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Before we Begin

Before we Begin. Practice Logging in to ensure your password works appropriately Once you have logged in, select the status board Select Lists Select Find Patient by Inpatient Location Select TEST.MOH Location Find patient : Launch the Open Chart Select to suspend your session

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Before we Begin

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  1. Before we Begin • Practice Logging in to ensure your password works appropriately • Once you have logged in, select the status board • Select Lists • Select Find Patient by Inpatient Location • Select TEST.MOH Location • Find patient: • Launch the Open Chart • Select to suspend your session • Enter your PIN – To re launch the session • If you need to reset your PIN – Please call the support center 5999

  2. Meditech 6.0 Upgrade Dietary Session I

  3. Acronyms • PCS: Patient Care System • Intervention and Assessment Documentation • Notes • EMR: Electronic Medical Record • Review patient information • OM: Order Management • Review Orders

  4. Agenda • PCS: Patient Care Systems • Overview • Status Board • Worklist • Care Planning • Documentation Functions • OM: Order Management • Enter Orders • Clinical Data Screen • EMR: Electronic Medical Record • Reviewing patient information • ITS: Imaging and Therapeutic Services • Charge Entry

  5. Registered Dietician Main Menu • List of Routines and Reports • PCS Status Board will provide most nursing care routines

  6. RD Main Menu • PCS Status Board • Desktop – Patient Care Routines • Patient Data Screen (Tech Desktop) • Reconciliation Menu • Therapists Desktop – Charge Entry • Reconciliation Reports • Billing Reports • Dietary • List of Dietary Reports • Nutrition Custom Reports • List of Custom Dietary Reports

  7. PCS: Patient Care Systems

  8. Status Board

  9. Status Board/My List Patient Assignment List • Patient Assignment List/Home Page • Displays Pertinent Patient Information • Relevant to the particular patient location • ie: Psych, MedSurg, Rehab, etc • Continuously Refreshes with new information (every 5 minutes) • Launching pad to various patient care routines Status Board Function Buttons Patient Care Routines & Function Buttons

  10. My List • Manually Add Patients to your list • Pts are Retained From One Log-on to the Next • Discharged Patients Remain on your Status Board until manually removed • Enables Care Provider to Complete Documentation even after the patient has left the facility • Manually Remove Patient from your List • Once you have Completed your Documentation and the patient has been discharged (or you are leaving for the day) • The more patients on your List the longer the status board will take to load

  11. Adding Patients to your List • [Lists] Button provides options to search for and add patients to your List • Find Account • Search for single patient by patient name • Find Patient by Inpatient Location • Provides a list of patients admitted to each location • Provides the ability to add multiple patients to your list at one time • My List • Launches your patient assignment list

  12. Video Demonstration II PCS Status Board PCS Status Board

  13. Exercise A: Find Patient by Location • Click [Lists] • Click [Find Patient by Inpatient Location] • Select [TEST.MOH Location] • Click [Assignments] - Right hand panel • Place a checkmark to the left of your TEST patient’s name • Click [Add to My List] -Footer Button • Click [Lists] - Right hand panel • Select [My List] • Confirm the patient has been added to your assignment list, then remove

  14. Exercise B: Find Patient by Account • Click [Lists] • Click [Find Account] • Type Patient’s Name (Last Name, First Name) • Use your TEST patient • Click to the select the patient account • Select the Account Number with the Admin In Registration Type • The status Board will Appear • Click [Add to My List] – Footer Button • Click [Lists] • Select [My List] • Confirm this new patient has been added to your List

  15. Open Chart

  16. Open Chart • All Inclusive Patient Care Routine • Review Patient Data • Complete Assessment Documentation • Enter Orders

  17. Open Chart • EMR Electronic Medical Record • Review Patient Data • OM Order Management • Review Orders • PCS Patient Care System • Worklist • Intervention/Assessment Documentation • Write Note • Clinical Data • View Allergies • View Home Medications • Enter/Review Patient information EMR OM PCS

  18. Open Chart: Patient Header Medical Record Number Location, Room, Bed Age, Sex DOB Height/Weight/BSA Allergies Admit Status Account Number

  19. Worklist

  20. Worklist Worklist • Open Chart defaults to the worklist tab • Documentation Routine • Interventions, Assessments, & Outcomes • Worklist is shared by all Care Providers • Care Items display based upon Care Provider Type • PT Assessments display for Physical Therapist • OT Assessment Display for Occupational Therapists • SLP Assessments Displays for Speech Language Pathologists Open Chart Routines Worklist Functions

  21. Adding a New Intervention • Interventions may be added to the worklist • To add new intervention or set use the [Add] button

  22. Add Intervention Routine • The Quickest Method of searching for an Intervention is by [Any Word] • Searches the entire intervention name • Click [Any Word] and type the intervention name you wish to add

  23. Add Intervention Routine • Type the Intervention Name • Select the Intervention • And click save to add to the worklist

