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EMR & EDR - Building Templates - Form Elements

Form Elements are the individual building blocks that make up an EMR or EDR Patient Form. They are added to Form Sections, which are arranged collections of Form Elements.

This article covers each Form Element as it appears in the Forms Palette, which you can read about here. We'll include a screenshot of the Element icon as it appears in the Forms Palette for easy recognition, and explain the unique options available in the Options Tab for each of these Form Elements.

Form Elements are listed in the order they appear in the Forms Palette. You can easily add a Form Element to a Form Section by clicking and dragging the Element from the Forms Palette into the section.

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The vast majority of Elements can have their position and size adjusted in the General Tab of the Forms Palette. We'll only mention if there are items specific to that particular element in the General Tab.

Text Field

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The Text Field Element captures a line of text. It is best used for short responses that don't require lengthy answers or elaboration.

When you first add a Text Field to a Form Section, editing the text while in the Form Section will change the label of the Text Field. 

Text Field General Tab

  • Required Field: Sets the Text Box as a required field
  • Hide Label: Prevents the name of the element from appearing on the form.
  • Label on Left: Sets label to appear on the left of the text, rather than above it.
  • Display Border: Displays a border with the color of your choosing.
  • Color Selector: Allows you to set the Color of the text in the Text Field

Text Field Options Tab

  • Allowed Text Drop Down: This drop down contains several options to help you restrict what kind of text a patient can fill out in this form. You can choose from the following:
    • Free Form: Allows free format entry
    • Alphanumeric: Allows the numbers 0 to 9 and letters A to Z, with a checkbox to Capitalize all letters
    • Letters Only: Allows only letters with a checkbox to Capitalize all letters
    • Numbers Only: Allows only numbers
    • Date Only: Allows only a date with a 00/00/0000 sequence
    • Phone Only: Allows only a phone number with area code and number (000-000-0000)
  • Max Length: This field sets the amount of characters allowed in the Text Field. By default, 40 characters are allowed, however the field can be set anywhere from 1 to 255 characters.
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Label
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The Label Element adds a text label to other Form Elements. It is a very simple Element with no Options to customize other than the position, size, and color of the Label.
Textbox
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The Textbox element generally functions like a normal Text Field, except with more space available for additional detail. This should be used for fields where you want to give the recipient plenty of space to fill out a longer response.

There are no Options under the Options Tab for customization.

Checkbox
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The Checkbox element adds a checkbox that the user can check and uncheck. This Checkbox can be customized to change how this is reflected in the Narrative View of the Form Section.

Narrative Behavior

By default, when this Element is included on the Narrative View, the Narrative will simply include the text listed in the Narrative Unchecked and Narrative Checked fields in the Options Tab of this Form Element in the Forms Palette.

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If you would prefer to instead have your checkboxes be listed under Positive and Negative Findings on the Narrative, you can include a Pull Field for this by switching to the Narrative View by pressing Command-\ on your keyboard, and then in the Forms Palette, locate the Pull Fields Section. There's an additional category of Pull Fields for your Form Section.

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Underneath it is an Others sub-category, where you can drag and drop the "Checkbox_Breakdown_Summary" Pull Field into your Narrative View, which will then list all checked checkboxes and unchecked checkboxes into "Positive Findings" and "Negative Findings" on the Narrative View.

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Options Tab

  • Default Checked on Patient Form: If this option is checked, when a patient form is generated using this Form Section, it'll check this Element's checkbox by default.
  • Narrative Checked/Unchecked: These fields will include their text onto the Narrative if the checkbox is checked or unchecked, respectively.

Popup button

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The Popup Button Element is designed to select an option from a list. This list is defined in the Options Tab in the Inspector of the Forms Palette. You can choose from one of many Reference categories in MacPractice, you can define your own.

The Options Tab has the following fields:
  • Reference: This table and menu allows you to select a Reference category from the MacPractice Database to populate a list of options that can be chosen. Family History, Sensitivities, and Social History pull from the EMR ability. You can create a custom list of options by choosing "None".
  • Value: The individual options within this Reference List.
  • Apply to Patient Checkbox: For some particular references, you can choose to also add items to the patient's file as well. For example, if you wanted to place an Account Alert on a patient's file from this form, you could do so by checking the Apply To Patient checkbox.

