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 Ad Hoc Order Entry Tips...4 Troubleshooting Ad Hoc Order Entry...5 Back Charting...6 Overdue Medications...7 Charting Not Given...8 Charting IVPBs... 10 Changing IVPB Infusion Time... 11 Correcting Medication Charting Errors... 12 Modify... 12 Unchart... 13 Rescheduling a Dose... 14 Insulin... 15 Scanning Insulin... 15 Insulin Correctional Scale Detail... 15 Vaccines... 18 PCAs... 19 Epidurals... 21 Charting epidurals on the PDA (CareMobile)... 21 Charting Epidural totals on the form... 22 NICU TPN Nurse Witness... 23 MAR Notes... 24 Isolation... 25 Discontinued Medications... 26 CareMobile... 26 MAR Summary... 27 MAR... 27 Transfers to Other Facilities... 28 1
Creating an Order in CareMobile (Ad Hoc Order Entry) Ad Hoc Order entry is a function that allows clinicians to enter med orders into CareMobile and administer medications before order is entered. Only use function for now and stat orders Must have medication as a floor stock item Most likely to occur in the critical care areas Ad Hoc Order Entry takes longer to chart than a medication that has been entered by pharmacy A pharmacist will not verify Ad Hoc orders During emergent times, the clinician is most likely to chart after the patient is stable. In this scenario, the orders will be entered and back charted. 1. Scan the med 2. Tap Yes on the alert 3. Drug Alert window opens Tap to view details 2
4. Consult the pharmacist or physician when making a decision to override the alerts 5. Tap Continue to enter the order 6. Tap Cancel to not enter the order 7. The Override Reason window pops up 8. Tap drop-down arrow and select a reason for the override 9. Tap Continue on Override reason window 10. Review medication information and change dose if needed. (An error occurs when 2 packages are scanned. Scan 1 package and change the dose.) 11. Complete the required fields (yellow) 12. Tap Save 13. Go to the To Be Signed folder. 14. Verbally confirm patient and Scan patient s name band. 15. Administer medication. 16. Tap Sign. Change dose if needed. Do not scan 2 packages. If having trouble entering physician, tap the binoculars and enter the name in the search window. 3
Creating an Order for med that is already ordered with a different dose/frequency. There are times when a stat med is ordered and a routine order already exists. For example, sliding scale insulin has been ordered ACHS. Physician gives verbal order for stat Regular Insulin 5 units. If the insulin is scanned the sliding scale order opens, not the order window. 1. Tap the Ad Hoc Order Icon 2. Scan the medication 3. Respond to the alerts 4. Complete the order window 5. Complete the med administration process. Tap Icon Scan med Do not use Product Search Ad Hoc Order Entry Tips When order has been entered into PowerChart a med task will be generated. The nurse must chart Not Given with the reason already given. Ad Hoc orders (order created by the nurse in CareMobile) go to discontinued status immediately. On the MAR all discontinued meds are listed at the bottom. On the MAR Summary Ad Hoc ordered meds are grayed and listed in the Scheduled section alphabetically with the active orders. 4
Troubleshooting Ad Hoc Order Entry An Ad Hoc Order for a pain medication does not generate a pain reassessment task in CareMobile Ad Hoc orders are considered one time orders in CareMobile and therefore do not generate a PRN Pain Response task. Go to Ad Hoc Charting in PowerChart to document the pain reassessment. Following current policy, the pain reassessment should be performed and documented within one hour of administering pain medication Entering an Ad Hoc Order for a medication that has multiple packages You can scan only one package to enter an Ad Hoc Order. If you attempt to scan 2 packages, two separate orders will be created, or an alert will prevent the 2 nd scan. Scan 1 package and change the dose in the order window Alert if scan 2 packages Change dose to correct amount. 5
1. Tap med task in Overdue Tasks folder Back Charting 2. Tap Yes on not verified by scan alert. Scanning is bypassed because the med was already administered. 3. Tap Back Charting Icon 4. Change time and/or date 5. Tap OK 6. Tap Save on the charting window 7. Go to the To be Signed folder 8. Verbally verify patient s name and birth date 9. Scan the patient s name band 10. Tap Sign 6
