Lorenzo Clinical Charts

Click to access Clinical Charts from the ED, Inpatient or Outpatient Tracking Grids

Edit Existing Notes

Collapse/Expand Note

Change Filter from Current Admission/Attendance to previous Admission/Attendance

Create New Notes

Collapse/Expand All Notes

Change to another Section/Tab

Create New Clinical Chart

View Existing Clinical Charts

Sections/Tabs

Notes

What is a Clinical Chart?

A Clinical Chart is simply a collection of Clinical Notes and Forms for a particular patient presented in a more user friendly manner – think of it as a folder rather than chart.

In a Clinical Chart, the Notes and Forms are “filed” automatically in different sections [tabs]

For example the Inpatient Clinical Chart contains the following sections:

o Medical Notes o Nursing Notes o Therapist Notes [under individual tabs] o Pharmacy Notes o Discharge Summary o Forms [VTE Form] o Operation Note

The Notes and Forms in each section are presented in reverse chronological order with the most recent entry expanded

Use the Expand/Collapse icon [on the header of the chart] to Expand/Collapse all notes

Use the Expand/Collapse icon [on the header of each note] to Expand/Collapse the note

Click on the “Notes” icon [on the header of each note] to “Append/Correct” a note

All the Notes and Forms in a Clinical Chart are stored the Clinical Notes and Forms section of the EPR so they can be accessed and used in the current way

Where do I find Clinical Charts?

Clinical Charts can be found under the Clinical Charts Tab in the EPR section of Lorenzo

The simplest way to navigate to the Clinical Charts for patient who is currently in ED or on an IP Ward is to click on the Clinical Chart icon

Click on this icon to access Clinical Charts

With the correct settings [see below], it possible to access the most recent medical note with a single click from any of the tracking grids

In Chart View, the list of Clinical Charts for the patient can be viewed by using the click handle [see previous screenshot] adjacent to the Action Menu on the left hand side of the screen to open the hidden pane

Select the relevant chart to view and/or edit

Currently there are three types of chart in use:

o Emergency Department Chart o Inpatient Clinical Chart o Inpatient Paediatric Chart

All three are “lifetime” charts so each patient will only ever have one chart

How do I write notes in a Clinical Chart?

The “Activities” icon can be used to launch various activities e.g. creating a clinical note directly from the Clinical Chart without having to return to the tracking grid or to navigate to the another section of the EPR

Click on the “Activities” icon and select “Notes” to open the relevant sub-menu which will contain the Clinical Note Templates relevant to that section of the Clinical Chart

There is no need to set up any Clinical Note Templates as this is done automatically

Select the required template and the note will open in the usual manner

With a dual screen workstation, it is possible to have a Clinical Note open on one screen and to navigate and view the remainder of the Clinical Chart contents e.g. previous notes on the other screen

[If a particular type of note does not appear under the appropriate section of the chart – please contact

the IT Helpdesk as it is very easy to add further note templates]

How do I view historical data?

The three charts currently in use are “lifetime” charts so just like a set of case notes, each patient will only have one chart

These charts have a default filter set to the current Episode [ED Attendance or IP Admission] and are designed to be used for patient currently in ED or on an IP ward

The IP charts will include notes created in ED as long as the correct admission process has been followed [which links the ED and IP Encounters under the same Episode]

To view previous ED Attendances or IP Admissions, click on the “filter” symbol to open the filter screen

Select “Episode” from the “Filter By” list

Choose the relevant episode(s) from the list

Click “Ok”

The notes and forms under the individual tabs change to show those from the episode selected

If the patient is not currently admitted on in ED and has no active encounters, the Clinical Chart will appear to be empty until the process above is followed to select an episode

Failing this all Clinical Notes can be found under the Clinical Notes tab in the EPR

What if the patient doesn’t have an IP Chart?

Use the Clinical Charts icon on any of the tracking grids [ED, IP or OP] to navigate to the Clinical Charts section of the patients EPR

If there is no icon it means the patient does not have any Clinical Chart

Click in the empty space where the icon would be to navigate to the Clinical Charts section of the patients EPR

For the ED Clinical Chart, a “lifetime” chart will be created automatically at registration on the patients first attendance

For the Inpatient Clinical Charts, each patient will need to have “lifetime” chart created on their first admission – this will only need to be done once and currently this is a manual process [in the future this will be automated]

If there is no IP Clinical Chart in the list of charts follow the process below:

o Click “Create Clinical Chart” in the Action Menu o If necessary search for “Inpatient%” o Select “Inpatient Clinical Chart” [for adults] or “Inpatient Paediatric” Clinical Chart o Click Finish

It will save a lot of time if you modify your personal settings as this will ensure you access the chart of your choice in the correct view with the minimum number of clicks – see below

Clinical Charts User Setup

Click on “Standard Lorenzo” to access “My Settings” and select “Clinical Charting”

Change the “Default Chart Template” to the chart you will use most frequently using the search facility:

o Emergency Department [search for Emergency%] o Inpatient [search for Inpatient%] o Inpatient Paediatric [search for %paed%]

Under “EPR View” select “Display Configuration” and “EPR View Configuration”

Highlight “Clinical Charts” in the Tab Order list

Ensure the “Default Tab View” is set to “Chart View”