DetainEMR contains medical progress notes to document each patient encounter. The system, through JMS integration, automatically populates the detainee’s name, date of birth, and ID number. The system also auto-populates the date and time. The user then may document the following:
Electronic Medical progress note- This form is complete with Subjective and Objective data including vital signs and an area to document a sick call that is problem-focused. There is an area for the final Assessment and Plan, as well as Education and Follow-up activities. The Electronic Medical progress note is part of a work flow that may be used for nursing sick call (with the nurse’s signature/timestamp where indicated), or prepared for the Practitioner/MD to see the patient. In the final stage of the workflow, the form is sent to the Practitioner/MD task list for signature/timestamp.
Narrative Medical progress note- This form was designed for Subjective, Objective, Assessment and Plan information and also is auto-populated with the same information as the Electronic Medical progress note. However, this narrative note is free-form and has no workflow assigned to it. It is commonly used for follow-up documentation and other notes. The note is automatically routed for physician signature/timestamp when completed.
Dental Progress Note- This form may be used by the nurse to assess a patient in sick call for a dental complaint or for the Dentist to see the patient in sick call. This form is much like the Electronic Medical progress note, but asks questions specifically for dental needs. It may be prepared for the Dentist to see the patient as part of a workflow. In the final stage of the workflow, the form is sent to the Practitioner or Dentist task list for signature/timestamp.