You will complete a set process of assessments and forms on a patient through the Admissions Process. Patients are added to either the Medical/Mental Health Admissions Queue or the Behavioral Health Admissions Queue via one of the following methods:

• When a new chart is created via the OMNI demographics feed
• Completing a General Informed Consent form (Medical/Mental Health) or a Behavioral Health RDC Intake Interview (Behavioral Health) for a patient

To access either of these queues, click the Admissions Process option from the Global Menu and select the appropriate queue.

For more information about each queue, click one of the links below:

• Medical/Mental Health Admissions Queue
• Behavioral Health Admissions Queue

You can easily view which part(s) of the admissions process still needs to be completed for a patient in the Medical/Mental Health Admissions Queue. From the Global Menu, click on Admissions Process, then select the Medical/Mental Health Admissions Queue option.

The system displays the Medical/Mental Health Admissions Queue, as shown below. You can use the filters at the top of the screen to filter your patient list.

You can search for a specific patient within the list of patients using the Find Inmate field. You can also adjust the Time Window field to narrow your list by patients who have been added to the queue from 1 hour through up to 30 days. The system defaults to 16 hours. You can change the Status field to show those patients whose admissions have been Completed. The system defaults to Not Complete, showing those patients who still need screenings completed.

Since multiple people can manage the admissions process, you can refresh your view at any time by clicking the Refresh button to provide you with updated information in the queue as you begin to complete the next form.

The bottom portion of the screen displays these additional fields:

• Offender Number – This field displays the patient number.
• NMCD Number – Displays the inmate number assigned by NMCD.
• Inmate Name – This field displays the name of the inmate.
• Housing Location – Displays the housing location to which the patient is assigned.
• Time Waiting – Displays the time the patient has been in the queue.
• Status – Displays the status of the patient in the queue.

The General Informed Consent, Receiving Screening, TB Screening, Intake Labs, Education Materials Receipt, Psychiatric Encounter, Physical Assessment, Medical Chrono, and Dental Chrono fields show which forms have been completed and which forms still need to be completed for the patient.

A blank checkbox located underneath each required form/assessment indicates the form has not been completed for the patient. 

Completing forms and Menu options

To complete any of the forms/assessments for the admissions process, simply right-click on the patient you are working to access the menu and select Complete, choose your form, and the system automatically opens the form for you to complete. If the form is greyed out, it has already been completed.

Other options available from the menu include:

• View – This menu displays all of the forms mentioned above. You can select one of the assessments to view the completed form.
• Remove From Queue – Select this option to remove the patient from the queue. The system will prompt you to enter a Quick Note or SOAP Note before you remove the patient from the queue.

You will continue completing the required forms for the patient. As you complete them, the system places a check mark in the field beneath the form. Once all of the forms have been completed for a patient, the patient’s status will change to Complete.

NOTE: The Physical Assessment form will remain disabled until the patient’s intake panel results are received.

Patients are added to the Behavioral Health Admissions Queue via the following method(s):

• When a new chart is created via the OMNI demographics feed.
• Completing a BH RDC Intake Interview Form.

You can easily view which part(s) of the admissions process still needs to be completed for a patient in the Behavioral Health Admissions Queue. From the Global Menu, click on Admissions Process, then select the Behavioral Health Admissions Queue option.

The system displays the Behavioral Health Admissions Queue, as shown below. You can use the filters at the top of the screen to filter your patient list.

You can search for a specific patient within the list of patients using the Find Inmate field. You can adjust the Time Window field to narrow your list by patients who have been added to the queue from 1 hour through up to 30 days. The system defaults to 24 hours. You can change the Status field to show those patients whose admissions have been Completed. The system defaults to Not Complete, showing those patients who still need screenings completed.

Since multiple people can manage the admissions process, you can refresh your view at any time by clicking the Refresh button to provide you with updated information in the queue as you begin to complete the next form.

The bottom portion of the screen displays these additional fields:

1. Offender Number – This field displays the patient number.
2. NMCD Number – Displays the inmate number assigned by NMCD.
3. Inmate Name – This field displays the name of the inmate.
4. Housing Location – Displays the housing location to which the patient is assigned.
5. Forms/Assessment – These fields show which forms have been completed and which forms still need to be completed for the patient. A blank checkbox located underneath each required form/assessment indicates the form has not been completed for the patient. 
   • Behavioral Health RDC Intake Interview
   • Mental Status Examination
   • Behavioral Health Rights To Confidentiality
   • Behavioral Health Notice To Incoming Inmates
   • Correctional Mental Health Screen
   • Substance Use Chrono
   • Behavioral Health Chrono
6. Time Waiting – Displays the number of hours the patient has been in the queue.
7. Status – Displays the status of the patient in the queue. 

