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:
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.
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.
Coming January 2nd there are several updates to HPF (Horizon Patient Folder), the patient document application, coming to Centegra. These updates are designed to improve the user experience.
Tabs have been cleaned up to be consistent and meaningful. There will be four tabs.
Full Medical Record – to look for everything
Physician documents – This is the tab that most physicians will spend greater than 90% of their time
Diagnostics – This tab will have less common diagnostic studies such as EMG, evoked potentials etc will appear here. This will make it easier to find a study if it was done in the past without going through every admission.
ED – This is for physician offices to quickly see ED visits.
The order in which document folders appear will now be in the order in which most physicians would review a chart.
History and physical
Pathology (yes; now path reports are next to the procedure!)
Similar documents from different sources such as templates and transcription will still be in separate folders by now they will appear in adjacent folders. This should improve speed and accuracy of the review.
Folders ending in “P” are coming from Paragon templates a.k.a Physdoc
Progress notes will now be names by the following convention
Date Time Author-Name
Progress notes will be in reverse chronological order and not by author.
Documents can be navigated by using the “page down” key to move from the current document to the prior document by time.
Less common diagnositics will be filed here (they can always be found in the “Medical Record” tab). This should allow users to find less frequently ordered diagnostics quickly. This should help avoid repeating tests such as echo etc that may have been done recently.