MediTech Navigation Mouse or Keyboard

SECURITY Toolbar Function Key stroke

File/Send/Save <F12>
Access only patients that are
directly under your care. Exit <F11>
No sharing of passwords. If you suspect
that somebody knows your password call
Meditech General
On-line HELP <Shift> <F8>
the helpdesk for a password reset.
Do not leave your screen open for others
to see patient information. Lookup <F9> Quick Reference Guide
Shift F12 to the Magic Menu to be able
to suspend session. Session can only be Session <Shift> <F12>
suspended for 5 min., after that the Management
computer will automatically log you off. Calculator / <Ctrl> <F12>
Calendar

select (check) <Right Ctrl>

select all <Shift> <Right Ctrl>

(check all)

Right Arrow In Right or Left Arrow

Left Arrow Out
“Go Right In”
“Be Left out”

Up / Down Up and Down

Arrow

Shift Up / Down Shift Up and Shift

Down key

Help Desk # __________________

Version 1A 12/09
 INTERNET BASICS
Homepage
Policies and Procedures EQUIPMENT/PC CARE MAILBOX MOX
Downtime Forms PC’s: Care: ACCESS FROM
Internet Links No liquids close to PCs 1. Status board
o Clinical Pharmacology Turn on PC - allow script , security agreement 2. Main menu mailbox 106.
o Lippincott PC name
o Krames Help Desk contact information READ MAIL
o Healthstream DO NOT change the settings, icons etc 1. Select Mail for you.
Printers: 2. Arrow to e mail. It displays. For large email, press
Name of the printer the right arrow to see the entire mail.
Add paper
GENERAL MEDITECH Change the print cartridge. SEND MAIL
Confidentiality/Security Error messages 1. Select #5 Send.
Meditech contains patient information and therefore is 2. Recipients: Type in the partial last name, comma,
covered under federal and state laws as well as hospital partial first name of the person (in that order only
policies related to patient/ physician relations. You will be RISK MANAGEMENT NOTIFICATIONS without SPACE), Press F9 Lookup
assigned a password, which is your electronic signature, and VARIANCE/ INCIDENT REPORT 3. Select the person from the choice
therefore should not be shared. You are responsible for any Three Kinds of Notifications: 4. Press Enter three times. You may enter a subject.
process that is performed on this system under your Patient 5. Press enter and type in your message.
password. If at any time you feel that your password has Employee 6. Press F12 to Send.
been compromised, please call the IS department Help Desk
Non Patient
so that we can inactivate that password and allow you to FORWARD MAIL ( To Reply to EMAIL)
choose a new one. 1. Highlight the email.
Patient and Employee
1. Type the Last name, First name. Press F9 Lookup. 2. Type or Click on F for forward.
Do not access patient information for patient’s that are not 3. At recipients, Press the space bar once and then
within your care. If you or a family member has a test or 2. Press the right arrow on the keyboard to select the
patient. Press Enter: the recipient’s name displays.
procedure done and you wish to view the results in the 4. Press enter and type in the email as usual.
system, you first need to go to Medical Records and sign a 5. Press F12 to Send.
“Release of Information”. Non Patient
1. Type N for New. Press Enter. Type: Press F9
READ CERTIFIED MAIL
Logon and Passwords Lookup and select the type of notification.
Certified mail: Must be ACKNOWLEDGED before proceeding.
To sign on to the system you will be given a "User ID" or 3/4 2. The demographics and the description of the event
1. Click on Acknowledge or Type a: email displays
ID which will consist of 3 letters and 4 numbers. On first sign is entered on page 1.
The sender can see if the recipient acknowledged
on the system will prompt you to choose a password. The or did not acknowledge the email.
new password must consist of 7 characters. One number at Screens that are the same for each notification type.
the beginning and 6 alphabetical characters. The system will 1. Demographic information,
SENT BY YOU
prompt you to change your password every 6 months.(ex: 2. Event Information
1. A list of the emails that the user sent is displayed.
1ABCDEF). 3. Description of the event.
2. Click on Recipients or type R to see the response.
4. Press Enter on the Description page and the
For example; Did the recipient read the email or
You will also be designated a Nursing ID to use for various cursor displays in the lower section.
delete the email ?
nursing routines such as co-signatures. 5. Press F12 when completed. The text page is
The letter designating the hospital which you work: highlighted. Press Enter. Answer all questions.
"E" for Mainland Medical Center, “G” for Clear Lake 6. Press F12 to File.
It will also signify your Department: 7. Type in the Last Name of your Director. Press F9
"NUR" for Nursing, “ERS” for Emergency Department Lookup and Select. Also send an email notice if
Next will be your initials: (Example: E.NUR.CGS) that is an option. Enter the name of your Director
Note: The initials you use for your Nursing ID may be and send a message.
different from your own, as someone with your same initials
may already be working within the facility
 BCMA/eMAR Quick Reference Card