Completing/Viewing Forms

To complete any of the forms/assessments for the admissions process, simply right-click on the patient you are working to access the menu and select Complete, choose your form, and the system automatically opens the form for you to complete. If the form is greyed out, it has already been completed.

Other options available from the menu include:

• View – This menu displays all of the forms mentioned above. You can select one of the assessments to view the completed form.
• Remove From Queue – Select this option to remove the patient from the queue. The system will prompt you to enter a Quick Note or SOAP Note before you remove the patient from the queue.

You will continue completing the required forms for the patient. When you click on any checkbox, the system opens the form for you to complete. You can also access many of these forms directly from the Forms dropdown menu on the Main Patient Screen. NOTE: Completing some of these forms automatically adds a flag to the patient’s chart. For example, when you complete the Substance Use Chrono form, a Substance Use Code flag displays in the patient’s chart. You are not able to add or remove this flag from a patient’s chart other than through this form. 

As you complete the forms, the system places a check mark in the field beneath the form name. Once all of the forms have been completed for a patient, the patient’s status will change to Complete.

Clinical Monitoring Protocols in TechCare^® allows you to enter patients into specific services that relate to their individual needs. Additionally, it allows for you to enter individualized notes per patient should the need for client specific documentation arise. To access this screen, click the Group Management option from the Global Menu, then click Clinical Monitoring Protocols.

The system displays the Clinical Monitoring Protocols screen, where you first choose the Type of Group Management from the dropdown menu.

When you select a Group Management Type from the list, the system displays all patients in that particular group. Group Management Types you can choose from include:

You can use any of the following Filters across the top of the screen to further narrow your search:

• Housing – Use the dropdown menu to select the housing location unit.  Only the housing locations of patients that have been added to the list based on Group Type will be available for selection.
• Search – Use this field to search for a specific patient in the list.
• Past Due – Select this checkbox if you want to view only the patients in the list who are past due.
• Active – Select this checkbox if you want to view only the Active patients in the list.
• Projected Release – Patients are automatically populated into this queue when their projected release date is within a certain timeframe. You can use this field to further narrow your search.
• Order by – Use this dropdown menu to filter all results in the list by Housing Location, Length of Stay (LOS), or Last Visit.
• Add Patient – Click this button to admit a patient into the Group.
• Print – Click this button to print a detailed list of patients.
• Print for Officer – Click this button to print a list of patients for the officer. This list will not contain any personal health information.
• Check All – Select this checkbox if you want to select all of the patients in the list for printing.
• Export – Click this button if you want to download the list.

Action menu

You can use the Action buttons next to the right of the Patient Name to do any of the following options:

• View – Click this button to view the historical Progress Note.
• Add Note – Click this button to choose which type of Note you want to add. You can add a Quick Note, SOAP-E Note, Discharge Planning, MH Discharge Checklist, or Release Summary. You will select the checkbox next to the note you want to add, and the system will open the appropriate form for you to complete. Note Types vary depending on the Group Type.
• Discharge – Click this button to make selections for various discharge options. You will enter a discharge note and click Add Note. The patient will be removed from the group and the Clinical Monitoring Protocols queue.
• Print – Click this checkbox to select the patient whose information you want to print.
• Comment(s) – Enter any comments in this field.

Add Patient

You can enroll a patient to a group using the Add Patient button.  The system displays the Admit Patient screen.  Type the patient’s name in the Search (1) box or scroll down the list to select the patient you want to add to the group, then click the Admit (2) button.

Complete either a Quick Note or SOAP-E Note for the patient to add them to the queue, then click Add Note. The patient will be added to the Clinical Monitoring Protocols queue.

In TechCare^®, you can use Group Notes to write one general note about all patients who participated in a group session and efficiently apply that note to multiple patients. Additionally, you can also write individualized notes for each patient if you need to have more patient-specific documentation. To access Group Notes, click the Group Management option from the Global Menu, then select Group Notes.

The system displays the Clinical Monitoring Protocols screen. You must first choose a Group Note Type (1) from the dropdown menu. The system displays a list of patients that are in the group you selected.

To add a new patient to a group, click the Add Patient (2) button at the top of the screen. Search for an individual patient and click Find. Once you have found the patient, click Admit to add them to the group.

