PCS/BMV Implementation RN PAT, SDC, PACU Session I

1. PCS/BMV Implementation RN PAT, SDC, PACU Session I

2. Acronyms • PCS: Patient Care System • Documentation • Interventions

3. Agenda • PCS: Patient Care Systems • Overview • Status Board • Worklist • Documentation Functions

4. Nursing Main Menu • List of Routines and Reports • PCS Status Board will provide most nursing care routines

5. Status Board

6. PCS Status Board Patient Assignment List Status Board Function Buttons Patient Care Routines & Function Buttons • 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

7. 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

8. 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 Outpatient Location • Provides a list of patients assigned to each location • Provides the ability to add multiple patients to your list at one time • Preferred method • My List • Launches your patient assignment list

9. Video Demonstration II PCS Status Board PCS Status Board

10. Exercise A: Find Patient by Location • Click [Lists] • Click [Find Patient by Outpatient Location] • Select [SDC.DSMH (Day Surgery) Location] • Click [Assignments] - Right hand panel • Place a checkmark to the left of two patient names • Click [Add to My List] -Footer Button • Click [Lists] - Right hand panel • Select [My List] • Confirm that both patients have been added to your assignment list

11. Exercise B: Find Patient by Account • Click [Lists] • Click [Find Account] • Type Patient’s Name (Last Name, First Name) • Use the Patient Assigned to you by your Instructor • Click to the select the patient account • Select the Account Number with the REG SDC 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

12. Open Chart

13. Open Chart • All Inclusive Nursing Care Routine • Review Patient Data • Complete Assessment, Outcome, and Medication Documentation • Enter Orders • Enter Allergies and Home Medications

14. Open Chart • EMR Electronic Medical Record • Review Patient Data • OM Order Entry • Enter Orders • PCS Patient Care System • MAR Medication Administration Record • Document Medications • Worklist • Intervention & Outcome Documentation • Write Note • Clinical Data • Enter/Review Patient information EMR OM PCS

15. Worklist

16. Worklist Worklist Open Chart Routines Worklist Functions • Open Chart defaults to the worklist tab • Documentation Routine • Interventions, Assessments, & Outcomes

17. Worklist: Standard of Care • Upon registration a Standard of Care Automatically defaults • Contains Standard Interventions most locations document • Only document the Interventions which pertain to the Surgical Areas

18. Care Plan Process: New Admission • Launch the Open Chart • Use Patient Assigned to you by your instructor • Confirm the Standard of Care Displays • Add the Standard of Care: *PAT/Amb - Day Surgery Admit-Set • Click Add • Select the Standard of Care Tab • Click *PAT/Amb – Day Surgery Admit-Set • Click Save • Confirm the following Interventions display • Ambulatory/Day Surgery Adm Information • Columbia Suicide Risk Rating Scale • IV/Invasive*Line Assessment • PACU Holding Area-Inpt/ED Preop Note • PACU*Record • Past Medical History • Phase II/*Outpt Post Procedure Recovery • Post Surgical Consult Review • Pre-Adm Testing (PAT) Admission Info • Pre-Surgical Documentation Reviewed • Skin Assessment

19. Sort by Frequency • Clicking the Frequency header will sort the list by frequencies

20. Documentation Overview

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

22. Documentation – Flow sheet Mode Current Date/Time Defaults Gray Background = View Mode White Column = Documentation Mode

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

24. Video Demonstration IV Documentation Documentation

25. Exercise D: Documenting PMH • Start from the worklist • Place a checkmark in the now column • 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 PMH: Asthma, Diabetes- Insulin Dependant, Tuberculosis, Eczema, Epilepsy, Patient is not at risk for aspiration • Any Body Systems with a Negative Response should be documented • Click [Save] • Confirm the last done column updates with the last time the intervention was documented

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

27. Exercise E: Reviewing Documentation - EMR • Click [Patient Care Panel] • Confirm that the [Assessment] Tab Defaults • Click the [Name] Tab – This simplifies the list of Assessments • Select to view the Past Medical History Documentation • 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

