Data Tec, Inc. (636)

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1 EMR Users Guide Data Tec, Inc. (636) Copyright Data Tec, Inc

2 EMR Electronic Medical Record Table of Contents Benefits 1 Overview EMR Desktop Patient Profile Patient Overview Vital Signs Screen SOAP Notes Layout ENTERING a New SOAP Note PRINTING SOAP Notes SOAP Note Pop Up Lists SOAP Note Templates SOAP Note Short Cuts PRINTING REFERRAL Letters DOCUMENTS Folder IMPORTING Documents SCANNING Documents DIAGRAMS IMMUNIZATIONS TREATMENT Notes Folder LETTERS Folder POP Up List Macros POP Up List Categories MESSAGE CENTER

3 Features & Benefits EMR Electronic Medical Records Features and Benefits Store entire patient charts: Storing documents in a computer folder greatly reduces physical storage space, expense of paper supplies, and the cost of large filing cabinets. View entire patient history: View patient history on tablet PC or work Station screens, eliminating pulling, misplacing, and re-filing of charts. Enter SOAP Notes fast and easy: A SOAP note uses Point and Click technology, making data capture much faster, more accurate and substantially reducing handwritten notes. Print or Fax Prescriptions: You can print or fax prescriptions directly from the SOAP Notes, reducing the time it takes compared to handwritten scripts. Automatically Generate Referral Letters: Reduces errors, omissions, and while saving time and labor. Enhanced Security: Requiring passwords to access patient information. Eliminates unauthorized persons from accessing confidential information, or walking off with personal files. Secure, and Safe Data back up capabilities: Keeping data back ups out of the office will ensure protection against fire and water damage, or other in office disasters. Direct interface of SOAP note diagnosis and procedures to billing. No more super bills to print, no ink, paper, and no sorting. Reduced data entry mistakes, and reduced man-hours. Importing Digital Images: Import digital images directly to the patient s electronic chart allowing you to store and organize pictures, x-rays, and EKG s. You can also enlarge the pictures for diagnostic tic purposes, and print the images. Message Center: Allows you to enter patient messages and telephone calls, and store them directly into patient charts. Scanning: Run your scanner directly from the patients EMR folder. Store and organize documents for each patient, like lab reports and the entire practice, like EOB s. Automatically store the documents in space saving PDF files, without any extra software.

4 Introduction 1.1 OVERVIEW PowerSoftMD Electronic Medical Records is called EMR for short. This feature allows you to create an electronic folder for each patient just like a paper folder. There are special screens to help you identify the patient and capture common medical information, such as vital signs, etc. There is a structured approach to entering patient encounter information commonly referred to as SOAP Notes. Additionaly, you can set up folders and use EMR to directly run your scanner to organize and store other paper documents, like lab reports and EKG s. The documents are automatically converted to PDF files. PDF files are a common format that s used to store computer documents in a highly compressed format (saving space) and display or print the files any time you want. PDF files are accessed using a program called the Adobe Acrobat Reader. This is a free program generally already on most computers. If you don t have the program you can obtain it by going to the website. You can also direct the scanning process to create JPG or GIF windows type files. In addition, you may import any digital document or file right into a patient s folder. PowerSoftMD EMR will use you windows default specified program to open any file wither you scan or import it. The patient chart is divided into folders and sub-folders. For example, the patient chart contains a folder called Documents, which is subdivided into Patient Info, Consent, Pathology, Lab Reports, etc. The enormous power of EMR comes from being able to customize the data entry. You can create pop up lists, short hand definitions, and even entry macros that prompt you to enter information quick and easily. The best way to get started is to watch the EMR flash videos from our training CD or web site

5 Introduction 1.2 EMR Desktop The EMR Desktop is the home position when using EMR. Your PowerSoftMD User ID has to be given access privileges for the EMR feature. The access is granted by using the PowerSoftMD Advanced Utility Menu Define User Security option. Only staff members with the proper authority can update these definitions. Access the EMR Desktop from the PowerSoftMD Primary Menu by selecting either the EMR top menu option or the EMR Icon. You can change the picture displayed on the EMR desktop by replacing the file \EZW\EMR\IMAGES\MENUDESK.JPG or even de-activate the picture all together by using the top menu Tools, then Options, the password is SECRET, finally checking the option Don t Display Desktop Picture. From the top of the EMR Desktop you can select Icons. The top menu Help displays a list of helpful topics to read about on the screen

6 Introduction The Group of People Icon will let you see a list of patients schedule for any specific day, and then you can select the patient name for the chart you wish to access. The Binoculars Icon lets you search for a patient by name, social security number, telephone number, account number, or birth date. Again, once you find the patient you want, you can select the name to access their chart. The Clip Board Icon takes you directly to a SOAP notes data entry screen. Once on the screen you can find a patient by name, social security number, telephone number, account number, or birth date. The Filing Cabinet Icon lets you access a High-level set of folders to store practice level information, for example EOB s that you have scanned in, etc. The Close Door Icon closes the EMR Desktop and returns you to the PowerSoftMD Primary Menu

