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EDM Training Manual
EDM Tracker/Worklist/Documentation 2
Temporary Status 14
Reception/Triage 15
Ordering Medications 18
Medication Reconciliation 22
Departing/Discharging 24
Admit Request 27
On Call List (ED HUC only) 30
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EDM Tracker/Worklist/Documentation
Pathway:
• EDM
• Clinical
• Emergency Department Tracker Purpose:
• The EDM Tracker provides a starting point to all the screens and functions
needed to view, edit and document patient information.
• The EDM Tracker displays pertinent information about your patient divided
into various columns.
• This screen is interactive; you have the ability to change some information
directly by double clicking on the specific column.
Tracker/Status Board
• ED Room/Bed/ED Priority: Assign a patient a room, assign multiple
patients to one room using the Bed or middle section, and ED Priority
allows user to assign a triage/priority classification to the patient.
The Folder Icon can click in this column to open chart of highlighted patient
ED Room, BED Triage/Priority Score
Name/Chief Complaint
Orders-type will be indicated.
Completed Results Indicator field
These buttons allow you to manage your patient list.
Time Status Event
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• Name/Chief Complaint: Same Names will appear highlighted in Yellow.
Unable to change the name field from the tracker. Can add or change the
chief complaint from the tracker.
• Orders: This field will show order indicators when new orders are placed
on the patient. Able to view these by clicking directly on the icon which
takes you into the orders screen to review the new orders placed.
• Results: When new results are completed the appropriate indicator will
appear in this field. Directly review the result when clicking on the label.
• Patient Status/Time: This column gives the user the ability to track and
record the patient flow thru the department. Clicking on this allows the
user to change what is happening to the patient during their visit and
record the length of time of each status. When clicking on the Current
Status, a lookup will appear to all Status Events. The most common next
status will be highlighted, if applicable, simply click or enter and the
patient’s status will be updated.
• RN/ERP: Assign or change a RN or MD providing care for the highlighted
patient.
• Visit Time/Reg Status: This column indicates the length of stay in the
department and registration status.
Right Verb Strip (right side of the screen)
• Lists: Can access different locations, Pods, find
accounts.
• Tracker: Returns you to the EDM Tracker.
• On Call Staff: Use this screen to view a list of
staff members currently on call.
• Assignments: Use this screen to change your patient assignments.
• Clinical Data: Use this routine to enter, edit, or view information for a
highlighted account. This is where you will document home medications
and allergies.
• Reassign ED Staff: Menu key to change multiple patients over to a
different provider all at once either as a physician or nurse.
• Manage Orders: Use this screen to view, enter, and edit acute care
orders, medications, and order sets. We will not train to this functionality
for nursing staff.
• Patient Reports: Use this function to print patient reports for one or more
patients. (patient snapshot, complete record (legal record)).
• Location Reports: Manager’s view of reports. Will be taught to leadership.
• Calls: Use this functionality to enter or edit information about calls to and
from your department.
• Reception: Menu key to receive new patients into the department.
• Triage: Menu key to enter triage documentation
• Patient Snapshot: Able to view quick synopsis of patient data. Formally
known as MD ED Summary.
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• Admit: Menu key to request admit of ED patients to your facility. This
function allows you to go to the admissions application. (BCH nursing
staff-will utilize admit as inpatient and obs).
• Sign Up: Will sign user up when clicking on this button as pt care provider
• Open/Close Chart: Opens and Closes the highlighted patient’s chart
• Ready for Discharge: updates patient status Ready to Discharge.
• Management: Statistical graphs/logs related to care in the ED.
• Preferences: Use this screen to define your Status Board/EDM Tracker
preferences.
Main: Facility, regular type of patients, can remove patients from
list in pre-determined amount of time.
Status Board/Tracker: Defines what is accessible in lists menu key
Chart/Plan of Care: Default page when opening patients chart-
expanded/contracted. .
Worklist: Determines Interventions or Medications to view in your
worklist. Outcomes do not apply to ED.
Medications: Display MAR preferences.
Preview-preview display preferences.
Footer Buttons
• Refresh: Allows user to manually refresh the tracker.
• Add to My List: Allows user to customize your own tracker by highlighting
a specific patient and clicking the footer button.
• Close All Charts: Allows user to close all charts if multiple charts are open
at a specific time.
