Diabetes Educators Calgary Charting Guidelines

• Documenting Class Attendance
• Non-registered e.g. AHLP patient Activity
• Joint Appointments

See this link for the Connect Care tip sheet. This video walks through the steps below.

Documenting group attendance as outlined below will automatically move patients to providers' schedules, without manually moving them.

See below for documenting the activity for non-registered patients.

Summary of the steps:

• Use the "Schedule" view in Connect Care. Click on "Document Group" at the top right (if it's not visible, use the "More" dropdown).
• In the window that opens, document the start time and end time, Topic = 'Education Class', Department as appropriate for the class. Click on 'Create'
• Select the patients that attended.
  • 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 the 'Group Name' and 'Group Summary' then click 'Continue'
• The Group Note will generate for the first person on the class list. You can confirm which patient you are looking at on the Storyboard.
  • If indicated, a personalized note may be added at the bottom of the Group Note for that specific patient
  • Ensure that the problem list is accurate, to the best of your knowledge.
  • Add a visit diagnosis at the bottom. 
• Click on 'Sign when signing visit', then 'Sign Note and Next'
• Continue the process through each chart of patients who attended the class.

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:

See this Tip Sheet  OR

7 minute video

For visits where there are 2 or more providers involved, notes can be combined into a single encounter. Individual free text notes clearly show who charted what.

• The first provider charts as usual, but doesn’t sign the visit.
  • Accept the note.
  • Do not Sign the visit.
• The second provider opens the unsigned encounter and charts as usual.
  • Accept their own note.
  • Send the communication, as appropriate. Use 'Send All Notes'.
  • Then Sign the visit.
• Note that activity is automatically recorded for the provider to whom the encounter is scheduled. The other provider needs to document activity using the 'Attendance/Visit' tab.