Electronic Medical Record View Access for Students

1. Electronic Medical Record View Access for Students A self-paced tutorial

2. Student Access Students will be given a temporary “view only” access to the electronic medical record User names and passwords will be distributed This tutorial must be viewed prior to access

3. After initial login, Select the Meditech icon from the hospital menu You will automatically begin logging into Meditech

4. Using the mouse or arrow keys, select “Children’s Hospital PCS”, another menu will open Click or arrow down to “EMR”. This is the medical record. Meditech operates on a single click system. Double clicking will open multiple screens and slow down the system

5. A new program window will open, The Enterprise Medical Record If no records have been recently viewed, no records will be displayed If you have recently viewed medical records, these records will appear in a list

6. Select “Any Location” to search by location White colored tabs are the currently selected tab on the menu Select “Any Record” to search by name To Find a Medical Record, Search by Location or Name

7. Then select the desired location A list of patients at that location appears, select the appropriate patient “Any Location” to Search by Location…

8. Then type at least: • the first three letters of the last name • a comma • the first letters of first name • Then select “OK” A list of similar names appears, select the appropriate patient “Any Record” to Search by Name

9. Use the “Back “ button at any time to return to the previous screen Select the appropriate name, using two identifiers (name, DOB, medical record number)

10. A list of visits for that patient appear; scroll down list The list of visits may be narrowed by changing the criteria, defaults to “all” • Clinic visits are marked with a thermometer • Emergency Room visits with an ambulance • Inpatientadmissions with a bed (current visits have a green dot by the pillow)

11. After Selecting a Visit, the default Patient Summary Screen Appears From this screen, one may access several areas of the patient’s electronic medical record

12. Electronic Medical Record • In June of 2011, Children’s will move to complete online documentation • Until that time only particular data is available in the electronic medical record: • Emergency department charting • Laboratory, microbiology, blood bank, pathology, & imaging data • Medications, allergies, weight & orders • Some care provider reports (physician, social work)

13. The header contains the patient name, height, weight, body surface area, body mass index, & allergies Patient HeaderAt the top of the Patient Summary Screen is the Patient Header It also displays their DOB, age, gender, account number, medical record number, location The account # correlates to the visit and begins with an “H”. The medical record # is a lifetime # and begins with an “M”

14. After Selecting a Visit, the Patient Summary Screen Appears “Summary” view is the default view. Other tabs offer other views

15. Other Views

16. Patient Summary Screen Tabs to the right side of the screen are the medical record menu tabs “Record List” takes you back to your list of recently viewed records “Other visits” goes to a list of that patients other visits

17. For example, selecting “Infectious Disease” allows all related data to be displayed Special Panels Special Panels gives the user a central location to view multiple data in a spreadsheet format

18. Vital Signs and I & O These categories will display recorded nursing data. However, at this time only the Emergency Department is utilizing online documentation, therefore, only ED information is displayed here.

19. Notes may be categorized by the type of notes available (dark blue writing) Select the return button to return to previous screen Notes Any note with the blue “i” icon indicates more information. Click on it and the additional information or report will be displayed

20. Displays active, discontinued, and all medications ordered for patient according to the selected panel at the top Medications

21. Order History All orders for the patient are displayed by order date & time. To change the sorting order, click on the column headers

22. Lab data is displayed first by visit or lifetime history And also displayed by type of lab test Laboratory Data Serial labs are displayed by dates

23. Microbiology & Pathology These tabs work the same way, displaying microbiology & pathology tests. The reports are displayed by clicking on the report icon.

24. Blood Bank Tests Blood bank tests are displayed by selecting the tab

25. Imaging Again, a reverse chronological list is shown of all exams. Selecting the comment bubble in the report column will display the written report. Selecting the camera icon (not shown), if available, next to the report will open PACS, Children’s online radiological images.

26. Other Reports Any report other than imaging, will appear under this panel, such as, discharge summary, progress notes, and history/physical.

27. Additional Panels All additional panels either: • Will not be utilized until Children’s moves completely to online documentation OR • Will not be accessible by the student in view only access.

28. To Complete this Module • Please print & sign the confirmation form and return to your instructor • Instructors create a list of all students from which you receive confirmation forms and send it to: Charlotte Simmons Mailstop GE08 Children’s Hospital Central California 9300 Valley Children’s Place Madera, CA 93636

29. Questions?? If you have questions regarding this module or the electronic medical record, please contact: Patricia “PT” Lindsey, MSN, RN. CNS, CPN @ 559-353-8112