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Student Electronic Documentation Training

This document has been created so that it can be used as a step-by-step guide through the process of training student nurses how to document and read the electronic chart at The Scarborough Hospital. There will be content on how to document different types of questions that students will encounter but there will not be details as to what the content of various assessments will be. Accessing the MEDITECH Application:

1. Double click on the MEDITECH icon on the desktop OR 2. Single click on the MEDITECH icon on the taskbar at the bottom of the desktop window.

The first page gives important information regarding how to contact the Helpdesk. They can assist if there is any problem with signing in. Hit the <Enter> key

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LIVE vs TEST:

**Do not use Live for training purposes as it contains current patient information. By using Test, students can practice with fictional patients and not be concerned that they are entering something incorrectly** Select TEST(5.66) either by clicking on the third option with the mouse (the text will turn green when the mouse is correctly placed)

or type the number 2 and <Enter>

If this screen appears: Click on <Cancel>

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User ID and Passwords: The User ID is NOT confidential. It is usually based on the first four letters of your last name followed by the first three letters of your first name. Helpdesk may ask to know your User ID. This is fine. NOTE: Never share your password with anyone for any reason. If you have forgotten your password, just call the helpdesk. The user ID combined with a password is the electronic version of a legal signature. For training have all students sign in with the following generic User ID and password: User ID: STUDENT (Hit <Enter> to get to password prompt) Password: ZH741 (Hit <Enter> when completed) This is a list of databases that are available to the students. The Student nurses will be using # 1 NUR.SCS

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Depending on which campus of the hospital that you have been assigned to you will enter the short form (mnemonic) of the facility here. GRA – The Scarborough Hospital – Birchmount Campus SCS – The Scarborough Hospital – General Campus NOTE: Meditech is case sensitive and requires entries to be made in CAPS…Puts CAPS on now This is the main menu for nursing students here at The Scarborough Hospital.

Status Board is the only selection student nurses will typically need and they will be able to access everything from there. Enter 1 in the selection box or click on the words “Status Board”

Name of Menu

Make sure you are in TEST

Mnemonic of person

signed in

Selection Box

Number to be entered into Selection Box or

Click on the label

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Status Board Navigation:

1. Shows the following information in order: Database(TESTenvironment/facility)user name

NUR.SCS G/TEST.566/GRA Student Nurse

Always check the user name to ensure it is correct

When you are logged in with your own personal user name and password, your name will appear instead of Student Nurse

Never document under someone else’s name

2. Column Headers

Explains the information that you see for each client displayed.

Contains 2 rows – e.g. Visit reason Diet

For each client you will see in that column the Visit reason on the first row and the diet on the second row.

1. Shows where and who you are

2. Column Headers 3. Menu Buttons

4. Side Buttons

5. Exit Button 6. Footer Buttons

7. Similar Name Alert

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3. Menu Buttons

Stay the same no matter what routine you are in.

Exit and Save work

Exit and NOT Save

Lookup or Help 4. Side Buttons

Can be different for different users. o Eg. Nurses vs Outpatient staff

Take you to additional routines to document/view your client’s info

No need to exit from the Status Board in order to use these functions 5. Footer Buttons

Perform functions related to the user rather than the patient o E.g. Manage your patient list

6. Exit Button

Exits from the Status Board back to the main menu. 7. Similar Name Alert

Patient Names are normally highlighted in Blue

If there are two or more patients on the status board that have similar or the same last names, they will be highlighted in YELLOW.

Manage List:

The Status Board (SB) works best if each student creates a list of patients at the beginning of the shift. Doing this, they do not have to “find” their patients each time as the names remain on the list until they are manually removed.

Mnemonic of user Signed in

Select patient by Name

Select multiple patients by Location

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There are 2 ways to find a patient to Assign to your SB

By location

By individual name Assign a Patient by Location Starting from the Status Board:

1. Click on “Manage List” (at bottom of window) 2. Click on “Location” (at bottom of window) 3. For Birchmount – Click on “G4D 4D Medicine” from the list then click on “Ok”

For General – Click on “H1CP 1CP Medicine” from the list then click on “Ok” a. ALL patients from that location are loaded into the list b. They are not yet Assigned c. Click on the patient’s name that you would like saved to the SB to highlight in

blue d. Have students click on a few patient names

4. Click on “Assign” 5. Click on “File”

What would you like to do with pre-existing patients?

