Transcript Slide 1

Health ePractice
Electronic Medical Record
Clinical Companion
Clinical Companion eClinicalWorks
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The eClinicalWorks Clinical Companion
This companion was created to assist you with the adoption of eClinicalWorks Medical Record
Software. It will help familiarize you with eClinicalWorks terminology and functionality and
offers an array of material pertaining to:
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Basic eClinicalWorks Navigation Functionality
How to Document Medications and Chief Complaint(s)
How to Document Vital Signs and Patient History
How to Document Results on an In-House Lab
How to Abstract a Paper Chart
Practice Scenarios
Your Companion will come in handy throughout your eClinicalWorks adaption process,
specifically:
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When Watching Web-Based Training Modules
To Prepare For Your Scheduled Training Sessions
To Practice in the TRN Environment.
To Help Assist You With Functionality During Your Go-Live
We look forward to working with you during your transition process and making this as
painless as possible for all staff members!
The Health ePractice Team
Clinical Companion eClinicalWorks
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How Do I Access?
St. John HealthPartners Website
1.
In Windows Internet Explorer address bar type: http://www.health-epractice.org/
2.
St. John HealthPartners Website will display.
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3.
On the main tool bar hover over
to display a drop-down menu.
4.
From the drop-down menu click on Practice Tools
5.
You have arrived at eClinicalWorks (PM/EMR) Practice Tools Home Page
Clinical Companion eClinicalWorks
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How Do I Access?
Web-Based Training (WBT) Modules
1.
2.
On the eClinicalWorks (PM/EMR) Practice Tools home page scroll down to the
Training Tools area.
Select your appropriate role by clicking on the role button
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3.
A list of mandatory WBT Modules display for the selected role.
4.
Click on the name of any module to open the content.
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How Do I Access?
How do I log into eClinicalWorks Train Environment?
1.
Click on the
button.
2.
Click on the
button.
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3.
The Run activity window displays. In the Open: field type in the following: MSTSC and
click the OK button.
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4.
The Remote Desktop Connection activity window displays. In the Computer:
field type in the following: Asp12.eclinicalweb.com:9328 and click the Connect
button.
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How Do I Access?
5.
The “Log On to Windows” activity window displays.
6.
Input the User name: and Password: that was provided to you by your
Implementation Coordinator.
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7.
eClinicalWorks Log-In screen displays.
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8.
Enter the Login ID and Password that was provided to you by the Implementation
Coordinator.
9.
Click on the
button.
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Basic eClinicalWorks Navigation
How do I log into eClinicalWorks Production Environment?
1.
Double-Click on the
the desktop.
2.
eClinicalWorks login screen appears.
3.
Type in your login ID and password as
appropriate.
4.
Click on the
icon located on
3
button.
How do I log out of eClinicalWorks?
There are two ways to log out of eClinicalWorks
1.
Click on
and select EXIT from the drop down menu.
OR
2.
Click on the
in the upper left hand corner of the screen.
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Resetting Your Password
From any area within the System
1.
Select the File Menu
2.
Select Change Password from the menu
3.
The Change Password window opens
4.
5.
Fill in the blanks
Click OK
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Local Settings – Hiding Canceled appointments
Local Settings – Hiding Canceled Appointments/Show only billable visits
Rescheduled and Canceled Appointments will appear on the Resource Schedule unless this
local setting is set.
1.
From the File Menu, hover over settings and select Local Settings from the sub
menu.
2.
In the Local Settings window, select the Show Only Billable Visits
3.
Click
to save changes.
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Basic eClinicalWorks Navigation
Basic Navigation Tools
eClinicalWorks application window has five standard navigation elements. These
elements appear in Resource Schedule, Office Visit, and Progress Note workspace.
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Element Details
1.
The Menu Bar:
Consists of the File, Patient, Schedule, EMR, Billing, Reports, CCD,
Fax, Tools, Community, Lock Workstation, and Help drop down
menus. Depending on your security, these menus can be used for
basic functionality throughout the application.
2.
Patient Look-up Icon:
Launches the patient search activity window. When a patient is
selected the Patient Hub displays. Clicking the down-arrow displays
the last five (5) Progress Notes accessed.
3.
Toggle Buttons (Olive Buttons):
Enables the user to show or hide application elements.
4.
Quick Launch Dashboard Taskbar (Jellybeans):
Shortcut buttons to access items needing attention. The shortcut
buttons also indicate the urgency and number of pending document
reviews, and unread messages.
5.
Bands and Left Navigation Pane:
Provides access to functionality granted to the user by their security
settings.
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Basic eClinicalWorks Navigation
Patient Look-Up and Patient Hub Overview
1.
You can look up a patient by clicking on the Patient Lookup Icon
2.
The Patient Lookup activity window opens which gives you a list of all the
patients in the system arranged alphabetically by their last name.
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3.
Patients can be searched by using a combination of different search options
such as; Name, SSN, DOB, Account No./Medical Record No., Phone No.,
Subscriber No., Previous Name or Home, Work, and Cell phone. Patients can
also be filtered by their default appointment facility.
4.
When a patient is selected the Patient Hub will display.
5.
The Patient Hub provides a convenient, single point of access to all information
available in a patient’s record.
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Basic eClinicalWorks Navigation
Quick Launch Task Buttons Overview
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3.
4.
5.
6.
7.
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E Menu: The total number of e-prescriptions refill requests received and
transmission errors displays on the button. Click to open the e-prescriptions
window to review all e-prescriptions.
