Physician EMR Manual Meditech 5 - Bridgepoint Health€¦ · Medical Resident and Student...

Physician EMR Manual Meditech 5.67. March 2, 2018 v.6.3

Updated by: Lorelei Roque-Reyes – Clinical Applications Specialist IS Department Bridgepoint SHS of 50

Physician EMR Manual

Meditech 5.67



Table of Contents Application Selection.......................................................................................................... 3

Physician Desktop ............................................................................................................. 3

Notifications (Desktop Tab) ........................................................................................... 4

Quick Links ................................................................................................................. 5

Coverage Routine ........................................................................................................ 5

Status Board ............................................................................................................... 7

Physician Messaging..................................................................................................... 9

Physician Documentation ................................................................................................. 11

Physician Template Types ........................................................................................... 12

Entering New Documentation ...................................................................................... 12

How to Grab Data in EMR ........................................................................................... 14

Documentation Status ................................................................................................ 17

Edit/Amend Documentation ........................................................................................ 17

Medical Resident and Student Co-Signing ........................................................................... 20

Co-Signing Steps for Supervisor .................................................................................. 22

Enter/Amend Allergies .................................................................................................... 26

Physician Dictation .......................................................................................................... 29

Viewing Dictated Notes in EMR .................................................................................... 30

Dictation & Co-Sign Process for Medical Residents ......................................................... 30

Electronic Medical Record ................................................................................................. 32

Visits by Date ............................................................................................................ 33

Viewing Interventions ................................................................................................ 34

Viewing Physician Documentation ................................................................................ 38

Viewing Reports ........................................................................................................ 38

Custom Special Panels ............................................................................................... 39

Summary Panel ......................................................................................................... 40

Lifetime Summary ..................................................................................................... 41

E-Sign Queue ................................................................................................................. 42

Signing a Document ................................................................................................... 43

E-Sign Alternates ....................................................................................................... 47

Editing Reports ............................................................................................................... 48

Addenda ................................................................................................................... 48

Access to PRO from Meditech..........................……………........................................................49

Access to Connecting Ontario from Meditech..........................……………...................................50



APPLICATION SELECTION

Meditech is accessible via a Single Sign On facility. Once you have logged into the hospital network click the Meditech icon on the task bar at the base of the screen.

No further password is required. The Physician Menu will appear.

The following options are available from the Physician Menu:

1. Physician Desktop – use this to access the Desktop, Physician Status Board screen and enter electronic documentation.

2. Electronic Medical Record – use this routine to view patient records and electronic documentation.

3. Enter/Edit E-Sign Alternates – use this routine to define alternate providers who can electronically sign documents and reports for a specific provider or trainee.

4. Change Your E-Sign PIN – use this routine to change your electronic signature PIN. You need these 4 numbers to sign your documents from Sign list.

PHYSICIAN DESKTOP From the Desktop, physicians have the ability to:

o Manage workloads o Review Patients’ Results o Document Care

o Electronically Sign Documents



NOTIFICATIONS (Desktop button)

The Desktop routine displays a list of several types of notifications available for Physicians. Notifications are sorted by Category and in reverse chronological order. The desktop will display the following types of notifications:

o Admission, Discharge, and Transfer notices (ADT) o Patient’s Laboratory Results o Consultation Requests

o Physician Messaging

The Physician Desktop has the following footer menu options:

View Detail – open the details of a selected notification Cover – enable the coverage routine to view notifications sent to physicians you are Covering.

Cover Selection – modify the list of physicians you are covering or cover by location. Return to All Tasks – return to the Desktop notification screen. Sign Up - Not applicable at Bridgepoint Health

Change Facility – Not applicable at Bridgepoint Health Send New Message – send a physician a message regarding the selected patient Preferences – modify custom Notification settings for your Desktop



The Physician Desktop has the following side menu options:

Desktop – Open Desktop routine Status Board – Open Status Board list Emergency – This feature is disabled

Oncology – This feature is disabled Practice – This feature is disabled Recent Access – Open recent access list

Any Record – Search for a patient record in the EMR

Quick Links The Physician Desktop also contains a “Quick Links” menu located in the bottom-right of the screen. A Physician can complete the following using quick links:

Open Chart – View electronic record of selected patient Discharge – this feature is disabled Orders – View current orders of selected patient

Document – Enter documentation on selected patient Check Out - this feature is disabled Sign – Open the Sign Document routine for one patient

Sign All – Open the Sign document screen with ALL patient list to sign Refresh– query the Meditech server for notification updates

Coverage Routine The Coverage routine is available in the Physician Desktop which allows a user to receive

notifications intended for physicians they are covering. Physicians can setup coverage using the Cover Selections button



The Coverage Selections screen will appear.

