Getting Started in PCP 3.0 Note
1. The PCP 3.0 note layout will display in two options. Provider can either view it in Category or All where the system will display the entire PCP note in full
2. Top Bar Navigation: This Top Bar is the Note Navigation Timeline. Once you Fill in the Start Time and click Start Note All of the options 1-6 will expand. Clicking any of the Options will navigate you to the page. Example: Click “5. Labs” will navigate you to the Labs section in the note
3. Start Time: Start Time: You can enter the Start Time manually by selecting the field, or you can click Set to Current Time (Located Underneath Field) and it will pull your computers' current time
End Time: This field is not required to start the note
4. Service Date: This will default to Today’s date, clicking the calendar icon will allow you to make any adjustments to the service date
5. Here you can begin to enter your notes for a patient such as the Chief complaint, HPI, and Patient History
Filling in History sections
Exam Tab
1. Exam Create: you are able to create specific templates for exams by selecting them and then hitting the create button. A pop up will appear prompting you to name the Exam and then once you hit OK it will save under the Template section. From here you can also update and delete a template. Template: Clicking this drop-down will allow you to select which template you would like to begin review. Once selected, all the categories corresponding to the selected template will populate
2. The system allows you to select three options to start the Exam. All reviewed and are negative, All reviewed and negative, except, and Display all Review of systems. Depending on the selection the system will display accordingly
3. . You can also manually Select each ROS by clicking on the negatives and positives. The book icon to the right of the exam allows you to add additional comments to each review. There will also be a clear button that allows you to clear that review and reset to appear blank
4. This section is similar in how you are able to create specific templates for exams by selecting them and then hitting the create button. A pop up will appear prompting you to name the Exam and then once you hit OK it will save under the Template section. From here you can also update and delete a template. Template: Clicking this drop-down will allow you to select which template you would like to begin review. Once selected, all the categories corresponding to the selected template will populate
5. Physical Examination section has a list of categories as you scroll down to select and fill out if necessary. Within each category there will be boxes with items you can click on pertaining to the review you are making. Some boxes will appear in green while others in red. Once selected a text box will appear where you can provide additional steps or information regarding the examination. The system also allows for an all Normal option within the category or to Clear the category completely
This section allows you to provide a full body examination through images. The human body section is clickable and will match to whatever observation you select to the right. See below for example.
1. There is Pre/Next arrow option that allows you to switch from the human body image to an image of feet where the same options apply based on your observation
2. At the bottom you are able to Undo or Reset completely any updates made
Patient Images
1. The Patient Images section allows you to add any pictures/images related to the Physical Exam review
2. Select a File: from here you are able to upload an image saved to your computer or phone
3. Comments: this section allows you to add any comments related to the image uploaded
4. You are able to remove the image from here
5. Add Image: this allows you to add multiple images.
Diagnosis Tab
- Diagnosis: The active tab will highlight in a Darker Blue color to indicate what tab you are working inside of. Simply Clicking any of the other tabs will navigate you to the appropriate section
- Assessment: Free text box to type in the Assessment for the encounter selected
- Plan of Care: Free text box to type in the plan of care for the encounter selected
- Precedence: Choose the precedence of each code. 1 being the highest precedence
- Code Status: Select whether the code is Active, Inactive or Resolved
- Add to Assessment List: Clicking on this button will allow you to add a new Diagnosis to the Assessment and Plan table above
Add to Assessment List
- Problem Code Search: Here you can search by keywords, full phrases or by the diagnosis code itself
- Status: Here you can select if it is an Active problem or if editing you can change the status to Inactive or Resolved
- Start/End Date: This will default to today’s date but can be changed to a previous date. The end date will be applied when the diagnosis code is no longer relevant
- Add to Favorites: You can check mark this to add to your favorites for next use
- Submit/Reset/Close: Reset will clear the page of data entered in the input fields, it will keep your search results to select from the list to enter a different diagnosis code. Submit will save the problem in Assessment and Plan table. Close will hide the panel to allow you to resume using the note
This section will also provide information on Dx codes that are non billable by marking them in red.
