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 February 2011 Page 1 of 36
Slide 2 The tutorial will review how to access the Patient's Medical Record in Meditech. Since users process information at various levels, please feel free to select the Pause, Rewind or Next button below to navigate through the screens. The Close button would allow you to close out of the tutorial. Page 2 of 36
Slide 3 Once you have logged into Meditech, select number 3 to access PCI (Patient Care Inquiry). Press Enter to continue. Note - PCI may be a different number for you on your menu. Page 3 of 36
Slide 4 The first screen in PCI is the "Identify Patient Screen". There are multiple ways to access a patient in PCI. Use your mouse to point to the method or double click on the option of your choice. The following screens will identify the most recommended ways for accessing Clinic (outpatients) and/or Inpatients. We are viewing an Outpatient screen. Page 4 of 36
Slide 5 BY NAME, NUMBER: look up by exact spelling of last name, first; or by unit #, but only accesses those who have visit history in 90 days. SOUNDEX: Use when you know the pt. first and last name. This is the most forgiving if you do not know the correct spelling. You are able to access pts. with AHS visit history, regardless of date range. BY UNIT NUMBER: Enter the patient's medical record # including any Alpha characters (i.e. L123456789). FROM YOUR LIST OF SCHEDULED APPTS: Compiles your list of pts. scheduled for any given day (**Most effective method when scheduled in clinic.) By Soundex name and by Unit Number are the only two look up methods that access our full master patient index. The other look up methods are more recent (less than 90 days). Remember - this is how an Outpatient screen will appear. We will review the Inpatient screen next. Page 5 of 36
Slide 6 YOUR LIST of Patients in a bed: those patients who are registered, attended or consulted by you and occupy a bed (inc.inpatient observation, 24 hr hold, etc.) Access a specific Provider's list of patients you may be on call for by entering their provider mnemonic. Access all of a Group of Provider's Inpatients that you may be on call for by entering that groups mnemonic. By Location is used when you know the location in a setting and want to access one or more inpatients in that location (such as a floor or unit of a hospital). Page 6 of 36
Slide 7 The first screen in a patients record is called the Table of Contents. This screen contains multiple categories and subcategories called "Data Sources". Data Sources will usually appear on a patient's Table of Contents if they have data or reports in that area. For example, if a patient has had no lab work done, then the data source of "Laboratory Data" will not even appear on the table of contents page. There are a few exceptions such as Visual Flow Sheet, Lab orders, Upcoming and Rehab outpatient reports, Redoc. Navigation in PCI for the most part will be mastered by double clicking on the topic directly, or you may select to navigate by using your arrows off of the tool bar on the right to go up and down one line at a time, or double arrows for page up and page down. Left and right arrows on the toolbar or keyboard take you in or out a page. Page 7 of 36
Slide 8 Many of the data sources are set up in a format of a main heading with subheadings. If you click on the main heading, you will see all choices will be in reverse chronological order. Selecting a subheading allows a more focused search within a topic/category. In this example, Microbiology Data is the main heading and there are eight subheadings indented under that data source. Microbiology data can be viewed by accessing all micro data, or by picking a specific data source and drilling in on that data source. Anatomical Pathology Reports can be accessed by clicking on the data source and then identifying the type of pathology report and clicking on it. (i.e. surgical path or cytology.) Page 8 of 36
Slide 9 Radiology Reports can by viewed by accessing all Radiology or a specific type like MRI or CT. If that subheading does not appear on the Table of Contents, that type of test has not been done on that patient. For Radiology reports, please see online tutorial on PAC's (PAC's - Archiving & Communication System) and handouts "PACS Quick Reference Guide" and "PACS comparison". Transcribed Reports contain all dictated reports (both in and outpatient). There are two types of Summary reports; Summary list and Prescriptions. The Summary list is a dictated running summary list that can be updated by clinic providers as needed. The Prescriptions summary list is a summary of current ambulatory medications compiled from our e-prescribing tool with a listing of allergies and adverse drug reactions on the bottom of the report. Page 9 of 36
