Chapter 5 - Multi Problem Visits Flashcards
From the Notes activity, how do you open NoteWriter?
Click the arrow next to Create Note > choose a note template > click one of the buttons that appear at the top of Notes (like HPI).
True or False: NoteWriter can be used for LOS and Follow-Up.
False
Dr. Mica is working on the Physical Exam tab in NoteWriter. How can he get to a PE form where he can do more detailed documentation?
Possible answer: Click the appropriate Physical Exam sub-tab.
True or False: On a NoteWriter +/- button, after you click plus, you can change it to a minus.
True
If you cannot find an appropriate HPI form, what SmartTools can you use to supplement your note’s HPI, and where do you do that?
You can use SmartPhrases and SmartTexts in the Note activity.
In the NoteWriter, besides clicking on the + symbol, how can you mark a button positive?
With your cursor over the button, left-click.
In my note template, when I try to type on the orange part that says “HPI,” nothing happens. How can I edit that text?
Go to the HPI form in NoteWriter and make choices (and enter comments) there.
True or False: Diagnoses on the problem list are not associated with orders for billing.
True
True or False: All visit diagnoses for chronic issues should be added to the patient’s problem list.
False (It is the clinician’s decision whether to add a problem.)
Arm fracture is on a patient’s problem list, and is no longer an ongoing issue, as it is healed. What should be done with this problem diagnosis? (Select one) A) Copy it as an encounter diagnosis. B) Mark it as resolved. C) Mark it as deleted. D) Click Change.
B) Mark it as resolved.
Where do you document the administration details for a facility-administered medication?
MAR activity
What is one example of why you’d add a charge in Charge Capture?
Possible answer: To add charges for the administration of a medication.
What diagnosis can be marked as “primary”, Visit Dx , Problem Dx or both?
Visit Dx.
What is HPI?
History of Present Illness
.acch
Glucose readings, “Glucometer readings at home are runnig ***.
