Pregnancy/Birth History
From the Intake template you are able to document the following Birth History information for the patient
- Maternal illness/complications for sickle cell status
- SpO2 measured during hospital course
- Spontaneous or Induced labor
- Umbilical cord blood test results
Birth History: Maternal Illness/Complications Detail
To document Sickle cell status/hemoglobin type you must select yes on Maternal illness/complications
SpO2 Measurement
In the Hospital Course section, if SpO2 was measured at birth select yes for SpO2 measured and document Methodology, percentage and Time of test.
Umbilical Cord Blood Test
Under Hospital Course, select abnormal in the Umbilical Cord Blood Test section and click Detail to enter results/findings.
Spontaneous or Induced Labor
In the Labor and Delivery section, select delivery type. The options are Spontaneous and Induced labor
Pediatric Vital Signs Alert
An alert will display if the height of the patient entered in current encounter is less than the height measured in the previous encounters
Adding Tare Weight
For Pediatric patients 2 years of age or older the Tare Weight is available to document weight for children with special needs.
In the Weight measurement section, select Tare Weight link to open the Tare weight pop-up template.
The following steps should be taken to enter Tare Weight:
- Total weight with device
- Name of device
- Input device's weight
- Click Add to save the device's information for future visits.
- Click Save & Close
Note: System automatically calculates patient's weight
To save the device's information for future visits, simply click Add and it will automatically save.
Bone Age Detail
The Bone Age Study Details can be added under Diagnostic Studies.
Note: Diagnostic studies can be located in the Intake and Histories template.
Bone Age Details Documentation
Enter the following information:
- Diagnostic study type: X-Ray Upper Extremity
- Study Performed: Bone Age Study
- Study Date: Date performed
- Study Result: Interpretation.
- Click on the Detail button to open the Peds Bone Age Detail pop-up template.
- Enter details
- Save & Close
Vital Signs Graph
Bone Age Details are now visible in the Vital Signs Graph.
Mid-Parental Height
In the Family panel in Histories template an active link is available to compute mid parental height by gender-specific parent height percentiles.
- Clink the Mid-Parental Height link
- Enter maternal height
- Enter paternal height
- Save & Close
Note: System automatically calculates Mid-Parental Height for you
Confidential History
Confidential History link can be located in the Histories template under Social History
Psychiatric/Placement Documentation
Psychiatric template has been updated to enable child's placement history documentation.
Child Abuse Documentation
Abuse template is now available under Confidential History. The Confidential History link is located in the Social History panel. This allows you to document child abuse history that the child may have experienced.
The confidential history details appears on the document only if you select the Include confidential information in the pediatric Social History document with patient/guardian permission check box on the Peds Confidential History-Substance pop-up template.
Nutrition/Elimination
For nutrition or elimination documentation, click the Nutrition/Elimination active text link to open the age appropriate Interval History-Nutrition pop-up template.
Click Special Needs nutrition/elimination active link at the bottom
Special Needs Nutrition/Elimination
Special needs nutrition/elimination active text link is available to document nutrition and elimination details of the pediatric patient with special needs.
Caries and Dental Sealants
The Dental Caries Risk/Sealants pop-up template enables you to capture the dental sealant information on all four first permanent molars for peds 5 years up.
SWYC Development Screening
A screening tool is available to document development milestones of children under 5 years of age. The provider/medical assistant can use the SWYC Milestone Full View template to to document development milestones.
Select Details active link on appropriate age group to generate SWYC pop-up.
Select appropriate answer for each question and then click save and close.
MCHAT-R
MCHAT-R is the Revised Checklist for Autism in Toddlers
MCHAT-RF
MCHAT-RF is the Modified Checklist for Autism in Toddlers with Follow -Up. To document MCHAT-RF screening, click the Add New active lnk under other screenings and select MCHAT-RF for Name of Screening tool.
Well Child Soap
The Well Child template contains all the elements necessary for documenting a complete well-child visit with minimal clicks and navigation.
General
You are able to view the patient's previous well child visits in the General panel
Reason for Visit
Reason for Visit panel has been improved to enable a comprehensive documentation of the well visit.
Well Child HPI
Select age-specific well visit information on the dynamic HPI templates
Screening
View multiple screening test all in one location
Immunizations
To track, order, and administer vaccines, open the Immunizations panel.
Assessment/Plan
Dx and assessment plan history button added
Dx/AP History
You are able to copy and paste diagnosis used in previous encounters onto your current encounter
Contagion Exposure
For children who may have been exposed to any contagious disease