Y khoa, y dược - Chapter 3: Essential documentation

Chapter 3Essential Documentation© 2012 The McGraw-Hill Companies, Inc. All rights reserved.McGraw-HillChapter 3 ContentLO 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 TreeLO 3.1 SpringCharts FeaturesLO 3.1 SpringCharts FeaturesCCHIT certifiedEasy to useRich in featuresCustomizable to suit a wide range of healthcare specialtiesPrinciples of electronic documentation transfer from system to systemLO 3.2 A Brief HistoryLO 3.2 A Brief HistorySpringChartsDeveloped over 10 yr period2004 – developed PMS/EHR interface2006 – CCHIT certified2009 – SureScripts certified for e-prescribing2010 – ONC certified, qualifies for financial rebates under HITECH ActLO 3.3 User PreferencesLO 3.3 User PreferencesEstablishment of personal user preferencesOffice Visit form viewSearch modePop-up textMeasurementTime FontRx Print AttendingLO 3.3 User PreferencesPreference 2PasswordSignatureLO 3.4 Setting Up and Editing PatientsLO 3.4 Setting Up and Editing PatientsAdding new patientsFirst & last nameDate of birthEditing patientModify demographicsDeleteArchiveView all patientsLO 3.5 Customizing Pop-Up TextLO 3.5 Customizing Pop-Up TextPop-up text Functions like pick lists Enables the user to select words, phrases, or paragraphs with the click of the mouseProvides rapid way to document Stored by user log-in nameModified without affecting any other user’s pop-up textLO 3.6 Understanding The Electronic ChartLO 3.6 Understanding The Electronic ChartElectronic chart Repository for patient health data created through computer automation in the healthcare settingStatic information such as demographics, allergies, health history, and health problemsDynamic information including encounter notes, nurse notes, tests, letters, and reports concerning the patientLO 3.6 Understanding The Electronic ChartFace sheetContains more constant patient information such as allergies, problem list, and past health history (PMHX) Used in inpatient and outpatient settingsLO 3.6 Understanding The Electronic ChartCare TreeEncounters (progress notes)TestsOther current recordsLO 3.7 The Face SheetLO 3.7 The Face SheetFace SheetDemographicsSocial historyPast health historyFamily health historyReferralsChart noteLO 3.7 The Face SheetFace Sheet (cont.)Routine medsOutside medsProblem listChart alertPatient annotationsDx, Rx, and procedure historyLO 3.8 The Care TreeLO 3.8 The Care TreeCare TreePreset categories cannot be altered 30 customizable categories