Tutorial Index

Main Window

  Introduction
  Main Window
   Overview
  Main Window Menus
  Appointments with
  NDC Medical Connect 

Managing Patients

  Patient Selection
  New Patients
  Patient Chart
  Demographics with
   NDC Medical Connect
+ Demographics with
   MacPractice MD

Charting Office Visits

  New OV Large -
    Tabs
  New OV Large -
    Menus
  New OV Classic
+ File Cabinet
+ Face Sheet Manager

Tests and Procedures

  Ordering Tests
  Managing Tests
+ SpringLabs
   Electronic Results
  Procedures

Templates

  Templates
  Templates–OV
  Templates–Orders
  Templates–Letters
+ Mini-Templates
  Templates - Import /
    Export

Communication

  Letter Writing
  Email
+ Messages
+ Urgent Messages
+ ToDo/Reminders
+ Bulletin Board

Clinical Tools

+ Chart Evaluation
  Patient Instructions
+ Epocrates Rx

Coding and Billing

+ E&M Coder
+ Superbill Form
  Medical Connect
   Flow
  Medical Connect
   Setup
  Medical Connect
   Billing

Utilities

  Import/Export Utilities
  Spell Check
  Set Categories
  Backup
  Search/Form Letters
  Duplicate Chart
   Manager
+ Time Clock
  Integrated Help

Standards

Introduction to the Patient Chart

This page is an introduction to the Patient Chart, and, as such gives only an overview of the functions available from the Patient Chart window.  There will often be links offered that go to other pages of instruction should the user want more information on that subject.  However, it the student is urged to consider staying with the flow of the Tutorials as we will get to the detail information once the overview is completed.

A Patient Chart is opened using the Patient Selection process, or by selecting a patient's name from the Calendar or the Patient Tracker.  A typical Patient Chart is shown below:

The Patient Chart is composed of three key areas:

1. The Care Tree on the right side, which records encounters (progress notes), tests and other records,

2. The Face Sheet, which is a series of panes on the left for recording and reviewing and editing persistent patient information such as Allergies, Problem List, PMHX, etc as well as presenting demographic, referral and insurance information,

3. The Preview Pane in the lower right hand corner of the window, and

4. The Patient Chart menu bar at the top of the window.
    

Care Tree

The Care Tree can be expanded by selecting the "+" sign in front of a Chart Tab of interest.  In the case below, Encounters was expanded to show a large number of notes. 

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Preview Pane

By selecting the "01/09/2005 Office Visit", the selected item is previewed in the Preview Pane in the lower right hand corner.  The following choices are available with the Preview Pane:

1. Review or Edit () the selected item,

2. Print () the selected item,

3. Prepare a Report () for the selected item, or

4. Close () the Preview Pane.

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Face Sheet

To edit an item in the Care Tree, select the item you wish to edit, and the Face Sheet Editor, shown below will appear.  In this case, we selected Routine Meds, so the editor offers the capability to:

1. Search for medicines using the box next to the binoculars ( ) in the upper right hand corner,

2. Include any of the Previous Medications by simply selecting the chosen medicine from the list,

3. Use Epocrates Rx to search for a drug, using the Epocrates Rx icon ().
    

Should the user want to change any of the other Face Sheet items, it is only necessary to select the appropriate button from the left hand side of the window.  The user will then generally be presented with the capability to search for an item, select an item from a short list of likely choices, or to manually enter data.

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Patient Chart menus

File menu

  Find Text - searches the entire chart for a matching word.  See  Search/ Form Letters for specifics.
  Evaluate Chart - checks this patient's care history for criteria set up by the user. These criteria can be very flexible and can be a powerful tool for preventative medicine. See Chart Evaluation for details.
  Export Chart allows the user select any or all of the chart entries to be exported to a text file.
  Print Chart allows you to print all or parts of the chart.
  Print Face Sheet allows the use to print the entire Face Sheet.
  Close Chart closes the chart and returns the user to the Main Window.
  Lock Chart prevents any user from viewing this chart other than the user who locks the chart.
  Change View allows the user to change the level of detail presented in the Care Tree.

Edit menu

The menu items Allergies through Chart Alert call up the Face Sheet Editor and initialize it to the selected category.

  Allergies allows entering and editing allergies and other sensitivities.
  PMHX allows entering and editing of past medical history.
  FMHX allows entering and editing of family medical history.
  Medications allows entering and editing of the patient's routine medications and OTC meds.
  Immunization allows entering patient's past immunizations. Any new immunizations are    automatically entered for you.
  Problem List allows editing of the problem list. Entries can be either diagnosis or text.
  Social Hx allows entering and editing social history.
  Chart Note is a location for entering information about a patient which is not an encounter-- it    replaces sticky notes.
  Referring Dr allows setting and editing the referring doctor - the user chooses the doctor from their address book.
  Chart Alert allows the user to place red text just above the Care Tree in the Patient Chart, calling attention to any exception, whether clinical, billing, behavioral, or whatever is desired.
  Set Default Pharmacy allows editing the patient's routine (default) pharmacy.
  Delete Default Pharmacy allows you to delete the default pharmacy.
  Edit Pt Photo allows placing the patient's photograph in the chart.

Windows menu

The Windows menu allows the user to switch among open windows for the current patient or to close all open windows.

Actions menu

New menu

Detailed instruction on these menu items is presented later in the Tutorials.  A brief summary is given below.

  New OV creates a new office visit which is filed in the tree under Encounters.
  New Note creates a blank note which is filed in the tree under Encounters.
  New Nurse Note creates a new nursing note which is filed in the tree under Encounters.
  New Rx Refill creates a new medication refill form which is filed in the tree under Encounters.
  New TC note creates a new telephone encounter form which is filed in the tree under    Encounters.
  New Vitals Only creates a new vitals form which is filed in the tree under Encounters.
  New Letter to Pt creates a new letter addressed to the patient which is filed in the tree under  
   Encounters.
  New Letter ABOUT Pt creates a new letter concerning the patient. Recipient name and
   address information can be easily retrieved from the Address Book.
  New Test Report creates a blank test reporting form. Completed tests for this patient can be    added from a PopUp Text list.
  New Excuse/Note/Order provides for the creation of printable forms for work/school excuses,    notes or orders.
  Flow Sheets allows the creation of a simple document for repeated use. Commonly used for    tracking diabetes results, allergy injections, etc. Once a Flow Sheet is created, it appears in the    tree from which can be later modified.

 

New / Import Items detailed menu

 

  Import New Text File allows the import of a text file into the patient’s chart. This approach may be used to import previous records.
  Import Picture (.jpg or .gif) provides for the import of pictures and other graphic data in *GIF or *JPEG format into the patient's Care Tree under Encounters.  Please note:  It is strongly urged that, for performance reasons, images be stored in the File Cabinet Document Manager.
  Import Document provides access to the File Cabinet Document Manager.  Instruction on the  File Cabinet Document Manager will come up in sequence shortly, but one can click here for immediate instruction.

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