Select the physician(s) to cover using the search look up tool.



Enable coverage for Provider and Location at the same time:

1. By Provider o Follow the instruction above

2. By Location/Unit

o Click the Location button and select the unit to cover

Status Board The Status Board is a snapshot view of all patients under the physician’s care.

It contains the following data elements: o Patient Name, o Location,

o Attending Physician o Quick Launch icons (Open Chart, Document, Other Report, Sticky Note) o Vital Signs

o Bowel Movement Information o Alerts for new Results



Physician Desktop applications defaults to Inpatient Cover Status Board. This would list the

patients under the physician’s care including coverage list. The Status Board is alphabetically sorted by patient surname. The patient highlighted in green would have the patient header. Sorting can be done by clicking on the top cells.

Features of the Status Board

1) Patient Header – first patient always highlighted to show the patient header. 2) New look with quick launch icons at the end of first column in each patient cell. 3) Select Board – to toggle from multiple status boards

4) Find Patient bottom tab – to find patient from your list 5) Print Report from the Reports tab 6) Recent Access tab – quick access to last patient seen.

7) Sign documents in draft status for highlighted patient or Sign All for all patients

The Status Board contains four additional quick link icons beside each patient name:

Click this icon to open the electronic record of the patient

Click this icon to enter/view physician documentation for the patient

Click this icon to enter a rounding note (sticky note)

Click this icon to enter the physician other reports in EMR

Click this icon to view similar name patients (alert)



Physician Messaging

A Physician can send messages to other physicians which will appear as notifications on the Desktop.

Physician Messages are separated into two categories on the Desktop:

1. Messages – incoming messages 2. Sent Messages – outgoing messages

To send a message to a physician, click on a patient name from your Desktop or the Inpatient Rounding List, and click on the footer menu button Send New Message.



The Compose a New Message window will appear.

Complete the following steps to send a message:

1. Enter the recipient(s) last name in the To Provider field and press the ENTER key or

press the F9 key for a lookup of quick options.

2. Complete Step #1 in the CC field if you wish to a send a copy of the message to another physician.

3. Type “Routine” in the Priority field of the Message. Always enter “Routine” for

electronic messages. Urgent/Stat messages should be communicated verbally. 4. Type the subject of the message in the Subject field.

5. Type the body of the message in the Message Editor window. 6. Click the Send button.



PHYSICIAN DOCUMENTATION To document patient care, select a patient from the Status Board and click on the Quick Link menu button Document. Ex. Selecting a patient from the Status Board to document care.



TYPES OF PHYSICIAN TEMPLATE FOR DOCUMENTATION:

Template Definition

Admission History & Physical

Documentation for patient admission.

Patient Summary report

- (Cumulative Patient Profile)

Brief summary statement by Physician highlighting significant events and ongoing health conditions,

treatments and milestone dates important in patient care.

Progress Note Documentation of patient’s ongoing medical condition.

Brief Note Physician template for quick note documentation.

Consultations Template for use by Consultants documentation and to communicate dictated consults done.

Palliative Care Note For documentation of Palliative Care.

Physiatry Progress Note

Template for use by Physiatry providers to document ongoing patient care.

Procedure note Documentation for any clinical procedures performed.

Interdisciplinary Note

Physician documentation for team meetings or family meetings.

Downtime Error/Amendment

Free text entry to indicate any downtime documentation correction post offline documentation.

ENTERING NEW DOCUMENTATION The Documentation routine will start and a list of all physician documentation for the selected patient will appear. The physician documentation is sorted by Category and in reverse chronological order.



Click The Enter New footer button to document care.

A List of available physician documentation templates will appear.

