Meditech EMR Introduction and Physician Training Tool James W Langley MD MS Director of MHS Medical Informatics October 2006

Transcription

1 Meditech EMR Introduction and Physician Training Tool James W Langley MD MS Director of MHS Medical Informatics October 2006 October

2 Methodist Dallas Medical Center Methodist Charlton Medical Center Methodist Mansfield Medical Center October

3 October

4 Interoperability and Connection MHS through the Meditech Health Information System is now interoperable for all three Medical Centers regarding sharing and medical access to patients electronic health records Future goals will be to have all MHS ambulatory services also fully connected to Meditech Long term goals will be to have a MHS regional health network that includes physician offices. October

5 Purpose This training module has been designed to help you learn and navigate through the Meditech EMR and its various functions This is one of four training sets which will soon be available at MHS web site and Physician Portal as Medical Training Tools Please take an opportunity to view the other three: Additional desktop tools Electronic signature Remote token use for off site access. October

6 MHS Key Resources Information Systems Help Desk Information Systems Help desk Medical staff offices : MDMC: MCMC: MMMC: PACS Radiology: Toby Lopez PACS training tobylopez@mhd.com Pamela McNutt Sr. VP of Information Systems pamelamcnutt@mhd.com Medical office Staff development and liaison: MDMC MCMC MMMC October

7 Meditech Icon and Sign On Screen Select the Meditech icon on the desktop The Meditech sign on screen will appear. October

8 Meditech User Name and Password Meditech username and password is provided by IS. Medical staff offices can help to obtain them. Use of tab key can help with the entry. You will be given a one time use password. A prompt will ask you to Change your password This should ideally be a 7 digit alpha-numeric one. Enter new password twice on blank spaces. October

9 Change Password Option You can change a password at any time by using desktop icon selection Change Your Password This will be same process to select a new pin number for electronic signature function Change your ES PIN October

10 EMR Desktop and Functions Functions most commonly used are View Patients Rounds Report Physician Medication Summary Sign documents Use green check as OK or F12 key Red X is exit button Black Binoculars are look up key or F9 October

11 How to Select for a Hospital When Prompted When select View patient and see MCMC listed on top and more Highlight more Use down arrow on keyboard MDMC or MMMC will be seen Highlight and select one by using F12 key or green check at top of menu October

12 View Patient and Recently Accessed Patient Screen Open View patient selection Your first Meditech visit will usually show you have no patients listed. Your patients are added to list every time you select a patient for viewing and open that record Patients remain on list unless you select Remove from recently accessed All in-patients can be added back to list anytime by just selecting and viewing the patient record again October

13 New Results in Recently Accessed Screen NEW RESULTS There is a white out area that is New results. If you had anything new this button would be magenta By opening New results, a list of all patients having new results are available to you to open and view their records. October

14 How Do I Find Patients? There are two ways to find patients Use menu selection Any Location Or use menu selection Any Record October

15 Patient Location If patient location known then select hospital and then unit This is easiest way to populate a patient list quickly through recently accesses patient list. October

16 Any Record Put your patient s last name with comma separating the first in the name blank. You can just add last name or just first few letters. Hit F12 or OK All names with same or similar spelling will come up Select your patient View patient record and it will be added to your recently accessed patient list October

17 Creating Your Own Patient List You can create a patient to list to use by either of two methods. You can use the Recently Accessed List choice which is automatic and involves you only having to open a patient and view results to add to your list. Patients automatically get dropped off after 14 days of discharge. Or you can make selection remove from recently accessed list You can alternatively make a Personal List. This requires more maintenance on your part but gives more control on who gets on your list and when they get taken off. October

18 Making a Personal List Create a personal list by selecting the patients you want to add to list and then hit Add to personal list. This adds a little more maintenance but allows a printout of your personal list and report with all your patient locations You can see your list at any time by selecting personal list October

19 Remove From Patient List It is easy to manage your patient list by removing those patients you discharge. Once you hit Remove from personal list, the name is removed as indicated. October

20 Printing Your Personal List You can select print or view Personal list report Select all or a specific facility Select View or Print The Personal List Report includes location, patient name, bed, room number, MD, sex/age, medical record number, physician, room, bed. October

21 Patient Visits Once you select a patient You now have choice in right hand menu of picking visits by date, type of admission, all visits or put X in box to select just the ones you want to see as collated results The symbols on patient list bed with a head = current admission, empty bed = a discharge, clipboard = outpatient or observation, scissors = a lab/radiology outpatient procedure October

22 Opened Patient Visit Right Menu Panel Interpretations Pale panels mean no data available in them Blue printed name means results present and looked at least once before. Magenta colored name highlighted equals new results in panel. October

23 24 Hour Default Patient Screen You can see the magenta color change on the internal panels also indicating new results. You can get to any of the panels by just double clicking on them to open. October

