Medication Documentation at University of Illinois Medical Center UIMC

1
Medication Documentation at University of
Illinois Medical Center (UIMC)

• UIC CON
• EHR STEP Grant Team

2
Objectives
At the end of this module the student will be
able to Correctly document PO, IM, IV
medication administration in the sample EHR
assessment.

• Medications are charted from the
• Task List
• Multi-Patient Task List
• PAL (Patient Access List - not addressed in this
  module)
• MAR (Medication Administration Record)

• PO (by mouth)
• IM (Intramuscular)
• IV (Intravenous)

3
Terminology Clarification

• You may hear people say, Gemini when referring
  to the Electronic Medical Record (EMR).
• The preferred term is Cerner PowerChart.

4
Accessing Medication Administration Homepage
1

• Click on the desk top Internet icon or type the
  website for the Hospital Home Page
• Medication Administration Policy is found under
  the drop down UI Medical Center

2
5
Location of Medication Administration Nursing
Policies

• When you click on UI Medical Center, you will see
  the drop down selections
• Click on Policies Nursing

6
Medication AdministrationFolder

• Click on the Medications Folder

7
Medication Administration Standards

• From M3 Standards Medications are allowed to
  be given 30 minutes prior to the scheduled time
  of the dose and up to 30 minutes after the
  scheduled time of the dose per nursing policy (a
  range of an hour)

8
Task List Tab

• The Task List Tab is bolded and pre-selected (as
  the default tab) for nursing when the EMR is
  opened by a nurse.

9
Task List - changing the time frame

• Right click on the thin light blue line with the
  day, month, date, year, time and select
• Change Time Frame Criteria

1
2
10
Task List - changing the time frame

• Select Generic Time Frame in the upper right
• Enter the From and To date range and time in
  the bottom of the box
• Click OK

1
2
3
11
Sub Tabs of the Task List Menu

• The sub tabs of the Task List for medication
  administration are
• Scheduled Meds
• PRN Meds
• PRN Response
• IVs

12
Scheduled Meds (Part 1)

• Scheduled meds have a light blue (or light green)
  background.
• There are 3 ways to chart medications
• From the Task List, you are able to Quick Chart
  by left clicking on the yellow box at the far
  left side of the screen.
• If an alarm clock is in the box, the medication
  is overdue.
• If the box is blank, the medication is pending.

13
Scheduled Meds (Part 2)

• Charting Medications (cont.)
• From the Task List you are able to Chart
  Details by right clicking on the medication
  itself - with the blue background.
• If it is grey, the pharmacy has not verified the
  medication.
• If the background is yellow, the medication is a
  single dose it is to be administered only one
  time.
• From the MAR You are able to right click on the
  medication to Chart Details or Quick Chart.

14
PRN Medications Tab

• PRN Medications are given for various reasons
  pain, itching/irritation, agitation or anxiety

15
PRN Response Tab

• This tab allows for documentation of patient
  response to PRN medications.

16
IVs

• This includes peritoneal dialysis solutions
  (CVVHD), bladder wound irrigation fluids.

17
Multi-patient Task List

• Default opening screen is the last time one
  charted
• Only scheduled meds display not IVs PRNs
• All the patients on the unit are listed
• All patients are marked with check marks
• Leave checks in place for your assigned patients
• Uncheck the other patients

18
Single Dose MedsTask List or Multi-patient Task
List

• One time dose medications have a yellow
  background on the Task List and the Multi-patient
  Task List.
• Examples of Single Dose Medications are On Call
  for OR or a procedure, STAT, and Now do not have
  a time associated with the order.

1
2
19
MAR Medication Administration Record

• The MAR defaults to the present time, 24 hours
  prior to the present time, and 12 hours in the
  future
• Overdue displays in red - the med has not been
  administered within the allowable time frame
• Next doses display in blue
• PRNs display in green

1
2
3
4
20
Quick Chart on the MAR

• Once you click on the med or right click and
  select Quick Chart (1) the med is time stamped
  with the time the medication was scheduled to be
  given.

1
21
MAR and Chart Details
1

• One is able to change the date or time when right
  clicking and selecting Chart Details (See slide
  20 for Quick Chart)
• Within the Chart Details window, you are able to
  chart on behalf of someone else.
• At UIMC most of the time physicians do not chart
  administration of medications.
• For example, you want to chart a medication was
  administered by a physician during a bedside
  procedure.

2
22
Charting on Behalf of Someone Else using the
Binocular Icon

• Within the Chart Details window, you are able to
  chart on behalf of someone else.
• Click on the binoculars icon
• Type in the persons last name and first name if
  needed
• Click on the persons name in the bottom window

1
2
3
23
Charting for an Agency Nurse

• The UIMC nurse is not able to locate agency
  nurses using the binoculars.
• When charting medication administration for an
  agency nurse, one is to click on the Comments
  section and enter the name of the agency nurse.
• Click on the Comment box in the lower right and a
  white box will open to allow you to type in text.
  
• Click OK in the lower right corner.

2
1
3
24
Code Gemini Planned or Unscheduled Downtime

• Notification is sent via email for planned
  downtime
• Notification for unscheduled downtime is sent via
  email and announced overhead
• When a Code Gemini (planned or unplanned
  downtime) is resolved, the nurse must chart all
  medications given during the time while the
  system was not available. This includes
  medications admistered by all previous nurses.

25
MARRescheduling a Dose (Part 1)

• Reschedule This Dose is allowed if it does not
  affect the administration time of the next
  scheduled dose. (It changes only the time of
  this dose not any other doses of the medication)
• Right click on the medication dose (not the name
  of the medication)
• Left click on Reschedule This Dose.

