PHYSICIAN USER EMR QUICK REFERENCE MANUAL

Transcription

1 PHYSICIAN USER EMR QUICK REFERENCE MANUAL Epower 4/30/2012

2 Table of Contents Accessing the system. 3 User Identification Area.. 3 Viewing ED Activity. 4 Accessing patient charts. 4 Documentation Processes. 6 Physician Documentation.. 8 Housekeeping

3 Login to System Personalizing Your Display Accessing the system Select the EPD icon on your desktop; this will open up the program on your computer (see box below) Click on your name from the list on the left side of the screen or input your user number in the USERNAME box. Enter your password into the PASSWORD box Click on Login User (Red box on right side) or hit Enter key You will now enter the system and will view the tracking board Open the program from the desktop Click on your name from the list on the left side of the screen Enter your password into the PASSWORD box DO NOT hit the Enter key Select the Change My Profile tab in the box below the keyboard display on the screen Select a color you would like as your display color You can also change your password via this same route After making your selections, click on Save and then Close User Identification Area A picture and/or name of the user logged in to the system Access to consultants, referral sources, etc Notification of and access to messages for the user Ability to minimize the screen Access point to Logout of the system Viewing ED Activity Viewing All PATIENTS in the Emergency Department Click on the All Patients tab at the top of the header bar The Tracking Board will display ALL patients currently in the Emergency Department Viewing ALL OCCUPIED BEDS in Emergency Department Click on the All Beds tab at the top of the header bar The Tracking Board will display ALL beds, with and without patients, in the Emergency Department 3

4 Viewing My Patients Click on the My Patients tab at the top of the header bar The Tracking Board will display ONLY patients to which you are assigned as the Primary Provider Display Tracking Board ED activity is displayed on the tracking and/or status board Columns detail patient activity, such as o Room # o Length of Stay o Stage of Care o Ancillary Studies (ordered, resulted, reviewed) Accessing Patient Charts Opening a chart Open the program to the Tracking Board page Click on the Chief Complaint column of the record desired. Patient Header The Patient Record Toolbar is visible when the patient record is open displaying pertinent patient data. Any functional zones will turn purple when hovered over to allow viewing or data entry into that zone. Provides information specific to the chart opened o Patient name and demographics, room number, primary nurse, height and weight are displayed along the left edge o The last set of vital signs are in the next column of the header (any VS outside of normal parameters display in red) o Primary Care Provider (PCP), Allergies, and Code Status are displayed to the right of the VS column o E & M Counter & Documentation Progress Tool initially show in red and turn to white as each is signed as completed Viewing and/or Printing of a chart The chart can be viewed / printed 3 ways: 1 The View / Print screen by clicking on the patient s name from the tracking board 2 Clicking on the Preview button located on the chief complaint line inside the patient s chart 3 from the Printing button in the disposition area 4

5 Prior Visits If a patient has prior visits entered into the system, the Prior Visits button will be highlighted in RED. Selecting the RED Prior Visits button will provide the user to access the chart of each prior visit. Navigational Tools Page Up / Page Down Arrows o The single Up or Down arrow takes the chart up or down a full page o Clicking the double up or down arrow will move screen to very top or very bottom of page Slide-Out Tool Allows quick navigation between all patients To Change patients o Click Slide-Out Tool o Click on desired patient chart o Can navigate between any patient listed on the slide bar tool o Broken into 2 categories: Charts not signed and Charts Signed Macro Keys Documentation Processes The red checkmark with a red circle around it is called a Macro button. If you click this button, all the normal responses will be selected. You can use the Macro and then choose additional prompts. Free Text options Click the Free Text button. After making the free text entry, select the red RECORD button to save your inputs. Click on a blank line and it will open a free text box Time entries Click on a line associated with a time input. Accept the current time or change to the correct time After selecting or inputting the time, select the OK button to save. Vital Signs Viewing Vital Signs The last set of vital signs will display on the patient header Any vital sign that is outside of established parameters will display in red font Vital sign history can be viewed by clicking on the letters of the vital sign column in the patient header, i.e., BP, HR, etc 5

6 Current Medications Medications input by the nursing staff will display in the current medications section Adding to the Medication List Click on Add/Edit button to enter medications takes you into medication screen Enter Medication o Use search box ο Use letter search o Use scroll bar ο Free text into top white line Enter Dose, Route, Frequency and Last taken Select from available options Free text Click on Add to List this adds the medication but does not exit the screen to enable additional medication input Click Record on Chart to go back to patient chart Editing the Medication List Click on medication takes you to current medication screen Highlight desired medication Change / Add / Delete information from the top white section Allergies To document patient allergies: Click None if patient denies allergies Click Add/Edit button to enter allergies Select Allergy - you can filter by selecting a particular category Select Reaction Click on Add to list then select the Record button Select Remove from List and Record button to remove an allergy Physician Documentation Physician documentation tabs are located on the right side of the chart. The physician can view the nursing documentation but is not able to change nursing documentation within the nursing module. History Tab Click on History tab to access Information from the Triage Section will pre-populate if input; you can change according to information provided to you. This will not alter RN documentation Complete HPI, ROS and PFSH sections, sign each off by selecting the complete button at the end of each section Note the HPI, ROS, PFSH and PE in the patient header next to the User Identification area turn from RED to WHITE when completed 6

