Re: Point Click Care
Have Question about Point Click Care!
When entering MD orders in Batch entry (Co is just starting/training in system) when you get done with the med our 'paper' orders have the reason for the med such as constipation, HTN, CHF, etc.) When charting this a drop box pops up and you have to choose from the above dx's for reason med is given...(not everything is entered as I found constipation issing from 1 dx...but...do you choose the best fit? for instance...a pain med on our paper orders states it is given for 'shulder pain'....shoulder pain was not a listed dx/ICD-9 but osteoparosis was...(yet there is an ICD-9 for shoulder pain as I saw it on another patient...) for all I know this person's pain could be muscle related and not bone....
Won't I be aking more work for the Med Records Dept when they have to go back and fix these? I asked this Q today and one of the Med Records girls got tisky...I'd rather do something right the first time...and am not getting answers...also...I have been out of nursing for some time and have never passed many of these meds...still learning them...I guess Ishould have a med book handy when doing this?
Am confused and would appreciate any help and/or tips as I am not getting it from the staff.
I looked for tools to this system online but have been unsuccessful to date.
To make atters worse, when the 1st training took place (overview) everyone who should have been there, like myself was not scheduled. The directions we were given are written as if you know what you are doing already...not for a newbie to the system....
Appreciate any/all help!
Thanks
KJW
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