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Meditech PCM Manual - Kootenai Health Information Technology

1. favorite list of panels you previously chose in Manage 08 21 13 _ P Favorites L YOUR Favorites if your access allows you RBC 5 00 Hgb 15 0 Het 45 0 Mcy 90 0 MCH 33 0 MCHC 34 0 RDW 12 0 Microbiology Plt Count 300 MPY 9 0 Neut 70 0 Lymph 20 0 Mono 8 0 Eos 2 0 Baso 0 0 Orders Absolute Neuts auto 7 0 Amb Orders J Absolute Lymphs auto 2 0 Absolute Monos auto 0 8 Absolute Eos auto 0 2 Absolute Basos auto 0 0 2 Graph Converted ECha Clinical Panels By Physician Care Manager HIM Dept KMC KOM KOM TEST6 07F KOM TEST6 07F TEST 6 07 ME PS 5 lel EES Testme Clinical Limited Code KM0001002112 KM00020127 44 M 07 11 1969 167 64cm 57 606kg BSA 1 65m BMI 20 5 H00020281 Ee ADM IN KM 2N KMO0226 01 Allergy Adv Penicillins codeine Sulfa Sulfonamide Antibiotics latex More Clinical Panel Anesthesia Summary Cardiopulmonary Core Measures Discharge Planning Discharge documenation 7 ED RN ISBARD My Notices _ B ED Visit Summary Patient Lists Glycemic Management Next Patient History Kardex Kardex OB Kardex Behavioral Health Multidisciplinary Team Summary Nursery NICU Pain Sepsis Test4925 Withdrawal Favo tel Standard Manage Favorites 2 alola e The Clinical Panels tab will bring you to the list shown above where youselect a specific Clinical Panel shown below kK KootenaiHealth With questions about an
2. Patient Information CEPI ROS Exam Data KAP The Daily Progress Note has five tabs _ Other notes can be longer and have more tabs Under the CC HPI tab there is specific patient information pulled into the note from admissions Also the hospital length ofstay is displayed A Chief Complaint needs to be completed as well as Subjective HPI e Click on the line to the right of the title where it says lt Entered gt Entered indicates that data has automatically pulled into a section of the note suchas X KootenaiHealth With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 32 demographics vital signs 1 amp O s and laboratory results This is a large free text area so when documenting Subjective HPI there is no limit to what can be documented y Physician Care Manager HIM Dept KMC KOM KOM TEST6 07F KOM TEST6 07F TEST 6 07 MD1 PCM PST Testme Clinical KMO0001002112 KMO000201 27 44 M 07 11 1969 167 64cm 57 606kg BSA 1 65m2 BMI 20 5 HO00020281 ADM IN KM 2N KM0O226 01 Allergy Adyv Penicillins codeine Sulfa Sulfonamide Antibiotics latex More Ee i E RMEESHSEH Ay y gt This report was generated by Physician Care Manager Initiated 03 07 14 1333 by PCM MD1 Length of Stay 185 days Chief Complaint Subjective HPI 4
3. gl Data Formats Text Saved Data canca oe e When documentation is complete click OK in the lower right corner forthis section e Documenting within a template is done by free text as noted above or bysimply pointing and clicking on the answer desired This places an oval around the selection e Continue documenting by clicking on the ROS tab e Report Denies option is available clicking on an option places a oval aroundit and right clicking puts a slash through the option On the report theoval indicates reports and the slash indicates denies e Example of how it will display in the report o Constitutional Reports Change in appetite Denies Fatigue Malaise Generalized Weakness SVS KootenaiHealth I With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 33 CC HPL G Daily Progress Note Review of Systems v Unable to Obtain Unable to Obtain ROS Constitutional No Symptoms Reported Good General Health GeneralizethwWeakness Report Deny Chills Poor General Health Falls Fever Recent Hospitalization Change in Sleep Pattern Night Sweats Fatigu Malaise Other Lethargy e Atthe bottom of the screen is a comment line When any answer in a question setis selected a comment can be made about that item and will show in parenthesis onthe report
4. Comment e Click on the Exam tab to continue the note The exam section has been set up with all items collapsed Click the sign will expand the individual sections A checkmarkto the left of the items in this section will indicate documentation is present G Daily Progress Note _ Physical Exam Constitutional iEye it Ear Nose Mouth and Throat Head and Face Neck Respiratory Cardiovascular Chest Breast GI Abdomen GU Rectal Musculoskeletal Integumentary it Incision Neurologic Psychiatric Lymphatic E E E E E E e Click on the sign to expand the section that wish to document on Below isan example of the Constitutional section Point and click on selections to document TheAll button under Reviewed By Me Today can be used to check all of the selections in that section if they have all been reviewed Continue by expanding additional sections documenting in the same manor e If you want to remove a circle click on it again The circle will now be removed gt k KootenaiHealth With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 34 Daily Progress Note _ Physical Exam v Constitutional JEye Normal PERRLA Conjunctivae Lids No Icterus Pupils Irises Ophthalmoscopic Exam Ot
5. Date Time 03 10 14 09 49 Status Draft O Signed PIN e The CC lines are used to send a faxed copy of your note to the indicated provider Enter the name of the provider that you would like the note faxed to First Name LastName gt k KootenaiHealth With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 44 e The Assign Providers option would be best used to send a report to a co signer s sign queue Type in the name of the provider on the first line of the Assign Providers box that you would like to co sign your report Your report will then be sent tot the provider s sign queue for electronic co signature e Click on the Signed status and enter your PIN and click Save to file the report You are returned to the Report List and this note is listed as Signed If there is a need to modify a Signed report and electronic addendum can be added Deleting Cancelling a Pending or Draft Report Date Document ______ Author Status 03 10 14 09 49 Daily Progress Note MD1 PCM Signed 03 07 14 09 44 Daily Progress Note MD1 PCM Pending 02 19 14 12 49 Test Note MD1 PCM Pending 02 13 14 15 14 Consultation Merry Megan M ISigned 02 06 14 11 07 Daily Progress Note Merry Megan M ISigned 02 06 14 11 02 OT Daily Note Merry Megan M Draft 02 06 14 10 55 History and Physical
6. Rectal Output Tube Feeding Residual Disca Rectal Chest Tube Drainage Laft eine 1 Hour 4 Hour 8 Hour 12 Hour 24 Hour Scroll left and right at the top of the I amp O screen to view additional dates andtimes Left click on the type of I amp O to view additional information about that particular item Medications Medication List displays the patient s current active and discontinued medications Mb 7N Testme Clinical 44 M 07 11 1969 ADMIN KM 2N KMO226 01 Acetaminophen Hydrocodone Bitart Norco 5 325 Acetaminophen Hydrocodone Bitart Norco 10 325 Acetaminophen Hydrocodone Bitart Norco 5 325 Acetaminophen Hydrocodone Bitart Norco 5 325 Albuterol Ipratropium Duoned Albuterol Ipratropium Duoneb Albuterol Tpratropium Duoneb Aspirin Ecotrin Aspirin Bayer Aspirin Clopidogrel Bisulfate Plavix Dexarnethasone Limited Code KMO001002112 167 64can 57 606kg BSA 1 65m BMI 20 5 Alleray Adv Penicillins codeine Sulfa Sulfonarmide Antibiotics latex More Selected Visits Ail Visits Medication List _MARY Medication Snapshot PRN Reason 1 2 tab PO Q6HP PRN Pain 1 tab PO STK MED ONE 1 2 t PO Q6HP PRN Pain 1 2 tab PO Q6HP PRN Pain 3 ml Inhale Q6HP PRN 3 ml Inhale QOSHP PRN S ml INH CONT SCH 50 mg PO DAILY SCH D 325 mg PO QAM SCH 81 mg PO QAM SCH 81 mg PO DAILY SCH 75 mg PO QAM SCH 34 mg PO ONCE iat ap
7. This view allows you to see the patient s current Medication Administration Record MAR Testme Clinical Limited Code KMO0001002112 KMO0020127 44 M 07 11 1969 167 64cm nearer BSA 1 65m BMI 20 5 H00020281 ADM IN KM 2N KMO226 01 Allergy Adv Penicillins codeine Sulfa Sulfonamide Antibiotics latex More Le wee a Al 02 27 14 21 00 PriLOSEC 20 mg PO 0600 2100 SCH Generic Omeprazole Active Rx MK00006958 LinAcknowledged hea Give 2 CapsuleS 10 mg Tao a Medications B Labe I 4 kK KootenaiHealth With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 19 Medication Snapshot tI MAR Medication Snapshot Medications Clopidogrel Bisulfate Plavix 75 mg Tab 75 mg PO DAILY Clopidogrel Bisulfate Plavix 75 mg Tab 1 tab PO DAILY traMADol Ultram 50 mg Tab 50 mg Tab 50 mg PO DAILY traMADol HCL Ultrarn 50 mg Tab 1 tab PO DAILY Lisinopril 2 5 mg Tablet 2 5 mg PO HS Confirmed Confirmed Confirmed Confirmed Confirmed 60xycodone 5 APAP 325 mg Percocet PACK 1 pack Pt Ready N 1 pack PO ONCE Divalproex Na Depakote 125 mg Et 125 mg PO Furosemide Lasix 20 mg Tab 20 mg PO DAILY Omeprazole Prilosec 10 mg Capsule 10 mg AS ORDER ASDIRECTED Aspirin 81 mg Tab 81 mg PO DAILY Provi Ac non 09 03 13 Medications Pr
8. Wound Location Chin 4 Soo ee e You will then be able to select the All Visits Most Recent Each column contains the most recent panel data for each visit Vital Signs estme Clinical Limited Code KM0001002112 KM000201 27 44 M 07 11 1969 167 64cm 57 606kg BSA 1 65m BMI 20 H00020281 T Sa ADM IN KM 2N KM0226 01 Allergy Adv Penicillins codeine Sulfa Sulfonamide Antibiotics latex More gt Patient Activity Position Vital Sign Position Sittina Vital Sign Activity Pre RT Tre At Rest Exercise Temperature Temperature 36 C 36C Temperature Source Temporal Temporal Temporal i Pulse Pulse Rate 80 Pulse Source Location Monitor Monitor Monitor Blood Pressure Blood Pressure Blood Pressure Mean Blood Pressure Source Location Right Arm Respiration Respiratory Rate 20 20 i Oxygen O2 Sat by Pulse Oximetry 90 90 Oxygen Flow Rate L min FiO2 Oxygen Delivery Method Room Air Room Air Nasal Can Respiratory End tidal CO2 Hemodynamics Arterial Line Location e Displays vital signs for the patient e Scroll left and right at the top of the page to see more days and times e Clicking on a particular vital sign result will provide o The normal range of the vital sign k KootenaiHealth With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5
9. Problem list defaults in Edit Current problems can be unchecked as not pertinent to the current visit Click New to enter a new problem Heart failure Acute Alcohol induced psychosis Acute Lung mass Acute Nausea and vomiting Acute Neutropenic disorder Acute Neutropenic fever Acute Alcohol abuse Chronic Problem breast cancer Code SNOMED Code SNOMED CT US Extension Mrs Testme is a 62 year old patient of Dr Kim test Comment This is a test Last Activated 11 21 13 10 30 by Morley Kimberly A MD First Entered 11 21 13 10 30 by Morley Kimberly A MD Last Edited TAA aloes by Bruning Johanna S Cancel Save gt K KootenaiHealth With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 39 e Current problems are listed Click in the Search field and type the problem thatis required You can search by starts with or any word Hit enter to display results breast cancer Heart failure Alcohol induced psychosis Lung mass Nausea and vomiting Neutropenic disorder Neutropenic fever Alcohol abuse Search Type Starts with O Any Word adds FreeText Search For e f matches are found in the dictionary a list of matches will be displayed Clickthe appropriate match to select the entry desired Click
10. lt 2 Document Sign Clinical Data Preferences x 000g Data Formats Text Saved Data Datasaver and Graphing e Data from the EMR can be saved and pasted into any free text area of a note Data must be selected before entering a free text screen The EMR is not available while in a free text screen Notice the example above with the side buttons grayed out While ina section of the template click on the EMR button to collect data from or graph withinthe EMR by right clicking data The example shown below is laboratory and glucose data Click Laboratory then Chemistry Note the Document button is green indicating anactive note is open and active X KootenaiHealth With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 36 HIM Dept KMC KOM KOM TEST6 07F KOM TESTO 07F TEST 6 07 MDLPCM POT Testme Clinical 44 M 07 11 1969 ADM IN KM 2N KMO226 01 167 64cm 57 606kg BSA 1 65m2 BMI 20 5 Selected visits All Visits Most Recent J All Hematology Blood Gas__ Chemistry Toxicology Immunology Serology Miscellaneous Scanned Reports Scanned Reports a ij nas Tata A4 04 1 PS WAP S01 0P Ae 1704 3 ie 4 21 ae OZA A Carbon Dioxide Anion Gap BUN Creatinine Estimated GFR Glucose POC Glucose Calcium Calciu
