Diabetes Educators Calgary Charting Guidelines
Optimization Tips
Optimization Tips
Thank you to all the staff who have contributed to the tips shown, or linked to below. Please submit all further tips that you'd like to share!
Use Ctrl+F to search one keyword.
Applicable to CC in General
- Search the entire chart
With a patient chart open, use the Search bar at the top to find every place a specific word is found, including in provider notes.
The date of the appearance, type of note, and the description of where in the chart the word is found, is shown.
Hover your mouse over the specific result to read the entry from that date. - Dietitians: PES statements
Create several macros to speed up the documentation of nutrition diagnoses. Use the Macro Manager to create and name the most common nutrition diagnoses that you use. Consult with one of your tech-savvy colleagues, Madeleine McIntyre, or with Dave, if you need help with this.
To add the PES statement to any note in CC, use the Smart Link {IP FN NUTRITION DIAGNOSIS FLOWSHEET:3047689} . The link has been added to the SmartLink table on our website: Department Smart Phrases | Cumming School of Medicine | University of Calgary - Adding Macros
Many sections (CGM Metrics, Safety Checklist, Foot Screening Tool, etc) allow you to add Macros to speed up entry of common values for fields. For example, you might have 2 or three common glycemic target levels that you use repeatedly. You could create a Macro called DIP, that allows you to fill DIP-specific targets with one click.
If you see the option "Macro Manager" in a section, click on it > Give the macro a name and enter the values. Click on 'Close'. Subsequently, you can fill all values by clicking on the name you gave the macro.
Applicable to Diabetes in General
- This Visit in sidebar
When you open a patient chart in 'Pre-charting' mode, consider adding This Visit to your sidebar (on the right-hand side). Use the search box at the top of the chart to look for "This Visit". Click on it. Once added to the Activity row, click on the down-arrow for This Visit tab and add to sidebar. This gives you a read-only view of the Patient Summary and DM Management Trends (CGM Trend, Insulin Trend, most recent Insulin Instructions, etc). - Expanded view for glucose documentation
Often people will use ranges when documenting CBG readings in the “Glucometer” section of the Diabetes Management tab. There are occasions, though, when you might want to record values day-by-day for a few days (e.g. tapering corticosteroids). For a quicker way to document several days click Flowsheets at the right side of the Glucometer section.
Then select “Expanded”, then “24h”:
You can now record data for several days, if that is the better option in the circumstances.
Diabetes in Pregnancy
- Gestational weight gain
Enter pre-gravid height, weight, number of fetuses through the OB tools tab.
After the initial entry described in a. above, RDs are able to use the Nutrition tab to enter current weight. As long as the encounter is linked to the pregnancy episode, the weight will show up on the maternal weight gain chart. RNs can continue to use the OB tab to enter current weight.
View gestational weight gain using the Growth Chart tab. Pin it to your Activity tool bar for quick access. - Possible euglycemic DKA
The following SmartPhrase [.KHDM1Overview] can be used to document the risk of euglycemic DKA in pregnancy in T1DM. The phrase will insert data entered in the "Diabetes Problem List SmartForm" under the Diabetes Management tab plus the wording: "<Name> is at risk of diabetic ketoacidosis. If unwell with symptoms of nausea, vomiting, abdominal pain, or if dehydrated or missed insulin doses, should be screened with serum or urine ketones, and if positive, for acidosis and anion gap. This can occur even with normal or slightly high blood glucose. If anion gap elevated and acidosis present in the setting of ketones, manage with IV fluids and IV insulin until resolved."