7 Physical Tab Physical examination documentation section Macro button available to use Course Tab Documentation for Medical Decision Making (Differential Diagnosis) Provides an area for additional note documentation and selections as appropriate Documentation area for consultants and patient reassessment Procedures Tab Area to select and document procedures completed on patient Click on the box in front of the appropriate procedure(s); multiple selections allowed Once finished selecting, click on Add Procedures to Chart button Select appropriate responses for each procedure selected Sign off procedures once completed Orders Tab The Orders Tab is shared by both physicians and nurses. Orders by category are located on the bottom right corner Orders actions are located on the bottom left May use individual orders by clicking the appropriate button, e.g., Laboratory, Medications, etc. May use Facility Orders, My Orders or Order Sets Facility Orders Are facility-approved protocols Selecting a facility order set will auto-populate the entire order set onto the ordering screen Individual orders within the set can NOT be removed prior to ordering, but can be cancelled AFTER the orders are recorded: 7

8 Order Sets Physician Quick Reference Guide Allows the provider option of selecting specific orders within the group without being forced to accept all of the orders within the set Eliminates the need to navigate within individual order areas, e.g., Radiology, Laboratory, Medications, etc to make order selections Order sets can be built to reflect Core Measure orders Customizable at the facility level Utilizing Order Sets The provider selects the order set he/she desires from the list within the Order Set column: The provider selects the orders he/she wants: 8

9 Physician Quick Reference Guide After selecting the desired orders, the provider will click the Add to Orders button Orders will auto-populate onto the orders sheet My Orders You may create your own specific orders to facilitate speedier ordering. My Order sets are provider specific and are NOT available to anyone else. For example, you may have specific tests you order for a female patient of child-bearing age presenting with a complaint of abdominal pain or a male patient presenting with flank pain. My Orders will allow you to order a complete order set with one click. Creating My Orders From the orders tab, click on My Orders button located on the bottom left corner of the screen: 9

10 Click on Add New Set if creating a new set. You may also use the Edit Set Name and Remove Set buttons as applicable to modify or remove orders, sets, etc. Highlight the set you want to add/delete/modify orders to and select the specific button for the orders, i.e., General Orders for nursing orders, lab, rad, meds for ancillary orders, etc. Once you have selected all orders, click Save and Close and your set is now ready for use When the My Orders set is selected, all orders in the set will auto-populate the orders screen Quick Notes Allows the user to quickly drop in statements created in advance Available throughout the chart 10

11 Can be created for private and/or public use Customizable to the individual provider Prescription Sets Allows the provider the ability to create his/her frequently prescribed medications in advance Access to the Rx sets is through the Create Rx/Excuses button 11

12 Creating Prescription Sets Physician Quick Reference Guide Click the Create Rx/Excuses button Click on Manage My Rxs button Create a new RX set o A RX set can be a group of medications for example, Lower Back Pain OR an individual medication e.g., Toradol 60mg 12

13 Using the active search box, locate the specific medication you desire Complete the RX build out 13

14 Click Save and Close button once all meds for the set have been added Once created the sets can be edited, removed and added to by selecting the appropriate button Disposition of Patients Final Diagnosis Click on the blank line next to Impression and select from list Disposition Click on appropriate choice Click on appropriate choice(s) for each line Time of Departure Must be documented in order to sign off the chart Discharge Instructions Provided by Exit Care May be edited and tailored for the specific patient encounter, BUT will not be saved 14

15 Creating Discharge Instructions Click the Discharge Instructions button within the disposition section Use the active search box to locate the appropriate discharge instructions Multiple discharge instructions can be selected Complete the appropriate instructions and follow-up information If the patient s PCP is documented within the chart, the information will auto-populate within the discharge instructions for follow-up as appropriate. Use of Quick Notes may be appropriate 15

16 Chart Sign Off Records your signature to the chart Click on the Sign Off box Warning box appears displaying any applicable critical, hard, or soft stops i. Critical stops appear in red and MUST be addressed before the chart can be signed ii. Hard stops appear in blue for the Primary Physician and can be overridden to sign chart iii. Soft stops appear in black and are simply reminders of possible deficiencies in the chart Click yes to continue with sign off, click no to go back into patient chart Housekeeping Locating your charts To find charts on only patients to which you are assigned the primary MD Use the Slide Bar to find charts of patients assigned to you Use the Incomplete Charts Tab in the Patient Header Signing off your charts All charts must be signed off by the end of your shift. Check the slide out tool on the Active Tracking Board i. The top box should be empty ii. If any charts are listed in the box, these must be transferred to the oncoming provider 16

17 Go to Recent Patients Check the slide out tool on the Recent Patients Tracking Board The top box should be empty All names on your slide out tool should appear in red and in the bottom table before you leave your shift Click on Incomplete label on Active Tracking Board i. Sign off any charts displaying in the Incomplete List 17