a. Select VIEWS tab - make sure that all the options in the first column are selected

Transcription

1 I. Initial Login Follow these steps on your first login: Select FILE-> CHANGE PASSWORD 1. Change your password 2. Select FILE-> SETTINGS->MY SETTINGS-> a. Select VIEWS tab - make sure that all the options in the first column are selected b. Select MY PROVIDERS tab select the providers you would like to view from the master list and click on arrow to move them over to the My Providers List c. Select SHOW/HIDE tab make sure Provider s Initials in Progress Notes Visit is checked Show d. Select USER SETTINGS make sure that Provider Selection Option in Office Visits has Pick List checked e. Click OK, log out to save settings and then log back in again 3. Select FILE-> SETTINGS->PRINT/FAX/LOCK SETTINGS-> 1

2 a. Set all three tabs (Print/Fax/Lock) for Modern I. Except for Optometry. They will set all three tabs for Bulleted b. Click SAVE 4. Log out of ecw to effect changes and then log back in 2

3 II. Review Jelly Beans Prior to Seeing Patients REVIEW MESSAGES (M): This is an internal messaging system to communicate NON-PATIENT related information between staff. After reviewing your messages, respond in the message section of the window or assign to someone if follow-up is require. You may delete the message(s) or leave them there for future reference. REVIEW LABS (L): After reviewing the lab results: 1) Normal results - check the reviewed box at the top of the window. 2) Abnormal results/intervention required - time stamp, add any instructions to be carried out, assign to the appropriate person for followup. 3

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5 REVIEW TELEPHONE MESSAGES (T): After reviewing the telephone messages, time stamp and add comments or instructions and then assign to appropriate staff for follow-up OR check Addressed if no further action is required. REVIEW REFERRALS (R): Allows you to view referrals that open, pending, or addressed for a patient, facility, or provider. REVIEW DOCUMENTS (D): After reviewing the documents, time stamp and add comments or instructions and then assign to appropriate staff for follow-up OR check Reviewed if no further action is required. III. Viewing Your Schedule After logging in screen will open to show a calendar and your schedule Click on the office button ( S ) to see your Office visit screen, keep setting on all day (under appointment time) Visit status shows you where the patient is in the process (from front office perspective) o PEN: Pending (patient has not yet arrived) o ARR: Arrived o CHK: Check out o CI/LA: Checked in, late arrival o CANC: cancelled o N/S: No show o N/SEEN: Not seen o R/S: Rescheduled Status shows you what is happening with the patient after being called into the back office o CHK: Patient has been checked in by med tech or nurse 5

6 o READY FOR: Patient has had vital signs done and is ready to be seen by provider After patient has been seen o LABorTX: Select this option to indicate that patient needs labs or a treatment by the Med Tech o NUR: Nurse needed o DISCHARGE: Patient has been seen by provider and does not need any other interventions (i.e. labs, immunizations, teaching, etc.) o DONE: Med Tech or nurse has finished with the patient, signaling that the front office can proceed to check the patient out. *Periodically click on refresh to update the information you are viewing* **MENTAL HEALTH, OPTOMETRY and PODIATRY SPECIALISTS use the Visit Status column: When you see ARR in this column, your patient is ready to be seen. When your patient visit is complete, change the Status column to, LABS, NURSE, or DISCHARGE ** Selecting a Patient To look up a patient: click the blue man, search for the patient highlight, click OK. This will bring you to the PATIENT HUB of your selected patient Progress Note Double clicking on a patient s name from the Office Visit screen will take you directly to the progress notes PROCEED WITH THE PROGRESS NOTE IN THE ORDER INDICATED BELOW: INITIAL & ANNUAL VISITS 1. Begin with the Smart Forms (SF) 6

