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

Basic Dynamic Documentation. W elcome! …to the Computer-Based Training on Basic Dynamic Documentation. Instruction. Basic Dynamic Documentation. This Computer-Based Training (CBT) does not contain audio. So be sure to follow instructions as you go through this CBT.

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

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

  2. Instruction Basic Dynamic Documentation • 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. • Click the Next button to advance to Next topic. • Click the Back button to go back to the Previous topic. • Click the Home button to return to the Introduction page.

  3. Introduction Basic Dynamic Documentation This CBT will introduce you to the basics of using Dynamic Documentation. Here are the topics for this CBT: Table of Contents (TOC) 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) Assessment Plan Creating a Note Diagnoses Procedures/Pending Results Quality Measures Discharge Orders Follow Up Care Orders Hospital Course 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 Let’s get started! Click on the individual topic listed under TOC or the Next button to continue. Quality Measures Discharge Orders Follow Up Care Orders Hospital Course

  4. Overview – Dynamic Documentation BasicDynamic 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

  5. Chief Complaint & HPI BasicDynamic 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

  6. Past Medical History BasicDynamic 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

  7. Review of Systems BasicDynamic 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

  8. Vital Signs & Physical Exam BasicDynamic 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

  9. Documents and Labs BasicDynamic 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

  10. Procedures/Consults BasicDynamic 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

  11. Order Entry BasicDynamic 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

  12. Assessment Plan BasicDynamic 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

  13. Creating a Note BasicDynamic 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

  14. Discharge Process: Diagnoses BasicDynamic 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

  15. Procedures/Pending Results BasicDynamic 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

  16. Quality Measures BasicDynamic 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

  17. Discharge Orders BasicDynamic 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

  18. Follow Up Care Orders BasicDynamic 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

  19. Hospital Course BasicDynamic 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

  20. Congratulations! You’ve completed the Basic Dynamic Documentation CBT.Please click to continue. BasicDynamic 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

  21. Basic Dynamic Documentation Pleasedo not closethis window untilyou’ve completed the step below! Click HERE to record your completion of this required CBT – Basic Dynamic Documentation.

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