Icon Name Description Medication Profile Color Indicators

Link Meds Displays medication that is linked Currently
to highlighted medication Selected
Query Display queries that need to be Order Medication order on BLUE background
filled out, e.g., Blood sugar, Heart
Rate
Discontinued
Co-Signature Medication administration requires
Order
co-signature Medication order on YELLOW background
Instructions Medication instructions, e.g.,
sliding scale, etc Scheduled BLACK text on GREEN
Historical Pharmacy has performed a Time background
Links Copy/edit.
Not
Administered WHITE text on GRAY background
Time
Administered
Time GREY text on WHITE background
Button Description Next
Document Full Document Scheduled
ACK Acknowledge Orders and View History Time BLACK text on GREEN background
Preferences Set for this session or permanently Overdue
Drug Data Displays drug monographs, interactions Time BLACK text on RED background
eMAR Reports Management reports Future
Change Order Hold or DC Medication Scheduled
Other Quick Charge & Manual Barcode BLACK text on WHITE background
Time
Submit Submits medication data after barcode Hold
scan Medication HOLD text on YELLOW background

Using BCMA

Scan Med Process Quick Charge/Document

Scan patient armband Scan patient’s armband
Scan bar code on each medication package Click Other button
Complete any screen presented Select Quick Charge/Doc
Click Submit button Fill in Order Doctor and press enter
Click Save and Recompile or Save and Exit button Accudose Med – Check Med (R Ctrl Key)
Non-Accudose – Enter MED type –and scan med
Full Document Fill out queries
Scan patient armband if at bedside Click F12 twice to File.
Or - If unable to scan armband
Click Other button Edit/Undo Administration
Click Manual Barcode Click the administration time of medication to edit
Manually enter patient’s account number Change information and data in pop-up box
Click the administration time of the medication to Click the Edit or Undo buttons
documented Click Submit button
On pop-up box Click Save and Recompile or Save and Exit button
Click “Given” or Not given”
Enter Reason Code
Click Document button
Click Submit button
Click Save and Recompile or Save and Exit
 BCTA - Bar Code enabled Transfusion Administration
Nursing Quick Reference Card
Getting Started Using BCTA
Process Transfusion Screen Layout Nursing Workflow
1. Submit/verify doctor’s order for blood transfusion in Order Entry.
2. Once Status Board transfusions indicator = Ready, add
P.ANEMIA problem to POC.
3. DOCUMENT a) V/S of V/S: Monitor then b) Complete the BCTA
Pre-Transfusion checklist on the Process Intervention screen.
4. Take patient’s paperwork to Blood Bank for product pickup;
Status Board indicator = Issued
5. Click TRANSFUSIONS on Status Board. Highlight the product.
Alt Method: Click Issued transfusions indicator and click
(Transfusions)
6. Click VERIFY to scan armband/product bar codes and enter
Cosigner ID.
7. Click BEGIN to start Transfusion documentation (Begin
Date/Time) within 30 minutes from Blood Bank issue. DO NOT
enter additional fluid volume here. Click OK
8. Click DOCUMENT to enter transfusion vital signs.
9. Click END to enter End Date/Time once transfusion finishes and
ready to discard product packaging. Enter additional fluid
volume. Click OK.
10. Click DOCUMENT to enter post-transfusion vital signs
A Next VS: Due date/time of next BCTA-related vital signs; view
per highlighted blood product.
Bar Code Scan Sequence
B Blood Product Status Indicator
Ready Blood product available for pickup
Issued Blood Bank filed information at pickup
Transfusing Product currently transfusing Patient Armband Acct Number
1
Hold Nursing clicked Hold and Transfusion was 2 Blood Bank Wristband # (if required)
temporarily stopped
Transfused Nursing clicked End and documented
transfusion is complete
C BCTA Constant Navigation Buttons
Highlight product and select enabled button.
Special Not used in our division
Instr
Assoc Data View Lab test values prior to transfusion
Document Enter transfusion-related vital signs
Verify Scan bar coded armband/product and
document second caregiver’s review on Pre-
Transfusion Checklist
View This is a future enhancement therefore
Checklist unavailable at this time.
Begin Document date/time transfusion begins
End Document date/time transfusion ends, product
volume administered, and volume of additional
fluids (i.e. saline) administered during the
transfusion
Hold Document time and reason to halt a 3 Product Unit#
transfusion 4 Product Type
Resume Document time a transfusion resumes Product Source Registration #
administration; Must receive and document a
5
6 Product Blood Type
physician order for resumption
Reaction Document information for possible transfusion 7 Product Expiration Date & Time
reaction Verify User (Optional)
D Integrated Desktop Buttons: Similar functions as Status
Board.

