Cerner PowerChart/FirstNet Home Medication History

Transcription

1 Cerner PowerChart/FirstNet Home Medication History Training Script Training and Education Services, IST Division

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3 Table of Contents INTRODUCTION...5 ICONS...6 TERMINOLOGY...6 SIGNING IN...8 OPENING THE PATIENT S CHART...9 DEMONSTRATION OF SETTING THE ICONS TO DISPLAY IN THE MEDICATION LIST...10 DOCUMENTING UNABLE TO OBTAIN INFORMATION...11 DOCUMENTING NO KNOWN HOME MEDICATION...12 DOCUMENTING A SINGLE MEDICATION...13 DOCUMENTING A COMBINED NAME DRUG THAT IS NOT LISTED...18 DOCUMENTING A MEDICATION WITH A CUSTOM DOSE...20 CANCELLING A DOCUMENTED MEDICATION...23 INDEPENDENT EXERCISE: DOCUMENTING A MEDICATION...24 DOCUMENTING A MEDICATION WITH DIFFERENT DAILY DOSES...25 PRINTING THE REPORT AND TAKING PHONE ORDERS...27 INSTRUCTOR DISCUSSION ON ASSEMBLING THE PATIENT CHART...29 INSTRUCTOR DISCUSSION ON PRINT AND REPLACE AND DOWNTIME PROCEDURES...30 PRINT AND REPLACE PROCEDURE...30 DOWNTIME PROCEDURE...30 DOCUMENTING COMPLIANCE FOR MULTIPLE MEDICATIONS...31 VIEWING COMPLIANCE INFORMATION...33 ON PAPER...33 ELECTRONICALLY...33 VIEWING MEDICATION ORDER INFORMATION...33 Rev. 08/2009 Home Medication History Training Script Page 3

4 DEMONSTRATION AND APPENDIX SECTION DEMONSTRATION INTRODUCTION...34 DEMONSTRATION OF DOCUMENTING A COMPLETED PRESCRIPTION MEDICATION...35 DEMONSTRATION OF DOCUMENTING A CHANGED PRESCRIPTION MEDICATION...36 DEMONSTRATION OF ADDING COMPLIANCE TO A PRESCRIPTION MEDICATION...38 DEMONSTRATION OF VERIFYING BOTH DISCONTINUED AND CONTINUED MEDICATIONS...39 FOR DISCONTINUED MEDICATIONS...39 FOR CONTINUED MEDICATIONS...39 APPENDIX...40 ADDING MEDICATION FAVORITES...40 DELETING MEDICATION FAVORITES...40 VIEWING (ALL MEDICATION) FOLDERS...41 SEARCHING MEDICATION ORDERS...42 SEARCHING FOR DETAIL VALUES...43 REPORT: KH DISCHARGE MEDICATION INFORMATION REPORT...44 REPORT: MEDICATION INFORMATION AND ORDER (MEDICATION RECONCILIATION) REPORT 46 REPORT: MEDICATION RECONCILIATION OBTAINED FROM FORM CENTRAL...47 Page 4 Home Medication History Training Script Rev. 08/2009

5 Introduction This training script contains exercises that are designed to instruct proper documentation of home medication history within the patient s electronic medical record in PowerChart/FirstNet. This training is not intended to provide training for PowerChart/FirstNet completely. For information on how to do other tasks not described in this script, refer to the PowerChart New Hire training manual available on KaleidaScope. Medication History is the first step in the medication reconciliation process. Currently, Medication Reconciliation is done by hand. Entering medication history into PowerChart/FirstNet will produce a legible record of the patient s home medication history, accessible throughout Kaleida Health. Rev. 08/2009 Home Medication History Training Script Page 5

6 Icons The icons used in the Medication List worklist area of the patient s chart within PowerChart are explained below. Documented Status icon: This icon indicates that the home medication has been documented. Ordered Status icon: This icon indicates that the prescription for the medication was written by a licensed provider from a previous visit, using Script Writer. Terminology 1. Home Medication List: This is a list of the patient s best-known medications that the Nurse collects. This includes all of the following types: Medications, herbal remedies, vitamins, over-the-counter drugs, respiratory treatments, prenatal nutrition, vaccines, weekly allergy shots, recent diagnostic/contrast agent and experimental drugs. 2. Medication Reconciliation: Is the process of comparing the patient s best- known list of current medications against physician s admission, transfer, and/or discharge orders. Discrepancies are brought to the prescribing physician s attention and, if appropriate, changes are made to the orders. 3. No Known Home Medications: This should be selected when the patient indicates they are currently not taking any of the above types of home medications. 4. Unable to Obtain: This is selected when information is not available due to the patient being in a non-verbal condition. 5. Miscellaneous Medication: Miscellaneous medication should be selected whenever a medication is not found in the search or can only be described by its indication (heart medication) or physical description (little blue pill), it must be documented as a miscellaneous medication. 6. Primary Medication: This is any medication with no dose, no strength and no route. This is the type of medication order that should be selected, whenever possible in the Add Order window. Page 6 Home Medication History Training Script Rev. 08/2009

