Electronic Medication Administration Process and Tips
|
|
- Sharlene Spencer
- 6 years ago
- Views:
Transcription
1 Updated: December 2003 This document summarizes the exact steps to be followed as you administer and chart meds using the emar. Step 1: Check and review all new orders Select the Orders chart tab, click Review/New/Modify/Add order. Click each order to review and then select order detail. Nurse review each order from written order to emar. ***Review orders for patients with non-critical needs every 60 minutes and for critical needs every 30 minutes. Add Nursing Order for Medication Alert/Communication emar communication if needed. Step 2: Review 24 hour view of all scheduled medications and PRN MAR Select Meds chart tab and click MAR Pt Sched Active Meds (PCMSA). Review PRN medication by select med tab and click PRN med. This is to review all of med. profile at the beginning shift for any missing charting in the action during previous shift or change of shift time. Look for one time dose medications both in PCMSA and PRN. PCMSA view can be use to prepare med. administration and chart. Or use other individual selected med page. (i.e. Sched. Diabetes, Chemo.) Reminders to read Comments for medication order. For IV Fluids,titrated drip infusion and PCA/Epideral use these selected page. Look at the STATUS column for ACTV for active medication. If medication is discontinued, ID = discontinued, PD/C= PRN discontinued will appear in the status column when pharmacy discontinues the order. Red highlight will appear in the action column when pharmacy enters the order. Step 3: Verify all 5 R s (Right Patient, Med, Dose, Route, Time) and ADR (Adverse Drug Reaction). Select Meds chart tab and click Pt Active Med Profile ( IPPMED1) or on Order Detail screen click on ADR. Identify medications that need to be verified before administration. Reminders! View comments. Check medication Source (P=pharmacy, M= Machine pyxis) notify pharmacy if unavailable. Take laptop computer (emar) with all medications in their packaging to the patient s bedside and identify patient by comparing two identifiers. The Patient s wristband name and date of birth with the name and date of birth on the emar. Step 4: Document on the emar Document after patient has taken the medication including site. If patient refuses a medication that is taken from pyxis, return the medication to pyxis before charting. With variable doses, chart exact dose in the action column including site and initiate. Step 5: IV/ Parenteral Fluid and Titrated Drip Infusion If it is not 2 hours before or 2 hours after IV time listed on the emar for incremental frequency i.e Q 8 hr.., change the time by selecting the Meds chart tab and click MAR change administration time and change time before taking medication from the pyxis. Mark the IV bag with the date and time it was hung. If maintaining same solution but changing rate on IV fluids document date, time, new rate, i.e. AdjTo125 For Heparin titrated drip document date, time Started & initiate then AdjTo1000 to show the starting rate. Document infused when the solution is discontinued indicating date, time, DC d and Notify Pharmacy. Step 6: Review PCMSA and PRN Review and update - chart on the emar if the medication was held or not given. Page 1 of 9 1/29/2004
2 Step 1: Check and review all orders Electronic Medication Administration Process and Tips Set up hotlist with patient assignment. Review orders under the orders chart tab. Nurse review all new orders. Review the active med profile (All current active medication orders) Review the All scheduled active meds mar (24 hours view of all scheduled meds) Review the PRN mar Review the Diabetes View Mar if necessary Review the 24 hour IV/Parenteral, titrated drip infusion n PCA/Epideral, Blood Products if necessary Place nursing orders button (found under Medication Alerts/Communications, then select emar Communication) to alert you to view the mars for patients on/with: Example, Alert: 1. Beta Blocker Protocol 2. KCL Replacement Protocol 3. Diabetes Mar 4. PCA/Epidural 5. IV flushes (Normal Saline or Heparin) For Warfarin patients the alert will be entered by pharmacy Review orders for patients with non critical needs every 60 minutes and for critical needs every 30 minutes Double Scroll Bars Double scroll bars will display for lists that have more than 60 items in them. Example: Patient Order Profile. When there are 60 or fewer items on the Patient Order Profile only a single scroll bar displays. When there are greater than 60 a second scroll bar to the right of the original scroll bar displays. How to use Double Scroll Bars When the double scroll bars display, use the first scroll bar to scroll through the list to find the item you are trying to locate. If the item is not listed, click the down arrow scroll bar to go to the next 60 items in the list. Use the first scroll bar to scroll through the second 60 items. Again if the item is not there use the down arrow scroll bar to go to the next 60 items. When you reach the end of the items listed you will receive an advisory message stating You re already at the end. Transfusing Autotransfusions This is a two part process. 1. Ordering Transfuse Autotransfusion. a. From the Patient Order Profile select Add Orders. b. Click the Blood Bank button, select Transfuse Autotransfusion. c. Click Process Orders button. d. Complete the details of the order including the type of Autotransfusion (Stryker or Orthopat), name of ordering and signing clinician who placed the original order for the Autotransfusion device and the order mode of W. Click Place Order button. 2. Charting Autotransfusion. a. On the Meds chart tab select the Blood Product Administration emar b. In the action field of the Transfuse Autotransfusion action, type in the amount of blood you have infused, click Initiate Charting. FYI: To print a slip without putting an action on the Blood Products administration emar,- need to choose the Out Patient pickup slips selection on the blood bank dropdown and then select the products pickup slip. Page 2 of 9 1/29/2004
