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Protected: Inpatient Documentation
Quick Guide
Comprehensive Guide
Quick Guide
Quick Guides
Inpatient Workflow
| Task you want to do | What is it called in Smartcare? | Pro-tip | Detailed Instructions/Video |
|---|---|---|---|
| View of the unit and the patients | Whiteboard [My Office]. If you want to toggle between different units, can select "Views" icon on upper right corner. | See Whiteboard Quick Guide. Whiteboard will give you an overview of the unit/beds/patients admitted. Click on the client’s name and it will bring you to the chart. | Whiteboard Residential Bedboard Census Summary |
| Reviewing Historical Data |
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| Review previous services/notes | Services/Notes [Client] | Filter “Complete” in Services/Notes screen. Click hyperlink under “Document” to access a specific note. You can also filter in Documents screen by “Signed.” If within a note’s PDF, use forward or backward arrow to look at notes. | How to Save Filters How to Use Filters |
| Review previous and current programs | Programs [Client] | Filter “enrolled” for current programs and remove date range to see all programs in the past. | How do I know what CDAG I have? |
| Review Labs | Lab Result Widget: A quickview of labs Lab Result Review: Complete list of client labs and/or outside lab results that have an appropriate interface with the EHR | You can also use: Individual Lab Flowsheet: Can trend and track individual lab trends and/or input POCT results manually. If scanning in any POCT/additional results can do this through Scanning [My Office] and the pdf will be saved within Documents [Client]. | How to Document Lab Results How to Order a Lab Panel How to Order Labs |
| Review Diagnoses | Diagnosis Document [Client] or within any psychiatric notes | Of note, when clinicians enter problems in their notes, this information will go to Client Clinical Problems, which is a separate list from Diagnosis Document. This is in development for merging together. | How to Add a Diagnosis How to Delete a Diagnosis How to Modify and/or Re-Order a Diagnosis How to Modify a Diagnosis After the Document is Generated How to Save a Favorite Diagnosis How to Add a Problem to the Problem List How to Remove a Problem That’s Been Resolved How to Filter/Sort a Client’s ProblemList |
| Write an inpatient admission and/or progress psychiatric note Prescribers | Search Service Note [Client] , select "Your Program" and "IP Medication Support". Choose radiobutton for either “IP admission” or” IP Progress Note.” | Of note, the admission and progress note are the same template, so will pull the last note's information into any subsequent note. | Prescriber: How to Complete the Psychiatric Evaluation How to Amend a Note |
| Documenting Vitals | Flowsheet[Client]--> Vitals Tab and/or Within IP Medication Support Note, "Exam" Tab | By using a flowsheet this allows you to view the recorded data in a graph format to track trends over time. | Vitals Flow Sheets |
| Documenting diagnoses within a service/note | Within all notes: Diagnosis Tab and/or Billing Diagnosis | You can enter the descriptive text or an ICD-10 code and it will auto- filter You will need to designate one primary diagnosis for the service and place it as the #1 spot of order By adding only in the psych note, it will not auto-populate the Diagnosis Document which we recommend to have transparency across users | Prescriber: How to Complete the History & Physical Prescriber: How to Complete the Psychiatric Evaluation |
| Add Problem within IP Medication Support note Prescribers | Within a note: MDM Tab | When you enter a "Problem" in MDM, it does not save to "Client Clinical Problems," which clinicians will be using. You will need to enter at least 1 problem to complete your note. We recommend that you create your diagnosis first, which will then auto-populate this "Problem." CalMHSA will be developing a different one in the future. | Prescriber: How to Complete the History & Physical Prescriber: How to Complete the Psychiatric Evaluation |
| Calculated Time for Spent (Prescribers) | Within a note: MDM Tab | Can enter a different time than what was scheduled under Service Tab. This is the official time that will be used for billing purposes | |
| Wrapping up IP Medication Support Note | Sign your note | You will get Validation pop-up with direction of where an error is if you cannot sign. | |
| Document Safety Checks/Seclusion and Restraint | From whiteboard, click on the time for "Next Check" and/or access through Flowsheet "Safety Check" and/or "S&R Check" | Every time the "Next Check" is selected, it will restart the timer based on time interval of the order | Prescriber: How to Order a Seclusion and/or Restraint Nurse: How to Document Seclusion and Restraints |
