INTER TRIBAL HEALTH AUTHORITY ELECTRONIC MEDICAL RECORD (EMR) CLINICAL TRAINING MANUAL

Transcription

1 INTER TRIBAL HEALTH AUTHORITY ELECTRONIC MEDICAL RECORD (EMR) CLINICAL TRAINING MANUAL PROFILE VERSION 7 July 1, 2014

2 TABLE OF CONTENTS Module 1: Sign On 1.1 Purpose 1.2 Icons and Definitions 1.3 Key Fields 1.4 Connection 1.5 Scenarios Module 2: Client 2.1 Purpose 2.2 Icons and Definitions 2.3 Key Fields 2.4 Insert New Client 2.5 Search for a Client 2.6 Alter Client Information 2.7 Creating a Family Group 2.8 Scenarios Module 3: Scheduling 3.1 Purpose 3.2 Icons and Definitions 3.3 Key Fields 3.4 View Appointments by Provider 3.5 New Appointment 3.6 Reoccurring Appointment 3.7 Editing an Appointment 3.8 Managing an Appointment 3.9 Walk-In Client 3.10 Block Out Provider s Scheduling 3.11 Staff Meeting 3.12 Client Group Session 3.13 Tasks 3.14 Messenger 3.15 Scenarios TABLE OF CONTENTS Page 1

3 Module 4: Medical Record 4.1 Purpose 4.2 Icons and Definitions 4.3 Key Fields 4.4 Opening the Medical Record 4.5 Segment List 4.6 Add a Note (Problem) 4.7 Alter a Note (Problem) 4.8 Measures (Vital Stats) 4.9 Add a Standard Medication 4.10 Discontinue a Medication 4.11 Create an Ad hoc Medication 4.12 Scenarios Module 5: New Encounters 5.1 Purpose 5.2 Icons and Definitions 5.3 Key Fields 5.4 Action Item List 5.5 Add an Encounter 5.6 Making a Charting Note Private 5.7 Displaying Images 5.8 Add a Diagnosis 5.9 Add an Adverse Reaction 5.10 Add a New Note to the Termset 5.11 Calculators 5.12 Clinical Details 5.13 Scenarios Module 6: Immunizations 6.1 Purpose 6.2 Icons and Definitions 6.3 Key Fields 6.4 New Care Plan 6.5 New Immunizations Within a Careplan 6.6 New Immunizations Without a Careplan 6.7 How to Print Summary Information for iphis 6.8 Scenarios TABLE OF CONTENTS Page 2

4 Module 7: Document Management 7.1 Purpose 7.2 Icons and Definitions 7.3 Key Fields 7.4 Setup 7.5 Importing a Document to a Medical Record 7.6 Editing / Re-Naming (Subject) Module 8: Referrals 8.1 Purpose 8.2 Icons and Definitions 8.3 Key Fields 8.4 Creating an Outward Referral 8.5 Closing Referral 8.6 Reporting Options Module 9: Home and Community Care 9.1 Purpose 9.2 Icons and Definitions 9.3 Key Fields 9.4 Identifying your HCC Clients in Profile 9.5 HCC Program Service Code List 9.6 esdrt Reporting TABLE OF CONTENTS Page 3

5 Module 1: Sign on 1.1 Purpose The sign on will allow to connect to the EMR servers that are located in the Harbor Tower at the Vancouver Data Center (VDC) and then on to Profile, so you will need to enter two user names and passwords. It is a two step sign on process: 1. Sign on to the server at VDC 2. Sign on to Profile 1.2 Icons and definitions Definitions a) Server: a computer that provides services used by other computers b) EMR: Electronic Medical Record c) VDC: Vancouver Data Centre d) RDC: Remote Desktop Connection e) End Point: Band Number (Snuneymuxw = 648) f) Training Server (vdc.train.intertribalhealth.ca): This set up used for training purposes and does not contain any sensitive information g) Production Server (vdc.intertribalhealth.ca): This is to be used for day-to-day operations, should not be confused with the training server, and is to be treated with the upmost concern for security and privacy of the sensitive patient information Icons a) RDC Icon b) Maximize 1.3 Key Fields Not applicable to this module. MODULE 1: SIGN ON Page 4

6 1.4 Connection Remote Desktop Connection 1) Open the Start menu > All Programs > Accessories > Remote Desktop Connection 2) In Computer: You type the name of the computer you are trying to connect to or the IP address. Training = vdc.train.intertribalhealth.ca Production = vdc.intertribalhealth.ca Step 2 Step 3 3) Click connect Logon to server IMPORTANT!! Make sure that Caps lock is turned off. 1) Enter your Windows username 2) Enter your Windows password 3) Click OK Step 1 Step 2 Step 3 MODULE 1: SIGN ON Page 5

7 1.4.3 Logon to Profile 1) Enter your Profile username 2) Enter your Profile password 3) Click Show Details 4) Check that the information is correct a. Server: i. Training: Local ii. Production: VDCIHS01 b. Protocol: Connection Orientated TCP/IP c. End Point: 554(Band Number) 5) Click OK Step 1 Step 2 Step 4 Step 5 Tip Usually the information in step 4 won t need to be changed after the first logon Set Defaults for the Work Centre widow 1) Change the size of the window by a. Click and drag window edge with b. Or using the Maximize icon 2) Change the size of the panes within the window with 3) Add or remove toolbar icons by right click and selecting or De-selecting icon 4) Save the changes by Window Menu > Workspace > Save Workspace Tip To show/hide the Main Toolbar use: Window Menu > Show > Toolbar IMPORTANT!! After 10 minutes the system will locked and you will have to enter your password again. To show the login screen you will need to press CTRL + F3 MODULE 1: SIGN ON Page 6

