PACU PRE-OP. Demographics
|
|
- Ella Fisher
- 5 years ago
- Views:
Transcription
1 Table of Contents Can you find this information that the Joint Commission will ask to see? Remember there may be multiple paths to locate the below information. Any route that you know will be fine! PRE-OP Demographics o Race and Ethnicity o Preferred Language Education o Learning Needs o Patient Education Nursing Assessments/Documentation o Initial/Ongoing o Alarm Settings o Plan of Care o Psychosocial (includes End of Life Care) o Social (includes alcohol, substance and tobacco abuse) o Immunizations o Nutritional/Hydration Status o Functional Screen o Fall Risk o Abuse/Neglect o Suicide Risk o Pain Assessment/Reassessment o Advance Directives OR ANY OTHER LEGAL DOCUMENTS (POA, Custody Papers) Physician Documentation o History and Physical o Consult Notes o Authentication of Orders Medication o Medication Reconciliation on Admission, Discharge or Transfer o Clarity of Orders PACU Demographics o Race and Ethnicity o Preferred Language Education o Learning Needs o Patient Education Nursing Assessments/Documentation o Initial/Ongoing o Alarm Settings o Plan of Care o Psychosocial (includes End of Life Care) o Social (includes alcohol, substance and tobacco abuse) o Immunizations o Nutritional/Hydration Status o Functional Screen o Fall Risk o Abuse/Neglect o Suicide Risk o Pain Assessment/Reassessment o Advance Directives OR ANY OTHER LEGAL DOCUMENTS (POA, Custody Papers) Physician Documentation o History and Physical o Consult Notes o Authentication of Orders Medication o Medication Reconciliation on Admission, Discharge or Transfer o Clarity of Orders 1
2 Table of Contents Can you find this information that the Joint Commission will ask to see? Remember there may be multiple paths to locate the below information. Any route that you know will be fine! PRE-OP (continued) Procedural Documentation o Informed Consent o Pre-Anesthesia Assessment o Immediate Pre-Induction Assessment o Pre-Procedure Checklist o Timeout o Immediate Post-Op Note o Post-Anesthesia Assessment Legal Documents ( POA, Custody Papers) Restraint Documentation o Orders o Monitoring o Inclusion in Plan of Care PACU Procedural Documentation o Informed Consent o Pre-Anesthesia Assessment o Immediate Pre-Induction Assessment o Pre-Procedure Checklist o Timeout o Immediate Post-Op Note o Post-Anesthesia Assessment Legal Documents ( POA, Custody Papers) Restraint Documentation o Orders o Monitoring o Inclusion in Plan of Care 2
3 APPENDIX You are asked to pull up a patient who had surgery on a previous date and the patient is discharged. The surveyor only provides you with a patient s Medical Record Number. How will you pull up that patient to begin the review? Patient Lookup > enter MRN > Find Patient > highlight and Select patient > Encounters > select desired Encounter 1
4 APPENDIX You are asked to pull up a patient who had surgery on a previous date but they are still admitted. The surveyor only provides you with a patient s Medical Record Number. How will you pull up that patient to begin the review? Note that this functionality will also work using a patient s name who is an inpatient. Patient Lists > enter MRN and click magnifying glass > double click on patient to open chart 4
5 DEMOGRAPHICS RACE & PREFERRED LANGUAGE Status Board > double click on patient to open chart > click on bolded patient name > Clinical Information
6 DEMOGRAPHICS ETHNICITY Status Board > double click on patient to open chart (as above) > click on bolded patient name > Contact Information
7 EDUCATION LEARNING NEEDS More > Education > view Learning Assessment 7
8 PATIENT EDUCATION PATIENT EDUCATION More > Education > All > view Education (orange circular arrows mean educational title not complete; green circle with white check means education resolved; white circle with green check means education initiated, not yet resolved) 8
9 NURSING ASSESSMENTS/DOCUMENTATION INITIAL/ONGOING Pre-Op Looking for Inpatient Assessment(s) Flowsheet > Pre-Op Assessment > pull bottom scroll bar to left to view inpatient assessment(s) 9
10 NURSING ASSESSMENTS/DOCUMENTATION INITIAL/ONGOING PACU Looking for Inpatient Assessment(s) Flowsheet > pull bottom scroll bar to far left (initial inpatient assessment) > pull scroll bar to right to view subsequent inpatient assessments 10
11 NURSING ASSESSMENTS/DOCUMENTATION INITIAL/ONGOING PACU Looking for Pre-OP Assessment on an Inpatient Flowsheets > Pre-Op Assessment > drag tool bar to start of the encounter CONTINUED. 11
12 NURSING ASSESSMENTS/DOCUMENTATION ALARM SETTINGS PACU Alarm Settings Phase II/III navigator > Head to Toe > Vitals > Alarm Parameter 12
