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Electronic Charting
The Electronic Charting module is a logical progression in long-term healthcare. An Electronic Health Record is a great business and quality of care investment. This module manages the full range of information to complete your legal record of care while ensuring focus remains on the resident. Quality of care within the guidelines of regulations and your standards is a natural by-product of our Electronic Charting Module.
Charting the record of care is managed with Care Paths and Progress Notes. This method captures analytical data and narrative information. A Care Path is an interdisciplinary standard of care (based on protocols for individual medical / psychological conditions) that dynamically combines the resident’s Care Plan, assessment data, and clinical chart into one place. The Care Path data provides an audit trail for survey purposes, as it provides detailed information on the care that was actually delivered relative to the plan. This data facilitates Management Reporting Systems, Outcome Measurement and Variance Tracking.
Features:
- Circle-of-care plan documentation (Documentation of care given matches the plan of care; this documentation matches the care given; care given flows into the assessment – the MDS; the MDS then guides the plan of care based on RAPs that have been triggered.)
- Multiple charts open simultaneously
- Framework for variance monitoring
- Comprehensive live medication error checking (Med-to-Med, Med-to-Allergy, Med-to-Diagnosis, Med-to-Food)
- Real-time documentation alerts staff to exceptions
- Instant chart audit capabilities
- Physician Favorites and facility-specific formulary
- Progress Notes with Templates
- Monitoring assessments with graphing capabilities (i.e. VS, Bates-Jensen Assessment Tool, I&O, Food Percentages, etc.)
- Mass charting (i.e. electronic medication pass)
- All charting can be linked to Problem/Focus
- Multi-disciplinary team alerts on healthcare-related messages
- Mass charting windows allows access to multiple resident charts and filters them by time, discipline and intervention category
- Tracks variances and outcomes
- Tracks completed and/or missed charting
- Vital Signs (charts, tracking, alerts, and weight change)
Benefits:
- Maximized revenue reimbursement with complete information capture that improves the accuracy of billing and coding.
- Hard costs of litigation and insurance are decreased with improved standards compliance.
- Staff communications are enhanced with legible, organized and clear charting.
- Better survey results as care standards are incorporated into daily care.
- Safer medication management with digital photos, medication order requisition, transcriptions and charting at the point of care.
- Reduced chart auditing.
- Clear organizational standards and protocols.
- Information guidelines and assistance is easily supplied to patient staff members.
- Escalation alerts are automatically directed to appropriate staff managers or physicians.
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We love the focus charting. We were able to find exactly what we needed and are also impressed with the flow of information throughout the chart. Progress notes, focus, MDS, assessments, care plan, and care planning guide were all well integrated. -Laura Saleen, Director of Nursing
Minnesota Veterans Homes, Minnesota
The electronic charting system removes the guesswork which comes with individual handwriting, and provides an accurate reading of what has been documented. -Joanne Creel, LPN
Royal Oaks Retirement Community, Sun City, Arizona
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