8 1.5 Scenarios Scenario 1 Create a short cut to the RDC on the desktop a) Open the RDC connection b) Enter the computer name that you want to connect to c) Click Options d) Click Save As e) Select Desktop f) Enter the shortcut name ex// Profile g) Click Save h) Click Cancel i) Check that the shortcut is on the desktop and opens the connection j) Optional: Give yourself a pat on the back and high five the person next to you Scenario 2 Hide and then show the main toolbar. How do you do this? Scenario 3 a) Open the RDC connection and change the server name and then connect. What happens? b) Change the End point to Snuneymuxw band number (648) and try to login. What happens? MODULE 1: SIGN ON Page 7

9 1.6 Frequently Asked Questions/ Problems a) What do I do if I forget my password or username? b) Why wouldn t the RDC connection be working? c) Who do I contact if my RDC connection isn t working? d) What do I do if I can t find my profile RDC icon? e) What are some common reasons for an incorrect password? f) Why does my Password have to be so complicated? g) I am getting a new PC do I need to do anything MODULE 1: SIGN ON Page 8

10 Module 2: Client 2.1 Purpose The purpose of this module is to enable the user to add clients, search for existing clients and update client information, such as address. Most of this information in this section will not change (i.e. Name, date of birth, Status Number), but very occasionally this information will need to be changed. 2.2 Icons and Definitions Icons a) New Client d) Find Client b) Alter Client e) Social Tab c) Expand icon f) Family Tab Definitions a) Demographics: Commonly-used demographics include sex, race, age, etc. b) PHN: Personal Health Number c) NoK: Next of Kin 2.3 Key Fields Mandatory a) Last name b) First Name c) Sex d) Date of birth e) Status number- This will be auto generated if not entered f) Health Centre Use default value IMPORTANT!! If possible, an accurate status number must be taken as it is used to uniquely identify clients Important a) PHN b) On/Off Reserve Located in the social tab c) FN Status Located in the social tab d) Band Located in the social tab 2.4 Insert New Client MODULE 2: CLIENT Page 9

11 IMPORTANT!! You should ALWAYS search for a client using Find Clients before you add a new client. 1) If the client s record is not found, Select the New Client icon or use (Ctrl +N) 2) Enter Last Name, First Name, Sex, DOB 3) Enter the Status Number and PHN Tip To enter DOB, Use the calendar to select the client s birth day and month and then change year using the keyboard 4) Enter additional information Address and Phone numbers 5) Select Social Tab Step 2 Step 3 Step 4 Step 5 MODULE 2: CLIENT Page 10

12 6) Enter On/Off Reserve and FN Status 7) Enter Band Name and Number 8) Click OK Step 6 Step 7 Step 8 MODULE 2: CLIENT Page 11

13 2.5 Search for a Client IMPORTANT!! When searching for clients it is better and quicker to provide less detailed information. Normally, the first 3 letters of the last name is sufficient. 1) Select Find Client icon from the toolbar or use (Ctrl+F) 2) Type the first three letters of the clients last name 3) Click Find Step 2 Step 3 4) Select the correct client from the produced list 5) Click Display 6) Verify that the client s address and phone number hasn t changed Step 4 Step 5 Tip If searching a common last name (i.e. White), add the first initial of the first name (i.e. White, J) MODULE 2: CLIENT Page 12

14 2.6 Alter Client Information IMPORTANT!! Do not use this function to search for clients 1) Select the Alter Client icon from the toolbar or use (Ctrl + A ) 2) Type the first three letters of the clients Last name 3) Click Search Step 2 Step 3 4) Select the correct client from the list 5) Click OK Step 4 Step 5 MODULE 2: CLIENT Page 13

15 6) Change contact information (Address, Phone, etc) Step Creating a family group 1) Select Alter Client 2) Type the first three letters of the head of the family s last name 3) Click search 4) Select the correct Client from list 5) Click OK Tip 2.7 Steps 1-5 are demonstrated in 2.6 above 6) Select the Family icon and 7) Type the family name 8) Click the Family Head check box 9) Click Apply Step 7 Step 6 Step 8 Step 9 MODULE 2: CLIENT Page 14

16 Tip If the family contains members then it already exists, so the family name needs to be changed and it is suggested to add a number to it (ex// White01) 10) Search for the NoK and if not already created, Create the NoK client See Section ) Click the family icon 12) Type or search for the family name 13) Check that the Family Head is correct 14) Click Apply Step 12 Step 13 Step Scenarios Scenario 1 Create a client with the following information: a) {Your First Name and initial} Seward b) {Your DOB and Sex} c) {Any Status Number with 10 digits} d) Any 10 digit PHN starting with 9020 (i.e. 9020xxxxxx) e) 877 Berry Point Road, Gabriola, BC, V0r 1x1 f) , g) Family is Seward{Your Address} h) They are Status First Nations that are living off reserve from the Esquimalt band MODULE 2: CLIENT Page 15

17 Scenario 2 Search for the client Joe Walsh, who is his son? Scenario 3 Create a child for the person created in Scenario 1 with any information and add to the Marley family you created in Scenario 1 Scenario 4 a) Find all male clients in the system that are 19. How many are there? b) Find all female clients that are 65. How many are there? c) You find a piece of paper with an appointment time and the phone number , who does this belong to? Scenario 5 Find client St. Andrews. What is his first name? 2.9 Reports a) Total Clients on or off reserve b) Total Client with or without status c) Elders list d) All children between 3-9 years old 2.10 Frequently Asked Questions and Problems a) Why can t I find a client when I have entered their last name? b) Should I search for a client using Alter Clients? c) What should I do if I find a duplicate client? MODULE 2: CLIENT Page 16

