Student Nurse and Instructor

MEDITECH Reference
2021
TriStar ITG Market Education

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Keyboard Functions and Icons

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 Function Icon Description
Reviews Clinical History displaying the last 15 Documented Values on a
F1
Documentation Screen in the last 14 days.
F2 Displays last documented information.
F3 Displays Clinical Review or PCI on a documentation screen.
F6 Previous Field: moves the cursor to the prior prompt
Shift F6 Joins a line: position cursor at the end of a space or place to be joined then press Shift
F6.
F7 Begin: moves cursor to the beginning of a page or list.
F8 End: moves the cursor to the end of a page or list.
Shift F8 or
Detailed information about the prompt or screen.
Help
F9 Look up is a list of possible responses in a prompt.

F10 Deletes or erases the entire line.

F11 Exit: exits screen without saving or filing information.
F12 OK – File or save information
Page Up Moves the cursor to prior section
Page Down Moves the cursor to next section
Backspace Erases to the left
Delete Erases to the right, cursor must be in front of the character
Home Moves cursor to the beginning of the line to the left
End Moves the cursor to the end of the line to the right
Selects or unselects an item on a list, which places a check mark next to an item.
Right Ctrl May use to select or check mark more than one item
Shift Right Ctrl
Selects or unselects all items on a list
Moves highlighter bar or cursor up one line
Moves highlighter bar or cursor down one line
 Moves cursor left one space
Moves cursor right one space and displays more information about the highlighted
→
item to the right.
Calculator
Calculator and Calendar (double click)
Ctrl/F12: Calculator
Hot Key or Magic key, allows access to another Menu.
Shift/F12 Suspend Session: locks the computer for a specific time parameter and holds your
place in MEDITECH.
Spacebar Enter
Recalls last patient that you selected in MEDITECH.

EBCD Functions

Use the mouse to navigate and enter information in the fields on Evidence Based Clinical
Documentation or EBCD.

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 EBCD documentation uses Point and Click (PnC) technology.
Item Click:
Click: the checkbox to select; a checkmark appears in the box.
Click: the box again to deselect or uncheck.
Click: the Ok button to move to the next field on a screen.

Click: the box (prompt) to the right of (Previous Page) or (Next Page) to
navigate back and forth between pages on a screen.

Click: the box to the right of (End) which is the last page of a screen.
May click (End) twice to File the documentation.

Click: Yes to file the data.

The standard MEDITECH keyboard functions are also available.

* An asterisk indicates a required response and cannot be bypassed.

Types of Answers

A number, a letter, e.g. Y for Yes or N for Nor

Look up F9 or black binoculars

Free Text

PCI or Patient Care Inquiry

• Clinical information including current and historical data may be located in the Electronic Health
Record or EHR.
• Health Information Management contains Provider dictation, e. g. History and Physicals, OR Notes,
etc.
• View Data best by using Arrows on the keyboard or icons, may also click to open.
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  Exit Open →

Clinical Review view patient's clinical data

Clinical Review can be accessed by the Review button on the Status Board, eMAR, or Order
Management.
Clinical Review is based on interactive panels, which may be sorted.

Integrated
Desktop
Constant Navigation Buttons Buttons

• Data is sorted by department, date, time or data item by clicking on the appropriate Panel Header,
e.g. Order History
• Integrated Desktop buttons are on the right.
 A blue button has new information you have not viewed.
 Bold black buttons have information available to view.
 Buttons low lit or gray, contains no data.
• Selectable items have a gray background. Click the gray item or cell to view the detailed
information.

The Evidence Based Clinical Documentation screens are based on the Clinical Care Classification or CCC
and consists of four healthcare patterns: Physiological, Functional, Psychological and Health Behaviors.

Process Care Items/Interventions

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Documentation Process
1. Find the Care Item/Intervention to document.
2.Highlight the Care Item/Intervention.
3. Choose an action function from the Verb Strip.
4.Enter all necessary and required information.
5. File: press F12 or click green check Icon , confirm the file.
Step 3

Action

Include determines which Care Items are displayed.

