Patient Charting
St. John Clinic
5/31/23 · 2:00 PM
May 2023
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Types of Schedule
Individual Appointment
Group Lesson
Meetings
+ Create Lesson
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Week ▾
MON
29
TUE
30
WED
31
THU
1
FRI
2
6 AM
7 AM
8 AM
9 AM
10 AM
11 AM
12 PM
1 PM
2 PM
3 PM
4 PM
5 PM
Frank Smith
10AM–11AM
Susie Gao
11AM–12PM
Group Lesson-Nutrition/Carb
2PM–4PM
Annual Meeting
10AM–4PM
Devon Lane · 9AM
Kristin Watson · 10AM
Guy Hawkins · 11AM
Esther Howard · 2PM
Annette Black · 3PM
Floyd Miles · 4PM
Group Lesson-Acute/Chronic
1PM–3PM
Staff Meeting
9AM–12PM
Gill Ty · 3PM
Carly Tang · 4PM
✕
Esther Howard
View History
DOB: 03/15/1975
Female / Caucasian
English & Spanish
Blue Cross Blue Shield – PPO
Diabetes Mellitus Type 2
Hypertension
Phone: (239) 555-0108 · Esther.Howard@gmail.com
Emergency: Devon Lane · (630) 323-4563
Upcoming Appointments
Initial Visit
Type 2/Initial
05/31/23 at 2PM
View Chart
Group Lesson
06/21/23 at 2PM
Dashboard
St. John Clinic
5/31/23 · Wed
Good afternoon, Mary 👋
Wednesday, May 31, 2023 · St. John Clinic · 6 patients today
6
Patients today
3 completed
3
Overdue charts
from previous sessions
2
High-risk patients
flagged today
4
Goals tracked
across patients
Today's Schedule
Wed May 31
9:00 AM
Devon Lane
Type II · 2019
Individual · Follow-up #3 · 45 min session
A1C 7.2% ↑
Labs overdue
Done
10:00 AM
Kristin Watson
Type I · 2015
Individual · Follow-up #7 · 38 min session
A1C 6.1% →
Stable
Done
11:00 AM
Guy Hawkins
Type II · 2021
Individual · Follow-up #2 · 52 min session
A1C 8.4% ↑
High risk
Done
2:00 PM
Esther Howard
Type II · 1998
Individual · Initial Visit · Charting in progress
A1C 6.5% ↓
Acarbose refill
Now
3:00 PM
Annette Black
Type II · 2020
Individual · Follow-up #5 · est. 40 min
A1C 7.8% →
New medication
Later
4:00 PM
Floyd Miles
Pre-diabetes
Individual · 1st DSME Session · est. 60 min
A1C 5.8% →
First visit
Later
Patient Goal Status
4 active
Devon Lane
Being Active · Set 05/15
75%
Target: 80% · Last: 60% ↑ improving
Kristin Watson
Monitoring · Set 04/30
50%
Target: 90% · Last: 55% ↓ declining
Annette Black
Reducing Risks · Set 05/20
90%
Target: 85% · Last: 80% ↑ met goal
Floyd Miles
Healthy Coping · Set 05/10
30%
Target: 70% · Last: 40% ↓ at risk
Guy Hawkins
Taking Medication · Set 05/17
60%
Target: 100% · Last: 50% ↑ improving
Esther Howard
Healthy Eating · Setting today
Initial visit — goal to be set this session
Documentation Tasks
3 overdue
⚠ Overdue
Frank Smith
05/28 session
Missing: Lifestyle History, Care Plan, Submission
8/11 sections done
Resume →
3d late
Susie Gao
05/30 session
Missing: E-signature, Submit to EHR
10/11 sections done
Resume →
1d late
Group Lesson Notes
05/29
Nutrition/Carb session — notes not submitted
8 patients · G0109
2d late
Due Today
Devon Lane
9:00 AM session
Chart open — submit before next session
11/11 sections done
Submit →
Today
Kristin Watson
10:00 AM session
Submit G0109 billing codes to EHR
38 min · qualifies G0108
Today
Open Chart →
✕
Patient Charting
← Calendar
St. John Clinic
5/31/23 · 2:00 PM
›
Fri May 31
‹
Devon Lane
9:00 AM
Kristin Watson
10:00 AM
Guy Hawkins
11:00 AM
Esther Howard
2:00 PM
Annette Black
3:00 PM
Floyd Miles
4:00 PM
Esther Howard
DOB: 03/15/1975 – Female / Caucasian / English & Spanish
Prep Notes
Medical History
Submit and send to EHR
Start Session
Blue Cross Blue Shield – PPO
Diabetes Mellitus Type 2
Hypertension
Phone: (239) 555-0108
Emergency: Devon Lane Phone: (630) 323-4563
DSME: 9/10 MNT: 1/3
Initial Visit
