Electronic Medication Reconciliation and Depart Process Overview Nursing Deck

Transcription

1 Electronic Medication Reconciliation and Depart Process Overview Nursing Deck Revised: 8/16/2011 1

2 Introduction To achieve the highest standard of care that our system aspires to, as well as to meet the reporting requests of multiple regulatory agencies, new functionality/enhancements have been developed in Cerner. This presentation will illustrate the following: Document Medications by Hx Electronic Medication Reconciliation Depart Functionality (including Medication Reconciliation, Discharge Meds/Prescriptions, Diagnosis, Discharge Details, Discharge Depart Order, Discharge Instructions/Education, Follow-up and Medication Leaflets). 2

3 Table of Contents Medication Reconciliation will be electronic. The old discharge process will be replaced with a new process. Several changes will occur in PowerChart as a result. The following slides will walk you though the changes: ELECTRONIC MEDICATION RECONCILIATION, and the NEW DEPART PROCESS. You may view the slides in order by pressing the Page Down key, the Enter key, or the Space bar on the computer keyboard. Document Medications by Hx Overview Slide 4 Document Medications by Hx Slide 5 Admission Medication Reconciliation Slide 14 Accessing the Depart Icon Slide 18 Depart Process Window Overview Slide 20 Completing the Depart Process Provider Only Actions Slide 27 Discharge Medication Reconciliation Slide 29 Discharge Prescriptions Slide 30 Discharge Details Slide 31 Discharge Depart Order Slide 35 Completing the Discharge Process Provider and Nurse Actions Slide 38 Discharge Instructions/Patient Education Slide 39 Reviewing Discharge Instructions Slide 42 Follow up Slide 48 Medication Leaflets Slide 53 Patient Summary Overview Slide 55 Clinical Summary Overview Slide 63 3

4 Document Medications by Hx Overview Must be completed within 90 minutes from the decision to admit Has been removed from the Admission Assessment form Document compliance on all medications including prescriptions (pill bottles) If unable to complete Document Medications by Hx an option is now available to mark the list Leave Med History Incomplete-Finish Later Accuracy and completeness are paramount when documenting drug, dose, route, frequency and compliance. Providers will use this list to complete the electronic admission medication reconciliation and medication orders. Compliance details are easily visible to Providers. When the decision to admit is made, two tasks will now fire to the nurse task list Document Medications by Hx - Rule (must be completed by nursing within 90 minutes admission) Admission Assessment - Rule (must be completed by nursing within 24 hours of admission) For a detailed description of Document Medications by Hx Click on the following link. Document Medication by Hx 4

5 Document Medications by Hx- Rule Task Double clicking on the Document Medications by Hx - Rule Task will open the Document Medications by Hx Form. 5

6 Document Medications By Hx Form Click on the Document Medication by Hx button. 6

7 Document Medication By Hx In the Find field, type in the medication name. Select the medication name that does not have dose information attached. An Order Sentences window will display, select the route and dose that match what is reported by the patient. 7

8 Document Medication By Hx Next, the Details window will open. Continue to fill in or modify any details. You may also enter Order Comments if needed on the next tab. The last tab is the Compliance tab. Information should be entered on the Compliance tab for new medications as well as updated for medications that pulled in from previous encounters. When finished, click on Document History. It is then necessary to sign the form by clicking on the green check mark. Status Bar: Complete Incomplete Status bar will update 8

9 Modifying Compliance-Prescriptions(pill bottles) Nursing is responsible to Add/Modify compliance for prescriptions. It is the responsibility of the nurse to review prescription medications with the patient. It is no longer necessary to re-enter these medications however, you must now Add/Modify Compliance for all prescription medications. 9

10 Med History Incomplete Finish Later If unable to complete the Document Medication by Hx, place a check mark in the box Leave Med History Incomplete-Finish Later. Click Document History. This will not place a green check mark on the Status bar for Meds History. Leave Med History Incomplete-Finish Later was added for nursing to indicate the Med Hx is incomplete. The status bar will not display a green check mark. 10

11 Document Medication By Hx Once a check mark is placed in the box indicating, Leave Med History Incomplete-Finish Later, the nurse must hover over the status bar to retrieve the Incomplete status information. The Leave Med History Incomplete-Finish Later box is no longer on view on the Document Medication Hx Window. 11

12 Medication: Status Bar Nurses must complete the Document Medication by Hx (patient s home medication list) within 90 minutes from the decision to admit. The Status Bar indicates when Meds History, Adm. Meds Rec and Disch. Meds Rec have been completed. Status Bar: Complete Incomplete Click on the Medication List to view medication information. Medication History Details Reconciliation History 12