11. 01 22 14 latex Allergy Mild Hives Verified 01 22 14 caffeine Allergy Unknown Abdominal Cramps Verified 01 22 14 acetaminophen Allergy Intermediate Hives Verified 01 22 14 Allergy Anxiety Verified 01 22 14 lisinopril eoeo8 6 6 amp 6 8 SB OB AdvReac Severe whatever Verified 01 22 14 Preferences metoprolol AdvReac Severe Coma Verified 02 05 14 coffee AdvReac Intermediate Delirium Verified 01 22 14 cherries Allergy Severe Facial Flush Uncoded 01 22 14 BOGE e Click on the sign next to any items on the page to get more information X KootenaiHealth With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 8 Allergies Blue Edit Button allows you to add new or edit existing allergies J Legal Indicators Scanned legal documents can be viewed _ O x Testme Clinical Limited Cace KMO001002112 KMO0020127 44 M 07 11 1969 here These include POISE forms and Advanged Directives H00020281 6 ADM IN KM 2N KM0226 01 Allergy Adv Penicillins codeine Sulfa Sulfonamide Antibiotics latex More 4 Problem Edit CUT v Status i Visit edical Summary documents from otherffacilities l G Past Problems 7 Pre Diagnosis My Notices 5 Past Problems acthat arecksarineclintimabhenete anpate Patient Lists
12. 7N With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk M Physician Care Ma r Physician Care Manager HIM Dept KMC KOM KOM TE Testme Clinical 44 M 07 11 1969 ADM IN KM 2N KMO0226 01 02 19 14 12 49 02 13 14 15 14 02 06 14 11 07 02 06 14 11 02 02 06 14 10 55 02 06 14 10 29 02 06 14 10 28 02 06 14 10 21 02 03 14 09 00 01 09 14 08 41 01 08 14 14 26 12 30 13 12 47 12 16 13 12 38 TZT 1132 11 26 13 08 52 11 26 13 08 43 11 26 13 08 15 11 26 13 08 00 11 26 13 08 00 11 26 13 08 00 11 26 13 08 00 11 21 13 10 45 11 21 13 10 43 11 21 13 10 35 EASTO C2 LOTS 11 04 13 10 27 11 04 13 10 13 10 24 13 12 06 10 24 13 10 23 10 24 13 10 19 10 18 13 14 25 10 03 13 11 53 09 20 13 14 42 09 20 13 12 45 ST6 H L 167 64cm 57 606kg BSA 1 65m2 BMI 20 5 Allergy Adv Penicillins codeine Sulfa Sulfonamide Antibiotics latex More Test Note Consultation Daily Progress Note OT Daily Note History and Physical PT General Evaluation Daily Progress Note Daily Progress Note Daily Progress Note Daily Progress Note Daily Progress Note Cardiology Progress Note Daily Progress Note Daily Progress Note Daily Progress Note Focused Progress Note Daily Progress Note Daily Progress Note Daily Progress Note Daily Progress Note Daily Progress Note Focused Progress Note Daily Progress Note Daily Progress Note Daily Progress Note Daily Pr
13. By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 55 e Click reduction User Preferences will be enhanced to allow user to select a defaultfor the Sign Status within PDOC Users may select Pending Draft or Signed Care Manager Initial Page Patient Lists Patient Selection List Default My Admitted Patients Pd Initial Panel Default Default Panel View Default Clinical Panel View Clinical Panel Default Clinical Panel Start I amp O Default Time Period hours Medications Display Default Medications List Default Medications Med Orders Default Sort eee Medications Frequency Sort New Results Default Po Laboratory Default O Laboratory All Panel Default Time Period Laboratory All Panel Start Po Reports Default Notes Default Graph Default Time Period Code Visit Default page Reports Sign Status Default v Clinical Panel Number of C e Click reduction When saving PDOC the document preview screen includes theoption to save the document add additional copies and assign additional providers to the report k KootenaiHealth With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 56 Schnur Bert L SP0001002309 SP00021186 68 M 04 19 1945 HO000201 76 ADM IN SP MS P222 01 Allergy Adv No Known Allergies t Daily Progress Note _ C
14. FE 8 aa OT dS ae 3 Als 8 i 48 Led My Notices B Patient Lists 9 Next Patient 2 Select Visits 3 i z5 esults i F j G me JN Z Graph Vitals Uv amp O m e If you right click on the name of the lab you will be given three options Reorder Lab Sends that lab to your orders screen immediately Queue for Reorder Allows you to queue more than one order to reorder When you go to the ordering screen these orders will alreadybe queued to reorder 3 Queue for References Takes you to the reference link to search for information about that lab example Google Web MD Results highlighted in Yellow are Low or High Results in Red are Critical Values The Delta Symbol indicates change in results NO e You can then select the information you would like to view by clicking on the sign to the left of the heading e To view an Exam Report you would click on the Clipboard icon under the report X KootenaiHealth With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 12 WEILL UIU LUN nepi t TUW LY view the report Viewing a Lab Report Z KOM KOM TEST6 O7F KOM MDL TEST6 O7F TEST 6 07 PCM PST Limited Code KM0001002112 o emae ottene Antibiotics Testme Clinical 44 M 07 11 1969 ADM IN KM 2N KM022
15. Hct 45 0 40 0 50 0 02 17 14 10 14 Plt Count 300 K uL 150 400 02 17 14 10 14 e This information comes from the Lab and the Transfusion Administration Record TAR e This allows users to access the history of blood bank items from all facilities including TAR documentation history AM TESTING KMDI020438 PCS Open Chart HIM Dept KMC KOM KOM TESTE A7F KOM TESTE OTF TEST 6 07 Leonard sinds TIAN Orm6 07 Testing KM0001000519 41 F 03 24 1972 ADM IN KM 2S KMO250 01 Allergy Adv No Known Allergies Product Summary Blood Bank Tests transfusions Y jones Product Order Assigned Compatible Ready Issued Transfused Leuk reduced RBC 2 a e Eo 0 2 Test Most Recent Result Blood Type amp POSITIVE 09 04 13 14 27 Antibody Screen Negative Time 09 04 13 14 27 X KootenaiHealth With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 23 lick on the comment yubble for additional nformation Transfusion Flowsheet and Comments In the Transfusions button view clicking on the comment bubble in the far column allows the user to view the TAR documentation of reactions Other TAR documentation is available as well including vitals etc in flow sheet or commentformat a f I l H f j fale ANANT GOL U H l g 09 05 13 08 15 Leuk reduced Pheresis RBCs
16. Merry Megan M Draft 02 06 14 10 29 PT General Evaluation Merry Megan M Draft 02 06 14 10 28 Daily Progress Note Merry Megan M Signed NDWINK AA ANS D4 Mail Draaracc Klata Marrs Macan MA Qiana e Click the Delete Cancel Document button at the bottom of the page Testme Clinical KMO0O 44 M 07 11 1969 167 64cm 57 606kg BSA 1 65m2 BMI 20 5 ADM IN KM 2N KM0226 01 Allergy Adv Penicillins codeine Sulfa Sulfonamide Eg E mj i E North Idaho Rural Health TEST6 07 Daily Progress Note Patient Name TESTME CLINICAL Date of Birth 07 11 69 Attending Doctor MD6 PCM Date 03 07 14 09 44 Chief Complaint HPI gt Patient Information This report was generated by Physician Care Manager Initiated 03 07 14 0944 by PCM MD1 CLINICAL TESTME a 44 y o M admitted on 09 03 13 Length of Stay 185 days Chief Complaint Subjective HPI Datar Vital Signs I amp O s per Nursing 24 Hour Vital Signs 03 07 14 06 59 03 07 14 04 00 24 Hr Vital Sign ranges T max BP Sys Dias Last 24Hr 37 c 38c s0 i5 20 89 90 24 Hour Intake and Output Delete Cancel Document e Clicking Yes at the prompt will cancel the report Status is now Cancel X KootenaiHealth With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 45 e If there is a need to cancel a report
17. Micand ITS results Bonner General Hospital Boundary Community Hospital Lab Results Patient Type X KootenaiHealth With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 29 Documenting in PCM Mb Ay To start documenting on an H amp P Progress Note or Discharge Summary first select a patient from the My Patients or Rounds Patients lists Click anywhere on the patient data line It will turn green showing this patient is selected and load the default EMR screen If there is nothing selected in preferences default will be the New CD 00 My Patients Rounds Patients My Discharged Cover Discharged S New Results Blood Bank Tests Rpt General Home Meds Incomplete ei ncomplete d f 10 Selected Ww Location Age Sex i Room Bed Name Birthdate Attending CRITICAL CARE II iy 2m M CRITICAL CARE II 31 M KM ICU 03 TEST DECEMBER 01 01 1983 MD1 PCM CRITICAL CARE III 234 M KMO342 01 DOVER BEN 01 01 1980 Daugharty Barbara 4 MD LABOR amp DELIVERY 33 M KMO003 01 WILSON JOSEF 09 11 1980 MD1 PCM MEDICAL 2 51M KMO212 01 PHA THERA607 05 15 1962 Daugharty Barbara 4 MD MEDICAL 2 42 M KMO217 01 emr testing 11 14 1971 MP1PCM MEDICAL 2 32 F KM0220 01 test megan 03 19 1981 MD1 PCM MEDICAL 2 l
18. Save to save the newproblem breast cancer Acute Depressed bipolar I disorder Acute Heart failure Acute Alcohol induced psychosis Acute Lung mass Acute Nausea and vomiting Acute Neutropenic disorder Acute Neutropenic fever Acute Alcohol abuse Chronic Search Type Starts with O Any Word Search For Depressed bipolar I disorder Depressed bipolar I disorder in full remission Depressed bipolar I disorder in partial remission Xk KootenaiHealth With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 40 e Note the new problem has now been added to the list Problems Depressed bipolar I disorder Acute Heart failure Acute acute on chronic heart failure breast cancer Acute Mrs Testme is a 62 year old patient of Dr Kim test This is a test This is a test early stage currently receiving chemo C3 Chemotherapy induced neutropenia Resolved This is a very long free text problem I am sure someone is Resolved Alcohol induced psychosis Acute Lung mass Acute Nausea and vomiting Acute Neutropenic disorder Acute Neutropenic fever Acute Alcohol abuse Chronic 4 e If there is no match to the search the system will prompt you to enter the selectionas free text Click on the search type option of Add as Free Text breast cancer iv Acute Depre
19. Visit Stat My Notices Patient Lists Curr Next Patient Deleted Problems User Da Select Visits Allergy AdvReac Edit Type Summary Review Visit Active Medication v Dose Route Freq Start Notices re Home Medication Esit Instructions Last Last a Rx New Results Taken Confirmed Clinical Panels e Signs ba O l ications a Patient Pharmacy amp ait CVS Caremark Mail Order Wal mart pharmacy 3511 Preferred Immunization Edt Administered Rees Age Influenza A 10 23 13 2 44 bratory P obiolog bd Bank Influenza B 10 23 13 2 Reports Measles Virus 08 28 13 44 Patient Care 0 Mumps Virus 08 28 13 1 44 E Pneumococcal PS 10 01 ja 1 44 l Rubella Virus 08 13 1 44 e Medical Summary Ext Rpt Last Date Health Maintenance Comment Last Date Substance Use Comment Documented X Koote naiHealth With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 9 Review Visits F Physician Care Manager HIM Dept KMC KOM KOM TESTS 07F KOM TEST6 O7F TEST 6 07 MDL PCM PST ace Es Testme Clinical Limite
20. box with Graph highlighted in green You need to left click the word Graph Under the word graph that is highlighted in green you will see a list ofany results you have already chosen to graph o Repeat the above steps to choose as many results as you would like to graph o Click on Graph at the bottom of your screen to view the graph Panels NS P detail orot laber Acminstrations ltrations JL History rlowshest Omeprazole Active Medicati Ordering Physician Merry Megan M Omeprazole Total Dose 20 mg Prilosec Start Date 02 27 14 21 00 an as FA EANN Stop Date 20 mg PO 0600 2100 SCH Rx Number MK00006958 3 Ambulatory Medications Drug Class a e Omeprazole Omeprazole Prilosec Panels 15 Min 30 Min 1H 4 Hr 12 Hr 24 Hr Graph Graph Vitals e Under Active Medications left click on a particular medication to viewadditional information about the medication e All Visits Most Recent is also available within Clinical Panels This allows users to view the panel across multiple visits e After selecting a Clinical Panel to view click on the Visits footer button A KootenaiHealth 77 With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 16 Mr PCS Crystal KM00020062 PCS Open Chart HIM Dept