S Menu: Provides links to the Office Visits, Resource Schedule, and Progress
Note windows. The number next to the “S” also indicates that number of
patients marked as arrived. This number only displays for the providers and
not for any other staff member; other staff members will see this number
change from “0”.
D Menu: Provides the option of going directly to the Fax Inbox or Fax
Outbox windows. The number next to “D” indicates the number of
documents assigned to the logged in staff member. Click the button to open
the Review Document window.
R Menu: Provides links to the Incoming Referrals or Outgoing Referrals
windows. The total number of referrals assigned to the logged-on user
displays in parentheses next to each link. The number next to the “R”
indicates the number of combined incoming and outgoing referrals. Click the
button that has the number to open the Outgoing Referrals window, or click
the “R” itself, which will give you a drop down menu and from there you can
select Incoming or Outgoing Referrals.
T Menu: Provides links to the Telephone/Web Encounters window, which
includes new telephone and web encounters. The total number of
encounters assigned to the user who is logged in will be displayed in
parentheses next to each category. The number next to the “T” indicates
the combined number of open telephone, web encounters and action items
assigned to you. Click the button to open the Telephone/Web window.
L Menu: The L menu opens the labs and imaging window. The labs/imaging
window opens directly to the To Be Reviewed Tab. The total number of labs
and imaging assigned to the logged in user will display in parentheses next
to each category. The number next to the “L” indicates the combined
number of labs and imaging.
M Menu: Provides links to the Inbox, Outbox, or Deleted Messages
windows, and includes a link to the Create New Message window. The
number next to the “M” indicates the number of new messages in the inbox
for the logged-in user. By clicking on the letter “M” you can choose to view
the Inbox, Outbox, Deleted Messages and even Create New Messages.
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Basic eClinicalWorks Navigation
Office Visit Schedule Overview
Office Visit view is the designated workspace for Physicians and clinical staff. This
workspace displays all scheduled appointments and distinguishes patients that have
completed the arrival process, and are ready to be seen by the Physician.
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6.
7.
P/R Radio Buttons:
Enables to view Provider or Resource patients.
Appointment Time and Date:
Defaults to the current date and enables the user to sort the schedule by using
Morning, Afternoon, or All Day selection.
Sort By:
Enables the user to sort patients by appt. time, patient name, or visit status.
Visit Status:
Indicates if the patient has arrived for their appointment
Room:
Indicates the exam room the patient is in.
Status:
Current status of the patient’s visit
Button Bar:
Displays the following options: Progress Notes, Check In/Out, Billing Data,
Refresh, View Orders, Lock Progress Notes (drop down displays several
Template options), and eCliniForms.
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Basic eClinicalWorks Navigation
Update a patient’s status code and enter a exam room identifier in the Office
Visit Screen
1.
Select the patient from the schedule.
2.
Click on the
button.
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2
3.
The Encounter Activity window
displays.
4.
Click in the Check In box.
5.
The Time In field will populate the
time.
6.
Click in the Room No field and enter
patient room number.
7.
Click on the
8.
The patient’s arrival time, room
number and status will appear on
the Office Visit schedule.
button.
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Basic eClinicalWorks Navigation
Accessing the Patient’s Visit
1.
To open a patient’s visit, double-click on the patient’s name from the
office visits screen.
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2.
The patient’s visit opens in the Progress Notes view. All clinical
documentation will be completed in this view.
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Abstracting
How do I Abstract Clinical Data into eClinicalWorks?
1.
Click on the
icon to search for the patient.
2.
The patient Look-up activity window displays.
3.
In the Search Patient field enter the patient’s name.
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4.
Select the desired patient from the list and click on the
5.
The Patient HUB displays.
6.
Click on the
7.
The Telephone Encounter activity window displays.
button.
button.
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Abstracting
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8.
In the Provider field click on the drop-down menu arrow and select the desired Provider.
9.
In the Pharmacy field click on the ellipsis button.
10. Search for the patient’s preferred pharmacy on file by entering the Pharmacy name in the
Lookup pharmacy field.
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11. Select the desired Pharmacy from the
list.
12. Click on the
button.
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13. In the reason field type in Abstract.
14. Click on the
tab.
15. The Message field displays the
outline of the Progress note.
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Abstracting
Documenting Current Medications
1.
Click on Current Medication: hyperlink to document the patient’s Current Medication.
2.
The Chief Complaint/Current Medication activity window displays.
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3.
In the Current Medication field click on the
4.
The Select RX activity window displays.
5.
In the Find field type in the PARTIAL name of the drug.
6.
Select the desired drug from the list.
7.
Select the desired strength.
8.
The drug appears in the Selected RX field.
9.
To add another medication repeat steps 3 – 8 or if you are done click on the
button.
button.
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7
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Abstracting
10. Update the dose/frequency at this time by clicking in the desired fields.
11. Indicate
12. Click on the
by clicking in the box.
button.
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Documenting Allergies
1.
Click on the Allergies/Intolerance: hyperlink.
2.
The Past Medical History/Allergies activity window displays.
3.
To add a Drug (RX) Allergy click on the
4.
To add a Environmental Allergy
click on the
5.
button.
button.
Select Structured for RX allergies
and Non-Structured for
environmental.
6.
In the Agent/Substance field click
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4
on the drop-down arrow to
select the desired allergy from
the list.
7.
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Click in the Reaction field and
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then click on the drop down
arrow to select the desired
reaction of the allergy.