3 Step 2: Review 24-hour view of all scheduled medications. Select Meds chart tab and click MAR Pt Sched Active Meds (PCMSA). Review PRN medication by select med tab and click PRN med. Look at STATUS column. ACTV means this is an active order to prepare for medication administration. Review comments by double click on the medication or highlight med..then order detail or click right arrow. Reviewing comment, will determine for when to give a dose, IV or PO medication route choice and protocol medications. One time medication will be in the PRN mar with daily max. of 1 dose. If then medication will be also in the PRN mar with comments. Other Status ID = Discontinued do not give PD/C = PRN discontinued do not give AHLD= Held indicates that nurse decided to hold the medication for short period of time. To read a comment in result detail, highlight the med and click result detail. To edit note in result detail, highlight the med and click result detail, click edit note, then click OK and Back. To audit each action of the med, highlight the med and click audit Step 3: Verify all 5 Rs and ADR(Adverse Drug Reaction) by Select Med chart tab and click Pt Active Med Profile or on the Order Detail screen, click on ADR button. Documenting Co-Signature (Verify) Use the chart word VERIFY to co-sign that you have verified a medication dose. To Chart Verify; Verifying nurse logs into LastWord. Verifying nurse checks the 5 R s. Verifying nurse then uses the Verify chartword to document verification on the emar. Verifying nurse logs off. Administering nurse logs on. Administering nurse checks the 5 R s. Administering nurse administers medication. Administering nurse documents administration on the emar. Pyxis dispensing timeframes Pyxis gives you a 4-hour window to dispense a scheduled medication. 2 hours prior to the scheduled time and 2 hours after. If the patient is not on the unit during this 4-hour period you will need to notify pharmacy to rescheduled the action Page 3 of 9 1/29/2004
4 Step 3: Verify all 5 Rs. (continued) To Notify Pharmacy Click, then right click in Action field of the medication you need to notify pharmacy about. Select Notify RX from chartword selections. Click Initiate Charting. In Comment field enter message to pharmacy. ( include your name and phone # ) Click Save and Continue. Click Notify Pharmacy. ( pharmacy may receive duplicate copies if click notify pharmacy more than once ) Click Back. For PRN Med. Follow above instructions. If you want to Notify Rx without charting in action field, highlight med/iv fluids and result detail to enter message to pharmacy. Retiming of scheduled medication actions. (I.e. BID, QID, TID) If the desired time the action(s) scheduled to be administered is off by more than two hours, notify pharmacy to retime all remaining doses. (Example currently scheduled for 08 and 20, you want it scheduled for 08 and 17) If the schedule is off by less than two hours, the nurse will chart the actual time the dose was administered. Do not notify pharmacy for retime action(s) for just today ( time period of ). You will; o Click in the Time field of the next scheduled action. o Enter time you wish the next dose to be administered. o Click Initiate Charting. If there are more doses that need to be adjusted to get action back on schedule, update remaining actions. If medication is scheduled incremental doses, change time by going to MAR Changing administration. Retiming of incremental medication actions. (I.e. Q4Hr, Q8Hr, Q12Hr) On the Meds chart tab select MAR Change Administration Time. On the Select Order to Change screen click enter 3 times. (Clicking enter on this screen will fill in the correct information and then take you to the next screen.) On the Retime Medication Action screen select the medication you need to retime by clicking in the box next to the med. Click the Retime button. On the Retime Actions for this Order screen find the next scheduled action. (You may need to click the Next button to page down to find the correct action.) In the time field enter the time you want the next action to start. Click the Recalculate Times button. (The selected action and all future actions will be retimed.) Page 4 of 9 1/29/2004
5 Step 4: Document on the emar Correct/Update Charted Data. Electronic Medication Administration Process and Tips Use to update another nurses charting. (Example, Nurse 1 vend a medication from pyxis and Nurse 2 administers it or Nurse1 charted and need to update by another nurse). Click in DO field. Enter C. Click then right click in action field. Select required chartword. (Update time, etc.) Click Initiate Charting. To Error Out an Action/Reactivate Action Click in DO field of action charted in error. Enter E Click Initiate Charting. Enter note concerning error in Note field. Click OK icon. Click Initiate. Look for Data Updated in Advisory Bar (left lower corner) Click Back. Held vs. Not Given Held is used for actions that are temporarily held in the edit note indicate which time dose (Ex. Patient in therapy and will return shortly or Patient is nauseated and you are giving an anti-emetic.) If the medication ends up not being given, update your charting on that action to Not Given. Not Given is used for actions that are never going to be given. (Ex. Patient has diarrhea and has a stool softener ordered.) Charting Not Given will remove the action from the Active MAR to Inactive MAR. If Not Given charting was done in an error and to reactivate/error this not given action --select med tab and click ( PCM ) MAR pt all meds.active/inactive 24 and type E in DO field and initiate and follow error process. For PCA/Epideral Document time Started or time Started by and time infused. All the specific dosing changes will be documented in the pca/epideral paper record. For Blood Products Document time Started and time Infused on emar. Double checking with another nurse verification are done in the blood bank slip. Normal Saline IV flushes protocol Vend from pyxis and this NS will show on the All Scheduled 24 hour Med. Next day after time 0001 this will disappear from this emar. Chart NS IV flush per protocol in the flow sheet at IV site box and change tubing. Heparin flushes for Central lines and PICC Send written order to pharmacy, heparin 2..5ml flushes per IV central line protocol every 12 hours and PRN specify by clinician. Then after pharmacy enters the order it will appear in the schedule mar and PRN for more flushes in between medications. Page 5 of 9 1/29/2004
