The Clinical Tab contains a comprehensive list of all information that has been entered for a chosen patient on an account, as well as fields to add in clinical information for the patient. In newer builds of MacPractice we've made some extensive improvements to a Patient's Clinical Tab, please select your build below for accurate information:
Clinical Tab (Pre-Gen 9)
For offices using builds of MacPractice older than Gen 9, the Clinical information will be located within the Patient ability within the list of tabs at the top. This tab is split into the Clinical Summary in the top half, and a variety of sections listed on the bottom half.
Clinical Summary
The Clinical Summary contains all information that has been added to the patient's chart. This includes Procedures and planned Treatments, prescriptions on the patient's Active Med List, Notes, Attachments, Digital Radiography images, Perio records, labs, orders, referrals, and much more. Each section of information contains links to each item. You can simply click on a link to bring you to that item in the relevant ability.
Incident Drop Down Menu: This drop down, located in the upper left of the Clinical Summary view, allows you to filter the results by Incident. This will also allow you to choose an Incident to export via the Export Incident option in the upper right.
History Drop Down Menu: This option, set to All History by default, allows you to filter items by their posted date. You can choose from Last Month, Last Three Months, Last Six Months, Last Year, and Last Two Years. You can also use the Start Date: and End Date: fields to filter to a particular date range.
Export Incident: This option allows you to export the currently selected Incident. This is largely built for exporting to the Patient Portal, but if you do not have this ability purchased, you can also choose to print the incident's Clinical Summary. You can choose to print for a patient, or for a Referral marked 'Transition To'.
Exporting will upload a copy of the Clinical Summary to the Patient Portal. You can choose to print a copy or not, and in the sidebar of the export box, you can choose which information is included.
For more information on exporting an incident, please refer to Portal - Export to Patient.
Clinical Tabs
The Clinical tabs will be used to record, adjust and review a patient's clinical information.
Problem List
The Problem List is used to record all of diagnoses for a patient.
At the top right of the Problem List tab there are a few fields and menus that are important to mention.
Problem Status: This option allows the user to view "Active" or "All" diagnoses.
When "Active" is selected, the Problem List will only display diagnosis codes where "Active" has been selected as the status.
When "All" is selected, the user will see all "Active", "Inactive", and "Resolved" diagnosis status. Also while "All" is selected a user is able to reorder the diagnoses as desired by clicking and dragging.
Last Checked Date: Here the user or doctor will enter the date they last checked the patient's diagnosis.
No Problems Checkbox: This is used to indicate that the patient did not have any issues to report.
Also at the top right of the tab is the green plus and red minus buttons. Use the green plus to select new diagnoses to add to the patient's Problem List. The red minus will remove the selected diagnosis from the list. We do not recommend removing diagnosis codes unless it was added by accident, rather choose "Inactive" or "Resolved as the Status for the diagnosis code.
Once the diagnosis is added to the Problem List, additional fields will appear:
Regularly Treated: This indicates if the diangosis is actively being treated by the office, and also allows the diagnosis to pull onto charges and claims.
Diagnosis Code: This field will show the code that you selected.
Description: This will display the description of the code selected.
Onset Date: This date field would be used record the date the patient initially observed their symptoms.
Diagnosis Date: This is the date the problem was diagnosed.
Created Date: This will display the date the record was added to the patient's chart.
Updated Date: This date will automatically update when/if anything on the selected diagnosis is changed.
Resolved Date: This date field will need to be manually filled in when the diagnosis for the patient has been resolved.
Type: This indicates the type of diagnosis/problem listed.
The Problem Types are: Condition, Symptom, Finding, Complaint, Functional Limitation, Problem, Diagnosis, and Cognitive.
Status: This field is used to indicate the status of the selected diagnosis.
The Problem Status are: Active, Inactive, Resolved.
Notes: This is a free text field where the user can and any notes about the diagnosis.
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.
Code Type: This will be automatically selected based on the diagnosis code that was selected. Within MacPractice there are a few different code types: ICD10CM, ICD9CM, and RxNorm. The type of code you used is based on what has been selected in the Macpractice menu > Preferences > Coding > Problems.
Provider: Use this field to list the provider that diagnosed the code.
Office: This field is used to select the office assigned when the code was diagnosed.
Note: Keep in mind that you can reorder these columns by clicking on the column header and dragging it to the position you want it.
Allergy
This section contains all allergy information recorded for the selected patient.
At the top left of the Allergy tab there are a few fields and menus that are important to mention.
Allergy Status: This option allows the user to view "Active" "Inactive" or "All" allergies.
When "Active" is selected, the Allergy list will only display allergies where "Active" has been selected as the status.
When "Inactive" is selected, the Allergy list will only display allergies where "Inactive" has been selected as the status.
When "All" is selected, the user will see all "Active", "Inactive", and "Resolved" diagnosis status. Also while "All" is selected a user is able to reorder the diagnoses as desired by clicking and dragging.
Last Checked Date: Here the user or doctor will enter the date they last checked the patient's allergies.
No Active Allergies Checkbox: This is used to indicate that the patient does not have any allergy issues to report.
Also at the top right of the tab is the green plus and red minus buttons. Use the green plus to select new allergy to add to the patient's Allergies list. The red minus will remove the selected allergy from the list. We do not recommend removing this information unless it was added by accident, rather choose "Inactive" as the Status.
Once the allergies are added to this tab additional fields will appear:
Allergy Type: This displays the type of allergy that is listed.
The Allergy Types are: Drug Allergy, Food Allergy, Food Intolerance, Propensity to Adverse Reaction to Drug, Drug Intolerance, Propensity to Adverse Reactions, Propensity to Adverse Reactions to Food, Propensity to Adverse Reactions to Substance, and Allergy to Substance.
Patient Allergy: This column will list the name of the allergy that was added.
Severity: Here the user can mark the severity of the allergy affecting the patient.
The Allergy Severities available are: Mild, Moderate, Severe, Fatal, Mild to Moderate, and Moderate to Sever.
Notes: This is a free text field where the user can and any notes about the allergy.
Reactions: When selected, a window will come up where the user can search by name or SNOMED code, and select the reaction the patient is having.
Reaction Description: This is another free text field where more details of the reaction can be added.
