axium User Guide University of Minnesota School of Dentistry axium User Guide Updated 9/20/2010 Page 1 of 61

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1 axium User Guide University of Minnesota School of Dentistry axium User Guide Updated 9/20/2010 Page 1 of 61

2 Table of Contents Searching for and Selecting Patient Records... 1 Rolodex Options... 2 Electronic Health Record... 3 Treatment History Tab and Odontogram Overview... 4 Completing Start Checks... 5 Updating Medical Alerts... 6 Approvals... 7 Approving Medical Procedures... 9 Chart Existing Findings and Conditions Entering Medical History...13 Updating Health History...14 Completing Electronic Forms Using Treatment-Specific Forms (Implant Tracking) Periodontal Resident/Faculty Perio Charting Entering Progress Notes Express/Chart Add Treatment Entry Creating Treatment Estimates Treatment Plan Entry Phasing and Sequencing Selecting a Plan Option for Faculty Approval and Acceptance Treatment Updates - Multiple Appointments Completing Planned Treatments Entering Treatment Plan Consult Notes Entering Medical Procedures Entering Treatment on Behalf of Another Provider Adjusting Treatment Fees Appointments and Schedules Viewing Appointment Information - Residents Entering Appointment Requests Undergraduate Dental Students Scheduling Appointments Residents (as applicable) Chart Management Creating a Chart Request Report Checking Out Charts for Individual Requests Scanning Charts In Chart Transfers Release a Chart for Check Out Duplicating Patient Records Entering Duplicate Record Charges Dispensary Creating a Daily Appointment List Checking Out Dispensary Items Checking In Dispensary Items Managing Unreturned Dispensary Items Billing Providers for Dispensary Items ii

3 Searching for and Selecting Patient Records Overview Searching for and selecting a patient record in the Rolodex module is the first step that must be completed before accessing a patient's electronic health record (E.H.R.) or account (Transactions) information. Searches can be completed using either the patient's last name or chart number. A name or chart number should always be entered before searching the Rolodex. Leaving the search field blank will search the entire database and may cause the system to lock. Once a record is selected, it will remain selected for the rest of the day. During an overnight process, records are deselected automatically. Search for and Select a Patient Record 1. Click the ROLODEX icon 2. Enter the patient's last name or the chart number in the SEARCH (blank middle) field 3. Press <ENTER> on your keyboard 4. Double-click the patient record in the RESULTS LIST (bottom grid) so that it is listed in the NOTEPAD 5. Click the applicable module icon (for example, ELECTRONIC HEALTH RECORD or TRANSACTIONS) 6. Make sure the patient's name and chart number appear at the top of the module Selecting a patient record 1

4 Electronic Health Record User Guide Rolodex Options Once a patient record has been selected, there are several right-click shortcuts that may be helpful. Select the patient record in the notepad, then right-click. Deselect All - removes all patient records from the notepad Hold patient in list - keeps patient record in the notepad so that it is not removed during the overnight process Patient Approvals - opens the Patient Approvals window Appointment request - opens a new appointment request window Chart request - chart requests are automatically entered when appointments are scheduled. Chart requests can also be entered manually using this right-click option Rolodex shortcuts for providers 2

5 Electronic Health Record Treatment Entry Overview There are two ways of entering treatment in the Electronic Health Record (E.H.R.): Express Entry/Chart Add tab - individual treatments are entered in the applicable status (planned, in process or completed). Treatment Plan module/tx Plan tab - includes several subtabs for treatment entry, including problems, diagnoses and plan options. The majority of undergraduate treatment entry (and some resident groups) uses the treatment plan module. Once a treatment plan is entered, approved and accepted by the patient, the treatments are managed on the TX HISTORY tab. Undergrads may have situations (such as emergencies) where using the CHART ADD tab to enter treatments may be more efficient. Undergrad dental and hygiene students should always check with a faculty member before using the CHART ADD tab method, as the faculty member may advise that a new treatment plan be created. The majority of resident and faculty practice treatment entry uses the EXPRESS ENTRY/CHART ADD tab. Charting is always completed using the CHART ADD tab. Treatment entry in the E.H.R. 3

6 Electronic Health Record User Guide Treatment History Tab and Odontogram Overview In the electronic health record, the TX HISTORY tab shows treatment, appointment and note history for a patient. All history can be viewed, or the view can be filtered so that only specific information is listed. The odontogram is an electronic intraoral chart that shows the most recent condition and treatment information for a site or surface. Only the most recent information is shown on the odontogram. Previous history can be viewed by clicking the history (sundial) button and selecting a date, which will show the odontogram as of the selected date. The Tx History tab and odontogram should be used together when viewing a patient's history; it may be most helpful to sort the TX HISTORY tab by site when reviewing history (click the SITE column heading to sort by site). Tx History tab Odontogram 4

7 Electronic Health Record (EHR) Completing Start Checks Overview When a treatment with an undergraduate provider is scheduled, a start check alert will appear at the bottom of the axium window, thirty minutes before the appointment time, when that provider logs in to axium. Approving a Start Check 1. Click the red or yellow highlighted alert at the bottom left of the axium desktop. The Appointment Start Check window will open. 2. Review the list of treatments in the right pane (these are the appointed treatments) 3. To add planned treatments to the appointment, double-click them in the left pane to move them to the right pane 4. Once the start check is approved, click the APPROVE button 5. Faculty members can swipe their U-Card or enter their ID and password Approving Start Checks 5