7 Terminology (Cont.) 7. Non-Primary Medication: This is a synonym to the Primary Medication. When searching for a medication, Non-Primary Medications will always contain one or more of the following in the order name: Dose, Strength or Route. 8. Modification of Medication List: Home Medications that were entered as Primary Medications can be modified. If you see a medication order on the Medication List that contains a dosage in the order name, then cancel that order and add it again as a primary medication. Example: You should not see Furosemide (Lasix 20mg); and you should see Furosemide (Lasix). 9. Prescription Medications: Medication that has been prescribed by a licensed independent provider (physician). If a Prescription Medication has changed or is no longer prescribed, then it will need to be removed from the home medication list by cancelling it. No prescription should ever be modified. Medications listed in Medication History should NOT be modified. Rev. 08/2009 Home Medication History Training Script Page 7

8 Signing In 1. In the User Name field, type the User Name found on your card. 2. Press the Tab key to move to the Password field. 3. In the Password field, type your password found on your card. 4. Press the Enter key or click the OK button. The Announcement Tool displays. 5. When you are done viewing the information, click the Close button. The Organizer displays. Page 8 Home Medication History Training Script Rev. 08/2009

9 Opening the Patient s Chart 1. From the Patient List that displays on the Organizer, Double-click the patient s name that has been assigned to you on your card. If this is the first time you have opened this patient s chart, you will be asked to select your relationship to the patient. 2. Select your relationship and click the OK button from the Encounter Selection window. 3. If the correct encounter is already selected, click the X in the top right corner to close the window. The chart opens. Table of Contents (TOC) Menu - This is displayed on the left side of the window and allows you to navigate to any area of the patient s chart by clicking a component in the TOC menu. This opens that component s workspace. Workspace - The workspace is displayed on the right side of the window and changes based on which component is selected from the TOC. Toolbars and Menus Table Of Contents (TOC) Menu Workspace Rev. 08/2009 Home Medication History Training Script Page 9

10 Demonstration of Setting the Icons to Display in the Medication List 1. Click Medication List from the TOC menu. Medication List is displayed with no current information. 2. Click Customize View located at the top of the workspace area. Add button Up/Down buttons The Customize View button will display this window. 3. In the Available Columns pane on the left, click on Type. 4. Click the Add button to add it to the Selected Columns pane on the right. 5. Click to select Type in the Selected columns pane. 6. Click the Up button continuously to move Type from the bottom of the list to the top, then click the OK button to close the window when you are done. This will enable Type icons to be displayed as the first column in the Medication List workspace as shown below. The Type column shown here illustrates the difference between a prescription medication and a documented medication. Page 10 Home Medication History Training Script Rev. 08/2009

11 Documenting Unable to Obtain Information The patient has arrived to the hospital unconscious. You are therefore unable to obtain any home medication history. 1. Click the Document Medication by Hx button. 2. Click the checkbox to the left of Unable to Obtain Information. This is selected when information is not available due to the patient being in a non-verbal condition. 3. Click the Document History button in the lower right corner. The ED will not complete the Meds by Hx event until the patient s family provides history for the patient. Unable to Obtain Information does not display on the Medication List tab. 4. Click the Document Medication by Hx button. The window displays Unable to obtain the medication history information. It also displays who documented this information and the date and time of when it was documented. 5. Click the Cancel button in the lower right corner. 6. Click Chart Summary Screen from the TOC menu. Unable to Obtain Information displays. Rev. 08/2009 Home Medication History Training Script Page 11

12 Documenting No Known Home Medication The patient wakes up and indicates they do not take any medications. 1. Click Medication List from the TOC menu. 2. Click the Document Medication by Hx button. 3. Click the checkbox to the left of No Known Home Medications. This should be selected when the patient indicates they are currently taking NO medications including all of the following types: Prescriptions Over-the-counter Supplements Herbs Home remedies Unable To Obtain Information automatically becomes unchecked. 4. Click the Document History button in the lower right corner. No Known Home Medications does not display on the Medication List tab. 5. Click the Document Medication by Hx button. The window displays No known home medications exist for this patient. It also displays who documented this information and the date and time of when it was documented. 6. Click the Cancel button in the lower right corner. 7. Click Chart Summary from the TOC menu. No Known Home Medications displays. The ED Nurse should complete the Meds by Hx event in FirstNet to remove the icon. Page 12 Home Medication History Training Script Rev. 08/2009

