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	<title>PatientOS Open Source EMR &#187; Nursing Documentation</title>
	<atom:link href="http://www.patientos.org/blog/?feed=rss2&#038;cat=6" rel="self" type="application/rss+xml" />
	<link>http://www.patientos.org/blog</link>
	<description>Guide to the PatientOS healthcare information system</description>
	<pubDate>Sun, 16 Oct 2011 11:37:18 +0000</pubDate>
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	<language>en</language>
			<item>
		<title>Nursing FIM Worksheet Assessment Part 2</title>
		<link>http://www.patientos.org/blog/?p=96</link>
		<comments>http://www.patientos.org/blog/?p=96#comments</comments>
		<pubDate>Tue, 11 Nov 2008 19:40:24 +0000</pubDate>
		<dc:creator>admin</dc:creator>
		
		<category><![CDATA[Nursing Documentation]]></category>

		<guid isPermaLink="false">http://www.patientos.org/blog/?p=96</guid>
		<description><![CDATA[With version 0.85 we have a a few new features in the form editor that automate many of steps to building new forms.
Paste Controls into a form
Since I had build a form per section in the FIM assessment I wanted to paste the first 21 controls as a template into each form.  Rather than [...]]]></description>
			<content:encoded><![CDATA[<p>With version 0.85 we have a a few new features in the form editor that automate many of steps to building new forms.</p>
<p><strong>Paste Controls into a form</strong></p>
<p>Since I had build a form per section in the FIM assessment I wanted to paste the first 21 controls as a template into each form.  Rather than going into each and using Paste, there is now a control on the form list that allows you to paste controls in your buffer into all selected forms.  The forms must be empty but still this saves a fair amount of time.</p>
<div id="attachment_97" class="wp-caption alignnone" style="width: 310px"><a href="http://www.patientos.org/blog/wp-content/paste_controls.png"><img class="size-medium wp-image-97" title="paste_controls" src="http://www.patientos.org/blog/wp-content/paste_controls-300x158.png" alt="Paste controls into empty forms" width="300" height="158" /></a><p class="wp-caption-text">Paste controls into empty forms</p></div>
<p><strong>Replicating controls for terms<br />
</strong></p>
<p>Now that we have a template set of controls in the form we want to replicate each line for each term in the subcategory.  This is where it became very convenient to have a subcategory per term.</p>
<p>First we open the template form and select the last 7 controls to replicate.</p>
<div id="attachment_98" class="wp-caption alignnone" style="width: 310px"><a href="http://www.patientos.org/blog/wp-content/replicate_controls.png"><img class="size-medium wp-image-98" title="replicate_controls" src="http://www.patientos.org/blog/wp-content/replicate_controls-300x194.png" alt="Select controls to replicate" width="300" height="194" /></a><p class="wp-caption-text">Select controls to replicate</p></div>
<p>Next we press the replicate toolbar button and select the term subcategory for the terms we need.  In this case typing the word &#8216;expression&#8217; filters the list to the subcategory we need.</p>
<div id="attachment_99" class="wp-caption alignnone" style="width: 310px"><a href="http://www.patientos.org/blog/wp-content/subcategory.png"><img class="size-medium wp-image-99" title="subcategory" src="http://www.patientos.org/blog/wp-content/subcategory-300x194.png" alt="Select the term subcategory" width="300" height="194" /></a><p class="wp-caption-text">Select the term subcategory</p></div>
<p>Next we are prompted to select the terms from the subcategory.  It is ordered the same as they were uploaded in order to match the originating form.</p>
<p>Note the form can be maximized by clicking the icon in the top right toolbar corner.</p>
