0% found this document useful (0 votes)

23 views224 pages

Reports & Attachments

reports

Uploaded by

Lisa

We take content rights seriously. If you suspect this is your content, claim it here.

Available Formats

Download as PDF, TXT or read online on Scribd

0% found this document useful (0 votes)

23 views224 pages

Reports & Attachments

reports

Uploaded by

Lisa

We take content rights seriously. If you suspect this is your content, claim it here.

Available Formats

Download as PDF, TXT or read online on Scribd

You are on page 1/ 224

Reports & Attachments User

Guide

Reports &
Attachments User
Guide
Reports & Attachments User Guide

by Evident
Reports & Attachments User Guide

Copyright © 2018 by Evident.

All rights reserved. This publication is provided for the express benefit of, and use by, Evident Client Facilities.
This publication may be reproduced by Evident clients in limited numbers as needed for internal use only. Any
use or distribution outside of this limitation is prohibited without prior written permission from Evident. The
reception of this publication by any means (electronic, mechanical, photocopy, downloading, recording, or
otherwise) constitutes acceptance of these terms.

Trademarks:
The Evident logo, as it appears in this document is a Trademark of CPSI.

Limitations:
Evident does not make any warranty with respect to the accuracy of the information in this document.
Evident reserves the right to make changes to the product described in this document at any time and
without notice.

Version : 20
Published : February 2018

Evident
6600 Wall Street
Mobile Alabama 36695
T 800-711-2774 F 251-639-8214
evident.com
Table of Contents I

Table of Contents

Chapter 1 Introduction
............................................................................................................... 1
Attestation Disclaimer
What's New ............................................................................................................... 1
.........................................................................................................
Change "Build CCDA" Paths -- WR 1703061530 1
.........................................................................................................
Add New Field to Privacy/Consent Screen for OAS CAHPS -- WR1708181157 1
............................................................................................................... 2
Online Presentations

Chapter 2 Overview
Chapter 3 Updated ChartLink Access
Overview ............................................................................................................... 5
...............................................................................................................
Signing On/Off Updated ChartLink 5

Chapter 4 Vital Signs

Overview ............................................................................................................... 7
Graphic I & O............................................................................................................... 8
Swan Ganz............................................................................................................... 11
O2 Sat Bar ...............................................................................................................
Graph 14
Critical Care...............................................................................................................
Flow Sheet 16
...............................................................................................................
All Critical Care Flowsheets 19
Growth Charts............................................................................................................... 22
Attachments ............................................................................................................... 24

Chapter 5 Medical Records

Overview ............................................................................................................... 27
...............................................................................................................
Medical Records Discipline - Version 5 28
Version 6 ............................................................................................................... 33

Chapter 6 Orders
Overview ............................................................................................................... 37
Physician's ...............................................................................................................
Nursing Order Report 37
............................................................................................................... 40
Attachments

Chapter 7 Laboratory
Overview ............................................................................................................... 41
...............................................................................................................
Comparative All - This Stay 42
...............................................................................................................
Comparative/Department - This Stay 44
...............................................................................................................
Comparative - All Stays 46
II Reports & Attachments User Guide

...............................................................................................................
Comparative/Departments - All Stays 48
...............................................................................................................
Comparative - Multifacility 50
............................................................................................................... 52
Detail Report
............................................................................................................... 54
Attachments

Chapter 8 Medication
Overview ............................................................................................................... 55
MAR Final ............................................................................................................... 56
.........................................................................................................
Dem ographics Box 58
.........................................................................................................
One Tim e Orders 58
.........................................................................................................
Scheduled/Routine Medications 59
IV Orders .........................................................................................................
60
............................................................................................................... 61
MAR Temporary
.........................................................................................................
Dem ographics Box 62
.........................................................................................................
One Tim e Orders 63
.........................................................................................................
Scheduled/Routine Medications 64
IV Orders .........................................................................................................65
.........................................................................................................
PRN Medications 65
All MARs ............................................................................................................... 66
............................................................................................................... 68
All 5 Day MARs
............................................................................................................... 70
Scheduled Medications
PCA ............................................................................................................... 72
.........................................................................................................
PCA Infusion Form 72
Medication ...............................................................................................................
Record 74
Medication ...............................................................................................................
Reconciliation Report 77
............................................................................................................... 80
Attachments

Chapter 9 Radiology
Overview ............................................................................................................... 81

Chapter 10 Multi Disciplinary

Overview ............................................................................................................... 83
............................................................................................................... 84
Discharge Planner
............................................................................................................... 87
Problem List
............................................................................................................... 90
Problem Activities
Care Plan ............................................................................................................... 93
............................................................................................................... 95
Discharge Summary
............................................................................................................... 98
Discharge Instructions
............................................................................................................... 101
Transfer Form
............................................................................................................... 105
Initial Interview
...............................................................................................................
Initial Physical Assessment 108
...............................................................................................................
Patient Progress Notes 111
............................................................................................................... 114
Attachments
Table of Contents III

Chapter 11 Nurses Notes

Overview ............................................................................................................... 115
............................................................................................................... 116
Initial Interview
...............................................................................................................
Initial Physical Assessment 120
...............................................................................................................
Patient Progress Notes 123
............................................................................................................... 129
24 Hour Summary
............................................................................................................... 136
Shift Summary
............................................................................................................... 139
Attachments

Chapter 12 Education
Overview ............................................................................................................... 141
Education ...............................................................................................................
Report 142
............................................................................................................... 145
Attachments

Chapter 13 Cardiopulmonary
Overview ............................................................................................................... 147
............................................................................................................... 148
Initial Interview
...............................................................................................................
Initial Physical Assessment 152
...............................................................................................................
O2 Saturation Graph 154
............................................................................................................... 156
Comparative
...............................................................................................................
Comparative-All Stays 158
............................................................................................................... 160
Comparative-Multifacility
............................................................................................................... 162
Detail Results
............................................................................................................... 164
Attachments

Chapter 14 Rehabilitation
Overview ............................................................................................................... 165
............................................................................................................... 166
Initial Interview
...............................................................................................................
Initial Physical Assessment 170
............................................................................................................... 172
Attachments

Chapter 15 Dietary
Overview ............................................................................................................... 173
............................................................................................................... 174
Initial Interview
...............................................................................................................
Initial Physical Assessment 177
Nutritional...............................................................................................................
Calculations 179
............................................................................................................... 181
Attachments

Chapter 16 Diabetic
Overview ............................................................................................................... 183
............................................................................................................... 184
Diabetic Flowsheet
IV Reports & Attachments User Guide

...............................................................................................................
Cumulative Report 187
...............................................................................................................
Daily Diabetic Report 189
............................................................................................................... 193
Weekly Report
............................................................................................................... 197
Attachments

Chapter 17 Miscellaneous
Overview ............................................................................................................... 199
............................................................................................................... 200
Census Report
............................................................................................................... 204
Attachments

Chapter 18 Face Sheet

Overview ............................................................................................................... 205
............................................................................................................... 206
Face Sheet
............................................................................................................... 209
Attachments

Chapter 19 Other
Overview ............................................................................................................... 211
............................................................................................................... 212
Attachments

Chapter 20 Growth Charts

Overview ............................................................................................................... 213
............................................................................................................... 213
Growth Charts
Introduction 1

Chapter 1 Introduction

1.1 Attestation Disclaimer

Meaningful Use attestation confirms the use of a certified Electronic Health Record (EHR) to
regulatory standards over a specified period of time. Evident and TruBridge Meaningful Use certified
products, recommended processes and supporting documentation are based on Evident’s
interpretation of the Meaningful Use regulations, technical specifications and vendor specifications
provided by CMS, ONC and NIST. Each client is solely responsible for its attestation being a
complete and accurate reflection of its EHR use during the attestation period and that any records
needed to defend the attestation in an audit are maintained. With the exception of vendor
documentation that may be required in support of a client’s attestation, Evident and TruBridge bear
no responsibility for attestation information submitted by the client.

1.2 What's New

This section introduces the new features and improvements for Reports & Attachments for
release Version 20. A brief summary of each enhancement is given referencing its particular
location if applicable. As new branches of Version 20 are made available, the original
enhancements will be moved to the Previous Work Requests section. The enhancements related
to the most current branch available will be listed under the main What's New section.

Each enhancement includes the Work Request (WR) Number and the description. If further
information is needed, please contact Client Services Support.

Change "Build CCDA" Paths -- WR 1703061530

DESCRIPTION: This work request removes the Build CCDA paths in the Med Rec discipline of
Reports & Attachments for Version 6.

DOCUMENTATION: See Version 6 33

Add New Field to Privacy/Consent Screen for OAS CAHPS -- WR1708181157

DESCRIPTION: This work request adds a checkbox to the Privacy/Consent screen to indicate
whether or not a patient is willing to participate in the survey.

DOCUMENTATION: See Medical Records Discipline - Version 5 28 and Version 6 33 .

1.3 Online Presentations

This section contains a list of available online presentations that are applicable for this user guide.
They are not intended to replace the detail of the user guide but are to be used in conjunction with
the user guides to enhance the process and/or procedures related to this application. To browse all
presentations currently available online, sign in to Evident.com and select Presentations or click on
one of the following links:

Click here to view all Online Presentations.

Click here to view all QuickCaps.

Updated ChartLink

Updated ChartLink: Home Screen and Whiteboard

Chapter 2 Overview

Reports & Attachments is designed to provide the physician and clinical staff an option to quickly
access patient reports from multiple disciplines and hospital departments.
Features and benefits of Reports and Attachments are:

Patient information is available interactively and in real time

Communication and security is compliant with current HCFA Internet Policy and proposed
HIPAA rules

Easy access to reports & attachments from one screen

Reports open in Adobe format in the same window and may be viewed or printed.

Users may toggle between reports on an account

NOTE: The Chartlink Tab in Image Titles determines which section a scanned image will be
available on in the Reports and Attachments application. For information on scanned images being
available in Reports and Attachments, see the Table Maintenance - Business Office user guide.

NOTE: Facilities outside of the United States may choose a date format of MMDDYY, DDMMYY
or YYMMDD to be used throughout the Reports and Attachments application. An Evident
Representative will need to be contacted in order for the date format to be changed.

Chapter 3 Updated ChartLink Access

3.1 Overview
This section will explain how to sign on and off the Updated ChartLink application.

3.2 Signing On/Off Updated ChartLink

The Updated ChartLink system requires the physician to sign onto the system before accessing
the application. The hospital’s Information Technology department issues physician numbers,
passwords and maintains security settings.

To track physician login and other physician functions within the software, consult the A/R audit
trail system that exists within the Special Functions module.

Users logging via a desktop icon will utilize the Evident runner for access.

Facility and Application access settings are configured by the Hospitals Information Technology
department.

NOTE: When accessing the CW Runner for the first time, the Application will default to Evident
System. Make sure to select the proper application for the role that is logging via the CW Runner,
keeping in mind that Updated ChartLink may also be accessed by staff other than physicians.
Access to Updated ChartLink is controlled by employee security. Refer to facility Information
Technology Department for further information.

Select Login > Enter login information > Application > Thrive UX Patient Care Portal

Runner

NOTE: If a Patient Account is selected in the traditional ChartLink application and access is gained
to either the Physician Problem List or Physician Documentation applications, the Updated
ChartLink application will open. The user may also access the Updated ChartLink application when
accessing the Medication Reconciliation application through Updated CPOE.

Chapter 4 Vital Signs

4.1 Overview
This section will discuss the Vital Signs section of Attachments.

Select Updated ChartLink > Charts > Select Patient Account > Attachments > Vital Signs

Vital Signs

4.2 Graphic I & O

The Graphic I & O is a document that includes the patient’s vital signs, weight, diet information, and
intake and output charted over a 3-day period. The forms print as “Temporary” until three days of
information is completed. After three days, the report prints as “Final” and is a part of the patient’s
permanent chart.

Select Charts > Select Patient Account > Attachments > Vital Signs > Graphic I & O

Vital Signs-Graphic I & O

Data included on the Graphic and I & O form is outlined below:

Demographics Box (located upper right-hand corner)

Patient's name
Admitting physician
Age, sex, & room number
Any drug allergies documented through Thrive
Medical Record number

NOTE: In addition to the above mentioned box, a single line containing the patient's name, account
number, age, sex, room number and page number will appear along the bottom edge of the page.

Vital Signs
Each 34-hour period is divided into either two or 4-hour intervals.
Temperature is reflected in a line graph format
Pulse, respiration, and blood pressure are reflected in numeric values below the graph.
Weight, is reflected in pounds or kilograms along with the patient's body-surface area and
basic metabolic index.