18 Module 3: Scheduling 3 Purpose The appointments module is extremely important as many significant reports, program and provider usage statistics are generated from the information captured in this section. This is information may be key in filling out your Health Canada reporting. 3.1 Icons and definitions Definitions a) Appointment Type = a listing of short codes that focuses on program (i.e. Immunization) that is important for reporting b) Appointment Reason = a listing of service codes that focuses on service (i.e. Flu shot) Icons a) Work Center f) Walk-in b) New Appointment g) Block Out c) Cancel Appointment h) Move All appointments for a provider d) Tasks i) Cancel All appointments for a provider e) Multiple Providers j) Add Multiple Clients/ Providers 3.2 Key Fields a) Appointment Type = This allows us to create usage reports by program type, which are important for funding purposes b) Provider = This allows us to create reports detailing the number of clients seen by provider, which is important when requesting additional employees MODULE 3: SCHEDULING Page 17

19 3.3 View Appointments for a single provider 1) Open Work Centre if not already open 2) Select Provider expand icon 3) Type first three letters of providers name 4) Click search 5) Select correct provider 6) Click OK 7) Select the number of days 1 Day, 5 Day, 7 Day, 1 month, 1 year Step 1 Step 2 Step 7 Step 3 Step 5 Step 6 Step 4 MODULE 3: SCHEDULING Page 18

20 3.4 View Appointments for multiple providers 1) Open Work Centre 2) Click the multiple provider button 3) Select date Only 1 day can be displayed Step 2 Step 3 Step New Appointment 1) Check that provider is visible 2) Click and drag on empty appointment slot to set time and duration Step 2 Tip You can create a copy of an appointment by holding Ctrl button and then click and drag appointment to new timeslot. MODULE 3: SCHEDULING Page 19

21 3) Type first 3 letters of client s last name and select Client from list 4) Click expand icon 5) Select type of appointment short code 6) Click OK 7) Check start and end time 8) Check provider Step 3 Step 4 Step 5 Step 7 Step 8 Step 6 IMPORTANT!! Appointment type will facilitate program reporting and allow for usage statistics. Appointment type is selected from a short code list, which can be altered to your centre s specific needs. MODULE 3: SCHEDULING Page 20

22 3.6 Reoccurring Appointment (NOTE: DO NOT USE UNTIL FURTHER NOTICE) 1) Open a new appointment and enter necessary information See Section 3.6 2) Click the Reoccurrence tab 3) Check first appointment date, time and duration 4) Click Recurrence pattern button 5) Enter recurrence pattern by day (The Last Friday of every month) or by date (The 2 nd of every month) 6) Click OK Step 2 Step 3 Step 4 Step 5 Step 6 MODULE 3: SCHEDULING Page 21

23 3.7 Editing Appointments 1) Right Click appointment 2) Select Edit 3) Change where necessary 3.7 Step 2 IMPORTANT!! Appointments have 3 stages of attendance and these should be changed by either a) Click and drag client into appropriate room or b) Right click and select correct status a) Arrived = Client is located in the waiting room b) Seen = Client is with the provider c) Closed = Client has left the health centre 3.8 Managing Appointments Cancelling an Appointment 1) Right Click the appointment 2) Select Cancelled 3) Click Yes 3.8 Step 2 Tip Appointments should NEVER be deleted. If the client calls because they can t make it then the appointment should be cancelled. If they do not come to the appointment, then open the appointment and then click Did Not Attend check box Did not attend 1) Right Click the appointment (See Section 3.7) 2) Select Edit from the Menu 3) Check the Did Not Attend box Step 3 MODULE 3: SCHEDULING Page 22

24 3.9 Walk-In Client 1) Select Provider or multi-provider view 2) Right click calendar 3) Select Walk-in client 4) Search for client Type first 3 letters and Select from list Double Click 5) Create New Client if necessary 6) Change Appointment Type 7) Enter in other necessary information Step 3 Step 4 Step 5 MODULE 3: SCHEDULING Page 23

25 3.10 Block out a providers schedule 1) Select Provider or multi-provider view 2) Select Block out icon from toolbar 3) Click and drag on time you want blocked out 4) Enter Rule Name 5) Click OK Step 2 Step 3 Step 4 Step 5 MODULE 3: SCHEDULING Page 24

26 Step Meeting 1) Create a new appointment See Section 3.6 2) Click the meeting check box Step 2 3) Click the Expand icon 4) Select Staff Member from list 5) Click OK and repeat as necessary 6) Repeat the process for Clients if they are attending Step 4 Step 3 Step 5 MODULE 3: SCHEDULING Page 25

27 7) Click Appointment Tab 8) Enter the appointment type 9) Check the Time, Date, and Duration 10) Click OK Step 6 Step 7 Step 8 Step 9 MODULE 3: SCHEDULING Page 26

28 3.12 Client Group session Tip Meeting vs. Group Session a) Meeting: Creates multiple appointments for clients and providers, but is not recorded in the medical record b) Group Session: Creates an entry in the all of the clients medical records. Similar to a Bulk Encounter. Doesn t create an appointment. 1) Create a new appointment See Section 3.6 2) Click the meeting check box B See Section ) Click Group Session 4) Click Yes 5) Click Yes again Step 4 Step 3 MODULE 3: SCHEDULING Page 27

29 6) Add Multiple Clients 7) Check Date, Time, and Duration 8) Enter the Appointment Type 9) Add other Providers if necessary 10) Click OK 11) Click Yes Step 6 Step 7 Step 8 Step 9 Step 10 MODULE 3: SCHEDULING Page 28