Overdue Medications 1. Tap Overdue Tasks list 2. Follow procedure for preparing meds 3. Scan med(s) 4. Select a Task window opens if there are multiple late doses 5. Tap the desired task (due time is in red) Select a Task window opens Tap the desired task 6. Go to the To be Signed folder 7. Scan the ID band 8. Sign 7
Charting Not Given There are times that you chart a med was not given such as, Dose held for 1 day due to a procedure Patient took the medication at home before coming to the hospital Patient refused Medication was given on a non-emar unit. Charting not given can be accomplished on PAL, MAR or CareMobile (PDA). PAL 1. Click on the task cell to open the Tasks window 2. Right-click on the med task 3. Click chart Not Done 4. Chart Not Done window opens 5. Click the drop-down arrow to select a reason 6. Click the sign button MAR 1. Right-click on the med task 2. Click Chart Not Done 3. Complete the Chart Not Done window as directed above 8
CareMobile 1. Tap on the med task in the To be Signed folder 2. Tap Not Given 3. Tap the drop-down arrow for the reason field and select a reason 4. Tap Save Tap on med to open charting window Tap Not Given Tap the Reason dropdown arrow and select a reason Tap Save 9
Charting IVPBs IVPBs scheduled to infuse for less than 2 hours (120 minutes) will automatically be confirmed and the volumes will be added to Intake and Output totals. IVPBs which are scheduled to infuse for more than 2 hours (121 minutes) will need to be confirmed to be included in the Intake and Output totals. To Confirm an IVPB: 1. Scan and Sign the IVPB as usual 2. From Interactive View, go to Intake and Output 3. Click the icon 4. Click Select All 5. Click Confirm 6. Once the confirmation has been completed that volume will become part of the patient s total volumes. 10
Changing IVPB Infusion Time Infusion times can be changed in CareMobile. For example, Vancomycin 1 gm has an infusion time of 1 hour. You are going to infuse the IVPB over 2 hours. 1. Tap the task in the To be Signed list to open the charting window 2. Tap the Infuse Volume icon 3. Change the Infuse Over field to the desired time 4. Tap Save 5. Continue with medication administration process Change the Infuse Over field IVPB volumes auto-chart on I&O under the Medication section The IVPB Infuse Over was changed to 2 hours. The volume is charted in three time columns because the start time is 1802 11
Correcting Medication Charting Errors All medication charting errors must be corrected on the MAR including IV Begin bags. Medication Drip rate changes charted on IV Drips section of Interactive View may be corrected on Interactive View. Modify 1. Open MAR 2. Right click charted dose cell 3. Select Modify 4. Make corrections such as changing time or dose 5. Click Comment and enter reason for correction. 6. Sign 12
Viewing Modified Documentation Corrected documentation displays with (c) Double click to view detail Unchart Use Unchart function for a charted med that was not administered or when medication has been charted on the wrong patient. 1. Open MAR 2. Right click charted dose cell 3. Select Unchart 4. Enter reason and click OK 5. Sign Uncharting displays as In Error and the task is available to chart 13
Rescheduling a Dose Reschedule doses only when administering a dose early (giving meds prior to discharge) or moving doses back on the standard administration time (rescheduling today s IVPB antibiotics following a procedure). 1. Open MAR 2. Right-click on the dose to be rescheduled 3. Select Reschedule This Dose 4. Enter the new administration time 5. Click OK Currently scheduled time Rescheduled time Enter new time Do not enter a reason. It does not display. Task has moved to new time on MAR. Task will display in CareMobile on the Due Tasks list 1 hour prior to the due time. 14
