OM/EMR Training. Agenda. Introduction to the EMR Non-Med Order and Order Set Entry Consults Acknowledgment and Incomplete Orders Post-Filing Edits to Orders Entering Requisitions. Intro to EMR. Electronic Medical Record
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Documented intake and output will be listed here. Again data will be trended by date and time and can be adjusted to display increments of 1, 4, 8, 12, and 24 hours.
The default on the Medications tab, is the medication list which is a simple list of all medications during this patient’s visit, but can be expanded to include medications from all visits.
Clicking the header of each column allows the list to be sorted accordingly. Additional filters can be applied using the footer buttons at the button.
The second tab on the Medications panel provides a view only display of the MAR. All information on the MAR can be viewed, but no documentation can take place here. You must visit the true MAR for this.
The detail footer button allows for viewing of additional medication information, such as the flowsheet, monograph, medication detail, protocol/taper schedules, and any associated data.
The Laboratory Panel displays all lab data separated out by category. This defaults to the visits selected, but all visit data can be displayed by choosing that tab. Clicking the name of the test will launch you to a list of all results for that test. Clicking the result itself will launch you to a screen to view additional test data, such as the reference range.
Lab reports can be printed by clicking on the date and time header of the lab panel. The user will be launched to a collection data screen, where he/she can select lab report and print the data.
The Microbiology panel displays all microbiology tests that have been received into the lab. The status and results will be displayed with the procedure. Clicking on the notepad will launch the user out to the final report.
The Blood Bank Panel allows for Blood related information to be tracked on the patients. The LAB/BBK department will update information in this panel along with the Blood Product Infusion Record/Reaction documentation done in nursing.
The reports panel shows all reports that have been entered on the patient, including radiology report, cardiology reports, dictated physician reports, physician documentation reports, as well as Allscripts reports once they are live in the system. *Initially Allscripts reports will be housed in the patient paper chart. Clicking the notepad will launch you to the report for viewing and printing.
The Patient Care tab provides a view only overview of all assessments and interventions documented on the patient. The plan of care is also viewable from here. The information can be sorted out by date, name, recorded by, and provider type.
Clicking onto the name of an assessment or intervention will launch you into a view only display of the documentation. No edits can be made from this panel.
The notes panel displays all notes entered on the patient by nursing, physicians, and other staff. Dictations and Physician Documentation reports (such as Progess Notes, H&P, Discharge Summary, etc) are not found here. They are on the reports panel. To view, either check off the box next to the desired note and click “View Selected” or clicking directly on the note.
Orders will be discussed in detail later in the training. For purposes of the EMR, however, the orders panel is accessible to all users on any desktop. All active orders will be displayed on the current orders table and the history panel contains these as well as cancelled, completed, and discontinued orders.
Code status can only be entered on the patient data screen of the Clinical Data Screen. Code status can be selected from a list of options and limits can be entered below if appropriate. This information can be viewed here as well as in the Kardex, the small “i” next to the patient’s name in the header, and in certain clinical panels.
Open the Select Visits tab of the patient’s electronic medical record (EMR)If the patient has PCI data available, the “View PCI” footer button will be illuminated.Clicking this button will launch you to a view only display of their PCI information in Magic.
Accessing Magic From 6.0
The patient’s PCI chart will display and can be navigated through.
Full orders functionality will be shown in the CBT coming up. To provide an overview, all nonordering providers will select an ordering provider and source upon selecting “New Orders”. This will launch you to your selection screen where you can order off of favorites, by category group, or by typing ahead in the name tab. With the type ahead, select the desired order. Multiple orders can be queued up by clearing the search field after selection and typing ahead again.
Clicking next will launch into the Edit Order list where all new orders and any potential duplicate orders will display. Any orders that have fields requiring edits will have an asterisk. Clicking that order will display the edit screen and fields with asterisks must be completed. Once these requirements are satisfied clicking next will take you to the Manage Orders screen where additional edits can be made if necessary.
Once you have reviewed on Manage Orders and click next you will be taken to the Current Orders table where new orders will be displayed with a green “New” status until filed. Clicking submit files the orders. Physicians require pin entry before filing.
Order sets are available for use by nursing should it be appropriate. They are especially useful in the ED where the Med Approved Protocols are available for use. The sets group orders together to support evidence based medicine and can be ordered by category or by searching by name. Multiple sets can be selected at one time.
Once the sets are selected, the manage orders list allows you to select the orders that are needed. Edits can be made by clicking the blue edit button on an individual order or by selecting edit all which will queue up orders for editing. The functionality here is identical to orders and they will be filed in the same way.
The edit screen of a consult order differs for ordering versus non-ordering providers. Physicians are not require to enter consulting provider, so their consults file as incomplete to be completed by the nurse or secretary. Once the consulting provider information is entered additional information regarding communication to the consulting provider should be entered. A notification is sent to the physicians desktop when this information is entered. Incomplete orders will display on the statusboard as such and on the current orders table.
All orders and order edits must be acknowledged by nursing. The Ack column on the statusboard allows for this to be done efficiently. Stat orders will be flagged as Stat and highlighted in pink. Routine orders will display with “Ack” in the column. Click into the column to acknowledge.
Each order must be selected and reviewed individually to acknowledge. Once you have reviewed each order, click the Acknowledge button. To restore them to unacknowledged before filing hit Undo. Otherwise click save to file the acknowledgment. You will then be brought to the manage orders screen.
To edit an existing order, click on the order in current orders, and make any edits on the edit order list page that you are brought to. Editing a connecting order (lab, pha, mic, rad, card) will place a stop request on the original order and file your edits as a new order.
Orders can also be edited from the Edit Multiple Button located on the Current Orders table. Multiple orders can be checked off here and edited using the available footer buttons. Again for connecting orders, edits made to the connecting orders (outside of the specimen collection field) will place a stop request on the order and file the edits as a new order.
Requisitions are a means of communication for information that is not patient specific.
Requisitions can serve as requests for supplies or communications to other departments.
On the edit screen simply enter in your message/communication. Once filed the order will print to the receiving party.