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Clinical Tab (Gen 9 & 10)

In the newly released MacPractice Generation 10+, we've made some extensive improvements to a Patient's Clinical Tab. Over the years we've received some strong feedback regarding how a patient's Clinical Summary was organized. We've taken that feedback into account and re-designed the Clinical Summary. We hope that this will help your practice organize your clinical information to better meet your needs.

This article will review the functionality of the new Clinical Tab, and address some of the changes that have been made.

Clinical Tab Overview

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The Clinical Tab, located in the Patients Ability, houses a summary of all clinical information stored within MacPractice. This information is broken up into several "widgets", which are the color coded section blocks  demonstrated in the above screenshot. By default, the Summary will display clinical information from all available Incidents to give you a comprehensive look at a patient's record.
If you want to narrow down to a specific Incident, you can use the Filter Incidents header in the upper left to select specific Incidents, or narrow down the results to a specific time range.
You can also export the Clinical Summary from this header. We'll cover exporting later in this article.

Editing the Summary
One of the new features in the Clinical Summary re-design is the ability to organize, hide, and customize the colors of each of these widgets. You can access the editing tools by clicking on the gear icon in the upper right of the Clinical Tab.

Note: Your MacPractice user must have the User Privilege "Edit Clinical View" enabled in order to edit the Clinical View's Summary. This privilege is located in the References Ability > User Group Privileges > Patient ability > Edit Clinical View.

All of these settings will be remembered on a per user basis, so your display will follow you from computer to computer based on your MacPractice user.

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The editing window is relatively self-explanatory. The Clinical Summary will display the widgets in the order denoted by these two columns.
If there is a widget that you don't foresee your practice using, you can click the checkbox by a widget to enable/disable them.
You can easily move widgets around by dragging and dropping them into the desired order.
Finally, you can change the color of a widget by clicking on the widget's color block.
Once satisfied with your changes, you can click the Done button. If you make a mistake or wish to revert your changes, you can use the "Reset to Default" option in the lower left corner of the edit window.

You can also Zoom In if you would like this to display in larger text. Simply hold the Command key and hit the +(plus) button to zoom in, or Command minus to zoom back out. This setting is remembered based on the specific computer's OS user (not the MacPractice user).

Elements of a Widget
Widgets are the individual blocks that make up the Clinical Summary. By default, the widgets are in a "dropped down" state, meaning that their contents are expanded much like nodes in the sidebar. You can click the triangle on the left of the widget name to shrink this widget until you need it.

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Let's take a look at a few widgets to demonstrate some of their differences.

Linkable Widgets

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For example, this is the Labs widget.
Nearly every widget will also have a filter option in the upper right as shown by the "Open/All" toggle button.
You can click on the name of this widget to take you directly to the Labs ability, or you can click each individual item listed to take you directly to that item. In this case, the Labs widget is designed mostly to list Labs information and take you to the Labs ability if you need to include additional information.

The Widgets that link directly to relevant areas in MacPractice are:

  • Medications (Rx Ability)
  • Imaging Visits (Imaging/DR Ability)
  • Orders (Orders Ability)
  • Labs (Labs Ability)
  • Attachments (Attachments Ability)
  • Notes (Notes Ability)
  • Procedures (Patients Ability > Ledger Tab, under the Transactions Node)
  • Planned Treatments (Patients Ability > Ledger Tab, under Treatment Plans node)
  • Perio Visits (Patients Ability > Dental Tab under Perio Visits node)
  • Optical Prescriptions (Optical Ability)
  • Referrals (Patients Ability > Referrals Tab)

Widgets with Drag and Drop Listing

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This is the Problem List widget. As you can see, there's another "Active/All" filter toggle, and an info button by the name that will provide detailed supplemental information that will assist with the Problem List.
In this widget, you can drag and drop diagnoses in order as you need.
You can also add diagnoses to the Problem List right from the Clinical Tab by clicking on the plus button in the upper right.

The Widgets that allow you to re-order entries from the Clinical Tab are: 

  • Problem List
  • Allergies 

Widgets with an Add Button

Another useful feature that the Problem List widget and some other widgets contain is the Add Button. These allow you to directly add a record into the relevant MacPractice area from the Clinical Tab.

