Placing a Contrast Order in PowerChart. 1 From the Online Worklist, highlight the appropriate patient, and click the PowerChart button.

Transcription

1 Radiology: RadTech Contrast Processes Placing a Contrast Order in PowerChart... 1 BCMA Process... 6 Documenting Contrast Administration on the MAR... 7 Chart a Medication as Not Done... 9 Voiding a Contrast Order Lines/Procedures Insertion PowerForm Placing a Local Anesthetic Medication Order NM Furosemide (Lasix) Ordering Process Inpatient Steps Outpatient Steps Placing a Contrast Order in PowerChart 1 From the Online Worklist, highlight the appropriate patient, and click the PowerChart button. 2 PowerChart opens to Pt Info. Select the appropriate encounter for the patient. Copyright Children s Hospitals and Clinics of Minnesota. Children s Hospitals and Clinics of Minnesota. All rights reserved. All trade names, trademarks and registered trademarks are the property of their respective owners. This content was developed for use in Children s patient care environment and may not be suitable for use in other patient care environments. Each clinician should use his/her own independent judgment to meet the needs of each individual patient. This content is not a substitute for professional medical advice, diagnosis, or treatment. Children s does not endorse, certify, or assess third parties competency. You hold all responsibility for your use or nonuse of the content. Children s shall not be liable for claims, losses, or damages arising from or related to any use or misuse of the content.

2 Radiology: Rad Tech Contrast Processes 3 From the Menu, click on Orders. 4 From Orders, click on the Add button. 5 The Add Order window displays: In the Find field, enter Radiology, and search for Radiology Contrast. Right-click on the order and click on Add to Favorites. Note: Once they are saved to your Favorites folder, you can simply click the Favorites, icon and your contrast orders will display. 6 Click on the appropriate contrast order. 2 Updated

3 Radiology: Rad Tech Contrast Processes 7 If the patient does not have a weight documented, the Allergy-weight alert window will display. Click on the Form button. 8 The Pediatric Growth PowerForm displays. Enter the weight, and click on Sign in the tool bar. 3 Updated

4 Radiology: Rad Tech Contrast Processes 9 Click on the appropriate component. 4 Updated

5 10 If the Ordering Physician window displays, do the following: In the Physician name field, type in the complete name, or the last 4 letters of the dictating Radiologist (if unknown use the Radiologist Medical Director), click the binoculars icon, and select the appropriate provider name from the Provider Selection window. For Communication type, select Radiology Guidelines. Click OK. 11 After you sign the Medical PowerPlan the appropriate contrast will display in the Orders Menu: IV Contrast: Note: icon indicates that the order is not yet verified by Pharmacy. Once verification has been completed, the icon is auto-removed. 5

6 BCMA Process 1 Open MAW (Medication Administration Wizard). 2 Scan patient ID band. 3 Scan medication or contrast. Note: For medications with required fields, open the medication administration window if it is not already opened (click on the yellow field in the results section). Complete required fields, and click OK. 4 Verify blue checkmark for medication on the MAW, and Sign MAW. 5 Administer medication or contrast 6

7 Documenting Contrast Administration on the MAR 1 From the Menu, click on the MAR, and double-click on the ordered medication. 2 The Medication Task window displays. Select the appropriate Site, and click to Sign. 7

8 3 If you need to change volume, click in the Volume field, enter new number, select Site, and click to Sign. Click on the Comment button to enter a comment 4 Once you sign your med, the dose changes to Complete with a blue check mark on the MAR. 8

9 Chart a Medication as Not Done Chart the Contrast order as Not Done when the study is performed, but contrast was not used due to patient condition. If the test is cancelled, Cancel the Radiology order and Void the Contrast order. If the test is credited due to not being completed, Void the contrast order. Go to Voiding a Contrast Order on page 10 for more information. Note: Charting a Medication as Chart Not Done completes the task, and prevents further documentation on that dose. 1 From the MAR tab on the patient s chart, right-click on the Pending task, Overdue task, or PRN Response task in the appropriate date and time box for the medication. Select Chart Not Done from the dropdown list. 2 The Not Done dialog box is displayed. Click the down arrow in the Reason Not Done box, and select a reason from the dropdown list. 3 Enter comments in the Comment box if needed. (For example, "Patient denies pain. Refused med.") 4 Click to Sign. 5 The MAR is redisplayed, and Not Done is displayed in the appropriate time and date box that administration event. for 9

10 Voiding a Contrast Order Void the Contrast order when the study is canceled for any given reason or exam stopped and to be credited due to incomplete exam prior to contrast administration. If the test is canceled, Cancel the Radiology order and Void the Contrast order. If the test is credited due to not being completed, Void the Contrast order. 1 From the Orders tab, right click on the order you want to void, and select Void. 2 Click on the Orders For Signature button in the lower right corner. 10

11 3 Click the Sign button in the lower right corner. 4 Order now displays as Voided in the Orders window. Lines/Procedures Insertion PowerForm If the RadTech starts an IV, the PIV/Insert/Care/Infiltrate PowerForm needs to be completed. 1 Click on Ad Hoc Charting from the tool bar. 11

12 2 In the Ad Hoc Charting window, click on the Patient Care folder, and double-click on Lines/Procedures Insertion. 3 Defaults open to the PIV #1 Insertion section. Complete the appropriate fields, and click Sign Form. 12

13 Placing a Local Anesthetic Medication Order Note: See Policy #501.00: Order Comment Conditional Order: Local Anesthetic for Vascular Access, for further information. When the Ordering Provider gives a conditional order Sedated patients: RN to enter the order set "RN Local Anesthetic for Vascular Access" per Conditional Non-Sedated patients: RadTech to enter medication order for local anesthetic per Radiology Guidelines 1 At the Add Order window, in the Find field, enter LMX. Select LMX 4 topical cream Select Order Sentence Dose = 1 application Topically PRN for IV start/access... 2 Complete the following fields: Volume Dose = 1 Duration from now to end point = 1 Duration Unit = Doses 13

14 3 Go to the MAR, and locate the medication. Right click, and select Quick Chart. 4 The 1 time application is now Completed. NM Furosemide (Lasix) Ordering Process Inpatient Steps 1 CPOE Ordering Provider will enter the PowerPlan. 2 Go to Orders, and click the Add Order button 3 Search for lasix, and select Renogram with Furosemide (Lasix) PowerPlan 4 Select the appropriate order sentence, and click OK. 14

15 5 In the Dosage Calculator, click Apply Standard Dose. 6 Complete Order details, and click Sign button. 7 The nurse and pharmacy will receive notifications for order review. 15

16 8 The RadTech or RN that administers the Lasix will go to the MAR to complete the order. Doubleclick on the medication task. 9 The Medication Task window will display. Document the medication, and click to Sign. 16

17 Outpatient Steps 1 The Ordering Provider will submit written or electronically written order to the Radiology department for NM Renogram w/pharm Intervent. 2 The appointment and order is entered into the Scheduling Application. 3 RadTech enters the Furosemide Lasix order through PowerChart. In the Ordering Physician box: Select Radiology Guideline for Communication Type For Ordering Provider, select the Radiologist that will be reading the exam 4 The nurse and pharmacy will receive notifications for order review. 5 The RadTech or RN that administers the Lasix will go to the MAR to complete the order. Double click on the medication task. 6 The Medication Task window will display. The RadTech will document the medication, and click to Sign. 17