Showing posts with label Documentation. Show all posts
Showing posts with label Documentation. Show all posts

Enhancement to Death Certification Workflow for Unidentified Patients

Enhancement updates provide short alerts to new, fixed or improved Connect Care functions...
  • Enhancement to Death Certification Workflow for Unidentified Patients
In response to prescriber requests, an enhancement has been made to the workflow for completing a Medical Certificate of Death (MCoD) in Connect Care for patients who were unidentified at the time of admission.

The ideal is still to wait for an unknown patient (UNK-) chart to be merged with the permanent chart with corrected patient demographics prior to creating a MCoD. However, if waiting for a chart merge is not possible, certifiers will now be able to manually enter discovered patient names, age at death, and legal sex in the unidentified patient's MCoD. 

See the updated tip sheet for details.

        Update for Personalized Notes Speed Buttons

        Enhancement updates provide short alerts to new, fixed or improved Connect Care functions...
        • Update for Personalized Notes Speed Buttons
        Users can create speed buttons in the Notes activity for personalized SmartPhrases and SmartText that can help speed up documentation and reduce the number of clicks. A recent update to this feature allows users to now also select a Service type and add NoteWriter Macros when creating a Notes speed button. Note that previously created speed buttons will need to be edited/re-personalized to include the Service type and/or Macros. 

        For steps on how to create, edit, or delete a Notes speed button, see pages 10 and 11 of the new CMIO SmartTools Quick Start Guide.

              Updates to Hospital Service Listings

              Enhancement updates provide short alerts to new, fixed or improved Connect Care functions...
              • Changes to Admitting/Transfer Hospital Service Listing in Connect Care
              A review of admitting services has resulted in a standardized Hospital Service list for inpatients. As of April 21, 2026, this updated list will be implemented in Connect Care and will reflect the specialty services to which a patient can be admitted at an inpatient facility. These updates support improved measurement of service demand, align with CIHI reporting requirements, and enable more accurate service occupancy reporting and patient cohorting.
              • If a specialty does not have beds assigned, it will not appear on the updated Hospital Service list, e.g., Rheumatology, Infectious Diseases, and Short Stay.
                • These specialties will remain available in clinical documentation lists and clinical consult service lists.
              • Some services have been renamed or slightly modified in the updated Hospital Service list.
                • Synonyms have been added to help guide prescribers to select the correct service.
              • When arranging admissions, please coordinate with the appropriate admitting service for the patient and facility. The best admitting service may vary depending on patient needs (e.g., Infectious Diseases may coordinate with General Internal Medicine, Hospital Medicine, or other such as Cardiology or Respirology).
              For more information about Hospital Service and the provider workflow, see:

                    POSTPONED - New Mental Health Act eForms

                    Enhancement updates provide short alerts to new, fixed or improved Connect Care functions...
                    • New Mental Health Act eForms
                    Edit (Mar 30): This change has been postponed, new detail TBD.

                    As of March 24, 2026, two additional Mental Health Act (MHA) Forms will be available within the Consent & eForms Navigator, allowing Connect Care users to leverage these eForms instead of the paper equivalent and streamline documentation processes:
                    • Form 23: Community Treatment Order Apprehension Order 
                    • Form 24: Community Treatment Order Examination on Apprehension 
                    For more information on how to access and complete MHA Forms within the Consent & eForms Navigator, see the guides and other resources:

                          Documentation of Vitamin K Consent/Decline for Neonates

                          Enhancement updates provide short alerts to new, fixed or improved Connect Care functions...
                          • Documentation of Vitamin K Consent/Decline for Neonates
                          As of February 19, 2026, new SmartText is available for prescribers to document consent or decline (whether partial or total refusal) by a parent/guardian for vitamin K intramuscular injection in a neonatal patient. When in the Consent Note, prescribers can type ".vitamink" to bring in the SmartText, rather than having to search via the SmartText box.

                          The SmartText will have a number of SmartLists within it for the prescriber to indicate who the discussion was with, what was discussed, and what the consent status was (click the camera icon for a screenshot).

