Height/Weight Standardization - September 24th

Height/Weight Standardization – September 24th

All heights will be measured in centimeters only (measured or estimated).

Your smart templates for PowerNotes will pull in the Height in cm, where appropriate.  Please note that you will still see the height converted to inches in the Flowsheets.

All measured weights will be documented via the weight (kg) field only.  Will not impact the newborn birth weight.  To accommodate this change, you will

 

BANNER BAR

First WT (This Encounter) = The first documented weight on the current encounter that you have open.

Most Recent WT = The last documented weight for this patient regardless of what encounter you have open.

 

SMART TEMPLATES

Both weights are encounter specific – they do NOT look across encounters.  If you are on a clinic or hospital visit and only one weight is documented, you will notice that the weight is duplicated.

 

GROWTH CHARTS

For those using   growth charts, please note that you will notice an increased number of data points on your growth charts, but they will be grouped together.

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Impression & Plan to be Included in the Patient Summary

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Starting Tuesday, September 2nd, prior to the start of morning clinics, the Impression and Plan section of the PowerNotes will be included in the patient summary (depart summary).  The Patient Summary is the printed handout (or via patient portal) that is being given to the patient upon leaving a clinic visit.

Anything entered in the Impression and Plan section of the providers note will now be included in the Patient Summary if the note is signed at the time the summary is generated. Every field in the Impression and Plan that has information entered will pull into the summary.  If a provider’s note is saved but not signed the Impression and Plan will not be included.

 

UPCOMING CHANGES RELATED TO HEIGHT/WEIGHT:

Changes coming for Height/Weight standardization in September:


As previously mentioned, there will be changes with the group effort to convert to a standardized measurement within PowerChart.

 

*All height will now be measured in centimeters only, measured or estimated

*All measured weight for inpatients will be documented via the weight (kg) field only, including daily weights.  The only exception to this will be the newborn birth weight-it will remain as currently built.

*More information will be in the September PUTTER newsletter to show how we will address these changes via nursing documentation, PowerNote Smart Templates, Banner Bar, etc...

Dietary Orders Upate

Below are the changes for the upcoming dietary orders.

Reminder: Changes occuring Wednesday, August 27th.

 

CURRENT DIET ORDERS AS VIEWED IN THE DIETARY FOLDER:


NEW DIET ORDERS AS VIEWED IN THE DIETARY FOLDER

NEW ORAL DIET:

 

NEW ADA DIET:

NOTE:  This diet is separated from the oral diet order due to the requirements for calorie amount and snacks definition.

 

NEW NPO DIET:

 

USE ORDER SENTENCES WHERE AVAILABLE:


Bedside Procedure Documentation

Reminder:  When you are doing a bedside procedure on an inpatient basis (in the ICU, on the floor, or in the ER) the correct Document type to be used is Bedside Procedure Documentation.  This applies regardless of the service you are with (internal med, family practice, surgery, etc.)  There has been some recent confusion with which note type to use and this is causing problems with billing, signature lines, locating the document in clinical notes, etc.

Below is an example of the note type you need and examples of possible note templates of procedures that may be used in conjunction with this note type.

Note:  Operative Note or Brief Operative Note should only be used as a note type if the procedure is performed in the operating room.

If you need assistance locating or adding this note type, please call the Physician Concierge Hotline @ 775-TALK (8255)

 

This will be placed in a subfolder and can be found by expanding out the tree under Physician Documentation and looking under Progress Notes - Physician

 


OTHER Boxes-What do you want your "enter" key to do?

Due to recent default changes, some users may notice that when they hit the enter button inside a WHAT box (or OTHER box) in PowerNotes, it doesn't work the same as it used to.  When you hit ENTER while typing, sometimes it will close the box, and sometimes it will give you another line to keep typing.  It is all dependent on your personal setup in the system.

If you wish to change your setup, follow the instructions provided below.  And of course if you have trouble, feel free to contact any of the Concierge or HELP desk numbers.  Thank your for your patience.