The Widgets that allow you to add entries directly from the Clinical Tab are:

  • Problem List
  • Allergies
  • Immunizations
  • Vitals
  • Smoking
  • Family History
  • Preventive Care
  • Patient Education
  • Goals
  • Care Team

Widgets with a Preview Button

In MacPractice Build 10.7.3, we've added a Preview button to some widgets that contain images or a viewable file.

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List of Widgets
All functionality that used to be in the Clinical Sub-Tabs prior to Gen 9 is now contained within the widgets themselves.

A widget that simply lists information from another Ability within MacPractice will not appear if there is no relevant information to display. For example, in order for data to appear in the Medications widget, valid medications must be entered into the Rx Ability.

However, any widget that would allow you to add records will appear here unless it is hidden via the Gear Icon as described in the "Editing the Summary" section of this article. We strongly encourage you to hide any widgets that don't apply to your practice. For example, a medical practice would have no need for the Perio Visits widget, as this only applies to periodontal practices.

Below is a list of all the Clinical widgets, and a brief description of what they do.

 

Filters

The Incident drop down sorts the Clinical Summary for the patient by specific Incidents. The History, Start Date and End Date fields allow sorting the Clinical Summary by a specific date. Export Incident allows clinical information to be sent to a patient’s Portal.

 

 

Problem List

The Problem list is a record of all diagnoses for a patient. These can be added through this widget, EMR/EDR, EHR, and the Ledger.

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The Active/All toggle functions much like a filter. When on Active, the Problem List will only display active Problem List items. When on All, every Problem List item will be shown.

When All is selected, you are also able to reorder the diagnoses as needed by clicking and dragging them into the desired order.

To add a new diagnosis code to the Problem List from the widget, click the green plus button  and select the diagnoses code.

Double-clicking on a diagnosis will bring up a detailed view of that specific diagnosis. By double clicking a diagnosis, you can also delete the diagnosis by clicking the delete button in the lower left corner. The delete button is shown in the screenshot below.
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  • Diagnosis Code: This is the numerical identifier of the diagnosis
  • Code Type: This will designate they typed of code (ex. ICD9, ICD10)
  • Description: A brief overview of what the diagnosis entails.
  • Onset Date: The date the problem began to affect the patient.
  • Diagnosed Date: The date in which the patient was diagnosed by the doctor.
  • Resolved Date: The date the problem was addressed.
  • Type: Select the Type of the problem entry: Condition, Symptom, Finding, Complaint, Functional Limitation, Problem or Diagnosis.
  • Status: Select the status of the problem entry: Active, Inactive, Chronic, Intermittent, Recurrent, Rule Out, Ruled Out, Resolved.
  • Regularly Treated: When checked, the diagnosis will pull to new charges. When unchecked, it will not.
  • Provider: The provider who was diagnosed the code.
  • Office: The office assigned when the code was diagnosed.
  • CQM Value: If a value needs to be assigned to the diagnosis, it may be added here. This field is intended for legacy purposes and not used in any reports.
  • Notes: A free text area that allows information to be added about the problem record. Anything entered in the Favorites Custom Description will be reflected here as well.

Medications

The Medications widget will show both the active and inactive medications listed in the Rx Ability on the patient's chart.

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At the top right of the section, the user can choose to view "All" medications or just "Active" medications.

Account Alerts

This widget will show you the alerts that have been added on the Account Tab of the Patients Ability.

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Procedures

The Procedure widget will show you all of the procedures that have been entered into the patient's Ledger Tab.

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Perio Visits

This widget will show you all of the different perio visits recorded in the Dental Tab, for the patient in MacPractice.

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Optical RX

This widget will display all of the optical prescriptions stored within the Optical Ability.

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Smoking Status

The Smoking Status widget will allow you to add and show a record of the patient's smoking status.
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To add a new record, click the green plus button to add a new smoking status to the table

Choose the patient's smoking status from the dropdown menu. For current and former smokers, enter the date the patient started smoking in the Start Date field. For former smokers, also enter the quit date.

Entering a smoking status of Current Smoker without checking the box for cessation counseling offered will trigger a clinical alert; though the alerts may be disabled through References. If cessation counseling was offered, check the Cessation Counseling Offered box and enter the date within the Date Offered field. Click the Done button to add the record.

Smoking Status entries will be displayed in the table as they are collected over time. Double click on the row to edit any details about a past record. To delete a record, select the Delete button in the edit window.