1. Select a documentation template from the list. 2. Click the OK footer button to begin documenting.

Tip: You can also double-click a template name to begin documenting

The documentation template will appear.



Documentation Templates may contain the following components: Quick Pick Lists – Ex. Brief Note: Patient Seen, Chart Reviewed, etc.

Comment – Free text line (75 characters max) Text – Free text window (rich text formatting included) Allergies – allows physicians to view/edit patient allergies

Tip: To quickly save and close your documentation in Draft status, click the Save as Draft footer button instead of using the Save button.

HOW TO GRAB DATA IN EMR

Add data in EMR into the Physician documentation (Example: Vital Signs)



Preview screen: Check box on the left column to delete

Add ‘My Data’ to Documentation

Click ‘My Data’ button below



Document screen – ‘My Data’ - Click Insert

Sample Document – Grab ‘My Data from EMR

Medication list and Vital signs added to Physician Documentation



DOCUMENTATION STATUS

The final step will be setting the Status of the document:

1. Select the status of your documentation

2. Click the Save button to complete. 3. Add Providers for as needed (for medical trainees)

EDIT/AMEND DOCUMENTATION

To edit existing documentation, select a patient from the Physician Desktop or Status Board and click on the Quick Link menu button Document. Select the documentation you wish to edit from the list.



A preview of the documentation will appear. Click the Edit/Amend button to edit the existing documentation.

The documentation template will appear.

Complete the necessary edits and click the Save footer button. The final step will be setting the Status of the edited documentation:



1. Select the status of your documentation 2. Click the Save button to complete



MEDICAL RESIDENT AND STUDENT CO-SIGNING DOCUMENTATION

Resident/Student will have pre-assigned Supervisor(s) that will default on the left side of the screen. It is vital to click the box to select the co-signer that will bring the document into that Supervisor’s e-sign list. It also flags the supervisor that you have signed your document and it

needs to be cosigned (‘ISigned Status’). Click Add Co-Signers button, bottom left, if additional co-signer is needed or if the assigned

supervisor is not showing in the Co-Signers box.

After saving document, it will queue to Supervisor’s ‘Sign’ List in “ISigned” Status

(meaning ‘incomplete signature’ status). NOTE: The co-signer is the trainee’s supervisor at the time when the document is saved to

Signed status. This may be the primary supervisor or, in their absence, a secondary supervisor. All trainees must have a designated supervisor at all times. The supervisor is not necessarily the Most Responsible Physician for the patient. In other hospitals this may be

termed the Attending Physician. If the trainee assigned the wrong supervisor and signed the document (ISigned Status),

Health Records need to be contacted in order to change back the document status to DRAFT and the trainee can assign the correct supervisor.



EMR -> Other Reports view of Document in ISigned status:

EMR report view of ISigned document: Student Signature shows in the first line of Signature field.

The second field will have the Supervisor’s Signature once document is co-signed, this will move the status of the document to ‘SIGNED’ in Physician Documentation List and EMR.



CO-SIGNING STEPS FOR SUPERVISOR

It is important for the student/resident to add the supervisor’s name by clicking the box beside the co-signers name before saving the document. This will bring the document to the Supervisor’s ‘Sign’ List for review and co-signing.



Sign Document Screen:

If signing more than 1 document, the ‘Sign’ button will be replaced by ‘Queue’ button and will get the sign button at the last report to sign.

Supervisor to sign document = from Isigned to Signed status



Supervisor had Signed the document = Signed Status

All Providers documentation entry can be viewed in EMR -> Other Reports

View of the document report in EMR:

Note: This report can be printed if needed by using the printer icon on top left of the screen. Both Signatures for Student and Supervisor is captured.



ENTER/AMEND ALLERGIES

Click on the (i) icon from the patient header or EDIT button from the documentation screen to get to this process screen.

The Allergy Management Panel will appear.

Click on the Process button to ENTER/EDIT patient allergies.

To enter a new allergy, click the Enter New footer button.

In the Allergy/Adverse Reaction field, start typing the allergy name and the drop down list will

populate coded allergies available in Meditech.



Select the appropriate allergy from the list. The Allergies Detail screen will appear. Complete the following fields:

1. Type 2. Severity 3. Verified

4. Reaction (drop down list) 5. Comment (additional information about the allergy who identified it, etc)

After completing all the fields, click the Save button. The new allergy will appear in green on

the list for your review before saving.