NOTE: An asterisk (*) denotes multiple values have been charted. The first recorded value
displays with subsequent values listed in the Patient Progress Notes.

Patient Diet & Percent Consumed

Up to three diet entries within a 34 hour period
Diet description, percentage consumed, and time the entry was charted

Breast Feeding
Displays for Pediatric and Nursery chart types only.
Prints breast feeding time, minutes and totals for L, R, L/R breast.

NOTE: If percentage of diet consumed has been charted on a diet through the MedAct, the Breast
Feeding section will not print on the report.

Intake and Output Record

Intake and output volumes reflect totals per shift and a 34-hour total.
Intake and output values charted by frequency display in the top left-hand corner of the boxes.
Volume entries display in the center of the box.
Intake displays up to 3 categories. Any entries beyond that will be reflected under "Other" and
will be detailed on the Patient Progress Notes.
Output displays up to eight categories. Any entries beyond that will be reflected under "Other"
and will be detailed on the Patient Progress Notes.
Option to use eight or 13-hour I&O total in control table.

The following is a full display of the Graphic I & O Report.

All reports listed in this section may be Exported to Adobe Acrobat Reader format.

4.3 Swan Ganz

The Swan Ganz report is a document that includes hemodynamics (CVP, PAP, PAWP, CO,
MPAP, SV, SVR, PVR, and CI) information.

Select Charts > Select Patient Account > Attachments > Vital Signs > Swan Ganz

Vital Signs- Sw an Ganz

Data included on the Swan Ganz Report is outlined below:

Demographics Box (located upper right-hand corner)

Patient's name
Admitting physician
Age, sex, & room number
Medical Record number
Any drug allergies documented through Thrive

NOTE: In addition to the above mentioned box, a single line containing the patient's name, account
number, age, sex, room number and page number will appear along the bottom edge of the page.

Entered Values
Date and time the information was charted
Name and title of the person who entered the information displays next to the first entry only.
Name and title will not display beside each entry made by that person.
Displays in columns, the following Swan Ganz values that have been entered into the system:
o (CVP) Central Venous Pressure
o (PAP) Pulmonary Artery Pressure
o (PAWP) Pulmonary Artery Wedge Pressure
o (CO) Cardiac Output

Calculated Values
Displays in columns, the following calculated values which are derived from the charted Swan
Ganz values:
o (MPAP) Mean Pulmonary Artery Pressure
o (MAP) Mean Arterial Pressure
o (SV) Stroke Volume
o (SVR) Systemic Vascular Resistance
o (PVR) Pulmonary Vascular Resistance
o (CI) Cardiac Index

The following is a full display of the Swan Ganz Report.

All reports listed in this section may be Exported to Adobe Acrobat Reader format.

4.4 O2 Sat Bar Graph

The O3 Sat Bar Graph is a document that displays the O3LM, FiO3, and O3SAT, which is graphed
and includes the method of delivery.

Select Charts > Select Patient Account > Attachments > Vital Signs > O3 Saturation Bar Graph

Vital Signs - O3 Saturation Graph

Data included in the O3 Sat Bar Graph is outlined below:

Demographics box (located upper right-hand corner)

Patient’s name
Account number
Admitting physician
Age, sex, and room number
Medical Record number
Any drug allergies documented through Thrive

O3 Information
O3 L/M, FiO3, and O3 Sat values display numerically
O3 Sat values display as a bar graph
O3 Sat values display on the bar graph along with the method

The following is a full display of the O3 Sat Bar Graph.

All reports listed in this section may be Exported to Adobe Acrobat Reader format.

4.5 Critical Care Flow Sheet

The Critical Care Flow Sheet is a document that includes specific patient information charted
within the 8-hour time frame. The report provides details of the patient’s condition and plan of care
and may also be used to track trends in the patient’s progress. It is primarily used in the ICU.

Select Charts > Select Patient Account > Attachments > Vital Signs > Critical Care Flow Sheet

Vital Signs - Critical Care Flow Sheet

Data included on the Critical Care Flow Sheet is outlined below:

Demographics Box (located upper right-hand corner)

Patient's name
Account number
Admitting physician
Age, sex, & room number
Medical Records number
Any drug allergies documented through Thrive

Vital Signs
Pulse and blood pressure display graphically in 15-minute intervals.

Temperature and respirations display numerically in 15-minute intervals.

Hemodynamics
CVP, PAP, PAWP, and CO/CI values display in 1-hour intervals.

Ventilation Mechanics (Optional)

Nursing Administration determines which seven out of twelve options will display.
Values display in 1-hour intervals.

Intake (Optional)
Nursing Administration determines which four out of twelve options will display.
Values display in 1-hour intervals.
The "OTHER" box combines all intake values not specified on the flow sheet which may be
seen in detail in the Patient Progress Notes.

Output (Optional)
Nursing Administration determines which four out of eighteen options will display.
Values display in one hour intervals.
The "OTHER" box combines all output values not specified on the flow sheet, which may be
seen in detail in the Patient Progress Notes.
Entries charted by frequency, display in the top left corner of the boxes where volume entries
also display.

NOTE: An asterisk (*) adjacent to any value on this flow sheet denotes multiple values have been
charted. The first recorded value displays, with subsequent values listed in the Patient Progress
Notes.

Medications
Medications administered during the selected time frame
Date and time of last administration
Medication description
Location of administration or reason if it is a PRN
Dosage

Neuro checks
Neuro checks charted through the VS application since last locked shift
Date and time information was entered
Name and title of person who charted the entry

Distinctive Nursing Assessments

Assessments charted in the eight hour period covered, that are flagged as distinctive and
should be noted by the nursing staff
Date and time of entry
In order for this information to be reflected, it must be set up by Nursing Administration.

Distinctive Physical Assessments

Assessments charted in the 8-hour period covered that are flagged as distinctive and should be
noted by the medical staff
Date and time of entry

The following is a full display of the Critical Care Flow Sheet:

All reports listed in this section may be Exported to Adobe Acrobat Reader format.

4.6 All Critical Care Flowsheets

The Critical Care Flow Sheet is a document that includes specific patient information charted within
the 8-hour time frame. The report provides details of the patient’s condition and plan of care and
can also be used to track trends in the patient’s progress. It is primarily used in the ICU.

Select Charts > Select Patient Account > Attachments > Vital Signs > All Critical Care Flow Sheet

Vital Signs - All Critical Care Flow Sheet

Data included on the All Critical Care Flow Sheet is outlined below:

Demographics Box (located upper right-hand corner)

Patient's name
Account number
Admitting physician
Age, sex, & room number
Medical Records number
Any drug allergies documented through Thrive

Vital Signs
Pulse and blood pressure display graphically in 15 minute intervals.
Temperature and respirations display numerically in 15 minute intervals.

Hemodynamics
CVP, PAP, PAWP, and CO/CI values display in one hour intervals.

Ventilation Mechanics (Optional)

Nursing Administration determines which seven out of twelve options will display.
Values display in 1-hour intervals.

Intake (Optional)
Nursing Administration determines which four out of twelve options will display.
Values display in 1-hour intervals.
The "OTHER" box combines all intake values not specified on the flow sheet, which can be
seen in detail in the Patient Progress Notes.

Output (Optional)
Nursing Administration determines which four out of eighteen options will display.
Values display in one hour intervals.
The "OTHER" box combines all output values not specified on the flow sheet, which can be
seen in detail in the Patient Progress Notes.
Entries charted by frequency display in the top left corner of the boxes where volume entries
also display.

Medications
Medications administered during the selected time frame
Date and time of last administration
Medication description
Location of administration, or reason if it is a PRN
Dosage

Neuro checks
Neuro checks charted through the VS application since last locked shift
Date and time information was entered
Name and title of person who charted the entry

Distinctive Nursing Assessments

Assessments charted in the 8-hour period covered, that are flagged as distinctive and should
be noted by the nursing staff
Date and time of entry
In order for this information to be reflected, it must be set up by Nursing Administration.

Distinctive Physical Assessments

Assessments charted in the 8-hour period covered, that are flagged as distinctive and should
be noted by the medical staff
Date and time of entry
The Critical Care Flowsheet for the last eight hours will appear on the screen. Use the scroll
bar or the page selector to access additional information for the last 34 hours.
To view previous days Critical Care Flowsheets select the date from the lower section of the
split screen.

The following is a full display of the All Critical Care Flow Sheet.

All reports listed in this section may be Exported to Adobe Acrobat Reader format.

4.7 Growth Charts

Various Growth Charts are available depending upon the patient's age range and gender. Weight
and height must be present on the account in order for the growth charts to be accessible.
Physicians will have the ability to view historical growth charts: all charts from birth through the
current age. Additionally, two different growth charts (5th to 95th Percentile and 3rd to 97th
Percentile) are selectable, either for the current age or to include historical weight and height
entries.

Data included on the Growth Charts is outlined below:

Birth to 36 Months
5 - 95 Percentile Length and Weight Growth Chart for the sex of the patient 3 - 97 Percentile
Length and Weight Growth Chart for the sex of the patient

3 Years to 5 Years
Weight for Stature Growth Chart for the sex of the patient

3 Years to 30 Years
5 - 95 Percentile Stature Growth Chart for the sex of the patient
5 - 95 Percentile BMI Growth Chart for the sex of the patient
3 - 97 Percentile Stature Growth Chart for the sex of the patient
3 - 97 Percentile BMI Growth Chart

The following is a full display of a Growth Chart.

All reports listed in this section may be Exported to Adobe Acrobat Reader format.

4.8 Attachments
The Attachments area will contain any Scanned Images, Electronic Forms or Photo Uploads that
have been assigned to this section.

Select Charts > Select Patient Account > Attachments > Vital Signs > Attachments

Vital Signs - Attachm ents

Data located in Attachments

Deleted Items will display

Vital Signs - Attachm ents

Setup to display items may be referenced in the Image Title User Guide or the Electronic Forms
User Guide.

will display if data is not present in this area to be viewed.

Chapter 5 Medical Records

5.1 Overview
This section will discuss the Medical Records section of Attachments.

The Medical Records section will display any scanned images for the patient account.

Select Updated ChartLink > Charts > Select Patient Account > Attachments > Med Rec

Medical Records

5.2 Medical Records Discipline - Version 5

The Med. Rec. area will contain any Scanned Images, Electronic Forms or Photo Uploads that
have been assigned to this section.

Select Charts > Select Patient Account > Attachments > Med Rec

Medical Records

Deleted Items will display

Setup to display items may be referenced in the Image Title User Guide or the Electronic Forms
User Guide.

will display if data is not present in this area to be viewed.

Select Charts > Select Patient Account > Attachments > Med Rec > Consent/Privacy Settings

Patient Consent/Privacy Settings

The Consent/Privacy Settings option will open the Patient Consent/Privacy Settings screen.

Consent/Privacy Notice: If checked, the Consent/Privacy notice has been received and signed
by the patient. The Date-Picker field should indicate when the notice was signed.

Med History Consent: Indicate the patient's Med History Consent by choosing one of the
following options from the drop-down:
o No Consent
o Prescriber
o Parental/Guardian consent from any prescriber
o Consent given
o Parental/Guardian consent from this prescriber only

Exclude from Portal: If checked, will prevent the patient from accessing the CCD in the patient
portal.

Exclude from API (Application Program Interface):If this field is selected, it will indicate that the
account is being excluded from API. If the check box is unchecked, this will indicate that the
account is not excluded from API.

NOTE: This option is also included in the Census Clinical Tab as a single-character field for Y
(YES) or N (NO).

HIE Shared Data (Health Information Exchange): When this option is selected, the current date
will appear to the side. The drop-down options include:
o Share data with HIE
o Do not share data with HIE:
o Share Data in emergency only

Data Sensitivity Level: When this option is selected, the current date will appear to the side.
The drop-down options include:
o Normal
o Restrictive
o Very restrictive

Protect Immunization Data: When this option is selected, the current date will appear to the
side. The drop-down options include:
o Y- Protect Data, do not share
o N - Not protected, can be shared

Participate in CAHPS Survey: Indicate whether patients are willing to participate in the OAS
(Outpatient and Ambulatory Surgery Center) CAHPS (Consumer Assessment of Healthcare
Providers and Systems) Reporting.
o Selected indicates YES
o Blank indicates NO

1. Double-clicking the Build Patient Summary item in the list will generate the CCDA and open the
document.

2. The Referral/Transition of Care Summary option will produce the exact same document as
the 'Patient Summary,' but the portal will need to be able to tell the difference in the entries.
Double-clicking the Referral/Transition of Care Summary item in the list will generate the
CCDA and open the document. CCDA documents that have been edited and/or printed, emailed
or saved to portable media are saved to Electronic File Management. They display in Updated
ChartLink in Reports and Attachments under the Medical Records (Med. Rec.) discipline as
z_CCDA:Patient Summary or z_CCDA:Referral/Transition indicating the date the document
was created.

