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Resident Chart: Medical Info, Health Monitoring, Notes, and LOA Tabs

This manual covers data entry in the Resident Chart: Medical Info (Information), Health Monitoring, Notes, and LOA

tabs.

The Medical Info tab is where you enter Diet, Evacuation Status, Code Status, Advance Directive details, Notes/Alerts,

and Durable Medical Equipment.

To access, click the Resident Chart icon on the EMAR home screen, or click on File – Resident.

The Resident listing screen will open.

To find a resident, type a portion of their first name, last name, or unit number into the ‘Find’ field. Do not press the

enter key on your keyboard. Let the system perform the search.

There are two filters that will shorten the list of residents displayed.

Hide Discharged: Select to remove discharged residents from the active list.

EMAR Resident Chart: Medical Info, Health Monitoring, Notes, LOA | Revised 06/12/17 2

Unit Station: Click on the drop down to select a Unit Station to display. Residents assigned to a unit that has the selected

unit station assigned (in the unit setup) will be displayed. To remove the unit station filter, click on the drop down and

select ALL Stations.

To view, add, or modify resident information, double click on the resident name in the list to open the record.

The resident record will open to the Main tab, click the Medical Info tab. Medical Info Tab:

Note: The other tabs shown in this print screen may be different in your database. The tabs shown are based on

modules used and employee access granted.


Diet and Evacuation Status: Click the lookup buttons to select the resident’s Diet and Evacuation Status.

If there is nothing in the master list, you will be prompted to create the list.

Diet: Diet is a multiple select lookup. Click one or more diets for this resident, and then click ‘Select’.

Evacuation Status: Evacuation Status is a multiple select lookup. Click one or more statuses for this resident, and then click ‘Select’.

Note: You are able to edit or add to the current Choices lists if you have been given access to modify them in the employee setup. Click ‘Modify’ to do so.


Code Status: All new residents default to a code status of Resuscitate.

Note: Your facility may use different terminology such as Full Code. Terminology can be changed by going to File – Setup – Community – User Defined Fields. If a resident changes from Resuscitate/Full Code to DNR/No Code, you will need to remove the checkmark from the box

already checked and add it to the appropriate code status. This is because multiple boxes can be checked, as shown in

this screen shot:

Advance Directives/Advance Directive Notes: Choose the Advance Directive Status here.

The text field to the right can by used for any additional notes about Advanced Directives.

Note: Your facility may use different terminology. The Advance Directives options need to be setup by going to File –

Setup – Community – User Defined Fields.

Note/Alert: Click ‘Add’. Enter the Start date. Enter the note or alert in the Note field. Examples of items that could be entered: Fall

Risk or Hospice.

Durable Medical Equipment: Click ‘Add’. Enter the start date. The Note field is used to describe the equipment. You may want to include a serial

number or other identification number. Examples of items that would be entered: Wheelchair, Walker, or CPAP

machine.


Health Monitoring tab: View, add, or modify Vital Sign information here.

To access the Health Monitoring tab, click on the ‘Health Monitoring’ tab.

The Source column in all areas will be populated with an “M” for Manual entry, “MD” for Medication Delivery

and “S” for confirmed Services.

Note: There is a Vitals tab and Results tab.


Vitals:

To enter the Blood Pressure, Pulse, Respiration, or Temperature, click ‘Add’.

The date and time are completed. They can be edited if needed. Press tab to move throughout the fields. When

recording Vitals, you are required to complete at least one response for Blood Pressure, Pulse, Respiration, or

Temperature.

Weight/Height:

To enter Weights or Height, click ‘Add’.

The date and time will be completed (edit if needed). Press Tab twice to enter weight. Weight is denoted in

either Pounds or Kilograms depending on your community settings. Press Tab again to enter height. Height is

manual entry only. It is denoted in either Inches or Centimeters depending on your community settings.


Meal Intake:

To enter Meal Intake, click ‘Add’.