8.
Document
9.
Repeat steps 3 – 8 to document another allergy or click on the
Clinical Companion eClinicalWorks
button.
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Abstracting
Documenting Past Medical and Surgical History
1.
Click on the desired history hyperlink: Medical History: Surgical History:
2.
The Activity Window displays.
3.
Click on the
4.
In the History field type in the past medical condition.
5.
Repeat steps 3 – 4 to enter another condition.
6.
Document
7.
To document the Surgical history click on the
button.
by clicking in the box.
icon.
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4
8.
6
7
The Surgical History activity window displays.
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Abstracting
9.
Click on the
button.
10. In the Date field enter the Month/Date of the surgery if available.
11. In the Surgery field enter the Surgery name.
12. Repeat steps 9 – 11 to document more surgical history for the patient.
13. Document
14. Click on the
button.
Documenting Family History
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4
1.
Click on the Family History: hyperlink.
2.
Family History activity window
displays.
3.
To indicate the status of a family
member click in the status field:
One Click = Alive, Two Clicks =
Deceased, and Three Clicks =
Unknown.
4.
To document DOB, enter only the year
the patient was born. Entering the
year will default the age of the family
member in the Age field.
5.
Click in the notes field to document any medical problems pertinent to the family
member.
6.
The keywords activity window displays.
7.
In the find field type in the partial name of the medical problem.
8.
Select the desired name from the list.
9.
The medical problem moves to the Selected field.
10. Select the appropriate relative to link the medical problem with.
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Abstracting
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11. To search for another medical problem, repeat steps 7 – 10.
12. Once you have completed the documentation click on the
13. Document
14. Click on the
button.
.
button.
Adding to the Problem List
1.
Click on the Assessment: hyperlink.
2.
The assessments activity window displays.
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Abstracting
3.
Enter the problem in the “Find In” field and click go.
4.
Click on the desired problem from the list.
5.
The problem appears in the Selected Assessments field.
6.
Add the problem to the patient’s problem list to by clicking in the box in the PL field.
7.
Repeat steps 3 – 6 to document another problem is applicable.
8.
Click on the
button.
Documenting Vital Signs
1.
In the Telephone Encounter activity window, change the date field to match the date of the
vital signs to be abstracted.
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2.
Click on the Vitals: hyperlink.
3.
Enter the Vitals Signs as appropriate in the designated field with the accurate date.
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Abstracting
4.
Once you have completed entering the vitals click on the
button.
5.
In order to abstract another set of vitals from a different date you will have to open a
NEW telephone Encounter and repeat steps 1 – 3.
Documenting Immunizations/Injections
1.
Click on the Immunizations: hyperlink.
2.
The immunizations/Injections activity window displays.
3.
Click on the
4.
The Immunization Details activity window displays.
button.
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5.
In the find field search for the immunization.
6.
Select the name from the list.
7.
Click in the box next to “Vaccination Given in the Past.” This enables you to document
the date the immunization was adminstered.
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Abstracting
4.
Enter all recommended fields as appropriate.
5.
If you need to add more than one immunization click on the
button
and repeat steps 5 – 8.
6.
Once completed click on the
button.
Completing the Abstract Process
1. In the Telephone Encounter activity window click on the
2. In the Actions Taken field click on the
tab.
button.
3. Type in the field “Chart Abstracted” and click on the OK button.
4. Your name and the date will be time-stamped in the field.
5. To close the encounter click on the
button.
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Document Management
Correcting Scanned Documents
If a scanned document is scanned under the incorrect patient, access the Patient Documents
module.
1.
Select the document and click on the View button.
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2.
Click on the “Save” button.
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3.
Save the document to your desktop or a documents folder, click Save.
4.
5.
6.
In “Document Category” click on Custom radio button.
Browse the folder you saved the document.
Documents in the folder will appear in the “Scan bucket”
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Document Management
Correcting scanned documents
If documented on the incorrect patient:
1. Search patient within the Document Management section using the “Sel” button,
follow the below steps:
2. Click on the document from the Scan Bucket.
3. Add to the appropriate folder.
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To delete the old document
1. Click on the document from the folder structure.
2. Click on the drop down arrow next to “Add.”
3. Click Delete
*Note: Only Super users and Office Managers have access to delete documents.
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Basic eClinicalWorks Navigation
Progress Note Overview
The progress note of the patient contains 3 major sections:
1.
Patient Dashboard
2.
Patient Chart Panel
3.
Patient S.O.A.P. Note
Patient Dashboard
The patient dashboard displays:
1.
The patient’s picture with demographic information.
2.
The patient’s insurance details, account balance, PCP first and last
appointment.
3.
A sticky note panel and secure notes (Physician to Physician) panel that can
be used for documenting any important non-chart information about the
patient.
4.
Advance Directive shows the code entered by the front office in the
demographics section.
5.
The menu bar gives a summary of all the data entered such as medical
summary, list of labs, DI, procedures etc.,
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3
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2
Patient Chart Panel
The patient’s chart panel is the storage panel of all
the previously entered information such as:
Problem List, Current Medication Summary,
Allergies, Immunizations, History, Comprehensive
Summary of the Patient’s Test Results, Telephone
Encounters, Web Encounters, and Clinical Decision
Support System that includes PCMH Alerts.
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Subjective and Objective Documentation
Documenting a Chief Complaint
1.
In Progress Note click on Chief Complaint(s):
1
2.
Chief Complaints activity window will display.
