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This article covers each Form Element as it appears in the Forms Palette, which you can read about here. We'll include a screenshot of the Element icon as it appears in the Forms Palette for easy recognition, and explain the unique options available in the Options Tab for each of these Form Elements.
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The vast majority of Elements can have their position and size adjusted in the General Tab of the Forms Palette. We'll only mention if there are items specific to that particular element in the General Tab.
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Text Field
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The Text Field Element captures a line of text. It is best used for short responses that don't require lengthy answers or elaboration.
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If you would prefer to instead have your checkboxes be listed under Positive and Negative Findings on the Narrative, you can include a Pull Field for this by switching to the Narrative View by pressing Command-\ on your keyboard, and then in the Forms Palette, locate the Pull Fields Section. There's an additional category of Pull Fields for your Form Section.
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Underneath it is an Others sub-category, where you can drag and drop the "Checkbox_Breakdown_Summary" Pull Field into your Narrative View, which will then list all checked checkboxes and unchecked checkboxes into "Positive Findings" and "Negative Findings" on the Narrative View.
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Options Tab
Default Checked on Patient Form: If this option is checked, when a patient form is generated using this Form Section, it'll check this Element's checkbox by default.
Narrative Checked/Unchecked: These fields will include their text onto the Narrative if the checkbox is checked or unchecked, respectively.
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The Options Tab has the following fields:
Reference: This table and menu allows you to select a Reference category from the MacPractice Database to populate a list of options that can be chosen. Family History, Sensitivities, and Social History pull from the EMR ability. You can create a custom list of options by choosing "None".
Value: The individual options within this Reference List.
Apply to Patient Checkbox: For some particular references, you can choose to also add items to the patient's file as well. For example, if you wanted to place an Account Alert on a patient's file from this form, you could do so by checking the Apply To Patient checkbox.
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To create a custom list for this Popup Element, select the
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None Reference and click the plus button, then Double-click the line entry to rename the new value.
#1 item as default: When the form is first loaded, if checked, the first option listed in this list will be chosen by default.
Import: This will import values from a file. Useful if you have a long list you want to include.
Abnormal checkbox: If checked, this option in the list will be listed with the Abnormal color, set in EMR Preferences. (MacPractice Menu > Preferences > EDR/EMR > Others Tab)
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Image View
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The Image View allows you to insert an image into a patient form. You can either add one during the Form Section construction such as a logo or other visual element, or you can leave it blank and add images specific to a patient when generating a patient form.
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Combo Box
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Combo Box
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The Combo Box Element is a special element that allows you to either create custom lists for a patient to choose, or you can pull in particular Reference data via the Forms Palette's Inspector.
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The Drawing View element allows drawing on a Form with the Drawing View tools in the Forms Palette.
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The Element itself does not have many customizations options in the Inspector of the Forms Palette, other than options to display and print the border around the element in the General Tab.
We do recommend creating a Label element to indicate the Drawing View element clearly.
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When a template contains the Drawing View element, when you generate a patient form, the Forms Palette will contain a Drawing Tools area with several tools available at the bottom of the Forms Palette. The selected shape tool is lit in blue, and clicking will switch tools.
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Let's break down each tool:
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Line Width Slider: By adjusting the slider at the bottom, you can increase and decrease the line width of any drawn shape.
Pencil: This tool lets you draw directly with the mouse cursor.
Line: This tool allows you to create lines by clicking and dragging in the Drawing View element.
Square: Places a square in the draw area
Circle: Places a circle in the draw area
Stroke Color: Sets the drawing color from the Color Palette.
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The Progress Note is designed to capture the progress of a patient's clinical status throughout care. An office can set up several pre-prepared Progress Notes which can then be quickly applied to a patient form.
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When adding this Element to a Form Section, you'll want to click on the Edit button, which will then show the table where you can add and remove Progress Note templates. Clicking the Green Plus will add a new Progress Note, and you can add or edit it on the right side. Clicking the Done button will flip you back to the normal view.