Type 2/Initial
Charting Documents
1
General Information
✓
2
Vital Signs/Labs
✓
3
Medication
✓
4
Glucose Range
✓
5
Chronic Complications
✓
6
Physical Activity
✓
7
Meals and Snacks
✓
8
Lifestyle History
✓
9
Care Plan
✓
10
Summary
✓
11
Submission
✓
General Information
Type of Diabetes:
Year Diagnosed:
Race:
Family History of DM:
Yes
No
Notes:
Vital Signs/Labs
*Reference Range
Labs on 01/12/2023
Edit
Glycemic Control Report
A1C:
6.5%
<5.7% or 117 mg/dl
eAG:
128 mg/dl
70–126 mg/dl
FBG:
110 mg/dl
70–100 mg/dl
Liver Panel
ALT:
4 mg/dl
7–56 mg/dl
AST:
20 mg/dl
10–40 mg/dl
Vitals
Height:
5'9
Weight:
140
Weight Change:
-12
Blood Pressure:
127/89 mmHG
Renal Panel
BUN:
6 mg/dl
6–23 mg/dl
eGFR:
103 mg/dl
70–110 mg/dl
UACR:
15 mg/dl
10–30 mg/dl
Creatinine:
2 mg/dl
0.57–1.11 mg/dl
LIPID Panel
TC:
150 mg/dl
below 200 mg/dl
LDL:
85 mg/dl
below 100 mg/dl
HDL:
55 mg/dl
above 60 mg/dl
TG:
221 mg/dl
Mild: 150–199 mg/dl
Medication
Oral
Injectable
Insulin
Supplies
Patient Medication
+ Add
Drag or Add Oral Medication
Medication Name
AM
Lunch
PM
HS
Notes
Insulin Lispro
currently taking
Metformin
currently taking
Glucose Range
Blood Glucose
CGM
Time
Range
Avg
Before Breakfast
After Lunch
After Dinner
+ Add Time
No
show
Complications
Chronic Complications:
Chief Complaints:
Date of last eye exam:
Date of last foot exam:
Date of last dental exam:
Physical Activity
Regular Exercise Program:
Walking on treadmill
Type of Exercise:
Duration:
Frequency:
Limitations:
Mobility issues
Diet Summary
Time
Hour
Notes
Breakfast
Morning Snack
Lunch
Afternoon Snack
Dinner
Bedtime Snack
+/– Time
Lifestyle History
Lifestyle
Emotional Assessment
Occupation:
Work Time/Shift Time:
Cultural/Religious:
Stressors/Concerns:
Coping Mechanisms:
Does this patient have a support person?
Mental Health:
Stressors/Concerns:
Care Plan
Assessment
Plans
Goals
✦
AI Goal Recommendations
Analyzing chart data...
✦
Suggest Goals
Based on Esther's chart data, these goals are recommended — click to apply:
Pick a Goal
Reducing Risks
Monitoring
Healthy Eating
Healthy Coping
Taking Medication
Problem Solving
Being Active
Healthy Eating
Targeted Goals %:
Actual Goals Achieved %:
Describe Patient's Goals:
Eating a balanced meal 3x a week. Avoiding sweets
Summary
General Information
Edit
Type of Diabetes:
Type II
Year Diagnosed:
1998
Race:
Caucasian
Family History of DM:
Great Grandparents and Grandparents have Type II
Vital Signs/Labs
Labs on 01/12/2023
Edit
Glycemic Control Report
A1C:
7.0
eAG:
126 mg/dl
FBG:
100 mg/dl
Renal Panel
BUN:
10 mg/dl
eGFR:
100 mg/dl
UACR:
500 mg/dl
Creatinine:
1.0 mg/dl
LIPID Panel
TC:
220 mg/dl
LDL:
110 mg/dl
HDL:
50 mg/dl
TG:
180 mg/dl
Liver Panel
ALT:
20 mg/dl
AST:
15 mg/dl
Vitals
Height:
5'9
Weight:
140
Weight Change:
-12
Medication
Edit
Oral Medication
Metformin
Time
Lunch
Notes
Take it 15 minutes after lunch
Glucose Range
Edit
Type
Blood Glucose
Time
Range
Avg
Before Breakfast
100
120
After Lunch
80
110
After Dinner
85
100
Complications
Edit
Chronic Complications:
Potential conditions that can be related to diabetes
Chief Complaints:
Care team to capture an health concern the patient may have
Date of last eye exam:
05/23/21
Date of last foot exam:
01/20/21
Date of last dental exam:
04/15/22
Physical Activities
Edit
Regular Exercise Program:
Walking on treadmill
Type of Exercise:
Cardio
Duration:
15-30 mins
Frequency:
3x a week
Limitations:
Mobility issues
Diet Summary
Edit
Time
Hour
Notes
Breakfast
8:00 AM
Breakfast Sandwich
Morning Snack
9:30 AM
Granola Bar
Lunch
12:30 PM
Sandwich/Salad
Afternoon Snack
