© 2013 The McGraw-Hill Companies, Inc. All rights reserved. Chapter 7 Clinical Tools

© 2013 The McGraw-Hill Companies, Inc. All rights reserved 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 Chapter 7 Learning Outcomes

© 2013 The McGraw-Hill Companies, Inc. All rights reserved. 7-3 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 Chapter 7 Key Terms

© 2013 The McGraw-Hill Companies, Inc. All rights reserved. 7-4 LO 7.1 Chart Evaluation

© 2013 The McGraw-Hill Companies, Inc. All rights reserved. 7-5 Define preventative health criteria on SpringCharts server Evaluate patient’s chart for set criteria Scan entire patient database for chart evaluations Chart Evaluation LO 7.1

© 2013 The McGraw-Hill Companies, Inc. All rights reserved Gender 2.Age 3.Actions 4.Recurring 5.Diagnosis(es) 6.Having Lab or Medication 7.High Clinical Priority Criteria Definitions LO 7.1

© 2013 The McGraw-Hill Companies, Inc. All rights reserved. 7-7 LO 7.2 Test Orders

© 2013 The McGraw-Hill Companies, Inc. All rights reserved. 7-8 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 Test Orders LO 7.2

© 2013 The McGraw-Hill Companies, Inc. All rights reserved. 7-9 LO 7.3 Evaluation & Management Coder

© 2013 The McGraw-Hill Companies, Inc. All rights reserved 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 Evaluation & Management Coder LO 7.3

© 2013 The McGraw-Hill Companies, Inc. All rights reserved LO 7.4 Superbill Form

© 2013 The McGraw-Hill Companies, Inc. All rights reserved 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 Superbill LO 7.4

© 2013 The McGraw-Hill Companies, Inc. All rights reserved LO 7.5 Patient Instructions

© 2013 The McGraw-Hill Companies, Inc. All rights reserved Can be created in SpringCharts or imported into SpringCharts Accessible from the Office Visit screen to print or to the patient Patient Instructions LO 7.5

© 2013 The McGraw-Hill Companies, Inc. All rights reserved LO 7.6 Care Plans or Practice Guidelines

© 2013 The McGraw-Hill Companies, Inc. All rights reserved Attach a document stored on the computer outlining care plans or practice guidelines Becomes a permanent record attached to the OV note Care Plan/Guidelines LO 7.6

© 2013 The McGraw-Hill Companies, Inc. All rights reserved LO 7.7 Drawing Program

© 2013 The McGraw-Hill Companies, Inc. All rights reserved 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 Drawing Program LO 7.7

© 2013 The McGraw-Hill Companies, Inc. All rights reserved LO 7.8 Importing Documents

© 2013 The McGraw-Hill Companies, Inc. All rights reserved Import documents to the File Cabinet Any file type: –.docx or.doc –.xlsx or.xls –.html –.pdf –.jpg –.DICOM – more Stores on SpringCharts Server in a separate folder Links to patient’s chart File Cabinet LO 7.8

© 2013 The McGraw-Hill Companies, Inc. All rights reserved Acquire – Imports files from scanners, cameras, webcams, etc. Existing – Imports file from the computer Acquire vs. Existing LO 7.8

© 2013 The McGraw-Hill Companies, Inc. All rights reserved 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 Importing Documents LO 7.8

© 2013 The McGraw-Hill Companies, Inc. All rights reserved 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 Chapter 7 Summary

© 2013 The McGraw-Hill Companies, Inc. All rights reserved 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 Chapter 7 Summary

© 2013 The McGraw-Hill Companies, Inc. All rights reserved 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 Chapter 7 Summary

© 2013 The McGraw-Hill Companies, Inc. All rights reserved 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 Chapter 7 Summary

© 2013 The McGraw-Hill Companies, Inc. All rights reserved 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 Chapter 7 Summary

© 2013 The McGraw-Hill Companies, Inc. All rights reserved 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 Chapter 7 Summary

© 2013 The McGraw-Hill Companies, Inc. All rights reserved 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 Chapter 7 Summary

© 2013 The McGraw-Hill Companies, Inc. All rights reserved 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 Chapter 7 Summary