<div id="attachment_100" class="wp-caption alignnone" style="width: 310px"><a href="http://www.patientos.org/blog/wp-content/selectterms.png"><img class="size-medium wp-image-100" title="selectterms" src="http://www.patientos.org/blog/wp-content/selectterms-300x202.png" alt="select terms by double clicking" width="300" height="202" /></a><p class="wp-caption-text">select terms by double clicking</p></div>
<p>Finally after clicking OK the system prompts for a shorter name for each term.  It is just used on the form and has no direct visibility to the user.  It is nice to have application control names under 50 characters though.</p>
<p><a href="http://www.patientos.org/blog/wp-content/replacement.png"><img class="alignnone size-medium wp-image-101" title="replacement" src="http://www.patientos.org/blog/wp-content/replacement-300x206.png" alt="" width="300" height="206" /></a></p>
<p>After all the prefixes are replace the system adds all the new controls to the form.  Press the refresh button to update the form display</p>
<div id="attachment_102" class="wp-caption alignnone" style="width: 310px"><a href="http://www.patientos.org/blog/wp-content/refresh_after.png"><img class="size-medium wp-image-102" title="refresh_after" src="http://www.patientos.org/blog/wp-content/refresh_after-300x199.png" alt="Press refresh to layout the form" width="300" height="199" /></a><p class="wp-caption-text">Press refresh to layout the form</p></div>
<p>Finally we need to fix up the labels.  We select each label control in the list (they end in label) and using the control key use that to select them all.</p>
<p>Press the command button and enter the following script:</p>
<pre>control.setLabel(control.getApplicationControlName().replace("label", ":"));</pre>
<p>Click OK and this form is now finished - click OK and we will complete the rest.</p>
<div id="attachment_103" class="wp-caption alignnone" style="width: 510px"><a href="http://www.patientos.org/blog/wp-content/form_ed_last.png"><img class="size-full wp-image-103" title="form_ed_last" src="http://www.patientos.org/blog/wp-content/form_ed_last.png" alt="Updated label and form is done" width="500" height="312" /></a><p class="wp-caption-text">Updated label and form is done</p></div>
<p>Here is a video on the process</p>
<p><a href="http://www.patientos.org/forum_temp/fim/fimassess2.htm">FIM assessment build</a></p>
<p><img src="file:///C:/DOCUME%7E1/GCAULT%7E1/LOCALS%7E1/Temp/moz-screenshot.jpg" alt="" /></p>
]]></content:encoded>
			<wfw:commentRss>http://www.patientos.org/blog/?feed=rss2&amp;p=96</wfw:commentRss>
		</item>
		<item>
		<title>Nursing FIM Worksheet Assessment</title>
		<link>http://www.patientos.org/blog/?p=51</link>
		<comments>http://www.patientos.org/blog/?p=51#comments</comments>
		<pubDate>Tue, 28 Oct 2008 12:01:41 +0000</pubDate>
		<dc:creator>admin</dc:creator>
		
		<category><![CDATA[Nursing Documentation]]></category>

		<guid isPermaLink="false">http://www.patientos.org/blog/?p=51</guid>
		<description><![CDATA[Now that the PatientOS tools are becoming more mature I am able to write up instructions for administrators to build clinical documentation content - without requiring a developer to build it for them.  Here are the instructions used for the FIM Worksheet Assessment.
Step 1 FIM Assessment Design
The assessment is divided into 20 or more [...]]]></description>
			<content:encoded><![CDATA[<p>Now that the PatientOS tools are becoming more mature I am able to write up instructions for administrators to build clinical documentation content - without requiring a developer to build it for them.  Here are the instructions used for the FIM Worksheet Assessment.</p>
<p><strong>Step 1 FIM Assessment Design</strong></p>
<p>The assessment is divided into 20 or more sections, each of which have several questions to assess the patient.  Each question is assigned a score and the lowest score in the section becomes the FIM score.</p>
<div id="attachment_52" class="wp-caption alignnone" style="width: 310px"><a href="http://www.patientos.org/blog/wp-content/fim_assessment.png"><img class="size-medium wp-image-52" title="fim_assessment" src="http://www.patientos.org/blog/wp-content/fim_assessment-300x189.png" alt="FIM Assessment Eating Section" width="300" height="189" /></a><p class="wp-caption-text">FIM Assessment Eating Section</p></div>