Append – adds the newly selected patients to the existing list

Replace – removes any patients not selected during this process

Cancel – return to Manage List routine to continue selections Once Append or Replace is selected you are returned to the SB and the new list of patients is already in place. Unassign a Patient

1. Click on “Manage List” 2. Remove the Blue Highlight from all of the patients on the list.

a. Click on the small checkmark in the header

3. Click on the name of the patient that you want to unassign which will highlight it blue. Have students unassign all the patients that were selected moments ago

4. Click on “Unassign” 5. Click on “File” 6. Click on “Yes” when asked to confirm the filing of this new information.

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Assign a Patient Individually by Name 1. Click on “Manage List” 2. Place your cursor in the white box beside “Patient” around middle of screen by clicking

on box 3. Type the name of the patient

Remember: LAST,FIRST with NO spaces E.g. PINK,TEST

4. Have students use the Patient name found on the cards at the side of each terminal with last names of colours e.g. GREEN,TEST/BLACK,TEST/YELLOW,TEST etc. This will be the patient that they will be using for this training session

5. Instructors use test patients

Birchmount – COX,TRAIN – GA000042/14 – G0001582 – in room 4419-1

General – COX,TRAINING – HA000131/14 – H0003251 – in room 496-2 6. <Enter> 7. Select the correct patient from the list presented

Black = outpatient Gray = discharged Blue = In Patient

8. Have students choose the patient highlighted in blue (In Patient) Click on the name or enter the number that is on the left side of name and <Enter>

9. Click on “Yes” when asked to confirm the patient name will be added to the list and automatically be highlighted blue.

NOTE: When in the LIVE system students should ensure they choose the correct patient by checking the Account # & Unit #. The Account # will be different each time patient has been registered at the hospital but will always have the same Unit #. Remember, there could be patients with the same name.

10. Click on “Assign” 11. Click “File” 12. Click “Append”

The system will return to the SB and your new patient will be on the list. **NOTE: Because all nursing students are signing in with the same user ID and password, the patient list will be populated with all the TEST patients that are being used during this session by all students. When in Live, only the patients that they choose will be seen.**

It is important that each student only document on their own patient

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Menu Buttons:

1. Allergies a. Click on the “Allergies” button

b. Note that the patient has an allergy or more entered.

i. Some patients will have more than others c. Students will not be entering/editing allergies but viewing only d. Click on “View Details” to see further comments about the allergy after clicking

on it to highlight e. Click on “Close” to exit the detail window f. Click on “Return” to get back to Status Board

2. Process Interventions a. Do not click b. This is where documentation is done for each patient c. Will go into more detail later

3. Pt Notes a. Do not click b. This is where narrative notes are entered c. Will go into more detail later

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4. Review a. Do not click b. This is “PCI” Patient Care Inquiry where results and documentation are viewed c. Will go into more detail later

5. References a. Do not click b. Will show at the end how to access the reference manual on iConnect

Process Interventions: This is the routine used to document specific interventions/assessments provided for

patient Starting from the Status Board…

1. Highlight the assigned patient a. “Click” on the patient’s name OR b. <Down Arrow> to scroll through the list until the correct patient is highlighted in

black 2. Click on “Process Int”

Each patient that students will have in the LIVE system will have interventions already in place and there will have been documentation already completed

3. Verify the correct patient name, account number in the patient identification section to ensure documentation is on the correct patient. Patients in TEST will have the generic Medical interventions already added.

