Posted on: January 3, 2024
Acute care hospital staff have access to the full patient chart of patients arriving from additional Long Term Care (LTC) facilities in South Island. This is increasingly possible as electronic clinical documentation rolls out through our LTC facilities in the South Island.
“It’s important that ED medical staff and clinicians realize that the complete electronic patient chart is now available!” says Dr. Ian Bekker, LTC Physician Informaticist Lead. “I know it has come on so slow its easy to miss. But now some of the charts have accurate complete Problem List, Medication List, MAR, Vitals, Labs, MOST, ACP forms and detailed narrative nursing notes and physician progress notes for the last few years.”
“This will eliminate hunting though consult notes or calling family to figure out the background to the patient. Of course I’m talking about LTC patients from select facilities, but it applies to Primary Care patients at UPCCs and some NP clinics, as well. It’s worth checking charts belonging to these patients for their completeness.”
Since 2021, a complete electronic chart has been available for patients arriving from The Summit. In Spring 2022, the LTC units at Gorge Road Health Centre went live with full electronic chart as well. On November 27 this year, The Priory added clinical documentation (not CPOE), with Glengarry and Aberdeen LTC facilities to follow in March 2024.
Look for the following documentation in PowerChart when working with patients arriving from the activated facilities:
- Emergency Department Transfer Note from MRP
- Advance Care Planning (ACP) form
- LTC Progress Notes from MRP
- Nursing Care Annotations
- List of Patient’s Medications and MAR
Instructions on how to find this information is available in the Quick Reference Guide, Locating LTC Provider and Nursing Documentation.