OB Physician Documentation End User Education

Agenda1. Brief Intro to Physician Documentation (PDOC)2. Features/Benefits3. Review list of OB Documents 4. How to Document in PDOC5. Signing Workflow

a. Resident to Attendingb. Medical Student to Resident to Attending

6. Sign Queue

Why PDOC?

FeaturesAutomatically imports data from Nursing

AssessmentsContinuously updates with latest lab results Integrates with Home Medications, Allergies and

Problems ListDocuments can be shared among several users

Why PDOC?

BenefitsReal-time documentation accessible in EMR Improves efficiency of documentation

processReduces the occurrence of conflicting

information Includes ICD-10 Specificity to maximize

billing

List of OB Documents

Accessing PDOCClick “Document” button within the Patient Chart.

Opening a New DocumentClick “New” and select a document from the Document List.

Document SectionsDocuments are organized into sections to simplify navigation.

Home Meds/AllergiesAutomatically pulls in Home Medications and Allergies if previously documented.

Free Text BoxesClick the drop down arrow to enter free text box. Can be used for typing or Dragon.

Review of SystemsResponses for symptoms are either “present” or “not present”.

Left Mouse Click• Circles the response• Indicates symptom

is present

Right Mouse Click• Slash thru response• Indicates symptom

is not present

Exam NormalsClick the “N” to automatically default the exam normals, or select responses on your own.

Instance QueriesClick the drop down arrow to select the instance. Associated questions populate.

Results DiagramLab results will populate the diagrams within the document in real time.

Patient ProblemsAdding Patient Problems within PDOC will update Problem List.

You are able to document an assessment and plan for each problem.

1. Click Drop down arrow2. Type in search field to find problem.

Problem w/ QualifiersCertain problems will include qualifier questions to be answered for increased specificity.

Sign RoutineClick “View/Save” to enter Sign Routine. Enter your pin to sign the document.

Add additional providers if appropriate

Additional Providers

Enter Pin

Resident to Attending WorkflowResident/PA

Attending

Initiates the

patient note

Completes the patient

note

Assigns Attending

for co-signature

E-Signs Note

(ISigned)

Locates Resident note in patient chart

Locates Resident note in

sign queue.

Edits note/adds Attending Attestation

E-Signs Note

(Signed)

OR

OR

Medical Student WorkflowStudent

Attending

Initiates the

patient note

Completes the patient

note

Assigns Resident for co-

signature

E-Signs Note

(ISigned)

Locates Resident note in patient chart

Locates Resident note in

sign queue

Edits note/adds Attending Attestation

E-Signs Note

(Signed)

OR

Locates Student note in patient chart

Locates Student note in

sign queue

Edits note/adds Attending

for co-signature

E-Signs Note

(ISigned)

Resident

Sign QueueDocuments in a draft status, or requiring co-signature will be in your sign queue.

Select the documents you would like to sign and click “View & Sign”.

Reason Column

Blank = your report

Cosign = you’ve been added as a cosigner