13 NURSING ASSESSMENTS/DOCUMENTATION PLAN OF CARE Pre-Op or PACU navigator > Care Plan > Care Plan (either pre or post procedure will display)
14 NURSING ASSESSMENTS/DOCUMENTATION PSYCHOSOCIAL ASSESSMENT (INCLUDES END OF LIFE CARE) Flowsheets > Psychosocial > Last Filed
15 NURSING ASSESSMENTS/DOCUMENTATION SOCIAL ASSESSMENT (includes alcohol, substance, and tobacco abuse) Chart Review > SnapShot > Pt Sum > scroll to locate Social History/Documentation 15
16 IMMUNIZATIONS Chart Review > ShapShot > scroll to Immunizations/Injections NURSING ASSESSMENTS
17 NURSING ASSESSMENTS Nutritional/Hydration Status Flowsheets > Fluid/Nutrition All > Last Filed (this information may pull over into patient summary as well. Chart Review > SnapShot > Patient Summary
18 NURSING ASSESSMENTS FUNCTIONAL STATUS (ADLs) Chart Review > SnapShot > Pt Sum > scroll to Activities of Daily Living
19 NURSING ASSESSMENTS FALL RISK PRE-OP AREAS Chart Review > Index > SBAR Handoff > scroll to Assessment > Fall Risk (Fall Risk is also found right on the Flowsheets as well)
20 NURSING ASSESSMENTS FALL RISK (currently being looked at by Dee B.) PACU AREAS Chart Review > look to right of screen > Fall Risk > Fall Risk information opens below (Fall Risk is also found right on the Flowsheets as well) 20
21 NURSING ASSESSMENTS/DOCUMENTATION SUICIDE RISK Flowsheets>click on magnifying glass>enter suicide risk >Search>Accept
22 NURSING ASSESSMENTS ABUSE AND NEGLECT Flowsheets > click on magnifying glass > enter screenings > search > select Screenings IP Screenings > Accept > Psychosocial > click on double chevrons > Domestic Vi 22
23 PAIN ASSESSMENT/REASSESSMENT PAIN ASSESSMENT/REASSESSMENT Chart Review > Index > Medications Category > Pain Monitoring 23
24 ADVANCED DIRECTIVES ADVANCE DIRECTIVES TO IDENTIFY IF PATIENT HAS AN ADVANCE DIRECTIVE Status Board>double click to open chart>click on bolded patient name>advance Directives 24
25 ADVANCED DIRECTIVES ADVANCE DIRECTIVES (To locate the actual Advance Directive) TO LOCATE AND VIEW ACTUAL ADVANCE DIRECTIVE OR ANY OTHER LEGAL DOCUMENTS (POA, Custody Papers) Chart Review>Media Click next to Document Type to alphabetize all Media/scanned documents 25
26 HISTORY AND PHYSICAL Chart Review > notes > scroll to locate H&P PHYSICIAN DOCUMENTATION Click next to Type to alphabetize all notes 26
27 PHYSICIAN DOCUMENTATION CONSULT NOTES Chart Review > Notes > scroll to locate Consultation Notes Click next to Type to alphabetize notes 27
28 PHYSICIAN DOCUMENTATION AUTHENTICATION OF ORDERS Orders > Active Orders > select order in question > Order Report and select order in blue hyperlink > scroll to see Order details 28
29 MEDICATIONS HOME MEDICATION RECONCILIATION ADMISSION Pre-op Navigator>Home Medications At the very bottom of the Home Med, you will see who last updated the list and when 29
30 MEDICATIONS HOME MEDICATION RECONCILIATION TRANSFER Phase II/III Navigator > Phase III > Med Rec Status 30
31 MEDICATIONS HOME MEDICATION RECONCILLIATION DISCHARGE Phase II/III navigator > Phase II > Med Rec Status 31
32 MEDICATIONS CLAIRITY OF ORDERS MAR > click on white area of MAR > View med order specifics CLICK 32
33 INFORMED CONSENT Chart Review > Media > select desired consent PROCEDUREAL DOCUMENTATION Click next to Document Type to alphabetize all Media/Scanned documents 33
34 PROCEDURAL DOCUMENTATION PRE-ANESTHESIA ASSESSMENT & IMMEDIATE PREINDUCTION ASSESSMENT Status Board > single click on patient > Anesthesia Record > Anesthesia Record opens > scroll down to Preprocedure Note AND/OR Immediate Preinduction Assessment FROM WITHIN PATIENT S CHART (No screenshots included) Chart Review>Encounters>locate and single click on desired Anesthesia Event>Anesthesia Record opens to right>scroll opens>scroll down to Preprocedure Note (If not able to see right panel, slide to left to open window) 34
35 PROCEDURAL DOCUMENTATION PRE-PROCEDURE CHECKLIST FROM PRE-OP Pre-op navigator > click on Checklist 35
36 PROCEDURAL DOCUMENTATION PREPROCEDURAL CHECKLIST FROM PACU Phase II/III navigator > More > Preop navigator > click on Checklist
37 PROCEDURAL DOCUMENTATION TIMEOUT More > Intraop > Timeout
38 PROCEDURAL DOCUMENTATION IMMEDIATE POST-OP NOTE Chart Review > Notes > Brief Op Note Click by Type to alphabetize notes 38
39 PROCEDURAL DOCUMENTATION POST-ANESTHESIA ASSESSMENT Status Board > Anesthesia Record > Anesthesia Record opens > scroll down to All Postprocedure Notes
40 RESTRAINT DOCUMENTATION Orders Orders > click on restraint order > select Order Report > displays order details/questions 40
