Www.quia.com



44 Document Order and Preventative Services for Diego Lupez

Objectives

• Search for a patient record.

• Document an order.

• Document preventative services.

Overview

Diego Lupez is seeing Dr. Martin today for anemia. Dr. Martin orders a fecal occult blood test to be performed during today’s encounter. The test results are positive and Dr. Martin instructs Diego Lupez to complete three specimen collections. Document the Fecal Occult Blood Test (using the ICD-10 code for anemia) and preventative services for Mr. Lupez.

Competencies

• Define coaching a patient, CAAHEP V.C-6, ABHES 5-c, 8-h

• Differentiate between normal and abnormal test results, CAAHEP II.P-2, ABHES 2-c

• Identify body systems, CAAHEP I.C-2, ABHES 2-a

• Report relevant information concisely and accurately, CAAHEP V.P-11, ABHES 7-d, 7-g

• Define the function of dietary supplements, CAAHEP IV.C-2

Estimated completion time: 20 minutes

Measurable Steps

1. Click on the Find Patient icon (Figure 3-87).

[pic]

FIGURE 3-87 Find Patient icon.

2. Using the Patient Search fields, search for Diego Lupez’s patient record. Once you locate his patient record in the List of Patients, confirm his date of birth.

[pic] Helpful Hint

Confirming date of birth will help to ensure that you have located the correct patient record.

3. Select the radio button for Diego Lupez and click the Select button.

4. Create a new encounter by clicking Office Visit in the left Info Panel (Figure 3-88).

[pic]

FIGURE 3-88 Office Visit in the Info Panel.

5. In the Create New Encounter window, select Follow-Up/Established Visit from the Visit Type dropdown menu.

6. Select James A. Martin, MD from the Provider dropdown.

7. Click the Save button.

8. Select Order Entry from the Record dropdown menu.

9. Select the TruCode encoder link in the top right corner. The encoder tool will open in a new tab (Figure 3-89).

[pic]

FIGURE 3-89 TruCode encoder tool.

10. Enter “Anemia” in the Search field and select Diagnosis, ICD-10-CM from the corresponding dropdown menu.

11. Click the Search button.

12. Click the code Anemia D64.9 that appears in red to expand this code and confirm that it is the most specific code available (Figure 3-90).

[pic]

FIGURE 3-90 Copy appropriate code from the search results.

13. Copy Anemia, unspecified D64.9 that populates in the search results (Figure 3-91).

[pic]

FIGURE 3-91 Expand the D64.9 code.

14. Within SimChart for the Medical Office, click the Add button below the In-Office grid to add an order.

15. In the Add Order window, select Fecal Occult Blood Test from the Order dropdown menu.

16. Click the Exam radio button in the Specimen Collected field.

17. Click the Positive radio button in the Results field.

18. Paste Anemia, unspecified D64.9 in the Notes field and click the Save button.

19. Select Preventative Services from the Record dropdown.

20. Click the Add button in the Procedures section.

21. Select Fecal Occult Blood Test from the Health Recommendation dropdown menu.

22. Document the date using the calendar picker.

23. Document “In office FOBT positive” in the Comments field.

24. Click the Save button. The preventative service you added will display in the Preventative Services table.

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download