Using Provider Charting Templates-PROCEDURES Tab

Summary

Document procedures such as laceration repair or providing the patient with a brace on the PROCEDURES tab. The text generated here goes into the Plan section of the SOAP note. Depending on the workflow in your clinic, this might be done by a clinician or by the provider. By default, only providers have access to this tab. Allowing clinicians this additional access requires special setup in EMR Parameters. Procedures Wizards can create Order records, for instance, a Wizard documenting that a brace has been ordered would generate an order record for the discharge nurse to provide the brace. Wizards create order records only when set up to do so.

Charges / Medical Activities

Wizards on the RESULTS, ORDERS, and PROCEDURES tabs can be set up to automatically add charges, or medical activities, to the visit when the Wizard is executed. This reduces the work to be done when the patient is checked out, and decreases the likelihood of charges being missed. (The possibility of a charge being missed cannot be eliminated since not all charges fit well within the structure of Wizards.) Medical activities with an Activity Type of Physical/Assessment, Surgery, Vaccine/Immunization, Administrative, Medication/Drug, or Other Medical Procedure, Supplies are displayed on the tab as seen below. Others can be seen on the RESULTS tab.

All activities must me marked as Complete. Some require additional entry, such as indicating a result is normal or abnormal. Activities that require additional work are typically seen on the RESULTS tab instead of here. The work of finalizing entry on activities is often handled by the front desk staff working on the visit record, but these tasks can also be performed here. This is one reason that clinicians can be given access to this tab.

An EMR Parameter can be set to automatically complete charges when they are added to the visit by Wizards. That eliminates the need to open activities that require no additional entry work.

Completing the PROCEDURES tab

  1. Click Medical Procedures.

  2. On the [EMR Charting Template Text Elements] window, check all items that apply.

  3. Click Done.

  4. Net Health Employee Health and Occupational Medicine will insert text and execute Wizards associated with selected Text Elements. Make entries as required on the [Smart Form Charting Wizard] window.

  5. If this visit has multiple diagnostic codes associated with it, on that same window you can associate procedures with a single diagnostic code:

    • Click the table icon beside Problem.

    • On the [Select Associated Problem] window, highlight the correct Problem Description, and click Select.

  6. If you would like to add any Visit Activities (i.e. billing charges) to the visit, click Add. (Note: Use of this feature by a provider should be an exception, not the routine. Effective setup of wizards will automate entry of most visit activities. When an unusual circumstance requires an activity to be added manually, it will typically be a clinician or support personnel.)

    1. On the [Enter Medical Activity] window, click the table icon beside Activity Code.

    2. On the [Select Medical Activity] window, search for and select the activity you want to bill.

    3. Click the drop-down arrow beside Result Code and make the appropriate selection.

    4. If your clinic is using Net Health Employee Health and Occupational Medicine messaging and you would like to send a message about this activity to someone else in the clinic, click the messaging icon and send the message.

    5. Click OK.

    6. Incorrectly entered activities can be deleted by highlighting the activity and clicking Delete. To alter the activity code or the result code, click Change.

    7. The status of all medical activities can be changed to Complete by clicking Complete All.

  7. If needed, you can make changes directly to the charting note using the editing features.

What Do You Want to Do?

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