Using New Office Visit Classic Form

Introduction

SpringCharts offers two office visit forms, The New OV Classic and the New OV Large.  Each user may choose to use one or the other form as their default form by choosing their preferred form from the Main Window by selecting File > User Preferences > Edit User Preferences.  For Training on the New OV Large form, click here.The New OV Classic form is designed for ease of use and to provide a complete view of the office visit at one glance.  It can be accessed from the Patient Window by selecting New > New OV.  It is in the SOAP format with subjectives (S), objectives (O), assessment (A) and plan (P) areas.  Included are areas for diagnoses (Dx), prescriptions (Rx), Tests, Procedures, other text (Oth Tx) and follow up reminders (f/u).   

 

Clicking on the red buttons () causes PopUp Text to appear that is matched to the particular field (the S field in this case).  In the example below, PopUp Text is offered, and can be included in the S field by simply tapping or clicking on the desired text.  

As shown below, several items can be clicked on and the text is added and compiled at the bottom of the window.  

The text can be initialed and date or time stamped and put in the chart by selecting Done, with the results shown here.  Text can be placed in any area of the chart by typing, handwriting recognition (Tablet PC) and voice dictation.  The text can also be edited by traditional methods for insertions, deletions and changes.

The Dx and Rx buttons operate a bit differently by offering a search on a particular diagnosis or drug, but also offering the user a choice from recent choices and items logged in the patient chart as significant.  For example, clicking Dx produces the following screen:

For selection of diagnoses, the user has three choices: to search for a diagnosis (by typing the starting letters of the diagnosis into the "find" box and clicking the binoculars), to select an entry from the past medical history (PMHX) and Problem List,  or select an entry from Previous Diagnoses.  Clicking any of the diagnoses adds them to the Selected Diagnoses as shown below:

 The Selected Diagnoses will be put into the New OV form by selecting Done with the results as shown here .

Procedures and Tests work in a similar fashion. The functions initiated by the buttons along the bottom of the above chart are also described elsewhere.

The office visit is placed in the patient's chart by selecting either Done or Sign.  Done allows the chart to be recalled and further changes to be made by anyone with chart access privileges.  Sign locks this office visit. The office visit cannot be unlocked or edited.