Meditech 6.0 Upgrade

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Meditech 6.0
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ED TRAINING SESSION 1

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Agenda

• My Steward Review
• Tracker Orientation (Main, RN, Charge RN)
• Reception Routine
• Triage and Allergies
• ED Visit Data
• RN Documentation and Screen Layout
• RN Additional Focus of Care
• RN Edit and Undo

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My Steward

• Locating Training Materials
• Training Process
• Intro
• CBT
• Questions

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Meditech Training Tutorials
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Tracker Orientation

• EDM Tracker
• Location Tracker (Main ED, Fast Track, etc.)
• These tracker are meant to be Standard Across the
  system.
• My RN Tracker
• This tracker allows you to keep track of only
  patients you are caring for. It also shows more
  detailed information.
• Charge RN Tracker
• This tracker will display all areas of the ED
  and show more detail on the patient.

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Tracker and Personalized View Tutorial
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Charge Nurse Tracker

• All RNs will have access to the Charge Nurse
  Tracker
• The Charge Nurse tracker contains detailed
  information on the patient
• Displays all patient in all areas Main, FT

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Tracker and Personalized view (My RN) Questions
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Reception Routine

• This routine is the quickest way to get the
  patient on the tracker.
• It consists of only 4 required questions.
• Patient Name is a required field and should be
  entered in mixed case (ex. Darling, Jean)
• Routine is meant to be used by Nursing only if
  Patient Access/Registration is not available to
  put the patient on the tracker.
• Primarily this is a patient access/registration
  routine.
• Through this routine you are able to print the
  patient wrist band and face sheet.
• When RNs must perform this routine they should
  enter the SS number whenever possible and click
  SEARCH for the MPI (master patient index).

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Triage and Allergies

• Triage can be accessed through the tracker

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Triage and Allergies

• This routine allows you to document the Triage
  assessment as well as
• Change the Location of the patient
• Change the Room for the patient
• Enter in the Patients Chief Complaint
• There are certain functions that even though you
  have access should not be updated on this screen
• Filling in the Providers of Care will update the
  statistics such as door to doctor time. This is
  being updated another way and should not be
  updated on this screen.
• The only fields that should be filled in on the
  screen in the first tab of the screen are
  Location, Room, Chief Complaint and Triage
  (Patients MOA must be entered) along with the
  ESI level.

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Allergies

• Allergies is accessed on the second tab of Triage
• Allergy information crosses to PCS, OM etc.
• Allergies must be entered to place orders in OM
• Allergy information is recalled on the medical
  record based on what was entered in the patients
  last visit.

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Triage and Allergies Tutorial
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Triage and AllergiesQuestions
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ED Visit Data Screen

• The ED Visit Data Screen is an additional screen
  where you can update the patients room and
  location.
• To access the screen go to Open Chart -gt ED Visit
  Data

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Documenting in Meditech

• Ensure that you are logged onto the computer
  under your own name and have a pin
• All entries are part of the patients legal
  Medical Record and time stamped
• Only answered questions appear as part of the
  Medical Record
• Be sure to lock down or sign out of your PC when
  leaving
• All documentation must be completed prior to
  Discharge or Admit and before end of shift.
• Always remember to SAVE your documentation!

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Things that MUST be Documented in Meditech on
every patient

• Complete Triage Assessment
• Allergies
• Patient History
• CC Assessment
• RN Disposition Documentation (part of Discharge
  Routine)

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Things that need to be documented in Meditech as
applicable

• Additional Focus of Care items
• Additional Vital Signs and Progress Notes
• IV site Intake and Output/ Add an IV or Add a
  Void
• Critical Value
• Treatments
• Other

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Chief Complaints

• By choosing a Chief Complaint at Triage you are
  driving documentation onto your work list.

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Notes

• You have the ability to add a Progress Note in
  the Vital Signs and Progress Note Assessment
  (typically this is what is being utilized for
  notes)
• You also have the ability to document anything in
  the comment section in each one of the CC driven
  assessments.

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RN Documentation and Screen Layout
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RN Documentation and Screen LayoutQuestions
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Additional Focus of Care

• Allows you to add assessments as needed

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RN Additional Focus of Care
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RN Additional Focus of Care Questions
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Oops!

• With edit and undo options you have the ability
  to edit incorrect documentation done on a
  patient.
• You also have the ability to remove the entire
  assessment
• If you need to back date the time that can be
  done as well either when initially documenting or
  at a later time through edit

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RN Edit and Undo
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RN Edit and Undo Questions
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Printing A Patient Report

• Click the ED Summary button from the Tracker
• Print the ED Summary this contains the complete
  SBAR format information of the patients visit.

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Things that are still on paper

• Codes
• Procedural Sedation
• State Mandated Forms
• Cobra
• Section 12
• Consents

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EMR Review

• Highlight the Patient and Open the
• Chart
• Click on Clinical Panel
• Choose the ED
• Here you can review all ED
• documentation (this is utilized by
• ED Physicians, medical records and
• inpatient Nurses)

EMR
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Discharge

• Accessed through Open Chart
• The discharge date/time should be entered for
  when the patient is leaving the department this
  function is done by the CAN staff
• The discharge intervention should also be filled
  in a the time of discharge
• Once both are complete and accurate the Discharge
  can be saved.

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Remove the Patient off the Tracker Status Event
change

• To remove a patient from the tracker you must
  update the status event to End of Visit
• This must be done after the patient has left the
  ED.

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Questions?

• Time to practice! Remember the more practice you
  have now the better off you will be!