<< Click to Display Table of Contents >> Navigation:  »No topics above this level« Clinical History Functionality

To access Clinical History, select Charts > Select Patient > Clinical History.

 

Clinical History

 

 

Clinical History displays documents for all encounters on a patient. By default, the display is sorted by Date and in reverse chronological order.

 

 

Clinical History Columns

 

•Type: Document type.

 

•Description: Document description.

 

•Date: Document date.

 

•Signed By: Name of the person who signed the document and the date the document was signed.

 

•Acct #: The account number the document was created under.

 

•Admit Dt: The account admission date.

 

•Disc Dt: The account discharge date.

 

•PACS (Picture Archiving and Communication System): VIEW displays in the column when an image is available. To view the image, select the entry and select PACS in the action bar.

 

•Attachments: VIEW displays in the column when an attachment is available. To view the attachment, select the entry and select Attachment in the action bar.

 

NOTE: Users can adjust the column widths and rearrange the order of the columns by dragging and dropping the columns. These column adjustments are "sticky," meaning they will remain on the user's last selection.

 

 

Filter Options

 

•The Facility drop-down displays a list of facilities that share profiles with the facility associated with the selected patient. If the facility does not share profiles, nothing will display in the drop-down. Select the desired facility from the drop-down to display documentation from that facility.

 

•The Search field allows the display to be filtered based on the entry in the Search filed. Users can search by account number, document type, document description, or the provider who signed the document.

 

•Selecting the This Encounter check box displays only documents for the patient encounter. When selected, the Facility and Date fields become disabled. This filter is "sticky," meaning it will remain on the user's last selection until changed again.

 

•Select Admit Date or Document Date from the drop-down. Enter a beginning date (optional) and an end date (optional) in the date fields. If no dates are entered, all documents will display. These entries are "sticky", meaning they will remain on the user's last selection until it is changed again.

 

•Documents in the following categories may be included (select the check box) or excluded (deselect the check box) in the display:

 

oMR: Medical Records transcription.

 

oDocumentation: Documentation from EDIS, TruBridge Provider ER, Physician Documentation, and signed narratives from MP-EHR.

 

oEForms: Electronic Forms documentation.

 

oLab: Laboratory and Pathology results.

 

oRad: Radiology transcription.

 

oNursing: Nursing documentation defined in Tables > Clinical > Nursing category > POC Control Maintenance (Page 2) > Report Codes to Send to Optical Disk.

 

oCardiopulmonary: Cardiopulmonary or Respiratory Therapy transcription.

 

oEKG: EKG reports.

 

oPT: Physical Therapy, Speech Therapy, and Occupational Therapy reports.

 

oDietary: Dietary reports.

 

oImages: Scanned images defined to display in Clinical History. This setup is in Tables > Business Office > Images category > Title. Scanned images set to copy forward will only display once, and deleted images will not display in Clinical History.

 

oOther: Special Procedures, Sleep Lab, and Cardiac Rehab documents.

 

oRetracted: Documents or signed/completed reports retracted in the Documentation application.

 

oAll: All documentation and reports listed above.

 

The filter selections above are "sticky," meaning they will remain on the user's last selection until changed again.

 

NOTE: If your facility has purchased the Communication Center, documents saved from the Communication Center to a patient's profile will display in Clinical History. Documents labeled as a "Secure Document (code SD)" will be excluded from Clinical History. Currently, Communication Center documents will display regardless of the selections made within the check box filter.

 

 

Document View - Full Screen

 

To view documents on a full screen, select the document and select View or Result TXN on the action bar. Result/TXN displays versus View if the document is a transcription. The Document Viewer opens with the selected document or documents.

 

Document Viewer - Full Screen

 

 

Action Bar Options

 

•Exit: Select to return to the previous screen.

 

•Export: Select to export the document.

 

•Note: Select to create and send an internal message via the Communications application.

 

The following options are available if your facility has purchased the Communication Center:

 

•Send As Fax: Select to send a fax.

 

•Send As Message: Select to send a message.

 

 

Document View - Split Screen

 

To view a document on a split screen, double-click on the document entry. The document displays in the Document Viewer on the right side of the screen. To close the Document Viewer, select the right-pointing arrow in the Document Viewer.

 

Document Viewer - Split Screen