PCC EHR – Navigating the Chart
PCC Videos & Podcasts / Jun 26, 2017
In this video, we’ll take a brief tour of the patient chart.
This is the second video in the PCC EHR overview series. In this video, we’ll take a brief tour of the patient chart. Pebbles Flintstone is here for a visit this afternoon. She’s with the nurse right now, but even though the nurse has Pebbles’ chart open, I can open it as well and work with the chart at the same time. I’ll double click on ‘Pebbles’ to open her chart. What’s this pop-up? My practice has a clinical alert configured for pneumonia patients. I can set up custom clinical alerts based on patient’s age, diagnosis, or other criteria and whenever someone opens a chart, a custom pop-up message will display. You can also set clinical alerts to pop-up when you save a chart to alert the clinician about something at the end of the visit. So, I’ll dismiss this alert and here I am at the medical summary.
On the right side of my screen, I have Pebbles’ medical summary. Over here on the left, I have all of my navigation tools. You’ll see here at the top I’ve got the PCC EHR button that will take me back to the home screen and this field that lets me find and open patients’ charts. Below that we have the current patient’s name and their unique identifier in the system. Beneath that is the medical summary with buttons that will take me directly to different areas of the medical summary. Below the medical summary in this navigation is the demographic section. Next is the history section, which includes things like visit histories, a patient’s immunization history, flowsheets and growth charts. Finally, the prescriptions button, which takes us to the prescriptions portal for this patient. Beneath all of these, I have a button that will take me to a chart note for today’s visit. If Pebbles wasn’t scheduled for a visit, I’d see a button here that allowed me to create one.
Okay, that’s a quick overview. Now let’s look at each one of these sections of the patient’s chart.
First, the medical summary. This is a face sheet for the patient. It contains all the most important details about the patient. This section of the chart is going to contain different components, depending on how your practice has set up PCC EHR. You can see in these anchor buttons most of the components I’ve chosen to include in my medical summary; recent and upcoming appointments, reminders, a problem list, siblings and family history, a care plan, and then, various allergy and history components. I can click on any of these anchor buttons to jump to a specific component, or I can scroll through them all, over here. Here we’re looking at the problem list. This can contain diagnoses made during charting a visit, or you can add diagnoses directly to this problem list component. You’ll notice this diagnosis here has a little red lock next to it. In PCC EHR, you can mark any patient diagnosis as locked or hidden. You can also hide labs and other orders in the same way. When you see this lock symbol, you know that the item will not appear on the patient visit summary, or other patient-facing reports, and it won’t appear in the patient portal either. The problem list, like many other components, gives you an option to filter what you see, so you could just look at active problems on the patient’s chart, for example. Many of these components appear right in the chart note, so they can be updated while charting a visit, but I can also edit them directly, in the medical summary, by clicking ‘edit.’ I’ll add a family history of heart disease, for example. I’ll click ‘save’ and you can see the family medical history has been updated.
If I want to review a sibling’s chart, I can go to the sibling’s component and click ‘open chart,’ and view both charts side-by-side. Oh look, here’s a clinical alert for Dino, set to appear based on his asthma diagnosis. Okay, I’m going to close Dino’s chart and go back to Pebbles’ chart; that’s the medical summary.
Now let’s look at the demographic section. When I click on ‘demographics,’ I see the demographics section here, and all the related navigation buttons here. Demographics contains non-clinical information about the patient and family. The first component contains basic information like date-of-birth, birth order, race, language, as well as the patient’s PCP and any custom flags and fields your practice has chosen to track. The contact information section includes information on the patient’s confidential communication preference (if it’s someone other than their custodian), as well as the families connected to the patient, the custodian and guarantor accounts. If I scroll down, I find a section where I can add other contacts. I can see insurance information here and here is the siblings’ component we saw before.
That’s a quick rundown of the demographic section; now let’s look at the history section. The first thing we see is the visit history. Here I can find all the patient’s past visit chart notes, phone notes, some documents, as well as patient portal messages from parents. Select any one of these, and the details of the visit will appear above, which you can then scroll through. I can go in and edit any past visit to make updates and changes, I can view associated documents, and I can print the visit chart. You can filter this visit history index list to narrow it down to a shorter list. If you want to just look at a patient’s phone notes, for example, you can do that here.
Next is the immunization history. Whenever an immunization is ordered and administered, we record that date and summarize it on this screen, so you can view a complete record of patient’s immunizations at a glance. You can see if an immunization is refused, or ordered but not fulfilled, and all of this information is available on this screen. I can also use this screen to add or edit immunization records. This immunization history is easy to access to give to a family. You can print a number of reports that include the immunization history, and if your families are using the patient portal, the immunization history is accessible through the portal at any time, day or night.
Third, in the history section, is the flowsheets tool. This is a useful way to review patient clinical data over time, such as a chronic problem, or when you want to see a history of patient lab tests, for example. Each flowsheet is a visual display of information in the patient’s history. First is the diagnosis flowsheet. Every diagnosis ever charted for this patient ever, including items added directly to the problem list, appears in this column, and then, going across, I see all the dates the patient has received each diagnosis. Labs, medical tests, radiology, and screening, each have their own flowsheet, as does a patient’s vitals history. Each flowsheet has a collection of filters to help me see just the things that I want to review. Maybe I just want to compare height and weight over time, for example; oh, I can use the filters to view just those vitals. One last thing; by default, flowsheets sort by date, so the most recent record is always going to be first.
Another way of looking at vitals over time is with growth charts. Your office collects patient vitals during each visit, and PCC EHR automatically plots that information on several different growth charts. I can choose from a variety of different growth charts here, and below, you see that the tabular data is plotted on the graph. I can click any point on the chart, and it will highlight the data in the table below. If you have some anomalous data, you can hide any point by deselecting it here. And, I can add or remove data for a patient manually here, but remember, every time you collect vitals during a visit, those vitals will automatically be added to the growth chart.
Along with charts from the World Health Organization and the CDC, PCC also provides you with Fenton pre-term growth charts, and Down syndrome growth charts from the AAP. By the way, you can have growth charts show up as a component within your chart note as well. You can also add them to the medical summary screen and, if you want, you can print them out and hand a copy to the family.
Okay, last, let’s look at the documents section. When forms come into your office; lab results, x-rays, paper chart notes, you can attach them to visits and see them in the visit history, but you can also find them quickly here in the documents section of the patient’s chart. All the documents loaded into PCC EHR for this patient ever can be found here. Your practice has a custom list of categories, in which to classify documents and in this section, documents are organized by those categories. I can look at the documents filed under each category, and can double click to review it. I can adjust the document view here, I can print using this button, and, if I want to add notes, give the document a title, change its category or maybe share it with a patient’s family in the patient portal, I can click on the ‘edit’ button and make any changes I would like. That’s it for the history section of the chart. Now that we’ve seen all the sections of the chart, we’ll use the next set of videos to see how to chart a visit.