Category Archives: ORCHID

MyWellness Portal and Flu Shot Reminder for Patients

After being seen at a DHS facility for health services, patients can now sign-up for MyWellness, a patient portal to access their medical record and communicate electronically with their clinic or providers.  Patients can visit https://dhs.lacounty.gov/wps/portal/dhs/mywellness/ to log in.

 

Patient Messages:

Welcome to the My Wellness Portal!

Thank you for registering for the LA County Department of Health Services MyWellness Portal, a platform for accessing portions of your medical record and secure online messaging with your provider. (https://dhs.lacounty.gov/wps/portal/dhs/mywellness/)

You may communicate via the MyWellness portal to relay NON-URGENT messages or questions to your Primary Care Provider. Please call the clinic directly for any clinical issue that requires urgent attention.

 

Flu Shot Reminder

As cold and flu season approaches, the Los Angeles County Health Agency would like to pass on this friendly reminder:

Colds and especially influenza can be very contagious and easily spread from person to person through the air. To avoid making others ill, if you are sick, cover your mouth when you cough or sneeze, wash your hands frequently, and stay home to avoid exposing others. This is particularly true during winter months when people stay indoors and are in close contact with one another. Most people who are sick will recover after a few days of rest.

It’s not too late to get your flu shot! In Los Angeles County, flu usually peaks in late December and lasts through March. It takes about two weeks for the flu shot to become effective so please be sure to contact your Primary Care Provider to get a flu shot if have not done so already.

While a flu shot cannot guarantee that you will not become sick this winter, it is the best protection against the flu and prevents serious illnesses and death especially among those who are most vulnerable.

For more information about the flu, you may call the LA Department of Public Health 1-800-427-8700 or visit www.lapublichealth.org/acd/flu.htm.

Communicate the Right Medications to Your Patients – Review of Discharge Workflow

Improve communication, accuracy, and patient safety by reviewing the discharge workflow.  See the attached slides that were presented at the Housestaff Meeting November 17, 2016.

The Setting

Hospital discharges

The Players

  • The provider
  • The nurse
  • The patient
  • The discharge instructions

The Situation

Patients, nurses, and providers want an accurate medication list when patients are discharged from the hospital.  However, we are often finding the medication lists on the the Patient Discharge Instructions are inaccurate.  Here are a few situations:

  • The provider hasn’t completed the Med Rec when the Discharge Instructions are printed.  Which medication is the patient supposed to take?
  • Medications appear duplicated on the Med Rec.  Which one is the patient supposed to take?
  • Prescribed medications don’t get listed as being electronically prescribed.  Did the provider ePrescribe the medication?

The Proper Discharge Workflow

  1. Problem List
  2. Patient Education
  3. Follow-up Instructions
  4. Medications
    1. Resident Proposes Medications
    2. Attending Co-signs Medications
    3. Medication Reconciliation*
  5. Discharge Orders**
  6. Discharge Summary

*Key Point: The Medication Reconciliation should occur after any proposed medications are co-signed by a licensed provider.  Un-signed proposed prescriptions do not appear on the Med Rec, and medication duplication often happens when the unlicensed provider performs the Med Rec prior to co-signing proposed prescriptions.

**Key Point: The Discharge Orders should occur after the Medication Reconciliation is completed. As soon as the Discharge Orders are initiated, the nurse may print the Discharge Instructions, which means all the discharge information should be completed at that point, including the co-signing of any proposed medications and the Med Rec.

Downtime When Daylight Savings Time Ends This Weekend

ORCHID will be down this weekend for a short period at the end of Daylight Savings Time.  That means the EHR across DHS will not be available for normal orders, documentation, and results review.  These general procedures will also be used during other downtime situations.

What do you need to know?  Depending on your clinical duties, please review the following.

If you are caring for inpatients, prepare beforehand and ensure recovery is accurately performed first thing Monday morning.

If you are working during downtime, review and be ready to perform downtime procedures (e.g. for order entry and admissions) and recovery procedures.

Two important resources:

Timeline

Preparation:

  • Saturday Night – Prepare for downtime by prepping patient lists, placing electronic orders, and completing any documentation BEFORE 12:30 am.

Downtime:

  • 12:30 am – Downtime starts. Follow downtime procedures, and use designated 724Access Level 2 workstations to review patient charts (see below).
  • 12:45 – Level 1 724Access is available on all ORCHID workstations for chart review.  See this for instructions to log-in. This is a full read-only chart copy.

Recovery:

  • Approximate 1:30 am post-daylight savings – ORCHID Production returns live. Begin Recovery.
  • Sunday Morning – Ensure recovery is completed, e.g. electronic back-entry of uncompleted orders, verification of back-entry, back-entry of notes.

