1. 3-1 Chapter 3 Essential Documentation © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill

2. 3-2 Chapter 3 Content LO 3.1 SpringCharts Features LO 3.2 A Brief History LO 3.3 User Preferences LO 3.4 Setting Up and Editing Patients LO 3.5 Customizing Pop-Up Text LO 3.6 Understanding The Electronic Chart LO 3.7 The Face Sheet LO 3.8 The Care Tree

3. 3-3 LO 3.1 SpringCharts Features

4. 3-4 LO 3.1 SpringCharts Features CCHIT certified Easy to use Rich in features Customizable to suit a wide range of healthcare specialties Principles of electronic documentation transfer from system to system

5. 3-5 LO 3.2 A Brief History

6. 3-6 LO 3.2 A Brief History SpringCharts – Developed over 10 yr period – 2004 – developed PMS/EHR interface – 2006 – CCHIT certified – 2009 – SureScripts certified for e- prescribing – 2010 – ONC certified, qualifies for financial rebates under HITECH Act

7. 3-7 LO 3.3 User Preferences

8. 3-8 LO 3.3 User Preferences Establishment of personal user preferences – Office Visit form view – Search mode – Pop-up text – Measurement – Time – Font – Rx Print Attending

9. 3-9 LO 3.3 User Preferences Preference 2 – Password – Signature

10. 3-10 LO 3.4 Setting Up and Editing Patients

11. 3-11 LO 3.4 Setting Up and Editing Patients Adding new patients – First & last name – Date of birth Editing patient – Modify demographics – Delete – Archive – View all patients

12. 3-12 LO 3.5 Customizing Pop-Up Text

13. 3-13 LO 3.5 Customizing Pop-Up Text Pop-up text – Functions like pick lists – Enables the user to select words, phrases, or paragraphs with the click of the mouse – Provides rapid way to document – Stored by user log-in name Modified without affecting any other user’s pop-up text

14. 3-14 LO 3.6 Understanding The Electronic Chart

15. 3-15 LO 3.6 Understanding The Electronic Chart Electronic chart – Repository for patient health data created through computer automation in the healthcare setting – Static information such as demographics, allergies, health history, and health problems – Dynamic information including encounter notes, nurse notes, tests, letters, and reports concerning the patient

16. 3-16 LO 3.6 Understanding The Electronic Chart Face sheet – Contains more constant patient information such as allergies, problem list, and past health history (PMHX) – Used in inpatient and outpatient settings

17. 3-17 LO 3.6 Understanding The Electronic Chart Care Tree – Encounters (progress notes) – Tests – Other current records

18. 3-18 LO 3.7 The Face Sheet

19. 3-19 LO 3.7 The Face Sheet Face Sheet – Demographics – Social history – Past health history – Family health history – Referrals – Chart note

20. 3-20 LO 3.7 The Face Sheet Face Sheet (cont.) – Routine meds – Outside meds – Problem list – Chart alert – Patient annotations – Dx, Rx, and procedure history

21. 3-21 LO 3.8 The Care Tree

22. 3-22 LO 3.8 The Care Tree Care Tree – Preset categories cannot be altered – 30 customizable categories