Electronic documentation reference guide final

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Electronic documentation reference guide final

  1. 1. Nursing Informatics Electronic Documentation Medication Administration Check (MAK) & Patient Care Documentation System (PCDS) REFERENCE GUIDE
  2. 2. WOW Care Guidelines ► Clean WOW at least every shift and as needed. ► Use germicidal wipes to wipe down the covered keyboard, mouse, scanner and cart handles. (Clean wherever your hands go). ► Do not bring WOW inside a room with “Isolation Precautions.” ► Keep the WOW away from touching immediate patient care environment (bed linens, side rails, privacy curtains, etc.) to reduce risk of contamination of the workstation and components. ► The wireless scanner is used without touching the armband.
  3. 3. MAK - Downtime Procedures During a downtime period (planned or unplanned) a manual system of data collection will be implemented in order to prevent any disruption of patient care services. Downtime is an interruption in the Siemens MAK system which is defined by the following parameters: Level 1 ( Up to 2 hours ) : All medications administered or Not administered are documented manually (on paper MAR), and must be re-entered in Siemens MAK by the nurse, as soon as the application becomes available. Level 2 ( greater than 2 hours ): All medications administered or Not administered are documented manually (on paper MAR) ,and do not need to be re-entered in Siemens MAK. All manual documentation recorded during this downtime period will be filed on the patient’s chart and will become a permanent part of the patient’s medical record. HOW TO OBTAIN A DOWNTIME eMAR : During an unplanned downtime, please contact your IT BA or After Hours IT Support at ext. 66062 in order to obtain a downtime Medication Administration Record. The IT BA will notify the “IT Pharmacy Support Person” to generate the Downtime MAR. The MAR will print on your unit’s printer. The IT BA information is located on a label attached to each computer monitor in your unit. Please note: Pharmacy does not generate downtime MAR, it has to be done by reporting the issue to BHSF IT.
  4. 4. eCHARTING - Downtime Procedures During a downtime period (planned or unplanned) a manual system of data collection will be implemented in order to prevent any disruption of patient care services. Downtime is an unplanned interruption in the Siemens Net Access Patient Care Documentation System which is defined by the following parameters: Level 1 (up to 2 hours): All assessments, patient notes, vital signs, I & O’s, advance directives and routines of care will be documented on paper form found at the nurse’s station. All information recorded manually must be re-entered in the Siemens PCDS as soon as it becomes available. Level 2 (greater than 2 hours): All assessments, patient notes, vital signs, I & O’s, advance directives and routines of care will be documented on paper form found at the nurse’s station. All information recorded manually does not need to be re-entered in Siemens PCDS. All manual documentation recorded during the downtime period will be filed on the patient’s chart and will become a permanent part of the patient’s medical record.
  5. 5. 1 HOW TO LOG INTO TO MAK ►Log into Net Access, Select your Hospital, Click on MAK Login, Select Location Census ►Select the Unit, Select your Patient from the Station Census. VERIFYING ORDERS A new order will be flagged with a red pen symbol; verify it against the physician’s orders in the chart. CLINICAL INTERVENTIONS When you are verifying a new medication order and it does not match the physician’s orders in the chart, DO NOT VERIFY the order in MAK, open an INTERVENTION for the pharmacy. ►Click on the "intervention" button ►Select the "problem" from the dropdown ►Use comments box to explain details ►Under Pharmacy Access select the “Update” button ►Select "Save" button ►Intervention will be sent to pharmacy ►A question mark symbol will appear next to medication ►Intervention will be saved under the "Intervention tab" ADMINISTERING MEDICATIONS ►Highlight medication to be administered under Active Work list Tab ►Scan medication barcode ►If correct medication : green check mark will appear / If incorrect: red x will appear Follow the same steps as above if administering more than one medication ►Once all medications to be administered are scanned, the next step is Patient Identification ►Click on the "ID Patient" button (bottom of screen). ►Scan the patient's ID bracelet If it is the right patient, a checkmark will appear with the following message: "Scan matches the patient selected" If it is the wrong patient, a STOP sign will appear with the following message: “The wrong patient has been scanned” NOT ADMINISTERED MEDICATIONS ►Highlight medication from the "Active Work list" tab ►Click on the "Not Admin" button (bottom of screen) ►Select reason from drop down or enter the reason ►Click on "Okay" Not administered medications will be highlighted in light blue with the N/A symbol ►Click on the "Chart" button to document Administering Medications that If a medication was charted as “Not Administered,” the dose is still available under the Charted List Tab. Click on the Charted List tab, highlight the “Not Admin” medication that you want to administer, scan the were charted as “Not Admin” Medication barcode, scan your patient’s ID bracelet. Fill out the “Revised Charted Occurrence” box and from the Charted List Tab Click on the “Chart” button to document administration. The status of the medication will change to “Admin.”
  6. 6. 2 CO-SIGNATURES A co-signature will be required by a second nurse prior to the administration of high risk medications in MAK. The second witness co-signature is done using the electronic bar code identification and indicates that the medications were prepared accurately for administration. CHART PHARMACY PENDING REVIEW This feature is used for EMERGENCY / STAT ORDERS – (Medications that need to be administered in less than 15 minutes) Very Important: Remember that you are administering the ►From the Tool Bar click on the Navigator (upper left corner of screen) medication on your own and bypassing the pharmacy. ►Click on “Show Navigator” Be very careful ►Click on “Chart – Pharmacy Review Pending by Patient Scan” ►Scan patient's ID bracelet ►Scan drug to be administered ►Enter the name of the ordering physician (Required) ►Make sure dose is correct as per physician's order ►Complete all clinical requirements if applicable ►Click on the "Chart" button to document OVERRIDING MEDICATION BARCODE ►Highlight medication to be given under Active Work list ►Click on the barcode icon on the bottom left corner of the screen ►Select override reason from drop down or enter the reason; click the OKAY button ►Click on the "ID Patient" button. Scan patient's ID Bracelet to identify the patient OVERRIDING PATIENT ‘s ID BRACELET ►Click on “ID Patient” button, click on the barcode icon on the bottom left corner of the Patient’s verification box to override patient’s wristband Very important: It is absolutely PROHIBITED to override a ►Select override reason from drop down or enter the reason; click the OKAY button patient’s ID wristband unless is an emergency or ►Click on the "Chart" button to document you are documenting Post-downtime TRANSFER MAR ►From the Tool Bar click on Options or Diagnoses (upper left corner of screen) ►Select “Request MAR/IVAR/Discharge MAR” from the Navigator ►Click on the "Print" button ►MAR will print at the designated printer on your unit VIEWING MAR FROM NET ACCESS ►Log into Net Access, select patient ►Select MAK ►Select “Display eMAR” or “Display Detailed eMAR ►MAR will display
  7. 7. Steps to go into MAK when Net Access is down Go to Start (Left bottom corner of your screen) Go to Programs Go to Siemens Select Med Administration Check Under Logon ID please enter your Net Access ID Under Password, if this is the first time you access MAK without going through Net Access, your initial password will be your Net Access ID. Once you enter your Net Access ID under password, you will then click on Change Password to change it. We recommend that your new password is the same password that you have for Net Access so that you will remember. Enter your New Password, Verify New Password and click on Update. The following message will appear if it was done correctly: “Password successfully changed” Once you click on OK, the MAK Login screen will appear again. Enter your Logon ID (Net Access ID) and then your new Password. Click on Log On. Enter your User ID by scanning your MAK barcode. If you have problems login in please contact your IT BA.
  8. 8. WHO TO CONTACT… IT BA (Information Technology Business Analyst) ►Computer Problems ►Wireless Issues ►Login problems ►Computer freezing ►Downtime ► Unable to save work ► Computer screen issues ►Application not working The IT BA information is located on a label attached to each computer monitor in your unit. MCE (Mobile Cart Engineer): WOW / SCANNER Problems ►Wireless Issues ►Drawers issues ►Locking of Carts ►Keyboards ►Scanners not working ►Battery depleted ► Other WOW issues The MCE information is located on a label attached to each WOW ‘s computer monitor. BHSF Nursing Informatics Monday through Friday: 9 am - 5 pm ► Education issues: MAK (Medication Administration Check) Net Access Electronic Documentation After Hours Support, Weekends or if unable to contact your BA or MCE, call the IT Data Center at ext. 66062.

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