Created Date: This will display the date the record was added to the patient's chart.
Identified Date: This date field is used to record the date the allergy was identified.
Onset Date: This date field would be used record the date the patient initially observed their symptoms.
Resolved Date: This date field will need to be manually filled in when the diagnosis for the patient has been resolved.
Status: This field is used to indicate the status of the selected diagnosis.
The Allergy Status options are: Active, and Inactive.
Note: Keep in mind that you can reorder these columns by clicking on the column header and dragging it to the position you want it.
Immunizations
The Immunizations tab is a record of a patient's Immunization information. A majority of the immunization information can be filled out in the References ability > Immunization. This can save users time on having to fill out immunization window for patients.
At the top right and bottom of the Immunization tab there are a few fields and menus that are important to mention.
Member of Special Risk Group Checkbox: If a patient is at high risk of contracting or developing a disease, this box can be checked.
New Historical Immunization Record: This button logs an immunization that was not administered by one of your office's providers for tracking purposes.
VFC Eligibility Status: This will indicate if the patient is eligible for the Vaccines for Children Program based off this criteria.
The Eligibility options are: None, Not VFC Eligible, VFC Eligible-Medicaid/Medicaid Managed Care, VFC Eligible-Uninsured, VFC Eligible-American Indian/Alaskan Native, VFC Eligible-Federally Qualified Health Center Patient (under-insured), CHIP, 317, Medicare, and State Program Eligibility.
Last Rabies Exposure Date: This date field allows the user to manage the most recent rabies exposure date for the patient in question.
Registry Reminder For Immunizations: This menu is generally used to indicate that the patient needs a reminder for vaccines.
The options for Registry Reminders are: None, No Reminder/Recall, Reminder/Recall - Any Method, Reminder/Recall - No Calls, Reminder Only - Any Method, Reminder Only - No Calls, Recall Only - Any Method, Recall Only - No Calls, Reminder/Recall - To Provider, Reminder to Provider, Only Reminder to Provider No Recall, Recall to Provider, Only Recall to Provider No Reminder.
Reminder Effective Date: This field is used to add the effective date of the registry reminder above.
Also at the top right of the tab is the green plus and red minus buttons. Use the green plus to select new allergy to add to the patient's Allergies list. The red minus will remove the selected allergy from the list. We do not recommend removing this information unless it was added by accident.
Once the Immunization had been selected a second window will appear asking for more specifics on the immunization that was added. If changes need to be made to the record, simply double click on the existing immunization.
After saving this window, the information will be added to the tab:
Immunization: This will display the name of the vaccine selected.
Dosage: This column will show the dosage amount entered in the previous window.
Number in Series: If multiple immunizations are entered, this designates in which number this immunization falls in the series
Ordered By: This column will display the user selected in the Ordered By field in the previous window.
Date: This will show the date entered in the previous vaccine window. By default, the date will display as the date the record was created, but can be edited.
Reaction: This field will pull from the previous window, be sure to select the reaction the patient has to the vaccine that was administered.
Incident: This section will pull the name of the incident associated to the vaccine in the previous window.
Note: Keep in mind that you can reorder these columns by clicking on the column header and dragging it to the position you want it. If you need to rearrange the order of the immunizations, simply click and drag the bottom one up to the top.
Vitals
This section allows you to add and maintain Vitals records for the patient.
At the top right of the Vitals tab there are a few fields and menus that are important to mention.
Vitals Chart Menu: Using this drop down, the user can choose which chart will be pulled up after clicking the Chart Button.
Chart Button: The Chart button is useful if there are multiple Vitals records This generate a chart that assists with comparing and contrasting the available Vitals data to assess trends.
Also at the top right of the tab is the green plus and red minus buttons. Use the green plus to create a new vital entry. The red minus will remove the selected vital from the tab. We do not recommend removing this information unless it was added by accident.
After clicking the green plus, a second window will appear requesting more information to be entered. Once the vitals have been added, click "Done". To make any changes to this record, simply double click on it within the tab.
After saving this window, the information will be added to the tab:
Weight: This will display the patient's weight based on the information entered in the previous vitals window.
Height/Length: This column will show the patient's height or length based on what was entered in the previous window.
BMI: This will also pull the body mass index recorded in the previous vitals window.
Blood Pressure: The patient's blood pressure will appear here after entering it in the previous window.
Temperature: The temperature of the patient will be recorded here after entering it in the previous window.
Heart Rate: Once the heart rate is recorded in the vitals window and entered, it will appear here.
SpO2: The oxygen saturation percent will appear here if it is entered in the vitals window.
Respiration Rate: This column will show the respiration rate entered by the user in the vitals window.
Date: By default, this will display the date the record was added, but can be edited within the vitals window.
Age: The age of the patient when the vitals were taken will be added here automatically.
Note: Keep in mind that you can reorder these columns by clicking on the column header and dragging it to the position you want it. You can also sort the rows based on a specific column by clicking on the column header.
Smoking
This section allows you to add and maintain information about the patient's smoking status.
At the top right of the tab is the green plus and red minus buttons. Use the green plus to create a new smoking status entry. The red minus will remove the selected status from the tab. We do not recommend removing this information unless it was added by accident.
After clicking the green plus, a second window will appear requesting more information to be entered. Once the information has been added, click "Apply". To make any changes to this record, simply double click on it within the tab.
After saving this window, the information will be added to the tab:
Smoking Status: On the previous window, the user will enter the patient's smoking status.
The status options are: Current Every Day Smoker, Current Some Day Smoker, Former Smoker, Never Smoker, Smoker Current Status Unknown, Unknown if Ever Smoked, Heavy Tobacco Smoker, Light Tobacco Smoker.
Updated Date: This will reflect the date this record was last updated.
Start Date: This will show the smoking start date for the patient based on what was entered in the previous window.
Quit Date: If a smoking quit date was entered, it will be reflected here.
Cessation Counseling Offered: Within the previous window there is a "Cessation Counseling Offered" checkbox. If checked "Yes" will appear in the column, otherwise it will show "No".
Date Offered: This will reflect the date cessation counseling was offered, based on the information in the previous window.