Insulin Scanning Insulin Because nursing does not send the insulin back to pharmacy for re-labeling every time the dose is changed, you must scan the manufacturer s barcode instead of the barcode on the patient label. 1. Select a task window will open. Tap the desired task. 2. Enter the site 3. Tap Save 4. Continue with the medication administration process 5. The medication charting will display on the Diabetic Flowsheet Tap the task Insulin Correctional Scale Detail To view Insulin Correctional Scale detail you must go to Order Detail on CareMobile, MAR Summary or MAR. CareMobile 1. Tap and hold on task 2. Tap Order Details 3. Tap Comments 4. Comments may have 2 options: MAR Note and Order Comments 5. Click the drop-down arrow and select the other option to view all comments Tap drop-down arrow and select other option 15
MAR Summary 1. Hover on the order 2. Click Order Info 3. Click the Comments tab Displays all comments entered by pharmacy 16
MAR 1. Hover to the order to view the detail that is partially displayed 2. Click the Push Pin icon to view the comments not displayed in the order Click the Push Pin Displays all comments entered by pharmacy 17
Vaccines Do not administer the vaccine(s) prior to Nurse Review. Notify the pharmacy of orders that have been placed incorrectly. A vaccine order is a one-time order with the start date and time of 0900 the day following admission: Frequency: Once Start time: 0900 Start date: Day following admission Reviewing the MAR Summary tab as part of the shift change report will further ensure the accuracy of vaccine orders that have been entered. Scan the vaccine barcode 1. Complete required fields (yellow or peach) VIS publication date is found at the bottom of the Vaccine Information Sheet Administration date is required so that the data will populate the AHA and AP for the next admission 2. The Vaccine lot number will not accept letters. Enter the number 3. Click the comment icon and enter the entire lot number including the letters 4. Tap Save 5. Continue med administration process Use scroll bar to view all the required fields. Verify that no other doses have been administered When the vaccine is not available from the manufacturer, pharmacy will enter an order indicating patient meets the vaccine criteria but it is not available. The order will display on the MAR, MAR Summary and Orders tab but does not generate a task in CareMobile (PDA). When the vaccine is available, pharmacy will enter an order to administer. 18
PCAs Charting on the PDA (CareMobile) PCA tasks display in the PRN folder in CareMobile. Chart the PCA when a new bag/syringe is started 1. Tap and hold on the task to view the comments 2. Tap Order Details 3. Tap Comments 4. Scan the med bar code 5. Complete the med administration process The PCA will display the entire dose on the MAR and MAR Summary. 19
Charting PCA totals on the form When a PCA order is placed, a PAL task will generate every 8 hours, 0800-1600 - 0000. The task opens the PCA/Continuous Narcotic Infusion form. Follow the instructions The charted data will display on a Pain Flowsheet. The specialty flowsheet is accessible from the Patient Assessment and Results Review. Click the Level arrow on the dashboard The PCA will not create a row for charting volumes on the I&O. 20
Epidurals Charting epidurals on the PDA (CareMobile) Epidural tasks will display in the Continuous IV folder in CareMobile. Chart the epidural when a new bag/syringe is started 1. Tap and hold on the task to view the comments 2. Tap Order Details 3. Tap Comments 4. Tap the drop-down arrow and select the other option to view all Pharmacy comments Charting is the same as continuous IV charting 1. Scan med bar code when hanging a new bag/syringe 2. Tap Add IV Events 3. Tap Begin Bag 21
4. Complete the Charting window Click the Calendar to change the Performed Date/Time when back charting Complete the required fields (peach or yellow) Dose and Dose unit refer to the medication Verify that you selected the correct dose unit for the medication Completing the dose field will auto calculate the rate. If rate is entered, then dose will auto-calculate. 5. Tap Save 6. Continue med administration process Click to change the Performed Date/Time Medication Verify that Dose unit is correct before tapping Save Charting Epidural totals on the form The Epidural Flowsheet will be tasked every 4 hours on the PAL for charting the cumulative volume of the current bag. 1. Complete all the required fields 2. The 4 Hour Pump Running Total will populate the I&O under Other Intake Sources The Epidural 4 Hr Running Total will not add into the Total volume on I&O. 22