8 Electronic Health Record User Guide Updating Medical Alerts 1. Select the patient record in the Rolodex, then click the E.H.R. icon 2. Click the alerts tab in the upper right part of the E.H.R. 3. Right-click under MEDICAL ALERTS 4. Select update medical alerts. A list of medical alerts will open 5. To add an alert to the patient's record, click the RIGHT ARROW to move it to the right column. 6. Click the CLOSE button. A red ALERT ICON will appear at the bottom of the patient's chart Updating Medical Alerts 6

9 Electronic Health Record (EHR) Approvals Overview Faculty approval is required for many undergraduate (and some resident) entries in a patient's electronic health record. If a patient record has entries pending faculty approval, the patient's chart number at the bottom of the axium desktop will be highlighted in aqua when the record is selected. The specific entries in the E.H.R. will be shown in blue. For providers requiring approval for completed treatments, treatment charges will be entered in the patient's account once treatment completions/updates are approved. Entries may be approved at any time during an appointment. Faculty may also approve entries from home or from their office. Faculty members may approve entries with a University of Minnesota U-card that has been registered with an axium administrator. Faculty members may also approve entries by manually entering their axium ID and password if they do have a U-Card. Once approved, chart entries and treatments from the treatment plan will be shown in black on the E.H.R. TX HISTORY tab Entries that Require Faculty Approval Undergraduates Chart entries Treatment plans Progress notes Treatment updates Perio charts Most electronic forms, including medical history and clinical exam Residents Prosthodontics Chart entries Treatment plans Progress notes Treatment updates Periodontics Treatment plans Pediatrics First-year residents planned treatment Endodontics No required approvals Oral Surgery Treatment entries and progress notes 7

10 Electronic Health Record User Guide Approving E.H.R. Entries 1. Select the patient record in the Rolodex 2. Click the aqua highlighted chart number at the bottom of the axium desktop. The Patient Approvals window will open. By default, all of the chart entries will be selected for approval. Approving Chart Entries and Treatment Updates 1. Leave all entries selected or, to select only specific entries for approval, hold down the <CTRL> key on your keyboard as you click the entries for approval 2. If in an operatory, swipe your U-Card to approve 3. If you do not have your U-Card or are not in an operatory, click the ADD DEFAULT button, then enter your axium username and password 4. Progress notes that are pending approval will open. The note can be modified before approving. Enter any changes, then click the APPROVE button Approving Perio Charts 1. From the Patient Approvals window, click the blue perio chart alert on the bottom of the window 2. Click the COMPLETE or INCOMPLETE button 3. If in an operatory, swipe your U-Card to approve 4. If you do not have your U-Card or are not in an operatory, click the ADD DEFAULT button, then enter your axium username and password Approving Electronic Forms 1. From the Patient Approvals window, click the blue EPR ALERT on the bottom of the window 2. Click the APPROVE button 3. If in an operatory, swipe your U-Card to approve 4. If you do not have your U-Card or are not in an operatory, click the ADD DEFAULT button, then enter your axium username and password to approve Approving Treatment Plans 1. Select the patient record in the Rolodex 2. Click the E.H.R. icon 3. Click the TX PLAN tab 4. Click the DETAILED PLAN subtab 5. Click the SELECT OPTION button (use the option arrows to view the treatment plan options) 6. If in an operatory, swipe your U-Card to approve 7. If you do not have your U-Card or are not in an operatory, click the ADD DEFAULT button, then enter your axium username and password to approve 8

11 Electronic Health Record (EHR) Approving Medical Procedures Overview Approving medical treatments and progress notes includes a few steps that are different from approving dental treatments: Medical treatment and its associated progress note should be approved at the same time to ensure that both the note and treatment are available for insurance claims. Updating the billing ID updating the billing ID ensures that the teaching faculty's name appears as the treating provider on insurance claims. Updating the facility if needed the facility shown on the claim must be the facility where the treatment was completed and should always be reviewed upon approval for accuracy. Approving medical treatment progress notes may include adding a countersignature for documentation purposes. Approve Completed Medical Treatments 1. Search for and select the patient record in the Rolodex 2. Click the aqua highlighted CHART NUMBER at the bottom of the screen. The Patient Approvals window will open 3. Select (highlight/click once) the medical treatment in the treatment list. Medical procedures are indicated with an M before the procedure code (for example, M11100) 4. Click the LOAD DOCTORS checkbox 5. Select your name and billing ID in the BILLING ID drop-down list 6. Select the applicable facility in the FACILITY drop-down. If approving in an operatory, swipe a registered U-Card 7. If approving remotely, click the ADD DEFAULT button. The approval authentication window will open. Enter your axium ID and password Approving medical treatment 9

12 Electronic Health Record User Guide Add a Countersignature to a Medical Treatment Progress Notes To add a countersignature to a medical progress note, first approve the note, then add a countersignature template and enter any updates to the template. 1. Search for and select the patient record in the Rolodex 2. Click the aqua highlighted CHART NUMBER at the bottom of the screen. The Patient Approvals window will open 3. Select (highlight/single-click) the treatment note in the Patient Approvals window. Notes are indicated with **Note** in the DESCRIPTION column. 4. Click the ADD DEFAULT button 5. Click the APPROVE button. This approves the note and moves it to the TX HISTORY tab with your name 6. Click the TX HISTORY tab in the E.H.R. 7. Double-click the approved note. The General Tx Note window will open 8. Scroll to the bottom of the note and click in a blank area below the note text 9. Click the CODE ELLIPSIS [...] button 10. Click the PLUS SIGN [+] next to oral surgery countersignature templates 11. Double-click a countersignature so that it appears in the lower grid 12. Click OK to close the codes window. This adds the countersignature template to the note. You can edit the countersignature text if needed. 13. Click OK to close the note Adding a countersignature to a medical progress note 10