7 2. Complete the forms in the order indicated below: (answering these questions first will populate your progress note in the relevant sections) a. Initial Visit click and next and it will bring you to: b. Tobacco Control- click save and next and it will bring you to: c. Audit C (alcohol CAGE questionnaire) click save and next it will bring you to : d. PHQ-2 (Depression Screen) -> Will lead you to the PHQ-9 if indicated based on responses to the PHQ-2. Click save The screen will then state that you have save the data successfully and bring you back out to the progress note. IF THE PATIENT IS A KNOWN ASTMATIC, GO BACK TO THE SMART FORM (SF) DROP DOWN MENU AND SELECT ASTHMA. Asthma answer the questions to populate your note and the form will fill the classification of asthma severity. *In the near future patients will be filling out some of these forms while in the waiting area and bring the forms with them into the exam room. You will then review the responses and enter the information into the form.* CHIEF COMPLAINT & CURRENT MEDICATIONS (click on blue main category) Reason for visit will populate based on what was entered in the registration window by the front office staff, med techs and will also include any triage notes added by the nurses. ( The reason you selected from the appointment window of your last scheduled visit will also populated in chief complaint) Check this section for accuracy, EDIT/ADD/REMOVE as indicated CURRENT MEDICATIONS: this category is located in the same window. (ALL PROVIDERS INCLUDING SPECIALTY NEED TO COMPLETE THIS SECTION. THE ENTRY OF CURRENT MEDICATIONS IS BASED ON JUST WHAT THE PATIENT REPORTS TO YOU. THIS WINDOW DOES NOT INDICATE THAT ANY MEDICATION WAS ORDERED BY THE PROVIDER) 7

8 o Proceed to populate the current meds: If the patient s current meds have already been entered then click on the current meds button, select the medications you would like to bring over into your progress note. If you would like all the medications to be brought over into your note, click on the Select All button, select OK. Initially entering medications or adding more medications: click on the ADD button and select desired medications. If the desired dose for a particular medication is not listed as an option, select the one that is closest to what you want. After the medications have been brought over into the progress note you can go into each column of medication description and change as needed.. If the patient only knows the name of the medication but not the dose, click on the Rx Name Only box to the right, above the section the Current Medication window. This will allow you to add just the names of the medications.( Specialty providers may also check off Rx name only) Entering more than one dose for a single medication (i.e. Insulin 30 units in AM, 40 units in PM): 1) Select the name of the medication and the dose that is closest, click OK. 2) Modify by deleting everything from all the boxes except for the status and name. 3) Enter ALL the instructions for that medication in the Take column. 4) complete the frequency field and the refill field. o Before exiting this screen check the following box in the right corner of the box: Medications Verified *Close the CHIEF COMPLAINT window* HPI (click on blue main category) Click on the folders in the order indicated and answer the questions in the order presented - as applicable to your patient: Health Maintenance ( only needs to be completed on initial and annual exam) 8

9 ID Screen( only needs to be completed on initial and annual exam) Pain assessment (each visit) PPD/Immunizations( only needs to be completed on initial) General Complaints (you can go to any of the specific complaints listed or go into the folder labeled Other complaints and enter the information in the notes section.) HIV -> Initial: if patient has a known diagnosis Specialists: select pertinent folder(s) and follow questions in order presented General/Peds: complete this section is you see patients 12 years of age or younger. Occupational Exposure if indicated MEDICAL HISTORY/ALLERGIES-INTOLERANCES (click on blue main category) New patients: click browse and select your choices Existing patients: any medical history that was obtained will already be listed ADD, REMOVE OR MODIFY AS NEEDED If there is no significant medical history, check off the box History verified and the Pregnant Breastfeeding boxes if applicable Continue on to bottom portion of same window ALLERGIES/INTOLERANCES (located in same box): New Patients: click Browse Rx, select pertinent allergies->reaction->type To enter intolerances Click on ADD Select from choices in Agent/Substance column (second column) Select from choices in Reaction column (third column) Select from choices in Types column (fourth column) 9

10 Free text in any of the columns if your choice is not in the pick list Existing patients: any allergies or intolerances that were obtained will already be listed ADD, REMOVE OR MODIFY AS NEEDED Before exiting this screen check one of the following boxes in the right corner of the box: NKDA OR Allergies Verified Close out of window SURGICAL HISTORY/HOSPITALIZATIONS (click on blue main category) New patients: click browse and select your choices Existing patients: any surgical history that was obtained will already be listed ADD, REMOVE OR MODIFY AS NEEDED If there is no significant surgical history, check Denies Past Surgical History box Continue on to bottom portion of same window HOSPITALIZATIONS (located in same window) New patients: click browse and select your choices Existing patients: any hospitalization history that was obtained will already be listed ADD, REMOVE OR MODIFY AS NEEDED If there are no past hospitalizations, check Denies Past Hospitalizations box 10

