EMR DOCUMENTATION LYNX. Instructor Script

Transcription

1 EMR DOCUMENTATION LYNX Instructor Script

2

3 Table of Contents TABLE OF CONTENTS INFORMATION SECURITY AND CONFIDENTIALITY... 4 OVERVIEW... 5 LEARNING OBJECTIVES... 5 TIPS AND TRICKS... 5 SOLUTION ICONS... 5 SIGNING ON... 6 PRESCRIBING... 7 ADDING PATIENT PREFERRED PHARMACIES... 7 TIPS FOR USING THE PHARMACY SEARCH... 9 PATIENT PREFERRED TAB... 9 DOCUMENTING HOME MEDICATIONS ENTERING A NEW PRESCRIPTION PRESCRIBING ROUTING ERRORS RENEWAL REQUESTS TELEPHONE RX RENEWAL REQUESTS EXAMPLES: Amoxicillin: Enalapril: Diazepam: ORDERS TO SIGN RENEWAL REQUESTS SAME MEDICATION, DIFFERENT FORMULATION REPLACING A RENEWAL REQUEST WITH A DIFFERENT MEDICATION REJECTING RENEWAL REQUESTS RENEWAL REQUESTS FOR CONTROLLED SUBSTANCES RECOMMENDED WORKFLOW: RENEWAL REQUESTS FOR CONTROLLED SUBSTANCES LOGGING OUT

4 EMR Documentation eprescribe (Rev. 12/16/2011) INFORMATION SECURITY AND CONFIDENTIALITY When dealing with computerized health care records, specific confidentiality and security issues must be followed to protect the patient. There are increasing HIPAA and Joint Commission regulations that dictate how these records are handled. When signing on to PowerChart use your own User Name and Password, do not share. The application keeps an audit trail, or record, of who enters each chart and when. PowerChart records who signed into the chart and who documented each piece of information in the chart. Do not leave the computer while still signed on. Do not access any information that does not apply to your current job and caseload. 4

5 Overview OVERVIEW This reference guide was designed to supplement a hands-on, instructor led session. Pictures of various screens have been included in order to show general information placement. Please note that these are standard screens and may not match exactly to those at your site. LEARNING OBJECTIVES Send a new prescription to a pharmacy via eprescribing Reject an erenewal request from a pharmacy Modify an erenewal request before accepting Find a patient match for erenewal requests that have no match Address routing errors from new prescriptions in the Message Center Verify preferred pharmacy information (add new, delete old information) Pull in external Rx medication hx into medication hx list TIPS AND TRICKS Press and release the secondary (usually right) mouse button and see if any of the menu items apply. Use your cursor to hover over the buttons to see if any of the button names jog your memory. If a single mouse click doesn t work, try a double mouse click. SOLUTION ICONS Solutions use unique icons to designate buttons that have specific functionality. To view the icons and their meanings for a particular application, open the table of contents, located in the left pane of the application s Help viewer. Expand the Menus and Toolbars book, and then select the Toolbar topic to display the application s icons in the main pane of the Help viewer. 5

6 EMR Documentation eprescribe (Rev. 1/12/2012) SIGNING ON Follow this procedure to log into the application: 1. Double-click the PowerChart icon on the desktop. The Cerner log-in screen displays. 2. Type your user id into the User Name field. 3. Type your password into the Password field. 4. Click the OK button. 6

7 Error! Reference source not found. PRESCRIBING eprescribing allows a physician or practitioner to electronically write a prescription and transmit the prescription to the pharmacy electronically. eprescribing software utilizes a network to provide a secure, HIPAA compliant encoded communication link to and from participating pharmacies. Providers must be valid prescribers and be registered with our credentialing medical staff office and have an SPI #. Users will have the ability to receive and respond to prescription renewal requests from pharmacies. When prescription renewal requests are received from a pharmacy electronically, an erx renewal request is created and is viewable in PowerOrders and the Message Center. New Functionality: ADDING PATIENT PREFERRED PHARMACIES When using eprescribe for the first time, you will need to add a Patient Preferred Pharmacy. Any subsequent visits will require verification or modification from the patient. 1. While in a patient chart, select the Patient Pharmacy icon on the toolbar. The Custom Patient Preferred Pharmacies window displays. 2. Click the Search tab. The city and state will default in the search field based on the patient s demographic information. 3. Type in the pharmacy name you would like to add and click the Search button. Note: If multiple pharmacies result, add additional information (street, zip) to narrow your search results. 7