13 Electronic Health Record (EHR) Chart Existing Findings and Conditions Overview Missing teeth are entered directly on the odontogram. Additional findings and existing conditions are entered using the CHART ADD tab. If a condition or finding that you want to add is not listed, the SEARCH tab can be used to look for specific dental treatments. Existing findings or conditions are entered with a status of "A" or "E." Undergraduate provider charted findings require faculty approval before being added to the patient's record. Chart missing teeth Missing teeth are entered using the odontogram (the online intraoral chart shown at the top of the E.H.R.) 1. Click the sites on the odontogram 2. Right-click, then select MISSING. The sites will be indicated with a red M Tip: to indicate an entire arch or all teeth are missing, right-click and choose select teeth. Select the arch or all teeth. Right-click again and select MISSING. Chart findings (existing materials) 1. Click the CREATE NEW button on the top right of the E.H.R. The CHART ADD tab will open 2. Select the FINDINGS option 3. Click the FULL LIST tab 4. Select material as the CATEGORY 5. Select the material on the FULL LIST tab 6. Select the sites and surfaces on the odontogram 7. Click the ADD FINDING button Chart existing conditions 1. Click the FULL LIST tab 2. Select condition as the CATEGORY 3. On the FULL LIST tab, click a PLUS SIGN (+) next to a condition heading 4. Select the sites and surfaces on the odontogram 5. Click the ADD FINDING button Note: when entering implants, the site (s) must first be indicated as missing Using the search tab Use the SEARCH tab to search for a finding or treatment. 1. Select the applicable OPTION (for example, if you want to search dental treatments, select the dental tx option) 2. Click the SEARCH tab 3. To search by description, enter a description in the CRITERIA field, then click the SEARCH button 11

14 Electronic Health Record User Guide 4. To search by code, enter the code (for example, D1111) in the CRITERIA field, select code in the SEARCH ON drop-down, then click the SEARCH button 5. Select the treatment from the list of search results 6. Select the sites and surfaces on the odontogram 7. Click the ADD FINDING button Entering findings - Chart Add tab 12

15 Electronic Health Record (EHR) Entering Medical History Overview The Medical History form is an online version of the University of Minnesota School of Dentistry Medical and Dental Questionnaire. The form is added to the patient's E.H.R. once, then updated at subsequent appointments. A patient signature is required for each update. Undergraduate providers require faculty approval for forms that they complete or update. Add a Medical History Form to the Patient Record 1. Select the patient record in the Rolodex, then click the E.H.R. icon 2. Click the FORMS tab 3. Click the CREATE NEW button 4. Select 1MDHIS from the drop-down list 5. Click OK Complete Medical History Form Enter Summary Information The first set of questions are yes/no or text entry. To enter responses, click in the answer column and enter or choose a response. Select Applicable Health Conditions Health conditions are entered using a checklist, as indicated by the checkmark icon [ ] next to each health condition category. 1. To indicate that a patient has a health condition associated with one of the listed categories, double-click in the ANSWER column. The condition checklist will open. 2. Select the applicable conditions 3. Click OK. A "yes" response will be shown next to the condition 4. A NOTES field will appear beneath the condition. To enter notes, click in the ANSWER column and enter notes Enter Dental Information Dental information is entered as yes/no or in checklist format 1. Click in the ANSWER column for the yes/no questions and select a response 2. Double-click in the CHECKLIST responses and select additional information Enter Current Medications Medications are entered using a checklist, as indicated by the checkmark icon. Dosage, condition and start date may also be entered. 1. To enter a medication, double-click in the answer column next to the MEDICATIONS checklist. A list of medications will open. 13

16 Electronic Health Record User Guide Collect the Patient's Signature 2. Select a medication (or several) that you commonly see in clinic 3. Enter a dose, start date and condition 4. Enter any notes in the NOTES answer column 5. If a medication is not on the list, you may enter it in the OTHER DRUGS answer column 1. Click the aqua-highlighted SIG REQUIRED field 2. The patient can sign using the operatory signature pad Updating Health History Overview Once a health history form has been added to patient's electronic health record, it is updated at subsequent appointments. A patient's signature is required when the form is updated. Undergraduate providers require faculty approval for updates to this form. Update the Health History 1. Select the patient record in the Rolodex, then click the E.H.R. icon 2. Click the FORMS tab 3. Under the FORMS ON FILE heading, select Medical/Dental Questionnaire. The Medical History form will be displayed 4. Enter a reason for the visit in the REASON FOR TODAY'S VISIT answer column (example, continue treatment). The existing reason may be typed over. 5. Update the rest of the form as applicable 6. Click the aqua-highlighted SIG REQUIRED field 7. The patient can sign using the operatory signature pad Updating medical history form 14

