Meditech Scanning & Archiving

Transcription

1 Meditech Scanning & Archiving

2 Overview Effective November 14, 2012, Children s Hospital will go-live with Meditech Scanning & Archiving. Documents will no longer be scanned in ChartMaxx. Exception: Orders to Pharmacy will still be done in ChartMaxx until further notice.

3 Why are we moving from ChartMaxx to Meditech Scanning? This integration will provide a centralized location for medical record documents. Both electronic, and scanned documentation will be available through Meditech s Electronic Medical Record [EMR].

4 What happens to ChartMaxx? ChartMaxx will still remain accessible for historical documents until all records have been successfully migrated. Anticipated document conversion will be approximately 2 ½ -years (2015)

5 At the end of this module, learners will be able to: Differentiate a scanned document versus an electronic document. Identify how to use the image options when viewing a scanned document. Identify the EMR panels where scanned documents can be found.

6 Accessing the EMR

7 Logging in to Meditech Enter Meditech Initials Click Enter Enter Meditech Password Click Enter Click Enter

8 Accessing the EMR Since Meditech requires users to be placed in specific access groups, the menu to access the EMR may look slightly different between users Once the user has clicked on EMR or View Patients, the information should be exactly the same The next few slides will display the most common menus seen when accessing the EMR

9 Accessing the EMR This screen is typically seen by Providers From the Main Menu, Click on EMR

10 Accessing the EMR This screen is typically seen by Nurses From the Main Menu, Click on EMR

11 Accessing the EMR This screen is typically seen by those dealing with Billing or Accounts From the Main Menu, Click on EMR

12 Accessing the EMR This screen is typically seen by those in the Pharmacy From the Main Menu, Click on EMR

13 Accessing the EMR This screen is typically seen by those in Medical Records From the Main Menu, Click on EMR

14 EMR Recently Accessed Once you have clicked on the EMR, the screen will default to the recently accessed records screen A list of the patients for whom you have viewed records in the last 14 days will display

15 EMR Accessing Records not on Recently Accessed List You can search for other records thru Any Location or Any Record

16 EMR- Accessing Records by Any Location

17 EMR Accessing Records by Any Record Can enter any of the identifiers, Then click OK to find the record

18 EMR- Choose the Patient Several records may display depending on the search criteria. Click on the correct patient. The screen to select the patient s visit will appear. You can select either all visits or specific visits at that point

19 Selecting All Visits Click on All visits Click on View All

20 Selecting a Single Visit 2. Click Selected View 1. Click on the visits you would like to view

21 EMR Menu Overview Record List Returns to previous list Other Visit Select another Visit for the patient. Will take you to the Visits by Date screen Special Panels A central location to view data in spreadsheet format 24 Hour Quick view of results posted in past 24 hours Vital Signs Displays specific vital signs recorded. I &O Information entered in PCS module Notes Access to notes written by care providers Medications Displays all medication ordered for patient with active as default display Orders Displays all orders for the selected visit Laboratory View laboratory data in the form of a spreadsheet Microbiology View all microbiology tests/results for the patient Blood Bank Displays transfusion summary data Pathology Displays pathology test/results Imaging This panel includes codes, impressions, current reports, history reports and images. PACS link located here Other Reports Any report other than imaging Care Trends Displays assessment data grouped by body system History Response from Medical History Assess Summary General information about an account Encounters Lists encounters with various physicians Referrals Displays list of referrals sent from PRV & ADM Orders Launches Order Management Med Access Ambulatory Order Management Reconciliation The EMR will default into the summary screen

22 Geography & Color Code Color Description Text color and background color both indicate availability of data. Color Blue text on white background Blue text on light blue background Red text on light blue background Lightly shaded blue text on light blue background Description This is the selected option (you are viewing this panel). You can click on this option to view data. You can click on this option to view new data since you last viewed this individual's information. No data is available for you to view. White The result is in the normal background range. Yellow The result is in the abnormal background range. Red background The result is in the critical range. The following symbols indicate result information. Symbols Description H The result is above the normal range. L The result is below the normal range. Comment A comment is associated with the result. Asterisk * The result is in the critical range. Abnormal Delta LAB performs a delta check on Difference Flag specimen results. abn The result is a non-numeric abnormal result.

23 Differentiating scanned & electronic documents

24 How do I know the document is scanned versus an electronic document? Scanned documents will be identified by a camera icon. The electronic documents in the EMR are identified with a callout.

25 Viewing scanned documents What will the scanned document look like?

26 IMAGE OPTIONS When a scanned document is selected it will open into this active window. If you would like to know more about the Image Options click within the highlighted box.

