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Chapter 7

Clinical Tools

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• 7.1 Chart Evaluation• 7.2 Test Orders• 7.3 Evaluation & Management Coder• 7.4 Superbill Form• 7.5 Patient Instructions• 7.6 Care Plans or Practice Guidelines• 7.7 Drawing Program• 7.8 Importing Documents

Chapter 7 Learning Outcomes

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• Care Plan and practice guidelines• Chart Evaluation• Clinical Decision Support (CDS)• Draw Program• National Guideline Clearinghouse (NGC)• Patient Instructions Manager • Rich Text Format (RTF)• Superbill• Wellness Screenings• Well Patient Visit

Chapter 7 Key Terms

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LO 7.1 Chart Evaluation

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• Define preventative health criteria on SpringCharts server

• Evaluate patient’s chart for set criteria

• Scan entire patient database for chart evaluations

Chart Evaluation

LO 7.1

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1. Gender2. Age3. Actions4. Recurring5. Diagnosis(es)6. Having Lab or

Medication7. High Clinical

Priority

Criteria Definitions

LO 7.1

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LO 7.2 Test Orders

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• Use Test tab to search for test name in database

• Select test(s)• Order selected test(s)• Send to Pending Tests

area to wait for results• Can be done by clinician

or physician

Test Orders

LO 7.2

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LO 7.3 Evaluation & Management Coder

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1. Set up on a server2. Define keywords for ROS, Exam of Body Areas,

and Organ Systems3. Helps to determine correct E&M code

Evaluation & Management Coder

LO 7.3

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LO 7.4 Superbill Form

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• Customizable to contain additional codes not usually selected from within the Office Visit screen

• Set up Superbill on server

• Available in the Routing Slip windows

Superbill

LO 7.4

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LO 7.5 Patient Instructions

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• Can be created in SpringCharts or imported into SpringCharts

• Accessible from the Office Visit screen to print or e-mail to the patient

Patient Instructions

LO 7.5

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LO 7.6 Care Plans or Practice Guidelines

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• Attach a document stored on the computer outlining care plans or practice guidelines

• Becomes a permanent record attached to the OV note

Care Plan/Guidelines

LO 7.6

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LO 7.7 Drawing Program

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• Enables the provider to indicate the procedure that was conducted by drawing on inbuilt templates

• Elaborate illustrations can be imported from within the computer or a computer on the network

Drawing Program

LO 7.7

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LO 7.8 Importing Documents

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• Import documents to the File Cabinet

• Any file type:– .docx or .doc– .xlsx or .xls– .html– .pdf– .jpg– .DICOM– more

• Stores on SpringCharts Server in a separate folder

• Links to patient’s chart

File Cabinet

LO 7.8

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• Acquire– Imports files from

scanners, cameras, webcams, etc.

• Existing– Imports file from

the computer

Acquire vs. Existing

LO 7.8

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• File Cabinet Documents are accessible from the Productivity Center

• Global searches are available from across all charts by document name, date range, or other search field

• Clinic non-patient documents can be stored here, outside of patient charts

Importing Documents

LO 7.8

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LO 7.1 Create and conduct a chart evaluation• Define preventative health criteria and evaluate based on criteria• Categories for criteria to be set• Information windows for criteria • Performed on individual patients or the entire database• Reminder notices can be sent

Chapter 7 Summary

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LO 7.2 Demonstrate how to order a test in the Office Visit screen• Pending Tests wait for results– Available for viewing in the OV note

• Tests from outside testing facility

Chapter 7 Summary

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LO 7.3 Describe the function of the E&M Coder • Uses keywords to search for which body system or area has been reviewed• E&M recommends a code– Terms and phrases– # of diagnoses– # of procedures– History of encounters

Chapter 7 Summary

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LO 7.4 Demonstrate how to add items to a superbill• Contains additional billable terms and codes outside of what is in the OV note• Items can be added to the routing slip

Chapter 7 Summary

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LO 7.5 Create and administer a patient instruction sheet• Educational material• Create sheets in the EHR program or import• Access and print in the OV note• Map to diagnoses, labs, procedures, or medications• Record is made that information was given to the patient

Chapter 7 Summary

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LO 7.6 Describe how to add a care plan to an office visit• Create and administer within the OV note• Becomes part of the OV note record

Chapter 7 Summary

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LO 7.7 Explain the purpose of the Draw program• Provides a supplement of illustrations for the OV note• Draw templates can be used to illustrate findings• Illustrations and photos can be imported into Draw Program• Illustration is stored in the OV note under Follow-up

Chapter 7 Summary

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LO 7.8 Demonstrate how to import a document to a patient’s chart• Import files to the File Cabinet– Any type– Originating program must be available on the

computer to view or edit document• Documents can be stored in our outside of a patient chart• Link is created in chart• Document is stored in a separate folder on the server

Chapter 7 Summary