Fillable Guideline Request Form Instructions (Office Ally)

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Guideline Request Form Instructions (Office Ally)

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Guideline Request Form Instructions
We at Office Ally realize that the process of creating Guidelines can be time consuming. In an effort to help
speed up the process we have implemented a new solution. Now, instead of you creating your guideline(s), we
will do it for you. While we will do the work of creating the guidelines we will still need information from you.
The following Guideline Request Form (pages 2 to 14 of this document) is a full list of all items that can appear
in your guideline(s). Each section has a box for you to list all of the statements and responses that fit within that
category that you want to be displayed as clickable links in your progress note(s). The boxes include a
breakdown by Question and Answer (Q1, A1, Q2, A2, etc.). All separate responses within one category (i.e.
separate possible answers) need to be separated by a semi colon (;) in order for us to know where to break up
the text when inserting it into your guidelines.
Here are a couple of examples on how to best complete these fields:
Example 1:
Q1: How long have you been experiencing these issues?
A1: 1 day; 2 days; 3 days; 4 days; 5 days; 6 days; 1 week; 2 weeks; 3 weeks; 1 month
Q2: Have you experienced these issues in the past?
A2: Yes; No; Occasionally; Sometimes
Example 2: You are asking the patient what symptoms they are currently experiencing in order to
complete the Chief Complaints section. In this situation you do not want any questions listed, just
simply a list of possible chief complaints. Any time in which you don’t have a statement to add and
simply want to include the Patient’s possible responses simply fill in the “A” line only.
Q1:
A1: Coughing; Sneezing; Congestion
Q2:
A2: Pain in; right; left; arm; leg; foot; ear
Once you have successfully completed the attached document please send it via email to
guidelines@officeally.com. If you have any questions about this document and how to complete it please call
Technical Support at (866) 575-4120 opt. 2.
Once Office Ally receives your request we will begin building your guidelines. Please be aware that by
submitting this to us you are authorizing us to add it to our Guideline Library. We will make every effort to
complete all guideline requests within 2 weeks. Once the guideline(s) have been created an Office Ally
representative will contact you to obtain the password for the account username provided. Once we have the
password we will log into your account and insert the guideline. Upon inserting the guideline into your account
an Office Ally representative will send an email to the email address on file stating that your guideline is now
available in your account.
EHR 24/7 Guideline
Request Form
Office Ally Account Username:_____________________________ Date: ________________
Specialty:_______________________ Guideline Name: _____________________________
SUBJECTIVE
Chief Complaints ___ Include in Guidelines
History of Present Illness ___ Include in Guidelines
Subjective – Custom Field #1: ___________________________ ___ Include in Guidelines
Subjective – Custom Field #2: ___________________________ ___ Include in Guidelines
Past History: Medical History ___ Include in Guidelines
Please return completed form via email to guidelines@officeally.com. 1 | Page
Additiction Medicine
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EHR 24/7 Guideline
Request Form
Past History: Surgical History ___ Include in Guidelines
Past History: Gynecological History ___ Include in Guidelines
Past History: Family History ___ Include in Guidelines
Past History: Social History ___ Include in Guidelines
Allergies ___ Include in Guidelines
Immunization ___ Include in Guidelines
Please return completed form via email to guidelines@officeally.com. 2 | Page
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EHR 24/7 Guideline
Request Form
Current Medications ___ Include in Guidelines
Subjective – Custom Field #3: ___________________________ ___ Include in Guidelines
Subjective – Custom Field #4: ___________________________ ___ Include in Guidelines
Review of System: Constitutional ___ Include in Guidelines
Review of System: Head ___ Include in Guidelines
Review of System: Eyes ___ Include in Guidelines
Please return completed form via email to guidelines@officeally.com. 3 | Page
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EHR 24/7 Guideline
Request Form
Review of System: Ears ___ Include in Guidelines
Review of System: Nose ___ Include in Guidelines
Review of System: Mouth ___ Include in Guidelines
Review of System: Throat ___ Include in Guidelines
Review of System: Neck ___ Include in Guidelines
Review of System: Cardiovascular ___ Include in Guidelines
Review of System: Respiratory ___ Include in Guidelines
Please return completed form via email to guidelines@officeally.com. 4 | Page
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EHR 24/7 Guideline
Request Form