 If you wish to change your preference for what the "WHAT" or "OTHER" box does...

From within a patient's chart, select ADD PowerNote (like you are going to start a note) and then...

 

1. Select VIEW in the top toolbar

2. Select Customize in the dropdown

3. Select the MORE tab

4. Select the preference you wish to occur each time you open a PowerNote

     *Create New Line (creates a new line to keep typing)

     *OK/Accept Text (closes the box)

     *Prompt When Opening (asks you every time)

 

Click HERE for Handouts

Definity/Echo Order Updates

Starting July 23rd...

To streamline the process of obtaining echo's using Definity to enhance the image, we will be making the following changes to the ordering process...

1. Definity med order inactivated/hidden,

2. Echo orders changed to add 'with contrast if needed' and an order sentence allowing Definity to be administered (shows dose/frequency),

3. Tech's will notify nursing staff if contrast is needed so they can prepare/administer it in a timely manner, and

4. Nursing staff to begin documenting via ad-hoc "nurses notes".  This will continue to only be administered by ICU or COPS nurses as per policy.

How Echo orders will now appear:

 

 

How the order sentence will display in the order details (as pulled from the Special Instruction field):

Lab Add Test Order Reference Text

Starting July 16th...

To help ensure that providers/nursing are not placing ammonia or lactic acid on the Lab Add Test Order, the information below will pop-up when the order is clicked on.  Once the pop-up has been available for about a month it will then be changed to show as reference text only on the order which can be accessed at any time.

 

 

Restraint Alert Upon Open Chart

For all providers with admitting privileges...

Starting July 16th

If a provider with admitting privileges (excludes residents and mid-levels) opens a chart that contains a Restraint Authorization - Medical/Surgical or Restraint Authorization - Behavioral order, that has not been co-signed by a provider, they will recieve the following pop-up.  This is alerting them that these orders need to be addressed.  This change is to help improve the timely signing of restraint orders to meet regulatory guidelines.  This can be accomplished by clicking on the "Order for Co-Signature" button at the bottom of the orders page or right-clicking on the order and choosing 'Co-Sign'.

New PowerForm Field - LMP for Post-Menopausal Women

When nursing staff document the intake for ambulatory patients, they previously had one place to document all LMPs.  The field was mandatory and did not repopulate with previous visit data each time.  This is great for women of child bearing years who still have their menses, but not so much for the post-menopausal patients. 

 

PowerForm Example

 

There is now a field that will activate or open when "menopausal" is selected.  This field will copy forward to each visit so the nursing staff will not have to re-ask the patient each time about their last menstrual period that was back in 1975.

 

PowerNote Example

                             

Flowsheet Example

 

The data goes to the flowsheet, just like the regular LMP.  It will also pull into any notes that have LMP as an autopopulation option.  Next time you open your note, just check that the box has been selected.

Enjoy!

 

RxNorm Update: Searching for Removed Medications

As you know with meaningful use, we are required to utilize RxNorm to normalize naming of brand and generic names of medications.  Because of this, the clinical IT team is running programs to "clean-up" the names of drugs in the system, and remove names of drugs that are no longer in existence, i.e. Phenergan versus Promethazine.

Even though in the end, only Promethazine will be in the system, if you change your search criteria to "contains" instead of "starts with"...you should be able to still find medications by Phenergan.

This update is provided to assist you with the RxNorm transition, thank you for your continued patience with the meaningful use process.

 

 

Transition of Care

Why?

The Transition of Care is Stage II Meaningful Use functionality.  Objective #15 states:  “the eligible provider (EP) who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide summary care record for each transition of care or referral” (CMS, 2013). 

The short version of this is that if you transfer care of your patient to an outside provider or facility that does NOT use PowerChart, your department should send a summary of care. 

To meet Measure 1 criteria for this objective, more than 50% of the patient transfers should have a summary of care.

Beginning in July, the process will be available to start using.  During this time your departments should discuss workflows and team members that will need to be involved in this process.  Call any of the HELP desks for more information.

 

Please click HERE for full tutorial