1. The Office Visit Clinical Tools
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 figure
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/ 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) 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

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