Note: Keep in mind that you can reorder these columns by clicking on the column header and dragging it to the position you want it.
Patient Education
This section allows you to track educational information that has been given to the patient. Before the resources are available to add, the Patient Education Resource Reference will need to be setup.
At the top right of the tab is the green plus and red minus buttons. Use the green plus to add a education resource to the patient's records. The red minus will remove the selected resource from the tab. We do not recommend removing this information unless it was added by accident.
After clicking the green plus, a second window will appear showing the results for patient education resources available for the patient based on the qualifications outlined in References > Patient Education Resource. Once the resource is selected click "OK" to add it to the patient's records. Unlike the other tabs, double clicking on the resource will bring up the full description.
After saving this window, the information will be added to the tab:
Name: This will show the name of the patient education resource that was selected.
Description: This column will reflect the short description of the resource selected in the previous window.
User: This will reflect the user who added the resource to the tab. However, the drop down can be updated to reflect a different user.
Incident: This column will reflect the incident/visit you want to tie the resource record too. By default, the first incident on the list will be selected, but this can be updated by clicking the drop down menu.
Date: This date will reflect with the patient education resource was added to the patient's record, but can also be updated by clicking on the text field and entering a new date.
Note: Keep in mind that you can reorder these columns by clicking on the column header and dragging it to the position you want it. If you need to rearrange the order of the immunizations, simply click and drag the bottom one up to the top.
Preventive Care
This section helps track routine preventive procedures performed at a different practice. Before the resources are available to add, the Preventive Routine Care Reference will need to be setup.
Above the list of Preventive Care resources is a "Show Archived" button, this will be active if a resource has been removed from the list.
At the top right of the tab is the green plus and red minus buttons. Use the green plus to add a education resource to the patient's records. The red minus will remove the selected resource from the tab and add it to the "Show Archived" button.
After clicking the green plus, a second window will appear requesting more information to be entered. Once the information has been added, click "Select".
After saving this window, the information will be added to the tab:
Preventive Measure: This column will show the name of the selected preventive care that was added to the list.
Code: This field will show the procedure code for the screening.
Date Ordered: Before an order is created, a "Make Order" button will show in this column. After the order is created the order creation date will show instead.
Date Preformed: This will be the date the order status is set to "Closed".
Order Link: This column will give a bit more information regarding the order the preventive is tied to.
Next Visit: This will show the date of the next visit. This is calculated based on the information entered into the Preventive Care Routine Reference.
Note: Keep in mind that you can reorder these columns by clicking on the column header and dragging it to the position you want it.
Goals
The Goals tab displays the patient's clinical goals and instructions.
At the top right of the Goals tab you can filter the table below by the goal status. When "Show All" is selected a user is able to reorder the goals as desired by clicking and dragging the item up to the top of the list.
Next to the status filter, there is the green plus and red minus buttons. Use the green plus to add a a new goal to the patient's records. The red minus will remove the selected goal from the tab. Generally we do not recommend deleting these records, as there is not a way to retrieve them later.
After saving, the information will be added to the tab:
Goal: This will list the name of the goal that was selected in the previous window.
Instructions: This is a free text field where the user can enter additional instructions for the selected goal.
Set Date: By default, this field will pull the date the goal was added to the tab. This field can also be edited to a different date.
Target Date: This column can be edited to show the target date the goal should be achieved.
Done Checkbox: Once the goal has been accomplished, check the checkbox in the Done column.
Note: Keep in mind that you can reorder these columns by clicking on the column header and dragging it to the position you want it. You can also sort the rows based on a specific column by clicking on the column header.
Care Team
This section contains Care Team information for the patient. This is largely intended for internal purposes, as it allows you to mark particular MacPractice Users that are responsible for the patient's care.
At the top right of the Care Team tab there is a green plus and red minus buttons. Use the green plus to add a user to the patient's care team. The red minus will remove the selected goal from the tab. Generally we do not recommend deleting these records, as there is not a way to retrieve them later.
After choosing a user to add to the care team list, click "OK" at the bottom right. Multiple users can be added to this tab.
Note: You can reorder the list of users by clicking and dragging the name up to the top of the list.
Family History
This section will allow you to maintain a log of the past or present issues in a patient's family which could contribute to the patient's health in the future.
At the top left of the Family History tab, there is a "No Significant Family History" checkbox. This will be available if there are no findings recorded in the list below. Users can check this if the patient has no family medical history worth noting.
On the right of the tab there is a green plus and red minus buttons. Use the green plus to add a condition to the family history tab. The red minus will remove the selected goal from the tab. Generally we do not recommend deleting these records, as there is not a way to retrieve them later.
Once added, the information will be added to the tab:
Finding: This will display the name of the condition that was selected.
Family Relationship: Use this column to select the family member the finding relates to.
Clinical Tab (Gen 9 & Gen 10)
For offices running MacPractice Gen 9 or 10, we've made some extensive improvements to a Patient's Clinical Tab. Over the years we've received some strong feedback regarding how a patient's Clinical Summary was organized. We've taken that feedback into account and re-designed the Clinical Summary.
This article will review the functionality of the new Clinical Tab, and address some of the changes that have been made.
Clinical Tab Overview
The Clinical Tab, which was previously broken down into two sections, is now a single section within the Patients Ability. This information is broken up into several "widgets", which are the color coded section blocks.
By default, the Summary will display clinical information from all available Incidents to give you a comprehensive look at a patient's record. To narrow down to a specific Incident, use the Filter Incidents header in the upper left to select specific Incidents, or narrow down the results to a specific date range.
A user can also use the Export drop down in the header to export the Clinical Summary.
Editing the Summary
One of the new features in the Clinical Summary re-design is the ability to organize, hide, and customize the colors of each of these widgets. You can access the editing tools by clicking on the gear icon in the upper right of the Clinical Tab.
Note: Your MacPractice user must have the User Privilege "Edit Clinical View" enabled in order to edit the Clinical View's Summary. This privilege is located in the References Ability > User Group Privileges > Patient ability > Edit Clinical View.
All of these settings will be remembered on a per user basis, so your display will follow you from computer to computer based on your MacPractice user.
The editing window is relatively self-explanatory. The Clinical Summary will display the widgets in the order denoted by these two columns.