7 Profile Screen 2.1 PATIENT PROFILE SCREEN Once you open the EMR Chart for a patient, the home position for the chart is the patient s Profile screen. This screen identifies high-level information about the patient. The name, address, and telephone numbers automatically show the PowerSoftMD patient information. You can enter specific emergency contact information on this screen. While the information is part of the patient s chart, it is not connected to the PowerSoftMD patient billing record. A detailed list of Habits can be kept up to date. You can customize this list of Habits by using the Top Menu Tools option then Edit Pop Up Lists, then Patient Profile then Habits. Take time to set up the list of Habits you want to track initially so as not to have to change it at a later date. Once habits have been entered for patients, changing your master list could affect their charts. You can create a short list of any family members that you feel are important medically speaking. You can create or update a security question that patient s could be asked to identify themselves over the telephone. To enter or change the password info

8 Profile Screen just click the Password button. You can indicate if a patient has allergies, has had an abnormal screening, and/or is pregnant. Allergies If the patient has allergies just click the Allergic check box, then click on the flashing Allergic label. A window will pop up where you can enter the specific allergies. You should create a pop up list of common allergies so that there is consistency among patient charts. Use the Tools option on the Allergies Window to create and/or update this list. Then you can use the Pop Up List button to select from this list. Abnormal Screening If the patient has an abnormal screening you can click the Abnormal Screen check box, then click on the flashing abnormal label and enter in the appropriate comments. From the Patient Profile screen you can switch to other portions of the patient chart by clicking either the folder tab, or Icon, located at the top of the screen. Many screens have both a folder tab and an Icon. While on a specific patient chart you can click the Binoculars, Arrow, or Group of People Icon to switch to other patient s without having to return back to the EMR Desktop screen. When you are on another portion of the Patient Chart you can quickly return back to this Profile screen by using the Persons Head Icon

9 Patient Overview Screen 3.1 PATIENT OVERVIEW SCREEN A handy screen to set up is the Patient Over View Screen. You can access this from the Patient Profile Screen by clicking the Yellow notepad Icon. This screen allows you view the overall condition and brief history of a patient. You can quickly enter information into this screen by using the Tools top menu option, and setting pop up lists to make data entry a simple process of Point and Click. After you have been using the EMR features like SOAP Notes and Vital signs for awhile, you can click on the View Entire Patient Chart button to scroll through the entire patient electronic chart on the screen! The display is organized where you will see the most recent visits, notes, and vital signs entered first. In addition, you can zero in on a specific date, or range of dates. This Overview Screen is much easier than just writing on the inside of a patient s paper chart. Many offices that convert from paper systems to EMR, fill out the basic information on this screen as the returning patient s come back to the office. In addition, they can scan any paper documents into the patient Documents folder under Old Records. We will cover scanning documents a little later

10 Vital Signs 4.1 VITAL SIGNS SCREEN You can enter several different vital signs into the patient s electronic chart. When you click on a vital sign data field, a list of typical values will be displayed to select from. You can select from the list, or manually enter your own value. A history window of vital signs is automatically listed with the most recent measurements listed first. You can scroll back through, and click on a specific entry, and a screen will pop up showing you the detailed information in a large format. This screen also lets you delete an invalid entry. From the pop up, vital sign viewing screen, you can also select a top menu option to display graphs. You can display a graph over any specified date range for several vital sign measurements, such as height and weight. If you check the View Deleted Entries check box, you will see a list of deleted entries for the patient. On the SOAP notes screen there is a button View Vital Signs that lets you view the historical list of vital signs while staying on the SOAP notes data entry screen

11 SOAP Notes 5.1 SOAP NOTES Layout You can enter patient encounters on the SOAP Notes screen. This is the central part, or heart of the EMR system. Setup The first thing you should do is use the top menu Tools option, then select Options Setups, the password is SECRET. Then we would recommend that you check the yellow Recommended options, and uncheck any red options. We also recommend you quickly return to the EMR Desktop and select the top menu Tools option, then Options, and set the number of minutes for the time out to a large number. Be sure and use the top menu Tools option from the EMR Desktop, and set your time out in minutes. If you don t want the screen to ever time out, use Screen Setting The SOAP notes are specifically designed to work well on tablet PC s, and any computer screen with a resolution of 1024 by 768. If the computer screen is set any smaller, it may not work as well. All data entry is designed to be Point and Click capable with a stylist, or mouse. We recommend using the Tablet PC in the Landscape mode rather than Portrait