3.
To add a chief complaint click on the browse button.
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4.
In the “Find:” field type in the name of the complaint.
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Subjective and Objective Documentation
5.
6.
Select the appropriate complaint from the list.
Click
button.
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6
7.
The chief complaint is added. Click
to close.
8.
Chief Complaint entry will appear on the Progress Note.
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Subjective and Objective Documentation
Current Medication Documentation
1.
From the patient’s progress note, click on “Current Medications”.
2.
The Current Medications Activity window will display.
Note: this window is also shared by chief complaints.
3.
To document a current medication click on the
button.
3
4.
The RX Select activity window displays.
5.
In the Find field, type the medication name.
6.
The medication name will appear in the left hand column and the strength(s)
appear in the right column.
7.
Select the appropriate strength of the medication and it will populate under the
Selected RX area.
8.
Repeat steps five through seven to add another medication..
9.
To complete this documentation click on the
button .
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Subjective and Objective Documentation
10. The Current Medication window displays with the added medication.
11. Document that Medications have been verified by clicking on the Medication
Verified box.
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Documenting Past Medical History
1.
From the Progress Notes, click on “Medical History”
2.
Click on the “Browse” or “Add” Button to add Medical History documentation to
the patient’s chart.
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3
3.
Once documentation of Past Medical History has been completed, make sure to
indicate the history has been verified by clicking on the History Verified box.
NOTE: The “Browse” button shows a general list of keywords that can be selected
for the patient’s Medical History. The “Add” button allows you to free-text the
history compared to selecting from a list. Past Medical History gets carried
forward from visit to visit and history information from the previous visit is
automatically displayed on the Progress Note.
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Subjective and Objective Documentation
Documenting Allergies
1.
2.
Select Allergies/Intolerance from the Progress Note
The Allergies activity window displays (this window is also shared by Past
Medical History).
3.
To indicate the patient has No Known Drug Allergies (NKDA) click in the box next
to NKDA.
4.
To search for a drug allergy, click on the
button.
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3
5.
In the Find field, search for the name of the drug allergy.
6.
Select the appropriate allergy by clicking on the allergy name. The name will
populate in the Selected RX field.
7.
Click on the
button.
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6
7
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Subjective and Objective Documentation
8.
To search for a Environmental or Food Allergy click on the
button.
9.
In the Structured/Non Structured field click on the drop-down menu arrow.
10. Select Non Structured from the menu.
11. A warning will appear indicating if you free-text in the field it will be excluded
from automated drug-allergy testing. Click
12. Click in the Agent/Substance field.
13. Click on the drop-down menu arrow and select the allergy from the list.
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13
14. Click in the Reaction box.
15. Click on the drop down menu arrow and select the appropriate reaction.
16. Mark the allergies as verified by clicking in the Allergies Verified box.
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Subjective and Objective Documentation
Documenting Surgical and Hospitalizations History
1.
From the patient’s progress note, click on “Surgical History”. The following
window opens:
2
2.
3
4
Click on “Browse” or “Add” button to either add or update a new surgical history or
hospitalization.
3.
When a patient has no surgical history or hospitalization, you can click on “Denies
Past Surgical History” or “Denies Past Hospitalization”.
4.
Once documentation of Surgical History / Hospitalizations have been completed,
make sure to indicate the components have been verified by clicking on both the
Surgical History Verified and hospitalization Verified boxes.
Documenting Family History
1.
From the patient’s progress note, click on “Family History”. The following
window opens:
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3
4
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Subjective and Objective Documentation
2.
Under “Status” click in the field box to indicate a status of “alive,” “deceased,”
or “Unknown”.
3.
Click in the DOB field and enter a birth year. This will automatically calculate the
age of the family member.
4.
Click in the notes column to open the keyword window.
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6
5.
Select condition from the left pane to add it to the Selected Category in the center
pane.
6.
Select the relative on the right pane that are known to have the condition. NOTE:
you can select multiple relatives that have the condition by pressing the control
key on the keyboard and holding it down while selecting the family member with
the mouse.
Documenting Vital Signs
1.
In the progress note click on “Vitals”
2.
Vitals intake activity window will display
3.
Click in first field box (in this instance: *HR) and type value
4.
Use the tab key to move to following fields and continue typing values in
appropriate fields. (Note: BMI will auto-calculate for you)
5.
When you have completed entering vitals, click on the red “X” to close the
window.
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Subjective and Objective Documentation
5
3
6.
The vitals information will appear in the progress note time stamped with the
date, time, and name of the individual who documented the information.
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Subjective and Objective Documentation
How do I access the Initial Visit Smart Form to document certain components for PCMH
certification?
1.
In Progress Note click on the drop down menu arrow in the Smart Form (SF)
field.
1
2.
Select Initial Visit from the drop down menu.
2
3.
The Initial Visit smart form displays.
4.
Fill in the appropriate
information provided by the
patient by using the drop
down menus (if provided)
or clicking in the box by the
selection.
NOTE: You do not need to
complete all of the fields
on the form to move
forward!!
5.
Click on the
button to save the
information that you
documented and move to
the next screen.
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5
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Subjective and Objective Documentation
6.
The Tobacco Control form displays.
7.
Depending on what you
select under the “Are you a:”
field, options will appear for
specific documentation
pertaining to the choice
selected.
8.
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8
After completion click on the
button.
9.
The Alcohol Misuse/Abuse form displays.