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Preventive Care

The Preventive Care widget helps track routine preventive procedures performed at a different practice. For example, if you refer a patient to have a mammogram at a nearby facility, you can record this information here.
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Click the plus button above the table. This will bring up a list of your Preventive Routine Care references. Search for and select a preventive care item. Press the plus button on the pop up window to create a new type of preventive care.

Note: Adding References on the fly may be restricted by user privileges; records can be created or edited in the References ability > Preventive Routine Care node. 

The Preventive Measure will be added to the Clinical record. At this time, it is just a theoretical procedure. You do not know the patient has had it performed, just that you referred them to another provider to perform the procedure. Click the "Make Order" button to create an Order record for the procedure with the Preventive Measure name listed in the Short Description field. Select the relevant referral from the Referral menu, enter any other necessary information, and save your changes.

When the Order Status is set to "Closed", you will see an alert asking if the procedure associated with the Preventive Care record was performed. Click "Yes" if applicable. A new 3rd Party Procedure area will be added to the patient's Clinical summary. The procedure code and the referral the patient was sent to will be listed.

You can specify a Next Visit date for the procedure, to indicate the next time the procedure is recommended to be performed. When you access a patient's record after the Next Visit date, you will see an alert.
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Orders

This widget can be used to show open or all Orders on the patient's account.

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At the top right of the section, the user can choose to view "All" orders or just "Open" orders.

Digital Radiography Visits

This widget is used to quickly navigate to a unique DR visit for the patient.

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Referrals

All different Referral Types will show in this widget for the patient. This allows the user to easily see where the patient is coming from and the office that they will be going to.

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Care Team 

The Care Team tab displays members of a patient's care team.

Care Team members can be any MacPractice user within the office. Both providers and regular users may be added to this list. This information is just for the office record and does not interact with other abilities within MacPractice. 

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To add a new member of the Care Team, click the green plus button. In the next window, search for the user or click the Show All button to display all users. Select the user and click "OK".

Double click on a record to remove users from the table. The information displayed will pull from the References ability > User. Visit the User Reference to make changes if the information is incorrect.

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Allergy

The Allergies widget will show a list of allergies the patient has. Allergies, or a status of No Active Allergies, may also be entered into the patients record via EMR, EHR, or iEHR. This table will update dynamically with the information entered. 

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Note: Coding Preferences allow offices to select which set of allergies are used. Once the data is entered into patient records, reports like the Patient Clinical may be filtered using this information.

When selected on Active, only active allergies will appear. When selected on All you will see all active and inactive allergies. Also when selected on All, you are able to reorder the allergies as desired by clicking and dragging.

To add a new Allergy from this widget, click the green plus button, search and select allergies to add for the patient. Once added, Double-clicking on an allergy will bring up a detailed view of that specific entry. The record can be deleted from here as well.

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  • Identified: The date the allergy was discovered.
  • Onset: The date the patient first noticed this reaction. 
  • Severity: The severity of the allergy: Mild, Moderate, Severe, Fatal, Mild to moderate, Moderate to severe.
  • Allergy Type: Designate if this is an allergy, intolerance, or propensity to adverse reactions.
  • Status: This indicates whether the allergy is active or inactive.
  • Reaction: The codified reaction the patient has.
  • Reaction Description: Additional details about the reaction.
  • Notes: A free text area that allows information to be added about the allergy record. 

Once added and saved Allergy information will pull forward into many places in MacPractice such as Rx and ePrescribe, EMR and EHR, and printed forms and notes.

Automatic Alerts 

It will also display in the patient selector as a yellow alert triangle and pop up when the patient's record is selected; though these features may be restricted by user privileges or preferences. 

Immunizations

The Immunizations tab records a patient's Immunization information within a table.

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To add a new immunization to the patient's records, click the green plus at the top right. This information can also be added through EMR/EDR. EDI, and iEHR app. You can also double click on the record to make changes or delete it.

The drop down menu at the top right will allow you to filter the viewable immunizations by "All", "Hide Registry Downloads" and "Hide Historical".

The "Historical" button at the top right allows the user to log an immunization that was not administered by one of your office's providers for tracking purposes. 

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The "More" button will open the Patient Immunization Detail window, which will allow the user to enter more information regarding the patient's immunization.

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Patient Alerts

This widget will show you the alerts that have been added on the Patient tab of the Patients Ability.

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Planned Treatments

This shows you all the treatments that have been added to the patient's Treatment Plans in the Ledger tab for the patient.