• Edit Coverage: Kootenai ED Only: Gives you the option of customizing
the tracker to a specific area directly.
• Minus/Plus: Clicking these allows expanding or contracting the amount of
lines visible per patient. (tracker is set to 3 lines)
• Show Empty Stations: Clicking this button allows user to show or hide
empty rooms on the tracker.
• Question symbol: Help function key
• World symbol: Reference/Lookup function, possible link to reference
websites.
• Printer symbol: Printer function
• Lock symbol: Suspend function
• Mail symbol: possible future link to email system
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On Call Staff
• Click on “On Call Staff” this will bring user to the on call list for that present
day. This will take the place of the current Mox on call list and is available
to all nursing staff via status boards or trackers.
• To return to On Call list click on “Back” tab and it will bring user back to
the main On Call Staff list.
Printing/Viewing Patient Reports
To print or view patient reports
• From tracker choose Patient Reports tab from Right side of screen.
• Select patient/patients by putting a check in the box. The Report button
at the bottom of the screen will highlight. This will allow the user to select
the type of chart to print or view.
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• After making the selection click on Ok the user will have a prompt come
up to select whether the user wants to: View, Print, Download, or Mail.
• Selecting View brings up the patient summary on the computer screen.
• Selecting Print and this will print out the complete patient report that has
been selected. After the user has viewed or printed the report it will bring
the user back out to the current tracker.
Management Menu Key Manual
Management
• Allows you to access graphs regarding the Census and statistics. Click on
the management on the right verb strip.
• Once a specific graph is chosen, there are function keys at the bottom of each graph that allow you to view daily, weekly, or monthly statistics.
Types of Graphs Available:
• Current Status: Use this graph to view the current number and location of
Emergency Department patients.
• Arrivals: This reflects the new arrivals to the Department
• Historical Status Count: Use this graph to view a patient status history.
• Average Length of Stay: Use this graph to view length of stay statistics.
• Average Time in Status: Use this graph to view patient status progression
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Open Chart
Worklist
• Purpose: The worklist is used to document on assessments and
interventions you have for your patient.
• To access the worklist go to your tracker and highlight your patient. Click
on the Open Chart tab on the right of your tracker.
• Once you open the chart click on the worklist tab on the right side of your
screen.
• The 1st column tells if it is and A-Assessment or T-Treatment.
• The 2nd column gives the name of the Care Item to be done
• The 3rd column (with the clipboard) is the frequency to be done. Edit
frequency by clicking on the empty space, a time lookup is provided.
• The 4th column lets you know there is additional data associated with that
item. Clicking on the [?] will give you definition for the icon listed.
P=protocol, I=Item detail (detailed information associated with
intervention).
• The 5th column is the time the activity was last completed.
• The 6th column indicates when this intervention is due. Red indicates
time intervention is overdue.
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ED Visit Data: Looks to Current data, patient demographics, mini audit trail Mar:
Medication Administration Record.
Write Note: Able to write free text note.
TAR: Transfusion Administration Record-for administration of blood.
Discharge: Discharge occurs within a patients open chart. Will learn this
functionality during section C.
Documenting in EDM
Documenting an Intervention:
• To Document: Click in the appropriate cell (NOW) and a check mark will
appear. User can check off as many cells across and down as needed.
Once items are checked, the Document button will be high lit at the
bottom of the screen. Clicking on document will launch the screens
checked off on the worklist. Assessments and treatments will populate into
worklist based on chief complaint.
• Contracting and Expanding: Contracting or expanding documentation may
be done by clicking the + or – buttons to the left of the Assessment or
Treatment, such as Social History and Functional above. See blue arrow
on screen shot below.
• Assessment/Treatment: Point and Click Functionality.
• The 7th column is Document NOW.
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• Free text, comment or text boxes.
• Square answers: can choose more than 1.
• Circle answers: can only choose 1.
• Instance Types: allows the user to choose a body part location or time to
document on, such as a left wrist. The documentation field remains
collapsed until the body location is filled in. There are different instance
types: time, body part, location, can ad lib free text. See example below.
Question Types
• Questions requiring dates or time Can use drop down arrow or type in date, time or “N” for now.
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Adding Assessments/Treatments:
• To add an assessment or intervention not present on the worklist, click the
add button at the bottom of the page.
