OB – GYN Overview
OB Overview
This is an overview of the normal workflow for a returning OB patient in the DigitChart app.
- Scheduling and Initial Tab: Obstetric patients are indicated in pink on the schedule. After selecting a patient, the flow sheet tab appears initially.
- Visit Documentation: Unlike the original appointment, all documentation for a return OB visit is on a single sheet. Adding a pregnancy concern is as simple as clicking once. The configurable OB shortlist, which includes often used diagnosis codes, makes it easier to diagnose patients.
- Lab Orders and Education: A configurable lab shortlist simplifies lab ordering. Patient education items can be readily selected and ordered.
- Interactive Flowsheet: The interactive flow sheet (highlighted in green) enables for the recording of visit notes, fundal height, fetal weight, and other pregnancy-related data.You can schedule a follow-up session and obtain an ultrasound immediately from this page.
- Antepartum Record: The antepartum record is a non-editable document that populates automatically based on information in the patient’s chart. Any hospital’s labor and delivery department can access this information for free.
- OB Notes: You can include an OB note, or virtual sticky note, in the antepartum record for the labor and delivery department to reference.
- Delivery Process: The delivery symbol at the top of the patient record starts the delivery process; however, it should only be selected after the patient has delivered. This workflow guarantees that all required actions and information for returning OB patients are easily accessible and streamlined within DigitChart.
GYN Overview
Overview of a Gynecologist Visit the DigiChart
When you start the DigiChart app, the first thing you’ll see is your schedule. The Medical Check-in area allows users to record vital signs, first lab results, allergies and bad reactions, prescriptions, preferred pharmacies, notifications, and any eligible implantable devices. Throughout the visit, the patient information bar remains visible for convenient reference.
Visits Module
Entering the Visits module allows you to easily review and document the medical check-in process. The Patient Summary tab is a useful resource during visits because it displays previous encounters, significant GYN history, issues, medications, and relevant bloodwork. Any relevant documents will also show here. The Patient History tab allows you to update the patient’s health information while also documenting the system review. Patients are invited to enter their medical history through the DigiChart patient portal prior to their appointments.
By using the patient portal, all patient information is pre-populated. The physical exam portion has a rapid exam capability that allows for exception-based documentation. Setting the fast exam to “all normal” during an annual Well Woman exam allows for documentation of any anomalies discovered throughout the session. For example, if an atrophic vulva is discovered, simply indicate it, and the system will uncheck “no atrophy.” This data is then recorded and presented in the findings.
The rapid exam setting also normalizes the breast and general exams, and any deviations can be reported identically. The Pelvic Exam area contains templates for colposcopic exams, endometrial biopsies, and IUD insertions, among other things.
Medical Decision Making (MDM).
The MDM page is where you may manage your treatment plans, patient assessments, visit notes, diagnoses, lab orders, prescriptions, educational resources, and return appointments. Building treatment plans enables effective workflow by dragging and dropping complete strategies for certain scenarios.
When you click “Complete,” you will be taken to the Encounter Note tab, which contains a summary of your whole visit. This page allows you to print the encounter note, add a body diagram for processes, and use several templates and a color wheel for documentation and comments. Saving brings you to the encounter note, which includes the body diagram.
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