The Chief Complaint tab allows the data abstractor and quality reviewer to enter information about the patient’s chief complaint, or main reason for making the visit.
NOTE: Depending on the encounter status and the user’s role, the Chief Complaint tab may be read only.
To enter information:
1. Complete the following fields, where applicable:
• Chief Complaint: Enter the patient’s main reason for the visit in the free text field.
• Current Symptoms: Select all check boxes that correspond to the patient’s current symptoms.
• Comments: Type additional comments related to the encounter in the free text field.
2. Click Save to save the information, or Cancel to exit without saving.
Review comments can be added to the Chief Complaint tab by the quality reviewer. The data abstractor can then view the comments and address them.
If a field is enabled for review comments, three comment buttons will be visible over that field.
•
To expand the comment if it is not visible,
click the Expand button.
•
To close the comment, click the Close button.
•
To save the comment, click the Save button.
NOTE: Any changes made to the Review Comments area will
not be saved unless the Save button is clicked. That is, clicking the Save
button on the Encounter Actions menu will not save these changes.
To update the record after review comments have been received (Data Abstractor role)
1. Make the necessary revisions to the Chief Complaint tab based on the corresponding review comment.
2.
Once the comment has been addressed, click (select) the
Resolved
check box and click the Save button to save the changes.
3. When all comments have been addressed and the encounter is ready to be re-submitted, click the Send for Review link on the Encounter Actions menu.
4. The quality reviewer will review the encounter, locating each comment and marking off the Approved check box for each revision that is approved.
To add review comments (Quality Reviewer role)
1.
Go to the area where the comment will be added and
click the Expand button
to open the review comments box.
2.
Type the comment in the free text field and click the
Save button. (The comment will not be saved unless
this button is clicked.)
3. When all comments have been added, click the Return to Abstractor link in the Encounter Actions menu to return the record for further processing. This will remove the encounter from the Reviewer Tasks grid until the data abstractor re-submits the record for review.
To approve changes after the data abstractor has made revision (Quality Reviewer role)
1. Go to the field where the comment was added and resolved.
2.
If the review comment was addressed satisfactorily,
click the Approved check box to
select it, and then click the Save button. (The setting will not be saved unless
this button is clicked.)
3. Repeat this procedure for all resolved comments.
After all comments have been approved, the Review Comments grid in the General Tab will show the Is Approved check boxes as selected.
The Encounter Actions menu allows the data abstractor to save the record, send it for review, or cancel out of the current revisions.
Quality reviewers can use the Encounter Actions menu to save the record, return the record to the data abstractor after adding comments, send the completed, approved record to DVEIVR, or cancel out of the current operation.