Chart a Visit in 5 Minutes with PCC EHR
PCC Videos & Podcasts / Jun 27, 2017
Love your work but miss your life outside of it? Every minute you save charting is extra time in your day to spend doing what you love. Want to get home in time for dinner with your family? Want to spend time catching up with friends after work? PCC EHR makes it so easy to chart a visit, you'll have time in your day to see more patients, and still leave the office on time. Watch this quick video to see how.
Hi, this is Douglas at PCC, and I’m going to chart a visit using PCC EHR.
First I log in to PCC EHR. Next, I look at today’s schedule and pick a visit to chart. There are lots of custom options and filters on the schedule screen to help me find exactly the visit I want; right now the schedule is showing me my patients for today, and I can use the status and location over here to see where patients are and who is ready for me. I could use the ‘find’ field up here to grab and open a chart, but I’m going to double-click right here to open up this patient’s chart. The chart opens and the first screen I see is my practice’s custom medical summary; a patient face sheet. In my practice, we chose to display recent and upcoming appointments, the patient problem list, medications and so forth, but you can put anything on here you like to see when you first open a chart.
How do I get around the chart and today’s chart note? All chart navigation is over here on the left. Sections of the chart are going to be up here, and since I opened up today’s visit, I also see navigation to today’s appointment chart note, down here. Now, before I go to the chart note (if I want) I could update demographics, or click the ‘history’ button and look at the patient’s chart note history, or their immunizations history, lab result flow sheets, growth charts and so forth. So, after I optionally review a patient’s chart sections, I click down here to jump to today’s chart note. The chart notes navigation buttons opens up and I see today’s four-year well visit chart note. At the top of the chart note, I can tell everyone that I’m with the patient, and review appointment details. I’ll click ‘intake’ because I want to see all the information my nurse collected. I can see the answers she entered and also enter any updated information that I collect; I could retake blood pressure if I wanted to. The chart note in PCC EHR is a ribbon of these components, specifically tuned for this patient’s age, and this visit reason. So, I could scroll down the ribbon over here and do my charting, but instead of scrolling, I just like to click one of these navigation buttons to jump to the section I want. My practice designed this chart note, they based it on Bright Future’s recommendations; this is the stuff we want to appear on four-year well visit chart notes. For example, to save time, we put the patient’s growth charts right here in the chart note. I’ve got screenings and other orders, and further down the note I’ve got custom sections for review-of-systems, immunizations, other tools I may need as I’m charting this encounter. Everything I need is right here; no hidden windows or pop-ups. Now if I were charting a sick visit or an earache visit, I’d see different components in here. Some physicians just like to grab a simple soap-notes chart note. Naturally, I can switch chart note protocols, or add an extra one if this physical turns into a sick visit and I need other components to chart my visit. These protocols are customizable, so you can design one that matches your practice’s workflow.
Today, I’ll show you just a few features of the great features you can use while charting. We do a hearing, vision and ASQ at our four-year well visit, so I can place these orders right here under screening. I just click the ‘order’ button and that’s it. I might edit and complete these myself, or a nurse in my practice will see these orders back on their schedule screen. The order includes all my desired preferences and instructions. Recording notes is fast and easy in PCC EHR. For example, PCC EHR tracks answers visit to visit. So, for this history question, I can see the family’s last answer to this question. I can click ‘last answer’ to fill in that note and then optionally add any additional information. PCC EHR also makes taking notes on review-of-systems and physical exam incredibly fast. I can click ‘make all normal’ and PCC EHR enters my specific four-year well visit default normal note for each item. I entered these notes into PCC EHR just one time, and now I always have them at the ready. Now I’ll click “abnormal” on this one and add a note. PCC EHR remembers my last ten answers for fields like this, so once I’ve been using PCC EHR for a while, I don’t even have to type that note in. I can pick from a list, or just start typing, and it will offer me the full note to pop into place.
Let’s look at immunizations. My practice naturally put the patient’s immunization record right on the chart note and PCC EHR automatically compares the patient’s immunization record with the CDC’s ACIP schedule; it tell me what the patient should probably receive today and alert me if they are behind. So, right here, I can see they’re in for their next dose of DTaP, MMR, polio and Varicella, and I can also tell they didn’t get a flu shot last year, and they’re behind; it looks like they missed Hep A shots. Right underneath their schedule and these forecasting recommendations, we can order these shots we expected to order today, or any immunization. I think I’ll do the DTaP, IPV, and we’re going to do a MMRV, and, optionally, down here, I could enter the Hep A and do a catch-up vaccine right now. As I mentioned, my clinical staff will be able to see that these orders are waiting right on the schedule screen; they can pick these up, or I could click ‘edit’ right here, make any changes, and complete the order myself. By the way, if I need to prescribe medication, I can use the PCC eRx chart note section, which is a complete suite of medication management and electronic prescribing tools. Have you got a sibling in the room during a sick visit? I can click right here to pop open the sibling’s chart and chart them, side-by-side, with these tabs at the top.
As I wrap up a visit, I will select one or more diagnoses. When I enter diagnoses, PCC EHR automatically suggests matching ICD 10 billing codes and gives me other options, like adding a new diagnosis to the problem list. I might also chart anticipatory guidance notes, plan notes, and I can click here to have the patient instructions and other information appear on a customizable, printable, patient visit summary report, which I hand to the patient. Mom and Dad might lose that piece of paper, or course, so a summary of today’s visit is also uploaded to PCC’s patient portal. Patients and families can securely log in to review their medical records, get an immunization report, or check when their next appointment is. They can even use the portal to securely send your office a message.
Okay, there are many more powerful tools in PCC EHR’s chart note components; what happens after you are done charting? Your clinical staff will see the patient’s updated status, back here on the schedule screen. They can use PCC EHR’s other great tools to complete orders, track lab results and so forth and I can go on to the next patient. But, if everything is complete for today, I can click ‘bill’ to review and send an electronic encounter form over to PCC’s partner billing system. The ‘bill’ window shows me all the billing codes for the diagnoses, procedures and orders that I charted. Administration and supply codes can pop-up here automatically; I can add office visit codes, link diagnoses to procedures; do everything else I need so it is all ready for the claim.
Stepping outward a few steps, PCC EHR and partners’ wealth of reporting features, and your practice vitals dashboard are available to help you track your revenue, and evaluate clinical and financial progress. Find ways to improve your efforts to become a clinical home for your patients.
Finally, PCC’s most powerful feature is that we include unlimited support and training on all of our products. We will train and retrain your staff, we will help you customize and redesign your workflow; you can call us at any time. And, your PCC client advocates will also call you on a regular schedule to help proactively respond to the needs of your practice. Want to learn more? There is a PCC EHR overview video series, and our online help library can show you even more. Call or email us at any time, and we can help you discover if PCC’s comprehensive support, services and software will meet the needs of your practice.
Thanks for watching; we hope to talk to you soon.