If you need to remove a patient from a group for any reason you can click the Discharge button for the patient and then enter a discharge note to properly dismiss them from the group. Once you click Add Note, the patient will be discharged from the group and removed from the Clinical Monitoring Protocols queue.

Group Note Documentation

To document on the entire group of patients, first select the Group Type from the dropdown list, then click the Group Documentation button on the Clinical Monitoring Protocols screen.

The system displays the Group Note screen.

Enter information in the following required fields:

1. Date of Group – Enter the date the group encounter occurred in this field. The default date is today’s date.
2. Practitioner – Enter the name of the practitioner who conducted the session.
3. Group Type – This field displays the specialized Group Type you originally selected from the Clinical Monitoring Protocols screen.
4. Attendance – You can use the check boxes beside the individual group members to include or exclude them from the group note. If a patient enrolled in the Group was absent from that session, or you want to not apply the Note to their patient record for any reason, simply deselect their name before you click the Add Note (7) button.
5. Group Name – Enter the specialized name of the group (if applicable) in this field.
6. Note – Enter all comments in this field regarding the group session.

Individual Note Documentation

You can also add an individual note for a specific patient using the Add Note option from the Action menu beside the patient. Common reasons you may need to make individual notes include properly documenting a patient’s absence from group, noteworthy information the clinician observed during a group session, general observations about appearance, mood, and many other patient specific items.

Enter information in the following fields:

1. Practitioner – Enter the name of the practitioner who conducted the session.
2. Group Name – Enter the specialized name of the group (if applicable) in this field.
3. Note – Enter all comments in this field regarding the group session.

Once you have entered all information for the patient, click Add Note.

You can enter vital signs for a patient by selecting the Vital Signs option from the Medical Dropdown Menu just beneath the Print All Records button on the Main Patient Screen. Scroll through the list and select the option, then click the View button.

The system opens the Vital Signs Screen, where you can view any vitals that have previously been captured for the patient. To add a new set of vitals, click the Add Vitals button. The system displays the Add Vital Signs screen where you can record new vitals for the patient.

Enter the patient’s vitals in the following required fields. If you click OK, the system displays a red exclamation mark indicating these fields are required:

• BP
• Temperature
• Pulse
• Height (feet and inches)
• SaO2
• Weight (pounds)

You can also enter additional information in the following fields:

• Reported Pain Level – enter a number from 0-10, with 0 being no pain and 10 being the worst pain.
• Position – Use this dropdown menu to indicate the position of the patient when taking the vitals. Options include NA, Lying, Sitting, and Standing.
• Orthostatic – Use this dropdown menu to indicate the orthostatic position of the patient when taking the vitals. Options include NA, Sitting to Standing, and Lying to Standing.
• Location – Use this dropdown menu to indicate which arm or leg you used to measure the vitals. Options include NA, Left Arm, Right Arm, Left Leg, or Right Leg.
• Type – Use this dropdown menu to indicate whether you took the vitals Manually or with an Automatic blood pressure monitor. You may also enter NA.

The Vital Taken (Date/Time) fields default to the current date and time. Click the checkbox if you want to change the date and time to be different.

NOTE: You may type in NA (not case sensitive) in any field for any vital sign that is not available.

Once you have entered in all of the information, click the OK button. You will see the vitals you just added on the Vital Signs screen.

You may print the list of vitals recorded for the patient by clicking the Print Vitals button. You can also view a graph of all vital signs collected for the patient by clicking the Graph Vitals button.

Graphing Vitals

Once you click the Graph Vitals button from the Vital Signs screen, you can use the dropdown menu to select which graph you want to view. The system defaults to the Blood Pressure Readings graph.

You can select the graph you want to view for the patient by using the dropdown menu (1). Available options include:

• Blood Pressure
• Blood Sugars
• Blood Sugars and Insulin
• Body Mass Index
• Fetal Heart Rate
• Height
• Insulin Administration
• Pain
• Peak Air Flow
• Pulse
• Respirations
• SaO2
• Temperature
• Weight

You can choose a specific timeframe (2) in which to search.

Click the Generate (3) button once you have selected which graph you want to view and entered any additional parameters. The graph will appear in the top portion of the screen.

You can use the checkboxes next to Show Position and Show Orthostatic (4) to include or exclude this data from the table on the left. The default value is that these fields are checked and will be included in the results.

You can print the graph by clicking the Print Graph (5) button. This prints the graphed vitals as shown in the top window of this screen. You can print the results of the vitals (information displayed in the lower left window of the screen) by clicking the Print Results (6) button.

Lastly, you can add another vitals entry from this screen by clicking the Add Entry (7) button.