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.

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.

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.

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.

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.

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.

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.