13 The Benefits of Medication Reconciliation Transitioning from a paper process to an electronic process completed by Provider (Physician, PA and CRNP) Home medications are easily converted to admission orders Home medications and inpatient orders can be easily converted to prescriptions Ensures a more complete medication list for discharge Discharge medication list available electronically when patient returns (Document Medication by Hx will be updated with new medication list) 13

14 Admission Medication Reconciliation Reconciliation button available to Providers only Icon guide Compliance icon - Patient is not taking Prescription Documented Medication by Hx (home med) Orange asteriskunreconciled meds 14

15 Admission Medication Reconciliation The Provider can hover over the compliance icon to display the details of the medication compliance. 15

16 Admission Meds Reconciliation Unreconciled Order(s) button: Indicates the number of unreconciled medications. Continue: Will convert to Inpatient Medication. Click radio button under continue and medication will display under Medications After Admission Reconciliation. Do Not Continue : Leaves Documented Meds by Hx as Documented Leaves Prescriptions as Ordered 16

17 Benefits of Depart Process Can begin the depart process at any time during the patient stay (as early as day of admission). Providers are able to complete discharge Medication Reconciliation, Discharge Meds/Prescriptions including printing prescriptions, Diagnosis, Discharge Details, Discharge Instructions/Education and Follow-up Information. Nurses are able to complete Discharge Instructions/Education, Follow-up Information and print Medication Leaflets. Process may be started/stopped at any time. Multiple Providers can contribute to the document. Document may be saved by selecting Sign/Close. Consulting physicians may enter their follow-up information before the patient has been discharged. That information will pull into the Discharge Instructions which is a huge benefit for physicians so that patients receive correct follow-up information for all consulting physicians. CORE/Quality Discharge instructions such as CHF, Stroke and Warfarin will automatically pull into the new format. Multiple discharge instructions can be incorporated in the patient instructions, however, these instructions need to be reviewed to eliminate conflicting information (for example diet and activity). This is the responsibility of both the Provider and the Nurse. The actual Discharge Depart order can be done at a later time - this is the final step. 17

18 Customizing the Toolbar to Access the Depart Icon The Depart icon is located in the Actions Toolbar. In order to see the Depart Icon, you will need to customize it to your view. You can expand the toolbar by clicking on the arrow at the end of the toolbar to see all the icons. To move the icon on the toolbar, click on the arrow located at the right edge, hover over Add or Remove Buttons, and select Customize. While the Customize Toolbars window remains open, click on the icon and drag it to the preferred position. For more information on customizing the toolbar, click on the following link. Customizing Toolbars 18

19 Accessing the Depart Icon The Clinical Note will no longer be used for discharge. Providers (Physicians, CRNPs, and PAs) will now be ELECTRONICALLY entering patient discharge action items including: medication reconciliation and creating a final medication list, discharge meds /prescriptions (printing electronic prescriptions), diagnosis, and any other details or orders related to discharge using the Depart icon on the Actions Toolbar. To open Depart, click on the Depart icon from the Toolbar. 19

20 When you click on the Depart icon, the Depart window will open: Once the Depart window is open, action items will be displayed on the left. You will notice highlighted options - Provider Only Actions Provider & Nursing Actions Nursing Only Action The Provider will complete the first group of action items, the Provider and/or Nursing will complete the second group, and Nursing will complete the third group. 20

21 Notice the blue circles in front of each action item. If an action item has not been started, it will be empty. If it has been started, but not completed, it will be half full. A full circle indicates that action item has been completed. Changing from an empty circle to a half full one is automatic. However, the full circle is dependent on the user clicking on it when the action item is completed. Completed Started Not Started 21

22 To complete the Depart Process, users will open and enter information into each action item. To open an action item, click on the icon on the right. 22

23 On the right, you will see two tabs Patient Summary and Clinical Summary. The default is the Patient Summary Tab. As action items are completed on the left, the Patient Summary will be created. These are the discharge instructions that will be printed and given to the patient. 23

24 The Clinical Summary Tab - As action items are completed on the left, the Clinical Summary will also be created. This is the discharge information that will be printed and sent with patients who are discharged to other facilities. 24

25 Current State Clinical Note Current State Sign -creates a final document which cannot be edited Future State Sign/Close stores the document and allows for future modification Future State Depart Process 25

26 Signing the Depart Process To sign the documentation click on Sign/Close button. Selecting the X will cause the documentation to be lost. 26

