Preoperative, Phase I & II Training Meditech 6

Transcription

1 Preoperative, Phase I & II Training Meditech 6 Logging on: o Login to Meditech 6 (login and Password are case sensitive). o Enter KOM and Job Choice if you have more than one position (CNA/HUC). o Ancillary Operating Room Management Nurse Desktop Choose the location (BGH or KMC) A screen with My Worklist and Big Board will open Phone call nurse can create a worklist for the day by utilizing T+1, etc., on From Date and Thru Date. Here choose T for From Date and T for Thru Date. No need to choose Surgeon/Anesthesia/Status field. Type in patient s last name Preoperative phone call: MY Worklist is created from the list of surgical patients on the Big Board. 1

2 o Again, compile a new worklist for the day by clicking on that footer button on the lower left of screen. o Leave OR rooms and room group fields blank; tab to From Date and enter T for today. Thru date also enter T for today. o Tab past surgeon, anesthesia and status fields to patient name. o Click on patient name field to highlight (green). Enter patient s name: Last name, first name. You can repeat this process to add all of your patients for the day to your worklist. Click OK to add all patients to your worklist and return to previous screen. Choose the patient you want to document on: o Click on Patient s name and it will highlight green. If you have patients not shown, you can click on go to case and type in patient s name to be taken directly to that name on the worklist. Patient Admission History & Profile o Access through the PCS tab on the right of the screen. o You may need to add the documentation section by clicking on Add at the bottom of the screen. Type admission in the free text field at the top of that pop-up screen. Choose admission history and patient profile (you can choose as many screens that you need to work on here) and click Save. o Patient s Admission History & Profile will appear in Worklist. o Check now box next to assessment you wish to document and click the Document tab at the bottom of screen. You can check several assessments to complete at once. (Here we will just check one at a time). 2

3 Answer yes or no to patient history questions. IF THE PATIENT ANSWERS NO (no history)...there is no need to document any further in that system. If the patient answers yes, go through that systems assessment. There is a comment box after each as well as an Other... to document any uncommon issues not listed. NOTE: The patient may have a history listed in the system (as above) verify this history and document changes. o Click Save Document on the Admission Patient Profile screen: o Radial buttons (round) you only have one choice; square buttons are multiplechoice (you can choose more than one) o Save When finished documenting in PCS on this patient, close out the screen by clicking the x at the top right corner of screen. And Yes when asked Close current chart to return to your worklist. To document allergies, medications, pharmacy, Click on Open Chart on right side of screen Click on the blue edit buttons to edit 3

4 You can click on + next to meds/allergies to find out more information. FOR ALLERGIES: Click blue edit button Click on enter/edit at bottom of screen o To ADD a new allergy click on new at top of screen. Search for is free text. o Click edit to edit current allergies already listed. To left of medication, check the box to verify, confirm, or remove. If all are correct, you can check all and confirm all at the same time. 4

5 Documenting medications: Click on blue edit button o Highlight the medication field (green) and type in medication (generic OR trade) o Click on the + next to the medication name to choose the correct dosage. DO NOT CHOOSE DAILY choose AM or PM Another screen pops up check the box to the left of medication and fill out med screen. Last taken is a required screen. Documenting Height & Weight o Click on preoperative tab to right of screen and select Height and Weight Surgical. (NOTE: BMI will not work here as rules don t apply in ORM) Pre-procedure call instructions: This will take the place of our current documentation. DAY OF SURGERY PREOP ADMISSION Click on preoperative tab to right side of screen. Three tabs at top of screen o Assessment: patient documentation here o Preoperative Record: This is where time in/time out/any patient notes are documented o Misc Charges: Ignore--not used at this time Assessment o Click on box to the left of each assessment to place a in the box. You can check all assessments you are documenting or one at a time. o Click on document at the bottom of the screen. Admission Assessment Surgical 5

6 o Patient physical assessment upon arrival to preop. Education Record o Education choices specific to the patient s needs. Height and Weight Surgical o Patient s height and actual weight upon arrival to preop. Pain Assessment o Patient s pain assessment upon arrival to preop. Pre Procedure Checklist o Verification of patient s readiness for procedure. o This is no longer printed out OR nurses will view. We will view sending units documentation (in spreadsheet) to see what was documented/needs documented. Pre Procedure PONV Assessment o Patient s assessment for PONV risk. Procedure Time Out o Time out for procedures in preop (blocks, etc). o MUST BE COMPLETED. Vascular Access Management o Establishment of intravenous access. Vital Signs Surgical o Vital signs upon arrival to preop. When assessment is chosen & document tab used: o Prompt will come up with date, time, and user and an option to document in spreadsheet mode (not the preferred mode but can be used to see previous assessment documentation side-by-side). Click OK Each assessment will sub divide and give you options to document by body system (or specific content). 6

7 o Within those areas of documentation, once a specific system or content has been documented, you can select save and be taken back to the preoperative assessment worklist or you can select go to and you will be directed to the next specific assessment under the main assessment. o Some screens will go directly into the documentation section. o Once documentation has been saved, a + will appear next to the assessment in which you documented and time of last assessment will appear under history. o To view the assessment documentation, click on the blue + and go to the specific documentation you wish to view. DOCUMENTING MEDS: o From OR Nurse Desktop, click on Open Chart on right column. o The new screen may default to the new results tab if this occurs, click on summary button at top right side of column to document meds. Printing medication reconciliation: o From summary tab After editing/reviewing medications & entering last dose times, click save Click drop down arrow on forms screen that pops up Select Admission Order Medication Profile (this is Admission Med Recon) Click Print at bottom of screen Click OK on print destination (correct printer should default in) 7

8 o Spreadsheet mode looks like: 8

9 ORM Side Tab Function review: o Big Board: the surgery schedule where you will find your patients. Within the big board, you can manage your patients under My Worklist. o Open Chart: the patient s electronic medical record, access PCS from here. o PCS: the documentation of patient care outside of ED and ORM, view the electronic medical record from here. o Allergies: the ability to enter and edit allergies for your patients. (OR IN OPEN CHART ) o Reports: access to reports concerning ORM and print the OR schedule. Phase I Recovery o Click on Phase I side tab. o Phase I assessments will appear. o Phase I Recovery Assessment includes Aldrete score. o Phase I in and out times and transfer data are documented under the Phase I Record Header. 9

10 Phase II o Click on Phase II side tab. o Phase II assessments will appear. o Phase II Recovery Assessment is the same as the Phase I but includes PARSAP score instead of the Aldrete. o Phase II in and out times and transfer data are documented under the Phase II Record Header. 10

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