Tag: Medical

Problem List

Kayce Cole

BEST PRACTICE: Add Dx from the Visit screen. Use the Problem List for reference to see Dx history and cases sise-by-side.

problem-list

  1. Delete – Remove all record of Dx
  2. Edit – Change a property of the selected record
  3. Description – As defined for Billing Code library
  4. Problem Code – As defined for Billing Code library
  5. Diagnosed – Date first entered/diagnosed
  6. Modified – Most recent date the record was altered/modified/edited
  7. Visit Type – Associated visit type for case management
  8. Index – Not editable. Reflects order of Dx from Visit Screen

Adding a Diagnosis

tools-problem-create

  1. Problem Code – Description and Code listed in Billing Code library
    1. Add Problem Code
  2. Visit Type – Associated visit type for case managemnt
  3. Status – Active, resolved, or chronic
  4. Diagnosed Date – Use calendar tool to select or type in date
  5. Save and Return to Problem List

SUBMENU: Medical

Judy Barnes

NAVIGATION:

  1. Access the patient page
  2. Expand the Medical Menu from the Patient Navigation Menu<
  3. Select the Submenu item

The Medical tab is in the Patient Navigation Menu for each Patient. By clicking on the arrow at the right side of the tab, a drop down list will display. This list includes: Problem List, Vitals, Family History, Social History, Past Illness, Hospitalization, Injuries and Medications and Allergies. Click on each tab to be able to create, review or update records.

An overview of the Medical Tab can be seen from the Dashboard Tab also. Any tab on the Dashboard that has a plus sign can have data entered through the Dashboard and will store with in the selected Medical Sub-menu.

Vitals

Judy Barnes

Vitals Record List

  1. Access the patient page
  2. Expand the Medical Menu
  3. Select Vitals
    Patient_Vital

Add Vitals from Vitals Widget

  1. Access the patient dashboard
  2. Click the ‘+’ sign on the bar above the graph.Medical Menu
Plot of patient height, weight & BMI are available on the Vitals Widget
The vitals widget is available on the Patient Dashboard

ENTERING DATA:

From the Vitals Record List, select the pencil icon to edit a record or the Add New Vital button to open the Vitals Entry Tool.

Vital entry tool tracks blood pressure, height, wieght, temperature, heart rate, pregnancy status, and calculates BMI automatically.
Enter and edit patient vital records using the Vitals Entry Tool

Medications

Judy Barnes

Medications

  1. Medication
  2. Strength
  3. Dosage
  4. Frequency
  5. Start Date
  6. End Date
  7. Active
  8. Entry Date
  9. NDCID
  10. Edit
  11. Delete
  12. Create (see below)

Adding a Medication

tools-medicine-create

  1. Medicine
    1. Launch Select  Medicine/Medication Tool
  2. Dose – Select Dose from drop down list
  3. Frequency – Select frequency from drop down list
  4. Strength  – Enter strength
  5. Start Date – Date patient stater taking medication
  6. End Date –  Date patient stopped taking medication
  7. Active – Patient is currently taking medication
  8. Save Button and Navigate back to Medication List