The MEDICAL INFORMATION section stores clinical patient data. This clinical information can either be manually entered directly into the appropriate tab within the chart, or will automatically pull from an encounter note and populate the tabe if entered into the encounter during a patient visit. For exampl, in the Labs, Radiology, and procedures tabs, there are two sections; Point of Care and Outside Orders. All tests listed in the Point of Care sections were conducted during a patient visit, and therefore documented in the visit encounter note. Once it was documented in the encounter note, the data also populated the Point of Care section in the patient chart to be stored and referenced when necessary. The Outside Orders section in each tab allows a user to create an order directly within the chart if that test happens to be ordered outside of a patient visit.
In this course we'll cover all areas included in the Medical Information area;
Summary
Past Visits
Details
Forms
HX
Medical History
Surgical History
Social History
Family History
Conservative Therapy
Allergies
Problem List
Labs
Point of Care
Outside Labs
Documents
Radiology
Point of Care
Outside Radiology
Other Results
Procedures
Point of Care
Outside Procedures
Imm/Injections
Immunizations
Injections
Immunization Table
Immunization Record
Request History and Forecast
Supplies
Meds
Medications
Point of Care
Refill Summary
Health Maintenance
Health Maintenance Plans
Patient Reminders
Health Maintenance Flow Sheet
Vitals
Custom Plan Sections (if applicable)
This course is intended for those with the following roles: Practice Administrator, Medical Assistant, RN, Nurse Practitioner, Physician Assistant, Physician