Tutorial IndexMain Window
Managing Patients
Charting Office Visits
Tests and Procedures
Templates
Communication
Clinical Tools+ Chart
Evaluation Coding and Billing+ E&M Coder Utilities
Standards
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Using the New Office Visit Large Form - TabsNew OV Large Form OverviewThis Tutorial will focus on the use of the colored tabs a the top of the New OV Large form. These tabs allow the user to quickly move to the phase of the visit they choose to chart. The next Tutorial will deal with the New OV Large menu bar. The New OV Large form, as shown below, is designed to facilitate the rapid and accurate documentation of an office visit. The New OV form can be accessed from the Patient Window by selecting New > New OV. If the New OV large form has been selected as the user’s preference, the New OV Large form appears as follows with data from the Face Sheet initially displayed in the right panel.
The screen shot below shows how selecting the navigation buttons at the top of the window places the appropriate Mini-Templates (also called PopUp Text) into the panel in the upper right hand side of the New OV form. In this example below, the blue CC or chief complaint button is selected and the S, or Subjectives, Mini-Templates are made available for use.
Tap-N-Go / Click-N-Go OperationOne can easily add text from the Mini-Templates in the S Panel at the right of the window by selecting the desired line. This is done by tapping the desired text once (Tablet PC) or clicking it once (mouse operation). This is called Tap-N-GoTM or Click-N-GoTM. In the example below, the user has tapped 'Ear ache.' 'Congestion.' and 'HA.' which are staged in the Staging Area in the lower left hand corner.
Changing TextThe user who can make changes, insertions, deletions or replacements to the text in the Staging Area using normal editing techniques . In the example below, the user keyed the word "Severe" in front of HA. Data can be entered in any number of ways, including keying, handwriting recognition (Tablet PC), Tap/Click-N-Go selection of Mini-Template text, speech recognition and insertion of Templates. (See Templates–OV for more on using Templates.)
Review of Systems (ROS)Selecting ROS from the tabs across the top causes the staged CC text to be placed in the chart and makes the ROS-Normals Mini-Templates available for selection. In the example below, "GENERAL" and "No weight change, fever, chills, night sweats, generalized weakness." were placed in the Staging Area with only two taps on a Tablet PC.
Use of Mini-Templates / PopUp TextA user can access additional PopUp Text lists in either of two ways in the New OV Large form. The first is by selecting the down arrow to the right of the PopUp Text list name (in this case in the upper right corner next to ROS-Normals. SpringCharts will then present PopUp Text for the selected list. See below.
Alternatively, one can select the red box with the black down arrow () in the lower left corner of the New OV Large form and the following window will appear. In either case the selected text will appear in the staging area.
It is important to note that in general, wherever the red box with the black down arrow () appears, one can call up PopUp Text for insertion into the current form. This option is widely available in SpringCharts and is a key element supporting rapid documentation, rapid construction of letters, and the various forms of electronic communication. VitalsSelecting Vitals from the navigation tabs places notes which have been assembled so far into the chart and presents the Vitals panel. Note past Vitals are presented for reference. All vitals are range checked for reasonableness.
The buttons at the top
right of the Vitals panel (
ExamWe have added a few more items to the chart in the manner shown above. Note in the box in the lower right side there is a log of examination entries from previous charts. By highlighting text from the previous charts and selecting the Copy Prev Note icon ( ), one can place previous notes into the current chart as was done below by copying 'EARS: external auditory canals and TMs normal. Hearing normal as tested by whisper and Rinne/Weber.'.
DiagnosesWe will cover several things with the screenshot below:
PrescriptionsThe approach for handling prescriptions is similar to that of diagnoses and will not be repeated here. However, there are two additional functions that are available.
TestsIn the example below, in the TEST box we searched on 'CBC', and it was placed in the Select Test To Order list. We then selected it, and it was placed in the Selected Test list. Finally, we selected it and it was placed in the Staging Area to be charted.
Then we selected the printer icon () in the staging area and the Orders dialog box appeared to assist us with writing an order. Note the Orders PopUp Text and Previous Dx log are offered for inclusion in the Order. For use of Templates at this point, see Templates–Orders.
The printed order looks like this:
ProceduresProcedures are entered into the chart in a manner similar to the items discussed above. For more on procedures, see Procedures. Other TxOther Tx - Other Treatment is handled similar to the tabs above and can be used to document a referral to a specialist, or chart any other treatment that might be discussed with the patient. Follow Up / ReminderF/U-Rem allows the user to set follow ups for themselves or other members of the staff. Final StepsOnce the charting activity is complete, select Done. SpringCharts will then present the following dialog box below. The visit can be saved in the Care Tree under the default of Encounters or, using the drop down menu, at a tab defined by the user:
Finally, the user can select
Save and Edit Routing Slip, which prepares the note for the
billing process, or Save and Skip Billing, which files the note
and completes the charting activity. New OV Classic FormWith Version 6.5, SpringCharts added the New OV Large, in addition to the original new office visit form, now called the New OV Classic form. Users may choose to use the old New OV Classic form or the New OV Large form by selecting the chosen form under the Edit > User Preferences menu.
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offer Vitals graphs. One example is shown below. The other
graphs are available from the buttons at the bottom of the screen.
