Data Entry at the Point of Care/Ch.4

15 terms by Raquel1972 

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Testing Your Knowledge

How do you select a list?

Locate and click on the "Lists" button in the toolbar at the top of the screen

How do you select Forms?

Locate "Active Forms" on the bottom left corner on the screen, then locate and click "forms" on the top middle section of the toolbar

List three features Forms have that Lists do not

...

Describe what the Prompt button on the toolbar does

generates a list of findings that are clinically related

ROS

Review Of Systems, an inventory of body systems starting from head down

HPI

History of Present Illness; chronological description of the patient's present illness

HEENT

Head, Eyes, Ears, Nose, and Throat

URI

Upper Respiratory Infection; infection affecting the nose, nasal passages, or upper part pharynx

Sig

instructions for labeling a prescription

How do you indicate a "possible" diagnosis?

Dx tab with drop-down list for prefix on left bottom corner of screen, select "possible" in the drop-down list

Auto-Negative (the Negs button) functions on what two tabs?

Hx (history) and Px (physical exam)

Describe how to record a test that was ordered and describe how to record a test that was performed

Record Test ordered: Tx tab locate and highlight test category;on bottom left corner of screen locate and click the "prefix" drop-down list and select "ordered"
Record Test Performed: Tx tab locate and highlight test category locate and click on red button of the test performed.

What entry details field is used with a finding to indicate the patien's fever was "mild"?

Sx tab locate and click on the red button next to "no fever" to indicate the patient has mild fever, on the bottom left corner of screen locate and click "modifier" on drop-down list locate and click on "mild"

How do you change the numbers on the size button and what do the numbers do?

Click the mouse on the Size List button in the toolbar on top of screen, it increases and decreases the number of findings in the displayed list. List size are 1-3

Four completed narrative documents of patient encounters and hand to instructor

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