Inpatient Form

Table of contents:

Overview

Initiate the Inpatient Form

Locate an Inpatient Form that is Parked (in progress)

Entering Documentation

Editing Documentation

Late Entry

Entered in Error

Viewing and Sorting Documentation

Overview

The Inpatient form is a documentation tool used by inpatient programs who document in Profile EMR. There is one Inpatient form, per client, per one stay. Multiple disciplines can document within the same form for all documentation regarding a single admission. For example, at admission the Inpatient form is launched & parked and then at discharge it is completed.  If the client returns to the inpatient program, a new form is created.    

The Inpatient form replaces multiple encounter notes with one easy-to-use, searchable, and printable form that is linked to the client’s medical record in one primary Encounter

Initiate the Inpatient Form

• Open a New Encounter (this will be the primary Encounter that is linked to the Inpatient form)
• Use typing template code specific to your POS to initiate the form
• The Form Status will remain in Parked status (in progress) for the duration of the admission
• The Encounter Contact will auto-title “Start of Inpatient Form for (POS Name)”and the following text is added to the Primary Encounter Note: "For all notes associated with this admission, please click the Inpatient Form hyperlinked to this encounter".

Locate an Inpatient Form that is Parked (in progress)

• There are two methods to locate the Inpatient form that is parked (in progress):
  1. Via the Notifications window within the client's Medical Record
     • Click Inpatient Form within the Notifications window to open the parked form
  2. Via the Primary Encounter Note
     • To locate and open the “Inpatient Form”, go to the Primary Encounter titled “Start of Inpatient form for (POS Name)” and double click to open Encounter
     • The Primary Encounter opens, double click on the Inpatient Form link to open the form

Entering Documentation

• Select the type of note (Nursing, Allied, Physician/NP, other)
• Use applicable typing templates depending on site workflows
• Click the Save Note button to save documentation
• To exit click on "X" 
  

Editing Documentation

• Select the Note you want to edit and click the Edit the Selected Note button (bottom of form).  This will bring up an Edit Note window, where you can modify the selected note. Select Apply to save your changes.
• Version history is saved and viewable within the form.
  

 

Late Entry

          

 

Delete Note Entered in Error

• Select the Note you want to remove and click the Delete the Selected Note button (bottom of form). This will create a new version of the note stating the note was deleted. The deleted text is still viewable in previous version of the note.
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Viewing and Sorting Documentation

• Default Sort Order: Newest notes appear at the top (reverse chronological).
  • Use the Filters:
    • By Discipline (e.g., show only Nursing or Social Work notes)
    • By Keyword (search terms inside notes)
• Sort Columns:
  • Click Note Type, Date, or Author headers to re-order.

Review Inpatient Form from a specific POS

To review documentation related to a patient's admission at a specific POS that uses the Inpatient Form:

1. Navigate to the Forms module within the client’s medical record.

2. Locate the Inpatient Form in the list of available forms.

3. The Created At column indicates which POS the form was initiated at.

Double-clicking the form will open it in read-only mode if you are not a member of the initiating POS