Review basics of documentation (Parts of the note, HPI, PE, ROS, A/P) and where to find area to

document each of these in Centricity.

Review how to use the click boxes for PE/ROS **AND** how to use the text view for
documentation in these areas.

- How to create auto-texts:

- Options  preferences  patient charts  quick texts ----There is a character limit, so

some of these have a second “dot” phrase built in to the end so that you can extend the quick text

.babyros
General: Denies fever, lethargy, inconsolability
HEENT: No congestion, cough, runny nose
Cardiovascular: Denies cyanosis and edema
Respiratory: No wheezing, coughing, or increased breathing effort
GI: Denies N/V, diarrhea, constipation
GU: No polyuria or oliguria
Neurologic: Alert, interactive

.babype
(Vitals reviewed)
General: alert, interactive, well-appearing
HEENT: normocephalic, conjunctivae/lids normal, bilateral red reflex, anterior fontanel is flat
and soft
Bilateral TMs flat and pearly, canals clear
No cleft, no natal teeth
Lungs: CTAB, no wheezing/rales, normal work of breathing
Heart: S1, S2, RRR, no murmur .babype2

.babype2
Abdomen: no distention tenderness or organomegally
GU: normal external genitalia, bilateral distended tests, circumcision without adhesions, no rash
Vascular: Peripheral pulses 2/4 b/l
MS: full ROM all extremities, normal O/B bilaterally
Neuro: no focal deficits, normal Morrow, up going Babinski bilaterally
Skin: warm, no rashes/bruising

.pedsros
General: Denies fever, chills, sweats, somnolence, irritability
HEENT: No congestion, cough, runny nose, sore throat, ear ache/tugging on ears
Cardiovascular: Denies cyanosis and edema
Respiratory: No wheezing, coughing, sputum production, or increased breathing effort
GI: Denies N/V, diarrhea, constipation
GU: No polyuria, oligouria, or dysuria
Neurologic: Alert, attentive
.pedspe
(Vitals reviewed)
General: alert, interactive, well-appearing
HEENT: normocephalic, conjunctivae/lids normal, EOMI, no strabismus
Bilateral TMs flat and pearly, canals clear
MMM, oral pharynx pink no tonsilar hypertrophy or exudate, Good dentition
Lungs: CTAB, no wheezing/rales, normal work of breathing .pedspe2
Heart: S1, S2, RRR, no murmur
Abd: no distention tenderness or organomegally
GU: normal external genitalia, bilateral distended testes, no rash
Vascular: Peripheral pulses 2/4 b/l, no edema
MS: full ROM all extremities
Neuro: no focal deficits
Skin: warm, no rashes/bruising

.ros
General: Denies fever, chills, night sweats, fatigue
HEENT: No congestion, cough, runny nose, sore throat
Cardiovascular: No chest pain or palpitations
Respiratory: No SOB, wheezing, coughing, or sputum production
GI: Denies N/V, diarrhea, constipation, and abdominal pain
GU: No polyuria or dysuria, discharge or bleeding
Neurologic: Denies numbness, tingling, and any focal deficits
Psych: Denies depression and anxiety

.pe
(Vitals personally reviewed)
General: Alert, NAD
Eyes: Normal conjunctiva and eye lids bilaterally
ENT: MMM, oral pharynx pink without exudates, bilateral TM flat and pearly
Neck: No masses, symmetrical
Lungs: CTAB, no wheezes/rhonchi, no increased work of breathing
Heart: S1, S2, RRR, no murmurs S3 or S4
Abdomen: non-tender, no distention or organomegally
Vascular: No peripheral edema, radial & pedal 2/4 b/l
Neurologic: No focal neuro deficits
Psych: A&O x3, appropriate mood & affect

.GU
GU: normal external genitalia, pink vaginal mucosa, cervix closed and pink, minimal clear/white
discharge, uterus with normal size, no obvious masses on bimanual

.obhpi
Ms. ** is a ** y/o G*P* at presenting today for routine Ob care. No concerns today. She is
feeling baby move. She is compliant with PNV. She denies HA, change in vision, SOB, CP,
N/V, contractions, dysuria, discharge, bleeding, edema.