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To create a custom list for this Popup Element, select the None Reference and click the plus button, then Double-click the line entry to rename the new value.
  • #1 item as default: When the form is first loaded, if checked, the first option listed in this list will be chosen by default. 
  • Import: This will import values from a file. Useful if you have a long list you want to include.
  • Abnormal checkbox: If checked, this option in the list will be listed with the Abnormal color, set in EMR Preferences. (MacPractice Menu > Preferences > EDR/EMR > Others Tab)

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Image View

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The Image View allows you to insert an image into a patient form. You can either add one during the Form Section construction such as a logo or other visual element, or you can leave it blank and add images specific to a patient when generating a patient form.

There are two additional customization options in the General Tab of the Form Palette's Inspector View.

  • Display Border: This option will include a small border around the image view element.
  • Print Border: This option will include that small border around the image view element when printing the form.

To add an image to a Patient Form when editing the Form Section, simply drag the image file into the Image View box.

When interacting with the Patient Form itself, you can right click (or hold Control and click the box) to bring up two options to either Select or Clear the Image. Select will open up a file browsing window to select the image, while Clear Image will remove any image added to the Image View element.

You can also simply drag and drop the image into the box.

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Combo Box

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The Combo Box Element is a special element that allows you to either create custom lists for a patient to choose, or you can pull in particular Reference data via the Forms Palette's Inspector.
The main difference between a Combo Box and a Popup Button element is that with a Combo Box, the person filling out the form can add additional entries on the fly. This restricts the available Reference categories that can be pulled into a Combo Box, and thus some kinds of lists may require that you use a Popup Button Element instead.
Within the Inspector, you can customize the Combo Box in the Options Tab:
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  • Reference: This table and menu allows you to select a Reference category from the MacPractice Database to populate a list of options that can be chosen. Family History, Sensitivities, and Social History pull from the EMR ability. You can create a custom list of options by choosing "None".
  • Value: The individual options within this Reference List.
  • Apply to Patient Checkbox: For some particular references, you can choose to also add items to the patient's file as well. For example, if you wanted to place an Account Alert on a patient's file from this form, you could do so by checking the Apply To Patient checkbox.
To create a custom list for this Combo Box Element, select the None option and click the plus button, then Double-click the line entry to rename the new value to the desired option.
  • #1 item as default: When the form is first loaded, if checked, the first option listed in this list will be chosen by default. 
  • Import: This will import values from a text file. Useful if you have a long list you want to include. You'll want to use a text program, we recommend either Text Wrangler or BBEdit.

Drawing View

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The Drawing View element allows drawing on a Form with the Drawing View tools in the Forms Palette.
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The Element itself does not have many customizations options in the Inspector of the Forms Palette, other than options to display and print the border around the element in the General Tab.
We do recommend creating a Label element to indicate the Drawing View element clearly.
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When a template contains the Drawing View element, when you generate a patient form, the Forms Palette will contain a Drawing Tools area with several tools available at the bottom of the Forms Palette. The selected shape tool is lit in blue, and clicking will switch tools. 
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You can use these tools by clicking inside the Drawing View. Holding down the mouse button will allow you to draw shapes or freely draw with the Pencil tool selected. 
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Right clicking the Drawing View will open a menu where you can clear the drawing or undo the latest change.
Let's break down each tool:
  • Line Width Slider: By adjusting the slider at the bottom, you can increase and decrease the line width of any drawn shape.
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  • Pencil: This tool lets you draw directly with the mouse cursor. 
  • Line: This tool allows you to create lines by clicking and dragging in the Drawing View element.
  • Square: Places a square in the draw area
  • Circle: Places a circle in the draw area
  • Stroke Color: Sets the drawing color from the Color Palette.

Progress Note

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The Progress Note is designed to capture the progress of a patient's clinical status throughout care. An office can set up several pre-prepared Progress Notes which can then be quickly applied to a patient form.

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When adding this Element to a Form Section, you'll want to click on the Edit button, which will then show the table where you can add and remove Progress Note templates. Clicking the Green Plus will add a new Progress Note, and you can add or edit it on the right side. Clicking the Done button will flip you back to the normal view.