8 EMR Documentation eprescribe (Rev. 1/12/2012) 4. Right-click on the pharmacy you would like to add to the patient s preferred pharmacy list and click the Add button. Note: If the patient has multiple pharmacies on the Preferred Pharmacy list, you can choose the default pharmacy by right-clicking the pharmacy name and choose Set as Default. 5. During subsequent visits, verify with the patient that the pharmacy information is correct. If patient has changed pharmacies, follow the steps above to add the new pharmacy. 8

9 Error! Reference source not found. TIPS FOR USING THE PHARMACY SEARCH Less is more. Do not enter the entire pharmacy name or address into the search fields. Search with one word from the name or the street name. For mail order pharmacies remove the city and state only and search using the pharmacy name. (example: Medco) If you have a pill bottle or fax from a pharmacy in hand, search by the Street Number. M ake sure the defaulted city and state are correct. If you do not have the street address and are seeing the patient, search by Pharmacy Name or by Pharmacy Name in combination with Street Name. Make sure the default city and state are correct. Do not enter extra street information into the address like Ave, Dr, St, etc. Have the patient present and engage them when trying to search for a pharmacy. PATIENT PREFERRED TAB The list is automatically updated when new prescriptions are sent or electronic renewal messages are received from Pharmacies. This is the default tab when a pharmacy has been selected for the patient previously. Note: When renewing an existing prescription routed to a pharmacy with eprescribing, the system will not retain the original pharmacy as the routing selection because it cannot be assumed that the pharmacy is still valid. 9

10 EMR Documentation eprescribe (Rev. 1/12/2012) The following are two options for multiple prescriptions with a mix of scheduled or controlled (pain medications, sedatives) and non-controlled medications (antibiotics, blood pressure medications, etc). 1. If you want to, Print all prescriptions (per patient request). Enter the scheduled medications first and the printer will default for the remaining orders. 2. If you want to, Send non-scheduled medications electronically and print the scheduled medications. Enter the non-scheduled medications first, select the pharmacy, and use this for all nonscheduled orders Enter the scheduled medications last and the printer will default for the remaining orders Note: This is a recommendation to help organize the workflow when ordering multiple scheduled and non-scheduled medications at the same time. It is possible to place them in any order and any grouping. 10

11 Error! Reference source not found. DOCUMENTING HOME MEDICATIONS 1. Confirm Documented History displayed on the profile at the bedside with the patient. 2. Enter any missing details. 3. Provider confirms verbal consent for SureScripts. Consent o Every time you access SureScripts, you need to verify that the patient gave consent for you to view. External History 4. Click the external hx button on the toolbar. 5. When the verbal consent displays, obtain consent and click consent granted. NOTE: This is a sample; our verbiage will be different. The external data will display. If the patient denies the consent click consent denied and it will display each time the External History button is clicked. 6. Review the External Medication History with the patient. NOTE: If there is a medication on the External History that is not on the patient s documented history, you may convert that to Documented Medication. 7. Right-click the medication and select Convert to Documented Medication. This step must be completed for each individual medication. 11

12 EMR Documentation eprescribe (Rev. 1/12/2012) Plans o The Patient Prescription coverage will be listed here. NOTE: External Rx History is a tool to verify the accuracy of the Medication History, gather additional details or prompt the patient for medications that have not yet been documented. ENTERING A NEW PRESCRIPTION The eprescribing process begins by placing a new prescription order. 1. Within PowerNote, Orders or Depart, click the Add button. This launches the order search dialog box. 2. Set the prescription ordering conversation type as Ambulatory Meds as Rx. 3. Search for and select the medication to be prescribed. Note: With eprescribing, a preference has been set restricting the list of medications that can be ordered to a list of products. This reduces the risk that pharmacies will not be able to recognize what to dispense and in turn reduces the potential for eprescribing error messages. For example, brand names and generic names without product details are not descriptive enough. 12

13 Error! Reference source not found. 4. Click the Send To button. The Prescription Routing window opens. 5. Select the Pharmacy from the Send to list; verify that this is where the patient wants the prescription sent. After the order is signed and the order profile is refreshed, the order displays on the profile in an ordered status and the name of the pharmacy displays in the clinical display line. 13

