COVID-19 Connect Care Documentation Supports

Clinical documentation supports include tools to facilitate the easy capture of clinical observations as well as tools that help make that information easy to access and incorporate into clinically impactful progress and summary documentation.

This section describes standardized text blocks, information displays, calculators and summative documentation (e.g., discharge summary) enhancements supporting the care of patients with COVID-19 related illness.

Please see the COVID-19 Content page for general information about COVID-responsive clinical system design, the COVID-19 Workflows page for ideas about how to integrate content into workflows, and the COVID-19 Resources page for links to general COVID-19 guidance and protocols.

SmartTools

Most of the following COVID-19 documentation supports make use of new SmartPhrases, SmartLinks, SmartLists, SmartText and SmartForms that enable interactive documentation. Some users may want to include these in their own COVID-19 documentation templates or within personalizations of AHS standard templates.

A full list of published COVID-19 related SmartTools appears in the Connect Care Builder Handbook:

Problem Lists

Some documentation tools become easier to find if a patient is explicitly identified as having one or more COVID-19 related problems. Be sure to update the problem list. This will activate the COVID-19 Sidebar as well as some documentation templates.

Problem Overview

As soon as a COVID-19 related problem is added or activated in a patient's problem list, a link becomes available just below the overview edit box ("Problem Overview Data - COVID-19"). This is used to edit structured data for a standardized problem overview.

The associated interactive text block (".COVIDOVERVIEW" SmartPhrase) can be inserted into the Problem Overview edit box. It can also be added to progress or summative documentation as easy-to-read text. Behind the text is the structured data representing the minimum information needed to characterize a COVID-19 illness. The text block is dynamic. It has a subtitles and keywords, highlighted in a dark blue font, which can be clicked to re-expose the data form for edits or additions.

COVID-19 Sidebar

An inpatient "Sidebar" is available (default right side of screen) within any patient chart opened to an inpatient or emergency context. This has a standardized index of links to alternate Sidebar views that can be selected. Upon selecting the "Notes & Reports" index item (bottom of left column), note a "COVID-19" row within an "Other Sidebar Reports". This has a link for two COVID-19 Sidebar views, one attuned to inpatient acute care and another more relevant to patients who have had COVID-19 and may manifest complications or post-COVID-19 syndromes.

The COVID-19 "Acute Sidebar" displays the most important standardized text blocks (together with SmartPhrase mnemonics that can be used to include the different types of documentation in things like progress notes) so that the current state of key structured information can be reviewed at-a-glance (click on titles to review more detailed information about each block):

  • COVID-19 Overview
    Lists key information that should be captured for all COVID-19 patients, including when symptoms started, morbidity risks, functional status, interventions experienced and course of illness.

  • COVID-19 Status
    Summarizes information about infection testing, serology, isolation and immunizations.

  • COVID-19 Markers
    Pulls in key laboratory tests and risk prediction scores.

  • COVID-19 Acute Symptoms
    Lists the most recent observations from a standardized COVID-19 acute symptom tracking flowsheet that is updated daily by team clinicians.

  • COVID-19 Chronic Symptoms
    Lists the most recent observations from a standardized post-COVID-19 symptom tracking flowsheet that
    may be updated during clinic visits.

  • COVID-19 Medication Administrations
    Lists all medications received during the current encounter that relate to COVID-19 care.

Most of the COVID-19 Sidebar blocks are "interactive". Although formatted in prose to make the text easy to read text appearing in a dark blue font can be selected to activate popup data-entry tools for entering or editing the structured data behind the prose. Consistent review of the COVID-19 Sidebar, and interacting with it to keep core clinical data current, has the advantage of pre-generating documentation while also maintaining structured data that enables better tracking and continuing improvement of COVID-19 healthcare.

COVID-19 Summary Note

Standardized summative documentation can be generated via a single click from the inpatient Sidebar for COVID-19 patients. First select the "Notes & Reports" index item (bottom of left column) in the Sidebar. Then note the "Other SideBar Reports" section with a row for COVID-19. The COVID-19 transition documentation is produced by selecting the "Summary Note" link.

The Summary template has an optional pick-list (SmartList) in the title for indicating whether the summary is used for general intake, history and physical, consult, discharge, transfer or handover documentation. The document type can also be changed. Consult, H&P and Discharge types are shared with Netcare.

When editing the summary, observe that any dark blue text can be selected to open a popup editor for adding or editing data. The summary includes most of the Sidebar text blocks described above. The summary template has a number of helpful COVID-19 specific SmartLinks. These can be exposed for incorporating into personalized documentation templates by pulling the ".COVIDSUMMARY" SmartPhrase (or search for "COVID SUMMARY" SmartText) into a personal SmartPhrase template.

COVID-19 Progress Note

A standardized progress note can be quickly generated by selecting the link for "Progress Note" in the same locations where the Summary note link is found (see above). This works best when basic problem-oriented charting tools are used to keep Assessment and Plan notes attached to problems and updated.