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Log onto the Network Ensure that the Check XenApp application is highlighted and then click on that to activate the log on screen. Once you get a log on screen please in lower case enter in your user ID. The initial password for the network will be: password1234. Then please hit the enter key. You should then be prompted for a password change. Your new password will need to be 8 characters long and can be alpha, numeric, or an alpha/numeric combination. After you have entered this again hit the enter key and the passwords will be changed. Please remember that you are now logged onto the device as yourself and when you are completed using any device please ensure that you log off in order to allow anyone else to be able to utilize the device. Please remember that your user ID and password are yours and yours alone and per policy should no be shared with anyone else for use of the system. Log onto Meditech

You will have a one time password on the paperwork – when you change the password here please

ensure that you use the same one as you did for the network.

User Name Password

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Click on PCS - then select the PCS Status Board

The Status Board__________________________________________________________________________________________________________

The Status Board is the routine from which you will launch all documentation activities to be carried out for the patients you are responsible for. These routines include such activities as;

Standard DocumentationPatient Care NotesNext scheduled medications or interventions

The Status Board will vary depending upon your care provider type and the

department in which you work. Options for viewing via the Status Board might include:

New Orders and Lab ResultsInterventions due to be documented onResults of last documented interventions such as TPR or patient weight

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The Status Board Colors__________________________________________________________________________________________________________

The Status Board is a color coded to inform you of what is happening on your worklist.

Magenta: New

Red: Overdue

Green: Active

Gray: Interactive

Yellow: Headers are yellow but also are similar patient names as a safety feature to alert you to be careful.

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Selecting a Record

You can choose the “Any Location” option. A list of patient care locations within the organization will appear. Choose the appropriate location. Patients assigned to that location will appear. Highlight the patient you would like to complete documentation on and press enter. You can also place a checkmark in front of multiple patients and click on add to my list. Your screen will refresh, the check marks will disappear and then you will click on the My List feature on the bottom left of the toolbar. Your selected patients should be the only visible to you on that list.

In order to remove a patient follow the same process of highlighting and checking the patient chart and then click the remove from list feature on the bottom tollbar and the patient chart will be removed from your list.

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Document Interventions

To document an intervention click on the “Intervention” option. This will take you to a screen that lists the interventions assigned to the patient. Interventions will appear on this list based on the following criteria;Overdue Interventions (highlighted in red)Interventions with Next scheduled times in the order in which they become dueInterventions with only free text directions and no Next Scheduled time such as prnInterventions with no directions or frequencies.Interventions with an “Active” Status

The Intervention List displays the following information:The Name of the InterventionThe Status of the Intervention.How often the Intervention needs to be documented (Frequency).How long ago the Intervention was last documented The next scheduled documentation time

Note: If the Frequency column is blank, it indicates that no frequency has been assigned to the intervention. If

the History Column is blank, the intervention has not yet been documented or edited. If the Next Scheduled

Column is Red it indicates that it is overdue.

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Document Interventions (cont)

To select an intervention for documentation, use the up and down arrows on your keyboard and highlight the appropriate choice. If you prefer to use the mouse, click in the space to the left of the intervention description. A checkmark will appear. Click on the Document Option on the bottom of the screen.If the intervention contains a screen with questions that will need to be answered, you will be taken to that screen and can complete your documentation. Such as an Admission Assessment.

Note: In the event that you have several interventions to complete, you can check mark them all. When you click on the “Document” option, you will be taken directly into the first document on the worklist that you have check marked. When you have finished with the assessment, click on the Save. The information will be saved and you can now choose from the remaining list of interventions. Continue until all interventions have been completed. If there were “I did its” among the list of interventions, the background of the last done field for the “I did it” will have turned green. Before leaving this screen, click on Save to file the data.

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Document Interventions (Go To)Some interventions have been designed so that they may contain several individual assessments within one intervention, such as Admission Assessment.

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Using your mouse click on the intervention you want to complete.

Once you have finished this assessment, choose “Go To” from the panel at the bottom of the screen.

The list will reappear and you can now choose the next assessment you want to complete.

As you complete the individual assessments, the lettering identifying them will change to magenta, indicating the information is new but not yet filed.

Once you have completed all the individual assessments, click on “Return”. This will take you to your worklist.

