EHR v7.3 Release Notes

Transcription

1 EHR v7.3 Release Notes 70 Royal Little Drive Providence, RI Copyright Ingenix. All rights reserved.

2 Document Information Author(s) G.Caldera Release Date 09/23/2011 Date Last Updated 09/27/2011 Version 1.05 Document Control Version Date Changed Completed By Description of Changes /15/2011 G.Caldera First Draft /22/2011 G.Caldera Viewing Results- Removed statement about the Complete button as it is removed from the View Results dialog box. Updated the screenshot to comply with the User Interface (UI) change in the product Patient Communication Method- Updated the method for accessing the Patient Communication field. 4.9 Prescriptions (New Jersey Clients Only) Removed information about the Dispensing field as the functionality is removed from the release. 6.5 Immunization Administrator Maintenance- Added override information needed to access the Immunization Administrator Maintenance application. 7.1 ipad- Added screenshots for clearing cache. 7.2 Internet Explorer 9- Added a screenshot for clearing cache /05/2011 G.Caldera 3.1 Appointments- Updated to include information about the patient information pop-up window and the ability to print the appointment list New Order- Updated information about adding a facility as a favorite from the search results. 6.7 Vital Sign Ranges- Removed the medcin tree to the left of the window. ii of 46 CareTracker EHR 7.3 Release Notes v1.05

3 Document Information Version Date Changed Completed By Description of Changes /12/2011 G.Caldera Before You Begin- Removed pre-requisite information about reinstalling the attachment tool. Added requirement to set up favorite lab tests and order sets again with the help of the new reports provided New Order- Added information about the ability to free type a test name without having to search or select from the favorite list Order Sets- Added information about changes to order sets that include favorite lab and imaging tests. 5.2 Favorite Clinical Orders Provider Report- Updated report name. 5.3 Favorite Order Sets Reports- Added information about the three new reports to help with redefining order sets. 7.3 Internet Explorer 6- Added information about not supporting CareTracker on Internet Explorer /23/2011 G.Caldera Viewing Results- Added a note about the availability of the options Patient Communication Method- Updated the Patient Communication list to include Sent to HealthTracker. 4.8 Progress Note Templates Updated the section with the list of new and updated templates, template changes made for Meaningful Use, and more New Order- Update with the user interface changes to the new order form Adverse Reactions- Updated None-Pt Tolerated Well option in the Adverse Reactions field to Pt Tolerated Well. 7.1 ipad- Updated with additional requirements to run CareTracker on ipad /27/2011 G.Caldera 6.5 Immunization Administrator Maintenance- Updated with the new role required to access the application. 7.1 ipad- Updated with icon changes to the ich text box of a progress note template when accessing CareTracker on an ipad. CareTracker EHR 7.3 Release Notes v1.05 iii of 46

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5 Contents About this Document... 7 Purpose... 7 Before You Begin... 7 Document Conventions Release Highlights Home Module Open Orders Open Orders Action Menu Results Viewing Results Patient Communication Method Clinical Today Module Appointments Patient Information Pop-Up Window Printing the Appointment List Health Record Module Module Name Health Record Module Access (For Multi-Group Companies) Patient Detail Bar Clinical Toolbar Alerts Clinical Alerts: Estimated Gestational Age (EGA) Chart Summary Problem List Lab Results Printing the Chart Summary Chart Viewer Progress Note Templates New Templates Template Changes for Meaningful Use Reporting Additional Features Prescriptions (New Jersey Clients Only) Orders New Order Lab Order Form Lab Compendiums Order Sets Immunizations Immunizations Application Attached and Scanned Immunizations Adding Past or Refused Immunization Information Immunization Writer Updates Adverse Reactions Document Management Upload Problem List Medication Reports Allergies Attached and Scanned Allergies Adding Allergies Allergies Report Reports Module Meaningful Use Quality Measure (QM) Reports Favorite Clinical Orders Provider Report Favorite Order Sets Reports CareTracker EHR 7.3 Release Notes v1.05 v of 46

6 5.4 Medication Sample Given Report Administration Module Module Updates Full EHR Import Favorite Labs Custom Attachment Types Immunization Administrator Maintenance Manage Immunization Lots Application Updates Adding Immunization Lots Vital Sign Ranges Miscellaneous ipad Internet Explorer Internet Explorer Help System vi of 46 CareTracker EHR 7.3 Release Notes v1.05

7 About this Document Purpose This document outlines new and updated features for the 7.3 release of CareTracker Electronic Health Record (EHR) version 7.0. Before You Begin Clear the Cache You must clear your computer and ipad cache at every CareTracker release. Online Help For instructions on clearing your cache, see the following topic in CareTracker Online Help: Support > Support Knowledge Base > How to Clear Cache. Favorite Orders As a result of updates to the Orders application and addition of new compendiums, you must set up your favorite lab and imaging tests via the Orders application. In order to assist you with the setup, CareTracker is providing a report with your favorite lab and diagnostic imaging tests that were set up prior to this release. For more information on the report, see section 5.2 Favorite Clinical Orders Provider Report on page 37. Favorite Order Sets As a result of transitioning to the new CareTracker compendium, laboratory and imaging tests included in your saved order sets will not be available with the release. Therefore, you must redefine the list of order sets that include lab and diagnostic imaging tests. In order to assist you with the setup, CareTracker is providing three reports with order sets defined at the provider, company, and group levels. For more information on the reports, see section 5.3 Favorite Order Sets Reports on page 37. CareTracker EHR 7.3 Release Notes v of 46

