Community Health – Facilitating, Preparing and Documenting Multidisciplinary Patient Case Conference Within PowerChart there are two forms to facilitate preparation and documentation of patient Case Conference.
The two PowerForms, which are available from Adhoc Charting are:
1. Goal Based Case Conference
2. Multidisciplinary Case Conference Powerform
Creating a new Case Conference PowerForm
1. Login to PowerChart
2. Open the relevant Patient Medical Record
3. Click the button located on the ieMR Toolbar
4. The Ad Hoc Charting window will open
5. Click on the All Items Folder
6. Click on the Case Conference Folder
7. Click in the square to select the Multidisciplinary Case Conference form or the Goal Based Case Conference form
8. Click Chart
9. The selected Case Conference PowerForm will now open
Multidisciplinary Case Conference from
The Multidisciplinary Case Conference form is divided into four sections:
Icon toolbar: contains key icons available
Signs and closes down form
Saves and closes down form
Cancels and closes down form
Clears data on selected page of form
Displays result information
Previous and Next buttons to move through sections of the form
Opens calculator
Performed on details: displays the form’s commencement date and initiating clinician. The date and time can be amended if required.
Menu: Lists the case conference section headings available to be completed. Clicking on the section heading highlights the heading and displays the corresponding fields in the Menu Details section.
Menu Details section: Displays the fields for the section heading selected from the Menu.
Completing the Multidisciplinary Case Conference form
1. Click on the Case Conference Administration section heading
2. Enter case conference details in the Case Conference Administration window, see image above.
Do not complete the
field until the end of the case conference process and all documentation is complete. Completing this field will finalise the case conference form and publish the results to several
Patient Menu sections. Click the save
or sign button/s to store the forms content.
3. Click on the Case Conference Event section heading
4. Click within the cell to enter text, e.g. Baseline Function, Short Term goal, Current Status, Long Term goals.
5. To add a comment within the cell:
Double click within the cell
The Add Results Comment window will open
Click within the Comment box and enter a free text comment as required
Click OK
6. When you have finished documenting in the form, click
sign . The PowerForm window will close.
To view or modify the Case Conference form (Activities and Interventions – Community Nursing Staff ONLY)
1. On the Patient Menu click Activities and Interventions
2. Click Refresh
3. In the Scheduled Patient Care tab, locate the correct case conference task in the Task Description field.
4. Double Click to open the form
5. Modify or view the form as required
6. Click sign to save changes
7. Click cancel to exit without saving
Finalising the Case Conference form
When the case conference process is finalised and documentation within the form is complete, complete the following steps to submit the form content.
8. As previous, locate and open the Multidisciplinary Case Conference PowerForm
9. Modify form details as required and lastly, complete the Case Conference end time mandatory field
10. Click sign
The PowerForm will close and you are returned to
the Scheduled Patient Care tab
11. Click refresh
The Case Conference task will be removed from the Scheduled Patient Care list
Viewing the Multidisciplinary Case Conference details
Content for the Multidisciplinary Case Conference PowerForm can be viewed in the following Menu sections:
Clinical Notes View. Double click the PowerForm Textual Rendition Notes folder and then double click the Case Conference – Text folder. Case Conference forms are listed in date order.
Documentation. Displayed in date order.
Results. Click on Documents tab, listed under the PowerForm Textual Rendition Notes field.
Contiguous Notes. Displayed in date order or use search function.
Uncharting the Multidisciplinary Case Conference PowerForm details
If the PowerForm is accidentally submitted, or entered in the wrong Patient’s Medical Record, you can unchart the PowerForm,. This action marks the form as being In Error. To unchart:
1. In Menu, click Forms
2. Locate correct PowerForm, click to select
3. Right click, select and click Unchart
4. Enter uncharting reason in free text Comment box
5. Click, sign
The form will now appear with a red line through the form title.
If the form is selected, the user will be notified that the form has been marked In Error. See below.
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