Review of System: Gastrointestinal ___ Include in Guidelines
Review of System: Genitourinary ___ Include in Guidelines
Review of System: Musculoskeletal ___ Include in Guidelines
Review of System: Integumentary (Skin and/or Breast) ___ Include in Guidelines
Review of System: Neurological ___ Include in Guidelines
Review of System: Psychiatric ___ Include in Guidelines
Review of System: Endocrine ___ Include in Guidelines
Please return completed form via email to guidelines@officeally.com. 5 | Page
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EHR 24/7 Guideline
Request Form
Review of System: Hematologic/Lymphatic ___ Include in Guidelines
Review of System: Allergic/Immunologic ___ Include in Guidelines
ROS – Custom Field #1: ___________________________ ___ Include in Guidelines
ROS – Custom Field #2: ___________________________ ___ Include in Guidelines
ROS – Custom Field #3: ___________________________ ___ Include in Guidelines
ROS – Custom Field #4: ___________________________ ___ Include in Guidelines
Please return completed form via email to guidelines@officeally.com. 6 | Page
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Enter Field Name Here
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EHR 24/7 Guideline
Request Form
OBJECTIVE
Objective ___ Include in Guidelines
Physical Examination: Constitutional ___ Include in Guidelines
Physical Examination: Eye ___ Include in Guidelines
Physical Examination: Ears, Nose, Mouth, and Throat ___ Include in Guidelines
Physical Examination: Ear ___ Include in Guidelines
Past History: Gynecological History ___ Include in Guidelines
Physical Examination: Nose ___ Include in Guidelines
Please return completed form via email to guidelines@officeally.com. 7 | Page
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EHR 24/7 Guideline
Request Form
Physical Examination: Mouth ___ Include in Guidelines
Physical Examination: Throat ___ Include in Guidelines
Physical Examination: Neck ___ Include in Guidelines
Physical Examination: Lungs ___ Include in Guidelines
Physical Examination: Respiratory ___ Include in Guidelines
Physical Examination: Cardiovascular ___ Include in Guidelines
Please return completed form via email to guidelines@officeally.com. 8 | Page
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EHR 24/7 Guideline
Request Form
Physical Examination: Chest/Breasts ___ Include in Guidelines
Physical Examination: Heart ___ Include in Guidelines
Physical Examination: Gastrointestinal (Abdomen) ___ Include in Guidelines
Physical Examination: Genitourinary ___ Include in Guidelines
Physical Examination: Lymphatic ___ Include in Guidelines
Physical Examination: Musculoskeletal ___ Include in Guidelines
Physical Examination: Skin ___ Include in Guidelines
Please return completed form via email to guidelines@officeally.com. 9 | Page
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EHR 24/7 Guideline
Request Form
Physical Examination: Extremities ___ Include in Guidelines
Physical Examination: Neurological/Psychiatric ___ Include in Guidelines
Physical Examination: Head/Face ___ Include in Guidelines
PE – Custom Field #1: _______________________________ ___ Include in Guidelines
PE – Custom Field #2: _______________________________ ___ Include in Guidelines
PE – Custom Field #3: _______________________________ ___ Include in Guidelines
Please return completed form via email to guidelines@officeally.com. 10 | Page
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EHR 24/7 Guideline
Request Form
Test Result Exams: ECG ___ Include in Guidelines
Test Result Exams: Image ___ Include in Guidelines
Test Result Exams: Labs ___ Include in Guidelines
ASSESSMENT & PLAN
Assessment Notes ___ Include in Guidelines
Assessment – Custom Field #1: __________________________ ___ Include in Guidelines
Please return completed form via email to guidelines@officeally.com. 11 | Page
PE – Custom Field #4: _______________________________ ___ Include in Guidelines
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EHR 24/7 Guideline
Request Form
Procedure Notes:
___ Include in Guidelines
Plan Notes ___ Include in Guidelines
Patient Instructions / Follow Up ___ Include in Guidelines
Patient / Parent or Guardian Comments ___ Include in Guidelines
Plan – Custom Field #1: _____________________________ ___ Include in Guidelines
Please return completed form via email to guidelines@officeally.com. 12 | Page
Assessment – Custom Field #2: ___ Include in Guidelines
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EHR 24/7 Guideline
Request Form
Please return completed form via email to guidelines@officeally.com
Plan – Custom Field #3: _____________________________ ___ Include in Guidelines
Plan – Custom Field #4: _____________________________ ___ Include in Guidelines
. 13 | Page
Plan – Custom Field #2: _____________________________ ___ Include in Guidelines
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Guideline Request Form Instructions (Office Ally)

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Completed 8 April 2021

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