13 Documenting a Single Medication The family has arrived to the ED and provides you with further medication information about the patient. The following exercises will take you through entering the patient s home medication list. 1. Click Medication List from the TOC menu. 2. Click the Document Medication by Hx button. 3. Click the Add button found in the Document Medication by Hx window that displays. The Add Order window displays message box prompting to uncheck the No Known Home Medications field. This patient had No Known Home Medications documented. This warning will prompt you to uncheck this option whenever new medication history is entered. 4. Click the Done button to close the Add Order window. 5. On the Document Medication by Hx window that is still open, uncheck the No Known Home Medications field. The display area reads No medications are available for the medication history. 6. Click the Add button again. The Add Order window displays with Document Medication by Hx as the default in the Type field. Rev. 08/2009 Home Medication History Training Script Page 13

14 Documenting a Single Medication (Cont.) 7. In the Find field, type lasix. All instances of Lasix display in the search results area. Notice among the four Lasix medication results listed, the primary medication is the one without any dose, strength or route. Choose the Primary Medication whenever possible! 8. Right-click the Lasix order name. 9. To view optional information about Lasix, click to select Reference Information from the shortcut menu. The Additional Information window displays related information regarding this medication. 10. Click the OK button in the lower right corner. 11. Click the Lasix (Primary Medication) order name. 12. Click the Done button to close the Add Order window. The scratchpad is displayed. Note the Order details in the lower left corner of the screen. There are no required details for this order, but Dose, Route of Administration, Frequency, PRN and Indication are required by process. Page 14 Home Medication History Training Script Rev. 08/2009

15 Documenting a Single Medication (Cont.) If you inadvertently add a medication to the scratchpad, right-click and select Remove. Compliance tab Order details Detail values The term scratchpad refers to this entire window, which is a temporary location where orders are compiled for signing. Colored shapes will display in the Detail Values pane and Order Detail panes to indicate the following about the selected choice: Green circle: Most common choice Blue diamond: Common choice Yellow triangle: Uncommon choice White square (not shown): Least common choice. Verify Dose is highlighted in the Order details pane. 13. Under Common Dose in the Detail values pane select 20mg. 14. Click Route of Administration in the Order details pane. 15. Under Common Routes in the Detail values pane click Oral. Rev. 08/2009 Home Medication History Training Script Page 15

16 Documenting a Single Medication (Cont.) 16. Click Frequency in the Order details pane. 17. Under Common Frequencies in the Detail values pane click BID. 18. Click Indication in the Order details pane. If Indication is unknown, type TBD in the Order details pane. 19. Type CHF in the Detail values pane. 20. Click the Compliance tab. This tab displays Still taking, as prescribed in the Status tab, as well as Patient in the Information Source field. 21. Click the Information Source drop-down and click to select Family. 22. Type in a T in the Last Dose/Date field. Today s date displays. 23. Type in 0800 in the Last Dose/Time field. 24. Click the Document History button in the lower right corner. Lasix now displays in the Medication List worklist area. The Type Column displays the icons. The Order Name column displays the medication in generic (trade) name format as the Primary Medication without dosage. The Status column indicates the medication is Documented. The Details column indicates the selected dose, frequency and indication. Note the equals sign is displayed in the Details, but is only significant if a Non-Primary Medication is selected. Page 16 Home Medication History Training Script Rev. 08/2009

17 Modifying a Documented Medication 1. Click the Document Medication by Hx button. 2. Right-click on Lasix that was documented in the previous exercise. 3. Click to select Modify from the shortcut menu that displays. 4. Verify Dose is highlighted in the Order details pane. 5. Click to select 40mg under Common Doses in the Detail values pane. 6. Click the Document History button in the lower right corner. The Medication List order detail now displays 40mg instead of 20mg. 7. Watch how the instructor demonstrates the display of medications when the Non-Primary medication, Lasix 20 mg, is selected. 8. Watch how the instructor then demonstrates the modification of the order from 20 mg to 40 mg and observe how it displays. Rev. 08/2009 Home Medication History Training Script Page 17

18 Documenting a Combined Name Drug That is Not Listed The family indicates this patient is taking Lortab, and has brought the pill bottle with them. This is a combination drug. 1. Click the Document Medication by Hx button. 2. Click the Add button found in the Document Medication by Hx window that displays. The Add Order window displays. 3. Type lortab in the Find field. After searching, note that there is not a primary choice for Lortab. 4. Click lortab 7.5/500 in the Add Order window. Note: If you did not know the dose, enter this drug as Miscellaneous Medication instead. 5. Click the Done button to close the Add Order window. 6. Verify Dose is highlighted in the Order details pane. 7. Under Common Doses in the Detail value pane, click 1 tab. 8. Click Route of Administration in the Order details pane. 9. Under Common Routes in the Detail values pane click Oral. 10. Click Frequency in the Order details pane. 11. Under Common Frequencies in the Detail values pane click q4-6 hr. 12. Click PRN in the Order details pane. 13. Under Common PRN Reasons in the Detail values pane click as needed for pain. 14. Click Indication in the Order details pane. 15. Type pain in the Detail values pane. 16. Click the Compliance tab. Page 18 Home Medication History Training Script Rev. 08/2009