41 RESTRAINT DOCUMENTATION MONITORING Preop or Phase II/Phase III Navigator > Head to Toe > select FALLS/SAFETY ALL > scroll to Safety (Please note that as of now, Restraint documentation is only in the PACU Flowsheet; ticket was placed on 2/9 to add to Preop Flowsheet as well. Will add screenshots when changes are made. Restraint monitoring is also not added and user needs to add that particular flowsheet as demonstrated below for now. This too was requested to be added) Preop or Phase II/Phase III Navigator > click on magnifying glass > type in restraint > click search > select type of restraints > Accept
42 RESTRAINT DOCUMENTATION MONITORING FROM PACU Phase II/Phase III Navigator > Head to Toe > select FALLS/SAFETY ALL > scroll to Safety (Please note that as of now, Restraint documentation is only in the PACU Flowsheet; ticket was placed on 2/9 to add to Preop Flowsheet as well. Monitoring IS NOT yet included and will need to be accessed as demonstrated on slide 29)
43 RESTRAINT DOCUMENTATION MONITORING (This is being added to both Preop and Phase II/Phase III Head to Toe under Safety) To view details of Performed Safety Monitoring, click on the cell If Row Information box does not show, the side panel may need to be opened by clicking on either of the two arrows 43
44 RESTRAINT DOCUMENTATION INCLUSION IN PLAN OF CARE Currently, there is no inclusion in OpTime. If asked by TJC, point out the Performed Safety Monitoring information in previous screen. 44
Inpatient Cerner Navigation and Documentation For Nursing Students
Inpatient Cerner Navigation and Documentation For Nursing Students Audience Note: Purpose: Objectives: Cerner PowerChart training is for all students in the following inpatient areas Med/Surg, OSN, Oncology,
More informationElectronic Medication Reconciliation and Depart Process Overview Nursing Deck
Electronic Medication Reconciliation and Depart Process Overview Nursing Deck Revised: 8/16/2011 1 Introduction To achieve the highest standard of care that our system aspires to, as well as to meet the
More informationUniversity of Miami Clinical Enterprise Technologies
Provider Manual 1 Our Mission: To design and deliver ongoing support for a network of Business and Clinical Information Management Systems which enhance the academic and research vision while implementing
More informationParagon Clinician Hub for Physicians (PCH) Reference
Paragon Clinician Hub for Physicians (PCH) Reference Logging in to the Clinician Hub Paragon Clinician Hub (PCH) is available on any Carroll Hospital Network. VMWare View must be utilized to open the application.
More informationPC EP 2 & 6 PC EP 4 & 5
Record Review Inpatient Only 3/10/2016 Data Definition Tool The Tracer Packet is to be completed in each inpatient unit by the manager or designee on a monthly basis. It is suggested that the manager does
More informationHigh 5s Project: Action on Patient Safety. SOP Flow Charts. 20 th International Forum on Quality and Safety in Healthcare April 2015 London, UK
High 5s Project: Action on Patient Safety SOP Flow Charts 20 th International Forum on Quality and Safety in Healthcare 21-24 April 2015 London, UK Performance of Correct Procedure at Correct Body Site
More informationCompleting a Medication History Inpatient Nurses
Completing a Medication History Inpatient Nurses Inpatient nurses may complete a medication history completing the following steps: Open the patient s chart Click the Ad hoc button Double click the Nursing
More informationBack Office-General Quick Reference Guide. Enter a Home Health Referral
Back Office-General Quick Reference Guide Enter a Home Health Referral Table of Contents Enter a Referral... 3 Common Buttons & Icons... 3 Enter a New Referral... 4 Document Basic Info... 5 Document Demographics...
More informationLearner Manual. Document Best Possible Medication History (BPMH)
Learner Manual Document Best Possible Medication History (BPMH) Table of Contents Medication safety... 1 Medication errors impact everyone... 1 Who should obtain the BPMH?... 1 When is the BPMH obtained?...
More informationPowerChart Review Guide
PowerChart Review Guide How do I find: Administered Medications MAR Summary Admission History Nursing Charges IV Team, Respiratory Clinical Discharge Summary Content appropriate for next care provider
More informationParagon Clinician Hub (PCH) Replaces WebStation for Physicians
Paragon Clinician Hub (PCH) Replaces WebStation for Physicians Patient Overview The overview screen allows you to view Recent vital sign data Recent intake and output data Active and recently ended inpatient
More information724Access Viewer User Guide
724Access Viewer This explains how to access and use the 724Access Viewer application in the event of a COMPASS downtime. 724Access Viewer provides near real-time transfer of clinical data to workstations.
