Diabetes Educators Calgary Charting Guidelines

• Documenting Class Attendance
  • No Shows for Classes
• Non-registered e.g. AHLP patient Activity
• Joint Appointments
• Printing Class Lists

• There is a CC tip sheet located here. Below, we have directions specific to our program.
• An unlisted video is here. 
• We've updated our directions for documenting group attendance, with 2 main changes:
  1. Do not move the appointment to your own schedule (i.e. DO NOT click on "Change provider to me").
  2. Be sure to capture activity by using "Visit with Allied Health or Specialty Encounter".

Summary of the steps:

1. Use the "Schedule" in Connect Care near top left. Select the date of the class. 
2. Ensure that you have the correct department (Dept) selected on the left under the calendar. e.g. "CGY SMG Endocrinology DIP"  or  "CGY RRDTC Diabetes Educators"    
3. On the left, in the big rectangle where you see  "My Schedule" you will also see the department name. Click the black triangle (arrow) to the left of the department name. It opens up all the resources (all your peers schedules, and all the classes for that department). You may already have this section open.
4. Scroll down and click on the resource that corresponds to the class name you are teaching. 
   • e.g. department name "CGY SMG Endocrinology DIP" teaching resources
     • CGY SMG Endocrinology DIP Insulin Class
     • CGY SMG Endocrinology DIP GDM Class
   • e.g. department name "CGY RRDTC Diabetes Educators" teaching resources
     • CGY RRDTC Diabetes Medtronic Pump Class  
     • CGY RRDTC Diabetes Automode Pump Class 
     • CGY RRDTC Diabetes Tandem Pump Class 
     • CGY RRDTC Diabetes Omnipod Pump Class 
     • CGY RRDTC Diabetes Any Indiv Pump Class. (This a class of 1 person)
     • CGY RRDTC Intro to Pump 
     • CGY RRDTC ZOOM Intro to Pump 
     • CGY RRDTC ENTRY CLASS
5. Check-In people as they arrive to the class.
6. Mark as "no show" if they did not attend and send appropriate Documentation encounter. 
7. After class, on the Schedule view, click on one person in the class, then click "Document Group" at the top right (if it's not visible, use the "More" dropdown). If you have two individual pump starts that morning (.e.g two CGY RRDTC Diabetes Any Indiv Pump Classes)  click on one patient, click Document Group and finish. Then do the same for the second patient as they are in separate classes of "1". 
8. In the window that opens
   • Document the start time and end time (you can free text the time e.g. 1330 as easier than the time selector). 
   • Topic = 'Education Class',
   • Department as appropriate for the class. 
   • Click on 'Create'
9. Select the patients that attended, so their names move up to the first section. Note that all scheduled patients will show up, even if you have already marked them as 'No Show'. Be careful to select only the patients that did show up.
   • If unscheduled patients attended the class, click on 'Open Patient Lookup' at the bottom left, and search for the patients individually.
   • Add Facilitator(s) 
   • Add a 'Group Name' and 'Group Summary'. Use the same plain language that is easy to understand for both e.g.  DM Insulin Start Class or Omnipod Individual Start or Tandem Individual Start or Tandem Group Start Class etc. 
   • Click 'Continue'.
10. The first chart opens. You can confirm which patient you are looking at on the Storyboard.
11. Add Visit Diagnosis at bottom.
12. The Group Note will be visible. You can put a smartphrase at bottom of this note if you wish. Click Sign When Sign Visit. 
13. Optional: Click "Note" tab on top right (the individual note tab you normally use) and use smartphrase (e.g.  .dcccpumpeducationintroduction ) or write a short note (e.g. Attended Intro to Pump) if you did not do this in the group note. Sign. 
14. You MAY see a summary tab with these warnings. These will be addressed below.  
    • No diagnosis for this encounter 
    • You have an incomplete note (Be sure you've saved it)
    • ! Recommended – The encounter provider CGY SMG Endocrinology DIP INSULIN CLASS is a generic resource. Ignore this warning.
15. Ensure that the problem list is accurate, to the best of your knowledge.
16. Reason for Visit (Rooming tab or Nutrition Tab if RD) = Group Education. Use type of class as further information for the Chart Review tab.
17. Send the Note to appropriate providers per usual practice. (Only send to patient's regular diabetes educator if this in Intro to Pump Class. The MD does not need a letter). 
18. Summary tab:  
    • Ignore the warning “! Recommended – The encounter provider CGY SMG Endocrinology DIP INSULIN CLASS is a generic resource. Please change the encounter provider to the actual provider”  
    • If there are 2 facilitators in the class, see the final step 19, below.
19. Under the Attendance/Visit tab, 
    1. RNs click the chevrons to expand the section "Activity STAT Charges quick list". [For RDs this is likely not be necessary.]
    2. Click the button "Visit with Allied Health or Specialty Encounter" 
    3. then click "Accept Charges".
20. Click 'Sign note and Next'.
21. Continue the process through each chart of patients who attended the class. 
22. If there are 2 educators in the class, the second educator documents goes to the generic resource (class name) in the schedule, as described in instructions above. 
    • Double-click on the name of the first person in the class. Choose 'Create Addendum'.
    • Go to the Attendance/Visit tab; click the button "Visit with Allied Health or Specialty Encounter" then "Accept Charges".
    • Sign Addendum, then go to the next attendee and repeat until you've documented your activity for each person who attended.

To document the activity for patients who are not registered to the program, e.g. Alberta Healthy Living Program (AHLP) patients who do not register with PHN:

7 minute video

For visits where there are 2 or more providers involved, notes should be combined into a single encounter. Individual free text notes clearly show who charted what. Note that if both providers are together in the same office, this works best if one is on a desktop PC and the other is on a laptop.

• All providers associated with that encounter (e.g. DIP clinic visit) log in and open the encounter as usual.
  • If the patient is scheduled to someone else, you open the encounter from that person's schedule.
• Charting happens as usual. Note that 2 or even 3 providers can have the same encounter open at the same time. Data entered by one provider will update for each provider.
  • Each provider creates their own note, and Accepts the note as usual.
  • Once all providers are done with their notes, a communication can be sent, using "Send all Notes."
  • Once all providers are done with their notes, Sign the Visit.
    • Note that CC will not allow you to sign the visit until all providers have accepted their notes.
    • Until the encounter is signed, there will be an In Basket message alerting providers that there's still an open encounter.
• Note that activity is automatically recorded for the provider to whom the encounter is scheduled. The other provider(s) needs to document activity using the 'Attendance/Visit' tab.