10. Depending on what you select
under: Did you have a drink
containing alcohol in the past
year? More questions will
appear for specific
documentation.
11. At the completion of the form,
you will receive a point value.
This value will be used to select
the interpretation of the form,
Positive or Negative.
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11
12
12. Once the form is completed click
on the
button.
13. The Depression Screening form displays.
14. Complete the form as
appropriate.
15. Click on
button to
complete the Initial Visit Smart
Form.
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15
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Subjective and Objective Documentation
16. A pop-up activity window will display stating that the Form Data Saved
Successfully.
17. Click on the
button.
18. You will return back to the Progress Note.
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Subjective and Objective Documentation
ePrescribe
1.
From the patient’s progress note, click on “Treatment”.
2.
The Treatment Activity window will display.
Note: The individual tabs allow the physician to specifically address each
symptom.
3.
Click on the “tab” corresponding to the diagnosis for which medications need to be
prescribed or refilled.
4.
To refill patient’s current medication, click on the “Cur Rx” button, select the meds
that need to be refilled and simply type in the number of refills in the “refills”
column.
5.
To document whether the patient was asked to increase/decrease/stop the current
dose, click on the “comment” column and choose the respective comment.
6.
To prescribe a new medication, click on the “Add” button and choose a new
medication from the pre-populated medication list. Once the medication is chosen
and when you click “OK”, the dosage details can be modified back on the
“Treatment” screen.
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Subjective and Objective Documentation
ePrescribe
7.
The medication can then be printed or faxed or electronically prescribed to the
patient’s pharmacy by clicking on either the “Print” button (to print on prescription
paper) or the green arrow next to the “Print” button (to fax or e-scribe).
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Subjective and Objective Documentation
Updating Clinical Data Support Services (Scenario 1)
1.
From the Treatment Activity Window, Click on the CDSS button.
2.
The CDSS & Alerts Activity window will display.
Exiting the Progress Note
Click on the “X” in the top right corner of the screen.
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Subjective and Objective Documentation
Updating Clinical Data Support Services eCW notes
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Subjective and Objective Documentation
Updating Clinical Data Support Services “CDSS” (Scenario 2)
1.
In Progress Note Click on the CDSS link in the Patient Dashboard Menu.
2.
The CDSS & Alerts Activity window will display.
2.
All “non-compliant” CDSS alerts (i.e. alerts for which either the numerator or
the denominator criteria is not satisfied) show up on the patient chart panel.
3.
Note: If any of the CDSS alerts on the chart panel are linked with an order set, it
is indicated by a ‘+’ symbol before the alert name. Clicking on the ‘+’ symbol
shows the order set associated with that alert. The order set can be applied to
the patient’s progress note by either clicking on the ‘OS’ button or by clicking on
the arrow button, if it is a quick order set. For quick order sets, in addition to
applying the order set, a status for the order can be chosen.
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Subjective and Objective Documentation
Updating Clinical Data Support Services (Scenario 2)
1.
In Progress Note Click on the CDSS link in the Patient Dashboard Menu.
2.
The CDSS & Alerts Activity window will display.
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Result Documentation
Viewing Patient Orders (In-House and Outpatient Services)
1.
From the Office Visits screen select the Patient with outstanding orders by clicking
on their name.
Note: Patients with outstanding orders names will be highlighted in green.
3.
Click on the View Orders button.
4.
Patient Orders Window opens.
Note: The In-House Orders will be highlighted in green.
5.
Click on the Quick Transmit button to open Transmit Orders window.
6.
Or Click on the individual order, then click on the view button (or double click
on the order) to individually submit each order to its selected destination.
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Result Documentation
Viewing Patient Orders (In-House and Outpatient Services)
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Checking Logs
Fax Outbox Log
1.
To verify the status of a sent fax, click the Documents band on the left navigation
panel.
2.
Click Fax Outbox icon.
3.
The Outbox lists the outgoing faxes. Fax Status column shows the status.
4.
Click Refresh to update the statuses.
5.
If desired, double click on a fax to view. This can only be done with faxes that have
a Completed status.
1
2
3
4
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Checking Logs
ePrescription Logs (list of only ePrescribed medications)
1.
Click the Documents band on the left navigation panel.
2.
Click the ePrescriptions icon.
3.
Change the filters if you are looking for specific criteria.
4.
This logs lists only the Rx’s that have been sent via ePrescribe.
5.
View the Status column to verify if the ePrescription status.
6.
Click Refresh to update the status column.
7.
A RED Success status means a denial was sent to the Pharmacy successfully.
8.
These denials include:
a.
Physicians denying an electronic Rx request.
b.
Controlled substances that cannot legally transmit via ePrescribe.
Provider needs to open a telephone encounter and send the controlled
substance via fax (or it can be printed and picked up by patient).
It
is set up like this to prepare for when we can transmit controlled Rx’s
electronically.
3
1
7
2
6
5
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Checking Logs
Prescription Logs (list of only faxed and printed prescriptions)
1.
Click the Documents band on the left navigation panel.
2.
Click the Prescriptions icon.
3.
Change the filters if you are looking for specific criteria.
4.
This logs lists only the Rx’s that have been faxed or printed.
5.
Click Refresh to update the status column.
6.
Double click on any line item to view the prescription that was sent/printed.
7.
Status Columns
a.
Faxed-Only successful faxes will appear. Check the Sent Date column.
b.
Printed-Printed fax status will appear as Logged.
