Training Script: Documenting Provider

Transcription

1 Training Script: Dcumenting Prvider Training Script: Dcumenting Prvider Agenda Item Intrductin Lg int Cmputer EMR Mdule Desktp Mdule Review Desktp and EMR in Meditech Test CPOE Sessin 1 Discussin Intrduce yurself, explain hw tday s training will be structured, and explain the WBT training mdule frmat. Give the prvider their New User Frm with their lgin infrmatin. Help them lg int the cmputer and create a new passwrd. Explain the passwrd must be at least 8 characters with ne upper case and ne number. Infrm the prvider passwrds will expire every 180 days. Instruct the prvider t lg int SABA t search fr and/r launch the Meditech EMR Mdule. Instruct the prvider t lg int SABA t search fr and/r launch the Meditech Desktp Mdule. Instruct the prvider t lg int Meditech Test. Change/explain Preferences. Ntify the prvider that Preferences will als need t be dne in the LIVE system. Instruct the prvider t change PIN Number t smething that is fur numbers. The PIN Number will never expire and is used as an electrnic signature fr placing rders and signing dcuments. Instruct the prvider t set up Build Cver fr bth Inpatient and Outpatient. Explain hw prviders can have multiple Cver Lists by using Favrites in the Build Cver rutine. Explain the Sign Up feature. It is imprtant t knw that if yu add yurself as a prvider in this lcatin yu are actually affecting the patient s registratin infrmatin. This is imprtant fr sme billing areas. Explain Patient Lists. My Patients prvides yu a list f patients that have been assciated with yu as either an admitting r attending prvider. Runds Patients is a list that cntains all patients listed n yur My Patients List, any ther patients assciated with prviders that are part f yur grup, r that yu have identified in yur Build Cver rutine. My Discharged Patients and Cver Discharged Patients Lists cntain patients discharged by either yu r yur grup in the last seven days. Find a patient frm yur Runds List Click n the Lists fter buttn at the bttm f the screen. Select Find Patient t search fr desired patient. Add a patient t yur Runds List Click n the Add Patient fter buttn frm either yur My Patients List r yur Runds List. Once in that screen yu can select multiple patient accunts and add them t yur list. Yu will be prmpted t add them t yur My All Patients List as well. Yu may r may nt want t use this list. Instruct the prvider n hw t edit and sign reprts in the system. If a dcument r rder has been placed in the prvider s queue t sign there will be a prmpt when lgging in. The sign buttn will als be highlighted with red lettering. Instruct the prvider t lg int SABA t search fr and/r launch Meditech With questins abut any prjects r services, please cntact the 24/7 Ktenai Health Infrmatin Technlgy Help Desk. By Phne: (tll free) r Page 1

2 Training Script: Dcumenting Prvider Review CPOE Sessin 1 CPOE Sessin 2 Review CPOE Sessin 2 CPOE Sessin 1. After the prvider cmpletes the mdule, explain the prcess f hw rder sets were created initially and hw they can be changed r updated: There was a cmmittee f prviders fr each specialty that spent many mnths determining what rder sets shuld be created fr each specialty. If yu want t request changes t the rder sets, the first step is t talk t yur specialty grup t get all parties t agree with changes. The next step wuld be t call r the Help Desk t request these changes. Smene will cntact yu t get further clarificatin and keep yu updated n the changes. Explain diet rders in mre detail: Imprtant t remember abut diet rders is t always fall back t the previus meal time. This will allw the patient t receive a meal even if the time has passed. Shw the prvider hw t add a mdifier r sub-diet (i.e., n caffeine). Instruct prvider t lg int SABA t search fr and/r launch Meditech CPOE Sessin 2. Review Recncile Recnciling hme medicatins must be cmpleted n admissin and at discharge and may be cmpleted anytime a patient is transferred t a different level f care; r anytime yu want t make changes t their hme medicatin list. The recncile buttn will be emphasized with red lettering anytime there is a change in the hme medicatin list. Review Manage Transfer Manage transfer is the prcess yu will use t enter transfer rders when the patient changes levels f care r when admitting a patient directly r thrugh the Emergency Department. Manage transfer allws yu t stp r cntinue each f the patient s current rders fr the new level f care and add any additinal rders r rder sets intended fr use in the receiving department. When rders are entered via manage transfer, they are held in a pended status and nt visible until the nurse prcesses the transfer. If there are rders yu wish t place nw, befre the patient transfers, thse rders shuld be entered first under current rders prir t pening manage transfer. Yu will still need t cntinue the new rder(s) when entering the manage transfer rutine. Review Discharge T begin yur discharge prcess yu will need t place a Discharge Ambulatry Order frm the Orders panel buttn. Yu can prepare this ahead f time and cntinue t edit as yu anticipate yur patient discharging. Nne f the fields are required. These are the instructins that nursing uses t help facilitate the discharge rder. The next step wuld be t click n the Discharge Plan panel buttn and begin filling ut the required fields. Prescriptins must be edited frm the prescriptin sectin. Yu will be prmpted t g t cnvert t make decisins n inpatient medicatins that yu wish fr yur patient t g hme with and als make changes t the hme medicatin list. Yu will be able t electrnically prescribe allwed medicatins, r With questins abut any prjects r services, please cntact the 24/7 Ktenai Health Infrmatin Technlgy Help Desk. By Phne: (tll free) r Page 2