Charting on IV Drips section of IView Chart the rate/dose on IV Drips in Interactive View q 4 hours *Critical Care units will chart epidural doses and volumes hourly on IV Drips and I&O. NICU TPN Nurse Witness NICU RNs will document a Witness when administering TPN. 1. Scan the IV Bag, Select Begin Bag. 2. Tap Witness button. 3. Enter PowerChart password. 4. Tap continue, click To Be Signed. 5. Tap Sign. The Witness is viewable on the MAR in the View Details Action List. The Witness can also be added by going to the MAR and selecting Begin Bag. The yellow Witness field will display and allow the user to enter the Witness name. 23
MAR Notes Mar Notes are entered by pharmacy as reminder notes or charting fields. 1. Tap the task 2. Tap Yes on the bypass scanning alert 3. Tap Not Given (MAR reminder rotes) or complete charting window. 4. The patient s name band must be scanned to sign, except Not Given charting. The documentation displays on the MAR tab. MAR Reminder Notes These notes do not require charting, i.e., the Warfarin note reminding the nurse to check the chart daily. Chart Not Given (CareMobile) or Chart Not Done (PAL or MAR) with the reason Note Acknowledged. The patient s name band does not need to be scanned when Not Given is charted. CareMobile PAL MAR Notes for Charting Notes such as the BP MAR Note allows the user to chart the BP via the PDA and view the data on the MAR and MAR Summary. If the BP has already been documented via PowerChart, go to the PAL or MAR, and Chart Not Done. The charted blood pressure is viewable on the MAR, and all other tabs and specialty flowsheets that currently display blood pressure. 24
Isolation When PDA is left in room and patient has vacated the room: 1. Clean with Sani-Cloth Plus Wipes. 2. Squeeze excess fluid from wipes. Isolation Process for PDA when it is not possible to have a dedicated PDA Duplicate patient ID bands placed in the anteroom for scanning is a violation of hospital policy and a significant safety risk. You must scan the ID band on the patient. Outside Patient Room: 1. Scan and prepare meds outside room. 2. Gown up to enter the room. 3. Take PDA into the room. In the patient room: 1. Scan the patient ID band. 2. Set down the PDA in the patient room. 3. Administer medications. 4. Complete charting on the PDA. After Medication Administration: 1. Remove gown and gloves in the room. 2. Perform hand hygiene with alcohol gel. 3. Re-glove and squeeze excess liquid from Sani-Cloth Plus Wipes so the solution does not run onto the screen. 4. Clean PDA with Sani-Cloth Plus Wipe. 5. Leave room with the PDA and discard gloves. 6. Perform hand hygiene with alcohol gel. 25
Discontinued Medications CareMobile Medications that have been discontinued will drop off the Due Tasks List. The med order will display in the Discontinued folder. 1. Tap Due Task or the arrow to open the list of folders. 2. Tap Discontinued folder Tap on the med to view order information 3. The med order will display for 24 hours. Overdue medications will display in the Overdue folder until charted as given or not given. Indicates Discontinued Continuous IVs that have not been started will not display in the Discontinued folder. 26
MAR Summary Discontinued meds are grayed and continue to display in the Scheduled, Unscheduled, PRN and Continuous IV sections. Continuous IVs that have not been started will drop off the MAR Summary. MAR Discontinued meds move to the Discontinued sections of the MAR. Meds ordered in CareMobile go to Discontinued status as soon as the med is signed. It is recommended to view medications on the MAR Summary where the discontinued meds remain in the active sections. Continuous IVs that have not been started will not display in the Discontinued Continuous Infusions section. 27
Transfers to Other Facilities The MAR will not be printed except for a transfer outside the Munson Healthcare system. The Mercies, Kalkaska and Paul Oliver can view the MAR and MAR Summary sections of the chart and therefore, will not need a pmar with transfers. Discharges to other institutions Print the MAR using Publish Medical Record function. 28