27 Completing the Depart Process - Provider Only Actions 27

28 Provider Only Actions Providers will complete Medication Reconciliation and Discharge Meds/Prescriptions. As providers complete Medication Reconciliation the blue circle will be filled in. As Diagnoses are added, they will be listed below the action item on the left. 28

29 Discharge Medication Reconciliation Continue After Discharge: Documented Medication remains as Documented No Prescription is created. Create New Rx: Creates New Prescription. Do Not Continue After Discharge: Discontinues Document Medication by Hx no longer on patients profile Continue After Discharge and Create New Rx for Inpatient Medications that have NOT been verified by Pharmacy will be grayed out (dithered). 29

30 Discharge Prescriptions Providers will now be creating electronic prescriptions for medications, labs, DME and radiology. These prescriptions will print to the default printer attached to the PC and require a signature by the Provider. Prescriptions must be signed by Provider 30

31 Discharge Details Provider Only Action Current state Discharge Order with 6 required fields (must be placed when patient ready for discharge). Future state Activity, Diet, and Disposition (along with other non-required details) can be started ahead of time. 31

32 The Discharge Details window will open to the Depart Discharge Form. The Provider will select appropriate details for the patient. Required fields include: Activity, Diet, and Disposition and are highlighted in yellow. Additional Discharge Instructions can be provided by selecting radio buttons at the bottom of the form (not required). 32

33 Disposition Current State - Facilities use various processes (paper and electronic) when patients are discharged to Post Acute Facilities or Behavioral Health Units. Future State -When Skilled Nursing Facility or WPIC-Inpatient BHU are selected under Disposition, another section will open for Provider to complete. 33

34 Orders for Next Facility The additional section contains the necessary information required by the facility the patient is being discharged to. Once information is selected use the circle back button to return to the main section. The following information will pull-forward from the Admission Assessment: Pneumonia vaccine administered Pneumonia vaccine date/time Flu vaccine Flu vaccine administered Flu vaccine date/time Healthcare Decision Maker (s) name and phone number 34

35 Discharge Depart Order The final Provider Only action item is Discharge Depart Order. The discharge order (Discharge Depart Order) is the last step in getting the patient discharged. If the patient is ready to leave when the Provider is completing the depart process, the Provider can enter that order from here (Discharge Depart Order action item). OR If the depart process has been completed in advance, this order can be entered from the order matrix. 35

36 Current State: Completing the Discharge Order with all the details such as activity, diet, follow up etc. is the first step when discharging a patient and is not entered ahead of time. Future State: Entering the Discharge Depart Order without details will be the last step to let nursing know the patient can leave the hospital. 36

37 Entering the Discharge Depart Order Clicking on the Discharge Depart Order action icon will open the Add Order window. This order will be entered when the patient is ready to leave the hospital. The order has 3 fields Requested Start Date/Time, Special Instructions, and IV Therapy (Remove IV). There are no required fields. 37

38 Completing the Discharge Process - Provider & Nursing Actions The first Provider & Nursing action item is Discharge Instructions/Education. 38

39 Discharge Instructions/Education Current State The Discharge Instructions Form is a multi-select PowerForm used by Providers and Nursing. Future State Clicking on the Discharge Instructions/Education action item will open the Patient Education window. Providers and/or Nursing can add the Discharge instructions from here. 39

40 Once the Patient Education window opens, a search field and several buttons across the top of the tab will display. Suggested instructions may display based on the diagnosis entered by the Provider. Click on All and type in the instruction you are looking for in the search field, all results will display in the window below alphabetically. Double-click on desired instructions. Departmental and Personal allow you to save favorite type instructions. All allows you to search all the instructions in the system.. 40

41 Searching Discharge Instructions Using All Function Double click on selected instructions on left to display in the window on right. As you add instructions, all the ones that you have chosen will be listed to the left. 41

42 Reviewing Review the discharge instructions by checking the Patient Summary. Review for conflicting information (such as diet and activity) and redundancy. Discharge instructions cannot be modified from inside the Patient Summary. Modifications must be made by opening the action items Discharge Details or Discharge Instructions/Education. If making changes to Discharge Instructions/Education, these forms can be treated like Microsoft Word Documents and modified as such. Please be aware that certain Discharge Instructions/Education cannot be modified due to quality measures. Examples include: CHF, stroke, warfarin and VTE. 42

43 Reviewing When Provider chooses a diet from the Depart Discharge Powerform, the selection will appear under What should I eat? in the Patient Summary. In this example the Regular diet has been selected. 43

