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Diabetes Educators Calgary Charting Guidelines

Diabetes in Pregnancy

Diabetes in Pregnancy

  • The information on CC on this website is being moved to diabetes > Connect Care> !CC How To - START HERE. Then use ctrl+F in that document to find the your keyword.
  • Transferring to another DIP is a recent procedure. See the document listed in the bullet above and search for transfer.

 

DIP How To ...

 

Triage - DIP

 

Visits - DIP

 

DIP Clinics Prep

  • Video: Upload Glucose Records to media manager - future encounter - 2 min
    • Top Right Magnify class > type Media > choose Media Manager 
    • Search patient name 
    • Under patient name, click the small arrow, choose Encounter
    • Then select the encounter date/person you will associate this upload with
    • Click Scan at top of new open window (hit ok to error notice) 
    • Choose date, Document type (clincal), Write a description 
    • Click “import” at top of the box > hit upload (bottom right) 
  • Video: Status of Glucose Record Attachment for DIP Clinic (AHS Sharepoint limited access) (I min) 
    On the day’s schedule for MD, left of the patient name, click to see a round dot. Assign as green colour if you've uploaded glucose records, or yellow if you've contacted patient to remind them to send records.

 

Ordering Labs, Reprinting Lab Requisitions

  • Ordering Labs
    • Click "+ Add Order" at the bottom of the open chart
    • Search for HbA1c or A1c or meter check (add twice if requesting both).
    • Indicate "Future", "Routine", "Lab Collect" 
    • Sign orders - Authorizing Provider is usually the Referring Physician.
    • The lab requisition will print to your configured printer 
  • Reprinting a lab requisition
    • Go to Chart Review > Labs
    • Single-click the lab you need printed
    • On the right hand side where the preview opens, click "Order Details" 
    • Click "Reprint Order Requisition" to your printer to provide patient

 

Insulin Orders/Prescriptions

Of note: Prescriptions can be read in MD notes but cannot be printed by educators or clerks. 

  • MDs may print a paper copy of prescription, sign and give to patient or call prescription into pharmacy, as well as chart the Insulin Instructions (doses) in Connect Care (Diabetes Management Tab). If the MD forgets to put into Insulin Instructions, educators can see the order/prescription in the note and chart doses in the Insulin Instructions. 
  • or MDs may provide a verbal order for insulin to educator. See instructions HERE. 

Sending Post-partum Letters

The following process can be used whether post-partum information is reviewed during a scheduled visit or a phone call.

  1. Complete the regular visit “notes” (noting that post-partum teaching has been done).
    • In Wrap Up, add a Communication to send the Notes to the Primary Care Provider, and others, as appropriate
  2. To send post-partum letter to MD
    • In Wrap up > communications, add another new communication
      • Recipient = Primary Care Provider
      • Template = Blank
      • Within the open window, type and choose ".DIPCPPForMD"
      • Click "Send at sign visit"
  3. To send post-partum letter to patient
    • In Wrap up > communications, add another new communication
      • Recipient = Patient
      • Template = Blank
      • Within the open window, type and choose ".DIPCPPEnglish" (or translated letter if applicable)
      • Print for patient (letter can be mailed to patient, if the visit is by phone or virtual)

Both letters will be available for viewing under Chart Review > Letters. When looking under “Letters” they are not specifically labelled as post-partum letters. It will be evident if a team member sent them; you can quickly click to open them in order to verify they are the post-partum letters.