11 Close window FAMILY HISTORY (click on blue main category) No significant history: 1) check the box non-contributory OR 2) to specifically state pertinent negatives - click the Browse button in the notes section to select from any of the choices listed. You can also free text any information Positive history: Click on the appropriate family member(s) and select the relevant medical conditions in the left column STATUS, DOB,AND AGE are not mandatory fields to complete If you would like to specify whether a relative is alive or deceased, click on Status column next to each family member. Each click in the box will cycle through your options: alive, deceased or unknown. If you would like to enter the age of the family member, entering the year in the DOB column will automatically place the correct age in the Age column o Close out of window NOTE section on the bottom of the window can be utilized to document any additional family history you may want to add. The BROWSE button has significant negative histories you may also want to include in your note i.e. NO significant family history of breast or cervical cancer All Specialty providers need to populate this section based on the family history of their specialty. i.e: Optometry would document pertinent occular family history. SOCIAL HISTORY (click on blue main category) Click on the folders in the order indicated and answer the questions in the order presented (some sections will already have been completed because the data from the Smart Forms will populate them): Tobacco (already completed via Tobacco Control Smart Form) 11

12 Enter any smoking cessation counseling that you do in this section Drug/Alcohol Alcohol section will be filled in via Smart Form Complete the questions in the drug section Enter any drug/alcohol counseling that you do in this section Misc answer questions Sexual History (Form) Sexual Hx there is a second folder that needs to be filled out Domestic Violence answer questions if applicable Physical/Verbal/Sexual Abuse: answer questions if applicable Pediatrics answer questions if applicable ROS (click on blue main category) If the ROS is negative, click Default per Category to enter all the default norms at one time for that category For positive findings click on the note section of the category you want to document in. This opens a window. Clear the normal default by clicking the clear button to remove existing text and choose from the pick list located on the left or add free text, then click OK NOTES can be utilized to document any individualized information pertaining to this patient under ROS. May also be untilized to discuss any counseling you may have done during the ROS i.e. Taught patient self breast exam VITALS Vital signs taken prior to the start of the patient visit will be listed, they will also appear on the progress note PAST ORDERS 12

13 This section is used for you to discuss: Labs that have not been reviewed and have not been discussed with patient Labs that have been reviewed (by you or another provider) but not yet discussed with the patient. Labs/DI (located in the panel on the right hand side of the progress note) o Click on the tab Labs/DI, This will bring up a list of labs and/or /Diagnostic Imaging that has been ordered for your patient. o o Labs with a blue box and a white circle in the center are labs that have been ordered for this patient and either are not back yet or they are back but have not been reviewed by a provider. Click on the lab(bold and underlined) itself to bring you to the Lab Result window, review the results and check off reviewed, click OK. o This will move the lab to the bottom of the overview panel in the lab section (the lab will no longer be bold) o The lab will now have a blue box with an arrow on it. o Click on the arrow (in front of the lab) to bring the lab into your current progress note. It will be placed under PAST ORDERS indicating that you have discussed the lab result with the patient. Once you bring it into the progress note the lab will no longer appear on the overview panel. o If you would like to elaborate/document details of your discussion regarding these labs with your patient, return to the LAB REIVEW folder in the ROS section and free text any notes you would like. o Repeat the same steps for Diagnostic Imaging if needed EXAMINATION (click on blue main category) [ This section is not to be used by primary care] This section is to be used by the following specialties/patients only: Optometry Podiatry Pediatrics 13

14 PHYSICAL EXAMINATION (click on blue main category) Perform your head-to-toe exam in your usual manner To document Select the appropriate category Click on each item and pick from options given (you may add any additional information in the notes section) If your findings are normal click on the Default per category box and the findings will populate that section (you may add/edit/delete any information you would like) Note section: this section can be utilized to document any additional information you may want to add that is pertinent to physical examination ASSESSMENT (click on blue main category)( Refer to posting in exam rooms) Open Assessment Window Always start your list of diagnoses for your patient with one of the following: o NEW ADMISSION OR INITIAL EXAM AND ANNUAL EXAMINATION: V70.0 Routine Medical Exam (Use for initial or annual visit in non- HIV patient) V08 HIV disease (Use for initial or annual visit when patient is asymptomatic) 042 HIV/AIDS (Use for initial or annual visit in HIV/AIDS when patient is symptomatic or has an a diagnosis of AIDS) o Select any additional diagnoses if applicable If there are no other medical diagnoses that apply to your patient you must select a substance/alcohol related diagnosis as the second diagnosis FOLLOW UP VISITS 14

