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Lecture Nursing documentation using electronic health records: Chapter 3 - Byron R. Hamilton, Mary Harper, Paul Moore

Chapter 3 - Essential documentation. After completing Chapter 3, the students will be able to: Describe the basic features of SpringCharts EHR, describe the history of SpringCharts EHR, apply user preferences, carry out setting up and editing patients, use pop-up text, explain the concept of an electronic chart, use the electronic chart’s face sheet, use the SpringCharts EHR care tree. | Chapter 3 Essential Documentation © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill Chapter 3 Content LO 3.1 SpringCharts Features LO 3.2 A Brief History LO 3.3 User Preferences LO 3.4 Setting Up and Editing Patients LO 3.5 Customizing Pop-Up Text LO 3.6 Understanding The Electronic Chart LO 3.7 The Face Sheet LO 3.8 The Care Tree LO 3.1 SpringCharts Features LO 3.1 SpringCharts Features CCHIT certified Easy to use Rich in features Customizable to suit a wide range of healthcare specialties Principles of electronic documentation transfer from system to system LO 3.2 A Brief History LO 3.2 A Brief History SpringCharts Developed over 10 yr period 2004 – developed PMS/EHR interface 2006 – CCHIT certified 2009 – SureScripts certified for e-prescribing 2010 – ONC certified, qualifies for financial rebates under HITECH Act LO 3.3 User Preferences LO 3.3 User Preferences Establishment of personal user preferences Office Visit form view Search mode Pop-up text . | Chapter 3 Essential Documentation © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill Chapter 3 Content LO 3.1 SpringCharts Features LO 3.2 A Brief History LO 3.3 User Preferences LO 3.4 Setting Up and Editing Patients LO 3.5 Customizing Pop-Up Text LO 3.6 Understanding The Electronic Chart LO 3.7 The Face Sheet LO 3.8 The Care Tree LO 3.1 SpringCharts Features LO 3.1 SpringCharts Features CCHIT certified Easy to use Rich in features Customizable to suit a wide range of healthcare specialties Principles of electronic documentation transfer from system to system LO 3.2 A Brief History LO 3.2 A Brief History SpringCharts Developed over 10 yr period 2004 – developed PMS/EHR interface 2006 – CCHIT certified 2009 – SureScripts certified for e-prescribing 2010 – ONC certified, qualifies for financial rebates under HITECH Act LO 3.3 User Preferences LO 3.3 User Preferences Establishment of personal user preferences Office Visit form view Search mode Pop-up text Measurement Time Font Rx Print Attending LO 3.3 User Preferences Preference 2 Password Signature LO 3.4 Setting Up and Editing Patients LO 3.4 Setting Up and Editing Patients Adding new patients First & last name Date of birth Editing patient Modify demographics Delete Archive View all patients LO 3.5 Customizing Pop-Up Text LO 3.5 Customizing Pop-Up Text Pop-up text Functions like pick lists Enables the user to select words, phrases, or paragraphs with the click of the mouse Provides rapid way to document Stored by user log-in name Modified without affecting any other user’s pop-up text LO 3.6 Understanding The Electronic Chart LO 3.6 Understanding The Electronic Chart Electronic chart Repository for patient health data created through computer automation in the healthcare setting Static information such as demographics, allergies, health history, and health problems Dynamic information including encounter notes, nurse notes, tests, letters, and reports concerning the patient LO 3.6 .