Chapter 1 Flashcards
Handoff
How to copy handoff to note
Notes from handoff are not part of the record. From pt chart click “copy handoff” to note (on right upper corner)
Navigator
Found on the left side on the activity row
Handoff
How to open activity
Select pt click “write handoff”( upper left next to edit button in pt list screen) to open handoff activity in the sidebar
What is the 1st screen the user sees
Start up activity
What is my list
A list of patients that I am following during my shift, I control the columns, the default report, and I manage the list of patients
What is a system list and how can it be used to organize patients
A list of pts that is automatically updated by the system. You can make a shortcut to these list in a My List
How can a surgeon quickly sort list of pts by unit
Click the units column in pts list
What types of information can a surgeon gather from reports at the
Bottom of the startup activities?
Default report is V/S, notes from staff, I/O, meds, etc
How to open a pt chart
Double click pt chart
Attesting
A way to indicate that the documentation was reviewed, was discussed with the house staff and is approved by other clinicians
Attesting a note that does not require co -signing or an addendum
Select a relevant note from note activity and click attest. Attestation window opens, message can be added. Clinician who is attesting does not take over authorship of note. Attestation user is flagged as Such and the Attestation message appears at the top of the original note. Attestation and co- signatures can be removed by providers and the notes goes back to the original form
How to attest a note
Type in the big box .attest to bring in the smart phases highlight type F2 write name to get rid of xxx F2 lt click right click
Limitations of accordion reports
Do not provide information that might assist in determining what cause a change in pt’s assessment.
Values can not be hid or show additional values in the graph format
Show data from only the current admission
I/O activity table view
most detailed and focused review of a pt fluid I/O . View is compiled in a chart format like a flow sheet
Columns represent time intervals
By default there are 4 columns each representing 8 hours and 1 for daily total
Index report
Table of contents that links to other reports