19 Documenting a Combined Name Drug That is Not Listed (Cont.) 17. Click the Status drop-down and select Still taking, not as prescribed. A blue circle icon displays on the Compliance tab indicating there are missing required details. There is another missing required detail indicator in the lower left corner. The button will dither once the requirements are met. 18. Click the Information Source drop-down and select Family. 19. Click the large arrow drop-down in the Last Dose/Date field. The calendar picker displays as shown in the image below. Click the arrow to display the calendar. Use the arrows on the calendar to toggle through dates. 20. Click to select a date one week ago, from today. 21. Type 2200 in the Last dose/time field. 22. Click the Document History button in the lower right corner. The Orders Services window displays, prompting you to click the First Detail button. 23. Click the First Detail button. 24. Type ran out in the Comments box. 25. Click the Document History button in the lower right corner. Rev. 08/2009 Home Medication History Training Script Page 19

20 Documenting a Medication with a Custom Dose The family indicates this patient is taking Tylenol as an over-the-counter medication. 1. Click the Document Medication by Hx button. 2. Click the Add button found in the Document Medication by Hx window that displays. The Add Order window displays. 3. In the Add Order window change Starts with to Contains. 4. In the Find field, type Tylenol. 5. Click Childrens Tylenol in the Add Order window. 6. Click the Done button to close the Add Order window. 7. Verify Dose is highlighted in the Order details pane. 8. Under Custom Doses in the Detail value pane, type 7.5mL. 9. When entering a custom dose, include the ml unit of measure. 10. Click Route of Administration in the Order details pane. 11. Under Common Routes in the Detail values pane click Oral. 12. Click Frequency in the Order details pane. 13. Under Common Frequencies in the Detail values pane click q6h. 14. Click PRN in the Order details pane. 15. Under Common PRN Reasons in the Detail values pane click as needed for fever. Do not choose None as the PRN reason. 16. Click Indication in the Order details pane. 17. Type fever in the Detail values pane. 25. Click the Compliance tab. Page 20 Home Medication History Training Script Rev. 08/2009

21 Documenting a Medication with a Custom Dose (Cont.) This tab displays Still taking, as prescribed by default in the Status tab, as well as Patient in the Information Source field. 26. Click the Information Source drop-down and click to select Parent. 27. Type in a T in the Last Dose/Date field. Today s date displays. 28. Type in 0615 in the Last Dose/Time field. 29. Click the Document History button in the lower right corner. Documenting a Miscellaneous Medication Later in the patient s visit, the family indicates that they now remember another medication that the patient is taking and describe it as a little blue pill. Whenever a medication is not found in the search or can only be described by its indication (heart medication) or physical description (little blue pill), it must be documented as a miscellaneous medication. 1. Click the Document Medication by Hx button. 2. Click the Add button found in the Document Medication by Hx window that displays. The Add Order window displays. 3. In the Find field, type misc. 4. Click to select Miscellaneous Medication in the Add Order window. Miscellaneous medication should be selected whenever the name for the medication is unknown or if the only indication of a medication is known. For each miscellaneous medication there is, you must have a separate miscellaneous entry. (i.e. blood pressue pill, heart pill etc ) 5. Click the Done button to close the Add Order window. 6. Verify Drug Name is highlighted in the Order details pane. Rev. 08/2009 Home Medication History Training Script Page 21

22 Documenting a Miscellaneous Medication (Cont.) 7. In the Detail values pane, type little blue pill. If the patient indicates that they know the Dose, Route, Frequency and/or Indication, then you should enter the details. Otherwise, if the medication details are unknown, leave the details blank. 8. Click Route of Administration in the Order details pane. Note: The Detail values list displays with a long list due to the Short List field being unchecked. (You can scroll to select an item from Detail values, however step 9 will illustrate another method of typing in the value to find it faster.) 9. Under Common Routes in the Detail values pane click the area that says Type Route Here. 10. Type or under Common Routes in the empty field. A message displays indicating it has found Oral and prompts you to press Enter to select it. 11. Press the Enter key on your keyboard to select Oral. 12. Click Indication in the Order details pane. 13. In the Detail values pane, type depression. 14. Click the Compliance tab. If the Compliance details are unknown, leave the details blank. 15. Click the Information Source drop-down and select Family. 16. Type in the yesterday s date in the Last Dose/Date field. 17. Type 2200 in the Last Dose/time field. 18. Click the Document History button in the lower right corner. It is the responsibility of the Physician to clarify the medication name and details. Page 22 Home Medication History Training Script Rev. 08/2009

