BaptistMedicalCenter

PowerChart

Basic

Clinical Documentation

Instructor Guide

Participant Guide

BaptistMedicalCenterBasic Clinical Documentation Participant Guide

Effective date: 11/15/004Version: 2003.02Tracking: 2004.03

Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express written consent of Cerner.


Preamble

To enhance the nurse’s knowledge base regarding the EMR, HIPAA Laws, and Data as it relates to Patient Safety and patient confidentiality.

Overview

The electronic medical record (EMR) also known as the electronic health record (EHR) has been recognized as a tool to provide patient confidently in accords with the Health Insurance Portability and Accountability Act (HIPAA), while providing a more efficient and effective means of sharing and disseminating vital health care information (Banks, D.L., 2006, February).

“As the country moves towards its goal of a National Health Information Infrastructure (NHII), and greater use of electronic health records, protecting the confidentiality, integrity, and availability of electronic protected health information (EPHI) becomes even more critical. The security standards in HIPAA were developed for two primary purposes. First, and foremost, the implementation of appropriate security safeguards protects certain electronic health care information that may be at risk. Second, protecting an individual’s health information, while permitting the appropriate access and use of that information, ultimately promotes the use of electronic health information in the industry – an important goal of HIPAA” (Centers for Medicare & Medicaid Services (CMS). 2007, March, p. 4).

The Privacy Rule set the standards for persons who may have access to protected health information (PHI) and requires covered entities to have in place appropriate administrative, physical, and technical safeguards and to implement those safeguards reasonably(Centers for Medicare & Medicaid Services (CMS). 2007, March).

The security rule is a set of national standards for safeguards to protect the confidentiality, integrity, and availability of electronic protected health information 1). Implementing administrative, physical, and technical safeguards 2) Developing security policies and procedures 3). Documenting the assessment of the reasonableness of certain implementation specifications for the organization 4). Training all of the organization's workforce on the security procedures 5). Revising agreements with business associates to incorporate security obligations for the business associate (Centers for Medicare & Medicaid Services (CMS). 2007, March).

“It is important to note that the Privacy Rule applies to all forms of patients’ protected health information, whether electronic, written, or oral. In contrast, the Security Rule covers only protected health information that is in electronic form. This includes EPHI that is created, received, maintained or transmitted. For example, EPHI may be transmitted over the Internet, stored on a computer, a CD, a disk, magnetic tape, or other related means. The Security Rule does not cover protected health information (PHI) that is transmitted or stored on paper or provided orally” (Centers for Medicare & Medicaid Services (CMS). 2007, March, p. 4).

Common Misperceptions Explained

  1. Examples of different devices used by staff to enter patient information and policies which protects patients’ information when devices are in use. Examples of EMR software and how information is protected.

Hardware:

  • Does not matter the type of device (home computer, PDA’s Laptop’s) that is used to access the software program that supports the EMR.
  • Hardware encryption system technology (for transmitting information electronically) (Department of Health and Human Services, 2008).

Software program safeguards:

  • Firewalls
  • Access control (sign in / log on).
  • Individual tracking audit trail
  • No paper charts for “accidental viewing”
  • National Provider Identifier (NPI)
  • CCHIT certified. The CCHIT Certified mark - an industry "seal of approval" for EHR software products - provides the first consistent, consensus-based benchmark for ambulatory products (Amant, M., Gardner, C., Kramer, J., Ly, T., Neeld, B., Nicholas, R., 2007, October 29).
  1. Definition of types of data which can be extracted from the Electronic Medical Record (EMR) without compromising patient confidentiality. Explanation of the term “near miss”, defining the Joint Commission verbiage.

Performance Improvement (PI) is a continuous process. It involves measuring the functioning of important processes and services, and, when indicated, identifies changes that enhance performance. PI focuses on outcomes of care, treatment and services. An important aspect of improving organizational performance improvement is to identify high risk areas that may impact the safety and outcomes of care by assessing, recognizing and acknowledging potential adverse events in patient care.

Examples of reports from Baptist Health include:

Custom reports available:

  1. Critical value /Interpretation Tracking
  2. Blood Bank Report
  3. Rapid Response QI report
  4. Fall Risk Assessment Report
  5. Restraint Order Report

2009 Joint Commission definition of “near miss”:

2009 Standard: LD.04.04.05 2009 EP: 7 2009 EP Text:

The practice defines “sentinel event” and communicates this definition throughout the organization. (See also EC.02.01.01, EP 1)

Note: At a minimum, the organization's definition includes those events subjectto review in the "Sentinel Events" section of this manual. The definition may include any process variation that does not affect the outcome or result in an adverse event, but for which a recurrence carries significant chance of a serious adverse outcome or result in an adverse event, often referred to as a “near miss.” (Joint Commission, 2008).

