Inpatient

Where did Evident get the questions and content for the new documentation areas?

Evident development staff formatted the questions and sections to match requirements set forth by CMS as part of the specifications. For questions regarding the logic behind the documentation required, sites should refer to the specifications published on the USHIK website.

Which pieces of documentation should I address for my patients? Should I address all questions?

Familiarize your staff with the measures your facility is trying to meet, and familiarize yourself with the parts of the content that correspond with those measures. Evident Documentation support can assist with making those questions required and hiding questions that are not needed.

How do I access CQM documentation (Inpatient)?

Three methods are available to access the CQM documentation. First, it can be accessed through the Clinical Quality Measures document in the Clinical Documentation application. Second, it can be accessed through the CQM Documentation launch point in the Point of Care Virtual Chart. Last, the CQM documentation can be accessed through Physician Documentation by setting up Quality Measures sections and adding those sections to a document. Please refer to the online presentation for Structured Documentation for Clinical Quality Measures for details on the setup and pathways for all three methods of accessing CQM documentation.

Can flowchart widgets still be used?

Yes. Some questions no longer apply as some measures have been retired. We have no plans to enhance the functionality of the widgets as we move toward using the CQM content.

What security setup will my staff need to allow them access to the CQM documentation?

Staff members who will be entering documentation using the new CQM content will need to have the application Documentation added and marked as active.

What modifications can be made to CQM documentation (Inpatient)?

Within Clinical Documentation, facilities can choose to hide any questions that they will not be using. Questions can also be set as required so that the user is prompted to address the question before proceeding. Reflexes can also be set up for additional documentation, orders, and charges. Within Physician Documentation, CQM Sections can be added to any existing Physician Documentation templates, and you can customize how these sections are labeled. The specific wording of the questions was created based on CQM specifications. We welcome feedback from facilities on the CQM content. For more information, please refer to the Documentation Setup User Guide and the Physician Documentation User Guide. For assistance in customizing the documentation, please open a situation for A CLIN DOC to have our Documentation support team assist. Or a situation can be opened for A PHYS DOC for assistance in customizing the Physician Documentation.