MEDITECH 6.14 HOW TO ACCESS THE PATIENT S ELECTRONIC MEDICAL RECORD (EMR)

Transcription

1 MEDITECH 6.14 HOW TO ACCESS THE PATIENT S ELECTRONIC MEDICAL RECORD (EMR)

2 Table of Contents How to Log on to MEDITECH How to Access Patient Information... 5 Recently Accessed... 5 Find Patient... 6 Navigating the Patient Electronic Medical Record (EMR)... 7 Summary... 7 Navigating the Function Buttons of the EMR Patient Lists Select Visits Summary Review Visit New Results Vital Signs I&O Medications Laboratory Microbiology Blood Bank Reports Patient Care Patient History Orders Amb Orders

3 How to Log on to MEDITECH 6.14: Log on to Click on the red Connect to Valley s Network for access to MEDITECH and more. Enter username and password on next screen. 3

4 Click on the VAHLIVE MEDITECH icon. Enter user name and password. 4

5 How to Access Patient Information: After logging in you will be given two choices to search for patients: o o Recently Accessed patients that you have recently looked up and viewed. Find Patient search for patient using patient information including name, account number, or medical record number. Choose from Recently Accessed or Find Patient. Recently Accessed Using this list, you would click the box to the right of the name to choose the patient. 5

6 Find Patient To find a single patient you will need some patient identifiers. Here, we entered the patient s name. *The best way to search for a single patient is by Social Security Number or Account Number. After the patient identifier is entered, click Search at the bottom of the page. After entering the SSN or Patient Name above, a list of patients will appear here. Click on the correct patient to enter the chart. After clicking Search, the system will search the master patient index (MPI) for the patient. Above shows the search results. Here, you would check to make sure it is the correct birthdate and medical record number. From here you can click on the patient to open the electronic medical record. To return to the Patient List, click Lists. 6

7 Navigating the Patient Electronic Medical Record (EMR): The chart will open on the summary page. Patient header contains the patient name, age, DOB, admit status, location, weight with BSA and BMI as well as the visit number, medical record number and account number. Summary Pages/screens of the summary page: Clinical Use the Clinical Summary Panel to review the selected patient s clinical information (for example, Active Medications). This information includes data collected during all of the patient s visits to any health care organization and physician s practice. 7

8 Legal/Indicators Use this sub-panel to view legal information and clinical indicators. This information may be displayed for selected visits or across all visits. Some of the information could include: o Resuscitation status o Presence of advance directives or a living will o Whether the patient is an organ donor o Blood type o Patient measurements (such as height, weight, or body surface area) o Precautions Each included item displays the most recently recorded value from the selected visits and the date that the value was recorded. 8

9 This is showing the current visit, you will have the ability to view all visits Demographics Includes the patient s contact information and that of their contacts (such as their employer, next of kin or guarantor); insurance(s); and medical record number. 9

10 Appointments Auth/Referrals Surgeries These will populate with any appointments, authorizations, referrals and surgeries that the patient may have had. Care Team Will display a list of the care team for the patient. Navigating the Function Buttons of the EMR: 10

11 Patient Lists How you search for a patient. Select Visits Allows you to select any visit the patient may have. Summary Patient information (see page 7). Review Visit Use this panel to review visit information. The panel opens first to a screen with non-clinical information. If you selected multiple visits, the screen displays information for one visit at a time. Use the footer buttons (Prior and Next at the bottom of the screen) to view the other selected visits. 11

12 New Results Any results new to you; this will be red when there are new results you have not viewed. Vital Signs View any recorded vital signs on that patient in real time. 12

13 I&O View any recorded intake and output on that patient in real time. Medications View any active or discontinued medications on the patient, including the medication administration record (MAR). This screen shot is showing the Medication List. The body buttons at the top of the page allow you to look at select visits, like the current visit or for all visits. 13

14 This screen shot is of the Medication Administration Record (MAR). The other two body buttons on the top of the page include a Medication Snapshot which includes another view of the list of meds with list of physicians. The Current Inf/Titr tab is a list of infusions and titration medications. Laboratory View any lab results on that patient from the current visit or prior visits. The lab button on the right is in RED because the results are new to you. The body buttons at the top of the page allow you to view the current visit or other visits. You can view all of the labs or break them up by viewing Hematology or Chemistry. 14

15 Microbiology View any Microbiology results on a patient from the current visit or prior visits. Blood Bank View any blood products ordered/received on the patient and type and crossmatch information. The body buttons above allow you to view the blood bank information. If any transfusions had been received by the patient those buttons would be lit and transfusion information or transfusion reports could be viewed. To view an entire blood bank history, choose the footer button at the bottom of the page. 15

16 Reports View any recorded physician documentation and imaging reports, including CAT scans, MRIs, X-Rays, etc. The reports tab will allow you to view any physician documentation as well as any imaging reports and OR reports. Using the body buttons at the top of the page you can view the current visit or other visits. To view the report, click on the clipboard that is circled above. After clicking on the clipboard as instructed above, the following screen would show an example of an Emergency Physician s Note. You will be able to print from the screen as shown here by clicking on the printer icon. 16

17 Patient Care View any nursing documentation including nursing assessments as well as respiratory assessments, OT/PT assessments and the patient s medical history. As nursing Assessments and Interventions are documented they would populate this screen. If you wanted to view an Assessment or Intervention, select the body button on top of screen, then select the item above, for example vital signs, then click the footer button to view history 17

18 To view the most up-to-date Past Medical History on a patient, click on the History body button at top of screen. Note: To sort in the patient care tab, you can click on the Provider Type body button at the top of the screen. This will allow you to sort by provider type. For example, if all you want to view is the swallow eval from speech therapy, choose Provider Type. A list will populate, and you can choose just speech therapy. 18

19 Patient History Orders A view-only screen of the current orders table and order history on the patient. This is a view of the current orders; to see a history of all orders, click on the body button History at the top of the screen. 19

20 Ambulatory Orders A view-only screen of any current ambulatory orders and order history on the patient. The screen on the previous page shows a similar example. 20