowsheet. If a Triage and Nurse Assessment has been completed, they will appear at the bottom of the Quick Flowsheet under the heading ED Department Documentation. 4. Double click on Triage or Nurse Note(s) to view the textual rendition of the form. 5. Click X to close the textual rendition of the form. You can access the patient s chart from the Quick Flowsheet by clicking the Flowsheet button at the bottom of the screen. 6. Close the patient s chart. To access the Patient Summary, do the following: 1. With the patient highlighted, click on the Patient Summary icon located on the toolbar. The Patient Summary Report displays. 2. Close the patient s chart. 23

24 Introduction CRITICAL RESULTS Objective: This exercise will show you how to identify the critical lab results indicator on the Tracking Board and mark the results as reviewed. TO MARK A RESULT AS REVIEWED: 1. Double-click in the To Do column. The ED Quick FlowSheet opens. Critical results should appear in red font within the FlowSheet. C= Critical Value 2. Click on the Lab tab. 3. Click the Review button. The Quick FlowSheet will close. 24

25 PowerChart Overview POWERCHART OVERVIEW Topics in this Unit: Title bar Menu Bar Organizer Bar Action Bar Print and Refresh Bar Patient Defining Area Toolbar The PowerChart environment contains toolbars, menus, and buttons. This unit focuses on their functionality and explains the different ways to navigate through the application.. This Unit focuses on the general features and functions of the PowerChart window. 25

26 PowerChart Overview TITLE BAR The Title bar displays your legal signature and the name of the window. MENU BAR The Menu bar is a row of buttons that contain drop-down menus used to select common functions or to set different preferences. ORGANIZER BAR Located below the menu bar is the Organizer Toolbar. defined for your role. This toolbar contains the Organizer components Note the downward arrow at the right of the toolbar. This down arrow allows you to customize the toolbar (see Appendix for detailed instructions on how to use this feature). ACTION BAR The Action bar is the longest of all the toolbars and consists of buttons that allow you to perform common daily tasks. The toolbar is so long that all buttons will not fit horizontally on the screen (A). In order to see the overflow of all the buttons, it is necessary to click the grey chevron button (B) on the far right of the toolbar. There is a preferred placement of buttons. You may want to set the display order of these buttons, whether to set by the preferred placement or by your own preferences. Exit: This will prompt you about how you wish to exit the system and allow you to exit. Change: This suspends the application and displays the Change User dialog box to allow the next user to log in. Upon log in, the next user s patient lists and other defaults are displayed. If the next user does not have a defined patient relationship of the active chart and doesn t assign one, then the Organizer will open. 26

27 PowerChart Overview Suspend: This suspends the application and displays the Suspend User dialog box. The original user must be the one to log back in as it will not allow another user to log in. AdHoc: This opens a series of PowerForms for charting purposes. (i.e. Immunization Refusals, etc.) PM Conversation: This function should only be utilized when you are inside the patient s chart. Clicking on the PM Conversation button displays various options that can be selected to initiate an electronic conversation with other applications such as Eclipsys. KH Transfer Pending This conversation will send a request to the facility s Bed Coordinator/Transfer Center for a room/bed and accommodation code assignment. The Bed Coordinator/Transfer Center will make this assignment in Eclipsys and a printed bed reservation will be sent to the Sending and Receiving Units. KH Transfer This conversation will complete the transfer and change the patient s location in both Cerner PowerChart and Eclipsys. KH Discharge Pending Use this conversation to let the Bed Coordinator/Transfer Center know that a bed will be available. KH Discharge This conversation will discharge the patient in Cerner PowerChart and Eclipsys. KH Transfer Interfacility This conversation is used when a patient is being transferred from one Kaleida facility to another Kaleida facility (i.e. BGH to DeGraff). KH Modify Use this conversation when a patient s Attending Physician or Hospital Service has changed. PowerChart will send this information to Eclipsys. KH Check In This conversation is used to check in a patient when they arrive. KH Check In is also used when a patient is a Direct Admit to your nurse unit. Conversation Launcher button: This launches options for various other conversations related to Transfer/Discharge functions, however this button should only be accessed from the Organizer and only utilized to perform the following two functions: KH Bed Swap This conversation allows you to select two patients from within one facility and swap their beds. KH Discharge Cancel This conversation is used to cancel a discharge for a patient that was discharged in error. Scheduling Appointment Book: This is used to access to the scheduling system in order to schedule an appointment and its details, such as the appointment type, appointment location, person name, and other detailed information. Batch Charge Entry: Used to enter a single charge (or credit) or a batch of charges (or credits) for one or more patients. Explorer Menu: This opens up the Discern Explorer window and provides the ability to print specific department or nurse station reports. 27

