Documentation Specialty CSD Work Package

This "Documentation” work package is a next step for groups growing more customization-capable. There are eleven decisions to tackle: one question homes in on how outpatient intake activities are documented; three questions seek essential specialty additions to those parts of a patient’s health history that persist across encounters; one question elicits quantitative measures, such as health function scores, that are unique to a specialty and important to document; and the remaining questions are all about how chart navigation might need to be customized for admission, discharge and transfer activities.

The associated tasks relate to:

  • Determining whether any chart organization adaptations are essential to specialty function

  • Validating standard medical, surgical and other health history sections and considering whether there are specialty-specific additions that must be added to these patient-level chart sections

  • Familiarizing to AHS standard admission, discharge and transfer navigators while advising about any essential customizations that cannot otherwise be handled through text-automations (e.g., SmartText) within the standard navigators

Objectives

The following questions need to be addressed as part of this work package:

  1. Is there anything completed in your typical Intake workflow that is not captured by the Rooming tab?

  2. Does the Medical History section require any essential customizations to address unique specialty needs?

  3. Does the Surgical History section require any essential customizations to address unique specialty needs?

  4. Are additions to the History section essential for your specialty? If so, what needs to be added?

  5. Are there discrete measures (assessments, scores, etc.) essential to document and track outside of chart notes?

  6. Are there essential changes to the inpatient admission navigator required by your specialty?

  7. Are there essential changes to the inpatient discharge navigator required by your specialty?

  8. Are there essential changes to the inpatient transfer navigator required by your specialty?

  9. Are there essential changes to the inpatient nursing admission navigator required by your specialty?

  10. Are there essential changes to the inpatient nursing discharge navigator required by your specialty?

  11. Are there essential changes to the inpatient nursing transfer navigator required by your specialty?

Presentations

Resources