17 Electronic Health Record (EHR) Completing Electronic Forms Overview In addition to the medical history form, several other forms are available electronically in axium. Electronic forms are updated on the FORMS tab in the E.H.R. An electronic form must first be added to the patient's record, then completed. Some forms, such as the medical history form, are added only once and then updated at each patient appointment. Other forms may be added to the record as often as needed. A list of forms currently in the patient record is shown under the FORMS ON FILE heading on the FORMS tab. Forms completed by undergraduate providers and some resident groups require faculty approval. If a form is pending faculty approval, the responses will be shown in blue and the chart number at the bottom of the axium window will be highlighted in aqua. Forms may also require patient signatures. If a form requires a patient signature, a "sig required" alert will also appear on the form. Add a form to a patient record 1. Select the patient record in the Rolodex, then click the E.H.R. icon 2. Click the FORMS tab 3. Click the CREATE NEW button on the FORMS tab 4. Select the applicable form from the FORM drop-down list 5. Click OK Complete a form Responses may be entered in a variety of formats, depending on the form. Yes/No responses Click in the answer column next to the question. Select one of the options, then click outside of the answer column Checklists Checklist responses are indicated with a checklist icon. To select items on a checklist, double-click the answer column next to the checklist, then select the applicable responses. Click OK to close the checklist Images Responses that include an illustration are indicated with a highlighter icon. To enter an image, double-click the answer column next to the question. Select a color from the palette, draw the applicable image, then click OK to save the image with the form. An "image on file" alert will appear in the answer column. 15

18 Electronic Health Record User Guide Summary of electronic forms currently available on the forms tab in axium at the University of Minnesota. You may not have access to all forms listed. Form Name 1MDHIS - Medical and Dental Questionnaire BIOPSY - biopsy form CLNEXM - Clinical exam DENPRO - Denture Prosth Oral History/Diag ENDSF - Endo subjective findings MMPBP - Medical Management/ BP and Pulse MMPMP - Medical Management/ Plan OMSC - Oral/Maxillo Surgery Consult ORLSED - Criteria oral sedation sheet PEDO1 and PEDO - Pediatric dentistry forms Requires approval? Yes, for undergraduate providers Yes, for undergrad providers Yes, for undergrad providers Yes, for undergrad providers Yes, for undergrad providers Yes, for undergrad providers Yes, for undergrad providers Yes, for undergrad providers Yes, for undergrad providers Yes, for undergrad providers Added to patient record multiple times? No Yes Yes Yes Yes Yes Yes No Yes Patient signature required? Yes Yes No No No No No No No No 16

19 Electronic Health Record (EHR) Using Treatment-Specific Forms (Implant Tracking) Overview Some treatments have specific forms used to help manage updates. At the School of Dentistry, some prosthodontic treatments use the Implant Tracking form. The form will not be accessible until the treatment is added to the patient record. Update the Implant Tracking Form 1. Select the patient record in the Rolodex, then click the E.H.R. icon 2. Click the TX HISTORY tab 3. Click the prosthodontic treatment on the TX HISTORY tab 4. Right-click, then select ADD/EDIT TX form 5. Select IMPL in the FORM drop down 6. Complete or update the implant tracking form Treatment-specific forms 17

20 Electronic Health Record User Guide Undergrad Perio Charting 1. Select the patient in the Rolodex, then click the E.H.R. icon. 2. Click the PERIO tab 3. Click the CREATE NEW button on the PERIO tab. A new perio chart will open. 4. Select the exam type in the EXAM TYPE drop-down 5. Click in a perio value to begin charting for that value. The cursor will auto-advance through the sites as you chart a value. Attachment loss (CAL) is automatically calculated from the free gingival margin and pocket depth values Completing Perio Charts and Perio Chart Approvals Once you have entered a perio chart, it can be saved several ways. SAVE button - saves the perio chart without approval. An unapproved perio chart alert will appear in the Patient Approvals window INCOMPLETE - saves the perio chart and prompts for faculty approval. The perio chart can be approved as entered, then resumed and completed at a later date Complete - saves the perio chart and prompts for faculty approval. Once approved, completed perio charts can not be edited. Resuming an incomplete chart 1. Click the CREATE NEW button on the PERIO tab 2. Click YES at the prompt to resume a previous exam 3. Select the incomplete exam from the list 18

21 Electronic Health Record (EHR) Periodontal Chart - Undergrad/non-perio residents 19

22 Electronic Health Record User Guide Periodontal Resident/Faculty Perio Charting 1. Select the patient in the Rolodex, then click the E.H.R. icon 2. Click the PERIO tab 3. Click the CREATE NEW button. A perio chart will open. 4. In the EXAM TYPE drop-down, select initial exam 5. Click in the block that corresponds to the site and condition you want to chart (for example, to chart pocket depth on site three, click in the site three column, in the pocket depth (PD) row 6. To enter a value, click on the keypad to the right of the perio chart. Or, to enter a value with a keyboard, look at the bottom right list of values, which shows the key to use for each value. 7. Click the NEXT, UP, DOWN or PREV buttons to move to the next location (or, use the keyboard arrow keys) Navigation tips o Click the arrow keys above the to the QUADRANT LOCATION to navigate quadrants o To clear all values for a site, click in the site, then click CLEAR TOOTH o To clear one value for a site, click the value, then click CLEAR. 8. After you have entered values, you can save the perio chart one of two ways SAVE or INCOMPLETE will save the chart and it can be resumed or edited at a later date COMPLETE completes the chart and it cannot be edited or resumed later Periodontal Chart - Perio residents/faculty 20

23 Electronic Health Record (EHR) Entering Progress Notes Overview Progress notes can be entered as general or S.O.A.P. notes. Undergraduate and most resident progress notes require faculty approval before being added to the patient's history. Unapproved notes are shown on the TX HISTORY tab in blue. Progress notes for medical procedures are entered slightly differently than progress notes for dental procedures or general dental appointments. Please refer to Entering Medical Procedures to learn how to enter a note so that it is tied directly to the medical treatment Enter a progress note 1. Select the patient record in the Rolodex, then click the E.H.R. 2. Click the ADD NEW NOTE icon at the top right of the E.H.R., or on the TX HISTORY tab 3. Select general or S.O.A.P. note 4. Enter the note text 5. Click the OK or add new button to enter the note 21

