Guide to Observations

Observations are notes that staff can create to record resident information to include in their clinical chart. Observations can also be used to document community messages to be shared with staff or third parties.

Create an Observation note

You can create a new Observation note from one of these three main locations:

• • Dashboard: Click on the New Observation icon.
  • Observation Center: Click the +Record New Observation button. 
  • Resident Profile: Click the +Observation button under the resident photo. 

Each of these options opens a righthand pane for you to add note details:

• At the top of this pane, you can move the blue toggle to determine whether you will record a Resident or Community Observation note.
  • • • Resident Observation Examples - Notes about a single resident's observed physical or mental health status for staff and/or family communication; Notes about a group of residents' participation in activities or reporting on vaccinations and evaluations.
      • Community Observation Examples - Notes or questions about building maintenance, staff meetings, or overall safety protocols.

Fill in Resident note fields: 

• Resident - Typically you will select one person from this menu, however you also have the option to multiselect names if you wish for a particular note to be on multiple residents' charts. 
• Type - Refers to the subtype of note, such as a Shift Change or Nurse's Note. It is very important for staff to understand which note types to utilize depending on the scenario for which they are recording.
  • • • The note types to appear on this dropdown menu can be completely customized in Resident Settings. Customization options include the names of note types, which types can be viewed by specific staff members, and if the note type always appears on the Daily Standup Report. For assistance with configuring Observation Note Types, contact your Account Manager or our ALIS Customer Success Team.
• Date and Time - These prepopulate based on when you clicked to record the note and both can be adjusted in real time if needed.
• Observation Summary - This free text field is where staff can type what they want to communicate, and there are editing options to assist with formatting, linking, and editing information. It is best practice to establish a policy at your building about the content you want staff to include in the notes.
• Severity - This menu defaults to "Normal" indicating that there is nothing unusual or highly sensitive about the note. You have the option to mark any note as "Critical" which tags the note with a red "Critical" badge in the Observation Center.
  • • • Notes tagged as Critical appear in the Daily Stand-Up Report. Read this Daily Stand-Up Report guide for more information.
      • You can also set up alerts for staff to be notified when notes marked Critical are added. These alerts are configured in Alerts Settings. For assistance with configuring alerts, contact your Account Manager or our ALIS Customer Success Team.
• Keep Active For - This menu determines how long the note will be editable once created. After the specified time (i.e., 1 Day) the observation note becomes locked and unable to be edited. Note:
  • • • Administrators with access can always edit any note at any time. 
      • Regardless of the Keep Active For time set, all observation notes are accessible in ALIS indefinitely. They can always be viewed and printed from in the Observation Center, and you can search for a note using criteria such as Observation Type, resident name, and date.

The Observation Center

The Observation Center is an interactive report containing all Observation notes created during a specified date range. The Dashboard icon shows a red badge notification with the number indicating hoe many Observations have been added to ALIS since you last visited the Observation Center page.

Staff with access should regularly visit the Observation Center in order to review important information recorded by other staff members. This page by default shows Observations added at the community for the last two weeks.

Locate and Export Observation Notes

Navigate to the Observation Center and use the filters at the top of the page to locate the correct information. The below filters can be particularly helpful in narrowing the data you plan to export: 

• • • Observation Type - This menu provides the note types. When you select a note type, the data only displays Observations that have been created as that type.
    • Resident (Search Bar) - This field allows you to search and click on a resident name to pull up only the Observations that have been created for this resident. 
    • Recorded By (Search Bar) - This field allows you to search and click on a staff member name to pull up only the Observation notes that that staff member has recorded.
    • Severity - This menu allows you to sort between "Normal" and "Critical" note types. This can be useful for quickly identifying any notes that have been tagged as "Critical."
    • Date Range - This option allows you to select notes recorded by the dates you select.

Once you have filtered for Observations you wish to export, you can use the Print button to generate the notes in PDF format, or use the Export to Excel button to view the data in a spreadsheet.

For state surveys, a good practice is to use the Observation Type filter to view a specific note type (i.e., Nurse's Notes), search for a specific resident the surveyor is requesting in the Resident filter, and then use the Date Range filter to either type a range of dates or click the calendar to select the date range your surveyor requests. When the desired list of notes shows on the page, click the Print button to present the information to the surveyor on paper.

Vitals in Observation Notes

The ALIS team can help you update staff security roles to include the permission to add Vitals records while recording Observation notes. Any staff member given this security role permission will have the Record Vitals section for all Observation note types they have access to create and/or view. For assistance with updating security roles per Observation type, contact your Account Manager or our ALIS Customer Success Team. 

Vitals that are recorded on Observation notes will be viewable in the Observation Summary section of the note when viewed or edited. The Vital Sign Details and Vital Sign Summary reports also show this data in table format that is able to be printed or exported to Excel. 

Related Articles: 

• How do I edit an Observation? 
• Recording Vitals

For more assistance with Observations,

Contact our ALIS Customer Success Team:

888.404.ALIS (2547) or support@medtelligent.com