Workflow Exceptions
Downtime – follow facility’s policy Suspected Transfusion Reaction
Transfer In/Out BCTA Location – If started on BCTA stays on 1. Follow HOLD TRANSFUSION process (per facility policy).
BCTA – If on paper then finishes on paper. 2. Select the held transfusion from lookup list and click REACTION.
Hold Transfusion 3. Enter date/time and click OK.
1. On Process Transfusion screen, highlight product to be held. 4. Choose BBKSTXN – Suspected Transfusion Reaction and click OK.
2. Click HOLD. 5. Suspected Reaction documentation pre-populates. Complete the
3. Enter date/time and hold reason. documentation. Click ENTER key.
4. Click OK. 6. Click SAVE and RECOMPILE or SAVE and EXIT.
Viewing PCI Blood Bank History Resume Transfusion
1. Click BB HISTORY DATASOURCE. 1. On Process Transfusion screen, highlight product being held.
2. View previous blood bank history. 2. Click RESUME.
3. Scroll to view transfusion information. 3. Enter date/time and reason for resuming.
4. Click OK. 4. Click OK.
 BCTA: QUICK REFERENCE GUIDE FOR NURSING
Nursing Workflow – Status Board

1. Enter/Verify the order for the blood products

2. Add P. ANEMIA problem to the Plan of Care
3. Monitor & Document VS and Complete the BCTA Pre-Issue checklist, on the Proc-
ess Intervention screen
4. Once BBK on Status Board displays, Ready, blood product is ready to be picked
up
5. Obtain the blood product from the Blood Bank per facility process
6. When BBK on Status Board displays, Issued, Click TRANSFUSIONS on Status
Board & highlight the blood product.

(Alternative Method: Click Issued under BBK & select TRANSFUSIONS from the
presenting screen)

7. Click VERIFY to scan armband & product barcodes and enter Meditech Mnemonic
of the Cosigner.
8. Click BEGIN to enter transfusion starting Date/Time. (after the blood gets ISSUED,
transfusion must begin within 30 minutes. DO NOT enter the blood or NS volumes
at the BEGIN time.
9. Click DOCUMENT to enter transfusion vital signs
10. Click END to enter transfusion completion Date/Time & enter the Blood & NS
volumes
11. Click DOCUMENT to enter Post-Transfusion vital signs.
12. HOLD/RESUME & TRANSFUSION REACTIONS must be documented in BCTA
screen, if required.
BCTA: QUICK REFERENCE GUIDE FOR NURSING
Bar Code Scan Sequence
1. Scan patient’s Armband Barcode
2. Scan Product Unit Number and Source on Blood Bag
3. Scan Type of blood product on the Blood Bag ( eg: packed cells,
FFP etc)
4. Scan Blood Type on the Blood Bag (eg: A+, O- etc)

Do NOT
Scan this
Barcode
 Enter Orders Enter Orders

Individual Orders / Order Sets Individual Orders / Order Sets

OM-CPOE Quick Reference for Go-Live

OM-CPOE Quick Reference for Go-Live

Enter Orders Enter Orders

Individual Orders / Order Sets Individual Orders / Order Sets

OM-CPOE Quick Reference for Go-Live
OM-CPOE Quick Reference for Go-Live
 Submit Orders Submit Orders

Verify / Acknowledge Orders Verify / Acknowledge Orders

OM-CPOE Quick Ref for Go-Live 04192011 OM-CPOE Quick Ref for Go-Live 04192011

Submit Orders Submit Orders

Verify / Acknowledge Orders Verify / Acknowledge Orders

OM-CPOE Quick Ref for Go-Live 04192011 OM-CPOE Quick Ref for Go-Live 04192011
 ALLERGIES
Enter New Allergy MediTech Navigation Mouse or Keyboard
1. Click on “New” & type the first 3-4 letters of allergy to be Toolbar Function Key stroke
entered. The “type ahead” lookup feature will display the <F12>
possible choices File/Send/Save
2. Click on the correct choice and that will be highlighted
3. Determine whether allergy or adverse reaction Exit <F11>
4. Determine severity (do not choose the Intermediate)
5. Enter reaction and, if needed, add a comment
6. Click the OK button to File the allergy
Meditech 5.6.4 Order Entry
On-line HELP <Shift> <F8>
Edit Allergy

