West Suburban Medical Center Emergency Department Mc Kesson

West Suburban Medical Center Emergency Department Mc. Kesson EMR Training Module for Attending Physicians Updated 10. 1. 2017

Welcome to the emergency department at West Suburban Medical Center! This Powerpoint module will help orient you to Mc. Kesson, the EMR used in our ED. You will receive your login and password during your first orientation session. Please review these slides and if you have any questions, feel free to contact me at any time. Dave Anthony, MD, MPH Medical Director, Emergency Department West Suburban Medical Center Email: danthony@epmg. com

I. Using the Tracking Board

Using the Tracking Board Once you log into the computer, the first screen you will see is the ED tracking board above. You will have to log in a second time in at the top of the tracking board to begin charting or entering orders. You will only have to do this once, at the start of your session.

Using the Tracking Board The tracking board is fairly straightforward. Beds 1 through 17 are designated main ED beds, and 18 through 25, as well as “overflow” (OF) beds, are designated Fast Track beds (which are staffed exclusively by the midlevel providers). Across the top you will see fields such as Name, Chief Complaint, Sex, etc.

Using the Tracking Board The ED is divided into “East” and “West” sides, each staffed with a physician during double-coverage hours (7 am to 3 am). The “West” physician covers rooms 1 through 9, and the “East” physician covers rooms 10 through 17. You can filter the tracking board to only show your side by selecting “East” or “West” from the drop-down menu highlighted above.

Using the Tracking Board In order to sign up for a patient, double-click in the “EDMD” column.

II. Charting on a Patient

Charting on a Patient To open a patient’s chart, highlight the patient on the tracking board and click the “Chart” button.

Charting on a Patient This window will pop up. The entirety of the patient’s ED chart is contained in this window. The most recent set of vital signs are listed across the top, and triage nurse comments will appear under “RN History” in the “History of Present Illness” section.

Charting on a Patient To begin charting on a patient, click the “HPI” button.

Charting on a Patient You will do the majority of your charting, including HPI, ROS, past medical/family/social, and physical exam, from this “HPI” window. You may choose to click some of the options in the “Onset”, “Source”, “Additional Sources”, and “Reliability of History” fields, but this is definitely not necessary (and most choose not to).

Charting on a Patient Some clinicians do find the “Complete history not available” radio button to be useful – it will open an additional window allowing you to document why history is unavailable (nonverbal, too sick, unresponsive, etc). This will then auto-populate ROS and past medical/social/family fields with a statement to that effect.

Charting on a Patient Most people choose to free-text their HPI – to do this, click the “Add Note” button and then type in your HPI.

Charting on a Patient Social history is relatively easy to document, as seen above (aside from substance abuse). For past medical and family history, the options are limited. You can click any of the options above but these only apply if the patient has no history (!). Most people choose to free-text the patient’s PMH in their “HPI” note, but the coders often miss this.

Charting on a Patient To ensure the coders don’t miss your documentation of past medical and family histories, the easiest thing to do is to click the “Health Summary” button above.

Charting on a Patient This will take you to the “Health Summary” window. These fields automatically import from prior ED charts and from nursing documentation. You can click that you have “reviewed” each of these, and it will be reflected in the patient’s chart.

Charting on a Patient ROS is documented by clicking the button above.

Charting on a Patient Above you can see the ROS window.

Charting on a Patient Alternatively, you can choose to document pertinent positives and negatives in your freetext HPI. If you then select “Except as noted all ROS negative”, it indicates that you have done a full 10 -point review of systems. This is a quick way to document an otherwise negative ROS, but beware of fraudulently documenting ROS elements you did not discuss.

Charting on a Patient Click here for physical exam. Most patients should be able to have their exam documented via the “Quick Click Medical” option.

Charting on a Patient Whatever elements you click under each organ system will show up in your chart. You can also select the “Other (FT)” option under any organ system and free-text whatever you like.

Charting on a Patient The “Quick Click Trauma” exam has a useful templated exam for any trauma patient. If the patient is a pediatric patient an additional “Peds Survey” button will show up with a templated pediatric exam which many clinicians find useful.

