Document Editing

PCS Lesson 4

Objectives

• List situations that require you to edit and undo documentation

• Demonstrate how to edit your documentation• Demonstrate how to undo documentation you

have mistakenly entered on the wrong patient• Demonstrate how to document an intervention

that was performed in the past• Learn how to return to incomplete documentation

and finish

In a perfect world, you would always document as soon as you provided your cares and you would never make any mistakes. All of your documentation would be completed according to schedule, and you would never forget to answer a question.

Despite being careful about our documentation, inevitably you will make mistakes or forget to document information that needs to be a part of the patient’s record.

This lesson will teach you how to correct mistakes, how to undo documentation that was mistakenly entered on the wrong patient, how to retrospectively document, and how to complete interventions you did not get a chance to finish yet.

All of our editing, back-timing, and undoing is possible to accomplish from our Intervention worklist for our patient. Right now, we are viewing our patient list, or status board. The patient whose documentation we wish to edit has been highlighted. To access our intervention worklist for our patient, we will now click on the Interventions button on the right side of the screen.

We are now on our intervention worklist. We will first look at how to undo documentation we have entered in error on our patient. Whenever we wish to undo documentation of an entire intervention, we will click in the History column for that intervention.

Let’s say we want to undo a height and weight we had documented earlier because we had accidentally entered it on the wrong patient. We will first click in the history column for this intervention.

This will open up a screen that displays all of the past episodes of documentation for the height/weight intervention. The most recent documentation episodes will be listed at the top of the screen. You will look for your name in the Done by column, and then find the correct episode of documentation you wish to undo by looking in the Date/Time Done columns.

Now that we have identified which episode of documentation we wish to undo, we will click on the intervention. This will highlight the row green, as seen on our screen now.

Once the row is highlighted, all we have to do is click on the Undo button located at the bottom of our screen. Let’s see what happens when we click on Undo.

After clicking on Undo, we must select a reason why we are undoing the documentation. Here, we have selected Incorrect Time. Now, we will click on OK.

Now we see an extra row added to our screen. Notice the word Undo with a green background in the Type column.

Note that the original episode of documentation still appears, just below the episode where we have undone our intervention, as seen highlighted here.

We cannot save what we have done from this screen. In order to save our actions, we must return to the intervention worklist by clicking on the Return button in the bottom right corner of our screen. Let’s do that now.

This has brought us back to our intervention worklist. Notice the new line of purple text underneath our height and weight intervention. This is our reminder that we still need to file our actions. Let’s click on Save now.

Now that we have clicked on save, our previous height/weight documentation has been undone and will not be viewable in the EMR/Chart for our patient.

Sometimes we may wish to edit what we have documented instead of undoing the entire episode of documentation. The edit process is similar to the undo process. Let’s see how we can edit our documentation.

We realize we made a typing error when we entered in the temperature for our patient in the last vital signs documentation. Once again, we will use the History column to access the list of our previous documentation. Let’s click in the history column now for vital signs.

We are now on the documentation detail screen for the vital signs intervention. Let’s locate the episode of documentation we wish to edit. The temperature mistake was entered in our vital signs documentation at 0900.

To change the temperature, we must double click on the row that represents the time when the error occurred. We will double click on the documentation row for 0900 now.

This opened up a screen that contains our entire 0900 vital signs documentation for our patient. Changing values is easy. All you have to do is click on the answers you wish to change and Meditech will allow you to correct them right on the screen. We will now click on the pink/green box to change our temperature.

Just like when you documented vital signs originally, the temperature keypad will open on the screen. We will use the back arrow symbol on the keypad to erase our previous documentation.

Our previous value has been erased and now we will type in the correct temperature value using the keypad buttons.

We will now click the OK button on the keypad to deposit our new temperature into our previous vital signs documentation.

We can now see the changes to the temperature displayed with the rest of our previous vital signs documentation. We have no more changes to make on this screen. We will click on the Return button in the bottom right hand corner to get back to the edit screen.

Notice that just like when you Undo documentation, a new row appears on our edit screen. This time, the word Edit appears in the Type column with a green background.

Note that the original episode of documentation still appears, just below the episode of editing, as seen highlighted here.

Same as before, we must click on the Return button to get back to our intervention worklist, where we will be able to save our changes.

Back on our intervention worklist, we see a row of purple text showing our name with the date, time, and the word edit, reminding us we still need to file the edited information. Let’s click on Save now.

Now that we have saved our changes, only the correct documentation will appear in the EMR/Chart. It is important to note that even through we won’t be able to see the previous temperature documentation in the EMR, Meditech will still have a record of you changing the temperature.

Meditech will allow you to make changes to your documentation for 3 days, even after the patient is discharged. Remember you should only be editing your own documentation – NOT someone else’s.

