Electronic Nursing Records (ENR®)

Qlinical ENR® is compliant with both SGNA and AORN standard language and data sets, resulting in seamless integration with a facility’s current processes and procedures. The application also meets the compliance standards of TJC, HIPAA, HHS, OIG, and other regulatory bodies, ensuring quality documentation, reporting, privacy and patient care. Integrated G-codes ensure compliance with Medicare guidelines for ASCs.

An integrated medication reconciliation feature significantly reduces the chance of medication errors, improving patient safety.

A patient’s vitals are monitored and recorded automatically throughout the procedure process. The application interfaces directly with all major vital sign monitors, scheduling, and EHR systems.

Patient tracking allows nurses to manage, monitor and track the flow of patients through a facility.

The inventory management tool enables the appropriate staff to order, access, track, charge, and maintain medical inventory levels in real time. The tool also monitors equipment repairs and sterilization as well as manages vendors and purchases. Detailed reports are readily available for repairs, sterilization, inventory, reorders, and items list.

Integrated time and material billing accurately tracks items used along with procedure and recovery room utilization.

The nursing history evaluation collects pertinent data including indications for exam, allergies, patient history, medications, prior anesthesia complications and more. Pre-procedure allows nurses to capture all of the required data prior to beginning a procedure, including NPO status, prep results, advanced directives, sedation plan, anesthesia classification, vitals, allergies, and isolation precautions.

The intra-procedure evaluation documents intubation, IV site assessment, vitals, condition log, medicines used, intra-sedation score, post-procedure diagnosis and more. Post-procedure documents a patient’s pain scale, IV site assessment, adverse events, level of consciousness, vitals, fluids intake, and post-procedure comments.

The nursing discharge documents when the IV was discontinued, prescriptions, ambulation, post-sedation score, medication reconciliation, and discharge comments. The nursing charge tab accurately tracks items used along with procedure and recovery room utilization.