23 Cancelling a Documented Medication Medications in the Medication List may need to be removed from the list by using the Cancel/DC method. In this example, the little blue pill has been indentified as Zoloft and will need to be documented appropriately, but first the miscellaneous medication documentation should be cancelled and Zoloft should be entered as a new medication entry. Another reason a medication may need to be cancelled is because the medication treatment has been completed (such as an antibiotic) or when the medication name is not correctly displayed in the Medication List. 1. Click the Document Medication by Hx button. 2. Right-click on miscellaneous medication in the Document Medication by Hx window. A shortcut menu displays. 3. Click Cancel/DC from the shortcut menu to cancel the miscellaneous medication documentation. 4. Verify Discontinue Reason is highlighted in the Order details pane. 5. Click Additional Information available in the Detail values pane. Typing the letter A on the keyboard will go directly to Additional Information available. 6. Click the Document History button in the lower right corner. Discontinued medications will only display on the Medication List as long as the order filter is set to All Medications (All Statuses). Rev. 08/2009 Home Medication History Training Script Page 23

24 Independent Exercise: Documenting a Medication On your own, document that the patient is taking medication with the following parameters: Medication Information Drug: Zoloft Dose: 100mg Route: Oral Frequency: Daily Indication: Depression Compliance Information Status: Still Taking as Prescribed Information Source: Family Date: Yesterday Time: 2200 Page 24 Home Medication History Training Script Rev. 08/2009

25 Documenting a Medication with Different Daily Doses Family has identified that the patient is taking 10mg of Coumadin on Monday, Wednesday and Friday and 5mg on Tuesday, Thursday and Saturday. Different dosages are treated like different medications; each medication is added with its own specific details. 1. Click the Document Medication by Hx button. 2. Click the Add button found in the Document Medication by Hx window that displays. The Add Order window displays. 3. In the Find field, type coum. 4. Click Coumadin in the Add Order window. 5. Click the Done button to close the Add Order window. 6. Verify that Dose is highlighted in the Order details pane. 7. Under Common Doses in the Detail values pane select 10mg. 8. Click Route of Administration in the Order details pane. 9. Under Common Routes in the Detail values pane select oral. 10. Click Frequency in the Order details pane. 11. Uncheck short list field located in the upper right corner of the Detail values pane. The list expands in the Detail values pane. 12. Scroll down to locate q MWF and click to select it. 13. Click Indication in the Order details pane. 14. Type blood thinner in the Detail values pane. 15. Click the Compliance tab. 16. Type in a T in the Last Dose/Date field. Today s date displays. 17. Type in 0800 in the Last Dose/Time field. Rev. 08/2009 Home Medication History Training Script Page 25

26 Documenting a Medication with Different Daily Doses (Cont.) 18. Click the Add button found in the Document Medication by Hx window that displays. The Add Order window displays. 19. In the Find field, type coum. 20. Click Coumadin in the Add Order window. 21. Click the Done button to close the Add Order window. 22. Verify that Dose is highlighted in the Order details pane. 23. Under Common Doses in the Detail values pane select 5mg. 24. Click Route of Administration in the Order details pane. 25. Under Common Routes in the Detail values pane select oral. 26. Click Frequency in the Order details pane. 27. Uncheck the short list field located in the upper right corner of the Detail values pane. The list expands in the Detail values pane. 28. Scroll down to locate q TuThSa and click to select it. Be careful not to select q TuThFSa. 29. Click Indication in the Order details pane. 30. Type blood thinner in the Detail values pane. 31. Click the Compliance tab. 32. Type in yesterday s date in the Last Dose/Date field. 33. Type in 0800 in the Last Dose/Time field. 34. Click the Document History button in the lower right corner. Page 26 Home Medication History Training Script Rev. 08/2009

27 Printing the Report and Taking Phone Orders The patient is going to be admitted as an inpatient. You will be taking admission orders from the admitting physician. You must print a copy of the KH Medication Information and Order (Medication Reconciliation) report to review all of the patient s home medications with the Admitting Physician. 1. To print the KH Medication Information and Order (Medication Reconciliation) report, click the Task menu. 2. Click on Reports. The Reports window displays. 3. Click in the checkbox to the left of KH Medication Information and Order (Medication Reconciliation). 4. Select your printer from the Printer destination drop-down. 5. Click Set as Default button to save printer. 6. Click the Cancel button. Normally, you will click the print button. To view a large sample copy see page 46. Rev. 08/2009 Home Medication History Training Script Page 27

28 Printing the Report and Taking Phone Orders (Cont.) 7. Read the printed home medication list to the MD, as the MD gives the order of Yes or No to Continue on Admission for each medication, document the MD s response in the Admission Orders column for each medication. 8. Complete the Date/Time and add your signature to the bottom of the form. This report is known as Medication Information and Order (Medication Reconciliation) and should be faxed to pharmacy. NO further additions are made to this report. If there were any modifications to the patient s medication history, you must update the patient s Medication List within PowerChart. After a modification, perform a Print and Replace procedure for the Discharge Medication Report. Page 28 Home Medication History Training Script Rev. 08/2009

