...
| Table of Contents | ||||
|---|---|---|---|---|
|
Problem List
...
The Problem list is a record of all diagnoses for a patient.
...
Diagnosis Code: This is the numerical identifier of the diagnosis
Code Type: This will designate the type of code (ex. ICD9, ICD10)
Description: A brief overview of what the diagnosis entails.
Onset Date: The date the problem began to affect the patient.
Diagnosed Date: The date in which the patient was diagnosed by the doctor.
Resolved Date: The date the problem was addressed.
Type: Select the Type of the problem entry: Condition, Symptom, Finding, Complaint, Functional Limitation, Problem or Diagnosis.
Status: Select the status of the problem entry: Active, Inactive, Chronic, Intermittent, Recurrent, Rule Out, Ruled Out, Resolved.
Regularly Treated: When checked, the diagnosis will pull to new charges. When unchecked, it will not.
Provider: The provider who diagnosed the code.
Office: The office assigned when the code was diagnosed.
CQM Value: If a value needs to be assigned to the diagnosis, it may be added here. This field is intended for legacy purposes and not used in any reports.
Notes: A free text area that allows information to be added about the problem record. Anything entered in the Favorites Custom Description will be reflected here as well.
Medications
...
The Medications widget will show both the active and inactive medications on the patient's chart.
...
The Info Button in the Medications widget allows you to map a prescription to an RxNorm code if this code has not been mapped yet. If the prescription has already been mapped, this will instead behave as the Info Button typically does, providing you contextual information for the indicated medications.
Account Alerts
...
This widget will show you the alerts that have been added on the account tab of the Patients Ability.
The Account Alerts widget is a linkable widget. Clicking the title of the widget will take you to the Account Tab of the Patients Ability where you can find the Account Alerts on the patient's chart. These are located in the "Alerts" tab.
...
Procedures
...
The Procedure widget will show you all of the procedures that have been completed.
...
You can go directly to a given Procedure by clicking on the blue procedure code link. This will take you directly to the ledger and highlight the charge. If this does not occur, you may need to adjust the View Options drop down menu and ensure that "Show All Transactions" is toggled.
Perio Visits
...
This widget displays the perio visits on the selected patient's chart.
Clicking on either the widget title or the blue visit name links will take you to the Dental Tab. The title will pre-select the Perio Chart node for you, while clicking on an individual visit will take you to that visit within the Dental Tab.
Optical RX
...
This widget will display all of the optical prescriptions stored within the Optical Ability for the selected patient.
Much like other widgets, clicking the title or the visit date will take you to the Optical Ability. Clicking the date will take you to that particular optical prescription.
Smoking Status
...
This widget tracks the patient's logged Smoking Status. You're able to add and manage the patient's smoking status by either clicking the Green Plus in the upper right corner, or you can double-click a status line to open up a pre-existing status.
...
Entering a smoking status of Current Smoker without checking the box for cessation counseling offered will trigger a clinical alert; though the alerts may be disabled through References. If cessation counseling was offered, check the Cessation Counseling Offered box and enter the date within the Date Offered field. Click the Done button to add the record.
Preventive Care
...
Preventative Care is used to help track routine preventive procedures that were performed at a different practice.
...
Double clicking a line item will allow you to edit the details of a specific Preventative Care measure. You can adjust the code, the Next Visit date, and the Performed Date. There's also a button that will take you directly to the generated order for the Preventative Care measure.
Orders
...
This widget contains a list of orders on the patient's account. The Orders widget can be filtered by clicking on the Open/All toggle in the upper right to display either All orders, or any currently Open orders.
...
Clicking on an Order link in the Order column will take you directly to that order.
Digital Radiography Visits
...
The Digital Radiography Visits widget keeps track of all visits logged in the Digital Radiography Ability for the currently selected patient.
...
If you just want to quickly review a patient's visit layout, you can click the Preview button to pull up the Layout to review. This can take a few moments to load.
Patient Forms
...
The Patient Forms widget contains a record of any patient forms in the EDR/EMR Ability and the EHR Ability that are associated with the selected patient.
Clicking the Form name will take you to the EDR/EMR ability with that form pre-selected. You can also click the Preview button to take a quick glance at the filled out form.
Referrals
...
The Referrals widget displays all referrals added to the patient's record, located in the Patient Tab of the Patients Ability.
...
Clicking on the Referral name will take you directly to that Referral.
Care Team
...
The Care Team widget allows you to define a provider as belonging to this patient's Care Team.
...
It is important to note that if you want to assign an incident to a Care Team member, you'll first need to select the appropriate incident in the Incident drop down menu at the top of the Clinical Ability. If "All" is selected here, any added Care Team member will not have the Incident column populate with an incident.
Gender Identity and Sexual Orientation
...
The Gender Identity and Sexual Orientation widget displays relevant information regarding the currently selected patient's gender identity and sexual orientation.
...
By clicking the Green Plus, you're able to add to this widget and define the patient's gender and sexual orientation. Double clicking a line will allow you to edit that line.
HIE Downloads
...
The HIE Downloads widget is used in conjunction with the HIE Manager to track any received patient data from a Health Information Exchange for this patient. Follow the HIE Manager link to learn more about how the HIE Manager works.
...
The Request for Data Sent checkbox is used when the office does not have their MacPractice linked to a particular Health Information Exchange. This will store the date the checkbox was marked for MIPS-qualifying purposes.
Allergies
...
The Allergies widget displays both active and inactive allergies on file for the patient. You can filter the displayed results by toggling the Active/All toggle in the upper right.
...
You can also drag Allergies into a particular order if you have the Active/All toggle set to "All".
Immunizations
...
The Immunizations widget contains records of the patient's immunizations.
...
Patient Alerts
...
The Patient Alerts widget contains a list of any Patient Alerts added to this patient's account. Clicking the name of the widget will take you directly to the Patient Tab of the Patients Ability, with the "Alerts" sub-tab selected.
Clicking on the name of an alert will take you directly to that alert within the "Alerts" sub-tab.
Planned Treatments
...
The Planned Treatments widget contains any treatments in the patient's Treatment Plans, located in the Treatment Plan node of the Ledger Tab of the Patients Ability.
Clicking on a procedure code will take you directly to that treatment in the ledger.
Clinical Notes
...
This widget displays all of the Clinical Notes that have been entered into the Clinical Notes Table under the Dental Tab. This particular widget allows you to scroll left and right to view all columns. Not shown in the screenshot above are columns for the Procedure Date, Posted Date, and a preview button. The Preview button allows you to get a quick glance at the Clinical Note in question.
...
The drop down selector in the upper right allows you to filter the Clinical Notes.
Vitals
...
The Vitals widget contains all recorded Vital entries for the patient. By clicking the Green plus, you can add a new Vitals record.
...
If you've been taking multiple Vitals records, you can use the Growth Charts button to generate a chart that assists with comparing and contrasting the available Vitals data to assess trends.
Patient Education
...
The Patient Education widget allows you to track any educational materials you have provided to patients. These materials can be defined in the Patient Education Resources reference node, located in the Clinical Sidebar.
...
When you add a Patient Education record, you'll be prompted to select an appropriate resource from the above window. It is important to note that the only resources that will be available to select depend on the conditions set in the Patient Education Resources Reference node. The most common example of a requirement would be that a particular diagnosis code must be present in the patient's Problem List before you can assign the Blood Sugar Management resource that is present in the above screenshot.
Family History
...
This widget contains the patient's Family History records.
...