Charting

In emergency a triage front end where nursing staff could collect patient demographics, determine triage level, type free text assessment and then print out charting document based upon the chief complaint. The solution delivers a Physician, Nurse chart based upon the complaint. Each of these is built using a pre-defined set of variables that are evidence-based and best practice:
• Aligns order sets with standards including ICD 10 and SNOMED
• Controls order set development lifecycle
• Reduces content creation time, validation and CPOE integration time by 70%
• Combines local input/practice with evidence based research
• Streamlines all phases of input and review

Charting Process Diagram

The software delivers the entire charting process including the ability to deliver arm banding (wristbands) for the common alerts and meets the National Patient Safety Agency standards. Not only does this best practice reduce the possibility of errors it reduces the workload of nurses and front line clerks.

At discharge the charting process can be completed with a simple discharge document of the patient and the emergency chart.

How it Works

This explains the steps that take place from that point of data entry at Registration until the data is attached to an electronic Form and printed.

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Process Explained: Patient Registration

Registration

Patient Registration
Demographic Data is entered and then sent to the HIS system
• All patient information is entered
• Once completed, data file is stored in the HIS

registration_diagram-his

Storing and Capturing the Data
The the Data will make its way through the workflow in one of two ways:
Option 1: EHR Encounter Data Stream is sent through
Option 2: The unchanged HIS Data stream is
• Captured by MIDDS

registration_diagram-workflow

Data Use and Application
At this stage the Data (Option 2) is attached to Forms.
Step 1: Based on the content and workflow, the data is sorted
Step 2: The data is entered into a Form template based on Business Rules
• i.e. Order Sets for Surgical Procedures

Process Explained: Patient Registration

Send to Print
At this point the, once the data has been merged with an electronic form, it is printed out of a specific printer (related to area). There are a variety of areas that this can be specified (Examples based on Health Facility) as a document ready to capture care instructions or documentation.

• Finance
• Operating Room
• Day Surgery Registration
• Ambulatory Care
• Clinic Registration
• In-Patient Registration (Fig. 4)
• Emergency Room
• Nursing Unit (Fig. 5)

Figure 4

Figure 5

Figure 5

Figure 6

*Note: The printing processes are Industry specific and can be modified for any business or administration. The samples are based on the Health Care Industry.