If there is a widget that you don't foresee your practice using, you can click the checkbox by a widget to enable/disable them.
You can easily move widgets around by dragging and dropping them into the desired order.
Finally, you can change the color of a widget by clicking on the widget's color block.
Once satisfied with your changes, you can click the Done button. If you make a mistake or wish to revert your changes, you can use the "Reset to Default" option in the lower left corner of the edit window.
You can also Zoom In if you would like this to display in larger text. Simply hold the Command key and hit the +(plus) button to zoom in, or Command minus to zoom back out. This setting is remembered based on the specific computer's OS user (not the MacPractice user).
Clinical Widgets
All functionality that used to be in the Clinical Sub-Tabs prior to Gen 9 is now contained within the widgets themselves.
A widget that simply lists information from another Ability within MacPractice will not appear if there is no relevant information to display. For example, in order for data to appear in the Medications widget, valid medications must be entered into the Rx Ability.
However, any widget that would allow you to add records will appear here unless it is hidden via the Gear Icon as described in the "Editing the Summary" section of this article. We strongly encourage you to hide any widgets that don't apply to your practice. For example, a medical practice would have no need for the Perio Visits widget, as this only applies to periodontal practices.
Problem List
The Problem list is a record of all diagnoses for a patient. These can be added through this widget, EMR/EDR, EHR, iEHR and the Ledger.
At the top of the Problem List widget there are a few items worth mentioning:
Drop Down Arrow: By default, the widgets are in a "dropped down" state, meaning that their contents are expanded much like nodes in the sidebar. You can click the triangle on the left of the widget name to shrink this widget until you need it.
(i) Button: The Info button is a content retrieval system which uses the patient's information to locate relevant clinical decision support information from online health knowledge resources. More information can be found HERE.
Active/All Toggle: These function much like a filter.
When "Active" is selected the Problem List will only display active Problem List items.
When "All" is selected every Problem List item will be shown. The list of diagnosis codes can also be rearranged when "All" is select by simply clicking and dragging.
(+) Green Plus Button: This allows a user to add a new diagnosis code to the list.
After clicking the green plus a second window will appear where you can select the diagnosis code. In the next window, enter the additional information regarding the diagnosis and patient.
Diagnosis Code: This is the numerical identifier of the diagnosis.
Code Type:This will be automatically selected based on the diagnosis code that was selected. Within MacPractice there are a few different code types: ICD10CM, ICD9CM, and RxNorm. The type of code you used is based on what has been selected in the Macpractice menu > Preferences > Coding > Problems.
Description: A brief overview of what the diagnosis entails.
Onset Date:This date field would be used record the date the patient initially observed their symptoms.
Diagnosed Date: The date in which the patient was diagnosed by the doctor.
Resolved Date: This field will need to be manually entered with the date the problem was addressed.
Type: This indicates the type of diagnosis/problem listed.
The Problem Types are: Condition, Symptom, Finding, Complaint, Functional Limitation, Problem, and Diagnosis.
*Status: This field is used to indicate the status of the selected diagnosis.
The Problem Status are: Active, Inactive, and Resolved.
Regularly Treated: This indicates if the diangosis is actively being treated by the office, and also allows the diagnosis to pull onto charges and claims.
Provider: Use this field to list the provider that diagnosed the code.
Office: This field is used to select 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.
If a mistake has been made, double click on the diagnosis to open the diagnosis information window again. Within this window you can also choose "Delete". However, we do not recommend deleting a diagnose code unless it was added by mistake. It would be best to update the status to "Inactive" or "Resolved".
Medications
The Medications widget will show records of all medications listed for the patient.
At the top of the Medications widget there are a few items worth mentioning:
Drop Down Arrow: By default, the widgets are in a "dropped down" state, meaning that their contents are expanded much like nodes in the sidebar. You can click the triangle on the left of the widget name to shrink this widget until you need it.
(i) Button: The Info button is a content retrieval system which uses the patient's information to locate relevant clinical decision support information from online health knowledge resources. More information can be found HERE.
Active/All Toggle: These function much like a filter.
When "Active" is selected, the medications within the Rx ability > Active Med List will show.
When "All" is selected every medication will be shown.
Users can click on the blue text throughout the section. The "Medications" link will take the user directly to the Rx Ability with the patient selected. Clicking on the blue text of a specific medication will take the user to that medication record in the Rx Ability. This allows users to get around MacPractice more quickly.
There is not a way to add medications from this widget, instead go to the Rx Ability, EMR/EDR, EHR or iEHR and create a new record.
Note: Keep in mind that you can click on the column headers to sort the items in ascending or descending order based on the selected column.
Account Alerts
This widget will show you the alerts that have been added on the Account Tab of the Patients Ability.
Like the above widgets, the Account Alerts widget has the ability to expand/condense the section by selecting the arrow on the left of the widget name.
Users can click on the blue text throughout the section. The "Account Ability" link will take the user directly to the Patient Ability > Account tab > Alert sub-tab with the patient selected. Clicking on the blue text of a specific alert will take the user to that alert in the Alerts sub-tab. This allows users to get around MacPractice more quickly.
There is not a way to add Account Alerts from this widget, instead go to the the Patient ability > Account tab, and add a new alert under the Alert sub-tab.
Note: Keep in mind that you can click on the column headers to sort the items in ascending or descending order based on the selected column.
Procedures
The Procedure widget will show you all of the procedures that have been entered into the patient's Ledger Tab.
This widget is pretty basic, it can expand and contrast using the arrow to the left of the widget name. A user can also click on the procedure code text to be taken to the patient's Ledger with that specific charge selected.
There is not a way to add procedures from this widget, instead go to the Ledger Ability, EMR/EDR, EHR or iEHR and create a new record.
Note: Keep in mind that you can click on the column headers to sort the items in ascending or descending order based on the selected column.
Perio Visits
This widget will show you all of the different perio visits recorded in the Dental Tab, for the patient in MacPractice.
There isn't much to this widget, it has the ability to expand/condense by selecting the arrow on the left of the widget name.
Users can click on the blue text throughout the section. The "Perio Visit" link will take the user directly to the Patient Ability > Dental tab > Perio Chart for the selected patient. Clicking on the blue text of a specific visit will take a user to the that visit in the Perio Chart. This allows users to get around MacPractice more quickly.
