ACUITY SCREEN
This is the screen where the choice of how to document occurs. Three choices exist. As illustrated at the top of the screen, the recommended acuity level for Shortness of Breath, is a level 5. This will be the level that the intuitive interface proceeds from. This doesn't mean that an interaction that results from a diagnosis normally triggering a level 3 charge, will be billed at a higher level. i.e. A diagnosis of bronchitis will not trigger a level 5 charge.
The choice within the red circle is the Quick Record template activation. Choosing this will activate an archive of preformatted, diagnosis specific templates, that require minimal data entry in 3 areas of the record to create a chart customized to that patient. Each template was developed from a query of commonly used pertinent negatives and pertinent positives that pertain to a specific diagnosis and/or mechanism of injury. The included descriptors have been historically shown to be included within a standard work-up for a specific diagnosis. To initially utilize the software system the user would benefit by becoming familiar with the top 30 most common diagnosis's templates, and the data included in them . This way they can decide if their style of documentation is consistent with the template, or they will know how to rapidly change included data to meet their needs.
PEARL: Once a Quick Record template has been altered to fit a practitioners documentation style, all that they need to do is save it within their own Private Standards archive, for future use.
The area within the yellow circle represents the users Private Standard archive. The activated user archive will be that user that is currently logged on.
The area within the blue circle represent the method in which to document a patient completely from scratch. This is the method that will be illustrated in this module.
Press the Document Patient selection within the blue circle
Copyright © 1999 [ER RECORDS, INC]. All rights
reserved.
Revised: November 26, 2000
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