Clinical Documentation Supports

Core clinical decision supports apply to all clinical areas across the continuum of care. Accordingly, the core level attends to common building blocks, templates and modules that are widely used. Core documentation design provides the standards, style guides and formats that are to be adhered to by all specialty documentation design activities.

Context

The Connect Care Clinical Documentation Committee and related working groups provide the governance (including conduit to subject matter experts) and processes for supporting the establishment of standards, templates and decision-making as it pertains to broad or core clinical documentation clinical system design content decisions, communication and change management within Connect Care.

Oversight

• Committee: Clinical Documentation Committee

  • Nursing Content Standards & Practice Working Group

  • Allied Health Content Standards & Practice Working Group

  • Physician Content Standards & Practice Working Group

Principles

• Clinical Documentation Framework

• Clinical Documentation Directive

• Clinical Documentation Process Directive

• Documentation Norms – Providers

• Documentation Norms – Nursing & Allied Health

• Connect Care Minimum Use Norms

Processes

• Change (Progress) Documentation

• Clinical Copy-Paste

• Shared Documents

• Problem Oriented Charting

More Information

• Flowsheet Documentation

• Scales, Scores and Tools

• Smart Stuff

• Patient Portal and Related Documentation

• Summative Documentation

• Navigators

• Dictation

Resources

• Insite: CKCM Clinical Documentation Resources