• Click on Treatments or Assessments on the menu to the right, and choose
from the Items listed on the page. If the choice is not showing, the Prior
and Next buttons at the bottom may be used to change pages. Multiple
choices may be made at one time if need.
• The selected items will be highlighted at the bottom of the page. If your
highlighted choice is correct, click Save in the bottom right corner. If the
highlighted choice is incorrect, click on the highlighted item again and the
checkmark to the left of the item will be removed.
Adding a Note to the Assessment or Treatment
• A free text note may be added to any assessment by clicking on the Add
Note button at the bottom of the documentation screen.
• This note will stay with the documentation section it is attached to in the
Electronic Medical Record (EMR).
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• Choose the type of note to be documented on and click on it. This will
bring up a free text screen to type in.
• When complete click on OK to save this will bring the user back to the
documentation currently being utilized. A clipboard will appear at the top
of assessment when note attached.
Saving:
• To save all documentation click Save in the bottom right corner. This will
return you to the worklist.
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• Done will appear in the NOW column showing that documentation has
been completed.
• The Last Done column will show the number of minutes the assessment
or intervention was last documented on.
Documenting Detail “I did it Treatment Type”: An “I did it” type of Treatment
has preset documentation attached to allow the user to simply say they did the
Treatment. An example of an “I did it” Treatment is the FAST Exam shown
below.
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• To document from the worklist click on the treatment in the NOW box,
which will highlight the Treatment in green.
• To view or edit the “I did it” Treatment documentation click on the “I” in the
box in the highlighted line.
• The documentation is in the green highlighted box and may be edited to
suit the patient.
• To edit the text in the Item Detail box click the Edit button in blue next to
the Text box.
• This document edit text is available with all assessments/treatments.
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• The user is now able to remove documentation or add observations, when
documentation is complete click the Save button.
• To complete this type of documentation, simply click the Save button
again at the bottom.
Viewing and Editing Existing Documentation
• To view documentation previously done select the Assessment or
Treatment, then click the View/Edit button at the bottom of the page.
• Previous documentation may now be viewed.
• If edits need to be made, click the Edit button at the bottom of the page.
Click Save when edits are complete.
Recalling Previous Documentation to New Documentation
• To recall documentation previously done, click the Recall button at the
bottom of the screen.
• Diamonds will appear to the right of each question, and may be clicked
on to pull previous documentation into the current Assessment or
Treatment.
• If the previous documentation is not correct, the provider may enter the
new information instead.
• Click Save when complete to return to the Worklist. See example below.
Changing the ModeTo change the Mode the provider views and enters
information, click the Mode button at the bottom of the Assessment.
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• The Mode of documentation is a provider preference and may be
changed at any time.
• To document in this Mode the provider must click on the down arrow to
make a choice then OK.
Hiding Text: The Hide/Show Text button will allow the provider to remove
instruction type text from the Assessment or Treatment screen, such as the WNL
statements.
Temporary Status
Purpose: ANY INPATIENT needing to be seen by ED Physician for
issues that attending MD cannot care for at any time during In patient visit.
(including youth: acute/residential and adult psych for KMC)
• ADM will relocate patient back on ER tracker using Clinical Data:
Additional tab and changing temp location status, updating patient room
assignment at this time.
• ER RN will Triage patient following normal procedures once patient is
temp located by ADM Staff.
• Continue care of patient thru rest of visit as ER Patient, there are some
differences to consider.
• Status event of Temporary Status when first placed on tracker by ADM
can be updated to reflect patient flow thru the department.
• Nursing: Triage/Discharge Assessments will not show under
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Triage/Discharge Routine. These will have to be documented from the
worklist, each assessment will have to be added to the worklist.
• From Triage Routine, Triaged At (time field)/Time Seen by provider (time
field) Cannot be updated to reflect the new triage time, please bypass
these fields.
• Orders from floor will show on main tracker under orders column and
also under current orders in Orders tab.
• eMAR will also reflect all inpatient medication orders.
• MD: In discharge routine prior Clinical impressions should not be deleted,
please add new impressions to these.
• Discharge date and time Not able to change this information.
• Use status event of Admitted when Patient ready to go back to floor. This
will remove patient off tracker.