There is not a way to add new Perio Visits from this widget, instead go to the the Patient ability > Dental tab, and add a new Perio record from the Perio Chart node.
Note: Keep in mind that you can click on the column headers to sort the items in ascending or descending order based on the selected column.
Optical RX
This widget will display all of the optical prescriptions stored within the Optical Ability.
Much like the Perio Visit section, the Optical Rx widget is fairly simple. It has the ability to expand/condense by selecting the arrow on the left of the widget name. Each column can also be sorted by clicking on the column header.
Clicking on the blue text throughout the section will take the user to the Optical Ability or the specific optical visit when the date is selected. This helps users get around MacPractice a bit faster.
There is not a way to add new Optical Rx from this widget, instead go to the the Optical Ability and select the Optical node in the sidebar, then click the green plus above the sidebar to create a new Rx.
Note: You can click on the column headers to sort the items in ascending or descending order based on the selected column.
Smoking Status
The Smoking Status widget show all of the patient's smoking status records added to the patient's chart. These can be added through this widget, EMR/EDR, EHR, and iEHR.
At the top of the Problem List widget there are a few items worth mentioning:
Drop Down Arrow: By default, the widgets are in a "dropped down" state, meaning that their contents are expanded much like nodes in the sidebar. You can click the triangle on the left of the widget name to shrink this widget until you need it.
(i) Button: The Info button is a content retrieval system which uses the patient's information to locate relevant clinical decision support information from online health knowledge resources. More information can be found HERE.
(+) Green Plus Button: This allows a user to add a new smoking status code to the list.
Note: You can also click on the column headers to sort the items in ascending or descending order based on the selected column.
After clicking the green plus a second window will appear where you can select the diagnosis code. In the next window, enter the additional information regarding the diagnosis and patient.
Smoking Status: Select the option that best fits the patient.
The status options are: Current Every Day Smoker, Current Some Day Smoker, Former Smoker, Never Smoker, Smoker Current Status Unknown, Unknown if Ever Smoked, Heavy Tobacco Smoker, Light Tobacco Smoker.
Start Date: For current and former smokers, enter the smoking start date.
Quit Date: For former smokers, enter a quit date.
Cessation Counseling Offered: Within the previous window there is a "Cessation Counseling Offered" checkbox. If checked "Yes" will appear in the column, otherwise it will show "No".
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.
Date Offered: This will reflect the date cessation counseling was offered.
Updated Date: This will reflect the date this record was last updated.
If a mistake has been made, double click on the status to open the information window again and make changes. Within this window you can also choose "Delete", however please remember that once these records are deleted they cannot be retrieved.
Preventive Care
The Preventive Care widget helps track routine preventive procedures performed at a different practice. These can be added through this widget, EHR and iEHR.
For example, if you refer a patient to have a mammogram at a nearby facility, you can record this information here.
There isn't much to this widget, but there are a few items worth mentioning:
Drop Down Arrow: By default, the widgets are in a "dropped down" state, meaning that their contents are expanded much like nodes in the sidebar. You can click the triangle on the left of the widget name to shrink this widget until you need it.
(+) Green Plus Button: This will bring up a list of your Preventive Routine Care references. Search for and select a preventive care item.
Note: Keep in mind that you can click on the column headers to sort the items in ascending or descending order based on the selected column.
When a Preventive Measure is added to the Clinical record, it is just a theoretical procedure. The office does not know the patient has had it performed, just that they referred them to another provider to perform the procedure.
To add additional information to the preventative care, double click on the line item. These additional options will be available:
Code: This field will show the procedure code for the screening.
Next Visit: This will show the date of the next visit. This is calculated based on the information entered into the Preventive Care Routine Reference, but can be edited if the date is not correct. An alert will be created if a user access a patient's record after the Next Visit date.
Date Ordered: This date will appear when an order has been created from this window.
Preformed: This field will be available when the order status is set to "Closed", and can be edited.
Make Order/Go to Order Button: This button will take you to the Orders ability to create a new order or view the existing order.
Delete/Archive Button: If no Order has been created for this measure, "Delete" will be an option. If an order was created a user can "Archive" the screening.
After the preventative item has been added and associated to an order, the name within the Order column can be selected, and will take the user to the Orders ability with that order selected.This helps users get around MacPractice a bit faster.
Orders
This widget can be used to show open or all Orders on the patient's account. There is not a way to add new orders from this widget, instead go to the the Orders Ability or Patient tab > Orders Tab or iEHR and create a new Order.
There are a few items worth mentioning on this widget:
Drop Down Arrow: By default, the widgets are in a "dropped down" state, meaning that their contents are expanded much like nodes in the sidebar. You can click the triangle on the left of the widget name to shrink this widget until you need it.
Open/All Toggle: These function much like a filter.
When "Open" is selected, only the orders with Order Statuses of "Open" will show.
When "All" is selected every order will be shown.
Clicking on the blue text throughout the section will take the user to the Orders Tab/Ability or the specific order when the order name is selected. This helps users get around MacPractice a bit faster.
Note: You can click on the column headers to sort the items in ascending or descending order based on the selected column.
Digital Radiography Visits
This widget is used to quickly navigate to a unique DR visit for the patient.
This is another simple Widget with a few items:
Drop Down Arrow: By default, the widgets are in a "dropped down" state, meaning that their contents are expanded much like nodes in the sidebar. You can click the triangle on the left of the widget name to shrink this widget until you need it.
Preview Button (10.7.3+): This button will quickly bring up a preview window for the selected image without having to go to the ability.
Like many of the other widgets, click on the "Digital Radiography Visit" text and the user will be taken to the DR Ability. Clicking on the actual visits will take you to the DR Ability with that specific visit selected.
There is not a way to add new DR Visits from this widget, instead go to the the DR Ability and and click the green plus above the visit list.
Note: You can click on the column headers to sort the items in ascending or descending order based on the selected column.
Referrals
All Referral will show in this widget for the patient. This allows the user to easily see where the patient is coming from and the office that they will be going to. Referrals can be added from the Patient Ability > Referrals sub-tab or iEHR.