29 Instructor Discussion on Assembling the Patient Chart The person who assembles the inpatient chart is responsible to print the KH Discharge Medication Information report and place it in the Medication Reconciliation section of the paper chart. Any modifications or additions to the Medication List prior to the patient being discharged will require a Print and Replace procedure to occur. Follow the same steps as in the previous exercise to print this report, instead selecting KH Discharge Medication Information the Reports window as shown below. To view a large sample copy see page 44. Rev. 08/2009 Home Medication History Training Script Page 29

30 Instructor Discussion on Print and Replace and Downtime Procedures Print and Replace Procedure When making modifications or additions to the Medication List, you must print the Discharge Medication Information report and place it in the Medication Reconcilation section of the paper chart and remove the previously printed report. The bottom right corner of the report displays the date and time the report was last printed. Blank Medication Reconciliation form is utilized when additional home medications have been identified. This form is obtained from Forms Central (located on your desktop). The blank form is completed by hand and then faxed to Pharmacy and placed in the Orders section of the paper chart. These additional home medications are then entered into PowerChart, followed by a Print and Replace procedure. Downtime Procedure Utilize the Blank Medication Reconciliation form during downtime. This form is obtained from Forms Central (located on your desktop). The blank form is completed by hand and then faxed to Pharmacy and placed in the Orders section of the paper chart. When PowerChart becomes available these home medications are entered into PowerChart for the Discharge Medication Information report to be utilized at the time of discharging the patient. Page 30 Home Medication History Training Script Rev. 08/2009

31 Documenting Compliance for Multiple Medications The physician has identified that the patient is taking both Digoxin and Aspirin for heart problems. The physician writes the newly identified home medications on the Blank Medication Reconciliation form obtained from Forms Central (located on your desktop). The handwritten form will be faxed to the pharmacy and the nurse will enter the newly identified home medications in PowerChart. 1. Click the Document Medication by Hx button. 2. Click the Add button found in the Document Medication by Hx window that displays. The Add Order window displays. 3. In the Find field, type dig. 4. Click Digoxin in the Add Order window. 5. Click the Done button to close the Add Order window. 6. Verify that Dose is highlighted in the Order details pane. 7. Under Common Doses in the Detail values pane select 0.25mg. 8. Click Route of Administration in the Order details pane. 9. Under Common Routes in the Detail values pane select oral. 10. Click Frequency in the Order details pane. 11. Under Common Frequencies select Daily from the Detail value pane. 12. Click Indication from the Order details pane. 13. Type heart problems in the Detail values pane. 14. Click the Add button found in the Document Medication by Hx window that displays. The Add Order window displays. 15. In the Find field, type aspir. 16. Click Aspirin in the Add Order window. 17. Click the Done button to close the Add Order window. Rev. 08/2009 Home Medication History Training Script Page 31

32 Documenting Compliance for Multiple Medications (Cont.) 18. Verify that Dose is highlighted in the Order details pane. 19. Under Common Doses in the Detail values pane select 81mg. 20. Click Route of Administration in the Order details pane. 21. Under Common Routes in the Detail values pane select oral. 22. Click Frequency in the Order details pane. 23. Under Common Frequencies select Daily from the Detail value pane. 24. Click Indication from the Order details pane. 25. Type heart problems in the Detail values pane. 26. In the upper area of the Document Medication by Hx window click on Digoxin so that it is selected. 27. Hold down the CTRL key on the keyboard and simultaneously click on Aspirin so that it is also selected. 28. Click the Compliance tab. 29. Click the drop-down for Information Source and select Physician. 30. Type in yesterday s date in the Last Dose/Date field. 31. Type in 1800 in the Last Dose/Time field. 32. Click the Document History button in the lower right corner. The Medication List displays all medications. 33. Click the Order Name column heading to sort the medications in ascending order. 34. Click the Order Name column heading once more to sort the medications in descending order. 35. Perform a Print and Replace procedure for the Discharge Medication Report. Page 32 Home Medication History Training Script Rev. 08/2009

33 Viewing Compliance Information On Paper The printed Medication Information and Order (Medication Reconciliation) report will display medications alphabetically and display compliance information. However, the Compliance Comment field (from the Compliance tab) will not display on this report. For instructions on printing this report see page 27. Electronically The Document Medication by Hx window is the only place where all compliance information is displayed within PowerChart. 1. Click the Document Medication by Hx button. Note the compliance information for Last Occurred (Last dose date/time), Information Source, Compliance Status and Compliance Comments are documented here for each medication. Note the Compliance Information that was documented simultaneously in the previous exercise (Digoxin and Aspirin) displays here with the same information listed in the compliance fields Note the Compliance Comment for Lortab. 2. Click the Cancel button in the lower right corner. Viewing Medication Order Information 1. Right-click on any medication in the Medication List. 2. Click to select Order Information from the shortcut menu. The Order Information window displays. Note the Patient Demographic Bar contains the person who entered the medication along with the date and time of entry in the Original order entered by field. This same information is also available by clicking the History tab in this same Order Information window. 3. Close the patients chart by clicking the X in the upper right corner, or by clicking the X on the patient name tab. Rev. 08/2009 Home Medication History Training Script Page 33

