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    美国某医院电子病历医生说明书
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    美国某医院的电子病历医生使用手册

    Review of Windows Terminology .................................................................................................................... 1
    Terms to Know............................................................................................................2
    2. PowerChart Office Basics ............................................................................................................................... 4
    Information Security and Confidentiality .....................................................................4
    Logging On to PowerChart Office ...............................................................................4
    The Organizer View ....................................................................................................5
    PowerChart Office Buttons..........................................................................................6
    Opening a Patient’s Chart through the Inbox................................................................7
    Patient Search..............................................................................................................7
    Using Open Application ..............................................................................................9
    3. Adding Patient Information ........................................................................................................................... 12
    Viewing Encounter Information.................................................................................12
    Adding a Drug Allergy ..............................................................................................12
    Adding an “Other” Allergy Type ...............................................................................16
    Saving Allergy Substances and Reactions to Favorites...............................................18
    Using Substances and Reactions from Favorites ........................................................18
    Modifying an Allergy ................................................................................................19
    Canceling an Allergy .................................................................................................21
    Documenting No Known Allergies ............................................................................22
    Viewing a Problem....................................................................................................24
    Adding a Problem......................................................................................................25
    Adding a Problem to Favorites...................................................................................28
    Adding a Problem from Favorites List .......................................................................31
    Modifying a Problem.................................................................................................33
    Adding a Medication by History................................................................................35
    Adding a Medication to Favorites ..............................................................................39
    Adding a Medication by History from Favorites ........................................................44
    4. EasyScript ...................................................................................................................................................... 47
    Creating a New Prescription ......................................................................................47
    Creating Multiple Prescriptions..................................................................................52
    Adding Medications to Favorites ...............................................................................54
    Removing a Started Prescription................................................................................55
    Completing a Prescription..........................................................................................56
    Reprinting a Prescription ...........................................................................................58
    Refilling a Prescription ..............................................................................................60
    Making a Historical Prescription Current ...................................................................62
    Discontinuing a Prescription......................................................................................64
    5. Superbill ........................................................................................................................................................ 67
    Superbill Orders Buttons............................................................................................68
    Creating a New Order Using Superbill.......................................................................68
    Adding an Order to Favorites in Superbill..................................................................70
    Creating an Order from Favorites in Superbill............................................................70
    Reprinting and Order in Superbill ..............................................................................70
    6. Clinical Notes ................................................................................................................................................ 73
    Entering a New Document in Clinical Notes..............................................................73
    Using Auto Text ........................................................................................................77
    Viewing a Clinical Note.............................................................................................78
    Modifying a Document in Clinical Notes...................................................................80
    Labeling a Note In-Error............................................................................................81
    7. AdHoc Charting ............................................................................................................................................ 83
    Completing a Patient History Form............................................................................83
    Viewing Information in the FlowSheet ......................................................................84
    View and Modifying a Document in the Form Browser .............................................87
    8. PowerNotes ................................................................................................................................................... 89
    Creating a New PowerNote........................................................................................89
    Saving a PowerNote to Favorites ...............................................................................94
    Inserting an Encounter Pathway.................................................................................96
    9. Using the Inbox ........................................................................................................................................... 100
    Using Inbox Messages .............................................................................................100
    Using Results to Endorse .........................................................................................104
    Using the Sign and Review......................................................................................108
    Using Orders to Approve .........................................................................................113
    Using Inbox Proxies ................................................................................................116
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