EMAR Medication Pass

Transcription

1 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 will vary based upon the shift times for the provider and are specific to each community. Once a Med Provider is selected, you will see a listing with a preview of the provider s shift. The residents are listed in the order of the Currently Due medication administration times. Residents will be on the Select a Resident screen if they have any routine medications due, PRN medications without results recorded, missed medications, held medications, or have future times medications are due during the provider s shift. Note: The passing window is specific to each community. Click on the resident name to select. Click Show All Active if you need to give a PRN medication to a resident not on the list.

2 Currently Due: This column indicates residents with medications due during the current passing window. This is usually one hour before to one hour after the scheduled passing time, but is setup individually per community. The medications will be listed with a preview of the passing times. The number in parentheses indicates the total number of medications due at that time for that resident. If there is no number in parentheses, there is only one medication to be administered at that time. PRN Rslt: This column will list out the number of PRN s waiting to be resulted for each resident. The number reminder will remain on this list until the results are recorded for up to 24 hours. Missed: The Missed column will show the number of medications that were missed during the providers shift. Held: The Held column will show the number of held medications during the providers shift. Future Due: The Future Due column shows all scheduled medication administration times during the providers shift and the count of medications for each time. If there is no number in parentheses, there is only one medication to be administered at that time. Record items are listed in parentheses in the Currently Due and Future Due columns. Once you select a resident, it will open the Medication Passing screen for the resident. Buttons/Information at the top of the screen: The Photo, Resident Name, Unit, and Current Time auto populate. Click Change Resident or press the F1 key to open the Select a Resident list to move on to a different resident. Click on the resident s name to open the Resident s Chart. EMAR: Medication Pass Revised 8/10/17 2

3 The tabs listed at the top of the screen are Scheduled, PRN, Recent PRNs, Missed/Held, and Allergies. The number in parentheses on the tabs will change per resident and throughout the medication pass. For example, this now shows the resident has 2 Recent PRNs, zero Missed or Held medications, and 5 Allergies. Scheduled tab: A listing of medications that are due within the passing window will be displayed on the Scheduled tab. The Scheduled tab will show the Time Due, Medication, Record at Passing items, Status, Previous Pass information, Refill Requests, and Adverse Effects. The Medication column lists the Medication/Strength or Treatment Name, Instructions, Indicated For and Record at Passing. To select the medications you are going to administer, click once on the line that contains the medication. Note the change to the Scheduled tab after selecting medications. The number of medications will show in parentheses on the schedule tab. The medication row will turn a darker yellow, showing it has been selected. If you are using a scanner, you will see the word Scanned in the Select column rather than the X. Note: Record items are listed in the instructions of the medication order. The Previous Pass column includes the Record information from the previous administration of this medication. Once a medication is selected, the Note field, Attempted, Med Not Given, and Med Given buttons appear at the bottom of the screen. How to Lock a Windows computer screen: It is recommended to lock the screen if you are walking away from the computer to protect Resident Information. EMAR: Medication Pass Revised 8/10/17 3

4 If you are using a Windows laptop or computer, you can lock the screen by pressing the windows key on your keyboard + the letter L. Press these two keys together to lock the screen so no one can see the Resident Information. You will need to put in the password for the computer when you return to unlock the screen. Charting Medications as Attempted, Given, or Not Given: When you return to the computer after giving meds, you will need to enter any Record at Passing items and select Attempted, Med Given, or Med Not Given. Attempted: If you attempt to administer a medication, highlight the medications that were attempted and click the Attempted button. The date and time of the attempt will appear in blue. All attempts will be stored in the new Medication Delivery Record Delivery Attempts box (page 9). Given: Highlight the medications that were given and click the Med Given button. You will see the time and your initials in green in the Status column. Med Not Given: If a medication is not given, highlight the medications and click the Med Not Given button. A Med Not Given Reason choice list will appear. Select the Med Not Given Reason. Note: If the resident takes some of the medications, but not all of the medications, deselect the medication(s) they did not take by clicking on the medication before clicking on the Med Given button. Then reselect the medication(s) that were refused and click on Med Not Given. EMAR: Medication Pass Revised 8/10/17 4