<p>We will have one form per section and then a single form which adds the others as sections.</p>
<p><strong>Step 2 Data Elements</strong></p>
<p>In this form will we create 2 new data elements for the FIM assessment and assign the OpenEHR identifier for a global assessment.</p>
<ul>
<li>Evaluations &#8211;&gt; SOAP &#8211;&gt; Assessment &#8211;&gt; System FIM Assessment
<ol>
<li>System FIM Assessment Item<br />
- Integer<br />
- openEHR-EHR-OBSERVATION.global.v1/data[at0001]/events[at0002]/data[at0003]/items[at0067]/value</li>
<li>System FIM Assessment Score<br />
- Integer</li>
</ol>
</li>
</ul>
<div id="attachment_53" class="wp-caption alignnone" style="width: 310px"><a href="http://www.patientos.org/blog/wp-content/fim_assessment_dataelements.png"><img class="size-medium wp-image-53" title="fim_assessment_dataelements" src="http://www.patientos.org/blog/wp-content/fim_assessment_dataelements-300x221.png" alt="FIM Assessment Data elements" width="300" height="221" /></a><p class="wp-caption-text">FIM Assessment Data elements</p></div>
<p><strong>Step 3 Term Subcategories</strong></p>
<p>Ahead of time we create the term subcategories using the reference builder</p>
<table style="border-collapse: collapse; width: 257pt;" border="0" cellspacing="0" cellpadding="0" width="342"><col style="width: 257pt;" width="342"></col></p>
<tbody>
<tr style="height: 12.75pt;" height="17">
<td style="height: 12.75pt; width: 257pt;" width="342" height="17">System - FIM   Worksheet Eating</td>
</tr>
<tr style="height: 12.75pt;" height="17">
<td style="height: 12.75pt;" height="17">System - FIM Worksheet Grooming</td>
</tr>
<tr style="height: 12.75pt;" height="17">
<td style="height: 12.75pt;" height="17">System - FIM Worksheet Bathing</td>
</tr>
<tr style="height: 12.75pt;" height="17">
<td style="height: 12.75pt;" height="17">System - FIM Worksheet Upper Body   Dressing</td>
</tr>
<tr style="height: 12.75pt;" height="17">
<td style="height: 12.75pt;" height="17">System - FIM Worksheet Lower Body   Dressing</td>
</tr>
<tr style="height: 12.75pt;" height="17">
<td style="height: 12.75pt;" height="17">System - FIM Worksheet Toileting</td>
</tr>
<tr style="height: 12.75pt;" height="17">
<td style="height: 12.75pt;" height="17">System - FIM Worksheet Bladder</td>
</tr>
<tr style="height: 12.75pt;" height="17">
<td style="height: 12.75pt;" height="17">System - FIM Worksheet Bladder Accidents</td>
</tr>
<tr style="height: 12.75pt;" height="17">
<td style="height: 12.75pt;" height="17">System - FIM Worksheet Bowel</td>
</tr>
<tr style="height: 12.75pt;" height="17">
<td style="height: 12.75pt;" height="17">System - FIM Worksheet Bowel Accidents</td>
</tr>
<tr style="height: 12.75pt;" height="17">
<td style="height: 12.75pt;" height="17">System - FIM Worksheet Transfer Bed   Chair Wheelchair</td>
</tr>
<tr style="height: 12.75pt;" height="17">
<td style="height: 12.75pt;" height="17">System - FIM Worksheet Transfer Toilet</td>
</tr>
<tr style="height: 12.75pt;" height="17">
<td style="height: 12.75pt;" height="17">System - FIM Worksheet Transfer Tub   Shower</td>
</tr>
<tr style="height: 12.75pt;" height="17">
<td style="height: 12.75pt;" height="17">System - FIM Worksheet Locomotion   Ambulation</td>
</tr>
<tr style="height: 12.75pt;" height="17">
<td style="height: 12.75pt;" height="17">System - FIM Worksheet Locomotion   Wheelchair</td>
</tr>
<tr style="height: 12.75pt;" height="17">
<td style="height: 12.75pt;" height="17">System - FIM Worksheet Locomotion Stairs</td>
</tr>
<tr style="height: 12.75pt;" height="17">
<td style="height: 12.75pt;" height="17">System - FIM Worksheet Comprehension</td>
</tr>
<tr style="height: 12.75pt;" height="17">
<td style="height: 12.75pt;" height="17">System - FIM Worksheet Expression</td>
</tr>
<tr style="height: 12.75pt;" height="17">
