Show:
Chart Evaluation
Resources and Clinical Tool Terms
Documentation
Importing Documents
Patient Instructions/Face Sheets
100
What does a user select to setup chart evaluations?
What is Chart Evaluation from the Administration Menu
100
Define Chart Evaluation?
What is a CDS Tool that define preventative health criteria and allows providers to search patient charts to ensure the criteria are met, thereby supporting disease management, providing routine preventive services, and ensuring healthcare wellness standards.
100
Where in SpringCharts can the user set up a Superbill?
What is in the Administration panel on the SpringCharts server (or under the Administration menu for a single user version).
100
Where are users allowed to enter all text into the SOAP note and view the entire note?
What is in "Show Chart Summary".
100
Which navigation tab allows the user to add a portion of the entire face sheet to the office visit note by simply clicking on one or more of the category icons?
What is {FS}
200
Define the SpringCharts Chart Evaluation feature?
What is an application which allows users to define preventative health criteria and then assess patients' charts for these criteria.
200
Define Wellness Screenings?
What are Periodic medical check-ups to test for or inoculate against significant diseases. Wellness screenings are preventive services given to patients to prevent medical conditions.
200
In the SpringCharts EHR program, where does the clinician records the patient’s vitals?
What is under the {Vitals} tab of the office visit notes.
200
In which screen can the Patient Instructions be accessed?
What is: patient instructions can be created in SpringCharts or imported into SpringCharts then accessed in the Office Visit screen to print or e-mail for the patient.
200
The Date of Service will automatically default to which date?
What is the date of the office visit note was first created.
300
If a patient is current with the evaluations and health management screenings, what message will a user receive?
What is "Patient is up to date with recommendations".
300
In the Edit Chart Evaluation Item window, users define criteria by what?
What are by gender (male or female), age, actions (indicate the test, procedure, or encounter required meeting the criteria), recurring (specify if this is a recurring criterion or one-time event), diagnoses, having lab or medication, and high clinical priority. *(The diagnosis criteria are optional)
300
In the SpringCharts EHR program, where does the clinician initially records the patient’s symptoms and complaints?
What is under the chief complaint {CC} tab of the office visit note.
300
Editing an unlocked office visit note as a future date updates what?
What is: the last modified date
300
Define Patient Instructions Manager?
What is: The patients Instructions Manager is a central location in SpringCharts that houses all patient education material. From here patient instructions can be created, modified, and linked to diagnoses, and medications for flagging in a patient’s OV screen.
400
When should the process of evaluations of all charts take place?
What is after hours because the process takes some time.
400
Define Clinical Decision Support (CDS)?
What is an EHR-integrated system designed to assist physicians and other healthcare professionals with evidence-based decision making concerning patient healthcare using clinical databases.
400
Define the Draw program?
The Draw Program is accessed in the OV screen and enables providers to document injuries, pain locations, skin abnormalities, and so on, on templates of body areas or imported images. The completed drawing remains a permanent part of the OV notes.
400
There are many ways that tests can be added into the office visit note, but the use of ____________and ___________ is the most rapid way of building documentation.
What are: pop-up text and templates
400
Define Rich text format (RTF)?
What is a document file format developed by Microsoft for cross-platform document interchange so that most word processors are able to read and write in the RTF format.
500
What message will a user receive to indicate that no chart evaluations have been set up on the SpringCharts server?
What is "No criterion set".
500
Define the National Guidelines Clearinghouse (NGC)?
What is a comprehensive database of evidence-based clinical practice guidelines and related documents.
500
Name the nine basic vital signs that appear by default in SpringCharts?
What are temperature, respiration, pulse, blood pressure, height, weight, head circumference, body mass index (BMI), and body fat.
500
How does a user access the New Patient Handout window to import a RTF file or create his/her own patient instructions document?
What is under the new menu on the main window the users will select New Patient Instructions. The users are then given the option to either import a RTF file or to create their own patient instruction document.
500
Define Care Plans and Practice Guidelines?
What are specific documents that guide all individuals involved in a patient’s care, outlining the appropriate treatment that will ensure the optimal outcome. A caregiver unfamiliar with a patient should be able to find all of the information needed to care for the patient in these documents.