21. name User name is your first and last name in lower case witha period between o User Name first last o Password Password e Click Signon at the Meditech Signon Screen Once signed into the system you will enter PCM and you can set up your preferences CLF 0 of 10 Selected v lt i Location Name Age Sex Attending New Results Home Meds T DC Consult Ordered Flag v Room Bed Birthdate 3 3 OORA nee TESTESION ty ait gt Crook Albert A Incomplete CRITICAL CAREI TEST DECEMBER 31M lt MOLPCM d CRITICA AL CARELL DOVA BEN 34M ap Daugharty Barbara A ME LABOR amp DEI IVERY WILSON JOSEF 3M cer MDIPCM MEDICAL 2 PHA THERAGOT EMO MEDICAL 2 emir testing odes roy MD1 PCM DC ME DICAL 2 test megan z Wt Oe MD1 PCM T MEDICAL 2 PLUM BABY anai ff 4 MEDICAL 2 TESTME CLINICAL 93 jogo MD6 PCM Blood Bark Test si URGICAL TEST COSIGN N p jers E 4 r Visit TEST es ath oF 77 sien Date 2 18 1 al Sign Result Diagrams ADM I Game fio ame ocens gt K KootenaiHealth This material is the intellectual property of Kootenai Health Do not download share or redistribute without prior permission With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 2 Preferences e Under Defaults tab O O Care Manager Initial Page select Patient Lists Patient S
22. that has already been signed contact HIM e Cancelling a Signed Report If a report has been signed and there is a need tocancel the report your HIM Department will need to be contacted There is no way for a userto cancel a signed report Electronic Signature e Whenthe Sin 4 button is Red this indicates there are orders and or documents reports that require your electronic signature Clicking on the Sign button accesses the Esign queue e The documents to be signed list shows the date and time of generation priority patient name MR number age and gender reason for it needing Esigned and documenttitle Signing Provider MD1i PCM Items for Provider MD1 PCM w L Eui ea S iyesi Maoa oa aN Physician Orders Protocol TESTME CLINICAL KMOO01002112 44 M Progress Notes TESTME CLINICAL g KMO001002112 44 M PROGRESS NOTE 1216 0001 LAEE 1123 12 16 13 12 40 R e Documents that are in your queue will be pre selected to be signed and are indicated by the check mark in the left column Remove the check from any document you donot wish to sign at this time gt k KootenaiHealth With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 46 Electronically Signing Reports e After selecting a report by placing a check in the box in the left column there is one option at the bott
23. the query details o Patient Care Scanned Forms This screen lists scanned Patient Care forms for the selected visits Click a report in the list to view it o Patient Care Surgery Assessments Use this screen to view a list of the assessments documented for a patient in Operating Room Management or Surgery and to access the details of those assessments ys KootenaiHealth With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 27 VIII CY VIN VV IIV CCSS lII WVWIII Click to select all notes l o l l Click on Select Visits tothhewcategories patient information in PCI Click the box to Nates View the first line of text for deselect a note simple notes _ iv Date Note Links Author Status Text 02 05 14 13 17 Nursing Note Jordan Julie L Cancel j i C 02 05 14 13 12 Nursing Note Ea Jordan Julie L adden Hck to view Gancel reason C 02 05 14 13 11 Nursing Note Jordan Julie L Addendum enter 01 27 14 09 44 Nursing Note Wiedenhoff Rochelle A Cancel C 01 22 14 13 26 Respiratory Therapy Note SUPER3 CLKM Signed IS q 4hrs 01 22 14 13 20 Nursing Note Wiedenhoff Rochelle Cancel Includes patient information prior tO 5 30 13 ens fy Nursing Note Wiedenhoff Rochelle 4 Cancel j 0 i ie Bewick Shelly D Signed Addendum enter ie Welhiee neb
24. 001002112 Unmit KM00020127 Reg S703 als Disch DOB 07 11 1969 Age Sex 44 M Status ADM IN Attend Dr Location 1003 HO00015 Coll Recd 10 703 713 1423 10 03 13 1426 Spec Status Subm Dr Othr Dr COMP MD1 PCM MD6 PCM CBC W PLT amp AD Ordered Result Reference CRC WPIT amp AD WBC PR l ea E AE 4 an S 7N M nT 10 0 a nn l T Lab Report PAGE 1 208 666 2800 MD6 PCM KM 2N KMO226 01 Reg 00000204 Merry Megan M Verified 10 03713 1427 ML linzvnavi12 14771 MT e The Labs button has an option to exclude Point of Care tests such aglucose and urine tests e The Most Recent All Visits button gives you a quick view of the most recentlab results of all prior visits Se 7X With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org KootenaiHealth Page 13 All Visits Most Recent button gives quick view of the most recent lab results of all visits Labs Window Ne PCS Crystal KM00020062 PCS Open Chart HIM Dept KMC KOM KOM TEST6 07F KOM TEST6 07F TEST 6 07 Richardsa PCS Crystal Full Code kmooo1000896 KMoo020062 29 F 05 04 1984 457 2cm 30 5kg BSA 2 60m2 BMI 1 5kg me2 Ho0020103 ADM INO KM 3N KMO310 01 4llergy Adv Penicillins Allows you to sele om Allows you to che
25. 112 44 M Physician Orders Protocol ZAG BAI t3 Preferences View amp Sign 00608 X KootenaiHealth With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 49 Number of pages in the 2 The scanned document defidiengieswill be presented K MRM NID Signing for TEST MD130 of 8 Sigs Cleared BCH KOM KOM TEST6 07N KOM TEST6 OTN Test PCM MDL a SS ket RA Testme Clinical 09 03 13 16 42 KM0001002112 44 M 07 11 69 HO0020281 ADM IN KM 2N KM0226 01 PO MMM A Ta be Electronically Signed by MDL PEM MO an OVOG Xx at k eee Prey Next Prev Next 4 Prev Next a oe GS cot fsan f unsigned unsigne Il Rect Ext BOSE 3 Select one of the footer buttons e Prev Document navigate to the previous document in your sign queue e Next Document navigate to the next document in your sign queue e Prev Page navigate to the previous page within the current document youare viewing e Zo00m Zoom in and out of the document e Opt Define preferences on how the document will display Thefollowing options are available WE MRM NID Viewer Options Initial Image View Fit All Fit Width One to One Cancel OK x J e Sign sign date and time the deficiency that is currently selected X KootenaiHealt
26. 3 02 05 14 13 19 C 02 05 14 13 15 C 02 05 14 13 08 C 02 05 14 09 10 01 31 14 14 54 J 01 31 14 14 51 Cj 01 31 14 14 51 C 01 22 14 13 39 T 01 22 14 13 23 C 01 22 14 13 02 01 22 14 11 00 C 01 21 14 08 00 na i gt X KootenaiHealth Intake and Output Intake and Output Vital Signs Intake and Output Vital Signs Skin Risk Assessment Scale Intake and Output Vital Signs Vital Signs Intake and Output Vital Signs Intake and Output Vital Signs Admission History Adult Shift Assessment Adult Fall Assessment Tool Vital Signs Shift Assessment Adult Shift Assessment Adult Education Record Vital Signs Admission Assessment Adult Admission Assessment Adult Education Record Assess Cardiac Shift Assessment Adult Fall Assessment Tool Shift Assessment Adult Admission Assessment Adult Vitel Signs Education Record Vital Signs List ssessments from earlier apie i 167 64cm 57 606kg BSA 1 65m BMI 20 5 Allergy Adv Penicillins codeine Sulfa Sulfonamide Antib Megan M Merry Megan M Merry Megan M Merry Megan M Merry Megan M Merry Jocelyn L Drake CLKM SUPERS CLKM SUPER3 CLKM SUPER3 CLKM SUPERS CLKM SUPER3 CLKM SUPER3 CLKM SUPER3 Jacquelyn D Alexander Gary L Breuner Melinda J Leonard Julie L Jordan Julie L Jordan Julie L Jordan Julie L Jordan Julle L Jordan Julie L Jordan Julie L Jordan Julie L Jordan Melinda J Leonard Melinda J Leonard Me
27. 5 5555 By Email helpdesk kh org Page 7 EMR Enterprise Medical Re ored view information about providers associated with this This tab contains cormatineress particular information RAA the EMR by using the tabs on the right of the screen From Summary to Notes If the text on a particular tab is highlighted in Red New Information has been updated since you last clicked on it 3 Review Visit Notices fy New Results Clinical Panels G2 Vital Sig I amp O Medications Laborato Microbiolog Blood Bank Reports Patient Care Notes lS OPIS lolol Summary Tab ician Care Man lept KMC KOM KOM TEST6 07F KOM TESTO OTF TEST 6 07 MDLPCM PST TTET EET Code KM0001002112 KMO0020127 44 M 07 11 1969 167 64cm 57 606kg BSA 1 65m2 BMI 20 5 H00020281 ADM IN KM 2N KM0226 01 Allergy Adv Penicillins codeine Sulfa Sulfonamide Antibiotics latex More GED ITE CATERED CREE kcas Lean Curr Diagnosis Visit Status N Ponty Pie et N Ponty Pie et as jer HIM C E Gw Problem Ea breast cancer Heart failure Lung mass Neutropenic disorder Neutropenic fever Alcohol induced psyq Nausea and vomiting Alcohol abuse COSeoeoods v Resolved vV Resolved Reaction Status _ Allergy Severe Coma Verified 01 22 14 Penicillins we G Gl fol A Jll codeine Sulfa Sulfonamide Antibiotics Allergy Intermediate Agitation Verified
28. 555 By Email helpdesk kh org lolx ED Visit Summary PCS Crystal Full Code kmoo01000896 kmooo20062 29 F 05 04 1994 457 2cm 30 5kg BSA 2 60m2 BMI 1 5kg m2 Hoo020103 Page 17 I amp O Scrolling Teature dilOWS YOU TO SCrOII between dates o The person who entered the vital sign If you click on the name of the results like Blood Pressure it will give you alist of all the blood pressures of the patient for that visit o This works for all vital signs Laj FW 02 26 14 02 27 14 02 28 14 03 01 14 23 59 23 59 23 59 23 59 Intake Total Output Total Balance Intake Intake IV Fluid Amount Intake TPN PPN Amount Intake Lipid Amount Intake Blood Product Amount Intake Blood Product Amount Rbc Aph Lr Cp2d gt As3 ist Unit W063 Rbe Lr Cp2d gt 4s3 500m Unit WO685 Rbc Lr Cp2d gt 4s3 500m Unit WO0685 Rbc Lr Cp2d gt As3 500ml Unit WO68S Rbe Lr Cp2d gt As3 S00m Unit WO6BS Intake Oral Arnount Intake Tube Feeding Amount Intake Other Amount Intake Breast Feeding Amount ac pc Intake Expressed Breast Milk Amount Intake Formula Amount Intake OQup Tube Breast Milk Amount Intake Cup Tube Formula Amount Intake Gavage Breast Milk Amount Intake Gavage Formula Amount Output Voided Amount Urinary Device Output Urethral Output Liquid Stool Amount Output Urine Stool Mix Amount Output Emesis Amount Gastrointestinal Tube Output Amount
29. 5555 By Email helpdesk kh org Page 3 PCM My Patients or Rounds Patients Lists Lists e Patients are separated on the list by location within your facility My Patients Rounds Patients My Discharged Cover Discharged 0 of 13 Selected v amp Location Age Sex Room Bed Name Birthdate Attending New Results Home Meds T DC Consult Ordered Flag w CRITICAL CABET TEST ESIGN ty alee Crook Albert A Incomplete CRITICAL CARE II 31 alae TEST DECEMBER i jy 993 MD1 PCM d E CRITICAL CARE III r 39 M KMO330 01 testing sdc 05 08 1974 Lahr Stephanie J J MOSS OL MAZUR GRAMMA M Zo gt 1934 Emry Geoff T Rpt Cardiovasc d m a pelea TIT DOVER BEN oF Jorsigs0 Daugherty Barbara A MD Incomplete c occa SAHE Persag46 TEST T o sigs Craig Arthur B Incomplete LABOR amp DELIVERY 33 M eT Boas ot WILSON JOSEF 39 11 1989 MD1 PCM Incomplete MEDICAL 2 Tine DE mem mae Sam s T Er e The list is separated by several columns New results that are available are indicatedin the New Results Column and can be opened by clicking on the description Facilityand patients names are separated by unit Patient name is shown as Last First Age and Gender Attending Provider Account and Medical Record numbers are listed Ifthe check box is selected it will allow manual removal of a patient from the list e My Patients Any patient registered to you as an admitting or attending provider orany patients you have added manua
30. 6 01 KM00020127 H00020281 latex More My Notices BD Patient Lists Next Patient Select Visits GF 02 17 14 10 14 10 0 5 00 15 0 12 20 13 950i 10 0 5 00 15 0 P 09 24 13 10 03 13 1 10 03 13 14 23 10 9 N 3 j L of 02 07 14 15 17 1423 12 53 WBC RBC Hgb POC Hgb POC Hct Het MCV MCH MCHC RDW Plt Count MPY Neut Lymph Mono Eos Baso Absolute Neuts auto Absolute Lymphs auto Absolute Monos auto Absolute Eos auto Absolute Basos auto Smear Scan Bld Parasites Smear smear Review By 45 0 45 0 oO ON D E 44 w N Aa B NO a DOONNON AN YO ONwMOOD0ODDOL LD Diff confirmed No parasites seen See below Preferences 00008 Test White Blood Count Red Blood Count Hemoglobin Hematocrit Mean Corpuscular Volume Mean Corpuscular Hemoglobin 6 0 pc Mean Corpuscular Hemoglobin Concent 31 0 g c Red Cell Distribution Width 16 Platelet Count Mean Platelet Yolurne Neutrophils 9 Auto Lymphocytes 9 Auto Monocytes 9 Auto Eosinophils 9 Auto Basophils Auto Absolute Neutrophils fauto Absolute Lymphocytes auto Absolute Monocytes auto 0 Absolute Eosinophils auto 0 Absolute Basophils auto 0 RUN DATE 03 04 14 RUN TIME 1054 RUN USER TEST MD13 KOOTENAI HEALTH 2003 Kootenai Health Way Coeur d Alene ID Inquiry Broadcast Report FAX TO Name TESTME Clinical Acct KM0
