Overview of Point Click Care Electronic Medical Record...Overview of Point Click Care Electronic...
Transcript of Overview of Point Click Care Electronic Medical Record...Overview of Point Click Care Electronic...
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Overview of Point Click CareElectronic Medical Record ‐ eMAR
Introduction• An eMAR user is able to log in and out of the eMAR by entering his/her credentials in the appropriate fields.
Procedure1. On the eMAR touch screen: touch PCC icon
on the desk top screen. (stethoscope)
2. Using the keyboard, type in your org code (cat.)user name and password
Note: the org code is the facility code and proceeds the user ID for logging into the eMar
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cat.bg123
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eMAR Step 1.Click onto “Clinical Tab”
Step 2. In the drop down box
under ModuleSelect “eMAR”
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Step 3.All patients/residents in your assignment/team will appear.
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The color red indicates the administration documentation is overdue according to schedule
The color yellow indicates the administration documentation is due according to the schedule. Yellow is also displayed in case a PRN medications that require follow‐up
The color green indicates the administration documentation is complete
The color white indicates that the scheduled administration documentation is not due yet. Administering meds at this time will generate a warning.*NOTE – the patient icon will remain white until all of his/her scheduled medications are complete for the shift.
FYI: Color Codes
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The heart icon indicates that supplementary documentation (vitals, labs or other documentation is required prior to administration. You will be prompted to record when you click the “Y” button
The page icon indicates there are Administration Notes specific to this pass time
The N icon indicates that the medication is a narcotic
FYI: icon indicators
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Step 4. Click on your patient’s name
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Step 5.Prepare medication(s) listed for administration
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Step 6. Click on the “Y” box next to each medication you are going to administer
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Step 7. Click on the padlock icon to lock the eMAR while administering the medications
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Step 8.After the medications have been administered, click on the word “Locked” to unlock the eMAR.
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Step 9.If patient/resident took all the prepared medications Click “Save”If patient/resident refused a medication, or the medication could not be administered for some other reason, click the “N” box (see next slide)
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Step 10.If the patient/resident refuses a medication, or there is another reason why the medication could not be administered, after clicking on the “N” box, this screen will display. Select “Administration Details”.
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Step 11.Select reason for refusal/inability to administer medication.
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Step 12.Select “Record”
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Step 13.Select “SAVE”
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FYI: To check recorded medications, select “Other Actions” in the drop down box select“Administration Record”
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FYI: Recorded Administration of Medications
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Administering Insulin per sliding scale
Step 1.Select “Y” box next to insulin order
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Step 2.Select “Supplementary Documentation”
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Step 3.Select “Record New Entry”
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Step 4.Enter results of Blood Sugar
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Step 5.Click on the drop down box and select appropriate site; click on “Add Location”
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Step 6.a. Select “Chart Code”b. Select “Record”c. Select “Save” on the next screen
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Administering ordered dose of insulin
Step 2. Under site, select “Not Applicable”
Step 1. Select “Supplementary Documentation”
Step 3. Under witness, select “Record New Entry” the nurse verifying the correct insulin/dose was drawn up, records his/her initials.
Step 4. In the drop down box select appropriate site and the click on “Add Location”
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Administering PRN Medications
Step 1. Click the “Y” box
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Step 2.Select “Administration Details”Under “Chart Code” select O ‐ Administered
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Step 3.Select “Supplementary Documentation”If administering APAP for a temperature, click on “Record New Entry”, enter temperature next to New Value, select Route, and then click “Record” at the bottom of the screen, and then electronically sign with your password.
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Step 4.If administering a PRN pain medication, under “Supplementary Documentation,” select “Record New Entry” and then select a number on the numerical pain scale, click “Record” at the bottom of the screen.
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Step 5. Enter your “Password” under “Attestation Statement” and then click “Sign”
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Step 6.Click on “SAVE”
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Step 7. Once you have clicked “Saved”, the PRNmedication order turns “yellow” indicating that a follow up is required.
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Step 8.Click on “Follow Up”, this action brings you to the “PRN Progress Note(s) screen. Fill in the Effective Date and Time boxes, and the click on “Enter Follow up Pain Level”
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Step 9.Select the appropriate number on the numerical pain scale and click “OK”. Click “Record” at the bottom of the screen and then sign electronically with your Password.
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Step 10.The medication window now displays the color “Yellow” and the “gold box” indicates that the medication was effective, click “Save” to complete the follow up documentation. The window will now disappear.
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Overview of Point Click CareElectronic Medical Record‐ Documenting Nurses’ Notes
Step 1.Log into PCC and left click “Clinical” tab; to get list of residents/patients.
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Nursing Documentation
Step 2.Selecting your resident/patient: If resident/patient isn’t already listed; left click on the “All Residents” tab and then click on the first letter of their last name. To select your resident/patient, double click on his/her name.
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Nursing Documentation
Step 3.Selected Patient/Resident
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Nursing Documentation
Step 4.Left click “Prog Note” tab
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Step 5.Left click drop down box in “Select Appropriate Type” field
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Nursing DocumentationStep 6. Select “Health Status Note” from the list by left clicking on the heading. Document in the field labeled “Note Text”
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Nursing DocumentationStep 7.Once documentation is complete, left click the abcicon to spell check the note. Next click “Sign” located at the bottom of bottom of the screen
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Nursing Documentation
Step 8.Enter password here
Step 9.Left click “Sign” this step saves your documentation to the EMR
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