Steps
1-2

Process Care Items Columns

Columns Description
Care Items List of Active Care Items, which may be used for documentation. The plus symbol +
indicates there is a documentation associated.
Sts (Status) Status of the Care Item, which are shown as Active.
Specific directions for a Care Item. May be entered as it relates to an order or to
Directions facility policy.
OD Order Details of Care Items when an asterisk are displayed.
Displays when the Care Item was last documented. The information is shown in
Doc minutes (m), hours (h) and days (d)
Source Indicates the origin of the Care Item.
D(uplicates) More than one of the same Care Item.
C/N Comments or Notes, displays a C or an N, if a comment or a note has been attached
to the Care Item.
KI Key Indicators, not in use.
Prt Protocol, not in use.

Verb Strip Descriptions and Definitions

Actions Description Definition

Document
DI To change the date and/or time or document multiple times.
Interventions
Allergy
AL Allergies may be viewed.
Link
View View, Edit, or Undo documentation.

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 VH History There are specific time limits for managing documentation.
Patient
PN Enter, amend, undo and view Patient Notes.
Notes
<More or
<> View additional actions.
>More
Document
DN Documentation of current date and time.
Now
If there is an asterisk in the OD column in Process Care Items, you may view
Order the details of order information.
OD
Detail It assists with providing effective care based on the provider’s detailed
instructions.

Status Board and Assign Patient(s) Instructor knowledge point

 The Status Board provides a list of your assigned patients and serves as a central point to process
aspects of a patient’s record.
 Same name alerts will have a yellow background.

Managed List allows you to create an assignment of your patient(s).

Assign Individual patients

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 1. From the Status Board, click: the button or type the underlined letter: g for Manage
List
2. At the top left is
3. Click: in the Patient prompt
4. To select an individual patient’s name, type last name and press Enter. Select the correct patient’s
name by identifying the age, gender and room number.
5. Confirm this is the correct patient!
6. You may repeat the process to add more assigned patients.
7. The patient’s name is added to the list but not assigned.
8. Click: Assign, your initials will be black.
9. File and confirm.

Assign by Location for Multiple patient(s)

1. From the Status Board, click: Manage List or type the underlined letter: g
2. To select multiple patients, click which will display all patient names on a specific unit.
3. Type and highlight the mnemonic for your unit.
4. Press Enter or click: Ok to display the patient’s names on the unit.
5. The list with patient’s names defaults to the last room on the unit.
6. Locate your patient(s) names as indicated.
7. Click on the patient(s) name, to select the assigned patient(s), which will highlight blue.
8. Ensure the correct patient(s) name by identifying the age, gender and room number.
9. Never assign by room number.
10. Once all of your assigned patient’s names are selected, click: Assign.
11. File and confirm.
12. If there are assigned patient names on the Status Board, you will be asked: What would you like
to do with the preexisting assignment?
• Replace: remove old assignment and add new.
• Append: add to your list of patient names.
• Cancel: to Exit
13. Click: Append to add your assigned patients.
14. The assigned patient’s names will default onto the Status Board.
Unassign patient(s)
1. Click: the Manage List button or type: g
2. Under : your assigned patient’s name(s) will default and are highlighted
blue.
3. Click the patient’s name you want to remain on the Status Board and the blue highlight is
removed.
4. To unassign or remove patient(s) name, ensure the name(s) are highlighted blue.
5. Click: to remove the highlighted patient’s name.
6. In the Assigned column, your initials will be red.
7. File and confirm.
8. The Status Board will display your assigned patient’s names.
9. At the end of your shift, unassign ALL patient’s names.

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 Status Board Buttons may be facility specific
Short cut tip: type the underlined letter for quick access.
Buttons Definition
Location Temporarily adds all patient’s names from a location.
Find Patient Temporarily adds individual patient’s name.
Manage List Manage and assign your specific patient assignment.
Options Preset by job description. Do not change without discussing.
Select Board Changes the Status Board according to department.
My List Removes a non-assigned patient’s name added from the Status Board.