31. By Email helpdesk kh org Page 53 e PDOC will display in the documents list for any provider assigned not justthe originator Date a Document Author Status 03 03 14 07 37 Daily Progress Note Merry Megan M Pending DRAFT e Initialized and saved e Awaiting signature e Available in reports tab of EMR ISIGNED e Multiple signers on document e Report is awaiting signature from at least one provider e Similar to DRAFT status e Available in reports tab of EMR SIGNED e All signatures have been obtained e Report is ina RESULTED status e Edits must be made via an addendum ADDENDUM e Additional information has been added by a user after it has reached asigned status e Awaiting signature on Addendum e Available in reports tab of EMR Ability to change the service date and time of document e The PDOC will file to the identified date and time in the EMR and documents list e The date and time will default to the date and time there PDOC report was initialized and may be changed to the service date and time ifneeded Do not remove the date and time and save if this occurs your note will not save tothe Document List KootenaiHealth With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 54 Schnur Bert L l SP0001002309 SP00021186 68 M 04 19 1945 HOO0201 76 ADM
32. Chemotherapy induced neutrfpenia l en v Resolved Next Patient 8 This is a very long free texproblem I amackive medication to spe additional ETET Deleted Problems r Date gt information Summary llergy AdvReac Edt Type Severity Reaction Status Dates bstance Use this information Le Patient Pharmacy Use the _ Active Medication Dose Route Frec ome vied UsbGIMELS ham diy sie ache issig ta is alls uz TaS na Pbdit Buttomita ec 20 mg PO 0600 2100 adit tHe existing home Heaidation list edit or add a pharmacy to the patien s pha Macys ctructions ital Signs bi Go z 4 de eed eed lig Ee Nears Taken Confirmed Ist edications 7 Patient Pharmacy fdt aboratory CVS Caremark Mail r icrobiolo Wal mart pharmacy 3p11 Preferred Blood mm Eligible F ENEs W Hee cis Discharge Plan Document FF Physician Care Manager HIM Dept KMC KOM KOM TEST6 07F KOM TEST6 07F TEST 6 07 MDLPCM PST Testme Clinical Limited Code KMo0001002112 KMO000201 27 44 M 07 11 1969 167 64cm 57 606kg BSA 1 65m BMI 20 5 HO0020281 ADM IN KM 2N KM0226 01 Allergy Adv Penicillins codeine Sulfa Sulfonamide Antibiotics latex More Demographics Legal Indicators N Diagnosis Date EOE g Problem fait jij Y Status Priprity Past Problems Y
33. IN SP MS SP222 01 Allergy Adv No Known Allergies Daily Progress Note a Patient Name SCHNUR BERT L Medical Record Number SP00021186 Date of Birth 04 19 1945 Patient Status Inpatient Attending Doctor CPOEIN MDBGH Account Number SP0001002309 Date 03 10 14 07 36 Initialization Date 03 10 14 07 36 Chief Complaint HPI gt Patient Information This report was generated by Physician Care Manager Initiated 03 10 14 0736 by Megan M Merry BERT L SCHNUR a 68 y o M admitted on 02 17 14 Length of Stay 21 days Chief Complaint Subjective HPI 4 Enter Code View Details Assign Providers Additional CC s Provider Outside Location Insurance Date Time 03 03 14 07 37 Preview coleman aiir J ff e Files to this date and time in the Documents List and EMR Author Status The service date is reflected on the Report in the Document List in the Date field Initialized date will display as well and will reflect the date and time the PDOC was initialized Schnur Bert L SP0001002309 SP00021186 68 M 04 19 1945 HO00201 76 ADM IN SP MS SP222 01 Allergy Adv No Known Allergies Daily Progress Note Patient Name SCHNUR BERT L Medical Record Number SP00021186 Date of Birth 04 19 1945 ending Doctor CPOEIN MDBGH Date 03 03 14 07 37 Ab KootenaiHealth I With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk
34. INR C 10 01 13 PRERCR KM ECHO KMO0001003704 MD6 PCM Clinical Panels 3 Vital Signs 4 J 09 12 13 DISRCR KM ACC 09 30 13 KMO0001002635 Jacobsen Cher Ann INR 09 09 13 DISRCR KM ECHO 09 30 13 KM0001002767 MD6 PCM L Z 09 03 13 ADMIN KM 2N KM0001002112 MD6 PCM PDOCness Monster LaO LO 09 03 13 DIS IN KM 2N 09 03 13 KM0001002104 MD6 PCM PDOC ness MONSTER Medications ie C 08 28 13 DISIN _KM 3S__09 03 13_ KM0001001868_MD6 PCM Testing 1 2 3 Laboratory Microbiology Blood Bank Reports Patient Care Notes Orders RJ Amb Orders R Discharge Plan amp Document Sign a Clinical Data amp Preferences x CS CE es a ED kK KootenaiHealth With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 28 Preferences e Allows physicians to customize where they will default in PCM and EMR My Notices Start Recent Consults List days in past My Emergency List days in past Clinical Panel 1 amp 0 Offset Hours from 24000 DataSaver Format E amp M Code Guidelines po Display Units Length Weight Fe Temperature Default Units Length ee Weight kilograms New Results ree Mager Panel y Admitted List relationship Notices e Notices can be configured for individual facilities and types of patients for Lab
35. KMC KOM KOM TEST6 07F KOM TEST6 07F TEST 6 07 Richardson Barbara P PDT lolx Eo PCS Crystal Full Code KMoo0 1000896 KMooo20062 29 F 05 04 1984 457 2cm 30 5kg BSA 2 60m2 BMI 1 5kg m2 HO0020103 ADM INO KM 3N KMO0310 01 Allergy Adv Penicillins ae Clinical Panel Anesthesia mary Cardiopulmonary Core Measures Discharge Planning 7 ED RN ISBARD J PCS Crystal KM00020062 PCS Open Chart HIM Dept KMC KOM KOM TEST6 07F KOM TEST6 07F TEST 6 07 Richardson Barbara PIPOT Glycemic Managemeni History Kardex Kardex OB Kardex Behavioral Hee Multidisciplinary Team Nursery NICU Pain Sepsis Withdrawal ADM INO KM 3N KMO0310 01 Allergy Adv Penicillins l vit ns Pulse Rate O02 Sat by Pulse Oximetry ga Oxygen Delivery Method Room Air Intake amp Output Panel i Intake Total 1000 ml 300 ml 770 ml 950 ml Output Total 1401 ml Balance 1000 ml 300 ml 770 ml 451 ml Intake Intake TPN PPN Amount 500 ml Intake Blood Product 4 500 ml Intake Blood Product A 300 ml 770 ml Rbc Lr Cp2d gt 4s3 500ml 300 ml Rbc Lr Cp2d gt A4s3 500ml 385 ml Rbc Lr Cp2d gt 4s3 500ml 0 ml 385 ml Intake Oral Amount 950 ml Output voided Amount 701 ml Output Drain Tube Amo 700 ml Chin 4 700 ml Other Bowel Movements 1 Percent of Breakfast Con 100 Weight 5 Ji I l l z e Standard Mar 30 5 kg Wound l
36. Physician Care Manager Documenting User Manual Prepared by Training and Communications Kootenai Health Information Technology March 2014 Table of Contents Physician Care Manager 2 Logging into Meditech 2 Preferences 3 PCM Rounds Patients or My Patients Lists 4 Selecting a Patient 6 Buttons on the Right Hand Side of Screen My Notices to Preferences T Enterprise Medical Record EMR 8 EMR Summary 8 Review Visits 10 New Results 11 Viewing a Lab Report 13 Clincal Panels 14 Vital Signs 17 Input amp Output I amp 0 s 18 Medications 18 MAR 19 Laboratory 21 Microbiology 22 Blood Bank 23 Transfusion Flowsheet and Comments 24 Reports 29 Patient Care 26 Notes 28 PCI link 28 PCM EMR Preferences 29 Notices 29 Documenting in PCM 30 Datasaver and Graphing 36 Deleting Cancelling a Pending Draft or Report 45 Electronic Signature 46 Electronically Signing a Report 47 Editing Reports Before Signing 47 Esigning of Scanned Document Deficiencies 49 Report Statuses 03 Logging into Meditech Locate the Meditech Icon on the desktop Double clicking on this icon will bring up alogin window 855 554 4440 2 naa a a 24 Hour Help Desk Messages A Preferences Kootenai Health Information Technology Enter your Meditech Username and Password User name Password Domain ME 9 tog On e Log in with your user
37. S PEA 3 0 yjalo Page 26 e Header Buttons o Patient Care Assessments Above screen shot Use this screen to view a list of the assessments documented for a patient and to access the details of those assessments o Patient Care Interventions Use this screen to view a list of the interventions already documented for a patient o Patient Care Outcomes Use this screen to view a list of the outcomes documented for a patient and to access the details of those outcomes o Patient Care Plans of Care Use this screen to view a list of the plans of care documented for a patient and to access the details of those plans of care Click the buttons to expand or contract Click on a plan of care item to view details P or P indicate text or protocol information The buttons above the table allow you to restrict the viewto different components of a plan of care the Problems Outcomes and Interventions The Overview page displays all components of the patient s plans of care o Patient Care History Use this screen to view a list of queries documented for patient and family history and to access the details of those queries The Positives box will display only abnormal charted inthe Admission Assessment The All Responses box will display normal and abnormal from the Admission Assessment Click on the query name to view information history Click the Recorded date to view
38. The default screen is the New Results screen in the Enterprise Medical Record EMR This can be changed in Preferences e Notice the header at the top of the screen it includes information on the patients name age date of birth admit location registration status height and weight a limited amount of allergies resuscitation status and account numbers e The little i This area has a complete list of allergies resuscitation status height weight and isolation precautions e The buttons on the right are now available KootenalHealth JY With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 6 Buttons on the Right of the Screen My Notices Patient Lists Next Patient Select Visits Look at previous visits and select ones that you Ba Pye My Notices Currently we are not using notices unless they are setup in Preferences Patient Lists Returns to the Patients lists screen Next Patient Moves to the next patient on the list Select Visits fH want to view Link to PCI 5 Summary through Notes This is all information from the summary Enterprise Medical Record or EMR Detailed information is in an TST appendix of this manual Any of these buttons that are red Review Visit 4 indicates new information since it was last reviewed by you fey Summa
39. and you are prompted to enter your PIN number 7 Electronic Signature User TEST MD1i3 e Enter your PIN Number and press Enter to the reports X KootenaiHealth With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 48 Meditech Esigning of Scanned Document Deficiencies e Scanned documents tagged with signature deficiencies will display in a Provider s Sign Queue under the Documents Tab like electronic reports currently do e The name of the document will display along with the patient When the documentis check marked and View and Sign is selected the Provider is then able to reviewthe scanned document and proceed with electronic signing using your pin e Once the document is signed the signature deficiency that was tagged on the document gets burned onto the image itself which will be reflected whenever the documentis viewed going forward Steps 1 Mark items to be signed using the check mark and then select view and sign Sr Physician Care Manager HIM Dept KMC KOM KOM TEST6 07F KOM TEST6 07F TEST 6 07 MDL PCM PST Signing Provider MD1 PCM Items for Provider MD1 PCM Orders J Notes J Documents J Date Pri Patient Reason Documents My Notices B l TESTME CLINICAL 2 16 13 11 34 KMOO01002112 44 M Progress Notes TESTME CLINICAL KMOO01002
