Once an encounter is started, you will be able to record the patient’s charting elements, such as chief complaints/history of present illnesses (HPI), problem list, vital information, medications, history, treatment plan, review of system, immunization, health maintenance, results/orders queue, physical exam, diagnosis, review of results, supplementary, and Care Plan. Each element is explained in detail in a separate section.
Upon starting an encounter, a ribbon is displayed on the top, from where you can choose to record the charting elements. The arrangement of charting elements is configurable from the Administration section.
The following are 2 ways of accessing charting elements from Facesheet:
| • | On the top menu bar, click Patient Search. The Patient Search screen opens up. From the right side, click Facesheet link next to the patient. The Facesheet screen appears. |
or
| • | On the top menu bar, click Facesheet. The Patient Search screen opens up. Click any patient name link. The Facesheet screen appears. |
| • | Click Start Encounter. The charting elements will appear on top. |
The charting elements that are not configured can be revealed by clicking the plus icon (+) displayed towards the end of the charting elements ribbon. For details on configuring charting sequence, refer to the Charting Sequence under Administration.
When you record details in the charting elements, they appear in green bold fonts, and the charting elements in which details are not recorded will appear in black fonts. Recording a charting element helps in increasing numerator for “Menu Set 2: Record electronic notes in patient records” of MU-2. Please refer to the above sections in Meaningful Use Stage – 2 User Guide for more details.
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