                                Delivery Documentation Update - Subgaleal Hemorrhage Risk

                                Enhancement updates provide short alerts to new, fixed or improved Connect Care functions...
                                • Delivery Documentation Update - Subgaleal Hemorrhage Risk
                                As of February 17, 2026, changes will be made to delivery documentation, to allow for documenting an impacted head or difficult extraction and subsequently indicating in various places in the Connect Care chart that a baby is at risk for subgaleal hemorrhage. Below are the specific changes prescribers will see:
                                • Documentation:
                                  • A new "Impacted Head" field will be added to the "Delivery Details" section of the Delivery Summary (click camera icon for a screenshot).
                                  • In the Admit Newborn order set, under "Vital Signs", there will be a new row to check "For Infants at Risk of Subgaleal Hemorrhage".
                                • Risk indication in chart:
                                  • After a Delivery Summary is signed, if an impacted head has been documented, it will show up in the Delivery Report in the "Delivery (Newborn)" section. 
                                  • An "At Risk for Subgaleal Hemorrhage" warning box will also appear in the Postpartum Newborn Overview report in the Summary activity if either an impacted head was documented in the Delivery Summary or risk was indicated in a relevant nursing flowsheet.

                                      Anesthesia Update - Documentation of Bite Block Events for ECT

                                      Enhancement updates provide short alerts to new, fixed or improved Connect Care functions...
                                      • Anesthesia Update - Documentation of Bite Block Events for ECT
                                      As of January 23, 2026, to improve documentation, Anesthesia prescribers can enter a bite block insertion or removal event in the Anesthesia record for patients undergoing Electroconvulsive Therapy (ECT) procedures. 
                                      • In the Intraprocedure tab, select "Events" and then "Add New". The new "Insert Bite Block" and "Remove Bite Block" events can be found in the "Misc" tab (click the camera icon for a screenshot).
                                      • If an insertion is documented without a corresponding removal, a soft stop notification will appear in the record checklist to remind users to document removal.

                                      For details, see the updated tip sheet:

                                            NEW DATE - New Inpatient Cirrhosis Care Support Tools

                                            Enhancement updates provide short alerts to new, fixed or improved Connect Care functions...
                                            • New Inpatient Cirrhosis Care Suite of Support Tools
                                            Managing cirrhosis is complex and, despite clear guidelines, many patients do not receive optimal care. After consulting directly with clinicians, conducting focus groups, and successfully soft-launching new functionality, the Digital Health team has created a new and improved approach to the management of this chronic disease within Connect Care, complete with new tools designed to simplify workflows, support evidence-based decisions, and improve patient outcomes. 

                                            As of January 15, 2026, the following cirrhosis care tools will officially go live. We will provide more information on these tools in the new year including tip sheets and demos, but encourage prescribers in the meantime to explore to learn more. The summary report in particular (search for "cirrhosis" in the "Summary" activity) is essentially a one-stop shop for cirrhosis care, and users can learn how to navigate and use simply by clicking through.
                                            • Admission Our Practice Advisory (OPA) – Prompts clinicians to review recommended care items during admission and guides next steps.
                                            • Cirrhosis Summary Report – A one-screen dashboard for labs, meds, complications, and trends.
                                            • Cirrhosis Profile – Structured data for continuity and longitudinal tracking.
                                            • Note Templates – Streamlined documentation for cirrhosis and comorbidities.
                                            • Discharge OPA – Alerts and recommendations to ensure safe transitions of care. Together, these tools aim to standardize care, reduce missed opportunities, and make cirrhosis management more efficient and consistent across Alberta.
                                            • Cirrhosis Disease Management Sidebar Summary – Enabled for patients with cirrhosis-related medical histories or problems, is available for inpatient and outpatient.
                                            Watch this space for updates, as well as the below Manual page, where tip sheets and demos will be linked.

                                                  Enhancements to Medications in Anesthesia Procedure Notes

                                                  Enhancement updates provide short alerts to new, fixed or improved Connect Care functions...
                                                  • Enhancements to Medications in Anesthesia Procedure Notes
                                                  As of November 25, 2025, to improve documentation of medications administered, ordering workflows, and clinical utility, medications in the following Anesthesia Procedure Notes will be updated to have a default dosage unit and route of administration applied: 
                                                  • Epidural Block
                                                  • Combined Spinal Epidural Block
                                                  • Eye Block
                                                  • Pediatric Neuraxial Nerve Block
                                                  • Regional Nerve Block
                                                  • Spinal Block
                                                  For an example, click the camera icon for a screenshot of the Epidural Block Procedure Note.