Charting on a Patient So that’s your HPI, ROS, PMH/PFH/PSH, and PE. Click “Next” to return to the patient’s chart.

Charting on a Patient Unfortunately there is no good place to document your assessment, plan, and medical decision-making. I generally recommend you document this separately in a “Free Text Note” after you’ve documented your HPI, ROS, PE, etc.

Charting on a Patient Document your assessment and plan using the “Reassessment / Progress” note. You can also additional “Reassessment / Progress” notes later with brief patient updates. These will appear as separate update notes with their own individual time stamps, and are generally the best way to keep a running narrative of the patient’s clinical course in the ED.

Charting on a Patient If you are working with a resident, they should be completing the vast majority of the note (including HPI, ROS, PMFSH, PE, etc). You must, however, document a brief note that you have seen and examined the patient, and link it to the resident’s note. Unfortunately, Mc. Kesson does not have a built-in feature to facilitate this.

Charting on a Patient A common practice is to write a brief “Reassessment / Progress” note that begins as follows: “ED attending note. Patient seen and examined. Agree with resident note above with the following additions/exceptions: ” You can copy this phrase and simply paste it every time you write a note on a resident patient.

Charting on a Patient A few other brief features of the patient chart: Labs automatically import into the chart

Charting on a Patient Radiological studies do not automatically import. You can manually import them through the “XRay” tab but this tends to be a laborious process. Another option is to just “Ctrl-C” copy the radiologist’s interpretation and paste it into a Free Text Note.

Charting on a Patient EKGs can be easily documented via the “EKG – Monitor” tab.

Charting on a Patient NIHSS should be documented on *all* patients presenting with acute stroke, or on any patient being admitted to rule out stroke (whether acute or subacute).

Charting on a Patient Document any procedures using the “Procedures” tab.

Charting on a Patient You must double-click whichever procedure you wish to document, so that it shows up in the “Selected Items” column. Then click “Next” and the EMR will walk you through a templated procedure note.

III. Charting Patient Disposition

Charting Patient Disposition When you are ready to dispo your patient, click the “Disposition” tab.

Charting Patient Disposition The “Disposition” window will pop up. First select “Diagnosis”.

Charting Patient Disposition Select the “Search” tab and you can search for appropriate diagnoses. You can choose as many diagnoses for your patient as you wish. Simply check the box beside the desired diagnosis, then click “Add”. Continue doing this until you are finished, then click “Submit”.

Charting Patient Disposition Select “Prescription Writer” if you are discharging a patient home and want to write prescriptions for them.

Charting Patient Disposition Search for the medications you wish to prescribe, then follow the prompts. Submitted prescriptions will appear in the “Prescriptions” section at the top of the window. Once you have submitted all of the prescriptions you wish to prescribe, click the “Submit” button to print them.

Charting Patient Disposition Next, if the patient is being discharged home, select “Discharge Instructions”.

Charting Patient Disposition Start with the “Prewritten” tab at the top. These choices will print out pre-written templated information and instructions about whatever diagnoses you select for the patient (similar to Exit. Care).

Charting Patient Disposition The “Recommended” diagnoses will auto-populate with choices based on the diagnosis you have entered for the patient. You can choose any of these by clicking them and then clicking the “Add” button.

Charting Patient Disposition If you can’t find a relevant diagnosis, select the “All Procedures and Diagnoses” tab and you can search for an appropriate diagnosis.

Charting Patient Disposition Next, move on to the “Custom” tab. Click the “New” button. This will allow you to free-text any specific instructions for the patient (e. g. what medications to take, when to follow up, return precautions, etc).

Charting Patient Disposition Finally, move on to the “Follow-up” tab. You can use this tab to select specific physicians for referral. Click the “New” button in the “Referral” section and a window will pop up allowing you to search for any physician name or specialty. This will print an office address and phone number for referral on the patient’s discharge instructions.

Charting Patient Disposition You can also select the “Primary Care Follow-up Instruction”, which will print the “Follow up with your primary care physician…” text shown above in the patient’s discharge instructions.

Charting Patient Disposition You’re now ready to print the discharge instructions. Click the “Print” button.

