Documentation_Functionality

Documentation Functionality
User Guide
Documentation
Functionality User
Guide
Documentation Functionality User Guide
by Evident
Documentation Functionality User Guide
Copyright © 2023 by Evident.
All rights reserved. This publication is provided for the express benefit of, and use by, Evident Client Facilities.
This publication may be reproduced by Evident clients in limited numbers as needed for internal use only. Any
use or distribution outside of this limitation is prohibited without prior written permission from Evident. The
reception of this publication by any means (electronic, mechanical, photocopy, downloading, recording, or
otherwise) constitutes acceptance of these terms.
Trademarks:
The Evident logo, as it appears in this document is a Trademark of CPSI.
Limitations:
Evident does not make any warranty with respect to the accuracy of the information in this document.
Evident reserves the right to make changes to the product described in this document at any time and
without notice.
Version : 20
Published : August 2023
Evident
6600 Wall Street
Mobile Alabama 36695
T 800-711-2774 F 251-639-8214
evident.com
Table of Contents I
Table of Contents
Chapter 1 Introduction
............................................................................................................... 1
Attestation Disclaimer
What's New ............................................................................................................... 1
Documentation Web Client -- EVI-104253
......................................................................................................... 1
Chapter 2 Overview
Chapter 3 Security for Documentation
Chapter 4 Accessing Documentation
Overview ............................................................................................................... 5
From Point of...............................................................................................................
Care 5
From ED and...............................................................................................................
Thrive Provider EHR 5
Chapter 5 Documentation
Overview ............................................................................................................... 6
............................................................................................................... 6
Accessing Documents
Document Tree
......................................................................................................... 6
Document Search
......................................................................................................... 9
............................................................................................................... 10
Flowchart Documentation
...............................................................................................................
Multi Clinician Documents 13
Show More/Show All
.........................................................................................................15
Forms ............................................................................................................... 15
............................................................................................................... 17
Merging Documents
...............................................................................................................
Documentation Controls 18
Late Entry ............................................................................................................... 20
............................................................................................................... 20
Charting Options
Add Note ......................................................................................................... 21
Clinical Data......................................................................................................... 22
Instructions ......................................................................................................... 22
Markups ......................................................................................................... 22
Photos ......................................................................................................... 23
Sections ......................................................................................................... 23
Questions ......................................................................................................... 24
Signatures ......................................................................................................................................... 24
Medication List
.........................................................................................................
25
Problems .........................................................................................................26
Plan of Care.........................................................................................................
26
Health History
.........................................................................................................
26
Patient Education Documents
.........................................................................................................
27
Add Group Note
.........................................................................................................
27
............................................................................................................... 28
Copy Forward
II Documentation Functionality User Guide
............................................................................................................... 28
Default Answers
Resolve Default Conflicts Screen
......................................................................................................... 29
............................................................................................................... 30
Special Questions
Overview ......................................................................................................... 30
Advance Directives
......................................................................................................... 30
ED Arrival Date and Time
......................................................................................................... 31
ED Departure Date and Time
......................................................................................................... 31
ED Follow-up Care
......................................................................................................... 31
Pain Scale ......................................................................................................... 31
Patient Status......................................................................................................... 32
Pregnant ......................................................................................................... 32
Fetal Development
......................................................................................................... 33
Smoking History
......................................................................................................... 33
Smokeless Tobacco History
......................................................................................................... 34
Triage Level......................................................................................................... 35
Vital Signs ......................................................................................................... 36
Widgets ......................................................................................................... 41
Allergy ......................................................................................................................................... 41
Immunizations ......................................................................................................................................... 42
Family Health History......................................................................................................................................... 42
......................................................................................................................................... 43
Functional/Cognitive Status
Group Note ......................................................................................................................................... 44
Medical History ......................................................................................................................................... 44
Past Medical Procedures.........................................................................................................................................
and Interventions 45
......................................................................................................................................... 45
Physician Reason for.........................................................................................................................................
Admit 46
......................................................................................................................................... 47
Problem List or Diagnosis
Referral/Transition of .........................................................................................................................................
Care 47
Social History ......................................................................................................................................... 48
Quality Measures
......................................................................................................... 49
Reflexing ............................................................................................................... 49
Overview ......................................................................................................... 49
Orders and Charges
.........................................................................................................
49
Sections .........................................................................................................
50
Questions .........................................................................................................50
Markups .........................................................................................................
50
Instructions .........................................................................................................
51
Prescription.........................................................................................................
Writer 51
Messages ......................................................................................................... 52
Preventative.........................................................................................................
52
Reflex History
.........................................................................................................
53
...............................................................................................................
Accordion Style Documentation 53
ED Provider...............................................................................................................
Documentation after Admit to Inpatient 54
Chapter 6 Amending Documentation

............................................................................................................... 55
Amending Multi-Clinician
Amending a .........................................................................................................
Document 55
Amending a .........................................................................................................
Section 56
Amending a .........................................................................................................
Question 58
...............................................................................................................
Amending Flowcharts Columns 59
...............................................................................................................
Super Amend Functionality 60
Table of Contents III
Chapter 7 Reviewing Documentation

Overview ............................................................................................................... 61
............................................................................................................... 61
Flowchart Documentation
...............................................................................................................
Multi-Clinician Documentation 62
Merged Documents
......................................................................................................... 62
............................................................................................................... 63
Review Options
Chapter 8 Completing Documentation

Overview ............................................................................................................... 65
Completing ...............................................................................................................
Documents and Flowcharts 65
Chapter 9 Retracting Documentation

Retracting a...............................................................................................................
Document or Flowchart 66
Chapter 10 Reports
Overview ............................................................................................................... 67
Generating ...............................................................................................................
Reports 67
Completing ...............................................................................................................
Multi Visit Reports 70
Completing ...............................................................................................................
Documentation Reports 70
............................................................................................................... 70
Review Options
Retracting a...............................................................................................................
Report 71
...............................................................................................................
Clin Doc Documentation Status Report 72
Cosignature...............................................................................................................
Deficiency List 73
Chapter 11 Signing Documentation

...............................................................................................................
Signing Documents and Reports 76
.........................................................................................................
Cosigning Documents and Reports 78
Introduction 1
Chapter 1 Introduction
1.1 Attestation Disclaimer

Promoting Interoperability Program attestation confirms the use of a certified Electronic Health
Record (EHR) to regulatory standards over a specified period of time. Evident and TruBridge
Promoting Interoperability Program certified products, recommended processes and supporting
documentation are based on Evident’s interpretation of the Promoting Interoperability Program
regulations, technical specifications and vendor specifications provided by CMS, ONC and NIST.
Each client is solely responsible for its attestation being a complete and accurate reflection of its
EHR use during the attestation period and that any records needed to defend the attestation in an
audit are maintained. With the exception of vendor documentation that may be required in support of
a client’s attestation, Evident and TruBridge bear no responsibility for attestation information
submitted by the client.
1.2 What's New

This section introduces the new features and improvements for the Documentation application for
release Version 20. A brief summary of each enhancement is given referencing its particular location
if applicable. As new branches of Version 20 are made available, the original enhancements will be
moved to the Previous Work Requests section. The enhancements related to the most current
branch available will be listed under the main What's New section.
Each enhancement includes the Work Request (WR) Number and the description. If further
information is needed, please contact Client Services.
Documentation Web Client -- EVI-104253
DOCUMENTATION: A new behavior control, Web Client Documentation, has been added for
Documentation that will allow users access to the Documentation application within Web Client.
DESCRIPTION: See Security for Documentation 3
© 2023 Evident
2 Documentation Functionality User Guide
Chapter 2 Overview
Thrive’s Documentation application provides a complete ambulatory charting system for

management of patient care in the Emergency Department and Thrive Provider-EHR Software. It
allows multiple users to access, view and document on the same patient record while the Thrive
maintains the integrity of the individual entry without interrupting work flow. The Documentation
application uses both Provation® and Evident documents which, together, provide the most up-to-
date clinical content. It also allows for customized Documentation Reports that may be built to bring
together all pertinent information into one final note.
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 Evident 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
Evident EHR.
NOTE: Facilities outside of the United States may choose a date format of MMDDYY, DDMMYY or
YYMMDD to be used on all date fields in the Allergies Application. Where four-digit dates display, a
date format of MMDD, DDMM or MMDD, respectively, will be used. Whichever date format is
selected will be reflected in all date fields and column displays throughout the application. An
Evident Representative should be contacted in order for the date format to be changed.
© 2023 Evident
Security for Documentation 3
Chapter 3 Security for Documentation

Evident has developed new security that will create "rules" through what is called the Rule Builder to
define security access to user logins. A rule states what the "behavior" for a user must be in order to
perform a particular function in the system. How the rule is set up in the rule builder determines what
the user's behavior is when accessing a Thrive Patient Care Portal screen. Please see the Identity
Management User Guide for additional setup information.
To access the Behavior controls for Documentation:
Select System Administration > Select Login > Ctrl > Converted Rules > New > Select Condition(s) >
Select Action(s) > Edit The Rule Description > Add
The following Documentation Behavior Controls are:
User is allowed to document: This option allows or denies access to the Entry Mode and
Document Search options on the action bar within Documentation. It also allows access to the
Document and Report folders within the document tree. The default is to allow for the following
roles: Physicians, Nursing Staff, Registered Nurse, Licensed Practical Nurse, Rehab Services and
Cardiopulmonary.
User is allowed to complete documents: This option allows or denies access to the Complete
option on the action bar within Documentation. The default is to allow for the following roles:
Physicians, Nursing Staff, Registered Nurse, and Licensed Practical Nurse.
Amend Clinical Documentation For Any Login: This option allows or denies the user the ability
to amend flow chart or documentation data entered via another user. The default is deny. Options
include Change date and time for all entries in current section or entire document, Amend all
entries for this document, and Remove all entries for this section or document.
NOTE: Currently the Super Amend Functionality does not allow amending Vital Sign documentation
by another user.
Copy Forward Documentation: This options allows or denies the users to copy forward
questions that are flagged in setup to copy forward documentation from visit to visit. The default is
to allow for the following roles: Registered Nurse and Licensed Practical Nurse.
Edit Instructions: This option allows or denies the ability to Create New Instructions, Edit
Instructions and Delete Instructions from the Instruction table. The default is to allow for the
Physician Role.
Save Default Answers for Clin Doc Documents: This option allows or denies the user the ability
to save and apply default answers. The default is to allow for the following roles: Physicians and
System Administrator.
Sign Documentation: This option allows or denies a user the ability to sign documentation and
reports and allows access to Key Maintenance to create or change the user's passphrase. The
default is to allow for the Physician Role.
© 2023 Evident
Skip required questions in documentation: This option allows the user the ability to skip
questions in documentation which are set up as required or warning in order to continue
documenting in additional sections. The user, however, is prompted to address the required or
warning questions prior to completing or signing a document.
Web Client Documentation: This option allows the user to have access to the Documentation
application from within Web Client instead of launching it from Thrive UX.
NOTE: If only the Documentation application is added to a login, without specific behaviors added,
Documentation displays in View Only mode.
© 2023 Evident
Accessing Documentation 5
Chapter 4 Accessing Documentation
4.1 Overview
Documentation is the process used within Point of Care, Emergency Department Information
System (EDIS) and Thrive Provider EHR to document data relating to the patient visit. This chapter
will discuss the available paths that may be used to access Documentation from Point Of Care,
EDIS and Thrive Provider EHR.
4.2 From Point of Care

Documentation may be accessed from a Virtual Chart tab. The Documentation link may be added to
any Virtual Chart tab, and this set up will be department specific. See the POC Setup User Guide for
additional information.
Select the patient from the White Board to access their Virtual Chart.
Select the appropriate tab.
Select Clinical Documentation.
4.3 From ED and Thrive Provider EHR

Documentation may also be accessed from within the patient's virtual chart.
Select Charts.
Select Tracking Board.
Select the patient from the tracking board.
Select Documentation from the Navigation Panel.
© 2023 Evident
Chapter 5 Documentation
5.1 Overview
Documentation has 3 different types of documents available for documentation: Flowcharts, Multi-
Clinician, and Forms. This chapter will discuss the different types and how to access the documents.
Flowchart: A document with pre-defined questions and answers. It is intended for multiple entries
and provides a Grid View for comparison of the entries.
Multi-Clinician: A document with pre-defined questions and answers. It is intended for one-time
documentation by multiple users.
Form: A document with pre-defined questions and answers that has the ability capture a signature
via a signature field. It is intended for one-time documentation.
5.2 Accessing Documents

Documentation documents may be accessed from the documents setup per department within the
Document Tree or searching for documents available in the Document Search.
Document Tree
The Document tree displays on the left hand side of Documentation screen and displays the
following headers:
New Documents: Displays a list of favorites or commonly used documents that pull from the
Department Categories table in Table Maintenance. The documents that display are patient
specific, which are based upon the gender, age and diagnosis of the patient. This defaults to open
when the patient does not have any documents open on their account. In the event the document
Description has been edited in Table Maintenance, the edited Description will display instead of
the default title.
Diagnosis Specific: Displays documents that apply specifically to the patient's gender, age,
location (Clinic or Emergency Department) and the patient's chief complaint and/or problems within
the Physician Problem List. This list will display the same listing of documents that display from the
Document Search screen when the check boxes Diagnosis and Demographics are selected.
Current Documents: Displays a list of documents that have been initiated for the patient's current
visit. Once a document has been saved, the Current Documents folder defaults to open, and the
New Documents folder defaults to collapsed.
© 2023 Evident
Documentation 7
New Reports: Displays a list of favorites or commonly used reports that pull from the Report
Department Categories table in Table Maintenance. Once a report is selected, it displays on the
right hand side window. The reports may display all data from documentation, including
documentation that was reflexed as well as clinical data.
Current Reports: Displays a list of reports that have been initiated for the patient's current visit.
Completed: Displays a list of documents and reports which have been completed on the patient.
Completing a document will allow a new version of the document to be created.
Retracted: Displays a list of documents which have been retracted. Documents that have been
retracted will have all information display with a strike though. See Retracting a Document or
Flowchart 66 for more information.
The action bar displays the following options:
Document Search: Allows to search for documents giving the option for patient specific or all
documents. See Document Search 9 for more information. In the event the document Description
has been edited in Table Maintenance, the edited Description will display instead of the default
title.
Report Search: Allows to search for reports.
Inpatients: Allows access to the Phys Doc application. If a physician selects the inpatient option,
the Phys Doc document tree will be available. If a Nurse or non-physician Login selects the
inpatient option, only the signed current documents will be available. The inpatient option will be
enable only if the Phys Doc application is active.
© 2023 Evident
Select Home Screen > Track > Patient > Documentation
Documentation
When a document is listed under Current Documents and is selected to be opened from the New
Documents folder or from within the Document Search, the following prompt displays, "The selected
document already exists. How would like to proceed?" with the following options:
Use Current will open the existing version of the document selected.
Open New will complete the existing document and open a new version of the selected
document.
Exit will take the user back to the at its previous state.
© 2023 Evident
Documentation 9
Document Search
To access the Document List Screen, select Document Search from within Documentation.
Select Patient Chart > Documentation > Document Search
Document Search
The Document List screen will display a maximum of 250 documents at one time.
Document type: May be used to narrow down the document search results. Select the Document
type from the drop-down menu to establish the document type filters. The available document
types are:
All: Allows all document types to display. This is the default option for the document type.
Flowcharts: A document with pre-defined questions and answers. It is intended for multiple
entries and provides a Grid View for comparison of the entries.
Multi-Clinician: A template-based document with pre-defined questions and answers. It is
intended for one-time documentation by multiple users.
Forms: A document that will be used to capture signatures for consent forms and doctors'
notices.
Additional Document Search filters include:
Diagnosis: Limits the search results to only the documents that apply specifically to the patient's
chief complaint and problems within the Physician Problem List. The default is to be checked,
but the check box is 'sticky,' and the last document search parameters used for the UBL will
display.
Demographics: Limits the search results to only the documents that apply specifically to the
patient's gender, age and location (Clinic or Emergency Department). The default is to be
checked, but the check box is 'sticky,' and the last document search parameters used for the
UBL will display.
Department Specific: Limits the search results to only the documents that display in the "New"
folder on the Document Tree for that department.
© 2023 Evident
Description Search: This option allows the user to search documents by document title or
synonym within the Document List. The Title Search utilizes smart search capabilities so that the
result list will automatically populate. The document title and synonym will display the Search
Document list. In the event the document Description has been edited in Table Maintenance, the
edited Description will display instead of the default title.
Once the document has been located within the Search Document List, double-click the document
title to open the document.
Search Document is a multi-select list, and the documents that display are based on the filters
selected.
Pending Documents is a multi-select list that displays documents that have been selected or
moved to pending from the Search Document list. If no documents are displayed based on filters,
'Empty List' will display.
The action bar displays the following options:
Back Arrow: Allows the user to move back to the Documentation screen
Process: Allows any documents displayed in the Pending Documents list to merge and launch the
user to the merged document. This option is disabled if no documents are in the Pending
Documents list.
Move to Pending: Allows documents that are highlighted to be moved to Pending Documents list
in the Search Document list. This option will be disabled if no documents are highlighted in the
Search Documents list.
Remove: Allows any documents highlighted in the Pending Document list to be removed. This
option will be disabled if no documents are highlighted in the Pending Documents list.
Clear All Pending: Allows all documents in the Pending Document list to be removed at once.
This option will be disabled if no documents are in the Pending Documents list.
5.3 Flowchart Documentation

