Clinical

Clinical documentation: medications and the MAR, vitals, allergies, conditions, incidents, and nurse notes.

Conditions Diagnoses

Add and manage member conditions and diagnoses.

Adding and Managing ConditionsThe Diagnoses & Conditions tab lets you record and maintain a member's medical conditions and diagnoses. Each condition captures the condition name, the physician associated with it, an Active or Inactive…

Allergies

Record member allergies, or mark no known allergies.

Managing Member AllergiesThe Allergies tab records a member's medication, food, and environmental allergies. Each allergy captures a type, name, description, severity, and the intervention and reaction, plus any file attachments.Recording "No Known Allergies"Documenting that a member has no known allergies is as important as recording actual allergies — it confirms an allergy assessment was completed rather than skipped.

Vitals

Record vitals and glucose, and view vital-sign history.

Recording Member VitalsThe Vitals tab records a member's vital signs. Each reading captures one vital type and its value, along with the date and time and the staff member who recorded it.Recording Glucose with HI/LO ValuesBlood Glucose is one of the vital types you record on the Vitals tab. When a glucose meter reads outside its measurable range it displays HI or LO instead of a number.Viewing Vital Sign HistoryThe Vitals tab is also where you review a member's vital sign history. Past readings appear in a table showing the date, vital sign, value, and who recorded it.

Medications

Manage medications, record administration, and use the MAR.

Managing Member MedicationsThe Medications tab holds a member's complete medication list. Each medication records its name (from the formulary or a custom entry), quantity, unit, dosage, route, schedule, prescriber, pharmacy, and…Using the MAR (Medication Administration Record)The Medication Administration Record (MAR) is a monthly grid of a member's center-administered medications. Each medication appears as a row showing its name and details, alongside a grid of scheduled times…Recording Medication AdministrationYou record each dose from the MAR. Selecting a scheduled cell opens the administration form for that dose, where you complete any prerequisite tasks (such as a vital check), mark the dose as administered, or…

Documentation

Incidents, advance directives, and nurse notes.

Writing Nurse NotesThe Nurse Notes tab is where you document clinical observations, interventions, and member responses. Each note records the author, optional type and tags, the note content, and any file attachments.Documenting IncidentsIncident reports capture events involving members, such as falls, injuries, behavioral incidents, and medication errors. This article covers creating a new incident report and submitting it for review.Managing Advance DirectivesAdvance directives are legal documents that record a member's wishes for their medical care. The Advance Directives tab lets you file these documents so care staff can find them quickly.Reviewing, Finalizing, and State Reporting IncidentsEvery incident report moves through a lifecycle: it is created in Pending status, submitted for review to move to Review, and then finalized to become Final.