BENEFITS... 2 FEATURES... 2 ADD-ONS... 2

Transcription

1 Electronic Health Record - EHR OVERVIEW BENEFITS... 2 FEATURES... 2 ADD-ONS... 2 THE ELECTRONIC HEALTH H RECORD LOGGING ON... 3 REVIEWING FORMS AND PAGES... 6 LOOKING UP A PATIENT... 8 THE PATIENT FORM REVIEWING THE EHR CREATING A NEW EHR ENTERING A NEW PROBLEM VIEWING/EDITING A PROBLEM ENTERING A NEW PRESCRIPTION FINDING A PROBLEM FINDING A FOLLOW UP USING SHORTCUT KEYS ebill.ca Page 1 Electronic Health Record

2 Overview Ebill s Electronic Health Record (EHR) allows physicians to record patient health care in a clear, concise, chartless environment. Access to the health record is quick with easy review of essential information during a primary or follow-up visit. EHR is designed for single and multi-user environments and is accessible anywhere an internet connection is available. Benefits Easy access to information - online, anywhere, anytime Clear and concise display of data User friendly Saves time Features Secured login Patient Demographic / Billing Information Health History Prescription History and PIN Lab Results Diagnostic Code, Service Code and Drug Name database Online Forms Claim History Add-ons Digital Dashboard Ebill ebill.ca Page 2 Electronic Health Record

3 The Electronic Health Record Logging On Go to on the internet and access Member Logon. Enter your User ID and Password and click Sign On ebill.ca Page 3 Electronic Health Record

4 Once logged onto the website, the following page displays. Click on Forms from the left side of the screen. ebill.ca Page 4 Electronic Health Record

5 The UserForms Page displays. There are five options: 1. Addon Features Subscribe to addon features 2. AHC Health Care forms 3. AHC Find Find Forms for Health Care Claims 4. Patient Record Patient View and Edit Form 5. FormZ Printable forms formset Click on the Patient Record to access the Electronic Health Record. ebill.ca Page 5 Electronic Health Record

6 Reviewing Forms and Pages The EHR is comprised of a series of forms and pages. A form is a structured screen of fields reserved for entering information. There are many forms that comprise a record. Some are FIND forms used for finding information, others are INPUT forms used for inputting and storing data. This is a list of standard Forms within the EHR. o Find a Patient o Find a Follow up o Find a Problem o Patient o Problem ebill.ca Page 6 Electronic Health Record

7 o Follow up o Lab o Prescription o WCB A Page is a section of information contained within a form and is represented as a tab. Some pages contain sub-pages that enable entry of more information related to the subject. There are two types of pages within a form: 1. Input page: a section of information where data is input and allows movement within the form. ebill.ca Page 7 Electronic Health Record

8 2. Status page: a section of information where data is viewed or edited and movement within the form is limited to selective action buttons. Looking Up a Patient To find or lookup a patient, the Find a Patient form must be selected. Select the form from the ebill.ca Page 8 Electronic Health Record

9 form field. The Find a Patient form consists of several components: Form the name of the active form selected Profile the profile of the provider completing the EHR Patient Lookup tab the page where criteria is entered to lookup a patient List of Patients tab the page that lists the patients who meet the lookup criteria Action Buttons buttons that perform a task On the Patient Lookup tab these are the options to find a patient by: All or part of the last name All or part of the first name The sex of the patient The date of birth The personal health number The recovery code (province) Enter the criteria in the field(s) of choice Click the Find button or (Ctrl F) to initiate the search ebill.ca Page 9 Electronic Health Record

10 A list of patients matching the search criteria displays in the List of Patients tab. Select the patient from the list and click the View/Edit Patient button (Ctrl V) to open the record If the search does not find the patient: Click on the Patient Lookup tab to change the search criteria or Click on New Patient (Ctrl N) to create a new patient record The Patient Form ebill.ca Page 10 Electronic Health Record

11 The patient form is a screen of fields reserved for entering information. In the Form field, select the Find a Patient form. Enter the criteria to lookup the patient Click on Find (Ctrl F). If nothing displays in the patient list Click on New Patient (Ctrl N) to create a new patient record The Patient form displays. The Patient form is one of several forms the EHR is comprised of. This form contains: Feature buttons buttons that provide access to AHC billing AHC Find databases. These features are accessible at anytime while in the EHR to assist in diagnosing and billing the record. Form options forms are vital components of the EHR that change at various stages of the record. Changing the form displays different information. Profiles - the provider ID that is linked to the EHR. It is the provider who is completing the record. It must be selected before creating or starting the EHR. Action buttons - buttons used throughout the record to perform various actions/tasks. Patient segment the segment identifying the patient that displays for the duration of the EHR. Tabs pages containing data. As a tab is selected, the page changes relative to the tab description.. Reviewing the EHR ebill.ca Page 11 Electronic Health Record