For patient that needs a higher level of care or needs transfer to another facility after
evaluated in ED this patient treated like an inpatient needing transfer and is done
through the attending physician.
Reception Purpose: Use this function to receive a new patient into the Emergency
Department.
RECEPTION : (note Ambulance symbol for quick access to this menu button)
• The screen below will appear, input patient name. The more information
in the fields the greater likelihood of the exact patient displaying.
• Function button: Select the appropriate function button on the bottom of
the screen.
• Search: Use this function button initially for all patients, this will assist
you in choosing the correct patient account if the patient has had a prior
visit.
• Find More: Select this function key if there are multiple people with similar
identify characteristics chosen and you do not see the correct patient.
• New Patient: Select this function key if you are unable to find your
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patient using the above keys.
• Cancel: Select this function key if you need to cancel the new reception
or you have entered information in error and do not want to save it
• Choose patient from list, verify birth date! If there is any doubt have
registration receive patient.
• Once a patient has been chosen the following screen will appear. If
patient has been in the system before the header and demographic
section will auto fill. All questions with asterisks are required before filing
(arrows).
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• Verify DOB: re-enter in Date of birth to verify information.
• Stated Complaint: free text area. This is displayed on the triage tracker.
• Status: Pending triage defaults in. Can change by typing in field or using
drop down arrow. Registration not required to complete. .
• Arrived At: Self populates to date and time when patient entered into
system.
• Arrived By: You can begin typing or use the drop down arrow to choose
from a list of modes of arrival for patient.
• Priority: This is the triage classification of the patient based on the five
level triage classification system. You can begin typing or use the drop
down arrow to choose your triage class. Registration not required to fill
this out.
• Condition: This field does not need to be filled in, Registration and/or RN
do not need to assign a patient condition.
• Triaged At: Time of beginning default in. Able to type in “n/N” to populate
the time now, you can also choose the drop down arrow to enter a
different time if need.
• ED Location: Emergency Department defaults. Can change to correct
pod. Registration not required to complete.
• Area: Lobby defaults can change room according to pod. Registration
not required to complete.
• PCP: Can assign PCP using drop down arrow or start typing. Nursing not
required to complete.
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• Save: At this time you will be prompted if any asterick (required) are left
blank. Once saved the following print face sheets, armbands menu will
automatically appear. Click ok to print the necessary forms.
Triage
Purpose: Triage can be completed from reception using the triage assessment
section or from triage tab (right verb strip). They are the same assessments in
both fields, same screen design as reception.
• Chief Complaint: This is a look up to chief complaints existing in the
system. You can begin typing your complaint into this area and it will
automatically populate into the field or you can use the drop down arrow
at the side to look to all the chief complaints to choose from. (Using the
space titled Other, can add in multiple
additional chief complaints if appropriate.
• ED Provider: Assign ED physician by
typing in provider name or use the drop
down arrow,
• ED Nurse: Assign Nurse by typing in
name or using the drop down
arrow.
• ED Location: Change location to correct
pod or leave in KMC ED.
• Area: Change to correct room or leave
lobby if going back to lobby.
• Status: In triage will default once triage assessments are completed.
Change by typing in field or using drop down arrow.
• Triage Assessments: Check the assessments and document. The triage
list will be different based on variations in patient ages. This list can
include:
ED Triage Assessment (Chief complaint, Vaccination, Social
and Functional History, Tobacco Usage, and Advanced
Directive)
Admission History or Pediatric Admission History
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Vital Signs
Pain Assessment
Height and Weight
Fall Assessment Tool (over age 60).
• Triage information other then assessments is saved at time that a field is
completed.
• Allergies/medications: Click on the tab at the top. Choose the edit button,
you are able to add new or edit existing allergies or meds at this time.
Required information has an asterisk. Click Save at the right hand when
completed. You have the ability to print a home medication list.
Order Management –Medications
Purpose: to order ED physician RBVO or written ED orders.
• Open patient tracker to view patients to start your order process. Click on
patient name to select and highlight patient to open the chart. After
highlighted click on Open Chart it will then open to the Order
Management Screen.
• At the top of the page displayed a Current Orders tab and a History tab.
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The Current Orders tab will automatically open and display active orders.
