CLINICAL CHARTING USER INTERFACE The new (UI) is a significant step forward. The new UI offers several significant enhancements: One-click to create clinical charting from patient homepage Capture Time, Electronic Visit Verification, and multiple charting activities in one step Fewer clicks to create multiple clinical chart entries Cleaner homepage: fewer links, less scrolling Role-based set of clinical charting items: only see those items relevant to your Role Sortable, searchable history of clinical charting. Quickly review by date, user, discipline, etc. Optimized for Tablets: clinical charting screen scales to the user s display; Time and Date helpers are tappable; clinical charting screen minimizes scrolling Agency-level control of chart cloning. All new charting is blank by default. Content from previous charting can be cloned only (a) if the user has role permission and (b) actively elects cloning True lock-down of e-signed charting. E-signed clinical charting cannot be changed or destroyed. Addendums may be added. CREATING CLINICAL CHARTING The first thing you ll notice is that most of the links in the Clinical Charting section of the patient homepage are gone. You no longer need to click on each clinical chart type (e.g. Nurse Note, Social Note), create it, save it, and then navigate back to the patient homepage to create another chart entry (e.g. Physician Order, Bereavement Assessment). To create clinical charting for a patient, just click the + next to Clinical Charting. 1 Page
Now, the new Clinical Charting screen will appear: Click Related Links to access Performance Scales. Help Menu replaces Training Tools Menu. Alphabetical List of all Clinical Charting Options. Include as many as desired in this Clinical Charting Event. Only items you have Role Permissions for will appear. Click the More button to see Patient Details like Diagnosis, Location, etc. User Status Bar shows Login, Connection, Refresh, Logout Info. And option to switch to immediate Offline charting: NOTE: A Clinical Charting Event includes all clinical charting completed by one User, for one visit, contact, activity, or episode. A Clinical Charting Event may include only one item, like Physician Order. Or, it may include many items, such as a Pain Assessment, Fall Assessment, and Nursing Assessment. It may or may not include Patient Time and Electronic Visit Verification. A Clinical Charting Event is called simply a Chart. To create a clinical charting event: 1. Complete the General Clinical Chart Details. These fields will default to today s date, and your Role and User Name. If charting late, on behalf of someone else, or if you have multiple Roles, you may change any of the fields by clicking in them. 2 Page
2. If necessary, click the Patient Time button on the left side of the screen. Enter Time In, Time Out, and Mileage, Travel Start and Stop, and Clinical Care Type, as necessary. If Patient Time is not needed for this clinical charting event, skip this step. Date In and Out will default to Today. Click in the date field and use the calendar helper to change the date. Or, manually type in dates using MM/DD/YYYY format. Enter time using either of these methods: o o Type 4-digit military time using your device s number pad; Click in the Time Fields to use the new Time Picker: Click the Now button to enter the current time. Use your finger (on tablet devices), cursor, or arrow keys to move the slider bar to the proper times. As the slider is moved left-to-right, the Time will update. Click Done to enter the time. 3 Page
3. If necessary, click the Electronic Visit Verification button on the left. Complete the EVV fields as desired. If you are not charting a visit, or if you do not need to verify this visit, skip this step. 4. Click on a clinical charting type on the left side of the screen. For example, click on Fall Event. It will open on the right. Only items you have Permissions for will appear. The Nursing Assessment has been separated into Mini Assessments. Select only those needed. Related Links Click on Related Links to access Performance Scales. These open in a new Tab for reference: 4 Page
ENABLE, CLONE, RESET ALL ASSESSMENTS AND NOTES ARE NOW BLANK BY DEFAULT. When you click on a clinical charting type on the left side of the screen, it opens enabled on the right side. That means you can immediately start charting. Cloning means charting by exception or copying the last Fall Event and pasting it into this Fall Event. If there is no previous Fall Event for this patient, nothing happens. If you do Clone, be sure to edit or change any necessary fields. Clone is only available if you have Role Permissions. Cloning only copies information from the previous chart of the same type. For example, clicking Clone on the above screen will only copy forward previous Fall Event information. It will not copy forward any other information. To completely remove contents, click the Reset button to remove it from this charting episode. This clears the data entered in the Fall Event, and changes it from Enabled to Disabled : Click the Section is Disabled button to re-enable the Fall Event; resume charting. To make navigation easier, try tabbing from field to field. Once finished charting the Fall Event, you may click Create at the bottom of the screen, if you are finished charting this event, OR 5. Select another type of clinical charting from the left. For example, Physician Order: Notice a check-mark has appeared next to the Fall Event. This reminds you of clinical charting you ve already completed. Complete the Order as desired, then Create if finished, or add another element, like Visit Note. 5 Page
