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 3 years ago
in Documentation
2
Future Development
When giving a PRN Med, the "Reason" is autofilled from what the Doctor ordered. This causes nurses to just go with what's autofilled instead of actually checking and updating the reason. This is definitely a nurse training issue, but we also can't...
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...
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
about 1 year ago
in Documentation
4
Open for Comment
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...
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 3 years ago
in Documentation
2
Open for Comment
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.
2
Future Development
0