12 SOAP Notes Navigation: On the left hand side of the screen is a listing of dates showing all previous SOAP notes for the patient. The most recent dates are listed first. You can open any previous SOAP note by simply clicking on the date. If you don t need to select a previous note you can click the top menu Left/Right option to scroll the entire screen to the left, removing the dates column. This way you can see the right side of the screen more easily. The screen is divided into 3 major sections, the Subjective, Objective, Assessment and Plan, areas. The form is larger than the screen, so you will need to scroll up and down to view the area you wish to use. There are 3 ways to move up and down the SOAP note form. 1. Clicking the top menu Sub, Obj, or A/Plan options. 2. Use the scroll bar on the far right hand side to move up and down. 3. Click either the yellow or blue label for an area, and that area will become The top area on the screen; For example clicking either the Yellow EXAM, or Blue Objective labels will make the Objective section be the top section Displayed. The column to the right of the date s column allows you to view several items of interest available to you while working on the SOAP note. This includes the patient s allergies, major medications, social history, occupation, hobbies, etc. This second column also has the Review of Systems. You can modify and customize many aspects of the SOAP notes screen. For example, you can customize the Review of Systems titles. To customize, just click the top menu Tools option, and then select the area you wish to change. To customize an area, select the top menu Tools option, and then click on the area you wish to change. If you are prompted for a password, it is the word SECRET. The password is just used to keep you from accidentally selecting an area to change by mistake. You can also customize the headings, or titles in the Objective or Exam area. The power of the EMR SOAP notes is realized by setting up customized tables or lists. The lists are called Pop Ups and are accessed to make data entry a snap

13 SOAP Notes Icons The icons at the top of the screen perform the following functions. 1. Save Icon save the contents of the currently open SOAP note. PowerSoftMD EMR should automatically save the changes if you switch screen. But, you can always press this Save Icon as a check point incase of any unforeseen computer problems. 2. Profile Icon Switches to the current patients Profile screen. 3. Over Icon Switches to the Overview Screen. Kind of like the old inside page of a paper chart. 4. Pats Icon Allows you to easily select patients from the schedule. If the schedule includes the patients account number. 5. Find Icon Lets you search for a patient by name, account number, telephone number, birth date, or social security number. 6. Prev Icon Jumps to the previous patient record, alphabetically. 7. Next Icon Jumps to the next patient record, alphabetically. 8. Post Icon Switches to the patients posting screen. 9. Temp Icon displays your list of templates to select from. 10.Sched Icon Switches to the schedule. 11. Print Icon use the down arrow to the right of the print icon to select what you specifically wish to print. 12. Exit Icon close the patient record and return to the PowerSoftMD EMR Desktop. 13. On Screen Keyboard allows you to enter text without having to use the keyboard, or the Windows Tablet PC on screen keyboard options

14 SOAP Notes 5.2 ENTERING A NEW SOAP NOTE To create a new SOAP note, make sure you have scrolled back to the top of the SOAP note form, and then click the Sub top menu option if needed. Now, click the New top menu option, and a calendar will pop up with today s date highlighted. Either click on today or select another date for the SOAP note. Subjective Next, you can enter information into the data windows like Chief Complaints and HPI (History of Present Illness) in the Subjective section. You may click on a data window and type in information, or click on a button like Chief Complaints and pick from a customized list of items you have pre-loaded. Creating these customized lists are one of the most important tasks you need to complete to make the SOAP notes system work with speed, and accuracy. You may customize these lists two ways. Pick the Tools top menu option and find the list you wish to customize, or when you click on a button to display a list, the list pop up window will have a Tools menu option, which will allow you to modify the current list, displayed. Once you edit and change the items in the list you will have to close the pop up list and bring it up again to see the changes. Scroll down through the SOAP note form to fill in information for the different

15 SOAP Notes SOAP note sections. We will cover customizing these lists later, in more detail. Periodically as you are entering a SOAP note, it s a good idea to click the Disk Icon to save any change you have made so far. You can always leave a SOAP note and come back to finish it up later. Refer to the topic Signing SOAP Notes for further information. Signing SOAP Notes Once you are satisfied that a SOAP note is compete you may Sign the note so that it can t be altered. To sign the SOAP note, click the top menu Sign Form option, and follow the on screen prompts. A useful feature you can utilize is the Open Visit Records selection list. This list will allow you view all SOAP notes that haven t been signed. To use this list, select the top menu Find option, then select the Open Visit Records option. You may also press the Ctrl and O keys to display the list. Once the list is displayed, merely click on any entry to bring up the specific SOAP note. Objective The Objective part of the SOAP note has multiple parts. Review of Systems You must customize the Review of Systems headings for your practice. To do this, use the top menu Tools option then Edit Pop Up Lists, and Review of System Headings. Take time and think about exactly what you want. Once you begin creating SOAP notes, you should not alter these headings; otherwise previously entered notes will change. Scroll down to fill out a Review of Systems, or click the small RV button next to the Vital Signs button on the left hand side of the screen. You should set up the Review of Systems headings by using the top menu Tools option, then Edit Pop Up Lists, etc. If you click on the Y button for a review of systems topic, it will be indicated as a positive response. The name topic will be highlighted in yellow. If you wish to enter a specific note about the positive result, click the yellow highlighted topic and a box will pop up to enter notes in, for that topic, then the topic will be colored red. If you click on the N button for a review of systems topic, it will be indicated as a negative response. The name topic will be highlighted in white. If you wish to enter a specific note about the positive result, click the yellow highlighted topic and a box will pop up to enter notes in, for that topic, then the topic will be colored magenta