Verb Strip

Selection Box

Patient Identification Account # followed by

Name

Interventions

Last Documented

Headers

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Scroll through the list of interventions by using the down arrow key or the <Page Down> key. The black line highlights the intervention that you would like to document on. The interventions are divided into groups by “Headers” such as “Assessment”, “Physiological Monitoring”, “IV”, and then by body systems. The down arrow will scroll down one intervention at a time. The <Page Down> will jump down by header. To go back up, use the up arrow or the <Page Up> keys Add an intervention The only time that an intervention will have to be added by the student, is when there is a new occurrence of an intervention that has not been previously documented on i.e. the patient has a new ulcer that requires a dressing, IN: Wound Care will have to be added **Make sure that the intervention is not already on the list before attempting to add it**

1. Click on “Add Interv”

2. Or, enter “AI” into selection box to the left of the verb strip and <Enter>

3. Type “IN” in the “Description” space

4. <F9> for lookup - <Enter> will not work

5. <Down Arrow> until you find the “Wound Care” intervention or “click” on it (All interventions are prefixed with the Header that they are found under i.e. IN – for Integumentary)

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6. <Right Crtl> key or “click” on the intervention a second time to add checkmark beside the correct intervention (not the Paediatric ones)

7. <F12> to file – brings you back to the add intervention screen

At this point additional interventions may be added if needed. If a mistake has been made, the intervention can be removed from the Add Intervention screen by backspacing it out and then do the lookup again to select the correct intervention.

8. <F12> to file The system returns back to the Process Intervention screen and the added intervention can be found under the appropriate Header.

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The next function of the verb strip is to Document on an intervention. For this, use the Vital

Signs intervention. This documentation screen will show examples of most of the types of

questions that are found on the various screens. This manual will not cover appropriate

content, but rather the types of questions and responses that students will encounter.

Document Intervention: **NOTE: if you double click on the intervention name, it will put a check mark in the far left column. This is telling the system that you want to go into this intervention. But, if you do not remove the check mark then it will continue to open up that intervention regardless if you are highlighting another one. It can be removed by double clicking on the intervention name or hitting the Right <Ctrl> key. It is not necessary to put a check mark on the intervention. Encourage the students not to use the check mark to avoid frustration.

1. Scroll down through the list of interventions until you have highlighted PM: Vital Signs

2. Click on “Document Interv’s” or Type DI into the selection box <Enter>

3. Ensure that you have the correct date and time for when the assessment was done, not just the time you are currently charting.

a. The default is for the current date and time b. If this is correct just type “Y” for “Yes” at the “Ok?” prompt.

DI in selection box or

Click on Label

Highlight Vital Signs Last Documented on one day ago.

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c. If the assessment was done earlier and you need to change the time i. “Click” in the Time column

ii. Backspace out the current time iii. Enter the corrected time iv. Type “Y” at the “OK?” prompt

4. Fill in the appropriate fields. **Note** It is not required to fill in every field in each documentation assessment. Only complete what is applicable for your patient.

5. If you are unsure of what type of answer the field requires, you can use the <F9> key to do a “lookup” and you will receive a message with respect to which response type the system is looking for.

Enter a Number Enter a blood pressure format. Example: 135/65

Enter “Y” for yes, “N” for No

The response entered does not match with the defined group response

This is a group response; enter the number of the choice you desire. Example: 5= Tympanic

To change the time, click here If date and time are

correct, type “Y” here

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Some fields will be skipped automatically based on a previous answer. For example, if the patient is on room air you will skip the questions about oxygen levels.

6. <F12> to file or “Click” the Green Checkmark

a. Once all of the information has been entered b. Not all questions must be answered c. You do not have to be at the end of an assessment to file it.

**Be careful not to hit <F11> which is exit as you will lose everything that you have entered. Always read the prompts as they verify the function that you have chosen.