40. any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 35 My Physician Care Manager HIM Dept KMC KOM KOM TEST6 07F KOM TEST6 O7F TEST 6 07 MDL PCM POT a Testme Clinical KMO0001002112 KMO0020127 44 M 07 11 1969 167 64cm 57 606kg BSA 1 65m BMI 20 5 HO0020281 ADM IN KM 2N KM0226 01 Allergy Adv Penicillins codeine Sulfa Sulfonamide Antibiotics latex More E i Am ee E s B n aE go v 3 4 gt 24 Hour Vital Signs Pp Temp Pulse Resp BP Pulse Ox 03 10 14 09 43 38c so is 90 60 s9 My Notices Patient Lists Next Patient 24 Hr Vital Sign ranges T max Period Temp Pulse Resp BP Sys Dias Pulse Ox Last 24Hr 38c s0 18 90 50 89 24 Hour Intake and Output Summary Select Visits Intake Total New Results Clinical Panels Vital Signs Perioperative Phase Preoperative Intake IV Fluid Amount Intake IV Fluid Amount 1000 ees Medications Laboratory Microbiology Blood Bank Oral Intake ss Intake Oral Amount 78 Void Output oo o S voided amount 0 Related Information J o Jo o o o Bowel Movements A a er T Percent of Breakfast Consumed 10 Percent of Lunch Consumed 75 Percent of Dinner Consumed _ 100 Patient Care Amb Orders Discharge Plan
41. as Chemistry Toxicology I m Miscellaneous Scanned Reports Click a test name to view the History of My Notices thatitem 02 17 14 10 14 J RS 10 03 13 tas 14 23 09 50 10 0 10 0 10 5 00 tS 0 15 0 12 20 13 02 07 14 1253 3 0 9 POC Hct a9 m Hct ele a 270 Ll 45 0 45 0 MCV 90 0 90 0 MCH 33 0 33 0 MCHC 34 0 34 0 RDW _ inte TED Plt Count 300 300 MPY 9 0 9 0 9 0 Neut 70 0 70 0 70 0 Right clic Lymph 20 0 20 0 20 0 Mono 8 0 8 0 8 0 Eos 2 0 2 0 2 0 Baso 0 0 0 0 0 0 Absolute Neuts auto 7 0 ZO 7 0 Absolute Lymphs auto 2 0 2 0 2 0 Absolute Monos auto 0 8 0 8 0 8 Absolute Eos auto 0 2 OS 0 2 Absolute Basos auto 0 0 0 0 results from the z 0 Document Smear Scan Diff confirme Bid Parasites Smear Selected test Clinical Data Smear Review By See below G J Preferences 00008 poet Lymphs auto shenlite Sr auto Grapr to auto Graph Favorites Re Order Now Queue for Re Ordey lear Queue for Referee X KootenaiHealth With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 21 IICN UIT CYUHOCLLOEU VI JUUILGS IITAGAUCISO LU shange the specimen sort method Click to view a list of organisms found within all speci
42. ctronically Signed by MD1 PCM MD on 12 23 13 at 0949 X KootenaiHealth With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 51 5 When all the deficiencies have been signed or exit is selected the following screen will be presented a Save Signatures before Exiting Don t Save Signatures and Rejections Cancel Exit e Select Save to save your signatures If you would like to cancel your work select Don t Save If you would like to return to the document select Cancel Exit e After you select Save you will be prompted to enter your pin User Pin TEST MD14 OO e Once all signatures for one provider on the document are signed the signature deficiencies that are tagged on the document gets burned onto the image itself which will be reflected whenever the document is viewed going forward Electronically Signed by MD1 PCM MD on 12 23 13 at 0949 SVS KootenaiHealth qa With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 52 Meditech EMR Report Statuses e Report status is located in the 4 column Gelected Visits All Visits Most Recent at X if All Psychosocial Rehabili
43. d Code KMO0001002112 KMO00020127 44 M 07 11 1969 167 64cm 57 606kg BSA 1 65m BMI 20 5 HO0020281 col ADM IN KM 2N KM0226 01 Allergy Adv Penicillins codeine Sulfa Sulfonamide Antibiotics latex More Status ADM IN Attending MD6 PCM Account KMO0001002112 _ Admitting MD6 PCM Reg Date Time 09 03 13 16 42 Reason for Visit PDOCness Monster f Hanson Carl L MD Active Staff Facility Kootenai Medical Center Discharge Referrals Stackow John C MD Active Staff TETE B Location MEDICAL 2 Burnett Robert J MD Active Staff Room Bed KM0226 01 Discharge Instructions PCS mate Lcis G Discharge Forms Discharge Additional SS More Deta iAcavidae AM RE PAUE EE GREE all ue O a the adBHiggdntanp alianteiny oMfopAtien Preferences e More Detail Screen E View Account x Testme Clinical 09 03 13 16 42 KMO001002112 KMO0020127 44 M 07711 1969 H00020281 ADM IN KM 2N KM0226 0i1 a TStration Prov Accom Demographics Employer Billing J Revisits Sees Registration Discharge Facility K ehai Medical Center Discharge Date Time Account Number KMO001 U0 Discharge Disposition Status ADM IN Registration Date Time 09 03 13 16 42 Reservation Date Reservation Taken _Expected Length of Stay Privacy Confidential Comment Alternate Address Facility Directory Yes Clergy Visit Yes Visit Reason PDOCness Monster Visit Comment VIP Comment Sens
44. ded to the Chief Complaint Click Save to file any changes X KootenaiHealth With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 47 North Idaho Rural Health TEST6 07 Patient Name TESTME CLINICAL Date of Birth 07 11 69 Attending Doctor MD6 PCM Date 12 16 13 12 38 Chief Complaint HPI Patient Information This report was generated by Physician Care Manager Initiated 12 16 13 1238 by PCM MD1 CLINICAL TESTME a 44 y o M admitted on 09 03 13 Length of Stay 104 days Chief Complaint Diabetes Subjective HPI Datar Latest CBC and BMP Results lt Problem Assessment and Plan Patient Problems Depressed bipolar I disorder Acute Heart failure Acute acute on chronic heart failure breast cancer Acute Daily Progress Note 02 17 14 10 14 01 02 14 10 31 Problems Medical Record Number KM00020127 Patient Status Inpatient Account Number KM0001002112 Initialization Date 12 16 13 12 38 Mrs Testme is a 62 year old patient of Dr Kim test This is a test This is a test early stage currently receiving chemo C3 tia Acute e The changes are then saved and you can Review to confirm and then click Sign When viewing and or editing of the reports is completed you are prompted with three options Sign Go Back and Cancel e Click Sign
45. election List Default select Rounds Patients Care Manager Initial Page Patient Selection List Default Initial Panel Default Default Panel view Default Clinical Panel View Clinical Panel Default Clinical Panel Start I amp 0 Default Time Period hours Medications Display Default Medications List Default Medications Med Orders Default Sort Medications Frequency Sort New Results Default Laboratory Default Laboratory All Panel Default Time Period Po Laboratory All Panel Start Reports Default Notes Default Graph Default Time Period Code Visit Default page Reports Sign Status Default e Defitions of some preferences you can set o Medication Frequency Sort Allows the user to choose the behavior of the Frequency sort either direction DAILY BID or schedule STA ONE SCH PRN o New Results Default New to You Last 24 hours or Last 48 hours o Laboratory Default New option available to default to All o Laboratory All Panel Default Time Period Define the time frame utilized forinitial display Will use settings 15 min 30 min 1 hr 4 hr 12 hr or 24 hr o Laboratory All Panel Start Expanded or Collapsed KootenaiHealth This material is the intellectual property of Kootenai Health Do not download share or redistribute without prior permission With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625
46. ent and Plan is completed click OK to save Click on View Saveto preview and sign the report My Physician Care Manager HIM Dept KMC KOM KOM TEST6 07F KOM TESTS 07F TEST 6 07 MDL PCM PDT EN F EE EA Testme Clinical KM0001002112 KM00020127 44 M 07 11 1969 167 64cm 57 606kg BSA 1 65m2 BMI 20 5 H00020281 Gi ADM IN KM 2N KM0226 01 llergy dv Penicillins codeine Sulfa Sulfonamide Antibiotics latex More Gogol 2 North Idaho Rural Health TEST6 07 a Daily Progress Note Patient Name TESTME CLINICAL Medical Record Number KM00020127 Date of Birth 07 11 69 Patient Status Inpatient Attending Doctor MD6 PCM Account Number KM0001002112 Date 03 10 14 09 49 Initialization Date 03 10 14 09 49 Chief Complaint HPI gt Patient Information This report was generated by Physician Care Manager Initiated 03 10 14 0949 by PCM MD1 CLINICAL TESTME a 44 y o M admitted on 09 03 13 Length of Stay 188 days Chief Complaint Subjective HPI Review of Systems Constitutional Reports Change in Appetite Denies Fatique Malaise Generalized Weakness test Physical Exam Constitutional Constitutional Well Developed test Datar Vital Signs I amp O s per Nursing Document 24 Hour Yital Signs sign Temp Pulse Resp BP Pulse Ox SEATER 03 10 14 09 43 38c eo is oos0 eo fens 24 Hr Vital Sign ranges T max Period Temp Pulse Resp BP Sys Dias Pulse Ox Las
47. ert 2 4 ribitesecords ex s igsyaibnotes 56 opm th esse ed Cliek toz wiew the assessmenNiheium enter L 09 23 13 02 datgene Note eS Leonard Melinda J Signed AdWendum enter j j C 09 19 13 12 ial Service Merry Me icli Initited DC plan may need authorizatio C 09 19 13 12 51 Speech Pathology AE IS linked te toleratgd sweallo C 09 19 13 12 50 Nursing Note erry Megan M Signed Patient Nleratin e Includes Nursing Notes Care Manager Physical Therapy Progress Notes Etc e Click the Refresh tab anytime to refresh the EMR e The Notes tab will appear in red when notes are filed PCI Link ES Physician Care Manager HIM Dept KMC KOM KOM TESTS6 07F K jI _ Oj ET Testme Clinical Limit KM0001002112 KM00020127 Pa 44 M 07 11 1969 167 64cm 57 606kg BSA 1 65m BMI 20 5 HO0020281 oe ADM IN KM 2N KM0226 01 Allergy Adv Penicillins codeine Sulfa Sulfonamide Antibiotics latex More Time Period Visit Type O 7 days 1O Inpatient 30 days O Outpatient O 90 days All 12 months 24 months My Notices O All Patient Lists Selected Visits Next Patient O Time Frame __ Select Visits Reg Date Type Loc Dis Date Account Num Provider Reason for Visit Summary amp C 11 08 13 SCH SDC KM KDS KMO001006975 Ettinger Andre A Review Visit lt LJ 11 04 13 REG REF KM ALPHA 140001001086 Lab Alpha Notices C 10 01 13 PRERCR KM ACC KMO0001003712 Jacobsen Cher Ann
48. g Johanna Kim Kevin Bruning Johanna MD1 PCM Mulvey Kevin Merry Megan Bruning Johanna Bruning Johanna Bruning Johanna e A Report may be listed in one of the following reportstatuses PENDING Applies to PDOC only 02 06 14 02 06 14 02 06 14 02 06 14 02 06 14 02 06 14 02 03 14 01 09 14 01 08 14 12 30 13 12 16 13 09 13 13 09 13 13 11 27 13 11 26 13 11 26 13 11 26 13 11 26 13 11 26 13 11 26 13 11 26 13 11721713 11 21 13 11 21 13 Ea ggo o 00000000000 Patient Lists Next Patient Select Visits oF Summary Reports Patient Care Notes Orders Amb Orders Discharge Plan lt Document Clinical Data Preferences e Does not flow to ITS so will not display in the reports tab EMR e Only available for viewing by the initiating provider in the Document tab of EMR e Initialized and saved e Awaiting signature e Once placed in DRAFT or SIGNED status will be available in EMR Pending reports can display on the documents list for any provider assigned to the document Enter Code View Details Additional CC s O Provider Outside Location O Insurance Assign Providers MD1 PCM Date Time 03 03 14 07 37 Status Pending O Draft O Signed Preview q f Required Questions X KootenaiHealth With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555
49. h With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 50 e Prev Unsigned navigate to the previously unSigned deficiency e Next Unsigned navigate to the next unSigned deficiency e Reject allow the provider to reject the deficiency A rejection commentis required this field is a free text Rejection Comment Not my order Cancel Save x Jf e Exit Allows you to leave the document you are currently viewing You may select 4 You may note the following when Esigning a deficiency e Red The selected deficiency for the provider To be Electronically Signed by MD1 PCM MD on XX XX XX at XXXX e Yellow Other deficiencies for the provider l To be Electronically Signed by MD1 PCM MD on XX XX XX at XXXK e Blue Deficiencies for another provider To be Electronically Signed by MD2 PCM on XX XX XX at XXXX e Green A deficiency that has been signed but the document is has missing signatures for the provider To be Electronically Signed by MD1 PCM MD on XX XX XX at XXXx e Purple A deficiency that has been rejected but the document is has missing signatures for the provider To be Electronically Signed by MD1 PCM MD on XX XX XX at XXXK e Once all signatures for one provider on the document are signed those signatures will be burned to the image Ele
