Patient Chart

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The Patient Chart is the central point of access to all areas of a patient's complete Medical record.

NOTE: Just like a paper chart, the Office Practicum chart, and other forms in Office Practicum, contain personal health information that should be kept confidential. You should treat all forms in Office Practicum (like F8 Chart) just like you would treat a paper record of patient health information, never leaving that record out in the open for others to see. More specifically, you should always close all forms on your screen and log out of Office Practicum when you are done at your workstation.

Contents

[edit] Opening

To open the Patient Chart:

  • Press F8, or
  • On the main menu bar at the top of the Office Practicum screen, click Work Areas --> Chart, or
  • Click the F8 Chart button in the row of smart buttons at the bottom of the OP screen

[edit] Choosing a patient

All patients entered in your Patient Register have a Chart. To choose the patient whose chart you would like to view:

  1. Click the Choose button in the upper left corner to open the Patient Directory.
  2. Enter the last name of the patient in the field provided, then click the Search button on the top right.
  3. To include patients who have outgrown the practice, moved away, or transferred to another practice, click the Include Not Active check box to the left of the search field.
  4. To search by either the patient's first name, the first name of a parent or other member of the family, or provider name, enter the name, then click the appropriate check box to the right. Click the Search button.
  5. To search by telephone number, type "#" first, then 4 digits (at least) of the phone number in the search field. Click the Search button.
  6. To search by insurance ID, type "@", then the insurance number. Click the Search button.

[edit] Navigating

The Patient Chart features, in order from left to right:

  • A Checklist of tasks for providers, nurses, and staff members
  • A column of buttons in the center
  • A series of fields

Click on a button, or double-click on a field, to access an area of the chart. The chart section will open in a new window.

[edit] Buttons

Each button opens to a form, table or database in the patient's medical records. The buttons, and their associated forms, are described below:

  • Event Chronology - Opens the Event Chronology, a complete list of the patient's medical records.
  • Flow Sheet - Opens the Preventive Care Flow Sheet, or "Flow Sheet", a form which organizes and displays the patient's health maintenance schedule.
  • Vitals/Growth (Vitals/Growth Charts) - Opens the Vital Signs and Growth Measurements table, which includes fields for entry of the patient's measurements, and displays growth charts on basis of weight, stature, BMI, and length.
  • History - Opens the Detailed Patient History, where you can quickly and easily enter the patient's past medical, family and social history using a check-box format, as an alternative to using Chart Notes.
  • Developmental - Opens the Developmental Evaluation table in either narrative or graphic format. Click on the Image:Down Arrow.jpg to the right of this button and select either Narrative Milestones Chronology or Graphic Milestones Chronology from the drop-down menu.
  • Chart Notes - Displays a list of Chart Notes, which you can use to enter the patient's medical, family and social history in narrative (text) format.
  • Medications - Opens the patient's Complete Medication List or Medication List, a chronological list of all prescriptions entered in the patients chart.
  • Asthma Plan - Opens the Asthma Plan Wizard, an application you can use to create and print a unique Asthma Action Plan for the patient's family.
  • Diagnostic Tests - Opens the Diagnostic Test Management table, where you can enter and track labs and preventive screening tests.
  • Immunizations - Clicking this button to opens a pop-up window where you can choose to open either the Immunization Chart for entry of vaccines given in the office, Immunization Related Medical History ("Vac. Related Med Hx") for entry of vaccine-related medical information, or the Quick Entry Chart for entry of a patient's prior vaccine record.
  • Referrals - Opens the Patient Letter / Referral Information table, a complete list of entered and scanned referrals and general letters.
  • Surveys - Opens the Survey Notes / Questionnaires table, where you can access and complete questionnaires linked to the Patient Chart.

[edit] Fields

Each of the fields on the right side of the Patient Chart screen displays a section from a list pertaining to the patient's medical record. Double-click on a line item to be taken to the specific chart note. More information on each list can be found at the links below.

  • Ongoing Problem List - Displays list of items from the patient's Ongoing Problem List. If there are any (Exempt from reporting) items in this list, the number of items will be indicated in the EFR count, to the upper right of the field.
  • Allergies - Displays items from the Allergies section of the patient's chart note. See Entering patient allergies for details.
  • Pertinent Positive History (optional) - Click the Show Hx check box to view a list of positive answers to the patient's Detailed History.
  • Current and Ongoing Medications - Displays current and ongoing items from the patient's Medications List. If there are any (Exempt from reporting) items in this list, the number of items will be indicated in the EFR count, to the upper right of the field.
  • Immunization Forecast - Links to the patient's Immunization Chart.
  • Health Summary - Recommendation - An overview statement about the child's health, with special instructions for school/camp personnel.
  • Primary Insurance - Shows the patient's primary insurance and VFC eligibility.

