Documentation of TB/PPD testing and Resulting Read, Step-by-Step Guide | Scribe

Documentation of TB/PPD testing and Resulting Read, Step-by-Step Guide

    1
    Open a New Nurse note, or if patient is here for a visit, a New Liberty FNC note. On the CC tab, choose Other from the System pick list
    2
    From the resulting List from the System Other, choose the PPD/TB Test from the pick list.
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    Once all CC's have been added, go to HPI Tab
    4
    Answer all Questions resulting from the PPD/TB Test.
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    Example of answering all questions
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    Example, answering all applicable PPD/TB questions
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    Next go to the DX tab of the visit note
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    In the search window, type in TB Screen then click on the Magnifying Glass to search the DX look up.
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    Choose by clicking the Tuberculosis Screening from the resulting pick list.
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    The item will be added to the right side of the screen.
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    Click "OK" to add this DX to the patient list
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    Once the DX has been added, go to the SP tab.
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    Choose the Adult Lab Services POC or the Peds Lab Services POC from the Left Column and choose the PPD/TB test from the resulting list.
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    Open the DPN to add additional information for this Procedure.
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    Add all needed information in the DPN that opens.
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    Example of adding all DPN information to the PPD/TB Test procedure.
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    Click "OK" once all information has been added to the DPN.
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    Continue adding any additional information needed for the note. Once you have added all to the note, Click "OK" to save and close this note.
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    Click "Complete Note" if you are done with your documentation.
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    Click "OK"