Slide 10 Orders contain all of the hospital orders that are placed on patients in all categories. Visit History contains all registered visits (inpatient stays, Lab, Rad, Clinic visits, etc.); usually with free text reasons for the visit. including visits scheduled into the future. Medication Order History includes all med's that were ordered and/or dispensed during hospitalizations. For medications on current inpatients, see the Visual Flow Sheet data source. Page 10 of 36
Slide 11 After you have selected the data source from the table of contents screen, you will be brought to the "Summary Screen". No matter what Summary screen you are on (transcribed reports, Lab or Rad) they will all work in the same manner. If you wish to view all reports in that category, you would double click on "All Reports" and view all available types in that category (in this case, all office notes, consults, ER visits, OP notes, etc.) If you are more interested in viewing notes only from one specific area, double click on that line item. Page 11 of 36
Slide 12 The Report column will identify the type of report or test. The Status column will indicate the status of the report (i.e. draft, signed, or cancelled) or test (ordered, drawn, pending, taken, resulted). The Date column reflects the date of the most recent report dictated or test taken in that type. The small lines on the right reflect the number of times during that time frame, that there is an occurrence of that report or test type. Page 12 of 36
Slide 13 Laboratory Summary Screens Although all summary screens in PCI are set up similarly, the lab data summary screens have some additional functionality. The Test column will identify the types of lab tests that have been done on this patient. The Result column will reflect the most recent numeric value of that specific test. The Flag column will warn you if the result is High (H) or Low (L), Comment or a Panic value. The Date/Time column will reflect the date of the most recent test value. The area to the right will record all the test values of each test taken during that identified time frame. Page 13 of 36
Slide 14 Labs with Rough Graphing Certain labs display some rough graphs (ex. Sodium). The date, results and flag appear along the left hand side and the graph appears on the right hand side. Page 14 of 36
Slide 15 Labs in a Flowchart Format There are several Table of Content choices that display labs in a flowchart format. There are departmental labs (Primary Care, Nehprology, OB/GYN, Cardiology, Endocrinology, Gastroenterology, Rheumatology), and Health Management labs like Endocrine Center Flowsheet, Anticoagulation Patient Management, etc. Primary Care Labs may contain some vital signs, if recorded in the flowsheet. The next screen will display examples. Page 15 of 36
Slide 16 An arrow pointing to the right signifies additional columns exist that are not displayed on the screen. Page 16 of 36
Slide 17 To view the additional columns, use the + to scroll right and the - to scroll left: on the keyboard or on the toolbar click on the options -Scroll Left or +Scroll Right as shown below. Page 17 of 36
Slide 18 To see the reference range for any lab in the flowchart format, double click on the particular data box and the full lab will be brought up or highlight the line for that lab and right arrow in to see the full lab. Left arrow back to return to the flowchart. Visual Flow Sheet (VFS) is an overlay to PCI designed to view inpatient clinical data. It contains 2 possible lab tabs; Labs and Labs by MR#. The Lab tab contains labs specific to this admission only. The Labs by MR# tab may pull in labs from prior to the admission and is the only exception to the fact that the VFS is specific to one episode of care or billing encounter. The VFS has hover technology which allows the user to hover over the value to see the reference range. If there is a + sign in the box, there are multiple lab values that should appear when hovering over that box. Page 18 of 36
Slide 19 History Screens After you have selected the category from the previous summary screen, you will be taken to the History Screen. From this history screen you will be able to select the specific report or test that you would like to view. All reports/tests in that category will be listed in reverse chronological order, from most recent at the top to oldest at the bottom. To view a specific report, double click on the report of your choice. Page 19 of 36
Slide 20 Reports The attached are samples of a Lab Report on a TEST patient. Page 20 of 36
Slide 21 This is an example of a dictated report on a test patient. Page 21 of 36
