Components are the building blocks of protocols, which are used to generate chart notes for visits. By understanding the different component types and the available specialized components, you will be able create useful new sections for your chart notes and configure them.
Read the sections below to learn more about each component type and the various options available when creating or configuring. For more information about creating a new component, read the Component Builder article. For more examples of adding and configuring components in protocols, see the other Protocol Builder articles.
The Generic Header component is a simple title. You can add it to any protocol to serve as a divider between sections on your chart note.
When creating a new Generic Header component, you need only enter the title of the header.
When you add a Generic Header component to a protocol, you can indicate whether or not the component should have an anchor button for navigation and set the anchor text.
While charting, a Generic Header component will look like this:
Generic Text Edit
The Generic Text Edit component is a large text box. You might use a Generic Text Edit component if your chart note needs a large area for notes. It is suitable for paragraphs and longer text-entry. Generic Text Edit components do not use “answer memory”; use components of this type when you need a notes box that is unlikely to be precisely repeated for another visit.
When creating a new Generic Text Edit component, you need only enter the name of the section.
When you add a Generic Text Edit component to a protocol, you can indicate whether or not the component should have an anchor button for navigation.
While charting, a Generic Text Edit component will look like this:
The Generic Note component is for simple text notes. They appear as a single line, but can contain as much text as needed. Generic Note components use “answer memory”, either based on the provider or the patient. Use the Generic Note component when you want a place for the provider to enter simple notes that may be reused.
When creating a new Generic Note component, you need to enter the name of the section, and indicate if it should provide single or unlimited input fields.
Single or Multiple?: A “Single” Generic Note will provide only one line of text for entry. A “Multiple” Generic Note will add additional lines of text as you type, so you can enter a series of notes.
When you add a Generic Note component to a protocol, you can indicate whether or not the item has an anchor button for navigation, and you can set whether answer memory should be filtered by provider, patient, or unfiltered.
While charting, a Generic Note component will look like this:
The Generic Check component displays a list of items with checkboxes next to them. While charting, a user can check or uncheck items in the list, and add notes for each item that will be stored in “answer memory”, either by provider or by patient.
Creating a Generic Check Component
When creating a new Generic Check component, you must name the component and then add the list of items that will be available for the component.
You can also indicate that the component should display the patient’s last answer on the chart note.
Adding the Component to a Protocol
When you add a Generic Check component to a protocol, you must specify which of your list of items will be available by default on the chart note. You can also indicate whether or not the item has an anchor button for navigation, and you can set whether answer memory should be filtered by provider, patient, or unfiltered.
Charting with a Generic Check Component
When charting, a Generic Check component will look like this:
If the “Display last saved answer” option was checked for the component (before the particular patient was checked in), then you will see the most recent saved note as well:
A Generic QA component contains a list of questions and a list of available drop-down answers for each question.
Creating a Generic QA Component
When creating a new Generic QA component, you must name the component and create a list of possible questions and answers.
You can also indicate that the component should display the patient’s last answer on the chart note.
Adding a Generic QA Component to a Protocol
When you add a Generic QA component to a protocol, you must indicate which questions should appear by default on the chart note. You can also indicate whether or not the item has an anchor button for navigation, and you can set whether answer memory should be filtered by provider, patient, or unfiltered.
Charting With a Generic QA Component
When charting, a Generic QA component will look like this:
A Generic Radio component presents a list of questions with three columns for selecting an answer and a space for notes. The notes field uses “answer memory” and will provide a drop-down menu of past notes based on the provider or the patient.
When creating a new Generic Radio component, you must set the three column answers (such as “Yes, No, N/A”), indicate the default selection column, and then create a list of available questions.
When you add a Generic Radio component to a protocol, you must indicate which questions should appear by default on the chart note. You can also indicate whether or not the item has an anchor button for navigation, and you can set whether answer memory should be filtered by provider, patient, or unfiltered.
When charting, a Generic Radio component will look like this:
Specialized Components for Charting and Orders
In addition to the customizable component types listed above, PCC EHR has several pre-defined components for accomplishing specific tasks while charting.
Each of these pre-configured components either has an “order” element for selecting orders that may trigger tasks, or else contains fields filled out for specific needs. For example, the order-based components can kick off tasks, and the Vitals component data populates PCC EHR’s growth charts.
Can I Edit These Components?: You can not create new components of these types. However, you can:
- Use the Protocol Builder to add any of the specialized components to your protocol.
- Use the Protocol Builder to determine exactly which items appear. Your protocols can display exactly the vitals that you collect for a specific age, for example.