The date and time will be completed (edit if needed). Press Tab twice to enter the percentage of meal intake.

Bowel Movement:

To enter Bowel Movement, click ‘Add’.

The date and time will be completed (edit if needed). Use the drop down to record on the Bowel Movement

Size.

Intake/Output

To enter Intake and/or Output, click ‘Add’.

The date and time will be completed (edit if needed). Press Tab twice to enter Intake value. Press Tab again to

enter Output value.


Blood Sugar:

To enter Blood Sugars, click on the Results tab and click ‘Add’.

The date and time will be completed (edit if needed). Press Tab twice to enter BS.

INR:

To enter INR, click on the Results tab and click ‘Add’.

The date and time will be completed (edit if needed). Press Tab twice to enter INR Result.

Pulse Oximetry:

To enter Pulse Oximetry, click on the Results tab and click ‘Add’.

The date and time will be completed (edit if needed). Press Tab to enter O2 Sat.

Printing options: Click the Print button located at the bottom of the screen.


The Select Health Monitoring Report to Print screen will open.

Note: The current month will default into the From and Thru fields. Use the calendar lookups to change the date

range, or manually enter the dates into the appropriate fields.

Selected Vitals: When this box is checked, the look up button will become active.

When you click on the look up button, the Select Vital Signs screen will open. This is a multiple select screen.

Click to highlight which options you would like to print and then click ‘Select’.


Once you have made your selection(s), the Select Health Monitoring Reports to Print screen will display your

choice(s).

Note: This option is required to print all of the Vital Signs together. Vital Signs, Blood Sugar, and Pulse Oximetry

are otherwise single choice items.

Notes tab: The Notes tab is used to enter progress notes and other narrative documentation.

To access Notes, click on the ‘Notes’ tab.

Click ‘Add’ to enter a new progress note or double click a line to review a note.


Note: Modifying/Deleting permissions are set up in employee access. Depending on how your profile is set up, you may

or may not be able to modify/delete a note once it is saved.

Note entry screen:

Select “Late Entry for” to document for an earlier period. The Date and Time will be required to save the Note.

Note: When the Note is printed, the Date and Time the Note was entered will print in the Date/Time column. The Note

will start with Late Entry for and the date and time entered for the late entry.


Click the lookup to select the Note Type.

The Choices list will open.

Double click to select or click to highlight and click ‘Select’.

Type your note in the note field and click ‘Save’. Spell check will run if you have any mispelled words.

The Modifications section is found on the Other tab.

Note: You can also access/print notes from File – Notes or Forms – Progress Notes. It is possible to view Notes for all residents or specific residents in these areas. Use a Query to view the same Note Type for all residents, to view a date range of notes for all residents, or to print a selected group of Progress notes for a resident.

For more information on printing Progress Notes, refer to the reference document titled Clinical Reports: Progress Notes.


LOA (Leave of Absence) tab: Document a resident’s time out of the community here. The resident will be on a Leave of Absence from the Leave Start Date until the Leave End Date. To access the Leave of Absence records, click on the ‘LOA’ tab.

Click ‘Add’ to enter a new Leave of Absence record.


The New Resident Leave of Absence window will open:

This should be completed in advance to the resident leaving if possible. It can be modified as needed.

Leave Start Date: Click on the calendar to select the date, or manually enter the date into the field. Enter the

Time the resident is leaving as well.

Reason: Select the Description of why the resident is on the Leave of Absence (Hospital, Family Visit, etc.) by

clicking on the lookup. The Reason Type/Report Code is used for the Hospital/Leave Report.

Note: If no LOA Reasons are listed, go to File – Setup – LOA Reason to set up the list.


When the Reason Type/Report Code-Hospital is selected, additional fields for To, Why, Hospital Visit Outcome,

and Hospital Discharge Diagnosis will be available for entry on the resident LOA record.

Note: These additional fields will pull to the Hospital/Leave Report. See Clinical Reference: Hospital/Leave Report

manual for more information.

