Skip to main content
Not seeing an article?
Phoenix Ortho

Multiple Body Parts #2 of 4: Use of Previous or Prior, Procedures and Diagnosis

Overview

This session will provide the user with the skills, knowledge and ability to properly and accurately chart for today’s visit.  The use of the "Previous" or "Prior" icon where available, appropriate selection of the body part for Procedures and for Diagnosis are detailed. Users should review the Webinar: Multiple Body Parts, #1 of 4 in this four part series for Basic Charting of Multiple Body Parts.  Review of other Webinars available in the “How-To” section at help.phoenixortho.net assist in following Best Practices while documenting the patient’s chart.

Goal

Complete documentation of multiple body parts in the manner that will enable accurate coding for the charge ticket and generation of appropriate notes.  

Launch the visit

Launch the visit and select the body parts

Highlight the body part on the home dashboard to begin documenting

Documenting two body parts in the HPI

Select HPI from the clinical workflow row

Locate the body part on the top right corner within this screen to ensure that the correct body part is being documented

Select New HPI to add the documentation line

Select the Previous icon

Patient’s previous documentation on the selected body part will populate into the Description box below

Review and edit as appropriate

Locate the additional body part on the top right corner within this screen to ensure that the correct body part is being documented

Select New HPI to add the documentation line 

Select Previous

The patient’s previous documentation on the selected body part will populate into the Description box below

Review and edit as appropriate

Documenting two body parts in Exam

Select Exam drop down from the clinical workflow row

Select first Exam for body part exam

Select the Prior icon on the top of the exam screen

The patient’s previous documentation on the selected body part will populate into the Description boxes on the exam

Review and edit as appropriate

Documenting two body parts in Follow Up

Select Exam drop down from the Workflow Row

Select Follow Up

Review the Body Part showing at the top of the Follow Up  Exam screen

Verify the correct body part is displayed

Select Previous

The patient’s previous documentation on the selected body part will populate into the boxes below

Review and edit as appropriate

Save screen and close

Repeat process for additional body parts by highlighting the body part on the front screen 

Then proceed to Follow Up Exam process described above

IMPORTANT NOTE:  If you choose to finish the first body part and save, then change the body part from the Follow Up Exam body part drop down, respond NO to append.  This will add a second body part Follow Up Exam on the History Tree under the day's visit node.  HOWEVER, verify the the body part side in the documentation you bring forward when selecting Previous.   

Documenting two body parts in Plan

Select plan from the clinical workflow row

Verify and select the correct body part in the top right corner of this screen

Select Previous

The patient’s previous documentation on the selected body part will populate into the Description box below

Review and edit as appropriate

Select the second body part in the top right corner of this screen

Select Previous

The patient’s previous documentation on the selected body part will populate into the Description box below

Review and edit as appropriate

Documenting two body parts in Dx

Select the Dx icon from the clinical workflow row

Verify the correct body region is selected in the top right corner of the Dx screen

New patient or a new complaint: 

Search for diagnosis code by ICD Code or Diagnosis Description