 marykay
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| Joined: 10 Aug 2009 |
| Total Posts: 2 |
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medical records
Posted: 12 Aug 2009 02:13 PM |
| I was recently hired by our center as the nurse manager. I am looking foreward to the NIFLA ultrasound training course and other training sessions to help educate me on everything going on with pregnancy resource centers. I am looking at how to chart when we are a limited medical clinic and would love to keep all of my charting on e-kryos along with the counselors and wondering if that is appropriate. Also I don't see any of the pre-ultrasound history or anything separating "nursing" or medical from counseling. I have seen your sonography report and was wondering if there are any other forms such as pre-ultrasound history, or a place for vital signs available. I was also wondering what other pregnancy centers that have gone medical are doing for charting-digital or paper? Thanks. |
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Re: medical records
Posted: 12 Aug 2009 02:38 PM |
Hi MaryKay-
Great to hear from you! The center I previously worked with provides sonograms, STI testing, as well as pregnancy tests. They utilize CenterPiece for all their inputting needs. Can you clarify what it is that you exactly are wanting to track that is unavailable? What do you gather vital signs for? I would love for you to talk with the Nurse Manager at Life Options as they have gone through this process and you may not have to reinvent the wheel. Please feel free to contact me directly and I can provide you with her contact information. I look forward to hearing from you soon.
Blessings,
Ashleigh
469-293-3079 ext:103 |
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Koda
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| Joined: 11 Oct 2012 |
| Total Posts: 3 |
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Re: medical records
Posted: 11 Oct 2012 11:52 AM |
I am wondering how to document correctly on the sonogram form in ekyros when the outcome is a miscarriage that has been confirmed by our Medical Director. Should it be left as "inconclusive" with a comment that this was a miscarrige? I attempted to document as "conclusive" but could not because that requires a gestational age. Is there any additional documentation I may be missing?
Another question I have is concerning a Medical History and Assessment form that is used prior to the ultrasound. At present, this is filed in a paper chart. Is there anything similar from eKyros? What are the rest of the Nurse Managers doing?
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Re: medical records
Posted: 15 Oct 2012 03:48 PM |
Hi Koda,
It's great to hear from you! I apologize in the delay of getting back to you as we were out of the office last week attending the CareNet Conference.
Are you all affiliated with Focus on the Family Option Ultrasound Program?
If not this is up to you and your center on how you'd like to document, whether as conclusive (as it was read and confirmed) and then set the outcome of the case to miscarriage or inconclusive (as it is not a viable pregnancy) and then set the outcome of the case to miscarriage. My suggestion would be to mark the sonogram as inconclusive as it is *not* a viable pregnancy.
Blessings,
Ashleigh |
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