The MEDICAL INFORMATION section stores clinical patient data. This clinical information can either be manually entered directly into the appropriate tab within the chart, or will automatically pull from an encounter note and populate the tab if entered into the encounter during a patient visit. For example, in the Labs, Radiology, and procedures tabs there are two sections: Point of Care and Outside Orders. All tests listed in the Point of Care sections were conducted during a patient visit, and therefore documented in the visit encounter note. Once it was documented in the encounter note the data also populated the Point of Care section in the patient chart to be stored and referenced when necessary. The Outside Orders section in each tab allows a user to create an order directly within the chart if that test happens to be ordered outside of a patient visit.
In this course we’ll cover all the areas included in the Medical Information Tab of the Patient’s chart.
- Summary
- I. Past Visits
- II. Details
- III. Forms
- HX
- I. Medical History
- II. Surgical History
- III. Social History
- IV. Family History
- V. Conservative Therapy
- Allergies
- Problem List
- Labs
- I. Point of Care
- II. Outside Labs
- III. Documents
- Radiology
- I. Point of Care
- II. Outside Radiology
- III. Other Results
- Procedures
- I. Point of Care
- II. Outside Procedures
- Imm/Injections
- I. Immunizations
- II. Injections
- III. Immunization Table
- IV. Immunization Record
- V. Request History and Forecast
- Supplies
- Meds
- I. Medications
- II. Point of Care
- III. Refill Summary
- Health Maintenance
- I. Health Maintenance Plans
- II. Patient Reminders
- III. Health Maintenance Flow Sheet
- Vitals
- Custom Plan Sections (if applicable)
This course is intended for those with the following roles: Practice Administrator, Medical Assistant, RN, NP, PA and Physician
Course Instructor