5 The date, time, and held reason will show in the Status column in red. There is a setup option to enable Delivery of Held Medications at a later time (page 9). Record Items: If Record items have been setup for a medication, these will also be listed in the Medication column. When this medication is selected, you will see the Record items at the bottom of the screen, or in the Passing column. The Previous Pass column will list the previous Record information for the medication. The Record items must be recorded before the medications can be marked as Given. Completion of Record items is not required to save an Attempt. If you do complete Record items with the attempt, they will be saved. If you edit the Record result when the medication is administered, the change will be recorded in the Medication Delivery Change History. Site, Amt, and Other Record items must be recorded on the medication line in the Record column instead because they could be different for the medications selected. Site, Amt, and Other are not shared as these could require different responses on medications selected at the same time. For those Record items, you will see them listed in RED in the Passing column. Click to record your response. EMAR: Medication Pass Revised 8/10/17 5

6 Click where you see <Click here to record >. Another window will open to record your response. Choose the appropriate site from the look up choice list. After choosing the site, the corresponding numerical code will appear in the site field. Click OK to save and return to the medication passing window. To edit the Record item in the Passing window, click where you see <Click to change>. Click on Site Key hyperlink for a table with numerical code and body site specification. EMAR: Medication Pass Revised 8/10/17 6

7 For all other Record items, you only need to enter it once and the result will be recorded on selected medications as appropriate. For example, if you have weekly vitals scheduled at the same time as a Lanoxin with a pulse, you only need to enter the pulse once and it is recorded on both. You must enter the results into the fields below before you will be able to mark Med Given. An alert will prompt and remind you to fill in vital sign entries if Record fields have not been completed. Click OK and complete your Record at Passing items, then select Med Given. Med Delivery Record: To view the delivery history of a medication, right click within the medication line and choose Show Med Delivery Record. EMAR: Medication Pass Revised 8/10/17 7

8 This will show the delivery history, delivery attempts, change history, and notes for the scheduled date and time. Continue with Medication Pass: Once you have completed passing this resident s medications, click Change Resident in the upper left corner or press the F1 key on the key board to bring up a list of resident names to select the next resident. EMAR: Medication Pass Revised 8/10/17 8

9 Click on the next resident to open their EMAR window. Continue until all resident s medications are charted. Medications that are on the screen when the resident s Medication Passing record is open, will remain on the screen even if their Time Due has passed. If you close the selected resident record by changing Residents or clicking Finished without administering the medications that are no longer in the currently due column, those medications will move to the Missed/Held tab. Missed/Held tab: Click on the Missed/Held tab to see all medications that have been missed (not charted on) or held during this med provider s shift. Missed medications can always be recorded. There is a setting to require a reason when recording a missed medication (page 10). Held medications can be recorded as administered if the setup option is turned on. This is based upon your state s regulations. The Missed/Held tab will list the Medication, Instructions, Date, and Time the medication was due. The Status column will either read Missed or Held. The # of Attempts column will list how many times it was charted as Attempted. The Passing column will list any Record items set up for this Medication order. Allow Delivery of Held Medications: If this setting is turned on, it will allow the medication provider to administer a medication previously held during their shift. This setup option is located in the File Setup Communities Clinical tab EMAR Setup. EMAR: Medication Pass Revised 8/10/17 9