More informationMA/Office Staff: Proposing Surgical Procedure Orders and PowerPlans (Order Sets)
Acute Surgical Procedure Orders and PowerPlans Affiliated MA/Office Staff: Proposing Surgical Procedure Orders and PowerPlans (Order Sets) This document walks you through: 1. Requesting a FIN (Financial
More informationA complete step by step guide on how to achieve Meaningful Use Core Set Measures in Medgen EHR.
Medgen EHR A complete step by step guide on how to achieve Meaningful Use Core Set Measures in Medgen EHR. Contents Important information regarding Meaningful Use... 2 How to generate your measure report
More informationSoarian Clinicals View Only
Soarian Clinicals View Only Participant Guide Table of Contents 1. Welcome!... 5 Course Description... 5 Learning Objectives... 5 What to Expect... 5 Evaluation... 5 Agenda... 5 2. Getting Started... 6
More informationCPOE Instructor Guide: Direct Admit to Hospital from Office or Other Facility
Direct Admit to Hospital from Office or Other Facility Trainer Notes Section Name Duration Objective Direct Admit N number of minutes to teach, N number of minutes for practice, N minutes for questions
More informationCaptivate Wednesday, April 23, 2014
Slide 1 PATIENT CARE INQUIRY (PCI) ACCESSING PATIENT'S MEDICAL RECORDS IN MEDITECH Content provided by: Melinda Mauk-Templeton, IT Clinical Systems Analyst Development by: Deb Rodman, IT Training Analyst
More informationNICU Physician/NNP INet Talking Points
CNB1 NICU Physician/NNP INet Talking Points East Jefferson General Hospital NICU- 12/01/2009 Tiffany Paisant RN, MSN, Clinical Analyst 10/21/2009 Slide 1 CNB1 please make sure inet is standardized for
More informationInformation Technology Report to Medical Executive Committee
November 13, 2012 Information Technology Report to Medical Executive Committee Contents 1 Meaningful Use Stage 1 Attestation Results 1 Med Rec Optimization Task Force Update 1 2012.01.07 Cerner Code Upgrade
More informationPowerChart Maternity COLUMNs and ICONs- OB Beds Tab
PowerChart Maternity COLUMNs and ICONs- OB Beds Tab The tracking shell provides an overview of patient location, status, and workflow. Patient names will display after registration via STAR. The columns
More informationAcute. Proposing Surgical Procedure Orders and Orders. Surgical Procedure Orders and Orders Affiliated. Requesting a Surgical Encounter FIN#:
Acute Surgical Procedure Orders and Orders Affiliated Proposing Surgical Procedure Orders and Orders Requesting a Surgical Encounter FIN#: 1. Office calls Pre-registration at 801-387-7646 or 800-624-3972.
More informationUsing PowerChart: Organizer View
Slide Agenda Caption 3 1. Finding and logging into PowerChart 2. The Millennium Message Box 3. Toolbar Basics 4. The Organizer Toolbar 5. The Actions Toolbar 4 6. The Links toolbar 7. Patient Search Options
More informationPromoting Interoperability (PI) Formerly Meaningful Use
Promoting Interoperability (PI) Formerly Meaningful Use 1 What is Promoting Interoperability Formerly known as Meaningful Use In 2011 CMS established the Medicare and Medicaid EHR Incentive program to
More informationSeton Health Information Exchange (HIE) unifies inpatient & ambulatory patient data
Seton Health Information Exchange (HIE) unifies inpatient & ambulatory patient data On July 16, clinicians working at Seton hospitals will be able to access the Seton Health Information Exchange (HIE)
More informationDowntime Viewer User Guide for All Users
Downtime Viewer User Guide for All Users Overview... 1 Logging into Downtime Viewer... 1 Opening a Patient Chart in Downtime Viewer... 2 Patient Lists... 2 Clinics... 4 Navigating in the Patient s Chart...