Baptist Health internal link to the Joint Commission Comprehensive Accreditation Manual for Hospitals: The Official Handbook.

3. Examples of how patients are assured of confidentiality in regard to their information and verbiage nurses can use as talking points during patient education.

For discussing privacy & confidentiality issues:

  • Safeguards are in place to protect anything written in the EMR.
  • We have hospital polices that determine who (within our organization) may be able to view “your” chart.
  • The computer automatically tracks anyone who has read “your” chart.
  • Anything that is transmitted is encrypted.
  • You have the ability to consent or not consent to anyone, any organization, or insurance company to be able to read your chart.

Conclusion

“Security is not a one-time project, but rather an on-going, dynamic process that will create new challenges as covered entities’ organizations and technologies change” (Centers for Medicare & Medicaid Services (CMS), 2007, March, p. 3). At Baptist Health, we continually strive to exceed the privacy and security rules while providing ongoing performance improvement and educating our patients about the electronic medical record.

Amant, M., Gardner, C., Kramer, J., Ly, T., Neeld, B., Nicholas, R. (2007, October 29). HIPAA and EMRs. Retrieved November 1, 2008, from

Banks, D. L. (2006, February). The health insurance portability and accountability act: Does it live up to the promise? Journal of Medical Systems. 30(1). 45-50. Retrieved November 14, 2008, from

Centers for Medicare & Medicaid Services (CMS). (2007, March). HIPAA security series. Department of Health and Human Services. Retrieved November 14, 2008, from

Department of Health and Human Services. (2008). Health information technology. Retrieved November 1, 2008, from

Joint Commission. (2008). Accreditation program: Hospital. Chapter: Leadership. Retrieved November 1, 2008 from

Table of Contents

1.Starting your Shift

Select a Shift Timeframe

2.Viewing Your Patient Assignment

Nursing - Set the PAL with Assigned Patients

Update Your Multi-Patient Task List

ACP - Set the Organizer with Assigned Patient List

Create Your Personal List

3.Creating a Shift Assignment

Shift Assignment Window

How to Create Assignments

Creating a Care Team

To assign patients to teams or individuals

Establishing a Patient Relationship

Now You Try Exercise # 1

4.Documenting with PowerForms

Guides for Completing Fields on Forms

Completing a HT/WT/Allergy Form

Documenting Allergies in a Patient Chart

Reviewing Allergy Information

Adding a New Allergy

Search to find allergies not available in the Catalog list

Canceling an Allergy in a Patient Chart

Entering No Known Allergies

Reviewing Existing Allergy on Admission

Modifying an Allergy

Creating My Favorites

To view Your Favorites List

Completing a Vital Signs Form

Documenting Fluid Intake and Output

Completing a Intake and Output Form

Documenting on the I&O tab

Now You Try Exercise # 2

5.Reviewing Completed Forms in the Patient Chart

View Documents in the Completed Form Tab

Sorting Forms

Form Icons

Modifying Forms

To View Details of Modified forms

Uncharting Forms

Reviewing history of Completed Forms

6.Reviewing Results in the Patient Chart

Last 2 Day Tab

Rad Tab and Lab/EKG Tab

Care Team Doc Tab

Clinical Documents Tab

7.Multi-Patient Task List – Teamwork for Patient Care

Multi-Patient Task List Process with ACP and Nurses

Working with the Task List and the Multi-Patient Task List

Now You Try Exercise # 3

8.Patient Management Conversations

Using the Patient Management Conversation

Adding a Consulting Physician

Transfer

Discharge

Cancel Discharge

9.Working with Charges

Using Forms to Enter Charges

View Charges using ChargeViewer

Credit a Charge Using ChargeViewer

Now You Try Exercise # 4

1.Starting your Shift

When you initially logon, the very first task you are presented will be to define the shift you are working. Select the shift on the Timeframe Selection window that you will be working that day. The Workstation PC is set up to default to the unit’s patient list however you will have the ability to set up a custom patient list.

Select a Shift Timeframe

Each time you log into Cerner, you must select the appropriate shift or time frame. The timeframe window displays the available shift choices for you.

1. Select a Shift or Select a TimeRange.

2. Click OK.

As a nurse, your default Organizer tab is the Patient Access List (PAL).

As an ACP your default Organizer tab is the Multi-Patient Task List. (MPTL)

2.Viewing Your Patient Assignment

The very first time you log on to PowerChart with your personal unique log on, you will be presented with a blank patient list until there are shift assignments or patient lists created.

Nursing - Set the PAL with Assigned Patients

Your initial logon will not display any patients because you do not have your personal assignment list established. Once you establish a personal list, the PAL will be automatically updated with the patient assigned in the Shift Assignment.

