4 Single Problem Visits Flashcards
What are some things a provider would do in the chart?
Review what was entered by a nurse Review allergies Review any surgery and family history I progress that's Update the problem last Place orders and prescriptions Right patient instructions Document level of service and billing codes Examine an interview the patient
What are some items and nurse would do?
Enter height and weight Review allergies Document immunizations Review medications Document any point of care transaction results
The epic term for one visit for example office phone is called what?
An encounter
What is the keyboard commands to navigate the chart
F8 to navigate
Press tab to…
Used instead of enter to quickly move to the next field
The nurse typically use this medication section while rooming their patient.
Can you add a pharmacy in this section?
Yes adding a pharmacy in the medication section is where nurses document
Well the medication section show archived medications?
No the medication section only shows current medications not discontinue are expired these are seen in chart review and synopsis or the medications and order section
Do you enter provider in patient reported medications?
No as long as you leave it empty historic call provider will be documented automatically
Why is it important to Mark medications long-term?
Long-term is considered to be current medication even after it’s in the day passes to allow for crosschecking drug interactions these can be marked with a red pen
When placing an order and the purple square signifies what?
Future order
When placing an order two small separate circles signify what?
The order has not been associated with the diagnosis
What is EnROL?
This allows matching completion on multiple words you must use a space between each
What is a summary sentence?
Beneath appended order is a blue hyperlink that is a subset of details
What is the order composer?
This is a box of details for that order to open it click the name of the pended order are the summary sentence beneath it
What is an authorizing provider
The person who is legally responsible for the orders. An ordering user can be a nurse or an intern are the physicians assistant
Where do you release a child order. A child order is an open order for future and standing orders
Release the order in order review activity. Access it via more activities -> order review
Can you remove an order after it’s been signed?
No you have to formally cancel it and give a reason
Allergies with a yellow background signify severity high true or false
True
what displays if patient has never been asked about allergies?
Unknown:Not on file
If allergies or previously entered and then deleted what messages is displayed?
No active allergies
To release a standing order
Go to more activities at the bottom of the screen
Select order review
Select order and then release
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