More informationPATIENT PORTAL USERS GUIDE
PATIENT PORTAL USERS GUIDE V 5.0 December 2012 eclinicalworks, 2012. All rights reserved Login and Pre-Registration Patients enter a valid Username and secure Password, then click the Sign In button to
More informationPharmacy Medication Reconciliation Workflow Emergency Department
Objectives of the Pharmacy Forum Page To become familiar with EPIC functionalities used in prior to admission (PTA) medication reconciliation (Section 1) 2 7 To understand the pharmacy technicians role
More informationSide-by-Side Triage Activity Quick Start Guide
Side-by-Side Triage Activity Quick Start Guide Physicians, RNs, APNs, Paramedics, Medical Students Triage Activity Tab: The Triage Activity Tab allows clinicians to review relevant triage information,
More informationa. It is very important to link a visit before or during the visit. This will drive billing functionality
Epic FAQs 1. Adding patients to a list a. Only recommended for studies not in Epic i. Use the My Patients on Research Studies or Patients Associated with (Specify Study) Reports to find your patients on
More informationSoarian Clinicals Results Viewing Quick User Guide
Soarian Clinicals Results Viewing Quick User Guide Physicians, Medical Secretaries, Residents and Nurse Practitioners (For clinicians who provide care in one unit/location) December, 2008 Vs. c5 Table
More informationBar Code Medication Administration and MAR Resource Manual
Bar Code Medication Administration and MAR Resource Manual Creating Orders Creating an Order in CareMobile (Ad Hoc Order Entry)...2 Creating an Order for med that is already ordered with a different dose/frequency....4
More informationIBD Registry Web Tool User Guide
IBD Registry Web Tool User Guide Entering the data required for the 2016 / 2017 Biologics Key Performance Indicators IBD Registry. All rights reserved http://ibdregistry.org.uk/ *Please note all data in
More informationMAR Training Guide for Nurses
MAR Training Guide for Nurses Medication Ordering Fields Verbal Orders Workflow And Navigating the MAR Contents HOW DO I BEGIN?... 3 Update Adverse Drug Reactions... 3 Enter Verbal Orders from Nursing
More informationBHH Dashboard Instructional Document for Providers. Introduction
Introduction The NJ2026 BHH Dashboard is a quarterly report covering a wide variety of metrics that relate to the BHH population. (NJ2026 is the reference number assigned to this report.) The report will
More informationtraining Computerized Physician Order Management (CPOM): Medical Staff Training
training Computerized Physician Order Management (CPOM): Medical Staff Training Table of Contents CarePoints Performance...4 VMView System Requirements...4 What is CPOM?...5 Current Encounter... 5 Inpatient
More informationValidation Process for Student Nurse Documentation
Canopy Education Goal: Use this job aid to successfully sign and validate documentation performed by nursing students. Note: There is no validation for Continuous IV Infusions. If you leave any documentation
More informationIP = Inpatient OP = Outpatient Standard Location YES No. HED: Admission History tab or paper record Admission /History/ Discharge form
Tracer Record Review - ECT-Periop Only 9-30-2016 Data Definition Tool The Tracer Packet is to be completed in each Periop area by the manager or designee on a monthly basis. It is suggested that the manager
More informationINTERGY MEANINGFUL USE 2014 STAGE 1 USER GUIDE Spring 2014
INTERGY MEANINGFUL USE 2014 STAGE 1 USER GUIDE Spring 2014 Intergy Meaningful Use 2014 User Guide 2 Copyright 2014 Greenway Health, LLC. All rights reserved. This document and the information it contains
More informationKansas University Medical Center ecrt Department Administrator Training. June 2008
Kansas University Medical Center ecrt Department Administrator Training June 2008 KUMC Process Timeline Effort Reporting Period 3 Week Pre-Review Period 3 Week Certification Period Post Certification Period
More informationBar Code Medication Administration and MAR Resource Manual
Bar Code Medication Administration and MAR Resource Manual Administering Medications Administering Meds using CareMobile (PDA)... 2 Viewing Allergies in CareMobile... 8 Determining Which Meds to Give When...
More informationMobile Lite Training Key Notes
Mobile Lite Training Key Notes Home Health Aides can do nothing on the mobile device until their schedule has been created. The Scheduler is responsible for assuring that an Aide care plan has been initiated
More informationProviders Course 2 Participant Guide Med Reconciliation & Discharge Process
Providers Course 2 Participant Guide Med Reconciliation & Discharge Process Carolinas HealthCare System Revised June 2012 Table of Contents 1. Enhanced Medication Reconciliation 1-1 Introduction... 1-1
More informationWelcome to Inpatient Peds!!
1 Welcome to Inpatient Peds!! General Structure Admissions 1. Daily schedule 6am Pre-rounding 6:30-6:45 Senior resident Peds Surg Huddle 7-8a Early rounds with NF intern 8-9a Morning report or Grand Rounds
More informationEffective Date. Patient Status Initial Inpatient Order. 1 of 5
1 of 5 Effective Date The Admit Patient order has been redesigned to meet CMS guidelines. Effective May 8, 2012, three orders will replace the Admit Patient order: Patient Status Initial Inpatient Patient
More informationMEDICAL SPECIALISTS OF THE PALM BEACHES, INC. Chronic Care Management (CCM) Program Training Manual
MEDICAL SPECIALISTS OF THE PALM BEACHES, INC. Chronic Care Management (CCM) Program Training Manual September 2017 Table of Contents CCM PROGRAM OVERVIEW... 4 3 STEPS TO BEGIN CCM:... 5 Identify the Patient...
