Cerner Update October, 2010

Transcription

1 Cerner Update October, 2010 Facility: All Facilities Audience: All Staff doing Downtime Recovery Charting Charting by Proxy: Ad Hoc Forms and Medications Charting by Proxy on an Ad Hoc Form When you enter information into the patient s medical record for another person, it is called Charting by Proxy. On an Ad Hoc Charting form, the Result Info toolbar icon is used for proxy documentation. The system records the charting in the name of the person who obtained the data and also tracks the name of the individual who actually entered the results into the online patient record. Form Toolbar Step Action 1. Open the Powerform to chart and click the Result Info icon located on the upper right of the screen. The Result Info dialog box opens with your name in the Performed By field. 2. Remove your name and look up the name of the person for whom you are charting (did the original documentation) in the Performed By search field. Either type in the name of the person you are charting for (proxy), or type in a few letters until the name appears in the field, or says Multiple Matches. For Multiple Matches, click the binoculars button to select the name you need. 3. Select the date/time when the event you are charting occurred. 4. Click OK. 5. Complete charting the information on the form. Continued on next page Page 1 of 8

2 Charting by Proxy: Ad Hoc Forms and Medications, Continued 6. Sign the form. You have completed charting this information by proxy. If you need to modify or unchart any of the information, the form can be accessed on the Forms tab. Note: To chart I&O by proxy, you will need to use the I&O form. You cannot chart by proxy directly on the I&O tab. Drains and Tubes have to be documented on the I/O / I-Flowsheet and it doesn t allows proxy. Charting Medications by Proxy: Introduction During extended downtimes medications will be charted on the Downtime MAR. Downtime MARs will need to be printed prior to any scheduled downtime, using the Explorer Menu. When the system comes back up, you will chart medications on the emar by proxy to recover that documentation if the person who administered the medication is no longer available. The Downtime MAR will be used to document date and time of administration, as well as the name of the person administering the medication. Note: The printed MAR is the legal record since it is the first place that a patient s medications are charted during a downtime. It is important that the printed Downtime MAR remains with the patient s chart so it can be scanned after discharge. Charting Medications by Proxy Follow these steps to successfully chart a medication on the emar by proxy: Step Action 1. When the system comes back up, open the patient s chart, go to the MAR tab, and look for the tasks that were charted on paper. In this example, you will find an overdue task associated with a dose of phenytoin that was due on 3/11/07 at NOTE: You will need to wait for Pharmacy to enter the new medication orders before you can chart them on the emar. Page 2 of 8

3 2. Click on the task to open the charting window. As the nurse who is charting by proxy, your name defaults in the Performed by field. 3. You need to remove your name from that field. Place the cursor next to your name, hold down the left button on your computer mouse, and drag the cursor across your name to highlight it. Pressing the Delete key removes your name. 4. When you remove your name, the field turns yellow (remember that the system highlights all required fields). Page 3 of 8

4 5. Enter the name of the nurse who actually administered the medication. You can do this by entering the last name and clicking on the binoculars if there are multiple matches. You can also get a direct match by entering the last and first name. 6. Once you have entered the original nurse s name, verify that all the other information is correct including the administration date and time, and sign the charting documentation. The result displays on the emar. 7. To verify the result, right-click on the result and select View Details from the dropdown menu. Page 4 of 8

5 8. The Results Details window opens and the Medication tab displays when the medication was scheduled to be administered. Page 5 of 8

6 9. While you are still in the Results Details window, select the Action List tab to view the name of the nurse who actually administered the medication and your name as the Proxy Personnel who actually charted it for them on the emar. The Performed Date is the time the medication was actually charted. The Verify action (red highlight) indicates the person who verified that the information on the charting window was correct. Continued on next page Page 6 of 8

7 Charting by Proxy: Ad Hoc Forms and Medications, Continued Downtime Recovery for Nurse Witness Meds After a Cerner downtime, patient records have to be recovered to the Cerner system; this includes medications administered and charted on Downtime MAR during the downtime. If the downtime recovery occurs on another shift, a process is needed to document medications requiring Nurse Witness completion on the emar. Follow these steps to document nurse witness: Step Action 1 Change the Performed by field to the nurse who administered the medication. This information is available on the Downtime MAR. In the Witnessed by field, type Downtime. Downtime Recovery populates the field. 2 Click the Comment button and enter a comment identifying the nurse who witnessed administration. This information is available on the Downtime MAR. Continued on next page Page 7 of 8

8 Charting by Proxy: Ad Hoc Forms and Medications, Continued Downtime Recovery for Nurse Witness Meds (continued) Step Action 3 In the Verify User window, enter the following password: downtimerec Click OK. Then, sign the emar charting window using the upper left corner green checkmark as you always do. 4 The administration details, including the witness is displayed in the Result History as shown in this screen shot. The name of the nurse witness displays when the Comment tab is opened. Note: This provider name and password can only be used during a downtime when the administering/witnessing nurses are no longer available to recover the medication administration and witness information in the system. Page 8 of 8