Physician EMR Updates

   Communication & 
   Education

Status:  Live on All Adult Med/Surg Units in Main Hospital and Ashley Rutledge Tower

ClinDoc provides a comprehensive charting tool in a flowsheet format. With this application, you can record multiple types of information in a patient's chart and while charting, you can view information entered previously in the patient's chart.

Forms and flowsheets currently in ClinDoc:

•  Adult Admission Assessment
•  24 Hour Adult Patient Record
•  Interdisciplinary Patient Plan of Care
•  Interdisciplinary Patient/Family Teaching Record
•  Vital Signs

Updates to Forms:

24 Hour Adult Patient Record

New Pain Scales Added:

• Assume Pain Present (APP)
• PAINAD

Also in Comfort: a "pain reassess" category has been added which allows users to give a reassess pain score, a reassess patient goal and reassess comfort measures.

Interdisciplinary Patient/Family Teaching Record

Disease specific patient/family teaching records have been added to the Patient Family Ed tab:   

• Diabetic Teaching Record
• Heart Failure
• Myocardial Infarction
• Post Op Heart I
• Post Op Heart II
• Stroke

The disease specific patient/family teaching record is used in the same way as the existing patient/family teaching record.  Remember to “show all” if you only see the generic patient/family teaching record in the grey area of your Interdisciplinary Patient/Family Ed tab.

Horizon Care Record

A database of clinical data that uses common clinical communications architecture and common clinical services.

Horizon Care Record is integrated with Oacis.   A backup of 5 years of data from Oacis will be available at initial go-live date, afterwards, additional years of data will continue to be added.