Click the Save footer button to confirm the new allergy.

Click Done from the footer button.

Depending on the utilization of the Meditech servers, the new allergy will appear in the Patient Header after a few seconds. For example: B 50 Complex will now appear.



PHYSICIAN DICTATION Physicians and medical trainees will be provided with a Dictation user ID by the Health Records Department.

Please follow these instructions provided by Health Records: o The note will be transcribed within 24 hours and uploaded in DRAFT format into the

electronic record.

o Physician should electronically view, edit and sign the note within 7 days of transcription.

o If the note is not electronically signed within 7 days, it will be considered authenticated

14 days after dictation. Medical Trainees

o Please provide your name, the patient name and the name of your supervisor at the start of every dictation

o If your primary supervisor is absent you must name the secondary supervisor under whose supervision you saw the patient

o Please note your supervisor is not necessarily the Most Responsible Physician for the

patient. [In other hospitals this may be termed the Attending Physician]

(For more information, please check the Electronic Signature Policy)



VIEWING DICTATED NOTES IN EMR

Go to EMR: Click on ‘Other Reports’ on the right side of the menu

Click on the bubble under ‘Report’ column to view the document.

DICTATION & CO-SIGNING PROCESS FOR MEDICAL TRAINEES

Note: For Dictation:

All dictated notes will come back to the EMR in ‘DRAFT’ status. Review and edit the notes through the SIGN button in EMR. You will need your Meditech password and Meditech eSign PIN for this. If you do not have your Meditech eSign PIN or if you forgot it, you can create a

new one by going back to the Physician Applications Menu and choose ‘Change your eSign PIN’. Follow the instructions from that screen.

Make sure that there is no Word document open when you go to the SIGN button as this would interfere with signing or editing the dictated notes. If you cannot see the document or it is not

coming out on your screen, it is an indication that you have a ‘Word document open’ in your computer. Close the word document and come back to open and edit your dictated note.

After editing your note, Click the F12 function button from your keyboard to SAVE the edited note. (Refer to Editing Report on page 48)

See page 42 for an image of the signing screen.

Once dictated note is in status ‘ISIGNED’ – it will queue to the designated Supervisor for co-signature. Once co-signed by Supervisor – the status will be in complete ‘Signed’ status.



ELECTRONIC MEDICAL RECORD (EMR) The Electronic Medical Record (EMR) is used to view patient records and electronic documentation. After selecting Electronic Medical Record from the Physician Desktop menu, the Recently Accessed Records window will load.

Used for acute care facilities only.

List records associated to you, your provider group, or for coverage providers.

Used for acute care facilities only.

List records that are not found in the Admitting Department (ex. Day Treatment).

Displays new, unviewed completed results.

List records that you have viewed in the last 14 days.

The most recently viewed record appears at the top.

List records that you have added to your personal list. This personal list is the same as PCS My List.

List patients in a specific location.

List patients using the search tool.

View /Print EMR Reports for all records associated to you, your provider group, or coverage providers.

Sign documents and orders electronically

Link to Connecting Ontario Non- Patient



After selecting a patient from the Record List, the Visits by Date screen will appear. This screen contains a list of visits by the selected patient. Each visit will begin with the admission date.

Current visits will show the location of the patient and will be marked with a green dot. Previous visits will show the discharged date.

VISITS BY DATE:

The new visit selection screen will consist of three tables at the top: Time Frame, Visits, and View.

Only appropriate time frames will display. For example, if the patient does not have any visits over 5 years, than 7 Years and 10 Years will not display in the table.

Only appropriate visit types will be illuminated. If a patient does not have any visits of a particular type then that button will be low-lit.

The view table will default to ALL. The 75 most recent visits for the selected record. These visits

appear in reverse chronological order by visit



Record List Return to the previous list of records

Return Not applicable button is low-lit

Summary List Allows view of the Patient Summary

Allergies Opens the Allergies Management Screen, where

allergies and adverse reactions may be viewed

View PCI

Not applicable button is low-lit

Moved to Other Records Not applicable button is low-lit

Add to Personal List Add the patient to your Personal List of records

Remove From Recently Accessed List

Remove patient from the list of Recently Accessed Records

Sign Up Not applicable button is low-lit

VIEWING INTERVENTIONS

After selecting a patient visit from list, the EMR patient record will load. To view interventions

in the EMR, click the Notes button from the side menu.

