Description

The CT-E system contains an available, integrated module for electronic clinical documentation. The Nurses Notes component is designed to enable point-of-care patient charting for the Surgical Services department. Nursing personnel will have access to a patient's chart from any of the system access points (with valid I.D. and access rights).

Each section of the Nurses Note (pre-op / intra-op / post-op), contains lock-down and addendum functionality in compliance with regulatory guidelines. This clinical information may be passed electronically to an electronic medical record, (EMR), or may be printed and filed under the same protocol as printed forms utilized for nurses notes.

Each hospital may design their own charting templates by choosing data elements from a master list of peri-operative charting data elements. Input into data fields may be set as required or optional. This functionality ensures that all required fields are complete prior to closing the patient record and eliminates the problem of incomplete charting. All data collected in Nurses Notes is available for reporting purposes (ex. Quality Assurance and Risk Management) in the SQL database.