24 Electronic Health Record User Guide Express/Chart Add Treatment Entry Overview Faculty providers and most resident groups enter treatments using the CHART ADD tab. Treatments may be entered in the applicable status (planned, in-process or completed) and the fee may be adjusted prior entering the treatment. Once entered using the CHART ADD tab, the treatments are shown on the TX HISTORY tab and, if applicable, displayed on the odontogram. For example, if an exam is completed and an implant is planned, the completed exam and planned implant entries will be listed on the TX HISTORY tab and the planned implant will be shown with a yellow dot and applicable graphic on the odontogram. Entering Initial Exam Charges 1. Select the patient record in the Rolodex, then click the E.H.R. icon 2. Click the CREATE NEW button on the top right of the E.H.R. The CHART ADD tab will open 3. Select the DENTAL TX option 4. Click the FULL LIST tab 5. Select diagnostics as the treatment CATEGORY 6. On the full list tab, click the plus sign next to D Clinical Oral Evaluations 7. Select the applicable exam 8. Click the ADD COMPLETED TREATMENT button. The Treatment Split window will open. To adjust the fee for the exam, enter the adjusted amount in the TOTAL field, then click OK. Entering Planned Treatments 1. Select the patient record in the Rolodex, then click the E.H.R. icon 2. Click the CREATE NEW button on the top right of the E.H.R. The CHART ADD tab will open 3. Select the DENTAL TX option 4. Click the QUICK LIST tab, the select the applicable treatment CATEGORY. 5. Select the treatment on the QUICK LIST tab 6. If applicable, select a site and/or surfaces on the odontogram for treatment 7. Click the ADD PLANNED TX button 8. If the treatment is not listed on the QUICK LIST tab, click the FULL LIST tab, then select the applicable treatment CATEGORY. Select the treatment on the FULL LIST tab, select applicable sites and surfaces on the odontogram, then click the ADD PLANNED TX button. 9. The Treatment Split window will open. To adjust the fee for the treatment, enter the adjusted amount in the TOTAL field, then click OK. Entering Emergency/Unplanned Treatments 1. Select the patient record in the Rolodex, then click the E.H.R. icon 2. Click the CREATE NEW button on the top right of the E.H.R. The CHART ADD tab will open 3. Select the DENTAL TX option 4. Click the FULL LIST tab 22

25 Electronic Health Record (EHR) 5. Select the DENTAL TX option 6. Click the QUICK LIST tab, the select the applicable treatment CATEGORY. 7. Select the treatment on the QUICK LIST tab 8. If applicable, select a site and/or surfaces on the odontogram for treatment 9. Click the ADD COMPLETED TX button 10. If the treatment is not listed on the QUICK LIST tab, click the FULL LIST tab, then select the applicable treatment CATEGORY. Select the treatment on the FULL LIST tab, select applicable sites and surfaces on the odontogram, then click the ADD COMPLETED TX button. 11. The Treatment Split window will open. To adjust the fee for the treatment, enter the adjusted amount in the TOTAL field, then click OK. Entering Radiographs 1. Select the patient record in the Rolodex, then click the E.H.R. icon 2. Click the CREATE NEW button on the top right of the E.H.R. The CHART ADD tab will open 3. Select the DENTAL TX option 4. Click the QUICK LIST tab, then select the applicable treatment CATEGORY 5. Select the treatment on the QUICK LIST tab 6. If the treatment is not listed on the QUICK LIST tab, click the FULL LIST tab, then select the applicable treatment CATEGORY. Select the treatment on the FULL LIST tab. 7. If the radiographs will be completed by a radiologist or radiology tech, click the ADD PLANNED TX button (the radiologist or tech will update the status once they complete the radiographs) 8. If the provider is completing the radiographs, click the ADD COMPLETED TX button once the radiographs are complete 9. The Treatment Split window will open. To adjust the fee for the treatment, enter the adjusted amount in the TOTAL field, then click OK. Entering Treatment Macros A macro is a set of treatments most often planned or completed at the same time (for example, an exam and radiographs). Macros are indicated with a macro icon [ ]. To view the treatments included in a macro, hover your mouse over the macro. 1. Select the patient record in the Rolodex, then click the E.H.R. icon 2. Click the CREATE NEW button on the top right of the E.H.R. The CHART ADD tab will open 3. Select the macro on the QUICK LIST tab 4. Click the applicable TREATMENT STATUS button. The Treatment Macro Edit window will open. To delete treatments from the macro, select them, then click the delete button To add treatments to the macro, click the CODE ELLIPSIS button and select the procedure code. Enter the quantity if applicable, then click the ADD NEW button 3. Click the OK button to add the treatment macro to the patient record 4. If any of the treatments require site or surface specification, a window will open where these can be entered 5. The Treatment Split window will open. To adjust the fee for any of the treatments, enter the adjusted amount in the total field, then click OK Creating Treatment Estimates 23

26 Electronic Health Record User Guide 1. Click the TX HISTORY tab 2. Click planned under the VIEWS heading (this will show only planned treatments on the tab) 3. Click the ESTIMATE button. A list of planned treatments will open. 4. Click the SELECT ALL button to select all the treatments in the estimate. To select individual treatments, hold down the <CTRL> key as you select treatments 5. Click OK. The estimate window will open. 6. If any comments appear in the comments field, delete them, then enter any applicable comments for your estimate 7. If you want to collect the patient's electronic signature for the estimate, select the PATIENT signature checkbox 8. Click PRINT 9. Select the printer, then click OK. Once you close the estimate window, a patient signature window will open if you selected the patient signature checkbox. The patient can sign the estimate using the electronic signature pad in the operatory 24