When a Flow Chart is accessed for the first time through the Document Search or the New
Document option from the document tree, it will display in a document view as it has been defined in
its setup with the cursor in the first documentation field.
The title of the Flow Chart will display in the upper left corner.
The date and time will display at the top of the screen and may be changed by selecting the
Change Date and Time option from the action bar.
© 2023 Evident
Documentation 11
If a section title is selected, it will open up the document to allow the user to document on any of
the questions within the section.
If a question is selected, the document will open with the cursor populated into that specific
question.
The Section Menu on the left side of the screen may be used to quickly navigate to that area of
the Flow Chart.
Once documentation for the current section has been completed, several options are available.
The Action Bar has several options that may be used for charting.
Back Arrow: This option exits without saving; prompts with the Save and Exit prompt
Update: This option saves the information that has been documented and takes the user back
to the Grid View
Prev: This option exits back to the previous section and saves the current section
Next: This option moves forward to the next section and saves the current section
Charting Options: See Charting Options 20 for further information.
Repeat Questions: This option allows for multiple entries in the document
Amend: This option is only available once the data is saved; opens up fields in the section to
amend the documentation. See Amending Flowchart Documentation 59 for further information.
Amend Options: Allows an entire section or for an entire flowchart to be amended at one time.
See Amending a Multi Clinician Document 55 or Section 56 for further information.
Pending: This option displays the number of Pending Reflexes that exist. See the Reflexing
chapter for additional information.
All PE: Physical Exam sections relevant to the patient's account display automatically. Selecting
All PE allows the user to document on additional PE sections not initially displayed.
Show More: This option allows sections, questions and answers, that have been hidden, to
display. Once Show More is selected, the option to Show All may become available, where
additional comprehensive questions and answers will display. See Show More/Show All 15 for
Quick Add: This option allows users to quickly add in a free text note to the current section of
the document.
o The note may be entered by scrolling to the bottom of the section and typing in the Note field
that was created.
Save Defaults: This option allows a user to save the selected answers within the current
section of a document. See Default Answers 28 for more information.
Apply Defaults: This option allows a user to apply any previously saved default answers to the
selected section. See Default Answers 28 for more information.
Merge: Allows the ability to merge additional documents with an original document after it has
been created. See Merging Documents 17 for more information.
NOTE: Thrive will auto save any documentation completed within a section prior to selecting All PE,
Show More/Show All or Merge.
Select Update once all documentation has been entered for the assessment.
© 2023 Evident
Select Patient Chart > Documentation > New Document
Documentation Flow Chart Grid View
The action bar may be used to change the display format from Grid View to Narrative View. This
will allow the user to view any documentation that has been recorded on the selected form.
To continue documenting under the same date and time column after update has been selected,
select the empty cell next to the question. The document will open to document the answer to that
question. Select update, and the newly entered documentation will appear under the selected date
and time column. If a previous user started the date and time column, only the questions that have
not been answered will be available for documentation. The questions that have been previously
answered will display in review mode.
When viewing documentation in the grid view, longer answers containing more than 15 characters
are denoted with trailing periods. Hovering over the cell opens a tool tip that will display the full
answer.
The Complete option will then display on the action bar.
Select Complete to indicate that documentation for this flowchart has been completed. Complete
will display in the upper right corner of the document. Completing a document allows the user to
open a new version of the document.
Retract will allow the user to retract the document. See Retracting a Document or Flowchart 66 for
more information.
Completing documents will cause the document to move from the Current Documents folder in the
Document Tree to the Completed Option.
To return a document to Entry Mode, select Amend from the Action Bar. This will revert the form
to its incomplete status, and the document will be accessible from the Current Documents folder.
NOTE: The Clin Doc Documentation Status Report may be run to display all signed/unsigned and
complete/incomplete Documentation documents. See Clin Doc Documentation Status Report 72 .
© 2023 Evident
Documentation 13
5.4 Multi Clinician Documents

When a new Multi-Clinician Document is opened, the first section of the document will display in the
documentation area of the screen.
The title of the Multi-Clinician document will display in the upper left corner. In the event the
document Description has been edited in Table Maintenance, the edited Description will display
instead of the default title.
The date and time will display at the top of the screen and may be changed by selecting the
Change Date and Time option from the action bar.
All subsequent sections will be listed in the Navigation area on the left hand side of the page. The
sections may be selected from the Navigation area to launch that section of the document.
NOTE: Section preferences that have been added to a user login or Department from Section
Preferences in Table Maintenance will also display in the Navigation Area. Hard coded sections
include History of Present Illness, Review of Systems, Physical Exam, Assessment and Plan. If a
section does not exist for a document, it will not display in the section list. Selecting a section will
automatically pull all documented information in a rich text format. The user then has the option to
remove data from the screen by highlighting and deleting the data. This removes the data from the
document only, not from within the application.
Select Patient Chart > Documentation > Document Search > Document Type: Multi-Clinician > Entry
Mode
Multi-Clinician Document Entry Mode
If the document is currently being edited by another user, the fields currently being addressed will be
grayed out. Once the user saves the documentation, the fields may be accessed.
The Action Bar has several options that may be used for charting.
© 2023 Evident
Back Arrow: Exits without saving; prompts with the Save and Exit prompt
Update: Saves the information that has been documented and takes the user back to the Grid
View
Prev: Exits back to the previous section and saves the current section
Next: Moves forward to the next section and saves the current section
Charting Options: See Charting Options 20 for further information.
Repeat Questions: This option allows for multiple entries in the document
Amend: This option is only available once the data is saved; opens up fields in the section to
amend the documentation. See Amending a Multi Clinician Question 58 for further information.
Amend Options: Allows an entire section, or an entire document, to be amended at one time.
See Amending a Multi Clinician Document 55 or Section 56 for further information.
Change Date/Time: Allows a user to adjust the date and time of documentation.
Pending: This option will display the number of Pending Reflexes that exist. See the Reflexing
chapter for additional information.
All PE: Physical Exam sections relevant to the patient's reason for visit display automatically.
Selecting All PE allows the user to document on additional PE sections not initially displayed.
Show More: This option allows sections, questions and answers, that have been hidden, to
display. Once Show More is selected, the option to Show All may become available, where
additional comprehensive questions and answers will display. See Show More/Show All 15 for
Quick Add: This option allows users to quickly add in a free text note to the current section of
the document
The note may be entered by scrolling to the bottom of the section and typing in the Note field
that was created.
Save Defaults: This option allows a user to save the selected answers within the current
section of a document. See Default Answers 28 for more information.
Apply Defaults: This option allows a user to apply any previously save default answers to the
selected section. See Default Answers 28 for more information.
Merge: Allows the ability to merge additional documents with an original document after it has
been created. See Merging Documents 17 for more information.
NOTE: Thrive will auto save any documentation completed within a section prior to selecting All PE,
Show More/Show All or Merge.
To begin documenting an assessment, address the questions as they apply.
Once a section has been completed, select Next from the action bar to move to the next section
of the document. The section may also be selected from the Document Tree. Documentation that
has been entered will automatically be saved when a new section is accessed.
Once each section has been addressed, select Update to save all documentation and view the
documentation in the narrative format.
After documentation has been fully addressed, select Complete. Complete will display in the upper
right corner of the document. Completing a document allows the user to open a new version of the
document.
more information.
© 2023 Evident
Documentation 15
When a document has been marked as complete, it will be stamped in the upper right corner with
the word Complete.
Completing documents will cause the document to move from the Current Documents folder in the
Document Tree to the Completed folder.
To return a document to Entry Mode, select Amend from the Action Bar. This will revert the form
to its incomplete status, and the document will be accessible from the Current Documents folder.
NOTE: The Clin Doc Documentation Status Report may be run to display all signed/unsigned and
complete/incomplete Documentation documents. See Clin Doc Documentation Status Report 72 .
Show More/Show All
Provation® Multi Clinician documents are set to display only the sections, questions and answers
that are relevant to the patient's reason for visit. Each document contains 3 levels of questions.
Priority 1 which display questions/answers that are relevant to the patient's reason for visit and is the
level that will display when a document is initially opened. Priority 2 displays additional questions and
answers to add additional detail when needed in the document. Show All is the last level, which will
display all comprehensive questions and answers in the document. The user may expand upon their
documentation by selecting the following options:
Selecting Show More will add additional Priority 2 questions and answers to the document. It will
also display any section, questions or answers that were manually hidden using Display Status in
setup. See Display Status in the Documentation Setup User Guide for additional setup
information.
Selecting Show All will display all comprehensive questions and answers within the document.
NOTE: Once Show More or Show All is selected, the information that is displayed will not collapse
back to the original questions and answers that were viewable prior to selecting Show More/Show
All.
5.5 Forms
When a new form is opened, it will display in the documentation area of the screen.
The title of the form will display in the upper left corner.
The following options are available on the action bar:
Save: This option will save the information documented within the form.
Complete: This option allows the form to be completed and a PDF to be generated. Once
completed, forms cannot be amended.
NOTE: Forms do not have E-Sign capabilities. The signature box is available for signing the form.
© 2023 Evident
Select Patient Chart > Documentation > Document Search > Document Type: Form
Form Document
The user must fill out the appropriate questions on the form.
A signature box is available on forms to capture an electronic signature of the person who needs
to sign the form. The person signing the form will type his/her full name in the signature box. The
signature will display next to the signature box with a date and time stamp of when it was signed.
Once all documentation is complete, the form can be saved or completed. If the form is
completed, no changes may be made to it after the Complete option is selected.
Select Patient Chart > Documentation > Document Search > Document Type: Form > Complete
Complete Form
Once the form is completed, the Print Document option becomes available on the action bar. The
Print Document allows the completed form to be printed.
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NOTE: A Retract option is available to the creator of the Form. This option is also available for
users with the Clinical Documentation Behavior Option "Amend Clinical Documentation for any
Login." Once selected, the Form will display under Retracted on the Document Tree. Only
completed Forms that have been retracted will display in Clinical History and Print EMR.
5.6 Merging Documents

Multiple documents may now be selected to merge together as one document.
To merge documents:
1. Select the documents from the Search Document list and select Move to Pending. Double-
clicking the document will also move the document to pending.
Select Patient Chart > Documentation > Document Search > Document > Move to Pending
Document Merge
2. Once all documents have been selected and moved to pending, select Process to merge the
documents.
When Documents are merged, they will display with the following format:
The title of the merged documents will display as Multi-complaint with the name of document that
was selected first in parenthesis followed by a plus sign to show to represent the number of
addition documents merged.
HPI: Each document selected will have its own HPI Section. A section will display on the
navigation bar with HPI: 'Name of Document' for each document.
Review of Systems: All documents will merge into one Review of Systems section.
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Physical Exam: All documents will merge into the individual Physical Exam sections. If a Physical
Exam section only exist in one document, then it will not merge and display on navigation bar.
Assessment: All documents will merge into one Assessment section but each document will have
its own subsection within the Assessment section.
Plan: All documents will merge into one Plan section but each document will have its own
subsection within the Plan section.
ED Course: Each document selected will have its own ED Course Section. A section will display
on the navigation bar with ED Course: 'Name of Document' for each document. ED Course
section is only available within Emergency Department Documents.
If a merged document is closed by using the back arrow before it is documented, the document will
not appear under Current Documents folder on the document tree.
NOTE: The documents will list in the order they were added to the Pending Document list.
The merge functionality may also be utilized after a document has been created by selecting Merge
from the action bar on the Documentation Entry screen. Once selected, if any unsaved data exists in
the document, Thrive will auto save the information.
The Document List screen will display from within Documentation Entry, the existing document from
which Merge was launched will display in the Pending column. No action can be taken on this
document at this time. The user will then have the option of searching and selecting an additional
document(s), which will then be added to the Pending column. Selecting Process will merge all
documents. Once processed, merged documents will display as Multi-Complaint documents.
NOTE: The second document selected will merge into the first document and take the form of the
first document's narrative.
See Merged Documents 62 to see how they will display when reviewed.
5.7 Documentation Controls

A variety of controls are used in Documentation documents. Controls include the following:
Checkboxes: Allows for multiple selections for a question.
Radio Buttons: Allows for a single selection for a question.
Drop-down Menus: Allows for a single selection for a question.
Text Box: Allows for continuous type, free-text answers.
Date/Time Question: The date-picker icon will open a calendar, when selected. The date may be
searched for and selected from the calendar or it may be entered manually with the format
mmddyyyy. If the date is the current date, entering a period in the field will populate the current
date. The time may be entered manually with a four digit military time format. If the time is the
current time, entering a period in the field will populate the current time.
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Date/Time Question
Expanding Question: Allows additional answer options to open when certain Yes radio buttons
are selected. The user must select at least one additional answer once it is opened before moving
to another section or selecting Update.
Expanding Question
Required Questions: Prevents a user from moving between sections until the question is
addressed. A prompt will display that reads "You must enter a value for...". After the user is prompted
to answer the required question, Thrive will automatically scroll to the area of the document which
needs to be addressed.
These questions will display in red until the question is addressed.
If the user does not access a section containing a required question, the prompt will not display.
Required questions may be skipped while documenting if the behavior control for the user is set to
"Skip required questions in documentation." This will enable the required question to be treated as
a warning question, allowing the user to move between sections to continue documentation. The
ability to address skipped, required, or warning questions, however, will be available before a user
completes or signs a document or report.
See Behavior Controls for Documentation 3 .
Warning Questions: Questions that are set as warning will display the prompt that reads " ...should
be addressed. Do you wish to address the question?" The user may then select Yes to answer the
question or No to return to the section without addressing the warning question.
NOTE: Any required fields will turn red if not addressed, including radio button labels, text box labels
and drop-down menu labels. Once Update is selected or the user attempts to move between
sections, Thrive will automatically scroll to the area of the document which needs to be addressed.
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5.8 Late Entry