34 Demonstration Introduction The following section will be an instructor based demonstration. It is not necessary to use your computer at this time. Please log out of PowerChart completely. You will be going through a realistic scenario of a patient who has both documented home medications and prescription medications. Putting everything together you have learned thus far, you will walk through the steps of how to update the Medication List accordingly to match the MD s orders. Page 34 Home Medication History Training Script Rev. 08/2009

35 Demonstration of Documenting a Completed Prescription Medication Consider you have now fast forwarded through time, and the patient had been discharged a month ago. Today, they arrive back in the hospital. Their previous medications need to be verified and updated. 1. From the Patient List that displays on the Organizer, Double-click the patient s name that has been assigned to you on your card. 2. Click Medication List from the TOC menu. 3. Click the Status field header to sort the status column in ascending order. 4. Verify the patient is still taking the prescription medication(s). If Patient states they have completed the prescription, then you must Cancel/DC the prescription. 5. Right-click on the medication(s) with a pill bottle in the Type column in the Medication List that patient states are completed. 6. Click to select Cancel/DC from the shortcut menu. According to Kaleida Health policy, do not modify prescription medications. Rev. 08/2009 Home Medication History Training Script Page 35

36 Demonstration of Documenting a Completed Prescription Medication (Cont.) The Ordering Physician window displays the prescribing physician in the window. 7. Click the OK button to close the Ordering Physician window. 8. Verify Discontinue Reason is highlighted in the Order details pane. 9. Select Patient Status Change in the Detail values pane. 10. Click the Orders for Signature button in the lower right corner. 11. Click the Sign button in the lower right corner. Demonstration of Documenting a Changed Prescription Medication The patient stated the prescribed Lasix dose has changed, and must be cancelled because no prescription should ever be modified. 1. Verify Medication List is displayed. 2. Right-click on Lasix. 3. Click to select Cancel/DC from the shortcut menu. The Ordering Physician window displays the prescribing physician in the window. 4. Click the OK button to close the Ordering Physician window. 5. Verify Discontinue Reason is highlighted in the Order details pane. 6. Select Patient Status Change in the Detail values pane. 7. Click the Orders for Signature button in the lower right corner. 8. Click the Sign button in the lower right corner. Page 36 Home Medication History Training Script Rev. 08/2009

37 Demonstration of Documenting a Changed Prescription Medication (Cont) 9. Click the Document Medication by Hx button. 10. Click the Add button found in the Document Medication by Hx window that displays. The Add Order window displays with Document Medication by Hx as the default in the Type field. 11. In the Find field, type lasix. All instances of Lasix display in the search results area. 12. Click on Lasix (Primary Medication) order name. 13. Click the Done button in the lower right corner. 14. Verify Dose is selected in the Order details pane. 15. Under Common Dose in the Detail values pane select 40mg. 16. Click Route of Administration in the Order details pane. 17. Under Common Routes in the Detail values pane click Oral. 18. Click Frequency in the Order details pane. 19. Under Common Frequencies in the Detail values pane click BID. 30. Click Indication in the Detail values pane. 31. Type CHF in the Detail values pane. 32. Click the Compliance tab. This tab displays Still taking, as prescribed by default in the Status tab, as well as Patient in the Information Source field. 33. Type in the date for two days ago in the Last Dose/Date field. 34. Type in 1800 in the Last Dose/Time field. 35. Click the Document History button in the lower left corner. Lasix now displays in the Medication List worklist area. Rev. 08/2009 Home Medication History Training Script Page 37

38 Demonstration of Adding Compliance to a Prescription Medication You have verified all prescriptions from the Medication List. All that is left to do on the continued prescriptions is to add Compliance information. The following steps will be repeated for each medication. 1. Click the Document Medication by Hx button. 2. Right-click on a medication row. 3. Click to select Add/Modify Compliance from the shortcut menu that displays. The scratchpad now displays the Compliance tab active at the bottom of the screen with Still taking, as prescribed by default in the Status tab, as well as Patient in the Information Source field. 4. Type in yesterdays date in the Last Dose/Date field. 5. Type in 1200 in the Last Dose/Time field. Page 38 Home Medication History Training Script Rev. 08/2009

