Purpose/Goal: This course introduces the purpose and use of Smart Chart as a means of legal documentation.

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1 Title of Activity: UHS-Smart Chart, Part 1 (P8469) Total Number of Contact Hours: 1 Intended Level of Learner: Beginner Purpose/Goal: This course introduces the purpose and use of Smart Chart as a means of legal documentation. Objectives Content (Topics) Teaching/Learning Resources Describe the purpose of using Smart Chart Examine legal issues related to Smart Chart use. List three goals that will lead to success when using Smart Chart. Explain key terms associated with Smart Chart. Introduction Computer use CMS (Centers for Medicare/Medicaid) requirement for medical records Requirements User name and password Electronic signature Attestation Point of Care (POC) System Goals Terminology & Using Smart Chart Smart Chart Screen Wake up Unscheduled Care/ Scheduled Care Screen Sorting Unit, Location Written material online Post test Written material online Post test Written material online Post test Written material online Post test

2 Introduction: Smart Chart is a computer program for Certified Nursing Assistants (CNAs) to record the work they complete with a patient. What is Smart Chart? Smart Chart is very easy to use-it is a touch screen; no mouse or keyboard is needed. Even if you do not utilize computes very much, it is as simple as using your cell phone for texting. There are several stations around the healthcare center to use-these are called Kiosks.

3 Topic 1: Why are we using Smart Chart instead of paper? The Centers for Medicare/Medicaid (CMS) is the Federal Government agency that makes the laws Nursing Homes, Assisted Livings, Hospitals, etc. They have made it mandatory that we move to all electronic records in the next couple of years. Electronic records make it more efficient to track patient information. Anyone with access to the program can look in one location and find all of the information on the patient, for example, how much they ate that day, their medicines, whether they are in rehab, their diagnosis. They do not even have to be in center-they can access it from anywhere there is an internet connection. for the It is faster and the information is more accurate than documenting on paper because you document as you go; that is the reason for so many kiosks. This type of documentation is called a POC or Point of Care system because it allows you to chart near the residents rooms shortly after care is given. Topic 2: Am I going to need a user ID and password? Before you can use the system you must be issued your own user ID and password. You have to make sure you have signed a document called the Electronic Signature Attestation. This states that you understand you can never share your user ID or password with anyone because it is against the law even if your boss asks you to do so. If, in the future, there is a question from CMS or a possible lawsuit, and someone else used your ID and password, you are the one held responsible. It is no different than if a nurse signed another nurse s notes-the legal results are very serious. This would be considered fraud and the results are serious. The information you enter into Smart Chart is an official, legal, and very important part of the patient s record.

4 Topic 3: What can I do to be successful with Smart Chart? There are three goals to keep in mind that will lead to your success. 1. Chart as you go. This is the reason we chose a Point of Care (POC) system and why there are so many kiosks around the center. 2. Chart everything on your electronic to-do list by the end of your shift. 3. Chart each time you give care to show all the work you have done. Let s Review 1. Smart Chart is a computer program for Certified Nursing Assistants (CNAs) to record the work they complete with a patient. a. True b. False 2. What is the Federal Government agency that makes the laws for Nursing Homes, Assisted Livings, Hospitals, etc. and has made it mandatory that we move to all electronic records in the next couple of years? a. The Centers for Disease Control (CDC b. The Centers for Medicare/Medicaid (CMS) c. The Office of the Inspector General (OIG) 3. Before you can use the Smart Chart system what must you be issued? a. An identification badge b. A certificate of course completion c. A Personal User ID and password 4. What are goals to keep in mind that will lead to your success? a. Chart as you go. b. Chart everything on your electronic to-do list by the end of your shift. c. Chart as you give care to show all the work you have done. d. All of the above Continue to the next page to view the answers. Answers:

5 1. a. True 2. b. The Centers for Medicare/Medicaid (CMS) 3. c. A Personal User ID and password 4. d. All of the above In the next section, we will get started on how to use the Smart Chart program. You will learn how to: 1. Enter your User ID and Password. 2. Get to the main Smart Chart screen, which lists all patients in the center. 3. Scroll through the list of patients. 4. Sort by a unit or a block of rooms.

6 Topic 4: Terminology and Using Smart Chart LET S GET STARTED! We are going to Wake Up the computer screen if there is nothing on it: Just touch the screen anywhere and you should get this on your screen:

7 User ID and Password Remember that Smart Chart is a touch-screen program, so you do not need a keyboard or mouse. To open the program you must first log in using the user ID and password you were provided. Simply tap on the letter you wish to type and enter your user ID. Once entered, tap once in the white portion of the Password line then type your password using the keyboard. Once you are finished press OK and the program will open. Note: If you are unable to log in due to user ID or password problems, contact your supervisor immediately. The problem must be addressed as soon as possible. In addition, remember never work with anyone else s user ID and password.

8 Scheduled Care/ Unscheduled Care When you log in, you are taken to the Smart Chart Unscheduled Care/ Scheduled Care screen. This is the main screen of Smart Chart. What you will see is a list of all residents currently admitted in the center. You will see names highlighted in red, yellow, and white. Within each color grouping the names are listed alphabetically, last name first. Each color means something different, and that will be explained later. The system also shows you the resident s unit, room number, and bed.

9 To make the program easier to use, you can choose to filter the number of residents that display in the list. Tap the Selection Criteria button located in the top right of the window to set your filter: When you do, a new window will pop up. Here you can choose to sort by Room Group (Note: Never select this option. We do not use this feature and selecting it will return a blank list of residents), by Unit, or by a block of room numbers. The most useful way to filter is to filter by unit. Tap on the unit button. In our example, there are three units; 1, 2, and 3. Let s pick unit 3 then click OK. Now we see only the residents on the selected unit. The system will remember the last criteria you entered using your User ID. If you exit the program and then log back in, you will see the hall you selected. This is important to remember if you change units, because you will need to go back to the selection criteria button and change it to the correct unit.

10 To scroll through the list you can click on the up or down arrow to advance one resident at a time. You can click in the white portion of the slider to advance the list one page at a time. You can also tap the slider bar, and while holding your finger against the screen slide the bar up and down. This is the end of the Smart Chart, PART I. There are 2 more modules to complete the Smart Chart Course. Now you take the test, then the Competency Assessment. The Competency Assessment will be completed with the designated observer. You will complete the Competency Assessment as you are observed completing the tasks on the kiosk.

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