6 Step 5: IV / Parenteral Fluid and Titrated Drip Infusion To Chart Started on IV Vended From Pyxis Before removing IV from Pyxis; o On the IV/Parenteral Fluid emar check the time the next scheduled action is to occur. o If the actions scheduled time is greater than 2 hour before or after the current time, perform Change Administration Time function. The word Vend will display in the status field on the emar. Click, then right click in action of IV. Select Started. Click in site and select site of IV Click Initiate Charting. Documenting on Basic IV with ordered rate change. Use to chart an ordered rate change for the same IV solution. To chart an ordered rate change on an action that is currently running (old rate). 2. Click, then right click in the action field of the action of IV fluid currently running. (The old order.) 3. Select AdjTo. 4. Click in the action field again. 5. Arrow over to the other side of Adj. To using the right arrow key on the lower right side of the keyboard. 6. Type in the new rate that has been ordered for the IV to run at. 7. Click in the Time field and enter the time you adjusted the rate. 8. Click Initiate Charting. To Chart Started and monitor Adj. To for Titrated Drip Medications To display what rate in units the IV is running at. To chart an ordered rate change on an action that is currently running (old rate, old order). Update time and Click, in the action field then right click and select Started and initiate. Go back to action field with Started and right click and select AdjTo and follow monitor adjusting rate to show started rate. To monitor adjusting rate: Click, then right click in the action field. Select Adj. To. Click in the action field. Arrow over using the right arrow key on the lower right side of the keyboard. Type in the rate in units the IV is running at. i.e. AdjTo1500 Click in the Time field and enter the time you adjusted the rate. Click Initiate Charting. Do not modify the heparin order!!! To see all the actions for the heparin titrated drip infusion, highlight heparin and audit. Page 6 of 9 1/29/2004
7 Troubleshooting and updating IV parental fluid/titrated drip infusion documentation Post-op/post procedure pt. coming from pacu/cath lab with vend IV/Medication, Paperchart if IV fluid not present with pt and verified document on their flow sheet. Started by, if IV fluid is presently infusing. VEND in status but not charted, Highlight the med/ fluid, result detail to find who and when this was vended or check their flow sheet. Type C in the DO field and chart started by, initiate and chart person s name. Previous shift missed charting, started, of Non-vended IV fluids. (Med/fluids, Source from Pharmacy) Check the IV fluid bag for date, time and initial to see by whom and when this was hung. Or clarify by phone call and chart started by. Before taking IV fluids out of pyxis, change time by MAR change administration time, if it is not 2 hour before and 2 hour after time range. If IV fluid is discontinued and charted infused, if remaining order for this IV fluids present on the emar. Chart Not Given to get this action off from active to inactive MAR. Or this old dc d order will disappear when pharmacy completes dc order. IV Override from Pyxis If you remove an IV from Pyxis using override because pharmacy has not entered the order yet and the IV needs to be started Stat, the rate will not display on the MAR. It will show as a floorstock instead of rate and frequency. If patient is going off your unit, chart Started and initiate, highlight IV/Med and click result detail, edit note of the rate and which clinician ordered this IV/Med. When order profile gets into emar, Change time for next IV fluids action by MAR Changing Administration Time to appropriate time for next action. INDEX Summary of process steps page 1 Reviewing orders page 2 Add nursing order for medication alerts/communications page 2 Double scroll bar to review orders page 2 Transfusiing Autotransfusions page 2 Review 24 hour view for all schedule med page 3 Status column, page 3 Comments page 3 One time dose medications page 3 Verify 5 R s ADR and verification of medications page 3 Pyxis time frame page 3 Notify Pharmacy page 4 Retiming medication actions (mar changing administration time) page 4 Document on the emar Held vs Not Given page 5 Correct/Update Charted Data page 5 Error Out an Action/ Reactivate Action page 5 PCA/Epideral page 5 Blood Products page 5 IV Parenteral fluid/ Titrated drip infusion documentation page 6 Troubleshooting and updating IV fluids/ Titrated drip infusion page 7 Superuser Responsibilities page 8 How to report/ Get Help page 8 What to Print, transfer process grid page 8 Page 7 of 9 1/29/2004
8 Superuser Responsibilities Assist staff during 2 weeks of activation period by using review tool and report emar issues/ communicate with other superusers. ( keep review tool in the log book each shift with report) Complete a Criterion Checklist by third week of activation. Superuser that have been completed with Criterion Checklist signoff, validates other staff and signoff emar competency by using a Criterion Checklist by third week of activation. (Each Nurse keeps the original copy and sends a copy to their manager). Communicate activation news/updates to coworkers- by checking s and epages Report any emar issues by following how to report/ get help. How to report/ get help Non-urgent Log Book or IMR@parknicollet,com Urgent Help Desk ( ) or other superusers Patient Safety Issues Quality Tracking (Right click anywhere on your screen except med. charting field. And then select Help and click quality tracking or click on Help on the top of the screen). Transfer Process Grid and know what to print ( will be posted in the units when final copy available). MAR Patient Review Report/Print (PCMR) for pt from emar transfer to papermar. MAR Order Rev Transfer WL (PRALL) for pt from COE/eMAR transfer to papermar. MAR Med Profile Report (PCHTREP) for pt discharge to another facility. Unit Med Profile Report (UCHTREP) for Lastword down times. Page 8 of 9 1/29/2004
9 Quick Tips 0d=Today 0= zero 0H= current time -1d= yesterday and +1d= tomorrow Orders All written orders need to be faxed to pharmacy even non medication orders. Fax orders to pharmacy Follow the fax machine instructions and include an initials, date, time and room number. Medication order turnaround time Stat=15 minutes, Priority=30 minutes, routine=60 minutes.(routine processing for night shift will be 120 minutes). All stat medications need to be call to pharmacy after faxing the orders. Contacting pharmacist If the order is entered wrong in the emar or need any stat medications e-page decentralized pharmacist by going into phone book and type pharmacy and select. Charting in the flow sheet INT Normal Saline flushes per protocol, document on the flow sheet at IV site area. Any titrated drip infiusion except Heparin and Insulin document adjusted rate in the flow sheet. For next bag or cassette Notify Rx for second or next bag /cassette for titrated drip and PCA. Then pharmacy will enter for extra action to appear in the emar with original order. One time PRN Orders This will be entered by pharmacy as Daily PRN maximum one dose orders: This will prevent a one time PRN order from falling off the emar at midnight. The frequency will be entered as DAILY, PRN, with a maximum dose of one. Reviewing 24 hour emar by using hotlist When selecting next icon to review 24 hour emar of hotlist patients, you must scroll down on the each page to view 24 hours even though advisory bar does not indicate more to show. Page 9 of 9 1/29/2004
