美國某醫(yī)院的電子病歷醫(yī)生使用手冊
Review of Windows Terminology .................................................................................................................... 1
Terms to Know............................................................................................................2
2. PowerChart Office Basics ............................................................................................................................... 4
Information Security and Confidentiality .....................................................................4
Logging On to PowerChart Office ...............................................................................4
The Organizer View ....................................................................................................5
PowerChart Office Buttons..........................................................................................6
Opening a Patient’s Chart through the Inbox................................................................7
Patient Search..............................................................................................................7
Using Open Application ..............................................................................................9
3. Adding Patient Information ........................................................................................................................... 12
Viewing Encounter Information.................................................................................12
Adding a Drug Allergy ..............................................................................................12
Adding an “Other” Allergy Type ...............................................................................16
Saving Allergy Substances and Reactions to Favorites...............................................18
Using Substances and Reactions from Favorites ........................................................18
Modifying an Allergy ................................................................................................19
Canceling an Allergy .................................................................................................21
Documenting No Known Allergies ............................................................................22
Viewing a Problem....................................................................................................24
Adding a Problem......................................................................................................25
Adding a Problem to Favorites...................................................................................28
Adding a Problem from Favorites List .......................................................................31
Modifying a Problem.................................................................................................33
Adding a Medication by History................................................................................35
Adding a Medication to Favorites ..............................................................................39
Adding a Medication by History from Favorites ........................................................44
4. EasyScript ...................................................................................................................................................... 47
Creating a New Prescription ......................................................................................47
Creating Multiple Prescriptions..................................................................................52
Adding Medications to Favorites ...............................................................................54
Removing a Started Prescription................................................................................55
Completing a Prescription..........................................................................................56
Reprinting a Prescription ...........................................................................................58
Refilling a Prescription ..............................................................................................60
Making a Historical Prescription Current ...................................................................62
Discontinuing a Prescription......................................................................................64
5. Superbill ........................................................................................................................................................ 67
Superbill Orders Buttons............................................................................................68
Creating a New Order Using Superbill.......................................................................68
Adding an Order to Favorites in Superbill..................................................................70
Creating an Order from Favorites in Superbill............................................................70
Reprinting and Order in Superbill ..............................................................................70
6. Clinical Notes ................................................................................................................................................ 73
Entering a New Document in Clinical Notes..............................................................73
Using Auto Text ........................................................................................................77
Viewing a Clinical Note.............................................................................................78
Modifying a Document in Clinical Notes...................................................................80
Labeling a Note In-Error............................................................................................81
7. AdHoc Charting ............................................................................................................................................ 83
Completing a Patient History Form............................................................................83
Viewing Information in the FlowSheet ......................................................................84
View and Modifying a Document in the Form Browser .............................................87
8. PowerNotes ................................................................................................................................................... 89
Creating a New PowerNote........................................................................................89
Saving a PowerNote to Favorites ...............................................................................94
Inserting an Encounter Pathway.................................................................................96
9. Using the Inbox ........................................................................................................................................... 100
Using Inbox Messages .............................................................................................100
Using Results to Endorse .........................................................................................104
Using the Sign and Review......................................................................................108
Using Orders to Approve .........................................................................................113
Using Inbox Proxies ................................................................................................116 |
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