PATIENT CARE NOTES IN MEDITECH

1. PATIENT CARE NOTES IN MEDITECH July 2008

2. Learning objective • After completing this topic, you should be able to view existing notes, enter a new note, amend existing note, and Undo existing note.

4. Use the arrow keys to highlight the Note function you wish to do. ** To Open, Use the Right Arrow ** To Close, Use the Left Arrow ** To Open, Use the Right Arrow ** To Close, Use the Left Arrow

5. Highlight Type of Note

6. Type of Note • No Type: Can be used in any situation to enter documentation. • Nursing Diagnosis: The user is brought to screen displaying all the Dx. and the user can select the diagnosis they want the note they are entering to be associated with. • Goal: The user is brought to a screen displaying all the Goals and the user can select the goal they want their note associated with. • Intervention: The user is brought to a screen displaying all the Interventions and they can select the intervention they want their note associated with.

7. Use the F6 key to get the cursor to the date or time fields to change date or time. The user may now Free Text the note and F12 to file when finished. Remember to use DAR charting.

8. When entering an Intervention Type of note, start from the Process Intervention screen. Check mark the intervention using the right Ctrl key.

9. Then enter PN for Patient note. Notice the 1 by Intervention Highlight the intervention

10. Note the Note Type and Description

11. CANNED TEXT NOTES Another option instead of doing Free Text notes is to use Canned Text. At the beginning of the note press the < F4> key, the cursor will change to look like this _. Then do a < F9> look-up. Select which Canned Text is appropriate.

12. CANNED TEXT NOTES [g RNLOCATION] etc is a group response. Select the appropriate response. When you see a [ ] bracket or a blinking _ the cursor willstop for free text to be entered. Select “Enter” and the print will change from pink to black. To edit or add to the cannedtext the print must be black. Then select F12 to file note.

13. View an Existing Note Advance by using the right arrow

14. Category: Denotes which Department originated the note Type: Note attached with a Diagnosis, Intervention, Goal, or No Type Date, Time and By: Who entered the note and when was it entered Start of First Line: Should start with the Focus of the note. When using the right arrow key the user will be able to view the note in it’s entirety, including the Addendum’s.

15. Amend Existing Note

16. Highlight the Note you wish to Amend

17. The top part of the screen is where you can view your original note. Press enter until your cursor stops in the bottom blank box. This is where you will either Free Text to Amend the note, or use the Canned Text format (F4 and then F9). Remember to F12 to SAVE!!!

18. After the user files the Amended note an (*) will appear to denote an Amendment. Use the left arrow key or F11 to return to menu.

19. Amended Note

20. Undo Existing Notes

21. To Undo a note, use your arrow keys to highlight the Type of note you want to Undo. Right Arrow in again to choose the note you want to undo. REMEMBER, You may only undo YOUR OWN notes, no one else.

22. Once inside the note to be undone, press Enter so your cursor stops in the “Reason for Undo” box. There you will do a F9 lookup and choose the reason you are undoing this note. After choosing your reason, you must answer “yes or no” to “Undo this Note?” • Once you choose “Yes” it automatically files your undone note and takes you back to the previous screen.

23. View Undone Notes You can only view Undone Notes from the “Patient Notes” function when when entered from your Status Board or Process Intervention Screen. If you are viewing your Patient Care Notes in PCI, you will not be able to “view” any notes that have been “undone”. It will list the note in PCI but no text that was entered on that note is viewable.