Chart & Sign
Stays on this computer
Start here

How this works
  1. Pick the note type along the top. Admit, Readmit/Sig Chg and Annual share the full assessment template — only the title line changes. Quarterly, Weight Change, Follow-Up, EN, Dialysis and Wound use the shorter review template. Rename any of them under Customize.
  2. Tap the diagnoses that apply, or just type them into Current Presentation and they switch on by themselves. They write the at-risk sentence, back up the diet order in your recommendations, and pull forward any PES statements you have set to appear for them.
  3. Enter height and weight. BMI and its class, the percent-change sentence with its significance flag, and the whole EEN block all compute from there.
  4. Work down the sections. Click a phrase to drop it in, or type a shortcut like ;none followed by a space. Gold chips are sentences built from what you've already entered. Flip a section off if it doesn't apply and it leaves the note.
  5. Copy note, paste it into your EMR, then hit Clear this resident so nothing is left behind.

Paste last note takes a note copied out of your EMR and fills these fields back in, so you can keep editing the previous one instead of starting over. Customize is where you make every list your own: phrases, diagnoses, diets, supplements, formulas, PES statements and shortcuts. Settings holds your signature and clinical conventions.

Example note loaded so you can see how it works. The resident is invented. Hit New note to start clean.
Step one

Active diagnoses

These drive the at-risk sentence, the diet-appropriateness line, and which of your PES statements get suggested. Pick them once and the rest of the note follows.

No diagnoses selected yet.
Step two

Weight, BMI and estimated needs

Everything below writes itself into Weight History and the EEN block. This does only the math that ends up in the note.

Enter height and weight.
Add a comparison weight for % change.
Amputation adjustment not applied

An amputation lowers measured weight without changing adiposity, so measured BMI reads low. Pick the highest level present on each side and the weight sentence, BMI class and any actual-weight-based needs all switch to the adjusted figure.

Segment percentages per Osterkamp LK, J Am Diet Assoc 1995;95:215–218 . Entire-arm and foot values vary slightly across published sources; verify against your facility protocol before charting.

Estimated energy needs
Enter height and weight to see the EEN block.

Hamwi IBW; adjusted weight = IBW + 0.25 × (actual − IBW). How actual and adjusted weight are abbreviated in the note is set under Settings.

Step three

The note

Click a phrase to drop it in. Type a shortcut like ;none then space in any box to expand it. Click a header to rename it.

Ready to paste

You've typed into the note directly, so the form has stopped feeding it. Rebuild drops these edits and writes it fresh from the form.
Pasted it? Clear this resident so nothing about them stays on this computer.

Nothing typed here leaves this computer. The note in progress is kept until you close this tab, so a reload doesn't cost you the note.

Privacy · Terms of use · Guide