Select Charts > Select Patient Account > Attachments > Med Rec > Build Patient Summary

Build Patient Sum m ary

3. Any edited version of the CCDA that is saved will display, listing with an indication of date/time
the document was saved. The screen will display the contents section at the top of the
document that will allow the user to select a section and scroll to that section of the document.

The action bar on the Document View screen contains the following options:

Back arrow: If selected, this option will direct the user back to the Med. Rec. screen.

Edit: This option will open the document for editing. (see below)

Submit to Provider: If the document has not already been edited and saved, selecting this
button will save the document and open a screen that will allow the user to create an e-mail
message with the CCDA attached.

Print: This option will save the document and open the "Select a printer" screen. The user may
select a network printer from the printer list, Workstation or View

Portable Media: If the document has not already been edited and saved, selecting this button
will save the document and display the windows pop-up "Browse for Folder" that will allow the
user to select the location on the PC to save the document. Once addressed, a screen for the
encryption key entry displays. The user will then type in an encryption key of their choice, Cancel
(to go return to the document) or OK to accept and apply. A 'Submitted' message will then
display..

4. Selecting Edit will display a list screen of all the CCDA document sections with columns
indicating the Total Records and Excluded Records count for each section. Sections may be set
to Include/Exclude entire section. If any section has been set to be excluded, the Save
Document button may be selected to save the changes. View Document will open the CCDA
in another window to view.

Select Charts > Select Patient Account > Attachments > Med Rec > Build Patient Summary >
Edit

Build Patient Sum m ary

5. Select a section and Edit to select individual records within that section to Include/Exclude.

Select Charts > Select Patient Account > Attachments > Med Rec > Build Patient Summary >
Edit > select section title > Edit

Build Patient Sum m ary

5.3 Version 6
The Medical Record area will contain any Scanned Images, Electronic Forms or Photo Uploads
that have been assigned to this section.

Select Charts > Select Patient Account > Attachments > Med Rec

Reports & Attachm ents

Select Charts > Select Patient Account > Attachments > Med Rec > Consent/Privacy Settings

Patient Consent/Privacy Settings

The Consent/Privacy Settings option will open the Patient Consent/Privacy Settings screen.

Consent/Privacy Notice: If checked, the Consent/Privacy notice has been received and signed
by the patient. The Date-Picker field should indicate when the notice was signed.

Exclude from Portal: If checked, will prevent the patient from accessing the CCD in the patient
portal.

NOTE: This option is also included in the Census Clinical Tab as a single-character field for Y
(YES) or N (NO).

Data Sensitivity Level: When this option is selected, the current date will appear to the side.
The drop-down options include:
o Normal
o Restrictive
o Very restrictive

Protect Immunization Data: When this option is selected, the current date will appear to the
side. The drop-down options include:
o Y- Protect Data, do not share
o N - Not protected, can be shared

Participate in CAHPS Survey: Indicates whether patients are willing to participate in the OAS
(Outpatient and Ambulatory Surgery Center) CAHPS (Consumer Assessment of Healthcare
Providers and Systems) Reporting.
o Selected indicates YES
o Blank indicates NO

NOTE: The options for Build Patient Summary and Build Referral/Transition of Care Summary are
no longer available from this pathway when Version 6 is turned on in the facility tables.

Chapter 6 Orders

6.1 Overview
This section will discuss the Orders section of Attachments.

6.2 Physician's Nursing Order Report

The Physician's Nursing Order Sheet is a document that includes the patient’s verified nursing
orders (CPOE and orders placed via Thrive).

Select Updated ChartLink > Charts > Select Patient Account > Attachments > Orders

Orders

Demographics Box (located upper right-hand corner)

Patient's name
Admitting physician
Age, sex, and room number
Any drug allergies documented through Thrive

NOTE: In addition to the above mentioned box, a single line containing the patient's name, account
number, age, sex, room number and page number will appear along the bottom edge of the page.

Nursing Order Box

Shaded in gray, each box contains one nursing order of up to 75 characters

Nursing Order Comment

Displays any comment that was added, the last time the order was addressed by the nursing
staff.

Nursing Order Status

Appears directly below the comment
The status indicates the last action taken on an order
The date and time will indicate the last time the order was addressed
Displays initials of the person who charted the nursing order

Additional Notes
Unverified nursing orders will NOT be included in this report
Nursing orders discontinued within eight hours of the printing of this report, will be included.

The following is a full display of the Physician's Nursing Order Sheet.

6.3 Attachments
The Attachments area will contain any Scanned Images, Electronic Forms or Photo Uploads that
have been assigned to this section.

Select Charts > Select Patient Account > Attachments > Orders > Attachments

Orders - Attachm ents

Deleted Items will display

Setup to display items may be referenced in the Image Title User Guide or the Electronic Forms
User Guide.

will display if data is not present in this area to be viewed.

Chapter 7 Laboratory

7.1 Overview
This section will discuss the process of reviewing Laboratory orders, results and reports.

Select Updated ChartLink > Charts > Select Patient Account > Attachments > Laboratory

Laboratory

7.2 Comparative All - This Stay

The comparative vertical report is an update of all test results for a patient account. The report is a
comparative summary presentation of all data with test names along the vertical axis and results
listed chronologically along a horizontal axis. Collection dates and times are printed on the
horizontal axis. Up to seven events will print per row with subsequent results wrapping below the
most current results. Scroll to view all available reports related to this hospital stay.

Select Charts > Select Patient Account > Attachments > Laboratory > Comparative All - This Stay

Com parative All-This Stay

The following is a full display of the Laboratory-Comparative Report.

The Comparative All – This Stay and all the other laboratory reports listed in this section will display
in Adobe Acrobat Reader format.

7.3 Comparative/Department - This Stay

This option will display a columnar version of the patient results by the sub-department of the
laboratory for a single account.

Select Charts > Select Patient Account > Attachments > Laboratory > Comparative/Department -
This Stay

Com parative/Departm ent-This Stay

The following is a full display of the Comparative By Dept – This Stay report.

The Comparative By Dept-This Stay and all the other laboratory reports listed in this section will
display in Adobe Acrobat Reader format.

7.4 Comparative - All Stays

This option allows access to comparative results for more than one stay.

Select Charts> Select Patient Account > Attachments > Laboratory > Comparative/Department -
All Stay

Com parative -All Stays

The following is a full display of the Comparative - All Stays report.

7.5 Comparative/Departments - All Stays

This option will display a columnar version of the patient results by the sub-department of the
laboratory for more than one stay.

Select Charts > Select Patient Account > Attachments > Laboratory > Comparative/Department -
All Stay

Com parative/Departm ent-All Stay

The following is a full display of the Comparative By Dept – All Stay report.

The Comparative By Dept-All Stay and all the other laboratory reports listed in this section will
display in Adobe Acrobat Reader format.

7.6 Comparative - Multifacility

This option allows access to comparative results from all associated Multifacility locations.

Select Charts > Select Patient Account > Attachments > Laboratory > Comparative - Multifacility

Com parative - Multifacility

The following is a full display of the Comparative- Multifacility report.

7.7 Detail Report

This option allows access to a detail report of all laboratory results for this patient account.

Select Charts > Select Patient Account > Attachments > Laboratory > Detail Report

Detail Report

The following is a full display of the Detail Report.

7.8 Attachments
The Attachments area will contain any Scanned Images, Electronic Forms or Photo Uploads that
have been assigned to this section.

Select Charts > Select Patient Account > Attachments > Laboratory > Attachments

Laboratory - Attachm ents

Deleted Items will display

Setup to display items may be referenced in the Image Title User Guide or the Electronic Forms
User Guide.

will display if data is not present in this area to be viewed.

Chapter 8 Medication

8.1 Overview
This section will discuss the process of reviewing Medication reports.

Select Updated ChartLink > Charts > Select Patient Account > Attachments > Medication

Medication

8.2 MAR Final

The MAR-Final is a document that includes the patient’s complete medication administration
record.

Select Charts > Select Patient Account > Attachments > Medication

MAR Final

The previous 34 hours of Medication documentation display is based on one of the following time
periods determined by administration: 0700 – 0659, 1500 – 1459 or 3300 – 3359. The medications
are grouped by categories (X1, Scheduled/Routine, IV orders, and PRN) and display in the order
that they were entered into the system. The previous 34-hours display in eight-hour time periods,
with the medication administration time(s), the initials of the nurse who administered the
medication, and the actual time the medication was administered appearing below the initials.

All continuous IVs that were ordered, scheduled, administered or discontinued during the 34-hour
period are covered by the report

Start date, stop date if applicable, stop code if applicable, and "Unverified" if the IV has not been
verified

Medication description, flow rate, frequency, and components

Initials of the person who administered the IV or a "G" (Given) will appear under the appropriate
hour of the 8-hour block.

The following is a full display of the MAR Final report.

The MAR Final report and the other reports listed in this section will display in Adobe Acrobat
Reader format.

Demographics Box

Patient's name

Admitting physician

Age, sex, & room number

Drug allergies documented through Thrive

In addition to the above mentioned box, a single line containing the patient's name, account
number, age, sex, room number and page number will appear along the bottom edge of the page.

One Time Orders

All X1 medications that were ordered, scheduled, administered or discontinued during the 34-
hour period are covered by the report

Start and stop date, stop code and "Unverified" if the medication has not been verified

Medication description, dosage, frequency, and instructions

Scheduled time appears under the appropriate hour of the 8- hour block.

Initials of the person who administered the medication or "G" (Given) will appear under the
appropriate hour of the 8-hour block.

Scheduled/Routine Medications

All routine medications that were ordered, scheduled, administered or discontinued during the 34-
hour period covered by the report

Start date, stop date if applicable, stop code if applicable and "Unverified" if the medication has
not been verified

Medication description, dosage, frequency, & instructions

Components and flow rate on piggybacks

Scheduled time appears under the appropriate hour of the 8-hour block.

Initials of the person who administered the medication or "G" (Given) will appear under the
appropriate hour of the 8-hour block.

IV Orders

All continuous IVs that were ordered, scheduled, administered or discontinued during the 34-hour
period and covered by the report

Start date, stop date if applicable, stop code if applicable, and "Unverified" if the IV has not been
verified

Medication description, flow rate, frequency, and components

Initials of the person who administered the IV or a "G" (Given) will appear under the appropriate
hour of the 8-hour block.

8.3 MAR Temporary

The MAR - Temporary is a document that includes the patient’s medication administration record
for the current 34 hours.

Select Charts > Select Patient Account > Attachments > Medication > MAR Temporary

MAR Tem porary

The MAR - Temporary is a document that includes the patient’s medication administration record
for the current 34 hours, based on one of the following time periods determined by nursing
administration: 0700 – 0659, 1500 – 1459 or 3300 – 3359. The medications are grouped by
categories (X1, Scheduled/Routine, IV orders and PRN) and display in the order that they were
entered into the system. The 34 hour displays in eight-hour time periods, with the medication
administration time(s), the initials of the nurse who administered the medication, and the actual
time the medication was administered appearing below the initials.

The following is a full display of the MAR Temporary report.

Demographics Box

Patient's name

Admitting physician

Age, sex, & room number

Drug allergies documented through Thrive

In addition to the above mentioned box, a single line containing the patient's name, account
number, age, sex, room number and page number will appear along the bottom edge of the page.

One Time Orders

All X1 medications that were ordered, scheduled, administered or discontinued during the 34-
hour period are covered by the report

Start and stop date, stop code and "Unverified" if the medication has not been verified

Medication description, dosage, frequency, and instructions

Scheduled time appears under the appropriate hour of the 8- hour block.

Initials of the person who administered the medication or "G" (Given) will appear under the
appropriate hour of the 8-hour block.

Scheduled/Routine Medications

All routine medications that were ordered, scheduled, administered or discontinued during the 34-
hour period covered by the report

Start date, stop date if applicable, stop code if applicable and "Unverified" if the medication has
not been verified

Medication description, dosage, frequency, & instructions

Components and flow rate on piggybacks

Scheduled time appears under the appropriate hour of the 8-hour block.

Initials of the person who administered the medication or "G" (Given) will appear under the
appropriate hour of the 8-hour block.