16 SOAP Notes Exam You must customize the Exam text box Normal and Abnormal check box headings. To do this, use the top menu Tools option then Edit Pop Up Lists, and Exam Button Headings. Take time and think about exactly what you want. Once you begin creating SOAP notes, you should not alter these headings; otherwise previously entered notes will change. You will also need to take time and set up the pop up lists and short cuts for this Exam text box. The purpose of this box is for you to enter your detailed examination findings and notes

17 SOAP Notes Reports This area is broken down into 3 sub areas. Labs - where to document your review of previous lab reports and results. Report - where to document your analysis of other types of reports. Special where to document special diagnosis procedures like MRI s. Assessment/Plan The Assessment and Plan area is grouped together so that you can easily create a continuum of diagnosis and treatments. For example; you could have 3 diagnosis and the treatment plan, then another 2 diagnosis and the treatment plan, etc. Assessment Pop Up Use this window to document your diagnosis. You can type text into the top window, or use the Pop Up list button. Remember the pop up list entries can contain macros. The Diagnosis codes that are automatically listed are the codes from your PowerSoftMD Diagnosis list, the first 1000 entries in this list are the codes your office customizes. Use the Red button to search the entire ICD9 Code list, over 13,000 entries

18 SOAP Notes A technique for entering multiple codes might be as follows. First enter all the diagnosis for the entire office visit, then use the Apply button. Use the Plan Pop Up window to document the proper office visit code(s). Then return to the Assessment Pop Up window, and document each specific group of diagnosis codes, using the Recent Codes box on the bottom right. Apply each set, and follow through with the Plan Pop Up. Plan Pop Up The pop up plan window provides several different tabs to document the different types of treatment options. This interface lets you build the various parts of your treatment plan and then use the red Apply button to add the specifics to the SOAP note. Procedures this displays a list where you can specify the specific CPT procedure codes that were used. These codes not only become part of the patients SOAP note, but are also available to be selected from the PowerSoftMD financial posting screen, via a yellow colored SOAP button. So taking the time to select the correct codes will not only enhance the SOAP note, but also reduce clerical time and possible errors. You will need to create you list of CPT Codes to select from. You can start by importing all the PowerSoftMD financial billing CPT Codes. Do this by using the top menu Tools option, then Import CPT Codes. This should only be done once to get you started. After the import you will want to edit the EMR CPT Code list so that you can do special things, like categorize them. Use the top Tools option, then Edit Pop Up Lists, Assessment & Plan Tables, then CPT Code and Description Table. Medications enter the medications dispensed and/or prescribed. You will need to create you list of Medications. Do this by using the top menu Tools option, then select Medications. Once entered and applied as part of the SOAP note, you can use the top menu Printer Drop down arrow Icon to print and/or fax a prescription. You can make the list much easier to use by using macros and categories. For example: {Pain Relief} Aspirin take &num mg dosage, &choices(once twice) daily. Tylenol &num mg capsules, &choices(once twice three times) daily. {end} Macros and categories are documented in detail, elsewhere. Treatment used to document non-cpt Code treatment. For example; you washed the area with mild soap, etc

19 SOAP Notes Education documents type of instructions, written or oral, the patient was given. For example; medicine brochure, or how to care for the wound at home, etc. Labs laboratory test you ordered or requested the patient to complete. Not the results. This information will automatically be added to the Lab Work Requested window below the A/Plan window. Referrals any outward referrals you made regarding patient treatment. Comments general comments, for example; discussed risk factors with the patient, warned the patient that they should stop smoking immediately, etc. Appointments list of future recommended appointments for the patient. It is true you could lump many of these things together, for example just in the treatment window. We recommend that you break them apart. The intent of having so many different parts of the Plan allow internal headings to be generated so that PowerSoftMD EMR can generate documents and procedures, like prescriptions or a list of required appointments, etc. Plus it might add a little more structure to your notes for later analysis. Lab Work Requested Use this window to document any laboratory work that is being done or requested. You can consider leaving the note unsigned until the lab results are in, then you could document the results here as well. Be sure and date the lab results. Hint: You could set up a pop up or short cut to document the results using the &datestamp macro. Additional/Notes This window allow you to add notes onto the end of an existing SOAP note, even after it has been signed. 5.3 PRINTING SOAP NOTES You can print a SOAP note two ways. 1. Click the down arrow to the right of the Printer ICON, then select the Print Visit Record option. This will print the current SOAP Note being displayed. 2. Display the date s column on the left of the screen, and then select the View

