Using the Patient Window

Using the Electronic Medical Records (EMR) Features

The Electronic Medical Records (EMR) window displays the patient’s clinical information. Use the EMR features to access and enter medical and surgical histories, prescriptions, progress notes, and to manage treatment plans, clinical images, and documents.

Chart Status

The Chart Status displays a list of elements to complete and track for the patient's current appointment.

indicates the element needs action
indicates the element is complete

The list is based on the elements selected in the Appointment Type Data Entry window for the appointment type. The list includes EMR Consents, EMR Notes, Anesthesia, Encounter Slip, and Referral Letters. Some, all, or none of these can be included for a particular appointment type. The default is None, but items are added when you select an EMR type for the appointment type.

• Click to configure the Chart Status settings for the Appointment Type.

Accessing EMR Data and Functions

Use the side panel to access the specific EMR functions. Click a link on the left to display the associated information and options in the window.

Information is displayed in line-item format. Use the buttons on the right to:

Add a new line item

Edit a line item

Delete a line item

Save a new or edited item

Expand the list

Collapse the list

EMR Summary

Click to view and edit details of the patient's Medical History, Surgical History, Allergies, and Medications. You can add items to the summary lists, or edit existing items.

For more information, see Medical History Data.

Procedure Hx

Click to view a list of procedures that have been performed on this patient, beginning with the most recent. Use the buttons on the right to add or edit items.

Patient Reg

Click to view patient registration documents.

• Patient documents from the TruForm patient registration service are automatically displayed.

• Add a document by using the or feature and choosing the Category Health History Form before saving.

Encounter Slip

Click to open the Encounter Slip. This enables you to enter details regarding patient visits, including diagnoses, shortcuts, pre-treatments, procedures, prescriptions, recalls, letters, and notes. You are also able to create actual as well as PTE charges for a specific ticket on this window.

The Visit tab is displayed first. Select a Type and Ticket type from the list, then use the other tabs to finish documenting the encounter:

• ShortcutsShortcuts group related data, such as a set of procedures commonly associated with a specific diagnosis, along with related prescriptions, letters, and recalls. Use the shortcut categories to select details about the patient's visit.

• DiagnosisSelect Diagnosis codes for the visit. Use the Categories list to filter the codes displayed. Categories are based on the type of visit selected.

• Treatment PlansSelect elements and details from the patient's treatment plan to include in this encounter.

• ProceduresClick Show/Hide Tooth Grid to select teeth and the associated procedures for the encounter.

• PrescriptionsAdd prescriptions to the encounter.

• RecallSelect the appropriate recall code.

• LettersSelect any letters to attach or send in response to this encounter.

• NoteType any additional notes in the space provided.

• Use the Interaction link to access the Lexicomp Data Integration feature for the patient's medications and prescriptions.

Rx

Click to view and manage prescriptions for the patient.

For more information, see Managing Prescriptions.

Follow-ups

Click to add Recall information.

Click to create a new line item. With the cursor in the Code column, select from the list of recall codes. The Description is automatically populated.

Implants

Click to view and manage Implants.

Click . The Add Implant Procedure window is displayed. For more information, see Implants.

EMR Consents

Click to view and manage EMR consent forms. If a consent form is required for the current appointment type, EMR Consents is displayed in the Chart Status portion of the window.
( = needs action; = complete)

Click . The Complete Consent Form window is displayed.

For more information, see Using Consent Forms.

Anesthesia

Click to view and manage the patient's Anesthesia records.

Click . The Create Anesthesia Record window is displayed.

For more information, see Anesthesia Records.

Notes

Click to access EMR Notes, Digital Forms, and Narratives.

• EMR Notes Click to view and create EMR Notes. Click to display the Create EMR Note window.
  For more information, see EMR Components and Creating an EMR Note.

• Digital Forms Click to view the patient's digital forms. Select Completed to view completed forms, Appointment to view forms associated with the current appointment, or All Forms for a list of forms to edit and attach to the patient.
  For more information, see Digital Forms.

• Narratives Click to view narratives for the patient. Click to display the Narrative Merge window and select a narrative to add.
  For more information, see Generating and Printing Narratives.

Images

Click to view the patient's images. Select Clinical, Non-Clinical, or both.

Select a line item to view the image in the Preview panel.

For more information, see Patient Images.

Attachments

Click to view documents and files attached to the patient's record. Select Clinical, Non-Clinical, or both.

You can attach images or documents in the following ways:

• Click to scan a document or image. The Document/Image window is displayed.

• Click to attach a document or image. The Select File to Attach window is displayed.

• In the Attachments panel, click . The Select File to Attach window is displayed.

Use the tabs to view specific types of attachments: Referral, Documents, or iConsult.

Select a line item to view the attachment in the Preview panel.

Treatment Plans

Click to access and manage the patient's treatment plans.

Click . The Create New Treatment Plan Visit window is displayed. For more information, see Treatment Plans.