New Results Flags

 Color indicators in the Results Column have different meanings and may be in hierarchy.

• Green • Normal results

• Yellow• Abnormal indicates results are abnormally high/low.

• Red • Critical indicates results are critically high/low.

•

• Click the colored flag to view the results.

• Once viewed, the results flag is removed.
• Department mnemonic , etc. displays if all the results are from the same department.
• Res: results are from more than one source or department.
• Result flags for the table above:
• Refer to your
Instructor knowledge points
Bar Coded Medication Administration or BCMA or
electronic Medication Administration Record or eMAR

Medication Administration Process

1. Acknowledge Medication Order(s)
a. Click to select the Medication indicated by blue highlight
b. Click Ack(knowledge) or click the A in the Acknowlge Box
c. In the View Order screen, click any icon, tab or ellipsis … to view additional information,
instructions or conflicts on medications.
d. After reviewing the HCA Statements: select the appropriate button: Acknowledge or Hold
Acknowledge.
2. Take medications to patient’s bedside
3. Access eMAR Desktop using Status Board
4. Scan patient’s armband, the barcode will be to the right of the patient’s name.
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5. Scan barcode on medication(s)
6. Complete any information needed.
7. An asterisk * is to the right of the scheduled or nonscheduled time.
8. Review the administration, click Submit, F12 or green check icon.
9. Click Save and Exit or Save and Recompile button

Constant Navigation buttons on eMAR Desktop

Buttons Description bottom of the eMAR Desktop screen.

Document Is inactive until the patient’s barcode armband is scanned.
Ack Acknowledge and/or view order information.
May view more data for this session or permanently.
Preferences Determines what is displayed.
Recommendation: leave the predetermined settings.
Drug Data Access to medication information.
May view scanned or Management Reports.
Hold or DC Medication, facility specific.
Other Alternative method to document medication and/or IV fluids administration, may
be facility specific.
Submits medication data after barcodes scanned or press F12.
Return to eMAR Returns to eMAR Desktop, does not document the medication administration.
Other medication(s) may be scanned, if needed.
Save and Exit Files the administration and exits eMAR Desktop.
Save and Recompile Files the administration and returns to the eMAR screen or F12.

Icon Name Description

Link Medications Displays medication linked to a highlighted medication
Notebook or query Displays information needed, e.g., glucose, heart rate
Co-Signature Co-signature is required for medication administration
Instructions Medication instructions, e.g., sliding scale, etc.
Historical Links Pharmacy has performed a Copy/edit.

Medication Indicators Color Description

Scheduled Time Green background, BLACK time

Not Administered Time, Medication Not Given Gray background, WHITE time

Administered Time, Medication Given White background, GRAY time

Next Scheduled Time Green background, black time
Overdue Time Pink background, black time

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 Future Scheduled Time White background, black time
Hold Medication Yellow background, HOLD time
Currently Selected Order
Medication order on blue background

Discontinued Order
Medication order on yellow background

Edit Administration, may edit within 72 hours of administered time.

1. Click: Administration time of medication to Edit
2. Change and/or add information and data in information box
3. File
4. Click: Edit
5. Click: Submit, Icon or press F12
6. Click: Save and Recompile or press F12, or click: Save and Exit

Undo Administration, may undo within 72 hours of administered time.