Documentation may be tagged as Late Entry. It will display as "Late Entry: (actual date/time)" and be
added to the existing user/date/time stamp. The time frame in which documentation will display as
"Late Entry" is set up in the Clinical Documentation Control Table. See Documentation Setup for
Changing the date and time past the designated number of hours time frame setup in the Clinical
Documentation Control table will stamp the entry as a late entry.
To change date and time:
1. Select Change Date/Time from the 24 Hour Narrative or from within Entry Mode.
2. Select Save to begin documenting in the selected date and time.
If documentation is made past the designated number of hours as the time frame setup in the
Clinical Documentation Control table, Thrive will mark the entry as a late entry. This Late Entry
stamp may be viewable on the 24 Hour Narrative, Review Options and while in Entry Mode.
5.9 Charting Options

Charting Options allows the user to insert additional topics into the current Document. A split screen
displays for the user. The left side lists out each charting option available to insert in the document.
The right side lists all recently entered data that has been charted on the patient's account. The
Charting Options button will display the number of newly updated information added to the list on the
right side of the screen. This serves as an alert to the user that new information is available.
Select Charting Options from the action bar to view the available options.
Upon accessing Charting options, the entry location must be selected. This will determine where
the documentation will be displayed within the document.
End of Section: Designates the added chart option will be added to the end of the current
section
Question Title: Each question title that is within the document will be displayed. Select the
appropriate question title to insert the added chart option display after a specific question title.
Once the location has been selected, the chart option may be selected from the left side of the
screen. The following charting options are available:
Add Note: Allows a free text section to be added to the document
Clinical Data: Allows the user to add vital signs, lab results or diabetic monitoring to the
document
Instructions: Allows the user to look up instructional documents; the instructional documents will
be included within the document
Markups: Allows the user to select a markup to add to the document
Photos: Allows the user to select an image / photo to add to the document.
Sections: Allows an entire section to be pulled into the document
Questions: Allows specific questions to be pulled into the document
Medication List: Allows a patient's medications to be pulled in the document.
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Documentation 21
Problems: Allows entries from the Physician's Problem List to be pulled into the document
Plan of Care: Allows the Plan of Care to be documented on the patient's account and then
inserted into the document
Health History: Allows an entries from the Health History application to be pulled into the
document.
Patient Education Documents: Allows Patient Education documents to be pulled into the
document.
When applicable, information will remain on the right side of the screen according to the time set in
hours in the Clinic Control Table, ED Control Table and Clinical Documentation Table. Please see
the Clinical Documentation Table for more information. Once the time frame has been reached for
each updated entry, it will no longer display on the right hand side of screen.
The following applications will pull recently charted information to the right side of the Charting
Options screen:
Vital Signs: Allows the patient's recently entered vital signs to display.
Health History: Allows the patient's recently entered Surgical/Procedural History, Family Health,
Medical History, Social History, Functional/Cognitive Status and Referral/Transition of Care to
display.
Problem List: Allows the patient's recently entered problems from the Physician Problem List to
display.
Plan of Care: Allows the patient's recently entered problems from Plan of Care to display.
Allergies: Allows the patient's recently entered allergies to display.
Immunizations: Allows the patient's recently entered immunizations to display.
Medication Reconciliation: Allows the patient's recently entered medications from Medication
Reconciliation to display.
Patient Education Documents: Allows the patient's recently added Patient Education
Document titles to display.
Order Chronology: Allows the patient's recently entered Nursing, Ancillary and Medication
orders to display.
Order Results: Allows the patient's recently entered lab results to display.
Administered/Omitted/Discontinued Medications: Allows the patient's recently administered,
omitted or discontinued medications to display.
The Insert option on the action bar is only enabled when an item from the right side of screen
has been selected to be inserted into the document.
The right side of the screen has multi-select functionality using the Shift or Control keys.
When Charting Options is used to insert information into the Flow Chart, an icon will display in the
answer column for that section that will alert the user that additional information has been charted on
the section. To view the additional information, select the icon.
Add Note
To insert a free text textbox, select Add To Location, then select Add Note. The rich text box will
display in the document based on the Location selected.
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Clinical Data
To insert clinical data, select Add To Location, then select Clinical Data.
Select the type of clinical Data by choosing one of the Clinical Data Options.
Lab Results: Select to display lab values.
Vital Signs: Select to display the patient's vital signs.
Diabetic Monitoring: Select to display Diabetic Monitoring.
NOTE: Labs resulted in the clinic and labs ordered from Hospital Orders on the clinic visit will be
available from the Thrive Provider EHR documentation in Charting Options.
The Clinical Data screens will default to show clinical data from the past 24 hours but may be
filtered to view the most recent values and results or all values and results that have been recorded
on the patient's account.
To insert clinical data, select the data that should be imported into the document. The Clinical Data
screens are multi-select screens.
Once the clinical data has been selected, select Insert to pull the information into the document.
Instructions
To insert instructions, select Add To Location, then select Instructions.
The instruction List Type will default to the user's My Favorites list. To view all documents, select
the All List Type.
Once the instruction has been located within the table, select the check-box next to the document
to preview the document in the preview area.
The following options are available on the action bar if the user has the Control Behavior Edit
Instructions set to Allow:
Created New Instruction: Allows the ability to to enter a new instruction into the table.
Delete: Allows the deletion of Instruction from the table.
Edit: Allows the instruction to be edited by the user.
Select Add to My Favorites to add the document to the user's My Favorites list.
Select Insert to add the instruction into the document. An unlimited number of instructions may be
inserted in the patient's documentation.
Markups
To insert a markup, select Add To Location, then select Markup.
The Markup List Type will default to the My Favorites list. To view all markups, select the All List
Type.
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Select the check-box next to a markup to preview the document in the preview area.
Once the correct markup has been located and selected, select Insert to add the markup to the
document.
After the markup has been inserted, notes may be added to the markup image.
Select the location on the markup to add a note. The note style will default to lettered circles but
may be changed by selecting the tool icon in the upper left corner.
Once all notes have been added to the markup, select Save to insert the annotated markup into
the document.
Photos
To insert a photo, select Add To Location, then select Photos.
The Photo List screen will display available photos for documentation. The photo name, date and
time the photo was loaded into Image Storage and Retrieval will also display.
Select the check-box next to a photo to preview the image in the preview area.
When the correct photo has been located and selected, select Insert to add the photo to the
document.
Users are able to insert photos in the following formats:

PNG
JPG
TIFF
GIF
After the photo has been inserted, notes may be added to the photo image using the markup tools.
Select the location on the photo to add a note.The note style will default to lettered circles but may
be changed by selecting the Tool icon in the upper left corner.
Once all notes have been added to the photo, select Save to insert the annotated photo into the
document.
NOTE: An image title set up with an alternate name, will display the alternate name in the Photo List
screen followed by the date and time.
Sections
To insert a section, select Add To Location, then select Sections.
The Section/Question List page will then display.
The Type field will default to Section and may not be changed.
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The Status field will default to Active and may not be changed.
The Title field may be used to search for a section by the Section Title.
Select a section from the list to display the section in the preview area.
Select Add to insert the section into the document.
Questions
To insert a question, select Add To Location, then select Questions.
The Section/Question List page will then display.
The Type field will default to Question and may not be changed.
The Status field will default to Active and may not be changed.
The Title field may be used to search for a question by the Question Title.
Select a question from the list to display the question in the preview area.
Select Add to insert the question into the document.
Signatures
Signatures may be added within a document/flowchart through Charting Options. Text typed in the
signature text box will display in cursive Homemade Apple Pie font with a date/time stamp next to the
signature. Signatures will be viewable on the narrative, PDF formats and entry mode of documents
and flowcharts. Amend functionality will function as it does for all questions, in that a user may
remove or amend a signature. The original text will be saved and display with a strike through.
To add a signature to a section within a document:
1. Select Charting Options
2. Select the location for the signature to display using the Add to dropdown menu.
3. Select Questions.
4. Use the Title Search field to locate the desired signature.
5. Select the desired signature to move it to the preview pane.
6. Select Add and back arrow.
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Medication List
To insert medications, select Add To Location, then select Medication Lists.
The Medication screen will display and will allow home, active, discharge, discontinued orders and
removed home medications to pull into the document.
The Check filter options are:

All will display all medications types.
Home Medications will display home medications entered in Medication Reconciliation.
Active Medications will display home medications entered in Medication Reconciliation.
Discontinued Orders will display discontinued pharmacy medications.
Discharge Medications will display discharge medications selected in Medication
Reconciliation upon discharge reconciliation and prescription writer.
Removed Home Meds will display home medications that have been removed in Medication
Reconciliation.
The Pull to documentation filter options are:

Alphabetically will pull medications to their categories in alphabetical order.
Chronological will pull medications to their categories in the order the item was entered into the
system.
The Admission Reconciliation Status and Discharge Reconciliation Status will also display on
the far right of the Medication List Screen. The date and time of the admission reconciliation or
discharge reconciliation will display when they have been performed. If they have not been
performed, 'Not performed' will pull.
Select the medications needed to pull into the document and select Insert. Double-clicking the
medication will also insert it into the document.
NOTE: More then one medication may be selected at time, this is a multi-select screen. Holding
down the shift key will all the user to select a block of medications and holding do the control key will
allow the user select multiple individual medications.
The selected medications will display on the screen as follows:

Description will display the medication description, dose, units, route and frequency.
Type will display whether the medication is a home medication, discharge medication, active
medication, removed home medication or discontinued medication order.
Status will display the status of the medication. The following status' will display:
o Confirmed will display for confirmed Home Medications.
o Unconfirmed will display for unconfirmed Home Medications.
o Removed will display for removed Home Medications.
o Active will display for active pharmacy orders.
o Discontinued will display for discontinued pharmacy orders.
o Faxed will display for discharge medications that are faxed within the system. This will only
display if Prescription Writer is activated.
o Electronic will display if the prescription is sent electronically. This will only display if
Prescription Writer is activated.
o Printed will display for discharge medications if the prescription was printed. This will only
display if Prescription Writer is activated.
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o No Rx Needed will display for discharge medications no prescription was needed. This will
only display if Prescription Writer is activated.
Start Date/Time will display start date and time for active pharmacy orders.
Stop Date/Time will display stop date and time for active pharmacy orders.
Problems
To insert a problem from the Physician's Problem List, select Add To Location, then select Problem
List.
The Active Problems will display when the screen is first opened. Select the Display radio button
to choose Inactive, All or Entered in Error.
Select the Problem to insert it into the document. This screen allows multi-selecting so that more
then one Problem may be inserted at one time.
New problems may be added or existing problems may be edited. Please see the Physician
Problem List User Guide for additional information on the options within the action bar.
Select the problems to be pulled into the documentation and select Insert.
The selected problem's diagnosis description, diagnosis date and addressed date will pull into the
document in a rich text box underneath the Problem List widget.
Plan of Care
To insert a plan of care into the document, select Add To Location, then select Plan of Care.
If the patient has already had a Plan of Care documented, it may be pulled into the document by
selecting the entry, then selecting Insert.
Add may be selected from the action bar to create a new Plan of Care entry.
Health History
To insert the patient's health history into the document, select Add To Location, then select Health
History
The Health History screen will default to the List View when accessed via Charting Options.
To insert the patient's health history select the category or an entry from within a category from the
list. For example select the category Family Health. All of the entries within the category will pull
into the document when the category is selected. If just an entry under a category is selected the
category title will pull into the document along with the selected entry. The categories or entries
within a category may be multi-selected.
Choosing the Select All option from that action bar will select all categories within the Health
History list.
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Select the Insert option from the action bar once all items have been selected to insert the
information into the document. The inserted Health History data will display in the List View format
once it has been inserted. The insert option is disabled until an item has been selected from the
Health History list.
New may be selected from the action bar to create a new Health History entry.
Edit may be selected to edit any of the entries displaying beneath a category. The edit option is
disabled until an entry within a category is selected.
NOTE: Please see the Health History User Guide for additional information on adding new entries
and editing existing entries to the Health History application.
To insert an education document from the Patient Education Documents, select Add To Location,
then select Patient Education Documents.
The education documents will display when the screen is first opened.
Select the education documents to insert it into the document. Multiple documents may be
selected at one time using the shift key from the keyboard.
Select Insert to insert the title of the selected education documents into the document.
NOTE: Please see Patient Education Documents for additional information on the Patient
Education Documents application.
Add Group Note
To insert a group note into the document, select Add To Location, then select Add Group Note.
The Group Note Selection screen will display so the user may insert a group note into the selected
documentation document. All group notes for the patient will display with the following columns:
Appointment Date/Time: Displays the date and time of the scheduled task that the group note
was entered within the Scheduling application.
Appointment Type: Displays the name of the task that the group note was entered within the
Scheduling application.
Location/Resource: Displays the location of the scheduled task that the group note was entered
within the Scheduling application.
Select the appropriate Group Note and then select Insert to pull the group note into the document.
This screen is multiselect and will allow more then one selection using the shift or control keys. Notes
may also be inserted into a document by a double-click on a single note.
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5.10 Copy Forward

Documentation Documents may be set to copy forward information from visit to visit.
Once a document is opened, if the first section has data set to copy forward the user will be taken to
the Copy Forward screen. If no data in the first section is set to copy forward, the first section will
open as usual. As the user moves to another section, the Copy Forward screen will open first if data
in that section is set to copy forward.
The Copy Forward screen will display the question description in bold with the answers following a
colon. The user name and date/time of the person that originally entered the data will display below
the question and answers. The following options are available in the action bar:
Back Arrow: Allows the user to go back to the entry screen for the section and not copy forward
any documentation from the previous visit.
Accept: Allows any selected questions to pull in the documentation from the previous visit.
Accept All: Allows all questions to copy the documentation into the section from the previous
visit.
The Copy Forward screen is a multi-select screen that will allow multiple questions to be selected.
To insert the copy forward documentation select the questions to be inserted and then select
Accept. The question selected will insert in the selected section.
NOTE: A user will need the Behavior Control "Copy Forward Documentation" to be allowed to pull
information into a document from the Copy Forward screen. See the Documentation Setup User
Guide for additional information on Copy forward Setup.
5.11 Default Answers