15 Primary diagnosis must be the presenting reason the patient is here for the visit o CD4 Monitoring visit (quarterly) o Select additional diagnoses if applicable by clicking on the appropriate folder on the right hand side or going to the All Codes folder if you are unable to find the assessment you would like Check the PL box on the right side in the Selected Assessment window to add your diagnoses to the Problem List. Clicking the top most box will add all of your assessments to the Problem List. Do not remove anything on the Problem List unless it was entered by mistake. Problems that are no longer current can be indentified as: active, resolved, wellcontrolled, or poorly controlled by selecting the appropriate option in the Clinical Status column within the Problem List window. Psychiatry/Mental Health Assessments: o Select your diagnoses in the Assessments window and add to Problem List in the Selected Assessments window. o Identify your diagnoses as Axis 1, 2, or 3 by clicking in the Axis box (first column in Selected Assessments window and choosing the appropriate one. o Axis 4 and 5 are designated by clicking on the appropriate box and entering relevant information in the notes section 15

16 TREATMENT (Includes Medications, Labs, Diagnostics, Procedures) Ordering Medications: Medications o START BY making sure that the Pop-Up box at the top is checked off. o Ensure that you are under the appropriate diagnosis code ( tabs are labeled on top of treatment screen) for the medication you will be ordering o Click on current medications if tab is active: Click on the medications that are relevant to your visit or click on select all medications. This will bring those selected into your treatment plan. Designate the status of each medication by clicking in the comments column (first column) and choosing from the options provided: start, continue, increase, decrease, or stop. Make any changes to dosing if needed. 16

17 o Entering more than one dose for a single medication (i.e. Insulin 30 units in AM, 40 units in PM): 1) Modify by first deleting everything from all the boxes except for the comments and name columns. When you click on the first box click on clear to remove contents of that box. 2) Click on Next in the same pop-up window and repeat. 3) Enter ALL the instructions for that medication in the Take column. o To add a new medication: Click ADD which brings you to the select RX window. o If you need to change a strength / frequency or duration you do it from the treatment window once you have selected the medications. (click on the box you want to change and make the changes). o Review all medications for accuracy and number of refills. o Print out the prescriptions: Clicking Print Script will open a window with all of the medications you ordered, check off which prescriptions you want printed,click OK. o Prescriptions will now print out from the top tray of the printer. Validate that the print out is correct, sign them, and then give them to the patient. o DO NOT COPY SCRIPTS THEY ARE HOUSED WITHIN THE ELCTRONIC RECORD o If you order a STAT medication, you must type in STAT in the order so that the nurses know that it is an immediate order (ie. Tylenol 500mg po STAT) Do Not print this out on a prescription The documentation of administration of a STAT medication will be made in the notes section of the Treatment window **Unless you have made an error in the selection of medications, do not delete any medications from the Current Medications list. Indicate that the medication has been stopped or otherwise changed in the comment column of the treatment window. LABS Ordering Labs: o Today s Orders: 17

18 Select the appropriate diagnosis tab Click Browse to open lab ordering window Check to see that the future orders box is not checked off Find the lab you want to order click on the correct lab Immediately link that lab to an assessment before proceeding Repeat the same procedure to add more labs Check to see that labs are ordered under the correct diagnosis tab Check to see that each lab is linked to an assessment Click OK Labs will then be seen in the Lab section under the treatment window (must click on the assessment tabs on top to view all labs) o Ordering In-house labs To be performed after patient has been seen by the provider From treatment window click browse under Labs Change the Type from both to In-house Labs This will bring up the list of available in house labs Click the in house lab you want This will open up another window ICD-CPT Association Check off the appropriate assessments from the ICD and CPT windows as they related to the in-house labs ordered Click OK The Med techs will then perform the in-house lab and document the results in the Lab Result window. The provider will review this lab in the same way that out-going labs are reviewed (See Reviewing Labs Section) Labs/procedures that are done prior to the patient being seen by the provider 18