10 NEW!! INSULIN DRIPS Insulin drips now appear on the MAR Pt Titrated Drip Meds (PCTID) emar. New!! View Critical Care Labs in LastWord: How to view the paper yellow lab sheet (Laboratory and Ventilatory flow record) information in LastWord 1. Go to the CLIN DATA tab 2. Then under "SPECIALTY VIEW" 3. Select "Critical Care Labs". Note: Ventilator settings are not populated in the viewer. These will remain on paper. NEW!! ALERT: CONDITIONAL TITRATED DRIP NURSING EMAR ORDER Follow these steps to have the alert display on the emar in the Order Pad screen. 1. In the Lookup field type alert then press enter on the keyboard. 2. From the Order Name Search screen select ALERT: Conditional Titrated Drip. 3. Click the Process Orders button on the Order Pad screen. 4. Enter the name of the clinician who ordered the drip in the Ordered by and Signed by fields. 5. Put a W in the Order Mode field. 6. Enter drug name in comment field. 7. Click Place Order button. 8. ALERT: Conditional Titrated Drip will now appear on the Scheduled emar. New!! Lookup alerts from the Order Pad screen by typing in alert. This will get you to a list of all of the Nursing Alerts for the emar. Premature Discharge of Patient Nursing/HUC If someone accidentally discharges a patient from Lastword, pyxis deletes the patient s medication profile in 2 hours for In-Patient and 8 hours for OR, ER patients. You can see if a discharge has occurred by using the ADTLOG function: 1.Enter the MR number 2.Look at all transaction, for a discharge transaction 3.Cancel discharge transaction Canceling the discharge will allow the patient to remain in pyxis. But PHARMACY needs to be called to keep the medication profile in the pyxis. So even though the patient will remain in pyxis, the patient s entire med profile will disappear, 2 hours after the discharge is performed, unless pharmacy is notified. Pharmacy The only way to repopulate the pyxis profile is to use the change function from the active medication profile. The change function only relates to medication orders. It is a function that allows updates to comments in medication orders and is only avialiable to pharmacists. COE Units: Clinician placed orders need to be discontinued and re-entered. (Be sure to use the correct clinician when re-entering these orders). Page 10 of 9 1/29/2004
Bar Code Medication Administration and MAR Resource Manual
Bar Code Medication Administration and MAR Resource Manual Creating Orders Creating an Order in CareMobile (Ad Hoc Order Entry)...2 Creating an Order for med that is already ordered with a different dose/frequency....4
More informationBar Code Medication Administration and MAR Resource Manual
Bar Code Medication Administration and MAR Resource Manual Administering Medications Administering Meds using CareMobile (PDA)... 2 Viewing Allergies in CareMobile... 8 Determining Which Meds to Give When...
More informationGo! Guide: Medication Administration
Go! Guide: Medication Administration Introduction Medication administration is one of the most important aspects of safe patient care. The EHR assists health care professionals with safety by providing
More informationGo! Guide: Adding Medication Administration History
Go! Guide: Adding Medication Administration History Introduction Past medication administrations are often an integral part of a patient scenario. It may be important for students to review the patient
More informationMAR Training Guide for Nurses
MAR Training Guide for Nurses Medication Ordering Fields Verbal Orders Workflow And Navigating the MAR Contents HOW DO I BEGIN?... 3 Update Adverse Drug Reactions... 3 Enter Verbal Orders from Nursing
More informationEMAR Medication Pass with Pre-Pour
EMAR Medication Pass with Pre-Pour This manual includes the setup of medications with Pre-Pour and the recording of resident medication passes. The Pre- Pour options must be turned on in File Setup Community.
More informationEMAR Medication Pass
EMAR Medication Pass This manual includes recording of resident medication passes on a computer. To begin your Medication Pass, click on the EMAR icon, then select a Med Provider. The listing of Med Providers
More informationCRAIG HOSPITAL POLICY/PROCEDURE
CRAIG HOSPITAL POLICY/PROCEDURE Approved: P&T, MEC, NPC, P&P 03/09 Effective Date: 02/95 P&T, MEC, P&P 08/09; P&P 08/10; P&T, MEC 10/10, P&T, P&P 12/10 ; MEC 01/11; P&T, MEC 02/11, 04/11 ; P&T, P&P 12/11
More informationUsing Clinical Data Categories with the Pyxis MedStation
Using Clinical Data Categories with the Pyxis MedStation system Using Clinical Data Categories Clinical Data Categories (CDCs) are a Pyxis MedStation system software tool that will allow facilities the
More informationSupplementary Appendix
Supplementary Appendix This appendix has been provided by the authors to give readers additional information about their work. Supplement to: Poon EG, Keohane CA, Yoon CS, et al. Effect of bar-code technology
More informationMedication Module Tutorial
Medication Module Tutorial An Introduction to the Medication module Whether completing a clinic patient evaluation, a hospital admission history and physical, a discharge summary, a hospital order set,
More informationEMAR Pending Review. The purpose of Pending Review is to verify the orders received from the pharmacy.
EMAR Pending Review This manual includes Pending Review, which is the confirmation that the information received from the pharmacy is correct. This is done by verification of the five (5) rights of medication
More informationUniversity of Miami Clinical Enterprise Technologies
Provider Manual 1 Our Mission: To design and deliver ongoing support for a network of Business and Clinical Information Management Systems which enhance the academic and research vision while implementing
More informationLearner Manual. Document Best Possible Medication History (BPMH)
Learner Manual Document Best Possible Medication History (BPMH) Table of Contents Medication safety... 1 Medication errors impact everyone... 1 Who should obtain the BPMH?... 1 When is the BPMH obtained?...
More informationAdmission Medication History and Reconciliation Documentation. Froedtert Hospital, Milwaukee WI
Overview of Medication History and Reconciliation Process 2 Overview of Icons Used in the Medication History 2 and Reconciliation Process The Admission Navigator 3 SureScripts Medication Reconciliation
More informationMillennium PowerChart Orders Reference Guide Created by Organizational Learning & Development, Clinical IT/Nursing Informatics: June 4, 2013
Millennium PowerChart Orders Created by Organizational Learning & Development, Clinical IT/Nursing Informatics: June 4, 2013 Providers: Look for the caduceus symbol to locate provider-focused items within
More informationParagon Clinician Hub for Physicians (PCH) Reference
Paragon Clinician Hub for Physicians (PCH) Reference Logging in to the Clinician Hub Paragon Clinician Hub (PCH) is available on any Carroll Hospital Network. VMWare View must be utilized to open the application.