30 3.13 Tasks 1) Click the Tasks Icon 2) Click New Tasks 3) Enter Subject and Provider 4) Enter Date and Time 5) Enter Client, Priority and Status 6) Click OK Step 2 Step 1 Step 3 Step 4 Step 5 Step 6 MODULE 3: SCHEDULING Page 29

31 3.14 Messenger 1) Click on the Messenger Icon 2) Click the Conference Icon 3) Click New Conference 4) Enter the Name 5) Select Health Centre 6) Click OK Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 7) Select User 8) Click Invite and repeat for all participants Step 8 Step 7 MODULE 3: SCHEDULING Page 30

32 3.15 Scenarios ***Nurses don t have to complete ALL scenarios in this section*** Scenario 1 Create an appointment a) Client : John Doe b) Date: tomorrow c) Time: 10:00 am d) Duration: 20 min e) Provider: FN Nurse f) Type: Immunization Scenario 2 Create an appointment for a walk-in client who wants a diabetes consult Scenario 3 Create a Family Consult group session for 3 members of the Gump Family for next Tuesday at 09:00 am for 1 hour Scenario 4 Provider Dean Driver is going to Hawaii for three weeks and wants his schedule blocked for while he is away Scenario 5 Heather Tea did not show up to her weekly diabetes consult. What should you do? What if she called and said that she can t make it? Scenario 6 A mother {enter client} enrolls her child {enter client} in the Early Childhood Development (ECD) Program Kolour Kids. The program runs ever 2 nd week on Friday from 10am-2pm Scenario 7 A new program Better Parenting is starting up hosted by the ECD department. Add four members/ clients to group meeting that runs on the first Wednesday of every month at 7pm for 2 hours, ending Jan Scenario 8 Start a new messenger conference, add users to conferences and have each send at least one comment so everyone can see who sent it and when. Scenario 9 A nurse asks you to make an appointment for a new program at the health centre. You cannot find the program on the appointment type list. What do you do? Scenario 10 A nurse has just called and she is running late and wants one appointment moved back an hour. What if she called in sick and needs to have all her appointments cancelled? MODULE 3: SCHEDULING Page 31

33 Scenario 11 Send a task to the CHR asking if they can contact {Enter Client} about an upcoming TeleOphthamology clinic on July 15 starting at 9am. Scenario 12 Send a message to your neighbor congratulating on completing Module Reports a) Number of clients seen by program b) Number of clients seen by provider c) How many times a client has used a service d) How many times a client Did Not Attend appointments 3.17 Frequently Asked Questions and Problems a) Why do I need to fill in appointment type? b) A new program has started, what do we need to do? c) MODULE 3: SCHEDULING Page 32

34 4.1 Purpose Module 4: Medical Record The medical records section is main module of the EMR. All clinical and patient information can be accessed and modified from this section. 4.2 Icons and Definitions Definitions Icons a) ICD 9= International Classification of Disease b) a) Medical Record d) New Encounter b) New Icon e) Graphs c) Open/ Edit f) Refresh 4.3 Key Fields a) Codes = Reportable ICD codes for diagnosis, adverse reactions, medications and procedures b) 4.4 Opening the medical record 1) Search for the client using Find Clients See Section 2.5 2) Select client from list 3) Click Display 4) Select the Medical records icon from the main toolbar (Ctrl+y) MODULE 4: MEDICAL RECORD Page 33

35 4.5 Segment List Located on the left side of the Medical Records window a) Overview: Is a listing of family members, problems, medications, Immunizations, Medical and social history, recent contacts, b) Summary: is a clinical summary of medications, immunizations, histories and notes c) Encounters: is a summary of encounters listed by date d) Measures: a record of all the measurements that are entered into the medical by the use of key words e) Tasks: view of all pending tasks f) Care plans: list of plans and schedule of interventions for the patient g) Immunisations: view of immunizations given to the clients h) Notes: list of diagnosis, adverse reactions, social and risk factors i) Audit: list of what users accessed the medical record and for how long j) Medications: view of usual medications taken by the client k) New Encounter: Used to create a new encounter for the clients l) Care Team: provider list including pharmacy, radiology, laboratory regularly used a b c d e f g h i j k l MODULE 4: MEDICAL RECORD Page 34

36 4.6 Add a Note (Problem) 1) Select Notes from the segment list 2) Select the area (Diagnosis, Adverse, Procedure, etc) for the note 3) Right Click > New or click the new icon 4) Enter first 3 letters of code 5) Double Click correct code 6) Add any other important information 7) If Necessary, Click to Add an alert 8) Add when the alert should be seen 9) Click Ok Step 3 Step 2 Step 1 Step 4 Step 5 Step 7 Step 8 Step 9 MODULE 4: MEDICAL RECORD Page 35

37 Tip If a note cannot be located (usually an adverse reaction or a procedure) in the initial search. a) Click the expand button b) Select ICD 9 from the drop down list and click search 4.7 Alter a Note (Problem) 1) Click Note on segment list 2) Select Note to be altered 3) Right Click > Open 4) Alter any necessary information 5) Click Ok Step 2 Step 3 Step 1 MODULE 4: MEDICAL RECORD Page 36

38 4.8 Measures (Vital Statistics) Tip You cannot add a measure in this section. A measure must be added through an encounter See Section 5.5 to add a measure 1) This section allows you to view a summary of all the measures added on the Encounter 2) Can create a graph of the measure by: a. Select the measure b. Click the graph button 3) To view changes made in the encounter section, must use the Refresh button Step 2b Step 2a Step 1 MODULE 4: MEDICAL RECORD Page 37