| Other inpatient documentation | All providers: Interdisciplinary Treatment Plan History and Physical Discharge Summary Discharge Instructions Transfer Summary Brief Contact Note Shift/Quick Note Nurses/non-MD staff: Shift Summary Personal Effects Inventory Nursing Assessment Nutritional Screening | See Inpatient Documentation Quick Guide. There are few codes that are typically used in the outpatient setting but can be used on the day of admission. Please check with your billing admin about how to use these codes. | How to View What Intake Documents and Tasks Need to be Completed How to Complete the Nutritional Screening How to Do Initial Medication Reconciliation Nurse: How to Complete the Nursing Assessment How to Complete the Personal Effects Inventory (PEI) Prescriber: How to Complete the History & Physical How to Document an End of Shift Summary How to Document Quick Notes During a Shift How to Complete the Transfer Summary How to Complete the Discharge Summary How to Complete the Discharge Instructions |
| Orders and MAR |
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| Order Inpatient Orders | Can order within an IP Medication Support Note under MDM and/or Client Orders. | See Orders and MAR Cheatsheet for more details This will auto-populate your note if done prior. Refresh to load into your note. | Orders (My Office) How to Create an Order Nurse: How to Document Follow-Up on an Order Prescriber: How to Order a Seclusion and/or Restraint Nurse: How to Document Seclusion and Restraints |
| Medication Reconciliation of medications within the programs/systems | No SmartCare Functionality, in development | Currently, there is not a good way to do a medication reconciliation, except manually in a note. Can visualize which medications inpatient (Client Orders) and outpatient medications (Medication Management Rx) within the IP Medication Support Note and/or when in client orders can select "add additional orders." The top half is from Client Orders (Inpatient) and the bottom half is from Medication Management Rx (Outpatient). | |
| Add outpatient medications external of programs/systems | In Medication Management Rx, click on "Add Medication" button | Can add the source of the prescription, who is the prescriber | Adding Medications (Prescribed Elsewhere) |
| Record Allergies | In Medication Management (Rx) [Client], click on box “Allergies/ Intolerance/Failed Trials.” | This will auto-populate your note if done prior. Refresh to load into your note. | In case of a substance giving an allergy |
| Documentation of administered medications and/or other orders that have been preselected to show up on the MAR | MAR [Client] | See Orders and MAR Quick Guide for more details | Client MAR Nurse: How to Document Follow-Up on an Order |
| Misc . |
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| To assign any documents and/or client orders to a co-signers | Once a document is a pdf, can click (+) in the upper right corner. Add cosigner. | ||
| Co-sign notes and/or sign client orders that need to be co-signed | In provider's dashboard's assigned document widget, can click on "co-sign" to see what orders have been placed by nurse. Click on "client order" to open and co-sign document. | If order is to be acknowledged, then can search for "Orders/Rounding, Client" and click on checkboxes. Select "Acknowledge Order" icon in upper right corner. | |
| Order discharge medications | In Client Orders, discontinue any inpatient orders. Add medication that you wish to continue and modify for the discharge date. Go into Medication Management Rx to finalize before submitting to pharmacy. | See Medication Management Rx Quick Guide. If you are prescribing controlled substances, you will need Identrust's HID mobile app and you will need a staff signature (Your Profile--> My preferences) Any queued order by nurses will be sent to prescriber's Queued Qrder widget on their dashboard. | Rx: Patient Summary Screen Adding Preferred Pharmacies Discontinuing a Medication Re-Ordering A Medication Changing a Medication Order Patient Consent Adding Medications (Prescribed Elsewhere) Medication List Drug/Allergy Interaction Warnings Medication Order Screen |
| Send/Review Messages | Messages/Alerts or "New Messages/Alerts" widget on Provider's Dashboard | Providers can view incoming new messages from other providers and respond by clicking on the widget's hyperlink. Can also search all messages/alerts under Message/Alert screen. Can attach a document by going to the completed document PDF and sending it as part of a message. Nurses can be added as a proxy by admin to answer messages for physicians. | How to send a message How to send a document in a message |
| Documenting that Tracking Protocol/Client Flag is complete | Client Tracking and select checkbox if not assigned. Complete pop-up and/or Client Flag by selecting specific flag and filingl in completion date with username. | Tracking widget How to Manually Add a Tracking Protocol to a Client How to Manually Remove a Tracking Protocol from a Client’s Record How to Track Clozapine Labs Using Tracking Protocols |
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Comprehensive Guide