Building Individual/Resident eCharts
When setting up your new account one of the first steps you should take is to begin entering individual/resident information. It is very important to build an e-Chart with accurate and up to date information. A manager level user may, with permission, enter this information. There are sections in the e-Chart that require medical information that may be best for an RN or DN to enter. All information that is entered is easily edited at any time as well as updated. Let's begin.
To access individual information section click/touch the person icon on the side.
Once you are in this module you will note the green box that says add individual. Click/touch to get started.
This pop up field appears and this is where all data is entered. Once you have this complete click/touch Add.
You are now in the e-Chart for this individual/resident. You can begin to build the profile.
Start with the basic information section. Make sure all information is accurate. You can enter information as you have it or wait for other staff assistance.
You can add a photo once the individual is in the facility. You need to have the photo downloaded to your computer. Click/touch the gray area to upload your photo. Pictures are an important identifier.
The next section is Medical Info. When this section is filled out the information will appear on e-MAR The DNR section will be reflected on many documents including the e-MAR and the emergency send out packet.
The next section is Monitors and Baselines. This section is very important and you will see why. Here you will set parameters for your individual regarding blood sugar, blood pressure, pulse, weight and temperature. Once you activate these fields the parameters you set will drive alerts for this individual should readings be entered by staff outside the set parameter. This information is best entered by an RN or under his/her direction.
Again, once the feature is turned on without any data entry on your part the system has a preset range of 70-150. This means that any blood sugar below 70 and above 150 and an alert will be generated. If you have an individual with chronic elevated blood glucose then constant alerts can become frustrating. You are able to set the range: for example. 70-400. With this range staff is able to give medication as ordered and no additional alerts are generated. Once a reading is entered by staff on e-MAR and it's over 400 then an alert will go out. You are able to set the range to whatever you would like.
The same process holds true in the next section for vital signs. You may have an individual with chronic elevated blood pressure due to medication condition. You can set the parameter and once staff enters a reading outside that parameter then an alert will be sent. The orange "are you sure" message is a safeguard for data entry. If you are certain you want the parameter you entered you can override the message and click/touch save.
The next tab is programs. For assisted living residents this will be the location where they reside. For DDA individuals there may be a long list of programs they attend.
In this section you will enter contact information for each individual in your care. This information is very important in the event of an emergency.
In this documents section you will be able to scan and upload copies of important documents. When an emergency packed is generated you can select a copy of the uploaded document be generated and sent along. This allows for all pertinent information to travel with the individual and wishes to be followed.
You have the ability to keep track of billing in the Administrative section.
The supports tab is very important. The information that is entered here will help to drive tasks in the caretracker and the information populates through out the e-Chart.
Here you will associate this individual with their primary care and other physicians or groups they may see for their care.
The final and a very important step is to associate the pharmacy with the resident. This is of the utmost importance if you are integrated with your pharmacy for orders.
This has been a general overview of the iCM individual/resident e-Chart and how to add and build this information. This e-Chart section changes as do the individual and residents you care for. Keeping up with the changes and updating the charts is very important.
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