© 2013 The McGraw-Hill Companies, Inc. All rights reserved. Chapter 5 The Patient Chart

© 2013 The McGraw-Hill Companies, Inc. All rights reserved 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 Chapter 5 Content

© 2013 The McGraw-Hill Companies, Inc. All rights reserved. 5-3 Care Tree Category Preferences Chart Alert Co-pay Deductible Encounters Face Sheet Family Medical History (FMHX) Mandated Reporters Past Medical History (PMHX) Surveillance Reports Chapter 5 Key Terms

© 2013 The McGraw-Hill Companies, Inc. All rights reserved. 5-4 LO 5.1 Overview of the Patient Chart

© 2013 The McGraw-Hill Companies, Inc. All rights reserved. 5-5 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 Overview LO 5.1

© 2013 The McGraw-Hill Companies, Inc. All rights reserved. 5-6 From the chart menu in the Patient Chart screen, click the OPEN FACE SHEET icon Editing the Face Sheet LO 5.1

© 2013 The McGraw-Hill Companies, Inc. All rights reserved. 5-7 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 Editing the Care Tree LO 5.1

© 2013 The McGraw-Hill Companies, Inc. All rights reserved. 5-8 LO 5.2 Creating a Face Sheet

© 2013 The McGraw-Hill Companies, Inc. All rights reserved. 5-9 Obtain information – One-on-one patient interview – Patient Portal – Intake Forms Face Sheet LO 5.2

© 2013 The McGraw-Hill Companies, Inc. All rights reserved 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 Allergies LO 5.2

© 2013 The McGraw-Hill Companies, Inc. All rights reserved Pop-up text is available to choose defining or descripting text Up to 30 items can be entered Social History LO 5.2

© 2013 The McGraw-Hill Companies, Inc. All rights reserved 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 Past Medical History (PMHX) and Family Medical History (FMHX LO 5.2

© 2013 The McGraw-Hill Companies, Inc. All rights reserved Referring physicians must be set up first in the address book before being chosen from the Face Sheet Referrals LO 5.2

© 2013 The McGraw-Hill Companies, Inc. All rights reserved Enter important information about patient that needs to be seen in Face Sheet Pop-up text is provided for rapid selection of text Chart Note LO 5.2

© 2013 The McGraw-Hill Companies, Inc. All rights reserved Enter patient’s current routine medications and OTC medications Medications can be edited in the Edit Rx Window Routine Medications LO 5.2

© 2013 The McGraw-Hill Companies, Inc. All rights reserved 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 Outside Medications LO 5.2

© 2013 The McGraw-Hill Companies, Inc. All rights reserved Documents patient ongoing medical problems Select by code or description Pop-up text is available to select predefined text Problem List LO 5.2

© 2013 The McGraw-Hill Companies, Inc. All rights reserved 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 Chart Alert LO 5.2

© 2013 The McGraw-Hill Companies, Inc. All rights reserved 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 Patient Annotations and Requests LO 5.2

© 2013 The McGraw-Hill Companies, Inc. All rights reserved 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 Saving and Printing LO 5.2

© 2013 The McGraw-Hill Companies, Inc. All rights reserved LO 5.3 Procedures in a Patient’s Chart

© 2013 The McGraw-Hill Companies, Inc. All rights reserved 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 Adding Primary Insurance LO 5.3

© 2013 The McGraw-Hill Companies, Inc. All rights reserved 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 Entering Past Immunizations LO 5.3

© 2013 The McGraw-Hill Companies, Inc. All rights reserved Allows viewing of: – blood pressure – height/weight data – body mass index – body fat percentage for adults – head circumference for infants Graph Vital Signs LO 5.3

© 2013 The McGraw-Hill Companies, Inc. All rights reserved LO 5.4 New Activities in a Patient’s Chart

© 2013 The McGraw-Hill Companies, Inc. All rights reserved Creates a new telephone call encounter form Available from the New menu and New TC submenu New TC Note LO 5.4

© 2013 The McGraw-Hill Companies, Inc. All rights reserved 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 New Vitals Only LO 5.4

© 2013 The McGraw-Hill Companies, Inc. All rights reserved Creates a new letter addressed to the patient Available from the New Menu and New Letter to Pt submenu New Letter to Patient LO 5.4

© 2013 The McGraw-Hill Companies, Inc. All rights reserved Creates a new letter concerning a patient Available from the New Menu and New Letter ABOUT Pt submenu New Letter ABOUT Patient LO 5.4

© 2013 The McGraw-Hill Companies, Inc. All rights reserved 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 New Test Report to Patient LO 5.4

© 2013 The McGraw-Hill Companies, Inc. All rights reserved 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 New Excuse/Note/Order LO 5.4

© 2013 The McGraw-Hill Companies, Inc. All rights reserved 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 Chapter 5 Summary

© 2013 The McGraw-Hill Companies, Inc. All rights reserved LO 5.2 Demonstrate how to build a patient’s face sheet Face Sheet – Taken from intake forms, interview, or patient portal Allergies Routine medications Social history Outside medications Past medical history Problem list Family medical history Chart alert Referrals Patient annotations Chart note Patient requests Chapter 5 Summary

© 2013 The McGraw-Hill Companies, Inc. All rights reserved 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 Chapter 5 Summary

© 2013 The McGraw-Hill Companies, Inc. All rights reserved 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 Chapter 5 Summary