20 SOAP Notes All button below the list of dates. You will see a window showing the entire Patients SOAP notes, Vital Signs, and Message Center Notes. You can use the print button to print them all. Additionally, you can select a range of dates To view, or click on a specific date, and when you want to use the print button, Only those notes you are viewing will be printed. This method has an additional advantage, when selecting the print button, You will be allowed to filter out specific types of information you may not Want to print, like the patient s occupation, hobbies, or other private information. 5.4 SOAP Note Pop Up Lists There are lots of Pop Up List buttons right below each SOAP note text box. You can create lists of detailed text to select from to reduce your typing to a minimum. The items in the lists can even contain macros that will prompt you to enter patient specific information. Check out all the macros you can use in chapter 11. Create these lists by clicking on the Pop Up list button on the screen, then select Tools and Edit Pop Up List, the password is SECRET You may also use the top menu Tools option to edit the lists. Here is an example of a list. In addition to macros, you can also create categories or groups of items; they are listed on the right hand side of the list. Please refer to chapter 12 to learn how to create these category groupings

21 SOAP Notes 5.5 SOAP Notes Templates One of the most powerful tools is called Templates. You set up predefined text for typical types of visits. This text can be specific to any or all of the specific text boxes on the SOAP notes screen. In other words, the Template could fill in just the HPI box, or the Exam Box, or ever text box including the Assessment and Plan. It s easy to create these General Templates. They are called general because they can be used on any patient. There are also patient specific templates, which is a separate topic. From the SOAP Notes screen select the top menu Tools option, then select Templates Create/Revise, and next General

22 SOAP Notes 5.5 SOAP Notes Templates continued. Use the Red Create button to start a new Template. Once you give it a name and an optional category, the template name will appear alphabetically in the list of templates. Click on the template name in the list, then select the SOAP notes text box you wish to create or revise, for example Subjective Chief Complaints, etc. Then use the Edit button. Below you will see and example of this Edit function. Notice the Template text box can contain macros to prompt you for specific results when you are using the template to create a live SOAP note. There are many macros, again, you can learn about them in Chapter 11, Macros. Once you set up the macros it s simple to use them. When you open a new SOAP note for a patient click on the top Temp Icon to select the template you want to use

23 SOAP Notes 5.6 SOAP Note Short Cuts Another method to make data entry faster, is to create short cut paragraphs or sections of text. Naturally, the short cuts text can contain embedded macros (see chapter 11) to prompt for patient specific information. Use the top menu Tools option then Short Cut Definitions, the password is SECRET Next, select if you are creating a Global short cuts file or a file specific to a certain SOAP notes text box. You can use the short cuts two ways. (1) If you are typing in text free format and you type in the short cuts file name preceded and followed by a space, automatically the short cuts will activated. (2) If you created short cuts for a specific SOAP notes screen text box, click the Short cuts button below the box to pop a list of short cuts files to select from

24 SOAP Notes 5.7 PRINTING REFERRAL LETTERS EMR will generate a referral letter interfacing with Microsoft Word. You can create one or more model referral letters to serve as a template or form letter. The letters must be saved as a RTF (Rich Text Format) files. From the SOAP Notes screen you can select the down arrow next to the printer icon. Pick the Print Referral Letter option. The Quick Forms menu will be displayed. To create a brand new referral form letter you would type in a new form name, like Refer then click either the Edit button (to use the PowerSoftMD simple form editor) or the Windows Editor button to use Microsoft word. In the letter you can insert special symbols to fill in information from the patient record and SOAP note. You can use the Symbols button to scroll through a list of the symbols and see an example of what they supply. Once a form letter exists you can click on its name then either print the letter using the Print button or create an actual word document that is stored in the patient s folder by using the Create button. If you create the document as a word document it will be opened with Microsoft word and you can modify and/or print the document whenever needed. Generated word documents are stored in the patient s Documents folder. You can always access this folder from the patient s EMR Profile screen, selecting the Documents tab

25 Documents Folder 6.1 DOCUMENTS Folder The EMR Patient s documents folder contains specific folders such as Pat Info, Consent, etc. You can make up your own folder names by using the top menu Tools option. Use care when creating your folder names. Once you establish a folder name it will be used from that point on for all patients! Remember, there is already a separate folder called Letters available from the Patient Profile Screen to store generated word processing letters. So don t create a documents folder called Letters. You can place documents into the patient folders two separate ways. 1. If the document is already in digital format you can use the top menu option Import Document to copy the document into the patient s folder. You can Also set an option to delete the original file once it s copies to the patient Folder. 2. You can scan any documents directly into the patient s folder. Place the Document into your scanner and select the top menu Acquire Documents Option. This is a wonderful option that will start your scanner, scan the Document or documents, and create a PDF file for efficient storage

