Protected: Inpatient Documentation

Quick Guide

Quick Guides

EHR Essentials

Inpatient CSU Visual Quick Guide

Whiteboard Quick Guide

Client Order MAR Quick Guide

Inpatient Documentation Quick Guide

Medication Management Rx

Inpatient Workflow Sheet

Inpatient Workflow

Task you want to doWhat is it called in Smartcare?Pro-tipDetailed Instructions/Video
View of the unit and the patientsWhiteboard [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.
Census Summary

Reviewing Historical Data

Review previous services/notesServices/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 programsPrograms [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 LabsLab 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
How to Document Lab Results
How to Order a Lab Panel
How to Order Labs
Review DiagnosesDiagnosis Document [Client] or within any psychiatric notesOf 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
Search Service Note [Client] , select "Your Program" and "IP Medication Support". Choose radiobutton for either “IP admission” or” IP Progress
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

How to Amend a Note
Documenting VitalsFlowsheet[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

Flow Sheets
Documenting diagnoses within a service/noteWithin all notes: Diagnosis Tab and/or Billing DiagnosisYou 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 PrescribersWithin a note: MDM TabWhen 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

Within a note: MDM TabCan 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
Sign your noteYou will get Validation pop-up with direction of where an error is if
you cannot sign.
Document Safety Checks/Seclusion and RestraintFrom whiteboard, click on the time for "Next Check" and/or access through Flowsheet "Safety Check" and/or "S&R
Every time the "Next Check" is selected, it will restart the timer based on time interval of the orderPrescriber: How to Order a Seclusion and/or Restraint
Nurse: How to Document Seclusion and Restraints
Other inpatient documentationAll 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

Order Inpatient OrdersCan 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/systemsNo 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
Add outpatient medications external of programs/systems
In Medication Management Rx, click on "Add Medication" buttonCan add the source of the prescription, who is the prescriberAdding Medications (Prescribed Elsewhere)
Record AllergiesIn 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 .

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-signedIn 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 medicationsIn 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 MessagesMessages/Alerts or "New Messages/Alerts" widget on Provider's DashboardProviders 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 completeClient 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
Comprehensive Guide

Quick Guides

Overview of Primary Screens


Intake: First Tasks


Managing a Client's Placement