Chapter 3 - Essential documentation. After completing Chapter 3, the students will be able to: Describe the basic features of SpringCharts EHR, describe the history of SpringCharts EHR, apply user preferences, carry out setting up and editing patients, use pop-up text, explain the concept of an electronic chart, use the electronic chart’s face sheet, use the SpringCharts EHR care tree.
3-1 Chapter Essential Documentation McGrawHill © 2012 The McGrawHill Companies, Inc. All rights reserved 3-2 Chapter Content LO 3.1 SpringCharts Features LO 3.2 A Brief History LO 3.3 User Preferences LO 3.4 Setting Up and Editing Patients LO 3.5 Customizing Pop-Up Text LO 3.6 Understanding The Electronic Chart LO 3.7 The Face Sheet LO 3.8 The Care Tree 3-3 LO 3.1 SpringCharts Features 3-4 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 3-5 LO 3.2 A Brief History 3-6 LO 3.2 A Brief History • SpringCharts – Developed over 10 yr period – 2004 – developed PMS/EHR interface – 2006 – CCHIT certified – 2009 – SureScripts certified for eprescribing – 2010 – ONC certified, qualifies for financial rebates under HITECH Act 3-7 LO 3.3 User Preferences 3-8 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 3-9 LO 3.3 User Preferences • Preference – Password – Signature 3-10 LO 3.4 Setting Up and Editing Patients 3-11 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 3-12 LO 3.5 Customizing Pop-Up Text 3-13 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 3-14 LO 3.6 Understanding The Electronic Chart 3-15 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 3-16 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 3-17 LO 3.6 Understanding The Electronic Chart • Care Tree – Encounters (progress notes) – Tests – Other current records 3-18 LO 3.7 The Face Sheet 3-19 LO 3.7 The Face Sheet • Face Sheet – Demographics – Social history – Past health history – Family health history – Referrals – Chart note 3-20 LO 3.7 The Face Sheet • Face Sheet (cont.) – Routine meds – Outside meds – Problem list – Chart alert – Patient annotations – Dx, Rx, and procedure history 3-21 LO 3.8 The Care Tree 3-22 LO 3.8 The Care Tree • Care Tree – Preset categories cannot be altered – 30 customizable categories .. . 3- 2 Chapter Content LO 3. 1 SpringCharts Features LO 3. 2 A Brief History LO 3. 3 User Preferences LO 3. 4 Setting Up and Editing Patients LO 3. 5 Customizing Pop-Up Text LO 3. 6 Understanding... Stored by user log-in name • Modified without affecting any other user’s pop-up text 3- 14 LO 3. 6 Understanding The Electronic Chart 3- 15 LO 3. 6 Understanding The Electronic Chart • Electronic chart... Measurement – Time – Font – Rx Print Attending 3- 9 LO 3. 3 User Preferences • Preference – Password – Signature 3- 10 LO 3. 4 Setting Up and Editing Patients 3- 11 LO 3. 4 Setting Up and Editing Patients •