In institutional healthcare, the interaction between physician-providers and nurses is critical to a safe and efficient operating environment. HealthSecure provides several functions that are tailored for this environment.
VERBAL ORDERS WITH SIGN OFF NOTIFICATION
All orders entered by nurses are marked as “Verbal”. The nurse is required to indicate the provider who gave the order. In turn, the provider is given a “Sign Off” task. Medication orders, non-medication orders (including lab/radiology tests) all require sign off. However, good system design mandates a certain amount of flexibility, and institutional policies and protocols may vary. For this reason, HealthSecure has a robust configuration system where the “Sign Off” requirement can be selectively turned off for certain types of orders.
SBAR FORMAT COMMUNICATIONS WITH EMAIL INTEGRATION
HealthSecure includes the specialized SBAR system, a form of communications that is specifically developed for the “team” model of healthcare. Originally based on naval military procedure and then refined in private organizations, the SBAR is a tool for nurse to physician communication.
SBAR stands for Situation, Background, Assessment, Recommendation. It guides nurses in exactly what information they need to collect, summarize and transmit to the physician-provider about a particular situation with a patient.
HealthSecure’s powerful SBAR forms allow the nurse to pre-populate with data collected at Booking and other parts of the inmate’s medical record, guides their choices of recommendation, and then handles the workflow of transmitting the SBAR to physicians and making sure those are viewed and signed off.
SBARs are also integrated with email over a secure virtual private network. The benefit of this is that offsite/on-call providers can interact with nurses while away from the facility. Furthermore, the system is not “individual-nurse” based, but “pool-of-nurses” based. Since nurses work in shifts, this helps the nursing staff as a whole provide timely service and prevents work from “falling through the cracks.”
PROGRESS NOTE SYSTEM WITH TEMPLATES
HealthSecure comes with a number of built-in progress note types for physician, mental health, nursing, detox, dental and many more.
Some of these progress notes are integrated with an extensive tool for clinical followup to manage chronic care issues.
As part of our philosophy of continuous innovation, we are currently developing a state of the art customizable template system to help both nurses and physician-providers further reduce the burden of data entry.