Documents may be set up to save and apply default answers within each section. Default Answers
may be set up on the following types of questions:
Radio buttons
Check boxes
Drop downs
To save default answers within a section of a document:
1. Select the answers that are to be set as default answers for that section of the document. The
option is enabled once new answers have been selected within the section.
2. Select Save Defaults
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NOTE: One set of default answers may be saved per section. For Multi-clinician Documents, the
Save Defaults option is disabled on sections that already have saved documentation in the selected
section. For Flow Charts, the Save Defaults option is disabled on sections that already have saved
documentation in the selected section for that date/time column. If a new date/time column is
selected from the flow chart, the save defaults option will become enabled.
To apply default answers within a section of a document:
1. Select Apply Defaults. The default answers will be applied and highlighted in yellow to alert the
user of the applied default answers. Selecting Next or Previous or using the navigation tree will
allow the user to navigate through the document to view all sections with saved default answers
that have been applied to the document.
NOTE: If any of the questions that are part of the user's defaults have been answered, Thrive will not
apply that default answer. It will only apply to questions/answers that have not been addressed
within that section.
The user may modify, add or remove any documentation within the current section after applying
the default answers.
The apply defaults option becomes Deselect Defaults once it has been selected and default
answers are applied.
Selecting Deselect Defaults will deselect any default answers in that section. The option name will
change back to Apply Defaults.
If any changes are made to the default answers, the user is able to select the Save Defaults
answers option to save new default answers again.
Update, Next, Previous or selecting a new section from the navigation menu, must be selected in
order to save the selected answers.
NOTE: The Save Defaults option does not save the selected answers on a patient's chart. Only
users who are set with the behavior control "Save default answers for Clin Doc Documents’" will be
able to save and apply default answers.
Resolve Default Conflicts Screen
If a content update affects any previously saved default answers, the Resolve Default Answer
Conflicts screen will display when the document section containing the defaulted answers is opened
and Apply Defaults is selected.
Conflicts are triggered based on the following criteria:
Answers have been removed or added to a question containing default answers.
The content update removed a defaulted answer from the question.
The description of the defaulted answer or question with the default answer has changed.
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This screen enables the user to address new defaults. Selecting an answer and then selecting
Acknowledge Conflicts will allow the new answers, along with previously defaulted answers to save to
the section addressed. After selecting Acknowledge Conflicts, new defaults may also be applied in
the section by selecting Save Defaults prior to moving to a new section or choosing Update.
If the back arrow is selected without addressing questions affected by the content update from the
Resolve Default Answer Conflicts screen, a prompt will appear which states “Exiting without
acknowledging the conflicts will prevent all default answers from appearing in this section.” The user
will then be taken back to the previously addressed section with no new default answers being
applied. Only the defaults that were not conflicted will be displayed to that section.
5.12 Special Questions
Overview
Special questions are any questions that will upload information to other areas of the Thrive system.
Advance Directives
The Advance Directive special question is set up as a radio button question with the answer yes, no
and not answered.
When this special question is answered within Documentation, it will populate the following areas:
Census: System Menu > Master Selection > Select Patient > Census > Patient Tab > Advance
Directives
Demographics Drop-down Menu (review screen only): System Menu > Enter Account > Blue
Arrow to Left of Patient Name > Advance Directives
POC Demographics Drop-down Menu (review screen only): System Menu > Hospital Base
Menu from a Nursing Department > POC Access > Numeric Look up > Enter Account > Blue
Arrow to Left of Patient Name > Advance Directives
POC Flow Chart Demographic Clipboard: System Menu > Hospital Base Menu from a Nursing
Department > POC Access > Numeric Look up > Enter Account > Flowchart Tab > Flow Chart
Menu > Select a Flow Chart > Clipboard (Top right corner) > Advance Directive
Clinical Information: System Menu > Enter Account > Clinical Information > Miscellaneous Tab >
Advanced Directives
POC Virtual Chart Demographics (review screen only): System Menu > Hospital Base Menu
from a Nursing Department > POC Access > Numeric Look up > Enter Account > Demographics
Area on Virtual Chart > Advance Directive
Utilization Review Look Option (review screen only): System Menu > Master Selection >
Medical Records > Utilization Review > Numeric Selection > Enter Account > Look >
Demographics > Advance Directives
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Infection Control Look Option (Review screen only): System Menu > Master Selection > Medical
Records > Infection Control > Account Number Look up > Enter Account > Look > Demographics
> Patient Tab > Demographics
Profile Demographics: System Menu > Profile Listing > Select Patient > Clinical Info Tab >
Advance Directive
ED Arrival Date and Time
The Emergency Department Arrival Date and Time special question is set up with the calendar date
picker and time entry field.
ER Log: System Menu > Master Selection > Account Number > Census > ER Log > ED Arrival
Date and Time
ED Departure Date and Time
The Emergency Department Departure Date and Time special question is set up with the calendar
date picker and time entry field.
ER Log: System Menu > Master Selection > Account Number > Census > ER Log > ED
Departure Date and Time
ED Follow-up Care
The ED Follow-up Care special question is set up as a check box question to document follow-up
care when ordered for a discharge patient after he/she has been admitted to the emergency
department.
When this special question is answered within Documentation, it will update any POC Flowchart or
Electronic Form that contains the ED Follow-up Care check box with the hard coded database code
MUEDFUCARE attached. It will also trigger the software to include the patient in the denominator for
the Transitions of Care Create and Transmit measure of Meaningful Use Stage 2.
Pain Scale
The Pain Scale special question is set up as a drop-down.

The different table options are:
0 - No Pain
1
2
3
4
5 - Moderate Pain
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6
7
8
9
10 - Worst Possible Pain
NOTE: The special question, Pain Scale, is consistent with the Pain Scale question in the Vitals
application.
Patient Status
The Patient Status special question is set up as a drop-down.
The table options pull from the Patient Status list setup for the department. See Patient Status for
specific setup from within the Emergency Department User Guide.
If the Patient Status field has been populated in Patient Location Maintenance, it will pull into the
Documentation document when it is opened on the patient's chart. Once the Patient Status field has
been updated within a Documentation document, it will also update the Patient Status field within
Patient Location Maintenance.
Pregnant
The Pregnant special question is set up as a radio button question with the answer yes, no and not
answered.
Clinical Information: Hospital Base Menu > Enter Account > Clinical Information > Dietary/Height/
Weight Tab > Pregnant
POC Flow Charts Demographics Clipboard: Hospital Base Menu from a Nursing Department >
POC Access > Numeric Look up > Enter Account > Flowchart Tab > Flow Chart Menu > Select a
Flow Chart > Clipboard (Top right corner) > Pregnant
POC Virtual Chart Demographics (review screen only): Hospital Base Menu from a Nursing
Department > POC Access > Numeric Look up > Enter Account > Demographics Area on Virtual
Chart > Pregnant
NOTE: This field only appears if the field is answered in of the areas that allow the field to be
accessed/changed.
POC Demographics Dropdown Warnings (review screen only): Hospital Base Menu from a
Nursing Department > POC Access > Numeric Look up > Enter Account > Blue Arrow to the Left
of Patient's Name > Warnings
NOTE: This shows the word "Pregnant" in red if Pregnant=Y
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Fetal Development
Three Fetal Development special questions can be used in documentation and are also visible in the
Vitals application.
They include the following:
Fetus allows for the documentation of the number of fetus and separate fetal heart rates for up to
six fetuses using a drop down with the values one through six. The default is one.
Fetal Heart Rate and Method allows for the documentation of heart rate in beats per minute in a
text box that is limited to three numeric characters and a dropdown box to document the method
for obtaining the fetal heart rate. The following options are available within the dropdown:
Handheld Doppler
Transabdominal ultrasound
Transvaginal ultrasound
Other (which allows a free text answer)
Fundal Height allows for the documentation of fundal height in cm in a text box and is limited to
three numeric characters.
Fetal Development vital signs pull to Documentation Reports if documented within the
Documentation application or the Vitals application.
Fetal Development vital signs documented within a document also pull to the Vitals application for
review.
NOTE: Fields for Fetal Development only appear in the Vitals application for female patients that
have been marked as pregnant in Thrive.
Smoking History
The Smoking History special question is set up as a drop-down.

1 - Current every day smoker
2 - Current some day smoker
3 - Former smoker
4 - Never smoker
5 - Smoker/current status unknown
6 - Heavy tobacco smoker
7 - Light tobacco smoker
8 - Unknown if ever smoked
The special questions, Smoking Start Date and Smoking End Date, are set up with the calendar date
picker that allows a free text entry.
NOTE: The Smoking Start Date question will only open if the answer to the Smoking History
question is 1, 2, 3, 5, 6 or 7. The Smoking End Date question will only open up if the answer 3 is
selected in the Smoking History question.
© 2023 Evident
Census: Hospital Base Menu > Master Selection > Select Patient > Census > Smoking History,
Smoking Start Date and Smoking End Date
POC Flow Charts: Hospital Base Menu from a Nursing Department > POC Access > Numeric
Look up > Enter Account > Flowchart Tab > Flow Chart Menu > Select a Flow Chart > Does
Patient Smoke?
POC Flow Chart Demographic Clipboard: Hospital Base Menu from a Nursing Department >
Flow Chart > Clipboard (Top right corner) > Smoker Status, Smoker Start Date and Smoker End
Date
POC Virtual Chart Demographics (review screen only): Hospital Base Menu from a Nursing
Department > POC Access > Numeric Look up > Enter Account > Demographics > Smoke,
Smoke Begin Date and Smoke End Date
Electronic Forms: Any electronic forms set with the following database code
PATSMOKES - Does Patient Smoke
PATSTART - Smoking Start Date.3
PATSTOP - Smoking End Date
Clinical Information: Hospital Base Menu > Enter Account > Clinical Information > Miscellaneous
Tab > Smoking Status, Smoking Start Date and Smoking End Date
Utilization Review Look Option (review screen only): Hospital Base Menu > Master Selection >
Demographics > Patient Tab > Patient Smoke, Smoker Status, Smoker Start Date and Smoker
End Date
Infection Control Look Option (Review screen only): Hospital Base Menu > Master Selection >
Medical Records > Infection Control > Account Number Look up > Enter Account > Look >
Demographics > Patient Tab > Smoker Status, Smoker Start Date and Smoker End Date
Smokeless Tobacco History
The Smokeless Tobacco History special question is set up as a drop-down.

1 - Does not use moist powdered tobacco
2 - Never used moist powdered tobacco
3 - Ex-user of moist powdered tobacco
4 - Never chewed tobacco
5 - Snuff user
6 - User of moist powdered tobacco
7 - Chews tobacco
8 - Tobacco consumption unknown
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Documentation 35
Census: Hospital Base Menu > Master Selection > Select Patient > Census > Smokeless
Tobacco
Electronic Forms: Any electronic forms set with the following database code
PATUSAGE - Tobacco Usage
Clinical Information: Hospital Base Menu > Enter Account > Clinical Information > Miscellaneous
Tab > Smokeless Tobacco User
POC Flow Chart Demographic Clipboard: Hospital Base Menu from a Nursing Department >
Flow Chart > Clipboard (Top right corner) > Smokeless Tobacco
Utilization Review Look Option (review screen only): Hospital Base Menu > Master Selection >
Demographics > Patient Tab > Smokeless Tobacco
Infection Control Look Option (Review screen only): Hospital Base Menu > Master Selection >
Medical Records > Infection Control > Account Number Look up > Enter Account > Look >
Demographics > Patient Tab > Smokeless Tobacco
Triage Level
The Triage Level special question is set up as a drop-down.
The different table options pull from the Triage Level Table. To set up the triage level table, see
the Tracking Board user guide.
ER Log: System Menu > Master Selection > Account Number > Census > ER Log > Triage Level
Patient Location Maintenance: Tasks > Charts > Track > Patient Room Number > Triage Level
© 2023 Evident
Vital Signs
Vital signs are available for documentation through Documentation documents. Vital signs that are
documented will pull to the Vitals application and the patient's Virtual Chart.
The following Vitals Signs are available:
Temperature
Pulse
Respiration
Blood Pressure
O2 Saturation
Pain Level
Height
Weight
BMI
BSA
Head Circumference
Blood Glucose Level
Intake/Output
Temperature is set up as a text box that will allow up to five characters to be documented in
Fahrenheit or Celsius. A drop-down box is used to document site. Site is required when temperature
is addressed.
The drop-down options for site are:

Oral
Rectal
Axillary
Tympanic
Bladder
Saw Ganz
Temporal Scanning
Temporal
Temporal Artery
Monitor
Other: Allows the user to free text an answer not on the drop-down list.
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Documentation 37
Pulse is set up as a text box that will allow up to three numeric characters and a drop-down box to
document site. Site is required when the pulse is addressed.
The drop-down options for site are:

Pulse Ox
Radial
Brachial
Femoral
Carotid
Apical
Monitor
Respiration is set up as a text box that will allow up to three numeric characters.
Blood Pressure is set up as a text box that will allow up to three numeric characters for systolic and
diastolic. Position and Site are set up as drop-down boxes and are required when blood pressure is
addressed.
The drop-down options for Position are:

Lying
Sitting
Standing
Doppler
Other: Allows the user to free text an answer not on the dropdown list.
The drop-down options for Site are:

Right Arm
Left Arm
Right Leg
Left Leg
NOTE: Blood Pressure position and site can be set up to have default answers.
O2 Saturation is set up as a text box that will allow up to three numeric characters.
O2 Method is set up as a drop-down box.
The drop-down options for O2 Method are:

O2 Cannula
Partial Rebreathing Mask
Room Air 21%
Simple Mask
T-Piece
Venti Mask
Ventilator
Other: Allows the user free text an answer not on the dropdown list.
O2 L/M is set up as a text box that will allow up to five characters.
FiO2 is set up as a text box that will allow up to three numeric characters.
© 2023 Evident
Height is set up as a text box that will allow up to five characters in the inches field and six characters
the centimeters field. Both fields will auto calculate for the other field that is not addressed.
Weight is set up as a text box that will allow up to five characters in the Pounds, Ounces, Kilograms
and Grams fields. All fields will auto calculate for the other fields not addressed. Scale is set up as
drop-down box.
The dropdown options for Scale are:

Stated
Bed Scale
Sling Scale
Floor Scale
Chair Scale
Newborn Scale
Estimated
Other: Allows the user free text an answer not on the drop-down list.
BMI and BSA are display only and calculate once height and weight have been addressed. If height
and weight are readdressed, the BMI and BSA will recalculate.
Blood Glucose is set up as a series of radio buttons with the following answer options Level, High,
Low, No BG, and Not Addressed. The radio button option for Level is followed by a text box that
will allow up to three numeric characters. If any other radio button is selected other than Level, the
Level Text box will display disabled and blank. Type and Method are set up as a drop-down.
The drop-down options for Type are:

Average
Daily
Fasting
Random
The drop-down options for Method are:

Arterial
Finger Stick
Heel Stick
Venipuncture
Head Circumference is set up as a text box that will allow up to five characters in the centimeters
and inches field. Both fields will auto calculate for the other field that is not addressed.
Pain Scale setup is the same as the Pain Scale 31 special question.
Intake options are as follows:
NOTE: Intake Type options pull according to the chart type selected on the POC Virtual Chart.
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Documentation 39
Intake Type is set up as a drop-down box with a hard coded drop-down box with one of the
following drop down list:
Adult Intake Pediatric Intake Nursery Intake

Options: Options: Options:
Oral Oral Oral
NG/Peg Tube Oral - Formula Oral-Formula
Feeding
Hyperalimentation Oral - Baby Food Oral - Pedialite
Lipids Oral - Pedialite Oral - Sterile Water
Hespan NG/Peg Tube Oral - 5% Glucose
Feeding Water
Albumin Irrigation Solution NG/Peg Tube
Feeding
Packed Red Blood Fresh Frozen Left/Right Breast
Cells Plasma
Fresh Frozen Platelets Left Breast
Plasma
Platelets Packed Red Blood Right Breast
Cells
Irrigation Solution Hyperalimentation OTHER (allows
free text entry)
OTHER (allows Left/Right Breast IV FLUIDS
free text entry)
IV FLUIDS Left Breast
Right Breast
OTHER (allows
free text entry)
IV FLUIDS
NOTE: IV FLUIDS option will pull the POC Control Table on Page one, the field labeled "Use
Pharmacy for IV Intake." See POC Setup for further information.
Volume: Enter amount consumed displayed in milliliters up to six digits. If NG/Peg Tube Feeding
is selected, enter the capacity of the source displayed in milliliters. If the Intake Volume field is left
empty, the alert will display "Need an Intake Volume Value". Once the user has selected OK, a
volume should be entered in the volume field or the check box None should be selected.
None: Options are unchecked and checked ( )