To: Click on the lookup to select the Hospital the resident was sent to. This field uses the same Choices list as

the Hospital Preference field on the resident Contacts tab. Completion is required to save the record.

Why: Enter the symptom(s), condition, or diagnosis that requires the resident to be sent to the hospital.

Completion is required to save the record.

Hospital Visit Outcome: Select the Hospital Visit Outcome. This can be entered at any time, since you may not

know at the time the resident is sent to the hospital if they will be admitted or not. Example: ER Visit, 23 Hour

Hold, Observation, Hospital Admission, etc.

Leave Note: Enter any additional, short note you might have about the Leave.

Enter Resident Progress Note: Click this button to enter a Resident Note. This will bring you directly to the

Notes screen to enter a new note.


Bed Hold Letter Sent: Check box if Bed Hold Letter has been sent. Some states require bed hold letters in

Assisted Living. The Hospital/Leave Report has an optional column to display this as well.

Leave Return Date and Time: Enter the date and time that the resident will be returning to the community. The

information can be edited if the resident does not return on the date/time entered.

Note: On some occasions, the Leave Return Date and Time is not known. Leave it blank. When the resident returns,

double click on current Leave of Absence record to enter the Leave Return Date and Time. Click ‘Save’. This is necessary

to remove the applicable holds on medications and/or services.

Hospital Discharge Diagnosis: Free text the hospital visit discharge reason, or click on the drop down arrow at

the end of the field to select a Diagnosis from the Resident Chart.

Resident on Leave: This option defaults to selected. When selected, the resident will be counted as On Leave in the

Resident List Report. The resident will not be included in any head count numbers on census reports, unless there is a

specific option to include Residents on LOA selected on the report.

All Services on Hold: This option defaults to selected. When selected, the resident’s services will be placed on hold and

will not appear on the Service Schedule for the duration of the Leave of Absence.

Note: All Services on Hold is also used by Billing Transaction Types that are set to prorate by Service on Hold.

If Maximum Package hours are set on the Service Package, the hours will also be prorated.

All Medications on Hold: This option defaults to selected. When selected, the resident’s medications will be placed on

hold for the duration of the Leave of Absence. When the medication sheet is printed, an “H” for hold will print in the

passing times for each medication. The reason for the hold will be printed on the Med Notes Sheet.

Note: To place an individual medication on hold, go to the Orders tab within the Resident Chart and complete the

information on the Hold History tab. Refer to the EMAR Chapter 5 – Resident Chart: Orders manual for more

information.

Send Meds: Select to allow Pre-Pour of medications being sent with resident going on leave. When selected the Pour

Meds button is enabled. Click on Pour Meds to record the medications as poured. To Pour Meds, the To Date and Time

must be completed.

Note: You do not need to mark ‘Send Meds’ if you plan to send the medication cards home with the family. This step is

only needed if you plan to set up the medications for each passing time.


Once you click ‘Pour Meds’, the following window will open.

Click ‘Select Time’ to Pour for the applicable Passing Time(s).

The Select a Passing Time window will open. Double click the line you want to setup or highlight the line you want

to setup and click ‘Select’.


Select the medication(s) that you setup, and click ‘Med Poured’.

Click ‘Select Time’ to select any other passing time(s). When you have all zeros (0) in the ‘Not Poured’ column, you

have completed the Pour for the scheduled leave. Click ‘Finished’ in the bottom right.

Once all information is correct on the resident LOA screen, click ‘Save’.

LOA records can be accessed from the File menu. Click on File – Resident on LOA.


The Resident LOA listing screen will open.

This listing shows all LOA records for all residents. Current residents on LOA will also be shown in bold when the Hide

Closed Items box is not checked. You can filter the listing to only current residents on LOA by selecting Hide Closed

Items.

resident hart: medical info, health ... - eldermark training...loa (leave of absence) tab: document...

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