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.
Hospitalist colored phones will no longer be available and will change into AlertMD messaging, starting and Go Live on..
CH-Huntley, August 29 @ 0700 || CH- McHenry, August 30 @ 0700
All of the hospitalists’ schedules are built so you will be able to see which hospitalist is covering the area you want to message.
Please review the visual instruction below on how to message and to view the naming titles for each of the hospitalist areas in McHenry and Huntley, via AlertMD.
PERT is an interdisciplinary effort to provide rapid assessment and treatment based upon the patient’s condition and best practice guidelines. Research has shown that a systematic approach to treating pulmonary embolism (PE) patients will increase time to treatment and decrease adverse events including mortality and long term heart failure.
A PERT ALERT is initiated on all patients diagnosed with a Sub-Massive or Massive PE to establish a mechanism for key personnel to rapidly evaluate and accurately risk stratify to provide evidence-based care and treatment. Patients are risk stratified in to 3 categories: Low Risk, Sub-Massive, or Massive. Potential patients appropriate for Catheter Based Treatment (CBT) are those stratified as Sub-Massive and Massive. Most patients qualify for Catheter Based Treatment. The goal of CBT is the removal of the obstructing thrombi from the pulmonary arteries to facilitate right ventricular recovery, and to improve symptoms and survival. This includes reduction of long term heart failure. CBT uses significantly less tPA than medical treatment (or systemic treatment), thus reducing bleeding complications. Few patients receive Surgical Pulmonary Embolectomy. By providing a systematic evidence based approach, we may be able to get patients to surgery before they decompensate to a point of no return.
The initial key person to contact is the Interventional Cardiologist on call for PERT ALERT. Additional persons can include pulmonologist, surgeon, hospitalist, hematologists and pharmacist. Nursing provides support by closely monitoring the patient’s condition for deterioration, ensuring rapid completion of tests such as Stat CT Scan, Stat Echo, EKG and lab work, and administering medications.
PERT Alerts should be called by the physician receiving the report of a confirmed PE. Once a PERT Alert has been activated a PERT Alert Algorithm will be followed as indicated in the PERT Alert Policy, #9856-261. The PERT Alert Policy went into effect system wide effective May 1st, 2018. The interventional cardiologist on call for PERT Alert can be found via the ED Call schedules.
PERT – PE Risk Stratification- pocket card- working document
Malnutrition Flowsheet is now available in Paragon Clinician Hub. Please follow the visual instructions to add “Malnutrition” flowsheet to your favorites.
AlertMD has released app version 16.9.5 for Apple and Android devices. This is a mandatory update to stay compliant with CMS regulatory updates. Devices MUST be updated by Monday, August 13th as previous versions will no longer be accessible after this date.
AlertMD will send out two push notifications to all those who have not yet updated their app. Please update your device as soon as possible. Thank you!
Apple – alertmd.com/apple
Android – alertmd.com/android
AlertMD MANDATORY Application Update – August 2018
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.