8 Document Conventions This document uses the following formatting conventions: Formatting Convention Description Indicates a note about online help, training or support. Indicates an important message or warning. Italics Bold [PLACEHOLDER] Italics are used to denote paths and cross references. Denotes the name of a CareTracker application element, such as a module, application or field name. Currently under development or information unavailable. 8 of 46 CareTracker EHR 7.3 Release Notes v1.05

9 1 Release Highlights Listed in the table below are highlights of the EHR 7.3 release. Table 1 Release Highlights Section Viewing Results on page Progress Note Templates on page Orders on page 22 Description The ability to access the Results section of the Chart Viewer when viewing a result. The ability to group plan items associated with a diagnosis in the patient s note. The Orders application used for entering new orders is redesigned to comply with the new CareTracker standards. Additionally, the application is enhanced with some of the features listed below. Ask at Order Entry (AOE) questions related to a specific test. 5.1 Meaningful Use Quality Measure (QM) Reports on page Immunization Administrator Maintenance on page 39 The ability to pull diagnosis codes directly from a progress note into an order. 12 new Meaningful Use Quality Measure reports are added to help report clinical data required to meet Meaningful Use requirements. The ability to define the list of providers or operators to display in the Administered By list in the Immunization application used for recording new immunizations. 7.1 ipad on page 43 The ability to use CareTracker on ipad. CareTracker EHR 7.3 Release Notes v of 46

10 2 Home Module 2.1 Open Orders The Open Orders application accessed via the following locations is redesigned to comply with the new CareTracker standards. Home module > Dashboard tab > Open Orders link Clinical Today module > Tasks tab > Open Orders link under the Quick Tasks section Additionally, the application includes the following updates highlighted in Figure 1. Figure 1 Open Orders A new Type list is added enabling you to view open orders by type. The types of orders include lab, diagnostic imaging, and procedure. The Test Filter box used for searching orders with a specific test is renamed to Test Keyword. Inactive orders such as orders entered in error are updated to appear dimmed on the window. You can view inactive orders by selecting the Show Inactive check box. The Status and Diag columns are removed, and the Order Type column is renamed to Type. The Print action column is removed. However, you can print the order by clicking the order number. In the Order dialog box, select Print, and then click Save. The ability to sort the list of orders by clicking the Sort icon next to each column. The Due Date column displays Stat if the urgency of the new order you create is set to Stat. The Complete check boxes are moved to the left of the list, enabling you to select one or more orders to mark as complete. Open orders with multiple tests are indicated with an Expand icon. You can click the Expand icon to view tests included in the order, and mark individual tests on an order as complete. A new Note icon is added enabling you to move the pointer over to view notes pertaining to the open order. However, the Note icon is unavailable if notes were not recorded for the order. The Enter Manual Results and Link to Result action columns are removed and grouped under the Arrow icon with additional action items. For information on the Open Orders Action menu, see section Open Orders Action Menu on page of 46 CareTracker EHR 7.3 Release Notes v1.05

11 The ability to pull the patient associated with the order into context when the order is clicked Open Orders Action Menu The Open Orders application is updated with a new actions menu that is accessed by pointing over the Arrow icon. Table 2 describes the tasks you can perform via the Actions menu. Table 2 Open Orders Actions Menu Action Image Enter Results Copy Order Link to Result Description Opens the Document Viewer if the order is scanned or attached to the patient s health record and is marked as an open order during upload. Opens the Enter Result dialog box enabling you to enter results manually. Opens the Copy Order dialog box enabling you to make a copy of the order. Opens the Links to Result dialog box enabling you to link the order to a result. Online Help For information on the Open Orders application, see the following chapters in CareTracker Online Help: Home Module > Dashboard > Clinical > Open Orders, or Clinical Today Module > Tasks > Open Orders. 2.2 Results The Results application accessed via the Dashboard, Clinical Today module, and Health Record module is updated with the items listed below Viewing Results The Test Results dialog box that displays detail information about a result is updated with the following items: The View Chart button and the Activity Log icon are replaced with an Arrow icon next to View enabling you to access the patient s health record and the clinical log. A Chart Viewer option is added to the View menu enabling you to directly access the Results section in the Chart Viewer. This helps reduce the number of clicks required when accessing results through the Chart Summary. Note: If the result is accessed via the patient s health record, the Medical Record option is unavailable. If the result is accessed via the Chart Viewer, the Chart Viewer option is unavailable. To access the Test Result dialog box, click the result you want from the Result application. CareTracker EHR 7.3 Release Notes v of 46

