Student RN-Reviewing the Chart Lesson Plan

Transcription

1 Student RN-Reviewing the Chart Lesson Plan Agenda... 1 Reviewing Patient Information... 2 Reviewing Past Encounters Chart Review... 5 Past Lab Results Results Review... 7 Agenda The following is a breakdown of time for each major part of the lesson. Time (min) 15 Topics Reviewing Patient Information 5 Leave a sticky note 15 Chart and Results Review 35 TOTAL TIME

2 2 Reviewing Patient Information QSGs Pages 8-11 We received our patient assignments, now it is time to review patient information and get report We will look at some of the tools you can use to review the chart Background: Jace is a 33 year old male who has Cystic Fibrosis and was admitted with pneumonia. You may want to view more or less of the screen on the right by dragging the border up or down (Instructor demonstrate) On your Patient Lists, highlight your Jace patient Jace s Profile Report appears in the bottom half of the screen Take a moment to review the information under the profile report Do you see your Student Nurse s name listed under the Treatment Team section? There are other reports available that allow you to get an overview of each patient Click the report for Due Meds We will skip the Scheduled Medications for now Find the PRN Med section: what PRN medication(s) are ordered for Jace (Tylenol) What Continuous medication(s): (NS with 20 of KCl) You can also see the rate and Last Admin Date/Time You can hide this report pane by clicking the tab with the black arrow inside and bring it back the same way Key Point: You can review some pertinent patient information without having to open the patient s chart Let s open Jace s chart.

3 3 Double Click on his name (or have his name highlighted and click Open Chart on the toolbar) A new tab opens at the top of the screen; this is the patient s chart The screen that opens by default is the Patient Summary activity (it is highlighted on the left side of the screen) The blue tabs along the left side of the screen are the activities We will use the word activity throughout training. An activitiy is a place to do something Report buttons are also part of the Patient Summary activity the Index report is the default These reports offer a lot of patient information about the patient s hospitalization Click the magnifying glass at the end of the Report box to view a list of all reports available to you These reports can be added permanently to your toolbar Click the wrench button at the top right The add or remove box appears with all of the report buttons you currently have on your toolbar Scroll down and click in the first blank report cell Click the magnifying glass For this example, we will select IP Labs Since Admission and click Accept We want this Labs button as our third report button To change the position, click the up arrow until IP Labs Since Admission is in the third report cell Click Accept The Labs button is now your third report button The changes you make to the report buttons only affect you What questions do you have so far?

4 4 ***************This section is for the Instructors only**************** Cosigning Nursing Student Documentation Any documentation done by student nurses requires a cosigner. This documentation will appear under the Administrations with Cosign Requests section. You can cosign the documentation under this section using the various blue Cosign hyperlinks. You can also Cosign flowsheet documentation under Doc Flowsheets by clicking on the yellow Cosign Report button. Click the Prof Exchange report button on the tool bar. This is ProHealth Care s Shift Report Tool/SBAR ) This information will help when you receive face to face report from the Registered Nurse from the previous shift Scroll down and find the Hospital Problem List section What is Jace s Principal Problem (blue diamond)? (Pneumonia) Find and Click on the Last Day s Vitals hyperlink (scroll down) To return to the Professional Exchange Report click on the yellow arrow to the left of the index report button. Scroll down to the bottom of the Prof Exchange report Click on the Active Orders hyperlink Click on the Meds report button on the toolbar Look familiar? (we also viewed this information on Patient Lists) Key Point: In EPIC, the same information will be located in several different places.

5 5 Leave a Sticky Note Find the Treatment Team Sticky Notes section under the Professional Exchange report In the Treatment Team Sticky Notes section, review the note Patty Del Mar entered regarding Jace s code word Anything documented in this section does NOT become part of the patient s permanent medical record Jace told you that he had some specific questions for the physician about his home medications Under the Sticky Notes to Physicians section, click the Comment hyperlink to open the Comments window Enter this note: Patient has questions about his home medications After each note you must include your name and the date-epic has a shortcut After your note, type.me then press SPACE BAR Type.td then press SPACE BAR Click Accept Notice the Last edited by It is your student nurse s name. This changes everytime a clinician types in a note. That is why it is important to include your name and date when entering a new note What questions do you have so far? Chart Review Click on the Chart Review activity Chart Review contains information from all past and current encounters; this is the patient s electronic medical record Click the Encounters tab

6 6 An encounter is defined as a specific instance in which the patient receives care Examples include hospitalizations, surgeries, outpatient visits, orders, or telephone calls A real patient will have hundreds of encounters Jace only has four but we can go through the features of Chart Review Double click on the Current Admission encounter Take a moment to scroll through this encounter The blue hyperlinks will take you to the documentation for this specific encounter Click on one of the blue hyperlinks Click on the yellow back arrow to return Click the close button near the top right of your screen to return to Encounters The Filters button is helpful when there are multiple encounters to sort through It limits the amount and type of information you see Notice the other tabs across the top of the screen. Chart Review helps you sift through a lot of information quickly by clicking on the various tabs Click on the Labs tab; here you can see the status of lab specimens as well the results

7 7 Results Review Click the Results Review activity Results Review contains past and current results The Date Range Wizard opens Select Data for Current Hospitalization and click Accept Live patients will have more results than training. We can narrow our searches two ways: 1. Use the Tree Click the plus sign next to Blood Click the plus sign next to Chemistry Click the plus sign next to Chem Profile Highlight Chem Profile to see just those results 2. Use the Search box Type White in the Search box and Press Enter The Search option is great for looking up individual lab values If you need to see several values together, like the Chem Profile or CBC, use the tree The red exclamation point indicates an abnormal value If needed, use the Legend button to find out what the various icons indicate Click on All Topics to see all of the results

8 8 There are two ways to see the Reference Ranges: (not working in training environment) Hover over the value Click the Ref Range button Click the button again to hide the ranges Click on Jace s Chest Xray To view these results, click on the paper icon Which part of the patient s chart you would use to see past visits or hospitalizations? Chart Review What is the definition of a patient encounter? A specific instance in which the patient receives care. Some examples include hospitalizations, surgeries, outpatient visits, orders, or telephone calls. Where in the chart are you able to review lab results? Chart Review or Results Review In Results Review, how can you search for a particular lab? Tree on the left or the search field. How do I see the reference ranges for these labs? Click the Ref Range button or hover over value.

9 9 Click on the Notes Activity This is another place to review patient information Jace only has two notes We will look at Ellie s notes under this activity later in class Close Jace s chart by clicking the X next to his name What questions do you have?