Electronic Medical Record

EMR for Long Term Care

When you admit a resident, you create the resident’s Electronic Medical Record (EMR) by recording Face Sheet information that will be shared throughout the Clinical Information System. You continue to build the EMR with Physician Orders, a Flow Sheet, a Calendar schedule, and other clinical information required to achieve quality of care for your residents.

Continue to build the resident's EMR through EMR Documentation.

Face Sheet

Personal and demographic information
Admission details for the current stay
Family, Legal and Financial contacts
Medicare, Medicaid, other government and commercial insurance numbers
ICD9-coded Diagnoses and Allergies
Primary Physician, Dentist, and other physicians identified by specialty
Advance directives
Religion, church, language, hospital, mortuary, and discharge plan
Documents from other sources that have been scanned and/or saved in the resident’s record
Stay Tables that record the resident’s separate stays based on admit date, level of care or payer
Additional information not defined by the program

Print the completed Face Sheet for the resident’s chart.

Physician Orders

Maintain and print Routine, Diet, Medication, Treatment, Lab and Standing Orders.
Print Order Listings for the physician to review and sign.
Print monthly Medication and Treatment Administration Records (MARs and TARs).
Print separate MARs and TARs for different requirements, such as PRNs vs. Routine Meds, or Licensed vs. Non-licensed Orders.
Add the IMAR Electronic Medication Administration paperless option.

Flow Sheets and Resident Kardex

Maintain Routine, Restorative, Behavior and Wound Care Flow Sheets on separate forms.
Create and print a resident's monthly Flow Sheet that addresses specific daily needs.
Chart ADLs and Care Plan approaches performed by CNAs.
Import Kardex details from the Face Sheet, MDS and Physician’s Orders and print a one-page snap-shot of the resident’s needs and conditions.

Calendar