39 Demonstration of Verifying Both Discontinued and Continued Medications Under the Document Medications by Hx area of the scratchpad, verify with the patient/family if they are still taking each of the medications or if the medication has been discontinued by the physician. If the medication has been discontinued, you must cancel/dc the medication. If the medication has been continued, then you must add Compliance information to the medication. For Discontinued Medications 1. Right-click on a medication row of a medication that has been discontinued. 2. Click to select Cancel/DC from the shortcut menu that displays. 3. Verify Discontinue Reason is highlighted in the Order details pane. 4. Select Patient No Longer on Medication in the Detail values pane. For Continued Medications 5. Right-click on a medication row of a medication that has been continued. 6. Click to select Add/Modify Compliance from the shortcut menu that displays. The scratchpad now displays the Compliance tab active at the bottom of the screen with Still taking, as prescribed by default in the Status tab, as well as Patient in the Information Source field. 7. Type in yesterdays date in the Last Dose/Date field. 8. Type in 1200 in the Last Dose/Time field. 9. Click the Document History button in the lower right corner. Rev. 08/2009 Home Medication History Training Script Page 39

40 Appendix Adding Medication Favorites Favorites allow you to quickly locate frequently used Medications. 1. Click the Document Medication by Hx button. 2. Click the Add button found in the Document Medication by Hx window that displays. 3. Search for the medication in the Find field. 4. Once the desired medication is displayed in the search results area, right-click on it. 5. Select Add to Favorites from the shortcut menu that is displayed. 6. The Add Favorite window displays. 7. Click the OK button. By default the next time the Add Order window is opened, your favorites will be displayed. Deleting Medication Favorites 1. Click the Document Medication by Hx button. 2. Click the Add button found in the Document Medication by Hx window that displays. Your favorites are displayed in the Add Order window by default. 3. Right-click the Medication order to remove from favorites. 4. Click Remove from Favorites. The Medication order will no longer be listed. Page 40 Home Medication History Training Script Rev. 08/2009

41 Appendix (Cont.) Viewing (All Medication) Folders Viewing the (all medication) Folders allows you to view a complete listing of all medication subfolders which contain medication orders. This is an optional method used to locate a medication as opposed to using the Find field in the Add Order window. 1. Click the Document Medication by Hx button. 2. Click the Add button found in the Document Medication by Hx window that displays. The Add Order window is displayed. 3. Click the Folders button. All medication subfolders are displayed. Double-clicking the folder will display all medications within that folder category. Rev. 08/2009 Home Medication History Training Script Page 41

42 Appendix (Cont.) Searching Medication Orders Use Contains versus Starts with when you do not know the placement of the letters. The below example shows a search result for children using Starts with. The result displays every medication that starts with children. The next example illustrates the same search for children but using Contains. The result displays every medication with children in the title. Maximize Scroll If the results are numerous, either maximize or scroll to see additional medications not in the current view. If you still can t find what you are looking for, check your spelling. If you are unsure of the spelling, type in fewer letters (Example: Change children to child or ch or chi ). Page 42 Home Medication History Training Script Rev. 08/2009

43 Appendix (Cont.) Searching For Detail values After you have selected the order and it is visible on the scratchpad, the Order detail pane on the left are the questions, and the Detail value pane on the right is the answers. It is a required Kaleida Health process to answer the first five Order details if known for the medication selected. (They will not be highlighted in yellow as required fields but still must be addressed.) Dose Route of Administration Frequency PRN (if applicable) Indication For each of these Order details there are several methods to selecting the current answer from the Detail values pane. Method #1: 1. Scroll through the list and then click to select the desired answer. The Order details Route of Administration and Frequency have a larger list that doesn t display fully by default. To display the entire list, uncheck the Short List box in the Detail values pane. Method #2: 1. Uncheck the Short List (described above). 2. Click to select None in the Detail Values pane under the Common section. 3. Once the None area is highlighted, type the letter(s) of the answer and you will be directed to that area of the list. For example typing a B on your keyboard will take you to the Detail values that start with B. Be cautious when doing this, you may need to type a space after the letter if it doesn t work correctly. For example typing q space m takes you to q MFSa, while typing qm takes you to qmonth. Method #3: 1. If the answer is not located among the search values, use the Custom section in the Detail values pane to type in the answer directly (using approved units of measure when applicable). Rev. 08/2009 Home Medication History Training Script Page 43

44 Appendix (Cont.) Report: KH Discharge Medication Information Report This is a sample image page 1 of the Discharge Medication Information report. Page 44 Home Medication History Training Script Rev. 08/2009

45 Appendix (Cont.) This is a sample image page 2 of the Discharge Medication Information report. Rev. 08/2009 Home Medication History Training Script Page 45

46 Appendix (Cont.) Report: Medication Information and Order (Medication Reconciliation) Report Page 46 Home Medication History Training Script Rev. 08/2009

47 Appendix (Cont.) Report: Medication Reconciliation Obtained from Form Central This is an example of a blank Medication Reconciliation report obtained from Form Central. Rev. 08/2009 Home Medication History Training Script Page 47