Electronic Medication Administration Process and Tips

Updated: December 2003 This document summarizes the exact steps to be followed as you administer and chart meds using the emar. Step 1: Check and review all new orders Select the Orders chart tab, click Review/New/Modify/Add order. Click each order to review and then select order detail. Nurse review each order from written order to emar. ***Review orders for patients with non-critical needs every 60 minutes and for critical needs every 30 minutes. Add Nursing Order for Medication Alert/Communication emar communication if needed. Step 2: Review 24 hour view of all scheduled medications and PRN MAR Select Meds chart tab and click MAR Pt Sched Active Meds (PCMSA). Review PRN medication by select med tab and click PRN med. This is to review all of med. profile at the beginning shift for any missing charting in the action during previous shift or change of shift time. Look for one time dose medications both in PCMSA and PRN. PCMSA view can be use to prepare med. administration and chart. Or use other individual selected med page. (i.e. Sched. Diabetes, Chemo.) Reminders to read Comments for medication order. For IV Fluids,titrated drip infusion and PCA/Epideral use these selected page. Look at the STATUS column for ACTV for active medication. If medication is discontinued, ID = discontinued, PD/C= PRN discontinued will appear in the status column when pharmacy discontinues the order. Red highlight will appear in the action column when pharmacy enters the order. Step 3: Verify all 5 R s (Right Patient, Med, Dose, Route, Time) and ADR (Adverse Drug Reaction). Select Meds chart tab and click Pt Active Med Profile ( IPPMED1) or on Order Detail screen click on ADR. Identify medications that need to be verified before administration. Reminders! View comments. Check medication Source (P=pharmacy, M= Machine pyxis) notify pharmacy if unavailable. Take laptop computer (emar) with all medications in their packaging to the patient s bedside and identify patient by comparing two identifiers. The Patient s wristband name and date of birth with the name and date of birth on the emar. Step 4: Document on the emar Document after patient has taken the medication including site. If patient refuses a medication that is taken from pyxis, return the medication to pyxis before charting. With variable doses, chart exact dose in the action column including site and initiate. Step 5: IV/ Parenteral Fluid and Titrated Drip Infusion If it is not 2 hours before or 2 hours after IV time listed on the emar for incremental frequency i.e Q 8 hr.., change the time by selecting the Meds chart tab and click MAR change administration time and change time before taking medication from the pyxis. Mark the IV bag with the date and time it was hung. If maintaining same solution but changing rate on IV fluids document date, time, new rate, i.e. AdjTo125 For Heparin titrated drip document date, time Started & initiate then AdjTo1000 to show the starting rate. Document infused when the solution is discontinued indicating date, time, DC d and Notify Pharmacy. Step 6: Review PCMSA and PRN Review and update - chart on the emar if the medication was held or not given. Page 1 of 9 1/29/2004

Step 1: Check and review all orders Electronic Medication Administration Process and Tips Set up hotlist with patient assignment. Review orders under the orders chart tab. Nurse review all new orders. Review the active med profile (All current active medication orders) Review the All scheduled active meds mar (24 hours view of all scheduled meds) Review the PRN mar Review the Diabetes View Mar if necessary Review the 24 hour IV/Parenteral, titrated drip infusion n PCA/Epideral, Blood Products if necessary Place nursing orders button (found under Medication Alerts/Communications, then select emar Communication) to alert you to view the mars for patients on/with: Example, Alert: 1. Beta Blocker Protocol 2. KCL Replacement Protocol 3. Diabetes Mar 4. PCA/Epidural 5. IV flushes (Normal Saline or Heparin) For Warfarin patients the alert will be entered by pharmacy Review orders for patients with non critical needs every 60 minutes and for critical needs every 30 minutes Double Scroll Bars Double scroll bars will display for lists that have more than 60 items in them. Example: Patient Order Profile. When there are 60 or fewer items on the Patient Order Profile only a single scroll bar displays. When there are greater than 60 a second scroll bar to the right of the original scroll bar displays. How to use Double Scroll Bars When the double scroll bars display, use the first scroll bar to scroll through the list to find the item you are trying to locate. If the item is not listed, click the down arrow scroll bar to go to the next 60 items in the list. Use the first scroll bar to scroll through the second 60 items. Again if the item is not there use the down arrow scroll bar to go to the next 60 items. When you reach the end of the items listed you will receive an advisory message stating You re already at the end. Transfusing Autotransfusions This is a two part process. 1. Ordering Transfuse Autotransfusion. a. From the Patient Order Profile select Add Orders. b. Click the Blood Bank button, select Transfuse Autotransfusion. c. Click Process Orders button. d. Complete the details of the order including the type of Autotransfusion (Stryker or Orthopat), name of ordering and signing clinician who placed the original order for the Autotransfusion device and the order mode of W. Click Place Order button. 2. Charting Autotransfusion. a. On the Meds chart tab select the Blood Product Administration emar b. In the action field of the Transfuse Autotransfusion action, type in the amount of blood you have infused, click Initiate Charting. FYI: To print a slip without putting an action on the Blood Products administration emar,- need to choose the Out Patient pickup slips selection on the blood bank dropdown and then select the products pickup slip. Page 2 of 9 1/29/2004