- Use the Component Builder to add new procedures, handouts, referrals, and other items that can be ordered and can trigger tasks.
- Use the Component Builder to adjust other behavior for components. For example, you can clear out the answer memory for a component in the Component Builder.
The Diagnoses component, used for charting today’s diagnoses, has special features including a link to the built in electronic encounter form and tools for adding diagnoses directly to a patient’s Problem List.
The Vitals component contains special fields for collecting vitals, and includes automatic calculations for percentile and BMI.
In the Protocol Configuration tool, you can customize the English or Metric settings of the Vitals component, and add two optional features.
The Immunization component displays a patient’s immunization history and also displays a custom pick list of immunizations for the specific protocol (often configured by age). A user can click to create an order for an immunization, and it will include special fields for recording immunization data.
For more information, read the Immunizations Configuration help article.
Follow-Up Orders, Handout Orders, Lab Orders, Medical Procedure Orders, Medical Test Orders, Radiology Orders, Referral Orders, Screening Orders, Supply Orders, Surgical Procedure Orders
These components have buttons for creating orders, and they incorporate all of PCC EHR’s tools for completing orders and tasks.
After you click “Order” in one of these components while charting, you can edit and complete the order, either in the chart note or elsewhere in PCC EHR.
Orders may include discrete LOINC result fields, they can include notes, have tasks added to them, and they can be marked with various statuses (Signature Required, Refused, etc.)
Here is a Depression Screening order, seen while the user is editing it.
This order includes a discrete LOINC test (Adolescent depression screening assessment) that requires a result to be complete. Currently, no clinician signature is required, the order is not refused, contraindicated or canceled, and the order is allowed to appear on patient reports (and in the patient portal). The user can change any of these settings. Your practice can define default behaviors for these settings in the Component Builder.
Smoking Status (For the 2011 ARRA Medicaid EHR Incentive Program)
The Smoking Status component stores a patient’s answer to smoking status questions as defined by Meaningful Use guidelines.
The 2011 standards for the ARRA Medicaid EHR Incentive program required the tracking of this data for each patient visit. While the more recent and finalized “Meaningful Use Stage 2” standards do not include this requirement, and you do not need to submit reporting around it of the ARRA Medicaid EHR Incentive program, it is still considered best practices. If a pediatric practice attests for the program and is later audited, they must show that they collected smoking status for patients 13 years old and older.
The Office of the National Coordinator for Health Information Technology (ONC) defines the status options and definitions.
|Never Smoker||has not smoked 100 or more cigarettes during|
|Current Every Day Smoker||smoked at least 100 cigarettes during his/her lifetime and still regularly|
smokes every day
|Current Some Day Smoker||smoked at least 100 cigarettes during his/her lifetime and still regularly|
|Former Smoker||smoked at least 100 cigarettes during his/her lifetime but does not currently smoke|
|Heavy Tobacco Smoker||greater than 10 cigarettes per day or an equivalent (but less concretely defined) quantity of cigar|
or pipe smoke
|Light Tobacco Smoker||less than 10 cigarettes per day, or an equivalent (but less|
concretely defined) quantity of cigar or pipe smoke
|Smoker, Current Status Unknown||known to have smoked at least 100|
cigarettes in the past, but their whether they currently still smoke is unknown
|Unknown If Ever Smoked||Unknown|
In addition to components for entering chart notes and creating orders, you can add a sibling list, a summary of a patient’s appointments, growth charts, and many other useful components to chart notes.
Medical Summary Components
If a component appears on the Medical Summary, it can also be added to a chart note protocol. Commonly added Medical Summary components include the Problem List, Medication History, or custom Care Plan components.
You can add components from the Demographics section of a patient’s chart to any chart note protocol, including phone notes.
Demographics components can also appear on the Medical Summary.
Available Demographics components include Patient Information, Contact Information, Siblings, and Policies.
You can add Growth Charts to any chart note. You can also add the Growth Charts to the Medical Summary or the Phone Note protocol.
Recent and Upcoming Appointments
You can add the Recent and Upcoming Appointments component to the Medical Summary screen, your phone notes, or any chart note protocol.
Use the PCC EHR Configuration tool to add the component.
Next, click “Edit” to configure the component.
Click and drag items to rearrange them, or click “Add Items” or “Delete” to customize which appointments appear. You can choose to display the patient’s last appointment, last physical, next physical, and upcoming appointments. Add or remove these items anywhere the Recent and Upcoming Appointments component appears in order to best suit your office’s workflow needs.