                                                        Anesthesia Users - Handoff Activity Update

                                                        Enhancement updates provide short alerts to new, fixed or improved Connect Care functions...
                                                        • Anesthesia Users - Handoff Activity Update
                                                        The "Handoff" report(s) can be accessed from Patient Lists within an open chart. Previously, anesthesia users were able to view but not update existing Handoff reports. As of August 5, 2025, anesthesia users will see a "Write Handoff" button in the Patient List toolbar. When this button is clicked, updates can be written within the text fields of the Handoff tab in the right sidebar (click the camera icon below for a screenshot)


                                                        Note that only one Handoff report will be kept for users from the same specialty, the next provider from the same specialty will be updating the same Handoff report. 

                                                              Updates to Anesthesia Difficult Airway Documentation and Reminders

                                                              Enhancement updates provide short alerts to new, fixed or improved Connect Care functions...
                                                              • Updates to Anesthesia Difficult Airway Documentation and Reminders
                                                              As of July 17, 2025, a number of improvements will be implemented related to Anesthesia difficult airway documentation and difficult airway reminders, to ensure documented difficult airways are reflected in key places on the patient's chart.

                                                              Difficult Airway Documentation
                                                              • When a difficult airway is documented in the Procedure Note, it will automatically be reflected in Notable Events.
                                                              • When a difficult airway associated complication is documented in Notable Events, the relevant diagnosis will automatically be added to the patient Problem List (see below diagnosis mapping):
                                                                • Unable to intubate complication --> Failed or difficult intubation diagnosis
                                                                • Difficult to intubate – expected or Difficult to intubate – unexpected complication --> Difficult intubation diagnosis
                                                                • Difficult mask airway complication --> Difficult airway diagnosis

                                                              Document Difficult Airway Reminder
                                                              While documenting a difficult airway in a Procedure Note will not make it automatically flow to the patient Problem List, a "Document Difficult Airway" reminder will fire if the below conditions are met (click the camera icon below for a screenshot):
                                                              • One of the following exists in the Notable Events:
                                                                • Difficult mask airway
                                                                • Unable to intubate – expected
                                                                • Unable to Intubate – unexpected
                                                              • AND none of the following diagnoses exist under the Problem List:  
                                                                • Difficult airway
                                                                • Difficult intubation
                                                                • Failed or difficult intubation
                                                              • Clicking on the Document Difficult Airway reminder will then launch a Notable Events window. From there, the difficult airway notable events can be reviewed and manually added to the Problem List if appropriate, by clicking the "+ Add Problem" button.  

                                                              • Once the difficult airway notable event has been added to the Problem List, it will automatically be reflected in the Storyboard's hover bubble and Airway Alert, and the status board Difficult Intubation column. 
                                                               

                                                                    Improvements to Mental Health Act Forms and Workflows

                                                                    Enhancement updates provide short alerts to new, fixed or improved Connect Care functions...
                                                                    • Improvements to Mental Health Act Forms and Workflows
                                                                    As of June 17, 2025, multiple improvements will be available in Connect Care for Mental Health Act (MHA) Forms and related workflows:
                                                                    • Signer name field changes:
                                                                      • When an MHA Form is signed, the name of the signer will auto-populate in the "Add Signer Name" field above the e-signature (click the camera icon below for a screenshot).
                                                                      • For Form 1 and Form 2, the Add Signer Name field will replace the Provider name field in the left pane. 
                                                                      • If the name in the Add Signer Name field needs to be edited, instructions to do so can be found on page 7 of the Mental Health Act Quick Start Guide
                                                                      • This functionality will be available in other eForms (e.g., Consent eForms) in the future. 
                                                                    • Two new MHA eForms now available:
                                                                      • Mental Health Patient Advocate Request Form
                                                                      • Competency at time of Admission/Renewal Form
                                                                    • Two new MHA workflows:
                                                                      • Release of Information (ROI): Using Quick Release and RightFax to fulfil MHA-related ROI requests (e.g., Patient Advocate Office).
                                                                      • Corrections, Amendments, and Addendums: How and when to properly print, annotate, re-scan, and update metadata for changes made to Forms.
                                                                      • Details of these workflows can be found in the Mental Health Act Quick Start Guide.
                                                                    Users are welcome to use the PLY (practice) environment to familiarize themselves with these new changes prior to the change date. For questions or issues, please submit a ticket.

