EHR Chapters 6,8,9

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EHR Chapters 6,8,9

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What is a lab panel composed of?
Multiple analytes that will undergo analysis
What is a lab analyte?
A blood test compound that is the subject to its own specific chemical analysis
To export popup text from the practice view screen the administrator will select the utilities menu, then which option must be selected?
Import/Export SpringCharts
When the results are recieved and manually put into the pending test, where is the test sent?
Completed tests
Specific lab companies that transmit electronic data to SpringCharts using HL7 language and protocals are?
Reference Labs
What is amatch choice task that SpringLabs will automatically perform using the patient's name and date of birth?
Identify patient
How may lab test results be enetered into the pending test?
Manually and automatically via SpringLabs
In the complete test window how may the listed tests be organized?
-Test name or patient name -Test order date -Ordering physician
Where will test results be available if the tests were ordered within the office visit encounter?
Test results
What button can a user select in the New IMaging Test or New Medical Test window to access the CPT code dictionary database?
How does a user add a new procedure?
Select New>New procedure from the practice view screen
In the New Diagnosis window, which button will give access to the ICD-9 database?
EDI is an acronym for what?
Electronic Data Interchange`
Which window must a user access to modify popup text?
Edit popup text window
When inserting a letter template, how can a user amend the letter?
The user may use line items from the popup text window
Using the menu bar, how can a user create a letter template from the practice view screen?
New>New Template>New Letter Template
Why would an order form be created in the patient's chart?
ONly if the patient was not being seen as part of a normal office visit
If the order templates are used in th OV screen what will automatically be added to the order from from the OV note?
Diagnoses and the ordered tests
What is used to rapidly populate the New OV window?
Order templates
What are some of the medical specialties that TemplateWare caters to?
-Pediatrics and family practice -Internal medicine and gastroenterology -Psychiatric and pulmonary medicine
What screen must a user access to create a new template?
Practive View Screen
What is a Template?
A document that is predesigned with a set structure
What is an Addendum?
A medical note added subsequent to the original note that will supplement the clinical information
What does an E&M coder look for?
Keywords used within the review of the systems and exam of body areas, organs and systems in the office visit note
What is a routing slip?
A form that contains the medical office's most common procedure and diagnosisi codes and descriptions
TemplateWare is a SpringCharts add-on feature that provides what?
Pre-built office visit notes, orders and letters as well as popup text for specific specialists
What is the purpose of the AMA?
To promote the art and science of medicine to improve our health care system
What does CPT stand for?
Current Procedure Terminology
What does ICD-9 stand for?
International Classification of Diseases, Volume 9
What kind of information on drugs can you get from a drug monograph?
-compostition -description -method of preperation -dosage -adverse side effects -overdose -warnigns -research
What are drug monographs?
Highly detailed and thoroughly documented studies on drugs
What kind of information does a drug formulary include?
-preperation -safety -effectiveness -cost .... of drug therapy medications
What is a drug formulary?
A database of approved medications in drug therapy catagories
What is Body Mass Index(BMI)?
A mathematical formula that divides a person's weight by their height in meters squared
What is an H&P (or History and Physical Report)?
Documentation of the patient's medical history combined with the physical exam
What does SOAP stand for?
Subjective Objective Assessment Plan
An office visit is defined in SpringCharts as what?
An encounter with a medical provider in which the patient's chief complaints, vitals, ect. are reviewed and documented
When will the otion to add an addendum to an OV note be available?
When the OV note was permanently signed and locked
Which button is selected to view the E&M code factors that were used to deterine the specific recommended code?
which feature in the Tools menu in the OV screen enables the user to save an existing office visit note under a different care tree tab than where it was originally saved?
The chart tab feature
In which menu of the OV screen can a patient's immunization record be viewed?
It cannot be accessed in the OV screen.
How does a user create a report without having to open the OV screen?
Click the report once the office note has been selected in the care tree.
Which icon in he Edit Rx window will open up the patient's list of previous diagnoses, PMHX and Problem List diagnoses?
The diagnoses search icon
What has become the international standard diagnostic classification for all medical data dealing with the incidence and prevelance of disease in large populations?
What is the function of the time and initial button?
It enables a clinician to time and initial stamp a portion of the office visit note
What are drug formularies?
Databases of approved medications in drug therapy catagories.
What feature in SpringCharts enables the user to proceed through the office visit in a logical flow?
The navigation panel at the top section of the OV window