More informationPatient Safety and Quality Measures for CRRT: The UAB Experience. Ashita Tolwani, M.D. University of Alabama at Birmingham CRRT 2012
Patient Safety and Quality Measures for CRRT: The UAB Experience Ashita Tolwani, M.D. University of Alabama at Birmingham CRRT 2012 Quality Healthcare Quality is the extent to which health services for
More informationHospital-wide Lean Project:
Hospital-wide Lean Project: Reducing the number of ADE s related to High Alert Medications Patrice Chatterton, RNC, CPHQ Donna Berning, BS, RN, MS, CPHQ Agenda Slide What is lean? What does the training/project
More informationIntroduction to the Parking Lot
Introduction to the Parking Lot In ARK Epic training sessions, The Parking Lot" is used to capture all questions for which your trainer may not have an immediate answer during session. Your ARK Epic Training
More informationAdmission from ED and PowerPlans (Order Sets)
Admission from ED and PowerPlans (Order Sets) 7 17 12 Admission from the ED (Initiate PowerPlan) 1. Ensure patient is ready for Orders: i.e. In Virtual Bed (Loc: ED & a number) Ready Not Ready Must order
More informationElectronic Documentation/BMV Training For Nursing Students and Instructors. Tammy Galindo MSN/ed, RN Education Coordinator
Electronic Documentation/BMV Training For Nursing Students and Instructors Tammy Galindo MSN/ed, RN Education Coordinator 1 Mission Statement Madera Community Hospital is a not-for-profit community health
More informationN.C.P.M emar-12 Page 1 of 10 BRIGHAM AND WOMEN S HOSPITAL DEPARTMENT OF NURSING ELECTRONIC MEDICATION ADMINISTRATION RECORD (EMAR) DOWNTIME POLICY
Page 1 of 10 BRIGHAM AND WOMEN S HOSPITAL DEPARTMENT OF NURSING ELECTRONIC MEDICATION ADMINISTRATION RECORD (EMAR) DOWNTIME POLICY APPROVED FOR: RN LPN PCA GENERAL ICU OTHER PURPOSE: To insure a process
More informationPATIENT ACCESS LIST (PAL)
PATIENT ACCESS LIST (PAL) The Patient Access List (PAL) helps clinicians work effectively and efficiently by providing key patient and workflow information in an easy-to-access format. The PAL is built
More informationElectronic Medication Reconciliation and Depart Process Overview Nursing Deck
Electronic Medication Reconciliation and Depart Process Overview Nursing Deck Revised: 8/16/2011 1 Introduction To achieve the highest standard of care that our system aspires to, as well as to meet the
More informationCaptivate Wednesday, April 23, 2014
Slide 1 PATIENT CARE INQUIRY (PCI) ACCESSING PATIENT'S MEDICAL RECORDS IN MEDITECH Content provided by: Melinda Mauk-Templeton, IT Clinical Systems Analyst Development by: Deb Rodman, IT Training Analyst
More informationPharmacy Medication Reconciliation Workflow Emergency Department
Objectives of the Pharmacy Forum Page To become familiar with EPIC functionalities used in prior to admission (PTA) medication reconciliation (Section 1) 2 7 To understand the pharmacy technicians role
More informationCompleting a Medication History Inpatient Nurses
Completing a Medication History Inpatient Nurses Inpatient nurses may complete a medication history completing the following steps: Open the patient s chart Click the Ad hoc button Double click the Nursing
More informationDepartment Policy. Code: D: MM Entity: Fairview Pharmacy Services. Department: Fairview Home Infusion. Manual: Policy and Procedure Manual
Department Policy Code: D: MM-5615 Entity: Fairview Pharmacy Services Department: Fairview Home Infusion Manual: Policy and Procedure Manual Category: Home Infusion Subject: Chemotherapy Purpose: Ensure
More informationPlacing a Contrast Order in PowerChart. 1 From the Online Worklist, highlight the appropriate patient, and click the PowerChart button.
Radiology: RadTech Contrast Processes Placing a Contrast Order in PowerChart... 1 BCMA Process... 6 Documenting Contrast Administration on the MAR... 7 Chart a Medication as Not Done... 9 Voiding a Contrast
More informationCLINICAL DOCUMENTATION
ekids PowerChart tra Emergency Nursing CLINICAL DOCUMENTATION Training Guide Presented by the IS Training Department Revised July 2013 Introduction to Clinical Documentation for Nursing ekids PowerChart
More information724Access Viewer User Guide
724Access Viewer This explains how to access and use the 724Access Viewer application in the event of a COMPASS downtime. 724Access Viewer provides near real-time transfer of clinical data to workstations.
More informationIn-Patient Medication Order Entry System - contribution of pharmacy informatics
In-Patient Medication Order Entry System - contribution of pharmacy informatics Ms S C Chiang BPharm, MRPS, MHA, FACHSE, FHKCHSE, FCPP Senior Pharmacist Chief Pharmacist s Office In-Patient Medication
More informationDowntime Viewer User Guide for All Users
Downtime Viewer User Guide for All Users Overview... 1 Logging into Downtime Viewer... 1 Opening a Patient Chart in Downtime Viewer... 2 Patient Lists... 2 Clinics... 4 Navigating in the Patient s Chart...