IV Orders

All continuous IVs that were ordered, scheduled, administered or discontinued during the 34-hour
period are covered by the report

Start date, stop date if applicable, stop code if applicable, and "Unverified" if the IV has not been
verified

Medication description, flow rate, frequency, and components

Initials of the person who administered the IV or a "G" (Given) will appear under the appropriate
hour of the 8-hour block.

PRN Medications

All PRN medications that were ordered, administered or discontinued during the 34 hour period
are covered by the report.

Start date, stop date if applicable, stop code if applicable, and "Unverified" if the medication has
not been verified.

Medication description, dosage, frequency, and instructions.

Initials of the person who administered the medication or a "G" (Given) will appear under the
appropriate hour of the 8-hour block.

8.4 All MARs

The All MAR - is an area that includes the patient’s medication administration record for 34 hour
time periods

The desired date may be selected from the lower section of the split screen for display.

Select Charts > Select Patient Account > Attachments > Medication > All MARs

All MARs

34 hours of Medication documentation display is based on one of the following time periods
determined by administration: 0700 – 0659, 1500 – 1459 or 3300 – 3359. The medications are
grouped by categories (X1, Scheduled/Routine, IV orders, and PRN) and display in the order that
they were entered into the system. The previous 34-hours display in eight-hour time periods, with
the medication administration time(s), the initials of the nurse who administered the medication,
and the actual time the medication was administered appearing below the initials.

All continuous IVs that were ordered, scheduled, administered or discontinued during the 34-hour
period are covered by the report

Start date, stop date if applicable, stop code if applicable, and "Unverified" if the IV has not been
verified

Medication description, flow rate, frequency, and components

Initials of the person who administered the IV or a "G" (Given) will appear under the appropriate
hour of the 8-hour block.
© 2018 Evident
Medication 67

The following is a display of the All MARs report.

8.5 All 5 Day MARs

From Updated ChartLink it is possible to display the Temporary and/or Final 5-Day MAR from each
day of the selected patient’s stay.

Select the desired date from the bottom of the split screen to display the 5-Day MAR for that date.

Select Charts > Select Patient Account > Attachments > Medication > All 5 Day MARs

All 5 Day MARs

All continuous IVs that were ordered, scheduled, administered or discontinued during the 34-hour
period are covered by the report

Start date, stop date if applicable, stop code if applicable, and "Unverified" if the IV has not been
verified

Medication description, flow rate, frequency, and components

Initials of the person who administered the IV or a "G" (Given) will appear under the appropriate
hour of the 8-hour block.

The following is a full display of the All 5 Day report.

8.6 Scheduled Medications

The Scheduled Medications report is a document that includes all of the current scheduled
medications for an 8-hour time period for an individual patient or group of patients. PRNs and large
volume IVs do not print on the report.

Select Charts > Select Patient Account > Attachments > Medication > Scheduled Medications

Scheduled Medications

Data included on the Scheduled Medication Report is outlined below:

Patient Information
Patient's name
Room number
Age
Sex
Attending Physician
Any drug allergies documented through Thrive

Medication Information
Medication description, dosage, frequency, instructions
"Unverified" if the medication has not been verified
Flow rate and components on IV Piggybacks

Omission Information
Date, time, and reason medication was omitted

Check time which indicates that a medication was not administered within thirty minutes before
or 30 minutes after the scheduled time

Administration Schedule
An eight-hour time frame prints beside the Omission Information section.
Indicates the scheduled time for each medication
A "G" (Given) displays below the appropriate time, indicating when the medication was given.

The following is a full display of the Scheduled Medications report.

8.7 PCA
The following section will describe the PCA order entry and the PCA Infusion form.

PCA Infusion Form

The PCA Infusion Form is a comparative document that includes the patient’s PCA administration
chart and assessment from the beginning of stay.

Select Charts > Select Patient Account > Attachments > Medication > PCA

PCA

Data included on the PCA Infusion Form is outlined below:

Demographics Box (located upper right-hand corner)

Patient's name
Admitting physician
Age, sex, & room number
Medical Records number
Any drug allergies documented through Thrive

Medication
The PCA medication description will be highlighted in a gray box.

Protocol
Date and time protocol was entered

Continuous infusion rate (Optional)

Name & title of person who entered the protocol
Lock-out time
Bolus / loading dose
Four-hour limit
Patient administration dose
Initial syringe volume

The following is a full display of the PCA form.

8.8 Medication Record

The Medication Record Report is a document that includes all ordered medications for an individual
patient.

Select Charts > Select Patient Account > Attachments > Medication > Medication Record

Medication Record Report

Data included on the Patient Drug Information sheet is outlined below:

Patient Information
Patient's name
Room number
Age
Sex
Attending Physician
Drug allergies documented through Thrive

Medication Information
Medication description, dosage, frequency, route, and instructions
Start/Stop information
Flow rate and components on IV Piggybacks

Omission Information
Date, time, and reason medication was omitted

Administration Record
Date/Time
Nurse
Dose/Unit
Site
Comments/Reason

The following is a full display of the Medication Record Report

8.9 Medication Reconciliation Report

This report can be used to track a patient's medications from admit to discharge or transfer to
another care giver or facility.

Select Charts > Select Patient Account > Attachments > Medication > Medication Reconciliation
Report

Medication Reconciliation Report

The Medication Reconciliation report will display all medications. The "Home Medications" taken
during the Point of Care Initial Interview will be at the beginning of the report followed by a page
break. The following pages will present the patients hospital medications. A Continue/Discontinue
option for both home and hospital medications will be included beside medication descriptions. The
physician will have a section on the report for additional medications.

NOTE: This is a displayed report. It is not interactive.

Data included on the MEDICATION RECONCILIATION REPORT is outlined below:

Patient Information
Patient's name
Account Number
Age
Sex
Room Number
Medical Record Number
Attending Physician

Consulting Physician
Diagnosis
Height, Weight, BAS
Any drug allergies documented through Thrive

Medication Information
Medication description, dosage, frequency, route, and instructions
Start/Stop information, including the stop codes
Flow rate and components on IV Piggybacks
PCA Medications and protocol
Diabetic Record Medication and sliding scale
The option to continue or discontinue the medication

NOTE: “Med continued on the next page” will print at the bottom of the page if information continues
to the next page. “Med is continued from previous page” will print at the top of the subsequent page.

The following is an example of the Medication Reconciliation Report.

8.10 Attachments
The Attachments area will contain any Scanned Images, Electronic Forms or Photo Uploads that
have been assigned to this section.

Select Charts > Select Patient Account > Attachments > Medication > Attachments

Medications - Attachm ents

Deleted Items will display

Setup to display items may be referenced in the Image Title User Guide or the Electronic Forms
User Guide.

will display if data is not present in this area to be viewed.

Chapter 9 Radiology

9.1 Overview
This section will discuss the Radiology Transcriptions.

Select Updated ChartLink > Charts > Select Patient Account > Attachments > Radiology

Radiology

Radiology Transcriptions may be viewed from the Transcriptions icon located on the Updated
ChartLink navigation panel.

Chapter 10 Multi Disciplinary

10.1 Overview
This section of the Updated ChartLink User Guide will discuss Multi Disciplinary documentation.

Select Updated ChartLink > Charts > Select Patient Account > Attachments > Multi Disciplinary

Multi-Discipline

10.2 Discharge Planner

The Discharge Planner is a document that includes financial and environmental concerns,
expectations for discharge, potential for activities of daily living, etc. for the patient.

Select Charts > Select Patient Account > Attachments > Multi Disciplinary > Discharge Planner

Discharge Planner

Data included on the Discharge Planner is outlined below:

Demographics Box (located upper right-hand corner)

Patient's name
Admitting Physician
Age, sex, & room number
Medical Record number
Drug allergies documented through Thrive
In addition to the above mentioned box, a single line containing the patient's name, account
number, age, sex, room number and page number will appear along the bottom edge of the
page.

Discharge Planner
Up to 50 hospital-defined questions that can be answered to document a plan for the patient's
discharge
The questions appear in bold text with the responses listed below.
Once charted, the date, time, name, and title of the person who charted the information will be
reflected.

Signature Line
A signature line is provided in lower right-hand corner of the report.

The Discharge Planner report and the other reports listed in this section will display in Adobe
Acrobat Reader format.

The following is a full display of the Discharge Planner report.

10.3 Problem List

The Problem List is a document that includes the patient’s identified problems and goals and the
current status of each. It can be used as a reference for the latest activity charted without having to
review the Patient Progress Notes.

Select Charts > Select Patient Account > Attachments > Multi Disciplinary > Problem List

Problem List

Data included on the Problem List Report is outlined below:

Demographics Box (located upper right-hand corner)

Patient's name
Admitting physician
Age, sex, & room number
Medical Record number
Any drug allergies documented through Thrive
In addition to the above mentioned box, a single line containing the patient's name, account
number, age, sex, room number and page number will appear along the bottom edge of the
page.

Problem List Box

Shaded in gray, each box contains one problem order of up to 75 characters.

Problem List Activity

Displays last action taken to the problem and any comment that was added
Next to the action it will display the date, time, and name of person entering the information
Below the Problem and Action to the problem the goals related to that problem will be listed in
order of entry and will be preceded with an asterisk
Below all goals, report will display last action taken and any comments
Next to all goals it will display the date, time, and name of person entering the information

Problem List Status

The status indicates the last action taken on the problem
Appears directly below the comment
The date and time will indicate the last time the problem was charted on
Displays name and title of the person who charted on the problem or goals

Additional Notes
Problems that have been resolved will display on this report

The following is a full display of the Problem List report.

10.4 Problem Activities

The Problem Activity report is a document that includes the patient’s identified problems and goals
as well as any activities charted on each while in Problem Mode within a flowchart. It displays the
path of progression toward resolution from the beginning of stay.

Select Charts > Select Patient Account > Attachments > Multi Disciplinary > Problem Activities

Problem Activities

Data included on the Problem Activity Report is outlined below:

Demographics Box (located upper right-hand corner)

Problem List Box

Shaded in gray, each box contains one problem order of up to seventy-five characters

Problem Activity
Just below the problem box will be list of goals with date, time, and name of person who
entered the information

Following the goals will be the action taken related to the problem contained in a box
All goals and goal activity will follow the last action to the problem box in chronological order
All entries will be preceded by the date, time, and name of person who entered the information
The last action taken will appear in bold with comments listed below

Problem List Status

The status indicates the last action taken on the problem
Appears directly above the comment
The date and time will indicate the last time the problem was charted on
Displays name and title of the person who charted on the problem or goals

NOTE: Problems that have been resolved will display on this report

The following is a full display of the Problem Activities report.

10.5 Care Plan

The Care Plan is a document that includes information regarding the patient’s plan of care.

Select Charts > Select Patient Account > Attachments > Multi Disciplinary > Care Plan

Care Plan

Data included on the Care Plan is outlined below:

Demographics box (located upper right-hand corner)

Patient’s name
Account number
Admitting physician
Age, sex, and room number
Any drug allergies documented through Thrive

Medical Diagnosis and definition

Nursing Diagnosis

Goals

Interventions

Evaluation column

The following is a full display of the Care Plan report.

10.6 Discharge Summary

The Discharge Summary is a document that includes the patient’s diet, current medications, other
instructions, and any other information pertinent to the patient’s discharge status. It is part of the
patient’s permanent chart. The Discharge Instructions are included in the Discharge Summary.

Select Charts > Select Patient Account > Attachments > Multi Disciplinary > Discharge Summary

Discharge Sum m ary

Data included on the Discharge Summary is outlined below:

Demographics Box (located upper right-hand corner)

Patient's name
Admitting physician
Age, sex, & room number
Medical Record number
Any drug allergies documented through Thrive
In addition to the above mentioned box, a single line containing the patient's name, account
number, age, sex, room number, and page number will appear along the bottom edge of the
page.

Diet
The patient's diet will display in the top left-hand corner of the report just below the header,
preceded by the date, time, name and title of the person who charted the information.

Medications
Description of the medications the patient is taking home

Dosage, frequency, and instructions

Date and time of last administration

Other Instructions
Up to 30 hospital-defined questions that can be answered to detail the instructions given to the
patient
The questions appear in bold text with the responses listed below.
Once charted, the date, time, name, and title of the person who charted the information will be
reflected.
This section of instructions also prints on the Discharge Instructions report.

Other Information
Up to thirty hospital-defined questions can be answered to describe other pertinent patient
information
The questions appear in bold text with the responses listed below.
Once charted, the date, time, name, and title of the person who charted the information will be
reflected.
This section of information will ONLY print on the Discharge Summary report.