26 Documents Folder Documents that are in a specific folder are listed by name. If you click on a documents name, you will be prompted to View, Rename or Delete the document. Documents that were scanned and stored as PDF files will be viewed by your default PDF reader program. We recommend the Adobe Reader, which is a free program available at The default program on your computer to handle that type of document will view any document selected to be viewed. For example, the paintbrush program may display an image file, and your word processor program might display a word document. 6.2 IMPORTING Documents Select the top menu Import Document option to copy any existing digital document to the patient s folder. There are several options you can select when importing digital documents. For example you can check the box to Delete after Transfer, this way once the document is copied to the patient s chart the original will be deleted, thus cleaning up afterwards. You can also select to use a generated file name, the

27 Documents Folder original file name, or to be prompted for a name you wish to call the document once it s in the patient s folder. After a digital document is imported into the patient s folder, you can view it by clicking on its name, and EMR will automatically use your default windows program to open the type of document indicated. 6.3 SCANNING Documents EMR comes with a powerful scanner interface called Acquire built in. This software will start your scanner and scan single or multiple pages, creating a PDF document right into the patient folder. Just select the Acquire Documents top menu option. A file name beginning with the date and time will automatically be used. You can add an option user description to the file name. Increasing the resolution DPI number will make a clearer image, but the larger the resolution numbers the larger amount of disk space the image will take. We would recommend a resolution from 150 to 300, and Black & White. Try different settings while using your scanner, to see how the images appear. Remember you want to use the lowest setting possible that lets you clearly see the scanned documents

28 Diagrams 7.1 DIAGRAMS Legacy Standard diagrams of body areas or what ever you need can be scanned and stored as diagram templates that you can draw and make notes on. From the Patient s Profile screen just select the top menu Diagrams option. Diagrams are dated and stored in the patient s chart. You can also print these charts. Data Tec will assist you in finding and scanning appropriate diagrams for your type of practice

29 Diagrams 7.1 DIAGRAMS Journal This option lets you use the Windows Journal program to create your own forms that can be use just like paper. These could be diagrams or any forms you want, like consent forms, etc. Data Tec staff can assist you in learning how to create you own form backgrounds, called stationary. This is extremely powerful

30 Diagrams 7.2 DIAGRAMS Exam-Tablet Area You can also create diagrams right in the middle of the SOAP note by clicking the Tablet label

31 Immunizations 8.1 IMMUNIZATIONS From the Patient Profile screen you can open the Immunizations folder. Here you can keep a quick list of immunizations given. You can customize the specific immunizations you want to track. Use the top menu Tools option to customize your own list. If you are using our PowerSoftMD Billing software you can set specific CPT Codes to trigger the automatic updating of this list when posting charges. To set this up you would use the Windows top menu option from a patient s general screen, and then select Clinical, next, select Immunizations. Finally, use the Tools option on the top menu and select the option referring to CPT Codes

32 Treatment Notes Folder 9.1 TREATMENT Notes Folder In addition to SOAP Notes you can enter and keep specific detailed notes in the patient s Treatment Notes folder, from the Patient Profile screen. Here you can press the Date Top button to add the new note on the top of the list (so the most recent notes are seen first) or use the Date Bottom button to add the new note onto the end. You can also review notes stored via the Message Center by using the Message Ctr Notes button. You can also use a spell checker and even set up your own shorthand codes to save typing time. To set up the shorthand codes, which can be automatically expanded to complete paragraphs, use the top menu Tools option. Notes entered using the Message Center are available directly from the patient s SOAP notes screen and can optionally be printed when you print SOAP Notes. The notes on the Treatment Notes window will only print if you use the Print button on this screen

33 Letters Folder 10.1 LETTERS Folder The Letters folder is used to hold letters sent to the patient. You can open the Letters folder by selecting the Letters tab from the patient profile screen. View or print existing letters by double clicking the letter name. You will notice the letter name will typically have the date the letter was created as part of the letter name. Use the New button or the Quick Forms option to create a new letter. The New button will launch Microsoft Word to open a new letter. If you select Quick Forms you will be given different options on how to create the letter. Quick Forms allows you to select from a form letters, thus making letter writing much easier! If you use Quick Forms from SOAP Notes or even the patient s PowerSoftMD screens, any Created letters will be stored here in the patient s letter folder. Delete a letter by highlighting it s name then pressing the Delete button. Please use caution when deleting letter, once you delete them they are gone forever (unless you have them on a back up system)

