document editing l.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Document Editing PowerPoint Presentation
Download Presentation
Document Editing

Loading in 2 Seconds...

play fullscreen
1 / 64

Document Editing - PowerPoint PPT Presentation


  • 68 Views
  • Uploaded on

Document Editing . PCS Lesson 4. Objectives. List situations that require you to edit and undo documentation Demonstrate how to edit your documentation Demonstrate how to undo documentation you have mistakenly entered on the wrong patient

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Document Editing' - kalin


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
document editing

Document Editing

PCS Lesson 4

objectives
Objectives
  • List situations that require you to edit and undo documentation
  • Demonstrate how to edit your documentation
  • Demonstrate how to undo documentation you have mistakenly entered on the wrong patient
  • Demonstrate how to document an intervention that was performed in the past
  • Learn how to return to incomplete documentation and finish
slide3
In a perfect world, you would always document as soon as you provided your cares and you would never make any mistakes. All of your documentation would be completed according to schedule, and you would never forget to answer a question.
slide4
Despite being careful about our documentation, inevitably you will make mistakes or forget to document information that needs to be a part of the patient’s record.
slide5
This lesson will teach you how to correct mistakes, how to undo documentation that was mistakenly entered on the wrong patient, how to retrospectively document, and how to complete interventions you did not get a chance to finish yet.
slide6
All of our editing, back-timing, and undoing is possible to accomplish from our Intervention worklist for our patient. Right now, we are viewing our patient list, or status board. The patient whose documentation we wish to edit has been highlighted. To access our intervention worklist for our patient, we will now click on the Interventions button on the right side of the screen.
slide7
We are now on our intervention worklist. We will first look at how to undo documentation we have entered in error on our patient. Whenever we wish to undo documentation of an entire intervention, we will click in the History column for that intervention.
slide8
Let’s say we want to undo a height and weight we had documented earlier because we had accidentally entered it on the wrong patient. We will first click in the history column for this intervention.
slide9
This will open up a screen that displays all of the past episodes of documentation for the height/weight intervention. The most recent documentation episodes will be listed at the top of the screen. You will look for your name in the Done by column, and then find the correct episode of documentation you wish to undo by looking in the Date/Time Done columns.
slide10
Now that we have identified which episode of documentation we wish to undo, we will click on the intervention. This will highlight the row green, as seen on our screen now.
slide11
Once the row is highlighted, all we have to do is click on the Undo button located at the bottom of our screen. Let’s see what happens when we click on Undo.
slide12
After clicking on Undo, we must select a reason why we are undoing the documentation. Here, we have selected Incorrect Time. Now, we will click on OK.
slide13
Now we see an extra row added to our screen. Notice the word Undo with a green background in the Type column.
slide14
Note that the original episode of documentation still appears, just below the episode where we have undone our intervention, as seen highlighted here.
slide15
We cannot save what we have done from this screen. In order to save our actions, we must return to the intervention worklist by clicking on the Return button in the bottom right corner of our screen. Let’s do that now.
slide16
This has brought us back to our intervention worklist. Notice the new line of purple text underneath our height and weight intervention. This is our reminder that we still need to file our actions. Let’s click on Save now.
slide17
Now that we have clicked on save, our previous height/weight documentation has been undone and will not be viewable in the EMR/Chart for our patient.
slide18
Sometimes we may wish to edit what we have documented instead of undoing the entire episode of documentation. The edit process is similar to the undo process. Let’s see how we can edit our documentation.
slide19
We realize we made a typing error when we entered in the temperature for our patient in the last vital signs documentation. Once again, we will use the History column to access the list of our previous documentation. Let’s click in the history column now for vital signs.
slide20
We are now on the documentation detail screen for the vital signs intervention. Let’s locate the episode of documentation we wish to edit. The temperature mistake was entered in our vital signs documentation at 0418.
slide21
To change the temperature, we must double click on the row that represents the time when the error occurred. We will double click on the documentation row for 0418 now.
slide22
This opened up a screen that contains our entire 0418 vital signs documentation for our patient. Changing values is easy. All you have to do is click on the answers you wish to change and Meditech will allow you to correct them right on the screen. We will now click on the pink/green box to change our temperature.
slide23
Just like when you documented vital signs originally, the temperature keypad will open on the screen. We will use the back arrow symbol on the keypad to erase our previous documentation.
slide24
Our previous value has been erased and now we will type in the correct temperature value using the keypad buttons.
slide25
We will now click the OK button on the keypad to deposit our new temperature into our previous vital signs documentation.
slide26
We can now see the changes to the temperature displayed with the rest of our previous vital signs documentation. We have no more changes to make on this screen. We will click on the Return button in the bottom right hand corner to get back to the edit screen.
slide27
Notice that just like when you Undo documentation, a new row appears on our edit screen. This time, the word Edit appears in the Type column with a green background.
slide28
Note that the original episode of documentation still appears, just below the episode of editing, as seen highlighted here.
slide29
Same as before, we must click on the Return button to get back to our intervention worklist, where we will be able to save our changes.
slide30
Back on our intervention worklist, we see a row of purple text showing our name with the date, time, and the word edit, reminding us we still need to file the edited information. Let’s click on Save now.
slide31
