Developed by: Lorelei Roque-Reyes – Applications Specialist IMS Department

May 25, 2016 v2 Page 1 of 22

Electronic Medical Record (EMR) Viewing Guide

Meditech 5.66

Disclaimer: The information contained in this document is for Meditech EMR general viewing only. This package does not include information on how to enter documentation. The access on the EMR menu is role-based and may not necessarily reflect similar menu as shown here.

Developed by: Lorelei Roque-Reyes – Applications Specialist IMS Department

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Table of Contents Protecting Patient Privacy ................................................................................................... 3

Electronic Medical Record (EMR) ......................................................................................... 4

Outpatient visits ................................................................................................................ 6

Visits By Date ................................................................................................................... 6

Summary Panel ................................................................................................................ 7

Custom Special Panels ....................................................................................................... 8

24 Hour ........................................................................................................................... 9

Vital Signs ...................................................................................................................... 10

Intake and Output (I & O) ................................................................................................ 10

Notes and Interventions ................................................................................................... 11

Medications .................................................................................................................... 15

Orders History ................................................................................................................ 15

Laboratory ..................................................................................................................... 16

Microbiology ................................................................................................................... 16

Laboratory Reports from Active Link Interface .................................................................... 17

Lifetime Summary ........................................................................................................... 17

Imaging Panel ................................................................................................................ 19

Other Reports ................................................................................................................. 19

Care Trends .................................................................................................................... 20

Care Activity ................................................................................................................... 20

History ........................................................................................................................... 21

Menu Definition ............................................................................................................... 21

The General Function Buttons ........................................................................................... 22

EMR Colour Coding .......................................................................................................... 22

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By the end of this document, you will be able to:

� Ensure privacy and confidentiality on patient Electronic Medical Record (EMR)

� Differentiate Outpatient and Inpatient visits

� Identify the different menu and the panels

� Know where to find specific clinical information

� Demonstrate where to find the ‘one stop shop’ for panel information

� Illustrate the use of trending and graphing information

� Assess knowledge by defining or paraphrasing items on the menu

Protecting Patient Privacy Safeguarding patient health information (PHI) is more than simply keeping it under lock and key. It is also about appropriate collection, use, disclosure and when the information is no longer required, its secure disposal. (eHealth Ontario)

• In accordance with privacy legislation you must only access documentation for patients/clients within your circle of care

• Heath Records performs periodic audits to help ensure patient privacy

• You must ensure you are logged off if you leave the computer for any length of time

• Be mindful of other eyes (visitors, staff outside the circle of care) who may be able to see the EMR

• Be mindful of policies relating to printing the EMR. These are available on the Bridgepoint Portal

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Electronic Medical Record (EMR) The Electronic Medical Record (EMR) is used to view patient records and electronic documentation.

After selecting Electronic Medical Record from the Applications, the Recently Accessed Records window will load if there is recent access done on any record.

If no ‘Recently Accessed Records’ – Go to Any Location on the menu, Select Bridgepoint Hospital facility and search by specific Unit for Any Location or Any Record.

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After selecting a patient from the Record List, the Visits by Date screen will appear. This screen contains a list of visits by the selected patient. Each visit will begin with the admission date. Current visits will show the location of the patient and will be marked with a green dot. Inpatient accounts will be shown with ‘Wheelchair’ icon and Outpatient Accounts will be shown with ‘Clipboard’ icon. Previous visits without the green dot will show the discharged date.

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Outpatient visits

Visits By Date The new visit selection screen will consist of three tables at the top: Time Frame, Visits, and View.

Only appropriate time frames will display. For example, if the patient does not have any visits over 5 years, than 7 Years and 10 Years will not display in the table.

Only appropriate visit types will be illuminated. If a patient does not have any visits of a particular type then that button will be low-lit.

The view table will default to ALL. The 75 most recent visits for the selected record. These visits appear in reverse chronological order by visit

Developed by: Lorelei Roque-Reyes – Applications Specialist IMS Department

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Record List Return to the previous list of records

Return Not applicable button is low-lit

Summary List Allows view of the Patient Summary

Allergies Opens the Allergies Management Screen, where allergies and adverse reactions may be viewed

View PCI

Not applicable button is low-lit

Moved to Other Records Not applicable button is low-lit

Add to Personal List Add the patient to your Personal List of records

Remove From Recently Accessed List

Remove patient from the list of Recently Accessed Records

Sign Up Not applicable button is low-lit

View Converted Charts Not applicable button is low-lit

Summary Panel This panel contains general information about an account and the selected visit that is grouped in sub-panels.

- Default EMR panel to EMR viewers not designated in Special Panels group - Allows view of the Patient Summary

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Custom Special Panels Custom special panels are user-defined panels that can serve as central location to view a wide range of data normally found on several different panels. These panels appear on the Special Panel list in EMR by a unique display name defined for the custom special panel (ex. Neuro-Rehab Panel, Medical-Rehab Panel and Ortho-Rehab Panel)

Special Panel View: (Ex. Neuro-Rehab Panel)

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24 Hour This panel displays vital signs, intake and output information, laboratory results and diagnostic reports. The buttons at the top of the screen let you select the current day or one of the preceding four days for which to view data. Each day you view the panel, the weekday button labels change, so that the last five days always appear.