Within this widget you can use the drop down arrow to expand to condense the section. A user can also click on the blue text to navigate to the the Patients Ability > Referral sub-tab.
Note: You can click on the column headers to sort the items in ascending or descending order based on the selected column.
Care Team
The Care Team tab displays members of a patient's care team. Care Team members can be any MacPractice user within the office. Both providers and regular users may be added to this list. This information is just for the office record and does not interact with other abilities within MacPractice.
At the top of the Problem List widget there are a few items worth mentioning:
Drop Down Arrow: By default, the widgets are in a "dropped down" state, meaning that their contents are expanded much like nodes in the sidebar. You can click the triangle on the left of the widget name to shrink this widget until you need it.
(+) Green Plus Button: This allows a user to add a new member of the Care Team.
Note: You can click on the column headers to sort the items in ascending or descending order based on the selected column.
After clicking the green plus a second window will appear where you can select the a member of the Care Team. Once selected, it will be added to the widget.
Double click on a record to remove users from the list. The information displayed will pull from the References ability > User. Visit the User Reference to make changes if the information is incorrect.
Allergy
The Allergies widget will show a list of allergies the patient has. Allergies, or a status of No Active Allergies, may also be entered into the patients record via EMR/EDR, EHR, or iEHR. This table will update dynamically with the information entered.
Note: Coding Preferences allow offices to select which set of allergies are used. Once the data is entered into patient records, reports like the Patient Clinical may be filtered using this information.
At the top of the Allergies widget there are a few items worth mentioning:
Drop Down Arrow: By default, the widgets are in a "dropped down" state, meaning that their contents are expanded much like nodes in the sidebar. You can click the triangle on the left of the widget name to shrink this widget until you need it.
(i) Button: The Info button is a content retrieval system which uses the patient's information to locate relevant clinical decision support information from online health knowledge resources. More information can be found HERE.
The Active/All Toggle: These function much like a filter.
When "Active" is selected the Allergies will only display active items.
When "All" is selected every Allergy will be shown. The list can also be rearranged when "All" is select by simply clicking and dragging.
(+) Green Plus Button: This allows a user to add a new Allergies to the list.
After clicking the green plus a second window will appear where you can select the allergy. In the next window, enter the additional information regarding the allergy and patient.
Allergy Name: The name of the selected allergy will appear at the top left of the window.
Identified Date: This date field is used to record the date the allergy was identified.
Onset Date: This date field would be used record the date the patient initially observed their symptoms.
Severity: Here the user can mark the severity of the allergy affecting the patient.
The Allergy Severities available are: Mild, Moderate, Severe, Fatal, Mild to Moderate, and Moderate to Sever.
Allergy Type: This displays the type of allergy that is listed.
The Allergy Types are: Drug Allergy, Food Allergy, Food Intolerance, Propensity to Adverse Reaction to Drug, Drug Intolerance, Propensity to Adverse Reactions, Propensity to Adverse Reactions to Food, Propensity to Adverse Reactions to Substance, and Allergy to Substance.
Status: This field is used to indicate the status of the selected diagnosis.
The Allergy Status options are: Active, and Inactive.
Reactions: When selected, a window will come up where the user can search by name or SNOMED code, and select the reaction the patient is having.
Reaction Description: This is another free text field where more details of the reaction can be added.
Notes: This is a free text field where the user can and any notes about the allergy.
Note: Once an Allergy is added to the patient's chart, an alert will also display in the patient selector as a yellow alert triangle and pop up when the patient's record is selected.
Double clicking on the Allergy also allows the user to edit or delete the record. However, we do not recommend deleting as it cannot be retrieved. Instead change the status of the allergy to "Inactive".
Immunizations
The Immunizations tab records a patient's Immunization information within a table. This information can be added from this widget, EMR/EDR, EHR, or iEHR.
Drop Down Arrow: By default, the widgets are in a "dropped down" state, meaning that their contents are expanded much like nodes in the sidebar. You can click the triangle on the left of the widget name to shrink this widget until you need it.
(i) Button: The Info button is a content retrieval system which uses the patient's information to locate relevant clinical decision support information from online health knowledge resources. More information can be found HERE.
All/Hide Drop Down: These function much like a filter.
When "All" is selected every Immunization record will be shown.
When "Hide Registry Downloads" is selected all registries that were downloaded will be hidden.
When "Hide Historical" is selected all historical immunizations will be hidden.
Historical Button: This allows user to log an immunization that was not administered by one of the office's providers for tracking purposes.
More Button: Clicking this button will allow a user to enter more information regarding the patient's immunization.
(+) Green Plus Button: This allows a user to add a new Allergies to the list.
Note: Keep in mind that you can click on the column headers to sort the items in ascending or descending order based on the selected column.
Once a vaccine is selected from the list, a second window will appear some of this information will pull directly from the References ability > Immunization node. Otherwise information can be added to these fields once the vaccine is added:
Immunization Name: The name of the vaccine selected will display at the top left of this window.
Incident: This drop down menu is used to select the incident/visit the vaccine was administered.
Date/Time: Within these two fields, enter the date and time the vaccine was administered.
Ordered By: Select the user who ordered the vaccine to be done.
Administered By: Select the user who administered the vaccine to the patient.
Office: Use this drop down to select the office the immunization was administered at.
Status: This should be used to indicate the status of the vaccine.
The status options are: Complete, Refused, Not Administered, Partly Administered.
Refusal Reason: When "Refused" is selected as the immunization status, this field will be required.
The Refusal Reasons are: None, Parental Decision, Religious Exemption, Other, Patient Decision.
Other Refusal Description: This field is a free text field, and allows the user to add more information about the vaccine refusal.
Manufactures: Select the name of the manufacture of the selected immunization.
Dose: This field will allow the user to enter the dosage amount.
Unit: This field will allow the user to enter the unit amount for the vaccine.
Route: This will reflect the route in which the vaccine was administered.
The Route options are: None, Intradermal, Intramuscular, Intravenous, Nasal, Oral, Percutaneous, Subcutaneous, Transdermal.
Site: Use this field to indicate where on the patient's body the immunization was administered.