                                                                        New eForm Available - Primary Care Opioid Treatment Patient Agreement

                                                                        Enhancement updates provide short alerts to new, fixed or improved Connect Care functions...
                                                                        • New eForm Available - Primary Care Opioid Treatment Patient Agreement
                                                                        As of May 28, 2025, the Primary Care Opioid Treatment Patient Agreement is available in Connect Care as an electronic signature form (previously, it was in Connect Care as a letter template).

                                                                        To access the new form:
                                                                        • Open the Consent & eForms Navigator, and, under the "Consent Forms" section, click on the "+ Add" button and select "Consent Agreement Waiver" (click the camera icon below for a screenshot).
                                                                        • In the window that opens, click the "Change Template" button at the bottom, select "Primary Care Opioid Treatment Patient Agreement", and click the "Accept" button.

                                                                        For more information on completing forms electronically, see the guide:

                                                                            New Anesthesia Required Event and SmartText for Uncrossmatched Blood [New Date]

                                                                            Enhancement updates provide short alerts to new, fixed or improved Connect Care functions...
                                                                            • New Anesthesia Required Event and Associated SmartText for Uncrossmatched Blood 
                                                                            The Anesthesia Specialty Working Group has approved a new Emergency Event in the Anesthesia Intraprocedure Workspace for Uncrossmatched Blood. This required event features an associated SmartText for documenting the attestation of administering uncrossmatched blood products to comply with accreditation standards. As of May 21, 2025, anesthesia providers must use this event to mark the administration of uncrossmatched blood product(s) and utilize the SmartText for attestation documentation (click on the camera icons for screenshots).


                                                                            If there is no associated event with an uncrossmatched blood transfusion, anesthesia providers will be required to create an event before signing the record.

                                                                                  New Stillbirth Documentation Workflow

                                                                                  Enhancement updates provide short alerts to new, fixed or improved Connect Care functions...
                                                                                  • New Stillbirth Navigator and Documentation Workflow
                                                                                  As of April 29, 2025, there will be a new Connect Care documentation workflow that must be followed when a stillbirth occurs. A new Stillbirth Navigator will help Obstetricians, Geneticists, and Neonatologists complete the necessary documentation and ordering.

                                                                                  For more information, see:

                                                                                        Additional Update to Consent eForms - Telephone Consents [Updated]

                                                                                        Enhancement updates provide short alerts to new, fixed or improved Connect Care functions...
                                                                                        • Connect Care Upgrade Update: Additional Changes to Telephone Consent Forms
                                                                                        As previously posted, the recent Connect Care Spring Upgrade brought some changes to select eForms such Consent for Procedure forms, including the removal of the signer name entry fields from the left pane and moving name entry to the e-signature boxes. However, it was discovered that the new method of entering the signer’s name via the e-signature box prevents users from being able to enter the signer’s name when no signature is applied, i.e., in telephone consent workflows where signatures are not collected. 

                                                                                        As of March 20, 2025, when the "Telephone" button is selected under the "Telephone/Fax Consent" section for the consent form types listed below, a name field will again appear (click the camera icon for a screenshot). For more information, see page 40 of the Consent & eForms Navigator
                                                                                        Quick Start Guide. Non-telephone consents will continue to use the new workflow detailed in the previous post.

                                                                                        • Consent forms affected:
                                                                                          • Consent to Surgery or Invasive Procedure 
                                                                                          • Consent to Treatment Plan or Procedure 
                                                                                          • Consent Withdrawal or Refusal  
                                                                                          • Consent Immunization  
                                                                                          • Consent for pre-mortem interventions  
                                                                                          • Consent to Organ and Tissue Donation 
                                                                                          • Informed Consent Subject to the Mental Health Act
                                                                                        [Edit: Post updated April 1]

                                                                                            H&P Lookback Setting and Prep for Procedure Updates

                                                                                            Enhancement updates provide short alerts to new, fixed or improved Connect Care functions...
                                                                                            • Linked H&P Interval Setting and Prep for Procedure Updates
                                                                                            As of October 10, 2024:
                                                                                            • The History and Physical (H&P) Interval ("Link other H&P" in Admission Navigator) setting has been updated to look for appropriate admitting H&P notes (i.e., existing H&P, or a Consult Note or other summative document that can be used as an H&P) up to 1 year in the past, as H&P notes are good for up to 1 year. Previously, the lookback time was set to 90 days.