[edit] Customizing your view

Users can adjust the size and appearance of the fields on the right side of the Patient Chart by clicking on the lower border of a field and dragging to the desired size.

[edit] Marking sections as 'reviewed'

Providers can click the Log button accompanying the Problem List, Allergies, Current Medications or Immunizations sections to indicate that that section was reviewed. The 'reviewed' status and user ID will be entered in the Action Audit Trail.

[edit] Security

[edit] Access permissions

The following buttons and fields are disabled if the logged-in user does not belong to the Medical Records group:

  • Encounter
  • Well Exam
  • Chart Notes
  • Newborn History
  • Ongoing Problem List and Allergies - Double-clicking on these sections is disabled.
  • All buttons in Medications page disabled, but the grid can be viewed.
    NOTE: User permissions/groups can be edited in the Security Settings table.

[edit] Audit Trail

Access to or opening of most medical records in the patient's chart are logged in the Action Audit Trail.

[edit] Troubleshooting & Questions

[edit] Navigating and managing the Patient Chart

  • How do I add/edit Hospitals which appear in the Newborn History?
    • To add/edit a hospital appearing in the Newborn History form, enter the following information in the fields:
      1. Registry Lookup: Select Birth Facility.
      2. List Position: Enter the number that you would like the facility to occupy in the list of Birth Facilities.
      3. Code: The code may be obtained from the hospital, or from the Office Practicum website, under the Downloads section (select "CMS 1500 Related" as the Category).
      4. Description: Enter the name of the hospital.

  • How do I find a history of deletions or changes to a patient's record?
    • You can view a full list of changes or deletions to a specific patient record, or all patient records, in the Audit Trail, accessed by going to Records --> Audit Trail. Please see Viewing changes to patient records in the Audit Trail page for instructions on looking up changes to a patient's record.

  • How do I copy a patient's chart onto a CD-ROM or a folder on my computer?
    • This can be done from the Event Chronology:
      1. Open the Event Chronology and click on the print button.
      2. In the pop-up window select Print to File from the drop-down menu, then choose pdf (Adobe).
      3. This will generate the report as a pdf document, which you can then save onto a CD or on your workstation's hard drive.

  • How do I document that a visit was not completed because patient left?
    • Document why the visit was not completed in Chief Complaint box.
    • If you are not going to charge anything for the visit, make a note in the Chief Complaint box as well, so that when you reconcile the schedule you know why you didn't post any charges for the visit.

  • How do I toggle between sibling charts?
    • Currently, you cannot have two patient charts open at the same time in Office Practicum. You can, however, use the Patient Directory to easily switch from a patient's chart to the chart of his/her sibling:
      1. Press F8 to open the Patient Chart.
      2. Click the Choose button in the upper left corner to open the Patient Directory.
      3. Click the button underneath the Search field that displays the patient's phone number. A list of patients with the same phone number, the patient's siblings, will appear.
      4. Select the sibling's chart.

  • Why does Patient of Outside PCP appear in the Immunization Summary of Patient Chart?
    • The Patient of Outside PCP will appear in the Immunization Summary of F8 chart if the option is selected in the "Immunization Related Medical History" screen. To remove this:
      1. Select F8 chart.
      2. Choose the patient from the Patient Directory.
      3. Double-click on the Immunization Summary area of Patient Chart.
      4. Click on Enter Immunization at the top right of the screen.
      5. Select another Overall Immunization Status option other than Patient of outside PCP.

  • Can OP send automatic appointment reminders to patients?
    • OP interfaces with an automatic phonecall software called, "Televox", which you can program to call patients to remind them of scheduled appointments. For more information on interfacing OP with Televox, click here. You can also learn more about Televox at their website.
    • If you should decide to purchase Televox, or if you have any questions or concerns, please do not hesitate to email or call us, and we will answer your questions and assist you in setting up the software with OP.
    • Connexin Software, Inc does not endorse Televox and has no relationship with the product or company. It is recommended as a product which other clients currently use and which we have confirmed to work with OP. You should also discuss the software with your IT technician as they may have other recommendations for you.

  • Where do I enter medications taken by the patient prior to an encounter visit?
    • Medications (tylenol, motrin, etc) administered at home prior to an encounter visit can either be recorded in the CC/HPI box on the Encounter Note or they can be entered into the Medications section of the chart. Medications will be entered as if writing a RX, but the purpose will be med reference only rather than to dispense. If the nurse enters the medication, it will automatically default to this.

