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