27 Electronic Health Record (EHR) Treatment Plan Entry Overview Treatment plans are entered on the TX PLAN tab, which is divided into subtabs that correspond with the steps of treatment plan entry: problems, diagnosis, detailed plan treatments and options, and patient acceptance. A treatment plan option must be approved by faculty and accepted by the patient before being added to the patient's treatment history and shown as planned treatment on the TX HISTORY tab. Enter the Treatment Plan 1. Select the patient record in the Rolodex, then click the E.H.R. icon 2. Click the TX PLAN tab 3. Click the CREATE NEW button 4. In the DESCRIPTION field, enter a description of the plan 5. In the CHIEF CONCERNS field, enter the patient's chief concerns to be addressed Adding a treatment plan 25

28 Electronic Health Record User Guide Enter Problems to be Addressed with the Treatment Plan 1. On the PROBLEMS tab, click the UPDATE button. The Update Problems window will open. 2. Select a problem from the PROBLEM list 3. Select a status from the STATUS list (ex. treat, non-urgent) 4. Click the ADD NEW button 5. Once you have entered the sample problems, click the red X to close the Update Problems window. The problems will be listed on the PROBLEMS tab Selecting treatment plan problems Enter Diagnoses Codes for Treatment 1. Click the DIAGNOSIS tab 2. Click the UPDATE button. The Diagnosis Codes window will open. 3. From the CATEGORY drop down, select a diagnosis code 4. Click the DESCRIPTION column heading to view the list of diagnoses for the selected category 5. Double-click a diagnosis to enter it in the treatment plan 6. If you do not find a diagnosis, you can enter it in the FREE TEXT field, then click the DOWN ARROW 7. Once you've entered all diagnoses, click OK to close the Select Diagnosis Codes window. The diagnoses will be listed on the DIAGNOSIS tab. 26

29 Electronic Health Record (EHR) Selecting treatment plan diagnoses Enter the Treatment Plan Options Treatment plans are entered on the DETAILED PLAN tab. This tab consists of two views: DISPLAY (the view shown when the details plan tab is first clicked) - shows entered treatment plan options ENTRY - used to enter treatments. This view includes the DIAGNOSIS tab, from which a diagnosis must be selected, and the CODES and DETAILS tabs, from which treatments can be selected 1. Click the DETAILED PLAN tab. 2. Click the CREATE NEW OPTION button to open the entry view 3. Double-click a diagnosis on the DIAGNOSIS tab 4. Select a treatment on the CODES - FULL LIST tabs 5. Select applicable sites and surfaces on the odontogram 6. Click the ADD NEW button 7. Once you have entered all treatments for this option, you can create a second plan option. Entering an alternate plan option 27

30 Electronic Health Record User Guide 1. Click the DISPLAY button 2. Click the COPY OPTION button 3. Click the ENTRY button 4. To delete treatments not included in this option, select them, then click the DELETE button 5. Enter the alternate treatments Treatment Plans - Detailed Plan Subtab Copying Plan Options 28

31 Electronic Health Record (EHR) Phasing and Sequencing Overview Phasing and sequencing can be completed during treatment planning or from the TX HISTORY tab. Phase and Sequence an Unapproved Plan Option 1. Select the patient record in the Rolodex, then click the E.H.R. icon 2. Click the TX PLAN tab 3. Click the DETAILED PLAN subtab 4. Click the ENTRY button if the entry view is not currently shown 5. Use the TOGGLE ARROWS to select the plan option 6. Select a treatment, right-click, then select ASSIGN. The Detailed Plan Assign window will open. 7. Enter the phase and sequence number of that treatment Phasing and sequencing a plan option Updating Phase and Sequence Assignment for Approved, Accepted Treatments Once treatments are approved and accepted, the phase and sequence can be updated on the TX HISTORY tab. 1. Select the patient record in the Rolodex, then click the E.H.R. icon 2. Click the TX HISTORY tab 3. Double-click a treatment on the TX HISTORY tab. The Edit Treatment window will open. 4. Enter the updated phase and sequence 5. Click OK 6. For undergraduates and some residents, the update will require faculty approval, so the treatment will be shown in blue and the patient's chart number will be highlighted in blue at the bottom of the screen. 29

32 Electronic Health Record User Guide Selecting a Plan Option for Faculty Approval and Acceptance Overview Faculty approval is required for treatment plans before a patient can sign them or the treatments added to the patient's treatment history. Once faculty has approved a plan, an estimate of the treatment plan can be created for the patient. Select the Treatment Plan 1. Select the patient record in the Rolodex, then click the E.H.R. icon 2. Click the TX PLAN tab 3. Click the PLAN subtab 4. Select the treatment plan 5. Click the DETAILED PLAN subtab, 6. If necessary, click the ENTRY button so that the display view is shown 7. Click the ARROW buttons to review the plan options 8. Select the option for approval 9. Click the SELECT OPTION button to select the treatment plan. The Treatment Plan Approval window will open 10. click the APPROVE button. The authentication window will open. 11. The faculty member can approve the plan by swiping a registered U-Card or entering h/her axium ID and password Selecting a treatment plan option Create an Estimate and Consent 1. On the TX PLAN tab, click the PATIENT ACCEPTANCE subtab 2. Click the ACCEPT/PRINT button. A copy of the treatment plan with estimated costs and consent verbiage will open. Note, if the patient wanted to review the plan and sign later, or if the patient needs to review the plan with fee contracting before signing, the VIEW/PRINT DRAFT button creates a draft of the plan. 3. Click the CLOSE button to close the estimate. A signature window will open to collect the patient's signature. 4. The patient can sign using the signature pad 30