50. he top left of the main panel to collapse your menus You can then use the next to each lab category to expand results e You have two footer buttons at the bottom of the screen Graph and Graph Vitals o The Graph button allows you to choose a lab value and graph it to see trends o The Graph Vitals button allows you to see how vital signs are trending e To Graph results right click on the result name o This will bring up a drop down box with Graph highlighted in green Youneed to left click on the word Graph Under the word Graph that is highlighted in green you will see a listof any results you have already chosen to graph Repeat the above steps to choose as many results as you would like to graph e Click Graph at the bottom of your screen KootenaiHealth With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 11 Limited Code KM0001002112 KMOo00201 167 64cm 57 606kg BSA 1 65m BMI 20 5 HO00020281 ADM IN KM 2N KMO0226 01 Allergy Adv Penicillins codeine Sulfa Sulfonamide Antibiotics latex More Qi N _ New Labs and Reports Chaw to you Last 24 hr Last 48 hr Graph Favorites Re Order Now Queue for Re Order A ucue for References amp lt amp rr SIQI 3 ojej ne be a8 a ALS ie ojo SER EREEER Flos iSieiel FREE D a
51. her Abnormal Tearing Scleral Icterus Red Reflex Eye Discharge Pupils Other Pale Conjunctivae Cataracts Ear Nose Mouth and Throat iHead and Face Neck Respiratory Cardiovascular Chest Breast G1I Abdomen GU it Rectal i Musculoskeletal i Integumentary iA Incision Neurologic Psychiatric Lymphatic Comment e The Data tab includes Vital Signs amp O s and Lab data that is defined to pull intothe report Different templates have different data elements defined to be pulledin G Daily Progress Note Data Vital Signs I amp 0 s per Nursing M v Latest CBC and BMP Results 02 17 14 10 14 01 02 14 10 31 150 7 ri 4 450 N 2 00H N Lad Results M Reviewed by Me Today Allergies Medications Vital Signs Diagnostics Nursing Notes Other H amp P Old Records Ambulatory Discussed with Family 1 amp 0 s Old Records Meditech Labs Discussed with Consultant e To review the Vital Signs I amp O and Lab sections simply click on the line indicated by lt Entered gt Vital signs and I amp O data are shown in tables If you wish to remove any of these tables right click on the table and click Delete Table at the bottom of themenu The title of the table will need to be removed manually It does not get removed with the table e The data tab may be where you choose to insert data that you saved while reviewing the EMR b KootenaiHealth oe With questions about
52. hief Complaint HPI Vv E Patient Information e Upon Clicking Save the provider will be presented with a split screen This screen will allow the provider to both view and sign and sign the document Users will no longerbe presented with a seperated doucment preview screen e Provider may select Expand View for an expanded preview of the document k KootenaiHealth With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 57 Schnur Bert L SP0001 002309 SP00021186 68 M 04 19 1945 H000201 76 ADM IN SP MS SP222 01 Allergy Adv No Known Allergies Daily Progress Note a Patient Name SCHNUR BERT L Medical Record Number SP00021186 Date of Birth 04 19 1945 Patient Status Inpatient Attending Doctor CPOEIN MDBGH Account Number SP0001002309 Date 03 10 14 07 36 Initialization Date 03 10 14 07 36 Chief Complaint HPI gt Patient Information This report was generated by Physician Care Manager Initiated 03 10 14 0736 by Megan M Merry BERT L SCHNUR a 68 y o M admitted on 02 17 14 Length of Stay 21 days Chief Complaint Subjective HPI 4 Assign Providers Additional CC s O Provider Outside Location Insurance Date Time 03 10 14 07 36 Status O Pending Draft O Signed e Selecting the collapse Preview Button will col
53. ient Problems CC HPI O G Daily Progress Note _ Problem Assessment and v Patient Problems Edit Heart failure Acute breast cancer Acute Chemotherapy induced neutropenia Resolved This is a very long free text problem I am sure someone is Resolved Alcohol induced psychosis Acute Nausea and vomiting Acute Neutropenic disorder Acute Neutropenic fever Acute Alcohol abuse Chronic Estimated Date of M Comment Discharge Assessment and Plan M Click on the Problem or the blank line if no problems exist to enter PatientProblems Existing problems will be listed or be blank if there are none A X KootenaiHealth With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 38 SE AE Problems a Heart failure Acute acute on chronic heart failure breast cancer Acute Mrs Testme is a 62 year old patient of Dr Kim test This is a test This is a test early stage currently receiving chemo C3 Chemotherapy induced neutropenia Resolved This is a very long free text problem I am sure someone is Resolved Alcohol induced psychosis Acute Lung mass Acute Nausea and vomiting Acute Neutropenic disorder Acute Neutropenic fever Acute Alcohol abuse Chronic 4 e Click the Edit button at the bottom of the screen to add a problem
54. imited Code 1000 ml Preoperati 1 100 75 75 KM0001002112 KMO0020127 167 64cem 57 606kg BSA 1 65m BMI 20 5 HO00020281 Allergy Adv Penicillins codeine Sulfa Sulfonamide Antibiotics latex More 20 Blood Pressure 110 45L ss 110 45L 4 O2 Sat by Pulse Oximetry Oxygen Flow Rate L min Oxygen Delivery Method ex vital Sighs LEAL EGA 90 90 3 Room Air Room Air Nasal Can t yt a ty i inter a Gulab panel S p Intake Total Output Total Balance E Intake Intake IV Fluid Amount Intake Oral Amount Output Yoided Amount Other Perioperative Phase Bowel Movements Percent of Breakfast Cons Percent of Lunch Consumed Percent of Dinner Consumed Active Medications a pee Ambulatory Medications 1000 ml 1500 ml 2000 ml 1000 ml Preoperati Preoperati 1 sey ol 100 100 75 75 75 75 Xk KootenaiHealth With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 15 e Clicking a number value will give you a normal range for that test e Clicking a bubble next to a number value will give you more information aboutthat test e To Graph results Right click on the text name o This will bring up a drop down
55. itive Visit Code Visit Diagnosis A ff LP p KootenaiHealth TI With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 10 New Results Sy Physician Care Manager HIM Dept KMC KOM KOM TEST6 07F KOM TEST6 07F TEST 6 07 MDL PCM PST lee ES Testme Clinical Limited Code KMO0001002112 KMO00020127 44 M 07 11 1969 167 64cem 57 606kg BSA 1 65m BMI 20 5 H00020281 ADM IN KM 2N KMO0226 01 Allergy Adv Penicillins codeine Sulfa Sulfonamide Antibiotics latex More New Labs and Reports o you Last 24 hrj Last 48 hr ae 03 03 14 Bee Foe creer OE l Blood Gas VBG Lactic Acid 2 8 H My Notices Patient Lists 2 Next Patient amp Select Visits oF Summary E Review Visit Notices fe New Results amp Medications fi Laboratory Microbiolo Blood Bank Reports Patient Care Notes Orders a Amb Orders lt Discharge Plan lt Document Sign 4 Clinical Data Preferences xt aly es 00008 e New Results displays any New Labs and or Reports on your patient e You can view your results by clicking on the tabs New to You Last 24 Hours orLast 48 Hours e You can either scroll down your page to view everything or you can click on the at t
56. lapse the Document Preview into the spilt screen view k KootenaiHealth With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 58 Schnur Bert L SP0001 002309 SP00021186 68 M 04 19 1945 HO00201 76 ADM IN SP MS SP222 01 Allergy Adv No Known Allergies rE Foe North Idaho Rural Health TEST6 07 a Daily Progress Note Patient Name SCHNUR BERT L Medical Record Number SP00021186 Date of Birth 04 19 1945 Patient Status Inpatient Attending Doctor CPOEIN MDBGH Account Number SP0001002309 Date 03 10 14 07 36 Initialization Date 03 10 14 07 36 Chief Complaint HPI gt Patient Information This report was generated by Physician Care Manager Initiated 03 10 14 0736 by Megan M Merry BERT L SCHNUR a 68 y o M admitted on 02 17 14 Length of Stay 21 days Chief Complaint Subjective HPI 4 g Preview q ff X KootenaiHealth With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 59
57. lick in the Results section by the drop down field to enter free text By default the cursor falls to the bottom of the automatically pulled data To insert the glucose results into the note click on Saved Data at the bottom of the screen A screen showing what data has been saved in the Datasaver will display Checks on the left indicate that all data selected will be inserted into the note To remove any of these items uncheck the unwanted data X KootenaiHealth With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 37 v Name Value Date Type Kee Glucose 166 mg dL H 09 10 13 07 00 Lab L Glucose 145 mg dL H 09 10 13 13 37 Lab C v Omeprazole PO 20 mg 0600 2100 SCH 02 27 14 13 12 Med Rx L To remove all of the data click Remove at the bottom of the screen To continue to insert into the note click the Insert button instead Inserted data is seen in the table format in the note Click OK to save the inserteddata Trade Name Freq PRN Reason Stop Dose Admin Omeprazole 02 27 14 21 00 Prilosec PO 0600 2100 SCH 09 10 13 09 10 13 07 00 13 37 Click on the A P tab to document Problems and the Assessment and Plan The Problem List uses SNOMed as the list of problems or problems can be entered via free text Problems present for this patient appear in the column next to Pat
58. linda J Leonard c Rochelle A Wiede CLKM SUPERS a amer m TOENE PROM EET Registered Nurse Twedt Angela View the de Registered Nurse Registered Nurse Registered Nurse Registered Nurse Registered Nurse Registered Nurse Registered Nurse Registered Nurse Registered Nurse Registered Nurse Registered Nurse Registered Nurse Registered Nurse Registered Nurse Registered Nurse Registered Nurse Registered Nurse Registered Nurse Registered Nurse Registered Nurse Registered Nurse Registered Nurse Registered Nurse Registered Nurse Registered Nurse Registered Nurse elle A Wiedenhoff Registered Nurse wef Wiedenhoff Registered Nurse adenhoff Registered Nurse Registered Nurse agistered Nurse With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Assessment Ails of the selected H00020281 selected type Gutcome Ji Plan Of Care History Scanned Form Syg ge 08 19 13 Patient Lists Next Patient Select Visits Summai Review Visit Notices New Results Clinical Panels Vital Signs I amp O Medications Laborator Microbiolog Blood Bank Reports Patient Care Notes Orders Amb Orders Discharge Plan Document Sign Clinical Data Preferences PISS P 0 teise PRSE
59. lly via the Add Patients routine If an order fora consultation has been entered in OM that patient will also be on this list Thewords consult ordered will be listed under the attending physician s name if an order has been entered through OM for you to consult this patient e Rounds Patients The list includes all patients from the My Patients list and any patients of groups or physicians for which you can cover e My Discharged When patients are discharged they are removed from the My Patients and Rounds Patients lists and will stay on the discharged list for four days e Covered Discharged This list contains patients that have been discharged thatare assigned to the providers for which you were covering Buttons at the Bottom of the Screen l l RAAR Add to ii Lists Build Cover Add Patient Remove w i f Patient Lists e Lists This shows all of the Patient Lists that are available The My Admitted Patients first four are available as buttons above the patient list Thesewill Se eee parents return you to the patient list under that button To return to the My esvenbscharged Patients y Emergency Patients Patients list click on My Admitted Patients ea TE My Scheduled Outpatients Cover Scheduled Outpatients My Recent Consultations My All Patients Recent Visit Activity Personal List Recently Accessed Admissions Discharges By Date Any Location Find Patient AL KootenaiHealth qv With q
60. lth qv With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 5 e Remove This is available only if the box in the column to the right of the patient nameis checked This allows removing selected patient s from your My Patients and Rounds Patients lists e Add to Personal List This is available only if the box in the column to the right ofthe patient name is checked This is available from the My Patients and Rounds Patients lists as well This allows adding the selected patient s to your personal list This will not add a patient to your My Patients or Rounds Patients lists You can view yourPersonal List by clicking on the List button and choosing the Personal List option Patients must be removed manually from the Personal List e Report Allows printing of the My Patients and Rounds Patients lists If no patients are selected in the right column the entire list will be printed If patients are selected only these patients will be printed There is also an option to select a specific facility which is available on the Select Report Parameters page Default is All e Refresh Manually refreshes any list Selecting a Patient e To select a patient click the empty space in the first column 44M 07 11 1969 Blood Bank Tests athnoloay TES TME CLINICAL MD6 PCM Incomplete e