<F12> This verifies that you want to File and save the data entered

<F11> This verifies that you want to Exit and date will not be saved

7. Click on “Yes” a. A confirmation screen will always appear to confirm that the information

has been filed.

info filed. info not filed

8. The system returns to the Process Intervention Screen Document Shift Assessment:

This assessment is the initial head-to-toe assessment of the patient at the beginning of shift. The first page is a summary of the various assessments. It is necessary to make a selection for each body system on the first page before you can move on to each body system assessment page(s). By choosing “Significant findings” you will be able to enter the assessment

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of that body system. By choosing “Within normal limits” you will skip that body system. It is important to choose the appropriate response as to the patient’s condition. **NOTE: Due to the student’s inexperience, it is the clinical instructor’s responsibility to review with each student the response they choose for each body system.**

For each System use the <F9> key to “look up” the options

** Note **: Each system question has an arrow instead of a colon. This means that there is some reference material provided to give further guidance when filling out the form. Click on

the to view the information. The <Esc> key or the must be used to get out of this screen and back to the assessment. Have students enter: Neurological – “Significant findings” Respiratory - “Significant findings” Cardiovascular – “Within normal limits” Gastrointestinal – “Significant findings” Genitourinary – “Within normal limits” Integumentary – “Within normal limits” Musculoskeletal – “Significant findings” Then press <Enter> to get to the next section The computer will now take you through each body system that you answered “Significant Findings”. Have the students fill out the assessments, making note of the following items:

1. Not every question must be filled out, only those that are appropriate 2. Comments

Comments are intended for adding something that may not have been covered on that page

Enter any significant findings in Patient Notes (covered later in training) as comments are not as easily read by other people

You can only view 2 lines but more can be entered

There are only two ways to move on: use the <Esc> key or “Click” onto the next question

Enter the number of the choice you want

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3. Page Navigation

<Enter> will take you to the next question

<F6> will take you to the previous question

<Page Up> will take you to the previous page/section

<Page Down> will take you to the next page/section

4. Neuro Assessment

If “Yes” is answered to “Oriented x 3” the next 3 queries will be skipped but if “No” is answered, the next 3 queries can be accessed

Boxes with only one character for an answer are usually “Y/N”

A right arrow beside the query instead of a colon signifies that there is some

reference material available by clicking on the to view the information. The

<Esc> key or the must be used to get out of this screen and back to the assessment.

Behaviour question: this is a group response with multiple lines. This allows multiple selections for the response. There is no limit as to how many items can be added. Continue to press <F9> and choose an item until completed

Neuro Vitals:

i. if you respond “Y”, you are able to access a Neuro Vitals page ii. If you respond “N” you will skip it and go to the next system

5. Respiratory Assessment

Demonstrates again that some boxes are skipped if the preceding query is not answered i.e. if Cough is not answered with “Y” then it will skip the Cough descriptions

Chest tube will allow you to go to another page if responded to with “Y” (only need to answer “Y” if the patient has a Chest Tube, if not either leave blank or “N” to skip that page

6. Gastrointestinal Assessment

NG Tube and Feeding Tube will allow you to go to another page if responded to with “Y”

7. Musculoskeletal Assessment

Check CSM and Cast will allow you to go to another page if responded to with “Y”

Have students practice above concepts by entering data and navigating through the assessments.

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**If you are unable to access a section/questions that you require, go back to make sure that you have answered “Y” to the query before it** **If you are stuck in a field, hit <Esc> to exit it** Pain, Vital Signs and IVs are not included in the Shift Assessment. These are documented as individual interventions. **Note** Always save your data before you leave the computer. If you do not file it, all the information documented will be lost. You can always go back into your assessment and complete the documentation. We will cover this later. The final question on the assessment is “Progress Note”, if you answer “Y” it will take you to the notes. We will go into more detail regarding this later. Have them leave this blank. File the assessment using the <F12> key. The Shift Assessment is how you found the patient at the beginning of the shift. If anything changes throughout your shift, you will document on the changes. Example: The patient becomes short of breath and you perform a Respiratory Assessment

There are individual body system assessments found under each of the body system headers. All of the questions are the same as those found in the Shift Assessment. If you are just documenting on the Respiratory Assessment, you can do that by using RE: Respiratory Asmt

Or Use the Shift Assessment intervention and just indicate “SF” for Respiratory

PM: Pain Asmt/Reasmt:

This intervention contains 2 sections for documentation Assessment Reassessment

You have to indicate which section that you want to document on by answering “Y” to the appropriate query on the first line of the page (it will only allow you to access the section that you answer “Y” to and skip the other section)

Have students answer “Y” to “Assessment”

If the patient doesn’t have any pain then answer “N” to “Pain” and then <File>. This will show that you assessed your patient for pain.