28 PowerChart Overview Calculator: This launches the Clinical Calculator which provides forms for various clinical formulas. When you complete the required data boxes, the calculator solves the equation. Scheduling Database Tools: If you apply templates to your scheduling book, you will have access to this functionality. (Not all users have this functionality). PRINT AND REFRESH BAR Print: This allows you to print the records selected on a particular list tab. Refresh (Minutes Ago): This displays the total elapsed minutes since the Organizer, Patient Chart or selected component (on the TOC menu) was last refreshed. It does not refresh all of PowerChart simultaneously. Once clicked the button will reset to zero minutes. PowerChart does not automatically refresh. Always click this button prior to reviewing electronic data. PATIENT DEFINING AREA TOOLBAR The Patient Defining Area includes several options for opening patient charts. Person of Interest: If a patient is selected on the List tab, then this patient s name will display here. There is a drop-down available that contains all of the different components of the selected patient s chart. Clicking any of these areas will open the chart to that component. Recent: This drop-down displays the last five patients charts that were accessed by you; selecting a patient opens his/her chart. Person Search: By default this area allows you to search for a patient by MRN. This can be changed to search by Name by selecting that option from the drop-down. After entering the search criteria, press Enter to perform the search. Search for Specific Patient: This opens the Advanced Search window. If you wish to search for a patient by additional criteria such as: FIN #, Name, MRN, Universal Identifier, Birth date, Gender, or SSN then this button will need to be used. The preferred method is to search by the FIN# or Patient# located on the Plue sticker. 28

29 Patient Chart Overview PATIENT CHART OVERVIEW Topics in this Unit: Opening a Patient s Chart Patient Chart Layout Menu Components Menu Component Definitions Menu Pin and Unpin Patient Demographic Bar Patient Demographic Bar Menu Component Definitions Viewing Results Review Examples of Results Things You Should Know View Result Legend Customize Results Review for Easier Viewing Filter and Find Data Filter by Navigator Filter or Search Viewing Results Using the Navigator Using the Results Display Changing the Clinical Date Range Similar to the Organizer, the Patient Chart also resides in the PowerChart environment, so it shares the same toolbars and buttons. The Patient Chart is the area used to document all clinical related information for the patient, place orders for the patient or view results for the patient. This Unit provides a layout of the Patient Chart and common features and functions available. 29

30 Patient Chart Overview OPENING A PATIENT S CHART Objective: This exercise will demonstrate the multiple ways to access the patients chart from the FirstNet Organizer and the multiple tabs associated with the Patient s Chart. 1. Highlight the patient row. 2. Double-click the blue arrow on the patient row. OR 3. Click on the Open Chart icon on the toolbar. PATIENT CHART LAYOUT The Patient Chart begins directly underneath the toolbars and buttons found in the PowerChart environment. There are two main areas that make up the Patient Chart window: The Menu on the left and the related Workspace on the right. The data in the Workspace is always related to the selected Component on the menu at left. 30

31 Patient Chart Overview PATIENT TOOLBAR This toolbar displays Patient Chart tabs of the patient s whose charts are currently open. Up to four charts may be open at one time, but it is recommended that only one chart should be open at a time. Clicking on a Patient Chart tab will display that patient s chart and clicking the X on a tab will close that patient s chart. THE STATUS BAR This bar is located at the bottom of the window and displays relevant user information about the current session of PowerChart. MENU COMPONENTS The Menu is displayed on the left side of the patient s chart and is used to access different components of the patients chart by clicking on them. The active chart component is always highlighted in purple and also displays in the horizontal bar. The Menu also contains Quick Add buttons that allow you to quickly open and document a new allergy or order without going directly to that chart component. Pushpin Quick Add button 31