<td style="height: 12.75pt;" height="17">System - FIM Worksheet Social   Interaction</td>
</tr>
<tr style="height: 12.75pt;" height="17">
<td style="height: 12.75pt;" height="17">System - FIM Worksheet Problem Solving</td>
</tr>
<tr style="height: 12.75pt;" height="17">
<td style="height: 12.75pt;" height="17">System - FIM Worksheet Memory</td>
</tr>
</tbody>
</table>
<p><strong>Step 3 Terms</strong></p>
<p>We open the Term Builder and create a term hierarchy</p>
<p><em>Evaluations&#8211;&gt; FIM Assessment </em></p>
<p>and right click on the category to get the menu choices.</p>
<p><a href="http://www.patientos.org/blog/wp-content/fimassessment_termbuilder.png"><img class="alignnone size-medium wp-image-54" title="fimassessment_termbuilder" src="http://www.patientos.org/blog/wp-content/fimassessment_termbuilder-300x198.png" alt="" width="300" height="198" /></a></p>
<ol>
<li>This time we want &#8220;add terms and details to FIM assessment&#8221;</li>
<li>We are then prompted and select the appropriate term subcategory</li>
<li>We say no to the prompt for a coded entry</li>
<li>We say yes to apply the same detail to all items</li>
<li>We then search for System FIM Assessment Score</li>
</ol>
<p><a href="http://www.patientos.org/blog/wp-content/fimassessment_score.png"><img class="alignnone size-medium wp-image-55" title="fimassessment_score" src="http://www.patientos.org/blog/wp-content/fimassessment_score-300x194.png" alt="" width="300" height="194" /></a></p>
<p>6. Finally we enter the list ensuring one term per line and a semi-colon and the score at the end of the line</p>
<div id="attachment_56" class="wp-caption alignnone" style="width: 509px"><a href="http://www.patientos.org/blog/wp-content/fimassessment_terms.png"><img class="size-full wp-image-56" title="fimassessment_terms" src="http://www.patientos.org/blog/wp-content/fimassessment_terms.png" alt="Term name with detail value" width="499" height="247" /></a><p class="wp-caption-text">Term name with detail value</p></div>
<p><strong>Step 5 Template Form</strong></p>
<p>A form is created for each term subcategory and opening each form we sent the view properties to</p>
<ul>
<li>Columns 11</li>
<li>Column spec</li>
</ul>
<p>We then add 3 rows labels</p>
<ol>
<li>Row 1
<ul>
<li>Blank label</li>
<li>Label &#8220;Day 1&#8243; 3 columns wide</li>
<li>Label &#8220;Day 2&#8243; 3 columns wide</li>
<li>Label &#8220;Day 3&#8243; 3 columns wide</li>
<li>Blank label</li>
</ul>
</li>
<li>Row 2
<ul>
<li>Subcategory label</li>
<li>Label for day 1 shift 1</li>
<li>Label for day 1 shift 2</li>
<li>Label for day 1 shift3</li>
<li>Label for day 2 shift 1</li>
<li>Label for day 2 shift 2</li>
<li>Label for day 2 shift 3</li>
<li>Label for day 3 shift 1</li>
<li>Label for day 3 shift 2</li>
<li>Label for day 4 shift 3</li>
<li>Label for FIM score</li>
</ul>
</li>
<li>Row 3
<ul>
<li>Label for first term</li>
<li>3 state (Yes Unvalued N/A) checkbox<br />
- FIM Assessment record item<br />
- First term value<br />
- Term Sequence 1</li>
<li>3 state (Yes Unvalued N/A) checkbox<br />
- FIM Assessment record item<br />
- First term value<br />
- Term Sequence 2</li>
<li>3 state (Yes Unvalued N/A) checkbox<br />
- FIM Assessment record item<br />
- First term value<br />
- Term Sequence 3</li>
<li>etc up to Term Sequence 9</li>
<li>Integer field with<br />
- FIM Assessment score record item<br />
- First term value</li>
</ul>
</li>
</ol>
<p>The template form now looks like this</p>
<div id="attachment_58" class="wp-caption alignnone" style="width: 310px"><a href="http://www.patientos.org/blog/wp-content/fim_form.png"><img class="size-medium wp-image-58" title="fim_form" src="http://www.patientos.org/blog/wp-content/fim_form-300x188.png" alt="FIM assessment header and first term" width="300" height="188" /></a><p class="wp-caption-text">FIM assessment header and first term</p></div>
<p><strong>Step 4 Replicating the Form</strong></p>
<ol>
<li>First we open the FIM Worksheet Eating form and select the last 11 controls</li>
