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Chapter 3

Essential Documentation

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.McGraw-Hill

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Chapter 3 Content

LO 3.1 SpringCharts FeaturesLO 3.2 A Brief HistoryLO 3.3 User PreferencesLO 3.4 Setting Up and Editing PatientsLO 3.5 Customizing Pop-Up TextLO 3.6 Understanding The Electronic ChartLO 3.7 The Face SheetLO 3.8 The Care Tree

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LO 3.1 SpringCharts Features

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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

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LO 3.2 A Brief History

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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

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LO 3.3 User Preferences

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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

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LO 3.3 User Preferences

• Preference 2–Password– Signature

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LO 3.4 Setting Up and Editing Patients

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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

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LO 3.5 Customizing Pop-Up Text

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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

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LO 3.6 Understanding The Electronic Chart

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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

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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

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LO 3.6 Understanding The Electronic Chart

• Care Tree– Encounters (progress notes)– Tests–Other current records

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LO 3.7 The Face Sheet

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LO 3.7 The Face Sheet

• Face Sheet–Demographics– Social history–Past health history– Family health history–Referrals–Chart note

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LO 3.7 The Face Sheet

• Face Sheet (cont.)–Routine meds–Outside meds–Problem list–Chart alert–Patient annotations–Dx, Rx, and procedure history

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LO 3.8 The Care Tree

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LO 3.8 The Care Tree

• Care Tree–Preset categories cannot be altered –30 customizable categories