33 Electronic Health Record (EHR) Creating an estimate/consent 31

34 Electronic Health Record User Guide Treatment Updates - Multiple Appointments Overview If a planned procedure requires multiple appointments, you can indicate that the treatments are in an in process STATUS and continue to add progress notes at each appointment. In process treatments may be shown as red dots on the odontogram Update the Treatment Status 1. Click the TX HISTORY tab 2. Under the VIEWS heading, select PLANNED 3. Double click the planned treatment. The Update Treatment window will open. 4. Select the IN PROCESS status option 5. Click OK Treatment history tab - planned treatment updates 32

35 Electronic Health Record (EHR) Completing Planned Treatments Overview Most planned treatments are shown with yellow dots on the odontogram. For example, a planned extraction would appear as a red x with a yellow dot on the applicable site. A planned amalgam would appear with yellow dots over silver shading on the applicable surfaces. Planned treatments are updated and completed using the TX HISTORY tab: The procedure code should always be double-checked and updated if applicable - for example, if a planned two-surface amalgam changes to a three-surface amalgam. Undergraduates may enter anticipated surgical or prosthodontic treatment with a "placeholder" code. This code must be updated when the treatment is completed for accurate billing. Undergraduates should always check with a faculty member when updating a planned procedure so that the faculty member can advise whether an entire new treatment plan should be entered instead of updating the planned treatment. Additional treatments provided during the completion of the treatment (for example, anesthesia used during oral surgery) are added using the CHART ADD tab Patient consent for any changes can be collected either on a paper form or a patient's signature may be collected electronically Treatment updates entered by undergraduates (and some resident groups), require faculty approval before any charges for completed treatment are added to the patient's account Update the planned treatment status 1. Click the TX HISTORY tab 2. Under the VIEWS list, select PLANNED (oral surgery providers may find it helpful to select the PLANNED SURGICAL PROCEDURES view, which will show planned surgical treatments) 3. Double-click the procedure to update. The Edit Tx window will open Review and update the procedure code if applicable 1. Review the code listed in the code field. To update the code, click the CODE ELLIPSIS BUTTON [...]. The procedure code list will open. 2. Select the treatment category in the CATEGORY drop-down, then click the category column heading to show the list of treatment headings 3. Click the PLUS SIGN [+] next to the applicable treatment heading 4. Double-click the applicable treatment 5. Click OK to close the Edit Tx window Update treatment status 1. Select the COMPLETED status option in the EDIT TX window 2. Click OK Enter any additional treatments provided during treatment completion 33

36 Electronic Health Record User Guide 1. Click the CREATE NEW button on the top right of the E.H.R. to open the CHART ADD tab 2. Select the DENTAL TX option 3. Click the QUICK LIST tab, the select the applicable treatment CATEGORY. 4. Select the treatment on the QUICK LIST tab 5. Click the ADD COMPLETED TX button 6. If the treatment is not listed on the QUICK LIST tab, click the FULL LIST tab, then select the applicable treatment CATEGORY. Select the treatment on the FULL LIST tab and click the ADD COMPLETED TX button. Collecting a Patient's Electronic Signature for Treatment Updates 1. Click the TX HISTORY tab 2. Click the ADD PATIENT TX CONSENT button [ ]. The Add Patient Consent window will open. 3. Leave TXPLCO selected in the consent drop down and click OK 4. Select the treatments for which the patient is signing (if the treatment's status was changed to completed prior to the patient's signature, select the COMPLETED checkbox at the top of the window to show completed treatments in the list). A parameter values window will open 5. If the patient is signing for h/herself, leave self selected in the VALUE drop down. If someone else is signing for the patient (for example, a guardian), select the applicable role in the VALUE drop down 6. Click OK. A consent form will open with the selected treatments listed. 7. Close or print the form. An electronic signature window will open. The patient can sign using the electronic signature pad located in the operatory. 34

37 Electronic Health Record (EHR) Updating planned procedures 35

38 Electronic Health Record User Guide Entering Treatment Plan Consult Notes Overview Consult notes for undergraduate treatment plans may be entered on the TX PLAN tab, NOTES/RECOMMENDATIONS subtab, under the consulting provider's log in. 1. Search for the patient record in the Rolodex, then click the E.H.R. icon 2. Click the TX PLAN tab 3. Click the NOTES/RECOMMENDATIONS subtab 4. Click the CHANGE USER button 5. The consulting provider can swipe a registered U-Card or enter h/her axium ID and password to log in to enter the note (this does not log the consulting provider into axium) 6. To select a consult note template heading, click the CODE ELLIPSIS button. 7. Double-click the template. The template heading will be shown in the TEXT field 8. Enter the consult note in the TEXT field 9. Click the ADD NEW button on the side of the NOTES/RECOMMENDATIONS tab Consult note entry - tx plan tab 36