12 Figure 2 Results: Test Results Dialog Box Patient Communication Method A new field is added enabling you to select the patient communication method used for sending the results that are reviewed and committed to the patient s health record. Patient communication methods include the following: No patient communication required Mailed result to patient Called patient with result Discussed with patient Sent to HealthTracker You can select the communication method when you click Commit & Add Comment to commit the result to the patient s health record. 12 of 46 CareTracker EHR 7.3 Release Notes v1.05

13 Figure 3 Results: Patient Communication Method List When the result is committed to the patient s health record, CareTracker displays the patient communication method selected in the Results application of the Health Record module. Additionally, the patient communication method displays when you print the list of results by clicking Print on the Clinical toolbar. Online Help For information on the Results application, see the following chapters in CareTracker Online Help: Home Module > Dashboard > Clinical > Results, Clinical Today Module > Tasks > Results, or Health Record Module > Results. CareTracker EHR 7.3 Release Notes v of 46

14 3 Clinical Today Module 3.1 Appointments In order to allow practices to include or exclude certain appointment types from Meaningful Use reporting, CareTracker is providing the ability to link specific encounter types to appointments. You can associate an appointment with an encounter via the Appointment Types application in the Administration module. If an appointment is accessed via the appointment list in the Clinical Today module, and the appointment type is linked to an encounter, CareTracker triggers the encounter associated with the appointment type. If the appointment type is not linked to an encounter, CareTracker triggers the default encounter type set in the Encounter Types application of the Administration module. Note: For more information on linking an appointment type to an encounter, see the CareTracker Practice Management v7.3 release notes. Additionally, the Appointments application accessed via the following locations is updated with the ability to view patient information in a pop-up window and the ability to print the appointment list. The Appts button on the Name Bar The Appointments link on the Practice Dashboard The Appointments tab in the Clinical Today module Patient Information Pop-Up Window The Appointments application is updated to display a pop-up window when the pointer is placed over the patient s name. The pop-up window displays the following information: Patient s address and phone numbers Balance Unapplied payments Insurance, subscriber and group numbers Insurance balance and copay amounts Printing the Appointment List The Appointments application is updated with the ability to print a detailed report of all the appointments displayed by clicking the Print Appointments link above the appointment list. The report includes detailed appointment, patient, financial and insurance information. Online Help For information on the Appointments application, see the following chapter and topics in CareTracker Online Help: Clinical Today Module > Appointments, Home > Dashboard > Practice > Appointments or Name Bar > Viewing Appointments. 14 of 46 CareTracker EHR 7.3 Release Notes v1.05

15 4 Health Record Module 4.1 Module Name The Medical Records module is renamed to Health Record. 4.2 Health Record Module Access (For Multi-Group Companies) The Health Record module is updated with the ability to allow multi-group companies to view only group specific information entered in the following applications of the Health Record module. Orders Vital Signs Support: To set the above applications to display only group specific information, log a ToDo to the Support entity. This results in displaying group specific orders and vital information in the Chart Summary, Chart Viewer, and reports generated by clicking Print toolbar. on the Clinical When the above applications are set to display group specific information, CareTracker displays a Break the Glass icon on the Patient Detail Bar of the Health Record module. You can click the Break the Glass icon to access the patient s entire health record that includes orders and vital data recorded in all groups. However, you can access the entire health record only during the current CareTracker session. If you want to view information from all groups at a different CareTracker session, you must click the Break the Glass icon again. Figure 4 Health Record Module: View Entire Chart Note: To access a patient s entire record, you must have the Break the Glass-Group Specific Access override added to your role. To add the override to your role, contact your Practice Administrator. CareTracker EHR 7.3 Release Notes v of 46

16 4.3 Patient Detail Bar The Patient Detail Bar is updated to comply with the new CareTracker standards and includes the following updates: The patient name is updated to display in the following format: last name, first name (preferred name). The format for displaying the age for pediatric patients is updated as described in the table below. Table 3 Pediatric Patients: Units of Measure for Age Age Birth to 6 days Units of Measure Age is measured in days and is indicated with a d. 7 days to 1 month Age is measured in weeks and days, and is indicated by "wks" or "wk/d. 1 month to 36 months Age is measured in months and weeks, and is indicated by "mos," "mo/wks" or "wk." 3 years to 21 years Age is measured in years and months, and is indicated by yrs, "yr/mos" or mo. Note: The patient s age in the Chart Viewer is displayed in the same format described above. A new Patient Information icon is added to the left of the patient s name enabling you to view a summary of information pertaining to the patient. You can click the View complete Patient Information link on the lower right corner to view a read-only window that includes more details pertaining to each category of information. The Camera icon is removed from the Patient Detail Bar. However, you can click Info on the Clinical toolbar to view all of the patient information, including the patient s picture, if available. The alerts are now accessible by clicking the Alert icon to the left of the patient s chart number. For more information on alerts, see section 4.5 Alerts on page 17. The tooltips on the Patient Detail bar items are removed in order to support CareTracker access on the ipad. For example, if you now want to view a summary of the patient s medication list from the Patient Detail bar, you must click instead of moving the pointer over the Medications link. The Complete Screening icon is moved to the Clinical toolbar. Online Help For information on the Patient Detail Bar, see the following topic in CareTracker Online Help: Health Record Module > Patient Detail Bar. 4.4 Clinical Toolbar The Info button currently available on the Name Bar is also added to the Clinical toolbar. You can click Info to view a read-only window that includes more information pertaining to the patient. The information is organized based on the type of information and includes insurance, referral and authorization, appointment information, and more. The Chart Summary button is removed. 16 of 46 CareTracker EHR 7.3 Release Notes v1.05

