HEALTHSECURE EMR BUILT-IN FORMS
HealthSecure comes with many forms that guide your medical process. Not only do these forms capture information for record-keeping process, they are also important parts of our overall system design goal for preventative medicine. Information collected in forms flows into other parts of the EMR.
Here are the major forms and how they work
MEDICAL TRIAGE
When an inmate arrives in the jail, this basic evaluation is performed to determine the inmate’s medical clearance, general state of mental and physical health, etc.
Upon completion, the evaluating nurse or officer can indicate whether the inmate is suitable for acceptance into the jail, and also log whether a physician was contacted, security staff notified, etc.
BOOKING MEDICAL SCREENING
This comprehensive document collects well over 100 data points about the inmate’s medical history and condition.
Information collected includes current medications, allergies, detailed social history of drug/alcohol use, family medical history and mental health status. A full review of systems and brief physical assessment are performed. At the end, the booking nurse can enter a categorized assessment and plan.
This document is critical to achieving HealthSecure’s system goal of operating a prevention-oriented medical environment. By collecting this information up-front, medical staff can do the following and more:
- Assess mental health information and make necessary referrals, taking immediate action if there is potential for the inmate to harm himself or others;
- Start drug & alcohol detox protocols
- Ensure that urgent medical conditions are flagged for prompt medical attention
- Count and validate home medications the inmate may be on or may have brought with them (see how our Home Medication process can reduces costs for the jail)
The information entered here can be later auto-populated into other areas, e.g., SBAR referrals physician-providers and progress notes. Capturing the inmate’s medications here also results in less data-entry down the road.
HealthSecure has easy tools to show which inmates are needing this important screening to be performed. Finally, certain automatic processes are started from this document, such as immediately marking inmates with key chronic care conditions as needing a physician referral, including urgent mental health issues such as suicide watch.
The processes initiated from this screening can be helpful in identifying physical and mental health problems early, which can result in a safer environment with lower liability and costs for the jail.
HISTORY & PHYSICAL
A detailed History & Physical document, separate from the regular progress note, captures specific information on the inmate’s physical health. This document is tied to “14 day” and “annual” compliance reports. A jail can use these tools if desired to make sure that all inmates get a full H&P from a physician-provider once they are settled in the jail and then annually thereafter. This feature is helpful for jails who wish to become compliant with standards such as those set forth by the American Correctional Association.
MENTAL HEALTH SCREEN
Multiple forms are used in mental health management, starting with information collected at the booking intake. This information can be populated into a mental health referral form, which is then referred to a Mental Health provider. Finally, a full evaluation form is available which allows the provider to track a detailed psychiatric history, note concerns such as work program suitability, and make recommendations for mental health programming. Psychiatric diagnoses are captured and managed using standard DSM-IV criteria.
DENTAL SCREEN
This form is very detailed with specific questions for dental issues and separate note areas for each of the 32 teeth, presented visually. Related medical issues can also be viewed and captured here. Like all other forms, the dental provider can easily view results of prior visits and store a new document for the current visit.
OTHER DOCUMENTS
HealthSecure has many other built-in documents, including documents for inmates who are being moved to other facilities, so that the receiving facility has full medical information upon the inmate’s arrival; release-of-information authorization forms, to request an inmate’s documents from his previous provider; trustee screening forms, to ensure inmates are medically cleared to work in areas like the kitchen, etc. Some of these forms can also be interfaced with the jail’s JMS software for keeping relevant information synchronized.
CUSTOM FORM BUILDER
Recognizing that every jail’s needs are different, we are in the process of developing a “Form Builder” to allow jail administrators to create their own forms without needing IT department resources. Forms created by the “builder” share all the features of built-in forms such as “autosave” drafts, auditing and the ability to save multiple versions.
