Diabetes Educators Calgary Charting Guidelines

Login department is Calgary Zone Endocrinology

General Step by Step

Navigate Resources for Declined Patients

Review the Chart

Smart Phrases

1. Log in to Connect Care as a "Consult Nurse" in the department Calgary Zone Endocrinology.

2. One time only: Create "My Favorite Lists" to add the following. Note that only sites that have gone live already will be available. For sites that have not yet gone live, use SCM.

• CGY Peter Lougheed Centre > New Consult-Ancillary > Diabetes Educator
• CGY Foothills Medical Centre > New Consult-Ancillary > Diabetes Educator
• CGY Rockyview General Hospital > New Consult-Ancillary > Diabetes Educator
• CGY South Health Campus > New Consult-Ancillary > Diabetes Educator

Check the folder several times per day for Consult requests.

3. For consult requests:

• Review the chart (see below)
• Add your note.
  • Very important** Use Type = Progress Note.
  • Use "Smart Phrases" to make charting quicker. All IDNN smart phrases start with .IDNN
  • Route the note to specific providers, if desired.
• When your consult is complete, go to Patient List > Single click on patient > Rapid Rounds > Ancillary Consults > Click "Complete"
• **VERY IMPORTANT** If you see a tab "Attendance/Visit"... this is for stats. 
  • If you had an an encounter with a patient that was not scheduled to you, you need to document on that tab. e.g. choose “Visit with Allied Health or Specialty Encounter”  or if you spoke to family and the patient was not present, choose "Phone/Virtual Allied Health Specialty Visit with inpatient's family/significant other"
  • If do not have an encounter with the patient, e.g. interact with the nursing unit staff only, you do not record activity. 

CAT puts declined patient referrals in Diabetes shared drive → Restricted_IP

Nurse Navigator makes note of Connect Care site or not. If it is a CC site:

• Search Patient on CC
• Click Telephone Call
  • Enter the referring provider > Accept
• Click Outgoing Call
• Map out a plan of resources that would best fit the patient’s needs in the My Notes section
  • Letting them know patient has been declined but they will navigate resources for them
  • See if they are following up with anyone (e.g. Family doctor)
• Click Accept
• Click Sign Encounter
• Send note to referring physician and/or family doctor letting them know that Diabetes Centre will not be following up with pt (declined referral) and provided pt with resources.

Nurse Navigators use a 14 day window to reach pt. Within the 14 days, they will try to call them a few times. If unable to reach, they make note of it and close the file.

1. Storyboard (left side of screen) - Age, pt. location, diagnosis, etc
2. Summary tab
   1. Overview Tab – shows meds and when they were given last, Blood glucose results the last 24 h.
   2. Plan of Care – shows Care Team info, outpatient meds
   3. Glucose Management – graph of glucose levels, insulin doses given (helpful with s/s)
3. Results review tab
   1. Click on blood -> endocrine -> diabetes – it shows trend of A1c, glucose, glucose meter, etc over time.
4. Orders tab
   1. Can find info about the consult here (ie, reason for referral and referring provider).  Scroll down to Consults and Referrals > hover over the order > click on a little notepad on the right side (see screenshot below)
5. Notes tab
   1. Can find all notes, progress notes (hx and physical admitting notes
   2. This is where the IDNN charts, by creating “new note”.  Route the note to the ordering provider.

Making Smart Phrases Available to You:

See this link for a video demonstration of adding smart phrases and customizing your speed buttons. See this page for textual step-by-step directions.

IDNN Smart Phrases