32 Patient Chart Overview MENU PIN AND UNPIN You can hide the Menu to maximize the Workspace. The Menu can either be displayed as maximized (pinned) or minimized (unpinned). This allows more viewing space if desired. 1. Click the pushpin at the top of the Menu. The Menu is now in an unpinned status and the Menu minimizes into a Menu tab located vertically on the left side of the screen, underneath the patient demographic bar. 2. Display the Menu dynamically by hovering the mouse over the Menu tab. Any time you hover your mouse over the Menu tab, the menu will display. Any time you move your mouse away from the Menu tab the menu will hide. You can lock the Menu back in place by clicking the pushpin once more. PATIENT DEMOGRAPHIC BAR The yellow Patient Demographic Bar located horizontally at the top of the Patient Chart window contains basic information about the patient whose chart is currently open, including: Last Name, First Name Age Sex EMR (Electronic Medical Record)number Current location of the patient Allergies DOB (Date of Birth) Fin Number (Financial Number) Inpatient/Outpatient Status Dosing Wt Measured Wt Advance Directive Advance Directive Type There are several links contained within the Patient Demographic Bar that link directly to corresponding information regarding the patient. Those links include the Patient s name, Allergies, Location and Fin #. Clicking on any of these will take you directly to the corresponding information. Clicking on the patient name displays the Patient Information window shown below and provides basic more demographic information about the patient. 32

33 Patient Chart Overview Clicking on the Allergies displays the Allergies workspace. From this window you can document an allergy as if you had chosen the Allergy component from the menu. Clicking the Location or Fin # displays Encounter information for the patient. MENU COMPONENT DEFINITIONS The Menu consists of the different sections of the patient s chart. Click any section in the menu to view that portion of the patient s chart in the Chart Documentation section of the window. The sections on the menu include the following components: Each chart component and a brief definition are explained below: Results Review: Is used to view all results (i.e. laboratory results, radiology reports, dictated results, etc.) It provides a view over time so trends can be monitored in the patient s status. Microbiology: Orders: This displays a categorized list of orders for the patient. It displays the date/time of the order, the name of the order, status, and details of the order. This is also used to add, cancel, or modify orders. MAR Summary: This displays all medication administrations as well as meds documented as not given. Allergies: This displays an overall list of allergy substances and reactions for the patient. This is also used to add, cancel or modify allergy substance/reactions. Medication List: This displays a listing of the patient s Home Medication history, both active and inactive. Patient Information: This tab contains three sub tabs that display general demographic information about the patient such as Patient Demographics, Visit List, and PPR information. Document Viewing: Access to PowerNote. You can add, view, modify, correct or view pervious PowerNotes. Patient Care Summary: Patient Care Summary is a summary area for several components of the patient chart that include Critical Lab Results, Problems/Diagnoses, Results Review and Intervention Orders as well as the Reason for the current visit. Form Browser: The Form Browser window displays a directory tree that lists all the completed PowerForms for the selected patient. The recommended use for this area is to modify and unchart forms. 33

34 Patient Chart Overview Clinical Folders: Formerly called Clinical Notes, this area contains any clinical documents related to the patient: Face sheets, Progress Notes, Transcribed Reports, Consents and any other form which support patient care. Clinical Folders allows you to sort documents and view document history. Immunization Schedule: This facilitates the management of a patient's scheduled immunizations. This area is used to chart all areas concerning the patient s immunizations, as well as previously administered immunizations as historical form documentation. Interdisciplinary Summary: The Interdisciplinary Summary is populated by Nursing and Ancillary Documentation (PT/OT/Speech) from Clinical Folders, and Flagged Results/ Comments from IView in the Event & Procedure band. The Interdisciplinary Summary is a view-only screen. Problems and Diagnoses: Problems and Diagnoses is a patient profile within PowerChart. The Problem List is one aspect of this component. The Problem List provides a way to sort and track a patient s problems that cross encounters. Histories: A key part of a clinician s workflow is to gather and review historical information about the patient. The historical information is important as it assists the clinician in making the appropriate treatment decision based on the patient s previous experiences. This displays information related to the patient s past medical history, past procedure history and family history. Reference Text Browser: The Reference Text Browser is used to search and locate Education Items for the patient. Education Items include Drug Reference materials, Patient Education Leaflets and Provider Reference information. Interactive View/I&O: Interactive View is the solution for Critical Care, Med/Surg, PACU, ED, and Maternity documentation. It enables you to access relevant, up-to-date patient information when and where you need it. In addition you can review, enter, modify, and manage results as necessary. Pregnancy: This is a view only tab populated from documentation in Maternity areas. ED Summary: This is used to view clinical measurements populated from documentation. Chart Summary Screen: FlowSheet: 34