Slide 22 Printing Reports & Tests From the History Screen, select the report or test you wish to print by single-clicking on it to highlight it. At the top of the screen where the cursor is flashing, single click on the word "PRINT". When the pop up box appears; single click "print details of the highlighted item". Click on the printer that you want your printer to print to. You cannot print from the view screen. If you want to view the document, you will need to arrow in to view it, then arrow back to the list to print it. First highlight the document you wish to print. Next, click on the word "Print" or enter a capital "P" in the field provided. Page 22 of 36
Slide 23 Self Assign Self assign functionality allows users not linked to a patient in Meditech to have access to view any patient in Meditech. All previous look up methods can be used. If the user selects a patient that doesn't have a Meditech link to the user, a box will display for the user to select the reason access is needed. The next screen will display what you would view when you are not linked to a patient in Meditech. Page 23 of 36
Slide 24 This area was customized by Affinity Health System. This area was hard coded by the vendor so it could not be changed so focus on the reason for access only. Page 24 of 36
Slide 25 The reason for the access can be chosen by using your down arrow to highlight the correct reason. Right arrow into the correct selection. If "Other" is selected a reason must be typed in. Should you decide it is not the correct patient or you choose not to continue to access the patient, press F11 or the red X to exit. Page 25 of 36
Slide 26 If a patient is selected that may need to be accessed multiple times, the patient can be added to your list of patients. To add a patient to your list of patients, when the Select Patient screen appears, place an "A" (note-this field is to the left of the Id-Patient text) or you can also click on "Add" to add the patient to your list of patients. The patient will remain on your list of patients until it is purged by Meditech (because the user has not accessed the patient for a period of time) or the user chooses to delete the patient. Page 26 of 36
Slide 27 The screen below shows that SELF, AHS was added to my list of patients and the option to Delete if I choose to delete the patient prior to the predetermined Meditech purge parameter. Select the field to the left of Id-Patient and enter in a capital "D" or click on the word "Delete" to remove this patient from your list. Page 27 of 36
Slide 28 Notes: 1. Menus will still determine the access within a patient record (ex. Behavioral Health dictated notes). 2. The text in the top section of the Self Assign warning box was customized for Affinity Health System but the bottom section was hard coded so we could not modify the text to reflect our State Laws so we ask you focus on the reason for the access. 3. Users should only be accessing records necessary to perform their job duties and/or care for patients.. 4. Access using Self Assign is monitored and unauthorized access will be referred to the privacy officer for appropriate action. Page 28 of 36
Slide 29 Allergy and Drug Reaction Allergies and drug reaction information is stored in two places. Meditech allergy and adverse drug reaction information can be accessed by clicking on the Allergies option on the toolbar. Page 29 of 36
Slide 30 This page pulls information from all the various modules in Meditech. Page 30 of 36
Slide 31 Affinity Medical Group uses an e-prescribing tool which is separate from Meditech. A SUMMARY LIST Report is sent over to Meditech each time a new prescription is entered which contains the current ambulatory medications along with any allergies and adverse drug reactions as documented in that application. Since these are two separate applications, potentially used in two different health care environments, providers should check both the Allergies option on the toolbar and the bottom of the most recent Prescription summary list and also with the patient or someone reliable on the patient's behalf to make sure you have the most up-to-date allergy and adverse drug reaction information. The next few screens will walk you through how to verify allergies and adverse drug reactions with the second method. this way as well. Remember to always check Page 31 of 36
Slide 32 Arrow down to PRESCRIPTIONS and right arrow in. Page 32 of 36
Slide 33 Right arrow in. Page 33 of 36
Slide 34 Right arrow in again... Page 34 of 36
Slide 35 If there are any allergies, they will be listed below. Page 35 of 36
Slide 36 This ends the online tutorial. If you have any questions or concerns, please call the Affinity Health System Help Desk at 628-9400. You will now be taken back to the web page to view additional reference guides or online tutorials. Page 36 of 36