19 o Future Orders If the med techs or nursing personnel perform an in-house lab prior to the patient being seen by the medical provider this lab will appear under the blue section LAB REPORTS in your current progress note The results will be recorded by the personnel performing the lab Clicking on the lab itself will bring you to the lab review window The results will be in the results section in that window Review the results, check off the box Reviewed if no further action is required, or add comments/instructions to the Notes section in the lab review window, close out of window Check off the future in the top portion of the lab ordering window Choose the labs you wish to order, select the date on which you would like the orders to be carried out Link to a diagnosis at the time that the labs are ordered o Orange Form (Sliding Fee Scale patients) o Order sets Check off Bill to Physician Account box at the bottom right corner of the lab ordering window There are currently four (4) order sets avaible Initial-Annual Initial-HIV CD4 Monitoring Initial-Hepatitis C These sets can be accessed by clicking on the OS button in the top right hand corner of the Treatment Window. The button will be grey if you do have any conditions listed in your assessment that are associated with any of the order sets 19

20 o You can still click on the button and choose an order set The button will be red if you have any conditions listed in your assessment that are linked to any of the order sets After clicking on the OS button, select the order set you would like from the drop down menu at the top left hand side of the window Review the orders listed, add any additional labs, imaging, or referrals you would like EITHER click the top most box in each section to order all the items listed in that section OR click on the specific ones you would like. Click on the blue Order button at the very top of the window The order will be brought into your progress note along with accompanying assessments Except for REFERRALS, all the orders have been executed REFERRALS: 1) Click into each of the referrals ordered as they are listed in your progress note. 2) Fill in the reason section at the bottom of the window and associate with any appropriate diagnoses. 3) Close out the window, select the next referral and continue these same steps. You will notice that initially the referral will not have any details next to it in the progress note. Once you have added a reason, that will also show up on the progress note. DIAGNOSTIC IMAGING o Diagnostics/Imaging Click on browse Select the appropriate test Link to an assessment Click Quick Print 20

21 Opens the Print/Fax window click browse in the comments box at the bottom of the window and select the reason for the diagnostic test being ordered or free text the reason Click CANCEL Select the printer and Tray 2 to print out the referral, click print Referral will come out of the second tray of the printer If you require more than one diagnostic referral repeat the steps for each referral o Procedures Click Browse Select the procedure that was done in house and link to an assessment This is done to capture all of the CPT codes The following procedures should be ordered through this window Nebulizer Treatments EKG Recording REFERRALS THIS WILL BE USED FOR ALL IN SYSTEM REFERRALS AND REFERRALS MADE TO OUTSIDE CONSULTANTS OR HOSPITALS 21

22 IN SYSTEM REFERRALS Click on the Outgoing Referral button below the diagnostic imaging box in the Treatment window. NOTE: Any time you click on this button a referral is generated, only click once for each referral you are making. Click on the specialty box in the Referral(Outgoing) window. Select one from the menu PSHS referral choices. In the Diagnosis/Reason box click browse and then choose from one of the PSHS options, click OK Select a diagnosis for this referral from the available when you click on the Previous Dx button or ADD a diagnosis if the appropriate only is not listed Prior to printing you must click consult pending You must print out each referral separately Only print out referrals to give to the patient if that was the practice prior to the electronic health record Click print Repeat the process for the remaining referrals (one at a time) To return to a referral form that has already been created, return to the Progress Notes->Treatment section, click on the desired referral and edit/complete the form After completing the referral, click the box Consult Pending Give the printed referral to the patient OUT OF SYSTEM REFERRALS Click the Outgoing Referrals button in the treatment window Click on the specialty box in the Referral(Outgoing) window. Select one from the menu of non-pshs referral choices. 22

23 In the Diagnosis/Reason box click browse and then choose from one of the PSHS options, click OK Select a diagnosis for this referral from the available when you click on the Previous Dx button or ADD a diagnosis if the appropriate only is not listed Prior to printing you must click consult pending You must print out each referral separately Click print Repeat the process for the remaining referrals (one at a time) To return to a referral form that has already been created, return to the Progress Notes->Treatment section, click on the desired referral and edit/complete the form After completing the referral, click the box Consult Pending Give the printed referral to the patient SPECIALISTS Document your visit/findings in the relevant sections of the progress note After seeing each patient click on HUB at the top of the progress note Click on the blue referral button at the top of the window Click on the Outgoing tab Look at the referrals for the current date and check the reason column to see if the patient has a referral to your specialty Double click on the referral that is for your specialty - if there is on. (As we go forward most of your referrals if made within the PSHS system will appear here.) In the Referral(Outgoing) window click on the box next to the current date (this signals that you saw the patient on that date) Click addressed Click OK to exit this window 23