34 Macros 11.1 POP Up List Macros You can use macro keywords in both your user defined shorthand codes and pop up lists to make them much more powerful. This way when you enter a shorthand code or select from a pop up list you can be prompted with a set of choices to complete the data entry exactly without any typing at all. Remember to update a pop up list or the user defined shorthand you can use the top menu Tools option, or if you bring up a pop up list you can use the Tools option on the list itself. All macros start with a special character, the &, ampersand. It s the character above the number seven on the top of your key board CHOICES Macro The choices macro is used to present the user with a list of choices to select from when they select an entry from a pop up list or enter a shorthand code. Syntax: &choices(xxxxxxxx yyyyyyyy zzzzzzz) &choices indicates the choices macro. xxxxxxxxx, yyyyyyyyy, zzzzzzzzz are the choices. You can have many choices. Each choice must be separated with the vertical character called the concatenation character. The choice list must begin and end with a parenthesis. Example: Blood in the stool &choices(is present is not present) NUM Macro The num macro is used to prompt the user to enter a number. Syntax: &num &num indicates the num macro, no other parameters are required. Example: Patient smokes &num packs cigarettes/day WORDS Macro The words macro prompts the user to fill in the blank with their own words. Syntax: &words &words indicates the words macro, no other parameters are required. Example: Patients described pain as &words

35 Macros LIST Macro The list macro is used to present the user with a list of choices where they can select multiple answers at one time. Syntax: &list(xxxxxxxx yyyyyyyy zzzzzzz) &list indicates the choices macro. xxxxxxxxx, yyyyyyyyy, zzzzzzzzz are the choices. You can have many choices. Each choice must be separated with the vertical character called the concatenation character. The choice list must begin and end with a parenthesis. Example: Acne is on the &list(arm face neck back) DATE Macro The date macro is pop up a calendar where the user can quickly scroll through and select a date. Syntax: &date &date indicates the date macro. Example: Patient will come back for follow up by &date or sooner DATE Stamp The date macro is used to automatically insert the current date into text. Syntax: &datestamp &datestamp that s all that is required. Example: I called the patient on &datestamp TIME Stamp The date macro is used to automatically insert the current date into text. Syntax: &timesm &timesm that s all that is required. Example: I called the patient on &datestamp at &timesm

36 Macros ANS= Macro The ans= macro is used to test a previous macro answer and branch to different locations in the text based on the answer the user supplied. This is a somewhat complex but extremely powerful macro! It lets you vary what the user will be presented based on answers to previous macro prompts. Syntax: &ans=(xxxxxxxx/label1 yyyyyyyy/label2 zzzzzzz/label3) &ans= indicates the answer equals macro. xxxxxxxxx, yyyyyyyyy, zzzzzzzzz are the values to look for from the last answer the user supplied a previous macro in the text. When the user answer matches the value the processing will jump to the section of text with the specified label. label1, label2, label3 are labels you place later on in your text to surround text segments you with to branch to. The labels can be any word you want. You must separate the answer choice and the label by the forward slash character /. Labels are indicated by the { and } symbols. Labels mark the beginning and end of text segments that you can branch to with the ans= macro. Example: Patient &choices(is is not) having pain. &ans=(is/painlab is not/nopainlab) {Painlab} Patient was instructed to go directly to the emergency room of their local hospital. As many lines of text and other macros as you want. {Painlabend} {NoPainlab} Patient was instructed to call our office and make an appointment. {NoPainlabend}

37 Categories 12.1 POP Up List Categories You can make your pop up lists easy to use by setting up simple categories, This way you can click on a category that will let you quickly zero in on what you want. It's easy to set up categories in your pop up lists. Begin a category with the special open-set bracket character, one character to the right of the letter P with a shift. Next, type in your category heading, and then end the heading with the close-set bracket. Then all the lines for the category will follow. To mark the end of the category, you must enter a special end category command. It simply the open set bracket the word end and the close set bracket. Example: {Back} Back pain in Cervical spine Back pain in Lumbar spine Back pain in Thoracic spine Back pain w/ radiation {end}

38 Message Center 13.1 MESSAGE CENTER One of the most power features of EMR is the Message Center. This lets you capture patient and other important office messages, assign them to staff, and save the message along with the resolutions. You can access the Message directly from the Primary Menu, or by using the Tools option then Message Ctr while on the EMR screens. The first time a user enters the Message Center their user id will automatically be added to the list of In Boxes. You can see the list of In Boxes and how many messages each user has, listed on the bottom of the screen. Message Center Overview Message Center is designed to be a central place to create and distribute messages for the entire office. At the same time keep an optional record of all messages received and handled. You can create two general types of messages. 1. Messages regarding existing patients. 2. Messages for any other topic, including new patients that haven't arrived yet