PREPARATION

  • Orders
    • Place medication orders by 17:00 if possible.
    • Place laboratory orders (including AM labs for the next day) by 19:00 if possible.
    • Continue electronic order entry up until downtime at 21:00.
  • Patient Lists
    • Print your sign-out and/or patient list before 21:00.
  • Notes
    • Sign daily notes by 21:00. For uncompleted notes, make a back-up copy, and sign the note during Recovery.

DOWNTIME

724Workstation

  • Chart Review & 724Access
    • 724Access allows you to access patient charts with information from the last 10 days and upcoming 3 days only. Check your email for the generic username and password. A 724Access workstation is located in each inpatient nursing unit and ED pod.
    • Other ORCHID workstations will have special Level 1 724Access starting 12:45. Log in with your own username and password.   See this for instructions to log-in. This is a full read-only chart copy.
  • New Vitals, I/O’s, POCT Results, Medication Administration
    • These data will be recorded on paper by the nurse.
  • New Lab Results
    • STAT and Critical results will be called and/or faxed to the nurse. The nurse should verbally relay the result to you.
    • Other lab results will be printed and sorted in the Laboratory. To review the results, go to the 1st Floor Laboratory, enter with door code 24069, and search by patient name for a printout of your result.
  • New Radiology Results
    • New studies will be limited to STAT and Critical studies.
    • Reads may be limited to STAT studies and Critical results.  The Nighthawk is available for verbal communication.  Prelim reads/dictations will be placed in Synapse.  To review, open Synapse from your workstation desktop – don’t link to Synapse from ORCHID.
  • New Orders
    • All orders during downtime must be handwritten.  Please remember that all blocks of orders require your name, signature, date, time, and at least two patient identifiers (stickers with name, DOB, MRN).
    • Use designated order forms.  These are available from the OV Intranet > ORCHID Portal > Downtime Forms, or Intranet > Forms > OVMC > Medical Record Forms.
    • Place completed orders in the patient’s hard chart and place it in the designated orders bin/rack for the unit clerk/nurse to process (like old times!).  In the ED, place written orders in the designated bin in the ED pod. Be sure to alert the nurse and clerk about any STAT orders.
    • Keep track of placed orders because uncompleted orders will need to be re-entered electronically during recovery! Nonessential orders (e.g. orders that do not need to be carried out during downtime) can likely wait until recovery.
    • TIPS on handwritten orders: Use a pen with blue or black ink and medium thickness. Write clearly and legibly for others to read. If you make an error, use a single strikethrough to cross-out the error AND sign-date-and-time the correction. Avoid banned abbreviations.
  • New Documentation
    • Handwrite notes on physician Progress Note forms.  You must sign, date, and time all pages of notes. All pages must have patient identifiers (stickers).  Consider typing and saving your note in another place (e.g. Word), so that you can copy-and-paste your note into ORCHID during recovery.
  • New Admissions
    • Use the designated downtime General Admission form.  Follow procedures for placing new orders.  In the ED, place orders in the designated bin in the Pod for the nurse/clerk to process.
  • New Discharges
    • Limit discharges if reasonable.  Discharges require Patient Instructions (use the form) and the Discharge Order set.
  • Do not discard any written notes or orders. Leave them in the hard chart. These remain part of the permanent chart.

RECOVERY

  • Orders Placed During Downtime
    • For inpatients: Back-enter all ongoing/incomplete orders or changes to ongoing orders, except completed lab orders, completed radiology orders, or medications that were previously ordered on paper.  Orders that should be back-entered include the following:
      • Admit to Inpatient along with MED General Admit order set
      • Transfer order
      • Resuscitation status
      • Isolation status
      • Allergies
      • Diet
      • Restraints
    • The following will be back-entered by other services:
      • Medications (updated by Pharmacy)
      • Hold status (updated by Psychiatry)
      • Request for Admit from the ED (updated by the ED)
      • Place in Observation from the ED (updated by the ED)
  • Documentation Requiring Back-Entry
    • Back-enter all History & Physicals, Discharge Summaries, Ambulatory Provider Notes, and Procedure Notes electronically into ORCHID.
  • Vitals and I/O’s During Downtime
    • For downtime <4 hours, the nurse will back-enter these results
    • For downtime >4 hours, the nurse will back-enter at least the most recent results
  • POCT Results During Downtime
    • Results will be uploaded into ORCHID
  • Medication Administration During Downtime
    • The clinician who administered the medication should back-enter those meds into the MAR
  • New Orders and Notes
    • Resume normal workflows involving electronic order entry and documentation.
  • The recovery process must be completed within 24 hours!
  • Do not discard any written notes or orders. Leave them in the hard chart. These remain part of the permanent chart.