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The Diagnoses and Billing Element is used to add diagnosis codes and procedures to the form. It is a large Element that will take a full page, so make sure you set your Form Section to a Full Page in the Forms Palette (or manually adjust the Height to a minimum of 650 to ensure this Element fits)
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The Element is split into multiple tables, the Encounter Diagnosis table, the Past Diagnoses and Problems table, and the Procedures table.
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Past Diagnoses and Problems Table
This is a record of any Diagnoses that already exist in the Patient’s problem list. This also contains any diagnosis that may have existed in the Care Slip Element from previous versions of MacPractice.
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The Move All to Encounter Diagnoses button will move every listed Past Diagnoses into Encounter Diagnoses.
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Procedures Table
The Procedures Table allows you to add Procedures from your Fee Schedule to this patient.
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Clicking the green plus will bring up a window that allows the entry of billing codes. Codes will be listed with the Fee Description in the Charge column and the Fee Schedule they belong to in the Fee Schedule column. You can click these column headers to sort the results accordingly.
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You can easily search for codes by typing into the search bar at the top. If you'd rather browse, you can click "Show All" to display all your available codes.
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The Review and Bill button brings up another window that will create an order for the biller to add these Procedure Codes as charges to the patient’s ledger. You can assign the order to a particular MacPractice User in the upper left hand corner.
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Across the top of the window, the Assign Order To is a drop down list with a selector for which user should have the order assigned.
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The next two checkboxes ensure that the same Date or the same Diagnosis should be used for All Procedures listed.
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Clicking Create Order will generate an Order in MacPractice.
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Note: Creating an Order does not put billing information directly into a patient’s ledger. |
The Show Orders button in the Diagnoses & Billing Element shows any Orders that have been generated with information from the element.
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The checkbox to the right, when checked, shows the Order on the patient’s narrative. If an order has been changed or submitted by mistake, unchecking this box removes the order from the narrative.
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Signature Box
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The Signature Box Element is used to add a signature to the Patient Form. When a form with this element is generated, you can click the "Start Signature" button to be taken to a full screen signature field. You can use your mouse to click and drag to draw a free-form signature. There'll be three buttons at the bottom.
Clear Signature: Clears the signature. Control-right-click anywhere in the gray area for a Clear Signature box
Cancel: Returns to the form without saving any information
Done: Adds the signature to the patient form
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The Slider element is used to set a value between 1-100. You do this by using a simple slider to click and drag to the desired value. The value set will then be reported into the Narrative side.
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In the Options Tab of the Inspector in the Forms Palette, there are a few options to customize the Slider element:
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Min: Sets the minimum value of the Slider
Max: Sets the maximum value of the Slider
Precision: Set the increment by which the Slider is adjusted
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To add a Medication, click the Green Plus in the upper right. search for and select the medication.
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If the patient is not taking medications, select the No Medications checkbox. If there are no changes to the patient's medications, select the No Changes checkbox to add the information as it appears to the patient narrative.
If the patient is currently taking the medication, enable the Currently Taking checkbox. Next, add the Medication attributes, such as the form, route, frequency, duration, dispense count, and refill count of the medication. An Additional Sig can also be added. The Non-Printed Notes box captures your own clinical notes about the medication, which will not be attached to the patient's prescription. Add the Ordered, Prescribed, Dispensed, and Started Dates. If this is the first record of the medication, enable the First Record of Order checkbox.
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Reconciling Medications
The Medications Element can be used to perform a Medication Reconciliation. Click the Reconcile menu and select the Add New List for Reconciliation menuhttp://item..
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In the resulting window, select the radio button to add a new list of medications from the Patient or Referral. Where Referral is selected, set the Referral Source menu to None, an Existing Referral, or select to Add New Referral Record.
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With the list source selected, click the plus button to search for and select the medication and complete the medication attributes as usual (See
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RX Element for instructions. ) Once finished, click the Next button.