39 Electronic Health Record (EHR) Entering Medical Procedures Overview Medical treatment information is entered in the E.H.R. using the CHART ADD tab. When completed medical treatments are entered, the Medical Tx window will open, where more information can be entered regarding the treatment. Progress notes for medical treatments are entered slightly differently than dental treatment progress notes. Medical treatment notes are entered so that they are tied directly to the medical treatment, not as general progress notes. Resident progress notes for medical treatments may also require a teaching faculty countersignature. Enter medical treatment information 1. Click the CREATE NEW button on the top right of the E.H.R. The CHART ADD tab will open 2. Select the MEDICAL TX option 3. Click the FULL LIST tab 4. Select the applicable CPT code CATEGORY 5. On the FULL LIST tab, select the treatment 6. Click the ADD PLANNED TX button or ADD COMPLETED TX button, whichever is the applicable status. The Medical Tx window will open if the treatment is added as completed. Note: medical biopsies should be entered as planned treatment, then updated to completed once the results are received; this ensures that a diagnosis is entered for the biopsy upon completion. Entering medical information for medical treatments When medical treatments are entered as completed, a Medical Information window will open. Additional medical information can then be added to the treatment. 1. To select an ICD diagnosis code, click the ICD ELLIPSIS BUTTON [...]. The ICD diagnosis window will open 2. Select diagnosis description in the SEARCH ON drop-down list 3. Enter a description of a diagnosis (for example, "burn"), then click the DESCRIPTION column 4. Double-click the diagnosis 5. To enter a modifier code, click the MODIFIER ELLIPSIS BUTTON [...] and double-click the modifier from the list. 6. Click OK 7. Enter additional information in the Medical Information window as needed Enter medical treatment progress notes 1. Select the treatment on the CHART ADD tab 2. Right-click, then select ADD TX NOTE 3. Enter a progress note 4. Click OK. The note will be shown beneath the treatment with a yellow arrow icon, which indicates that the note refers to that specific treatment. 37

40 Electronic Health Record User Guide Entering medical treatment Frequently Asked Questions - Entering Medical Treatments Can progress notes be entered later or do they need to be entered at the appointment? \ Progress notes may be entered and approved at any time. If the Chart Add tab is not used to enter the note during the time of treatment entry, progress notes can be added using the Tx History tab. Progress notes for medical treatments that require a faculty countersignature should be entered and approved within two days of completing the treatment, which ensures that the progress note countersignature is available when the treatment is submitted to a patient's insurance. Entering Treatment on Behalf of Another Provider Overview Some providers may enter treatment on behalf of other providers (for example, a hygienist may enter a treatment to be completed by a faculty provider). To enter a treatment to be completed by another provider, use the CHART ADD and DETAILS tabs. 1. Click the ADD NEW button at the top right of the E.H.R. The CHART ADD tab will open 2. Click the DETAILS subtab 38

41 Electronic Health Record (EHR) Entering treatments - Details tab Select the provider 1. On the DETAILS tab, click the PROVIDER ELLIPSIS button. The Provider Search window will open. 2. Enter the provider s last name in the CRITERIA field 3. Click the LAST NAME column 4. Double-click the provider s name Selecting a provider 39

42 Electronic Health Record User Guide Enter the Treatment 1. On the DETAILS tab, click the CODE ELLIPSIS button. The Procedure Code window will open. 2. Select the treatment category from the CATEGORY drop-down 3. Click the PLUS SIGN [+] next to the applicable treatment heading 4. Double-click the treatment. The Procedure Code window will close 5. Click the COMPLETED TX button on the CHART ADD tab. The Treatment Split window will open. Click OK to close the window. The treatment fee cannot be adjusted unless a faculty or resident is logged in axium. 40

43 Electronic Health Record (EHR) Adjusting Treatment Fees Overview Treatment fees may be adjusted only when a faculty member or resident is logged in to axium and only adjusted for planned treatments. Patient accounting will manage adjustments to fees for completed treatments or other adjustments. There are two ways for a faculty member or resident to adjust a treatment fee: The fee can be adjusted as treatments are entered Faculty and residents can adjust the fee of a previously planned treatment from the TX HISTORY tab Adjusting Fees as Planned Treatments are Entered 1. Select the patient record in the Rolodex, then click the E.H.R. icon 2. Click the ADD NEW button to open the CHART ADD tab 3. Select the DENTAL TX option and treatment CATEGORY 4. Select the treatment from the FULL LIST tab 5. Select the sites and surfaces as applicable on the odontogram 6. Click the PLANNED TX button. The Treatment Split window will open. Adjust the Treatment Fee (Treatment Split Window) The total treatment fee is shown in the TOTAL field. If the patient has insurance, the amount that will be billed to insurance is shown in the COVERAGE column. When the patient has insurance, the recommended way to adjust the fee is to change the amount billed to insurance. However, you can adjust the total fee if needed. If a patient does not have insurance, the coverage column will be read-only (greyedout) and a zero will be shown. To enter an adjusted amount to bill the patient's insurance company. 1. Click in the COVERAGE column. 2. Enter the adjusted amount 3. Click OK To enter an adjusted fee 1. Click in the TOTAL field 2. Enter the adjusted amount 3. Click OK Treatment Split Window Adjust the Fee of a Previously Planned Treatment 1. Select the patient record in the Rolodex, then click the E.H.R. icon 2. Click the TX HISTORY tab 3. Under the VIEWS heading, select PLANNED 41

44 Electronic Health Record User Guide 4. Double-click the planned treatment. The Edit Treatment window will open. 5. Select the EDIT BILLING INFO checkbox and click OK. The Treatment Billing window will open. 6. Select the applicable billing ID in the BILLING ID drop-down. 7. Click the ADD SPECIAL button to open the Treatment Split window 8. Enter the adjusted amount in the COVERAGE column and click OK Adjusting Planned Treatment Fees - Tx History tab 42