Unchecked (default): Allows an amount to be entered in the Volume field.
Checked ( ): Sets the Volume field automatically to 0 ml.
Left to Count: Available when NG/Peg Tube Feeding is selected from Intake Type. Enter the
remaining volume in milliliters up to 5 numeric characters with one decimal place.
Rate Per Hour: Available when NG/Peg Tube Feeding is selected from Intake Type. Enter the
amount of fluid in milliliters consumed within one hour up to five numeric characters with one
decimal place.
© 2023 Evident
Feeding Quality: Available when Left/Right Breast, Left Breast or Right Breast is selected from
Intake Type. Radio button options are Poor, Fair and Well.
Feeding Type: Available when Left/Right Breast, Left Breast or Right Breast is selected from
Intake Type. This is a two digit field with radio button options for Times and Minutes.
Output options are as follows:
Output Measure: Radio button options are Volume and Frequency.
Output Site is set up as a drop-down box with a hard coded drop-down box with one of the
following drop down list:
Adult Output Pediatric Output Nursery Output

Options: Options: Options:
Voided Urine Voided Urine Voided Urine
Catheter Urine Catheter Urine Catheter Urine
Stool Wet Diapers Wet Diapers
Colostomy Stool Stool
Emesis Colostomy Emesis
NG Tube Emesis NG Tube Drainage
Estimated Blood NG Tube Drainage Chest Tube
Loss
T-Tube Estimated Blood Estimated Blood
Loss Loss
Jackson Pratt #1 T-Tube OTHER (allows
free text entry)
Jackson Pratt #2 Jackson Pratt #1
Chest Tube Jackson Pratt #2
Hemovac #1 Chest Tube
Hemovac #2 Hemovac #1
OTHER (allows Hemovac #2
free text entry)
OTHER (allows
free text entry)
Volume: Displays instead of Frequency when Volume is selected for Output Measure. Enter the
amount produced displayed in milliliters up to six digits. If the Output Volume field is left empty, the
alert will display "Need an Output Volume Value". Once the user has selected OK, a volume should
be entered in the Volume field or the check box None should be selected.
Frequency: Displays instead of Volume when Frequency is selected for Output Measure. Enter
the number of times output is produced.
None: Options are unchecked and checked ( )

Unchecked (default): Allows an amount to be entered in the Volume or Frequency fields.
Checked ( ): Sets the Volume field automatically to 0 ml or the Frequency field automatically
to 0 times. If documenting frequency, "NONE" will be displayed on the Review screen.
© 2023 Evident
Documentation 41
Drain Level: Available when NG Tube or Chest Tube is selected from Output Site. This is a 6-digit
field.
Stool Size: Available when Stool is selected from Output Site and None is unchecked. Radio
button options are Small (default), Moderate and Large
Widgets
Widgets have the ability to access another application from within Documentation documents. A
widget will allow the user to launch from Documentation to the selected application. Then, the user will
be able to insert any selected information from within the widget into the document.
All widgets will appear in boldface and highlighted in blue when the mouse moves over the widget
within the Documentation documents.
Widgets that are currently available are: Allergies, Immunizations, Patient Status, Problem List, ED
Follow-Up Care, O2 Sat, Social History, Family Health History, Functional/Cognitive Status, Past
Medical Procedures and Interventions, Referral/Transition of Care and Quality Measures.
NOTE: See Quality Measures 49 for more information on Quality Measures widgets.
Allergy
The Allergy widget allows access to the patient's allergies from within Documentation documents.
The allergy widget will appear bold in documentation and highlight blue when the mouse hovers over
it. The widget is also available by inserting the special question into the document via Charting
Options.
Select the allergy widget to launch the patient's allergy screen.

Add: Allows the Micromedex allergy listing of available drug, environmental and food allergies to
launch and functions as it does within the Allergy application. Please see the Allergy User Guide
for additional information.
Remove: Allows the selected allergy to be removed from the patient's account.This option is
only enabled once an allergy is selected.
Insert: Allows the selected allergies to be inserted into the Documentation document.
NKA: Allows No Known Allergies to be added to the patient's account.
NKDA: Allows No Known Drug Allergies to be added to the patient's account.
NKEA: Allows No Known Environmental Allergies to be added to the patient's account.
NKFA: Allows No Known Food Allergies to be added to the patient's account.
History: Allows access to the date, time and initials of the person who entered the allergies and
the changes that have been made. It also allows allergies to be reviewed.
Verify All: Allows the user to verify that all allergies listed on the patient's account are up to date
and correct.
© 2023 Evident
Select Patient Chart > Documentation > New Document > Allergy Widget
Select the allergies to be pulled into the documentation and select Insert.
Select Patient Chart > Documentation > New Document > Allergy Widget > Allergy > Insert
The selected allergy, reaction, severity and type will pull into the document in a rich text box
underneath the Allergy widget.
Immunizations
The Immunization widget allows access to the patient's immunizations from within Documentation
documents. The Immunization widget will appear bold in documentation and highlight blue when the
mouse hovers over it. The widget is also available by inserting the special question into the
document via Charting Options.
Select the Immunization widget to launch the patient's immunization screen.

Add New: Allows new immunizations to be added to the patient's profile and functions as it does
within the Patient Immunization History application. Please see the Patient Immunization History
User Guide for additional information.
Delete: Allows the selected immunization to be removed from the list of immunizations for the
patient. This option is only enabled once an immunization is selected.
Insert: Allows the selected immunizations to be inserted into the Documentation document.
Select Patient Chart > Documentation > New Document > Immunization Widget
Select the immunizations to be pulled into the documentation and select Insert.
Select Patient Chart > Documentation > New Document > Immunization Widget > Immunization >
Insert
The selected immunizations and the date administered will pull into the document in a rich text box
underneath the Immunization widget.
Family Health History
The Family Health History widget allows access to the patient's Family Health History from within
Documentation documents. The Family Health History widget will appear bold in documentation and
highlight blue when the mouse hoovers over it. The widget is also available by inserting the special
question into the document via Charting Options.
Select the Family Health History widget will launch the patient's Health History Review screen in a
List View.
Family Health History is defaulted as checked. This screen displays the available Types of health
history, which may be multi-selected and inserted into the document at one time.
© 2023 Evident
Documentation 43
Selecting the header for a Health History type will automatically insert all information included
within that header.

Edit: Allows the information that displays under a Health History header to be edited. This option
is only enabled when information below a Health History header is selected.
New: Allows the Health History Category screen to launch and functions as it does within the
Health History application. Please see the Health History User Guide for additional information.
Insert: Allows the selected information to be inserted into the Documentation document. This
option is only enabled when information is selected.
Select All: Selects all information displayed, which can then be inserted into the Documentation
document.
Select Patient Chart > Documentation > New Document > Family Health History Widget
Select the family health history entries to be pulled into the document and select insert.
The selected Family Health History descriptions and the associated relatives will pull into the
document in a rich text box underneath the Family Health History widget.
Functional/Cognitive Status
The Functional/Cognitive Status widget allows access to the patient's Functional/Cognitive Status
from within Documentation documents. The Functional/Cognitive Status widget will appear bold in
documentation and highlight blue when the mouse hoovers over it. The widget is also available by
inserting the special question into the document via Charting Options.
Select the Functional/Cognitive Status widget will launch the patient's Health History Review
screen in a List View.
Functional/Cognitive Status is defaulted as checked. This screen displays the available Types of
health history, which may be multi-selected and inserted into the document at one time.
within that header.

document.
© 2023 Evident
Select Patient Chart > Documentation > New Document > Functional/Cognitive Status
Select the Functional/Cognitive Status to be pulled into the document and select insert.
The selected Functional/Cognitive Status entry will pull into the document in a rich text box
underneath the Functional/Cognitive Status widget.
Group Note
The Group Note widget allows access to the Group Note Selection screen. This allows the user to
insert the PhysDoc Template that was documented through Group Note in the Scheduling
application. The Group Note widget will appear bold in documentation and highlight blue when the
mouse hovers over it. The widget is also available by inserting the special question into the
document via Charting Options. Please see Add Group Note 27 for additional information.
Medical History
The Medical History widget allows access to the patient's Medical History from within the Health
History application to be inserted into a document. The Medical History widget will appear bold in
documentation and highlight blue when the mouse hovers over it. The widget is also available by
Selecting the Medical History widget will launch the patient's Health History Review screen in a List
View.
Medical History is defaulted as checked. This screen displays the available Types of health
within that header.

document.
Select the Medical History entries to be pulled into the document and select insert.
The selected Medical History entries will pull into the document in a rich text box underneath the
Medical History widget.
© 2023 Evident
Documentation 45
Past Medical Procedures and Interventions
The Past Medical Procedures and Interventions widget allows access to the patient's Past Medical
Procedures and Interventions from within Documentation documents. The Past Medical Procedures
and Interventions widget will appear bold in documentation and highlight blue when the mouse
hoovers over it. The widget is also available by inserting the special question into the document via
Charting Options.
Select the Past Medical Procedures and Interventions will launch the patient's Health History
Review screen in a List View.
Past Medical Procedures and Interventions is defaulted as checked. This screen displays the
available Types of health history, which may be multi-selected and inserted into the document at
one time.
within that header.

document.
Select Patient Chart > Documentation > New Document > Past Medical Procedures and
Interventions
Select the past medical procedures and interventions entries to be pulled into the document and
select insert.
The selected Past Medical Procedures and Interventions entries will pull into the document in a rich
text box underneath the Past Medical Procedures and Interventions widget.
The Patient Education Documents widget allows access to the patient's Education Documents
from within Documentation documents. The Patient Education Documents widget will appear bold in
documentation and highlight blue when the mouse hovers over it. The widget is also available by
Select the Patient Education Documents widget to launch the patient's Education Documents
screen.

New Document: Allows a new document to be added and functions as it does within the Patient
Education Document application. Please see the Patient Education Documents User Guide for
© 2023 Evident
Edit: Allows the patient education document to be edited. This option is only enabled once a
patient education document is selected.
Delete: Allows the patient education document to be removed from the list. This option is only
enabled once a patient education document is selected.
Insert: Allows the selected patient education document titles to be inserted into the
Documentation document.
View: Allows the patient education document to display.
Print: Allows the patient education document to be printed.
Clinical Knowledge: Allows access to view education documents based on the patient's lab
results, medications and problems. Please see the Patient Education Documents User Guide for
Insert: Allows the selected patient education document titles to be inserted into the
Documentation document.
Select Patient Chart > Documentation > New Document > Patient Education Document Widget
Select the patient education document titles to be pulled into the documentation and select Insert.
The selected patient education document titles will pull into the document in a rich text box
underneath the Patient Education Documents widget.
Physician Reason for Admit
The Physician Reason for Admit allows access to the Physician Problem List from within
Documentation documents. The Physician Reason for Admit widget will appear bold in
documentation and the answer will highlight blue when the mouse hovers over it. The widget is also
available by inserting the special question into the document via Charting Options. If this widget is
already addressed on the Reason for Visit screen within Location Maintenance, the Physician Admit
Reason will automatically display next to the widget. If the Physician Reason for Admit has not been
addressed it will display "No Answer Given" and a reason may be selected.
Select the Physician Reason for Admit widget to launch the Physician Problem List.
The Active Problems will display when the screen is first opened.
Select the Display radio button to choose Inactive, All or Entered in Error.
Problem List User Guide for additional information on the options from the action bar.
Select the Physician Reason for Admit and select Insert.
NOTE: If more then one diagnosis is selected the Insert option becomes disabled. Only one
diagnosis may be selected as the Physician Reason for Admit.
© 2023 Evident
Documentation 47
Select Patient Chart > Documentation > New Document > Physician Admit Reason
The selected admit reason will pull into the document next to the Physician Reason for Admit
widget. Once a physician admit reason is populated in this field, it will copy to all other Physician
Admit Reason locations within Thrive.
Select Patient Chart > Documentation > New Document > Physician Admit Reason > Select Diagnosis
> Insert
Problem List or Diagnosis
The Problem List or Diagnosis widget allows access to the Physician Problem List from within
Documentation documents. The Problem List or Diagnosis widget will appear bold in documentation
and highlight blue when the mouse hovers over it. The Problem List widget is also available by
Select the Problem List widget to launch the Physician Problem List.
The Active Problems will display when the screen is first opened.
Select the Display radio button to choose Inactive, All or Entered in Error.
Select the Problem to insert it into the document. This screen allows multi-selecting so that more
then one Problem may be inserted at one time.
Problem List User Guide for additional information on the options within the action bar.
Select the problems to be pulled into the documentation and select Insert.
Select Patient Chart > Documentation > New Document > Problem List Widget
The selected problem's diagnosis description, diagnosis date and addressed date will pull into the
document in a rich text box underneath the Problem List widget.
Referral/Transition of Care
The Referral/Transition of Care widget allows access to the patient's referral/transition of care from
within Documentation documents. The Referral/Transition of Care widget will appear bold in
documentation and highlight blue when the mouse hoovers over it. The widget is also available by
Select the Referral/Transition of Care widget will launch the patient's Health History Review
screen in a List View.
Referral/Transition of Care is defaulted as checked. This screen displays the available Types of
health history, which may be multi-selected and inserted into the document at one time.
within that header.
© 2023 Evident

document.
Select Patient Chart > Documentation > New Document > Referral/Transition of Care
Select the referral/transition of care entries to be pulled into the document and select insert.
The selected Referral/Transition of Care entries will pull into the document in a rich text box
underneath the Referral/Transition of Care widget.
Social History
The Social History widget allows access to the patient's Social History from within documentation
documents. The social history widget will appear bold in documentation and highlight blue when the
mouse hoovers over it. The widget is also available by inserting the special question into the
document via Charting Options.
Selecting the Social History widget will launch the patient's Health History Review screen in a List
View.
Social History is defaulted as checked. This screen displays the available Types of health
within that header.