Orders are broken down into categories such as Medications, Radiology,
etc. The History tab when clicked on will display all orders placed on the
patient including canceled and discontinued orders.
• Please see order management manual for non medication orders.
• On the Order Management screen the Function buttons are at the bottom
of the screen (New Orders, New Meds, New Sets and Restorable). To
place a new Medication order, select the New Meds button at bottom of
screen. The New Meds button will open up a new screen which gives the
option to search by favorites, Category group, or specific name. Defaults
to favorites if exists.
• Nurses will be prompted to enter physician and order source. Read
Back Verbal Order will send the order to the providers esign queue. See
screen shot below. Once selected click ok.
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• To select a medication click on name or string below which bring up page
of associated strings. Click in box to choose appropriate medication.
Notice blue edit box, if starred edit is required if not, can click ok.
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Starred edit –cannot enter past without editing medication string. Click on Edit tab.
items need completed before filin g .
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• Click OK which will bring up the final editable order review before orders
are saved. If conflicts exist the conflicts page will appear prior to the final
editable order review. See screen shot below, the user must manage
these conflicts before orders can be saved. May override, replace, or
erase order. If override a reason list will appear to indicate reason why
override is occurring.
Complete the required information before filing. Once complete the Edit button will no longer have a *.
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• Once conflicts are resolved then the review order page will appear for
final edits prior to saving.
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Medication Reconciliation
• Home Medications: Nurse updates home medications in Triage
• Physician Reconcile: Physician responsible for reconciling medications
through Order management.
• Home Meds: Discharge: After the physician completes the reconcile
process in orders and ambulatory orders, the nurse reviews the home
med list for the correct medications as outlined in physician
prescription/discharge instructions and updates accordingly. Then nurse
updates the last dose/time taken. Then nurse prints the home medication
list after these updates via the discharge functionality it is also set to print
with the discharge packet.
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Discharging/Departing a Patient From EDM
Purpose: To depart a patient from the ED (admits and discharges).
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The patient status cannot be in a READY TO DISCHARGE status unless REG
ER admission status occurs. Can still enter information but cannot Discharge off
the tracker.
Discharge Plans Tab: This will bring you to the screen, noted with the button at
the top. To enter the discharge information, use the drop down arrows to the right
and make a selection from the menu.
• Instructions: Not utilized at this time, will have to input free text which
instructions are given.
• Stand alone forms: Release from school, PE, etc.
• Prescriptions: For physician use only.
• Forms: all forms created as stand alone.
• Referrals: Looks to referral lookup.
• Additional Free text: opens to word document. Can use canned text (if
created) or free text. Physicians should record instructions given here.
• Can click in item detail section to give patient further instructions (see
green arrow)
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projects or services, please contact the 24/7 Kootenai Health Information Technology Help Desk. By Phone: 855-554-4440 (toll free) or 208-625-5555; By Email: [email protected]
Page 29
Discharge Data Tab
• Provider: will default in.
• Status: will default in from current status on tracker, or when RDC
button is clicked.
• Time Seen by Provider: Time stamp from the ERP in Room Status
Event or can be manually entered.
• Triaged at: defaults in based on when triage occurred.
• Other ED Providers: can assign more then one ED provider.
• Clinical Impressions: Medical findings by the physician.
• Discharge Disposition: To be completed by physician.
• Condition: patient condition recorded by provider.
• Discharge comment: Free text box.
• Discharge date and time: Documenting in this field will take a patient off
the tracker. It will be grayed out until REG status occurs. This field is to be
used for all patients whether admitted or discharged from the ED.
• Discharge Interventions: Can associate required or recommended
assessments. Can add from here using “+” at bottom. To document,
check the assessments and click document. Warning can occur based on
facility decision which assessments are required upon discharge.
• Once discharge data and plan have been completed may print packet or
each form separately.
This material is the intellectual property of Kootenai Health. Do not download, share, or redistribute without prior permission. With questions about any
projects or services, please contact the 24/7 Kootenai Health Information Technology Help Desk. By Phone: 855-554-4440 (toll free) or 208-625-5555; By Email: [email protected]
Page 30
Printing Packet:
• To print the patient’s discharge packet, click the Print Packet button at
the bottom of the screen. Can print by type instead (discharge reports).
• Information previously entered in the Discharge screen will now print.