  • Why are some medications appearing as ongoing on the front of F8 when I did not check include in ongoing medication list?
    • The list on front of F8 chart documents both Current and Ongoing meds. The meds someone prescribed today will show up as current until days supply (or Rx End Date) is reached. For example, if you write a script for 2 tabs a day for 10 days on 5/5, then the medication will stay on the front of F8 for 10 days (until 5/15). If you choose to make this script stay on the ongoing list, edit the script and check Include in ongoing medication list.

  • How do I charge for counseling and/or co-ordination of care?
    • Counseling and co-ordination of care can be documented in the Encounter Comprehensive with suggested CPT code module.
      1. Go to the Assessment tab in the Encounter Note.
      2. Click on the Counseling tab.
      3. Select Time IS the key factor:Counseling and C.O.C.>50% of the total length of visit.

[edit] Printing

  • How can I print multiple scanned items from a patient chart all at once?
    • You can print multiple scanned items, rather than one at a time, from any patient's chart via the Event Chronology screen.
      1. Click on the Event Chronology button (titled "EC"; "CHRON" on 8.1) at the bottom of the OP screen.
      2. The Event Chronology screen will open. Click Choose in the top, left-hand corner to pick the patient for whom you wish to search and/or print scanned items
      3. You can refine your search findings further by choosing a date range, selecting to show all items in the chart, or messages and notes only etc.
      4. When you have set your criteria REFRESH the page by clicking on the button with a circular arrow next to the date range. This will update your search findings per your criteria.
      5. Scroll through the Event Chronology entries using the scroll bar on the right-hand side. There is a column in the grid with a scanner icon. Any scanned items will be designated by this scanner icon appearing in the column.
      6. To print the scanned items, check the boxes in the corresponding grid lines for each item you wish to print.
      7. Click the Image:Printer icon.jpg button in the upper left corner.
      8. FIRST, a Summary Page will appear. This Summary page will give you the DATE, PATIENT ID NUMBER, SCAN ITEM NUMBER, and DESCRIPTION of each item in a concise list. Click the print icon in the top left-hand corner to print this page.
      9. When the page/s is finished printing, click Close at the top of the screen. If you do NOT wish to print this page, simply click "Close" without printing.
      10. The scanned items will automatically display on the screen for printing. While the system gathers all of the scanned items, you may see a small screen titled, "accessing" - please allow some time for the system to compile all of the scanned items.
      11. When the system is finished compiling all the scanned items, they will appear in Print Preview on the screen.
      12. You can scroll through and look at each item by clicking on the arrow keys at the top of the screen (next to the item number).
      13. If you wish to print all of the items, simply click on the Image:Printer icon.jpg button in the left corner.
        • If you decide NOT to print all of the items, simply click Close.
      14. All of the scanned items will print, one after another.

  • How do I track who printed items for a patient such as school forms, immunization records and statements?
    • After each print job, the Medical Disclosure tracking screen pops up. Each of these entries is stored in the patients disclosure tracking log. All statements, school forms, claims and chart items printed will show up if you choose All Records. Note that if the staff member hits CANCEL on the Disclosure tracking screen, then the item will not be added to the log. It is very important that your staff properly fills in all of the information, including to whom the record is being released, who authorized the release and the Staff Member responsible for releasing the record.
    • To view the Medical Disclosure Tracking Log,
      1. Click on Records in the top tool bar of OP
      2. Select Disclosure Tracking and a new window will appear
      3. Choose the patient
      4. Select All records to view all items printed
    • The name of the staff member who printed the item, along with the date, and type of item will appear in the grid.

  • How do I print a Preventative Exam File copy?
    • In order to print out a Preventative Exam File Copy for each well visit for situations like insurance chart audits, you must select the "ExamComp" or "Exam" on the front of F8 chart.
      1. A screen will pop-up asking Do you wish to use the default template for age?
      2. Select Yes or No.
      3. Click the -Archive tab to the left of the screen.
      4. Click the printer icon at the top left corner
      5. Enter each specific preventative exam date of service in the From and To fields.
      6. Click Print at the bottom of the screen.

[edit] Errors

  • Why is the wrong age displayed in the Patient Chart when the DOB is correct?
    • The date added to the newborn history overrides the date of birth in the register. Always check that the DOB in the register matches the DOB in the newborn history, so that the chart displays the age correctly.
    • If a patient chart displays the wrong patient age and the DOB is correct, then you must do the following to correct it:
      1. In Patient Chart, Click the History button.
      2. Click on the tab that says Birth Info.
      3. On the right hand side of the Birth Info. tab click the Reset button.
      4. Click the save button and this should correct the problem.

