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

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

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

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

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.

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

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.

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.

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.

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.

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.

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.

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.

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.

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

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

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.

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

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