&
1. Click the allergy to edit and that will be highlighted in
blue Lookup <F9>
2. Click the Edit button
3. Edit type, severity, verified, reaction or comment as
needed Session <Shift> <F12>
PCI Quick Reference Guide
4. Click the Ok button Management
5. Click the File button
Calculator / <Ctrl> <F12>
Delete Allergy
Calendar
1. Select the Allergy or Adverse Reaction
2. Select the Delete button
3. You are then prompted to confirm deletion; click Yes select (check) <Right Ctrl>
4. Click the File button

Review existing allergies with the patient and confirm as still valid. select all <Shift> <Right
You should re-enter any Uncoded allergies as Coded allergies. Only (check all) Ctrl>
if an Uncoded allergy cannot be found in the Coded lookup should
it remain in the Uncoded section Right Arrow In Right or Left Arrow
Left Arrow Out
Steps to Confirm (Update)Existing CODED Allergies
“Go Right In”
1. Select all the Coded Allergies (all will be highlighted in
blue) “Be Left out”
2. Click the View Details Button
3. Review each allergy, reaction, and comments Up / Down Up and Down
4. Edit any as necessary Arrow
5. Click Close button to continue to cycle through View
Details on all allergies
6. After all allergies are reviewed, Click on the Confirm
button & file to update the date to current date.
Shift Up / Shift Up and Shift
Steps to Confirm (Update) Existing UNCODED Allergies Down Down key
1. Click the Uncoded allergy to select (can select multiple
uncoded allergies)
2. Click the Edit button and enter the changes if required
3. Click the OK button, the date will be updated to the
current date & then File .
NKA Button (No Known Allergies) - Use the NKA Button for Other Helpful Keys
a patient who does NOT have ANY allergy and has never been a F1- View last 15 documented values
patient at any HCA Hospital previously. F2- View last filing of entire page
Unobtn (No Allergy Information Available) is used to F3- Shortcut to PCI
document if no Allergy information is available F6 –Previous Filed
F7 -Top of List
Document only as Allergies and NOT as Intolerences F8 -Bottom of list
 ADMINISTRATIVE DATA
When you have identified the patient, the patient registration
information appears on the screen. You cannot edit any of these
fields.

Temporary Location - If the patient is moved to a temporary

location, enter the mnemonic from the Location Dictionary which
identifies the temporary location.
A Lookup is available.

Hold Tray (if available)- Enter the date that a diet should be on
hold for Date using the standard date format. If you do not enter a
response, the cursor bypasses the next two prompts.

Meal - Enter the meal which should be on hold. The choices of B, L,

D, for Breakfast, Lunch, and Dinner.

Release - Enter the time (in HHMM format) when you want the
system to automatically release the hold on the patient's meal

Condition - You can enter or edit the patient's condition. The

response choices are: G (Good) F (Fair) S (Serious)
C (Critical) A Lookup is available.

Visitors Allowed - Enter Y if the patient can have visitors, N if

he/she cannot.

Comment - Enter free text if desired, up to 60 characters, do not

enter any clinical diagnosis or lab values.

Visit Reason - Enter or exit the patient's reason for visit.

Height and Weight - Enter the appropriate information. You can

enter the information in feet and inches or metric units. The system
automatically calculates and enters the equivalent in the other unit of
measurement.

PCI – Patient Care Inquiry

KEYBOARD FUNCTIONS
Most functions can be accessed by using the Arrow keys.