option is only enabled once information is selected.
document.
Select Patient Chart > Documentation > New Document > Social History Widget
Select the social history entries to be pulled into the document and select insert.
The selected Social History entries will pull into the document in a rich text box underneath the
Social History widget.
© 2023 Evident
Documentation 49
Quality Measures
For MU3, the Clinical Quality Measures Documentation Document should be used for all quality
measure documentation. Please see the following document Structured Documentation for Clinical
Quality Measures for additional information.
5.13 Reflexing
Overview
Reflexing may be used to generate questions, sections, orders or charges based on the answer
choice that is selected during documentation. This chapter will discuss the use of reflexing within
documentation.
Orders and Charges
Orders and charges may be generated through a reflex by selecting the answer that is tagged to
reflex.
When an answer that has an order or charge reflex attached to it is selected, the Pending option at
the top will update to reflect that an item is pending.
Select Pending to view all pending reflexes.
Edit will allow maintenance to be performed for the order or charge.
Remove will change the status of the order or charge from PENDING to REMOVED. Removed
reflexes will not be processed.
Process will place the order or process the charge.
Select Process to launch Updated Order Entry to complete the order entry process. Please see
the Updated Order Entry user guide for additional information on placing orders.
Reflexes will display with a QUEUED status until the document has been updated. This is a view
only screen.
Select the Back Arrow to return to the document.
Once documentation has been completed and Update has been selected, the reflex queue will
automatically display so pending reflexes may be processed.
NOTE: If documentation that triggered a reflex is later amended, the user will receive a prompt that
an order or a charge was triggered based on amended documentation. Reflexed orders and charges
are not automatically canceled/discontinued/credited when amending; therefore, those operations
will need to be performed manually, if necessary.
© 2023 Evident
Sections
Subsections may be inserted into the document through reflexes that are attached to questions or
answers.
When an answer is set to reflex a section, the section will be pulled into the section once the answer
has been selected
The section will be inserted directly below the question or answer that triggered the reflex.
NOTE: If documentation that triggered the reflex is later amended, the reflexed section will no longer
display within the template.
Questions
Questions may be inserted into the Documentation document based on the answer choice that is
selected.
When an answer is set to reflex a question, the question will be pulled into the section once the
answer has been selected.
The question will be inserted directly below the answer that triggered the reflex.
NOTE: If the documentation that triggered the reflex is later amended, the reflexed questions will no
longer display within the document.
Markups
Markups may be inserted into a document from a reflex.
When a markup reflex is triggered, the markup will pull into a rich text documentation area directly
below the question or answer that triggered the reflex.
When an answer is set to reflex a markup, the markup will be pulled into the section once the answer
has been selected.
The markup will be inserted directly below the answer that triggered the reflex.
NOTE: If documentation that triggered the reflex is later amended, the reflexed markup will no
longer display within the template.
© 2023 Evident
Documentation 51
Instructions
Instructions may be inserted into a document from a reflex.
When an instruction reflex is triggered, instructions will pull into a rich text documentation area
directly below the question or answer that triggered the reflex. The instructions may be edited or
modified as needed.
When an answer is set to reflex an instruction, the instruction will be pulled into the section once the
answer has been selected.
The instruction will be inserted directly below the answer that triggered the reflex.
NOTE: If documentation that triggered the reflex is later amended, the reflexed instruction will no
longer display within the template.
In the Grid View, reflexed data will be indicated in the appropriate question grid cell with an icon.
Prescription Writer
Prescriptions may be set up to generate a reflex when a user selects a particular answer. An
action(s) will be added to Pending for the prescription associated with the selection. Once the
document is Updated, the Pending screen will launch. Pending prescriptions will list the Question/
Answer, medication description and status.
If the prescription reflex is set up as a blank reflex, the Medication Search screen will display with the
My Meds radio button selected to display the user's My Meds List. If the user does not have any
medications setup as My Meds, then the Medication Search screen will display and allow the user to
search the formulary for the needed medication.
To generate a prescription reflex, select the associated answer that was previously setup to trigger
the reflex.
Once the document has been updated the Reflex screen will display with the following options:
Edit will allow maintenance to be performed on the prescription.
Remove will change the status of the prescription from PENDING to REMOVED. Removed
Process will order the prescription.
If the prescription reflex is setup with a preselected prescription, select process to send the
prescription to RX Entry as a temporary prescription and "Pending prescriptions only" is defaulted as
checked. The user will then have the option of adding a new prescription(s) or processing all pending
prescriptions from within the RX Entry screen.
If the prescription reflex was set up as a blank reflex, an edit will be required. Select the prescription
and select Edit or select Process and Thrive will automatically launch the edit screen.
© 2023 Evident
NOTE: If Medication Reconciliation is set as required within the ED General Control table and a
Discharge Reconciliation has not been performed, the user will be notified that " A Discharge
Reconciliation is required to process the R/X reflexes." Thrive will keep the reflexes as pending until
a discharge reconciliation has been completed. Please see the Emergency Department User Guide
for more information.
The Medication Search screen displays with the My Meds radio button selected to allow the user to
choose a medication from their medication list. If the user does not have any medications set up as
My Meds then the radio button will be defaulted to All Meds.
Once a prescription is selected, if the site is using E-scribe, then the Coverage and Formulary
Information screen will display. If they are not, this screen is bypassed. Once the Payer field is
addressed select Continue.
The Pending Prescription screen will then display. Once all required fields have been addressed
select Process. If multiple reflexes were processed at once, the next reflex in the sequence will
display so it may be addressed.
For more information on the Prescription Entry screens, see the Prescription Entry User Guide.
Once all prescriptions are processed, the back arrow will take the user to the Reflexes screen in
Documentation. All processed prescriptions will display with a status of Processed.
Messages
A message can be set up to reflex when a user selects a question or answer. An action(s) will be
added to Pending for the message associated with the selection. Once the document is Updated,
the Pending screen will launch.
Pending messages will be available to Process by selecting Process.
If edits are needed, double-click to open the Message Detail screen or select Edit where edits can
be addressed. A Send option will then be available.
Selecting Remove will change the status of the message from PENDING to REMOVED. Removed
NOTE: This functionality is exclusive to the TP-EHR setting, as messages and preventatives are
viewable in the Communications application.
Preventative
A preventative can be set up to reflex when a user selects a question or answer. An action(s) will be
added to Pending for the message associated with the selection. Once the document is Updated,
the Pending screen will launch.
Pending messages will be available to Process by selecting Process.
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Documentation 53
"DUE DATE NEEDED!" and *Edit Required* will display.
1. Double-click the preventative to open the Preventative Edit screen where edits can be addressed.
A Save option will then be available.
2. Select Process.
NOTE: This functionality is exclusive to the Clinic setting, as messages and preventatives are
viewable in the Communications application.
Reflex History
The Reflex History screen displays all processed reflexes for the selected document from the
document tree.
Once a current or completed document has been selected from the document tree and processed
reflexes are present, the View Reflex History option will be available. If the document does not have
any processed reflexes, the View Reflex History option will be grayed out.
Reflexes listed will display with the reflex type (e.g. Order or Charge), status (Processed), the date/
time the reflex was triggered, the full name of the person who triggered the reflex, the question and
answer that triggered the reflex and the item being ordered or charged.
A smart search is available to delimit the reflexes in the list via the Search field.
The reflexes may also be sorted via the Sort drop-down. The sort options are:
Timestamp: This is the default.
Answer
Employee
Question
The PDF option will display the listed reflexes in a PDF format for printing.
Select the Back Arrow to return to the Documentation screen.
5.14 Accordion Style Documentation

Accordion style documentation appears when a section has more then 600 controls; it will appear
"collapsed" to only display subsection headers. A white plus (+) sign in a green box will appear next
to the subsection header. When selected, the questions and answers associated with that subsection
will display. Once a subsection is expanded, it cannot be collapsed again.
Select the appropriate plus (+) sign to open the subsection.
© 2023 Evident
Select Patient Chart > Documentation > New Document > Section > Plus Sign
Accordion Style Documentation
Address the section as needed.
NOTE: Once a subsection is expanded, it cannot be collapsed again.
5.15 ED Provider Documentation after Admit to Inpatient

If an ED patient is admitted to the hospital and becomes an inpatient, the ED Provider may
document or amend documentation within the Documentation Application.
The document must be previously opened on the patient's account prior to the patient being
discharged from the ED and admitted to the hospital.
The document must be selected from the Current Documents folder of the document tree.
The date and time must be changed back to when the patient was located in the Emergency
Department.
Once the Narrative View of the document displays, the provider will then have access to the Entry
Mode option to enter additional documentation.
© 2023 Evident
Amending Documentation 55
Chapter 6 Amending Documentation
6.1 Amending Multi-Clinician
Amending a Document
To amend an entire Multi Clinician Document:
Select the document from the Current Documents folder within the Document Tree.
Select Amend Options from the action bar. This will launch the Document Amend Options screen.
Document Amend Options are as follows:
Change date and time for my entries in the current section: Allows the user to change the date
and time for his/her entries within the current section. Once this option is selected and a new date
and time is entered, select Process to update. The prompt "Are you sure you want to modify the
date/time on your entries in this document to YYYY-MM-DD 00:00?" will display. Select Yes to
save or select No to cancel.
Change date and time for all entries in the current section: Allows the user to change the date
and time for all entries within the current section. This option is only available if the user has the
Super Amend Functionality 60 . Once this option is selected and a new date and time is entered,
select Process to update. The prompt "Are you sure you want to modify the date/time on your
entries in this document to YYYY-MM-DD 00:00?" will display. Select Yes to save or select No to
cancel.
Change date and time for my entries in the entire document: Allows the user to change the
date and time for his/her entries within the entire document. Once this option is selected, and a
new date and time is entered, select Process to update. The prompt "Are you sure you want to
modify the date/time on your entries in this document to YYYY-MM-DD 00:00?" will display.
Select Yes to save or select No to cancel.
Change date and time for all entries in the entire document: Allows the user to change the date
and time for all entries within the entire document. This option is only available if the user has the
Super Amend Functionality 60 . Once this option is selected, and a new date and time is entered,
select Process to update. The prompt "Are you sure you want to modify the date/time on your
cancel. This option is accessible only for users with Super Amend security.
Amend my entries for this document: Allows the user to amend his/her entries within the
document. Once this option is selected, select Process to save. The user may then access all
sections to amend.
Amend all entries for this document: Allows the user to amend all entries within the document.
Once this option is selected, select Process to save. The user may then access all sections to
amend. This option is only available if the user has the Super Amend Functionality 60 .
© 2023 Evident
Remove my entries for this section: Allows the user to remove his/her entries within the current
section. Once this option is selected, select Process to save. The prompt "Are you sure you want
to strike through your entries in this section?" will display. Select Yes to save or select No to
cancel.
Remove all entries from this section: Allows the user to remove all entries within the current
section. Once this option is selected, select Process to save. The prompt "Are you sure you want
to strike through your entries in this section?" will display. Select Yes to save or select No to
cancel. This option is only available if the user has the Super Amend Functionality 60 .
Remove my entries for this document: Allows the user to remove all of his/her entries
documented within the document. Once this option is selected, select Process to save. The
prompt "Are you sure you want to strike through your entries in this document?" will display. Select
Yes to save or select No to cancel.
Remove all entries for this document: Allows the user to remove all entries within the document.
This option is only available if the user has the Super Amend Functionality 60 . Once this option is
selected, select Process to save. The prompt "Are you sure you want to strike through all entries
in this document?" will display. Select Yes to save or select No to cancel.
NOTE: Only fields addressed by the user logged in will be available for amendment. Any
documentation by another user will display in review mode and may not be amended unless they
have the security to amend documentation for any Login. See Super Amend Functionality 60 below
for details.
Once a question has been amended and update is selected, the question will display the most
recent value on the screen. The prior/original documentation is reviewable on the Review Options
screen by selecting Include Stricken. Amended information will display with a strike-through to
indicate that it has been changed or amended.
Amending a Section
To amend an entire section within a Multi Clinician Document:
Select the document from the Current Documents folder within the Document Tree.
Select Entry Mode from the action bar to access the section.
Once the document opens, select Amend Options from the action bar. Selecting Amend
Options will open the Document Amend Options screen.
Document Amend Options are as follows:
Change date and time for my entries in the current section: Allows the user to change the date
and time for his/her entries within the section. Once this option is selected and a new date and time
is entered, select Process to update. The prompt "Are you sure you want to modify the date/time
on your entries in this section to YYYY-MM-DD 00:00?" will display. Select Yes to save or select
No to cancel.
© 2023 Evident
Change date and time for all entries in the current section: Allows the user to change the date
and time for all entries within the section. This option is only available if the user has the Super
Amend Functionality 60 . Once this option is selected and a new date and time is entered, select
Process to update. The prompt "Are you sure you want to modify the date/time on all entries in
this document to YYYY-MM-DD 00:00?" will display. Select Yes to save or select No to cancel.
Change date and time for my entries in the entire document: Allows the user to change the
date and time for his/her entries within the entire document. Once this option is selected and a new
date and time is entered, select Process to update. The prompt "Are you sure you want to modify
the date/time on your entries in this document to YYYY-MM-DD 00:00?" will display. Select Yes to
save or select No to cancel.
Change date and time for all entries in the entire document: Allows the user to change the date
and time for all entries within the entire document. This option is only available if the user has the
Super Amend Functionality 60 . Once this option is selected and a new date and time is entered,
select Process to update. The prompt "Are you sure you want to modify the date/time on all
cancel.
Amend my entries for this document: Allows the user to amend all of his/her entries for the
selected document. Select Process to update. The user is now in amend mode, and the document
opens to allow any changes that need to be made. When in amend mode, the word "Amend"
appears in the top right corner in bold to let the user know they are amending the documentation in
the document.To exit amend mode, select Update to save the changes or back arrow to cancel
changes.
Amend all entries for this document: Allows the user to amend all entries for the document. This
option is only available if the user has the Super Amend Functionality 60 . Once this option is
selected, select Process to update. The user is now in amend mode, and the document opens to
allow any changes that need to be made. When in amend mode, the word "Amend" appears in the
top right corner in bold to let the user know they are amending the documentation in the
document.To exit amend mode, select Update to save the changes or back arrow to cancel
changes.
Remove my entries for this section: Allows the user to remove all of his/her entries documented
within the section. Once this option is selected, select Process to update. The prompt "Are you
sure you want to strike through your entries in this section?" will display. Select Yes to save or
select No to cancel.
Remove all entries for this section: Allows the user to remove all entries within the section. This
option is only available if the user has the Super Amend Functionality 60 . Once this option is
in this section?" will display. Select Yes to save or select No to cancel.
Remove my entries for this document: Allows the user to remove all of his/her entries
documented within the document. Once this option is selected, select Process to save. The
prompt "Are you sure you want to strike through your entries in this document?" will display. Select
Yes to save or select No to cancel.
© 2023 Evident
Remove all entries for this document: Allows the user to remove all entries within the document.
This option is only available if the user has the Super Amend Functionality 60 . Once this option is
in this document?" will display. Select Yes to save or select No to cancel.
have the security to amend documentation for any Login. See Super Amend Functionality 60 below
for details.
Select update when all changes are complete.
Once a question has been amended and update is selected, the question will display the most
recent value on the screen.The prior/original documentation is reviewable on the Review Options
screen by selecting Include Stricken. Amended information will display with a strike-through to
indicate that it has been changed or amended.
Amending a Question
To amend individual questions within a section select Amend from the action bar. When a section
that has questions previously documented is accessed by the same user, the questions and answers
will display in review mode until Amend is selected from the action bar.
From the selected document, select the question or answer that needs to be amended.
Once the document opens, select Amend from the action bar.
Address any fields that may need to be amended.
have the security to amend documentation for any login. See Super Amend Functionality 60 below
for details.
Select Update when all changes are complete.
Once a question has been amended and Update is selected, the question will display the most
recent value on the screen.The prior/original documentation is reviewable on the review
documentation screen with a strike-through to indicate that it has been changed or amended.
© 2023 Evident
6.2 Amending Flowcharts Columns

To amend an entire flow chart column or change the date and time, double-click on the date and time
at the top of the column. Column Amend Options are as follows:
Change column date and time for my entries: Allows the user to change the date and time for
their entries within the column. Once this option is selected and a new date and time is entered,
select Process to update. The prompt "Are you sure you want to modify the date/time from "MM/
DD/YYYY 00:00 to MM/DD/YYYY" will display. Select Yes to save or select No to cancel.
Change column Date and Time for all entries: Allows the user to change the date and time for all
entries within the column. This option is only available if the user has the Super Amend
Functionality 60 . Once this option is selected and a new date and time is entered, select Process
to update. The prompt "Are you sure you want to modify the date/time from "MM/DD/YYYY 00:00
to MM/DD/YYYY" will display. Select Yes to save or select No to cancel.
Amend entries for this column: Allows the user to amend all of their entries documented for the
selected column. If the user has the Super Amend Functionality 60 , it allows the user to amend all
documentation for the column. Once this option is selected, select Process to save. The user is
now in amend mode, and the document opens to allow any changes that need to be made. When
in amend mode, the word Amend appears in the top right corner in black to let the user know they
are amending the documentation in the template.To exit amend mode, select update to save the
changes or back arrow to cancel changes.
Remove my entries for this column: Allows the user to remove all of their entries documented
within the column. If another user documentation exits within the same date/time column, it will still
be present under the original date/time column. If all data is removed for the date/time column by
removing the user's entries, the column will no longer display. Once this option is selected, select
Process to save. The prompt "Are you sure you want to strike through entries from MM/DD/YYYY
00:00" will display. Select Yes to save or select No to cancel.
Remove all entries for this column: Allows the user to amend all documentation within the date/
time column. This option is only available if the user has the Super Amend Functionality 60 . Once
this option is selected, select Process to save. The prompt "Are you sure you want to strike
through entries from MM/DD/YYYY 00:00" will display. Select Yes to save or select No to cancel.
NOTE: When any documentation is amended, the original documentation is reviewable with Review
Options, any printed reports and audit area with a strike-through to indicate that is has been
changed or amended along with the date, time, name and credentials of the original documentation.
© 2023 Evident
6.3 Super Amend Functionality

Super Amend Functionality
If a login is set to allow for the behavior "Amend Clinical Documentation for any login," the amend
option is available on the action bar regardless of the user that documented on the document.
The Super Amend Process works the same as outlined above.
NOTE: Super amend currently does not allow the amendment of vital signs.
© 2023 Evident
Reviewing Documentation 61
Chapter 7 Reviewing Documentation
7.1 Overview
This chapter will discuss how to review both complete and incomplete Flowchart or Multi-Clinician
documentation on a patient's account.
7.2 Flowchart Documentation

To access an existing flowchart, select the Plus Sign Next to Current Documents to view all available
documents, and select the document from list.
The document will display in the Grid format. Grid View will display the flowchart in date and time
columns, and a new column will be created for each new date or time entry.
Several Options are available from the action bar.

