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Manual Documentation Forms Moving to CRIS

 

The Medical Record Committee in conjunction with the MEC-IT Subcommittee has approved converting select manual medical record forms currently used for clinical documentation into the CRIS. There are approximately 50 manual medical record forms that will be phased out over the next year as they are reviewed, revised, and implemented in the CRIS clinical documentation. These new on-line forms will be used by clinical staff to enter and view patient information providing for a more comprehensive electronic patient medical record.

The implementation strategy is to complete the conversion process in several phases. The slow release of new on-line forms will allow the key users to become accustomed to documenting in CRIS. The project team will work closely with the end users (ICs and the Medical Record Committee) to identify specific requirements prior to the system configuration for each form. For more information on all the Phases go to the CRIS Website at: http://cris.cc.nih.gov

Phase II of the MRD Forms to CRIS begins November 14, 2006

All users of the forms listed below should discontinue using the paper form and begin documenting in the CRIS. The Medical Record Department will review any of these manual forms received after November 14, 2006 and contact users of the forms to provide further education/training as necessary to transition documentation to CRIS.

Form Name

Where to find in CRIS

Restraint Log Medical/ Surgical & ICU (NIH-2580)

Name in CRIS: Restraint Log - Medical/Surgical & ICU

 

  • Select patient and go to the FLOWSHEET Tab
  • If a flow sheet is active for a patient’s location, it will automatically display in the Flow sheet Selection summary box on the bottom left.
  • If you do not see the desired flow sheet, you must activate it.
  • To activate a flow sheet, select the ellipsis button.

    elipses button

  • The Search Flow sheet dialog box displays.
  • Type the first few letters of the flow sheet you are looking for and a list will display with all flow sheets that begin with those letters. For the Restraint/Seclusion Log type "res"
  • When you see the desired flow sheet, highlight it and click OK.
  • This will activate the flow sheet and add it to the list in the Flow sheet Selection summary box on the bottom left.
  • The selected flow sheet is now active for the patient.
  • Note: If the patient transfers to another location, their flow sheet(s) will transfer with them

Behavioral Health Restraint and Seclusion Log (NIH-2580-1)

Name in CRIS: Restraint/ Seclusion Log-Behavioral Health.

See Instructions above

Note: This form will only be available for Behavioral Health areas to select.


 

Critical Care Nursing Assessment Sheet (NIH-2841)

  • Select patient and go to the FLOWSHEET Tab
  • Select the Critical Care Nursing Assessment from the Flow sheet Selection summary box on the bottom left

    CCNA Flow Sheet

  • If you do not see the desired flow sheet, you must activate it. See instructions above.

If you are not familiar with how to use the documentation features in CRIS there are several learning options:

  1. Review the CRIS Clinical Documentation web-based training module at http://cris.cc.nih.gov/cristraining/cbt.html

  2. Register for a CRIS Clinical Documentation Course at http://training.cit.nih.gov/courselst.asp?lname=cris

  3. Review Chapters 9 and 10 of the CRIS User Manual at http://cris.cc.nih.gov/procedures/cris_user_manual.html

  4. Contact CRIS Support at 301-496-8400.

This page last updated 11/29/06

 

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