Point of Care
What is Point of Care??
Point-of-care is a general term defined as
“near the site of patient care”. The driving notion
behind POC is to document immediately while
you are with the patient. This increases the
likelihood that the patient will acquire results in a
timely manner and will prevent
miscommunication and omitted
information/documentation in the future.
What are some benefits to
Point of Care?
•Nursing & Multidisciplinary
data entry on the same patient
•Bedside documentation
•Real Time Data Entry
•User defined documentation
content
•System security-- unique id
access & password ensures
patient confidentiality
So how do we start?
Logging in
1. Each employee will be assigned a unique USER ID and
Password to access the system
2. Click on POC Access
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3. Select your patients from the Census by making them “ ”
4. Click on the “My Patients” tab to see your patients and
start charting.
5. To start viewing the “Virtual Chart” click on the Name of
the Patient
So what does a
virtual chart look
like and what are
its functions?
Patient’s Photo
Labs / Critical Labs
Allergies and
Immunization
Information
- See definitions on next page
Memo or Reminder
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•
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•
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•
•
•
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Flowchart - used for daily charting /
Nurses Notes
E-forms – used for one time forms
example: Present on Admission
Pharmacy – used for Medication
Administration / Med Verify / MAR
Diabetic Record – Diabetic Flowsheet
Order Entry – Orders
example: Labs, Dietary, Radiology
Reports – Printouts
Discharge – Discharge Summary /
Instruction
Chart Type – used to select type of
Patient (MedSurg / Telemetry / ICU/
CCU/CSU, etc.)
ALWAYS MAKE SURE YOU HAVE THE CORRECT
CHART TYPE!
What will change? In
the name game…
• Admission/Initial Assessment = Initial
Interview
• Nursing Flowsheet = Patient Care Daily
Flowchart
• Nursing Notes = Patient Progress Notes
• Kardex = MedAct
• Paper Medication Record/MAR = Electronic
MAR
• Daily Assessments, Activities & Vital Signs =
Flow Chart
• Plan of Care = Interdisciplinary Plan of Care
eform
So which forms do we keep in a
Flowchart, E-form and Paper?
Click here!!!
REMINDERS—Common Mistakes
• NEVER PRESS ON “COMPLETED“ icon–This
means patient will be discharged and you are
closing the flowchart or you have reached the limit
of 500 columns.
• If you wish to chart on the same time, always click
on the same column of the flowchart to keep the
same time.
• POLICY : CHARTING BY EXCEPTION
• For Nurses Notes: Chart only if there is a change
in patient status. However, all questions need to
be answered upon assessment every shift.
• Address Interventions by System.
Example: ( Respiratory Section to chart on “Lung
Sounds”)
Flowcharts
Flow Chart Functions
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Vital Signs
Intake/Output
Initial Interview (Initial Assessment)
Physical Assessment
Nurse’s Notes
Select a new flowchart from
the list or click Existing to
search for previously created
flowcharts
Answer the question and
click on Next to continue.
Click on Update to chart
in real time.
E-forms
How to open an e-form
S
A
M
P
L
E
E-forms
Navigation
Toolbar
Med-Verify
Pharmacy
• When selecting a tab from the Virtual
Chart, the user can access an application
directly.
• Click on the Pharmacy tab to access the
various applications associated with
pharmacy such as 24hr EMAR or
electronic MAR.
SELECT PHARMACY TO
ACCESS THE PHARMACY
APPLICATION
Verifying Orders
From Pharmacy tab, click on Pharmacy and
then click on Verify Orders; after you look at
or review the medication to be verified:
– click on the medication to turn it blue
– then proceed to Verify
•After medications have been ordered and
verified, you can go to the 24hr EMAR to
view the medications.
Medication Verification
Administration
• Medications are administered via the Point
of Care Pharmacy application. Select the
Pharmacy option and proceed to click on
Medication Verification Administration.
• This is a fully integrated and wireless point
of care method for safer medication
administration.
• It is designed to take patient safety a step
further by providing a final check at
administration.
What is Med-Verify?