14 EMR Documentation eprescribe (Rev. 1/12/2012) The following text is displayed when the system is unable to send the prescription to the pharmacy based on the current order details: Send to Pharmacy is not available because at least one of your unsigned prescriptions is not eligible. (Note the default Send to option is Printer in these situations). Send a prescription to the pharmacy is not an available option in the following situations: 6. Schedule medications are excluded by DEA regulation. These prescriptions may be printed, and the print option will default. 7. Critical Patient Demographics are missing (these are viewable on the demographic banner) Last Name, First Name, Gender, Date of birth. 14

15 Error! Reference source not found. PRESCRIBING ROUTING ERRORS If the transmission of a prescription order to a pharmacy fails for any reason, a routing error message is sent to the ordering provider s Message Center or a Message Center pool. There are three routing error messages that can be seen in Message Center: 1. Prescription routing temporarily unavailable. 2. Unable to communicate with pharmacy. 3. Prescription too long for pharmacy system. The total length of the combined order details is currently limited to 350 characters. The special instructions field is limited to 255 characters, but a combination of long special instructions, PRN instructions, or other SIG line order details may cause the character limit to be exceeded. Once a routing error is received, the prescription should be printed and given to the patient or if the pharmacy calls stating they did not receive the prescription, a verbal phone order is provided. Note: It is not recommended to attempt to re-transmit the prescription electronically because in most cases the cause for failure cannot be corrected by the end user and the prescription will fail again. Within the routing error message, the user can: 1. Click the pharmacy name to view information about the pharmacy and the prescription to place a call to the pharmacy. 2. Click the Med List button to open the patient s Medication List and print the prescription and hand it to the patient. 15

16 EMR Documentation eprescribe (Rev. 1/12/2012) 3. Enter a comment that includes the name of the prescription to the message indicating what action was taken After the prescription is called, faxed or given to the pharmacy/patient. 4. Save the message to the patient s chart and delete from the message center. erx Non-Match Renewal request for an order that did not originate from eprescribing is received. A single patient match cannot be determined because multiple or no patients meet the criteria for the suspect match on Last Name, Gender, Date of Birth, and Zip Code. erx Non-matches go to the Nursing Message Center pool. They are displayed in an erx Non-Matches folder. The Patient Name column is empty showing that no match could be made. 1. Double-click the non-match message to open it. The Patient Match window will automatically open. The Pharmacy Demographics section at the top of the window contains the patient demographic information sent by the pharmacy. 2. Search for the correct patient and match them to the renewal request. 3. Click the Cancel button and close the Patient Match window to reject the renewal request if a patient cannot be identified. RENEWAL REQUESTS Note that there are two folders in Message Center; one for Renewals and one for erenewals. TELEPHONE Renewal Requests will follow the current process with phone triage. Nurse will create a proposal and send to provider via message center. 16

17 Error! Reference source not found. Reminders: RN must get pharmacy info from the patient and verify that it is in the Patient Preferred tab. When building the Rx proposal, the RN must confirm that it is going to the correct pharmacy. Provider can send electronically. RX RENEWAL REQUESTS Renewal requests are sent back from the pharmacy with the ordering provider s. To pace your name on the renewal, as well as enter the indication, you must select the change option. You must enter the indication for the medication as well as the number of refills. You can then sign. This must be done for each erenewal Request. Once signed you will see who first ordered the prescription and who renewed the prescription as details in the order information. Note: You cannot accept all with erenewal Requests. You must click the delta icon for each Rx individually. Note: Click the refresh button after any action in the Message Center, or when returning to the Message Center after taking action in a patient s chart. This ensures that the information displayed is up-to-date. erx Renewal Renewal request for an order that was originally placed through eprescribing is received and a patient match has been determined from the patient associated to the original order. erx Renewals and associated documentation (Response tab in message) will be saved to the encounter that the original order was placed on, unless you selected the AMB communication encounter. 17