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Then, when you're generating a patient form, you can then use the drop down menu to quickly select a Progress Note, which then populates the text field with the Progress Note you selected and prepared. You can freely add to it here without impacting the template.

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It is important to note that if you click Edit in a generated Patient Form, you can still edit the Progress Note templates on the fly, and this will carry over to other generated forms.

Importing Progress Notes

Within the Inspector, the Options tab is used to import. Imported information should be created in a program such as BBEdit or TextWrangler. Each line of the text file should be formatted as such:  Title##Content.
Diagnoses and Billing

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The Diagnoses and Billing Element is used to add diagnosis codes and procedures to the form. It is a large Element that will take a full page, so make sure you set your Form Section to a Full Page in the Forms Palette (or manually adjust the Height to a minimum of 650 to ensure this Element fits)

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The Element is split into multiple tables, the Encounter Diagnosis table, the Past Diagnoses and Problems table, and the Procedures table.

Encounter Diagnosis Table

The Encounter Diagnosis table allows you to add a particular diagnosis code to this visit. Simply click the Green Plus or Red Minus to add or remove Diagnosis codes. The Code Selection window will appear when adding diagnoses.

Once a Diagnosis has been added, you can then add that diagnosis code to the patient's Problem List by clicking the Add Problem button next to the diagnosis. If you mistakenly click this button, it turns into an "Undo Add" button so you can quickly click it again to prevent it from being added to the patient's Problem List.

Saving the form commits the change, so if that is the case you'll need to navigate to the patient's Problem List in the Clinical Tab/Ability.

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The list of Diagnoses may be rearranged by dragging and dropping the diagnoses to their desired position.

Past Diagnoses and Problems Table
This is a record of any Diagnoses that already exist in the Patient’s problem list. This also contains any diagnosis that may have existed in the Care Slip Element from previous versions of MacPractice.

The arrow to the left of a Past Diagnosis, when clicked, will move that Diagnosis Code to the Encounter Diagnosis Table. (They still remain in the patient's Problem List)
If this was done by mistake, you can always click the arrow again next to that code in the Encounter Diagnosis table to bring it back to the Past Diagnoses Table.

The Move All to Encounter Diagnoses button will move every listed Past Diagnoses into Encounter Diagnoses.


Procedures Table
The Procedures Table allows you to add Procedures from your Fee Schedule to this patient.


Clicking the green plus will bring up a window that allows the entry of billing codes. Codes will be listed with the Fee Description in the Charge column and the Fee Schedule they belong to in the Fee Schedule column. You can click these column headers to sort the results accordingly.

You can easily search for codes by typing into the search bar at the top. If you'd rather browse, you can click "Show All" to display all your available codes.


The Review and Bill button brings up another window that will create an order for the biller to add these Procedure Codes as charges to the patient’s ledger. You can assign the order to a particular MacPractice User in the upper left hand corner.


Across the top of the window, the Assign Order To is a drop down list with a selector for which user should have the order assigned.

The next two checkboxes ensure that the same Date or the same Diagnosis should be used for All Procedures listed.

Procedures is a list of all of the procedures added into the element. When one of these are selected, on the right you will see a break down of the Procedure. If the Date needs to be changed, it can be changed here, as well as other details such as Units, Tooth Surface, etc. as necessary.

Diagnosis is the box that allows the selection of specific diagnoses (that have been added through the element) to be applied to a specific Procedure (if the Same Diagnosis checkbox has not been selected).

Notes is a text field that will translate to the Procedure Notes for a claim.

Clicking Create Order will generate an Order in MacPractice.
Note: Creating an Order does not put billing information directly into a patient’s ledger.

The Show Orders button in the Diagnoses & Billing Element shows any Orders that have been generated with information from the element.


The checkbox to the right, when checked, shows the Order on the patient’s narrative. If an order has been changed or submitted by mistake, unchecking this box removes the order from the narrative.

Signature Box

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The Signature Box Element is used to add a signature to the Patient Form. When a form with this element is generated, you can click the "Start Signature" button to be taken to a full screen signature field. You can use your mouse to click and drag to draw a free-form signature. There'll be three buttons at the bottom.