  24. Exercise: Adding a New Intervention • Use your TEST patient • From the Worklist, click [add] • Select the [Any Word] tab • Type Nutrition • Hit [Enter] • Select the Nutrition and Follow Up Assessment • Click Save • Confirm that the Interventions displays on the worklist as expected

  25. Worklist • Interventions/Assessments will display on the worklist to be documented • The worklist is clickable and sortable • Click any of the worklist headers to sort the list

  26. Documentation Overview

  27. Documentation Overview • Documentation mode defaults to flowsheet • Provides a view of prior documentation • Mode Button will toggle to Questionnaire mode • Similar to a paper assessment

  28. Documentation - Flowsheet Current Date/Time Defaults White Column = Documentation Mode Gray Background = View Mode Recall is Enabled for PMH

  29. Documentation - Questionnaire • Clicking Mode will toggle to Questionnaire Style • You may toggle between Questionnaire and Flowsheet mode at any time within documentation

  30. Video Demonstration IV Documentation Documentation

  31. Exercise: Document Nutrition Assessment • Use your TEST patient • Start from the worklist • Place a checkmark in the now column for the Nutrition Assessment • Click [Document] • Confirm the time column displays the current date/time in the header • Review the documentation • Displaying from the last admission • Click [Mode] to toggle to Questionnaire Mode • Document and click save • Click [Save] • Confirm the last done column updates with the last time the intervention was documented

  32. EMR Patient Care Panel • Displays PCS Documentation • Assessments • Interventions • Outcome • Care Plan

  33. Exercise: Reviewing Documentation - EMR • Use your TEST patient • Click [Patient Care Panel] • Confirm that the [Assessment] Tab Defaults • Select to view the Nutrition Assessment • Place a Checkmark to the left of the Assessment Name • Click [View History] • Confirm that all documentation displays • Click [Back] • Click [Plan of Care] Tab – Header • Click the [+] Symbol (in the description header) to Expand the Components of the Care Plan • Review the Care Plan Components

  34. Break

  35. Documentation Functions

  36. Documentation Functions • Temperature, Height and Weight Queries • Enable you to toggle between English and Metric Units within documentation • Instance Type Queries • Enable multiple instances of documentation for various body locations or situations • IV Insertions, Orthostatic Vital Signs, etc

  37. Documentation - Calculator • Enables you to toggle between English and Metric Units • Regardless of the units of documentation, the display will default to English

  38. Documentation – Instance Type • Enables multiple instances of documentation for various body locations, positions or situations • IV Insertions, Orthostatic Vital Signs • Click the drop down arrow to invoke the group response • Select the body location/situation • Click Ok

  39. Documentation – Instance Type • Document the fields for the situation/instance • You may repeat the instance type documentation for the new body location

  40. Documentation – Back Time • To back date/time your documentation, click the drop down arrow in the header • Adjust the date/time to reflect when the data was collected

  41. Documentation – Expand/Collapse • Clicking the [-] symbol will collapse the field within the section

  42. Documentation – Collapse • Notice the temperature section is now collapsed • You may now click the [+] symbol to expand • Some sections will default as collapsed • Documentation that is infrequently utilized will default as collapsed and must be manually expanded as needed • The Manual Expand/Collapse will stick for the current assessment only

  43. Exercise Part A: Documentation Functions - Back Documenting • Use your TEST patient • Select the [worklist] routine • Select Nutrition Asssesment • Click in the now column for Nutrition Assessment • Click [Document] • Back Document 1 Hour in the Past • In the Header, click the drop down to the right of the Date/Time Field • Change the time to 1 hour in the past • Document • Save

  44. Exercise: Review Documentation in EMR • Select [Patient Care Panel] in the EMR • Place a checkmark to the left of the Nutrition Assessment • Click View History • Confirm that the Nutrition Assessment displays under the adjusted time (1 hour in the past) • Click [Back]

  45. Recall Values

  46. Care Plan

  47. Care Plan/Goals/Plan • Nutrition Goals and Nutrition Plan are documented within the Nutrition Assessment • The Nutrition Goals section is an Instance Type • Multiple goals can be initiated and assessed

  48. Dietary Goals Documentation • Free text the short term goals in the instance field • Liquid Diet • Next you will document the time frame • Also, you will document the progress • The Rehab Goals Documentation will appear in the EMR

  49. Exercise: Documenting Patient Goals and Rehab Treatment Plan • Document the Nutrition Assessment • Place a checkmark in the now column • Click Document • Click Mode to toggle to questionnaire mode • Scroll to the bottom of the assessment and find the Nutrition Goals • Indicate two nutrition goals • Click new short term goal to start an instance and free text the first goal • Document the assessment • Document the nutrition treatment plan

  50. EMR Display: Nutrition Goals • Nutrition Goals will be viewable in EMR • Clinical Panels

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