10 Click once to highlight the Held medication(s) that you are going to administer. Click the Med Not Given button at the bottom of the screen. This will override your previous held charting on this medication. The Change History will be stored on the Medication Delivery Record. The Previously Held Med Given Reason screen will open. If the choice list has not been set up, you will be prompted to do so. Select a reason from the list. The status column will be updated with the time and employee s initials in green if the medication was charted as given or the date, time, and held reason if the medication was charted as not given. Require a Reason when Recording a Missed Medication: If this setting is turned on, it will require the medication provider to enter a reason for changing the medication with a status of Missed to either Held or Given. This setup option is located in the File Setup Communities Clinical tab EMAR Setup. Click once to highlight the missed medication(s) that you are going to administer. Click the Med Not Given button or the Med Given button at the bottom of the screen. This will override the previous missed charting on this medication. The Medication Late Entry Reason screen will open. If the choice list has not been set up, you will be prompted to do so. Select a reason from the list. EMAR: Medication Pass Revised 8/10/17 10

11 The status column will be updated with the time and employee s initials in green if the medication was charted as Given or the date, time, and Held reason if the medication was charted as Not Given. Override Reason to Exit Medication Pass: If your community has the Require Med Pass Completion to Exit Passing Window setting turned on, if you click Finished to exit the Medication Pass prior to completion of the medication pass, the following prompt will be displayed. This setup option is located in the File Setup Companies Clinical tab EMAR Setup. When selected, you will also need to complete the time frame in Allow Provider to close Passing window if remaining meds to be given have minutes or more remaining to pass. There are times when a resident will have medication passes that are more frequent, such as every 2 hours. If your medication passing window is set for 60 minutes before to 60 minutes after the scheduled time and you have residents with frequent medication passes, the medication provider will be allowed to exit the passing window if there are medications that still have remaining time to be administered within the passing window. This option will decrease the instance of missed medications. Click 'Continue Passing Meds' to complete the medication pass. Click 'Close EMAR' to exit the medication pass. The Override Reason to Exit Medication Pass screen will open. Highlight the reason and click 'Select' or double click the reason to select. EMAR: Medication Pass Revised 8/10/17 11

12 Note: These choices must be setup in the main database if your company uses Point of Care. Completion of a Medication Pass: Once the Currently Due column is empty for all residents, you have completed your medication pass for this passing window. To complete your medication pass for your shift or when there are no medications scheduled on your shift, click Finished or if you click Change Resident, you will receive an alert on the screen stating There are no residents with Meds Due or waiting for results. Click Close to exit out of the EMAR screen. Click Show All to see a list of all residents for this Med Provider. PRN tab: Click the PRN tab to see a listing of the resident s PRN medications and previous pass information. The last date and time that the PRN medication was given will be displayed in the Prev Pass (Previous Pass) column. Click on the medication to select. EMAR: Medication Pass Revised 8/10/17 12

13 If the PRN medication has only one indication to be given, it will automatically fill in the Reason Given (Rsn Gvn) column. If there is more than one indication that a medication can be given you will see <Click Here to Select> in the Rsn Gvn Column. When you click on <Click Here to Select>, you will have a list of indications to choose from. Click on the appropriate indication(s) and click OK. This is a multiple select choice list. If the ALL option on bottom left corner of the choice listing screen is chosen, all indications will be selected. If the None option on the bottom left corner of the choice listing screen is chosen, all indications will be deselected. EMAR: Medication Pass Revised 8/10/17 13

14 Once the medication is given, click Med Given at the bottom of the screen. The date, time, and your initials will show in the Passing column in green and the reason/condition you selected will show in the Reason Given column. The Result column will have <Click here to enter Results> and the PRN tab will change to PRN (1 Waiting Results). Residents that have PRNs waiting to be resulted will show a number notification in the Select a Resident window for up to 24 hours or until the PRN has been resulted. When you are ready to result the PRN Medication, select the resident from the list. Click on the PRN tab and click on <Click here to enter Results>. The PRN Med Results list screen will open. Click on the appropriate option. EMAR: Medication Pass Revised 8/10/17 14

