Transcript EHR_ch07_Clinical Tools

Clinical Tools
Chapter 7
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Chapter 7 Learning Outcomes
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7.1 Chart Evaluation
7.2 Test Orders
7.3 Evaluation & Management Coder
7.4 Superbill Form
7.5 Patient Instructions
7.6 Care Plans or Practice Guidelines
7.7 Drawing Program
7.8 Importing Documents
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Chapter 7 Key Terms
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Care Plan and practice guidelines
Chart Evaluation
Clinical Decision Support (CDS)
Draw Program
National Guideline Clearinghouse (NGC)
Patient Instructions Manager
Rich Text Format (RTF)
Superbill
Wellness Screenings
Well Patient Visit
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LO 7.1 Chart Evaluation
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Chart Evaluation
• Define
preventative health
criteria on
SpringCharts server
• Evaluate patient’s
chart for set
criteria
• Scan entire patient
database for chart
evaluations
LO 7.1
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Criteria Definitions
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6.
Gender
Age
Actions
Recurring
Diagnosis(es)
Having Lab or
Medication
7. High Clinical
Priority
LO 7.1
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LO 7.2 Test Orders
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Test Orders
• Use Test tab to search
for test name in
database
• Select test(s)
• Order selected test(s)
• Send to Pending Tests
area to wait for results
• Can be done by clinician
or physician
LO 7.2
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LO 7.3 Evaluation &
Management Coder
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Evaluation & Management Coder
1. Set up on a server
2. Define keywords for ROS, Exam of Body Areas,
and Organ Systems
3. Helps to determine correct E&M code
LO 7.3
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LO 7.4 Superbill Form
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Superbill
• Customizable to contain
additional codes not
usually selected from
within the Office Visit
screen
• Set up Superbill on
server
• Available in the Routing
Slip windows
LO 7.4
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LO 7.5 Patient
Instructions
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Patient Instructions
• Can be created in
SpringCharts or
imported into
SpringCharts
• Accessible from the
Office Visit screen to
print or e-mail to the
patient
LO 7.5
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LO 7.6 Care Plans or
Practice Guidelines
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Care Plan/Guidelines
• Attach a document
stored on the
computer outlining
care plans or
practice guidelines
• Becomes a
permanent record
attached to the OV
note
LO 7.6
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LO 7.7 Drawing Program
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Drawing Program
• Enables the provider
to indicate the
procedure that was
conducted by
drawing on inbuilt
templates
• Elaborate
illustrations can be
imported from within
the computer or a
computer on the
network
LO 7.7
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LO 7.8 Importing
Documents
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File Cabinet
• Import documents to
the File Cabinet
• Any file type:
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.docx or .doc
.xlsx or .xls
.html
.pdf
.jpg
.DICOM
more
• Stores on SpringCharts
Server in a separate
folder
• Links to patient’s chart
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LO 7.8
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Acquire vs. Existing
• Acquire
– Imports files from
scanners, cameras,
webcams, etc.
• Existing
– Imports file from
the computer
LO 7.8
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Importing Documents
• File Cabinet Documents
are accessible from the
Productivity Center
• Global searches are
available from across all
charts by document
name, date range, or
other search field
• Clinic non-patient
documents can be stored
here, outside of patient
charts
LO 7.8
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Chapter 7 Summary
LO 7.1 Create and conduct a chart evaluation
• Define preventative health criteria and
evaluate based on criteria
• Categories for criteria to be set
• Information windows for criteria
• Performed on individual patients or the entire
database
• Reminder notices can be sent
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Chapter 7 Summary
LO 7.2 Demonstrate how to order a test in the
Office Visit screen
• Pending Tests wait for results
– Available for viewing in the OV note
• Tests from outside testing facility
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Chapter 7 Summary
LO 7.3 Describe the function of the E&M Coder
• Uses keywords to search for which body
system or area has been reviewed
• E&M recommends a code
– Terms and phrases
– # of diagnoses
– # of procedures
– History of encounters
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Chapter 7 Summary
LO 7.4 Demonstrate how to add items to a
superbill
• Contains additional billable terms and codes
outside of what is in the OV note
• Items can be added to the routing slip
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Chapter 7 Summary
LO 7.5 Create and administer a patient instruction
sheet
• Educational material
• Create sheets in the EHR program or import
• Access and print in the OV note
• Map to diagnoses, labs, procedures, or
medications
• Record is made that information was given to the
patient
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Chapter 7 Summary
LO 7.6 Describe how to add a care plan to an
office visit
• Create and administer within the OV note
• Becomes part of the OV note record
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Chapter 7 Summary
LO 7.7 Explain the purpose of the Draw program
• Provides a supplement of illustrations for the
OV note
• Draw templates can be used to illustrate
findings
• Illustrations and photos can be imported into
Draw Program
• Illustration is stored in the OV note under
Follow-up
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Chapter 7 Summary
LO 7.8 Demonstrate how to import a document to a
patient’s chart
• Import files to the File Cabinet
– Any type
– Originating program must be available on the
computer to view or edit document
• Documents can be stored in our outside of a
patient chart
• Link is created in chart
• Document is stored in a separate folder on the
server
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