The Notes panel will open and list only Focus Notes by default.



Click the Assessments and Notes button from the footer menu to view all documentation.

The Notes panel lists all data in reverse chronological order by default. Click the column title ‘Type’ to sort by Intervention name.



To view an Intervention, click the blue ‘i’ icon

The selected Intervention will load in the Meditech Document Viewer.



The Meditech Document Viewer contains a header and a footer menu. The header menu has the following options:

Copy the selected text

Select all text in the documentation

Search for a word or phrase in the documentation

Print the documentation (the best option to print with proper formatting)

The footer menu has the following options:

Return to the Notes Panel

Print the documentation in plain text without formatting (Not recommended)

Used to navigate to other documentation entries

Print a screen shot of the Meditech Window (Not recommended)

Lock or suspend your Meditech session. You must enter your Meditech password again to unlock.



VIEWING PHYSICIAN DOCUMENTATION From the EMR Click the “Notes” button click the ‘Provider Tab’

VIEWING REPORTS

From the EMR, Click the “Other Reports” button and click the “All Reports” tab

Tip: Each Panel allows the user to click on the column headings to change sort order.



CUSTOM SPECIAL PANELS

Custom special panels are user-defined panels that can serve as central location to view a wide range of data normally found on several different panels. These panels appear on the Special Panel list in EMR by a unique display name defined for the custom special panel (ex. Neuro-

Rehab Panel, Medical-Rehab Panel and Ortho-Rehab Panel)

Special Panel View: (Ex. Neuro-Rehab Panel)



SUMMARY PANEL

What’s in Summary List:

Visit History – Last visit information from different visit “types” Patient Problems – List of Active/Acute and Chronic Problems

Medications – List of Active (PHA) and Ambulatory (RXM) medications (*no D/C meds) Health Maintenance – Hardcoded list of EMR ID results. Growth Charts – N/A at Bridgepoint (patient must be less than 21 years old)

Substance Use – List of Historical and Current Substance Use (uses EMR) Procedures – List of CPT codes and surgical CPT codes (N/A) My Personal Notes – text file for end-user’s notes – cannot be viewed by others (not

recommended for use at Bridgepoint by Health Records)



LIFETIME SUMMARY

Lifetime Summary View

The same concept will be applied to the Imaging, Pathology, and Other Reports panel.

1. Highlight a test 2. Select a time frame

3. Click the ‘i’ button to view specimen

Clicking the information icon will take you to the snapshot for the specimen that the result was

a part of.



E-SIGN QUEUE

Establishing Your E-Sign PIN For the initial e-sign process, a PIN should be established. To do this, click on the Change Your

E-Sign PIN from the Physician Desktop menu.

Enter the following information on the next prompt: 1. Enter current PIN – Call Helpdesk for reset as needed 2. Enter a new E-Sign PIN

3. Re-enter the new E-Sign PIN to verify



SIGNING A DOCUMENT

From Physician Desktop, the Sign button can be accessed from Desktop and

Status Board screen.

1. From Electronic Medical Record (EMR),

2. Select the Sign Documents button from the EMR side menu.



3. If you wish to only sign certain reports, click on the far right column beside the

report(s) you wish to sign. Click the Process X button on the side toolbar to sign these individual reports. Alternatively, click the Process All button to sign all your reports.

4. You will be prompted to enter your E-Sign PIN to continue.

Prompt to enter PIN:



The reports you selected will appear in the Meditech Viewer window.

5. The footer menu contains the following buttons: Sign – sign the current report

Unsign – unsign the current report Edit Document – edit the current report (See next step for more info) Send Message – this is a future enhancement (no action occurs)

Prior – view previous report Next – view next report Stop – Exit Report Viewer

6. When you click the Edit Document button from the footer menu, the report will open in Microsoft Word. Please remember to have all Microsoft Word windows closed on the computer before editing reports. This routine will not work properly if you already

have Microsoft Word open on your computer.