More informationIntroduction to the Parking Lot
Introduction to the Parking Lot In ARK Epic training sessions, The Parking Lot" is used to capture all questions for which your trainer may not have an immediate answer during session. Your ARK Epic Training
More informationAdmission Medication History and Reconciliation Documentation. Froedtert Hospital, Milwaukee WI
Overview of Medication History and Reconciliation Process 2 Overview of Icons Used in the Medication History 2 and Reconciliation Process The Admission Navigator 3 SureScripts Medication Reconciliation
More informationCLINICAL DOCUMENTATION
ekids PowerChart tra Emergency Nursing CLINICAL DOCUMENTATION Training Guide Presented by the IS Training Department Revised July 2013 Introduction to Clinical Documentation for Nursing ekids PowerChart
More informationLSU Ophthalmology ILH EPIC User Guide
LSU Ophthalmology ILH EPIC User Guide How to complete charting for Dr. Barron 1.) Patients who are ready to be seen will have a check-in paper in the box in the supply room (same place where charts were
More informationGuideline Complex Care Management Documentation in Valence Care Manager
Title: RN, Complex Care Management Purpose: Provide consistent and systematic documentation of all contact with Complex Care Management cases. Scope: Complex Care Management referrals, encounters, enrollments,
More informationThe Joint Commission Standards and the Patients
The Joint Commission Standards and the Patients 23 rd Annual National Forum on Quality Improvement in Health Care December 7, 2011 Orlando, Florida Pat Adamski, RN, MS, MBA Director, Standards Interpretation
More informationReviewing your 2017 CMS Quality Reports
Reviewing your 2017 CMS Quality Reports Anesthesia Quality Institute aqihq.org November 2017 Reviewing 2017 CMS Quality Reports - Monitor your providers measure compliance monthly using your NACOR/ArborMetrix
More informationPreoperative, Phase I & II Training Meditech 6
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
More informationMeaningful Use Roadmap
Meaningful Use Roadmap Copyright SOAPware, Inc. 2011 1 Introduction 1.1 2 3 Introduction 6 Registration and Attestation 2.1 1. Request the "CMS EHR Certification ID" for SOAPware 9 2.2 2. Register for
More informationMEDITECH 6.14 HOW TO ACCESS THE PATIENT S ELECTRONIC MEDICAL RECORD (EMR)
MEDITECH 6.14 HOW TO ACCESS THE PATIENT S ELECTRONIC MEDICAL RECORD (EMR) Table of Contents How to Log on to MEDITECH 6.14... 3 How to Access Patient Information... 5 Recently Accessed... 5 Find Patient...
More informationIntroduction to the Provider Care Management Solutions Web Interface
Introduction to the Provider Care Management Solutions Web Interface Release 0.2 Introduction to the Provider Care Management Solutions Web Interface Purpose Provider Care Management Solutions (PCMS) is
More informationNew Jersey Department of Community Affairs
Enter program-specific information in the green and yellow fields to clarify the application process. Green fields are mandatory, yellow fields are optional. New Jersey Department of Community Affairs
More informationOB/GYN Office Staff: Proposing PowerPlans (Order Sets)
Labor & Delivery Power Plans Affiliate Providers OB/GYN Office Staff: Proposing PowerPlans (Order Sets) Overview of Process: 1. Instruct your OB patient at 30-32 weeks to call Intermountain Patient Account
More informationCare Planning User Guide June 2011
User Guide June 2011 2011, ADL Data Systems, Inc. All rights reserved Table of Contents Introduction... 1 About Care Plan... 1 About this Information... 1 Logon... 2 Care Planning Module Basics... 5 Starting
More informationEFFORT CERTIFICATION GUIDE
SOUTH DAKOTA SCHOOL OF MINES AND TECHNOLOGY EFFORT CERTIFICATION GUIDE 1/1/2011 WEB-BASED EFFORT CERTIFICATION Version 2 What is Effort Certification? Effort Certification is the institution s process
More informationAdmission from ED and PowerPlans (Order Sets)
Admission from ED and PowerPlans (Order Sets) 7 17 12 Admission from the ED (Initiate PowerPlan) 1. Ensure patient is ready for Orders: i.e. In Virtual Bed (Loc: ED & a number) Ready Not Ready Must order
More informationMedication Module Tutorial
Medication Module Tutorial An Introduction to the Medication module Whether completing a clinic patient evaluation, a hospital admission history and physical, a discharge summary, a hospital order set,
More informationCare Management User Guide for Dashboards and Alerts. December 21, 2016
Care Management User Guide for Dashboards and Alerts December 21, 2016 Table of contents User Guide Care Management Dashboard and Alerts What are Care Management Alerts and Care Management Dashboards?...
More informationSCIP-Inf-2, SCIP-Inf-3, SCIP-Inf-4, SCIP-Inf- 9, SCIP-Inf-10, SCIP-VTE-1, SCIP-VTE-2 Anesthesia End Time 5
Release Notes: Alphabetical Data Dictionary Version 3.3 Surgical Care Improvement Project (SCIP) - Data Dictionary The General Abstraction Guidelines explain the different sections of the data element
More informationEMAR Pending Review. The purpose of Pending Review is to verify the orders received from the pharmacy.