The Site options are: None, Left Arm, Left Deltoid, Left Gluteous Medius, Left Lower Forearm, Left Thigh, Left Vastus Lateralis, Right Arm, Right Deltoid, Right Gluteous, Right Lower Forearm, Right Thigh, Right Vastus Lateralis.
Lot Number: Enter the number assigned by the manufacturer or repackager. This is used to identify a group with a common production period, manufacturing line, and so on.
Expiration Date: This is the date the selected vaccine expires, based on the packaging information.
Number in Series: If multiple immunizations are entered, this designates in which number this immunization falls in the series.
Reaction: If the patient has a reaction to the vaccine administered, select the reaction they are having within this drop down menu.
The Reaction options are: None, Anaphylaxis (Disorder), Disorder of Brain (Disorder), Collapse or Shock-Like State within 48 Hours of Dose, Convulsions (Fits, Seizures) within 72 Hours of Dose, Fever of >40.5C (105F) within 48 Hours of Dose, Guillain-Barre Syndrome (GBS) within 6 Weeks of Dose, Rash within 14 Days of Dose, Intussusception within 30 Days of Dose, Persistent Inconsolable Crying Lastings > 3 Hours within 48 Hours of Dose.
Evidence of Immunity: If the patient is showing signs of immunity towards the vaccine given, choose the evidence within this drop down menu.
The Evidence options are: None, Acute Poliomyelitis, Anthrax, Diphtheria, Disease Due to Rotavirus, Haemophilus Influenzae Infection, Hepatitis B Immune, Human Papilloma Virus Infection, Influenza, Japanese Encephalitis Virus Disease, Mumps, Pertussis, Pneumococcal Infectious Disease, Rabies, Rubella, Tetanus, Type B Viral Hepatitis, Typhoid Fever, Vaccinia, Varicella, Viral Hepatitis Type A, Yellow Fever.
Contraindications: If there is a reason the patient should not given the selected vaccine as it may be harmful, make a selection here.
Contraindication Date: Use this date field to add the date the Contraindication was discovered.
Notes: This is a free text field to add any additional notes about the immunization.
Vaccine Groupings and information Statement Distribution Table: If there are multiple vaccines are needed for a particular immunization series, they can be listed here.
VFC Eligibility Status: This will indicate if the patient is eligible for the Vaccines for Children Program based off this criteria.
The Eligibility options are: None, Not VFC Eligible, VFC Eligible-Medicaid/Medicaid Managed Care, VFC Eligible-Uninsured, VFC Eligible-American Indian/Alaskan Native, VFC Eligible-Federally Qualified Health Center Patient (under-insured), CHIP, 317, Medicare, and State Program Eligibility.
National Drug Code: Use this search bar to find the NDC for the selected immunization.
If a mistake has been made, double click on the immunization to open the information window. Within this window you can also choose "Delete". However, we do not recommend deleting a immunizations unless it was added by mistake. It would be best to update the status to "Completed" or "Not Administered".
Patient Alerts
This widget will show you the alerts that have been added on the Patient tab of the Patients Ability.
Like the above widgets, click on the Drop Down Arrow to expand or condense the section. Also, because these alerts are added from the Patient tab, you can click the blue text to navigate to the Alert sub-tab and view all of the alerts for the patient's account as well as edit them.
Note: Keep in mind that you can click on the column headers to sort the items in ascending or descending order based on the selected column.
Planned Treatments
This shows you all the treatments that have been added to the patient's Treatment Plans in the Ledger tab for the patient.
To expand/condense this widget, click the Drop Down Arrow to the left of the widget name. The procedure code text can also be selected, this will redirect a user to the Treatment Plan where any changes to the Treatment can be made.
Note: Keep in mind that you can click on the column headers to sort the items in ascending or descending order based on the selected column.
Clinical Notes
This widget will show all of the notes that have been entered within the Clinical Notes Table under the Dental Tab.
Drop Down Arrow: By default, the widgets are in a "dropped down" state, meaning that their contents are expanded much like nodes in the sidebar. You can click the triangle on the left of the widget name to shrink this widget until you need it.
Expand All Checkbox: When checked, this will expand Note column so the text appears on a single line.
Clinical Note Type: This drop down menu will work as a filter allowing the user to view the selected note types.
When "All Notes" is selected, all of the clinical notes will show.
When "Completed" is selected, all notes on completed procedures or completed clinical notes will show.
When "Treatment" is selected, all clinical notes under the Treatment Plan/Planned will show.
When "Conditions" is selected, all clinical notes label as a condition will show.
When "Existing" is selected, all notes added to existing procedures will be shown.
When "Deleted Notes" is selected, all of the notes that have been deleted in the Clinical Note column will appear.
Preview Button (10.7.3+): This button gives users a quick look at the clinical note information.
Note: Keep in mind that you can click on the column headers to sort the items in ascending or descending order based on the selected column.
Vitals
The Vitals widget is a record of a patient's recorded vital information. Patient's vitals may also be entered in EMR/EDR, EHR and iEHRforms; all of the details are recorded back to this widget. (Use the Localization Preferences to change the measurements to metric units if it applies to your office.)
At the top of the Vitals widget, there are a few things worth mentioning:
Drop Down Arrow: By default, the widgets are in a "dropped down" state, meaning that their contents are expanded much like nodes in the sidebar. You can click the triangle on the left of the widget name to shrink this widget until you need it.
Growth Chart Button: As vital information is being entered, this chart tracks certain statistics over time.
You can cycle through the different charts: BMI, Stature, Weight, Temperature, Heart Rate, Blood Pressure, Head Circum.
The "Show/Hide Key" Button will control whether the color key for the chart is visible.
The "Show/Hide Table" Button will control whether the table view of the charted information is visible.
(+) Green Plus Button: This allows a user to enter a new set of vitals for the patient.
Note: You can also sort the widget based on the available columns. Simply select the column header and the records will be sorted in ascending/descending order based on the selected column.
After clicking the green plus to add a new record, enter the details in the popup window:
Incident: Select the incident/visit you would like to associate these vitals to. This can help the office identify if vitals were taken at a particular appointment.
Date/Time Measured: Enter the date and time the vitals were recorded.
Weight: Record the weight of the patient here, if applicable.