Function Keystroke

Highlight desired function 

Access info in more detail 

Exits to previous screen 

Move highlight bar 10 fields Shift 

up or down
 Manually Added Problems
7. ADL Routines Provide: These problems are frequently added manually by the Care
Hygiene Meals% taken, Giver.
Bowel Movement Height/Weight
**NO CHARTING BY EXCEPTION** Ancillary Pain Monitor P.PROCEDURE:
8. Intake and Output: Complex: Includes IV Pre Procedure Checklist
IVPB, PO and Outputs.
The Status Board 9. Report Called: Document this when you are
Post –Procedure Assessment
Procedure -Time Out
transferring a patient from one Inpatient Location Transfer: Receiving Unit-Surgery/Outpt
to another Inpatient location. To select the name P.DIABROB
of the receiving nurse: Type N\few letters of Glucose Test: Blood
the last name of nurse and Press F9 to select. P.ANEMIA
10. Medication Reconciliation: Displays list of BCTA: Blood Bank Product I&O
home Meds charted in the Adm History. Clarify BCTA: Pre-Issue Checklist
Home medications here. BCTA: Suspected Transfusion Reaction
11. Meds New Medication Monitor: Any BCTA: Transfusion Documentation
medication that is new to the patient must be
documented.
12. Education: Pt/Family Record: Restraint Documentation
Interdisciplinary Patient Education documentation 1) Order
Task List: Enter Order
Advance Directive Suction Category: Nur Renew
Cardiac Monitor IV Peripheral Procedure: RESTRAINTS
CVC/PICC Insertion Education 2) Assess
Compression Dev. Cool/Heat Device A) Alternatives Utilized : Completed by staff Nurse
Bladder Scan 1st Void BEFORE Initiation of Restraints
Manage List (Add Your Patients) Urinary Cath Peri Care/Sitz Bath B) 2nd Tier Review: Completed by 2nd Tier Reviewer
1. Click Manage List Pin Care Sutures/Staples AFTER ALTERNATIVES AND BEFORE initiation of
2. Click location button Wound Dressing. Restraints – This will add P.RESTRAINT problem.
3. Choose your location with mouse , click OK 13. Discharge Instructions Provide: Documented 3) Document
4. Click to highlight your patients from location and printed at the time of patient discharge. Make PCD Intervention - Restraint Monitor
5. Click Assign, File, Replace sure that the medication list displays ONLY the Application On Initiation
medications that the MD prescribed at the time of Safety/Dignity Non/Viol 3X/hr Violent/SD q15min
Discharge. Status Monitor Non/Viol q2hr Violent/SD q15 min
Adult Standard Interventions 14. Transfer: Receiving Unit- Adult upon RN Access/DC Non/Viol and Violent/SD q2hr & DC
These interventions are suggested/added by the S.SOC
receiving a patient from another inpatient area. Violent/SD Debrief ASAP
1. Practice Guidelines: VP (View Protocol) to read
15. Physician Notified: Any time the physician is Paper Form (M/S Units Only) q30 min
the Practice Guidelines. Chart at the end of the
called All Critical Results are also documented
shift. No screen displays when charting. An
here.
asterisk * in the Prt column indicates a protocol.
2. Quick Start: Charted in Assessment Routine.
16. Interdisciplinary Plan of Care: Nurse Pain Documentation
prioritizes the patient problems, can personalize a “Drop the Pounds”
Quick Start brings the standard interventions (i.e.
goal(s) and add new problems. P.PAIN problem on Plan of Care
Vital Signs etc) to Process
3. Admission Assessment and Admission 17. Age Appropriate Guidelines: VP (View Document on Intervention – Pain Monitor
History: Charted in Assessment Change status to Protocol) to read the Age Appropriate Guidelines. Pain Assessment Types
C for Complete, this can later be retrieved by using Chart at the end of the shift. No screen displays Ongoing Monitoring
SI Select Interventions. when charting. An asterisk * in the Prt column Post Med
indicates a protocol. Pre Med
4. Shift Assessment: Charted at the beginning of
18. FOCUS Assessment: ex FOCUS Respiratory Preemptive/Pre-Procedure
the shift. (Uses WDP Within Defined Parameters)
Focus Assessments can be documented anytime Regional Block
5. DVT Assessment: Calculates automatically from
after the Shift Assessment has been documented, Post Procedure
the BMI (Basic Metabolic Index) Do not chart on
if something has changed with a new problem or Pre Med Assessment = ## on Status Board
this screen unless the patient has a new problem.
if an existing problem has improved. (Ex. Breath This is a reminder to re-asses pain
6. VS Monitor:
sounds clear) Post Med Assessment = . on Status Board
Routine VS Transfusion VS
19. Discharge Screening: Discharge /Treatment
Orthostatic VS Glasgow Indicates pain has been re-assessed