17 The Chart Viewer button is added to the Clinical toolbar enabling you to access the patient s Chart Viewer while you are documenting the patient's progress note. The ToDo(s), Patient Education, and Visit buttons on the Clinical toolbar are replaced with new buttons. The tooltip on each Clinical toolbar button is removed in order to support CareTracker access on the ipad. However, the buttons on the Clinical toolbar are now named for easy identification. Online Help For information on the Clinical toolbar, see the following topic in CareTracker Online Help: Health Record Module > Clinical Toolbar. 4.5 Alerts The clinical and patient care management alerts that were previously accessed via the Patient Detail Bar are now moved to the Clinical Alerts dialog box. The Clinical Alerts dialog box is accessed by clicking the Alert icon to the left of the patient s chart number. The Clinical Alert dialog box consists of three types of alerts as described in the table below. Table 4 Alert Categories Alert Category Clinical Alerts Patient Care Management Alerts Clinical Notes Description The clinical alerts are categorized to display alerts pertaining to patient allergies, medications, diagnoses, and more. Displays alerts when important health maintenance and disease management items are overdue for the patient. Displays clinical notes entered in the Demographic application of the Patient module Clinical Alerts: Estimated Gestational Age (EGA) For OB/GYN practices, EGA alerts are included in the clinical alerts. The EGA displays in the alerts if a patient has V22.0-V22.2, V23.0-V23.5, V23.7-V23.9, V23.41, V23.49, V23.81-V23.86, or V23.89 recorded as an active diagnosis. Support: To display the EGA in the clinical alerts when the above listed active diagnoses are recorded, log a ToDo to the Support entity. 4.6 Chart Summary The Chart Summary is enhanced with the following updates: Problem List The problem list is updated to display the date the diagnosis was first recorded for the patient Lab Results The unsigned results now displays in the Results section in addition to the Open Activities section of the Chart Summary. CareTracker EHR 7.3 Release Notes v of 46

18 4.6.3 Printing the Chart Summary The Powered by CareTracker statement is removed from all printed chart summaries including the formal health record. Additionally, if you print a chart summary or formal health record for the last encounter, the reports are updated to include all active problems, medications, and allergies pertaining to the patient. To print a chart summary report or the formal health record report, click Chart Summary in the Patient Health History pane, and then click the arrow next to Print on the Clinical toolbar. From the drop-down menu, click the report you want to print. Online Help For information on the Chart Summary, see the following chapter in CareTracker Online Help: Health Record Module > Chart Summary. 4.7 Chart Viewer The Chart Viewer is updated to include applications accessed via the Patient Health History pane that are currently not available. The new applications that are included in the Chart Viewer are Vital Signs, Progress Notes, Encounters, Orders, Referrals, History, and Correspondence. This avoids having to leave a progress note to access these applications. 4.8 Progress Note Templates The templates accessed by clicking Progress Note on the Clinical toolbar include the following updates: New Templates This release includes the new templates listed below. Medicare Wellness Visit Cardiac Stress and Stress Echo Cardiac Stress Nuclear Carotid Artery Evaluation Template Changes for Meaningful Use Reporting The new Estimated Date of Conception field will be added to the EDD tab on the OB templates to support the Quality Measure NQF Screening for Human Immunodeficiency Virus. The Medical History and Social History section on the History tab will be updated to include the following fields to support the new Meaningful Use QM Reports. Medical History: Cardiac Pacer Y N Terminal Illness Y N Progressive Neurological Disorder Y N 18 of 46 CareTracker EHR 7.3 Release Notes v1.05

19 Social History: Birth Control Device Insertion Date The Quality Measure tab on all global templates will be updated with eleven additional fields to support the New Meaningful Use QM Reports and the Depression Screening section will be removed as these fields do not currently support any of the Meaningful Use QM Reports Additional Features The scroll bar is removed from the multi-select drop-down lists available in templates. This enables you to view all options including the Save & Close option that allows you to save your multiple selections in the drop-down list. Figure 5 Progress Note: Drop-Down List The ability to cite lab results in the patient s progress note. You can view the patient's recent lab results while in a template and indicate the lab results that were reviewed with the patient. All results marked as reviewed are saved under the Results Reviewed with Patient section in the narrative with pertinent information. The ability to group plan items and diagnoses. For example, if two diagnoses and two plan items are selected, the information lists the two diagnoses first followed by the two plan items indicating that the selected plan items pertain to the two diagnoses. You can click the Diagnosis/Assessment header in the narrative to do the following: Change the order in which the diagnoses display in the note. Link multiple plan items to diagnoses. CareTracker EHR 7.3 Release Notes v of 46

