Nursing Documentation

Quick Guide

Quick Guides

EHR Essentials

Outpatient Nurse Visual Quick Guide

Nurses Workflow Sheet

Medication Management

Outpatient Prescriber Visual Quick Guide

Outpatient MD Nurse Documentation Quick Guide

Outpatient Nurse Workflow

Thing You Want to DoWhat is It Called?Pro Tip
See Appointment Schedule, Schedule Appointment, Start Client's ServiceStaff Calendar and/or Appointment for Today widget on Provider's DashboardSave Staff Calendar as a Quick Link to easily access yours and other providers'/offices' calendars. "Appointment for Today" will autopopulate, if a client is assigned to you as the primary provider.How to Create an Appointment from Your Calendar

The Appointments For Today Widget
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 to answer messages for physicians.
How to Create an Appointment from Your Calendar

The Appointments For Today Widget
Look up ClientPerson Search IconThe Person Search icon will autofilter when you type in the first 3 letters and or medical record number.

For a more extensive search, under Person Search icon, select “Client Search.”
How to Create an Appointment from Your Calendar

The Appointments For Today Widget
Review Previous
Services/Notes [Client] and/or Documents [Clients]Filter “Complete” in Services/Notes screen. Click hyperlink under “Document” to access a specific note. You can also filter by “Signed” in Documents screen. If within a note’s PDF, use forward or backward arrow to see notes.How to Save Filters and/or Create Favorites
Review Previous and Current ProgramsPrograms (Client)Filter by “Enrolled” for current programs. Remove date range to see all current enrollments.How to Save Filters and/or Create Favorites
Review LabsLab Result Review screen: Complete list of client lab orders.

Can trend lab results within Flowsheets.
If outside lab vendor has appropriate interface with the EHR, the information will pull automatically for review. To mark that labs have been reviewed, select “Reviewed” vs. “Nurse Reviewed,” and assign to a prescriber
if needed. Of note, once reviewed, then this information will disappear from widget for all users. Nurses can send a notification to their Prescribers within the Lab Result Review screen, if a lab needs further attention.

How to View Interfaced Lab Results

How to Document Non-Interface Lab Results
Review DiagnosesDiagnosis Document [Client] and Client Clinical Problems
Of note, when clinicians enter problems in their progress notes, this information will go into Client Clinical Problems. For diagnoses entered by physicians, we recommend reviewing the Diagnosis Document.

This is in development for merging together.
Review/Document VitalsFlow sheet [Client], choose “Meaningful Vitals” from dropdown and select “New” if you want to input new vitals.Using a flow sheet allows you to view recorded data in graph format to track trends.How to Document Vitals
Choose Procedure Code/NoteSelect Service/Notes [Client] and/or click from Calendar or Appointments Today
if the service is assigned to you already. Under “Service” tab to access note, switch from “Scheduled” to “Show.” This will autopopulate with pre-selected
note template.
Common Nurse Procedure Codes based on RN role:
•Nursing Evaluation (T1001)
•Crisis Intervention/Mobile Crisis (H2011)
•Medication Training and Support (H0034)
•Medication Injection (96372)
•TCM/ICC (T1017)-Targeted Case Management
•Brief Contact Note (Non-billable)
•Team Case Conference, Client/Family present (99366)
•Team Case Conference, Client/Family absent (99367)
Choosing Procedures
Add to the Client Clinical ProblemsClient Clinical Problems screen and/or within the Progress Note. Please note this is shared list with non-psychiatrist roles and not used for billing but to provide transparency of which problems a patient has that are being addressed by different team members.If your note is a “Progress Note” it will have this functionality. This is different from the Diagnosis Document, which will autofill the Billing Diagnosis, but currently is under development to directly fill the Client Clinical Problems.
Confirm the Primary Diagnosis to the ServiceOnce in the note, select "Billing Diagnosis" tabYou may need to change the order of the diagnoses so that the primary/payable diagnosis for your service is in the #1 spot.
Order LabsClient Orders or Quick Orders. Any POCT can be added manually by your administrative team.

Please ensure that a lab diagnosis is included.
When you order a lab, it will automatically be sent to the lab. To notify your prescriber, then add as co-signer as all orders are live when sent to labs.

If you are only queuing the lab order, then switch the author to your prescriber’s name; if you are proxy, enter your password to send order to prescriber to sign.