2:00 PM
Fruits
Dinner
6:30 PM
Pasta, Steak, Wrap
Bedtime Snack
8:30 PM
Fruit Snacks
Lifestyle History – Lifestyle
Edit
Occupation:
Quality Assurance Specialist
Work Time/Shift Time:
Weekdays, 8AM-5PM
Cultural/Religious:
N/A
Stressors/Concerns:
Managing work and raising a family
Coping Mechanisms:
Working out and hanging out with friends
Lifestyle History – Emotional Assessment
Edit
Support person:
Yes, their mom
Mental Health:
Practicing meditation
Stressors/Concerns:
Not enough time to spend with mom
Care Plan
Edit
Goal:
Healthy Eating
Targeted Goal %:
80%
Actual Goal Achieved %:
N/A
Plan:
Eating a balanced meal 3x a week. Avoiding sweets
Submission
E-Signature
*
Charting complete for Esther Howard
Please close and exit
Exit
Medication History
Insulin Lispro
Last Refilled: 04/29/23 · CVS
Metformin
Last Refilled: 04/29/23 · CVS
Nateglinide
Last Refilled: 04/29/23 · Walgreens
Sitagliptin
Last Refilled: 04/29/23 · CVS
Insulin Glargine
Last Refilled: 04/15/23 · CVS
Acarbose
Last Refilled: 04/01/23 · Walgreens
Lisinopril
Last Refilled: 04/20/23 · CVS
Prep Notes
✦
AI
✦
Generate AI Pre-Session Brief
Analyzing patient data...
✦
AI Pre-Brief
Planning to spend majority of the appointment answering all of her questions concerning her new lifestyle. May not finish all documentation today.
Submit Note
Previous Prep Notes
5/01/23 – Esther is a new patient and is recently diagnosed with type II. She was nervous when making the appointment.
Patient History
Esther Howard · DOB 03/15/1975
Timeline
Encounters
Educator Notes
Prescriptions
24 hours
30 days
7 days
90 days
1980
Present
Doctor's Visits
Nephrologists
Apr 15, 2023
View Notes
Ophthalmologist
Apr 10, 2023
View Notes
Primary Care
Mar 31, 2023
View Notes
A1C / Lab Work
Apr 15, 2023
A1C: 9.2%
Avg Blood Sugar: 218 mg/dL
Jan 12, 2023
A1C: 8.7%
Avg Blood Sugar: 201 mg/dL
Oct 5, 2022
A1C: 8.1%
Avg Blood Sugar: 186 mg/dL
Encounters
Nephrologists
Albert Flores
Apr 15, 2023
View Notes
Ophthalmologist
Kathryn Murphy
Apr 10, 2023
View Notes
Primary Care
Annette Black
Mar 31, 2023
View Notes
Educator's Notes
CGM/Follow Up
Bessie Cooper
Apr 15, 2023
View Notes
CGM/Initial
Leslie Alexander
Apr 10, 2023
View Notes
DSME/Group
Ayesha Millath
Mar 31, 2023
View Notes
Prescriptions
Active Meds
History
Metformin
500mg · 2x daily with meals
May 15, 2023
CVS
Insulin Glargine
10 units · Once daily at bedtime
May 20, 2023
CVS
Refill soon
Acarbose
25mg · 3x daily with meals
Apr 30, 2023
Walgreens
Lisinopril
10mg · Once daily
May 5, 2023
CVS
No historical prescriptions on file
Patient's Snapshot
✕
Esther Howard
DOB – 03/15/1975
Female,
Caucasian
English,
Spanish
Blue Cross Blue Shield – PPO
DSME:
9/10
MNT:
1/3
Diabetes Mellitus Type 2
Hypertension
Contact Information
(239) 555-0108
Esther.Howard@gmail.com
Devon Lane
(630) 323-4563
Encounters
Nephrologists
Albert Flores
April 15, 2023
View Notes
Ophthalmologist
Kathryn Murphy
April 10, 2023
View Notes
Primary Care
Annette Black
March 31, 2023
View Notes
Educator's Notes
CGM/Follow Up
Bessie Cooper
April 15, 2023
View Notes
CGM/Initial
Leslie Alexander
April 10, 2023
View Notes
DSME/Group
Ayesha Millath
March 31, 2023
View Notes
Prescriptions
Active Meds
History
Metformin
500mg · 2x daily with meals
Last fill: May 15, 2023
CVS Pharmacy
Insulin Glargine
10 units · Once daily at bedtime
Last fill: May 20, 2023
CVS Pharmacy
Refill soon
Acarbose
25mg · 3x daily with meals
Last fill: Apr 30, 2023
Walgreens
Lisinopril
10mg · Once daily
Last fill: May 5, 2023
CVS Pharmacy
No historical prescriptions on file