Signature Lines
Signature lines are located at the bottom of the report for the patient and the nurse providing the
care.

The following is a full display of the Discharge Summary report.

10.7 Discharge Instructions

The Discharge Instructions is a document that includes the patient’s diet, current medications and
any other instructions pertinent to the patient’s discharge status. The Discharge Instructions are
included in the Discharge Summary. This report is given to the patient at discharge.

Select Charts > Select Patient Account > Attachments > Multi Disciplinary > Discharge
Instructions

Discharge Instructions

Data included on the Discharge Instructions is outlined below:

Demographics Box (located upper right-hand corner)

Patient's name
Admitting physician
Age, sex, & room number
Medical Records number
Any drug allergies documented through Thrive
In addition to the above mentioned box, a single line containing the patient's name, account
number, age, sex, room number and page number will appear along the bottom edge of the
page.

Diet
The patient's diet will display in the top left-hand corner of the report just below the header.

Medications
Description of the medications the patient is taking home
Dosage, frequency, instructions
Date and time of last administration

Signature Lines
Signature lines are located at the bottom of the report, for the patient and the nurse providing
the care.

The following is a full display of the Discharge Instructions report.

10.8 Transfer Form

The Patient Transfer Form is a document that includes the patient’s demographics, transferring
and receiving facilities, medical information, active pharmacy orders, transfer consent, request or
refusal, and other information pertinent for the transfer process.

Select Charts > Select Patient Account > Attachments > Multi Disciplinary > Transfer Form

Transfer Form

Data included on the Patient Transfer Form is outlined below:

Patient Demographic Information

Patient's name, address, sex, birth date and religion
Insurance company, policy number and address
Dates of admission, discharge and transfer
Facility transferring FROM and TO
In addition to the above mentioned information, a single line containing the patient's name,
medical record number, account number, age, sex, room number and page number will appear
along the bottom edge of the page.

Patient Medical Information - Displays the most recent:

Temperature
Pulse
Respirations
Blood Pressure
Allergies
Oxygen Saturation

Oxygen Delivery
Weight and Height
Diet

The following is a full display of the Transfer Form report.

10.9 Initial Interview

The Initial Interview is a document that includes information regarding the patient’s demographics,
pertinent history, and discharge planning.

Select the multidisciplinary chart type from the lower split screen to display the desired Initial
Interview.

Select Charts > Select Patient Account > Attachments > Multi Disciplinary > Initial Interview

Initial Interview

The Initial Interview is a document that includes information regarding the patient’s demographics,
pertinent history, and discharge planning.

Data included on the Initial Interview is outlined below:

Demographics Box (located upper right-hand corner)

Patient's name
The admitting physician
Age, sex, & room number
Medical Record number
Any drug allergies documented through Thrive
In addition to the above mentioned box, a single line containing the patient's name, account
number, age, sex, room number and page number will appear along the bottom edge of the
page.

Patient Information Box

Patient Name
Birth date and age
Sex
Marital Status
Occupation
Religion
Admitting Diagnosis
Admitting Physician
Consulting Physician
Emergency contact information:
o Name
o Relation
o Address
o Phone

The following is a full display of the Initial Interview report.

10.10 Initial Physical Assessment

The Initial Physical Assessment is a document that includes information regarding the patient’s
initial vital signs and assessment of body systems.

Select the multidisciplinary chart type from the lower split screen to display the desired Initial
Physical Assessment.

Select Charts > Select Patient Account > Attachments > Multi Disciplinary > Initial Physical
Assessment

Initial Physical Assessm ent

Data included on the Initial Physical Assessment Report is outlined below:

Demographics Box (located upper right-hand corner)

Initial Vital Signs

Temperature (including site)
Pulse (including site)
Respiration
Blood Pressure (including posture and extremity)
Weight
The date, time, name and title of the person who charted the information.

Assessment Categories - Each assessment will be preceded by the appropriate heading

below:
Metabolic/Integument
Gastrointestinal
Musculoskeletal
Pain
Wound
Pulmonary
Genitourinary
Neurological
Psychosocial
Cardiovascular
Reproductive
Injury Risk
Intravenous

The following is a full display of the Initial Physical Assessment Report.

10.11 Patient Progress Notes

Select the date from the lower split screen to display the desired Patient Progress Note.

Select Charts > Select Patient Account > Attachments > Multi Disciplinary > Patient Progress
Notes

Patient Progress Notes

Data included on the Patient Progress Notes is outlined below:

Demographics Box (located upper right-hand corner)

Patient's Name
Admitting physician
Age, sex, & room number
Medical Record number
Any drug allergies documented through Thrive
In addition to the above mentioned box, a single line containing the patient's name, account
number, age, sex, room number and page number will appear along the bottom edge of the
page.

Entries
Each entry will fall under the appropriate application heading.
The heading will be highlighted with bold text and preceded by the following:
o Time the entry was charted
o The name and title of the individual who entered the information
o Two to three character code indicating the application in which the entry was charted

Application codes and descriptions:

(P/A)-Physical Assessment
(MED)-Pharmacy
(MO)-Medical Order
(F/S)-Floor Stock
(NSS)-Shift Summary
(EDU)-Education
(BSU)-Diabetic Record
(NAC)-Nursing Activities
(PCA)-PCA Medications
(VS)-Vital Signs
(ORD)-Ancillary Orders
(PL)-Problem List

Signature Line
An optional signature line is provided at the bottom of this report for the nurse primarily
responsible for the patient's care.

The following is a display of the Patient Progress Notes.

10.12 Attachments
The Attachments area will contain any Scanned Images, Electronic Forms or Photo Uploads that
have been assigned to this section.

Select Charts > Select Patient Account > Attachments > Multi Disc > Attachments

Multi Disciplinary - Attachm ents

Deleted Items will display .

Setup to display items may be referenced in the Image Title User Guide or the Electronic Forms
User Guide.

will display if data is not present in this area to be viewed.

Chapter 11 Nurses Notes

11.1 Overview
This section of the Updated ChartLink User Guide will discuss Nurses Notes.

Select Updated ChartLink > Charts > Select Patient Account > Attachments > Nurses Notes

Nurses Notes

11.2 Initial Interview

The Initial Interview is a document that includes information regarding the patient’s demographics,
pertinent history, and discharge planning.

Select Charts > Select Patient Account > Attachments > Nurses Notes > Initial Interview

Initial Interview

Demographics Box (located upper right-hand corner)

Patient Information Box

Patient Name
Birth date and age
Sex
Marital Status
Occupation
Religion
Admitting Diagnosis
Admitting Physician
Consulting Physician

Emergency contact information:

o Name
o Relation
o Address
o Phone

The following is a full display of the Initial Interview report.

11.3 Initial Physical Assessment

The Initial Physical Assessment is a document that includes information regarding the patient’s
initial vital signs and assessment of body systems.

Select Charts > Select Patient Account > Attachments > Nurses Notes > Initial Physical
Assessment

Initial Physical Assessm ent

Data included on the Initial Physical Assessment Report is outlined below:

Demographics Box (located upper right-hand corner)

Initial Vital Signs

Temperature (including site)
Pulse (including site)
Respiration
Blood Pressure (including posture and extremity)
Weight

The date, time, name and title of the person who charted the information.

Assessment Categories

Each assessment will be preceded by the appropriate heading below:

Metabolic/Integument Pulmonary Cardiovascular

Gastrointestinal Genitourinary Reproductive
Musculoskeletal Neurological Injury Risk
Pain Psychosocial Intravenous
Wound

The following is a full display of the Initial Physical Assessment Report.

11.4 Patient Progress Notes

The Patient Progress Notes is a document that includes information from most POC applications
charted during a given time frame. The Initial Interview and Initial Physical Assessment are not
included in the Patient Progress Notes. Documentation from the multi-disciplinary applications
prints to the report, also. It is printed at the end of shift and may be signed by the nurse assigned to
the patient.

Select the desired date revealed in the lower split screen to display the appropriate Patient
Progress Note.

Select Charts > Select Patient Account > Attachments > Nurses Notes > Patient Progress Notes

Patient Progress Notes

Data included on the Patient Progress Notes is outlined below:

Demographics Box (located upper right-hand corner)

Application codes and descriptions:

(P/A)-Physical Assessment (NSS)-Shift Summary (PCA)-PCA Medications

(MED)-Pharmacy (EDU)-Education (VS)-Vital Signs
(MO)-Medical Order (BSU)-Diabetic Record (ORD)-Ancillary Orders
(F/S)-Floor Stock (NAC)-Nursing Activities (PL)-Problem List

Signature Line
An optional signature line is provided at the bottom of this report for the nurse primarily
responsible for the patient's care.

The following is a full display of the Patient Progress Notes.

Included:
The Physician Entered Orders Report will automatically be included at the end of Patient
Progress Notes. The report will include all verified medication, ancillary and nursing orders
placed for the patient via physician order entry. This report will also include Verbal and
Telephone Orders that are entered via Point of Care Order Entry.

Data included in the Physicians Entered Order Report is outlined below:

Patient Information
Patient's name
Account number
Medical record number
Date of Birth
Age
Sex
Room number
Any drug allergies documented through Thrive

Medication Information
Date/Time of order placement
Medication description, dosage, frequency, route, duration, priority and instructions*
Flow rate and components for IV medications
Physician's electronic signature with credentials

NOTE: Renewed medication orders should display the instructions and/or comments from the
original order.

Ancillary Order Information

Date/Time of order placement
Ancillary order description, quantity, frequency, duration, days and priority
Physician's electronic signature with credentials

Nursing Order Information

Date/Time of order placement
Description of Nursing Order
An Action, if taken (Discontinue)
Renewed nursing orders will display the instructions and/or comments from the original order
Physician's electronic signature with credentials

The following is a full display of the Physician Entered Orders Report

11.5 24 Hour Summary

The 24-Hour Summary is a document that includes specific patient information charted within the
previous 24 hours from the minute it is printed on the system. This worksheet provides both nurses
and physicians details of the patient’s condition and plan of care. It is one of the primary tools used
by nursing to conduct an organized and timely shift change. It is one of the reports preferred by
physicians to use as reference while making rounds.

Select Charts > Select Patient Account > Attachments > Nurses Notes > 24 Hour Summary

24 Hour Sum m ary

Data included on the 24 Hour Summary Format A is outlined below:

Demographics Box (upper right-hand corner)

Patient's name
Account number
Admitting and/or consulting physician
Age, sex, & room number
Medical Record number
Drug allergies documented through Thrive

Vital Signs
Pulse and Blood Pressure, displayed either graphically or numerically in one hour intervals
Temperature and respirations displayed numerically in one hour intervals

Hemodynamics (Optional)
CVP, PAP, PAWP and CO/CI values displayed in three hour intervals
In order for this information to be included, it must be set up by Nursing Administration.

O3/Ventilation Information
The user determines which seven of twelve options will be included.
Values display in three hour intervals

NOTE: An asterisk (*) adjacent to any value on this report indicates multiple values have been
charted within the specified time frame. The last recorded value is printed. Preceding values are
available on-line or in Patient Progress Notes.

Intake
The user determines which seven of twelve options will be included.
Values display in three hour intervals
The "OTHER" box combines all intake values not specified on the report. These details are
available on-line or in the Patient Progress Notes
For Pediatric/Nursery chart types, an option to record breast feeding will appear.

Output
The user determines which 4 out of 18 options will be included.
Values display in three hour intervals
The "OTHER" box combines all output values not specified on the report. These details are
available on-line or in the Patient Progress Notes.
Entries charted by frequency print in the top left corner of each box

Weight
Admission weight is printed in both pounds and kilograms.
Yesterday's weight in pounds and kilograms, with date and time charted is printed.
Today's weight in pounds and kilograms, with date and time charted is printed.

Diet
Date and time the information was charted
The diet, along with the date and time it was scheduled to begin.
Any comments entered
Percent consumed

Current Medications (Optional)

Includes all active medications at the time the report is printed
Medication description, dose, frequency, and autostop date if applicable
Does not include discontinued medications
In order for this information to be included, it must be set up by Nursing Administration.

Administered Medications (Optional)

Lists all medications administered during the previous 24 hours.
Date and time of last administration
Medication description
Location of administration, and the reason for PRN administration
Dosage
In order for this information to be reflected, it must be set up by Nursing Administration.

Omitted Medications (Optional)

Lists all medications omitted in the previous 24 hours.
Medication description
Omission date and time or check time
Reason for omission
Includes discontinued medications
In order for this information to be included, it must be set up by Nursing Administration.

