Clinical Decision Support

Transcription

1 Clinical Decision Support The Decision Support Admin screen allows you to search and filter Decision Support recommendations and decide how they should be applied within your practice. Amazing Charts includes United States Preventative Services Task Force (USPSTF), CDC, and other decision support information to suggest evidenced-based recommendations you can act on for your patients. Ensuring that these recommendations are addressed is a fundamental aspect of achieving Meaningful Use. Decision Support recommendations are regularly changing based on the latest available evidence. Using Decision Support within Amazing Charts can automatically remind you of the recommended screenings or procedures that should be undertaken if you are looking to practice with the best evidenced-based medicine. Decision Support recommendations are based on a patient's specific characteristics, and can be edited on a practice-wide or patient-specific basis. For example, since there is much evidence supporting the screening of patients for hypertension, this Decision Support recommendation will appear in a list for all patients that meet the age criteria for this USPSTF recommendation. Furthermore, certain risk factors (i.e., when patients have a diabetes diagnosis) will trigger additional recommendations. Editing your Patients' Risk Factors Decision Support recommendations will change depending on the risk factors you set for your patients. You can edit your patient's risk factors from their chart. How to edit your patients' risk factors 1. Open the Risk Factors screen in one of the following ways: a. From the Amazing Charts Desktop, select a patient in the Patient List. Then click on the Patient menu and select Health (Risk) Factors. b. From the Amazing Charts Desktop, select a patient in the Patient List. Then press CTRL+H on your keyboard. c. From the patient's Most Recent Encounter, click Risk Factors.

2 Edit which Risk Factors apply to your patient (or not) by checking and unchecking the boxes next to specific factors. Note: Clear all checked risk factors by clicking Patient DENIES Risk Factors at the bottom of the screen. Click OK to confirm this and the Risk Factors screen will close with all Risk Factors cleared away. Hint: To see how these risk factors will affect the Decision Support recommendations for your patient, select Analyze. This will open the Decision Support screen.

3 You can access the Clinical Decision Support from a few different areas in Amazing Charts. 1. You can access Clinical Decision Support from the Most Recent Encounter: 2. You can access Clinical Decision Support from the Summary Sheet of the chart: Whether you go to the Decision Support from Most Recent Encounter or Summary Sheet of the patients chart, you can view what is due for the patient.

4 To Access your Clinical Decision Support Rules, follow these steps: From the Most Recent Encounter of the patients chart click on the Decision Support button. The screen above allows you to view what is due for your patients, and you can edit what you see here by going into Administrator Options. (The information you see here depends on your CDS preferences)

5 Select a Clinical Decision Support recommendation to give:

6 The page will automatically open the Screenings & Tests page. Once you have selected what you want, in the Results /Comment area, document what you did, and select Save, or Save and Close.

7 Once completed, the item will disappear from the CDS list for that patient until it is due again (you may need to click on the Refresh button for it to remove from list): You can view completed Clinical Decision Support in the Summary Sheet, and the Plan from the Most Recent Encounter tab:

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9 Documenting Immunizations, and non HM injections The illustration below is the Immunizations window. From the CDS Due screen double click on the Vaccination, and it will take you to the Immunizations & Shots screen, the info will auto populate for you: On this page you can: view the schedule of recommended vaccines be linked to CDC or the USPSTF for current recommendations or supporting literature. You can view history, document the vaccine, document reactions or document the patient had the vaccine elsewhere. You can also view practice documents This can be literature you have downloaded as information for your staff, standing orders or patient education

10 You will need to select the appropriate Vaccine Name, then enter Body Site of Injection, Volume, Route, Manufacturer, Lot #, and the Expiration Date to save the information. Adding and Editing your Own Rules Decision Support rules can be added or edited based on the practice needs. To edit the decision support rules, click on View and then Administrator Options from the main screen

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12 In Administrator Options click on Set Decision Support Button, and select Set Practice Preferences for Decision Support the next illustration below will shows this: Once you click on that you will see the preferences to set for your practice. Choose the options that you need, and click on Save: (This is your baseline, and may be edited)

13 To add, or Edit Rules for Clinical Decision Support log into admin to edit the rules for the whole practice.

14 Add rules here you would like for all patients that come in for a Visit: To Add additional conditions to the rule, save the rule first, then click on Additional Settings Tab and then Edit Conditions:

15 Next select the criteria you want to apply to that rule. In this example, a diagnosis code. Select the Name, and pick the type of condition from the list Next, select the Operator to apply to that condition:

16 Then enter the Value for that condition and click Add:

17 To edit rules for a specific patient go to the Summary sheet for that patient. Rules can also be edited for the Entire Practice from here as well.

18 This window allows you to select the rule you want to edit, and change the age requirements and frequency you would like it to show up for the patient, and save.