EMR Navigation
When discharging a patient the first place in the chart a nurse should check is ....
Orders tab
When should the To Be Completed date on an order be updated?
When apt is made, when order is due
A medication list is given to a patient when...
with any medication changes
True or False...
Immunization Admin orders are located under the medication tab
False
True or False
Care Notes can be used for patient education in place of using the Info button to document patient education
False
What documentation should be completed before opening a nurse discharge note
Patient education using the info button
True or False
An order can be directly faxed from Allscripts
True
When is Medication Education required to be completed/recorded?
For all newly prescribed medication
Where is Immunization Administration Education recorded in the patient chart?
With the Immunization Admin documentation
If applicable to the patient, what mandatory education is required annually?
Smoking Cessation
Patient education print outs can be obtained from where?
Info Button
How would a nurse annotate multiple orders at one time?
Use the ctrl button and highlight the order to be annotated; right click and select edit selected and type in annotation
When discharging a patient a nurse should always verify the medication list for what?
New, discontinued and refilled medications and controlled substances
A VIS statement must be given when?
Prior to every vaccine given
True or False...
If a patient does not speak/read English; patient education does NOT have to be recorded
FALSE
True or False...
Nurse Discharge Notes must be completed on all patient who had any clinical skill performed in the office
True
Where would you look to find results for testing that has been ordered by the provider?
Chart viewer, Meditech, Healthelink
How are medications ordered to be administered documented in the EMR?
Right click on medication, select Record Med Admin and complete necessary documentation
Influenza vaccines require what prior to administration?
The Influenza screening questions
If applicable to the patient, what mandatory education is required every 6 months
Safe Use of Controlled Substances
A record of completed patient educations can be found where...
Under the Health Management Tab/Drop Down Education
Cancelling an order requires what and how would this be completed?
Providers privilege and right click on order and select cancel option and then select reason for cancelling
What information must be recorded in the discharge note with all Med Administration
Med Admin template; confirmation of name/DOB and Allergies
When a vaccine is administered to a patient older than 19 years of age, the Vaccine Consent to Registry Option must be changed to....
Denied
The most important part of recording patient education is to include what...
Evaluation of Understanding of the education