Show:
Activities within the OV Screen
Office Visit Reports
Components of an Office Visit
Building an Office Visit Note
Routing Slip and Miscellaneous
100
When an office visit is locked with the Permanent Sign & Lock feature, who may unlock or edit the office visit?
What is it cannot be unlocked or edited, even by the physician
100
The most common encounter with patients in an ambulatory setting is?
What is the office visit (OV)
100
What is the feature in Spring Charts that enables the user to proceed through the office visit in a logical flow?
What is the navigation panel along the right side of the OV screen
100
What is the function of the {time and initial} button and where is it located?
What is to the left of the previous note panel is a {time and initial} button that enables the clinician to time-and-initial-stamp that portion of the OV notes. This feature allows various medical providers to be involved in the same patients encounter.
100
Define Routing Slip (AKA Superbill, Encounter Form, Charge Ticket, Blue/White)?
What is a form that contains the medical office’s most common procedure and diagnosis codes and descriptions.
200
How do you add a patient’s primary insurance to a test order form?
What is the patient’s primary insurance information recorded in his or her chart can be added to the order form by selecting the {Add Pt Ins} button.
200
How would you define an office visit in SpringCharts?
What is an encounter with a medical provider in which the patient’s chief complaint, body systems, vitals, physical exam, diagnoses, and medications are reviewed and documented
200
Define Addendum?
What is a notation added to an office visit note, after it has been permanently signed and locked, to supplement the information in the original note.
200
Define Review of Systems?
What is a structured technique used by providers to gather healthcare history covering the organ systems from a patient. There are 14 body systems recognized by CMS.
200
Define an Evaluation and Management Code?
What is a 5-digit number used by a physician to report evaluation and management services provided to a patient.
300
An order form can also be used as?
What is a referral form
300
Define the acronym SOAP and define each:
What is: S-Subjective-symptoms the patient feels and describes to the health care professional. These symptoms arise within the individual and are not perceptible to an observer O-Objective-symptoms that can be observed, such as those that are seen, felt, smelled, heard, or measured A-Assessment-includes the diagnosis of the patient’s condition P-Plan-includes the management and treatment regimen for the patient; may include laboratory tests, physical therapy, diet therapy, medications, medical and surgical interventions, patient referrals such as counseling and finding a support group, patient teaching, and follow-up directions
300
Define and explain the acronym BMI?
What is Body Mass Index-is a measure of body fat based on height and weight that applies to adult men and women. BMI is the measurement of choice for studying obesity. It is calculated by a mathematical formula that divides a person’s weight in kilograms by their height in meters squared.
300
What is displayed when accessing the prescription {Rx} navigation tab?
What is the prescription {Rx} navigation tab allows the user to view information windows from the patient’s chart related to Allergies and Other Sensitivities. It also displays the patient’s previous medications prescribed by the clinic.
300
Define the E&M Coder?
What is a built-in function of many EHR programs that recommends the appropriate Evaluation and Management code for office visits. *The coder looks for keywords used within the review of systems and physical exam in the office visit note. The E&M coder then uses this information, in conjunction with the diagnoses, to determine the most appropriate E&M code level for billing.
400
Which signature option allows a note to be recalled for further edits?
What is Initial Only allows the office visit note to be recalled for further edits made by anyone with chart editing privileges.
400
Define the History and Physical Report?
What is the documentation of the patient’s medical history combined with the physical exam. The History and Physical Report is often referred to as an H&P. The H&P is the initial clinical evaluation and exam of the patient
400
What features are included in the navigational panel of the OV window?
What is Chief complaints, History of Present Illness, Review of Systems
400
Define Coordination of Care?
What is making available all resources to ensure healthcare providers have access to all required information on a patient’s conditions and treatments and that the patient receives appropriate healthcare services.
400
Define Business Associates?
What are persons or entities that perform activities that involve the use of disclosure of PHI on behalf of a covered entity are considered business associates under HIPAA regulations and must follow the practice’s guidelines to ensure the patients’ PHI remains secure and private.
500
Name the icon in the OV screen which allows a provider to send a To-Do/Reminder to another person in the clinic or to him/herself?
What is: in the lower left window of the F/U-Rem navigation tab the user will find a “create a reminder” icon that will enable the provider to send a T-Do/Reminder item to another person in the clinic or to him/herself/ Clicking on the icon will activate the New To-Do/Reminder window.
500
What is included in a physician’s diagnostic inquiry:
What is description of signs and symptoms, History of Present Illness, Social Conditions
500
What are the three main sections of the OV window (left to right)?
What is the face sheet overview, office visit note section and the pop-up text window.
500
Name the four ways data can be entered into the office visit notes?
What is: 1. Tapping on the pop-up text with a stylus tool (as with a tablet), 2. Clicking on pop-up text items with a mouse, 3. Typing directly into the text box at the bottom of the middle panel, 4. Dictating through a third-party voice recognition program, causing the dictated text to enter the text box.
500
What is the web-based e-prescribing clearinghouse?
What is SureScripts