  • Clear Signature: Clears the signature. Control-right-click anywhere in the gray area for a Clear Signature box
  • Cancel: Returns to the form without saving any information
  • Done: Adds the signature to the patient form
There are three additional options in the General Tab of the Inspector in the Forms Palette.
  • Required Field: Requires a signature before continuing or saving the Form
  • Display Border: Displays a border around the Image
  • Print Border: Hides the border in the patient form, but displays the border when printed.

There are no additional customization options in the Options Tab.

Slider

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The Slider element is used to set a value between 1-100. You do this by using a simple slider to click and drag to the desired value. The value set will then be reported into the Narrative side.

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In the Options Tab of the Inspector in the Forms Palette, there are a few options to customize the Slider element:

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  • Min: Sets the minimum value of the Slider
  • Max: Sets the maximum value of the Slider
  • Precision: Set the increment by which the Slider is adjusted

Medications

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The Medications Element allows you to add and Hahaha Medications in the Patient Form. These are pulled from the Rx Ability in MacPractice.
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The Active/All Toggle allows you to filter which Medications are displayed here, either Active for medications which the patient is currently taking, or All for all Medications whether they are being taken now or previously.
To add a Medication, click the Green Plus in the upper right. search for and select the medication.
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If the patient is not taking medications, select the No Medications checkbox. If there are no changes to the patient's medications, select the No Changes checkbox to add the information as it appears to the patient narrative.

If the patient is currently taking the medication, enable the Currently Taking checkbox. Next, add the Medication attributes, such as the form, route, frequency, duration, dispense count, and refill count of the medication. An Additional Sig can also be added. The Non-Printed Notes box captures your own clinical notes about the medication, which will not be attached to the patient's prescription. Add the Ordered, Prescribed, Dispensed, and Started Dates. If this is the first record of the medication, enable the First Record of Order checkbox.
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Reconciling Medications
The Medications Element can be used to perform a Medication Reconciliation. Click the Reconcile menu and select the Add New List for Reconciliation menu item.
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In the resulting window, select the radio button to add a new list of medications from the Patient or Referral. Where Referral is selected, set the Referral Source menu to None, an Existing Referral, or select to Add New Referral Record.
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If Add New Referral is selected, select the Referrer from the list within References > Referrer, or click the plus button to add a new Referrer.
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With the list source selected, click the plus button to search for and select the medication and complete the medication attributes as usual (See RX Element for instructions.) Once finished, click the Next button.
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The resulting window displays the entire medication list for the patient. The icons denote which medications were already on file for the patient and which medications were added during the current reconciliation. Disable the checkbox for any medication to set it as Inactive. Enable only the medications to keep on the patient's record, then click the Next button.
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As a final review, confirm the medication reconciliation list in the resulting window. Click the Next button to dismiss the Medication Reconciliation window.
Vitals
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The Vitals Element, when added to a Patient Form, adds a Patient Vitals table that allows you to add new Vitals Records, and display older Vital records. 
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To add a Vitals Record, click the Green Plus. You'll be presented with a Vitals sheet that you can fill out.
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Any changes to Vitals Records will impact the Patient's Clinical information, located in the Clinical Ability (or Patients Ability > Clinical Tab on older builds of MacPractice).
Allergies

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The Allergies Element, when added to a Patient Form, will add an Allergies Table that allows you to add records of allergies to the patient form.
The Active/All Toggle allows you to filter which Allergies are displayed here, either Active for Allergies currently impacting the patient, or All for all Allergies the patient has had, whether they are active now or not.
To add an Allergy record, click the Green Plus. This will open a search window where you can search for a relevant Allergy to add to the patient's record.
 
