Both the problem oriented charting (POC) navigator and the POC sidebar show the current state of each of the main POC text building blocks. These are used in both progress and summative documentation (e.g., discharge summary). Additionally, the sidebar provides SmartLink mnemonics to help clinicians pull these blocks into personalized documentation.
- Overview/Presentation
- One sentence summary of patient context, reason for seeking help and reason for admission or consultation.
- Patient Care Coordination Note
- Care Coordination notes support patient-level longitudinal documentation about overall health status and how health problems relate to one another.
- Hospital Course
- This Wiki-like tool is used to record key developments occurring during a patient's admission. Resolved problems can be summarized alongside milestones in a course of illness. The Hospital Course is pulled into discharge summary templates.
- Problem Notes
- Each problem in the Problem List section supports one Problem Overview (succinct summary of key features of the problem for the patient, crossing all encounters), and one or more periodic Assessment and Plan notes to document progress.
- Exceptional Care Plans
- Patients may be on one or more integrative care plans that cross all encounters and detail how specific problems should be (urgently) managed by all disciplines in all settings.
- Discharge Planning
- This interactive text block summarizes key information about where a patient comes from, how their functional capacity may have changed and current destination plans.
- History
- Medical, Surgical, Family and Social History summaries help clinicians when problems are moved between the Problem List and Medical History instead of newly entered or resolved.
The content of the text building blocks can be edited using the POC Navigator. Alternately, the text is interactive and can be edited by selecting its subtitle or any blue text within.