24 PROCEDURES (click on blue main category) Complete this section if you perform any procedures o Start by answering the questions in Pre-Procedure folder o Complete appropriate folder based on procedure being performed o Finish by completing questions in the Post-Procedure folder IMMUNIZATIONS (click on blue main category) This section is to be used for all immunizations and PPDs to be given plus all stat injectable medication that needs to be given to the patient during this visit o Click Add o For PPD and Hepatitis A and B series Choose PPD standing order, Hepatitis A series or Hepatitis B series. When the nursing staff or provider administers the PPD or first Hepatitis A or Hepatitis B (on this visit) they will Go to Immunizations Click ADD and select the PPD or immunizations from the list and document the giving of that PPD or immunizations within the window. o Click OK o If you have multiple immunizations/injections to order, order the first one, click on SAVE and NEW, then add the next immunization. Click OK when you are finished. o All patients must be given an appointment for a PPD read or second and third Hepatitis A and B injection. (Booked under nursing. If a provider is doing the read or injection then the visit can be combined with another visit if it is just for the read or immunization then it is a non billable visit) o When the patient shows up for the PPD read (since they have an appointment) there will be a progress note attached to this visit Document the read under HPI Click on PPD/ Immunization History Click on PPD Status Click on the folder Current PPD Administration enter date of PPD administration ( look at the Patient Panel for the date) Click on the folder Current PPD Results select 24

25 o This information will automatically populate in the health maintenance flow sheet and the Immunization record of the patient o If the patient converts to a positive reading on this visit click on the folder recent PPD conversion and complete the questions o Hepatitis A series and Hepatitis B series once ordered the patient should be given an appointment to return for the second and third injection. When the patient returns the visit is linked to a progress note under the nursing personnel or provider Click on Immunizations ( blue link) from the progress note Order the Hepatitis A or B ( and the number of the shot) Document the administration of this shot directly in the immunization window If a provider is giving the immunization unless it is linked with another visit this visit is not billable. DIAGNOSTIC IMAGING (click on blue main category) Clicking on this category will take you to the same area as is in the TREATMENT window Order appropriate testing Print out orders for patient LAB REPORTS Before closing out of the progress note, make sure that there are nothing listed in the Lab Reports or Diagnostic Imaging sections. If you find any orders sitting here, click on them and associate with a diagnosis and procedure if appropriate. 25

26 PREVENTIVE MEDICINE Select appropriate folder If patient is HIV positive: THIS SECTION MUST BE COMPLETED If patient has a diagnosis of depression : SELF MANAGEMENT GOALS MUST BE REVIEWED If patient has a diagnosis of diabetes : SELF MANAGEMENT GOALS MUST BE REVIEWED VISIT CODE / PROCEDURES CODES / NEXT APPOINTMENT (all in same window) This is the billing window 26

27 Office visit: o o To indicate level of visit click on E&M box, choose the correct folder and select the level of visit When you click DONE at the bottom right hand corner of the screen, this means that the billing elements of the visit are completed. You still have the ability to go back to continue or complete your progress note. FINAL CHECK AT THE END OF THE VISIT Check Jelly Beans they should all be green and the number should be zero Return to the office visit screen at the end of your day Click the top most box on the left hand side (this will select all the notes) and then Click on Lock Progress Notes. ***Locking the notes is equivalent to signing your note. You cannot return to edit your note. However, you can add an addendum in you wish.*** 27

28 ADDITIONAL NOTES: Anytime a date is required and you only know the month and/or year, put down the first day of the month, if the month is unknown put down the January, and then the year. Copy: means that any information present will be overridden Merge: means that any new information will be combined with information that is already present In the HUB, clicking on SEL (select) takes you to a patient lookup screen. When you select a patient, it will take you to the most recent note for that patient. 28