12 The EHR is comprised of a series of pages. A page is a section of information represented as a tab.. The following lists the pages or tabs contained in the EHR. Patient: Includes personal demographic data with contact information, spousal / guardian data and other medical information. PMH: Patient/Past Medical History includes allergies, medications, hospitalizations/surgeries, immunizations, pregnancies, medical history and additional information. SH: Social History includes patient s social history, sexuality and additional information. FH: Family History includes family history and additional information. Rx-H: Prescription History displays a history of dispensed prescriptions. Rx-PIN: Prescription information related to PIN (Pharmaceutical Information Network). Prob: A chronological list of problems recorded on the EHR. It displays the original problem, the last recorded update, the status of the problem and provider who recorded the problem. Lab: A chronological list of lab orders and their results. Follow-up: A chronological list of follow-ups recorded by date, priority and status. Creating a New EHR ebill.ca Page 12 Electronic Health Record

13 Log on to the ebill website in the usual manner. Find or lookup a patient using the Find a Patient form. Click on NewProblem (Ctrl N). A new page of tabs appears. Click each tab and enter data respectively. Save the record (Ctrl S). Entering a New Problem ebill.ca Page 13 Electronic Health Record

14 Log on to the ebill website in the usual manner. Find or lookup a patient using the Find a Patient form. Click on the Prob - problem tab. Click on the Refresh button to display the history of recorded problems. Click on NewProblem (Ctrl N). A new page of tabs appears. CC-Chief complaint Subjective Objective Assessment Plan Serv/Diag Codes Follow up Templates Prob Log Click on each tab and enter data respectively. Click on Save (Ctrl S) to save the record. Click on Back to Patient (Ctrl B) to move back to the beginning of the record. Viewing/Editing a Problem ebill.ca Page 14 Electronic Health Record

15 Log on to the ebill website in the usual manner. Find or lookup a patient using the Find a Patient form. Click on View/Edit Patient to display and view the patient record. Click on the Prob - problem tab. Click on the Refresh button to display the history of recorded problems. Hi-light the problem to view. Click on View/Edit Problem. A page appears displaying the previously recorded problem in the shaded area of the tab. Click on each tab to view history in the shaded area or addt new data pertaining to the problem. Click on Save (Ctrl S) to save the data if additions have been made. The screen will refresh and display the addition(s) to the problem with a date and time stamp. Click on Back to Patient to move back to the beginning of the record. Entering a New Prescription ebill.ca Page 15 Electronic Health Record

16 Find or lookup a patient using the Find a Patient form. Click on View/Edit Patient to display the record. Click on Rx-H to view or add new prescriptions. Click on the Refresh button to display the history of dispensed prescriptions. Click on NewPrescription (Ctrl N). A new page of tabs appears for prescription input The page displays the following tabs. Rx-N New Prescription ebill.ca Page 16 Electronic Health Record

17 Rx-H History of Prescriptions dispensed on this record Adverse Drug Reactions A list of drugs with reactions for this patient. Favorite Prescriptions A list of favorite or commonly prescribed medications Enter data in each field. Click on Save Prescription (Ctrl S) to save the record. Click on Rx-H to view or print the prescription. Click on Rx- N and then on Back to Patient to move back to the beginning of the record. NOTE: On the Medication field there is a button that accesses a Drug Lookup database. This database provides a list of drugs by name, PIN or manufacturer for assistance in dispensing medications. Finding a Problem ebill.ca Page 17 Electronic Health Record

18 Within the EHR is the ability to find problems by selective criteria. This information can be used for statistical analysis of your database or to lookup a problem on a specific patient. On the Find a Problem form these are the search options.. Last name First name Gender Date of birth range Begin/end date Status active/inactive/both Enter the search criteria on the Problem Lookup tab Click on Find (Ctrl F) to execute the search A list of problems displays on the Problem List tab Finding a Follow up ebill.ca Page 18 Electronic Health Record

19 Within the EHR is the ability to find a follow up by selective criteria. This information is generated from the follow-up record and is used as a guide to follow up with your patients. On the Find a Follow up form these are the search options. Last name First name Begin/end date of follow-up Priority Status active/inactive/both Find a follow-up using the Find a Follow-up form or by clicking on Find a Follow-up button. Enter the search criteria on the Followup Lookup tab Click on Find (Ctrl F) to execute the search A list of followups display on the Followup List tab ebill.ca Page 19 Electronic Health Record

20 Using Shortcut Keys Because EHR has a graphical interface, many people primarily use the mouse to move throughout the record. It is often faster and more convenient to use a keyboard shortcut. You can speed up your work by learning the shortcuts listed below. TASK SHORTCUT Display screen tip for active item Move from field to field Move backwards from field to field Move from tab to tab Move from section to section Move mouse pointer over item Tab Shift + Tab or Enter Ctrl + Tab Ctrl + Spacebar Find an appointment Move back to patient file Find requested form/item Clear the current form Find a problem Create a new record/item Print a prescription Find a patient Save a record save data Go to templates Go to third party billing information Use a prescription from favorite list View/edit selected item Find a follow-up Ctrl + A Ctrl + B Ctrl + F Ctrl + L Ctrl + M Ctrl + N Ctrl + P Ctrl + P Ctrl + S Ctrl + T Ctrl + T Ctrl + U Ctrl + V Ctrl + W ebill.ca Page 20 Electronic Health Record