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Diabetes Educators Calgary Charting Guidelines

Charting for Classes or Joint Appointments

Documenting Class (Group) Attendance

  • 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. You should no longer use "Visit with Allied Health or Specialty Encounter" to capture activity. It is automatically captured, by recording the providers who are facilitating the class.

 

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”  
  19. CHANGE: Do not use the Attendance/Visit tab, 
  20. Click 'Sign note and Next'. If the button is not working, click the “Next” button. Once you’ve completed the charting on each patient who attended, go to the Schedule view and open each of the charts where “Sign” did not take, and sign each chart.
  21. Continue the process through each chart of patients who attended the class. 

No Shows for Classes

Intro to Pump Class - Missed appt: 

  • From the schedule, highlight the appointment/patient’s name, and click “No Show” at the top.
    • The dialogue box allows you to chart Action, Outcome, Comments as relevant.
  • From the schedule, highlight the appointment/patient’s name and click on “chart.”
  • Create a documentation encounter. Reason for documentation = No show
    • e.g. DCCCMissedAppt and add patient missed Intro to Pump Class. 
  • Use the Communication tab to to send to the patient's regular Diabetes Educator and MD if required. 

 

Option 1 DIP : If patient is enrolled at your site call patient to reschedule.

  • From the schedule, highlight the appointment/patient’s name, and click “No Show” at the top.
    • The dialogue box allows you to chart Action, Outcome, Comments as relevant.
  • From the schedule, highlight the appointment/patient’s name and click on “chart.”
  • Create a documentation encounter. Reason for documentation = No show
    • Document brief note to send to PCP, or other provider as appropriate, informing them of No Show, and the outcome of the phone call. Use the Smartphrase DIPCMISSEDAPPT
  • Use the Communication tab to “Send All Notes” to PCP, or other providers as appropriate.

 

Option 2 DIP: If patient is enrolled at another site, do not contact patient to re-schedule. Defer to their original site to complete this task.

  • From the schedule, highlight the appointment/patient’s name and click on “chart.”
  • Create a documentation encounter. Reason for documentation = No show
    • Document brief note to send to PCP, or other provider as appropriate, informing them of No Show. Use the Smartphrase .DIPCMISSEDAPPT
    • Action: Patient did not attend the GDM class via Zoom. Educator will inform the RGH DIP clinic.
    • Plan: Other site [e.g. RGH DIP] clinic to re-schedule patient.
  • Use the Communication tab to “Send All Notes” to PCP, or other providers as appropriate.
  • Send In Basket message to the appropriate DIP clinical support pool (e.g. p CGY RGH Endocrinology DIP Clinical Support) to inform team that patient did not attend and to reschedule patient.

Non-registered patients (e.g. AHLP)

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

 

Joint Appointments

For visits where there are 2 or more providers involved, notes are combined into a single encounter. If the appointment is booked as a joint appointment, the patient is checked in for both scheduled appointments. Each provider opens the chart from their own schedule. Make note of the following:

  • Charting proceeds as usual.
  • Each provider creates their own note and accepts. 
  • Once all providers have completed their notes, a communication can be sent to the appropriate recipients. The Progress Report combines both notes, but clearly identifies who said what.
  • Once all providers are done charting, Sign Visit.
    • Note that you're not able to sign visit before all providers have accepted their note.
    • Until the encounter is signed, there will be an InBasket message alerting both providers that there's an open encounter. 
  • Activity is automatically recorded for the providers to whom the encounter is scheduled. 

Printing Class Lists

  • Go to Schedule (the page you "check in" your patients from).
  • Directly under where it says "Schedule", near top left, click "Open Slots"
  • Choose the day on calendar that corresponds with the class
  • Click your department, e.g. CGY RRDTC DIABETES EDUCATORS so it opens
  • Scroll down past some educator names, to click on your class name. E.g. CGY RRDTC DIABETES INTRO TO PUMP CLASS.  Now, on the right you'll see rows with patient names appear.
  • At the very top right on the Epic toolbar, choose "Print" > Schedule ...and choose your printer or print to PDF