Documentation

Showing 96 of 2105

Documenting signing off on labs and radiology

Has been on top of list for 5 years! Like other EMR's, we (providers) need to be able to sign off directly on our results with a date/timestamp/comments. This feels like a patient safety and legal issue. Currently, you can hit Acknowledge without ...

amy ellingson 12 months ago in Ancillary / Documentation 3

44 VOTE

Add standardized scales for fall, braden, sepsis, dvt, etc

Many EMR's have standard scales built in, so wondering if CPSI could build eforms, flowchart or notes that have all the standard scales and the group could put in votes for priority ones but i think many of them are national and we are all re-doin...

Diana Trechter over 2 years ago in Documentation 5 Product Owner Review

10 VOTE

Add RASS scale to the hemodynamic vital sign application

The RASS scale is a requirement for evaluating titratable sedation effectiveness. RASS scale assessment/reassessment is required and recorded every hour. This should be captured within the vital sign application, and an option within the MAR shoul...

Guest 8 months ago in Documentation / Vital Signs 0

42 VOTE

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 over 2 years ago in Documentation 2 Future Development

22 VOTE

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 over 1 year ago in Documentation / Health History 1 Future Development

16 VOTE

"denies" option for social history categories in health history.

This would be a nice alternative to only being able to put "Never" if a patient states they do not have any substance abuse or smoking.

Guest over 1 year ago in Documentation / Health History 0 Future Development

11 VOTE

ER Log

Change the order of the information to how workflow is actually performed.

Christi Keating 11 months ago in Documentation / TruBridge EHR - Clinical 3

8 VOTE

STEADI Fall Screen for Wellness Document

The Wellness Template in Evident CPSI that is used for Medicare Annual Wellness Visits has two fall screens in the ‘Screenings’ section; Morse Fall Screen (MFS) and STEADI from the Centers for Disease Control and Prevention. CMS does not have a pr...

Erin Schaible 8 months ago in Documentation / Quality 4

33 VOTE

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 almost 3 years ago in Documentation 2 Open for Comment

10 VOTE

Allowing transcriptions to flow into MyCareCorner

We have one main provider who continues to dictate documentation, not utilizing Notes. Currently, these documents as not flowing over to MCC because they are transcriptions. Patients are calling and asking for documents.

Trish Shelton 11 months ago in Documentation / HIM 0 In Development

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