                                                                                            • An “Op Note” section has been added to the Prep for Procedure navigator, allowing prescribers to create Op Notes for ambulatory operative procedures (click on the camera icon below for a screenshot). Previously, ambulatory operative procedures could only be documented as Progress Notes.
                                                                                              • Note: Op Notes are automatically sent to Netcare once signed.

                                                                                            Enhanced Discharge as Deceased Navigator

                                                                                            Enhancement updates provide short alerts to new, fixed or improved Connect Care functions...
                                                                                            • Discharge as Deceased Navigator Enhancements
                                                                                            A unique patient navigation workflow is needed when a patient dies in a healthcare facility, including when they are declared dead on arrival at the facility. This "patient movement" is a form of discharge, with death bringing the associated healthcare encounter to an end. The workflow is supported with a navigator.

                                                                                            As of October 1, 2024
                                                                                            , there are significant enhancements to the "Discharge as Deceased" navigator within the "Discharge" activity available to patient charts opened to an inpatient encounter.

                                                                                            The prescriber navigator has been simplified and provided with brief instructions highlighting tasks for prescribers. Data entry is streamlined, making it easer to complete organ and tissue donation criteria checks. A standardized pronouncement of death note (charting requirement) is generated with a single click. And there is easier access to discharge summary templates that meet provincial documentation requirements.

                                                                                            The deceased navigator update matches recent enhancements to admission and discharge navigators.

                                                                                            New SmartLinks Available for Scores and Results

                                                                                            Enhancement updates provide short alerts to new, fixed or improved Connect Care functions...
                                                                                            • New SmartLinks Available
                                                                                            "SmartLinks" are a text-automation tool available in Connect Care. When a SmartLink "token" is inserted into documentation (notes or templates), it pulls health information (e.g., problem lists, medication lists, vitals) from the health record, replacing the token with the desired information. 

                                                                                            Built on request of a Connect Care prescriber, other prescribers may find the below new SmartLinks useful to save as a personalization. To use in a note, ensure you type a dot followed by the token, as shown below; to use in a SmartPhrase, type an "@" before and after the token (no dot).
                                                                                            •  AHS CIWA TOTAL SCORE LAST 5 READINGS
                                                                                              • SmartLink: .GIMCIWA72HRX5
                                                                                              • Description: Pulls in the patient's total score of the last 5 readings entered within the last 72 hours for the 10-item CIWA alcohol withdrawal assessment. 
                                                                                            • AHS COW SCORE TOTAL LAST 5 READINGS 
                                                                                              • SmartLink: .GIMCOWS72HRX5
                                                                                              • Description: Pulls in the patient's total score of the last 5 readings entered within the last 72 hours for the Clinical Opioid Withdrawal assessment.
                                                                                            • AHS BLADDER SCANS 72 HRS LAST 5 READINGS
                                                                                              • SmartLink: .RESIDUALURINEX5
                                                                                              • Description: Pulls in the patient's last 5 readings entered within the last 72 hours for bladder scans/post-void residuals.
                                                                                            • AHS LAB RESULTS 7 DAY LOOK BACK
                                                                                              • SmartLink: .LABRESULTS7D
                                                                                              • Description: Can be used to construct SmartPhrases to bring in specific last results from the last 7 days (e.g., a SmartPhrase to bring in Hepatic Panel Results from the last 7 days). Requires specifying the appropriate name of the lab wanted.
                                                                                            • AHS LAB RESULTS 3 DAY LOOK BACK
                                                                                              • SmartLink: .LABRESULTS3D 
                                                                                              • Description: Can be used to construct SmartPhrases to bring in specific last results from the last 3 days (e.g., a SmartPhrase to bring in Renal Results from the last 3 days). Requires specifying the appropriate name of the lab wanted.
                                                                                            For more information on other approved SmartLinks in Connect Care, see: 

                                                                                            Ambulatory HOD Progress Note - Update to Display Time

                                                                                            Enhancement updates provide short alerts to new, fixed or improved Connect Care functions...
                                                                                            • Ambulatory HOD Progress Note Display Time 
                                                                                            As of July 9, 2024, progress notes created in ambulatory Hospital Outpatient Department (HOD) encounters will display the note creation time instead of the appointment time (click the camera icon below to see a screenshot). This matches the time displayed in non-HOD encounter progress notes.