EMR - Meditech

wfreemanwfreeman
in CDI Talk Archive
Does anyone here utilize Meditech for your EMR? If you do, do you post your clarifications on the EMR? We have transitioned to physician documentation and order entry through the EMR. Most of them do not have a need to pick up a hard copy chart. We are currently faxing our request to them, but many of the physicians want us to post it to the EMR. Also, if you are posting you clarification on the EMR as part of the record, how did your facility deal with the possible legal ramifications of doing this?

Comments

  • cstukenbergcstukenberg
    edited May 2016
    We use Meditech but are still currently a hybrid chart. Since our queries are not a permanent part of the chart, we would not want them to be in the EMR.

    Colleen Stukenberg MSN, RN, CMSRN, CCDS
    815-599-6820

  • Unknown
    edited May 2016
    Could you elaborate on what you mean by a hybrid chart? We're not EMR yet but when we are we do not want to include the query as permanent part of the medical record and I was wondering how you go about doing that?


  • wfreemanwfreeman
    edited May 2016
    By Hybrid, do you mean part paper, part EMR?

    Bill Freeman, RN, BSN
    Supervisor of CDMP®
    Case Management
    Jefferson Regional Medical Center
    P.O. Box 350
    Crystal City, MO 63019
    636-933-5324 - Office Telephone
    636-933-5702 - Office Fax
    wfreeman@jhsmo.com
    www.jhsmo.com




  • stacy.vaughnstacy.vaughn
    edited May 2016
    yup, hybrid is part paper and part electronic






  • cstukenbergcstukenberg
    edited May 2016
    Currently our queries are on paper that is placed on the charts. When we go to a complete EMR, we will have to adjust the process. I am not sure what that process will look like yet.

    Colleen Stukenberg MSN, RN, CMSRN, CCDS
    815-599-6820

  • Unknown
    edited May 2016
    We have Meditech and have gone completely electronic. I currently have not found a great communication tool to query the physicians through. It is my understanding that a "note" section will be available soon that will be available for my use. It is not a part of the medical record and is meant for nursing to send the physicians notes. Our lead hospitalist would not approve it for nursing to use but has approved it for my use only. I am anxiously awaiting for it to become live. In the mean time, I do a lot of verbal queries or hand deliver query sheets for their reference when they see the patient(s).

    Lisa, RN


  • cstukenbergcstukenberg
    edited May 2016
    What version of Meditech are you using?

    Colleen Stukenberg MSN, RN, CMSRN, CCDS
    815-599-6820

  • Unknown
    edited May 2016
    We have 5.63.


  • jskagenjskagen
    Bill Freeman,

    I was wondering since you have been working with Meditech, CPOE-physicain order entry for a little while if you had come up with a workable process for posting your queries in the EMR or are you still faxing them to the physicians?

    I am going to be in the same position in a short time.

    Also is there anyone out there that is utilizing the 3M CDI program and meditech? Do you have an interface and if so, how does it work for you. Any issues?

    Thanks,

    Julie A Skagen RN, BSN, CDS
    Bozeman Deaconess Hospital
    Bozeman, MT 59715
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