End User Education Agenda Brief Intro to Physician Documentation PDOC FeaturesBenefits Review list of OB Documents How to Document in PDOC Signing Workflow Resident to Attending Medical Student to Resident to Attending ID: 217192
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Slide1
OB Physician Documentation End User EducationSlide2
Agenda
Brief Intro to Physician Documentation (PDOC)
Features/Benefits
Review list of OB Documents
How to Document in PDOC
Signing Workflow
Resident to Attending
Medical Student to Resident to Attending
Sign QueueSlide3
Why PDOC?
Features
Automatically imports data from Nursing Assessments
Continuously updates with latest lab results
Integrates with Home Medications, Allergies and Problems List
Documents can be shared among several usersSlide4
Why PDOC?
Benefits
Real-time documentation accessible in EMR
Improves efficiency of documentation process
Reduces the occurrence of conflicting information
Includes ICD-10 Specificity to maximize billingSlide5
List of OB DocumentsSlide6
Accessing PDOC
Click “Document” button within the Patient Chart.Slide7
Opening a New Document
Click “New” and select a document from the Document List.Slide8
Document Sections
Documents are organized into sections to simplify navigation.Slide9
Home Meds/Allergies
Automatically pulls in Home Medications and Allergies if previously documented.Slide10
Free Text Boxes
Click the drop down arrow to enter free text box. Can be used for typing or Dragon. Slide11
Review of Systems
Responses for symptoms are either “present” or “not present”.
Left Mouse Click
Circles the response
Indicates symptom is
present
Right Mouse Click
Slash thru response
Indicates symptom is
not presentSlide12
Exam Normals
Click the “N” to automatically default the exam
normals
, or select responses on your own.Slide13
Instance Queries
Click the drop down arrow to select the instance. Associated questions populate. Slide14
Results Diagram
Lab results will populate the diagrams within the document in real time.Slide15
Patient Problems
Adding Patient Problems within PDOC will update Problem List.
You are able to document an assessment and plan for each problem.
1. Click Drop down arrow
2. Type in search field to find problem. Slide16
Problem w/ Qualifiers
Certain problems will include qualifier questions to be answered for increased specificity.Slide17
Sign Routine
Click “View/Save” to enter Sign Routine. Enter your pin to sign the document.
Add additional providers if appropriate
Additional
Providers
Enter PinSlide18
Resident to Attending Workflow
Resident/PA
Attending
Initiates the patient note
Completes the patient note
Assigns Attending for co-signature
E-Signs Note
(ISigned)
Locates Resident note in patient chart
Locates Resident note in sign queue.
Edits note/adds Attending Attestation
E-Signs Note (Signed)
ORSlide19
OR
Medical Student Workflow
Student
Attending
Initiates the patient note
Completes the patient note
Assigns Resident for co-signature
E-Signs Note
(ISigned)
Locates Resident note in patient chart
Locates Resident note in sign queue
Edits note/adds Attending Attestation
E-Signs Note
(Signed)
OR
Locates Student note in patient chart
Locates Student note in sign queue
Edits note/adds Attending
for co-signature
E-Signs Note
(ISigned)
ResidentSlide20
Sign Queue
Documents in a draft status, or requiring co-signature will be in your sign queue.
Select the documents you would like to sign and click “View & Sign”.
Reason Column
Blank
= your report
Cosign
= you’ve been added as a cosigner