Step 2: Review 24-hour view of all scheduled medications. Select Meds chart tab and click MAR Pt Sched Active Meds (PCMSA). Review PRN medication by select med tab and click PRN med. Look at STATUS column. ACTV means this is an active order to prepare for medication administration. Review comments by double click on the medication or highlight med..then order detail or click right arrow. Reviewing comment, will determine for when to give a dose, IV or PO medication route choice and protocol medications. One time medication will be in the PRN mar with daily max. of 1 dose. If then medication will be also in the PRN mar with comments. Other Status ID = Discontinued do not give PD/C = PRN discontinued do not give AHLD= Held indicates that nurse decided to hold the medication for short period of time. To read a comment in result detail, highlight the med and click result detail. To edit note in result detail, highlight the med and click result detail, click edit note, then click OK and Back. To audit each action of the med, highlight the med and click audit Step 3: Verify all 5 Rs and ADR(Adverse Drug Reaction) by Select Med chart tab and click Pt Active Med Profile or on the Order Detail screen, click on ADR button. Documenting Co-Signature (Verify) Use the chart word VERIFY to co-sign that you have verified a medication dose. To Chart Verify; Verifying nurse logs into LastWord. Verifying nurse checks the 5 R s. Verifying nurse then uses the Verify chartword to document verification on the emar. Verifying nurse logs off. Administering nurse logs on. Administering nurse checks the 5 R s. Administering nurse administers medication. Administering nurse documents administration on the emar. Pyxis dispensing timeframes Pyxis gives you a 4-hour window to dispense a scheduled medication. 2 hours prior to the scheduled time and 2 hours after. If the patient is not on the unit during this 4-hour period you will need to notify pharmacy to rescheduled the action Page 3 of 9 1/29/2004

Step 3: Verify all 5 Rs. (continued) To Notify Pharmacy Click, then right click in Action field of the medication you need to notify pharmacy about. Select Notify RX from chartword selections. Click Initiate Charting. In Comment field enter message to pharmacy. ( include your name and phone # ) Click Save and Continue. Click Notify Pharmacy. ( pharmacy may receive duplicate copies if click notify pharmacy more than once ) Click Back. For PRN Med. Follow above instructions. If you want to Notify Rx without charting in action field, highlight med/iv fluids and result detail to enter message to pharmacy. Retiming of scheduled medication actions. (I.e. BID, QID, TID) If the desired time the action(s) scheduled to be administered is off by more than two hours, notify pharmacy to retime all remaining doses. (Example currently scheduled for 08 and 20, you want it scheduled for 08 and 17) If the schedule is off by less than two hours, the nurse will chart the actual time the dose was administered. Do not notify pharmacy for retime action(s) for just today ( time period of 0001-2400). You will; o Click in the Time field of the next scheduled action. o Enter time you wish the next dose to be administered. o Click Initiate Charting. If there are more doses that need to be adjusted to get action back on schedule, update remaining actions. If medication is scheduled incremental doses, change time by going to MAR Changing administration. Retiming of incremental medication actions. (I.e. Q4Hr, Q8Hr, Q12Hr) On the Meds chart tab select MAR Change Administration Time. On the Select Order to Change screen click enter 3 times. (Clicking enter on this screen will fill in the correct information and then take you to the next screen.) On the Retime Medication Action screen select the medication you need to retime by clicking in the box next to the med. Click the Retime button. On the Retime Actions for this Order screen find the next scheduled action. (You may need to click the Next button to page down to find the correct action.) In the time field enter the time you want the next action to start. Click the Recalculate Times button. (The selected action and all future actions will be retimed.) Page 4 of 9 1/29/2004

