Electronic Clarifications

slamberson

Hi All-
We are a 200 bed Community Hosp. in Colorado transitioning to a fully electronic record. We're looking for any help / experience around where/ how to place our clarifications in the EMR. We use Meditech 6.05 version & the J.A. Thomas software- so are seeking others that use the same combination, if you are out there.
Any general advice would also be welcome.

ssalinas

I am very interested in how other Meditech users deal with queries and physician communications. We are in version 5.65.

There is a messaging feature in the EMR but all the messages indicate they are being originated by Nursing, Pharmacy or Lab.

Sharon Salinas, CCS
Barlow Respiratory Hospital
213-250-4200 Extension 3336

patricia.fountain

I am interested as well. We are not fully electronic yet and use Meditech (not sure of the version) and 3M. I would be interested in any information on this subject as well!

Unknown

I have Meditech 5.64 and will be upgrading to 6.0 later this year or next. I currently use the messaging feature for my queries and it works very well. Even though it says it is from nursing, nursing does not have access to this feature at my facility, neither do pharmacy or lab. I am the only person using it, therefore, the physicians always know the message is a query from me. My queries are not part of the permanent medical record. I am not aware of any other feature within Meditech that allows electronic queries. We are in the process of installing the 3M 360 software. They have said I will be able to use my same query process but I am not sure what it will all look like at the end.

Lisa McLuckie RN
Clinical Documentation Specialist
Wooster Community Hospital

cstukenberg

Are the physicians using P doc also?

Unknown

All of our hospitalists are using P doc for H&P's, progress notes, DC summaries and DC instructions.
Some of the surgeons are using it for their immediate postop notes and progress notes. The surgeons have not been mandated to use it. ED is not yet using it.


Lisa McLuckie RN
Clinical Documentation Specialist
Wooster Community Hospital

cstukenberg

Are they dictating using p doc or actually clicking and typing in the forms?

slamberson

HI Sharon-

We currently print our Clarifications from the JA Thomas software we use for Clin. Doc., and place it in front of the PNs in the physical chart.

Our Hospitalists have gone to electronic PNs, and sometimes don't need to look in the physical chart anymore- so are faced w/ decreased visibility of Clarifications & "How to" best notify the rounding doc that there is a clarification to look at.

Have heard from TECH at JA Thomas that Meditech is not very user friendly for this process. Apparently other applications have built in systems for the Clarification process.

One hospital told us they built an outside link for the Docs to access- but were not getting then to cooperate & go there.

Another hospital w/ Meditech/ JA Thomas told us that they now simply wait for the docs on the floors and catch them as they round- but it has hampered the effectiveness of their program significantly.

Our current process has our paper clarifications scanned into the Med Records portion of the chart- meaning it is not a part of the "Legal Med Record" as such, but still discoverable if requested- as it should be. The Electronic Clarifications would likely end up as part of the Legal Med Record. Some Docs here w/ concern about this- anyone else having similar conversations?

Sally Lamberson, RN
Clinical Documentation Specialist
Case Management and Discharge Planning
Direct: 303-938-3352

slamberson

Sharon:

I forgot to respond to your part about the messaging feature. Our version of Meditech has features called Notes & Notices. We had IT build a CDS selection in the list in addition to Nsg, therapies etc., We could then write a NOTE- with our Clarification template & clin info in it, and send it to a specific or multiple physicians as a Notice (for a test version) We currently have that option on hold d/t the concerns mentioned in the previous email.

Sally Lamberson, RN
Clinical Documentation Specialist
Case Management and Discharge Planning
Direct: 303-938-3352

Unknown

They dictate using a dragon program but have templates that they use for each. They can type if they do not want to use the dragon.

Lisa McLuckie RN
Clinical Documentation Specialist
Wooster Community Hospital

cstukenberg

Can you send me your e mail so I can talk to you more? We are just starting with Dragon.

cstukenberg

Sorry everyone-

Lisa
It is cstukenberg@fhn.org

ssalinas

Thanks Sally!

We are running into the same issue at our Main Campus. 99% of the physicians use pdoc or dictate their reports including progress notes and often do not look at the physical chart. Our IS dept told us the Notes or Messaging could be a part of the EMR or not. We are still looking at various methods of communicating with the physicians in the most efficient and effective manner for all involved. I think it is a work in progress at most facilities with electronic progress notes.

Sharon Salinas, CCS
Barlow Respiratory Hospital
213-250-4200 Extension 3336

evanspx@sutterhealth.org

Well - at this point I thank all of you that are testing and perfecting the EHR. I know this is the way of the future, but honestly, it seems I should be grateful we still using paper at this point. It seems the CDI function was not considered at many institutions with the rollout of the EHR.

Paul

donna.kent

You are so right Paul. We are about to make a hospital wide transition
to Cerner. Not one single part of it deals with CDI or the issues
associated with CDI. Now that I made loud noises, they are building a
CDI component. I haven't seen it yet because it is not ready to be
demo'd yet.
Donna

Donna Kent, RN, BSN, CCDS
Manager, Clinical Documentation Integrity Program
Clinical Quality and Accreditation
Torrance Memorial Medical Center
ph.:310 784-6884 fax:310 784-6899
donna.kent@tmmc.com