Context: As soon as a patient is declared deceased (something done by medical records), the Connect Care chart enters a state that issues a warning whenever the patient's chart is accessed.
Sometimes new information emerges after death that a prescriber may want to add to the chart. Examples include family discussions and post-mortem investigations.
Prescribers can open the deceased patient's chart (patient-level information) but cannot create an orders-only or documentation encounter (two of the more common ad hoc encounters that providers use to add information to a chart when patients are not in clinic, ER or facility). A message "The Encounter could not be created" is posted and the process is blocked. Are there alternatives?
Answer: There are three simple ways to add documentation to a deceased patient's chart.
- Inpatient - If the information pertains to a past hospitalization:
- Open the chart.
- Use the "Select Encounter" activity to open the hospital encounter of interest.
- Go to the "Notes" activity and create a new progress note or an addendum to an existing discharge summary or deceased note.
- Outpatient - If the information pertains to a past clinic (outpatient) visit:
- Open the chart.
- Use the "Select Encounter" activity to open the ambulatory encounter of interest (including telemedicine visits).
- If the past outpatient visit was already signed, there is an option to create an "addendum" to the visit.
- Use the "Notes" activity (in right sidebar) to record the new information.
- Patient - If the information is at the patient level and not specific to an encounter:
- Open the chart.
- Use the "Create Encounter" activity to create a new encounter of the type "Post Mortem Documentation".
- Use the provided note to record the observations of interest.