Template Name Changes in Old KBM Status Category Explanation of functionality in New KBM Add disease management active text link
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1 Template Name Changes in Old KBM Status Category Explanation of functionality in New KBM All template Add disease management active text link Dx Management will no longer be viewable next to the Health Maintenance link. Users will need to click on Disease Manament Link under the Assessment link and then select the Disease_Mngt template for the pick list Need to link "To do" button to trigger new task, not opening the "To Do" template pop up Users will no longer be able to click on To Do Icon and click on to select Task recipients. To Do task icon will now open to a To Do pop up window that user can enter subject and message. User will then select the attachement and select okay which will then allow the user to select the task recipient. Cardiovascular/Vascular Diagnostics Disease_mgnt Do we need to combine vascular system with card? default text is No chest pain, no syncope, no palpitation, no edema On Review of Systems Cardiovascular and Vascular will no longer be combined onto one template. Users will now need to complete the Cardiovascular and Vascular templates. Default text for Cardiovascular is "No chest pain, no syncope, no palpitation, no edema" Default text for vascular is "claudication". Currently the default is "No chest pain or palpitations, no edema, no syncope." remove claudication NA Training issue: teach users that Users will have to select an appropriate diagnosis for the test they they have to select an appropriate had ordered. diagnosis for the test they had ordered. check with MD on the default interval New Currently defaults are not set for the diseases on the disease management template. In the new version defaults are set. Users will need to check the check box next to the protocols the system will defaults. Family_hx_mrp Add mother and father birth year Currently users can add the mother and fathers birth year. In the new version users are not able to enter the age of mother and father on history template.?hide age onset and death field? In the current version users will see the age onset or death field right next to the diagnosis. In the previous version users did not see this field next to the diagnosis. HPI_depression Add irritability to associated symptoms. Need to check with MD Currently users can select irritability as an associated symptom on the HPI depression template. In the new version
2 IM_Chronic_condx im_ros_respirat Combine comments with Additional information Current default text is No shortness of breath and cough In the current version the comments and additional information fields have been combined. In the new version users will be able to enter data in both the comment field and the additional information field. Current default text is No shortness of breath and cough. In the new version the default text is "Cough, dyspnea and wheezing." master_im Musculoskeletal office_px Pe_nose Add Pediatric Visit, Birth History New Users will use Peds Home Template and Development Hx active text link on master IM Training issue: Need to teach NA users to select "Peds Home" template if the patient is a child incease font for "Alert" Current version Alert button is large and in the middle of the master IM template. On the new version the Alert button is located under the Historian field hide "view results" activel text Currently there is not a "view result" active text on the left navigational panel. In the new version there will be a link to the "view result" on the left navigational panel Add "Face Sheet" active text in the navigation area. Maybe next to the chart summary TMJ is on this template also, Need to add to HEAD/FACE Gait is on the current template, but not on the new KBM need to check with users regarding in house lab, might need to hide the test Current default text: No nasal deformity. Mucous membranes normal. Tongue and throat appear normal. Currently "face sheet" is an active text located on the left navigational panel. In the new version there will not be a link for the "face sheet" in the left navigational panel. TMJ is on the this template in the new version Gait is a selection on the old version of the template. Uses will see the Point of Care Test orders on the new version of the Office Template. Current default text" No nasal deformity. Mucous membranes normal. Tongue and throat appear normal." In the new version the default is " No nasal deformity. Mucous membranes normal. Tongue and throat appear normal. No mucus"
3 Pe_Gu_Female Current default text for female: Cervix and Vagina appear normal. No palpable ovarian, enlargement. No adnexal tenderness. Normal external genitalia exam. Current default text for female "Cervix and Vagina appear normal. No palpable ovarian, enlargement. No adnexal tenderness. Normal external genitalia exam." In the new version the default is " No CVA tenderness. Normal external genitalia. Bladder is nontender." pe_gu_male Current default text: Testes descended without masses. No palpable Inguinal Hernia. Normal external genitalia exam. For boy - remove inquinal hernia from default text Current default text: Testes descended without masses. No palpable Inguinal Hernia. Normal external genitalia exam.in the new version the default is "No CVA tenderness. Normal external genitalia". In the new version for boys < 18 years of age the default will be "Normal male genitalia, testes normal and descended; no CVA tenderness." In the current version the default text is "Normal male genitalia, testes normal and descended; no CVA tenderness. Inguinal Hernia. Normal external genitalia exam." Pe_Lymph_detail Current default text: No palpable cervical and supraclavicular adenopathy. Current default text is "No palpable cervical and supraclavicular adenopathy." In the new version the default text is "No palpable cervical, supraclavicular, or axillary adenopathy" Pe_Neck_Exam2 Current default text: Supple, without enlarged thyroid. Current default text "Supple, without enlarged thyroid." In the new version the default is "Supple, without adenopathy, or enlarged thyroid. Current default text is "No palpable cervical and supraclavicular adenopathy." In the new version the default text is "No palpable cervical, supraclavicular, or axillary adenopathy" Pe_Proctological Pe_Skin Current default text: Anus normal to inspection. remove fecal material from default checked normal Current default text: No suspicious moles or skin lesions or rashes Current default text is "Anus normal to inspection." In the new version the default text is "Anus appears normal. No masses. Stool is negative for occult blood." In the new version the fecal material is checked as a normal default. In the current version the fecal material is not checked as normal default. Current default text is "No suspicious moles or skin lesions or rashes." In the new version the default text is "No impressive skin lesions present."