Pain assessment is the initial assessment of a pain location. There is place for 4 different locations to document the PQRST of pain. When you choose a pain location it will default into the appropriate corresponding questions.

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You will also find that previous pain locations that have been documented on will default in. If you don’t want to document on the defaulted location then just remove it by backspacing out the location and add new one or leave blank

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Reassessment is done after the patient has received an intervention for the pain. i.e. Documenting the effect of pain medication that has been given. Have the students practice documenting a Pain Assessment. IV Peripheral:

The first line is used to indicate which function has been performed. Once you select that function you are then taken to the appropriate page to document. This functionality is used in many interventions. Have the students document “Y” for the Maintenance question then <Enter> twice.

Selected Here

Defaulted into Here

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The “*” indicate that these questions are required. They must be answered before proceeding to the next question. The lookup for “Site” is based on which vein was accessed. This is TSH policy. There are diagrams with the veins defined on each unit to assist with this selection. This screen is also used for documenting any changes to solutions or rates. ADL/Care Flowsheet:

1. This is to be completed each time an ADL is reported or performed. 2. Documentation should be done as close to the actual time the event occurred as

possible. E.g. The patient is given a bedpan

3. Multiple ADL’s can be documented simultaneously E.g. The patient had breakfast, a bath, voided, and had a bowel movement.

Have each student document ADLs for their patient.

Have them respond “Y” to the Braden Score

**Note** the last documented Braden Score and the date it was documented default into the appropriate spaces so that you can tell if it has been completed as required. It can always be done more frequently but the minimum is every Wednesday and Sunday Have them respond “Y” to Diet on page one, Urine output and Bowel Movement on page two. Complete the documentation.

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As with the systems assessments there are individual interventions for each of these activities as well. So, if later, the patient has lunch and you only need to document that, you can use the individual intervention under Gastrointestinal header. The same would apply if the patient just had a bowel movement etc.

View History:

This routine contains the complete history or audit trail of what has occurred for the intervention that has been highlighted. This is the legal documentation trail. It indicates every action that was made with the intervention, from when it was added to the chart to when the patient was discharged. This is also the routine used to make corrections to documentation that has been completed, or to continue documenting on an assessment that has been started but not completed.

Highlight an intervention to view that you have already documented on and saved i.e. Vitals, or Shift Assessment Click on “View History” or type in “VH” into the Selections box <Enter>

Verb Strip Functions

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Activity Type:

Create = when the intervention was added to this patient’s chart

Document = when a person has entered documentation on the intervention

Edit Result = when the original documentation has been edited for any reason o E.g. adding to an incomplete document, or correcting errors.

Undo = when documentation has occurred on the incorrect patient Note that the Edit Result and the Undo appear below the documentation that has been affected. When viewing documentation, always view the latest Edit result as it will show the most up to date documentation for that particular one. Occurred and Recorded The date and time of when the intervention occurred is shown as well as the date and time the intervention was actually recorded. This illustrates the importance of changing the time to when the intervention actually occurred. Remind students that this is a legal record. To view the documentation, highlight the document event and click “View” or use the right arrow button. <Enter> will take you through the pages of the intervention. Click on <Exit> to return to the View History screen. Have each student do the following

1. Highlight the Vital Signs intervention on their patient 2. Click on “View History” 3. Highlight the documentation 4. Click on “Edit”

a. Or, type “E” into the selection box 5. Change the temperature to a different value

a. E.G. was 37.3 change it to 36.8 6. File <F12>

Selected Intervention

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Note that the edit result now appears below the document event.

7. View the original documentation by using the right arrow button, then arrow down to the edit result and view that one.

