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PICKING UP A NEW PATIENT (physician)

PICKING UP A NEW PATIENT (physician). 1. Choose a patient 4. Click to begin documenting 2. Assign a doctor (if not already assigned at triage) 3. Confirm that the system chose the template which you want. If not, chose the template from the drop down list.

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PICKING UP A NEW PATIENT (physician)

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  1. PICKING UP A NEW PATIENT (physician) 1. Choose a patient 4. Click to begin documenting 2. Assign a doctor (if not already assigned at triage) 3. Confirm that the system chose the template which you want. If not, chose the template from the drop down list.

  2. Documentation begins on the HPI page

  3. Control buttons take the user to clinical sections of the chart HPI = This is the History of Present Illness section ROS = Review of Systems, PMH, SH and FH sections EXAM = the Physical Exam section of the chart MDM = Medical Decision Making (test results, Tx, Dx) Order 1 = Order sheet for Labs and X-rays Order 2 = written orders for nurses, respiratory therapy, etc. PROC = Procedure templates (36 different procedures) RX / DC = Prescription writing and Discharge Instructions X–T = Extra Typed Note (a blank page for typing) X–N = Extra Note (a blank page for hand writing) PICT = Picture Templates (body diagrams on which to draw findings) DICT = Dictation. This allows the user to document that the chart (or part of it) was dictated

  4. Templates contain reminders of documentation requirements

  5. Large body diagrams are available for documentation (in addition to the diagrams that are already on the Exam page)

  6. There are more than 36 procedure notes

  7. Lab and X-ray orders can be sent to the unit secretary

  8. Orders can be sent to the nurses

  9. Orders are signaled on the tracking board, and the nurse or secretary can indicate when the order is in progress or completed

  10. Care can be transferred from one physician to another

  11. Prescriptions and discharge instructions can be written (an optional feature)

  12. When the chart is signed by the physician (and mid-level/resident), a summary of the pages used for documentation is provided, as well as a warning if key pages have not been completed

  13. Nurses can also document electronically

  14. Your hospital’s current forms can be used, or customized forms can be created

  15. Nursing procedure notes are also available

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