ProMedica Electronic Charting (i-care) Horizon Expert Documentation, AdminRx

Transcription

1 ProMedica Electronic Charting (i-care) Horizon Expert Documentation, AdminRx

2 Tasks done in i-care Chart Allergies, Admission data, Home Meds Chart Vital Signs, I&O, Assessments, and so forth. Receive Care Alerts (Recognize alerts and warnings and take appropriate action) Administer medications Review, modify and/or inactivate your charting Chart IVs Locate your documentation and other data in Physician Portal Print Reports

3 HED Abbreviations for some of the i-care Modules Acronym Application Description Horizon Expert Documentation Clinical Documentation Admin Rx Horizon Admin-RX Med/IV administration CO Care Organizer Electronic task list Portal HHS Horizon Physician Portal Horizon Health Summary Clinical Documentation viewer Admission database, home med list, allergies

4 Log In The first time you use the i-care (McKesson) system, your user ID will be your ProMedica Student ID number (88xxxxxx) your password will be phs and the last 4 numbers of your school ID number- You will be asked to change your password after logging in Choose a password that you can remember

5 Log Out Do not use the X to log out of McKesson Do not click here Log out by going to file and then clicking on exit Click Here

6 icare (McKesson) Documentation USING HORIZON EXPERT DOCUMENTATION SYSTEM

7 The main elements and functions of all HED screens are the same.

8 The main elements and functions of all HED screens are the same. The Navigation panel displays the available charting classes. You can click on a class to quickly bring it to the top of screen. The Show All button is used to make sure all the classes are visible.

9 The main elements and functions of all HED screens are the same. The individual items that you may chart on are called result labels or just labels.

10 The main elements and functions of all HED screens are the same. The data that has been entered for a result label is called a result. A result is the result of your charting. A result is the data you entered.

11 The main elements and functions of all HED screens are the same. Each charting class has a class bar.

12 A HED screen is sometimes called a CRv Chartable Review This implies that a HED screen has two sides or views: HED is either in charting mode or in review mode.

13 This HED screen is in Review mode. Date/time columns of prior charting

14 This HED screen is in Charting mode. Documentation date/time No Chart Charting entry fields Save and Cancel

15 BUT WHAT IF I WANT TO GET OUT OF THIS CHARTING MODE AND RETURN TO THE REVIEW MODE

16 If you wish to leave the charting mode and return to the review mode... click Cancel.

17 The charting screen may come up with only a few, and perhaps NO, result labels. Click the Add button on the class bar to choose the labels you wish to chart on.

18 The Select labels screen appears when you click the Add button. Choose the labels you wish to chart on. Then click Add at the bottom.

19 If you click Show All on the class bar all the possible result labels are displayed.

20 The charting panel to the right of the label has charting fields and additional charting categories. Data entry and additional information fields

21 You took the patient temp it is 98 F, hover over the Temp in C (DAS) Area for conversion to C. You enter your data by typing it in fields or using drop downs. You can say how you obtained the Pulse by using the next drop down.

22 On the extreme right of the charting panel are two small icons: Significant which turns your charting red. Annotation for typing a short note regarding your charting for that label.

23 After entering your data, you save your work by clicking Save at the bottom right of the screen.

24 The Review Charting Session screen comes up and this is where you confirm that your charting is accurate. You can also change elements of your entries before you confirm them. Note: in the Admin RX Section - Scan Your ID Badge = Confirm

25 Modifying/Back Charting Rules 12 hours Post Discharge charting 12 hours Back charting 12 hours Modify/clear 12 hours Meds Back charting

26 Remember.. What can happen if your mobile device (WOW) is left unplugged? The battery dies You lose all unsaved data You have to redo all your work not previously saved

27 Save your documentation I-Care has some features built in to protect the patient PIH, so remember: Screen goes blank after 1 minute of inactivity-move mouse or hit a key to reactivate. System times out after 15 minutes and your charting is lost. SAVE YOUR CHARTING BEFORE WALKING AWAY FROM THE COMPUTER Quick log off-on the keyboard hit Ctrl and then the space bar

28 Log Out- Review Do not use the X to log out of McKesson Do not click here Log out by going to file and then clicking on exit Click Here

29 icare (McKesson) Medication Administration USING ADMIN RX

30 AdminRx is a HED screen, and a HED screen is sometimes called a CRv Chartable Review This implies that a HED screen has two sides or views: HED is either in charting mode or in review mode.

31 AdminRx may open showing prior med administrations. the Review mode

32 or it could show meds scheduled to be given. the Charting mode

33 The review mode of the AdminRx CRv shows prior administrations in date-time columns. notice the date-time columns these individual results are the record of what was charted

34 When you first open AdminRx to look at your med list, it will look something like this

35 When you first open AdminRx to look at your med list, it will look something like this If meds have already been charted on the patient, AdminRx will open in the Review mode.

36 The main section of the screen is where you do your meds charting.

37 The AdminRx screen will open, by default, on the Vitals/Meds/IO tab. You can chart your meds from this tab.

38 To open the charting mode of this CRv, click the Admin button on the class bar.

39 To emphasize: to get to the charting mode of AdminRx click the Admin button on the class bar. opens the charting screen

40 When you click the Admin button, the CRv displays in the charting mode

41 The Charting mode of AdminRx Navigation Panel Meds list Fields for administration details such as amounts, volumes, injection sites, etc. Save and Cancel are only found on the Charting mode of a CRv

42 The Charting mode of AdminRx Meds list The Charting mode will also show the documentation time, by default the time the screen was opened, the system date/time at that moment.