How to Order Labs
Order Outpatient Medications for Your PrescriberMedication Management (Rx) [Client] --> Queue Orders / Verbal Order read-backCan “Queue Order” if you need a prescriber to sign before sending. If you have permission to directly send to a pharmacy, then select your prescriber’s name and click “Prescribe.” You can checkbox the verbal order read-back to acknowledge that you did this verbally. Can add your prescriber to be co-signer, but the order will be live.How to Place a New Medication Order
How to Add Medications Prescribed Elsewhere

Making a QuickLink 
Wrap up a VisitSign Button on Upper RightYou will get validation pop-up with direction of where an error is if you cannot sign. After care instructions are pending development.
Send a Note to Be CosignedClick on + button on the upper right corner of a signed document, and can assign a co-signer
If notes are written on behalf of a prescriber, assign nurse to be a proxy within the set up role for a specific prescriber.
AssessmentsWithin Client Quick Links --> Assessment/ Screening Tools to find full list of other available toolsMaking a QuickLink 
Reconcile Outpatient Medications Within Programs/SystemsNo SmartCare FunctionalityFor external medications: Medication Management (Rx) --> “Add medications.”
Record AllergiesMedication Management (Rx) [Client] --> Allergies/ Intolerance/Failed TrialsHow to Add an Allergy, Intolerance, or Failed Trial
Medication Management

Medication Management Rx

Thing You Want to DoWhat is It Called?
Where Can You Find It?
√Pro Tip
Send Medications to a Preferred PharmacyPreferred PharmacyCan select most common site and save for future use as a dropdown when you order a specific medication. Of note, the pharmacy will default back to preferred pharmacy even if a specific medication was previously ordered for a different pharmacy.
Record AllergiesAllergies/Intolerance/Failed TrialsRecommended to put allergies here because it will autopopulate in other parts of EHR.

If the allergy is in a similar drug class as a medication
you are trying to order, you will not be able to
prescribe ̶ switch the allergy to “intolerance” and/or
“failed trial.”
Review Active MedicationsMedication ListOf note, the current medication widget shows all medications including discontinued or voided. Can go to Medication List and filter for "current." Recommend saving filter as a favorite.
Review Past MedicationsMedication HistoryUse the right-hand side darker blue button (rather than the lighter blue one, which is for Surescript's most recent list of medication in their system)
Review medication
Consent HistoryUse the right-hand side darker blue button. The other
Order New MedicationsNew OrderUse the right-hand side darker blue button.
Add External MedicationsAdd MedicationCan add the source of the prescription, who is the prescriber
Change an Existing OrderSelect Checkbox of Existing Medication and Choose “Change Order”
Refill an Existing OrderSelect Checkbox of Existing Medication and Choose “Re-Order”Cannot do this if controlled substance and will need a new order
Patient Medication ConsentSelect Checkbox of Medication and Choose “Patient Consent”This will pull up a document that both prescriber and client can sign. Can select and sign multiple consents all at once.
Sign Verbal or Queued Outpatient Medication OrdersQueued/Verbal Orders Widget in Providers Dashboard --> RxThis will automatically connect you to the orders pending your review.
Review New/Changed MedicationsAfter clicking “Prescribe” button, a review screen will appear. If you approve, then choose “prescribe” a second time.Make sure you check the checkbox under “ready to sign.”
Approve Conrolled SubstancesOn review screen, after clicking “Ready to Sign” and “Prescribe,” you will be prompted on phone’s HID appSwipe "Approve" green button
Review Prescription StatusClick on a hyperlink of a medication name --> Script History -- Check “Status”Prescribers can view a history of multiple clients in
Start Page > Outbound Prescriptions.

If nurses are set up as prescriber proxy they can also
see prescription status (and refill request).
Establishing nurses as “prescriber” does not
mean they can prescribe without doctor approval;
medication orders will still go through the verbal or
queued order approval process.
Discontinue Existing MedicationMedication List; click the “X” at leftThis will then save in medication history with end date recorded and a pop-up will allow you to record the reason.
Comprehensive Guide

Quick Guide

Smart Care Paper Consent Forms

Basic Smartcare Functionality

Logging in to Smartcare
User Login Process
Login Help
Common SmartCare Functionalities
List Pages Functionality
Client Search


Medical Clinical Documents

Rx Navigation Basics

Allergies, Intolerances, Failed Trials
Ordering Medication in Rx (Outpatient)
Medication-Related Consents


Diagnosis Entry

Problem List

Privacy and Consents

Clinical Data Access Group (CDAG)

Coordinated Care Consent & Authorizations to Disclose Confidential Information 

Care Coordination

My Calendar Management


Messaging in SmartCare


Other Functionality

Error Correction Processes

Service Note Errors

Supervisor Workflows

Revision Tracking