Orders Tab
1. Labs: The active tab will highlight in a Darker blue color to indicate what tab you are working inside of. Simply Clicking any of the other tabs will navigate you to the appropriate section
2. Filter: Selecting the filter field will allow you to select: Past 1 Year, Past 6 Months, Most Recent
3. Returned: Selecting the checkbox, “Only show lab orders with resulted returned” will only show labs with results
4. Requested By: This field will show you who ordered the lab
5. Lab Results: this column shoes if labs were returned or not returned
6. Action: You can select Acknowledge Lab, Associated files or Print lab
7. Add a Lab: Clicking on this link will open a new Laboratory stand-alone page where you can add a new lab
Internal Orders
1. Internal Orders: This table will display any history of orders added that are complete or incomplete, also allowing you to add new internal orders
2. Action: This is a drop-down menu that allows you to Edit information on incomplete orders
3. Add Internal Orders: This button will allow you to add any new orders
4. Internal Order Input: This button will bring forward a pop up modal to enter in Internal Order
5. Submit/Reset: These buttons will allow for Submit, Reset or Close Window
Specialist Referral
1. Specialist Referral History Table: From here you are able to view the history of specialist referrals submitted
2. Add Specialist Referral: Clicking on this button will open the chart detail specialist referral table to be able to add a new referral
3. Print List: Print List will print the Specialist Referral History for the selected patient
Prescription Tab
- Prescription: The active tab will highlight in a Darker Blue color to indicate what tab you are working inside of. Simply Clicking any of the other tabs will navigate you to the appropriate section
- Prescription History: This table will list all of the patient’s active prescriptions
- Open Prescription Sheet: Click Open Prescription Administration Sheet Page to manage the active patients’ prescriptions (Prescribe New, Refill, D/C)
Other Agency Medications
1. This table shows Other agency Medication history information
2. Add Other Agency Medication: this will open the table above to input any New Medication
3. Medication Input: In this table, you will need to select the appropriate fields to add a new medication
5. Save, Reset or Close: These buttons allow you to either save the order, reset the information in the order or close the order
Radiology
1. Radiology History: Here you will be able to view the history of entries on all Radiology entries for the active patient
2. Filter Action: You can filter the history view by most recent, Past 6 months or the Past 1 year
3. Change View: This will change the history from a view like the table above to a list view
4. Search: In this field, you can search across all entries in the Radiology history table
5. Action: This is where you can Edit, Cancel and View Associated Files and Print the record
Order Information
1. Order Information: In this section you will input all of the appropriate order details for the Radiology order
2. Order Date: Select the date of the order
3. Provider: Select the Provider placing the order
4. Order Details: Enter in all appropriate details for the order information in this section
Radiology input
1. Radiology Input: This section will allow you to input all the order details
2. Facility Location: Select the appropriate Facility for the Radiology order to be sent
3. Search box: type in the name of any order you need to look at to submit
4. Select: Select the appropriate order by clicking on the Checkbox corresponding to the name of the order you want to input
5. Free-Text Field: Enter in any additional information you would like to input on the order
6. Status: Once all information is correct, select the status of the order to save
7. Submit/Reset: click Submit to save and place the order. Or you can reset to start over again on the radiology section
Questionnaire
This section populates based on Gender of the client and past smoker history. In total 3 questionnaires will appear:
a. Well-Male Exam
b. Well- Female Exam
c. Tobacco Use Cessation
Services Tab
Step 1. Select Service site
Step 2. Once the service site is selected the service list drop down will populate
Step 3. Select the services that were completed (Multiple services can be selected one by one)
1. Once a note has been completed you can either Save complete or Pend for Coder. Once you Pend for a coder you have 24 hours to edit a note. If you save complete you will be able to return and edit a note at any time. Save incomplete refers to a note that was not finished but needs to be saved. You can return an edit this note at any time. You will be able to Reset the note completely, keep in mind this will erase your note data