EHR Final Exam Preparation Guide

ECW Screenshots

Questions include screenshots from the ECW program.

Documentation Focus

Know where to place information in notes.

Menu Button

Used to access settings and templates.

Patient Search

Search patients by last name, first name, or number.

Patient Hub

Access patient information and demographics.

Progress Note

Document patient assessments and treatment plans.

Subjective Info

Add patient history and symptoms in HPI section.

Objective Findings

Document examination results like ROM and inspection.

Assessment Codes

Use ICD10 codes for diagnoses.

Treatment Plan

Outline treatment and ordering procedures.

Log Out Procedure

Click initials to log out properly.

Template Usage

Pull templates into notes for efficiency.

DRTLA Panel

Access historical patient information in right chart.

Referral Management

Manage referrals to rehabilitation departments.

Lab Orders

Use the R jelly bean for lab tests.

Patient Documentation

Includes insurances and scanned records.

Initials in Progress Note

Ensure correct provider is noted in documentation.

Weekly Review

Review one week at a time for better understanding.

HPI

History of Present Illness, patient symptom details.

Subjective

Patient-reported information about their condition.

Objective

Doctor's findings during patient examination.

Inspection

Visual examination of the patient.

Assessment

Evaluation of patient's condition and diagnosis.

ICD-10 Codes

International Classification of Diseases coding system.

CPT Codes

Current Procedural Terminology for billing procedures.

Plan

Treatment strategy based on assessment findings.

Radiology Order

Request for imaging studies under treatment plan.

Procedure

Specific actions taken during patient care.

Care Plan

Document outlining follow-up and treatment goals.

Visit Code

Code used for billing patient visits.

Examination

Detailed assessment of specific body regions.

PART Findings

Documentation supporting adjustments in treatment.

Re-evaluation

Assessment for previously established patients.

Referral

Request for specialist consultation or treatment.

Contraindications

Factors that prevent certain treatments or procedures.

Active Range of Motion

Patient's ability to move joints voluntarily.

Passive Range of Motion

Movement of joints by an examiner.

Neurological Testing

Assessment of nerve function and reflexes.

Orthopedic Testing

Evaluation of musculoskeletal system for injuries.

Billing Information

Details required for processing patient charges.

Diagnosis Code

Code used to identify a patient's diagnosis.

Pin Template

Template for entering personal identification number.

Assigned To

Designates who is responsible for the note.

Lock Button

Finalizes note; only providers can use.

Tracking Board

Monitors patient and doctor locations in clinic.

PEN

Indicates patient scheduled but not arrived.

ARR

Patient arrived; timer for visit starts.

STUD

Patient is currently in room with student.

READY

Indicates student is prepared for doctor visit.

PROV

Identifies doctor's current working room.

CHK

Indicates patient has been checked out.

CANC

Patient has cancelled their appointment.

N/S

Patient did not show up for appointment.

R/S

Patient has rescheduled their appointment.

RAD/LAB/REF

Patient is in another department for services.

Daily Visit

Routine patient evaluation and treatment process.

ROS

Review of Systems; history questions for regions.

PFSH

Past Family and Social History relevant to patient.

Level of Service

Determines complexity of examination and billing.

New Patient Codes

Codes for billing new patient evaluations.

Established Patient Codes

Codes for billing returning patient evaluations.