<li>We press the TERM toolbar button</li>
<li>We search and find the first term &#8220;Completely Independent&#8221;</li>
<li>We apply the term to all 11 controls</li>
<li>We press the copy button</li>
<li>We press the paste button</li>
<li>We then repeat steps 1-4 for the second term</li>
<li>We optionally change the control name (see below)</li>
<li>We do need to update the first controls name (see toolbar with an A)</li>
</ol>
<p>We then repeat for all terms in this form.</p>
<p>Here is a video of the process to replicate the form design:</p>
<p><a href="http://www.patientos.org/software/video_files/085/fim/fimassessment.htm">FIM assessment replicating the forms</a></p>
<p>We then repeat for all forms and terms.  For each new form we first paste all of the header and first 11 controls (25 in total).</p>
<p>Note to change a control name you can use the command control button and enter the following script</p>
<p>control.setLabel(control.getLabel().replace(&#8221;independent&#8221;,&#8221;fed slower&#8221;));</p>
]]></content:encoded>
			<wfw:commentRss>http://www.patientos.org/blog/?feed=rss2&amp;p=51</wfw:commentRss>
		</item>
		<item>
		<title>Nursing Documentation - Care Plan</title>
		<link>http://www.patientos.org/blog/?p=37</link>
		<comments>http://www.patientos.org/blog/?p=37#comments</comments>
		<pubDate>Wed, 22 Oct 2008 13:48:40 +0000</pubDate>
		<dc:creator>admin</dc:creator>
		
		<category><![CDATA[Nursing Documentation]]></category>

		<guid isPermaLink="false">http://www.patientos.org/blog/?p=37</guid>
		<description><![CDATA[The care plan is based upon the nursing diagnosis (NANDA) with associated interventions and goals.
In our form design we will divide in form into one section per diagnsosis and then subdivide each section into interventions and goals.
So one diagnosis on the form looks like this.
Goals Section
Here is the design of a section for goals
Effectively we [...]]]></description>
			<content:encoded><![CDATA[<p>The care plan is based upon the nursing diagnosis (NANDA) with associated interventions and goals.</p>
<p>In our form design we will divide in form into one section per diagnsosis and then subdivide each section into interventions and goals.</p>
<p>So one diagnosis on the form looks like this.</p>
<div id="attachment_38" class="wp-caption alignnone" style="width: 310px"><a href="http://www.patientos.org/blog/wp-content/careplan_excel.png"><img class="size-medium wp-image-38" title="careplan_excel" src="http://www.patientos.org/blog/wp-content/careplan_excel-300x50.png" alt="Care plan single NANDA section" width="300" height="50" /></a><p class="wp-caption-text">Care plan single NANDA section</p></div>
<p><strong>Goals Section</strong></p>
<p>Here is the design of a section for goals</p>
<div id="attachment_39" class="wp-caption alignnone" style="width: 509px"><a href="http://www.patientos.org/blog/wp-content/careplan_mapping.png"><img class="size-full wp-image-39" title="careplan_mapping" src="http://www.patientos.org/blog/wp-content/careplan_mapping.png" alt="Care plan mapping for goals" width="499" height="180" /></a><p class="wp-caption-text">Care plan mapping for goals</p></div>
<p>Effectively we have</p>
<ul>
<li>One row maps to one Term</li>
<li>One row maps to one record</li>
<li>The first column is the active indicator on the record</li>
<li>The second column is the term text of the record</li>
<li>The third column is a detail record for the goal met date</li>
</ul>
<p><strong>Data Elements </strong></p>
<ul>
<li>Create a hierarchy<br />
- Evaluations &#8211;&gt; Plan of Care &#8211;&gt; Goal<br />
- Evaluations &#8211;&gt; Plan of Care &#8211;&gt; Followup</li>
<li>Import the OpenEHR Archetype openEHR-EHR-EVALUATION.goal</li>
<li>Import the OpenEHR Archetype openEHR-EHR-INSTRUCTION.follow_up</li>
<li>Since the followup archetype does not have a qualifying type we add our own specific Nursing Intervention data types - one per diagnsos e.g.<br />
- Nursing Intervention Barriers to Discharge</li>
