icare's Clinical, Care & Medication Management Solution

Transcription

1 icare's Clinical, Care & Medication Management Solution Progress Notes Software Version 2.10 March 2012 Copyright This publication has been prepared and written by icare Solutions Pty Ltd (ABN ) and is copyright. Other than for the purposes of and subject to the conditions prescribed under the Copyright Act no part of it may in any form or by any means (electronic, mechanical, micro copying, photocopying, recording or otherwise) be reproduced, stored in a retrieval system or transmitted without prior permission from the document controller. Note: The contents of this publication are subject to change without notice. All efforts have been made to ensure the accuracy of this publication. Notwithstanding, icare Solutions Pty Ltd does not assume responsibility for any errors or for any consequences arising from any errors in this publication.

2 Contents Progress Notes Resident Header... 3 Progress Notes Filter Options... 4 Multi-Resident Entry... 5 Automated Progress Notes

3 Progress Notes Resident Header The Resident Header of progress notes has been enhanced to include a full resident header. When viewing a previously written progress notes through Enter New or Add Additional Progress Note by Calendar Day the resident header will be static as at the day the progress note was written. This will ensure the resident data is accurate as at the time the note was written. The summary progress notes page header will change to include a compact header. All progress notes viewed through ACFI Evidence Explorer will display the compact header. Ensures accuracy and consistency of Resident Data and the identity of the Resident for the clinical documentation is assured. Resident Management (Part I) Training 3

4 Progress Notes Filter Options When selecting to Read or Search for a Progress Note by date range, the filter by options have been expanded. The filter options have changed to allow a pinpoint or expansive progress notes search. The ACFI filter will allow a specific ACFI question to be selected if required. Flexibility in search criteria to enable improved search results. Resident Management (Part I) Training 4

5 Multi-Resident Entry Progress Notes have been enhanced to include the ability to apply a progress note entry to one or more residents. When clicking on the Multi-Resident Entry button in progress notes, a new screen will open enabling multiple residents to be selected. A progress note can be entered, and when saved that progress note will be written to each of the selected residents files. Time saving for entry of group resident activities. Resident Management (Part I) Training 5

6 Automated Progress Notes Progress Notes for Care Plans will be triggered when a User Creates a New Care Plan, evaluates a Care Plan, evaluates a Care Plan Domain, evaluates an individual Goal or Intervention and when a new Observation, Goal or intervention is added to the Care Plan. If any of the evaluations are struck through a progress note will also be written to the resident file. New Occupancy Progress Notes will be triggered when either: 1. a resident is admitted to a facility, 2. an admission date for a resident is changed, or 3. when a discharge date for a resident is changed. When an ACFI form is completed a progress note will be written to the resident file. When an observation is written and saved for an Observation and Charting Tool, a progress note will be written to the resident file. The observation can be viewed and will be opened in a read only format. Handy Hint To enable the Progress Note to be written for ACFI Forms together with Observation and Charting Tools, the Organisation Manager will be required to tick the relevant checkbox for each, through Organisation Management <Forms Management and Business Rules <Create/Edit a Form. When an evaluation note has been added to an intervention written for a Behaviour, Bowel or Pain Chart, a progress note will be written to the resident s record stating the chart name together with the evaluation. If the evaluation is struck through, another progress note will be written to the resident record stating that the evaluation has been struck through and the reason. Automated progress notes eliminates the need for double entry, saving time. Resident Management (Part I) Training 6