39 4.9 Add a Standard Medication 1) Click Medication in segment list to review current Meds 2) Click New to Add Med 3) Type first 3 letters into search 4) Click Rx 5) Select correct medication, Right Click > Add instruction Step 2 Step 3 Step 4 Step 5 Step 1 6) Enter dose, frequency, Route, Quantity If necessary, 7) Click OK Step 6 Step 7 MODULE 4: MEDICAL RECORD Page 38

40 4.9 Discontinue a Medication 1) Select the Medication you want to discontinue 2) Click the Discontinue Icon 3) Click Yes Step 2 Step 1 Step 3 4) Select Reason 5) Click OK Step 4 Step 5 MODULE 4: MEDICAL RECORD Page 39

41 4.10 Create an Ad Hoc Medication 1) Click Medications Icon 2) Click the Ad Hoc Medications Icon 3) Add Necessary Information 4) Click OK Step 2 Step 3 Step Care Team 1) Click Care Team to view a providers list 2) Add New providers or Edit providers 3) To add a new family doctor, click type and change to external 4) Click provider and the click the expand icon Step 2 Step 3 Step 4 Step 1 MODULE 4: MEDICAL RECORD Page 40

42 5) Enter all or part of the provider s name and city 6) Click search 7) Select physician 8) Click ok Step 6 Step 5 Step 7 Step Scenarios Scenario 1 Find the medical record of Bubette Gump a) Does she smoke? b) Is she taking any medications? c) When was the last time she was in the health centre? For what reason? Scenario 2 Find the medical record of Aren Northey a) Does he have any due tasks? If yes, what is it? b) Is his blood pressure increasing or decreasing Scenario 3 Send a task to the receptionist asking if they can book an appointment for {enter client} for July 15, 1pm- 2:30pm for {enter appointment type} Scenario 4 A client {enter client} stops taking {enter drug} because it upsets their stomach and are prescribed a new medication {enter drug}. Go into their medical record and discontinue the old medication and add the new medication. Scenario 5 A client has changed their family doctor, alter the care team to reflect this MODULE 4: MEDICAL RECORD Page 41

43 Scenario 6 Who has viewed Forrest Gump s medical record in the last 6 months? Scenario 7 The client has just told you that they are severely allergic to hydracortizone cream, add this to the notes section of their medical record and create an alert to open when their medical record is accessed. Scenario 8 A client has told they are taking a new medication that is not currently listed in the system. Add this new medication into the list Reports a) Summary of clients medical history b) Show All clients with Diabetes c) Show all clients with asthma d) Number of clinical contacts within the last 6 months e) Providers that have accessed a medical record 4.14 Frequently Asked questions and problems a) How do I find the disease code that I want? b) How do I find the medication I want? c) Why are notes not called problems? d) What do I do if I can t find an external provider on the list? e) What do I do if I can t find a medication in the list? MODULE 4: MEDICAL RECORD Page 42

44 Module 5: New Encounters Note: Important to focus on how this information is reported and what are the key pieces of information? 5.1 Purpose Not only is charting made easier to read and auto dated, but also it gives the user the opportunity to actively graph and follow key health indicators such blood pressure and pulse rate. One can also code diagnosis and adverse reactions that can used to create meaningful reports on the overall health of the community. 5.2 Icons and Definitions Definitions a) ICD 9 = International Classification of Disease b) BMI = Body Mass Index Icons a) New Encounter d) Clinical Details b) Diagnosis and Adverse Reactions e) Histories c) Calculators f) Enter Data 5.3 Key Fields a) Diagnosis Code b) Measures c) Adverse Reaction Codes MODULE 5: NEW ENCOUNTERS Page 43

45 5.4 Action Item List a) Review: Let s you view a list of recent contact encounters, diagnosis, adverse reactions, and usual medications b) Diagnosis: List of Diagnosis and ICD-9 Code c) Adverse Reaction: Allows you to select an adverse reaction from a list of the most common or search for ones that aren t on the list d) Calculators: Can calculate BMI, Cardiovascular Risk among others for the client e) Care Plans and Tasks: List of Outstanding Immunization Care Plans for the client f) Immunization: List of all immunizations given and outstanding for the client g) History: Shows family and social history h) Service: Most Used services i) Encounter: Allows you to open and edit encounter properties j) Reference Series: Compares the client s measure( height, weight, length for newborns) against the standard range of values k) Guidelines: Recommends a set of actions to take when criteria for a situation are met or a clinical approach to a specific disease l) Consult: TBA MODULE 5: NEW ENCOUNTERS Page 44

46 5.5 New Encounter 1) Search for the client using Find Clients 2) Type first 3 letters of the clients last name 3) Select correct client from the list 4) Click New Encounter from the toolbar 5) Enter any necessary notes in free text or SOAP format Step 4 Step 5 MODULE 5: NEW ENCOUNTERS Page 45

47 5.6 Making a charting note private 1) Create a new Encounter See Section 5.5 2) Add Charting Notes 3) Click Private To: 4) Select role that will be able to view the note Step 3 Step 2 Step Coded notes Adding Measures IMPORTANT!! All measures are done using the metric system; therefore need to use cm for height and kg for weight 1) Open a new encounter 2) Type these to have the information coded: a) Blood Pressure (mmhg) bp 120/80 g) Height (cm) ht 170 b) Weight (kg) wt 75.3 h) Temp ( o C) temp 37.6 c) Pulse Rate (beats/min) pr 100 i) Head circumference (cm) hc 44 d) Respiratory Rate (breaths/min) rr 13 j) Blood Sugar Level (mmol/l) bsl 5.6 e) Girth (cm) girth 70 k) Oxygen Saturation (S O2) oxy 97 f) TB Skin Test (mm) tbst 3 3) Will be entered into the measures section and can be display in graph format by selecting measure and then clicking graph button See Section 4.8 4) Will only be displayed once encounter has been saved and closed or can refresh in measures MODULE 5: NEW ENCOUNTERS Page 46