More informationEmergency Care, Rx Writer, Exit Care
Sunrise Emergency Care Emergency Care, Rx Writer, Exit Care May 2013 v. 1.0 ED Display Board Log into Emergency Care/SCM. The View dropdown box will be populated with the views appropriate for your role
More informationPowerChart Review Guide
PowerChart Review Guide How do I find: Administered Medications MAR Summary Admission History Nursing Charges IV Team, Respiratory Clinical Discharge Summary Content appropriate for next care provider
More informationValidation Process for Student Nurse Documentation
Canopy Education Goal: Use this job aid to successfully sign and validate documentation performed by nursing students. Note: There is no validation for Continuous IV Infusions. If you leave any documentation
More informationeprescribe Training for Nurses and Pharmacy Techs Net Access Home Medication Pathway Clinical Informatics - Oct 2015
eprescribe Training for Nurses and Pharmacy Techs Net Access Home Medication Pathway Clinical Informatics - Oct 2015 Click Home Medications on the Navigator Home Medications Pathway Click on Select Default
More informationOncology Quick Start Guide
Oncology Quick Start Guide Oncology Provider - Beacon Version Date: 5/31/2017 Table of Contents Oncology Reports... 1 Treatment Plan Springboard... 1 Summary Phys Onc... 1 Summary Nurse Onc... 2 Scheduler
More informationtraining Computerized Physician Order Management (CPOM): Medical Staff Training
training Computerized Physician Order Management (CPOM): Medical Staff Training Table of Contents CarePoints Performance...4 VMView System Requirements...4 What is CPOM?...5 Current Encounter... 5 Inpatient
More informationEMAR: Medication and Pharmacy Setup
EMAR: Medication and Pharmacy Setup This manual covers EMAR System Setup: Medication Time Codes, Medication Schedule Codes, SIG Codes, Medications Treatment Setup, Medical Providers and Pharmacy. Medication
More informationSunquest Collection Manager Nurse and PCT Workflows. June 2012
Sunquest Collection Manager Nurse and PCT Workflows June 2012 Sunquest Collection Manager The product: Collection Manager is a Sunquest application that is used to positively identify patients and print
More informationHow to Document Unmade Visits
What is an Unmade Visit? A visit is considered an unmade visit when it is not made and cannot be made up within the Medicare week. Consequently, the patient s ordered visit frequency is not met for that
More informationHome Medication History in Horizon Health Summary (HHS)
Home Medication History in Horizon Health Summary (HHS) Medication history is longitudinal data which means it - Is retrievable (comes back) with each admission. Medications must be verified and confirmed,
More informationThe Impact of CPOE and CDS on the Medication Use Process and Pharmacist Workflow
The Impact of CPOE and CDS on the Medication Use Process and Pharmacist Workflow Conflict of Interest Disclosure The speaker has no real or apparent conflicts of interest to report. Anne M. Bobb, R.Ph.,
More informationClinical Skills Validation: Alaris Pump System
Clinical Skills Validation: Alaris Pump System These documents are intended for use by CW Nurse Clinical Leadership Team. The method used to implement the validation of the Alaris Pump System is unit specific.
More informationRxStation: Cerner s Medication Dispensing Cabinet
RxStation: Cerner s Medication Dispensing Cabinet Getting started o Touch screen functionality (Screen is called an ELO). o Keyboard and mouse can also be used. Logging In o Username and password are the
More informationPowerChart Maternity COLUMNs and ICONs- OB Beds Tab
PowerChart Maternity COLUMNs and ICONs- OB Beds Tab The tracking shell provides an overview of patient location, status, and workflow. Patient names will display after registration via STAR. The columns
More informationVAN WERT COUNTY HOSPITAL. Policy/Procedure: Interdepartmental No.: N Issue Date: 6-90 By: Nursing No. of Pages: 9
VAN WERT COUNTY HOSPITAL Policy/Procedure: Interdepartmental No.: N 7-14 Issue Date: 6-90 By: Nursing No. of Pages: 9 Reviewed: 6-14, 12-13, 5-11 Revised: 6-14 Distribution List: All Nursing Departments,
More informationThe Joint Commission Medication Management Update for 2010
Learning Objectives The Joint Commission Medication Management Update for 2010 U.S. Army Medical Command Fort Sam Houston, TX Describe most recent changes in The Joint Commission (TJC) Accreditation Program
More informationPoint of Care: Medication Pass with Pre-Pour
Point of Care: Medication Pass with Pre-Pour This manual covers completion of a Medication Pass with Pre-Pour in Point of Care. Click the Pre-Pour icon on the Point of Care home screen. Enter the time
More informationWHAT are medication errors?
Healthcare Case Study: Errors Cause Mapping Problem Solving Incident Investigation Root Cause Analysis Errors Angela Griffith, P.E. webinars@thinkreliability.com www.thinkreliability.com Office 281-412-7766
More informationCPOM TRAINING. Page 1
CPOM TRAINING Page 1 Physician Training For CPOM Patient list columns, Flag Management, Icons Icons added for CPOM: Columns added: Flags New Orders: GREEN - are general orders. RED means STAT orders included
More informationBack Office-General Quick Reference Guide. Enter a Home Health Referral
Back Office-General Quick Reference Guide Enter a Home Health Referral Table of Contents Enter a Referral... 3 Common Buttons & Icons... 3 Enter a New Referral... 4 Document Basic Info... 5 Document Demographics...
More informationDrug Events. Adverse R EDUCING MEDICATION ERRORS. Survey Adapted from Information Developed by HealthInsight, 2000.
Survey Adapted from Information Developed by HealthInsight, 2000. Adverse Drug Events R EDUCING MEDICATION ERRORS The Adverse Drug Events Survey will assist healthcare organizations evaluate the number
More informationAdvanced Practice Provider (APP): Nurse Practitioner (NP) or Physician s Assistant (PA).
GEORGIA DEPARTMENT OF JUVENILE JUSTICE Applicability: { } All DJJ Staff { } Administration { } Community Services {x} Secure Facilities (RYDC and YDC) Transmittal # 17-15 Policy # 11.26 Related Standards
More informationIDEXX Cornerstone* Up and Running With the Electronic Whiteboard 8.3 Participant Workbook
IDEXX Cornerstone* Up and Running With the Electronic Whiteboard 8.3 Participant Workbook Proprietary Rights Notice Information in this document is subject to change without notice. Companies, names and
More informationInpatient Cerner Navigation and Documentation For Nursing Students
Inpatient Cerner Navigation and Documentation For Nursing Students Audience Note: Purpose: Objectives: Cerner PowerChart training is for all students in the following inpatient areas Med/Surg, OSN, Oncology,
More informationMissed (Unmade) Visit Definition and Process
Definition of a Missed (Unmade) Visit: Missed (Unmade) Visit Definition and Process All patient visits are scheduled according to the physicians ordered visit frequency based upon MSA s Medicare week.
