Welcome! Basic Dynamic Documentation Basic Dynamic Documentation …to the Computer-Based Training on Basic Dynamic Documentation

Basic Dynamic Documentation Instruction This Computer-Based Training (CBT) does not contain audio. So be sure to follow instructions as you go through this CBT. To go through the CBT, you can either click on the topics listed under TOC or simply click the buttons on the bottom left corner to move through the lesson. Click the Next button to advance to Next topic. Click the Back button to go back to the Previous topic. Click the Home button to return to the Introduction page.

Basic Dynamic Documentation Introduction This CBT will introduce you to the basics of using Dynamic Documentation. Here are the topics for this CBT: Table of Contents (TOC) Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course Diagnoses Overview – Dynamic Document Chief Complaint & HPI Past Medical History Review of Systems (ROS) Vital Signs & Physical Exam Documents & Labs Procedures/Consults Order Entry (14:38) Assessment Plan Creating a Note Diagnoses Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course Let’s get started! Click on the individual topic listed under TOC or the Next button to continue.

Basic Dynamic Documentation Overview – Dynamic Documentation TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course Diagnoses

Basic Dynamic Documentation Chief Complaint & HPI TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course Diagnoses

Basic Dynamic Documentation Past Medical History TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course Diagnoses

Basic Dynamic Documentation Review of Systems TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course Diagnoses

Basic Dynamic Documentation Vital Signs & Physical Exam TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course Diagnoses

Basic Dynamic Documentation Documents and Labs TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course Diagnoses

Basic Dynamic Documentation Procedures/Consults TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course Diagnoses

Basic Dynamic Documentation Order Entry TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course Diagnoses

Basic Dynamic Documentation Assessment Plan TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course Diagnoses

Basic Dynamic Documentation Creating a Note TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course Diagnoses

Basic Dynamic Documentation Discharge Process: Diagnoses TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course Diagnoses

Basic Dynamic Documentation Procedures/Pending Results TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course Diagnoses

Basic Dynamic Documentation Quality Measures TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course Diagnoses

Basic Dynamic Documentation Discharge Orders TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course Diagnoses

Basic Dynamic Documentation Follow Up Care Orders TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course Diagnoses

Basic Dynamic Documentation Hospital Course TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course Diagnoses

Basic Dynamic Documentation Congratulations! You’ve completed the Basic Dynamic Documentation CBT. Please click to continue. TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course Diagnoses

Please do not close this window until you’ve completed the step below! Basic Dynamic Documentation Please do not close this window until you’ve completed the step below! Click HERE to record your completion of this required CBT – Basic Dynamic Documentation.