61. m Normalized Ionized Calcium Phosphorus Albumin Triglycerides Cholesterol LDL Cholesterol HDL Cholesterol Total Bile Acids Alanine Beta Alanine a Amino n Butyric Acid g Amino n Butyric Acid Alpha Aminoadipic Acid Anserine Arginine Level Argininosuccinic Acid Asparagine Aspartic Acid Level b Aminoisobutyric Acid Citrulline Cystine Cystathionine KMOG01002112 O1 2814 OA a Of KMO0020127 H00020281 Allergy Adv Penicillins codeine Sulfa Sulfonamide Antibiotics latex More My Notices A Patient Lists Next Patient Select Visits s E l g Clinical Data Preferences gogoe e Clicking on Glucose will show only glucose results for the patient To select data right click on the values Selected data is indicated by a black diamond Selected Visits I All Visits ote oo1 13 sft TON 10 16 2013 06 00 48 L mg dL 10 03 2013 14 23 522 H mg dL 09 16 2013 06 58 333 H A mg dL 09 16 2013 01 00 88 mg dL 09 10 2013 13 37 E SARE mg dL 09 10 2013 07 00 166 H mg dL ZENI LASZIEGS izan Selected Visits I All Visits Collected Result Units Range Group mg dL mg dL 2 mg dL 10 16 2013 13 38 99 AG 10 16 2013 06 00 10 03 2013 14 23 09 16 2013 06 58 09 16 2013 01 00 09 10 2013 13 37 09 10 2013 07 00 1i e Glucose values have now been selected and saved in the datasaver e Return to your note with the captured data by clicking the green Document button C
62. mens Microbiology Click to view the Susceptibilities Grid Click the Clipboard to view the aa specimen report Selected Visits All Visits 10 24 13 10 Gram Stain Final Complete Wound Culture Final Organisms appear 10 24 13 06 00 Blood Fungal Culture Preliminary Resulted NO FUNGUS ISOLATED IN 1 WEEK background 10 17 13 10 26 Pleural Legionella Culture Final Complete Fluid Misc Micro Reference Culture Status Final 09 17 13 06 30 Sputum Gram Stain Final Complete Respiratory Culture Final 09 13 13 13 00 Urine Gram Stain Final fz Complete Urine Culture Final 09 11 13 06 00 Blood Culture Final Complete NO GROWTH IN 5 DAYS Specimens Organisms T SVS KootenaiHealth I With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 22 VIVVVY NIVYU NUE iveywvl Ww ivi View results of all blood bank View all blood bank products tests for the selected visits in Transfused status the selected visit Products ordered during iRlood Bank selected visits Leuk reduced RBC 6 Leuk reduc Pheres RBCs 0 Fresh Frozen Plasma 0 Test ce Blood Type O POSITIVE 01 22 14 11 00 Antibody Screen Negative 01 22 14 11 00 Relevant tests when ord blood Hgb 15 0 g dL 13 7 16 7 02 17 14 10 14
63. nage Favorites If no favorites are et up a list of standard progress notes Reports and nursing notes are available Adding specific notes to your favoriteslist can be done by clicking the Manage Favorites button Click to check the notes to add to your favorites list Click Save and only the notes you Favorite Standard Manage Favorites selected will be seen when you document from now on You can select other reports from the list by selecting Standard at the bottom of the page KootenaiHealth By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 31 Cardiology Progress Note Consultation Critical Care Progress Note Report Daily Progress Note Report Discharge Instructions Report Discharge Summary Report Focused Progress Note Report History and Physical Report Orthopedic Post Op Progress Nt Report Psychiatric Progress Note Report Pulmonary Progress Note Report TEST PDOC Report HOUOUUOUOUUSNOOO _ _ e Select the desired template from the list Pa Test Note Note Cardiology Progress Note Report Consultation Report Critical Care Progress Note Report Discharge Instructions Report Discharge Summary Report Focused Progress Note Report History and Physical Report Orthopedic Post Op Progress Nt Report Psychiatric Progress Note Report Pulmonary Progress Note Report TEST PDOC Report e Example of a Daily Progress note CC HPI Chief Complaint HPI vo
64. ogress Note Daily Progress Note Daily Progress Note Daily Progress Note Daily Progress Note Daily Progress Note PT Daily Note Daily Progress Note History and Physical Consultation Code Encounter OFF KOM TESTS O7F TEST 6 07 MDLPCM PST MD1 PCM Merry Megan M Merry Megan M Merry Megan M Merry Megan M Merry Megan M Merry Megan M Merry Megan M Merry Megan M Loss Scott D MD Merry Megan M Merry Megan M MD1 PCM Triphahn Laura Bruning Johanna Bruning Johanna Kim Kevin T Bruning Johanna Merry Megan M Mulvey Kevin P MD MD1 PCM Bruning Johanna Bruning Johanna Bruning Johanna Bruning Johanna MD1i PCM Triphahn Laura Triphahn Laura Merry Megan M Merry Megan M Merry Megan M Leonard Melinda J MD4 RESIDENT PCM MD4 RESIDENT PCM Merry Megan M Visit Report KMO0001002112 Pending ISigned ISigned Draft Draft Draft Signed Signed Signed Signed ISigned Signed Draft ISigned Signed ISigned Signed ISigned Signed Signed Signed Signed Signed Signed Signed Pending ISigned Signed Signed Signed Signed Signed Signed Cancel Signed KMO0020127 My Notices B Patient Lists Next Patient 6 Select Visits ol amp Document Sign Preferences 00008 e To start a new note click New at the bottom of the screen Neither the Code Encounter nor Visit Report buttons are used at this time e Ma
65. olumn This groups like documents together X KootenaiHealth With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 25 heck the assess vant to view Access archived data e A sign indicates there are additional reports available Date a 09 05 13 17 34 09 03 13 15 49 09 03 13 12 00 08 29 13 12 11 More P Most Recent PIeUUe JUC CLUVUIIJ VIC VV UWIS VILU LUIS UIBVLVIIITICLILY Ny wu INUTIIV Interventions Outcomes Plans of Provider Type or by the user that Care History and scanned forms recorded them Click an assessment to view its details Selected Visits All Visits Most Recent Pathology Dictated Rpt Status MD6 PCM MD6 PCM Rpts Exam Report History amp Physical G Progress Notes F PTH Surgical Specimen Discharge Summary 09 05 13 09 03 13 Signed ISigned Signed Draft Appendix MD6 PCM 08 29 13 08 19 13 15 42 Patient Care ADM a Eg ee ee Ser 5 a Abdomen Ultrasound Testine Clinics DY fa er 44 M O7 11 IN KM 2 C 02 25 14 07 40 1 02 25 14 06 00 C 02 20 14 07 34 C 02 20 14 07 32 C 02 20 14 06 00 _ 02 20 14 06 00 02 20 14 04 00 C 02 16 14 08 55 C 02 11 14 12 42 Cj 02 05 14 13 37 C 02 05 14 13 32 _ 02 05 14 13 29 C 02 05 14 13 2
66. om of the screen View amp Sign Click this button and the first reportin the list will be shown in a preview window The numbers of reports that need tobe signed and number that are marked for signature are shown at the bottom ofthe screen E tse KOOTENAI MEDICAL CENTER Coeur d Alene ID 83814 Patient Name TESTME Clinical Chief Complaint HPI Patient Information This report was generated by Physician Care Manager Initiated 12 16 13 1238 by PCM MD1 CLINICAL TESTME a 44 y o M admitted on 09 03 13 Length of Stay 104 days Chief Complaint Subjective HPI Data Latest CBC and BMP Results 10 03 13 14 23 9 0L 4 10 0 120L 27 0L 10 16 13 13 38 gg Problem Assessment and Plan Patient Problems Problems Heart failure Acute acute on chronic heart failure Lung mass Acute Neutropenic disorder Acute Neutropenic fever Acute breast cancer Acute a 7 eee PT Y 219 Unsign D t Si foc Send Message View Image Prior Next Stop e All reports must be viewed before signing e Review the report for errors If there are none click Sign to mark this reportfor signature Editing Reports before Signing e If you need to edit a report prior to signing click the Edit Document button The reportis seen in a window similar to the original preview except it is now editable like aWord document Now any errors from transcription can be corrected or additions made Here diabetes has been ad
67. oviders l Medications Providers e Displays the list of Home Medications on Admission Admission Medications and Discharge Medications e Clicking on a medication anywhere in that row will give you a new screenwith more detailed information about that medication see below Lisinopril 2 5 mg Tablet 2 5 mg PO HS _ Pt History 12 05 13 11 10 ve _ 3120 511114589800 ber KM1 B20131205111145898 me 02 05 14 14 43 Jordan Julie L gt k i KootenaiHealth 4 With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Unconfirmed Confirmed Confirmed Confirmed Nov 07 2013 Nov 07 2013 Nov 07 2013 Nov 07 2013 Dec 05 2013 Bee 11 2013 Dec 27 2013 Jan 22 2014 Jan 22 2014 Feb 05 2014 Page 20 PITQGUCI I VULLYUTIO VICW FCOUILSD NOII multiple categories Laboratory Scroll Arrows Browse data by date WM Dhe 7 Physi cian Care Manager HIM Dept KME KOM KOM TEST6 07F KOM TEST6 07F TEST 6 07 MDLPCM PST Testme Clinical Limited Code KMOG01002112 KMO00201 27 44 M 07 11 1969 167 64cm 5 7 606fg BSA 1 65m2 BMI 20 5 HO0020281 ADM IN KM 2N KMO0226 01 Allergy Ady Penig ins codeine Sulfa Sulfonamide Antibiotics latex More Selected visits visits I All Visits Mos Most Recent T Hematology J BloodG
68. re unchecked To check all providers use the Check All on the provider list Click on Provider and you are able to search fora specific provider to cover for that is not in a group you are already associated with Click Save in the lower right of the screen to save your changes If you wish to clear all of the cover settings the Save as Favorite Reset Inpatient ust ge 54 Reset Patient List button at the bottom of the screen will eiea all of the coversettings e Add Patients This allows for finding a specific patient to add to your My Patients or Rounds Patients lists Enter the patients name Last First and click Search atthe bottom of the screen If a match is found the patient information will be seen undera Partial Name Matches header Click on the patient information and the Patients Selected list will show the patient Continue this process for additional patients if desired When completed click Save to add the patient s to your My Patients and Rounds Patients lists l Patients Selected v Name v Account Num Type Location Med Rec Num 4 V TESTME CLINICAL KMO0001002112 ADM IN JADE KM 2N KM00020127 fe Name testme clinical Provider Account Num Med Rec Num Location EMR Number Service Date Soc Sec Num Partial Name matches Name Birthdate Account Num Type Date Location Med Rec Num TESTME CLINICAL 07 11 1969 KM0001002112 ADM IN 09 03 13 KM 2N KM00020127 aY KootenaiHea
69. ronic heart failure breast cancer Acute Mrs Testme is a 62 year old patient of Dr Kim test This is a test This is a test early stage currently receiving chemo C3 tia Acute Chemotherapy induced neutropenia Resolved This is a very long free text problem I am sure someone is Resolved Alcohol induced psychosis Acute Lung mass Acute Nausea and vomiting Acute Neutropenic disorder Acute Neutropenic fever Acute Alcohol abuse Chronic e Click OK to return to the note e Estimated Date of Discharge is a date field Clicking on the down arrow brings upa calendar e Click by Assessment and Plan This is a free text box The cursor will default bythe second arrow gt K KootenaiHealth With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 42 Estimated Date of Comment Discharge Assessment and Plan f Physician Care Manager HIM Dept KME KOM KOM TEST amp 07F KOM TEST 6 07F TEST 6 07 MOLPOM PDT l 9 a a G x Testme Clinical KM0001002112 KM00020127 p 44 M O7 11 1969 167 64cm 57 606kg BSA 1 65m BMI 20 5 HO0020281 ADM IN KM 2N KM0226 01 Allergy Adv Penicillins codeine Sulfa Sulfonamide Antibiotics latex More H ka ae EE Cre E ee 2 Free text AZP4 My Notices Patient Lists Next Patient e When the Assessm