48 5.7 Displaying Images in the medical record 1) Open a new encounter 2) Use these codes to display images followed by a \ Example: imagebody\ 3) Double click the picture to open for editing 4) Paint image as necessary 5) Click close Step 3 Step 5 Step 4 MODULE 5: NEW ENCOUNTERS Page 47

49 5.8 Add a Diagnosis IMPORTANT!! Diagnosis is coded using ICD 9 and is an important factor for reporting 1) Open a New Encounter 2) Click Diagnosis in the Actions Menu 3) Click new button 4) Type in all or part of the diagnosis code 5) Select the correct diagnosis 6) Add any attributes that are necessary 7) If necessary, click Alert and select when the alert is to be displayed 8) Click OK Step 4 Step 5 Step 3 Step 2 Step 7 Step 6 Step 8 MODULE 5: NEW ENCOUNTERS Page 48

50 5.9 Add an Adverse Reaction 1) Open a new encounter 2) Click Add Adverse Reactions from actions menu 3) Check the Common tab for the reaction 4) If not located, Click New Step 1 Step 2 Step 4 Step 3 MODULE 5: NEW ENCOUNTERS Page 49

51 5) Type all or part of code 6) Select correct code from list 7) Enter the Nature of the reaction, click expand icon 8) Select Nature of Reaction from list 9) Click Ok 10) Add any attributes 11) If Necessary, click alert and select when to notify 12) Click OK Step 8 Step 5 Step 7 Step 9 Step 10 Step 11 MODULE 5: NEW ENCOUNTERS Page 50

52 5.10 Add a new note to the Termset IMPORTANT!! A new Note should only be added if one has searched the ICD-9 termset first. See section 4.6 Add a note for instructions on how to perform this task. 1) Search for code - See Section 5.8 or 5.9 when no matches appear 2) Click New Button 3) Type in Code 4) Enter Description 5) Click OK Step 3 Step 2 Step 4 Step 5 Tip Once the allergy, procedure or disease code has been created it will not need to be added again and can be found using a search. MODULE 5: NEW ENCOUNTERS Page 51

53 5.11 Using Calculators 1) Open a New Encounter 2) Select Calculators icon 3) Select Calculation needed from list 4) If measures have already been added, click calculate and insert into encounter 5) Check that Measure and calculations have been input into the encounter 6) If measure not added can add by turning on the Enter data key Step 5 Step 6 Step 3 Step 2 Step 4 MODULE 5: NEW ENCOUNTERS Page 52

54 5.12 Clinical Details 1) Click the Clinical Details icon or open new encounter and select Histories from Action menu then click open 2) Enter information on Family/ Social 3) If not already recorded in encounter, enter information on Past medical history, allergies, measures, notes, medications, immunizations MODULE 5: NEW ENCOUNTERS Page 53

55 5.13 Scenarios Scenario 1 Create a new encounter for Bob Havro. Record his height, weight, blood pressure and that he has sore knee using the image function. Scenario 2 A client {enter client} comes in for a routine appointment and tells the nurse that they have been diagnosed with diabetes. Create the appointment, enter the diagnosis, and enter the vitals temperature, height, weight, BMI, and blood sugar Scenario 3 A client {enter client} comes in and asks for a referral letter to see a counsellor {enter counselor} in your clinic. Issue one and attach it to their medical record. Scenario 4 A client {enter client} has requested a print out of their medical record. What steps are necessary to do this? Scenario 5 A client {enter client} tells the nurse that they have asthma and are taking the drug Advair. Record this information in their medical record Reports a) Number of people with diabetes b) Number of people who are allergic to penicillin c) Number of overweight or obese people d) Number of people with high blood pressure 5.15 Frequently asked questions and problems a) Why can t I add a measure in the measure section? b) Why do I need to MODULE 5: NEW ENCOUNTERS Page 54

56 6.1 Purpose Module 6: Immunizations Immunisations are simply care plans that have been set up to also appear in the Medical Record in a separate view called Immunisations. These are set up as structured templates, where you can specify which visits are part of the plan, when they should take place and how frequently, if applicable. Care plans are usually targeted against a specific health initiative such as vaccinating children against diseases and checking for breast cancers. Care plans collect related visits together, so that visits with a common purpose are logically grouped. 6.2 Icons and Definitions Definitions a) Care plan = An immunization schedule that creates dates for future immunizations according to BCCDC standards b) Intervention = individual immunization contained within a care plan c) iphis = Integrated Public Health Information System Icons a) Immunization c) Immunize Now b) New Immunization d) Print 6.3 Key Fields a) Batch b) Expiry Date MODULE 6: IMMUNIZATIONS Page 55

57 6.4 New Care plan BCCDC Immunization Schedule 1) Open a client s Medical Record 2) Click Immunization from the segment list 3) If the care plan exists skip to Section 6.5 4) If the care plan does not exist, Click the New care plan button on the toolbar 5) Open the Based on menu 6) Select the appropriate care plan 7) Check the enrolment date and the provider are correct 8) Click Ok Step 4 Step 5 Step 7 Step 2 Step 8 MODULE 6: IMMUNIZATIONS Page 56