ORCHID Tips for ED Up/Downgrades, Abx, IS, NPO after MN, Holding Meds

To Upgrade or Downgrade While the Patient is Boarding in the ED:

Do not use the Transfer Order! Explanation: Transfer Orders with an ED or ED Boarder location means transfer to another facility.

Do place a new Request for Admit and Admit to Inpatient order with the new level of care.  Both orders must agree on the level of care.  The nurse and bed control will follow the most recent orders.  Again, this applies to patients boarding in the ED.

orders-upgrade-to-icu-from-ed-boarder

If the patient is already on the ward or unit, continue to use the Transfer Patient order to change the level of care.

 

To Order Restricted Antibiotics:

For Restricted Antibiotics (refer to the cream-colored antibiotic card), if the antibiotic has a pre-approved indication, specify that in the Indication detail field.  If you have received verbal or written approval from the ID Fellow or Attending, specify the Indication and the Approving Consultant.

orders-zosyn-marked

Restricted Antibiotics with pre-approved indications at OVMC: Amikacin, Ampicillin/Sulbactam (Unasyn), Cefepime, Piperacillin/Tazobactam (Zosyn), and Vancomycin (oral and intravenous)

Fully Restricted Antibiotics requiring ID approval at OVMC: Aztreonam, Amphotericin B Liposomal, Ceftazidime, Cidofovir, Colistin, Dalfopristin/Quinupristin, Daptomycin, Foscarnet, Ganciclovir, HIV antiretrovirals, Isavuconazole, Linezolid, Meropenem, Moxifloxacin, Micafungin, Oritavancin, Posaconazole, Tigecycline, Voriconazole

icon-pharmacy-reject If you see this icon, it means the Pharmacy has rejected your order (e.g. incorrect order, unapproved indication, etc).  If you have not already been paged by Pharmacy, please speak to the inpatient pharmacist regarding your order.

 

To Hold a Dose of Medication:

The safest approach to “hold” a medication is to discontinue the medication and then re-order it when you are ready to restart the med or specify an appropriate First Dose Date/Time.  Avoid using Communication orders alone to “hold” a medication.

Explanation: Discontinuing a medication takes it off the MAR, so the nurse and pharmacy will not dispense or administer the medication. Communication orders are unreliable because although it may alert the nurse, no alert goes to pharmacy to hold the medication.  Direct verbal communication is also very helpful (e.g. holding a dose of enoxaparin before a procedure).

 

To Order NPO after Midnight:

The best practice is to both modify the previous diet order with a specific Stop Date/Time and add the new NPO order with a specific Start Date/Time.

orders-npo-after-mn

Your orders will look similar to the following:

orders-npo-after-mn-2

Please note, if there are two concurrent diet orders (e.g. the times on the diet orders overlap), Dietary Services will follow the most restrictive diet order.

 

To Order Incentive Spirometry:

Place both Incentive Spirometry Nursing and Incentive Spirometry Instruct orders.

orders-incentive-spirometry

Explanation: The instruction order will go to RT to provide the patient initial instructions on using IS.  The nursing order will go to the Nurse to document IS, but will not task the nurse with providing IS instruction.

Updated Remote ORCHID Access… MAC Users Included

If you are as yet unable to connect to ORCHID remotely, this update is for you.

You can now connect to ORCHID through VDI (virtual desktop infrastructure), and this will work for PC and MAC users alike.  Simply follow the attached instructions: DHS VDI for External Users.  They will guide you to download and install VMWare for your operating system, and then you can log-in via the new link: https://myremotepc.dhs.lacounty.gov

Some notes:

  • If you previously installed another version of VMWare, you may need to uninstall the old version and install the new one.
  • The Virtual Desktop includes access to workstation applications like Synapse.
  • Protect all health information! You should not allow others to access health information or leave your workstation or mobile device unattended or insecure.

Inpatient Reminders This Past Week

Admission Orders: Level of care must agree

  • The level of care must agree between the Request for Admit (placed by ED) and Admit to Inpatient (placed by admitting team) orders while the patient is boarding in the ED.  If one of these is not correct, re-order it. Don’t cancel the prior order.
  • If changing the level of care while still boarding in the ED, place a new Request for Admit and Admit to Inpatient order with the new level of care. Don’t cancel the prior orders. Let the nurse and bed control know.