Readiness Assessment: - Facility Specific Screen
ICU Vital Signs Infant VS
 ASSESSMENTS (ADMISSION)
On Admission:
1) Quick Start
2) Admission Assessment – RN Only
3) Admission History
4) Print
Steps to Complete Admission Assessments
1. Identify/select patient and the Patient Form Functions
screen appears.
2. Highlight “Enter Form” and press <R Arrow> or double
(L) click.
3. A choice of forms will appear
4. Highlight desired form
5. Press <R Arrow> or double (L) click
6. Complete form
7. Upon completion of form, File options box will appear –
Press <Enter> to File
8. After filing, a list of triggered Suggested Problems/needs
or Diagnosis may appear in a box asking, “Add Checked
Problems/Needs or Diagnosis to Plan of Care?”
9. Type “Y” Note: These will only be added to the plan of
care if answered “Y”.
10. Press <Enter>.
11. The E/E Patients Plan of Care screen will now display
12. Press <Enter> to have problem appear on the E/E Plan
of Care Screen.
13. Press <F12> to file Plan of Care screen.
14. Cursor returns to the “Select Assessment” screen.
THE CARE PLAN
Re-Sequencing Problems.
1. With cursor next to a problem, press Right CTRL key
2. Right Arrow, this will give you more directions in RED.
3. Hold Shift Key down and move arrow up or down to re-
sequence the problem.
4. Left Arrow out of the re-sequencing mode and File.
Transferring Patients to a New Unit
1. Press <Enter> until at the Problems/Needs area.
2. Change status of the Practice Guidelines for the old unit
to “I” (inactive). This will then inactivate all attached
interventions.
3. Add the new standards for the current unit to the plan
of care and Press <F12> to file.
Transferring Back to a Previous Unit
1. Press <Enter> until at the Problems/Needs area.
2. Highlight the Inactive or Complete standard and press
<Shift>+<R Arrow> twice to the interventions.
3. For all interventions needed, change the status from “I”
to “A”. The outcomes and problem will become active
by activating all necessary interventions
4. Press <F12>twice to file.
DAILY DOCUMENTATION
The Process Intervention Screen
Document Intervention (DI)
1. Highlight intervention and Type DI, press <ENTER>.
Verify that the date and time are accurate. Change the
date or time if required. <ENTER> to move cursor to
the OK Query and type Y, <ENTER>.
May Check (R CTRL) more than one intervention.
2. The documentation screen will appear for each
intervention chosen one at a time.
3. Document on the screen(s). At the end of the screen
the system will prompt you to file. .
Document Now (DN)
This routine is used to document interventions that are
performed for the patient at the current time.
View History (VH) EDIT and UNDO Documentation
1. Highlight intervention that you want to view history on.
Type (VH) and press <ENTER>. listing of previous
documentation done by date/time appears.
2. Highlight the documentation you wish to view by using
the  to move the highlight bar. To view
information.
3. To Edit- Type E and then <ENTER> Make
corrections and File using F12
To Undo- Type U and then <ENTER>. Answer Y to
undo the highlighted documentation
Change Directions (CD)
1. Move the highlight bar to the specific intervention.
2. Type in “CD” at the verb strip and press <Enter>. A
Directions screen will appear.
3. Press <Enter> or arrow down to go to a blank line and
enter start date, start time, and the new directions.
4. Type in a “Y” at the file prompt and press <Enter>.
Edit Text (ET)
The Edit Text function allows edit of an outcome or
intervention’s supplemental text.
Select Intervention (SI)
Allows changing the interventions displayed on the process
intervention screen.
Documentation from the Status Board
1. Click on the Next Intervention documentation time.
2. Click on an intervention to select it for documentation
3. May select/click on multiple interventions
4. Click Document button at the bottom of the screen
5. Set Time on time stamp for time intervention
completed
6. Document on screens
PATIENT NOTES
View Existing Notes
1. Highlight the View Existing Notes function and press <R
Arrow>.
2. Highlight the desired choice of note and press the <R
Arrow>.
3. A screen showing the dates, times, user and first line of
entered notes appears.
4. To see a particular note, highlight the desired date/time
and press <R Arrow>.
Enter New Note
1. Highlight the Enter New Note function and press <R
Arrow>. The “Note Type” screen appears.
*Notes should be attached to a problem/need.
2. Highlight the type of note and press/CLICK <R Arrow>.
A screen will appear showing the date, time, user ID,
