Progress / Resident Progress and Consultation Notes are now available by your “Specialty“. The breakdown of these documentation via specialty will make it easier for all Physicians’ to understand the type of note documented for each patient profile. The content for all the notes are the same for all of the specialties. This is active for all locations: Huntley, McHenry and Woodstock. When searching for a documentation, you can search by your specialty, so the result(s) can be populated unique to your specialty. Below are the new specialties added for each of the note title. Review the image below, on how the documentation list would view once signed.
Specialties included for Progress / Resident Progress and Consultation Notes are:
Naming convention to search for each specialty:
“Your Specialty” Consultation Note – example: Cardiology Consultation Note
“Your Specialty” Progress Note – example: Cardiology Progress Note
Resident “Your Specialty” Progress Note – example: Resident Cardiology Progress Note
In Paragon Clinician Hub, when a document has been entered under the wrong visit ID or for any other reason the document needs to be removed from the record, it needs to be Invalidated.
If you have received a notice stating that you need to make this change, please utilize the instructions below. For additional visual training, a screen shot and a link to a video has been added below as well.
- Go to Census, locate visit where the document should be entered by entering the Visit ID supplied by Medical Records into the search field.
- Recreate the note under the correct visit ID, noting that the date is editable.
- Go back to the Census Tab.
- Locate visit where the document is entered in error by entering the “wrong” Visit ID supplied by Medical Records into the search field.
- Open the note in question, and locate the icon next to red X in the upper right hand corner; click the invalidate icon and choose a reason for invalidating.
Video on how to Invalidate: https://youtu.be/3YlLdtKPqzY
History and Physical Short form is no longer available for any sites.
The new “History and Physical Update 1001” will replace the short form. Providers must use the History and Physical 1000 for INITIAL documentation.
History and Physical Update 1001 is to be only used for updates to H&P’s created within the last 30 days for out-patient procedures and inpatient admissions.
If a History and Physical 1000 does not exist, one must be completed.
Please review the visual below for additional information.
Malnutrition Flowsheet is now available in Paragon Clinician Hub. Please follow the visual instructions to add “Malnutrition” flowsheet to your favorites.
All medications, including home medications, in Admission Medication Reconciliation should be verified prior to completing / submitting the Admission Medication Reconciliation. If any home medication(s) requires a new order in house with a different dosage, it is important to “Defer” the original home medication in Admission Med Rec prior to placing a new order of the same medication with a different dosage.
Pulse Ox orders are now added into,
- Lurie General Pediatric Admission H
- Lurie Bronchiolitis Module H
- Lurie Asthma Module H
These Order Sets are Active at the Centegra Hospital Huntley location. Please review the attached image for additional information.
The “THERAPEUTIC HYPOTHERMIA” order set in Paragon Clinician Hub (PCH) now includes the Head CT STAT Imaging order. This order set is live at Centegra Hospital Huntley and Centegra Hospital McHenry location. Please review the image for additional details.
Did you know that you can now view orders and lab results on your Paragon patients through AlertMD?
This is a faster way to quickly check on a pending lab result especially if you are away from a computer.
Just follow the few steps below:
- Open AlertMD
- Tap on “Messages” at the top of the screen to open the menu
- Click on Census (if you do not see your census, change the filter from the bottom right corner)
- Select the patient
- Click on the third tab, shaped like a paper
- Select “Labs”
- Click on labs to view the results
Orders are also available in the middle tab.
Nursing and pharmacy will list patient allergies in the EMR. The severity of the allergy cannot be assessed by the nursing and pharmacy staff. Therefore the allergy severity will be listed as “unknown”. This will default to the presumed to be severe for the drug alerting.
Physicians can go and edit the severity based on history and clinical judgement.
Please edit the informant source to physician. This will allow the severity to flow from one admission to the next.