1 / 21

Basic Dynamic Documentation Training

Learn the basics of Dynamic Documentation in this Computer-Based Training without audio. Navigate through various topics such as Chief Complaint, Physical Exam, Diagnoses, Orders Entry, and more.

helenf
Download Presentation

Basic Dynamic Documentation Training

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Basic Dynamic Documentation Welcome! …to the Computer-Based Training on BasicDynamic Documentation

  2. Instruction Basic Dynamic Documentation • This Computer-Based Training (CBT) does not contain audio. So be sure to follow instructions as you go through this CBT. • To go through the CBT, you can either click on the topics listed under TOC or simply click the buttons on the bottom left corner to move through the lesson. • Click the Next button to advance to Next topic. • Click the Back button to go back to the Previous topic. • Click the Home button to return to the Introduction page.

  3. Introduction Basic Dynamic Documentation This CBT will introduce you to the basics of using Dynamic Documentation. Here are the topics for this CBT: Table of Contents (TOC) Overview – Dynamic Document Chief Complaint & HPI Past Medical History Review of Systems (ROS) Vital Signs & Physical Exam Documents & Labs Procedures/Consults Order Entry (14:38) Assessment Plan Creating a Note Diagnoses Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Diagnoses Procedures/Pending Results Let’s get started! Click on the individual topic listed under TOC or the Next button to continue. Quality Measures Discharge Orders Follow Up Care Orders Hospital Course

  4. Overview – Dynamic Documentation BasicDynamic Documentation TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Diagnoses Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course

  5. Chief Complaint & HPI BasicDynamic Documentation TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Diagnoses Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course

  6. Past Medical History BasicDynamic Documentation TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Diagnoses Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course

  7. Review of Systems BasicDynamic Documentation TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Diagnoses Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course

  8. Vital Signs & Physical Exam BasicDynamic Documentation TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Diagnoses Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course

  9. Documents and Labs BasicDynamic Documentation TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Diagnoses Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course

  10. Procedures/Consults BasicDynamic Documentation TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Diagnoses Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course

  11. Order Entry BasicDynamic Documentation TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Diagnoses Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course

  12. Assessment Plan BasicDynamic Documentation TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Diagnoses Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course

  13. Creating a Note BasicDynamic Documentation TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Diagnoses Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course

  14. Discharge Process: Diagnoses BasicDynamic Documentation TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Diagnoses Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course

  15. Procedures/Pending Results BasicDynamic Documentation TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Diagnoses Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course

  16. Quality Measures BasicDynamic Documentation TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Diagnoses Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course

  17. Discharge Orders BasicDynamic Documentation TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Diagnoses Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course

  18. Follow Up Care Orders BasicDynamic Documentation TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Diagnoses Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course

  19. Hospital Course BasicDynamic Documentation TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Diagnoses Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course

  20. Congratulations! You’ve completed the Basic Dynamic Documentation CBT.Please click to continue. BasicDynamic Documentation TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Diagnoses Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course

  21. Basic Dynamic Documentation Pleasedo not closethis window untilyou’ve completed the step below! Click HERE to record your completion of this required CBT – Basic Dynamic Documentation.

More Related