EMR Documentation

Continue to build residents’ Electronic Medical Records (EMRs) with the following information. Access a resident’s complete EMR from a single screen or from easy-to-use menus.

Clinical Assessments

Use risk assessment templates to assess residents for falls, contractures, dehydration, nutrition, bowel and bladder and skin.
Edit the 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 risk assessments for up to 5 dates and view trends and changes in levels of risk.

NOTE: Use the Hi-Tech Flow Sheets and Care Plan modules to set up management programs for high-risk areas, and document the procedures.

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 resident or easily select multiple residents who attend the same event.
Indicate that a resident was offered an activity, but chose not to participate.
Record Comments and Notes for a resident’s level of involvement and behavior at events.
Print a list of a resident's activity participation and share it with the family.

Events

Record health-related events like ER visits, falls, infection, and flu.
Apply additional security to guard access to these confidential records.
Update the MDS with Fall information.
Add comments and Notes to an Event record.

Inoculations

Record inoculations given to a resident, or easily select multiple residents who receive the same type of inoculation on the same day.
Update the MDS from a resident’s inoculation history.

Notes

Record Face Sheet, Nursing, Progress, or CAT notes that document residents’ care, status, behavior, and activities.
Add notes from many 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.