35 Patient Chart Overview VIEWING RESULTS REVIEW 1. Click the Results Review component from the menu. The Results Review Workspace displays. Note: Results are date-specific. You must change the Clinical Date Range to cross encounters. The Results Review component of the patient s chart is used to view results. Results are available for lifetime. Results are populated from documentation that was charted using a PowerForm, IView or PowerNotes. Tabs Clinical Range Navigator EXAMPLES OF RESULTS Dictated Reports ECGs Images Laboratory Tests Nursing Notes Pain Assessments Provider Notes Radiology Reports Respiratory Results Scanned Documents Triage Data Wound and Skin Assessments 35

36 Patient Chart Overview THINGS YOU SHOULD KNOW Information is shown in a spreadsheet format with flexible display features such as viewing the results as a Table, Group, or List. The default view is the Table view. The Table view displays event descriptions in row headings on the left and their respective dates/times as column headers. When Table view is active, the status bar at the bottom of the PowerChart window displays the associated normal reference range for the event description. The Group view displays the heading for a group of events as rows. Underneath each event heading are the associated dates for that event heading. The event descriptions are the column headers, but are anchored to their respective group. The List view displays patient events and results in linear list format. Results are displayed in a spreadsheet with column headings such as event date, event, result, reference range, and status. The Results Review is divided into two major sections: The Navigator on the left and the Results view on the right. By selecting categories from the Navigator, you can zoom immediately to its contents, which are displayed as values in the Results view on the right. Each column in the Results view area represents a specific date/time. Therefore, easy to see trends of how the patient s status has changed over time. Dates/times can be further filtered by changing the Clinical Range, where you can specify a timeframe to view. By default, the Results Review provides a view of results five days back and one day forward. By changing the Clinical Range, you can specify a different timeframe. 36

37 Patient Chart Overview VIEW RESULT LEGEND Lab Results display with unique color-coding and symbols to indicate the type of result that it is. If you are unsure about what these colors and symbols indicate, the Result Legend may be of assistance to you. This can be viewed by clicking Options > Result Legend from the menu bar. CUSTOMIZE RESULTS REVIEW FOR EASIER VIEWING There will be times when the default display width of the columns will be insufficient to display the full result. There are several techniques which are available to you. Option #1 Hover your mouse over the truncated result in the cell. A tooltip displays the full text of the result. Place your mouse pointer on the border between two columns, and then click and drag the column to the desired width. Option #2 Expand the column to see the full result by dragging the desired column edge to the right. Option #3 Change how the Results Review is displayed on screen by selecting Table, Group, or List mode. FILTER AND FIND DATA The Results Review can return several results and can be very long. It is possible to view the information simply by scrolling through the Results. However, if the list is very long there are ways to further define the filter of what you are looking for. FILTER BY NAVIGATOR The Navigator on the left can be used to temporarily hide the display of certain groups of clinical information. This is done by deselecting (clicking to uncheck) the groups you wish to hide. 37

38 Patient Chart Overview The Navigator can also be closed to expand the Results Review Workspace by clicking the X in the Navigator pane. To redisplay, in the menu bar go to Options > Show Navigator. 38

39 Patient Chart Overview FILTER OR SEARCH Use the drop-down and/or ellipsis button to filter or search for items as shown in the image below. Use the drop-down to quickly navigate to certain areas. Click the Ellipsis button to open a search window where you can search for particular items. Once you are finished viewing, you can return to all results by selecting All Results FlowSheet from the drop-down (displayed above). Whenever the Results are filtered, the changed display is not saved; everything will return to the default setting at the point of next PowerChart log in or upon entering another patient s chart. 39