58 6.5 New Immunizations Within a care plan 1) Open the client s Medical Record 2) Click Immunization from the segment list 3) Check existing care plans for outstanding immunizations 4) Double click the appropriate immunization 5) Select the appropriate tab on the menu 6) Check the concluded date and provider given by and change if necessary 7) Enter the Route/ Site, Needle size, and Batch/ Expiry 8) Repeat as necessary for each immunization given 9) Click OK Step 5 Step 6 Step 2 Step 4 Step 7 Step 9 MODULE 6: IMMUNIZATIONS Page 57

59 6.6 New immunization without a care plan 1) Open the client s Medical Record 2) Click Immunization from the segment list 3) Click the Immunize now button 4) Type the first 3 letters of the search term in the service search menu 5) Select immunization from list 6) Check the provider and date information 7) Enter the Route/ Site, Needle size, and the Batch/ Expiry 8) Click OK Step 3 Step 4 Step 6 Step 7 Step 8 MODULE 6: IMMUNIZATIONS Page 58

60 6.7 How to print the summary information for IPHIS 1) Open the client s Medical Record 2) Select Immunization from the segment list 3) Maximise the Medical Record Window 4) Ensure that the Batch Number is visible by widening the column, use 5) Click the print icon from the toolbar 6) Select the correct printer from the list 7) Click OK Step 5 Step 2 Step 4 Step 6 Step 7 MODULE 6: IMMUNIZATIONS Page 59

61 6.8 Scenarios Scenario 1 A client {enter client} comes into the health centre with their child {enter client} and wants to start them on a BC immunization care plan. Create the care plan and administer the necessary immunizations. Scenario 2 A client {enter client} comes in with their child that is about to enter grade 6 for their immunization boosters. Administer the vaccines and enter the necessary information in their medical record Scenario 3 A child come comes into the clinic that was born on November 15, Their mother doesn t know which BC immunization care plan the child was started on, but wants to continue with their vaccination schedule. Which care plan should we create in the medical record? Scenario 4 A mother {enter client} with a baby {enter client} comes in for an immunization. She is in the system, but the baby is not. The IMMBCI care plan has been started at another health centre and she has the 2 and 4 month marked {enter dates of immunizations} as complete. Enter all the necessary information into Profile. Scenario 5 Open a clients {enter client} medical record and find the record of their immunization history and print a copy of the form to send to IPHIS. 6.9 Reports a) Number of people in the community that immunised b) IPHIS summary report c) Number of people in the community with outstanding immunizations d) 6.10 Frequently asked questions and problems a) What does the New Immunization button do? b) Why doesn t the system connect electronically to iphis? c) Will the system connect electronically to Panorama? MODULE 6: IMMUNIZATIONS Page 60

62 Module 7: Document Management 7.1 Purpose The document management function in Profile is very robust and has many uses. The primary usages by ITHA clients thus far are twofold: Add an electronic document in PDF or DOC form to a patient medical record or Create a letter template to be used in the communication of patient care. Profile users have the ability to add electronic documents to a patient record, but ITHA will need to do some setup with you prior to using this function. With respect to letters, it is best to forward a sample letter to ITHA ehealth staff to model the letter into your EMR by way of helpdesk. You will then be able to select it from the appropriate folder once created. 7.2 Icons and Definitions a) document = A letter template or electronic file that may be appended to a clients medical record b) subject = descriptor of the document and is a filename in some sense c) import = the process of attaching a document to a patient medical file a) Documents c) Letter Button b) New Document 7.3 Key Fields Subject 7.4 Setup Setup Is required for a community Profile user to import documents into a client medical record in their EMR. ITHA needs to make a security change on the server to allow the moving documents from an outside source to a location inside the security wrapper. For this reason, ITHA will limit this function to a few key users. Under instruction from the ehealth department at ITHA, changes by the user to their Profile icon on their desktop to open the drives active on their local computer to the EMR. This allows the user to browse for the documents they would like to attach to the medical records Setup is also required for standard community letters to be added to your EMR. The EMR has the ability to insert/merge patient data fields into letters allowing for many letters to be created, printed and attached to patient medical records in a single action. Users send ITHA a sample letter they would like to use in this way ITHA with create letter and insert necessary data fields that will customize each letter MODULE 7: DOCUMENT MANAGEMENT Page 61

63 7.5 Importing a Document to a Medical Record The document manager exists on the segment bar inside the medical record for each patient. Step 1 Click on the Documents item in the segment bar on the left Step 2 Click on the down arrow next to the New Document Icon Step 3 Click on the Import File selection in the pop out list Step 2 Step 3 Step 1 Step 4 The browse file dialogue appears. Navigate to the where your electronic file is located. Remember it must be either PDF or DOC (Not DOCX). Do not select the local C drive as this is the server drive, NOT your local C. Your local C drive will show up as C on YourMachineName as in the example below. Once you find your file, double click on it to select. Step 4 Step 5 Once you have selected your file, you will get the interface below, type in a name for your file in the Subject line and press OK to attach to the current patient file. MODULE 7: DOCUMENT MANAGEMENT Page 62

64 Step Editing / Re-Naming (Subject) If you wish to rename the imported file, to make it more recognizable or meaningful: Step 1 - Simply right click on the subject item to get the popup menu below. Step 2 - Select Set Properties Step 3 Retype the filename in the Subject field in the dialogue (shown above), and Step 4 - select OK to commit to the new name. Step 2 Step 3 Step 1 Step 4 MODULE 7: DOCUMENT MANAGEMENT Page 63