Admit Request • Select patient that is to be admitted by highlighting. Then go to the
menu buttons on the right of the screen, and choose “Admit”. Choose
Admit request.
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projects or services, please contact the 24/7 Kootenai Health Information Technology Help Desk. By Phone: 855-554-4440 (toll free) or 208-625-5555; By Email: [email protected]
Page 31
• Bed request: Request service required to complete the admit request
form which will be presented upon choosing a location for admit. Do not fill
out any other questions in the bed request section.
This material is the intellectual property of Kootenai Health. Do not download, share, or redistribute without prior permission. With questions about any
projects or services, please contact the 24/7 Kootenai Health Information Technology Help Desk. By Phone: 855-554-4440 (toll free) or 208-625-5555; By Email: [email protected]
Page 32
• The following Fields are required:
• Registration Type: Inpatient defaults but it can be changed to
observation or outpatient.
• Request Accommodation: Choose a service level.
• Request Admitting Doctor: Use the drop down menu to select a
physician.
• Request Attending Doctor: Use the drop down menu to select a
physician.
• Request Reason: Allows the user to select from Inpatient,
Observation, or Outpatient.
• Request Time: Select time of request
• Request Date: Select date of request
• Choose location for admit.
This material is the intellectual property of Kootenai Health. Do not download, share, or redistribute without prior permission. With questions about any
projects or services, please contact the 24/7 Kootenai Health Information Technology Help Desk. By Phone: 855-554-4440 (toll free) or 208-625-5555; By Email: [email protected]
Page 33
• Room Assignment: Select a room number from the drop down
menu.
• Primary Diagnosis: Free Text
• Secondary Diagnosis: Free Text
• When complete with the information select the “Save” and it will send the
message to Admitting and Registration.
• The patient status will change automatically to pending admission on the
tracker.
This material is the intellectual property of Kootenai Health. Do not download, share, or redistribute without prior permission. With questions about any
projects or services, please contact the 24/7 Kootenai Health Information Technology Help Desk. By Phone: 855-554-4440 (toll free) or 208-625-5555; By Email: [email protected]
Page 34
Reprint Admission Forms/Labels
• Choose forms to reprint
• Click on Triage
• Click on reprint admission forms
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projects or services, please contact the 24/7 Kootenai Health Information Technology Help Desk. By Phone: 855-554-4440 (toll free) or 208-625-5555; By Email: [email protected]
Page 35
Building the Physician On Call List
Purpose: To build a view list of on call physicians.
Pathway:
• Clinical
• Emergency Dept
• EDM On Call
• In the upper left corner of the screen you are given a Service scroll box
that will allow the user to choose a specific specialty group. Below that is
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projects or services, please contact the 24/7 Kootenai Health Information Technology Help Desk. By Phone: 855-554-4440 (toll free) or 208-625-5555; By Email: [email protected]
Page 36
the “Date” of call and “Slot” which allows user to pick a group (On Call,
No Call, and Specific Providers office names etc.).
• To the right of the date and slot box is the “Provider” box, which allows the
user to choose the provider for the group of Physicians on call. We will not
be instructing or teaching to adding a comment for the end user to view.
This material is the intellectual property of Kootenai Health. Do not download, share, or redistribute without prior permission. With questions about any
projects or services, please contact the 24/7 Kootenai Health Information Technology Help Desk. By Phone: 855-554-4440 (toll free) or 208-625-5555; By Email: [email protected]
Page 37
• After complete with On Call list the user may also view by clicking on the
“Editable Preview” tab at top of page. This will bring up the Dates,
Service/Slot and list of Providers.
• On this screen the user can preview the information that was selected and
make edits as need by clicking on slot or provider the Slot or Provider that
needs to be edited and/or updated.
This material is the intellectual property of Kootenai Health. Do not download, share, or redistribute without prior permission. With questions about any
projects or services, please contact the 24/7 Kootenai Health Information Technology Help Desk. By Phone: 855-554-4440 (toll free) or 208-625-5555; By Email: [email protected]
Page 38
• To edit highlight the Provider’s name and choose the “x” this will allow the
user to remove the item and insert the correct Provider. This function
works the same for when user chooses On Call, etc.
• When user has finished with previewing and editing choose the “Save”
button at the bottom of the screen and this will save all changes made by
the user.