Basic Dynamic Documentation Welcome to the ComputerBased Training

Basic Dynamic Documentation Welcome! …to the Computer-Based Training on Basic Dynamic Documentation

Basic Dynamic Documentation Instruction This Computer-Based Training (CBT) does not contain audio. So be sure to follow instructions as you go through this CBT. To go through the CBT, you can either click on the topics listed under TOC or simply click the buttons on the bottom left corner to move through the lesson. ü Click the Next button to advance to Next topic. ü Click the Back button to go back to the Previous topic. ü Click the Home button to return to the Introduction page.

Basic Dynamic Documentation Table of Contents (TOC) Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Diagnoses Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course Introduction This CBT will introduce you to the basics of using Dynamic Documentation. Here are the topics for this CBT: 1. 2. 3. 4. 5. 6. 7. 8. Overview – Dynamic Document Chief Complaint & HPI Past Medical History Review of Systems (ROS) Vital Signs & Physical Exam Documents & Labs Procedures/Consults Order Entry (14: 38) 9. 10. 11. 12. 13. 14. 15. 16. Assessment Plan Creating a Note Diagnoses Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course Let’s get started! Click on the individual topic listed under TOC or the Next button to continue.

Basic Dynamic Documentation TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Diagnoses Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course Overview – Dynamic Documentation

Basic Dynamic Documentation TOC Overview – Dyn Doc Chief Complaint Past and. Medical HPI History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Diagnoses Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course Chief Complaint & HPI

Basic Dynamic Documentation TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical Review of Systems (ROS) History Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Diagnoses Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course Past Medical History

Basic Dynamic Documentation TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems Vital Signs& Physical Exam (ROS) Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Diagnoses Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course Review of Systems

Basic Dynamic Documentation TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Documents & Labs Exam Procedures/Consults Order Entry Assessment Plan Creating a Note Diagnoses Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course Vital Signs & Physical Exam

Basic Dynamic Documentation TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Procedures/Consults Labs Order Entry Assessment Plan Creating a Note Diagnoses Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course Documents and Labs

Basic Dynamic Documentation TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Con Order sults. Entry Assessment Plan Creating a Note Diagnoses Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course Procedures/Consults

Basic Dynamic Documentation TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Diagnoses Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course Order Entry

Basic Dynamic Documentation TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Creating a Note Plan Diagnoses Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course Assessment Plan

Basic Dynamic Documentation TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Diagnoses Note Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course Creating a Note

Basic Dynamic Documentation TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Diagnos Procedures/Pending Results es Quality Measures Discharge Orders Follow Up Care Orders Hospital Course Discharge Process: Diagnoses

Basic Dynamic Documentation TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Diagnoses Procedures/Pending Quality Measures Results Discharge Orders Follow Up Care Orders Hospital Course Procedures/Pending Results

Basic Dynamic Documentation TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Diagnoses Procedures/Pending Results Quality Discharge Orders Measures Follow Up Care Orders Hospital Course Quality Measures

Basic Dynamic Documentation TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Diagnoses Procedures/Pending Results Quality Measures Discharge Follow Up Care Orders Hospital Course Discharge Orders

Basic Dynamic Documentation TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Diagnoses Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Hospital Course Orders Follow Up Care Orders

Basic Dynamic Documentation TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Diagnoses Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course

Basic Dynamic Documentation TOC Overview – Dyn Doc Chief Complaint and HPI Past Medical History Review of Systems (ROS) Vital Signs& Physical Exam Documents & Labs Procedures/Consults Order Entry Assessment Plan Creating a Note Diagnoses Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course Congratulations! You’ve completed the Basic Dynamic Documentation CBT. Please click to continue.

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