3 Training Script: Dcumenting Prvider print. The last step wuld be t place the actual Discharge Order. PDOC Dcumenting Select a patient frm My Patients r Runds Patients list by clicking anywhere n the patient infrmatin line. Click the Dcument panel buttn. Reprt screen will be blank if n reprts have been dne n the patient. If reprts have been dne this list will include date, time, dcument name, authr and a status f pending, draft, signed, r Isigned if it is a c-signed reprt. T start a new reprt click n the New fter buttn at the bttm f the screen. A list f reprt types displays fr yu t chse frm. Ntice the Standard fter buttn is highlighted at the bttm f the screen. This is the standard default unless yu set up favrite reprts. Favrite reprts can be setup fr just the reprts that yu will be using. Once yu create a favrites list, that is what yu will default t ging frward. Select the Daily Prgress Nte t begin dcumenting. This is a template t assist in dcumentatin. The buttns n the tp assist in navigating thrugh different sectins in the template. Dcumentatin is dne by typing, pint and click r a cmbinatin. Left click means reprts and puts an val shape arund the answer. Right means denies and places a slash ver the answer. T remve simply left r right click again t remve. There is als an ptin t add a cmment by selecting the symptm and entering the infrmatin in the cmment field at the bttm f the screen. The icn next t the symptm will nw appear highglited in yellw. The CC/HPI sectin autmatically pulls patient demgraphic infrmatin int the reprt. Chief Cmplaint and Subjective infrmatin is dcumented here by the use f free text. The Review f Systems (ROS) allws yu t dcument n systems yu have reviewed. The Exam shws systems in cllapsed frmat. Yu can expand each sectin by clicking the plus sign next t each system. Yu can cllapse each sectin by clicking the minus sign. A checkbx will appear next t any areas yu have dcumented in. If yu see an All icn next t any sectin, yu can click this t select all f the chices within that sectin. Yu can still place individual cmments where wanted. The Data sectin will pull nursing and labratry data int the reprt. Results is a large free text area where yu can enter yur saved data. Data Saver feature is the ability t select data frm the EMR and insert int a free text area in the template. Selectin can nly be dne befre entering the free text area. Enter the EMR and right click n the data t capture. A black diamnd will indicate it is selected. Click the Dcument buttn (nte the buttn is green indicating yu are in an pen template). Click int a free text field like Results n the Data buttn. Click Saved Data at the bttm f the screen. A list f what has With questins abut any prjects r services, please cntact the 24/7 Ktenai Health Infrmatin Technlgy Help Desk. By Phne: (tll free) r Page 3

4 Training Script: Dcumenting Prvider been selected will display. Leave all checked t include. Uncheck t remve. Click Insert at the bttm t paste int the template. Click Remve t erase. The A/P sectin is where Patient Prblems are dcumented alng with Estimated Discharge Date and Assessment and Plan via free text. Patient Prblems can be edited by using the blue Edit buttn. Estimated Date f Discharge shuld be filled in. Yu als have the ptin f entering a cmment by clicking int the cmment field after putting an estimated date f discharge. Fter buttns t nte: The Add Sectin fter buttn allws yu t add an additinal dcumentatin sectin. Quick Save feature can be used if a prvider needs t be pulled away quickly. This ptin will save the dcumentatin in a pending status that nly yu can see. The user will be able t cntinue dcumenting at a later time by accessing the reprt frm the reprt list when entering the dcumentatin ptin. Click n the Edit fter buttn t cntinue the dcumentatin. When dcumentatin is cmplete click n the View/Save buttn at the bttm f the screen. This allws preview f what the final reprt will lk like. Sectins in the template are highlighted in blue. If dcumentatin in a sectin needs t be updated click n the blue header and it will take yu int that sectin f the template. Click View/Save again t return. Carbn Cpy lines are included fr faxing a cpy f the reprt t ther prviders. The first three are a search int the persn dictinary and the furth is a free text fr prviders that are nt in ur system. T search fr a prvider in the dictinary, type in the last name and select the prvider frm the ppulated list. If the prvider is nt in the system, enter the prvider as First Last. Assign Prviders Fr users wh require a c-signer. This is a lkup int the persn dictinary and the search fr the prvider can be dne by last name. If n c-signer is needed leave blank. The reprts save statuses are: Pending: Only saves the reprt fr yu t retrieve and cmplete later. Draft: saves the reprt and sends a cpy t the EMR. Signed: finalizes the reprt and sends a cpy t the EMR. Once a reprt is signed the nly changes that can be made are dne by dcumenting an addendum. Clicking Signed highlights the Enter Pin field where yu enter yur fur digit pin. Click Save and the reprt is filed. Once it is filed yu are returned t the reprt list. Ntice that nw the filed reprt is at the tp f the list. The reprt status will be visible. Cancelling a Pending r Draft Reprt: Click n pending r draft reprt t preview. Click n Delete/Cancel Dcument buttn at the bttm f the page. Once the cnfirmatin is answered the status will change t Cancel. Cancelling a Signed Reprt: If a reprt has been signed and there is a need t cancel the reprt the HIM Department will need t be With questins abut any prjects r services, please cntact the 24/7 Ktenai Health Infrmatin Technlgy Help Desk. By Phne: (tll free) r Page 4

5 Training Script: Dcumenting Prvider cntacted. There is n way fr a user t cancel a signed reprt. Scenari Explain the scenari prcess: This is scenari prepared especially fr yur specialty Walk thrugh the scenari with the prvider Refer t Sessin 2 verbiage Favrites Wrk with the prvider t create favrite rders, rder sets and medicatins in Meditech LIVE. Refer t the prvider scenari fr suggested rder set favrites. Cnclusin Give the prvider all reference materials and the IT Evaluatin frm. Exchange cntact infrmatin fr fllw up with the prvider. With questins abut any prjects r services, please cntact the 24/7 Ktenai Health Infrmatin Technlgy Help Desk. By Phne: (tll free) r Page 5