8. Exit back To “process interventions” by hitting <Left Arrow> 9. Document a new set of vital signs and file 10. Go back into “View History” 11. Highlight the documentation 12. Click on undo

**You are only able to Edit/Undo your own documentation**

Patient notes

Patient notes are used for the following situations: 1. A significant clinical change has occurred 2. Information concerning the outcomes of treatments or procedures needs to be

shared amongst health care team members 3. Information regarding planning patient care needs to be shared amongst health care

team members 4. A transition in patient care occurs

a. i.e. Patient admission, transfer or discharge 5. An incident in accordance with the Incident Reporting and Review policy

a. Remember to do a SAFE entry as well A comment box in an assessment is used only to add additional information regarding the assessment and should not contain the above information. They should be considered similar to finishing your thoughts about that particular assessment or procedure. **Note** it is not necessary to document in patient notes what has already been documented on an assessment/intervention especially if the findings are not significant i.e. Patient has no pain, IV insitu, vitals are stable etc. That is double documentation and is not required. If everything is captured in the assessment you do not need a note.

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Patient notes can be accessed from within process interventions (from the verb strip) or from the status board. Have students exit back to the status board by clicking on red “x” or <F11> .

1. Make sure you have highlighted the correct patient 2. Click on “Patient Notes” on Side Buttons

The following menu appears

3. Double click or <Right Arrow> on “Enter New Note” 4. Click or <Right Arrow> on “No Type” – this is just a feature we are not using, it will

always say no type 5. Click or <Right Arrow> on “Nursing Note” 6. If you need to change the date or time of the note use <F6> a few times to get

cursor into the appropriate box, enter the correct date/time 7. Press <Enter> a few times to get back into the text area

At TSH we use standardized text to enter notes. We access these templates or canned text by using a combination of function keys.

8. <F4> <F9> hit each separately one after the other a. You will receive a list of topics

9. Click on “Progress Note”

Date and time of

note

Topics

Confidential and

Abnormal are

not being used.

They should

always be left as

“N” for “No”

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The text will appear with the standard SOAP format.

A template window will appear with the printing in pink. The title of the note “Progress Note” should not be changed. The cursor is sitting at the “S/O” prompt. Type in the Subjective/Objective information then use the <Enter> key to move down to the next prompt when you are ready. Continue to do this until all the prompts have been completed. <Enter> again will then exit you out of the template screen and put the information into the text box for the notes. The text will now be black.

10. Have the students document a note in proper format. At this point, CAPS can be taken off as it is proper etiquette to type notes in proper Sentence Case.

Note that you cannot go back and make any edits to what has been typed until you are in the text box with the black text.

11. File the Note <F12> 12. <Left Arrow> once to get back to the notes menu.

Viewing Patient Notes

This routine can be used to view all patient notes for this patient. Patient Care Inquiry (PCI) is a much better viewing tool and will be covered later.

1. Double click or <Right Arrow> on “View Existing Notes” 2. Click or <Right Arrow> on “All Types”

a. This will allow you to view notes written by other disciplines who are caring for this patient

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3. Highlight the note you want to view

4. <Right Arrow> and then review the note content

You know you have read to the end of the note once you see the blue text at the bottom of the window. Use the <Left Arrow> key to exit back to the main Notes menu. Amending/Editing a Patient Note Policy dictates that you only amend or make edits to your own notes. If you have further information related to a note that someone else authored you can refer the reader to that note in your text. (E.g. with respect to the nursing note written this morning at 0745 on the patient’s interview, the following was also observed.)

List of Notes Entered Title of Notes (First line of the Note)

How to view Notes

Date Time and Initials of

Note author

Standard Text at end of every Note

Note difference in Time

Occurred and Time Filed

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1. Click or <Right Arrow> on “Amend Existing Notes” 2. Click or <Right Arrow> on “All Types” 3. Highlight the note that needs to be amended

a. The note that the students just entered 4. <Enter> or <Right Arrow> into the note

The computer system will allow you to review the content of the original note by scrolling down with the <Down Arrow> key until you have reached the end of the note that you are wanting to edit. However, you cannot make any changes to the original note. This complies with legal requirements You can however, make an addendum to the note in the text box at the bottom of the screen.