.obros
Patient reports: fetal movement
Patient denies: vaginal bleeding, loss of fluid, excessive vomiting, urinary complaints, rash with
viral illness, fever, physical trauma, surgery
General: Denies fevers, chills.
Musculoskeletal: Denies back pain.
Breasts: Denies nipple tenderness, discharge.
Respiratory: Denies cough, shortness of breath.
Cardiovascular: Denies chest pain, palpitations, feeling faint, peripheral edema.

.obpe
General Appearance: well nourished, well hydrated, no acute distress
Eyes, External: conjunctivae and lids normal
Respiratory, Auscultation: clear to auscultation bilaterally; no rales, rhonchi, or wheezes
Respiratory, Effort: no intercostal retractions or use of accessory muscles
Cardiovascular, Auscultation: RRR, 2/6 systolic murmur; no rub, or gallop
Peripheral Circulation: no clubbing, cyanosis, edema
Abdomen: gravid, soft, non-tender, FH 20 cm, FHT 150s .obpe2

.obpe2
Skin, Inspection: no rashes, lesions, or ulcerations
Deep Tendon Reflexes: 2/4 patellar reflexes bilaterally
Mood & Affect: no depression, anxiety, or agitation
Judgment & Insight: intact

.fu
Ms. is a 65 y/o female presenting for follow up on:
1.
2.
3.
4.

.end
Patient seen and plan discussed with Dr. ** .sign

.colpo
Written informed consent was obtained. Patient was placed in supine position with feet in
stirrups. External genitalia was normal. Speculum was then inserted and cervix visualized.
Cervix cleaned with swab. Acetic acid applied. SCJ visualized. No abnormalities noted under
white or green light. Speculum removed. Patient tolerated procedure well.

.uri
Acute
- Treat supportively with Tylenol/Motrin for fever, increased fluids, rest, humidifier in room,
nasal saline with bulb suction, honey for cough
- Return to clinic with increased WOB, wheeze, decreased oral intake, decrease urine output,
fever not controlled with medications

.wcc
Healthy m/o female
- Meeting growth and developmental milestones
- Anticipatory guidelines given
- Reviewed IRIS. Up to date
- Return at **mo for next WCC

.language
Spanish interpretation provided via in house interpreter today.

.diabetes
DM: Stable on (medications) . Last A1c ** in **. Fasting glucose is ** and postprandial glucose
is **. Is compliant with diet and exercise. Last eye exam was ** . Last foot exam was **. He
denies numbness or tingling in extremities. No recent hypoglycemic events.

Clinic EHR (Centricity) Tips

Labs

LAB ORDERS
In house lab list is posted in each pod.
To order- click on ASSESSMENT AND PLANORDERSuse quick pick or
SEARCH (only select labs in lower case letters) **show them the quick pick list (there is the
Mercy one you can select from the drop down menu, or there are the CLIA waved and MCL lists
under the second tab in the order window**
If searching for labs
for in house must pick the one that says service
for out of house must pick the one that says test **show them how to
differentiate between MCL and Quest labs (lower case letters = MCL)
**Must select venipuncture for ALL LAB DRAWS, finger/heel stick for all capillary
tests (lead, hemoglobin)** remind them of this!

Lab Results (open lab and click on text view—scroll to end of lab to write interpretation)
Lab --- Attending
 Normal: Attending will say normal and . sign  hold to resident (make note at end of
lab) hold to nurse for normal letter or call-(nurse to make note at end of lab when pt is
contacted (call or letter))hold to resident for final signature
Abnormal: Attending will write on bottom of lab- abnormal labs please address and
then .signhold to resident (make plan note at end of lab and call pt- document when they are
contacted then .sign at end of comments) hold to attending for final signature (attending will
give final signature if they agree and if they don’t will revise plan and resend to resident to
repeat process) **resident to contact patient with abnormal results**

Image/radiology result (open by clicking on attachment- add notes by appending and doing full
update-phone note)
Lab/Nurse- Attending
Normal: Attending  route to resident (make comments about study on phone
note)hold to nurse for pt to be informed (call or letter and .sign when done)-hold to resident
for final signature so they know pt has been informed
Abnormal: Attending route to resident (append with phone note- make note under
clinical advice what you want to do with abnormal labs, contact pt and let them know and
document pt informed then .sign at end of commentshold to attending for final signature so
they know pt has been informed and plan (attending will give final signature if they agree and if
they don’t will revise plan and resend to resident to repeat process) **resident to contact patient
with abnormal results**

.sign=not a final signature (just type .sign in any free text area then hit enter) your name and
time stamp will appear
Never officially sign off on a lab without a comment about the plan even if
labs are normal you must write that the patient was informed.

