Using the Electronic Medical Record EMR Module

Transcription

1 Using the Electronic Medical Record EMR Module Permanent electronic record of data entered into the computer regarding a patient s history at JBH. It collects stores and displays clinical and administrative data for patients. Some examples of the kind of information found in EMR: Lab results Order Summary Radiology reports Dictated consults, histories & physicals Medication Profiles Patient demographic information Allergies Patient Visit History All ED Nursing Documentation Locate Patients in the EMR There are a few ways to find a patient in the EMR Module: Isolation status Scanned ED documents post discharge 1. By Location - Click to view list of all patients admitted to that location. You can access patients for up to ten days after their discharge. 2. By Patient - Click on Any Record button Enter at least ONE of following to search for a patient: Name, EMR#, Medical Record Number, SSN/HCN, or Account # 3. Recently accessed Patients Click on Recent Access button to pull up list and click on patient you want to review. EMR keeps track of the patients you have accessed within the last 14 days. Stores 10 of these in Recently Accessed Patients list. 4. Patients that are associated with you can be found by clicking on: My Admitted My Emergency My Other. Patients are associated with you if you are the Attending, Admitting, Primary Care, Family, ER or Other Physician. (e.g.: Specialist or Consultant) 5. Patients in which you are covering for a Physician - Click on Cover and type in the first 3 letters of the surname of the Physician whose patients you wish to see. Click on OK or Press <F12>. Then select Get Records.

2 Choosing the Right Visit Visits are stored in reverse chronological order most recent at TOP. Ensure you are selecting the correct visit. Options: 1. Click in box next to visit(s) you want to view and then an X appears next to visit 2. Click on view x visits on menu panel. OR 3. Click on All Visits on menu Panel to see all visit information. ** If you are looking for a specific report or consultation, but are not sure which visit it is under, choose the View all Visits option. You will be able to find it more easily.**

3 Viewing Information in the EMR Default EMR Panel Each patient s EMR will open to the 24 Hour panel as shown below, as long as clinical information has been recorded within the last 24 hours. The 24 Hour panel displays laboratory results, and diagnostic reports. If data for any of these panels exists, the 24 Hour panel is the default panel. Otherwise, the Summary panel is the default panel. At the top of the screen, the buttons labeled by weekday let you select the data for today and the preceding four days. Each day you view the panel, the weekday button labels change, so that the last five days are displayed. The following table shows examples of how the buttons are labeled on consecutive days of the week. Summary Panel If no data exists for any of the 24 Hour panels, a Summary panel is the default panel. Summary panels display the information about a visit.

4 Menu Frame: Clinical Results & Information Panels Menu Frame: Located on right side of EMR screen. Lists different categories or departments that have information available for the selected patient. When you choose a specific panel you will be able to access the information contained within it. Colour Indicators for Navigation: Dark blue text on blue - more data available to view- cursor will turn to a hand Dark blue text on white - Current View you are on Pale blue text on blue - No data available Magenta text on blue New data available since you last viewed this patient s data. Viewing Patient Information 24 Hour Panel Easiest way to find current results for select categories. Displays results from last 24 hours for Laboratory, Diagnostic reports, Vital Signs and Intake + Output. Note: Presently Vital Signs and Intake + Output are NOT being documented On-Line please refer to the manual chart for these clinical measurements. Medications Information comes from Pharmacy module. Shows active, discontinued or both medication prescriptions. Click on the Medication name to review detailed information about each prescription. Order History Displays all orders from OE and other clinical modules (LAB,BBK, MIC, ITS) Default display is reverse chronological NEWEST at top Click on column headers to rearrange sort order Care Activity Includes all ED Nursing documentation on the patient, sorted under system headings View all of the documentation on the patient in one place. Users can sort by Date, Name of assessment or Recorded by. Click on to view text notes. Care Trends Select a highlighted tab to view data trends by system If there is no documentation on a specific system, you will be unable to select that tab To view the entire assessment click on the date and time To view the trending of data click on the title (bold black text) History This page includes medical history and home medications. You can sort by system or simply click on positives to see the complete list. Click on home medications to see the text Notes View ED Nursing notes in the DAR (Data, Action, and Response) format, by clicking on the blue i

5 Laboratory Results file into different sections within the Laboratory Panel. The panel selection buttons on the top allows you to switch between the different panel views. Legend: NB: Abnormal & critical results have H or L to indicate HIGH or LOW Graphing Laboratory Results 1. Click on Laboratory panel 2. Click on the test name you want to graph 3. A new window will open. Click on Graph button at the bottom of the screen.