More informationEMR Adoption: Benefits Realization
EMR Adoption: Benefits Realization John H. Daniels, CNM, FACHE, FHIMSS, CPHIMS Global Vice President, HIMSS Analytics Pressurring / Overload Automate to optimize clinical decision making Medical Knowledge
More informationA Randomized Trial of Supplemental Parenteral Nutrition in. Under and Over Weight Critically Ill Patients: The TOP UP Trial. CRS & REDCap Manual
A Randomized Trial of Supplemental Parenteral Nutrition in Under and Over Weight Critically Ill Patients: The TOP UP Trial CRS & REDCap Manual Intended Audience: Research Coordinators This study is registered
More informationMA/Office Staff: Proposing Surgical Procedure Orders and PowerPlans (Order Sets)
Acute Surgical Procedure Orders and PowerPlans Affiliated MA/Office Staff: Proposing Surgical Procedure Orders and PowerPlans (Order Sets) This document walks you through: 1. Requesting a FIN (Financial
More informationFind & Apply. User Guide
Find & Apply User Guide Version 2.0 Prepared April 9, 2008 Grants.gov Find and Apply User Guide Table of Contents Introduction....3 Find Grant Opportunities...4 Search Grant Opportunities...5 Email Subscription...8
More informationSharp HealthCare Safety Training 2015 Module 3, Lesson 2 Always Events: Line and Tube Reconciliation and Guardrails Use
Sharp HealthCare Safety Training 2015 Module 3, Lesson 2 Always Events: Line and Tube Reconciliation and Guardrails Use Our vision is to create a culture where patients and those who care for them are
More information4. If needed Add a home medication, right mouse click over a medication and Modify or Cancel/Dc medications that are inaccurate.
How to Admit a Patient 1. Please communicate to the ER Unit Secretary to Move the patient in the Cerner system to the Overflow Location. A bed request order needs to be initiated by the ED doctor. 4. If
More informationSafe Medication Management Practices 2017/2018
Safe Medication Management Practices 2017/2018 All medications being dispensed by students must first be reviewed and approved for administration by the on-site faculty or a Beaumont Health staff nurse
More informationeqsuite User Guide for Electronic Review Request Acute Inpatient Medical/Surgical DRG Reimbursed
eqsuite User Guide for Electronic Review Request Acute Inpatient Medical/Surgical DRG Reimbursed CONTENTS OVERVIEW OF SYSTEM FEATURES... 3 ACCESSING THE SYSTEM... 4 USER LOG IN - GETTING STARTED... 5 SUBMITTING
More informationMEDICATION USE EFFECTIVE DATE: 06/2003 REVISED: 2/2005, 04/2008, 06/2014
TITLE / DESCRIPTION: SAFETY PROCEDURES FOR MEDICATION USE DEPARTMENT: Pharmacy PERSONNEL: All Pharmacy Personnel EFFECTIVE DATE: 06/2003 REVISED: 2/2005, 04/2008, 06/2014 Leadership and Culture A culture
More informationBooking Elective Trauma Surgery for Inpatients
ADT31 Version 3.1 Trauma Team Operational Areas Included Trauma Co-ordinator Roles Responsible for Carrying out this Process All other areas Operational Areas Excluded GEN01 Logging into Lorenzo GEN02
More informationNICU Physician/NNP INet Talking Points
CNB1 NICU Physician/NNP INet Talking Points East Jefferson General Hospital NICU- 12/01/2009 Tiffany Paisant RN, MSN, Clinical Analyst 10/21/2009 Slide 1 CNB1 please make sure inet is standardized for
More informationMedicine Management Policy
INDEX Prescribing Page 2 Dispensing Page 3 Safe Administration Page 4 Problems & Errors Page 5 Self Administration Page 7 Safe Storage Page 8 Controlled Drugs Best Practice Procedure Page 9 Controlled
More informationPurpose: To create a record capturing key data about a submitted proposal for reference and reporting purposes.
Kuali Research User Guide: Create Institutional Proposal Version 4.0: vember 206 Purpose: To create a record capturing key data about a submitted proposal for reference and reporting purposes. Trigger
More informationPsychiatric Consultant Guide CMTS. Care Management Tracking System. University of Washington aims.uw.edu
Psychiatric Consultant Guide CMTS Care Management Tracking System University of Washington aims.uw.edu rev. 8/13/2018 Table of Contents TOP TIPS & TRICKS... 1 INTRODUCTION... 2 PSYCHIATRIC CONSULTANT ACCOUNT
More informationMedication Control and Distribution. Minor/technical revision of existing policy. ± Major revision of existing policy Reaffirmation of existing policy
Name of Policy: Policy Number: 3364-133-17 Department: Pharmacy Approvingofficer: Chief Executive Officer THE unrversity OF TOLEDO MEDICAL CERITER Responsible Agent: Scope: Director of Pharmacy University
More informationOverview What is effort? What is effort reporting? Why is Effort Reporting necessary?... 2
Effort Certification Training Guide Contents Overview... 2 What is effort?... 2 What is effort reporting?... 2 Why is Effort Reporting necessary?... 2 Effort Certification Process: More than just Certification...
More informationGo! Guide: Patient Orders (Non-Medication)
Go! Guide: Patient Orders (Non-Medication) Introduction The Orders tab in the EHR is where all members of the healthcare team find orders, or instructions, to care for, diagnose, and treat each patient.
More informationKroll Version 10 Service Pack 14. Release notes
Kroll Version 10 Service Pack 14 Release notes June 2018 Table of Contents Kroll Version 10 Service Pack 14 Release Notes...3 User Interface...3 [45822] Create New Rx from To Do screen enhancement...3
More informationClinical Transition Practicum Packet General Information Policies and Procedures Preceptor and Nursing Student Forms
Clinical Transition Practicum Packet General Information Policies and Procedures Preceptor and Nursing Student Forms Fall 2014 1 Description The McLennan Community College Clinical Transition Practicum
More informationHPHConnect for Providers. Habilitative & Rehabilitative Therapies Notifications User Guide
HPHConnect for Providers Habilitative & Rehabilitative Therapies Notifications User Guide December 2017 HPHCONNECT HOME REHABILITATIVE THERAPIES NOTIFICATIONS USER GUIDE Table of Contents A. HABILITATIVE
More informationOptima 101: PARTICIPANT GUIDE
Optima 101: Introduction to Care Operations Management (COM) PARTICIPANT GUIDE 2017 Optima Healthcare Solutions Page 1 CONTENTS CONTENTS... 2 ABOUT THIS GUIDE... 3 LEARNING OUTCOMES... 4 1. LOGGING INTO
More informationIf viewing a printed copy of this policy, please note it could be expired. Got to to view current policies.