Now let’s discuss how we can complete interventions that we have started documenting on but haven’t finished. Sometimes you will not be able to complete an entire assessment at one sitting without interruption.

If you were documenting on paper, you would put the documentation aside, perform your other duties, than return to the same paper assessment to complete the documentation you had started earlier.

The same process is true when you are documenting on the computer. If you Save an assessment in an unfinished state, you can go back to it later to enter the rest of the documentation. Let’s see how that would work.

Earlier, we began documenting on the personal hygiene assessment. Half way through, one of our other patients needed our help. We filed what we had completed documenting and logged out of Meditech. Now we are ready to finish the documentation.

First, we will click in the History column of our personal hygiene assessment.

Next we find the correct episode of documentation that we started earlier, and double click on the row.

This will open up what we finished documenting before. We will pick up where we left off and complete the rest of the intervention.

Our documentation is finished. Now we will click on the Return button.

A new row appears on our documentation screen. The word Edit appears in the green area of the Type column. We will click on Return to get back to our Intervention List.

To save our completed documentation, we have to click on Save.

We will now discuss two ways we can retrospectively document (or back-time) interventions.

It is important to remember to back-time your documentation in Meditech if it is greater than one hour later than the time you actually provided the care. For example, if you collect a set of vital signs on a patient at 0700, you have until 0800 to enter them into the computer. If it is past 0800, you must record the time you actually documented the vital signs correctly in Meditech, so that it doesn’t look like your documentation was completed later than the scheduled time.

The easiest way to retrospectively documentation is by using the Document button at the bottom of the Intervention worklist. Any time you click on the Document button after clicking on an intervention to select it, a date/time keypad will open, allowing you to change the time.

Let’s see how we would do this. We want to record that we cleared our patient’s breakfast tray this morning at 0900. It is now past 1000, and we have to make sure we document the time we actually cleared the try correctly. We will start this process by clicking on the Meal Intake Intervention on our screen.

Now that we have clicked on it, the Meal Intake Assessment is highlighted green. Now we will click on the word Document at the bottom of our screen.

This opens a date and time keypad. The time we enter on this keypad will be the time the computer records that we actually carried out the intervention. We will now change the time on this keypad to 0900 and the date to the day before – as it is after 1000 now.

The time on our keypad is changed. We will now click on OK to open the Meal Intake documentation screen.

Here is our Meal Intake Intervention. We have filled in the documentation for you on this screen. Now we will Save the documentation by clicking on Save in the bottom right hand corner.

Our Meal Intake Intervention has been saved. If you look in the History column, the time almost 2 hours past. This is because Meditech saved the Meal Intake as being completed at 0900, not the current time.

There is also an easy way to save several interventions completed at a certain time, instead of one at a time. Let’s take a look at how we can do that.

We want to record that we took our patient’s skin risk assessment and pain assessment at 0200 this morning. The first thing we will do is click on the Document Stamp at the top of the Intervention worklist. Right now the Document Stamp says Default Time, meaning the current time. We want to change it to 0200. Let’s see what happens when we click on the Document Stamp.

It opens our date/time keypad on the screen. First we will change the time to 0200.

Now that we have changed the time, we will click on OK.

Notice that the Document Stamp at the top of the screen is now showing 0200. Instead of saying Default Time, the document stamp now says Fixed Time. All the interventions we document now – up until the point where we save on this screen – will be saved as being done at 0200. Let’s start by double clicking on the skin risk assessment.

We have documented this screen for you. We do not want to Save yet because we still have to document the other intervention for 0200. To return to our intervention worklist, we will click on the Return button.

Notice the line of purple text that is under the Abdominal Girth Intervention. The time in the text is 0200. Let’s enter our second intervention for 0200 now. We will not Save yet. We will double click on pain assessment to open the intervention.

This opens up the Pain assessment page.

We have filled in the pain assessment documentation for you. Once again, we do not want to click on Save, we want to use the Return button to take us back to the intervention worklist.

Now that we are back on our Intervention worklist, we see the purple line of text added for the pain assessment documentation has the same time of 0200 listed. We are finished our documentation that we wanted to record as being done at 0200. We can now click on Save.

Notice that now that we have Saved, the Document Stamp has returned to the Default Time, which means it is back to the current time. If we had Saved when we were in the intervention at the end of our documenting, this clock would not have reset for us. This is why it is so important to use the return button when documenting several interventions for a past time and only save when you are back on your Intervention worklist.

It is a good idea to pay close attention to your Document Stamp when you are beginning to learn how to edit your documentation in PCS. The time that shows in the document stamp represents the time your documentation will be saved as being done in the the computer.

Great Job!!In this lesson, you have learned how to:- Edit your documentation- Undo documentation accidentally entered on the

wrong patient- Complete documentation started previously - Retrospectively document cares provided in the

past

* Remember if you need help, go to the Nursing webpage on the Infoweb and click on the Meditech Help Link.