20 Figure 6 Progress Note: Diagnosis and Plan Important: The Option 3 w A&P tool template is added to some specialties to include the ability to document a plan per assessment and cite results. The specialties that include the new template are Internal Medicine, Family Medicine, Pediatrics, GYN, Cardiology, Dermatology, ENT, Gastroenterology, Neurology, Podiatry, Rheumatology, and Surgery. The ability to display only referrals created during the current encounter in the narrative. The ability to display information recorded via the Immunization Writer application in the Immunizations Given Today section of the narrative. The information includes lot number, administered date, expiration date, series, Date VIS given to patient, and dosage. Note: To display detailed information about immunizations administered, log a ToDo to the Support entity. The ability to display in the narrative the growth, height, and head circumference percentiles calculated for children via the Flowsheet application. Listed below are the progress note templates that include the percentile values: Table 5 Templates with Percentile Values Specialty Template Family Medicine FP OV Option 3 FP OV Option 3(v1) FP OV Option 3(v2) FP OV Option 3(v3) FP OV Option 3(v12) 20 of 46 CareTracker EHR 7.3 Release Notes v1.05

21 Specialty Template FP OV Option 4(v1) FP OV Option 4(v2) FP OV Option 4(v9) Pediatrics FP OV Option 4(v17) 1 Week Well Child Visit 1 Month Well Child Visit 2 Week Well Child Visit 2 Month Well Child Visit 4 Month Well Child Visit 6 Month Well Child Visit 9 Month Well Child Visit 12 Month Well Child Visit 15 Month Well Child Visit 18 Month Well Child Visit 2 Year Well Child Visit 2.5 Year Well Child Visit 3 Year Well Child Visit 4 Year Well Child Visit 5-6 Year Well Child Visit 7-8 Year Well Child Visit 9-10 Year Well Child Visit Year Well Child Visit Year Well Child Visit Pediatric OV Option 3(v1) Pediatric OV Option 4(v1) The ability to return to the Chart Summary by clicking the Return to Chart Summary link while in the Progress Note application. Figure 7 Progress Note: Return to Chart Summary Link CareTracker EHR 7.3 Release Notes v of 46

22 Online Help For information on templates, see the following chapter in CareTracker Online Help: Health Record Module > Progress Note Templates. 4.9 Prescriptions (New Jersey Clients Only) The state of New Jersey requires you to use the New Jersey Prescription Blank (NJPB) form when printing prescriptions including prescriptions for controlled substances. Therefore, CareTracker has enhanced the Rx writer feature enabling you to print a prescription on three different versions of the New Jersey Prescription Blank (NJPB) form. The three versions are based on the provider type and include a version for a Physician (MD or DO), Physician Assistant (PA), and Nurse Practitioner (NP). You can order the approved versions of the NJPB form from Micro Format, Inc at Additionally, the New Jersey legislation also requires that all printed prescriptions have a handwritten signature. Therefore, the ability to include a digital signature on printed prescriptions is not available for NJ clients. Support When you receive the ordered Rx form, log a To Do to the Support entity to attach the form to the group or the provider. Online Help For information on prescriptions, see the following chapter in CareTracker Online Help: Health Record Module > Medications/Prescriptions > Prescriptions (Rx) Orders New Order The Order application accessed by clicking Orders on the Clinical toolbar is updated to comply with the new CareTracker standards and includes the following updates highlighted in Figure of 46 CareTracker EHR 7.3 Release Notes v1.05

23 Figure 8 Order: Entering a New Order The Patient Information bar is added at the top of the dialog box. The order status is added at the top of the dialog box. Additionally, a Mark Order Inactive check box is added enabling you to mark an order as inactive. The Radiology order type is renamed to Diag.Imaging. The Ordering Physician list is updated to default to the provider associated with the encounter. However, you can select a different provider if necessary. All facilities that previously displayed are removed from the Facility list. Instead, the Facility list displays the provider s favorite facilities. You can click the new Search icon to search for a facility, and add a facility from the search results to the favorite list by clicking the Add as Favorites icon. When a facility is added to the favorite list, CareTracker displays the On Favorites icon indicating that the facility is in the favorite list. Note: Each facility location is associated with a compendium supported by CareTracker. For more information on lab compendiums, see section Lab Compendiums on page 27. Therefore, when you select a facility for an order, CareTracker displays tests and associated Ask at Order Entry (AOE) questions based on the compendium associated to the facility location. However, if you do not select a facility when you create a lab order, CareTracker displays tests and associated AOE questions from the CareTracker master compendium. CareTracker EHR 7.3 Release Notes v of 46

24 Figure 9 Order: Facilities Search Dialog Box Note: You can search for a facility by name, city, or state. However, if you are searching by name, you must enter at least two characters in the Name box. The CC to Provider field is renamed to Copy Result To. Note: The Copy Result To list includes all providers in the group, the patient s active providers, and providers listed in the Refer Provider From and Refer Provider To lists in the Quick Picks application of the Administration module. If you select a provider from the search results, CareTracker displays the provider name under the Current Encounter section in the Copy Result To list. The Provider Search dialog box accessed by clicking the Search icon next to the Copy Result To list is updated to comply with the new CareTracker standards. Figure 10 Order: Provider Search Dialog Box The Current Encounter Diagnoses and Other Patient Diagnoses sections are replaced with a Diagnosis list. The Diagnosis list consists of two sections. The Current Encounter section contains any ICD-9 codes that are selected within the progress note or selected from the search result list, and displays at the top of the list. The Other section contains all active diagnoses on the patient's problem list. The Add Diagnosis button is replaced with a Search icon next to the Diagnosis list. The Diagnosis Search dialog box is updated to comply with the new CareTracker standards. You can search for a diagnosis by ICD-9 code or Keyword(s). 24 of 46 CareTracker EHR 7.3 Release Notes v1.05