and note category.
3. Add the narrative note information. Then press <F12>
to file.
Amend Existing Notes
1. <R Arrow> into Amend Exiting Notes.
2. Highlight the type of note to be amended and press <R
Arrow>.
3. Press <R Arrow> into the note you wish to amend.
4. A 2 section screen will appear. The note to be amended
is in the top section. Press <Enter> to access the
bottom section.
5. Type the changes and press <F12> to file.
PCI/REVIEW
1. Main Screen is table of contents. Right Arrow  into
category wanting to view.
2. To return to prior screen Left Arrow out.
***Helpful Keys for Nurses***
F1- View last 15 documented values
F2- View last filing of entire page
F3- Shortcut to PCI
F6 – Previous Filed
**NO CHARTING BY EXCEPTION**
 PCD - Medication Reconciliation
Medication Reconciliation is only accessible from the
button on the Status Board.*
Routines that are available to document home medications are:
• Document “No Home Medications Reported”
• Add a New Reported Home Medication
• Add an Undefined Medication (free text)
• Convert an “Undefined” medication to “Identified”
• Verify Existing Reported Home Medication from Previous
Visit
• Edit Reported Home Medication
• Discontinue Reported Home Medication
To document any of these routines, click the Upd
Med List button from the Med Rec home screen.
*Medication Reconciliation is no longer part of
the Admission History and the Standards of Care.
Document “No Home Medications Reported”:
1. Click on Upd Med List and Set Profile to No Meds. Once
Set Profile to No Meds is clicked, it will automatically save.
There is no “File” option.
Add a New Reported Home Medication:
1. Click Upd Med List. Type the first 3-4 letters of the
reported medication and medication “strings” will appear
(strings includes the drug, dose, strength, dispense form,
etc.). Click the correct medication string as reported by the
patient, then click Select.
2. Next, click the medication string with the correct
frequency. The information will default into the fields
above the string listings. If there is no string listed,
manually enter all information in the fields above. Click
“Done” upon completion. Once “Done” is clicked, the
medication is added to the patient’s Med Rec.
Remember, there is no longer a “File” option.
3. Enter all appropriate information on the Last Taken screen
and click OK.
If any clarification is needed or attention required, YES must be
checked. There will no longer be a message (on the Adm, Shift, and
Transfer Assessments) to remind staff that the Med Rec has
missing or questionable information. The only indication will be
displayed on the Med Rec home screen in yellow as shown below.
Add an Undefined Medication:
1. Click on Upd Med List. In the upper right corner of the
opened box, click Undefined Med and enter what the
patient reports (i.e. blue pill). Click Done when finished.
2. Enter what the patient reports on the Last Taken screen.
If clarification is needed or any other actions are required,
remember to click YES in the Attention Required field.
3. Upon completing the Last Taken screen, the Upd Med List
screen returns. More meds can be enter or click Done if
finished.
Convert an “Undefined” Med to “Identified”:
1. From the Med Rec home screen, click on the “blue pill”.
Next, click the Change button, then the Replace/Change
button.
2. Perform the same steps as if a new med is being added.
For example, type VALI, select the correction medication
string for Valium 10mg, and click Done.
3. Update the Last Taken screen and remember to check NO
at Attention Required. Click Done when finished.
Verify Existing Reported Home Meds (from Previous History):
Patients’ last reported home meds are recalled into the Med Rec at
the present visit. The Last Taken information will not default. If the
patient currently takes the same meds, a review of those meds (with
the patient) must occur to verify accuracy.
1. In the Review column, click the radio button for each
medication that the patient is currently taking. If the
patient is currently taking all of the meds listed, simply
click the Review header to insert a dot in all the radio
buttons (instantly).
2. Next, click the Last Taken column on each med to
document the last dose and time taken. Remember, if
attention is required, it must be manually indicated by
clicking YES, then the OK button.
3. Once, the Last Taken screen has been documented, the
Med Rec home screen will be displayed. Click the Submit
button. The Med Rec summary screen will display the
action/word, Review. Click OK.
 PCD - Medication Reconciliation

