Transcription

1 Orientation to Sevocity Electronic c Medical Record Geriatrics Rotation

2 INPATIENT OR OUTPATIENT? The First part of this presentation is the OUTPATIENT Orientation Special issues for INPATIENT documentation are located at the end of this presentation

3 Computer Workstations There are three workstations in the Nix office and one on the 19th floor in the Hospital They are to be used for entering patient visits and consultations All clinic visits are entered into the SEVOCITY EMR on the computer. Please ask the Clinic Supervisor if you have any problems logging on.

4 TRAINEE PASSWORD You must obtain a user name and password prior to beginning to use SEVOCITY Please coordinate this prior to your rotation or with ih the clinic i supervisor, Dr. Parker or Dr. Espino

5 MEDICAL STUDENTS Students are only allowed to do the following: Correct and update all Medications and Allergies Enter Past History, Family History, Social History and Review of Systems on Each Patient Seen Update Flow Sheets for health maintenance & illness specific sheets.

6 Computerized Medical Record To access the SEVOCITY program click on one of icons on the desktop. Sevocity Icon

7 Enter your name and password here.

8 Pulling Patient Charts Click here to pull a chart if pts name is not visible on the screen

9 Accessing Past Medical History Past Medical History Can be accessed here

10 Family History Click here to begin Filling in the FH Make sure this Box is checked

11 Social History Make sure this box is checked Click Here to add or update Social lhx

12 Review of Systems: You can check only one box on impaired i Pts. You only need to check the box You only need to check the box patient unable if the patient is cognitively impaired & can not answer reliably

13 Review of Systems No Normal Checkbox You Must mark the specific p ROS Item. Do not use Normal Checkbox

14 Flowsheet: Health Maintenance Scroll here to find the Health Maintenance Flow Sheet and complete it

15 Flowsheet: Other Diseases If the patient has diabetes HTN, etc. create a flowsheet for each one of those as well

16 Medications Add or Add or Change Medications to keep the chart up to date

17 Specific Medications SPECIFIC MEDS are available on the pull down menu. If not available you need to SEARCH MASTER LIST

18 Assessment Add or Add or Edit the Assessment Section

19 Encounter Summary You can always click Note Display to review a draft of the note as it is being developed

20 Done and Route When you complete your portion of the note hit DONE and then SAVE

21 Please Note Students are ONLY allowed to document in the following sections Past Family, Medical, Social History Review of Systems Medications Flowsheets No other documentation is allowed per federal regulations

22 Patient Privacy: Please log out of Sevocity Before you leave the clinic

23 Students, Please Stop Here. Residents & Fellows Continue

24 HPI (History of Present Illness) Click on the ADD HPI Button

25 SAVE TIME with Templates Familiarize yourself with the Templates Available by Clicking the Templates Button. It will save you lots of time Documenting.

26 HPI: Mix and Match Click back and forth for Narrative &Structured Under the HPI you can either add a Narrative portion or point-and-click portion under the Structured part You CAN mix both to come up with a blended HPI

27 Physical Exam You can used the Structured setting to rapidly come up with a physical exam

28 Physical Exam Because of the ease of the structured format Please make sure to document murmurs and other positive physical Findings. If you click the LAST.. Button, it will fill in information from the last exam done

29 Plan & Disposition You can Insert Assessments if you wish To complete the note in An A/P format. Disposition and Instruction sections can be completed via the pull down menus or By clicking Custom

30 INPATIENT ISSUES Preparing the Chart Consultations Followup Notes

31 Preparing The EMR Chart Computer Located at the End of the Hall on 19th Do A Patient Search Date of Birth is More Sensitive You Will Only Get A Patient Half The Time

32 If Pt. IS NOT In Sevocity Follow the Two Steps Below #1--CLICK ON THE PULL/ CREATE ICON #2--Then enter the patient Name and Date of Birth Hi d i Hit return and a new patient record will be created

33 Then Create A New Inpatient Encounter CLICK ON THE NEW ENCOUNTER ICON

34 Encounter Creation Choose BOTH MULTI-SYSTEM and UT medicine i Consult Service Then hit return.. A new encounter will be created!

35 CHOOSE Inpatient Care TEMPLATES Inpatient templates include a generic CONSULTATION Template, which you should use on all patients BUT You can add other templates from other sections as appropriate

36 CONSULT COMPLETION Attendings Must Co Sign the Note Before POSTING PRINT OUT and Get Signatures (yours & the attending) Put in the chart by the end of the day STUDENTS MAY NOT DOCUMENT ON THE IPS CONSULT

37 FOLLOWUP INPATIENT NOTES You can draw from any of the templates BUT Modify outpatient notes to reflect inpatient care

38 Questions? Ask an Attending Ask the office manager