3
1
2
6
7a
5
7b
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Checking Logs
Prescription Log Report (contains All prescriptions and is printable)
1.
The Prescriptions log report contains a printable list of ALL prescriptions sent.
2.
At the top of the screen, click Reports>EMR>Prescriptions Log Report.
3.
In the Prescriptions Log Report Screen, adjust the provider and dates and click
Get Report button.
4.
Print Preview and Print buttons are available at the bottom of the window.
2
3
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Telephone Encounters
Attaching a Document to a Telephone Encounter
From the Patient Documents window, you can attach a document to a
telephone encounter without first inserting it into a patient’s chart.
To attach a document to a telephone encounter:
•
From the Documents band, click the Patient Documents icon.
1
2
1
2.
Once in the encounter click on the “Sel” button and select a patient from the
Patient Lookup window
3.
Under “View” click on “File View”
4.
In File View, click a document from the list and select it to display a drip-down
list. .
5.
From the list, select “Create Telephone Encounter:”
The Patient Lookup window
Clinicalopens
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Telephone Encounters
Attaching a Document to a Telephone Encounter
6.
Select the patient and click the “OK” button.
The Telephone Encounter window opens.
The message, Document attached from fax inbox displays in the telephone
encounter indicating the document is attached.
6
The document is attached to a telephone encounter.
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Section III: “How To” Guides – Advanced Features
Document Management – Scanning: Results without an Order
For paper or electronically faxed results can be attached to an order to satisfy the “Results
Received.” At the Document Description window complete the below tasks.
1.
Scan document as directed in the Document Management “Scanning” Section, at step 7
click the Add Description box and click OK.
Click on the “Assigned To” ellipse
2.
3.
Click on the New button of the Orders window.
4.
Click on Sel. To search the order – Select the order. Assign the Facility, Assigned To,
Results Received and Result info. Click OK
5.
Check the newly added order and click OK.
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Section III: “How To” Guides – Advanced Features
Document Management – Scanning: Results to an Order
For paper or electronically faxed results can be attached to an order to satisfy the “Results
Received.” At the Document Description window complete the below tasks.
1.
Scan document as directed in the Document Management “Scanning” Section, at step 7
click the Add Description box and click OK.
Click on the “Assigned To” ellipse
2.
3.
Check the box for the order and click OK.
4.
Document that the result has been received by checking the “box.”
*Note: If this is a lab,
you can input the
discrete results in the
attribute fields in the
Results section.
Orders will appear with a paperclip to identify that there is a scanned report attached
to the order.
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Training Scenarios
In this section you will be given scenarios that will help you to learn the system as
it pertains to a daily workflow within your office.
Each scenario can be run through by using the patients you were assigned to at
training, if there is an item required in order to conduct the scenario it will be
listed in blue text for you.
Good Luck and enjoy your learning experience!
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Checking - In
Checking a Patient In at the Mid-Office Level
Training Scenario
Your Patient has been checked in at the front office for their appointment. You must now
document that they have been taken from the waiting room to an exam room.
1.
2.
3.
4.
5.
6.
7.
8.
9.
From the Practice band, click the Office Visits icon.
The Office Visits window opens.
Left click once on an appointment to highlight it.
Click the Check In/Out button.
The encounter window opens for the Patient, DOB, Sex,
Appointment Time, and Reason fields automatically populated.
Check the Check In check box.
The Time In field is automatically populated with the current time.
Type the exam room the patient is being taken to in the Room No. field.
Click the More (…) button next to the Status field.
The Status Codes window opens
Left-click once on the desired status.
Click OK to close the Status Codes window.
Click OK to close the Encounter window.
Your patient is now checked in at the mid-office level.
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Chief Complaints
Documenting a Chief Complaint for a Patient
Training Scenario
Your Patient has been checked in and taken to an exam room, You must now record their chief
complaint, which includes headaches and fatigue.
1.
2.
3.
4.
5.
6.
From the patients progress note, click Chief Complaints.
The Chief Complaints window opens.
NOTE: if a reason was documented in the Reason field on the Appointment
window by the front staff it will appear here.
Click the Add button.
A new row appears with a blank Complaint field.
Click in the Complaint field for row 1 and type “headaches”
Click the Add button.
A second row appears with a blank Complaint field.
Click in the Complaint field for row 2 and type “fatigue”
When asked which complaint is more severe, the patient states that the fatigue is
the primary complaint, so left- click once on the fatigue field and click the ^
button on the right.
The fatigue complaint is now moved up one row to row 1.
The patients Chief Complaints are now documented.
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Current Medications
Adding a Current Medication from the Database
Training Scenario
Your Patient has been prescribed two medications from another physician since their last visit.
These two medications are Aspirin, at an 81mg dose and Ibuprofen, which they do not
know the dose for. You must now document these medications.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Click on Current Medications from the patient’s progress note.
The Current Medications window opens.
Click the Add button in the Current Medications section.
The Select Rx window opens.
Ensure Medispan is selected from the Type drop-down list and type “aspirin” into
the find field.
A list of medications starting with “aspirin” displays in the left
pane.
Click the “aspirin” medication.
A list of the various strengths and formulations for this medication
displays in the top right pane.
From the list, choose the option with 81 mg in the Strength column and “tablet”
in the Formulation column.
The medication is now transferred to the Selected Rx pane.
Click OK to close the Select Rx window.
This medication is now added to the Current Medication list.
Since the patient only knows the name of his other prescription, and not the
strength, check the Rx Name Only check box.
