Lecture Nursing documentation using electronic health records: Chapter 3 - Byron R. Hamilton, Mary Harper, Paul Moore

Chapter 3 - Essential documentation. After completing Chapter 3, the students will be able to: Describe the basic features of SpringCharts EHR, describe the history of SpringCharts EHR, apply user preferences, carry out setting up and editing patients, use pop-up text, explain the concept of an electronic chart, use the electronic chart’s face sheet, use the SpringCharts EHR care tree.

Chapter 3 Content

LO 3.1 SpringCharts Features

LO 3.2 A Brief History

LO 3.3 User Preferences

LO 3.4 Setting Up and Editing Patients

LO 3.5 Customizing Pop-Up Text

LO 3.6 Understanding The Electronic Chart

LO 3.7 The Face Sheet

LO 3.8 The Care Tree

LO 3.1 SpringCharts Features

LO 3.2 A Brief History

LO 3.2 A Brief History

• SpringCharts

– Developed over 10 yr period

– 2004 – developed PMS/EHR interface

– 2006 – CCHIT certified

– 2009 – SureScripts certified for

e-prescribing

– 2010 – ONC certified, qualifies for

financial rebates under HITECH Act

LO 3.3 User Preferences

LO 3.4 Setting Up and Editing

Patients

LO 3.4 Setting Up and Editing

Patients

• Adding new patients

– First & last name

LO 3.5 Customizing Pop-Up

Text

LO 3.5 Customizing Pop-Up

Text

• Pop-up text

– Functions like pick lists

– Enables the user to select words,

phrases, or paragraphs with the click of

the mouse

– Provides rapid way to document

– Stored by user log-in name

• Modified without affecting any other user’s pop-up text

LO 3.6 Understanding The

Electronic Chart

LO 3.6 Understanding The

Electronic Chart

• Electronic chart

– Repository for patient health data created

through computer automation in the

healthcare setting

– Static information such as demographics,

allergies, health history, and health

problems

– Dynamic information including encounter

notes, nurse notes, tests, letters, and

reports concerning the patient

Electronic Chart

• Face sheet

– Contains more constant patient

information such as allergies, problem

list, and past health history (PMHX)

– Used in inpatient and outpatient settings

LO 3.7 The Face Sheet

– Past health history

– Family health history

– Referrals

– Chart note

LO 3.7 The Face Sheet

• Face Sheet (cont.)

LO 3.8 The Care Tree

LO 3.8 The Care Tree

• Care Tree

– Preset categories cannot be altered

– 30 customizable categories