15 If Recorded in Error: Remove is selected, the provider would have to verify through a secondary prompt that they would like to delete the passing of this PRN medication by clicking on Delete. This will remove the record of the PRN medication being given. Note: Recorded in Error: Remove should only be used if you recorded that you gave a PRN medication and did not give it. If you choose Other and click Select, you will be prompted to enter a specific reason. Results have been recorded on the Benadryl order below. The Prev Pass (Previous Pass) column has been updated to show the date, time, and employee s initials that gave the PRN medication. The Effective column is updated with how the PRN medication was resulted. Note: PRN meds given will also be shown in the Medication Dashboard. Recent PRN s: EMAR: Medication Pass Revised 8/10/17 15

16 To see the 24 hour history of PRNs click on the Recent PRNs tab. The Recent PRNs (#) will show the record of PRNs given in the last 24 hours. The number in parentheses refers to the number of PRNs that have been given. Note: Recent PRNs information is updated when you close the resident. The next time you select this resident, you will see any additional PRNs given. Medication Needing Refill: During a medication pass, you can mark Needs Refill on non-cycle fill medications. There is an option in the File Setup Companies Clinical tab EMAR Setup to Allow Refill Requests from Medication Passing Window. Select this option to send refill requests via the Pharmacy Interface or Docutrack Interface directly from the medication passing window. If this option is not turned on, you can still indicate a medication needs a refill in the medication passing window but it will not directly send via the pharmacy interface. You must use the Medication Dashboard to view and send the refill request. For scheduled or PRN medications, click the Refill column. A new window will open, or you can double click on the row to open the window. If you have the option turned on to Allow Refill Requests from Medication Passing Window, the refill window that opens will read Request Refill. Check the box for Request Refill and click OK to send the refill request directly to pharmacy via EMAR: Medication Pass Revised 8/10/17 16

17 Docutrack or the pharmacy interface. Refill Ordered cannot be selected from here. If you do not have the option turned on, the refill window that opens will read Needs Refill. Check Needs Refill and click OK to save. Refill Ordered cannot be selected from here. Now you will see Needs Refill in the Refill column. To close out of the EMAR passing screen, click Finished in the bottom right hand corner. To view prescriptions refills, click once on the Medication Dashboard icon to open. EMAR: Medication Pass Revised 8/10/17 17

18 Highlight the medication with the status of Needs Refill. If this medication was created from an interface message and refill requests have been turned on, you will see the Send Refill request button. Click on Send Refill request button, and the Status will change to Refill Ordered. The pharmacy will process the refill request. When a new message is received from the pharmacy, the status of the medication will be updated. Allergies Tab: Click the Allergies tab to view all of the allergies listed in the Resident Chart Medical History tab. The total number of allergies that the resident has will be indicated by the number in parentheses on the Allergies tab. The allergy type, reaction, severity, and status will be listed. EMAR: Medication Pass Revised 8/10/17 18

19 May Crush Meds: If May Crush Meds box has been checked in Resident Chart under Orders tab, May Crush Meds in red font will print on the paper Medication Sheet and at the top of the EMAR Passing screen. Do Not Crush: If a medication is not to be crushed, check the check box for Do Not Crush on the Medication record. EMAR: Medication Pass Revised 8/10/17 19

20 When selected, ***DO NOT CRUSH*** will be included in the medication instructions on the EMAR passing screen. Hazardous Drug: If a medication is a hazardous drug, check the check box for Hazardous Drug on the Medication Record. When selected, ***HAZARDOUS DRUG PRECAUTIONS*** will be included in the medication instructions on the EMAR Passing screen. Resident Information Tab: Additional resident information can be viewed directly from the EMAR Med Pass screen. Click on Resident Information tab. The Resident Information tab provides a read only list of Code Status, Date of Birth, Diagnosis, Diet, Evacuation Status, Durable Medical Equipment, Note/Alert, and Emergency Contacts. This information is pulled from the Resident Chart. The headings will disappear from this tab if nothing has been entered for that resident in the Resident Chart. EMAR: Medication Pass Revised 8/10/17 20

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