Length/Height: Add the length or height of the patient here, if applicable.
Blood Pressure: Enter the blood pressure of the patient, if applicable.
Temperature: Record the patient's temperature, if applicable.
Heart Rate: Record the patient's heart rate, if applicable.
SpO2: Enter the oxygen saturation percent here, if applicable.
Resp. Rate: Add the patient's respiratory rate here, if applicable.
Automatic Alerts If you enter any values that may indicate the patient needs attention, such as a high resting heart rate or hypertension, MacPractice will prompt you to take action in a clinical alert. These alerts may be disabled for certain users based on their privileges and new types of alerts and responses can be customized in the References.
If a mistake has been made, double click on the vital record to open the information window again. Within this window you can also choose "Delete". Keep in mind that these records cannot be retrieved once deleted.
Patient Education
The Patient Education widget tracks educational information that has been given to the patient. This information can be added from this widget, EHR or iEHR.
At the top of the Vitals widget, there are a few things worth mentioning:
Drop Down Arrow: By default, the widgets are in a "dropped down" state, meaning that their contents are expanded much like nodes in the sidebar. You can click the triangle on the left of the widget name to shrink this widget until you need it.
(+) Green Plus Button: This allows a user to select a education resource for the patient. These resources will need to be created in advance from the References ability > Patient Education.
Also, clicking on the Info (i) Button for the select widgetswill record that the information has been provided for the patient within this widget. Simply select the resource to provide, and check the "Gave Resource to Patient" box.
Note: You can also sort the widget based on the available columns. Simply select the column header and the records will be sorted in ascending/descending order based on the selected column.
If a mistake has been made, double click on the vital record to open the information window again. Within this window you can also choose "Delete". Keep in mind that these records cannot be retrieved once deleted.
Family History
Maintain a log of the past or present issues in a patient's family which could contribute to the patient's health in the future. This information can be added from this widget, as well as EMR/EDR, EHR or iEHR.
Drop Down Arrow: By default, the widgets are in a "dropped down" state, meaning that their contents are expanded much like nodes in the sidebar. You can click the triangle on the left of the widget name to shrink this widget until you need it.
(+) Green Plus Button: This allows a user to select a finding related to a family member of the patient.
Note: You can also sort the widget based on the available columns. Simply select the column header and the records will be sorted in ascending/descending order based on the selected column.
If a mistake has been made, double click on the vital record to open the information window again. Within this window you can also choose "Delete". Keep in mind that these records cannot be retrieved once deleted.
Goals
The Goals widget displays the patient's clinical goals and instructions. Use the popup to filter the result to All, Completed, Incomplete. Goals can also be added from iEHR and EHR as well as this widget.
Drop Down Arrow: By default, the widgets are in a "dropped down" state, meaning that their contents are expanded much like nodes in the sidebar. You can click the triangle on the left of the widget name to shrink this widget until you need it.
The All/Completed Drop Down: This drop down will filter the goals shown
When "All" is selected every Goal will be shown.
When "Completed" is selected all Goals with "Completed" checked will be shown.
When "Incomplete" is selected the Goals without "Completed" checked will show.
(+) Green Plus Button: This allows a user to add a new Allergies to the list.
Note: Keep in mind that you can click on the column headers to sort the records in ascending/descending order based on the selected column.
Once the goal has been selected and added, double click on the specific goal to add more information:
Goal Name: This will list the name of the goal that was selected in the previous window.
Set Date: By default, this field will pull the date the goal was created. However, this field can also be edited to a different date.
Target Date: This field can be edited to show the target date the goal should be achieved.
Completed Checkbox: Once the goal has been accomplished, check this checkbox to indicate it was completed.
Instructions: This is a free text field where the user can enter additional instructions for the selected goal.
Although we don't recommend it, you can also double click on the goal and choose "Delete" at the bottom left to remove it. Once deleted, the record cannot be recovered.
Labs
This widget allows the user to quickly see all of the labs test that are open and all lab results that are registered within the Labs Abilityfor the patient.
This widget gives you a quick view of Labs associated to this patient. Although there isn't much to it, there are a couple things worth mentioning:
Drop Down Arrow: By default, the widgets are in a "dropped down" state, meaning that their contents are expanded much like nodes in the sidebar. You can click the triangle on the left of the widget name to shrink this widget until you need it.
The Open/All Toggle: This drop down will filter the Labs shown
When "Open" is selected it will show all lab orders that are currently open.
When "All" is selected will show all lab orders, regardless of their status.
Note: Keep in mind that you can click on the column headers to sort the records in ascending/descending order based on the selected column.
As with many of the other widgets, clicking on the blue "Labs" header or the specific lab name, will take you to the Orders Ability for that patient.
Attachments
The attachments widget is the best way to navigate to a unique patient attachment added to the Attachment Ability.
There are a few functions of this widget that are worth mentioning:
Drop Down Arrow: By default, the widgets are in a "dropped down" state, meaning that their contents are expanded much like nodes in the sidebar. You can click the triangle on the left of the widget name to shrink this widget until you need it.
Attachment Type Drop Down: This drop down will filter the Attachments that appear in the widget. The list that appears here is based on the Attachment Types you have created within the Attachment Ability > Attachment Type node.
Preview Button (10.7.3+): Clicking this button opens a preview window, allowing the user to take a look at the attachment without going to the Attachment Ability.
Note: Keep in mind that you can click on the column headers to sort the records in ascending/descending order based on the selected column.
In order to make adjustments to these records, visit the Attachment Ability within your toolbar or click on the blue text to navigate to the record.
Notes
This widget allows users to quickly see all the documents that were made for the patient within the Notes Ability.
There are a few functions of this widget that are worth mentioning:
Drop Down Arrow: By default, the widgets are in a "dropped down" state, meaning that their contents are expanded much like nodes in the sidebar. You can click the triangle on the left of the widget name to shrink this widget until you need it.
Preview Button (10.7.3+):: Clicking this button opens a preview window, allowing the user to take a look at the note without going to the Notes Ability.
Note: Keep in mind that you can click on the column headers to sort the records in ascending/descending order based on the selected column.
In order to make adjustments to a note, visit the Notes Ability within your toolbar or click on the blue text to navigate to the record.