The “Print/Fax” window will appear – make sure both “Discharge Instructions” and “Transition-3” are selected (typically you have to manually select “Transition-3”). The pre-designated printer will appear in the “Printer” column – you should not have to change this. Click “Print Selected Report” and give the discharge papers to the patient’s nurse, or place them in the patient’s clipboard.

Charting Patient Disposition Now, click “Decision to Dispo”.

Charting Patient Disposition Select the appropriate disposition on the left. If you choose “Admit” or “Transfer”, an additional screen will appear prompting you to enter more details (e. g. admitting attending, etc). Also choose the patient’s condition on the right.

Charting Patient Disposition Selecting the disposition in the “Decision to Dispo” tab will flag the patient’s disposition on the tracking board. This alerts the nursing staff that the patient is ready for discharge, or to call for an inpatient bed if the patient is being admitted.

Charting Patient Disposition Finally, to completely close the chart, select “Final Disposition” tab. Closing the chart is the final step that allows the charts to be electronically sent to the coders for billing. If the chart is not signed and closed we cannot bill for it, so it is crucial that you close your charts.

Charting Patient Disposition However, closing the chart locks it to any further order placement, and any further charting needs to be done via a chart addendum. It is probably wise to wait until the patient is ready to leave the department to sign the chart via the “Final Disposition” tab.

Charting Patient Disposition Selecting “Final Disposition” will bring you to this window. Occasionally the order entry screen will appear first – simply click “Done” and you will pass through to this window. Select “Sign the Chart” and then click “Next”, and your chart will be closed.

IV. Using the Chart Finder to Sign Incomplete Charts

Using the Chart Finder Any open charts that have not been signed in the “Final Disposition” tab will show up in the “Chart Finder” once the patient has been removed from the tracking board, and will remain in your inbox until they are signed.

Using the Chart Finder Click the “Search” drop-down menu.

Using the Chart Finder Select “My Unsigned Charts” – “As Treating Provider” to see unsigned charts for patients you saw primarily. You will need to “Launch Selected Charts” and sign each one via the “Final Disposition” tab as previously described. (You may also see patients that were signed out to you that you dispositioned – you should close these out as well. )

Using the Chart Finder If, for some reason, a chart was erroneously assigned to you, you can reassign it to the appropriate physician using the drop-down menu and choosing the “Reassign Treating Provider” option.

Using the Chart Finder You should also make a habit of routinely cosigning your midlevel notes. To do this, at the end of each shift choose “As Cosigning Provider” in the Chart Finder. A list of charts assigned to you for cosigning will appear in the large box in the Chart Finder window.

Using the Chart Finder If you choose “Select All” all, then open the drop-down menu and choose “Auto Cosign Selected Charts” the Chart Finder will automatically cosign all your midlevel charts for you. Of course, you can individually open each chart to verify that you agree with the midlevel’s care by using the “Launch Selected Charts” button on each chart.

V. Viewing Results

Viewing Results One way to view results from the patient’s current ED stay is through the tracking board. When new results are returned, a blue “Y*” will appear in either the “Lab” or the “R-Rslt” column. Double-click on the “Y” to view results.

Viewing Results Lab results appear as shown above. Abnormal results will appear in red.

Viewing Results Mc. Kesson can sometimes be glitchy, and sometimes when you open results to view, some of the values will not appear, as shown above.

Viewing Results If this happens, “left-click” and drag your mouse down the empty cells where the values should be to make them appear. (Don’t ask why Mc. Kesson does this… nobody has ever figured it out. )

Viewing Results To view radiology results, you must “right-click” the cell next to the name of the study you wish to view.

Viewing Results The study results will appear in a separate window.

Viewing Results You can also view results from the patient’s current ED visit in the “Physician Portal”, which you will learn about next.

VI. Finding Old Records

Finding Old Records To find old records (ED charts, radiological studies, labs, discharge summaries, operative reports, echocardiograms, consultation notes, etc etc), open the “Physician Portal” from the main tracking board. This will open an additional external web-based screen called the Portal.