7. When you have finished editing the report, a small menu on the right side of the screen has a green checkmark symbol and a red “X” symbol. Use the checkmark symbol to save the changes to the report. Use the “X” symbol to cancel the changes to

the report. Alternatively, you can use the keyboard shortcuts: press the F12 key to save changes, or press the Esc key to cancel changes.

8. Once you have completed editing a report, you will return to the Meditech report

viewer. From this screen you can view and sign the edited report. At any time you can stop reviewing your reports by pressing the Stop button from the footer menu.

9. Once you have viewed all your reports and clicked the Sign button, you will be

prompted with the following window which will allow you to Sign, Go Back or Cancel.

10. After selecting the Sign option, you will be prompted to enter your E-Sign PIN again to continue.

11. You will return to the Sign Document window and observe the selected reports that

have been signed will no longer appear in your list.



E-SIGN ALTERNATES

Physicians who want to create alternate Physician(s) to sign their reports should use this routine. For example, Physicians who are going on vacation may want to create alternates to sign their reports in their absence.

1. Click on the Enter/Edit E-sign Alternates Routine from the menu. You will be

prompted to enter your E-sign PIN.

2. To add any provider(s) with e-sign access (your choice of alternates), select the Provider

field and click the drop down arrow or press the F9 key. Once you have selected a

Provider from the lookup window, click the OK button or press F12 to save. Now, your chosen alternate will be able to sign your reports in your absence.

3. Your alternates can sign your reports by launching the EMR and clicking the Sign Documents button. This will list the provider’s documents only.

The alternate provider must click the For Other Provider button as indicated by the arrow in figure below.



4. Your name appears at the top of the list followed by your alternative providers. Select an alternate provider from the list to view their reports. When an alternate signs your

report, the report will say “Dictated” by your name and “Signed” by your alternate’s name.

ALTERNATE SIGNER FOR MEDICAL TRAINEES:

The Supervisor(s) will be assigned as alternate signer for medical trainees by the Applications team during the onboarding process. The alternate signer routine would be

use by the Supervisor(s) when the trainee had left Bridgepoint and there are notes left in Draft status. The Supervisor(s) will follow the step above to sign as the alternate for their trainee. Both the name of the trainee and the Supervisor will be in the note.

NOTE: When to utilize Alternate Signer for Medical Trainee: When trainee left Bridgepoint with documents left in DRAFT status. The Supervisor will be

signing as the ‘alternate signer’.



Editing Reports

This process is used to edit a report during the electronic signature routine. Please remember to have all Microsoft Word windows closed on the computer before editing reports. This routine will not work properly if you already have Microsoft Word open

on your computer.

1. When you select the “Edit Document” button from the Report viewer screen, the report

will open in Microsoft Word.

2. When you have finished editing the report, a small menu on the right side of the screen

has a checkmark symbol and an “X” symbol. Use the checkmark symbol to save the changes to the report. Use the “X” symbol to cancel the changes to the report. Alternatively, you can use the keyboard shortcuts: press the F12 key to save changes,

or press the Esc key to cancel changes.

3. You will then be returned to the report you just edited and you must sign the document

using the “Sign” footer button. It is important to remember to sign the edited document before proceeding to the next report.

Addenda

Once a report has been e-signed by a physician, it is an official document and can only be altered by the physician dictating an addendum. The dictating physician will then need to e-sign this addendum by utilizing the same process as described above to e-sign the original

report.



ACCESS TO PRO AND LINK IN MEDITECH FOR MEDICAL TRAINEES

1. From Applications Desktop -> Click on the ‘globe icon’ below

2. Click on the Patient Result Online

3. You will be linked to the PRO website where you will need your screen name and

password



ACCESS TO CONNECTING ONTARIO:

From EMR access – click on the External Data button and then click the Connecting

Ontario Non-Patient. This will link to the Connecting Ontario website.

If you need any assistance regarding this manual, please call Helpdesk at ext. 5000 or email [email protected]

mailto:[email protected]

Physician EMR Manual Meditech 5 - Bridgepoint Health€¦ · Medical Resident and Student...

Documents

Transcript of Physician EMR Manual Meditech 5 - Bridgepoint Health€¦ · Medical Resident and Student...