If the patient does not have any allergies, select the No Allergies checkbox. If there are no changes to the patient's allergies list, select the No Changes checkbox to add the information as it appears to the patient narrative.
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Within the Patient Form, click the small plus button to add a new allergy record for the patient. In the resulting popover, search for and select the allergy.
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If the patient's allergy is currently active, enable the Active checkbox. Next, add the allergy attributes, such as the severity, Identified Date, Onset Date, Allergy Type, and any additional notes. You may search for and select a reaction by clicking the magnifying glass icon within the Reactions field. Click the Done button to add the new Allergy record.
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Reconciling an Allergy
The Allergies Element can be used to perform an Allergy Reconciliation. Click the Reconcile menu and select the Add New List for Reconciliation menu item.
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In the resulting window, select the radio button to add a new list of allergies from the Patient or Referral. Where Referral is selected, set the Referral Source menu to None, an Existing Referral, or select to Add New Referral Record.
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If Add New Referral is selected, select the Referrer from the list within References > Referrer, or click the plus button to add a new Referrer.
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With the list source selected, click the plus button to search for and select the allergy and complete the allergy attributes as usual (See Allergies for instructions.) Once finished, click the Next button.
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The resulting window displays the entire medication list for the patient. The icons denote which medications were already on file for the patient and which medications were added during the current reconciliation. Disable the checkbox for any medication to set it as Inactive. Enable only the medications to keep on the patient's record, then click the Next button.
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As a final review, confirm the medication reconciliation list in the resulting window. Click the Next button to dismiss the Medication Reconciliation window.
Race and Ethnicity
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The Race/Ethnicity Element, when added to a Form Section, adds a table to the patient form that allows you to set a patient's Ethnicity, Language, and Race. 
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This element interacts with the Patients Ability > Patient Tab > Race/Ethnicity Sub-Tab, and the fields are identical except for the "Review Performed" checkbox, which is simply an indicator that the patient was consulted with when filling out the patient form.

Problem List

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The Problem List Element, when added to a Form Section, adds a Problem List table that displays diagnoses previously entered in a patient's Problem List in the Clinical Ability of MacPractice. (Clinical Tab in older builds of MacPractice)

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The Active/All toggle allows you to filter the displayed results to Active diagnosis codes or diagnosis codes with a resolved date.
You can add codes by clicking the Green Plus in the upper right corner. This will bring up a window where you can select the desired code.
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Then, a window will appear with details related to that diagnosis code. 
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Problem List Reconciliation

The Problem List Element can be used to perform a Problem List Reconciliation. Click the Reconcile menu and select the Add New List for Reconciliation menu item.
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In the resulting window, select the radio button to add a new list of problems from the Patient or Referral. Where Referral is selected, set the Referral Source menu to None, an Existing Referral, or select to Add New Referral Record.
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If Add New Referral is selected, select the Referrer from the list within References > Referrer, or click the plus button to add a new Referrer.
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With the list source selected, click the plus button to search for and select the diagnosis and complete the diagnosis attributes as usual (See Problem List Element for instructions.) Once finished, click the Next button.
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The resulting window displays the each problem list diagnosis for the patient. The icons denote which problems were already on file for the patient and which problems were added during the current reconciliation. Disable the checkbox for any problem to set it as Inactive. Enable only the problems to keep on the patient's record, then click the Next button.
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As a final review, confirm the problem list reconciliation in the resulting window. Click the Next button to dismiss the Problem List Reconciliation window.

CQM Supplemental

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The CQM Supplemental Info Element, when added to a Form Section, is used to add SNOMED codes to a patient's clinical record for inclusion in the Clinical Quality Measure (CQM) reports. For a SNOMED code to count toward the CQM reports, it must be entered through this Element.
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To add a SNOMED code, simply click the Green Plus, which will bring up a search window. Typing into the search window will narrow the results down. Once you've selected the desired SNOMED code, click the Select button to add it to the table.

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Charting View
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The Charting Element, when added to a Form Section, displays information from the Charting Ability in the Patient Form.
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When this element is included on a form, a thumbnail of the patient's current chart will display with a table of the patient's Restorative Charting procedures that have been added in the Dental Tab of the Patients Ability. There are a few options available in this view:
  • Include In Narrative: In the table, any procedures done will be displayed and a checkbox will be available to include the procedure in the Narrative View. 
  • View Chartings for All Incidents/ In Selected Incident Only: These options allow you to either view procedures for all Incidents for this Patient, or for the selected Incident only.
  • Show Treatments Checkbox: Displays Treatment Plan items that have been added in the Treatment Plans node of the Dental Tab in the Patients Ability. Treatment Plan items will be highlighted in red or the Treatment Plan color you have set in the Dental Tab.
  • Show Previous Chartings Checkbox: Displays procedures that have been added in the Patient Chart node of the Dental Tab in the Patients Ability. Previous procedures will be highlighted in blue or the Preexisting Procedure color you have set in the Dental Tab.
  • Show Tooth Conditions: Displays tooth conditions, which may not be associated to a procedure.

