1. An up to date list of the diagnoses and conditions that affect a particular patients care.
2. To make sure everyone who touches the patient knows what conditions are present.
3. (1) Most clinical information recorded in the chart will be related to one
1. Electronic Health Records
2. EHR is defined as any information relating to the past, present or future
physical/mental health, or condition of an individual which resides in electronic
system(s) used to capture, transmit, receive, store, retrieve, link
1. Click on the List button in the toolbar to invoke the List Manager window, then locate
and highlight desired list, and then click on the button labeled Load List.
2. Click on the Forms button in the toolbar to invoke the Forms manager window, then
1. (1) Digital images, (2) Text Files, and (3) Discrete data
2. ICD-9-CM and CPT-4
3. A system of names created by a recognized group or authority and used in a field of science.
4. Codified observations that are medically meaningful to the clinician, les
1. Highlight a test description and do not click the red or blue button then click the order
button in the toolbar to order tests.
2. Select the diagnosis, and then use the Prefix field in the Entry Details section to select
possible from the list.
Age, sex, and past medical history
From the graph menu select length, weight, or BMI.
Immunization slows down or stops disease outbreaks.
By clicking on the column header it will change how the vaccines are ordered.
1. Hypertension and diabetes
2. A clinic can develop one form for each disease and then use those that apply to the
patient with multiple diagnosis.
3. The data was already cited in the flowsheet and the Diabetes form and the Hypertension
form had certain
3. Encounter Reason Field
6. Physical Exam
7. Tests (performed)
9. Therapy, plan and tests (ordered)
10. Headaches for more than 5 days
11. More than 5 days
12. Vasoconstrictor withdrawal headache fro
1. PHI stands for Protected Health Information and EPHI stands for Electronic Protected
2. Message integrity, non-repudiation, and user authentication
3. Signed consent is optional so the patient can consent for the provider to disclose
1. Because you will lose your work when you exit.
2. Output the printout to a PDF file
4. More than 5 days
5. The Status Field
6. 10 minutes
7. Watery (nasal discharge), sneezing
10. Common Cold
11. Fluids and bed rest
12. Stuffy sinus