Narrative View may be selected to leave the grid format. To add additional documentation,
select Entry Mode from the action bar.
Import Data will allow the user to import vital sign information from a Vital Sign Interface.
Review Options may be selected to apply data display parameters. See Review Options 63
for more details.
Retract will allow the user to retract the document. See Retracting a Document or Flowchart 66
for more information.
Information within the answer column will display in a truncated view. To review a cell's
documentation, select the answer.
The document will then display the recorded documentation. If the current user documented the
information, the Amend option may be accessed. If not, the Amend option will be grayed out.
Several Options are available from the action bar.

Grid View may be selected to leave the Narrative format.
Amend will allow the user to amend documentation that they recorded.
Review Options may be selected to apply data display parameters. See Review Options 63 for
more details.
Sign will allow the user to enter his/her passphrase and sign documentation.
The Retract option is available to the creator of the document. It is also available for users with
the Clinical Documentation Behavior Control "Amend Clinical Documentation for any Login."
Selecting Retract will take the user to the Narrative View screen. The Document will then display
under Retracted on the Document Tree. See Retracting a Document or Flowchart 66 for more
information.
NOTE: Review Options also contains the Retract option, where flowchart information may be
retracted and will display as strike through. See Review Options 63 for more details.
To display the document in Grid View, select Grid View from the action bar.
© 2023 Evident
Grid View will display the flowchart in date and time columns, and a new column will be created for
each new date or time entry.
Documentation that was recording via Charting Options or through a reflexed question or section
will not display within the grid view. An icon will display to alert the user that additional information
is available for that section.
7.3 Multi-Clinician Documentation

To access an existing Multi-Clinician Document that has not been completed, select the Current
Documents plus sign, and select the document from the list. The document will then display in a
narrative format. Several Options are available from the action bar.
Entry Mode may be selected to leave the Narrative format and will allow the user to record
additional information. Amend may also be accessed from the Entry Mode.
Review Options may be selected to apply data display parameters. Review Options also
contains the Retract option, where information may be retracted and will display as strikethrough.
See Review Options 63 for more details.
Sign may be selected by the physician only and allows for the physician to enter the passphrase
and sign the document.
View Signed Documents may be selected to view the signed document.
NOTE: Double-clicking the section title on the narrative will also allow the user to record additional
information with in the document.
To review documentation that has been recorded via a Multi-Clinician Document, select the plus
sign next to the Completed option to expand the Completed Document Tree, and select the
document from the list.
more information.
Merged Documents
To access an existing merged Multi-Clinician Document that has not been completed, select the
Current Documents plus sign, and select the document from the list.
The document will then display in a narrative format.
When Documents are merged, they will display with the following narrative format:
The title of the merged documents will display as 'Multi-complaint with the name of document that
was selected first in parenthesis followed by a plus sign to represent additional documents have
been merged.
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Reviewing Documentation 63
HPI section will display with a title HPI: 'Name of Document' for each document and the
documentation for that section will display underneath.
Review of Systems will display in one section labeled Review of Systems with the documentation
for that section displaying underneath.
Physical Exam will display in one section labeled Physical Exam with subsections dividing out the
different body systems.
Assessment will display in one section labeled Assessment with each merged documents own
subsection.
Plan: will display in one section labeled Plan with each merged documents own subsection.
NOTE: The documents/documentation will list in the order they were added to the Pending
Document list.
7.4 Review Options

Review Options may be selected to apply data display parameters.
Select Review Options from the action bar.
Section filters may be applied by selected a section from the Filter by Selected Sections menu on
the left side of the screen.
Date and Time filters may also be applied to the document.

Entire Stay will show all documentation that has been recorded on the Multi-Clinician Document.
Hours will allow a specific hour range to be entered, and only data that was documented within
this range will display.
o Select the radio button next to Hours, then type the number of hours in the Hour text-box to
the right.
Days will allow a specific number of days to be entered, and only data that was documented
within this range will display.
o Select the radio button next to Days, then type the number of days in the Day text-box to the
right.
Date Range will allow the user to select a beginning date and an ending date. Only data that was
documented within the designated date range will display.
o Select the radio button next to Date Range, and type the beginning and ending dates or select
the dates using the calendar date pickers.
User filters may also be applied to limit the data that is displayed.
The document will default to display documentation from All Users or My Documentation may
be selected to view only documentation the current user recorded.
Select the Include Stricken check-box to include any amended data.
© 2023 Evident
Exclude Credentials Date/Time allows for information to display without any user credentials and
corresponding date/time stamps. The check box default is unchecked. If the document or report is
already set to exclude credentials date/time from within the document settings or report settings,
this check box will display as checked. It may be unchecked to display the report or document with
the user's credentials date/time stamp.
Sort By parameters may be used to sort the documentation.

Date/Time may be selected to list the information in chronological order.
Section then Date/Time may be selected to list the documentation in section order, then
chronological order.
Select Reverse Chronological to display the documentation in Reverse Chronological Order.
NOTE: In the event the document Description has been edited in Table Maintenance, the edited
Description will display instead of the default title.
Once all filters have been added, select Process from the action bar to apply the filters.
The filtered documentation will then display in the bottom portion of the screen.
To clear the filters, select Clear Section Filters.
the Clinical Documentation Behavior Control "Amend Clinical Documentation for any Login." Once
retracted, the document or flowchart will be listed under the Retracted option on the Document
Tree. See Retracting a Document or Flowchart 66 for more information.
To view the documentation in PDF, select View PDF.
Select the Back Arrow to return to the entire document.
© 2023 Evident
Completing Documentation 65
Chapter 8 Completing Documentation
8.1 Overview
This chapter will discuss how to complete documentation on a patient's account.
8.2 Completing Documents and Flowcharts

Completing a document or flowchart will allow a new version of the document or flowchart to be
created.
Select Complete from the action bar.
When the document is completed, it will move to the Completed Folder and may be reaccessed
from this folder.
NOTE: Documentation Documents may be completed and signed together see Signing
Documentation 76 .
To remove the status of complete from a Multi-clinician Document or Flowchart:
1. Select the document from the Complete folder on the document tree.
2. Select Amend to move the document back to the Current Document folder so that additional
documentation may be added to the document.
© 2023 Evident
Chapter 9 Retracting Documentation
9.1 Retracting a Document or Flowchart

The ability to retract a document or flowchart that has been opened on an incorrect patient or opened
in error can be accomplished using the Retract option.
the Clinical Documentation Behavior Control "Amend Clinical Documentation for any Login."
Select Retract.
NOTE: The Retract option is also available for Group Notes where the retracted information will be
listed under the Retracted option on the Document Tree and displays as Stricken. It will also display
in Clinical History and print EMR.
The Retract Reasons table will display to allow the user to select the reason for retracting a
document.
Select the drop down to choose the retract reason and choose select to retract the document.
To cancel, select the back arrow. Once a retract reason and Select has been chosen, the
document has been retracted.
The retracted document will display under the Retracted folder on the Document Tree. The
document will display with a strike through all documentation in the narrative view.
Selecting Review Options will display all retracted information as Stricken Data in narrative and PDF
format, with the name/credentials of the user that retracted the document, the retract reason and
date/time that the document was retracted.
Retracted Documents and retracted completed and/or signed Reports can also be viewed from
Clinical History.
Selecting a retracted Document or Report from the Document Tree will display the stricken
information in a PDF format.
Retracted Documents and Reports can also be viewed in Print EMR and will display highlighted in
red with the Document or Report title followed by *Retracted* in PDF format. The ability for
viewing scanned images/reports must include "Allow Changing Scanned Docs" security.
NOTE: Retracted documents in Print EMR displays the following prompt when selected: "Electronic
File Warning: The electronic file you selected has been deleted. You have permissions to view this
file for historical purposes. Do NOT make clinical decisions based on the information in this file and
do NOT disseminate this information to others. I have read the statement above and O I agree or O I
disagree."
© 2023 Evident
Reports 67
Chapter 10 Reports
10.1 Overview
Documentation Reports allow facilities to create custom reports that may be generated based off of
Documentation documents. This chapter will cover generating, completing and signing
Documentation and Multi Visit Reports.
10.2 Generating Reports

To generate Documentation or Multi Visit Report, select New Reports or Current Reports from the
Document Tree.
Reports that have been assigned to the department will be listed under the New Reports folder.
See the Documentation Setup User Guide for Report Category Setup.
Select Report Search to view a complete list of available reports.
The Report List screen will display a maximum of 250 Documentation Reports at one time.
Select the type of report from the Report Type drop down. The following options are available:
All: Pulls up a list of all active reports
Documentation Report: Displays only active documentation reports. Documentation Reports

generate from documentation that was documented during the current visit of a patient's chart.
Applications and sections/question may be set up to pull information into a Documentation report.
See the Documentation Setup User Guide for additional information.
Multi Visit Report: Displays only active multi visit reports. Multi Visit reports generate from
documentation from several visits into one report to follow the care of OB patients, Diabetic
patients, Coumadin patients and etc. Sections, questions and report applications may be pulled
from Documentation into a Multi Visit report. When viewing documentation in the grid view, longer
answers containing more than 15 characters are denoted with trailing periods. Hovering over the
cell opens a tool tip that will display the full answer. See the Documentation Setup User Guide for
Double-click the report title to generate the report or select the report, then choose the Select option
from the action bar. A progress bar will display to show the current status of the report generation as
well as the title of the report that is currently being generated.
The Documentation report will be broken down into sections with bold headings, and all
documentation that has been recorded for the specific section will display.
© 2023 Evident
Sections that pull from Documentation documents will display the Section Type as the bold
heading and a sub header will display the document description it was pulled from. For example, a
Review of Systems section from a Fever document will display Review of Systems in bold with
Fever displaying below as a sub header. For documents that are multi-complaint, the Section Type
will display in bold as the header with a sub header for each document description included in the
multi-complaint. The data pulled from that section will display below its corresponding document
title sub header.
If no documentation has been recorded for a section, the text “No Documentation for This
Section” will display. The report will pull documentation based on the date/time filters set within the
Report Settings. For additional information please see Report Document Settings within
Documentation Setup.
Multi Visit Reports will display in a view only grid view with a column for each date documentation
was entered on the different visits that are pulling to the report.
The information that displays within both the Documentation and Multi Visit Reports may also be
filtered through Review Options.
Select Review Options from the action bar to filter the results. See Review Options 63 for more
Once all filters have been applied, select Process.
Select View PDF to view the filtered report in PDF format.
© 2023 Evident
Reports 69
Select Patient Chart > Documentation > Reports > New Report > Review Options > View PDF
PDF View of Report Documentation
Once a Documentation Report or Multi Visit Report has been opened on a patient's account, it will
appear under the Current Reports option in the Document Tree. This will allow the user to quickly
regenerate the report if needed. If the user attempts to open a report that has already been
generated on a patient's account, the following prompt will display: "The selected report already
exists. How would you like to proceed?"
The following options are available for selection:
Open New: Allows an additional report to be generated and lists under the Current Reports folder
on the patient's account.
© 2023 Evident
Use Current: Allows the existing report to regenerate and updates the generated date/time. This
option will only display one copy of the report in the Documentation Tree.
Exit: Allows the user to move back to the previous screen without generating a new report.
10.3 Completing Multi Visit Reports

Completing a Multi Visit Report will not only complete the report but it will stop the report from pulling
forward to any of the patient's subsequent account stays. Once a Multi Visit Report is completed on
a visit, it will also complete the report on all previous visits from which the report was pulling
information. The Multi Visit Report will move from the Current Reports folder to the Complete folder
and may be reaccessed from this folder.
NOTE: Multi Visit reports may be completed and signed together see Signing Documentation 76 .
If the report needs to be regenerated after it has been completed, select amend to move the
report back to the Current Reports folder.
10.4 Completing Documentation Reports

Completing a documentation report will allow a new version of the report to be created.
When the documentation report is completed, it will move to the Completed Folder and may be
reaccessed from this folder. If the documentation report needs to be regenerated, a new report
must be opened from the New Reports Folder.
NOTE: Documentation reports may be completed and signed together see Signing Documentation
76 .
To print the completed report, select Print Document.
10.5 Review Options

Review Options may be selected to apply data display parameters.
Select Review Options from the action bar.
Section filters may be applied by a selected section from the Filter by Selected Sections menu on
the left side of the screen.
Date and Time filters may also be applied to the documentation report.
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Entire Stay will show all documentation that has been recorded on within the visit.
Hours will allow a specific hour range to be entered, and only data that was documented within
this range will display.
o Select the radio button next to Hours, then type the number of hours in the Hour text-box to
the right.
Days will allow a specific number of days to be entered, and only data that was documented
within this range will display.
o Select the radio button next to Days, then type the number of days in the Day text-box to the
right.
Date Range will allow the user to select a beginning date and an ending date. Only data that was
documented within the designated date range will display.
o Select the radio button next to Date Range, and type the beginning and ending dates or select
the dates using the calendar date pickers.
User filters may also be applied to limit the data that is displayed. The documentation report will
default to display documentation from All Users but may be filtered to delimit by My
Documentation or By Dept when entering a three-digit department number. When documentation
reports are filtered by department, only information documented while the patient was located
within the selected department will display. The By Dept field uses the Patient Location Summary
log to determine the time frame that the patient was within the selected department.
Select the Include Stricken check-box to include any amended data.
Exclude Credentials Date/Time allows for information to display without any user credentials and
corresponding date/time stamps. The check box default is unchecked. If the document or report is
already set to exclude credentials date/time from within the document settings or report settings,
this check box will display as checked. It may be unchecked to display the report or document with
the user's credentials date/time stamp.
Sort By parameters may be used to sort the documentation.