24 Opening Patient Visit The top line of right menu is Record list to find another patient record The second line is Visit by date of same patient being viewed but different visit The admitted patient default screen will be the 24 hour view. Anything new is here: vital signs, I and O, reports, lab results etc. listed for 5 days. October

25 Special Panels The Special panels selection on third line of top right menu will take you to some prebuilt specialty results panels on left. One is called the Endocrine select it Then select endocrine again in drop down menu. October

26 Endocrine Data Choices One can toggle to close 5 panels to see better by using + or One can also select time intervals 1 hr, 4hr, up to 24 hrs. One can see entire encounter by selecting earlier or home Can be useful to find glucose levels and administered insulin October

27 Lab and Medication View in Endocrine Panel Can see finger stick glucose and venous acquired sample. Insulin administration on bottom panel Nursing IT working on creating a printed report for sliding scale determinations October

28 Nursing Notes The Notes selection has all the nursing notes, as well as other allied health notes. To see all the listed information double click on line or magnifying glass. Nursing notes can also be printed from physician rounds reports October

29 Medication Administration Record List in EMR Active, Discontinued and ALL medications choices can be selected. Toggling boxes below can also help to see earlier as well as current view. October

30 Medication Detail and History Click on lines and at top of each column and on each line This can sort and give more detail on each medication It also shows how administered and when. October

31 Order History And Audit Tracking This allows tracking and auditing of physician orders Go to top two boxes and select Audit to see who took off orders and when. The Audit trail shows when orders removed, completed and by whom. October

32 Allergies The Allergy selection is very important. Once an allergy is logged in any visit or hospitalization it will be in patient s record within system forever. This is called demo recall function. October

33 Laboratory Laboratory panel has all categories of lab results. Abnormal results are in yellow Critical results will be in red Comments about results will be in a balloon. Click to open or click on line where occurs. October

34 Microbiology Click on picture of Report/Grid to get more information on microbiology report. The report can be printed. When done hit return to go back to patient record. October

35 Opening Reports Opening all types of reports is a similar process for Pathology, Imaging and Other Reports You must click on a bubble or icon under report to open Status of report is either signed or draft October

36 Print Layout View To see patient demographics you need to go down to bottom of screen and select print layout to get all. (arrow) Reports can be printed through file print command top menu bar October

37 Exiting Reports You will need to close report by going to top right screen and hitting the X Then select return on right hand menu on next screen You will now see a green check in the bubble indicating you have already viewed a report October

38 Care Trends and Care Activity and Admission Nursing History These are nursing activities which are now available and better documented in Meditech. Nursing assessment History includes all positive findings including MRSA and VRE, allergies, and vaccination history October

39 Summary Selection This Summary screen can be default screen if patient discharged This selection has patient demographics contacts reason for visit patient directive DNR documentation Insurance providers associated with patient and other useful information. October

40 Graph You can right click on your mouse on each selected lab values up to three or vital signs and then select graph for viewing. You can then print screen the graph if desired. October

41 Physician Medication Summary Report Select this icon in EMR desktop Select correct medical center Hit enter October

42 Hit Enter Twice Through Pharmacy Prompts October

43 Finding Clinical Floor Use F9 lookup key when prompted for location of clinical floor Select unit desired for medication report October

44 Print Medication Report Choose print option All ordered and given medications can be seen Last dose given and time can be seen Report printed at 10 pm nightly on floors. October

45 EMR Desktop Rounds Report This report can be run for individual MD MD group location facility. It can also be run with a combination of any of the four factors Consultants must be entered into Meditech by a physician order to be linked to this report. Can be done by RN/ unit secretary with an order by MD October

46 What Report Offers All inpatients and 23 hour observation patients linked to any physician can be printed. Results include: 72 hr vital signs I&O, labs active medications nursing notes insurance allergies patient demographics 72 hr micro results. October

47 How to Get Rounds Report In blank doctor space hit F9 lookup key select correct physician and hit enter. Now Hit F12 key or the green checkmark = OK The same routine as above can be used for finding and selecting groups, location, and facilities report query. One can also combine queries ie. MD and location October

48 List versus Complete Report If you want a complete rounds report select yes on print all patients query If you want to only see list select no on this query. You can then select a patient and print individually. October

49 Printing Rounds Report Select view in bubble on top and OK on bottom for viewing report Select print in bubble and OK on bottom for printing October

50 Electronic Signature Contact medical records to get application form for E signing and training. Select Sign documents icon patient names All of your dictated pending patient records will be higlighted as noted in example with patient names in space Anything on this list is ready for review and e signature Training in electronic signature is in separate module October

51 Conclusion You have now completed Meditech EMR Introduction and Physician Training Tool You should be able to find patients, view any result or report, make personal lists. Remember if you forget your Meditech password call the help desk ext I would also recommend reviewing the additional Meditech training modules available including: Meditech Additional Desktop Icons Electronic Signature Training Remote Token Off Site Access Training October