4 ? Combine Detailed inspection and Palpation/Texture as 1 section for Lesions. In current version the Detailed inspection and Palpataion/Texture is combined at the top of the template. In the new version the palpation/texter is located in the middle of the template. Pe_Spine Current default text; No significant Kyphosis or Scoliosis. Current default text is "No significant Kyphosis or Scoliosis." In the new version the default text is "No kyphosis or scoliosis." Pe_Vascular Current default text: Carotid and dorsalis Pedis pulses are normal. Current default text is "Carotid and dorsalis Pedis pulses are normal." the new version default is "Well perfused. Carotid, femoral, and pedal pulses are normal." Review_of_system? Add see HPI on the template In current version users can select the HPI button to add "see HPI'. In the new version the HPI check box will not be available on the review of system template. At this time, Review of system is displayed alphabetically At this time, Review of system is displayed alphabetically ros_allergic Add alert message to Urticaria and hay fever "Consider ordering URD profile (place order through lab order template) alert message to Urticaria and hay fever "Consider ordering URD profile (place order through lab order template) will no longer be available in the new version ros_constitution ros_derm ros_grastro ros_gu, ros_gyn add Weight Gain and Weight Loss to default normal Default text is: No rash or itching, no change in moles. Default text include No nausea or vomiting, no change of bowel habits, no blood or black tarry stool. default text for female patient are: No dysuria or hematuria. No nocturia. No incontinence. No breast discharge or lumps. No vaginal discharge. In the current version Weight Gain and Weight Loss default to normal. In the new version the Weight Gain and Weight Loss will not default as a normal value. In the new version the default text is "Pruritus and rash.". In the current version the default text is "No rash or itching, no change in moles." Default text in the current version is" No nausea or vomiting, no change of bowel habits, no blood or black tarry stool." In the new version the default text is "Abdominal pain, constipation, diarrhea and vomiting." The current default text for female patient is " No dysuria or hematuria. No nocturia. No incontinence. No breast discharge or lumps. No vaginal discharge." In the new version the default text is "Dysmenorrhea, dysuria, hematuria, menorrhagia and vaginal discharge."
5 Need to add STD and Libido. STD is on confidential template, may just want to share the fields. In the current version users can slect STD and Libido to enter data. In the new version to enter date for STD will be located in the history template. ros_gu, ros_male ros_heent ros_hemat Look at Oral contraception, the way to do it is different in the new KBM If pre-menopausal, perimenopausal or post-menopausal is selected, write trigger to uncheck Dysmenorrhea and menorrhagia default text for male patient are: No dysuria or hematuria. No nocturia. No penile discharge. Default text need to be Visual Loss - None, Hearing Loss - No. Default text: No bruising or bleeding. In the new version there is a radio button to select either non oral contraception or oral contraception. User will then have to fill out the details for these radio buttons. In the current version the user selects either oral contraceptions or non oral contraceptions from a picklist. In the current verision if the user select pre-menopausal, perimenopausal or post menopausal the dysmenorrha or menorrhagia will be unchecked. In the current version if the user selects dysmenorrhea or menorrhagia and then selects pre-menopausal, peri-menopausal, or post-menopausal then it will not uncheck these two data fields. default text for male patient is "No dysuria or hematuria. No nocturia. No penile discharge." In the new version the default text is negative for "Dysuria, hematuria and penal dishcarge" Current Default text is "No vision changes, no hearing loss." In the new template the default text is negative for "Ear drainage, hearing loss and nasal drianage." also for the Eyes the default text is negative for "Eye discharge and vision loss". Current default text is "No bruising or bleeding." In the new version the default text is negative for "Bleeding and easy bruising" ros_metabilic Dafault text are: No cold/heat intolerance. Current default text is "No cold/heat intolerance.". In the new version the default text is negative for "Cold intolerance, heat intolerance, polydipsia and polyphagia." ros_musc Default text:no back or joint pain. Current default text is "No back or joint pain.". In the new version the default text is negative for "bone/joint symptoms and weakness" ros_neuro Default text are: No dizziness, no unusual headache, no parasthesia. The current default text is "No dizziness, no unusual headache, no parasthesia." In the new version the default text is negative for "Gait disturbance."
6 Social_hx? Do we need to bring Drug user information to the main social history from confidential information template? In the current version the drug user information is located on the history template. In the new version this information is located in the cofidential section of the history template. The user will have to select confidential information to enter data for drug user. VS_WA_Std Add active text "Add New VS" NA
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