25 Figure 11 Order: Diagnosis Search Dialog Box A Patient Note box is added enabling you to enter notes you want to display about the order in the order form. The ABN field is renamed to ABN given to Pt, and includes Yes and No options. A new Coll. Date & Time field is added enabling you to record the date and time for collecting the specimen. The Time of Day list is added enabling you to record the time for completing the order. The Frequency option is added enabling you to indicate if the order is a single order or must be repeated. If the frequency is set to Repeat, CareTracker displays the Test Frequency dialog box enabling you to record additional details about the tests that must be repeated. Figure 12 Order: Test Frequency Dialog Box Note: The fields in the Test Frequency dialog box is based on the frequency selected. You can select Daily, Monthly, Weekly, or Yearly from the Frequency list. The Test section is renamed to New Test. The section displays the favorite tests for the order type, provider, and facility selected. Additionally, you can add a test by entering the test name in the box, and clicking Add Test. This allows you to enter a test name you want without having to search or select from the favorite list. Note: If a facility is not selected and the Order Type is set to Lab, CareTracker searches the default master compendium and displays the favorite tests defined in the Favorite Tests dialog box. A new Order Test Search dialog box is added enabling you to search for a test when you click the Search icon in the New Test section. The Search For list defaults to the order type selected and displays tests pertaining to the order type. CareTracker EHR 7.3 Release Notes v of 46

26 Note: When searching for a test, CareTracker searches the compendium associated with the facility. Figure 13 Order: Orders Test Search Dialog Box The Manage Favorites link is replaced with a Manage Favorites icon in the New Test section enabling you to maintain a list of favorite tests. Note: You must always have an order type selected in order to view tests pertaining to the order type. Important: As a result of updates to the Orders application and addition of new compendiums, you must set up your favorite lab tests again via the Orders application. In order to assist you with the setup, CareTracker is providing a report as a reference with your favorite lab and diagnostic imaging tests that were set up prior to this release. For more information on the report, see section 5.2 Favorite Clinical Orders Provider Report on page 37. The Additional Fields link is renamed to Custom Order Questions. The Custom Order Questions link enables you to enter additional information pertaining to the test ordered. Note: The Custom Order Questions link is disabled if the facility selected has a lab specific compendium associated with it, for example Lab Corp. However, if the facility does not have a lab specific compendium associated with it, and additional fields are defined via the Order Questions application, the Custom Order Questions link is enabled. To access the Order Questions application, click the Administration module, Clinical tab, and then click the Order Questions link. Ask at Order Entry (AOE) represent questions you must provide to the lab when sending an order electronically, or submitting a printed order. The AOE questions are based on the compendium associated with the facility and the test selected. For more information on lab compendiums, see section Lab Compendiums on page 27. Note: By default, a test that is a part of the CareTracker compendium includes the fasting information as part of the AOE questions. The Test Notes link is replaced with a Test Note box. The Add button is renamed to Add Test. You can click Add Test to add the selected test to the Tests Summary section. You can edit, view notes pertaining to the test, or remove a test from an order when added to the Tests Summary section. The action buttons at the bottom of the dialog box is replaced with radio buttons and a Mark Complete check box. The Action buttons are described in the table below. Table 6 Order Actions Action Send Description Saves the order in the Orders section of the patient s health record and the Open Orders application of the Home and Clinical Today modules. Additionally, the order is send to the selected facility electronically. Note: The Send option is enabled only if an order interface is set up for the selected facility and your practice. 26 of 46 CareTracker EHR 7.3 Release Notes v1.05