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Vital Signs This panel displays temperatures, pulse rates, respiratory rates, blood pressure measurements, oxygen delivery methods, oxygen flow rates and fraction of inspired oxygen.

Intake and Output (I & O) This panel displays intake and output values. The buttons at the top of the screen allow you to specify the time intervals by which you want to break down the information. The Earlier and Later buttons allow you to view the next and prior six columns of information if available.

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Notes and Interventions The Notes menu option contains a group of panels that provide access to the notes by care providers. The Panel selection buttons allow you to select the notes you want to view. The list included a maximum of 50 signed notes. Use the Earlier and the Later buttons to view additional groups of 50 notes. After selecting a patient visit from list, the EMR patient record will load. To view interventions in the EMR, click the Notes button from the side menu.

The Notes panel will open and list only Focus Notes by default. Click the Assessments and Notes button from the footer menu to view all documentation.

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The Notes panel lists all data in reverse chronological order by default. Click the column title ‘Type’ to sort by Intervention name.

EMR initially sorts the notes by date and time in reverse chronological order (the most recent note is at the top of the panel. To change the sort order, click the column header by which you want to sort the notes (for example, User). EMR then sorts the notes by alphabetical order, and then by date and time.

Depending on the type of sort, Earlier and Later or Next Page and Prev Page buttons appear under selection buttons. If the sort was by date and time, the Earlier and Later buttons appear. For all other sorts, the Next Page and Prev Page buttons appear.

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To view an Intervention, click the blue ‘i’ icon

The selected Intervention will load in the Meditech Document Viewer.

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The Meditech Document Viewer contains a header and a footer menu. The header menu has the following options:

Copy the selected text

Select all text in the documentation

Search for a word or phrase in the documentation

Print the documentation (the best option to print with proper formatting)

The footer menu has the following options:

Return to the Notes Panel

Print the documentation in plain text without formatting (Not recommended)

Used to navigate to other documentation entries

Print a screen shot of the Meditech Window (Not recommended)

Lock or suspend your Meditech session. You must enter your Meditech password again to unlock.

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Medications All medications ordered during a patients visit appear on this panel. The view selection buttons allow you to view the Active, Discontinued or All medications

Orders History History of all Non-Medication Order Entries (NMOE) placed on the selected patient

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Laboratory Use the laboratory menu option to view information for Hematology, Blood Gas, Coagulation, Chemistry, Urine, Toxicology, Other Body Source, Immunology, Miscellaneous and Serology.

Microbiology Use this panel to view microbiology information for up to 75 specimens per screen. Click the notepad icon to view the report.

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Laboratory Reports from Active Link Interface Click on ‘Micro, ECG and MISC’ tab on top right of the menu

Click on Laboratory and Microbiology tabs on the Menu to look at results

- Results can be trended per visit - Click on Lifetime Summary to view the results on all visits

Lifetime Summary When you select the Lifetime Summary option, the system initially displays the most recent information for any items entered over the lifetime of the patient visit. However, you can also view a complete history of all items entered over a specified timeframe by clicking the item of interest. Upon clicking an item, a history screen displays all items entered within a 6 month timeframe.

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The same concept will be applied to the Imaging, Pathology, and Other Reports panel.

Clicking the information icon will take you to the snapshot for the specimen that the result was a part of.

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Imaging Panel Use this panel to view the Imaging and Therapeutic Services (ITS) procedures in reverse chronological order. The panel included codes, impressions, current reports, history reports and images that are associated with the procedures.

Other Reports You will find all the Physician documentations in this menu. This contains the various reports sent to EMR from other Meditech modules. To view the associated report, click this comment bubble icon From the EMR, Click the “Other Reports” button and click the “All Reports” tab

Tip: Each Panel allows the user to click on the column headings to change sort order.

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Care Trends This panel displays a group of panels grouped by body system and special categories. (Example, Psychosocial and Education).

Care Activity Use this panel to view care activity by accessing Assessments, Interventions, and Outcomes and Plans of Care. The activity information on each panel appears in reverse chronological order.

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History This menu displays a group of panels that shows responses to the questions asked during the Medical History Assessment.

Menu Definition

Used for acute care facilities only.

List records associated to you, your provider group, or for coverage providers.

Used for acute care facilities only.

List records that are not found in the Admitting Department (ex. Day Treatment).

Displays new, unviewed completed results.

List records that you have viewed in the last 14 days. The most recently viewed record appears at the top.

List records that you have added to your personal list. This personal list is the same as PCS My List.

List patients in a specific location.

List patients using the search tool.

View /Print EMR Reports for all records associated to you, your provider group, or coverage providers.

Sign documents and orders electronically

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The General Function Buttons This function bar displays a row of buttons in the lower right corner. The Reference or Globe icon is used to access the ‘external links’ attached per user. For example, Patient Results Online (PRO) or College of Nurses of Ontario (CNO).

EMR Colour Coding