Neuro Checks (Optional)

Neuro checks charted through the VS application during the previous 24 hour period
Date and time information was entered
Name and title of person who charted the entry

X1 {one-time} and PRN Medications (Optional)

Lists all X1 & PRN administrations in the previous 24 hour period
Medication description, quantity, frequency and time of administration
Includes a reason for PRN medications
Does not include discontinued medications
In order for this information to be reflected, it must be set up by Nursing Administration.

Blood Glucose Readings (Optional)

Includes all administrations in the previous 24 hour period
Date and time entry was charted
Blood sugar level
Description of medication given (sliding scale insulin only)
Unit(s) of medication given and frequency

Blood Glucose Readings (Continued)

Any other interventions charted
In order for this information to be reflected, it must be set up by Nursing Administration.

Immunizations will print on the final page of the 24 Hour Summary report for both formats A and
B.

NOTE: The 24 Hour Summary report (Format B) has some different options than Format A.
Format B also displays and prints in a horizontal format. The option that will display depends on the
Chart-type of the selected patient. Please refer to the hospital’s Nursing Administration department
for more information on the two different formats.

The following is a full display of the 24 Hour Summary report (Format A & B).

11.6 Shift Summary

The Shift Summary Report is a document that includes all shift information charted the previous 34
hours via Point of Care.

Select Charts > Select Patient Account > Attachments > Nurses Notes > Shift Summary

Shift Sum m ary

Data included on the Shift Summary Report is outlined below:

Demographics Box (located top center of screen)

Patient's name
Account Number
Medical Record Number
Diagnosis
Attending Physician
Second Physician
Room Number
Age
Sex
Working Diagnosis 1
Working Diagnosis 3
Length of Stay
Height
Weight
Food Allergies
Condition

Isolation
Diet
Special Diet Instructions
Advanced Directive
Violent Patient
MRSA
VRE
Fall Risk
Language
Ethnicity
Smokes
Allergies
Immunizations

Entries
All shift summary information charted the previous 34 hours through Point of Care.

The following is a full display of the Shift Summary report.

11.7 Attachments
The Attachments area will contain any Scanned Images, Electronic Forms or Photo Uploads that
have been assigned to this section.

Select Charts > Select Patient Account > Attachments > Nurses Notes > Attachments

Nurses Notes - Attachm ents

Deleted Items will display

Setup to display items may be referenced in the Image Title User Guide or the Electronic Forms
User Guide.

will display if data is not present in this area to be viewed.

Chapter 12 Education

12.1 Overview
This section of the Updated ChartLink User Guide will discuss the Education Report.

Select Updated ChartLink > Charts > Select Patient Account > Attachments > Education

Education

12.2 Education Report

The Education report is a document that includes multi-disciplinary information on how and when
the patient was educated regarding diagnosis, medication administration, etc.

Select Charts > Select Patient Account > Attachments > Education

Education Report

Data included on the Education Report is outlined below:

Demographics Box (located upper right-hand corner)

Patient's name
Admitting physician
Age, sex, and room number
Medical Record number
Any drug allergies documented through Thrive
In addition to the above mentioned box, a single line containing the patient's name, account
number, age, sex, room number and page number will appear along the bottom edge of the
page.

Education Categories
Each category will be highlighted with bold text within a shaded gray box.
There are 34 categories that are all user-defined and can be set up for multi-discipline use.
Within the category up to thirty hospital-defined questions with up to twelve answers for each
can be set up.
The questions appear in bold text with the responses listed below.

Under each category entries made will display in chronological order preceded by the date, the
time entry made, and name and title of individual that entered the information.
Education questions can be integrated with the Physical Assessment and Initial Interview
portions of the chart and will display on the Education report.

Entries
Each entry will fall under the appropriate category.
The Education Report and the other reports listed in this section will display in Adobe Acrobat
Reader format.

The following is a full display of the Education Report.

12.3 Attachments
The Attachments area will contain any Scanned Images, Electronic Forms or Photo Uploads that
have been assigned to this section.

Select Charts > Select Patient Account > Attachments > Education > Attachments

Education- Attachm ents

Deleted Items will display

Setup to display items may be referenced in the Image Title User Guide or the Electronic Forms
User Guide.

will display if data is not present in this area to be viewed.

Chapter 13 Cardiopulmonary

13.1 Overview
This section of the Updated ChartLink User Guide will discuss the reports associated with the
Cardiopulmonary department.

Select Updated ChartLink > Charts > Select Patient Account > Attachments > Cardiopulmonary

Cardiopulm onary

13.2 Initial Interview

The Initial Interview is a document that includes information regarding the patient’s demographics
and pertinent history.

Select Charts > Select Patient Account > Attachments > Cardiopulmonary > Initial Interview

Cardiopulm onary - Initial Interview

Data included on the Initial Interview is outlined below:

Demographics Box (located upper right-hand corner)

Patient Information Box

Patient's name Name (person to contact in an emergency)

Birth date and age Relation (of above person) Sex
Address Marital status Phone
Occupation Attending physician Religion
Consulting physician Admitting diagnosis

The Initial Interview report and the other reports listed in this section will display in Adobe Acrobat
Reader format.

The following is a full display of the Initial Interview report

13.3 Initial Physical Assessment

The Initial Physical Assessment is a document that includes information regarding the patient’s
initial vital signs and assessment of body systems.

Select Charts > Select Patient Account > Attachments > Cardiopulmonary > Initial Physical
Assessment

Cardiopulm onary - Initial Physical Assessm ent

Data included on the Initial Physical Assessment Report is outlined below:

Demographics Box (located upper right-hand corner)

Patient's name
Admitting physician
Age, sex, & room number
Medical Record number
Any drug allergies documented through Thrive

In addition to the above mentioned box, a single line containing the patient's name, account
number, age, sex, room number and page number will appear along the bottom edge of the page.

Initial Vital Signs

Temperature (including site)
Pulse (including site)
Respiration
Blood Pressure (including posture and extremity)
Weight
The date, time, name and title of the person who charted the information.

The following is a full display of the Initial Physical Assessment report.

13.4 O2 Saturation Graph

The O3 Sat Bar Graph is a document that displays the O3LM, FiO3, and O3SAT, which is graphed
and includes the method.

Select Charts > Select Patient Account > Attachments > Cardiopulmonary > O3 Saturation Graph

Cardiopulm onary - O3Saturaton Graph

Data included in the O3 Sat Bar Graph is outlined below:

Demographics box (located upper right-hand corner)

Patient’s name
Account number
Admitting physician
Age, sex, and room number
Medical Record number
Any drug allergies documented through Thrive

O3 Information
O3 L/M, FiO3, and O3 Sat values display numerically
O3 Sat values display as a bar graph
O3 Sat values display on the bar graph along with the method

The following is a full display of the O3 Saturation Bar Graph report.

13.5 Comparative
The comparative vertical report is an update of all test results for a patient account.

Select Charts > Select Patient Account > Attachments > Cardiopulmonary > Comparative Report

Cardiopulm onary - Com parative

The report is a comparative summary presentation of all data with test names along the vertical
axis and results listed chronologically along a horizontal axis. Collection dates and times are
printed on the horizontal axis. Up to seven events will print per row with subsequent results
wrapping below the most current results. Since this report is a complete record of all patient
results, each report should replace the report previously charted. Preliminary reports with results
that do not appear on the comparative report should remain on the chart until they print on the
comparative.

The following is a full display of the Comparative report.

13.6 Comparative-All Stays

The Comparative All Stays report is a cumulative report of all test results for a patient .

Select Charts > Select Patient Account > Attachments > Cardiopulmonary > Comparative - All
Stays Report

Cardiopulm onary Com parative All Stays

The following is a full display of the Comparative report.

13.7 Comparative-Multifacility
The Comparative All Stays Multifacility report is a cumulative report of all test results for a patient
across all site associated facilities.

Select Charts > Select Patient Account > Attachments > Cardiopulmonary > Comparative -
Multifacility

Cardiopulm onary Com parative Multifacility

The following is a full display of the Comparative - Multifacility report.

13.8 Detail Results

The Detail report can be used as an alternative comparative report; however it only provides a
results chart copy for inpatients.

Select Charts > Select Patient Account > Attachments > Cardiopulmonary > Detail Results

Cardiopulm onary Detail Results

This report is added to the previously printed comparative Detail reports on the patient's chart.
Inpatients whose results are completed after being discharged in the system do not print on this
report; they print on the M/R File report.

The following is a full display of the Detailed Report.

13.9 Attachments
The Attachments area will contain any Scanned Images, Electronic Forms or Photo Uploads that
have been assigned to this section.

Select Charts > Select Patient Account > Attachments > Cardiopulmonary > Attachments

Cardiopulm onary- Attachm ents

Deleted Items will display

Setup to display items may be referenced in the Image Title User Guide or the Electronic Forms
User Guide.

will display if data is not present in this area to be viewed.

Chapter 14 Rehabilitation

14.1 Overview
This section of the Updated ChartLink User Guide will discuss the reports located in Rehabilitation.

Select Updated ChartLink > Charts > Select Patient Account > Attachments > Rehabilitation

Rehabilitation

14.2 Initial Interview

The Initial Interview is a document that includes information regarding the patient’s demographics,
pertinent history, and discharge planning.

Select Charts > Select Patient Account > Attachments > Rehabilitation > Initial Interview

Rehabilitation Initial Interview

Data included on the Initial Interview is outlined below:

Demographics Box (located upper right-hand corner)

Patient Information Box

Patient's name Name (person to contact in an emergency)

Birth date and age Relation (of above person) Sex
Address Marital status Phone
Occupation Attending physician Religion
Consulting physician Admitting diagnosis

The Initial Interview report and the other reports listed in this section will display in Adobe Acrobat
Reader format.

The following is a full display of the Initial Interview report.

14.3 Initial Physical Assessment

The Initial Physical Assessment is a document that includes information regarding the patient’s
initial vital signs and assessment of body systems.

Select Charts > Select Patient Account > Attachments > Rehabilitation > Initial Physical
Assessment

Rehabilitation Initial Physical Assessm ent

Data included on the Initial Physical Assessment Report is outlined below:

Demographics Box (located upper right-hand corner)

Initial Vital Signs

Temperature (including site)
Pulse (including site)
Respiration
Blood Pressure (including posture and extremity)
Weight
The date, time, name and title of the person who charted the information.

The following is a full display of the Initial Physical Assessment report.

14.4 Attachments
The Attachments area will contain any Scanned Images, Electronic Forms or Photo Uploads that
have been assigned to this section.

Select Charts > Select Patient Account > Attachments > Rehabilitation > Attachments

Rehabilitation Attachm ents

Deleted Items will display

Setup to display items may be referenced in the Image Title User Guide or the Electronic Forms
User Guide.

will display if data is not present in this area to be viewed.

Chapter 15 Dietary

15.1 Overview
This section will discuss access to Dietary functions from Updated ChartLink.

NOTE: Specific diet items (example: Low Salt Diet, Clear Liquid Diet) can be ordered if the hospital
is using specific items in the Dietary item master (versus the use of generic dietary items). The
item description will update the diet field in Clinical Information, Medact, Diet reports, and POC
reports. Also, entering a new diet order replaces the previous diet order in Clinical Information and
the Medact.

Select Updated ChartLink > Charts > Select Patient Account > Attachments > Dietary

Dietary

15.2 Initial Interview

The Initial Interview is a document that includes information regarding the patient’s demographics,
pertinent history, and discharge planning.

Select Charts > Select Patient Account > Attachments > Dietary > Initial Interview

Dietary Initial Interview

Data included on the Initial Interview is outlined below:

Demographics Box (located upper right-hand corner)

Patient Information Box

Patient's name Name (person to contact in an emergency)

Birth date and age Relation (of above person) Sex
Address Marital status Phone
Occupation Attending physician Religion
Consulting physician Admitting diagnosis

The Initial Interview report and the other reports listed in this section will display in Adobe Acrobat
Reader format.

The following is a full display of the Initial Interview report.

15.3 Initial Physical Assessment

The Initial Physical Assessment is a document that includes information regarding the patient’s
initial vital signs and assessment of body systems.

Select Charts > Select Patient Account > Attachments > Dietary > Initial Physical Assessment

Dietary Initial Physical Assessm ent

Data included on the Initial Physical Assessment Report is outlined below:

Demographics Box (located upper right-hand corner)

Patient's name
Admitting physician
Age, sex, & room number
Medical Record number
Any drug allergies documented through Thrive

In addition to the above mentioned box, a single line containing the patient's name, account
number, age, sex, room number and page number will appear along the bottom edge of the page.