40 Patient Chart Overview VIEWING RESULTS The tabs within the Results Review Component are divided into two major sections. The left section is the Navigator, which consists of a list of categories that serve as an electronic index. By selecting a category, you can zoom immediately to its contents, which are displayed as values in the grid on the right. The right section is the Results Display that provides a two-dimensional view of events (tests, procedures, and documentation) against a time continuum. Each piece of clinical data qualifies as an event or result, including numeric results and clinical documents and notes. USING THE NAVIGATOR The Navigator is the area located on the left side of the tabs. This area is broken into several categories that serve as an electronic index. The Navigator is a simple feature to use. Following are some of the features: 1. Click on the category name you want to see. The selected category will scroll into view on the right. De-select the checkbox to the left of a category and that category will not be shown in the view on the right. Select the checkbox to the left of a category and to view it again on the right. 40

41 Patient Chart Overview USING THE RESULTS DISPLAY The right section of the tabs is the Results Display that provides a two-dimensional view of events against a time continuum. Tests Procedures Documentation You can use the Navigator buttons as described in the previous section to locate events or can use the vertical and horizontal scrollbars. A great deal of information can be obtained at a glance from the Results Display. For example: Red results indicate a critical reading. The letter C in front of a result also indicates critical or positive. The letter L in front of a result indicates a low reading. The letter H in front of a result indicates a high reading. The letter M at the beginning of a cell indicates a modified result. The symbol of!, *, or ' indicates a comment. A comment indicator (for example, a triangle) in the cell that contains a result with written comments attached. Three importance levels (high, medium, and low) can each have a different symbol. CHANGING THE CLINICAL DATE RANGE The Clinical Date Range (located above the Navigator and the Results Display) will default to a specific range each time you open the Results Review Component. When the proper clinical range is not displaying the necessary range to show the desired data; You will need to change the Clinical Range. There are 2 ways to accomplish this: 1. Click one of the scroll buttons located on the right and left sides of the Clinical Range bar to advance the date incrementally. 2. Right-click on the Clinical Range bar. Select Change Search Criteria. 41

42 Mar Summary MAR SUMMARY Topics in this Unit: How to Access the MAR Summary Workspace Overview Using the MAR Summary Applying Filters through Navigation Button Applying Filters through Show Views Button The MAR Summary is used to review all medication administrations as well as meds documented as not given.. It is the source of truth for all medication administration. The MAR Summary is a view-only tool for clinicians and providers who need to see medication administration information as part of their workflow. There are filtering capabilities to allow providers to quickly access the information they need. These are described in the following sections. 42

43 Mar Summary HOW TO ACCESS THE MAR SUMMARY The MAR Summary can be accessed two ways: 1. Within FirstNet, it can be accessed directly from the FirstNet toolbar as shown below: 2. Within the patients chart MAR Summary is accessed from the Menu. WORKSPACE OVERVIEW A sample screenshot of the MAR Summary is shown below. The four core areas are explained on the following page. 43

44 Mar Summary 1. Clinical Date Range Bar: defaults to a 48 timeframe. To change the date range complete the following set of sub-steps: a. Right-click anywhere on the bar itself. b. From the shortcut menu that displays select change properties. c. Make your desired changes in the MAR Summary properties dialog box that displays. d. Click OK when finished. 2. Medication Display: display medications alphabetically by generic names based on the way it is ordered (generic name vs. brand name). Medications are further categorized by the darker blue bands as explained below: Scheduled Scheduled medications have an assigned frequency. All scheduled medications display color coded as Blue. PRN All PRN medications display color coded as Green. Continuous - All Continuous medications display color coded as Blue. Discontinued All Discontinued medications display color coded as Grey. Additional clinical information charted with the medication administration will display along with the administration time and documentation information. 3. Time Columns: The Time columns are displayed in reverse chronological order and are also broken into four hour increments. The Time column intersects with the Medication Display column (above). 4. The area where the Medication Display rows and Time columns intersect is a group of cells that contains detailed charting information for those orders that require additional information. A few tips are listed below: Doses due display and the time due in the appropriate time column. Medications that have been administered display with of the actual time administered. Administered doses display the dose and time administered in the appropriate time column. Orange Border indicates a medication charted as Not Given. Hovering over any administration will display details: (shown in image) The Yellow column indicates the current time. 44