Admit order

Inpatient Lab Orders: Time it right

  • Routine Lab Collection times: 0000, 0400, 1000, 1300, 1700, 2100
    Labs with an order time set after one of these times will be rolled over to the next collection time.  So if you need “PM Labs”, set a Routine priority at 1700 or 2100.
  • Avoid using the Timed Routine lab priority.
  • Do not use the Label comment field or Order Comments to communicate to the Lab/Phlebotomy. They cannot see this information when drawing labs.  Instead, call Phlebotomy to let them know if special instructions, e.g. “Please use pediatric tubes”

Remember the Required Provider Note Details

  • Remember to fill out the Required Provider Note Information for every patient, every day in the hospital before you write your progress or procedure note

Procedure Note - Required Details

Choose the right Note Type, Correct it before you sign

  • Remember to choose the correct Note Type when creating your note.
  • If you initially selected the wrong Note Type, you can change it by clicking the blue hyperlink at the bottom of the note before you sign it.

Update Change Note Type

Write the right information on the Discharge Summary

  • Discharge Medication List: The auto-populated “Home” Medications should be the same as the Discharge Medications.
    Make sure to do the Med Rec prior to creating the note, or clicking the little refresh button in the Mediation section to update the list.
  • Hospital Course: Summarize the hospital course by problem.  A summary is a synthesis of the findings, assessment and course, including rationale to explain events or course of action
  • Discharge Plan/Follow-up: Be succinct! This includes the plan for the patient and follow-up.  Deleting the problem list in this section is okay. A bulleted list of plans is okay.

Be Prepared: ORCHID Downtime Scheduled Sunday, July 10 at 9pm

ORCHID is undergoing its first major upgrade this coming weekend, which will require downtime.  That means the EHR across DHS will not be available for normal orders, documentation, and results review.  Downtime is scheduled to start Sunday, July 10 at 9pm and end Monday, July 11 at 5am.

What do you need to know?  Depending on your clinical duties, please review the following.  I will be available Sunday night to ensure appropriate procedures.

If you are caring for inpatients, prepare beforehand and ensure recovery is accurately performed first thing Monday morning.

If you are working during downtime, review and be ready to perform downtime procedures (e.g. for order entry and admissions) and recovery procedures.

If you are returning to Monday outpatient, ORCHID should be up and running.

Two important resources:

 

Timeline

Preparation:

  • Sunday Afternoon – Prepare for downtime by prepping patients list, placing electronic orders, and completing daily documentation.
  • 17:00 – Finish placing electronic medication orders (as best as possible)
  • 19:00 – Finish placing electronic laboratory orders (as best as possible)

Downtime:

  • 21:00 – Downtime starts. Follow downtime procedures, and use designated 724Access workstations to review patient charts (read only access)
  • 21:30 – Level 1 724Access is available on all ORCHID workstations for chart review (read only access)

Recovery:

  • 05:00 – ORCHID goes live with upgrades. Begin Recovery.
  • Monday Morning – Ensure recovery is completed, e.g. electronic back-entry of uncompleted orders, verification of back-entry, back-entry of notes.

 

PREPARATION

  • Orders
    • Place medication orders by 17:00 if possible.
    • Place laboratory orders (including AM labs for the next day) by 19:00 if possible.
    • Continue electronic order entry up until downtime at 21:00.
  • Patient Lists
    • Print your sign-out and/or patient list before 21:00.
  • Notes
    • Sign daily notes by 21:00. For uncompleted notes, make a back-up copy, and sign the note during Recovery.