18 EMR Documentation eprescribe (Rev. 1/12/2012) 1. Double-click a message to open it and view the renewal request. Multiple renewal requests for the same patient, same prescriber, from the same pharmacy, where no action has been taken yet are rolled up into one message and the requests separated with a blue bar. The individual action icons are displayed to the right of the prescription. o o o The green circle with a checkmark is the individual accept icon. The red circle with a slash across it is the individual reject icon. The delta is the modify icon and will give you the options of same medication, different dose or formulation and different medication when selected. The system displays any previous prescriptions in the patient s chart that will be automatically completed upon accepting the renewal, below the standard prescription information. NOTE: You may launch the Medication List to review the patient s other medications before taking action on a renewal request. 2. Once you have reviewed the med list, click the Done button to return to the renewal message. 3. Click the Delta (modify) and choose Same Medication, Different Dose or Formulation. Enter the Indication Enter the refills If you need to change any other details, make those changes here. 4. When order details are complete, click the Sign button. You will be returned to the message. 5. If a message displays Placing orders on a Discharged Patient, do you wish to Continue? click the Yes button. 6. If there are additional medication renewal requests contained in that message, repeat steps 3 through When all renewals have been addressed, Delete the message. Every message has a Request and Response tab. The Request tab is the work queue of requests that still need to be addressed. 18

19 Error! Reference source not found. The Response tab is the documentation that includes the original request(s) from the pharmacy along with any responses and modifications made by providers and is saved to the patient s chart. Modifying a renewal creates an active prescription on the patient s profile for that orderable and sends an approval response to the pharmacy. The signature line details (dose, route, frequency, etc.) sent in the renewal request is stored in the special instructions field of the prescription. The Response tab shows the actions that the user has taken on the message. A status of Not Approved New Rx to follow status is sent to the pharmacy and includes the updated information and any note that may have been entered on the erx renewal request. 19

20 EMR Documentation eprescribe (Rev. 1/12/2012) 8. Click the Request tab in the message to view the renewal requests that have been addressed. EXAMPLES: Message with multiple renewal requests: Amoxicillin (non-scheduled) Enalapril (non-scheduled) Diazepam (scheduled medication) Scheduled medications are easily identified as they do not allow accept or different dose actions. Only reject or replace with non-scheduled medication. 1. Click the request window action options to take action on all orders displayed in the request message. The system warns if you try to accept a scheduled medication using the Accept All option or the Accept All and Next, and blocks the accept action. Note: Kaleida Policy states the Accept All option cannot be used because the indication must be documented. 20

21 Error! Reference source not found. 2. Select Med list in the message to review current active medications. In this example, the renewals are visible on the screen as well as current active medications. 3. Click the Done button to return the original order message. 21

22 EMR Documentation eprescribe (Rev. 1/12/2012) AMOXICILLIN: 1. Select Reject. You do not want to renew, because this is an Acute treatment and the patient needs to be seen. 2. Request the patient come to office for follow-up for Amoxicillin. 3. Click the OK button. 22

23 Error! Reference source not found. ENALAPRIL: You want to approve this renewal. 1. Select the Delta and choose Same Medication, Different dose or formulation. 2. Change the refill quantity to In the Indication field enter Heart Failure. Note: Accept with Modify only allows changes to refill quantity and notes to pharmacy. 23

24 EMR Documentation eprescribe (Rev. 1/12/2012) DIAZEPAM: You may want to replace with a different medication. 1. Select reject. Diazepam is a scheduled med, the list of valid order actions is smaller. 2. Click the Delta (modify) and choose Different Medication. The Order Entry window will display. 3. Search for the Medication you wish to prescribe and follow the new prescription process. 4. When you have entered all of the Order Details, click the Done button. 5. Click the Sign button. NOTE: Replace is not an available option for a controlled substance. You must reject it and write a new prescription. 24

25 Error! Reference source not found. ORDERS TO SIGN Rejected proposals are not included in Orders for Signature as these do not require additional signature. 1. Click the Sign button to sign the orders and return to the message. The renewal response is created with all order actions taken from the medication list: All order actions have been saved to the chart at this time. The scheduled medication has been printed as specified by the provider. 2. Provider may forward the message to a specific resource or a pool to complete the final communications with the pharmacy if needed. 25

26 EMR Documentation eprescribe (Rev. 1/12/2012) 3. Provider then deletes the original message as all actions are completed. 4. If forwarded for further communication, the staff may open the message and hyperlink to obtain pharmacy contact information. Note: The message is located in the erx Renewals folder because the original message was a renewal from the pharmacy. 5. Fax or call in the prescription. 6. Add a final addendum indicating when it was sent to the pharmacy. 26

27 Error! Reference source not found. 7. Click Save Addendum and close the message. Tip: The pharmacy fax number can be copied from the pharmacy information window into the note by using CTRL+C to copy and CTRL+V to paste. 27

