OB Physician Documentation End User Education

Agenda 1. Brief Intro to Physician Documentation (PDOC) 2. Features/Benefits 3. Review list of OB Documents 4. How to Document in PDOC 5. Signing Workflow a. Resident to Attending b. Medical Student to Resident to Attending 6. Sign Queue

Why PDOC? Features Automatically imports data from Nursing Assessments Continuously updates with latest lab results Integrates with Home Medications, Allergies and Problems List Documents can be shared among several users

Why PDOC? Benefits Real-time documentation accessible in EMR Improves efficiency of documentation process Reduces the occurrence of conflicting information Includes ICD-10 Specificity to maximize billing

List of OB Documents

Accessing PDOC Click “Document” button within the Patient Chart.

Opening a New Document Click “New” and select a document from the Document List.

Document Sections Documents are organized into sections to simplify navigation.

Home Meds/Allergies Automatically pulls in Home Medications and Allergies if previously documented.

Free Text Boxes Click the drop down arrow to enter free text box. Can be used for typing or Dragon.

Review of Systems Responses for symptoms are either “present” or “not present”. Left Mouse Click Circles the response Indicates symptom is present Right Mouse Click Slash thru response Indicates symptom is not present

Exam Normals Click the “N” to automatically default the exam normals, or select responses on your own.

Instance Queries Click the drop down arrow to select the instance. Associated questions populate.

Results Diagram Lab results will populate the diagrams within the document in real time.

Patient Problems Adding Patient Problems within PDOC will update Problem List. You are able to document an assessment and plan for each problem. 1. Click Drop down arrow 2. Type in search field to find problem.

Problem w/ Qualifiers Certain problems will include qualifier questions to be answered for increased specificity.

Sign Routine Click “View/Save” to enter Sign Routine. Enter your pin to sign the document. Add additional providers if appropriate Additional Providers Enter Pin

Resident to Attending Workflow Resident/PA Attending Initiates the patient note Completes the patient note Assigns Attending for co-signature E-Signs Note (ISigned) Locates Resident note in patient chart Locates Resident note in sign queue. Edits note/adds Attending Attestation E-Signs Note (Signed) OR

Medical Student Workflow Student Attending Initiates the patient note Completes the patient note Assigns Resident for co-signature E-Signs Note (ISigned) Locates Resident note in patient chart Locates Resident note in sign queue Edits note/adds Attending Attestation E-Signs Note (Signed) OR Locates Student note in patient chart Locates Student note in sign queue Edits note/adds Attending for co-signature E-Signs Note (ISigned) Resident

Sign Queue Documents in a draft status, or requiring co-signature will be in your sign queue. Select the documents you would like to sign and click “View & Sign”. Reason Column Blank = your report Cosign = you’ve been added as a cosigner