An Interactive Simulated Electronic Health Record using Google Drive

An Interactive Simulated Electronic Health Record using Google Drive

Double click on the SimEHRicon on theDesktop to Log in to the Simlab Hospital EHR

This is the SimLab Hospital Homepage. Here, students are required to choose the correct unit of their patient.

SimLab Hospital

Once the correct unit is opened, a list of patients will appear. The students then choose the correct patient.

Patient List

After choosing the correct patient, a list of all available chart forms will appear. Click on the name of the form to open. In the next slides we will examine each chart form.

Chart Forms

The Documentation Flow Sheet

This is where the physical assessment is charted. All of the patient’s identifying information appears at the top.

Use the scroll bar on the bottom of the screen to scroll right to left to view previous assessments.The black bar

indicates a previous assessment.

Documenting on the Flow Sheet

After reading the description of the assessment, click on the box next to the description. A drop down box will appear.

The time of the assessment is documented here

When the drop down box is clicked, two options appear: WNL (Within Normal Limits) and Exceptions. Click to choose the appropriate option.

Documenting on the Flow Sheet

If WNL is chosen, the box turns green. If exceptions is chosen, the box turns red, indicating part of the assessment is abnormal. If there is an exception, it must be charted under the “Comments” section.

Documenting on the Flow Sheet

Also located on the flow sheet is an IV Assessment.

At the bottom of each chart form is a place for the provider to document their initials and signature.

IV Assessment and Signatures

The Face Sheet

The face sheet has all of the patient’s identifying information including insurance information and emergency contacts.

Listed on the top left side are the various modes of intake. Chart appropriately for each hour. As entries are made, the

totals will be calculated for the hour, as well as a 24 hour total.

Intake and Output

On the lower left side are the routes for output.

When scrolling up and down the page the top rows stay fixed so that you are able to see the times.

As entries are made, the totals will be calculated for the hour, as well as a 24 hour total.

Intake and Output

The MAR has 5 tabs at the bottom. Click on the tab for the

appropriate medication or fluids.

Medication Administration Record (MAR)

Scheduled meds will have a time already entered in the MAR, unless it is the first dose. If it is the first dose a time will need to be entered for the time the med was administered. The providers initials are entered under the time.

MAR

Clicking on the PRN tab will open a new sheet.

No scheduled times will be entered for PRN meds. An administration time needs to be entered. The providers initials are entered under the time of administration.

MAR

IV fluids are charted when first initiated and every time a new bag is hung.

MAR

Once a med is discontinued all entries for that med will be shaded dark gray.

MAR

The physician’s order sheet will contain all active orders.

Each order will be electronically signed with the Physician’s name, the date, and the time the order was written.

Physician Orders

If the patient has previous orders that are no longer active they will be at the bottom of the order sheet in a grayed out box.

Physician Orders

Click on the box and enter the VS value.

If the value is above expected limits the text will be red. If the value is below expected limits the text will be blue.

Vital Signs

If a grey arrow appears in the box, choose the appropriate item from the list of items.

Vital Signs

A pain assessment should be documented at the bottom of the VS sheet. Type in comments in the boxes or choose from the drop down list if appropriate.

Vital Signs –Pain Assessment

This page is used to document anything that is relevant for the patient but is not included on the other flow sheets. Be sure to enter the date and time.

Nurses Notes

Labs

Lab values are listed with the appropriate ranges. Any high values are listed in red and low values are in blue.

Different lab specimens are listed on the bottom of the screen. Click to view the results.

Additional FormsThere may be additional chart forms for the patient, such as an operative checklist, Braden scale, or fall risk scale. Any yellow boxes indicate information that has not yet been completed.

Additional ChartingInformation You can open all chart forms

and navigate between them by using the tabs at the top of the screen. To get back to your patient’s list of documents, click on the Google Docs-”Patient Name” tab.

Remember HIPPA! Log out of chart forms when you are not charting. Do this by clicking on your user name at the top right and then select “sign out.”

All forms will be

saved when you close

out the EHR. You should return to

the desktop.

Additional Charting Information

Multiple Student Accounts During simulation each student is required to document

with an assigned account, such as simstudent, simstudent2, or simstudent3.

Having generic accounts is easier than sharing the documents with each individual student email account. In addition, having the generic accounts gives the lab staff more control over who has access to the account at a given time.

More than one student can have their account open at a time on different computers.

When viewed from the faculty account, the lab staff are able to see which students are documenting and what files they have open.

Multiple Student AccountsThe document shows which users are present in the upper right corner of the page

The cursor shows the location of that user in the document. Each user is indicated in a different color .

By using file revision, the chart can be reverted back to the original format with as few as four clicks.

This erases all student entries and has the lab ready to go for another simulation within minutes.

This feature makes it possible for a faculty member to debrief with a group of students while another group begins the same simulation.

Faculty Information: File revision

Faculty Information: File revision

After the students have completed their charting and simulation, the chart forms can be reverted to their original state for the next simulation. First, click “File” and “See Revision History”

Faculty Information: File revision

A list of revision histories appears on the right hand side of the screen.

Click on one to view the chart. Once the original chart form is located, click “Restore this session.” Now the chart

form is back to the original state! Students’ charting is also saved in

revision history, so it can be reviewed at a later time if needed.