65 Module 8: Referrals 8.1 Purpose Referrals are used to assist in the controlling of continuum of care for a patient when they are referred to an outside care provider. The two key actions used in the control of this are the appointment with the clinic and the formal letter of reference for the client or external provider depending on context. Profile is capable of inward and outward referrals, both manual and electronically communicated. The scope of this instruction is for a manual Referral Out only. 8.2 Icons and Definitions a) Referral Out = Action of the passing of care to an external agency b) External Provider = Caregiver that exists outside the current health centre c) Reason Letter = Letter to the client or provider concerning the referral d) Template Library of template Letters/documents used at the health centre e) Save Save Referral (or) letter within referral a-1) Referral Screen (segment list) c) Reason Letter (tab) a-2) New Referral (main icon) a-3) New Referral Out (submenu) b) External Provider (field) d) Template e) Save button f) Print button 8.3 Key Fields External Provider, Date/Time (Appt Section), Client Informed (checkbox), Subject, Template (button) 8.4 Creating an Outward Referral Step 1 From the appointment screen, under the work folder of the segment list (sidebar), select the Referrals icon on the left. Step 2 From the referrals screen, left click on the down arrow just to the right of the new referral icon Step 3 Select Referral Out MODULE 8: REFERRALS Page 64

66 Step 2 Step 1 Step 3 Step 4 If you are not currently working in the client record that you wish to refer, the search client dialogue will come up find the appropriate client and select Step 4 Step 5 From the Referral Out screen, go straight to the Ext Prov field and start typing in the last name of the external provider you wish to refer to MODULE 8: REFERRALS Page 65

67 Step 7 Step 5 Step 6c 666 Step 6a If the provider is in the database and is unique the Ext Prov field will just fill in blue or Step 6b - If not unique, then you will have to choose the appropriate one or Step 6c - If not found, click the new button and enter the correct contact info for the provider. Usually firstname, lastname, title, address, phone number. Step 7 Click the Save button This concludes the actual creation of the referral. *Once the appointment with the external provider has been verified: Step 8 Go the Appointment section of the referral out screen, click on the date/time field down arrow, then click on the down arrow that pops up to get the calendar Step 9 Select the date and time of the appointment as conveyed by the external provider. Step 8 Step 9 Step 10 Click on the Reason Letter tab MODULE 8: REFERRALS Page 66

68 Step 11 Click on the Template button Step 12 Navigate to the folder where the correct document template is located Step 13 Select template and click ok document is rendered inside the referral window Step 14 If necessary, modify filename in the Subject field on the right Step 15 Check over document to make sure it is ok. You may make any manual changes to the document where necessary. They will not save over top of the template. Step 16 Click on Save button This copies to client medical record (Documents) Step 17 Print Letter mail to recipient Step 10 Step 12 Step 16 Step 17 Step 15 Step 14 Step 13 Step 11 *Once the client has been notified: Step 18 If you have already notified the client, click the Client Informed checkbox. 8.5 Closing Referral Step 19 Once the referral out is complete, you will want to close the referral. From the General tab of the referral screen, click on the down arrow to the right of the Status field in the Status section, select closed, click on the save button MODULE 8: REFERRALS Page 67

69 Step 19 Step Reporting Options Reporting for referral out will be developed by request only and be made available through the BI Reporting Portal. Check with your Site Champion for details. MODULE 8: REFERRALS Page 68

70 Module 9: Home and Community Care 9.1 Purpose The Home and Community Care program that is managed by the First Nation Health Authority (formerly Health Canada) can be supported in Profile. This is achieved by an embedded and encoded library of all current esdrt service codes, reference via Profile smart text feature, esdrt file identifier on the client record, and the rollup report at month end via Business Intelligence reporting that is then ed to the HCC Co-ordinator. 9.2 Icons and Definitions a) esdrt = electronic Service Delivery Reporting Template b) HCC = Home and Community Care c) Smart Text functionality inside the encounter charting window that allows for a code word to be specified that hyperlinks or references an embedded preset code setup in the system d) Business Intelligence reporting software that exists on a server dedicated to extracting data from other systems and producing reports via or the web interface e) esdrt file identifier an anonymous code or ID assigned to a physical or electronic file representing a client in Profile recorded on the Alter Client screen 9.3 Key Fields esdrt # - file identifier 9.4 Identifying your HCC Clients in Profile For the esdrt functionality to work in Profile, the anonymous code or preset/existing esdrt # that you currently use to reference the client on the esdrt spreadsheet must be cross-referenced in Profile on the clients record. The number is entered into the esdrt# field. MODULE 8: REFERRALS Page 69

71 9.5 HCC Program Service Code List Use the HCC Program Service code list below to enter your HCC related services while doing your client charting. These codes map directly to the options listed on the dropdown on the current esdrt spreadsheet. 9.5 Charting your Services While charting in encounters, enter the appropriate code, then a space, then the number of minutes to complete that service, then either add another space if in a sentence or simply hit the enter key to go to the next line. The service is properly entered if you see the line turn blue and underline like an internet link. If it does not, double check the code against the list. MODULE 8: REFERRALS Page 70

72 Then add space or simply hit enter IMPORTANT It is important to be aware that you cannot report for other staff as the system uses the current sign on for month end reporting. Doing so will skew reporting and may result in high FTE on the HRTT report. If you have consultants without an EMR sign on that do HCC work, a request to ITHA for another code set must be made. If other HCC workers have EMR sign on, they should be encouraged to use these codes. Reporting will consolidate automatically at month end and will be received by the HCC Co-ordinator. 9.6 esdrt Reporting At month end, our BI (Business Intelligence) server accumulates all the HCC services against the clients by the providers into a consolidated report. The format of the report is on PDF and is received by the HCC Co-ordinator on the first day of each month. The layout of the report is such that the data can be transcribed verbatim onto the esdrt spreadsheet provided by FNHA (formerly HC). Below is an example of the report. MODULE 8: REFERRALS Page 71