STMO Ch 6 and 7

1. STMO Ch 6 and 7 The Office Visit Clinical Tools

2. The Office Visit • The most common encounter with a patient is the office visit. • SOAP • SUBJECTIVE • OBJECTIVE • ASSESSMENT • PLAN

3. SOAP • SUBJECTIVE- Patient’s current medical condition from patient POV • Includes symptoms, history of illness (present) and review of body systems • OBJECTIVE- doctor’s perspective • Vital signs and finding from physical exam • ASSESSMENT- Diagnosis(es) based on exam • PLAN- what the doctor will do as far as test or treatment • Includes prescribed medications, tests, counseling, or follow-up

4. What are the abbreviations? • Chief Complaint • History of present illness • Review of Systems • Face Sheet • Vitals, Exam, Diagnosis • Prescriptions • Tests, Procedures • Other Treatment CC PI ROS FS Dx Rx Proc Other Tx

5. Look on page 110-111 figure 6.2-6.4 • The CC, PI, ROS, Examination, Proc, Other Tx, and Follow-up/Reminder areas have the addition of notes from previous encounters in the bottom right window. • PI panel navigation button accesses the same S panel pop-up text as the CC panel button. • History and Physical report these categories are broken out into separate ones.

6. Spring charts and vitals • Spring Charts will display all four vitals: • Height • Weight • Blood Pressure • Body Mass Index (BMI)

7. Navigation tabs • The navigation tabs for Dx, Rx, Test, and Proc operate a little differently by offering a search feature of the database instead of the pop-up text. • Rx navigation tab allows the user to view information windows from the patient’s chart related to Allergies and Other Sensitivities.

8. prescriptions • Drug Formulary- reference information, allowing the provider to make clinical decisions more quickly, accurately, and confidently. • Drug Monographs- allows the doctor to access the internet to get information necessary to prescribe a drug to a patient • There is a Drug Allergy/Interaction button that scans the patients current medications and allergy list to make sure patient is safe.

9. Test • Test order forms can be printed out or faxed as a physician order to anywhere. • You will always place the patients PRIMARY insurance information on the order form.

10. Codes and drugs • ICD-9 and CPT codes are downloaded into this program already • They should be the most recent because you are required to have the most recent program in a working office • AMA has a dictionary of drugs/medications. • The doctor can access the database within the office visit screen.

11. Discontinued Medications • When stopping a medication you need to create an Encounter for the patient. • You always need to put the date stopped and the reason for stopping the medication in the patients chart.

12. Office visit reports • The report button in the office visit screen you can print/fax/email to the patient! • Any pending test are going to be in the pending test file. • H and P is a more elaborate report. • Shows allergies, current/past medications, FMHX,PMHX, and social history. • This is a report that you will see in hospitals and referring physicians. It is more suitable for them.

13. Edit menu • Edit menu provides quick access to the face sheet chart categories. • It enables the practitioner the ability to add additional items to the face sheet during the office visit encounters ex. FMHX/PMHX • Also from this menu you can find the patients immunization records. • When entering a immunization date you MUST type the date mm/dd/yyyy.

14. Addendums to an office visit • Providers have the ability to LOCK an OV note • They can either permanently sign or lock the note. • You can ONLY amend these notes • The addendum will be placed at the bottom of the existing office visit note. • The program will automatically date, time and initial-stamp the addendum when it is saved.

15. Tools Menu • H&P • Calculators (3) • Conversion • Pregnancy EDD • Simple • Care plan • Draw • New excuse/notes/order • Patient instruction • Resend Routing Slip/transaction • Spell Check • Template • Date of Service

16. Chart Evaluations • This allows users to define preventive health criteria and then assess patients’ charts by these criteria. • Enable the doctor to be proactive in the wellness screenings of patients

17. Patient instructions • You can create these instructions or import them • They have to be saved in RTF files • Rich Text Format • If you choose to write your own instruction a window is displayed in which patient instructions may be typed out or copied and pasted in Spring charts • Doctors can also attach a document with Plan of Care or Practice Guidelines to a patients chart.

18. Review! • What are the 4 vitals displayed in Spring Charts? • Height, Weight, Blood Pressure, Body Mass Index (BMI) • What do you have to state in a patients chart when stopping a medication • You always need to put the date stopped and the reason for stopping the medication in the patients chart. • Which report is more suitable for hospitals and referring physicians? • H&P Reports

19. Review Continued! • What are the three calculators in SpringCharts? • Conversion, Pregnancy EDD, Simple • Can you change a locked office visit note? • NO!!!!!!!! • If a patient has two insurances which one do you put on a lab order form? • Primary • What enables physicians to be more proactive in the wellness screenings of patients? • Chart Evaluations