Now that we have saved our changes, only the correct documentation will appear in the EMR/Chart. It is important to note that even through we won’t be able to see the previous temperature documentation in the EMR, Meditech will still have a record of you changing the temperature.
slide32
Meditech will allow you to make changes to your documentation for 3 days, even after the patient is discharged. Remember you should only be editing your own documentation – NOT someone else’s.
slide33
Now let’s discuss how we can complete interventions that we have started documenting on but haven’t finished. Sometimes you will not be able to complete an entire assessment at one sitting without interruption.
slide34
If you were documenting on paper, you would put the documentation aside, perform your other duties, than return to the same paper assessment to complete the documentation you had started earlier.
slide35
The same process is true when you are documenting on the computer. If you Save an assessment in an unfinished state, you can go back to it later to enter the rest of the documentation. Let’s see how that would work.
slide36
Earlier, we began documenting on the personal hygiene assessment. Half way through, one of our other patients needed our help. We filed what we had completed documenting and logged out of Meditech. Now we are ready to finish the documentation.
slide38
Next we find the correct episode of documentation that we started earlier, and double click on the row.
slide39
This will open up what we finished documenting before. We will pick up where we left off and complete the rest of the intervention.
slide41
A new row appears on our documentation screen. The word Edit appears in the green area of the Type column. We will click on Return to get back to our Intervention List.
slide43
We will now discuss two ways we can retrospectively document (or back-time) interventions.
slide44
It is important to remember to back-time your documentation in Meditech if it is greater than one hour later than the time you actually provided the care. For example, if you collect a set of vital signs on a patient at 0700, you have until 0800 to enter them into the computer. If it is past 0800, you must record the time you actually documented the vital signs correctly in Meditech, so that it doesn’t look like your documentation was completed later than the scheduled time.
slide45
The easiest way to retrospectively documentation is by using the Document button at the bottom of the Intervention worklist. Any time you click on the Document button after clicking on an intervention to select it, a date/time keypad will open, allowing you to change the time.
slide46
Let’s see how we would do this. We want to record that we cleared our patient’s dinner tray this evening at 1900. It is now past 2000, and we have to make sure we document the time we actually cleared the try correctly. We will start this process by clicking on the Meal Intake Intervention on our screen.
slide47
Now that we have clicked on it, the Meal Intake Assessment is highlighted green. Now we will click on the word Document at the bottom of our screen.
slide48
This opens a date and time keypad. The time we enter on this keypad will be the time the computer records that we actually carried out the intervention. We will now change the time on this keypad to 1900 and the date to the day before – as it is after midnight now.
slide49
The time on our keypad is changed. We will now click on OK to open the Meal Intake documentation screen.
slide50
Here is our Meal Intake Intervention. We have filled in the documentation for you on this screen. Now we will Save the documentation by clicking on Save in the bottom right hand corner.
slide51
Our Meal Intake Intervention has been saved. If you look in the History column, the time is several hours past. This is because Meditech saved the Meal Intake as being completed at 1900, not the current time.
slide52
There is also an easy way to save several interventions completed at a certain time, instead of one at a time. Let’s take a look at how we can do that.
slide53
We want to record that we took our patient’s abdominal girth and reapplied their SCDs at 0200 this morning. The first thing we will do is click on the Document Stamp at the top of the Intervention worklist. Right now the Document Stamp says Default Time, meaning the current time. We want to change it to 0200. Let’s see what happens when we click on the Document Stamp.
slide56
Notice that the Document Stamp at the top of the screen is now showing 0200. Instead of saying Default Time, the document stamp now says Fixed Time. All the interventions we document now – up until the point where we save on this screen – will be saved as being done at 0200. Let’s start by double clicking on the abdominal girth Intervention.
slide57
We have documented this screen for you. We do not want to Save yet because we still have to document the other intervention for 0200. To return to our intervention worklist, we will click on the Return button.
slide58
Notice the line of purple text that is under the Abdominal Girth Intervention. The time in the text is 0200. Let’s enter our second intervention for 0200 now. We will not Save yet. We will double click on SCD to open the intervention.
slide59
There is text added to the SCD Intervention. Before we can document our SCDs, we must read the text. After reading the text, we will click on the OK button. We will click on OK now.
slide60
We have filled in the SCD documentation for you. Once again, we do not want to click on Save, we want to use the Return button to take us back to the intervention worklist.
slide61
Now that we are back on our Intervention worklist, we see the purple line of text added for the SCD documentation has the same time of 0200 listed. We are finished our documentation that we wanted to record as being done at 0200. We can now click on Save.
slide62
Notice that now that we have Saved, the Document Stamp has returned to the Default Time, which means it is back to the current time. If we had Saved when we were in the intervention at the end of our documenting, this clock would not have reset for us. This is why it is so important to use the return button when documenting several interventions for a past time and only save when you are back on your Intervention worklist.
slide63
It is a good idea to pay close attention to your Document Stamp when you are beginning to learn how to edit your documentation in PCS. The time that shows in the document stamp represents the time your documentation will be saved as being done in the the computer.
great job
Great Job!!
  • In this lesson, you have learned how to:
  • Edit your documentation
  • Undo documentation accidentally entered on the wrong patient
  • Complete documentation started previously
  • Retrospectively document cares provided in the past
  • * Remember if you need help, go to the Nursing webpage on the Infoweb and click on the Meditech Help Link.