1
2
26
MARRescheduling a Dose (Part 2)

• Fill in the time and date
• Scroll down to select the appropriate reason
• If future doses need rescheduling, follow the
  Reschedule Administration Time process (Next
  Slide)

1
2
27
Reschedule Admin Times (Part 1)

• Overdue medications cannot be rescheduled
• Reschedules this dose, the next dose, and all
  future doses
• Right click onthe name of themedication in the
  column listing of all the medications
• Left Click on Reschedule Admin Times

1
2
28
Reschedule Admin Times (Part 2)

• Enter the time for the next scheduled dose in the
  first box followed by the time for the next
  doses.
• Follow the order. If it is ordered for every six
  hours, you cannot reschedule for every 4 hours.
• You cannot enter the same time in more than one
  box.
• Click Save

29
Reschedule Admin Times (Part 3)

• If the medication is ordered for QID and not q 4
  hours, you are able to enter the times the
  patient takes the medication when at home (for
  example with breakfast, with lunch, with dinner
  and before going to sleep). NOTE These times
  may not be an exact number of hours apart. The
  patient is taking the medication four times in 24
  hours
• Daily doses are scheduled at 9 am.
• Doses can be scheduled for every 24 hours. That
  time is attached to the time the order was
  placed. This time can be altered based upon
  nursing judgment.

30
MARChart an Additional Dose (Part 1)

• Instances in which you need to chart an
  Additional Dose
• medication has been discontinued
• the patient has been discharged and you want to
  chart a dose given prior to discharge or
• the patient was off the unit and missed a dose

31
MARChart an Additional Dose (Part 2)

• Right click on the name of the medication in the
  column listing of all the medications. The
  medication will be grayed out.
• Left Click on Additional Dose
• Enter the date and time the medication was
  administered. NOTE This cannot be performed from
  the Task List.

32
MARChart an Additional Dose (Part 3)

• Click on the Comment box in the lower right and a
  white box will open to allow you to type in text.
• In the comments section, document the reason you
  are administering the medication such as
  medication administered prior to discharge from
  the hospital or medication discontinued at 6
  pm 5 pm dose was given.
• Click OK.

medication administered prior to discharge from
the hospital or medication discontinued at 6
pm 5 pm dose was given
33
Chart Not Done (Part 1)

• Documentation for a medication which is unable to
  be administered for various reasons (For example
  medication has not arrived from Pharmacy,
  patients blood pressure is too low, patient is
  off the unit for a diagnostic procedure or in
  radiology)
• Right click on the medication
• Select Chart Not Done

1
2
34
Chart Not Done (Part 2)

• Enter the reason from the drop down list or
• Type in information

35
PRN Response Task List (Part 1)See Slide 13

• Once a PRN Medication is documented, a subsequent
  task for documentation of the Response is
  generated.
• It displays in the PRN Response Task List tab.
• UIMC policy is to document a response any time a
  PRN medication is given.

36
PRN Response Task List (Part 2)

• Select the patients response to the PRN
  Medication from the drop down list.
• If Other is selected, one is able to type in a
  Response Comment.
• If the medication was given for relief of pain,
  the Pain Assessment window at the bottom is
  completed. (Pain scoring documentation is not
  addressed in this module).

1
2
3
37
PRN Medication Administration and PRN Response MAR
1
2
3

• PRN medications have a green background and are
  display with a heading of Unscheduled.
• Double click on the Last given date and time
  green box or right click and select Chart
  Details.
• Double click on the Response box or right click
  and select Chart Details.
• You will see the same screen as shown on slide 36
  for entry of the PRN Medication Response and
  documentation of Pain score of the medication was
  given for pain.

38
PRN Response Policy

• University of Illinois Medical Center (UIMC) has
  chosen a 30 minute time frame for the PRN
  Response to activate
• The nurse does not need to chart a response
  within 30 minutes but does need to document a
  response to the medication

39
IV DocumentationTask List (See Slides 11 and 16)
40
IV Documentation MAR 1

• Double click on the box to the right of the name
  and amount of the fluid.

41
IV Documentation Chart Details
1
2

• Right click on the Pending box to modify previous
  IV documentation
• Left click on Chart Details (for example, site
  change, rate changes, or amount wasted)

42
IV Documentation Window

• You are able to change the bag number, site,
  volume, rate, amount wasted, and hang multiple
  bags.
• Apply is used between entries when more than one
  bag is hung for dialysis solution.

43
IV DocumentationApply

• When you click Apply, the entries made display in
  the top of the window alongside Begin Bag, Site,
  Waste, and Rate.
• Remember to change the time and date to reflect
  whatever change is entered.

1
2
1
44
IV DocumentationBegin Bag

• Click on Begin Bag and the bag number below is
  increased by one unit.
• Make sure to change the time for the next bag and
  the date if necessary (Not shown here.)

45
IV DocumentationSite

• The site can be changed by clicking on site cell
  you wish to change at the top
• Selecting another site from the drop down list.
• Make sure to change the time and date for the new
  site.

1
3
2
46
IV DocumentationWaste Amount

• Click the Waste cell correlating with the Waste
  row for the IV bag where fluid was wasted.
• Waste amount entry is completed in the bottom of
  the window.

1
2
47
IV DocumentationRate

• When Rate is clicked, one is able to enter the
  mL/hr or 999 for a bolus infusion.
• Make sure to change the date and time for the
  change in rate.

1
2
48
IV DocumentationSign Form

• When charting is complete one clicks the
  check/Sign Form in the upper left corner of the
  window

49
Feedback

• Please contact
• Ginevra Ciavarella gciava1_at_uic.edu or
• Yvette Roberts yroberts_at_uic.edu with comments or
  questions