Click the Add button in the Current Medication section.
The Select Rx window opens.
Type “ibuprofen” into the Find field.
A list of medications starting with “ibuprofen” displays in the left
pane.
Click the “ibuprofen” medication.
A list of various strengths and formulations for this medication
displays in the top right pane.
Choose any strength or formulation from the list .
This medication is now transferred to the Select Rx pane.
Click OK to close the Select Rx window.
This medication is now transferred to the Selected Rx pane with all
fields blank except the Name field.
The current medications are now added from the database
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Medical History
Adding Medical History
Training Scenario
Your Patient has a medical history of Hypertension and Measles. They also have had bouts of
Chicken Pox and influenza since the last time they were at the office, which must now be
documented in their medical history.
For this scenario you will need:
the keyword influenza added to the Medical History keyword database
1.
From the patients Progress Note, click Medical History.
The Past Medical History window opens with past visit medical
history already populated.
2.
Click the Add button.
A third row appears with a blank History field.
3.
Click once in the History field of row 3.
4.
Type “Chicken Pox” into the History field for row 3.
5.
Click the Browse button.
The Medical History List window opens.
6.
Type “influenza” into the find field.
All Medical history keywords beginning with “influenza” display in
the left pane.
7.
Click the “influenza” keyword in the left pane.
The “influenza” keyword is added to the right pane.
8.
Click OK to close the Medical History List window.
A new row is added to the Medical History section, populated with
the “influenza” option.
9.
Check the History Verified check box.
The patients medical history is now documented.
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Allergies
Documenting a Non-Drug Allergy
Training Scenario
Your patient has discovered since their last visit the they are allergic to hazelnuts, which gives them
a rash. You must now document this new allergy.
1.
2.
3.
4.
5.
6.
7.
8.
From the patients Progress Note, click Allergies.
The Past Medical History window opens with all allergies that have
been recorded on previous visits displayed in the Allergies section.
Click the Add button in the Allergies section.
A new blank row appears in the Allergies section.
Select Non-Structured from the Structured/Non-Structured column
Type “Hazelnuts” into the Agent/Substance field.
Click in the blank Reaction field for the new row.
Either type “rash” here or select it from the drop-down list.
The patients non-drug allergies are now documented.
Select Active in the Status column.
Check the Allergies Verified check box
Documenting a Drug Allergy
Training Scenario
Your Patient has recently discovered that they are allergic to the drug Levaquin, which gives them
severe stomach discomfort. You must now document this allergy in the system.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
From the patients Progress Note, click Allergies.
The Allergies window opens.
Click the Browse Rx… button.
The select Rx window opens.
Click Medispan in the left pane.
The middle pane displays only medications contained in the
Medispan database.
Type “Levaquin” into the Find field.
A list of medications starting with Levaquin displays in the center
pane.
Click on the “Levaquin” entry in the center pane.
The Levaquin entry now appears in the right pane.
Click OK to close the Select Rx window.
Click in the Allergy field of the Levaquin row
Type “stomach upset” into the Reaction field, or select it from the drop-down list.
Select Active from the Status column
Check the Allergies Verified check box
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Allergies
Documenting a Patient with No Known Allergies
Training Scenario
Your patient has come in for their routine physical examination. They have no allergies that
they know of. You must document their lack of known allergies in the system.
For this scenario you will need:
A scheduled appointment
1.
From the patients Progress Note, click Allergies.
The Allergies window opens.
2.
Check the N.K.D.A. (No Known Drug Allergies) check box.
The Allergies Verified check box is automatically checked.
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Surgical History and Hospitalizations
Documenting Surgical History
Training Scenario
Your Patient has undergone a Hysterectomy operation since the last time she was seen at the
practice. You must now document this information in her Surgical History.
For this scenario you will need:
A scheduled appointment
1.
From the patients Progress Note, click Surgical History.
The Surgical history window opens with all surgical history entries
automatically populated.
2.
Click the Add button.
A new row appears with blank Date and Surgery fields.
3.
Type the date that this surgery occurred into the Date field in mm/yyyy format.
4.
Type “hysterectomy” into the Surgery field.
The patients surgical history is now documented.
Documenting a Patient with No Surgical History
Training Scenario
Your Patient has never had surgery before, you must document this lack of surgeries in their
Surgical History.
1.
2.
From the Patient’s Progress Note, click Hospitalizations.
The Surgical history window opens with all Hospitalizations
entered in the past automatically populated.
Check the Denies Past Surgical History check box.
The patient’s denial of past surgical history is now documented.
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Surgical History and Hospitalizations
Documenting Hospitalizations
Training Scenario
Your Patient has been hospitalized for a bout of Chicken Pox since their last visit to the office.
You must document this information in their Hospitalizations history.
1.
2.
3.
4.
5.
From the patients Progress note, click Hospitalizations.
The surgical history window opens with all hospitalizations entered
in the past automatically populated.
Click the Add button
A new row appears with blank Date and Reason Fields.
Type the date that this hospitalization occurred into the Date field in mm/yyyy
format.
Type “Chicken Pox” into the Reason field.
Check the Hospitalization Verified check box
Your patients hospitalizations have been documented and verified.
Documenting a Patient with No Hospitalizations
Training Scenario
Your Patient had never been admitted to a hospital before. You must document this in the
system.
1.
2.
3.
From the patients Progress Note, click Hospitalizations.
The Surgical/hospitalizations window opens.
Check the Denies Past Hospitalizations check box.