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The resulting window displays the entire medication list for the patient. The icons denote which medications were already on file for the patient and which medications were added during the current reconciliation. Disable the checkbox for any medication to set it as Inactive. Enable only the medications to keep on the patient's record, then click the Next button.
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To add a Vitals Record, click the Green Plus. You'll be presented with a Vitals sheet that you can fill out.
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Any changes to Vitals Records will impact the Patient's Clinical information, located in the Clinical Ability (or Patients Ability > Clinical Tab on older builds of MacPractice).
Allergies
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The Allergies Element, when added to a Patient Form, will add an Allergies Table that allows you to add records of allergies to the patient form.
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To add an Allergy record, click the Green Plus. This will open a search window where you can search for a relevant Allergy to add to the patient's record.
If If the patient does not have any allergies, select the No Allergies checkbox. If there are no changes to the patient's allergies list, select the No Changes checkbox to add the information as it appears to the patient narrative.
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Within the Patient Form, click the small plus button to add a new allergy record for the patient. In the resulting popover, search for and select the allergy.
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If the patient's allergy is currently active, enable the Active checkbox. Next, add the allergy attributes, such as the severity, Identified Date, Onset Date, Allergy Type, and any additional notes. You may search for and select a reaction by clicking the magnifying glass icon within the Reactions field. Click the Done button to add the new Allergy record.
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Reconciling an Allergy
The Allergies Element can be used to perform an Allergy Reconciliation. Click the Reconcile menu and select the Add New List for Reconciliation menu http:// item.
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In the resulting window, select the radio button to add a new list of allergies from the Patient or Referral. Where Referral is selected, set the Referral Source menu to None, an Existing Referral, or select to Add New Referral Record.
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With the list source selected, click the plus button to search for and select the allergy and complete the allergy attributes as usual (See
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Allergies for instructions. ) Once finished, click the Next button.
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The resulting window displays the entire medication list for the patient. The icons denote which medications were already on file for the patient and which medications were added during the current reconciliation. Disable the checkbox for any medication to set it as Inactive. Enable only the medications to keep on the patient's record, then click the Next button.
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The Race/Ethnicity Element, when added to a Form Section, adds a table to the patient form that allows you to set a patient's Ethnicity, Language, and Race.
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This element interacts with the Patients Ability > Patient Tab > Race/Ethnicity Sub-Tab, and the fields are identical except for the "Review Performed" checkbox, which is simply an indicator that the patient was consulted with when filling out the patient form.
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Then, a window will appear with details related to that diagnosis code.
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Problem List Reconciliation
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The Problem List Element can be used to perform a Problem List Reconciliation. Click the Reconcile menu and select the Add New List for Reconciliation menu item.
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In the resulting window, select the radio button to add a new list of problems from the Patient or Referral. Where Referral is selected, set the Referral Source menu to None, an Existing Referral, or select to Add New Referral Record..
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If Add New Referral is selected, select the Referrer from the list within References > Referrer, or click the plus button to add a new Referrer.
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With the list source selected, click the plus button to search for and select the diagnosis and complete the diagnosis attributes as usual (See Problem List Element for instructions. ) Once finished, click the Next button.
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The resulting window displays the each problem list diagnosis for the patient. The icons denote which problems were already on file for the patient and which problems were added during the current reconciliation. Disable the checkbox for any problem to set it as Inactive. Enable only the problems to keep on the patient's record, then click the Next button.
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As a final review, confirm the problem list reconciliation in the resulting window. Click the Next button to dismiss the Problem List Reconciliation window.
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The CQM Supplemental Info Element, when added to a Form Section, is used to add SNOMED codes to a patient's clinical record for inclusion in the Clinical Quality Measure (CQM) reports. For a SNOMED code to count toward the CQM reports, it must be entered through this Element.
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For most use-cases, you will not need to use this element.