28. Documentation Functions

29. Documentation Functions • Temperature Query • Enables you to toggle betweenFahrenheit and Centigrade • Height and Weight Queries • Allows users to toggle between Metric and English • Instance Type Queries Documentation Functions • Enable multiple instances of documentation for various body locations or situations • IV Insertions, Orthostatic Vital Signs, etc

30. Documentation – Calculator Temperature • Temperature Query • Enables you to toggle between Fahrenheit and Centigrade • Will always default to Fahrenheit

31. Documentation – Calculator for Height and Weight • Enables you to toggle between English and Metric Units • Regardless of the units of documentation, the display will default to Metric

32. Documentation – Instance Type • Document the fields for the situation/instance • Repeat the instance type documentation for the new body location • In this case, BP and Pulse will be documented for Lying, Sitting, and Standing Positions

33. 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

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

35. Documentation – Collapse • Notice the temperature section is now collapsed • You may now click the [+] symbol to expand • Some sections will default as collapsed – Notice the Thermal Management Documentation defaults this way and can be expanded as needed • 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

36. Exercise F Part A: Documentation Functions - Back Documenting • Select the [worklist] routine • Select Vital Signs • Click in the now column for the Vital Signs • 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 • Next Step – Next Slide

37. Exercise G Part B Documentation Functions – Calculator & Instance Type • Document • Temperature: 98.6 Oral • Pulse: 62 • Orthostatic Vital Signs (Instance Type) • Click “New Orthostatic Vital Signs” to start a new instance • Lying Left Arm 120/80 Pulse 62 • Click “New Orthostatic Vital Signs” to start a new instance • Sitting 118/78 Pulse 63 • Click “New Orthostatic Vital Signs” to start a new instance • Standing 115/70 Pulse 65 • Click [Save]

38. Exercise H: Review Documentation in EMR • Select [Patient Care Panel] in the EMR • Place a checkmark to the left of the Vital Signs Assessment • Click View History • Confirm that the Vital Sign Assessment displays under the adjusted time (1 hour in the past) • Click [Back] • Click the [Vital Signs] Panel of the EMR and review the documentation

39. Recall Values

40. Recall Values • Recall Values provides the ability to pull prior documentation to the current assessment • To invoke the recall values function, click the [Recall] Button

41. Recall Values Recalls the entire assessment Recalls the section Recalls the individual query • Assessment displays in green • A column of diamonds appear to the right • Select the diamonds to recall individual queries, entire sections, or the whole assessment • It is critical that you review the recalled information to ensure accuracy before saving • Recalling & saving = Signing your name to the documentation

42. Exercise I: Recall Values • Document Past Medical History • Click in the now column to select the intervention • Click Document • Click Recall • Notice the screen turns green and diamonds appear in the right hand column • Click to recall one query: select to the right of the cardiovascular history • Click to recall the section: select to the right of the cardiovascular past medical history • Click to recall the entire assessment: select to the right of the Past Medical history • Confirm the entire assessment has recalled • Review all documentation to ensure accuracy • Update the GI Past Medical History Query • Click Save

43. Worklist Management

44. Worklist – Additional Functions Item Detail: Protocol, Associated Data, Item Detail Info Care Item: Intervention, Assessment, Outcome Frequency Last Done Status • Worklist displays active and discharge statuses by default • All other statuses are suppressed from view

45. Item Detail

46. Item Detail Column • Item Detail Column • P: Protocol • A: Associated Data • I: Item Detail

47. Item Detail • Clicking the Icons will launch the item detail screen • Within Item Detail there are multiple tabs • Detail, History, Flow sheet, and Associated Data

48. Item Detail Tabs • Detail • Info about Intervention • Intervention text (Post it note) • History • Audit trail of changes made to the intervention • Flow sheet • Documentation View in Flow sheet mode • Associated data • View of Data Fields related to the particular intervention

49. Item Detail History Tab • Audit Trail of Changes Made to the Intervention • Activity: Document, Edit, Undo • User that documented, Care Provider Type, and Detail related to the change • Footer buttons: Edit/Undo documentation • Allows you to edit or undo your own documentation only • You may not edit or undo another users documentation

50. Item Detail: Info • Item detail may be utilized as a communication tool • In the text field enter a note related to the intervention • In this case, the patient’s blood pressure must be taken on the left arm