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Global Setting:

The purpose of the "Global Office Note Setting" is to help the user quickly complete the patient's office note. Once you have selected a "Global Setting" from the "Global Setting" drop down menu, the templates and elements that correspond to the user setting you selected, will appear in the appropriate section of your office note.

Chief Complaint:

You can enter multiple chief complaints by typing in part of the phrase, then hit 'Enter' for each complaint. To delete a complaint in the complaint field, click on the complaint that you would like to delete.

HPI sentence creation:

Select one of the system level templates (templates that came with the program), then fill out the appropriate values. When you click on the "Append" button, the program will automatically create the sentence structure for you from the template that you filled in.

The HPI will start with the sentence like "This is a 45 year old woman with PMHx of..." where the past medical history information is taken from the "Medical & Surgical History" section of the PMH.

The HPI is now taken into account automatically in E&M coding.

If you do not want to used the autonarrative or autoconsider HPI in E&M coding, then go to MISC from the main navigation bar, then to Customize. You can change your preference in "User profile".

NOTE: The E&M coding for HPI will count the number of sections in the standard template that were filled in, except complaint and past treatment. Alternatively, if a non-standard format HPI template is used, you can enter the number of elements considered, and that number will be used.

Apply Default” function:

1. First select the HPI template that you'd like to use.
2. Then select your default values from the drop down menus in the appropriate fields of the template.
3. Click on "Set Default Values in Template". The next time you use this template and click on "Apply Default" button, those values that you saved will appear.

• This apply default function is different from procedure in that it does not pull up the default from the dropdown list
• Narrative will be generated if you use one of the system templates or any template you create that starts with “mode of onset “ or “complaint”

Tips to help you speed through your subjective using the textbox:

• Use Voice Dictation software. SynaMed is compatible with all major dictation suites. We recommend using Dragon Dictate.
• Tablet PC. You can write directly to the text box.
• Transcription Service. If you use a transcription service, we can set you up so that your service will deliver the note directly to your subjective. This will eliminate the need for filing when you get your transcriptions back.
• Copy/Paste text from any text source. Unicode is currently not supported, but will be implemented in the near future.
• Use templates either created by your practice or the defaults that come with SynaMed.

AutoComplete Tips:

• You can quickly edit dropdown lists by using "Edit..." at the bottom of every dropdown list or auto complete list.
• Use the Up and Down arrow keys to scroll the autocomplete list
• Use the Tab button to most to the next autocomplete field if you want to leave the text as it is in the textbox.
• Use the Enter button to select what's highlighted in the autocomplete list.

If you have a dictation that is in queue to be transcribed, click the transcription checkbox. You must have a transcription user set in [ Physician's Profile ] to see the transcription checkbox.

To quickly write up you subjective, pick a template from "Append using a template." You can create a template if it is not already listed by using [ Subjective Templates ] in Custom Settings from the Main Menu. You can also type in the subjective in the text box below directly. Templates are there to help you save time. All you have to do is fill in the blanks and do some quick grammatical corrections in the text box once you append the template to the existing text in the text box.

You can use and append as many templates as you need to.

IMPORTANT:

1. Fill in boxes for any template can be left empty if it is not necessary to fill out for the patient.
2. Choosing another template with content already populated in the current template will erase everything the populated information in the current template.
3. You must append everything you want to save and print the information from the textbox.

NOTE: Office visit information is saved every time you move onto a new tab or by clicking "Save and Go To Patient Menu". You may experience multiple listings of the same visit for a day. Select the session that you might have digressed from earlier and continue with that session. All other sessions for that day can be ignored or marked for deletion. Please exercise precaution when deleting office visit(s).

FAQ:

What does the global note settings do?

The purpose of the Global Note Setting is to help the user quickly complete the patient's office note. Once you have selected a setting from the "Global Setting" drop down menu, the templates and elements that correspond to the setting you selected, will appear in the appropriate section of your office note. This is a useful function for specialists, as well as for physicians who see patients with similar problems.  

Is it possible to select multiple HPI templates in the subjective section?

Yes it is possible to select multiple HPI templates in one office note. That can be achieved by first clicking on suggest templates. In this window, the user can select multiple components in the suggested list by pressing down on the Ctrl key and left click on the desired templates. Once all templates are selected, click on add. This action brings down the highlighted templates to the lower portion of the window. Next to each template is a number dropdown menu, which allows user to assign the order of the templates to be listed.

If the user wishes to add templates that are not on the suggested list, one can search for the desired template, and once they appear, one can highlight them and add to the list.

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