Step 4: Document on the emar Correct/Update Charted Data. Electronic Medication Administration Process and Tips Use to update another nurses charting. (Example, Nurse 1 vend a medication from pyxis and Nurse 2 administers it or Nurse1 charted and need to update by another nurse). Click in DO field. Enter C. Click then right click in action field. Select required chartword. (Update time, etc.) Click Initiate Charting. To Error Out an Action/Reactivate Action Click in DO field of action charted in error. Enter E Click Initiate Charting. Enter note concerning error in Note field. Click OK icon. Click Initiate. Look for Data Updated in Advisory Bar (left lower corner) Click Back. Held vs. Not Given Held is used for actions that are temporarily held in the edit note indicate which time dose (Ex. Patient in therapy and will return shortly or Patient is nauseated and you are giving an anti-emetic.) If the medication ends up not being given, update your charting on that action to Not Given. Not Given is used for actions that are never going to be given. (Ex. Patient has diarrhea and has a stool softener ordered.) Charting Not Given will remove the action from the Active MAR to Inactive MAR. If Not Given charting was done in an error and to reactivate/error this not given action --select med tab and click ( PCM ) MAR pt all meds.active/inactive 24 and type E in DO field and initiate and follow error process. For PCA/Epideral Document time Started or time Started by and time infused. All the specific dosing changes will be documented in the pca/epideral paper record. For Blood Products Document time Started and time Infused on emar. Double checking with another nurse verification are done in the blood bank slip. Normal Saline IV flushes protocol Vend from pyxis and this NS will show on the All Scheduled 24 hour Med. Next day after time 0001 this will disappear from this emar. Chart NS IV flush per protocol in the flow sheet at IV site box and change tubing. Heparin flushes for Central lines and PICC Send written order to pharmacy, heparin 2..5ml flushes per IV central line protocol every 12 hours and PRN specify by clinician. Then after pharmacy enters the order it will appear in the schedule mar and PRN for more flushes in between medications. Page 5 of 9 1/29/2004

Step 5: IV / Parenteral Fluid and Titrated Drip Infusion To Chart Started on IV Vended From Pyxis Before removing IV from Pyxis; o On the IV/Parenteral Fluid emar check the time the next scheduled action is to occur. o If the actions scheduled time is greater than 2 hour before or after the current time, perform Change Administration Time function. The word Vend will display in the status field on the emar. Click, then right click in action of IV. Select Started. Click in site and select site of IV Click Initiate Charting. Documenting on Basic IV with ordered rate change. Use to chart an ordered rate change for the same IV solution. To chart an ordered rate change on an action that is currently running (old rate). 2. Click, then right click in the action field of the action of IV fluid currently running. (The old order.) 3. Select AdjTo. 4. Click in the action field again. 5. Arrow over to the other side of Adj. To using the right arrow key on the lower right side of the keyboard. 6. Type in the new rate that has been ordered for the IV to run at. 7. Click in the Time field and enter the time you adjusted the rate. 8. Click Initiate Charting. To Chart Started and monitor Adj. To for Titrated Drip Medications To display what rate in units the IV is running at. To chart an ordered rate change on an action that is currently running (old rate, old order). Update time and Click, in the action field then right click and select Started and initiate. Go back to action field with Started and right click and select AdjTo and follow monitor adjusting rate to show started rate. To monitor adjusting rate: Click, then right click in the action field. Select Adj. To. Click in the action field. Arrow over using the right arrow key on the lower right side of the keyboard. Type in the rate in units the IV is running at. i.e. AdjTo1500 Click in the Time field and enter the time you adjusted the rate. Click Initiate Charting. Do not modify the heparin order!!! To see all the actions for the heparin titrated drip infusion, highlight heparin and audit. Page 6 of 9 1/29/2004