5. <Esc>, <F11> or <Enter> a. Takes you to the edit box

6. Add your additional information

Note identification. Confirm

that you were the author

Instructions on how to

get to the edit box.

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7. File your note <F12>

8. <Left Arrow> to exit back to the main Note menu

Undoing a Note

Again, you should only undo a note that you have authored.

1. Click or <Right Arrow> on “Undo Exiting Notes” 2. Click or <Right Arrow> on “All Types” 3. Select the Note that you created 4. Review the content of the note to ensure that this is the one that you want to “Undo” 5. <Esc>, <F11> or <Enter> 6. Type in the reason that you are “undoing” this note.

a. If you do not enter a reason than the “Undo” will not occur

The asterisk indicates that an

edit has been made to this Note.

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7. File the Note <F12>

8. Select “Yes” at the confirmation question a. Be sure you have the correct note. b. An undone note cannot be reactivated. If done in error, the note will have to be

re-entered.

Because this is a legal record, the undone note will never be completely erased. It is the same as stroking out the words on the paper and indicating that it was an error. When you go back into “View Existing Notes” the undone note will not appear. We will not be discussing the remaining options for patient notes. Please discourage students from printing notes.

Original Note.

Edit that was made to

the Note.

Reason for Undoing the Note.

The “U” indicates that this Note

has been undone

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Patient Care Inquiry (PCI)

This component of MEDITECH is the viewing of the complete clinical record for each patient. It pulls from every system that contains information for the patient. This includes not only what has been documented by all staff but also Lab results, Diagnostic Imaging, Pharmacy, Dictation Notes and any scanned paper records. The Arrow keys are the easiest way to move around in PCI. <Right Arrow> = more detail for the highlighted item <Left Arrow> = Less detail, back to the main menu (Table of Contents) The headers found on the Table of Contents (TOC) are based on the information available for each patient. A header will only appear if that patient has information filed under that category or department.

E.g. If a patient is a new admission the TOC is very small and may only contain some basic demographics that were collected when he/she was registered. A patient that has been in hospital for several days will have more information to be reviewed and the TOC may be very long and contain Lab results and other reports.

PCI is able to pull all information for your patient into one place. Information is displayed from any and all visits the patient has had to TSH. This allows clinicians to quickly review previous information and treatments. **Note** Remember, there is an audit of what you are looking at in PCI so only look at patients to whom you are assigned and only at information that you need in order to provide safe and proper care. Due to the limitations of the TEST environment, we are not able to provide you with examples of everything. Once you have your patient assignment, please review their chart in PCI

Have all students return to the SB and highlight their assigned patient.

1. From the SB Select “Review” in the Side Buttons a. This will take you into PCI b. Depending on the amount of information for a given patient this may take a few

moments to load. 2. <Arrow Down> until you find the heading “Assessment Forms”

a. This is where you will find all of the documentation screens from the Process Interventions routine.

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3. Arrow Right on ”Assessment Forms”

**NOTE: “All Forms” will provide you with a chronological list of all interventions documented. This is handy when reviewing the documentation done by the students.

4. Highlight the Shift assessment a. It should have today’s date and the time that the student documented

5. Arrow Right

a. You see a list of all the dates and times when this assessment was documented b. The most recent will be at the top of the list

6. Arrow Right

a. You will see the first screen of the shift assessment

Patient Identification

Table of Contents headers

Clinical Documentation (the

complete assessment forms)

Complete listing of ALL

assessment forms documented

on for this patient during any

visit

Date (and Time if recent) of

when each assessment was

documented.