Finding Old Records The primary tabs in Portal that are relevant to ED care the “Results” and “Transcription” tabs. “Transcription” contains all non-bloodwork information (such as ED charts, radiological studies, operative reports, discharge summaries, etc) from the patient’s current ED visit, as well as all prior ED visits and hospitalizations.

Finding Old Records Most items can be viewed by clicking the blue hyperlink.

Finding Old Records There are two exceptions: ED charts are viewed by clicking the red “ED” cross icon, and you can view the actual PACS images by clicking the “PACS” icon. (Radiology reports can be viewed by clicking the blue hyperlink for the specific study. )

Finding Old Records The results tab allows you to see all laboratory results for the patient’s current and all prior ED visits and hospitalizations.

Finding Old Records You can also view old EKGs by selecting the “ECG Tracing Westlake West Suburban” sub-tab in the “Results” section.

VII. Order Entry / CPOE

Order Entry The CPOE screen is accessed from within the patient’s chart, by clicking the “Enter Orders” button.

Order Entry This is the order entry screen. It is divided into four separate areas. Upon opening it, in the top right area you will see a list of common ED order sets. “Adult Common Orders” is a very commonly-used order set.

Order Entry This is the Adult Common Orders order set. There are four tabs at the top, each of which contains commonly-used ED orders.

Order Entry There additional order sets that are very useful in the ED. Please make sure to use the Stroke Order Set for ALL acute stroke activations (it flags CT for stat read).

Order Entry The Sepsis order set contains empiric antibiotic choices for septic patients based on West Suburban’s antibiogram and ID recommendations – please use it for antibiotic selection in your septic patients.

Order Entry Other helpful order sets are “Blood Component Transfusion Orders” (for giving a blood transfusion, “Chest Pain / SOB Orders” (for easy access to common asthma medications), and “Radiology Common Orders” (for a more extensive list of radiologic studies. Feel free to explore the sets.

Order Entry The box on the left shows all active and completed orders for the patient’s current ED stay. (It also contains additional information such as prior diagnoses, allergies, etc).

Order Entry If you can’t find an order, you can enter free text in the box in the lower right corner. Options for selection based on your search term will appear in the upper right corner. ED-specific orders are preceded by “ED” (these orders simply eliminate extraneous qualifiers that are necessary on inpatient floors, such as route, frequency, etc. Click on your desired order.

Order Entry After selecting your desired order, you may be prompted for any necessary qualifiers in the middle right box. Sometimes these are options that you are able to click to select, and sometimes (as above), you will be asked to free text something – the free text area in the lower right is the only place to enter free text, so you will enter the qualifier in this location.

Order Entry Orders you are actively placing in the current order entry session will show up in blue in the left side box. You can click on them to modify or delete them before signing the orders.

Order Entry Two other quick tips: use the “Outlines” button to return to the main screen containing the order entry sets at any time; and use the “Oops” button to go one step back in the order entry process if you’ve made a mistake.

Order Entry Finally, all patients being admitted to the hospital need to have a Bed Request order placed. This order is called “Request for Bed Outline” and can be found on the main CPOE page at the very bottom of the order set list.

Order Entry The Bed Request order has four fields that need to be filled out: “Status” (inpatient or observation), “Level of care”, “Attending Physician” (entered free text), and “Resident Team” (either internal medicine, family medicine, or none). These qualifiers can be decided upon at the time of discussion with the admitting attending. If any special circumstances (trach, vent, dialysis, etc) or isolation issues are present, you should click the appropriate boxes. You should ignore the “Patient type” and “Location” fields.

Order Entry The Bed Request order can only be placed by an attending physician. You must place the Bed Request order for any patient you are seeing with a resident (though the resident can document the disposition in the chart). Also, the midlevels in Fast Track sometimes admit patients; the orders for these admissions must be placed by an attending as well. Midlevels will come to you with all of the necessary information to place the order.

That concludes the Mc. Kesson orientation module. I hope it has been useful, and, of course, please email me or speak to me in person if you have any additional questions. Welcome aboard! Dave Anthony, MD, MPH Medical Director, Emergency Department West Suburban Medical Center Email: danthony@epmg. com