Date/Time may be selected to list the information in chronological order.
Section then Date/Time may be selected to list the documentation in section order, then
chronological order.
Select Reverse Chronological to display the documentation in Reverse Chronological Order.
10.6 Retracting a Report

The ability to retract a report, that has been opened on an incorrect patient or opened in error, may
be accomplished using the Retract option. The Retract option is available to all users if the report
has not yet been signed or completed. Once the report has been completed and/or signed, the
Retract option will be available only to the user who signed/completed the report. It is also available
for users with the Clinical Documentation Behavior Control "Amend Clinical Documentation for any
Login."
Select Retract. The Retract Reasons table will display to allow the user to select the reason for
retracting a report.
Select the drop down to choose the retract reason and choose select to retract the document.
© 2023 Evident
To cancel, select the back arrow. Once a retract reason and select has been chosen, the report
has been retracted.
Reports will not display as Stricken once they are retracted. Only reports that have been marked as
complete or signed will pull under Retracted folder on the Document Tree. To view a retracted
signed or completed report, select the desired signed or completed report under Retracted on the
Document Tree.
The Retract option is available from the Narrative View and from within Review Options. See
Retracting a Document or Flowchart 66 for more information.
10.7 Clin Doc Documentation Status Report

The Clin Doc Documentation Status Report may be run to display all signed/unsigned and complete/
incomplete Documentation documents. To access the report from the home screen, select Reports.
Select Add Report.
Select Clin Doc Documentation Status Report and select Insert.
Double-click the report to set the appropriate parameters. The options for Parameters are:
Facility: Allows the selection the facility the information for which the report will be pulled
Exclude Reports: Excludes all Documentation Documentation Reports from the report
Exclude Documents: Excludes all Documentation Documentation from the report
Signed: Allows the selection of pulling Signed, Unsigned or both types of documents and
reports
Completed: Allows the selection of pulling Complete, Incomplete or both types of documents
and reports
Admit Date Range: Allows the report to only include patients admitted within the entered date
range
Include Cover Sheet: Allows a cover sheet to be included with the report
Safe Mode: Allows the report to be built when bad data is used in a field. If the report has bad
data, a message will appear stating to run report using the Safe Mode. If selected, Safe Mode
will replace all of the bad characters with a ?. This will allow the intended report to generate. The
bad data may then be seen and may be corrected from the account level.
Output Format: Allows the selection of the report format. The format options are HTML, PDF,
XML, CSV and TXT.
NOTE: For more information on the following options: Advanced, Sort, Load, Save, Spool and
Reset see Report Writer.
Once all parameters are set, select Run Report. The report will display with the following columns:
Patient: Displays the patient's name
Number: Displays the patient's account number
Admit Date: Displays the admit date of the account that the document or report was created
Discharge Date: Displays the discharge date of the account that the document or report was
created
Created: Displays the date the document or report was created
Signed Status: Displays whether the document or report is signed or unsigned
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Complete Status: Displays whether the document or report is complete or incomplete

Provider of Care: Displays the assigned provider of care for that account
Attending Physician: Displays the assigned attending provider for that account
10.8 Cosignature Deficiency List

The Cosignature Deficiency may be run to display any documents with a signed/unsigned
Cosignature. The documents will include Documentation Documents, Documentation Reports and
PhysDoc Notes.
Accessing the Cosignature Deficiency Report
To access the report from the home screen:
1. Select Reports.
2. Select Add Report.
3. Select Cosignature Deficiency List Report and select Insert.
Setting up Report Parameters
Select the report and select Run from the action bar or double-click the report.
The Documentation Cosignature Deficiency screen will display where the following parameters may
be selected:
Facility: Allows the selection of the facility for where the information of the report will be pulled.
Signed Date Range: Allows the report to only include Documentation Document, Documentation
Report or PhysDoc Note that were signed or unsigned within the selected date range. The
following options are available within the drop down table:
Manual Selection (default): When this option is selected a date range must be manually
selected within the two calendar picker boxes following the Signed Date Range drop down.
Previous Day
Previous Week
Previous Month
Previous Quarter
Previous Calendar Year
Previous Fiscal Year
Last 7 days
Last 30 days
Last 90 Days
Department: Allows the report to only include the selected department. Selecting the magnifying
glass will display the Department List.
Account: Allows the report to only include a particular patient visit.
© 2023 Evident
Signing Provider: Allows the report to only include the selected mid-level that has signed the
Documentation Document, Documentation Report or PhysDoc Note. Selecting the magnifying
glass will display a Physician search by name that may include all physicians or staff only.
Cosigning Provider: Allows the report to only include the provider that has or has not signed the
Documentation Document, Documentation Report or PhysDoc Note. Selecting the magnifying
glass will display a Physician search by name that may include all physicians or staff only.
Signing User: Allows the report to only include the user (employee or mid-level) that has signed
the Documentation Document, Documentation Report or PhysDoc Note. Selecting the magnifying
glass will display an employee search that may be searched by Name (default), Employee ID, Log
Name or Physician ID.
Cosigning User: Allows the report to only include the user (employee, mid-level or provider) that
has or has not signed the Documentation Document, Documentation Report or PhysDoc Note.
Selecting the magnifying glass will display an employee search that may be searched by Name
(default), Employee ID, Log Name or Physician ID.
Cosign Status: Allows the report to include signed and/or unsigned Documentation Document,
Documentation Report or PhysDoc Note. The following options are available within the drop
down table:
Both
Signed
Unsigned
NOTE: When using the filters for Signing Provider or Cosigning Provider, the Signing User and
Cosigning User fields become disabled. When using the filters for Signing User and Cosigning User
the Signing Provider or Cosigning Provider fields become disabled.
Once all of the parameters are set, select one of the following options from the action bar:
Run Report: Allows the report to be generated.
PDF: Allows the report to be generated and display in a PDF format.
CSV: Allows the report to be generated and display in a CSV format.
The report will display with the following rows of information:
First Row
Patient Name: Displays the Patient’s full name.
Visit Number: Displays the Patient’s account number that the document was cosigned or not
cosigned.
Document Title: Displays the Document’s Description
Cosign Status: Displays the status of Cosigned if the document has both signatures and Not
Cosigned if it is still missing the Cosignature.
Second Row
Admit Date/Time: Displays the patient’s admit date and time.
Discharge Date/Time: Displays the patient’s discharge date and time
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Reports 75
Third Row
Sign Provider/User: Display the name mid-level that has signed the document.
Sign Date/Time: Displays the most recent date and time the mid-level signed the document.
Fourth Row
Cosign Provider/User: Displays the cosigner’s Name. If it has not been cosigned this will display
the name of the provider that the alert was sent too. If the alert was sent to a group it will display
the group name.
Cosign Date/Time: Displays the most recent date and time of when the cosigner signed the
document.
A fraction and percentage of the following calculation will display at the bottom right hand corner of
the screen:
Denominator: Displaying the number of documents yielded by the selected filters and date range.
Numerator: Displaying the number of documents in the denominator that have been cosigned.
NOTE: The Cosign status will depend on the last user to sign the document. For example if the
document was signed then cosigned, but then amended and resigned by only the mid-level, it will
have a status of Not Cosigned.
© 2023 Evident
Chapter 11 Signing Documentation
11.1 Signing Documents and Reports

Providers have the ability to sign documentation or documentation reports completed during a
provider's shift. Signing a document or documentation report will apply the provider's full name and
credentials along with the date/time of the signature to the bottom of document or report.
NOTE: Non-providers have the ability to sign documentation and reports with the appropriate
signature capability behavior control in place through Identity Management.
Providers will only need to sign their documents or documentation reports once all documentation
has been completed. If the report that is being signed is set up as a Progress Note, signing the
report will count towards the MU2 Electronic Notes statistic. Please see Documentation Setup for
additional information on the report setup.
Any documents or documentation reports that are signed by a provider requiring a cosignature will go
to the Home Screen folder for the selected cosigner group or individual.
For any documentation that has been amended, the provider will need to resign the document or
report. In the case the provider requires a cosigner, the amended documentation would be sent to the
cosigner again.
To sign a document or documentation report, select Sign from the action bar.
If multiple documents or reports are opened on a patient's chart, the Multiple Document Signing
Selection screen will display. The original documented that was selected for signing will display as
already selected in the list when the user enters the screen.The Multiple Document Signing
Selection is a "multi-select" screen that will allow multiple documents and reports to be selected.

Back Arrow: This option will exit the Multiple Document Signing Selection screen without saving.
Process: This option will take the user to the Passphrase Screen to sign the selected
documents or reports. If the user deselects or if no documents are selected, the Process option
will be disabled.
Select All: This option will select all documents and reports displayed in the list.
PDF: This option will allow the selected document or report to be displayed and viewed in PDF
format. Double-clicking a document or report will also display in PDF format. When multiple
documents or reports are selected, the View PDF option will be disabled.
The documents or reports may be filtered by My Documentation or Required. This options use the
sticky functionality.
My Documentation: Selecting this option will display only documents or reports that have been
documented by the user. Reports will be included if they have been opened and have
documentation from the user.
Required: Selecting this option will display only documents or reports that are checked to
"Require Signature" in the document settings. Reports will pull if they have been opened and if
they are checked "Required" in the report setup.
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Signing Documentation 77
Information will display as follows:

Description: This column will display the document or report title
Status: This column will display the status of the document or report as signed or unsigned.
Date and Time: The date and time that the document or report was signed will display in this
column.
User: This column will display who signed the document or report.
Type: This column will display document or report.
Select the documents that are to be signed and select Process.
Enter the appropriate Passphrase, and if the documents or reports need to be completed, select
the complete document check box. If a cosigner is required see cosigning steps below.
Select Accept to sign the document or report.
Information will display as follows:

Enter Passphrase: Must contain 10 characters to include a minimum of one upper case, one
lower case, one alpha and one numeric character.
Complete document(s) to be signed: Defaults as selected so the document is completed at the
same time as signing. If the provider does not want to complete the document or report at the
time of signing, select the check box to deselect it. See Completing Documentation 65 for
Additional statement with signature: Allows the user to select a pre-defined statement which
will display above the Signature line on documents and reports and will appear in the PDF
version. Upon selection, the pre-defined statement will appear in the rich text box below where
edits may be made. Users will not have the ability to save edits from this location, as only
changes made to the existing statement will be reflected on the document and report open. Any
permanent edits will need to be addressed in the Signature Statements table in Table
Maintenance.
Cosigner(s): Displays cosigner(s) selected by the user.
Once the signature has been accepted in the top right hand corner, Signed will display along with
the date/time stamp the document or report that was signed.
After a document or report has been signed, the View Signed Document option will become
available for selection. The View Signed Document option will remain unavailable until a document
or documentation report has been signed. The user will see a list screen of signed PDFs. Each line
will include the date/time the document was signed and the name of the signer.
Select the View Signed Document
The list screen will default to reverse chronological order and the columns will be sortable.
To view a document or documentation report, select the document and choose select. It will open
in the PDF Viewer for the document or documentation report.
© 2023 Evident
To exit, select the back arrow.
Cosigning Documents and Reports
Mid-level providers may require cosignatures on all or some of their documentation. Documentation
which requires cosignature will go to the selected cosigner's Home Screen folder.
If the mid-level provider has documentation which does not require a cosignature, the mid-level
provider may be set to select No Cosignature Needed during the signature process for those
documents. When the No Signature Needed check box is selected, the Select Cosigner option and
available cosigners will not be available.
If a mid-level provider requires a cosigning provider on all documents or reports, the security may be
set so that the mid-level provider is subscribed to a default cosigning provider(s), or physician group,
in the cosigner(s) box. The Select Cosigner option on the action bar will open the queue list screen
for the selection of a cosigning physician or physician group.
From the Select Cosigner option, the physicians or group selected from the queue's look-up
screen will be displayed for the user upon returning to the passphrase prompt. Once signed, the
report will be sent to the selected co-signer(s) Home Screen folder.
If multiple individual physicians are selected, then a signature from one cosigner will not remove
this document from the queue of the other selected cosigner(s). If a group is selected, then a
signature from one cosigner would remove the need for any other selected cosigner(s) in that
group to sign.
Once the signature has been accepted in the top right hand corner, Signed will display along with the
date/time stamp the document or report that was signed. The signed document will contain the
Electronically Signed by statement and will be available for the cosignature on the Home Screen of
the specified provider.
After a document or report has been signed, the View Signed Document option will become available
for selection. The View Signed Document option will remain unavailable until a document or
documentation report has been signed. The user will see a list screen of signed PDFs. Each line will
include the date/time and the name of the signer and cosigner .
When selecting the View Signed Document from the action bar the user, date and time of the
signing and cosigning provider will display from Signed Documents.
Once cosigned, the report will contain both the Electronically Signed and Electronically Cosigned
statement on the bottom of the report.
To exit, select the back arrow.
© 2023 Evident

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Chapter 6 Amending Documentation

Chapter 7 Reviewing Documentation

Chapter 8 Completing Documentation

Chapter 9 Retracting Documentation

Chapter 11 Signing Documentation

1.1 Attestation Disclaimer

1.2 What's New

Documentation Web Client -- EVI-104253

DESCRIPTION: See Security for Documentation 3

Thrive’s Documentation application provides a complete ambulatory charting system for

Chapter 3 Security for Documentation

To access the Behavior controls for Documentation:

The following Documentation Behavior Controls are:

Chapter 4 Accessing Documentation

4.2 From Point of Care

Select the appropriate tab.

Select Clinical Documentation.

4.3 From ED and Thrive Provider EHR

Select Tracking Board.

Select the patient from the tracking board.

Select Documentation from the Navigation Panel.

5.2 Accessing Documents

The action bar displays the following options:

Report Search: Allows to search for reports.

Select Home Screen > Track > Patient > Documentation

Select Patient Chart > Documentation > Document Search

The action bar displays the following options:

5.3 Flowchart Documentation

Select Patient Chart > Documentation > New Document

Documentation Flow Chart Grid View

The Complete option will then display on the action bar.

5.4 Multi Clinician Documents

Multi-Clinician Document Entry Mode

To begin documenting an assessment, address the questions as they apply.

Show More/Show All

The following options are available on the action bar:

5.6 Merging Documents

5.7 Documentation Controls

Checkboxes: Allows for multiple selections for a question.

Radio Buttons: Allows for a single selection for a question.

Drop-down Menus: Allows for a single selection for a question.

Text Box: Allows for continuous type, free-text answers.

Select Patient Chart > Documentation > New Document

Select Patient Chart > Documentation > New Document

These questions will display in red until the question is addressed.

See Behavior Controls for Documentation 3 .

5.8 Late Entry

To change date and time:

2. Select Save to begin documenting in the selected date and time.

5.9 Charting Options

To insert instructions, select Add To Location, then select Instructions.

To insert a markup, select Add To Location, then select Markup.

To insert a photo, select Add To Location, then select Photos.

Users are able to insert photos in the following formats:

To insert a section, select Add To Location, then select Sections.

The Section/Question List page will then display.

Select Add to insert the section into the document.

To insert a question, select Add To Location, then select Questions.