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7. Arrow Down a. You will be able to scroll down through the complete assessment b. Notice that you are viewing all of the unanswered questions as well as the ones

that you responded to. c. You have reached the end of the assessment/documentation when the scrolling

stops

8. Arrow Left until you get back to the TOC

All items can be reviewed in the same manner. TOC Summary Screen History Screen Details Also have the students view the “Patient Notes” Once you get to the History Screen note that you can see which notes have been undone but you are not able to arrow into the detail of the note but you do see the reason the note was undone. Viewing Documentation Trends Certain sections of documentation can be viewed together in groups so as to see everything that has been documented on i.e. Vitals Signs, Blood Glucose Monitoring, Neuro Vitals, Bowel Movements, Diets etc. These group sections are found in the TOC under the same Headings that they were documented on in “Process Interventions”. View Vitals

1. From the TOC Highlight “Physiological Monitoring”

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2. <Arrow Right> to the Summary Screen

3. Highlight “Vital Signs”

4. <Arrow Right> to the history screen

Values are presented with most recent at the top, comparisons can be made with documentation done previously. Numeric and non-numeric are visible. Not all queries from the assessment screen are presented. (E.g. source queries for Temp etc.)

5. <Arrow Right> to the detail screen

6. <Arrow Left> back to the TOC

7. View different body system tabs using the same method described above

Scroll down through the listed queries for

that particular documentation time.

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8. Not all data will fit on a page so if you see an arrow pointing to the right or down, it is signifying that there is more data to be seen by scrolling

“Intake and Output Summary” This is a very important aspect to view but difficult to demonstrate in TEST. Again, once they have a LIVE patient assignment, this datasource should be reviewed.

1. <Arrow Right> and you are prompted to select a time period

This will show 24 hours back

from the current time

Allows you to define the

24 hour period that you

would like to view ie.to

see from start of shifts

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2. <Arrow Right> or <Enter> to select the default of 24 hours from the current time (this will take you right into the Summary) OR Click on “Define another time period”

3. Click on period that you would like to view

4. Click on the date you want it to end

5. Click on the time you want it to end

Subtotals are given for both

Intake and Output

The total is given for the

24 hour period

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6. <Arrow Right> to view the detail for each intake or output question

7. <Arrow Left> back to the TOC Lab Results and Diagnostic Imaging It is very difficult to provide examples for students to view. You will be able to see actual results when you are viewing a Live patient.

1. Highlight the Header on the TOC

2. <Arrow Right> to the department selection a. All of the subcategories for Lab are listed that have results for that patient b. The top heading will list all values on the screen

Indicates which question you are looking at

(Oral (ml))

Each time the patient drinks it should be documented as

soon as possible so that you can see how well they are

hydrating. A one-time documentation of 1500ml per

shift provides no indication as to how much was

consumed in the morning at lunch, in the afternoon or

evening.

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3. Select “Chemistry” & <Arrow Right> to the Summary Screen

4. Select a test & <Arrow Right> to view the History Screen a. each time that test was performed it would display here

5. <Arrow Right> to the detail screen a. This will display the full report for that blood sample as it would if it were

printed. 6. <Arrow Left> back to the TOC

NOTE: Microbiology Data has its own header on the TOC. Radiology results are viewed using the same process. We are not able to produce these results in Test but can be viewed in Live once they start on the units. Old paper charts are scanned and can be found under “Scanned Medical Records” OR/PACU document in another program than Meditech and can be found under “Scanned Medical Records” as well

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Additional Reference Material

From the SB there is a Side Button called “References”. It provides a link to helpful information housed on the hospitals intranet. Unfortunately, you may not be able to view this in the training rooms due to the Generic log-in that is being used there but on the nursing units you will be able to view it.

1. Click on “References” 2. Click on “iConnect”

a. This will take you to the home page 3. Click on “Learning” on the top menu bar 4. Click on Electronic Documentation

On this page you will find many helpful documents to assist in how to use various assessment tools and also a reference guide with screen shots that will walk you through electronic documentation questions.

Please note that the “***deact 31 May 2013…” is referring to the user, not the document.

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Paper Chart Remains

There are still parts of the chart that are on paper. They are: Doctor’s Orders Doctor’s Progress Notes/ Consults Medications Patient signed documents – i.e. consents Death certificate/checklist/autopsy and donor Critical Care and ED documentation