Troubleshooting and updating IV parental fluid/titrated drip infusion documentation Post-op/post procedure pt. coming from pacu/cath lab with vend IV/Medication, Paperchart if IV fluid not present with pt and verified document on their flow sheet. Started by, if IV fluid is presently infusing. VEND in status but not charted, Highlight the med/ fluid, result detail to find who and when this was vended or check their flow sheet. Type C in the DO field and chart started by, initiate and chart person s name. Previous shift missed charting, started, of Non-vended IV fluids. (Med/fluids, Source from Pharmacy) Check the IV fluid bag for date, time and initial to see by whom and when this was hung. Or clarify by phone call and chart started by. Before taking IV fluids out of pyxis, change time by MAR change administration time, if it is not 2 hour before and 2 hour after time range. If IV fluid is discontinued and charted infused, if remaining order for this IV fluids present on the emar. Chart Not Given to get this action off from active to inactive MAR. Or this old dc d order will disappear when pharmacy completes dc order. IV Override from Pyxis If you remove an IV from Pyxis using override because pharmacy has not entered the order yet and the IV needs to be started Stat, the rate will not display on the MAR. It will show as a floorstock instead of rate and frequency. If patient is going off your unit, chart Started and initiate, highlight IV/Med and click result detail, edit note of the rate and which clinician ordered this IV/Med. When order profile gets into emar, Change time for next IV fluids action by MAR Changing Administration Time to appropriate time for next action. INDEX Summary of process steps-----------------------------------------------------------------------------------------page 1 Reviewing orders------------------------------------------------------------------------------------------------------page 2 Add nursing order for medication alerts/communications---------------------------------------------------page 2 Double scroll bar to review orders--------------------------------------------------------------------------------page 2 Transfusiing Autotransfusions--------------------------------------------------------------------------------------page 2 Review 24 hour view for all schedule med.---------------------------------------------------------------------page 3 Status column, -------------------------------------------------------------------------------------------------------- page 3 Comments---------------------------------------------------------------------------------------------------------------page 3 One time dose medications-----------------------------------------------------------------------------------------page 3 Verify 5 R s ADR and verification of medications--------------------------------------------------------------page 3 Pyxis time frame--------------------------------------------------------------------------------------------------------page 3 Notify Pharmacy--------------------------------------------------------------------------------------------------------page 4 Retiming medication actions-------------------------(mar changing administration time)----------------page 4 Document on the emar Held vs Not Given-------------------------------------------------------------------page 5 Correct/Update Charted Data---------------------------------------------------------------------------------------page 5 Error Out an Action/ Reactivate Action---------------------------------------------------------------------------page 5 PCA/Epideral------------------------------------------------------------------------------------------------------------page 5 Blood Products----------------------------------------------------------------------------------------------------------page 5 IV Parenteral fluid/ Titrated drip infusion documentation-----------------------------------------------------page 6 Troubleshooting and updating IV fluids/ Titrated drip infusion----------------------------------------------page 7 Superuser Responsibilities-------------------------------------------------------------------------------------------page 8 How to report/ Get Help-----------------------------------------------------------------------------------------------page 8 What to Print, transfer process grid--------------------------------------------------------------------------------page 8 Page 7 of 9 1/29/2004

Superuser Responsibilities Assist staff during 2 weeks of activation period by using review tool and report emar issues/ communicate with other superusers. ( keep review tool in the log book each shift with report) Complete a Criterion Checklist by third week of activation. Superuser that have been completed with Criterion Checklist signoff, validates other staff and signoff emar competency by using a Criterion Checklist by third week of activation. (Each Nurse keeps the original copy and sends a copy to their manager). Communicate activation news/updates to coworkers- by checking emails and epages Report any emar issues by following how to report/ get help. How to report/ get help Non-urgent Log Book or IMR@parknicollet,com Urgent Help Desk ( 31234 ) or other superusers Patient Safety Issues Quality Tracking (Right click anywhere on your screen except med. charting field. And then select Help and click quality tracking or click on Help on the top of the screen). Transfer Process Grid and know what to print ( will be posted in the units when final copy available). MAR Patient Review Report/Print (PCMR) for pt from emar transfer to papermar. MAR Order Rev Transfer WL (PRALL) for pt from COE/eMAR transfer to papermar. MAR Med Profile Report (PCHTREP) for pt discharge to another facility. Unit Med Profile Report (UCHTREP) for Lastword down times. Page 8 of 9 1/29/2004

