Download EHR_ch05_The Patient Chart

The Patient Chart
Chapter 5
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
Chapter 5 Content
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5.1 Overview of the Patient Chart
5.2 Creating a Face Sheet
5.3 Procedures in a Patient’s Chart
5.4 New Activities in a Patient’s Chart
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
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Chapter 5 Key Terms
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Care Tree
Category Preferences
Chart Alert
Co-pay
Deductible
Encounters
Face Sheet
• Family Medical History
(FMHX)
• Mandated Reporters
• Past Medical History
(PMHX)
• Surveillance Reports
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LO 5.1 Overview of the
Patient Chart
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Overview
• Patient Chart
– Face Sheet
– Care Tree
• Can view the entire
chart at a glance
• Can be opened and
edited by multiple
users at the same
time
LO 5.1
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Editing the Face Sheet
• From the chart menu in the Patient Chart
screen, click the OPEN FACE SHEET icon
LO 5.1
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Editing the Care Tree
• Use the + and – signs to
expand or collapse the list
• Select the specific branch
item and click EDIT at the
bottom of the screen
• Categories
– Preset and unmodifiable
– 30 customizable
LO 5.1
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LO 5.2 Creating a Face
Sheet
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Face Sheet
• Obtain information
– One-on-one patient
interview
– Patient Portal
– Intake Forms
LO 5.2
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Allergies
• Opens by default when accessing Edit Face Sheet
window
• Enter/edit drug allergies and other sensitivities
• Pop-up text is available to choose the allergen
LO 5.2
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Social History
• Pop-up text is
available to
choose
defining or
descripting
text
• Up to 30
items can be
entered
LO 5.2
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Past Medical History (PMHX) and Family
Medical History (FMHX
• Past Medical History is information about the
patient’s past healthcare history, such as major
illnesses, previous surgeries, injuries, and
operations relevant to the medical practice
• Family Medical History is important because it
enables physicians to evaluate probable
healthcare issues that may be family related
– Dx is chosen by ICD code or description
– Up to 30 items can be entered
LO 5.2
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Referrals
• Referring physicians
must be set up first in
the address book
before being chosen
from the Face Sheet
LO 5.2
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Chart Note
• Enter important information about patient that
needs to be seen in Face Sheet
• Pop-up text is provided for rapid selection of text
LO 5.2
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Routine Medications
• Enter patient’s current routine medications and OTC
medications
• Medications can be edited in the Edit Rx Window
LO 5.2
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Outside Medications
• Automatically populates with drug data prescribed
by other providers when the SpringCharts program
sends e-prescriptions across the Internet to the
clearinghouse
• Each physician who participates in e-prescribing is
able to view all medications that are electronically
transmitted by other physicians for that specific
patient
• The provider cannot edit this information
LO 5.2
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Problem List
• Documents patient ongoing medical problems
• Select by code or description
• Pop-up text is available to select predefined text
LO 5.2
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Chart Alert
• Allows for inclusion of important text that will
appear in red above the Encounters category on the
Care Tree
• Pop-up text is available
• Does not print on the Face Sheet Form
– Can be used to document special needs or circumstances
LO 5.2
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Patient Annotations and Requests
• Patient Annotations
– Includes information that has been mentioned that
provider feels is important to include
– E.G. Under stress from work or abuse issues
• Patient Requests
– Patient record requests
LO 5.2
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Saving and Printing
• Not all information will be filled out on one visit
• Information is saved when the [BACK] button is
pressed
• Use the [Print FS] button to print an updated Face
Sheet
LO 5.2
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LO 5.3 Procedures in a
Patient’s Chart
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Adding Primary Insurance
• Add to his or her face sheet by right-clicking on the
Insurance section at the bottom left of the chart and
selecting Edit
• Record information such as policy number, group
number, Social Security number, co-pay amount, and
guarantor
• Use the details field to list deductible and insurance
representative as available
LO 5.3
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Entering Past Immunizations
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Allows entry of patients’ past immunizations
Ensures that immunizations are up-to-date
New immunizations are added in Office Visit note
Enables a full print-out of all immunizations to be
kept or faxed
LO 5.3
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Graph Vital Signs
• Allows viewing of:
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blood pressure
height/weight data
body mass index
body fat percentage for
adults
– head circumference for
infants
LO 5.3
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LO 5.4 New Activities in
a Patient’s Chart
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New TC Note
• Creates a new
telephone call
encounter form
• Available from the
New menu and
New TC submenu
LO 5.4
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New Vitals Only
• Creates a new vitals
form for use when
a patient comes to
the medical clinic
for the sole
purpose of having
vitals taken
• Available from the
New menu and
New Vitals Only
submenu
LO 5.4
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New Letter to Patient
• Creates a new
letter addressed
to the patient
• Available from the
New Menu and
New Letter to Pt
submenu
LO 5.4
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New Letter ABOUT Patient
• Creates a new
letter concerning
a patient
• Available from the
New Menu and
New Letter
ABOUT Pt
submenu
LO 5.4
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New Test Report to Patient
• Creates a blank
test reporting
form that will
send test results
to the patient
along with test
explanation
• Available from the
New Menu and
New Test Report
submenu
LO 5.4
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New Excuse/Note/Order
• Provides printable forms for:
– work or school absentee excuses
– general notes
– ordering of lab, imaging, and medical tests
• Available from the New Menu and New
Excuse/Note/Order submenu
LO 5.4
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Chapter 5 Summary
LO 5.1 Understand the layout of an electronic
chart
• Patient Chart
– Accessed from many places within EHR
– Opened by multiple users at same time
– Composed of:
• Face Sheet
• Care Tree
– Toolbar displays speed icons
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Chapter 5 Summary
LO 5.2 Demonstrate how to build a patient’s face sheet
• Face Sheet
– Taken from intake forms, interview, or patient portal
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Allergies
Routine medications
Social history
Outside medications
Past medical history
Problem list
Family medical history
Chart alert
Referrals
Patient annotations
Chart note
Patient requests
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Chapter 5 Summary
LO 5.3 Perform various procedures in a patient’s
chart
• Processes and documents are always started
with patient chart open
– Primary Insurance
– Past immunizations
– Graph Vital Signs
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Chapter 5 Summary
LO 5.4 Create new documentation in a patient’s
chart
• New documentation
– New TC Note
– New Vitals Only
– New Letter to the Patient
– New Letter about a Patient
– New Test Report to Patient
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