Initial Vital Signs

Temperature (including site)
Pulse (including site)
Respiration
Blood Pressure (including posture and extremity)
Weight
The date, time, name and title of the person who charted the information.

The following is a full display of the Initial Physical Assessment report.

15.4 Nutritional Calculations

Items such as Nutritional Assessments that include the patient’s Basal Energy Expenditure (BEE)
and Ideal Body Weight (IBW) can be calculated through result entry.

Select Charts > Select Patient Account > Attachments > Dietary > Nutritional Calculations

Dietary Nutritional Calculations

The following is a full display of the Nutritional Calculations report.

Nutritional Calculation

15.5 Attachments
The Attachments area will contain any Scanned Images, Electronic Forms or Photo Uploads that
have been assigned to this section.

Select Charts > Select Patient Account > Attachments > Rehabilitation > Attachments

Dietary - Attachm ents

Deleted Items will display

Setup to display items may be referenced in the Image Title User Guide or the Electronic Forms
User Guide.

will display if data is not present in this area to be viewed.

Chapter 16 Diabetic

16.1 Overview
This section will discuss access to Diabetic Record information from Updated ChartLink.

Select Updated ChartLink > Charts > Select Patient Account > Attachments > Diabetic

Diabetic Record

16.2 Diabetic Flowsheet

The Diabetic Record Flowsheet will display a cumulative report of all documentation done through
the Diabetic Record application.

Select Charts > select Patient Account > Attachments > Diabetic > Diabetic Flowsheet

Diabetic Flow sheet

Data included on the Diabetic Flowsheet is outlined below:

Demographics Box (located upper right-hand corner)

Patient's name, Account Number and Medical Record Number
Admitting physician
Age, sex and room number
Any drug allergies documented through Thrive

Diet
The patient's current diet will display in the top right-hand corner of the report, just below the
demographics box.

Documentation Area
Date and time of each entry charted
Name and title of the person who charted each entry
Blood sugar level and dose (if administered)
Type of Insulin or Hypoglycemic agent administered
The site where the medication was given
Any additional interventions that were performed

Sliding Scale
The scale is highlighted in a gray box. It provides the following information:
o Date and time the scale was entered, as well as the name and title of the person who
entered it
o Low and high blood sugar values, as well as the appropriate insulin dosage
o Comments, if selected to print. This is an optional feature, please notify the facility Information
Technology Department.
If no sliding scale has been ordered or if one has been discontinued, it will be indicated by the
following values and dosage: 0 - 999 0.00

The following is a full display of the Diabetic Flowsheet report.

16.3 Cumulative Report

The Cumulative Report will display the report from the beginning of the patients stay to the current
date.

Select Charts > Select Patient Account > Attachments > Diabetic > Cumulative Report

Diabetic Cum ulative

Data included on the Cumulative Report is outlined below:

Demographics Box (located upper right-hand corner)

Patient's name, Account Number and Medical Record Number
Admitting physician
Age, sex and room number
Any drug allergies documented through Thrive

Diet
The patient's current diet will display in the top right-hand corner of the report, just below the
demographics box.

The following is a full display of the Diabetic Flowsheet report.

16.4 Daily Diabetic Report

The Daily Report will display 34 hours of data and is used to reveal frequently entered data such
that may be seen in an Intensive Care Unit.

Select the date from the lower split screen to view desired report.

Select Charts > Select Patient Account > Attachments > Diabetic > Daily Diabetic Report

Daily Diabetic Report

Data included on the Daily Flow Sheet is outlined below:

Demographics Box (located upper right-hand corner)

Patient's name
Admitting physician
Account number, age, sex and room number
Medical Records number
Any drug allergies documented through Thrive

Diet
The patient's current diet will display in the top right-hand corner of the report, just below the
demographics box.

Graphic Display
34-Hour graphic representation of all insulin and blood sugar levels.
All blood sugar levels plot on the graph; however, only the most recent level/time in each 1-hour
increment prints on the report.

Asterisks indicate more than one level charted within 1-hour increment.
Interventions print vertically under the time period for which they were performed.
Lab results plot separately and are indicated in bold.
Diet percent consumed also graphs. Information pulls from recordings performed in Medact.
Individual totals for NPH, Regular, IV and Miscellaneous insulin, as well as oral agents given,
print in 1-hour increments.

Sliding Scale
Sliding scales print on a separate page.
The date, time, name and credentials of the person who entered the scale will print.
Indicates if the sliding scale is IV or subcutaneous.
Gray indicates an inactive sliding scale.
White indicates an active sliding scale.
Comments: This is an optional feature. Please notify hospital Information Technology
Department.

Legend: Located bottom left hand corner of the Diabetic Flow Sheet.
"*" indicates more than one result during this time period
"^" indicates a blood glucose > 300
"o" or plain text indicates Point of Care entry
• or Bold indicates Lab result

NOTE: In order for lab results to pull to the Diabetic Flow Sheet, the POC control record must be
set up to include the items from lab. The item descriptions listed in the POC control record must be
set up in the Reference Range Tables.

The following is a full display of the ICU format of the Diabetic Flow Sheet.

16.5 Weekly Report

The Weekly Report will display the most recent seven days of entered data for the patient. This
report is utilized for capturing less frequently entered data such as seen on a Medical Surgical Unit.

Select Charts > Select Patient Account > Attachments > Diabetic > Weekly Diabetic Report

Diabetic Weekly Report

Data included on the Weekly Diabetic Flow Sheet is outlined below:

Demographics Box (located upper right-hand corner)

Patient's name
Admitting physician
Account number, age, sex and room number
Medical Records number
Any drug allergies documented through Thrive

Diet
The patient's current diet will display in the top right-hand corner of the report, just below the
demographics box.

Graphic Display
7-Day graphic representation of all insulin and blood sugar levels.
All blood sugar levels plot on the graph, however only the most recent level/time in each 6-hour
increment prints on the report.
Asterisks indicate more than one level charted within a 6-hour increment.
Interventions print vertically under the time period for which they were performed.

Lab results plot separately and are indicated in bold.

Diet percent consumed also graphs. Information pulls from recordings performed in Medact.
Individual totals for NPH, Regular, IV and Miscellaneous insulin, as well as oral agents give print
in 6 hour increments.

Sliding Scale
Sliding scales print on a separate page.
The date, time, name and credentials of the person who entered the scale will print.
It will indicate if the sliding scale is IV or subcutaneous.
Gray indicates an inactive sliding scale.
White indicates an active sliding scale.
Comments, This is an optional feature, please notify hospital Information Technology
Department.

The following is a full display of the Weekly format of the Diabetic Flow Sheet.

16.6 Attachments
The Attachments area will contain any Scanned Images, Electronic Forms or Photo Uploads that
have been assigned to this section.

Select Charts > Select Patient Account > Attachments > Diabetic > Attachments

Diabetic - Attachm ents

Deleted Items will display

Setup to display items may be referenced in the Image Title User Guide or the Electronic Forms
User Guide.

will display if data is not present in this area to be viewed

Chapter 17 Miscellaneous

17.1 Overview
This section will discuss access to Miscellaneous functions from Updated ChartLink.

Select Updated ChartLink > Charts > Select Patient Account > Attachments > Miscellaneous

Miscellaneous

17.2 Census Report

The Physician Census is a document that provides physicians with a concise listing of the patients
for whom they are the attending or consulting physician, as well as the patient’s most recent vital
signs.

Select Charts > Select Patient Account > Attachments > Miscellaneous > Census Report

Census Report

Data included on the Physician Census is outlined below:

Physician Name Box (located upper right-hand corner)

Physician's name
The name of the nursing unit
This information is duplicated along the bottom edge of the report as well.

Patient Information: Each page will display information for one patient and will include the
following:
Patient room number
Patient name, age, sex, and length of stay
Admitting diagnosis
Demographics: Condition, Advanced Directives, Restraints, Admit Date, Medical Record
Number, Violent, MRSA, VRE, Isolation, Fall Risk, Language, and Ethnicity
Most recent set of vital signs
Temperature (including site)
Pulse (including site)
Respiration

Blood pressure (including posture and extremity)

Oxygen: L/M, FiO3, O3 Sat, and Method
Most recent weight
Date and time the vitals were charted
Name and title of the person who charted the vitals

NOTE: Patients, for whom a physician is consulting, are highlighted in a gray box. The attending
physician's name is indicated at the top of the box.

The Census Report will display in Adobe Acrobat Reader format.

The following is a full display of the Census Report.

17.3 Attachments
The Attachments area will contain any Scanned Images, Electronic Forms or Photo Uploads that
have been assigned to this section.

Select Charts > Select Patient Account > Attachments > Census > Attachments

Census - Attachm ents

Deleted Items will display

Setup to display items may be referenced in the Image Title User Guide or the Electronic Forms
User Guide.

will display if data is not present in this area to be viewed.

Chapter 18 Face Sheet

18.1 Overview
This section will discuss the feature of the Face Sheet.

Select Updated ChartLink > Charts > Select Patient Account > Attachments > Face Sheet

Face Sheet

18.2 Face Sheet

The Face Sheet is the patient’s record of admission.

Select Charts> Select Patient Account > Attachments icon > Face Sheet

Face Sheet

The data included on a Face Sheet is facility defined. Some examples of patient data that can be
included on the Face Sheet is outlined below:

Patient Name
Room Number
Hospital Number
Address
Age
Birth date
Sex
Birthplace
City
State
Zip Code
Social Security Number
Religion
Patient Telephone
Spouse Information
ho to Notify in an Emergency
© 2018 Evident
Face Sheet 207

Patient Employer
Guarantor Name
Admitting Physician
Consulting Physician
Admitting Service
Admitting Diagnosis
Allergies
Date of Last Admission
Admission Date
Time of Admission
Financial Class
Medical Records Number

The Face Sheet will display in Adobe Acrobat Reader format.

The following is a full display of the Face Sheet .

18.3 Attachments
The Attachments area will contain any Scanned Images, Electronic Forms or Photo Uploads that
have been assigned to this section.

Select Charts > Select Patient Account > Attachments > Face Sheet > Attachments

Face Sheet - Attachm ents

Deleted Items will display

Setup to display items may be referenced in the Image Title User Guide or the Electronic Forms
User Guide.

will display if data is not present in this area to be viewed.

Chapter 19 Other

19.1 Overview
This section will discuss the Other section under attachments located in Updated ChartLink.

Select Updated ChartLink > Charts > Select Patient Account > Attachments > Other

Other

19.2 Attachments
The Attachments area will contain any Scanned Images, Electronic Forms or Photo Uploads that
have been assigned to this section.

Select Charts > Select Patient Account > Attachments > Other > Attachments

Other - Attachm ents

Deleted Items will display

Setup to display items may be referenced in the Image Title User Guide or the Electronic Forms
User Guide.

will display if data is not present in this area to be viewed.

Chapter 20 Growth Charts

20.1 Overview
Growth Charts consist of a series of percentile curves that illustrate the distribution of selected
body measurements in children. Growth charts are tools that contribute to forming an overall
clinical impression for the child being measured. Growth charts can be added to Virtual Chart tab
and printed at any time.

20.2 Growth Charts

Various growth charts, including WHO Growth Charts, are available depending upon the patient's
age range and gender. Growth Charts for boys display blue and girls display pink. Weight and
height must be present on the account in order for the growth charts to be accessible. Head
circumference must be present for WHO Growth Charts. Physicians will have the ability to view
historical growth charts: all charts from birth through the current age. Additionally, two different
growth charts (5th to 95th Percentile and 3rd to 97th Percentile) are selectable, either for the
current age or to include historical weight and height entries.

Select Reports and Attachments > Growth Charts

Grow th Charts

Include only Well Child Visits: If selected, the growth chart that is chosen will only display the vital
signs entered on a patient that has the Well Child check box selected in Vital Signs entry. If this is
deselected, all vitals display.

Show All Charts for Historical Comparison: If selected, all available Growth Charts that exist for
the patient will be displayed for selection.

Data included on the available Growth Charts is outlined below:

Birth to 36 Months
Length-for-age and Weight-for-age for the sex of the patient - Set 1 (5 - 95 Percentile)
Length-for-age and Weight-for-age for the sex of the patient - Set 2 (3- 97 Percentile)
Head Circ. and Weight -for-length for the sex of the patient - Set 1 (5 - 95 Percentile)
Head Circ. and Weight for length for the sex of the patient - Set 2 (3- 97 Percentile)

2 Years to 5 Years
Weight-for-stature for the sex of the patient - Set 1 (5 - 95 Percentile)
Weight-for-stature for the sex of the patient - Set 2 (3- 97 Percentile)

2 Years to 20 Years
Stature-for-age and Weight-for-age for the sex of the patient - Set 1 (5 - 95 Percentile)
Stature-for-age and Weight-for-age for the sex of the patient - Set 2 (3- 97 Percentile)
Body Mass Index for the sex of the patient - Set 1 (5 - 95 Percentile)
Body Mass Index for the sex of the patient - Set 2 (3- 97 Percentile)

WHO Birth to 24 Months

Length-for-age and Weight-for-age for the sex of the patient
Head Circ. and Weight-for-length for the sex of the patient

No attachments found displays when there are no vitals signs available for the age ranges
within a Growth Chart.