28 EMR Documentation eprescribe (Rev. 1/12/2012) 8. Click Search to open the Patient Search dialog box. The system enters the patient s last name from the pharmacy demographics by default. If there are multiple patients with the same name, add a comma and first initial after the last name to reduce the number of results. When the patient is located, select the Ambulatory Communication encounter. Once a patient is selected, the Patient Match dialog box closes and the system displays 28

29 Error! Reference source not found. the renewal message. The system displays the order information on the Request tab. 9. Click the Response tab to see if an addendum was added. This identifies who matched the patient and when it was done. The message will automatically move to the erenewals folder once the match is made. 29

30 EMR Documentation eprescribe (Rev. 1/12/2012) RENEWAL REQUESTS SAME MEDICATION, DIFFERENT FORMULATION 1. Click the Change icon to modify a prescription before it is accepted, click the Change icon. Same medication, with a change to dose or formulation. 2. Select the replace action to launch the Medication List with the order on the scratch pad ready to be modified. The order details can be modified as needed before signing the order. 30

31 Error! Reference source not found. REPLACING A RENEWAL REQUEST WITH A DIFFERENT MEDICATION The order search window opens and the venue type defaults to the prescription venue. 1. Create a new prescription. Once the new prescription is signed, the new prescription along with a reject message for the renewal request is transmitted back to the pharmacy. Note: Choosing a controlled substance as a replacement will result in an error message because controlled substances cannot be transmitted electronically with eprescribing. 31

32 EMR Documentation eprescribe (Rev. 1/12/2012) REJECTING RENEWAL REQUESTS 1. Click the individual reject icon on the left to reject the renewal request. You can also select the Reject All at the bottom. 2. Select the reject reason from the list or enter it as free text in the reason dialog. A rejection response is sent to the originating pharmacy when a rejection on an erx renewal request is confirmed. Text containing the erx renewal request rejection information is transferred to the Response tab within the message. Note: Messages to staff members can be included at this time. (i.e., call the patient and advise them to schedule an appointment). 32

33 Error! Reference source not found. RENEWAL REQUESTS FOR CONTROLLED SUBSTANCES Current legislation prevents controlled substances from being transmitted to pharmacies via eprescribing. Pharmacies are able to send electronic renewal requests into eprescribe for controlled substances. This scenario requires special consideration. RECOMMENDED WORKFLOW: RENEWAL REQUESTS FOR CONTROLLED SUBSTANCES 1. The provider of the day reviews the Renewal request for controlled Substance. 2. Double-click a message to open it and view the renewal request. 3. The Provider of the Day decides if they are going to approve or deny the request. If you approve, you must still click reject, as controlled substances may not be transmitted electronically. 4. To deny the request: The physician rejects the request and selects the appropriate reject reason (patient needs appt, refill not appropriate, etc.) 33

34 EMR Documentation eprescribe (Rev. 1/12/2012) 5. Enter the Reject reason. 6. Launch the patient s Medication List. 7. Write a new prescription. NOTE: You will have to choose a printer. 8. Print the new Prescription. 9. Forward the Message to the person on your staff who will fax the prescription to the pharmacy. 10. The Staff documents that the prescription has been faxed and saves the message in the patient chart. To accept the request: Controlled substances cannot be sent via eprescribing. The physician rejects the request and enters the reject reason stating that the request is approved and will be faxed. 11. Physician launches the Med List and enters a new prescription for the controlled substance. 34

35 Error! Reference source not found. 12. Print the new Prescription and fax to the pharmacy. The physician forwards the message for staff to pick up the printed prescription and fax it. The staff documents that the prescription has been faxed and saves the message to the chart. 35

36 EMR Documentation eprescribe (Rev. 1/12/2012) LOGGING OUT When you have completed your activities, remember to log out of the application you are working on for security purposes. Logging out can be done in one of the following three ways: 1. If you are exiting the application temporarily, but planning on returning to that computer shortly, click Suspend User on the toolbar. This returns the screen to the log on window and places the cursor in the password field. 2. If you want to shut down the application completely, click Exit on the toolbar or the X in the upper right hand corner of your screen. Keep in mind that shutting down the application will require the next user to re-launch the application, which requires a greater amount of time. 3. Select Exit Application, to open the Exit Application window. The first option available allows you to prepare the application for the next user. This returns the screen to the log on window and places the cursor in the user name field. The second option will completely shut down the application and the third option allows you to suspend the application. 36