Charting Restrictions and Editing
RTasks E-Charting records the date and time services are scheduled, as well well as the date and time they are charted (when a staff member marks the task as complete). As charting is a time sensitive issue, RTasks has settings to ensure charting is completed in a timely manner. These settings can prevent staff from completing charting on the wrong day and encourage them to chart in "real time" as they perform the service.
Other restrictions, such as the ability to edit notes, incidents, assessments, are based upon best practices for the integrity of the electronic health care record.
Settings are based upon provider types (e.g. Nurses vs Aides) and also by Roles granted (Supervisor = Role 11 and Manager = Role 13). For a quick reference to charting restrictions in RTasks, go to the Profiles > Staff > Staff Profile > Security > Provider type and this screen will summarize charting restrictions and access to reports for that person.
- Aides may chart a scheduled medication up to 2 hours early or up to 4 hours late; a note is required if a scheduled med is charted more than 1 hour late. (Note: Simplified times are an exception to this rule. A med with a simplified time (AM, PM, etc.) can be marked complete any time the same calendar day it was scheduled.)
- Nurses, Supervisors may chart a scheduled medication up to 12 hours early or up to 14 days late. A note is required if charting a scheduled med over 2 hours early or over 4 hours late
- A nurse can add a comment to any medication marked as administered, declined, or missed by going to Clinical > Med Charting History > Select the date range and resident > Select the med and add a comment. Comments made here will remove a missed med from being flagged as missed.
- Aides, Nurses, Supervisors or Managers may not chart a PRN medication as having been given at any future time
- Aides may not chart a PRN medication as having been given more than 1 hour ago
- Nurses, Supervisors, & Managers may chart a PRN up to 3 days late
- A nurse can also do a PRN Med Review or Declined Med Review and add a comment about any PRN med or declined med. Go to the Today screen > +More Button > Review Administered PRN Medications or Review Administered Declined Medications
- Aides can chart Home Care Services up to 12 hours early or up to 7 days late
- Nurses, Supervisors, & Managers can chart Home Care Services up to 3 days early or up to 14 days late.
- Any provider may chart Housing Services (housekeeping, laundry, etc...) up to 3 days early or up to 14 days late.
- Aides can enter the initial incident up to 4 days following the incident
- Nurses, Supervisors, & Managers can enter an incident up to 2 weeks late and enter a Clinical Review within 30 days of the initial incident entry.
Assessments are marked complete on the date and at the time that the "Marked Complete" button is selected. To edit this date/time would affect the user's ability to pull accurate historical data.
If the nurse wishes to document extenuating circumstances surrounding the performance of an assessment, he/she may go into Assessment History for that resident and add a note of explanation (e.g. Due 11/14, completed on 11/17 due to resident hospitalization).
Resident Notes allow the user to enter an Occurrence date and time, but behind the scenes, RTasks is tracking the actual date and time entered. This is important for the integrity of the electronic health record.
Resident notes may be edited by the person who entered the note for a period of time set as a configuration option.
Resident notes can be stricken by clicking the small garbage can icon to the right of a note. Striking a note removes it from view and from printing on most note reports, but can be retrieved and viewed using the report 'Stricken Notes'.
Scheduled vital signs can be edited by selecting the completed service from the "Done" list for that provider, clicking 'redo' and editing the data.
Unscheduled Vital Signs that are entered in error can be deleted by the Aide for up to 7 days, and up to 14 days from entry by a nurse or supervisor.