Screen #1-Patient
White Board, Highlight desired patient, and click document
patient 1 |
Screen #2-Arrival Information and previous
visit log. Can change arrival time here.
Click 2 to continue to
screen #3 |
Screen #3-Chief complaint screen.
1-Chief
complaint by Organ System or
2-Chief
complaint by Quick Search
Pearl-Double click a desired chief
complaint to have it place in chief complaint window. If you
make a mistake, Right mouse click the tab to the right ( 3
) of the chief complaint window to remove. A number
appears next to the chief complaint. This is the
recognized potential acuity for that chief complaint and a rules
intuitive is. This rules intuitive checks for whether
documentation guidelines are being followed for that level
acuity. This acuity can be changed on the next screen. |
Screen #4-This is the documentation selection screen. One of
three ways to document a patient.
1-Quick
Record-choosing this initiates screen #5.
2-Document
from Scratch
3-Personal
Template Archive
What is a quick record? This is a
diagnosis specific pre-formatted record that utilizes the most
commonly used pertinent negatives and pertinent positives for a
designated diagnosis. All that needs to be altered to make the
record specific for that particular patient is the HPI, MDM,
PMH, and any other patient specific findings that differ from
the norm. |