44 Reviewing When a Provider selects a discharge instruction there may be a diet associated with that instruction that will appear on the Patient Summary. 44

45 Reviewing Conflicting diets are noted on the What should I eat? section and the Discharge Instruction section of the Patient Summary. After discussing the conflict with the Provider, the Provider or Nurse can modify the discharge details by clicking the Discharge Detail action icon contained in the Provider Only Actions section. 45

46 Modifying Conflicting Data Once the Discharge Details Powerform opens, deselect the conflicting diet (in this example the Regular diet has been deselected) and select the See Diagnosis/Procedure Specific Instructions option. See Diagnosis/Procedure Specific Instructions now displays in the What should I eat? section in the Patient Summary. Sign the Powerform using the green checkmark (not shown). 46

47 As Discharge Instructions are added, they will be listed under the action item on the left. 47

48 Follow-Up Information The second Provider & Nursing action item is Follow-up Information. This is where a consulting physician can add follow up information for a patient prior to the patient s actual discharge. Follow up information can be added at anytime. 48

49 The Follow-Up Information window will open. Providers and/or Nursing can add Follow-up details. Who Search by Provider, Organization/Clinic, or add Free Text information When Date/Time Where Providers or Organizations/Clinics, business addresses will automatically populate 49

50 The check mark next to the address will indicate that it will be included in the patient discharge instructions. If you do not wish to include it, uncheck the box. To add a new address, click on Add Address and a new window will open to complete. The new address will now display. 50

51 A reason for follow up may be added by using the Quick Picks or Predefined Comments. The default for follow-up appointment will be with the patient s PCP in 1 week. To choose a Predefined Comment, double click on the comment. It will now appear in the Edit Comments box. If you need to modify the Predefined Comment update as needed within the Edit Comments box. Sign will add the information to the Patient Summary. Print will give you the ability to print the Patient Summary at this point in the depart process. Cancel will exit Follow-up Information without any actions. 51

52 As Follow-up Information is added, it will be listed under the action item on the left. 52

53 Medication Leaflets The Nursing Only action item is Medication Leaflets. Selecting Medication Leaflets opens the Medication Leaflet window. Medication Leaflets can still be printed from the emar and Medication Administration Wizard. 53

54 Medications Leaflets It is important to print medication leaflets from this window. The medication leaflets do not print with or save to the patient summary. Type medication in search field and click the ellipsis button to search. The Medication Leaflet will display. Selected instruction will display under the Selected Leaflets to the left. Previously selected instructions will display to the right. 54

55 Patient Summary Overview As action items are completed they pull to the Patient Summary. The next slides will highlight selected information. 55

56 Reviewing Patient Summary - Medicines When Medication Reconciliation is complete the medications will pull to the Patient Summary in the grid format. 56

57 Patient Summary- Medicines Medications will be listed in grid format Home Medications to be taken in the Morning Home Medications to be taken in the Afternoon Home Medications to be taken in the Evening Home Medications to be taken at Bedtime Home Medications to be taken As Needed Medications That You Should Stop Taking Medication List Summary 57

58 Patient Summary-Medicines 58

59 Patient Summary-Medicines 59

60 Patient Summary What is my main Medical problem? is added when the provider selected the diagnosis. When are my appointments? is added when the provider selected follow up. Activity/Exercise and What should I eat comes from the Powerform the provider completed. Allergies are pulled from documentation. 60

61 Home Care information pulls from Home Care documentation (not shown). Information pulls from the Discharge Depart Powerform completed by the Provider. If there are any topics that you need to add, you can add free text information by clicking on the blue hyperlink Visit Information Comment (see below). A box will open where you can add what is needed. Then Click ok and it will display in the patient summary. 61

62 Printing Patient Discharge Materials Print Patient Discharge Summary or Clinical Summary Patient Discharge Summary signature sheet - requires a patient s signature and this sheet is to be placed in the chart Print My UPMC Safe Discharge 62

63 Clinical Summary Overview The Clinical Summary contains information that will be used by other clinicians This document will be printed when a patient is discharged to all outside facilities (LTAC, SNF, BHU, and Rehab) At the top is patient demographic data, providers and medical information This is followed by last charted vital signs, final medication list, meds given today 63

64 Clinical Summary PendingTests/Exams, Order Information, Patient Education/ Follow Up, Home Health Care Information You will see an Additional Comments hyperlink. If you click on the hyperlink, you will get a pop up box where you can free text information (Not Shown.) When ready to print, click the print option in the lower right corner. 64

65 You have reached the end of this presentation. Thank you for taking time to review. 65