patient care notes in meditech
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PATIENT CARE NOTES IN MEDITECH

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PATIENT CARE NOTES IN MEDITECH. July 2008. 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. Use the arrow keys to highlight the Note function you wish to do.

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Presentation Transcript
slide2
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.

slide4
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

slide6
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.
slide7
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.

slide8
When entering an Intervention Type of note, start

from the Process Intervention screen. Check mark

the intervention using the right Ctrl key.

slide9
Then enter PN for Patient note.

Notice the 1 by Intervention

Highlight the intervention

slide11
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.

slide12
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.

slide13
View an Existing Note

Advance by using the right arrow

slide14
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.

slide17
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!!!

slide18
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.

slide21
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.

slide22
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.

view undone notes
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.

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