EMAR Pending Review This manual includes Pending Review, which is the confirmation that the information received from the pharmacy is correct. This is done by verification of the five (5) rights of medication
More informationPeopleSoft Recruiting Solutions
PeopleSoft Recruiting Solutions Student Job Posting January 22, 2013 Recruiting Solutions (Rec Sol) replaced Y-Careers for all on-campus job postings effective December 10, 2012 o Y-Careers is now the
More informationOVERVIEW OF ESSENTIAL CHARTING ELEMENTS FOR THE EMERGENCY DEPARTMENT
OVERVIEW OF ESSENTIAL CHARTING ELEMENTS FOR THE EMERGENCY DEPARTMENT ALL CHARTING NEEDS TO BE FINISHED AT THE END OF YOUR SHIFT PRIOR TO LEAVING THE ED IF YOU HAVE ANY QUESTIONS, ASK FOR HELP! All of the
More informationStudent RN Maintaining Patient Lists with Treatment Team Lesson Plan
Student RN Maintaining Patient Lists with Treatment Team Lesson Plan Agenda... 1 Class Activities... 2 Maintaining a List of Patient Assignments... 2 Finding Discharged Patients... 5 Agenda The following
More informationEpic Training Ambulatory and Inpatient Course Catalog
Epic Training Ambulatory and Inpatient Course Catalog One team. One record. One focus: Our patients. Table of Contents page About Training... 3 Courses Required Ambulatory Courses by Role... 4 Ambulatory
More informationInstitutional Handbook of Operating Procedures Policy
Section: Clinical Policies Subject: General Procedures Institutional Handbook of Operating Procedures Policy 09.13.09 Responsible Vice President: EVP and CEO Health System Responsible Entity: UTMB Health
More informationDesignated Record Set Health Record The health information described below may be maintained in any medium (paper, electronic, digital, etc)
Designated Record Set Health Record The health information described below may be maintained in any medium (paper, electronic, digital, etc) DEFINITION Designated Record Set A group of records (recorded
More informationMedicines Reconciliation Policy
Medicines Reconciliation Policy Lead executive Medical Director Authors details Senior Clinical Pharmacy Technician - 01244 39 7494 Document level: Trustwide (TW) Code: MP19 Issue number: 3 Type of document
More informationComputer Provider Order Entry (CPOE)
Computer Provider Order Entry (CPOE) Use computerized provider order entry (CPOE) for medication orders directly entered by any licensed healthcare professional who can enter orders into the medical record
More information2012 Medical Staff Update 2011 CHALLENGING STANDARDS/NPSGS
2012 Medical Staff Update Laurel McCourt, M.D. TJC Surveyor: Hospital and Office-Based Surgery Programs, and Special Survey Unit 2011 CHALLENGING STANDARDS/NPSGS 2 Standard/NPSG 2010 Non Compliance 3 2011
More informationPost-Production, Visual Effects and Digital Animation Grant GUIDE TO APPLICATION SUBMISSION
Post-Production, Visual Effects and Digital Animation Grant GUIDE TO APPLICATION SUBMISSION Introduction This guide will assist Post-Production, Visual Effects and Digital Animation Grant (PPG) applicants
More informationTJC Corrective Actions. Nursing Education January, 2015
TJC Corrective Actions Nursing Education January, 2015 TJC Finding Normal Saline fluids stored in the warmer did not have the revised expiration dates. Normal Saline fluids stored in the warmer had a temperature
More informationUsing the Just Culture Method. Stacey Thomas, BSN, RNC Risk Analyst
Using the Just Culture Method Stacey Thomas, BSN, RNC Risk Analyst Just Culture A system of Shared Accountability Everyone in the organization is responsible for maintaining a safe and reliable system
More informationAlberta Health Services. PCS 5.67 Care Planning
Alberta Health Services PCS 5.67 Care Planning 3/11/2015 Contents Care Planning in Central Zone... 5 Developing the Plan of Care... 7 Accessing the RAP Analysis Assessments... 8 Completing the RAP Analysis
More informationMARSHALLTOWN MEDICAL & SURGICAL CENTER Marshalltown, Iowa
Marshalltown, Iowa POLICY & PROCEDURES Policy Number: P2-01 Subject: Purpose: Inpatient Coding/ Abstracting Process All inpatient records must be reviewed, and appropriate diagnosis and procedure codes
More informationTransitions of Care: Primary Care Perspective. Patrick Noonan, DO
Transitions of Care: Primary Care Perspective Patrick Noonan, DO Disclosures None Bio Outpatient primary care internist at New Pueblo Medicine Completed residency at the University of Iowa Graduated from
More informationOncology Quick Start Guide
Oncology Quick Start Guide Oncology Provider - Beacon Version Date: 5/31/2017 Table of Contents Oncology Reports... 1 Treatment Plan Springboard... 1 Summary Phys Onc... 1 Summary Nurse Onc... 2 Scheduler
More informationF 5 STANDING COMMITTEES. Finance and Asset Management Committee. UW Medicine Clinical Transformation Project INFORMATION
STANDING COMMITTEES F 5 Finance and Asset Management Committee UW Medicine Clinical Transformation Project INFORMATION This item is being presented for information only. Attachment Clinical Transformation
More informationATTENTION A New Method for Medication Reconciliation at Admission Will Be Introduced on February 3rd
ATTENTION A New Method for Medication Reconciliation at Admission Will Be Introduced on February 3rd Our new Pharmacy System and Meaningful Use require a new medication reconciliation method. The current
More informationOverview What is effort? What is effort reporting? Why is Effort Reporting necessary?... 2
Effort Certification Training Guide Contents Overview... 2 What is effort?... 2 What is effort reporting?... 2 Why is Effort Reporting necessary?... 2 Effort Certification Process: More than just Certification...