70. ry Shows Problems Allergies Active Medications and Notices Clinical Panels E _ Home Medications etc Review Visit Provides admitting information Notices Notices only related to the selected patient Vital Signs Afel New Results Shows any new results on the patient 120 _ Vital Signs Review vital signs entered by nursing L amp O Review I amp O s entered by nursing Medications 0 2 NO Medications Review medications ordered Laboratory P _ Laboratory Review lab results yi iC Microbiology Review micro results Blood Bank Blood Bank Review blood administration oor ak 5 Reports Review any reports dictated radiology pathology Reports Lf Pdoc etc Patient Care Patient Care Review nursing documentation and therapies Notes Notes Notes from other disciplines nursing therapies Orders Access to Order Management for viewing all orders Orders R _ Amb Orders Used by ED physicians to prescribe discharge Amb Orders IR medications Document Used for Pdoc physicians Document F Sign When highlighted in red this indicates that there are a orders and or documents reports that require yourelectronic SIGN FA signature Preferences ze Preferences Allows modification of default settings A KootenaiHealth 77 With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 62
71. s _Last Admin Sme bug Crees Dose admin 09 09 13 06 00 Dpiate Ag 09 17 13 11 33 09 17 13 11 34 10 22 13 06 00 11 18 13 06 00 10 22 13 06 00 11 18 13 06 00 12 10 13 14 40 12 10 13 17 30 09 10 13 09 00 09 12 13 08 59 09 17 13 09 00 10 23 13 09 00 02 06 14 09 00 09 20 13 09 00 02 17 14 15 36 DC DC DC DC DC DC Cancelled DC DC DC Cancelled Cancelled Oplate g Opiate Ag Oplate Ag Beta Adre Beta Adre Beta Adre Nonsteroi Nonsteroi Nonsteroi Nonsteroi Platelet A Cort icoste a HO00020261 09 17 13 11 33 1 tab KootenaiHealth My Notices Patient Lists Next Patient Q 2 Select Visits lt g Summary SI Review Visit a Notices New Results _ amp l Clinical Panels OJ Vital Signs ae Medications Laboratory Sign 7 N F Clinical Data amp Preferences i With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 18 WIN Ww Oeu TAS UA VU G SU HOLA a rium Detail View _ Access archived data View medications currently Active on Hold or Discontinued within the last 24 hours Left click on the medication anywhere in the row to see additionalinformation about a particular medication e Below are the Footer Buttons and their functions MAR
72. ssed bipolar I disorder v Acute Heart failure v Acute Alcohol induced psychosis L Acute Lung mass c Acute Nausea and vomiting E Acute Neutropenic disorder c Acute Neutropenic fever L Acute Alcohol abuse O Chronic Search Type Starts with O Any Word ee re Search For tia ee No Matching Entries in the dictionary You may add to the patient s list as a free text problem e Click Save to add the free text option to the Problem List Xk KootenaiHealth With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 41 a pane Sr NCU Le lee ees tee i Problem GEk 7 Status Priority Diagnosis Date s1 Date breast cancer Acute Depressed bipolar I disorder v Acute Heart failure z Acute tia x Acute Alcohal induced psychosis Hil Acute Lung mass EJ Acute Nausea and vomiting O Acute Neutropenic disorder Acute Neutropenic fever O Acute Alcohol abuse O Chronic Problem Code SNOMED Code SNOMED CT US Extension Comment Last Activated 03 10 14 14 15 by MD1 PCM First Entered 03 10 14 14 15 by MD1 PCM Last Edited 03 10 14 14 15 by MD1 PCM lt Problem Assessment and Plan Patient Problems Problems Depressed bipolar I disorder Acute Heart failure Acute acute on ch
73. t 24Hr 38c so 18 soso 89 IP SVAN Beene Tast alen mand Ne bane et x 000e X KootenaiHealth With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 43 24 Hour Intake and Output 23 59 03 08 14 03 09 14 22 59 23 59 bo o y Output Total 700 Balance 1050 Surgical Amounts Jo o ooo S O Perioperative Phase Preoperative Intake IV Fluid Amount J M Intake IV Fluid Amount J Oral Intake o o ooo o o o y y y Intake Oral Amount O Ci f 750 Void Output o o tid MCT y Voided Amount o T S zoo Related Information O O J o J Cd Cd Bowel Movements een a Ge 5 Percent of Breakfast Consumed 100 Percent of Lunch Consumed OoOo O 75 Percent of Dinner Consumed Oo o eee m Latest CBC and BMP Results 02 17 14 10 14 15 0 100D Ka 01 02 14 10 31 Document Results Trade Name Freq PRN Reason Stop Dose Admin Omeprazole 20 mg 02 27 14 21 00 Prilasec PO 0600 2100 SCH cuir 00008 e Scroll down through the report to review Clicking the blue highlighted titles will quickly take you that location to make changes in your note To Esign and file the report click on Save Assign Providers Additional CC s O Provider O Outside Location Insurance
74. tation Respiratory ___ Surgery _ imaging _ Pathology Cardiovascular General Ed My Notices B Rpt Tissue Code Dictated By Dictated Hx l 02 06 14 11 07 02 06 14 11 02 02 06 14 10 55 02 06 14 10 29 02 06 14 10 28 02 06 14 10 21 02 03 14 09 00 01 09 14 08 41 01 08 14 14 26 12 30 13 12 47 12 16 13 12 38 IQA TAS 12 16 12 03 13 12 56 LZ OS AS12353 Ta 132 11 26 13 08 52 11 26 13 08 43 11 26 13 08 15 11 26 13 08 00 11 26 13 08 00 11 26 13 08 00 11 26 13 08 00 11 21 13 10 45 11 21 13 10 43 eli 21yt310 35 Progress Notes Occupational Therapy Progress Notes History amp Physical Physical Therapy Evaluation Progress Notes Progress Notes Progress Notes Progress Notes Progress Notes Progress Notes Progress Notes PTH Surgical Specimen Surgery Operative Surgery Pre Operative Progress Notes Progress Notes Progress Notes Progress Notes Progress Notes Progress Notes Progress Notes Progress Notes Progress Notes Progress Notes Progress Notes BUOHQRHRHH BB YY BOQBHBHHRE BY ISigned Draft Draft Draft Signed Signed Signed Signed ISigned Signed Draft Signed Draft Draft ISigned Signed ISigned Signed ISigned Signed Signed Signed Signed Signed e Bone marr Merry Megan Merry Megan Merry Megan Merry Megan Merry Megan Merry Megan Merry Megan Loss Scott Merry Megan Merry Megan MD1 PCM Triphahn Laura Bruning Johanna Brunin
75. uestions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 4 e Find Patient This function allows you to find an inpatient or an outpatient for documenting on or viewing the EMR Find Patient does not automatically add the patient to My Patients Outpatients cannot be added to the My Patients or Rounds Patientslists Click on Find Patient enter the patient s name Last First in the Name field and click Search at the bottom of the screen Click on the desired patient in the list If morethan one visit is shown on the Select Visits screen click the check box for the visit you wishto view You now have access to the patients EMR for that specific visit See details on EMR later in this manual The Anti Coagulation Clinic and Therapies will also have access to Document their templates in this manner e Build Cover You will see groups that you are associated with MeCN yourown group To cover for patients other than those registered to you click the box to the left of the group name All providers in the group are visible a oe ne and checked Uncheck providers you do not wish CHEMICAL DEPENDENCY UNIT to cover for or leave all checked If multiple PATIENT ONLY TEMI groups are associated with you the Check All icon in the title bar can select all groups With this option all providers a
76. us Complete Complete Signed Signed Draft igned Signed Signed Signed Signed Signed Signed Signed Addendum Scanned Scanned anned Scanned Scanned Scanned Dictated By MD4 RESIDENT P MD4 RESIDENT P Abdal Raheem S ae DENT or MD4 RESIDENT P Merry Megan Twedt Angela Twedt Angela Twedt Angela Twedt Angela Twedt Angela MD6 PCM MD6 PCM PICQGQUCSC VULLYUTIO CIICN LU VICVV reports from different categories 09 11 13 09 11 13 09 10 13 09 10 13 09 10 13 U9 09 1 09 09 13 09 09 13 09 06 13 09 06 13 09 06 13 09 06 13 09 06 13 09 06 13 09 03 43 chi lt j9000 00008000 e Access arc Anesthesia Evaluation e The information below is an enhancement to the Reports tab e All Visits button allows for quicker sorting e Displays the LAST documented report from any visit Selected Visit All Visits Most Recent Imaging Pathology Exam Report Rpt History amp Physical G Dictated 09 05 13 09 03 13 Status Signed Signed Signed Signed Draft Signed Signed Date 4 Tissue Code Dictated By MD6 PCM MD6 PCM Appendix MD6 PCM MD6 PCM MD6 PCM Twedt Angela Progress Notes Gf PTH Surgical Specimen amp History amp Physical G 08 29 13 12 11 Discharge Summary lt amp 08 22 13 14 21 Progress Notes G 09 19 13 15 42 Abdomen Ultrasound 08 29 13 08 29 13 08 22 13 08 19 13 e In addition there is a new More Reports c
77. wW068513361504 385 09 05 13 07 52 Leukocyte Reduced Red Blood Cells W068513311491 385 Vitals Signs Format Comments Format Palpation Source Location 02 Sat by Pulse Oximetry Ce Oxygen Delivery Room Air Method Xk KootenaiHealth With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 24 Date 09 11 13 12 52 09 11 13 12 52 09 10 13 16 00 09 10 13 15 59 09 10 13 14 50 09 09 13 11 25 09 09 13 11 20 09 09 13 11 19 09 06 13 14 05 09 06 13 13 55 09 06 13 13 54 09 06 13 13 54 09 06 13 13 54 09 06 13 09 51 09 03 13 16 44 09 03 13 16 42 09 03 13 16 42 09 03 13 16 42 09 03 13 16 42 09 03 13 16 42 09 03 13 16 42 Selected Visits All Visits Most Recent Pathology_ Cardiovascular General Psychosocial Rehabilitation Respiratory Exam Report Pre Operative Surgery Operative Surgery Complete Progress Notes History amp Physical History amp Physical Progress Notes Consultation History amp Physical Radiology Report Interventional Procedure Chest X Ray Abdomen Ultrasound Abdomen CT Progress Notes Progress Notes Speciality Clinic Report Scanned Respiratory Miscellaneous Scanned Pulmonary Function Test Scanned Progress Notes Progress Note Pre and Post Rpt rj g g rj g F g F g G a Stat
78. y 2m M KMO222 01 PLUM BABY 01 01 2013 Emry Geoff T MEDICAL 2 44M KM0226 01 TESTME CLINICAL 07 11 1969 MDG PCM SURGICAL B2 KM9T2S 01 eee 03 19 1981 Snyders Brian Reason For Visit TEST Length Of Stay 79 Admission Date 12 18 13 Vital Signs Result Diagrams N J 4 Problems All Active Height Weight 75 kg Other Providers Primary Care Provider Registration Status ADM IN T T DC DC DC rs anil Results screen Click on the Document button to start a note on the selected patient Thedocumentation screen will be blank if no documentation has previously been done on this patient If previous notes have been written a list of these will show A selection of All or Minecan be made at the top of the screen Any of these can be reviewed simply by clicking onthe note you wish to read Quick Save Feature Quick Save will quickly put a note in Pending status Pending notes cannot be seen by other providers until they are placed in Draft or Signed status To continue with the note simply click on the Pending note in the report listwhen entering Documentation A preview of the note will be seen Click the Edit at thebottom Go to where you left off in the note and complete your documentation KootenaiHealth With questions about any projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 30 Mb
79. y projects or services please contact the 24 7 Kootenai Health Information Technology Help Desk By Phone 855 554 4440 toll free or 208 625 5555 By Email helpdesk kh org Page 14 e Clinical Panels contain clinical information specific to the clinical panelname From the above screen you can choose to Manage Favorites or you can choose a panel from the list to view by clicking on it Testme Clinical 44 M 07 11 1969 ADM IN KM 2N KMO0226 01 P re Procedure PONV Vitals Signs Temperature Pulse Rate Respiratory Rate Blood Pressure O2 Sat by Pulse Oximetry Oxygen Flow Rate L min Oxygen Delivery Method M TEST6 07F TEST 6 07 MDL PCh Limited Code KMO001002112 KMO0020127 _ 167 64cm 57 606kg BSA 1 65m BMI 20 5 H00020281 Allergy Adv Penicillins codeine Sulfa Sulfonamide Antibiotics latex More In Sie COTEU Baga e Intake Total Output Total Balance Intake Intake IV Fluid Amount Intake Oral Amount Output voided Amount Other Perioperative Phase Bowel Movements Percent of Breakfast Cons Percent of Lunch Consumed Percent of Dinner Consumed Active Medications Testme Clinical 44 M 07 11 1969 ADM IN KM 2N KM0226 01 Pre Procedure PONV Ass Svea ee Temperature Pulse Rate Respiratory Rate 3 Room Air Nasal Can 1000 ml 1500 ml 2000 ml Preoperati 1 100 75 75 16 07F TEST 6 07 MDLPEM L

Meditech PCM Manual - Kootenai Health Information Technology

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