Ensure all sexually active women aged 16-24 are screened for chlamydia at least once within the measurement period. Use either the Test and Procedures section of the encounter, or enter the appropriate observation to the chart using the Observations chart tab.
1. While documenting the Visit encounter, document the results of a chlamydia screening one of two ways:
2.
1. Open the Tests and Procedures section.
2. Using the autocomplete, begin typing Chlamydia, and select the appropriate screening.
3. Click the Add to Exam button.
4. After adding the new section, open the screening section and enter the results.
5. Click the Next button, or close the section.
1.
1. Navigate to the patient chart.
2. Open the Observations tab of the Medical Records chart tab.
3. Click the Add Observation link in the upper-right corner.
4. Begin typing the name of the observation and select the appropriate one.
5. Enter the Date the screening was performed, its Result, and any relevant Comments.
6. Click the Submit button.
1. Continue documenting the encounter, as needed.
2. When completed, Close and Archive the encounter
Name | Value Set |
Assessment, Performed: Sexually Active | 2.16.840.1.113883.3.464.1003.121.12.1040 |
Diagnosis: Complications of Pregnancy, Childbirth and the Puerperium | 2.16.840.1.113883.3.464.1003.111.12.1012 |
Diagnosis: Diagnoses Used to Indicate Sexual Activity | 2.16.840.1.113883.3.464.1003.111.12.1018 |
Diagnosis: HIV | 2.16.840.1.113883.3.464.1003.120.12.1003 |
Diagnostic Study, Order: Diagnostic Studies During Pregnancy | 2.16.840.1.113883.3.464.1003.111.12.1008 |
Encounter, Performed: Home Healthcare Services | 2.16.840.1.113883.3.464.1003.101.12.1016 |
Encounter, Performed: Office Visit | 2.16.840.1.113883.3.464.1003.101.12.1001 |
Encounter, Performed: Online Assessments | 2.16.840.1.113883.3.464.1003.101.12.1089 |
Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up | 2.16.840.1.113883.3.464.1003.101.12.1025 |
Encounter, Performed: Preventive Care Services, Initial Office Visit, 0 to 17 | 2.16.840.1.113883.3.464.1003.101.12.1022 |
Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up | 2.16.840.1.113883.3.464.1003.101.12.1023 |
Encounter, Performed: Preventive Care, Established Office Visit, 0 to 17 | 2.16.840.1.113883.3.464.1003.101.12.1024 |
Encounter, Performed: Telephone Visits | 2.16.840.1.113883.3.464.1003.101.12.1080 |
Laboratory Test, Order: Lab Tests During Pregnancy | 2.16.840.1.113883.3.464.1003.111.12.1007 |
Laboratory Test, Order: Lab Tests for Sexually Transmitted Infections | 2.16.840.1.113883.3.464.1003.110.12.1051 |
Laboratory Test, Order: Pap Test | 2.16.840.1.113883.3.464.1003.108.12.1017 |
Laboratory Test, Order: Pregnancy Test | 2.16.840.1.113883.3.464.1003.111.12.1011 |
Medication, Active: Contraceptive Medications | 2.16.840.1.113883.3.464.1003.196.12.1080 |
Medication, Order: Contraceptive Medications | 2.16.840.1.113883.3.464.1003.196.12.1080) |
Medication, Order: Isotretinoin | 2.16.840.1.113883.3.464.1003.196.12.1143 |
Procedure, Performed: Procedures Used to Indicate Sexual Activity | 2.16.840.1.113883.3.464.1003.111.12.1017 |