Syndromic Surveillance 2015 Edition CEHRT Promoting Interoperability

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1 2015 Certification Criterion: Transmission to Public Health Agencies Syndromic Surveillance (Meaningful Use) Stage 3 Objective: Objective 8: Public Health and Clinical Data Registry Reporting Measure 2: The EP is in active engagement to submit syndromic surveillance data from an urgent care setting (Advancing Care Information) Objective: Objective: Syndromic Surveillance Reporting Measure: The MIPS eligible clinician is in active engagement with a public health agency to submit syndromic surveillance data from an urgent care ambulatory setting where the jurisdiction accepts syndromic data from such settings and the standards are clearly defined. This objective is met by the use of a Syndromic Surveillance Interface to the various public health agencies. Each state/public Health Agency requires information to be entered on the patient s account in order to transmit accurate information. They are as follows: Chief Complaint on Registration Working Diagnosis Final Diagnosis Physician Admit Reason Documenting a Chief Complaint NOTE: Chief Complaint must be documented on Initial Registration in order to capture the accurate information needed to transmit the initial message for the patient. Chief Complaint should be free text. Chief Complaint is defined as being the reason for the patient s visit (in the patient s own words). Revision Date: 06/19/2018 1

2 Pathway to enter a Chief Complaint: Thrive UX > System Menu > Profile Listing > Search for and Select Patient > Create new Visit > Check In > Chief Complaint > Free text Chief Complaint Revision Date: 06/19/2018 2

3 Working Diagnosis The Working Diagnosis can also be updated via the same screen as above. It can be free text or coded. Working Diagnosis should be utilized throughout the patient's stays. Once the patient has been checked in, a user can access the Working Diagnosis by double-clicking the Chief Complaint field from the Tracking Board. Upon choosing Working Diagnosis (if choosing coded), you may also get choices to further define working diagnosis: Revision Date: 06/19/2018 3

4 Physician Admit Reason The Physician Admit Reason can be updated via the same screen as Chief Complaint and Working Diagnosis. It can also be free text or coded. Revision Date: 06/19/2018 4

5 Upon choosing Physician Admit Reason (if choosing coded), you may also get choices to further define your Physician Admit Reason. Once the patient has been discharged, the Final Diagnosis should be added for the patient. Final Diagnosis Patient Account > Medical Records > Grouper > Diagnosis > Add Diagnosis Codes > select Finish Revision Date: 06/19/2018 5

6 Attestation Disclaimer: attestation confirms the use of a certified Electronic Health Record (EHR) to regulatory standards over a specified period of time. Evident and TruBridge certified products, recommended processes and supporting documentation are based on Evident's interpretation of the regulations, technical specifications and vendor specifications provided by CMS, ONC and NIST. Each client is solely responsible for its attestation being a complete and accurate reflection of its EHR use during the attestation period and that any records needed to defend the attestation in an audit are maintained. With the exception of vendor documentation that may be required in support of a client s attestation, Evident and TruBridge bear no responsibility for attestation information submitted by the client. Revision Date: 06/19/2018 6

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