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

PCS/BMV Implementation RN PAT, SDC, PACU Session II. Session II Agenda. MAR/BMV Documentation Daily Documentation Patient Reports Medication Reconciliation Process & Home Medication Entry Vaccine Documentation Process Review Exercises Admission Inpatient Transfer/Hand Off Discharge

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

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

  2. Session II Agenda • MAR/BMV Documentation • Daily Documentation • Patient Reports • Medication Reconciliation Process & Home Medication Entry • Vaccine Documentation • Process Review Exercises • Admission • Inpatient Transfer/Hand Off • Discharge • Home • Home with Services • Transfer to SNF • Additional Nursing Routines • Bed Board • Discharge Routine • Downtime • Go LIVE

  3. eMAR/BMV General Info • Acronyms • eMAR: Electronic Medication Administration Record • BMV: Bedside Medication Verification • Scan Patient • Scan Medication • Verify 5 Rights of Med Administration • Functions • View Scheduled Administrations • View Orders and Dose Instructions • Document Med Administration • Expected Outcome • Reduction in Medication Administration Errors • Improved Completeness of Documentation • Improved Safety

  4. MAR Overview/Acknowledge review

  5. MAR Overview/Acknowledge review • Explain

  6. MAR Layout: Functions • Refresh: Refresh new data manually • Change View: Changes the view of data displaying on the MAR • Document: Document an administration (manually-not using scanning) • Not Recommended! • Document Unscheduled: Document an administration that is not scheduled • Document Assess: Document an MAR assessment • Detail: View the detail of the MAR Order • Manual Barcode: Enter Medication Barcode Manually • Renewal: Flags when certain medications are approaching their renewal date/time • Med Review: Will not be utilized • Schedule Comment: Enter a comment for a medication schedule

  7. Medication Detail Panel Includes Many Tabs of Order Information • Med Detail Info Tabs • Detail • MAR Detail • History • Audit Trail • Flowsheet • Assessment Documentation • Associated Data • Related Queries, Labs, etc • Protocol/Taper • As Indicated • Order Detail • Audit

  8. Medication Detail: History Tab Order Information Audit Trail Line Items Audit Trail Detail

  9. Medication Detail: Flowsheet Tab Flowsheet Documentation associated to the particular Medication

  10. Medication Detail: Monograph Tab Order Detail • Medication Monograph • Viewable • Print-able • English/Spanish

  11. Medication Detail Associated Data Tab Order Detail • Associated Data • Query Documentation • Lab Results

  12. Medication Detail: Protocol/Taper Tab Order Detail • Associated Data • Query Documentation • Lab Results Protocol or Taper as Indicated

  13. Order Detail Order Detail Fluid Volume Info Titration Info & Protocol ACK Audit Trail

  14. Medication Detail Panel Review All of the info just covered, is viewable from the MAR Detail Tab • Med Detail Info Tabs • Detail • MAR Detail • History • Audit Trail • Flowsheet • Assessment Documentation • Associated Data • Related Queries, Labs, etc • Protocol/Taper • As Indicated • Order Detail • Audit

  15. Acknowledging Orders

  16. Acknowledging Orders • Two places to Acknowledge Med Orders • MAR Ack Routine • Status Board Ack Routine Acknowleding Orders from the Status Board will Auto - Ack on the MAR!

  17. Status Board Acknowledgement Routine • Preferred Method of Acknowledging Meds • Enables Acknowledging multiple meds at one time • Review Order Detail Screen in less clicks

  18. Status Board Acknowledgement Routine • Click Each Order to review the order detail • Click Acknowledge • Save Order Detail

  19. MAR Acknowledgement Routine Acknowledged Orders Acknowledged from the status board will be acknowledged on the MAR

  20. MAR Acknowledgment Routine To Ack from the MAR you will review the medication cell as well as the order detail. • Highlight Med • Review the medication cell • Five Rights • Click • the detail tab • to review the • Order detail

  21. MAR Acknowledgement Process Review all items of the medication detail screen

  22. MAR Acknowledgement Process • Click on the red Unacknowledged status • Select Acknowledge Order

  23. Reject Acknowledgement • If a medication order is incorrect, reject the order • Place a phone call to pharmacy • Acknowledgement may be edited as needed

  24. Acknowledging Medications • Acknowledging is signing your name to the order • Obtain/Review appropriate information before signing off On MAR • Review main MAR & Five Rights • Right Patient • Right Medication • Right Route • Right Dose • Right Time • Click Detail Tab to review the Order Tab and Audit Trail • Order Source • Edits Made • Status Board (ACK Routine) • All information on one screen • Five Rights • Order Audit

  25. Warning: Never ACK Upon Admin • Admin before ACK: “Medication has not be acknowledged” • Click Cancel and Review Order Detail! • Never select Acknowledge and Document • You will not be presented with enough info

