EMR Documentation
Continue to build residents’ electronic medical records (EMRs) with the following information. Access a resident’s complete EMR from a single screen.
Clinical Assessments
- Use risk assessment templates for falls, contractures, dehydration, nutrition, bowel and bladder and skin. Edit these templates and build your own.
- Create assessment questions with multiple-choice answers.
- Score each response to indicate level of risk so you can calculate the total risk score.
- Print or display the assessments for up to 5 assessment dates so you can view trends in a resident’s level of risk for various risk areas.
Vitals
- Blood Pressure
- Pulse
- Temperature
- Respiratory Rate
- O2 Saturation
- Pain Scale (verbal or non verbal)
- Glucose Scale
- Height
- Weight
- Edema Scale
- Intake and Output
Activities/Events
- Record activity attendance for a single resident or easily select several residents who attend the same event.
- Record Notes that describe a resident’s level of involvement and behavior at events.
- Record other events, such as falls or illness. Use these records to update Residential Care assessments.
Inoculations
- Record inoculations given to a resident, or easily select several residents who receive the same type of inoculation.
- Update the residential care assessment from a resident’s inoculation history.
Notes
- Record Face Sheet, Nursing and Progress notes that document residents’ care, status, behavior, and activities.
- Add notes from different areas of a resident’s electronic record, such as Activities or the resident’s Calendar record.
- Complete and lock a note so it cannot be changed.
Documents
- Scan or import documents into the resident’s electronic record. For example, scan insurance cards or save Transfer Forms from the hospital or other facility. View these on the screen and print copies when necessary.