Calling patients with lab results

If you are unable to reach a patient directly…
To make sure alternative communication is allowed: CLICK REGISTRATION--
Documents alternative communication.
NEVER LEAVE A MESSAGE WITH INFORMATION about patient labs if they have not
granted you permission to do so.

Patient Clinic Notes:

Nurse opens note (fill out vitals, intake)hold to resident (write note and orders).sign under
Vitals and HPIwhen note completed .sign at end of documenthold to attending (attending
will give final signature if they agree and if they don’t will revise plan and resend to resident
to repeat process)
Look at document under “documents” and not “summary” tab in order to see under comments
why note is being sent back to you by attending.
Other Tips

Immunizations SERVICE: In HOUSE

Adult- click on ASSESSMENT AND PLAN ORDERS-- use quick pick under Well
LABS
woman/ or Search to select each immunization (flu, etc)
You must ALSO pick Vaccine administration
for one shot – pick ADMIN 1st inj
For multiple shots- pick ADMIN 1st inj AND ADMIN ___ADD’L INJ (specify number)
To code for the reason for shots PROBLEMNEWReference listhealth screening
Child- click on ASSESSMENT and PLAN  ORDERS  use quick pick under the correct
well child check and the immunizations should be there otherwise use search box.
for one shot – pick ADMIN 1st inj
For multiple shots- pick ADMIN 1st inj AND ADMIN ___ADD’L INJ (specify number)
To code for the reason for shots PROBLEMNEWFamily Medicine Well child
(Medicaid/non-Medicaid)
Do NOT pick the labs under the well child check as they are billed incorrectly if you do that

Coding
Make sure you ADD OFFICE VISIT CHARGE for EVERY visit (preventative or level
depending on type of visit)
All level 4 visits must be seen by an attending. Pre-ops are usually billed as level 4 visit.
Medications
If you want meds to appear with frequency and route (like for a preoperative physical) type .med
(ENTER) and they will appear
FINAL TIP NEVER DISCARD A DOCUMENT or it disappears forever
For Days when you must do a note on a patient with a previous note that is not signed (See Page
13 in flow)
(1) Open the previous note
(2) Hit End
(3) Click the box that says sign clinical list changes
(4) If a pop up box come up about things that aren’t done click cancel or uncheck them
(5) Click Hold to the previous owner
(6) Then you should be able to finish your note and make prescription changes
***Be very cautious – the next time you end a note uncheck the (sign clinical list
changes) or it will stay as your preferred setting and you could accidently sign off on
things you don't mean to

For orders: Make sure you sign as you go- clicking ok just closes the window- it will not
sign your orders or send your prescriptions.

If you accidently order a lab or office visit go to the left hand side and click (CHART) then
(ORDERS)
Look for the order you want to remove- if it says (IN PROCESS) you can click remove to
remove it
 When writing a prescription
MAKE SURE THE PRESCRIPTION SAYS THE CORRECT ROUTE- Electronic or print- NOT
HISTORICAL (historical is used to enter a med in the history when not writing a
prescription)

In the bottom right corner it says AUTHORIZED BY- must say YOUR NAME- not the
ATTENDING NAME

Do not put duration unless you want the medicine to disappear when patient done taking
med (leave that box blank for chronic meds)

Histories (Family, PMhx, SHx, Soc Hx)

When entering in the history tab- you must click update/add or reviewed (check box in
each history area)- or it will not add your info and carry through to the next note. You
must select “include in note” if you want it to show up in your note for the day.

Please ask an attending or nurse for help if you have any questions