(Med Rec Review Summary Screen): View Details:

The View Detail button on the Med Rec home screen shows all
edits, including comments from the Last Taken screen. A
medication must be selected (from the home screen) prior to
viewing details. Be sure to click on the appropriate drug/dose to
view different details. Also, note the All Details button.
4. Once returned to the Med Rec home screen, the Review
Column will display the date and time the meds were
reviewed by the nurse.

On the Med Rec home screen, DO NOT CLICK the Reset Review
button. If the Reset Review button is clicked, the review column for
the meds previously reviewed will be cleared. The following
message will display prior to clearing the column:

***An audit trail will show the review history, even if the Reset
Review button has been clicked and confirmed.***

To Edit Reported Home Meds:

The patient originally reported taking Zantac 150mg PO daily. He Printing:
later remembers the dose is 300mg, not 150mg.
1. From the Med Rec home screen, click on the medication to To print a Med Rec, click the Print button on the Med Rec home
be edited. Next, click the Change button, then the screen. Select Other Reports. Click the drop box, choose the type of
Replace/Change button. Med Rec to be printed, and click OK. When the Print On option box
2. Perform the same steps as if a new med is being added. appears, enter the desired printer’s name and press the enter key.
Enter Zant, select the correction medication string for
Zantac 300mg PO Daily, and click Done. Update the Last
Taken screen (if needed) and click OK. No further action is
required.
Click the drop box to select the
To Discontinue Reported Home Meds: type of Med Rec for printing.
Use this routine if the patient is no longer taking a medication that
was reported in prior visits.

1. Discontinue the home meds by clicking the radio button in

the DC column. The discontinue reason box displays and a
reason is required. Click the Submit button, review the
screen, and click OK.
2. The medication is then moved from the Home Meds
section to the Discontinue Home Meds section of the Med
Rec home screen. Simply click on the plus sign (+) to Enter printer name here.
expand the Discontinued Meds list.
***The Med Rec will no longer auto-print. The Med Rec must be
printed manually on admission, transfer, and discharge, using the
Print option from the Med Rec home screen. ***
 Group Messages in Folders
Create folders to organize the messages in your
Outlook Web Access Inbox. You can group by topic,
project, sender, and more.
To create a new folder
1. In the folder list, right-click the existing folder
above where you want to place the new
folder.
For example, to create a subfolder within
your Inbox, right-click the Inbox folder.
Use Flags and Reminders to Organize
Messages
Use flags to remind yourself to follow up on specific
Microsoft Office Outlook
items in your Inbox or public folders. Outlook Web
Access provides five preconfigured reminder flags.
Quick Reference Guide
You can also set the due date yourself.
To set a default flag
On any item in the list view of messages,
notes, tasks, or contacts, right-click the
flag, point to Set Default Flag, and then
click one of the preconfigured flags.

2. Click New Folder.

3. Type a name for the folder.
4. Drag the messages you want from the
current folder to the new folder.
To manage e-mail attachments
You can now apply the default flag at any
time by clicking the flag in a message,
note, task, or contact.
To change the Reading Pane view
In the Mail toolbar, click the Show/Hide Reading
Pane icon, and then click Off, Right, or Bottom

1. Click a message with an attachment.

2. Click the attachment.

A message appears that asks if you want to (show hide reading pane)
open the file, save the message, or cancel You can use the Reading Pane to view messages
the process. before opening them, or you can open messages to
view them. The Reading Pane appears by default and
3. Choose what you want to do with the displays the text of a message next to a list of
attachment: messages contained in that folder.

To open the attachment without To Delete a message

saving it to your computer, click
Open. Click the message in the list.

To save the attachment to your

Press the or press delete on your
computer, click Save.
Version 1 07/11
keyboard.

**Always Log Off from OWA when you

have finished a session.
 Getting Started with Outlook Open/View e-mail messages Sending an E-mail
OWA = Outlook Web Access

1. Log on to SSO and click the OWA icon

OR
2. Launch internet explorer from any PC
3. Type in OWA in the address field
4. If prompted with this error message

click

To open a message
Double-click a message to open it. 1. In the Mail toolbar, click New.

The message opens in its own window.

If you want to use a more basic version of OWA,
select Use Outlook Web Access Light.
You will need to type in HCA\3-4ID At the
Domain\user name field along with your password to
access Outlook (e-mail)
OR
Log on to the Intranet, click Web Apps, select
Outlook Web Access (right hand side)
For security reasons, your OWA session ends
automatically after a period of inactivity.If you
choose:
Public or shared computer: By default
you are signed out after 15 minutes of OWA
inactivity.
Private computer: By default you are
signed out after 8 hours of OWA inactivity.
2.
Reply/Forward e-mail messages
Double-click a message to open it.
The message opens in its own window
Click Reply, Reply to All, or Forward
3.
Type the subject of the e-mail message in
the Subject box.
4.
Type your message. Use the icons above
the message to change fonts, add lists and
tables, change text alignment, and more.
5.
Click Send.
6.
**Always Log Off from OWA when you
have finished a session.
In the new message window, type the
primary recipients' names in the To box, (last
name,first name) Separating each name with
a semicolon.
To send copies of the message to other
recipients, enter their names in the Cc box.
Type the subject of the e-mail message in
the Subject box.
Type your message. Use the icons above the
message to change fonts, add lists and
tables, change text alignment, and more.
Click Send.