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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
• 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
• 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
• 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 3.4 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
• 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
• 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
• 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