Simulating the medical office Chapter 4 & 5 The Clinic Administration The Patient’s Chart

Spring Charts The practice view screen shows 4 things: Appointment Schedule Patient Tracker To Do/Reminders List Message List The appointment schedule and patient tracker are consistent for ALL users on the network! To Do/Reminders list and the Message list are user-defined. Spring Charts will only show information that is relevant to the specific user logged on!

Appointment Schedule Shows past present and future appointments for patients You are able to block time. For meetings or doctor out of office No show Patient missed a scheduled appointment without calling in advance to inform the clinic of his or her intentions and/or to reschedule.

Patient Tracker Enables all users across the network to see at a glance the current location and the status of all patients in the clinic. It records the time each patient entered and left the clinic. Why is this important? You will add a patient to the patient tracker AS SOON AS THEY WALK IN!!!

Patient Tracker continued There is a 6 color option used to flag patients in the tracker. These colors are defined by each clinic! Every patient that is tracked through the patient tracker is kept in the tracker archive. Why is this important?

To Do/Reminders In the To Do list you may: Notate the To Do item Send the item to another co-worker Link the item to a patient Schedule the To Do/Reminder for a future date Colors are also associated with this list: Green- the To Do is active Blue- the To Do is linked to a patient Orange- your communicating between you and an administrator. Red- completed item

Internal Messages Non-patient messages- do not concern a patient. Example: Staff meeting Messages concerning a patient- link patients chart to the message Lab results/insurance/billing Urgent messages- Like instant messaging Childs school called E-mails- attach patient charts/documents

Patient Chart Face Sheet Care Tree Encounters/ Progress notes Constant patient information such as allergies, problem list, and PMHX. Care Tree List of categories that hold the encounters, tests, notes, letters, and reports. Encounters/ Progress notes Stores the documents that are created from encounters with the patient

File Menu Evaluate Chart- makes sure patient is up to date with preset tests, screenings, and procedures. Lock Chart- When the chart is unable to be changed by anyone except the person who locked the chart CCR- Continuity of Care Record- transfer patient medical data from one provider’s EHR program to another.

Action Menu Managing and Charting Tests- once a test is ordered it moves into the Pending Tests list Order New lab, imaging, and medical tests- tests in spring charts includes: imaging, lab and medical tests Immunizations- allows you to enter patients’ past immunizations and view shot record

New Menu New OV- creates a new office visit New TC note- creates a new telephone call note New Vitals only- when a patient only comes in for BP check New letter TO patient- addressed to the patient. Normally lab results New letter ABOUT patient- letter concerning a patient. Normally to a referring physician/ER.

Review! What does the Practice view window show? What is a Face sheet? Appointment calendar, patient tracker, to/do reminders list, and message list. What is a Face sheet? Contains more constant patient information such as patient information. Who decides the color coding in the patient tracker? Each clinic. What is a NEW TC NOTE? New telephone call encounter

Review Continued When should you put a patient in patient tracker? As soon as the patient arrives in the clinic/office. What does the appointment calendar display? Past, current and future appointments for patients. What is PMHX? Past Medical History What is FMHX? Family Medical History