Save the information before leaving the worklist

Document Interventions (Repeatable)__________________________________________________________________________________________________________

There are some questions that have been set up to allow the same data to be entered for several situations. For instance, a patient may identify pain in both his/her back and knee, or you may record a patient’s pulse taken both apically and radially. These questions are defined as repeatables and their responses must be linked together as a group to be displayed in a meaningful way in the EMR.

When a question is a repeatable to the right of the label, such as Skin Assessment, you will see “Occurrence #1”, “Occurrence #2” etc. This means that for the series of questions that fall within that label you will be able to document any number of different types of tubes.

Within a repeatable there are key questions that allow you to distinguish one occurrence from another. You may have only one key field or you may have several. Key fields can be identified by the arrow that appears to the left of the question, such as “Location”. Key fields must be answered.If you have a patient that has a wound on his left arm and right thigh, you will document on them as two separate occurrences.

Occurrence #1 will always be the initial default. Identify the wound location, body part, and type for the left arm wound and complete the remaining questions.

To document on the right thigh wound you will need to Highlight a field within occurrence one, such as location modifier, and click on “Insert Occurrence”.

A second label for Wound Location will appear, followed by Occurrence #2 and the first question within that label will be highlighted. Complete both of the key fields and any additional questions, as appropriate.

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ADDITIONS AND DELETIONS OF INTERVENTIONS AND CHANGES TO

INTERVENTIONS CAN BE MADE TO THE DOCUMENT BUT ONLY BY THE

NURSE IN CHARGE OF THE PATIENT.

THE RN IN CHARGE OF THE PATIENT IS TO BE CONSULTED IF IN DOUBT OF

ANY DOCUMENTATION ISSUE OR CONCERN.

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Click on NOTES on the Right Hand SideThis will take you to Patient Notes Routine.

Enter Note Amend Note Print Note View Note Select Note

When you click to Enter Note you will see the attached screen. You will need to choose your Category. Tab to Note Text. Enter a brief Note Subject. You can then enter your Note or if applicable you can use a prewritten note. To access these notes do an F5 then an F9 for Canned Text (prewritten notes).

F5

F9

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To use a Canned Note. Highlight the note you want and click Enter. At the cursor your response is free text (you need to enter the information). Then click F12 to advance to next field which can be free text or it will give you a look-up box with choices. Highlight your choice then F12 and this will then advance you to the next area to be answered.

If your screen gives choices they will appear as below and you will have a box at the bottom as a reference for free text or choices.

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To Amend NoteUse this function to Add to or Edit an already existing note.

This needs to be added in the Note Addendum Space. A Y will be entered in the Edit column

The original note will show that an edit has been made.

Your edited / additional note will look as below. The document will be marked with the current time and date.

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EMR – Quick Overview

Vital Signs:

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Intake and Output: This screen displays a Spreadsheet of the patient’s I and O and their weight.

Notes

Click on the Blue i to open the Note

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There are multiple categories of notes – can select from the folders at the top of the

notes page which category of notes, provider, social service, etc. you are looking to

view and then open the note to view accordingly

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Other Reports: This is where you will find OR Reports, H & P’s, Consults.

Care Trends: Shows a spreadsheet version of data entered and filed by Care Providers that is organized by system.

Clicking on the date above data opens up the Assessment to display information that was entered.

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If you right click on an Assessment – it turns green – then click the Display button on the bottom to open that Assessment.

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History: This displays information from the patient’s Admission Assessment

Defaults to positives with the understanding that all else was answered in a negative

fashion. You can open each highlighted category at the top for more in-depth

information.

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Labs Any folder that is highlighted will have data behind it. Click on the folder you wish to

view and you will see all results. Any abnormal result (either L or H) will be yellow

highlighted. Critical values will be red highlighted. By clicking on the date and time at

the top of the column you can expand the view to see what the normal parameters are

for any given lab test.

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Medication Record The medication record has the yellow title bas which information defaults under

according to the header. There are also medications which has a + sign under them or

a label comment or protocol attached. It is vital to ensure information about the

delivery of the medication that you expand the plus sign in order to view this

information as seen below.

If there are any issues with the charting system your instructor and the staff on the unit

are your resources. Please ask for assistance if there is anything that your are

attempting to locate or chart and are unsure as to how or what to do.

For password resets please contact the IS help line – Extension 4889 option 1 and ask

for a Meditech password reset.