  1. On the PAL tab, right-click the left corner on the Information bar to open the pop-up menu. Select Change Patient List…
  1. Click New from the Modify Patient List window to open the Patient List Type.

  1. Select Assignment and click OK to create your personal patient list.

  1. Type the name your new patient list (Assignment Type). This list is unique to your user logon. It is suggested that you title the list using your firstname (example Mary’s List). Click Finish to complete the Name.

This will automatically update the left corner of the PAL. In the example that follows the list was named Cpoenurse.

Note: When you have selected your Patient List and there are no patients appearing in the PAL List, it means that there are not any patients assigned with the Shift Assignment.

Update Your Multi-Patient Task List

Once you have named your Patient list you can update your Multiple Patient Task list to select your patient list as well.

ACP - Set the Organizer with Assigned Patient List

Your initial logon will not display any patients because you do not have your personal assignment list established. You need to create your personal Patient list and associate it with the Organizer tabs. Once you establish a personal list, you can set the Multi-Patient Task List to display your assigned patients.

Create Your Personal List

Select Task List Properties from the Options menu to create your personal list. Build Custom list - Create new patient list (Assignment type) this is done only once, the first time you logon. This list name is unique to your logon and no one else will have access to this list.

NOTE: Show UNIT list…. If ACP does not have any assigned patients, then use the multi-patient unit list.

  1. Click New from the Modify Patient List window to open the Patient List Type. Select Assignment and click OK to create and name for your personal patient list.
  1. Type the name your new patient list (Assignment Type). This list is unique to your user logon. It is suggested that you title the list it using your firstname (example Mary’s List). Click Finish to complete.
  1. Once the list is set up, you will need to add the list to your Multi-Patient Task List and Patient List. In the example, Cpoeacp is the named patient list.
  2. Access the Task List properties and select the new list from the list.

Then go to each tab – right-click on Assigned TASK and select the new list.

3.Creating a Shift Assignment

Shift Assignment enables designated users to assign care providers (as an individual assignment or as part of a team) to patients, to empty rooms where admissions are expected, or to designate groups for care providers who work in multiple locations.

The Shift Assignment presents a list of the clinicians and associate care providers who will provide care for a shift. The designated user can assign clinicians to a team, and assign patients to the individual clinician or group of clinicians. The assignments for that location and shift are then saved and will be defaulted into the next day assignment for ease of use.

  1. Click the Shift Assignment tab in the Organizer to display the Locations box.
  2. Choose the location (floor, unit, department, bed) that you wish to assign. To expand the view of the available locations from the list, click on the plus (+) sign to the left of All Facilities.
  3. Once you selected the correct location, click OK.

NOTE: Select the Hospital or the Unit level only. Do not select the specific beds in this step.

Shift Assignment Window

Below are further descriptions of the main Shift Assignment window.

  1. Location: The left side is the list of patients based on the location selected in the pop-up Location window. The location list may be changed by clicking on the green “location” bar at the top of this section. This accesses the organizational hierarchy and allows the user to drill down to the unit level and choose a unit, that has been defined or an organization. Once the user saves the view, the location displays and will not have to be selected again unless there are changes.
  2. Team Assignment: The Team Assignment window displays the teams of providers created by the user and their assignments. Patients/locations that have been assigned to the entire team cannot be removed from a single provider.
  3. Individual Assignment: The Individual Assignment window displays all the individual providers and their assignments for the shift regardless of if they have been added to a team or not.
  4. To Change or select the shift timeframe, right-click the green information bar.

How to Create Assignments

  1. From the Shift Assignment tab, select a “location.”
  2. To begin selecting the care providers, click the yellow “scroll” icon located to the right of the “As Of” button. The Add Care Providers dialog box will be displayed.

Creating a Care Team

In order for multiple providers to share patient care responsibilities, create a care team with the caregivers needed (nurse and ACPs). The patient is then assigned to the care team.

  1. Type the name of the team in the Care Team Name window and click the Add button. The team name displays in the Teams window section.
  2. Search for the individuals or Personnel Groups and drag them to their care team. They will also appear in the individual section.

Note: If you add a person or group to the wrong care team, select the name to highlight, then click and drag the name back to the search field. Be sure to search for the individual or group again and then drag them to the correct team.

  1. Click OK.

To add individuals from a group or search for individual persons

  1. If the provider is an individual, type the name of the person in the Add Persons field.
  1. If the provider is in a group, click the drop down arrow under Personnel Group.
  1. Select the correct name(s) from the group list.
  2. When selecting names from the group, double-click the name to move it to the Assignment for Teams area.
  3. To move an individual to the provider area, double-click the name to place it in the white space in the field.
  4. From there, click the name to select, hold the mouse click and drag it over to the “Individuals” section.