VISIT NOTE FEATURES There is now a single visit note template, for all disciplines. o o o o o Visit Notes will be counted for the discipline selected in the General section of the clinical charting event (defaults to your discipline). Visit Notes will count as a visit if an *asterisked Visit Type is selected. Use the Related Link button to add Physician Charges, if necessary: Select a Therapy Type, if appropriate Check Call Report box to include this Visit Note in Call Report: 6. When you have finished adding elements to this clinical charting event, click the create button at the bottom of the screen: 6 Page
7. Now you will see a summary of this clinical charting event, with a prompt to Sign: If signed now, the chart is permanently locked. If you do not want to Sign now, just close the Add Your Signature Dialog box. This chart will be saved, unsigned. Return to Sign later, as shown: 8. Use Related Links to Add Signatures, Edit, Print, Fax, or Create another chart entry: NOTE: Once e-signed, charting cannot be edited or destroyed. However, Addendums may be added to signed, locked clinical charts. This is covered later in this Guide. 7 Page
9. Click Clinical Charts in the navigation links to see a summary of this patient s charting, on the Clinical Charts Summary screen: MINI ASSESSMENT SUMMARIES To view summaries of Skin Integrity, Fall Event, Pain, Wound, Morse Fall, Mini Nutritional, and Nursing Vitals Assessments, use the Clinical Summary section of the patient homepage. These summary links will compile just the relevant mini-assessments, and present their summary information for review: 8 Page
Here is an example of a Morse Fall Assessment Summary screen. It enables you to quickly compare results from all completed Morse Fall Assessments. View, print, and sort by column headers is also supported: 9 Page
USING THE CLINICAL CHARTS SUMMARY SCREEN Each patient s homepage contains a Clinical Charts link in the Clinical Charting section: Click the link to open the Clinical Charts Summary Screen: This screen includes several powerful new features. This screen will: Show a summary of all clinical charting related to this patient Sort all clinical charting chronologically, by discipline, chart owner, chart creator, E-Signature status, EVV status, or time units Print any clinical charting without having to open the underlying charts Filter, or search within, clinical charting for a particular set of charts Filter for specific types of charts 10 Page
Let s review the features of this screen. 1. Toggle Filter. Click the Toggle Filter button to Hide the Filter Options. This will allow you to see more clinical charting entries on the screen. In the screenshot above, the Filter Options are un-toggled. In the screenshot below, the Filter Options are toggled: 2. Enhanced Date Range Filter. The following Date Ranges can be selected by clicking in either of the Date Range Date fields: a. Today b. Last 7 days c. Month to date d. Year to date e. Previous Month f. Specific Date (opens a calendar picker) g. All Dates Before (opens a calendar picker) h. All Dates After (opens a calendar picker) i. Date Range (opens a calendar picker) 11 Page
3. Chart Attributes Filter. Clinical charting can also be filtered by: a. Chart Owner b. Chart Creator c. E-Signature Status d. EVV Status e. Patient Time Status f. Chart Type Use trash can icons to clear specific Filter Options. Use the Reset Filter button to clear all Filter Options. Click on a specific type of chart to search for only clinical chart events that include that type of assessment or note. 4. Summary of clinical charting Evaluate Signed, EVV, Time Unit status Click on column headers to re-sort. View, Print, Edit Icons. Note Signed charts have no Edit Icon. Click on Owner or Creator name to open a new email to that user. 5. Create new clinical charting by using the Related Link in the top-level menu bar: 12 Page
CREATING ADDENDUMS Once e-signed, clinical charting is permanently locked from editing. Users should take time to properly review their charting before signing, to ensure it is complete and accurate. In the event of errors or omissions, Addendums may be added to clinical charts. 1. From the clinical charts summary screen, click to View the chart: 2. Click Related Links, then Create Addendum 3. Complete the Addendum: 13 Page
Addendum Reason is required Why is the Addendum being added? o Wrong Patient Addendum added because chart was completed for wrong patient o Corrected Information Addendum added because chart contains erroneous information o Additional Information Addendum added because chart is missing information Clinical Chart Section Which section of the chart is being amended? o Leave blank if the Addendum is global; it applies to the entire chart o Specify a chart section if the Addendum relates to just that section Note What is the Information to include in the Addendum? o Text field captures the information entered by User Create / No Thanks Do you want to create this Addendum? o Once created, Addendums cannot be edited or removed o No Thanks will destroy the draft Addendum; nothing is Saved Addendums will display prominently at the bottom of the associated clinical chart: Addendums include: Date and Time created User who created Addendum Reason for Addendum Section (if any) being Addended Note NOTE: It is not possible to edit or remove Addendums. Amended charts are identified on the clinical charts summary screen by a tag icon: 14 Page
Addendums also display prominently on printed or faxed versions of the chart: 15 Page