27 Action Print Fax ToDo Record Mark Complete Description Saves the order in the Orders section of the patient s health record and the Open Orders application of the Home and Clinical Today modules. Additionally, the order opens in a PDF enabling you to print. If an order has multiple tests, CareTracker prints all tests at once. Saves the order in the Orders section of the patient s health record, and the Open Orders application of the Home and Clinical Today modules, and faxes the order to the facility. Note: Only the order form is sent to the facility. Additionally, a default fax number displays if the fax number is entered in the Favorite Labs application of the Administration module. If a fax number is not available for the lab, you must select the fax number from your address book. Saves the order in the Orders section of the patient s health record and the Open Orders application of the Home and Clinical Today modules. Additionally, the order is attached to a ToDo to send to a person or queue. Saves the order in the Orders section of the patient s health record and the Open Orders application of the Home and Clinical Today modules. Marks the selected tests or the entire order as complete. Note: By default, selecting the Mark Complete check box, selects check boxes pertaining to all tests included in the order Lab Order Form The Lab Order form is reformatted and includes the following changes. Location, account number, and fax number of the facility Due date for the order The CC Results To section is renamed to Send Copy of Report to, and includes the address of the provider receiving the copy of the result. You can print the order form when creating an order by selecting Print, and then clicking Save Lab Compendiums In order to comply with the government mandated standards and support Meaningful Use, the CareTracker compendium is updated to only include LOINC (Logical Identifiers Names and Codes) order codes. LOINC codes are universal identifiers for laboratory test orders. By utilizing LOINC order codes, you can share a patient's health record electronically via a Continuity of Care Document (CCD) or through a Healthcare Information Exchange (HIE). Additionally, the lab specific order codes are uploaded into CareTracker for Lab Corp, Quest, and Care New England. Note: As a result of transitioning to the new CareTracker compendium, you must recreate your favorite test list. The favorite test list is based on the order type, provider and facility selected. In order to help with this transition, CareTracker is providing a report with your favorite lab and diagnostic imaging tests that were set up prior to this release. To access the report, click the Reports module, and then click the Other Reports link under the Medical Reports section. In the Report list, click Global-Favorite Clinical Lab Tests by Provider. CareTracker EHR 7.3 Release Notes v of 46

28 Tip: You can create a list of favorite tests for one provider, and then use the Copy Provider Favorite application in the Administration module to copy the list of tests to other providers in your practice. Online Help For information on creating new orders, see the following chapter in CareTracker Online Help: Health Record Module > Orders > New Orders Order Sets As a result of transitioning to the new CareTracker compendium, laboratory and imaging tests included in your saved order sets will not be available with the release. In order to manage this transition, CareTracker is providing three reports with order sets that were set up prior to this release. You can use the reports to redefine your order sets with lab and imaging tests. For more information on the report, see section 5.3 Favorite Order Sets Reports on page Immunizations Immunizations Application The Immunization application accessed by clicking Immunizations in the Patient Health History pane is redesigned to comply with the new CareTracker standards. Additionally, the application includes the following updates highlighted in Figure 14 to improve the efficiency of maintaining a complete list of a patient's immunizations. Figure 14 Immunizations Application The Add Past/Refused Vaccination button is renamed to +Add Past/Refused Immunization. You can click +Add Past/Refused Immunization to record information about immunizations administered in the past and immunizations refused by the patient. For information on adding past and refused immunization, see section Adding Past or Refused Immunization Information on page 29. The Adult Immunization Schedule and the Child Immunization Schedule buttons are replaced with the Adult and Child links. You can click the links to access the Center for Disease Control (CDC) web site to obtain the recommended information on immunization schedules. Inactive immunizations such as immunizations entered in error are updated to appear dimmed on the window. You can view inactive immunizations by selecting the Show Inactive check box. The ability to quickly identify immunizations that are refused. The refused immunizations are now indicated with a Yes under the Refused column. You can move the pointer over Yes to view the refusal reason. 28 of 46 CareTracker EHR 7.3 Release Notes v1.05

29 The Log icon used for tracking activity related to recorded immunizations is replaced with a new Log icon. By default, the immunization list is sorted by the immunization administered date. However, you can sort the list of immunizations by clicking the Sort icon in the Immunization, CPT, Date, and Admin Provider columns Attached and Scanned Immunizations A new section is added to the right of the Immunization window enabling you to view information about immunizations that are uploaded or scanned via the Document Management Upload application. The list is sorted based on the document date entered when uploading or scanning the document. You can move the pointer over the document to view a summary of the immunization. Additionally, you can click the scanned or attached document to open in the Document Viewer. Figure 15 Immunizations: Documents Section (Attached or Scanned Immunizations) Online Help For information on uploading and viewing documents, see the following chapter in CareTracker Online Help: Health Record Module > Document Upload and Batch Scanning or Name Bar > Document Management (Doc Mgt) Adding Past or Refused Immunization Information The Patient Immunization dialog box used for recording a patient s past and refused immunization details is updated with the following items highlighted in Figure 16. CareTracker EHR 7.3 Release Notes v of 46

30 Figure 16 Immunizations: Adding a Past or Refused Immunization The Patient Information bar is added at the top of the dialog box. The ability to search for an immunization by CPT code or keyword using the new Immunization Search dialog box. To access the Immunization Search dialog box, click the Search icon next to the Immunization box. The Administered By and Ordering Provider fields are added enabling you to record information about the person who administered and/or ordered the immunization. The Administered By list is defined via the Immunization Administrator Maintenance application in the Administration module. For information on Immunization Administrator Maintenance, see section 6.5 Immunization Administrator Maintenance on page 39. The Refusal Date and Refusal Reason fields are now displayed in the Immunization Refused dialog box. The Immunization Refused dialog box displays when Refused is set to Yes. Figure 17 Immunizations: Immunization Refused The ability to record administration details pertaining to the immunization in the Administration section. All State Departments of Health require reporting the amount of an immunization administered in milliliters (ml). Therefore, the previous Amount list is replaced with the Amount box requiring you to indicate all amounts administered in milliliters (ml). Note: CareTracker will maintain and display different measurement units you selected for immunizations that were recorded prior to this release. The options in the Site list are updated to display in alphabetical order. 30 of 46 CareTracker EHR 7.3 Release Notes v1.05