DOWNTIME

724Workstation

  • Chart Review & 724Access
    • 724Access allows you to access patient charts with information from the last 10 days and upcoming 3 days only. Check your email for the generic username and password. A 724Access workstation is located in each inpatient nursing unit and ED pod.
    • Other ORCHID workstations will have special Level 1 724Access starting 21:30. Log in with your own username and password.
  • New Vitals, I/O’s, POCT Results, Medication Administration
    • These data will be recorded on paper by the nurse.
  • New Lab Results
    • STAT and Critical results will be called and/or faxed to the nurse. The nurse should verbally relay the result to you.
    • Other lab results will be printed and sorted in the Laboratory. To review the results, go to the 1st Floor Laboratory, enter with door code 24069, and search by patient name for a printout of your result.
  • New Radiology Results
    • New studies will be limited to STAT and Critical studies.
    • Reads may be limited to STAT studies and Critical results.  The Nighthawk is available for verbal communication.  Prelim reads/dictations will be placed in Synapse.  To review, open Synapse from your workstation desktop – don’t link to Synapse from ORCHID.
  • New Orders
    • All orders during downtime must be handwritten.  Please remember that all blocks of orders require your name, signature, date, time, and at least two patient identifiers (stickers with name, DOB, MRN).
    • Use designated order forms.  These are available from the OV Intranet > ORCHID Portal > Downtime Forms, or Intranet > Forms > OVMC > Medical Record Forms.
    • Place completed orders in the patient’s hard chart and place it in the designated orders bin/rack for the unit clerk/nurse to process (like old times!).  In the ED, place written orders in the designated bin in the ED pod. Be sure to alert the nurse and clerk about any STAT orders.
    • Keep track of placed orders because uncompleted orders will need to be re-entered electronically during recovery! Nonessential orders (e.g. orders that do not need to be carried out during downtime) can likely wait until recovery.
    • TIPS on handwritten orders: Use a pen with blue or black ink and medium thickness. Write clearly and legibly for others to read. If you make an error, use a single strikethrough to cross-out the error AND sign-date-and-time the correction. Avoid banned abbreviations.
  • New Documentation
    • Handwrite notes on physician Progress Note forms.  You must sign, date, and time all pages of notes. All pages must have patient identifiers (stickers).  Consider typing and saving your note in another place (e.g. Word), so that you can copy-and-paste your note into ORCHID during recovery.
  • New Admissions
    • Use the designated downtime General Admission form.  Follow procedures for placing new orders.  In the ED, place orders in the designated bin in the Pod for the nurse/clerk to process.
  • New Discharges
    • Limit discharges if reasonable.  Discharges require Patient Instructions (use the form) and the Discharge Order set.
  • Do not discard any written notes or orders. Leave them in the hard chart. These remain part of the permanent chart.

RECOVERY

  • Orders Placed During Downtime
    • For inpatients: Back-enter all ongoing/incomplete orders or changes to ongoing orders, except completed lab orders, completed radiology orders, or medications that were previously ordered on paper.  Orders that should be back-entered include the following:
      • Admit to Inpatient along with MED General Admit order set
      • Transfer order
      • Resuscitation status
      • Isolation status
      • Allergies
      • Diet
      • Restraints
    • The following will be back-entered by other services:
      • Medications (updated by Pharmacy)
      • Hold status (updated by Psychiatry)
      • Request for Admit from the ED (updated by the ED)
      • Place in Observation from the ED (updated by the ED)
  • Documentation Requiring Back-Entry
    • Back-enter all History & Physicals, Discharge Summaries, Ambulatory Provider Notes, and Procedure Notes electronically into ORCHID.
  • Vitals and I/O’s During Downtime
    • For downtime <4 hours, the nurse will back-enter these results
    • For downtime >4 hours, the nurse will back-enter at least the most recent results
  • POCT Results During Downtime
    • Results will be uploaded into ORCHID
  • Medication Administration During Downtime
    • The clinician who administered the medication should back-enter those meds into the MAR
  • New Orders and Notes
    • Resume normal workflows involving electronic order entry and documentation.
  • The recovery process must be completed within 24 hours!
  • Do not discard any written notes or orders. Leave them in the hard chart. These remain part of the permanent chart.

General Consents Show Patient Empanelment +/- Provider

Trying to figure out your patient’s primary care physician?

When your patient is admitted, under the Documentation section, look for a note type labeled Consents General. This may include a scanned document with identification of 1) if the patient is a DHS or non-DHS empanelled patient and 2) who that empanelment provider might be.

Use this information for discharge planning.  Remember, empanelled patients should follow-up with their empanelment provider, not in CCC-Post-Discharge Clinic (Clinic A).  CCC-PDC should be reserved for un-empanelled patients (call Clinic A for an appointment).

The “empanelment” provider listed in the patient’s banner bar is not reliable at this time.

The St. John Sepsis Module is Live

Recognize and treat sepsis early!

The St. John sepsis module detects patients with signs of sepsis using vitals and laboratory results.  When the screen is positive, the patient’s nurse will be alerted.  The nurse will then alert the provider.

It is up to the you as the provider to take action! Evaluate the patient and if the patient requires treatment for sepsis, start quickly.  Inpatients need antibiotics given within 1 hour of declaring sepsis!  Use the MED Sepsis Screening and Management Bundle order set to view guidelines and suggestions for management, including IV fluids and empiric antibiotic selection.  This order set will suppress alerts for a period of time.

Goals: *use the MED Sepsis Screening and Management Bundle

  • BLOOD CULTURES before antibiotics
  • LACTATE: Check it, and if >= 2.0, recheck within 4 hours!
  • IVF: At least 30cc/kg IV fluid bolus (about 2L) within 3 hours
  • Additional clinical assessment and orders as indicated to identify the source
  • Make the diagnosis and document: Use auto text (.sespsnotsepsis, .sepsisseveresepsis .sepsissepticshock)