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My ideas: Documentation

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Patient Education saves when printed

It would be beneficial that if a patient education document is printed to have it automatically saved in the chart. Currently there are additional steps that have to be taken to save the document to the chart and also to print.
Wendy Stuhr 29 days ago in Documentation 4 Open for Comment

Pull IV fluids and medications to intake when stopped

When IV stop time is entered by nursing staff in MAR the volume is pulled into the intake of I/O's. This will increase accuracy of I/O's and prompt nursing staff to complete stop times as mandated by CMS and billing.
Rose Shelburne about 1 year ago in Documentation / Medication Management 3 Open for Comment

Add Pain Scale to Medication Assessment options

When nurses are documenting a medication assessment in response to a dose given, it would be beneficial to have option to enter "Pain Scale ___/10" under that dropdown to simply fill in the blank, rather than having to use the OTHER option to type...
Cindi Gartman over 1 year ago in Documentation / Medication Management 9 Open for Comment

Ability to lock Documentation for behavior health and psychology patients

Locking of Documentation. There needs to be a way in CPSI to lock documentation for Behavior Health/Psychology patients. At BMH we have both services and currently using paper for documentation due to they need to be more secure than what CPSI cur...
Jennifer Brockhaus over 2 years ago in Documentation / HIM / Notes 11 Open for Comment

Date on each page of Patient Progress Notes

When patients documentation purges to clinical history - that is the only way we are able to view and keep patient records. When you look at the progress notes each page does not have the date of the documentation. So you have to remember when loo...
Nanci Richardson about 2 years ago in Documentation 2 Open for Comment

ADD patient screenings to Health History Application

Would like to see screenings added to the health history application or somewhere in the inpatient documentation. Screenings to Include- social determinants of health, suicide, depression, etc...
Trish Shelton about 1 year ago in Documentation / Health History 0 Open for Comment

REFERRAL/TRANSITION OF CARE NEEDS APPOINTMENT TIME ADDED

When entering outbound referrals for patients being discharged, a field needs to be available for entering the appointment time. With the current design of the screen, the only time field is for the Entered Date/Time of the referral. There's a fie...
Mark Boomhower 8 months ago in Documentation 0 Open for Comment

The ability to have profile based documentation

We need the ability to document things on the profile level. An example would be a telephone encounter. You should be able to document the phone call on the patient without having to create an account.
Guest over 2 years ago in Documentation 2 Open for Comment

Clinic discharge documents for patients

Create an easy discharge summary for providers to give to patients in the clinic as they leave. This paperwork should include current vitals and care plan for diagnosis.
Guest over 2 years ago in Documentation / TruBridge EHR - Clinical 1 Open for Comment

Converting Discharge instructions to another language

system menu-->POC Access-->choose patient-->discharge tab-->discharge instruction report-->no option to change language This is an obvious immediate need in our diverse country.
Guest 6 months ago in Documentation 4 Open for Comment