31 The Adverse Reactions field is updated to a list box enabling you to select one or more adverse reactions associated with an immunization administered in the past. For information on additional updates to the Adverse Reactions field, see section Adverse Reactions on page Immunization Writer Updates The Immunization application accessed by clicking Immunizations on the Clinical toolbar helps record information about immunizations administered. The application includes the following updates highlighted in Figure 18. Figure 18 Immunization Writer The Admin Provider list is renamed to Administered By. The Administered By list is defined via the Immunization Administrator Maintenance application in the Administration module. For information on Immunization Administrator Maintenance, see section 6.5 Immunization Administrator Maintenance on page 39. The Lot Number field is updated enabling you to view the CPT description of the immunization associated with the lot when you move the pointer over the lot number. All State Departments of Health require reporting the amount of an immunization administered in milliliters (ml). Therefore, the Amount list with different measurement units is replaced with the Amount box requiring you to indicate all amounts administered in milliliters (ml). Note: CareTracker will maintain and display different measurement units you selected for immunizations that were recorded prior to this release. The options in the Site list are updated to display in alphabetical order. The Adverse Reactions field is updated to a list box enabling you to select one or more adverse reactions associated with an immunization administered in the past. For information on additional updates to the Adverse Reactions field, see section Adverse Reactions on page 31. CareTracker EHR 7.3 Release Notes v of 46

32 Adverse Reactions The Adverse Reactions filed is updated enabling you to select one or more reactions associated with an immunization administered. By default, the list displays Pt Tolerated Well indicating the patient had no adverse reaction. However, if the patient had one or more reactions, select the pertinent check boxes. If another reaction is selected, the Pt Tolerated Well check box is deselected automatically. Additionally, the following updates are made to the Adverse Reactions field. The Redness/Swelling option is now available as two separate options that include Redness and Swelling. The Altered Heart Pain option is removed, and the Altered Heart Rate option is added. Online Help For information on Immunizations, see the following chapter in CareTracker Online Help: Health Record Module > Immunizations Document Management Upload The Document Management Upload application is enhanced to include Referral as a clinical sub type. This enables you to assign documents attached or scanned as a clinical-referral type to save in the Referrals application in the Health Record module. To access the Document Management Upload application via the Health Record module, click Attachments on the Clinical toolbar. Figure 19 Document Management Upload: Clinical Sub-Type 4.14 Problem List The Problem List application accessed by clicking Problem List in the Patient Health History pane includes the following updates: The Diagnosis Date column is renamed to Last Diagnosis Date. The Original Date column displays the date the diagnosis was first recorded for the patient. The Problem List report is updated to display No Known Problems when you have confirmed that the patient does not have active diagnoses. To confirm that the patient has no active diagnoses, click Confirm No Known Problems in the Problem List application. To print the Problem List report, click Problem List in the Patient Health History pane, and then click the arrow next to Print Active Problem List. on the Clinical toolbar. From the drop-down menu, click 32 of 46 CareTracker EHR 7.3 Release Notes v1.05

33 Online Help For information on the problem list, see the following chapter in CareTracker Online Help: Health Record Module > Problem List Medication Reports All Medication reports are updated to display No Known Medications when you have confirmed that the patient does not have active medications. To confirm that the patient has no active medications, click Confirm No Known Meds in the Medications application. To print a medication report, click Medications in the Patient Health History pane, and then click the arrow next to Print on the Clinical toolbar. From the drop-down menu, click the report you want to print. Online Help For information on medication reports, see the following topic in CareTracker Online Help: Health Record Module > Medications/Prescriptions > Printing the Medication List Allergies The Allergies application is redesigned to comply with the new CareTracker standards and is streamlined to improve the efficiency of maintaining a complete list of a patient's allergies. The application is accessible by clicking Allergies in the Patient Health History pane. Additionally, the application includes the following updates highlighted in Figure 20. Figure 20 Allergies: Application Updates The ability to view the name of the operator, date and time the allergy list is reviewed. To mark the allergy list as reviewed, you must click the Confirm No Known Allergies or the Mark Reviewed button. Note: The allergy list in the Chart Viewer and the Allergies application displays No known Allergies until an allergy is added. The Add Allergy button is renamed to +Add Allergy. You can click +Add Allergy to record past and current allergies pertaining to the patient. For more information on adding allergies, see section Adding Allergies on page 34. Inactive allergies such as allergies entered in error or the patient is no longer suffering from are updated to appear dimmed on the window. You can view inactive allergies by selecting the Show Inactive check box. A new Note icon is added enabling you to move the pointer over the icon to view notes pertaining to an allergy. However, the Note icon is unavailable if notes were not recorded for the allergy. Contra indications triggered when recording an allergy is displayed when you click the new Interaction icon. Interactions display as a read-only window with override reasons and notes entered during the screening. However, the Interaction icon is unavailable if CareTracker EHR 7.3 Release Notes v of 46