Quick Tips 0d=Today 0= zero 0H= current time -1d= yesterday and +1d= tomorrow Orders All written orders need to be faxed to pharmacy even non medication orders. Fax orders to pharmacy Follow the fax machine instructions and include an initials, date, time and room number. Medication order turnaround time Stat=15 minutes, Priority=30 minutes, routine=60 minutes.(routine processing for night shift will be 120 minutes). All stat medications need to be call to pharmacy after faxing the orders. Contacting pharmacist If the order is entered wrong in the emar or need any stat medications e-page decentralized pharmacist by going into phone book and type pharmacy and select. Charting in the flow sheet INT Normal Saline flushes per protocol, document on the flow sheet at IV site area. Any titrated drip infiusion except Heparin and Insulin document adjusted rate in the flow sheet. For next bag or cassette Notify Rx for second or next bag /cassette for titrated drip and PCA. Then pharmacy will enter for extra action to appear in the emar with original order. One time PRN Orders This will be entered by pharmacy as Daily PRN maximum one dose orders: This will prevent a one time PRN order from falling off the emar at midnight. The frequency will be entered as DAILY, PRN, with a maximum dose of one. Reviewing 24 hour emar by using hotlist When selecting next icon to review 24 hour emar of hotlist patients, you must scroll down on the each page to view 24 hours even though advisory bar does not indicate more to show. Page 9 of 9 1/29/2004

NEW!! INSULIN DRIPS Insulin drips now appear on the MAR Pt Titrated Drip Meds (PCTID) emar. New!! View Critical Care Labs in LastWord: How to view the paper yellow lab sheet (Laboratory and Ventilatory flow record) information in LastWord 1. Go to the CLIN DATA tab 2. Then under "SPECIALTY VIEW" 3. Select "Critical Care Labs". Note: Ventilator settings are not populated in the viewer. These will remain on paper. NEW!! ALERT: CONDITIONAL TITRATED DRIP NURSING EMAR ORDER Follow these steps to have the alert display on the emar in the Order Pad screen. 1. In the Lookup field type alert then press enter on the keyboard. 2. From the Order Name Search screen select ALERT: Conditional Titrated Drip. 3. Click the Process Orders button on the Order Pad screen. 4. Enter the name of the clinician who ordered the drip in the Ordered by and Signed by fields. 5. Put a W in the Order Mode field. 6. Enter drug name in comment field. 7. Click Place Order button. 8. ALERT: Conditional Titrated Drip will now appear on the Scheduled emar. New!! Lookup alerts from the Order Pad screen by typing in alert. This will get you to a list of all of the Nursing Alerts for the emar. Premature Discharge of Patient Nursing/HUC If someone accidentally discharges a patient from Lastword, pyxis deletes the patient s medication profile in 2 hours for In-Patient and 8 hours for OR, ER patients. You can see if a discharge has occurred by using the ADTLOG function: 1.Enter the MR number 2.Look at all transaction, for a discharge transaction 3.Cancel discharge transaction Canceling the discharge will allow the patient to remain in pyxis. But PHARMACY needs to be called to keep the medication profile in the pyxis. So even though the patient will remain in pyxis, the patient s entire med profile will disappear, 2 hours after the discharge is performed, unless pharmacy is notified. Pharmacy The only way to repopulate the pyxis profile is to use the change function from the active medication profile. The change function only relates to medication orders. It is a function that allows updates to comments in medication orders and is only avialiable to pharmacists. COE Units: Clinician placed orders need to be discontinued and re-entered. (Be sure to use the correct clinician when re-entering these orders). Page 10 of 9 1/29/2004