</ul>
<div id="attachment_41" class="wp-caption alignnone" style="width: 310px"><a href="http://www.patientos.org/blog/wp-content/careplan_dataelements.png"><img class="size-medium wp-image-41" title="careplan_dataelements" src="http://www.patientos.org/blog/wp-content/careplan_dataelements-300x164.png" alt="Care plan data element record item hierarchy" width="300" height="164" /></a><p class="wp-caption-text">Care plan data element record item hierarchy</p></div>
<p><strong>Term Tool</strong></p>
<ul>
<li>Create a hierarchy<br />
- Evaluations&#8211;&gt;Plan of Care &#8211;&gt; Plan of Care Goals<br />
- Evaluations&#8211;&gt;Plan of Care &#8211;&gt; Plan of Care Followup</li>
<li>Create term subcategories, one for each NANDA diagnosis e.g.<br />
- System Care Plan Barriers to Discharge</li>
<li>Add the terms</li>
</ul>
<div id="attachment_40" class="wp-caption alignnone" style="width: 310px"><a href="http://www.patientos.org/blog/wp-content/careplan_terms.png"><img class="size-medium wp-image-40" title="careplan_terms" src="http://www.patientos.org/blog/wp-content/careplan_terms-300x179.png" alt="Care plan term hierarchy" width="300" height="179" /></a><p class="wp-caption-text">Care plan term hierarchy</p></div>
<p><strong>Form Section Design - Goals</strong></p>
<ul>
<li>Create a form per section e.g.<br />
- System - Care Plan Barriers to Discharge Goals</li>
<li>The goals have 4 columns with the column spec of<br />
- 4dlu, 4dlu, 4dlu, 10dlu, 4dlu, 4dlu, 4dlu, 75dlu:grow(1), 4dlu, 4dlu, 4dlu, 75dlu:grow(1), 4dlu, 4dlu, 4dlu, 75dlu</li>
<li>Goals have the following header fields<br />
- Empty label, Long term goal, goal resolved</li>
<li>Goals have the following fields - each with a blank label to create a table look<br />
- Active column (Checkbox)<br />
&#8212;- Record Item: Goal Outcome<br />
&#8212;- Term: Patient will be discharged to ______<br />
&#8212;- Model: FORMRECORDS_ACTIVEIND<br />
&#8212;- Default Action Script:</li>
</ul>
<blockquote><p>importPackage(Packages.com.patientis.framework.scripting);</p>
<p>lockcontrols = !component.isSelected();<br />
ServiceUtility.setOtherComponentsWithTermLocked(controlpanel, control, lockcontrols);</p></blockquote>
<ul>
<li>
<ul> - Long term goal (Text field)<br />
&#8212;- Record Item: Goal Outcome<br />
&#8212;- Term: Patient will be discharged to ______<br />
&#8212;- Model: FORMRECORDS_TERMTEXT<br />
&#8212;- Locked<br />
- Goal resolved (Calendar)<br />
&#8212;- Record Item: Goal Outcome<br />
&#8212;- Detail Item: Goal Met<br />
&#8212;- Term: Patient will be discharged to ______<br />
&#8212;- Model: FORMRECORDS_VALUEDATE</ul>
</li>
<li>The active indicator checkbox is used to activate or inactivate the goal and will also unlock the text box to allow the goal to be edited and the goal met date to be entered.</li>
</ul>
<p><strong>Form Section Design - Interventions</strong></p>
<ul>
<li>Create a form per section e.g.<br />
- System - Care Plan Barriers to Discharge Interventions</li>
<li>The interventions have 3 columns with the column spec of<br />
- 4dlu, 4dlu, 4dlu, 10dlu, 4dlu, 4dlu, 4dlu, 100dlu:grow(1), 4dlu, 4dlu, 4dlu, 100dlu:grow(1)</li>
<li>Interventions have the following fields<br />
- Goal Active (Checkbox)<br />
&#8212;- Record Item: Nursing Intervention Barriers to Discharge<br />
&#8212;- Term: Patient / care giver conference with the interdisciplinary team<br />
&#8212;- FORMRECORDS_ACTIVEIND<br />
&#8212;- Default action script</p>
<blockquote><p>importPackage(Packages.com.patientis.framework.scripting);</p>
<p>lockcontrols = !component.isSelected();<br />
ServiceUtility.setOtherComponentsWithTermLocked(controlpanel, control, lockcontrols);</p></blockquote>
</li>
<li>- Intervention (Text field)<br />
&#8212;- Record Item: Nursing Intervention Barriers to Discharge<br />
&#8212;- Term: Patient / care giver conference with the interdisciplinary team<br />
&#8212;- FORMRECORDS_TERMTEXT</li>
</ul>
<p><strong>Creating New Sections - Goals</strong></p>