You cannot add procedures from the Charting View element.

Family History
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The Family History element, when added to a Form Section will include a Family History table on a patient form, which is then used to enter conditions related to the patient's family history. This interacts with the Family History Clinical widget in the Clinical Ability. (or Clinical Tab of the Patients Ability on older builds of MacPractice)

To add a new family history record, you can click the Green Plus in the upper right of the Element. After selecting the detail you'd like to add, a popup will appear with a window that allows you to select which family members to apply the detail to.

In addition, there are two checkboxes available on the Element itself:

No Significant Family History: If there is no significant family history, check this box.

No Changes: If there are no changes to the family history, check this box.


Chief Complaint

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The Chief Complaint Element, when added to a Form Section, displays the primary reason for a patient’s visit. This is displayed on CDA documents (clinical summaries).

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Clicking the green plus in the top right corner of the Chief Complaint window will add a new Complaint that can either be added, or pulled from an existing list in the Chief Complaint Reference.

Once a Chief Complaint has been added to the patient’s record, a prompt will appear that allows for Notes to be entered. Any information that expands on the Chief Complaint will be entered here. Notes can be added or edited to any existing Chief Complaint by double clicking on any existing Chief Complaint in the patient’s record.


A Chief Complaint can be removed by clicking the red minus when a complaint is selected. A prompt will appear verifying that the complaint should be deleted. Once deleted, a complaint cannot be retrieved, but a new one may be added.

Clinical Instructions

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The Clinical Instructions Element is a specialized text field that serves as directions from the doctor to the patient. When added to a Form Section, you can either write directly into the Clinical Instructions field, or you can use the Show Macros button to set up macros to quickly post pre-set information into this field.

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Clicking the New button will bring up the macros creation window. Enter in a Title for the macro in top bar. In the Expanded Text box, enter in the text that should be populated any time a macro is selected.


From the Clinical Instructions window, anything may be typed in the box on the right. Any time the title of a macro is clicked, the full text of the macro will be populated.


Clicking the gear icon next to the title of the macro will allow the content or title of the macro to be edited.

Immunizations

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The Immunizations Element displays the details of a patient’s Immunization history. This will display on CDA documents (clinical summaries).

Existing Immunizations on the patient's record that have been entered into the Immunizations widget of the Clinical Ability (or Clinical Tab on the Patients Ability on older builds of MacPractice) will be shown in this table.

You can add or remove these from the table with the Green Plus and Red Minus. Keep in mind that removing an Immunization from this element will also impact the patient's account.

You can also add a Historical immunization record by clicking the "New Historical Immunization Record button." This is when a patient indicates that they have received an immunization in the past but your practice hasn't been the one to administer the immunization.

Either method to add a new Immunization will bring up a search window where you can search for and select the desired Immunization.


Once you've selected the desired Immunization, a detail sheet will appear. Our "Immunizations in MacPractice 11" article here covers how Immunizations work in MacPractice and explains each of these fields.



Once you've set these fields to your liking, you can click the Done button to save the Immunization. Any Immunizations added here will be reflected in the patient's clinical record.

Smoking Status

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The Smoking Status Element, when added to a Form Section displays a table that contains the patient’s smoking status and history as entered in the patient's Smoking Status in the Clinical Ability of MacPractice (Patient Ability's Clinical Tab on older builds of MacPractice)

This will display on CDA documents (clinical summaries).


You can add to this table by clicking the Green Plus, or remove items with the Red Minus (although keep in mind removing items from this table will also remove them from the patient's clinical record). When you click the Green Plus, a prompt will appear allowing you to choose a Smoking Status and the date range for it, as well as a checkbox for whether Cessation Counseling was offered.

The Updated Date is a record of the date in which changes to the record were made. This date cannot be altered.

There is a checkbox to verify if Cessation Counseling has been offered, and a date field to verify on which day the counseling was offered.

Clicking Done will prompt you to save and the information will be added the information to the patient’s record.


Any existing Smoking Status may be edited by double clicking the status in the patient’s record.


A Smoking Status can be removed by clicking the red minus when a status is selected. A prompt will appear verifying that the status should be deleted. Once deleted, a status cannot be retrieved, but a new one may be added.

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