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To add a SNOMED code, simply click the Green Plus, which will bring up a search window. Typing into the search window will narrow the results down. Once you've selected the desired SNOMED code, click the Select button to add it to the table.
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The Charting Element, when added to a Form Section, displays information from the Charting Ability in the Patient Form.
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When this element is included on a form, a thumbnail of the patient's current chart will display with a table of the patient's Restorative Charting procedures that have been added in the Dental Tab of the Patients Ability. There are a few options available in this view:
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The Family History element, when added to a Form Section will include a Family History table on a patient form, which is then used to enter conditions related to the patient's family history. This interacts with the Family History Clinical widget in the Clinical Ability. (or Clinical Tab of the Patients Ability on older builds of MacPractice)
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To add a new family history record, you can click the Green Plus in the upper right of the Element. After selecting the detail you'd like to add, a popup will appear with a window that allows you to select which family members to apply the detail to.
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No Changes: If there are no changes to the family history, check this box.
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Chief Complaint
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The Chief Complaint Element, when added to a Form Section, displays the primary reason for a patient’s visit. This is displayed on CDA documents (clinical summaries).
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Once a Chief Complaint has been added to the patient’s record, a prompt will appear that allows for Notes to be entered. Any information that expands on the Chief Complaint will be entered here. Notes can be added or edited to any existing Chief Complaint by double clicking on any existing Chief Complaint in the patient’s record.
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A Chief Complaint can be removed by clicking the red minus when a complaint is selected. A prompt will appear verifying that the complaint should be deleted. Once deleted, a complaint cannot be retrieved, but a new one may be added.
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Clinical Instructions
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The Clinical Instructions Element is a specialized text field that serves as directions from the doctor to the patient. When added to a Form Section, you can either write directly into the Clinical Instructions field, or you can use the Show Macros button to set up macros to quickly post pre-set information into this field.
Clicking the New button will bring up the macros creation window. Enter in a Title for the macro in top bar. In the Expanded Text box, enter in the text that should be populated any time a macro is selected.
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From the Clinical Instructions window, anything may be typed in the box on the right. Any time the title of a macro is clicked, the full text of the macro will be populated.
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Clicking the gear icon next to the title of the macro will allow the content or title of the macro to be edited.
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Immunizations
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The Immunizations Element displays the details of a patient’s Immunization history. This will display on CDA documents (clinical summaries).
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Existing Immunizations on the patient's record that have been entered into the Immunizations widget of the Clinical Ability (or Clinical Tab on the Patients Ability on older builds of MacPractice) will be shown in this table.
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Once you've selected the desired Immunization, a detail sheet will appear. Our "Immunizations in MacPractice 11 " article here covers how Immunizations work in MacPractice and explains each of these fields.
Once you've set these fields to your liking, you can click the Done button to save the Immunization. Any Immunizations added here will be reflected in the patient's clinical record.
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Smoking Status
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The Smoking Status Element, when added to a Form Section displays a table that contains the patient’s smoking status and history as entered in the patient's Smoking Status in the Clinical Ability of MacPractice (Patient Ability's Clinical Tab on older builds of MacPractice)
This will display on CDA documents (clinical summaries).
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You can add to this table by clicking the Green Plus, or remove items with the Red Minus (although keep in mind removing items from this table will also remove them from the patient's clinical record). When you click the Green Plus, a prompt will appear allowing you to choose a Smoking Status and the date range for it, as well as a checkbox for whether Cessation Counseling was offered.
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There is a checkbox to verify if Cessation Counseling has been offered, and a date field to verify on which day the counseling was offered.
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Clicking Done will prompt you to save and the information will be added the information to the patient’s record.
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Any existing Smoking Status may be edited by double clicking the status in the patient’s record.
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A Smoking Status can be removed by clicking the red minus when a status is selected. A prompt will appear verifying that the status should be deleted. Once deleted, a status cannot be retrieved, but a new one may be added.