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Clinical Notes

This widget will show all of the notes that have been entered within the Clinical Notes Table under the Dental Tab.

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The "Expand All" checkbox will expand the Note column in order to view the information on one line. Uncheck this to condense the section so you don't have to scroll as much. Also, the drop down on the top right of the widget allows you to filter the viewable clinical notes by: "All Notes", "Completed", "Treatment", "Conditions", "Existing", or "Deleted Notes".

Vitals

The Vitals widget is a record of a patient's recorded vital information. Patient's vitals may also be entered in EMR, EHR and iEHR forms; all of the details are recorded back to this table. The data entered will pulls forward into Notes, Forms, EMR, EHR, and iEHR forms. Certain clinical reports will use the information entered in the vitals. 
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The green plus button allows you to enter a new set of vitals for the patient. Enter details in the popup window and press Done. To edit the patient's vitals record, double-click on the row to re-open the vitals pane.
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Note: Change localization preferences to metric units if it applies to your office.

  • Incident: Select the incident/visit you would like to associate these vitals to. This can help the office identify if vitals were taken at a particular appointment.
  • Date/Time Measured: Enter the date and time the vitals were recorded.
  • Weight: Record the weight of the patient here, if applicable. 
  • Length/Height: Add the length or height of the patient here, if applicable. 
  • Blood Pressure: Enter the blood pressure of the patient, if applicable.
  • Temperature: Record the patient's temperature, if applicable.
  • Heart Rate: Record the patient's heart rate, if applicable.
  • SpO2: Enter the oxygen saturation percent here, if applicable.
  • Resp. Rate: Add the patient's respiratory rate here, if applicable.

Automatic Alerts

If you enter any values that may indicate the patient needs attention, such as a high resting heart rate or hypertension, MacPractice will prompt you to take action in a clinical alert. These alerts may be disabled for certain users based on their privileges and new types of alerts and responses can be customized in the References
 

Growth Chart

As you enter new vitals records over time, you will be able to see and track trends in the patient's condition. Clicking on the Growth Charts button will bring up the chart window. This chart tracks certain statistics over time. You can cycle through the different charts using the dropdown menu in the upper left. The Show/Hide Key button will control whether the color key for the chart is visible. The Show/Hide Table button will control whether the table view of the charted information is visible.
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Patient Education

The Patient Education widget tracks educational information that has been given to the patient.

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There are two ways to give the patient these resources and record them.

  1. Set up references that you keep on hand in advance. Then record the items that were given to the patient by pressing the plus button above the Patient Education table. The Patient Education references must be set up ahead of time through the References ability; they cannot be added on the fly through the Patients ability. Each reference has specific requirements and will only be available if the patient meets the criteria.
  2. Click on the Info Button (the blue "i" icon) next to clinical items (problems, medications, allergies, lab results, smoking status, and immunizations) in the Clinical tab, select the resource to provide, and check the "Gave Resource to Patient" box. MacPractice will record that the information has been provided for the patient. 

Family History

Maintain a log of the past or present issues in a patient's family which could contribute to the patient's health in the future. 

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To add a new record, click the green plus, search for and select a history item, then select which family member the item is relevant to. Family History can also be added to the patient record through an EMR, EHR or iEHR from. 

Once added, you can double click on the record to make changed or delete it from the Clinical Tab.
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Goals

The Goals widget displays the patient's clinical goals and instructions. Use the popup to filter the result to All, Completed, Incomplete.

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To add a new goal for a patient, click the plus button above the table then search for a specific goal or click the Show All button. Select the goal from the list, then click "OK". To delete a goal, double click on the goal and choose "Delete" at the bottom left.

Goals are also available as a section in iEHR and EHR forms; when used on the form, the information will update this widget automatically.

Additional attributes within the Goals table can be updated within the table columns. Enter in instructions and target dates. The Set Date defaults to the date of creation, but may be edited. Check the Done box when the goal is completed.

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Labs

This widget allows the user to quickly see all of the labs test that are open and all lab results that are registered within the Labs Ability for the patient.

At the top right of this section, you can choose to view only "Open" labs or "All" labs. 

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Attachments

The attachments widget is the best way to navigate to a unique patient attachment added to the Attachment Ability.

At the top right corner of the widget, you can use the drop down menu to filter the visible attachments based on the Attachment Type. 

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Notes

This widget allows users to quickly see all the documents that were made for the patient within the Notes Ability.

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