More informationekids PowerChart Emergency Department Physicians CLINICAL DOCUMENTATION Presented by the IS Training Department
ekids PowerChart Emergency Department Physicians CLINICAL DOCUMENTATION Presented by the IS Training Department Revised February 2013 ekids PowerChart PowerChart for Emergency Department Physicians...
More informationPATIENT ACCESS LIST (PAL)
PATIENT ACCESS LIST (PAL) The Patient Access List (PAL) helps clinicians work effectively and efficiently by providing key patient and workflow information in an easy-to-access format. The PAL is built
More informationOptima POC PARTICIPANT GUIDE
Optima POC Point of Care PARTICIPANT GUIDE 2017 Optima Healthcare Solutions Page 1 CONTENTS CONTENTS... 2 ABOUT THIS GUIDE... 3 LEARNING OUTCOMES... 4 1. ACCESSING POINT OF CARE... 5 2. CLOCKING IN...
More informationPurpose/Goal: This course introduces the purpose and use of Smart Chart as a means of legal documentation.
Title of Activity: UHS-Smart Chart, Part 1 (P8469) Total Number of Contact Hours: 1 Intended Level of Learner: Beginner Purpose/Goal: This course introduces the purpose and use of Smart Chart as a means
More informationEmergency Care, Rx Writer, Exit Care
Sunrise Emergency Care Emergency Care, Rx Writer, Exit Care May 2013 v. 1.0 ED Display Board Log into Emergency Care/SCM. The View dropdown box will be populated with the views appropriate for your role
More informationEMAR: Medication and Pharmacy Setup
EMAR: Medication and Pharmacy Setup This manual covers EMAR System Setup: Medication Time Codes, Medication Schedule Codes, SIG Codes, Medications Treatment Setup, Medical Providers and Pharmacy. Medication
More informationeinteract User Guide July 07, 2017
einteract User Guide July 07, 2017 This document covers the use of the einteract features in PointClickCare. Table of Contents einteract... 3 einteract Quick Reference Guide... 3 Overview of einteract...
More informationMay 17, Volume III, Issue 5
May 17, Volume III, Issue 5 Violent Restraints: Accessing One Hour Face-to-Face Template in EPIC The Joint Commission requires a patient who is placed in restraints for violent behavior to be seen by the
More informationHELLO HEALTH TRAINING MANUAL
HELLO HEALTH TRAINING MANUAL Please note: As with all training materials, the names and data used in this training manual are purely fictitious and for information and training purposes only Login/What
More informationPC EP 4; PC EP 7. (Outpatient Only) If nutritional screen positive, plans for follow-up documented.
Dialysis - Patient Documentation & Observation Tool Data Definition Tool This audit is to be completed by the manager or designee on a monthly basis. "Dialysis - Patient Documentation & Observation Tool"
More informationSystmOne Templates. Progress and plans. May
SystmOne Templates Progress and plans May 2017 Overview NHS England H&J CRG agreed a series of national, templates to support key part of the H&J patient pathway NELCSU are leading the development and
More informationN C MPASS. Clinical Self-Scheduling. Version 6.8
N C MPASS Clinical Self-Scheduling Version 6.8 Ontario Telemedicine Network (OTN) All rights reserved. Last update: May 24, 2018 This document is the property of OTN. No part of this document may be reproduced
More informationA Randomized Trial of Supplemental Parenteral Nutrition in. Under and Over Weight Critically Ill Patients: The TOP UP Trial. CRS & REDCap Manual
A Randomized Trial of Supplemental Parenteral Nutrition in Under and Over Weight Critically Ill Patients: The TOP UP Trial CRS & REDCap Manual Intended Audience: Research Coordinators This study is registered
More informationLOGIN TO INFINITE CAMPUS: A. In Chrome or Firefox, copy and paste the following URL and hit return and the IC login window will open
A staff member that has been given IC rights to review and approve the application. Usually Office Support or staff member certified in Census/Enrollment. The staff member can only approve applications
More informationSevocity v.12 Patient Reminders User Reference Guide
Sevocity v.12 Patient Reminders User Reference Guide 1 877 877-2298 support@sevocity.com Table of Contents Product Support Services... 2 About Sevocity v.12... 2 Icons Used... 2 About Patient Reminders...
More information