Medication Verification checks medications scheduled
to be administered against the patient’s Pharmacy
Electronic MAR for accuracy.
Process:
Scan the barcode on the patient’s identification bracelet
and then scan the barcode of each medication that is to
be administered. The system then compares the
medication to the patient’s medication profile of
outstanding orders, ensuring that the specific
medication and dosage was in fact ordered for that
patient.
Accessing MedVerify via Point of
Care
Med Verify can be accessed the
following ways via Point of Care
–Patient Whiteboard (from the Hospital
Base Menu, click on POC access)
–Pharmacy Options Menu from the virtual
chart
–24hr. eMAR
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Scan the ID BRACELET
We will be using the bar scanners
on each mobile workstation to scan
patient’s ID armbands
Scan Bar Code Label
Some medications will have preprinted
barcodes from the manufacturer.
Others will have barcode labels
generated by pharmacy.
• When documenting the medication
administration the user will first scan the patient’s
ID armband at which point the system will display
the patient’s account number, name and date of
birth.
• The patient’s medication information will display
upon scanning each medication barcode.
• The scanned medication will be checked against
the Pharmacy Profile
• Once the user has completed scanning all the
medications, Update must be selected to save
the administrations.
• There is no need to scan the patient’s armband
between each medication.
Scan Bar Code Label
Med Count keeps track of the
total # of meds scanned
Med List allows review
of the current eMAR
This allows review of
instructions entered
on Pharmacy orders
Last 6: review of last 6
administrations documented on
this Pharmacy item
Allows review
of recent test
or lab results
Enter Free text in
Comment field;
for example,
when
documenting
First Dose Meds.
Administration
To document tolerance to
first dose meds., click on
plus sign to the right and
add your medication
administration
assessment
Update if no more meds to be
given at this time.
If more meds, continue scanning
When giving PRN meds.,
you will need to fill the
Reason field before
proceeding any further;
the Other option allows a
free text entry.
Any instructions that
were entered as part
of the order will
display if you View
Instructions.
Medication Administration
Times
• The system will also prompt if a scheduled
medication is scanned at a time outside the time
frame specified. First ensure scroll down menu
reflects current date and time.
• Select Yes to continue and document the
medication at the current time. You will be asked
to give a reason for the override.
• If the medication was actually given at the
scheduled time, but not documented at the time
given; for example, with stat or omitted meds.,
this must be documented via the 24hr eMAR
(from Pharmacy tab); don’t forget to adjust the
date and time to reflect the actual date and time
the medication was given.
Enter Reason for the Override
USE THE SCH TM/DT DROP
DOWN MENU TO ADDRESS
THE CORRECT TIME & DATE
WHEN ADMINISTERING
SCHEDULED MEDICATIONS
Medication Documentation
• To document a medication given via the 24hr EMAR,
select the medication to be given. Administering
medications via the EMAR is an alternate method of
documentation.
• To administer a medication via the 24hr EMAR select the
Medication Given option or Med Verify which takes the
user to Medication Verification. The user also has the
ability to Omit a medication.
• If documentation needs to be corrected the user can
choose the Amend data option. If Ancillary results need
to be viewed before administering a medication the user
can access Results to view resulted orders.
24 HR MAR Legends
• In reviewing the EMAR, once the user
documents the administration of a medication
the system will display a “G” under that
medication on the EMAR to indicate it has been
given.
• In the case of a one-time medication, the color
will now appear as black, since the medication
automatically discontinues once it is
administered.
• Omitted medications display with an “O” and
scheduled medications display with a “S” under
the appropriate time frame. A legend is located
across the top of the EMAR to serve as a
reminder.
Making Amends
• On each medication the last 6
administration times will appear on the
screen. If an error has occurred, the
system allows the user to Amend his or
her own data.
• A drop down menu is available for the user
to select why the documentation is being
amended
• Select the number that corresponds with
the line to be “erased.” Select Amend to
save the change.
• Select the line to be amended by clicking
on the corresponding box below.
• Once the chosen line blinks, click on the
Amend box.
• The Amended entry will display in black.