<ul>
<li>Open the first form and select the first 6 controls - 3 header labels and the first 3 controls</li>
<li>Create a new form e.g.<br />
- System - Care Plan Alteration in ADL goals</li>
<li>Paste the controls into the form using the toolbar or menu</li>
<li>Select the last 3 controls</li>
<li>Press the Term toolbar button</li>
<li>Enter the name of the new term</li>
<li>Click OK and OK to apply to the 3 selected controls</li>
</ul>
<p><a href="http://www.patientos.org/blog/wp-content/careplan_duplicate_goals.png"><img class="alignnone size-medium wp-image-45" title="careplan_duplicate_goals" src="http://www.patientos.org/blog/wp-content/careplan_duplicate_goals-300x213.png" alt="" width="300" height="213" /></a></p>
<ul>
<li>Select the last 3 controls again and repeat the process for each goal</li>
<li>Save the form</li>
</ul>
<p><strong>Creating New Sections - Interventions</strong></p>
<ul>
<li>Repeat the process for goals for each intervention</li>
</ul>
<p><strong>Creating Rollup Sections</strong></p>
<ul>
<li>Once we have all the goal and intervention sections created we create an additional form per NANDA diagnosis<br />
System - Care Plan Alteration in Mood goals<br />
System - Care Plan Alteration in Bladder goals<br />
System - Care Plan Alteration in Bowel goals<br />
System - Care Plan Alteration of Cognition goals<br />
System - Care Plan Alteration of Communication goals<br />
System - Care Plan Alteration in ADL goals<br />
System - Care Plan Alteration in Mobility goals<br />
System - Care Plan Alteration in Swallowing goals<br />
System - Care Plan Alteration in Nutrition goals<br />
System - Care Plan Alteration in Respiratory goals<br />
System - Care Plan Potential for Skin Breakdown goals<br />
System - Care Plan Alteration in Skin Integrity goals<br />
System - Care Plan Alteration in Mood interventions<br />
System - Care Plan Alteration in Bladder interventions<br />
System - Care Plan Alteration in Bowel interventions<br />
System - Care Plan Alteration of Cognition interventions<br />
System - Care Plan Alteration of Communication interventions<br />
System - Care Plan Alteration in ADL interventions<br />
System - Care Plan Alteration in Mobility interventions<br />
System - Care Plan Alteration in Swallowing interventions<br />
System - Care Plan Alteration in Nutrition interventions<br />
System - Care Plan Alteration in Respiratory interventions<br />
System - Care Plan Potential for Skin Breakdown interventions<br />
System - Care Plan Alteration in Skin Integrity interventions</li>
<li>In each form we add 2 sections</li>
<li>Press Add</li>
<li>Click on the Section option</li>
<li>Browse for the corresponding goal and intervention form</li>
</ul>
<div id="attachment_46" class="wp-caption alignnone" style="width: 310px"><a href="http://www.patientos.org/blog/wp-content/careplan_add_section.png"><img class="size-medium wp-image-46" title="careplan_add_section" src="http://www.patientos.org/blog/wp-content/uploads/careplan_add_section-300x153.png" alt="Care plan add an existing section" width="300" height="153" /></a><p class="wp-caption-text">Care plan add an existing section</p></div>
<ul>
<li>View the properties of each section and change the section to be system expand only.</li>
<li>This removes the expanding arrows</li>
</ul>
<div id="attachment_47" class="wp-caption alignnone" style="width: 310px"><a href="http://www.patientos.org/blog/wp-content/careplan_section_sys_expand.png"><img class="size-medium wp-image-47" title="careplan_section_sys_expand" src="http://www.patientos.org/blog/wp-content/careplan_section_sys_expand-300x188.png" alt="Remove user expand arrows" width="300" height="188" /></a><p class="wp-caption-text">Remove user expand arrows</p></div>
<p><strong>Create the Care Plan Form</strong></p>
<ul>
<li>Create a new form System Care Plan</li>
<li>Add each NANDA diagnosis section</li>
</ul>
<p>We now have the basic care plan form.</p>
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