39 Message Center Once you are done with a message you can delete it, or store it. If it's a note regarding an existing patient, it is stored in the patient s historical notes folder. If the note isn't about an existing patient, you can store it in the archive folder for the specific Message Center User. You can also print any message you want to. Each PowerSoftMD user will automatically have a message in box created the first time they access the Message Center display. All in boxes are listed on the bottom of the Message Center screen, along with a count of the number of messages each in box. Since multiple workstations can be adding messages at any time, the message count is automatically updated every 5 minutes. If you wish to refresh the message count at any time, just click the Refresh option. It you leave the Message Center Window idle for more that 1 hour, it will close automatically. Adding New Messages Add a new message by selecting the top menu Add Message option. Then indicate if you want to add a message for an existing patient or for another topic. If you are adding a message for an existing patient, the patient search window will be displayed. Here you can search for patients by name, social security number, account number, birth date, or phone number. Once you find the patient in the list you want, just click on the name, and their name and telephone numbers will be retrieved for you, and a new message will be created. Each new message will have a name consisting of the date and time of day it was created. The format is as follows: yyyymmddhhmmss yyyy is the year, mm the month, dd the day, hh the hour, mm the minutes, and ss seconds. In addition, the current user id will be saved as the person that created the message, along with the date and time. When changes are made to the message, automatically the current user id and date and time will be saved and displayed in the "Updated" fields. Actions List You can create a pop up list of sentences relating to actions taken for messages. Use the Tools option to create and update this list. An example would be; "Doctor called, then patient scheduled appointment." Use the Actions button on the message text window to select from the list

40 Message Center Clear Option The top menu Clear option used to quickly clear all the Message Screen fields. If any changes were made to a previously displayed message, they will be saved before the screen fields are cleared. Data Entry Simply type in the text you want in the message area. You can use the standard windows, insert, delete, cut and paste features. You should also set up shorthand lists. They can be used to pop up a quick list to select complete sentences or phrases that will be added to your message text. Refer to the topic Actions List the topic Short Hand Msgs. You can save your changes by pressing the Save option, or switching functions. Remember, after 1 hour of idle time your last message will be saved and the Message Center program will be closed. Printing It's easy to print a message. Just, display the message, then click the top menu Print option! Refresh Option The top menu Refresh option is used to refresh the message selection list and the in box message counts listed on the bottom of the screen. You can click this option to refresh the information at any time, but the Refresh option will be invoked automatically every 5 minutes. Save Option The top menu Save option will save your latest changes to the message you currently have displayed. Save also updates the Updated User ID, Date, and Time fields, unless the message text field wasn't really altered. This way you can now the last person that changed the message text. Short Hand Msgs You can create two separate Short Hand lists to help enter message text. Use the top menu Tools option to create and revise these lists. 1. Common Short Hand Messages - Short Hand Messages all users might like to use, for example: "Patient Called wants Refill". 2. User Short Hand Messages - Each user can have their own separate list of shorthand text that will be listed right along with the common list

41 Message Center Store Message Option The top menu Store Message option moves the displayed message either to a patient folder, if the message was added for an existing patient. Otherwise, the message is stored in an archival folder for the current user. It's a good idea to store most message regarding patient's, allowing you to keep a complete record of communications. But, if you are sure you don't need the message, for example: "Pizza Hut called to confirm lunch order", you can use the Delete option to get rid of the message without storing it. Switching Users You can switch to any user by simply clicking on the User Id displayed in the in box window. You can also, switch users by selecting the top menu Tools option, then Switch User Id. If you take a message for another person, you can create the message under your User Id, then simply use the Move Message option to place it in the other person's in box. There is no need to switch to their User Id, unless you want to read the message in the other persons in box. Tools The Tools option will let you update pop up lists that can be used to make data entry much faster, and easier. You can create a common list of message statments, for example: "Patient in Pain needs call back". Shorthand lists are designed for the original message text. The Action pop up list is designed to indicate actions taken like; "Called Patient, Schedule Appointment". Then use the button(s) on the message text window to quickly select from your customized list of statements. UnDo Option The top menu UnDo option will restore the Message Text window to the last value you saved for the open message

42 Message Center Deleting Messages If you don't want to keep any record of a specific message you can delete it. First, display the message, then click the top menu Delete Message option. You will be asked if you are sure you want to delete it. If the message is something that you want to keep a record of, use the Store Message option instead. Viewing Historical Patient Messages You can view any messages that were stored for a patient by selecting the patient from the EMR "Electronic Medical Records" desktop. Then select Treatment Notes and press the Message Ctrl Notes button. In Boxes Each PowerSoftMD user will automatically have a message in box created the first time they access the Message Center display. All in boxes are listed on the bottom of the Message Center screen, along with a count of the number of messages each in box contains. Since multiple work stations can be adding messages at any time the message count is automatically updated every 5 minutes. If you wish to refresh the message count at any time, just click the Refresh option. You can quickly switch to the in box of any user by clicking on the user id listed in the in box window. Move Message Option The top menu Move Message option allows you to move a message from one users folder to another. Thus, reassigning the message to another staff member. First, a message must be displayed, then click on the Move Message option and a list of users will be displayed. Simply click on the user id you wish to reassign the message to