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.
- 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.
- 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.
- 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.
- Schedule events such as medical appointments, order renewals or lab work.
- Require staff to acknowledge scheduled and completed events.
- Print or view the calendar sorted by resident, date or type of event.