Lecture Nursing documentation using electronic health records: Chapter 3 - Byron R. Hamilton, Mary Harper, Paul Moore

3-1

Chapter 3
Essential Documentation

McGraw­Hill

© 2012 The McGraw­Hill Companies, Inc. All rights reserved.


3-2

Chapter 3 Content
LO 3.1 SpringCharts Features
LO 3.2 A Brief History
LO 3.3 User Preferences
LO 3.4 Setting Up and Editing Patients
LO 3.5 Customizing Pop-Up Text
LO 3.6 Understanding The Electronic Chart
LO 3.7 The Face Sheet
LO 3.8 The Care Tree


3-3

LO 3.1 SpringCharts Features


3-4

LO 3.1 SpringCharts Features

•
•
•
•

CCHIT certified
Easy to use
Rich in features
Customizable to suit a wide range of
healthcare specialties
• Principles of electronic documentation
transfer from system to system


3-5

LO 3.2 A Brief History


3-6

LO 3.2 A Brief History
• SpringCharts
– Developed over 10 yr period
– 2004 – developed PMS/EHR interface
– 2006 – CCHIT certified
– 2009 – SureScripts certified for eprescribing
– 2010 – ONC certified, qualifies for
financial rebates under HITECH Act

3-7

LO 3.3 User Preferences


3-8

LO 3.3 User Preferences
• Establishment of personal user
preferences
– Office Visit form view
– Search mode
– Pop-up text
– Measurement
– Time
– Font
– Rx Print Attending


3-9

LO 3.3 User Preferences
• Preference 2
– Password
– Signature


3-10

LO 3.4 Setting Up and Editing
Patients


3-11

LO 3.4 Setting Up and Editing
Patients
• Adding new patients
– First & last name
– Date of birth

• Editing patient
– Modify demographics
– Delete
– Archive
– View all patients


3-12

LO 3.5 Customizing Pop-Up
Text


3-13

LO 3.5 Customizing Pop-Up
Text
• Pop-up text

– Functions like pick lists
– Enables the user to select words,
phrases, or paragraphs with the click of
the mouse
– Provides rapid way to document
– Stored by user log-in name
• Modified without affecting any other user’s
pop-up text


3-14

LO 3.6 Understanding The
Electronic Chart


3-15

LO 3.6 Understanding The
Electronic Chart
• Electronic chart
– Repository for patient health data created
through computer automation in the
healthcare setting
– Static information such as demographics,
allergies, health history, and health
problems
– Dynamic information including encounter
notes, nurse notes, tests, letters, and
reports concerning the patient

3-16

LO 3.6 Understanding The
Electronic Chart
• Face sheet
– Contains more constant patient
information such as allergies, problem
list, and past health history (PMHX)
– Used in inpatient and outpatient settings


3-17

LO 3.6 Understanding The
Electronic Chart
• Care Tree
– Encounters (progress notes)
– Tests
– Other current records


3-18

LO 3.7 The Face Sheet


3-19

LO 3.7 The Face Sheet
• Face Sheet
– Demographics
– Social history
– Past health history
– Family health history
– Referrals
– Chart note


3-20

LO 3.7 The Face Sheet
• Face Sheet (cont.)
– Routine meds
– Outside meds
– Problem list
– Chart alert
– Patient annotations
– Dx, Rx, and procedure history


3-21

LO 3.8 The Care Tree


3-22

LO 3.8 The Care Tree

• Care Tree
– Preset categories cannot be altered
– 30 customizable categories