27 The Select button allows you to select pages from the document you are currently viewing.

28 The View Selection button can be used to toggle between a list of selected pages or the full list of pages for the document.

29 The Rotate Left button can be used to rotate the document to the left.

30 The Rotate Right button can be used to rotate the document to the right.

31 You can then use the Zoom-In button to increase the document size.

32 The Zoom-Out button can be used to decrease the document size.

33 The Best Fit button can be used to resize the document to fit in the screen.

34 Use the Print button to print the selected document. Only one page can be printed at a time.

35 Toggle through the Page Number buttons to quickly jump from one page to the other.

36 Navigating the Electronic Medical Record [EMR] to locate scanned documents

37 Scanned documents will be found in 1 of 5 EMR side panels: 1. Notes 2. Laboratory 3. Imaging 4. Other Reports 5. Summary ❶ ❷ EMR PANEL ❸ ❹ ❺

38 Important With the go-live of ancillary documentation, it is important to note that inpatient ancillary documentation will be in the Notes panel and outpatient ancillary documentation that is completed electronically will be in the Other Reports panel. But...scanned images will be slightly different... ❶ ❷ ❸ ❹ ❺ EMR PANEL

39 Notes Panel EMR PANEL The types of scanned documents found in the Notes panel are: Nursing Notes Ambulatory Process Forms Ancillary Notes Nutrition Physical/Occupation Therapy Speech/Audiology ❶ Outpatient Patient Questionnaires IMPORTANT If these disciplines document electronically, the outpatient version of these documents are in Other Reports panel.

40 Laboratory EMR PANEL Under the Laboratory panel you will find different types of reference lab reports and labs from other facilities. ❷ If the lab result is for a Microbiology test, you will see that under Microbiology. The Lab Scanned Report will display the detail as shown in the following screen.

41 Laboratory Laboratory results for external Reference Lab tests will be named specifically to the test instead of just Reference Lab. SCANNED LAB REPORTS Note: The Laboratory will discontinue the process of reconciling the reference lab and mentioning See ChartMaxx for Results. When navigating this report screen, you will not be able to sort by the columns as in other screens.

42 Imaging EMR PANEL Under the Imaging panel you will find relevant documents related to medical imaging, such as: Preliminary radiology results MRI questionnaires ❸ IMAGING PANEL

43 Other Reports Most scanned documents in the medical record will go to the Other Reports EMR panel such as: Physicians documents, including, but not limited to Surgical documents Anesthesia records Ambulatory clinic notes Problem Lists Orders Other Outpatient Documentation Telephone logs ❹ EMR PANEL OTHER REPORTS

44 Organizing Reports Organize the list of documents by clicking on column headers.

45 Other Reports > All Reports All scanned documents will appear under the All Reports subpanel. EMR PANEL All REPORTS

46 All Reports Examples Cardiovascular System: Examples: EKGs Echocardiograms Holter Monitor Results Surgery: Examples: Anesthesia Records PICIS OR Manager documents Surgical Photographs Nutrition: Examples: Handwritten Growth Charts Nutritional Screening Tools Emergency: Examples: ALL REPORTS Emergency Clinical Reports Trauma Flow Sheets

47 Can I thin out the view so I don t have to see so many documents at once? EMR PANEL Yes, there are two filtering options that are found in the Other Visit Panel.

48 Filtering: Visits & View Encounters can be filtered by selecting patient type under the Visits menu or by selecting individual encounters and using the View menu. Selection of specific encounters OTHER VISITS This option will minimize the number of viewable documents in the various panels.

49 Summary Under the Summary Panel you will find critical documents that are routinely accessed. The types of scanned documents found in this panel are: EMR PANEL Consent forms Conditions of Admission Consent to Surgery Paul Gann for Blood Insurance Insurance cards Advanced directives ❺ SUMMARY PANEL

50 Consent Form EMR PANEL SUMMARY PANEL ❺ CONSENT FORM When navigating this report screen, you will not be able to sort by the columns as in other screens.

51 Course Review Effective November 14, 2012, Children s Hospital will go-live with Meditech Scanning & Archive. Exception: Orders to Pharmacy will still be done in ChartMaxx until further notice. ChartMaxx will still remain accessible for historical documents until all records have been successfully migrated. Scanned documents in the EMR can easily be identified by the camera icon. The five panels within the EMR where scanned documents can be found are: 1. Notes 2. Laboratory Questions? 3. Imaging 4. Other Reports 5. Summary Contact Health