# Cover Sheet

The Cover Sheet is the first screen you see after opening a patient record (unless the site or user defines another tab as the initial screen). The Cover Sheet displays an overview of a patient's condition and history. It shows active problems, allergies and postings, active medications, clinical reminders, lab results, vitals, and a list of appointments or visits.

You can quickly review the active problems from the Cover Sheet. Service Connected conditions are indicated by abbreviations in parentheses following the term name. Problems are identified using either the International Classification of Diseases Ninth Edition (ICD-9) or the Systematized Nomenclature of Medicine concept terms (SNOMED-CT) coding systems. After the ICD-10 activation date, all new problems will display the SNOMED code. ICD-10 codes will only display in the detailed view if providers have associated them with the SNOMED term. There is one exception. If a provider enters a free text problem, it will display as an R69 or undefined ICD-10 code and show the coding system as ICD-10 as well.

Below are two symbols that might display on the Cover Sheet in the Active Problems pane and their meaning:

· Asterisk (*): An asterisk preceding a problem means that the problem is acute.

· Dollar ($): A dollar symbol means that the problem is unverified. This usually occurs when a clerk enters a problem and a provider needs to verify the problem.

The File menu contains three menu items that you will use often:

· Select New Patient

This menu item opens the Patient Selection dialog.

· Update/Provider/Location

This menu item opens the Provider & Location for Current Activities dialog. This dialog enables you to change the clinician or location associated with an encounter.

· Review/Sign Changes

This menu item enables you to view the orders you have placed that require an electronic signature, select the orders you want to sign at this time, and enter your electronic signature code (if you are an authorized signer).

Select any item to get more detailed information. For example, you can select the Patient Identification box (or button) to get more information about the patient. You can select on a Visit to see details. For example, a patient could have Zantac listed in the Allergies/Adverse Reactions dialog. By selecting it, you bring up a details screen that contains information, such as the causative agent, signs and symptoms, originator, dates, etc.

Select a tab at the bottom of the screen to go to that section of the patient chart.

Related Topics

Menu bar

Patient Information Box

CPRS Tabs

Provider Box

Patient Postings

Active Medications Display

Cover Sheet Customization