The following page is an example of a growth chart.

The following information will display on the Growth Chart:

Name: Patient Name from the Patient Profile.

Record #: Medical Record Number from the Patient Profile.

Date: The date the vitals were entered from the Date/Time field in the Vitals application.

Age: The patient's age at the time the vitals were entered in y,m,d format.

Weight: The patient's weight in pounds.

Stature: The patient's height in inches.

BMI: The patient's calculated Body Mass Index from the weight and height.

Male patients will display in blue font. Female patients will display in pink font.

The Export option displays on the action bar allowing the growth chart to be printed.

Select the back arrow to return to the Growth Charts.

Intrusion Detection Honeypots
From Everand
Intrusion Detection Honeypots
Chris Sanders
3/5 (2)
Powerchart Review Guide v2 1rp
No ratings yet
Powerchart Review Guide v2 1rp
6 pages
V11.5 (EXE) Release Notes
No ratings yet
V11.5 (EXE) Release Notes
393 pages
I Don't Need an Acting Class
From Everand
I Don't Need an Acting Class
Milton Justice
5/5 (3)
Aquaponic Design Plans Everything You Needs to Know: Everything You Need to Know from Backyard to Profitable Business
From Everand
Aquaponic Design Plans Everything You Needs to Know: Everything You Need to Know from Backyard to Profitable Business
David H Dudley
No ratings yet
Data Administration Reference Guide
100% (1)
Data Administration Reference Guide
346 pages
VRV-4 Heat Pump Service Manual PDF
No ratings yet
VRV-4 Heat Pump Service Manual PDF
244 pages
Day Trader-Forex Trading
From Everand
Day Trader-Forex Trading
Murry Naga
No ratings yet
Audio, Video, and Media in the Ministry
From Everand
Audio, Video, and Media in the Ministry
Clarence Floyd Richmond
No ratings yet
How to Sell on Amazon and Product Research: Product Research Tips and Practical Guide on How to Find a Winning Product to Sell on Amazon Fba
From Everand
How to Sell on Amazon and Product Research: Product Research Tips and Practical Guide on How to Find a Winning Product to Sell on Amazon Fba
David L. Ross
No ratings yet
GE Centricity Practice Solution (CPS) Training For New Medical Providers
No ratings yet
GE Centricity Practice Solution (CPS) Training For New Medical Providers
39 pages
Msme-Technology Development Centre, Agra: Certified By: Government of India
50% (4)
Msme-Technology Development Centre, Agra: Certified By: Government of India
3 pages
Gray Hat Hacking the Ethical Hacker's
From Everand
Gray Hat Hacking the Ethical Hacker's
Çağatay Şanlı
5/5 (1)
Chart Link
No ratings yet
Chart Link
296 pages
Being Tchitaka
From Everand
Being Tchitaka
RODRIGUE TCHITAKA
No ratings yet
Options Trading for Income: Learn the strategies and techniques for maximizing returns and minimizing risk in the options market (2023 Guide for Beginners)
From Everand
Options Trading for Income: Learn the strategies and techniques for maximizing returns and minimizing risk in the options market (2023 Guide for Beginners)
Lane Conner
No ratings yet
BlockChain for Beginners
From Everand
BlockChain for Beginners
Matthew Smith
No ratings yet
SENIOR CITIZEN LIVING: Discover How You Can Make Your Senior Years As Golden as Possible!
From Everand
SENIOR CITIZEN LIVING: Discover How You Can Make Your Senior Years As Golden as Possible!
Karllo MELLO
No ratings yet
Aquaponics Design Plans, Construction, Operation, and Income: Organic Food
From Everand
Aquaponics Design Plans, Construction, Operation, and Income: Organic Food
David H Dudley
No ratings yet
Kellory the Warlock
From Everand
Kellory the Warlock
Lin Carter
No ratings yet
Aquaponics for Profit
From Everand
Aquaponics for Profit
David H Dudley
No ratings yet
Keys to Better Reading
From Everand
Keys to Better Reading
Judy McFall
No ratings yet
ChatGPT for Business: Strategies for Success
From Everand
ChatGPT for Business: Strategies for Success
Matthew C. Smith
1/5 (1)
Aquaponics How to do Everything from Backyard to Profitable Business: from BACKYARD to PROFITABLE BUSINESS
From Everand
Aquaponics How to do Everything from Backyard to Profitable Business: from BACKYARD to PROFITABLE BUSINESS
David H Dudley
No ratings yet
Nutrition Essentials
From Everand
Nutrition Essentials
Allen Nissanth
No ratings yet
Osama the Gun
From Everand
Osama the Gun
Norman Spinrad
5/5 (1)
Software Patterns Made Easy
From Everand
Software Patterns Made Easy
Justice Nanhou
No ratings yet
The Peptide Protocols: Exploring the Science for Human Optimization: Exploring the
From Everand
The Peptide Protocols: Exploring the Science for Human Optimization: Exploring the
W T Smith
No ratings yet
Aquaponics Construct and Operate: Instructions and Everything You Need to Know
From Everand
Aquaponics Construct and Operate: Instructions and Everything You Need to Know
PE David H. Dudley PMP
No ratings yet
Human Nature Potential in Nurture
From Everand
Human Nature Potential in Nurture
David L. Hawk
No ratings yet
The Amazing Biological Revolution and The Amazing New Health Care
From Everand
The Amazing Biological Revolution and The Amazing New Health Care
Bertil Lindmark
No ratings yet
10K Blueprint
From Everand
10K Blueprint
Cian O Farrell
5/5 (2)
Aquaponics Build and Operation Manual: Step-by-Step Instructions, 400+ Pages, 200+Helpful Images
From Everand
Aquaponics Build and Operation Manual: Step-by-Step Instructions, 400+ Pages, 200+Helpful Images
David H Dudley
No ratings yet
The Stock Market from A to See - 2nd Edition
From Everand
The Stock Market from A to See - 2nd Edition
John Nunez
No ratings yet
Web Video Business
From Everand
Web Video Business
MUHAMMAD NUR WAHID ANUAR
No ratings yet
Table Maintenance Clinical
No ratings yet
Table Maintenance Clinical
322 pages
QRDA HQR 2023 CMS IG v1.508
No ratings yet
QRDA HQR 2023 CMS IG v1.508
76 pages
Pharmacy
No ratings yet
Pharmacy
337 pages
Incoming Orders Reports
No ratings yet
Incoming Orders Reports
20 pages
reference_masters_paragon_23_2_pr6_caregiver_reference_master_2025-01-27-09-48-05
No ratings yet
reference_masters_paragon_23_2_pr6_caregiver_reference_master_2025-01-27-09-48-05
42 pages
Prescription Entry
No ratings yet
Prescription Entry
138 pages
Cerner Resource Guide
100% (1)
Cerner Resource Guide
87 pages
Medical Software Feature Checklist
No ratings yet
Medical Software Feature Checklist
8 pages
Pedrajeta-Documentation and Interprofessional Communication
No ratings yet
Pedrajeta-Documentation and Interprofessional Communication
12 pages
1documentation Reporting - Erin - 2020
No ratings yet
1documentation Reporting - Erin - 2020
35 pages
PHRED-student-quick-guide
No ratings yet
PHRED-student-quick-guide
2 pages
Documentation for Health Records - 2nd Edition all chapter
No ratings yet
Documentation for Health Records - 2nd Edition all chapter
15 pages
2024 Centene MRA Coding Guidelines Playbook 8.2.2024
No ratings yet
2024 Centene MRA Coding Guidelines Playbook 8.2.2024
62 pages
Documentation for Health Records, 2nd Edition Full-Resolution Download
100% (15)
Documentation for Health Records, 2nd Edition Full-Resolution Download
15 pages
Day 7 Part 2 Hosp Settings Req, and Reports Part 2
No ratings yet
Day 7 Part 2 Hosp Settings Req, and Reports Part 2
39 pages
Pocket Nursing Skills What You Need to Know Now 1st Edition Judith M. Wilkinson Phd Arnp 2025 scribd download
No ratings yet
Pocket Nursing Skills What You Need to Know Now 1st Edition Judith M. Wilkinson Phd Arnp 2025 scribd download
67 pages
Tracking Board
No ratings yet
Tracking Board
75 pages
Patient Education Documents
No ratings yet
Patient Education Documents
100 pages
Patient Data Console
No ratings yet
Patient Data Console
47 pages
9780803676909-TEST-BANK-TEST BANK-ch31
No ratings yet
9780803676909-TEST-BANK-TEST BANK-ch31
33 pages
AoT - Toward Airport Sustainability
No ratings yet
AoT - Toward Airport Sustainability
34 pages
Enzymes Concept Map
No ratings yet
Enzymes Concept Map
1 page
OceanofPDF.com Lout of the Counts Family Volume 1 - Yu Ryeo-han
No ratings yet
OceanofPDF.com Lout of the Counts Family Volume 1 - Yu Ryeo-han
348 pages
Concept Map On Hypertension
No ratings yet
Concept Map On Hypertension
1 page
1 - Gulfstream Park RETROSPECTO
No ratings yet
1 - Gulfstream Park RETROSPECTO
13 pages
Electrochemistry - Concentration Cells
No ratings yet
Electrochemistry - Concentration Cells
5 pages
DDS New
No ratings yet
DDS New
47 pages
Dicc Xii Chem 400 Mcqs
No ratings yet
Dicc Xii Chem 400 Mcqs
18 pages
Graboflex Gymfit 60 ENG
No ratings yet
Graboflex Gymfit 60 ENG
1 page
CSCE S850 2013 Vancouver PDF
No ratings yet
CSCE S850 2013 Vancouver PDF
2 pages
Introduction To G1000 Search Patterns: Minnesota Wing Advanced Aircrew Training
No ratings yet
Introduction To G1000 Search Patterns: Minnesota Wing Advanced Aircrew Training
42 pages
idirect-104-hub-ULC-R-0916
No ratings yet
idirect-104-hub-ULC-R-0916
1 page
66 Books
No ratings yet
66 Books
102 pages
Lecture 2
No ratings yet
Lecture 2
23 pages
MICROBIOLOGY BOARD EXAM QUESTIONS-questions
100% (4)
MICROBIOLOGY BOARD EXAM QUESTIONS-questions
6 pages
Technical Data Sheet Yipin Red Iron Oxide YPC33200
No ratings yet
Technical Data Sheet Yipin Red Iron Oxide YPC33200
2 pages
Mon Mar 29, 7:57 PM The Canadian Press: Calgary Police Charge Four After $60-Million Ponzi Scheme Investigation
No ratings yet
Mon Mar 29, 7:57 PM The Canadian Press: Calgary Police Charge Four After $60-Million Ponzi Scheme Investigation
2 pages
The Pulp, The Root-Treated Tooth and The Crown
No ratings yet
The Pulp, The Root-Treated Tooth and The Crown
11 pages
Safety_Presentation
No ratings yet
Safety_Presentation
12 pages
Tactical Aviation Tactics Techniques and Procedures
100% (2)
Tactical Aviation Tactics Techniques and Procedures
275 pages
Construction Machinery Brochur IGUS
No ratings yet
Construction Machinery Brochur IGUS
24 pages
(123doc) - Bai-Giang-De-Thi-Thu-Dh-Cd-2
No ratings yet
(123doc) - Bai-Giang-De-Thi-Thu-Dh-Cd-2
5 pages
Wireless Seminar Report
0% (1)
Wireless Seminar Report
36 pages
Storytime - August 2016
100% (1)
Storytime - August 2016
52 pages
Telefunken Replacement Black DataSheet EN
No ratings yet
Telefunken Replacement Black DataSheet EN
1 page
Kurukshetra
No ratings yet
Kurukshetra
66 pages
Wastewater Story Lesson Plan
No ratings yet
Wastewater Story Lesson Plan
3 pages
From Formation To Ecosystem Tansleys REsponse To Clements Climax
No ratings yet
From Formation To Ecosystem Tansleys REsponse To Clements Climax
30 pages