A clinician’s guide to using EMR efficiently for rounds and catching up on patients when starting your shift.
Table of Contents
EMR provides helpful tools so you can quickly catch up on patients at the start of your shift. After learning from clinicians at over 100 advanced care centers, we put together this handy guide:
Vitals Screen
The Vitals Screen is a great place to start your day to see how your patient has been progressing.
- From the Status Board, you can get to the Vitals Screen by clicking the 3-dot menu to the left of a patient name or simply click the ‘Vitals’ button at the top of any treatment sheet.
- Vitals show the high/low values for the visit on the left side of the graph and you can hover over each entry on the graph to view the exact time and any notes entered when this vital was recorded. To dive deeper, click on the name of the vital to view the ‘Order History’.
- To quickly find a vital in the list, use the search box (top left) or toggle the ‘Only Show Active’ button (top right) to hide vitals that are not currently being recorded.
View Progress Note history
After viewing vitals, head to the progress notes.
Progress Notes is an optional order located at the top of each treatment sheet where nurses or doctors often write notes about the patient for a given hour.
We recommend reviewing all Progress Notes at the start of your shift by utilizing the ‘Order History’ feature. Click the 3-dot menu to the left of any order on the Treatment Sheet and choose ‘Order History’ to read through all the notes in one place.
💡 ProTip: You can use the Order History to see the complete history for any order, such as tracking the quantity, frequency, route, the doctor assigned, mandatory notes, and changes with order notes, which is accessible via the Order History screen. To learn more about reviewing Order History, click here.
Some hospitals prefer creating a separate ‘Doctor Notes’, ‘Nurse Notes’, or even a general ‘Communication Notes’ order and scheduling this on every treatment sheet around shift changes.
Next, if desired to read through all nursing notes hour-by-hour to be complete, click the current hour at the top of the screen:
Using the left/right arrow keys towards the top of the page, scroll through each completed treatment hour-by-hour backward to read all notes.
You can also use the arrow keys on the treatment sheet to view the forward schedule.
View One-time and Discontinued treatments
Don’t forget to check the discontinued/completed section which includes treatments completed with no future schedule.
- We recommend viewing the ‘Discontinued/Completed’ section found at the bottom of the treatment sheet to see what has already been performed for completeness.
Scan the Complete Treatment Sheet for Doses/Schedules
- Start by scanning the treatment sheet and confirming doses, infusion rates, and schedules.
- Review the medication category to see when the last dose was given and what the mg/kg dosage is for each drug at a glance.
Predicted Billing
Finally, get up to speed on the invoice and where the bill is headed using our Predicted Billing features.
- Predicted billing is found in the lower left of the Treatment, Vitals, and Invoice screens and displays the current invoice total. Past 24 hours (total money spent in the past 24 hours on a rolling basis), and live predictions of what the bill will be if this patient continues to stay in your hospital for 12, 24, 48 or 72 hours.
- The predicted totals are calculated live based on what you have scheduled on the treatment sheet and will have the most up to date billing information at any given time.
🧠Test your knowledge with our Careville Quiz!