  26. Exercise: Acknowledge from the Status Board • Use the patient from your scan sheet • Click [Lists] • Select [Find Account] • Type Last Name, First Name • Add the Patient to your My List • From the status board click the ACK field • Find the Furosemide Order • Place a checkmark next to the Furosemide • Review the Order Detail • Who entered the order? • What time was the order entered? • Once you feel comfortable with the information click acknowledge • Click Save • Click Return to the Status Board • Scan the Patient’s Wristband • Enter your Pin • Confirm that the Furosemide has been acknowledged on the MAR

  27. BMV Scanning

  28. BMV: Scanning • Scanning the barcode will Automatically Locate the Medication on the eMAR • Multiple Medications can be Scanned and Administered Before Saving Documentation • Technique: • Position scanner near the barcode • Slowly move the scanner away from the barcode, and close again until beep is heard • View screen for confirmation • If the Wrong Patient is Scanned, you will be alerted that the account number is incorrect • You will not be able to scan medications until the patient’s wristband has been scanned

  29. Exercise: Acknowledge Meds/Basic Admin • Confirm the Header Displays “Verified” • This indicates you have scanned the wristband • Scan the Lasix (Furosemide) Barcode • Confirm a barcode displays in the Medication Cell • Confirm the admin date/time and barcode displays in the admin time field • Click Ok to Proceed to the Summary Screen • From the Summary Screen review the admin information • Click Save • Confirm that the Administration Date/Time displays in black text, indicating the admin has saved to the MAR

  30. Administration Documentation Process

  31. Administration Process Review • Scan Patient’s Wristband • Scan Medication barcode • Review & Update Med Administration screen • Review Med Protocol Information • Date/Time of Admin • Dose • Admin Comments • Assessment • Click Ok on the Admin Screen • Click Ok on the MAR to proceed to summary screen • Review summary screen for accuracy and click save when complete

  32. MAR AdminStep 1: Scan Patient & Medication • Scan Wristband • Scan Medication

  33. MAR AdminStep 2: Review/Document Admin Screen • Review & Update the Admin Screen • Ordered dose and scanned dose • Schedule Date • Administered Dose in mg • This information can be edited as needed • Once you have confirmed this documentation is accurate, click Ok

  34. MAR AdminStep 3: Review MAR • Once you click Ok from the admin screen, you are brought back to the MAR • The Admin Date updates the Admin Cell in Green Text (Green = Pencil) • Admin has been documented but has not yet saved to the record • You may scan multiple medications at one time • Proceed to Summary Screen • Document another med admin • Proceed to the summary screen to review and save

  35. MAR AdminStep 4: Review Summary Screen • Med Admin Summary Screen • Review Admin Documentation before saving • Confirm documentation is correct • Click back to edit the administration • Click save to save this to the EMR

  36. MAR AdminStep 5: Save the Administration • Once the admin has been saved it will display in black text • This confirms the administration has saved to the EMR

  37. Administration Screen Details

  38. MAR Administration Screen Main MAR Order info • Once the Medication is scanned, you are launched into the Admin Screen • Medication Administration Screen • Scan List • Admin List • Flowsheet • Protocol/Taper • Associated data • Monograph • Links Scan List

  39. Medication Administration Screen • MAR Order Information • Scanning Detail • Administration info • Scheduled Date • Administration Date/Time • Admin User • Administered dose • Non Admin Reason • Admin Comments • Admin Date: • Date med was given • Edit to Back Document Dose: Amount of med given Edit to adjust the administered dose

  40. Medication Administration Screen • Flowsheet Tab • Order Info • Scanning Detail • Administration Assessment

  41. Medication Administration Screen • Drug Monograph Tab • Order Info • Scan Detail • Monograph

  42. Medication Scenarios

  43. Split Meds • Dose Dispensed: 10 mg tab • Dose Ordered: 15 mg • Split one tab • Administer 1.5 tabs

  44. Split Medication • Scanning the first tab will launch the administration screen • Next, scan the second tab

  45. Split Medication • Now, the medication scanned is larger than the ordered dose • Split the second tab • And, edit the Administered dose to reflect the dose given to the patient • Meditech restricts the ability to save a dose greater than what is ordered

  46. Split Medication • Now the ordered dose matches the scanned dose • Once you have confirmed the information, click Ok

  47. Exercise: Split Medications • Document the Lisinopril Administration • Scan the patient’s wristband • Scan the first 10 mg tab of Lisinopril • Review the administration screen • Scan the second 10 mg tab of Lisinopril • Attempt to save • Notice you are prevented from saving a dose greater than what is ordered • Split the Medication • Edit the Administered dose to 15 mg • Click Ok • From the MAR Click Ok to proceed to the summary screen • Review the information on the summary screen and click save

  48. Bulk Meds • Examples of Bulk items • Creams • Ointments • Inhalers • Eye drops • Insulin (without a scheduled dose such as sliding scale) • The bulk items will require you to enter the number of….. • Applications, puffs, drops, units, etc.

  49. Bulk Medication • Timoptic 5 % Opth Soln  (Timolol) • Bulk Med • Dose Instructions Indicate Dose and Units • Dose and Units will be entered on the Admin Screen

  50. Bulk Medication • Indicate the Dose and Units for the first administration • For Each Admin moving forward, the units will default

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