43 Summary of the AdminRx Charting mode. no Admin documentation date/time list of meds charting entry fields Save and Cancel

44 But what if I want to get out of this charting mode and return to the review mode?

45 If you wish to leave the charting mode and return to the review mode... click Cancel.

46 You will also find a column of rectangular fields on the right, one for each med. These are special fields to state why you did not give a scheduled med.

47 These fields to the right of the med are used to document that a med was not given. If a med is not given, click the drop down carat and select a reason from the drop down list. Be careful in using these fields: NOT giving a med is not the same as giving a med late.

48 On the right side of the AdminRx charting screen are three items of special note The Override button The Deselect button The Significant and Annotation buttons

49 When you select a med, a backward-curving blue arrow will display This is the undo or deselect button and it reverses the selection of the med. It s like you never touched the med.

50 There are two important icons in the administration details area on the extreme right Significant a toggle switch Annotation for a short note

51 Your meds may have yellow warnings or alerts. You have to address each one. The most common alert is Admin Too Late

52 Deal with alerts using Override, just to the right of the Undo/Deselect arrow. Click Override A Override Reason box comes up.

53 Select a reason for overriding each alert, then click the Override button at the bottom. Clicking Override removes the alerts.

54 Some of these alerts are instructions, like Site Field Required. That s simple enough

55 Select a Site Field from the drop down immediately to the left of the Significant icon (!). Selecting a Site Field removes the alert.

56 BUT!... the alerts and charting details fields will only come up when you select the med. Alerts Charting details These items alerts and charting details won t be here in the Review mode.

57 If The fastest and safest method for selecting your meds is to scan the med s barcode. the scanner doesn t work, or the barcode is damaged, or there is no barcode on the med, then you can select the med by clicking on the name of the med. Only use this as a last resort since it circumvents certain safeguards, is slightly more complex and actually takes longer.

58 Scanner Solid blue light on Modem when linked If scanner is not working, scan bar code on modem to sync with handheld This assures the scanner is in sync with the computer. Solid Green Light on Base When Fully Charged.

59 When you have selected your meds, Scan the patient barcode ID band = Save (the bottom right of the screen). Save is only active if a med has been selected.

60 The Review Charting Session screen appears after you click the Save button. This is a final stop BEFORE you give the meds. Now you will give your meds.

61 After giving the meds, SCAN your student ID. That completes the meds charting.

62 icare (McKesson) IV Administration- I&O RECORDING IV INTAKE UTILIZING IV ADMIN

63 IV Intake In order to have accurate I&O you must record IV intakes from the Alaris smart pumps for each IV bottle (bag).

64 IMPORTANT: IV Intake Each IV bag that is given to the patient MUST be scanned. A shift total may not be greater than the bag scanned. This means: Bag not scanned = inability to obtain accurate total

65 IV Intake Intake volume infused must be separated into Primary and Secondary volumes These volumes cannot be totaled together when entering IV intake into icare

66 IV Intake To separate the primary and secondary volumes select the PRI/SEC volume in the lower left corner of the screen (Continued on next slide)

67 IV Intake The primary and secondary volumes will be displayed. The primary volume needs to be cleared with each new bag that is scanned. (Continued on next slide)

68 IV Intake The secondary volume needs to be manually added to the intake section in the Intake Section - IV meds, and then cleared.

69 Secondary IV Intake (IVPB s) IVPB amounts must manually be added to the IV Meds in the Intake section Add IVPB here This can be done at the time the medication was given or at 11a & 11p

70 Primary IV Intake (Large Volume, Medicated Drips) Primary IV intake will now be recorded in IV Admin: To record IV intake, open IV Admin and select the IV solution

71 Primary IV Intake Obtain and clear the IV volume (primary) infused from the patient s Alaris pump

72 Primary IV Intake Volume infused in the Alaris Smart pump must be cleared every time a new bag is added to maintain a continuous, accurate I&O

73 Primary IV Intake I&O must also continue to be completed at 11am and 11pm to: Count the IV fluids that are not changed frequently Count bags that have been added and not totally infused.

74 Recording IV Intake Record the volume infused for the IV solution in the Volume Infus field in IV Admin and hit the tab key on the computer keyboard

75 Primary IV Intake Each bag needs to be ended in the system. This is done by checking End bottle or entering the amount discarded

76 Recording IV Intake Select your patient s next IV and continue the process for the rest of the IV solutions

77 Saving IV Intake When all of the IV primary volumes have been recorded at 11 am &11 pm click on Save

78 Saving IV Intake After the Save button is clicked, this pop up will appear: Simply Scan your ID Badge, as there is no need to scan the patient since you are not hanging a new IV solution

79 IV Intake View in HED The volume infused flows over to HED in the IV Fluid class:

80 IV Intake View in HED The volume infused flows over to HED in the Intake class:

81 IV Intake View in HED The total volume infused displays in the intake class and in the I & O Summary

82 IV Rate and Dose The rate and dose of the medicated drips will also flow over to HED

83 Documenting I & O When ending or discontinuing an IV bag, you will need to clear the pump and record the volume infused for the ended or discontinued bag

84 Documenting I & O Each bottle (bag) needs to be recorded individually. The amount infused and the amount discarded.