Script: Introduction to Charting, Part 1 – Adding Assessment, Plan, Charges, and Notes and Using Basic Features

INTRODUCTION

In these videos, we are going to walk through how charting works with MD HQ's powerful and user-friendly Encounter Note screen. This first video gives an overview of all the basic features and functions. The next describes how you can use our built-in quick charting tools to chart faster than ever.

Let's get started with the basics. The Encounter Note screen is designed so that you can easily access any part of the patient's record as you're charting. To save space, these blocks around the charting window are minimized by default. However, you can always expand or collapse any box around the charting block by double clicking on its title bar. Then, save your preferred layout using the Preferences drop down menu.

In the charting block itself, the main text area is where you will enter your subjective and objective notes and, as we'll discuss in the next video, access MD HQ's text-based quick charting tools. One little thing to mention here, is that you can highlight text in the main text block to: assign it as a title for the note, create a chart part, which is a flexible template that adds autotext and/or actions to a note, using the highlighted text, or create a blank faxable form with the highlighted text in the body. Let's set this as the note title.

ASSESSMENT – DIAGNOSES

To the right of the main text block, the assessment box is used to enter diagnostic codes for the encounter. The MD HQ EMR uses a subset of the ICD9 diagnostic code database, which can be expanded or modified using the Administrative drop-down menu. Finding a diagnosis to add to the note is simply a matter of typing all or part of its name, nickname, or ICD9 code. For example, let's say Poseidon comes in with a bad sore throat, fever, and swollen tonsils, worried that he might have strep throat. To add a diagnosis of Pharyngitis, you can type in all or part of the name or ICD9 code (462). Sore throat, a nickname, also pulls it up. Let's also add tonsillitis here.

These diagnostic codes will now automatically appear on editable billing or insurance forms or lab orders generated from the note. Hovering over a diagnosis shows more information. And If you right click a diagnosis, you have the option to remove it, make it the primary diagnosis if it isn't already, add it to the patient's past medical history or, if it's a diagnosis for which additional information has been added, do things like add the differential diagnosis, workup, or suggested treatment to the note, plus manage the diagnosis definition to add or edit this type of information.

PLAN – PRESCRIPTIONS, ORDERS, VACCINES, ALTERNATE PLAN ITEMS

Moving on to the plan, this box is used to add your prescriptions, orders, vaccines, or custom plan types like lifestyle prescriptions or supplements.

The simple way to add a prescription is to click "add prescription" here in the plan menu. Then search by typing in all or part of the drug name, brand, ingredients, strength, delivery method, or form. The search will automatically return drugs from your preferred short list unless none match or you enter a "plus" in the search bar, in which case it will return all matching entries from the full NDA/NDF formulary database.

Select a drug and you'll be prompted to enter prescription details – the strength, method, frequency and so forth…. If you change the amount or number of refills, you can click on the calculator icon to automatically adjust the prescription's expiration date.

Up here at the top, you can select or manage the drug's dosing profiles, which can be used to automatically populate saved prescription details. To save current prescription settings as a new profile, make the changes you want and select "save current settings as a new profile." You can set the profile scope to be available to just you or to everyone in the practice, and specify whether it should be automatically used when this drug is selected or should just be available as a secondary profile in the drop down menu. Using dosing profiles speeds up the prescription process and, if different docs regularly use different dosing profiles, each can save his or her own preferences.

OK, let's go ahead and add this.

Next, clicking "Add Orders" brings up a search box, along with an automatically-generated list of the orders that you place most often and orders that have been placed for this patient in the past. If you don't see the order you want, use the search box to find it in your preferred short list or the full database.

To add a vaccine, click "Add Vaccination" to bring up the patient's vaccine chart. Then just click on the correct cell in the row for the vaccine you'd like to add. The vaccine form will be automatically populated with recommended or most recent values, which you can change as needed.

The system also supports supplements, lifestyle recommendations and custom plan types. MD HQ even has a standard supplement database that can be included in your build. Add or edit custom plan types or items via the Administrative drop down menu. Once custom plan types are added, they will appear in the "Add Plan" menu, and can be added to a note in exactly the same way as prescriptions or orders.

FAXING/TRANSFER TO LABS

Once you've created the plan for your note, you may need to communicate information to pharmacies, labs, radiologists, or specialists. You can have the system send a fax for you. Fax a single prescription or order using the item's right click menu. Use "Fax Rxs" or "Fax Orders" to transmit all prescriptions or orders in the note. And you can also always create and fax a form built from scratch via the Reports menu at the top of the page.

CHARGES

Next, to add charges or payments to the note and to assign CPT codes to the encounter. click on "Add Charge" to search by name, nickname, or CPT code. Available charges are drawn from a master list that can be edited via the Administrative drop down menu. We provide a built-in charges list, but you will need to modify the list to suit the needs of your practice. When you add a charge, you will have the option to adjust the default charge amount, modify the CPT code associated with the charge, and add CPT modifiers.

ATTACHING FILES

You can also dictations and documents or images to your note. Upload and attach an MP3 audio file, and add it to the dictation queue, by clicking the link below the save button. Or attach an image or document using the link below that. You can either upload a new file or attach a file that has already been uploaded to the system.

ENCOUNTER SUMMARY

When you're finished charting, you might want to generate a printable summary for Poseidon to take home. Do this by clicking on Reports, and "Generate Encounter Summary for Patient." Everything but the text of the note is included in the summary. Click to remove any blocks you don't want to share, or to edit any text. You can print or send as a fax and the summary will be automatically shared on Poseidon's Patient Portal account once the note is signed.

CONCLUSION

As you can see, MD HQ has all of the basic charting features that you need, with uncommonly usable tools for completing your note and communicating with facilities, pharmacies, and specialists, as well as effectively communicating recommendations and follow-up information to the patient. Next, check out part two to learn about our quick charting tools.