Dear Colleagues:
Island Health long term care (LTC) sites continue to implement the Cerner Electronic Health Record (EHR) with advanced functionality – clinical documentation and computerized provider order entry (CPOE) with an electronic medication administration record (MAR). The following LTC sites are using the Cerner EHR: Dufferin Place, the Summit at Quadra Village and Gorge Road Hospital Long Term Care.
As residents of activated long term care facilities are seen at emergency departments (EDs), on acute care wards and at ambulatory clinics, their record of care is now available in the EHR. Critical information including patient wishes and medication status will help acute care teams in ensuring that the best practice standards related to ordering electronic medical orders for scope of treatment (eMOST) and medication reconciliation are met. The information will support gathering a history to inform care – especially for residents who may have some level of cognitive impairment.
Information included below will significantly improve quality of care during these care transitions:
- Primary Care Provider Name
- Patient Contact Information
- MOST Status and Associated Advanced Care Plan Documentation
- Allergies
- Current Medications (which really constitute the best possible medication history – BPMH)
- MAR Indicating Medication Administrations
- Vitals
- Alerts (including behaviour risk)
- Histories
- Problem List and Clinical Notes
In thinking about transitioning residents back safely to their home from the ED, acute or ambulatory care, please remember how important clinical information in the EHR is for the receiving LTC team. Note that there also may be engaged family members who will be looking for acute care notes and consults in the resident’s MyHealth portal records.
Thank you.
Mary-Lyn
Dr. Mary-Lyn Fyfe
Chief Medical Information Officer
EMD, Medication Systems and Medical Informatics