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Flow charts may be used to document the Initial Interview - Pertinent History and Discharge Planner, Physical Assessment (Initial and Shift), Discharge Summary and Instructions, Transfer Form, Activities, and Shift Summary. Flow chart questions and answers are user-defined. This guide provides an overview of the flow chart functionality, special questions that may be associated with certain flow charts, the nursing problem list, and the vitals that may be included in a flow chart.

 

NOTE: HIPAA regulations require that Psychotherapy Notes be kept separate from the rest of the medical record and that only the originator of the document have access to them. The TruBridge EHR is built to be a collaborative tool and therefore does not have the ability to control access specifically to Psychotherapy Notes. For this reason, all Psychotherapy Notes should be stored outside the TruBridge EHR.