The BALL PROGRAMS - Electronic Charting for Nurses’ Notes and Doctors’ Orders software module is described below. The BALL PROGRAMS can be licensed with or without the Management module. However, two Management Software sections, Human Resource and Administration, will be included in the Electronic Charting software module.

The BALL PROGRAMS – Electronic Charting – for Nurses’ Notes and Doctors’ Orders.

The Facility's Administrator has complete control over access to the BALL PROGRAMS - Facility Manager, Electronic Charting and the encrypted databases on the facility's server. Access can be provided or limited on a case-by-case basis, taking into consideration each employee's job description and each individual's need to know.

The BALL PROGRAMS – Electronic Charting Main Menu options include Electronic Charting, Administration and Exit System. These functions are described below and allow designated users to access the software in order to more efficiently manage residents’ medical records and provide secure documentation required by surveyors:

• Administration - This feature was developed to assist the administrator and the director of nursing or his/her designee to administer and manage the residents’ electronic medical records using the BALL PROGRAMS Electronic Charting module and encrypted databases.
1. The EMR Administrator¹ - Is responsible for developing, naming and formatting new or existing charting topics, formatting care plan templates and dietary order templates to meet the specific needs of the resident.
2. The Administrator has control over access to the electronic charting module by in-house or pool nurses, in-house or outside therapists and outside doctors.
• Electronic Charting – This feature allows for the entry of Doctors’ Orders and Nurses’ Notes into the system.
1. A charting topic like “Vital Signs” would be formatted to capture each vital sign in a unique field plus a narrative note.  The charting topic would also include the (diagnosis); the frequency of the topic should be charted plus instruction on how to chart the topic to meet each resident’s need.  A new charting topic can easily be added and formatted to meet the needs of the residents. The Electronic Charting Module also has a screen saver to protect sensitive data.
2. Floor Nurses - A “Charting Topics To-Do Report” is printed at the beginning of each shift. The floor nurses can then use the To-Do Report as a charting guide for each resident. The nurses can access each resident’s chart and make entries into the selected topic forms. The software requires an entry into each field of the charting topic, before the nurse can save the charted topic and chart additional topics.  Anytime prior to the end of a shift, a second “Not Completed Charting Topics Report” can be printed that list those charting topics that have not been completed.
   
3. Care Plan - The Problem: Inadequate or poorly maintained resident’s Care Plan is one of the most frequently cited citations by state surveyors across the country.

   The Solution: Electronic Medical Records software can be used to address these problems.
   
   A Demonstration of Electronic Care Plan Software.

   Resident Info Tab – for Hazel V. Ahola who has a Right Femoral Fracture – MDS code 820.6.

   Note all of the tabs starting with Behavioral Patterns through Special Skills can be customized to meet the specific need of each resident.

   For demonstration purposes we will use the Behavioral Patterns tab to illustrate how the existing template can be edited to meet the specific needs of Hazel. The first step is to decide on the Long Care Goal is to:. This is accomplished by clicking on the down arrow at the right of the rectangle box and selecting the desired option, in Hazel case, the Long Care Goal is to Strengthen.

   The next step is to review the existing Behavioral Patterns Topics and Rating Scale Description template. Both can be changed to meet Hazel’s needs by pressing the “Edit Topics” button where Topics can be added or deleted. Since Hazel‘s fracture prevents her from bearing weight, we need to “Add Topics” to the existing list. The topics to be added are Orientation and Incapacitation.

   After the Orientation and Incapacitation topics have been added, the next step is to decide which topics should be charted at this time and assign the appropriate rating scale (see completed template). This customizing process, if needed, can then be repeated for the remaining tabs, Mental State through Special Skills.

   Electronic Care Plan Software can provide:

   The Nursing Department

   • Care Plan Template that allows the nursing department to easily develop Care Plans from their existing paper files and store them electronically for future use or develop new plans
   • Customized Care Plan Template to meet the specific needs of each resident
   • Choice of 3 or 6-month Progress Report for each individual Care Plan Main topic or the entire Care Plan
   • Choice of 30, 45 or 60-day warning for a resident’s Annual Care Plan Review
   • Built-in electronic tickler files can notify responsible parties of upcoming Progress Reports or Annual Reviews
   • The ability to easily compare Care Plan objectives and notes to the actual electronic Therapy, Nurses’ Notes or Doctors’ Orders.
   • These functions save time, provide a complete view of the resident’s progress or lack thereof, makes it easy to spot potential problems, provides increased accountability – all resulting in better resident care
   • The care plan is an integral part of our electronic charting of Nurses' Notes and Doctors' Orders
   • Additional EMR software attributes are listed below

   The Administrator

   • The Administrator, as with the management software, has the ability to monitor the nursing department functions
   • The Built-in electronic tickler files system can prevent missed Progress Reports or Annual Reviews, thus providing timely reviews, adequate documentation and excellently maintained Care Plans and lowers the risk of costly citations by state surveyors
   • The ability for the nursing department to quickly review Care Plan objectives with actual Therapy or Nurses’ Notes and Doctors’ Orders, saving time, money and facilitates the ability to provide excellent resident care
4. Therapy - Medicare A and B - The facility's in-house or contracted therapy unit enters their notes directly into the electronic charting forms provided, thus ensuring the needed documentation is recorded.
5. Diabetic Residents? We have an app for that. The Dietitian no longer has to waste time reading the Nurses' Notes to determine who has Type I or II diabetes.
6. Diet Order & Communication - Our electronic Diet Order can easily be customized to fit each resident's needs. The dietitian receives instant updates to a resident’s standing dietary order. 
7. Doctors’ Orders – Consist of Medication, Non-Medication, Therapy, and Dietary orders.  All Doctors’ Orders are entered into each resident’s chart by topic.
   

   Additional EMR software attributes:

   • Date and time stamp in every record
   • Individual’s name who made the entry
   • Readable Nurses’ and Therapy notes and Doctors’ orders
   • Elimination of mistakes due to illegible handwriting
   • Daily or historical data of a resident’s progress
   • Records are secure and cannot be lost

Going from Tickler Files to Triggers –We recognize the stress and confusion in going from paper records and tickler files to electronic records.  To assist our users we have developed triggers to inform employee(s) who are responsible when to take action.  These triggers are like a tickler file system, except no one has to manage the tickler file.  The software manages the tickler file and issues triggers as per the facility’s rules and regulations. An example is:

Expiring Certification Report –the Management Software Module begins listing employee(s)’ name(s) 90 days before their certification is to expire.  This report appears on the computer screen of administrative employees so that action can be taken to get the employee(s)’ recertified before their certification expires. Once the employee(s) has a new certification, their name(s) no longer appears on the list.

This example is just one of the many triggers that have been built into the system to help the Administrator and the staff to operate the facility more efficiently and provide great care to their residents.

^1. The EMR Administrator job responsibilities are on “as needed” basis in the nursing department.  The Business Manager serves the same capacity for the Management Software Module.