Check the Hospitalizations Verified check box.
The patient denial of hospitalizations is now documented.
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Family History
Documenting a Patient’s Family History
Training Scenario
Since the last time Your Patient was seen at this practice, their father has passed away, their brother
has been diagnosed with heart disease, and their mother has been diagnosed with diabetes. You
must now document these changes, as well as the date of birth and age of the patient’s mother
and father.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
From the patients Progress Note, click Family History.
The Family History window opens with all the information that was
recorded in past visits automatically populated.
Click twice in the Status field for the Father row to change the status to deceased.
Type the date Crystal’s father was born in the DOB field for the Father row.
(07/1925)
Type the age Crystal’s father was when he passed away into the Age(yrs) field for
the Father row.
Click in the Notes field for the Sibling row.
Type “Brother” into the middle pane.
Type “heart disease” into the Find field.
A list of keywords that begin with “heart disease” displays in the
left pane.
Click the “Heart Disease” option in the left pane.
The “Heart Disease” option is added after “Brother” in the middle
pane.
Click OK to close the Keywords window.
Uncheck the Healthy check box next to the Siblings section, if it has been
checked.
Type the date Crystal’s mother was born in the DOB field for the mother row.
(08/1927)
Click in the Notes field of the Mother row.
The Keywords window opens.
Click the “Diabetes” option in the left pane.
The Diabetes option is added to the middle pane.
Click OK to close the Keywords window.
Check the Family History Verified box.
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Family History
Documenting a Patient with a Non-Contributory Family History
Training Scenario
Your Patient was adopted as a child and has little to no information about his biological family
history. You must document this in the system.
1.
2.
3.
From the patients Progress Note, click Family History.
The Family History window opens.
Check the Non-Contributory box
Check the Family History Verified box.
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Social History
Documenting a Patient’s Social History
Training Scenario
Since their last visit to your office, Your Patient has retired from their job, traveled to England,
and bought a dog. You must document all these changes to their Social History.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
From the patient’s Progress Note, click Social History.
The Social History window opens with all the information that was
populated in past visits automatically.
Click in the Details field of the Occupation row.
Add “retired” in the right pane.
Click OK to close the Social History Notes window.
Click twice in the Travel Outside US row, options column.
A yes appears in the Options field
Click in the Details field of the “Travel Outside US” row.
The Social History Notes window opens.
Type “England” in the right pane.
Click OK to close the Social History Notes window.
Click once in the Options field of the Pets row.
Cats: Dogs: is added to the details column of the Pets row
Click in the Details field of the Pets row.
The Social History notes window opens.
Type “0” after Cats: and “1” after “dogs”
Click OK to close the Social History Notes window.
Check the Social History Verified box
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Recording Vitals
Documenting Patient Vitals
Training Scenario
Your Patient is being seen today and you must now record their vital signs.
1.
2.
3.
4.
5.
6.
7.
From the patients Progress Note, click Vitals.
The Vitals window opens with today’s visit highlighted in yellow.
After taking the patients temperature. She is slightly above normal, so type 98.8
into the Temp field.
Measure the height of your patient. Her height has not changed since the last
visit so type 60 into the Ht(in) field.
Weigh your patient on the scale. She has lost 2 pounds since her last visit so type
158 into the Wt(lbs) field.
Take your patient’s blood pressure. It is measuring at 140/85 so type this into the
BP field.
Take your patient’s heart rate. It is reading at 75, so type this into the HR field.
Check the Vitals Taken check box.
The patient’s vitals are now recorded.
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Patient Orders
Viewing Patient Orders
Training Scenario
Your Patient is being seen for a routine physical and the doctor has ordered a Chest X-ray as
well as a Urinalysis.
For this scenario you will need:
A scheduled appointment with an ordered chest x-ray and urinalysis.
1.
From the Office Visits screen your patients name will be highlighted in green
when there are pending orders.
2.
Check the box in for the row of the patient you would like to view orders on.
3.
Click the View Orders button.
The patient orders window opens.
4.
All requested orders for this patient will be listed in this window.
5.
Click on an order to highlight it.
6.
Select the View button to view the details for the highlighted order.
Documenting Completed Orders on a Patient
Training Scenario
Your Patient has completed their Urinalysis and you need to document the results.
For this scenario you will need:
A scheduled appointment with an ordered urinalysis
1.
From the patient orders window, select the Urinalysis order.
The lab results window opens.
2.
Click in the box for Collection Date to mark as today’s date.
3.
Within the Results section, check the Received box for today’s date, since this
test was performed in house.
4.
Document your results in the highlighted row in the results window.
5.
Click OK to exit the Lab Results window.
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Checking - Out
Checking a Patient Out at the Mid Office Level
Training Scenario
Your patients medical information has been documented, and a treatment plan has been
specified. You must now check them out at the mid office level and send them to check
out at the front office.
For this scenario you will need:
A scheduled appointment with the patient checked – in at the mid office level
1.
From the Practice Band, click the Office visits icon.
The Office Visits window opens.
2.
Left-click once on the row containing your patients appointment to highlight it.
3.
Click the Check In/Out button.
The Encounter window opens.
4.
Check the Check Out check box.
The time out field is automatically populated with the current
time.
5.
Click the More (…) button next to the Status field.
The Status Codes window opens
6.
Left-Click once on the desired status.
7.
Click OK to close the Status Codes window.
8.
Click OK to close the Encounter window.
Your patient is now checked out at the mid office level.
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