Exceeding Maximum Dosages
• In Point of Care, a warning message will display to
indicate that the patient is about to be given an amount
of the medication that exceeds the maximum allotted
dosage within the 24 hour period.
• If the maximum dosage has been exceeded on a patient,
a pill icon will appear on the Whiteboard in the Stats
column.
• The Information will show in red to indicate the patient
has exceeded the maximum dosage. It will stay on the
screen until the patient is underneath the allotted amount
within the 24 hour period.
• The system only looks back to the last 24hours for the
amounts.
Reminders – Common Mistakes
• Certain medications should be verified by
another nurse, according to hospital policy. The
other user should use his or her own employee
sign-on.
• For example, all insulin and PCA orders must be
viewed before they can be verified. Select LOOK
at the bottom of the screen, then select the
medication from the list of unverified
medications.
PCA orders must be viewed before VERIFICATION
Touch order to verify
Troubleshooting Tips for
Med Verify
Duplicate NDC Numbers
 Medication Not for This Patient
Bad NDC Number
Duplicate NDC Number
• The “Medications with the same NDC”
prompt only appears when a medication
label is scanned and the selected patient
has more than one active pharmacy order
for the same medication.
• Select the desired order from the displayed
list to proceed.
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Medication Not for Patient
• The “Medication not for this patient” warning
prompt will show up if a medication label is
scanned and that medication does not appear on
the pharmacy profile of the patient selected.
• You will need to verify that the medication
scanned has been ordered for the patient. Click
on the MedList option to display all current,
active pharmacy orders for the patient.
• Once it is confirmed that the patient has a
current active order for that medication, select it
from the MedList and Update in order to
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administer it.
Bad NDC Number
ASPIRIN
325mg (5 gr) TABLET
NDC 2514254
Lot 0p237 Exp. 6/08
PKG. BY: UDL, ROCKFORD, IL
Bad NDC Number
• The “Bad NDC Number “ warning prompt
displays if a medication label is scanned
and the NDC Number associated with it is
either wrong or discontinued.
• You will have to go through MedList in
order to administer the medication.
• Contact Pharmacy to report these
occurrences.
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Diabetic Record
Diabetic Record
Diabetic Record may be accessed via:
• From the virtual charts, under the Medact tab look
for Diabetic Record under Interventions and select
the corresponding glucose scale
• Under the Pharmacy Tab, click the Diabetic Record
option from the Virtual chart
• From any flowchart, access Chart Menu and select
Diabetic Record from the scroll down menu
• Medact icon
from any flow chart
Once blood sugar checks have been
ordered, they will need to be
verified. You can click on Verify
Medication. Reminder: same
applies to insulin.
Click on Look
Don’t forget to verify your
order after you click on Look.
Touch order to turn it blue,
then click on Verify button
Upon verifying the order, you can now return to
Pharmacy and access the 24hr EMAR to review or
document a blood glucose level
Within Diabetic Record, the Record
Blood Glucose Level Only will display.
Select this item to proceed with
documentation.
If we go to the 24hr EMAR, we will see a G display
where the blood sugar was checked
Hands on Practice
• Now let’s continue with our scenario
• We will need to return to the Diabetic
Record
• Click on the actual insulin order under
Diabetic Record Medications
Click on Insulin order to enter
documentation
After you enter the blood
glucose level, the dosage
according to the insulin
sliding scale order will
appear
Another nurse must enter
his or her witness
credentials
Click on Update once
the relevant fields have
been filled
We have now completed our documentation for the blood glucose level
and have returned to the Diabetic Record Medication Selection screen.
We see that the Blood Glucose level item has turned RED since
documentation has been performed. In addition, you will notice that the
“Last” entry displays so you can see when a particular item was last
documented on.
Reminders – Common Mistakes
• There is no need to scan insulin sliding
scale orders when administering coverage
to patients.
• However, you will need to scan routine
insulin orders prior to administration.
If we go to the 24hr EMAR,
you will see a “G”
indicating that the insulin
was given
Since there are associating due times to the Blood
glucose checks, there needs to be a way to
indicate when one was omitted.
The end