If viewing a printed copy of this policy, please note it could be expired. Got to www.fairview.org/fhipolicies to view current policies. Department Policy Entity: Fairview Pharmacy Services Department:
More informationLOGIN TO INFINITE CAMPUS: A. In Chrome or Firefox, copy and paste the following URL and hit return and the IC login window will open
A staff member that has been given IC rights to review and approve the application. Usually Office Support or staff member certified in Census/Enrollment. The staff member can only approve applications
More informationProviders Course 2 Participant Guide Med Reconciliation & Discharge Process
Providers Course 2 Participant Guide Med Reconciliation & Discharge Process Carolinas HealthCare System Revised June 2012 Table of Contents 1. Enhanced Medication Reconciliation 1-1 Introduction... 1-1
More informationNorth York General Hospital Policy Manual
ORIGINATOR: Clinical Informatics & Pharmacy Services REVISED BY: Professional Practice & Clinical Informatics APPROVED BY: Medical Advisory Committee, Operations Committee ORIGINAL DATE APPROVED: 2007
More informationReimbursements: Submit a Flat Rate Reimbursement
Reimbursements: Submit a Flat Rate Reimbursement Overview Tax-Aide volunteers may elect to receive a one-time, flat-rate expense reimbursement for which volunteers receive $35 and volunteer leaders receive
More informationPATIENT PORTAL USERS GUIDE
PATIENT PORTAL USERS GUIDE V 5.0 December 2012 eclinicalworks, 2012. All rights reserved Login and Pre-Registration Patients enter a valid Username and secure Password, then click the Sign In button to
More informationNURSING - TIP SHEET. READING THE TRANSACTION LINE SELECT anytime the transaction line says to. ENTER anytime the transaction line says to
NURSING - TIP SHEET Need Help? For assistance with computer issues, Contact HelpDesk, ext. 4357 (HELP) or Email: Help@uhn.ca Account Access: Your personal EPR account will be available within 48hrs following
More informationecrt System 4.5 Training
ecrt System 4.5 Training The Work List The Work List is displayed immediately after you log into the system. This screen lists the tasks that require attention. The Statements Awaiting Certification list
More informationPsychiatric Consultant Guide SPIRIT CMTS. Care Management Tracking System. University of Washington aims.uw.edu
Psychiatric Consultant Guide SPIRIT CMTS Care Management Tracking System University of Washington aims.uw.edu rev. 9/20/2016 Table of Contents TOP TIPS & TRICKS... 1 INTRODUCTION... 2 PSYCHIATRIC CONSULTANT
More informationQTP4P0X July 2018 PHARMACY TECHNICIAN. Outpatient Dispensing. OPR: SMSgt Jens W. Rueckert
QTP4P0X1-4 26 July 2018 PHARMACY TECHNICIAN Outpatient Dispensing OPR: SMSgt Jens W. Rueckert 1 TABLE OF CONTENTS MODULE OBJECTIVE PAGES 1. Dispense Prescriptions 3-12 2 INTRODUCTION 1. This Qualification
More informationPolicy Statement Medication Order Legibility Medication orders will be written in a manner that provides a clearly legible prescription.
POLICY POLICY PURPOSE: The purpose of this policy is to provide a foundation for safe communication of medication and nutritional orders in-scope, thereby reducing the potential for preventable medication
More informationUser Guide for Patients
User Guide for Patients December 2016 Contents Health365 Overview... 3 What can I do with Health365?... 3 How to get started... 4 Sign In... 4 Home Page - Patient options... 6 Appointments... 7 To make
More informationNurse Orientation. Medication Management
Nurse Orientation Medication Management Objectives Discuss basic principles/rights of medication administration, according to your site policy Describe principles of patient/family education related to
More informationUnderstanding Your Meaningful Use Report
Understanding Your Meaningful Use Report Distributed by Kowa Optimed EMRlogic activehr Understanding Your Meaningful Use Report, version 2.1 Publication Date: May 8, 2012 OD Professional and activehr OD
More informationAn Introduction to FirstNet for Nurses
V3 : 17-01-2017 An Introduction to FirstNet for Nurses Nursing Staff Induction Program The Townsville Hospital June 2017 1. Log into FirstNet 1. Double click on iemr icon form desktop screen 2. Enter user
More informationAmalga FAQs. When I print my patient s Form, there are no printer options. How do I get this fixed? Call the Support Center at
Amalga FAQs Amalga Access: How do I access Amalga from home or outside of Novant Health facilities? You would require Phone Factor or FOB to access Amalga from outside of Novant. Once you log in using
More information1. What are the two types of medication orders? Match the terms in Column A with the correct definitions in Column B.
LESSON PLAN: 6 COURSE TITLE: UNIT: II MEDICATION TECHNICIAN GENERAL PRINCIPLES EVALUATION ITEMS: 1. What are the two types of medication orders? a. b. Match the terms in Column A with the correct definitions
More informationGrants Application Completion Report Instructions. Table of Contents
Grants Application Completion Report Instructions Table of Contents Overview... 1 Step 1 - Logging into Grants Application Completion Report Portal... 1 Step 2 Loading a New Budget... 2 Step 3 Processing
More informationMEDICAL SPECIALISTS OF THE PALM BEACHES, INC. Chronic Care Management (CCM) Program Training Manual
MEDICAL SPECIALISTS OF THE PALM BEACHES, INC. Chronic Care Management (CCM) Program Training Manual September 2017 Table of Contents CCM PROGRAM OVERVIEW... 4 3 STEPS TO BEGIN CCM:... 5 Identify the Patient...
More information