What’s In…UCare?

The UCare electronic medical record provides access to physician/provider documentation, including electronic progress notes, history and physical, consult notes, and more. Nurses and other clinicians document on an electronic flowsheet while physicians, NPs, PAs, and several other providers document progress notes, histories and physicals, and admission notes in a text format.

Ancillaries including Respiratory Therapy, Rehab services, Nutrition services, Child Life and Care Coordination (including social workers and discharge planners) also document electronically in flowsheets, progress notes and/or consult notes within UCare.

All laboratory results, imaging and minor procedure reports can be viewed directly in UCare without logging out of the UCare record. PICIS, the perioperative electronic documentation record, can be viewed using UCare DocImage; a separate electronic application used by clinicians to view scanned documents such as patient consents for treatment, advanced directives, and currently pre-operative and PACU documentation. OR summaries are available for viewing in UCare, but full operative reports can be printed from PICIS and placed in patient paper charts. Various specialized documentation forms are under development to be converted to electronic format, such as, PICC placement and MRI checklist.

The core of the UCare project is UCSF Medical Center’s commitment to providing a safe environment for our patients. As the CEO, Mark Laret, says, "Nothing is more important to remaining a leader in the delivery of healthcare and patient safety than to have electronic tools at our disposal."