1. Click: Administration time of medication to Undo
2. Click: Undo
3. Document Reason for Undo in the Undo Comment box.
4. File, press F12 or click Icon
5. Click: Submit or press F12
6. Summary screen indicates Administration Date and Time as Undoc.
7. Click: Save and Recompile, press F12 or Save and Exit

Medication Not Given

1. If the patient present, scan patient’s armband barcode.
2. Find the medication on the eMAR Desktop and proceed to Step 6.
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 3. If the patient is not present, click: Other button
4. Select: Manual Barcode, type in the patient’s account number.
5. Press Enter, if you receive an error message, Exit and begin again at Step 3, if no error message,
proceed to Step 6.
6. Click: the selected time for documentation
7. Click: the Sched time; be sure cursor is on correct date
8. Review information on informational box
9. Click: Not given
10. Enter Reason Code, required.
11. Click: Document button
12. Click: Submit button or press F12
13. Click: Save and Recompile, press F12 or Save and Exit

Computer Downtime
1. Medication documented on paper MAR due to computer downtime.
2. Locate the medication on the eMAR Desktop
3. Scan patient’s bar-coded armband or select Manual Barcode
4. Click: the selected time for documentation
5. Click: the Administration time, document time medication administered to patient.
6. Enter the Reason Code: Down Time
7. Enter a comment, if indicated
8. File
9. Click: Document button
10. Click: Submit button
11. Click: Save and Recompile, press F12 or Save and Exit

Pain Medication Administration and Assessment

A. Administering one medication
1. Scan the patient’s armband barcode
2. Scan the medication barcode and document the Pain Assessment
3. Administering for pain: Answer Yes
4. Pain scale utilized: Answer appropriately.
5. Document the pain related questions based on the pain scale selected.
6. May press Enter or click: End prompt.
7. Ensure Dose and Time of Administration are correct and document the Site as needed.
8. Click: Document
9. The HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems which measures
patient’s perceptions of care) medication education screen may display, answer appropriately.
10. Click: Submit, press F12 or click the green check icon.
11. Click: Save and Exit, Save and Recompile, the green check icon or press F12.
12. When you return to the eMAR Desktop, locate the pain medication administration time in the
Today column.
13. The time of administration will be gray with white background and a Notepad icon will be
under the Administration Time.
14. Clicking on the Notepad indicates when the reassessment is due
a. Click: No to Exit
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 15. When the background of the Notepad highlights green , it is time to reassess the patient’s pain
level.
16. If the Notepad background turns pink, the reassessment is late.
B. Administering two or more of the same medication
1. Scan each medication barcode individually.
2. The Dose Verification screen will display after the Pain Assessment is complete.
3. Ensure the cursor is in the Barcode Scan prompt before scanning the medication.
4. Once the second medication is scanned, the Qty (Quantity), Total Scan and Admin(istration) Dose
will be updated.
5. When the correct amount of medication has been scanned, press Enter, press F12 or click the
green check icon.
Pain Reassessment for Medication Administration
1. Enter the eMAR Desktop
2. Scroll to find the previously administered pain medication
3. In the Today column, click the Notepad under Administration time.
4. Displayed is the Pain Reassessment #.
5. Ensure the time and date of the reassessment is correct or change to the time and/or date the
pain was reassessed.
6. Comments: Free Text any appropriate information, press Enter
7. Pain scale utilized: answer appropriate pain specific questions.
8. File information.
9. The Notepad icon no longer appears.
Index
Allergy Link .......................................................................................................................................... 7
Bar Coded Medication Administration or BCMA ........................................................................... 10-13
Clinical Care Classification ................................................................................................................... 6
Clinical Review ..................................................................................................................................... 5
Documentation Process in Process Care Items .................................................................................... 6
electronic Medication Administration Record or eMAR ............................................................... 10-13
Evidence Based Clinical Documentation or EBCD ...................................................................... 4 and 6
Help Desk .......................................................................................................................................... 14
Keyboard Functions and MEDITECH Icons ........................................................................................... 3
PCI or Patient Care Inquiry .................................................................................................................. 5
Process Care Items Columns ................................................................................................................ 6
Status Board .................................................................................................................................... 8-9
Types of Answers ................................................................................................................................ 4
Verb Strip Descriptions and Definitions ................................................................................................ 7

Computer access and issues

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Call the Help Desk → 615 - 886 - 5800
 Students are not to print any information at the hospital!
No printed patient information is to leave the facility.

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