  • Why is the patient's age displaying in hours instead of days on the Patient Chart?
    • If you enter an exact time of birth in the F8-History> Birth Info tab, then the age will be calculated in hours up until 4 days old.
    • If you would like to have the age displayed in days,
      1. Open the History.
      2. Click on the Birth Info tab.
      3. Edit the Birth date/ time field by hitting the Reset button to clear the exact time of birth.
      4. Upon hitting Exit, you will be prompted to save your changes.
      5. Close and reopen the patient's chart to see the age in days instead of hours.

  • Why does OP ask me to log in when I try to access a patient's chart?
    • If a patient has been marked as EFR (Exempt from Reporting) in the F2 Register window, then only the doctor will have access to the chart. They will be prompted to log in again in order to view the chart. If the chart has been marked EFR in error, here is how to correct this.
      1. Have the doctor log in.
      2. Click F2 Register.
      3. Click on the Privacy Constraints tab.
      4. Change the Privacy Constraints settings to Did Not Ask or another appropriate.
      5. Click the Image:Check.jpg (checkmark) button to save.
      6. Test this by having someone else log in and open the patient's chart.

  • Why is the last encounter not displaying when there is a claim in the account?
    • The last encounter does not pull from the billing component. The visit must be documented in a S.O.A.P or Comprehensive Encounter Note note to show up in the Add/Edit appointment screen or in the F8 Chart.

  • Why am I getting "Error LZW compression not supported" while trying to put faxes in charts?
    • You might setup all faxes as Tif format, but it can still create an error LZW compression not supported.
      1. Open the original document.
      2. Click on File --> Save As.
      3. A Pop-Up window will appear. Under File Name, the same file name should automatically appear.
      4. Under Save as Type, click on Drop Down Box.
      5. Choose JPEG.
      6. Click on Save.
      7. Go to OP and perform the Import File Procedure.
    • If you are still unable to Save Type as JPEG(Step 4),you must Print/Save as a PDF (This can only be done if you have a Adobe Writer (Acrobat)),then Convert to JPEG:
      1. Please open the original document
      2. Go to File --> Print.
      3. A Pop-Up Printer window will appear. Click on Drop Down Box and scroll down and click on ADOBE PDF.
      4. Click on OK/Print.
      5. A Pop-Up window will appear. Under File Name, the same file name should automatically appear.
      6. Click on Save.
      7. Open the PDF document
      8. Go to File --> Save As.
      9. A Pop-Up window will appear. Under File Name, the same file name should automatically appear.
      10. Under Save as Type: Click on Drop Down Box and Choose JPEG.
      11. Click on Save.
      12. Go to OP and perform the Import File Procedure.

  • Why do I get an error "vl2api_know_date (birthday) failed" when opening a chart from the schedule?
    • You may receive two error messages back to back: vl2api_know_date (birthday) failed followed by vl2api_know_date (today) failed. The date format in Windows is conflicting with what OP recognizes. You will need to change the date format, then restart OP:
      • On a Windows XP machine,
        1. Click Start --> Settings --> Control Panel.
        2. Look at the classic view and open the Regional Settings.
        3. Click on the Date tab and change the short format to mm/dd/yyyy.
        4. Date separator should be a / not a -.
      • For a Vista machine,
        1. Click Start --> Control Panel.
        2. Look at the classic view and open the Regional and Language Options.
        3. Click Customize this Format.
        4. Click on the Date tab and change the short format to MM/DD/YYYY.
        5. Date separator should be a "/" (slash), not a "-" (dash or hyphen).

  • Why do I no longer have access to the Event Chronology or Summary/ Finalize edit button after updating to OP 8.1?
    • OP 8.1 offers a little extra security to your Event Chronology and Summary/ Finalize > Edit Report Criteria window. If you do not see the Diagnostic Tests, Immunizations or Prescriptions in the Summary/ finalize section, you will need to edit the Encounter report criteria by adding the Manage_Form_RPT_Options right to the Group of your choice. To add the new report sections,
      1. Open a patient encounter note and choose a patient. It does not matter which patient you choose (including test patients).
      2. Click on the Summary/ Finalize tab
      3. Hit the Image:Edit Criteria.jpg button within the Summary Report Criteria box.
      4. Click the tab labeled Encounter Sections.
      5. Check the box for ALL so that medications, diagnostic tests and immunizations populate the summary sheet.
      6. Go back to any unfinalized note and hit Rebuild Summary on the Summary/ Finalize window.
    • After making these changes, close and reopen OP for them to take effect. The staff members associated with that group will have access to the Edit button and will be able to create and edit the report types in the Event Chronology drop down.

[edit] See also

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