Electronic Medical Records (EMR) Centricity EMR Updating the Patient Record

Transcription

1 Electronic Medical Records (EMR) Centricity EMR Updating the Patient Record

2 Table of Contents Introduction...1 The Chart Update...1 The Process...1 Accessing a Chart Update via your Desktop Summary Page...2 Accessing a Chart Update via your Desktop Documents Page...2 Starting a Phone Note...3 Starting a Full Chart Update (Example: Office Visit)...3 Ending a Chart Update...4 Sign clinical list changes...4 Ending the Update No Further Action and/or Additional Signature Required...5 End the Update Further Action and/or Additional Signature Required...5 Signing Documents...6 Problems...7 Updating the Patient s Problem List...7 Checking the Patient s Documented Problems...7 Checking the Patient s Documented Problems in a Chart Update...7 Adding a New Problem to the Patient Chart using a Custom Problem List...8 Adding a Problem to the Patient Chart Using the Reference List...10 Additional Ways to Add a Problem to the Patient Chart...11 Reactivating an Inactive Problem...12 New Occurrences of Old Problems...13 Duplicate Problem Notices...14 Removing a Problem from the Patient s Problem List - Unsigned...14 Removing a Problem from the Patient s Problem List - Signed...15 Changing a Problem on the Patient s Problem List...15 Assessing a Problem on the Patient s Problem List...16 Medications...17 The New Medication Window...17 Adding a Medication using a Custom Medication List...19 Adding a Medication using the Reference List...21 Removing a Medication from the Patient s Medication List New...23 Removing a Medication from the Patient s Medication List Previously Signed Update...24 Changing a Medication on the Patient s Medication List...24 Refilling Prescriptions...26 Beginning a Refill Chart Update...26 Adding the Prescriptions Form to a Chart Update...26 The Prescriptions Form...26 Using the Prescriptions Form...27 Allergies and Adverse Reactions...28 Recording No Known Allergies...28 Reviewing the Patient s Allergies during the Current Chart Update No Changes...29 Adding an Allergy or Adverse Reaction...29 Adding an Allergy or Adverse Reaction the Custom List...29 Adding an Allergy or Adverse Reaction Reference List...30 What a Critical reaction Looks Like...31 What a Non-critical reaction Looks Like...31 Allergy and Adverse Reaction Graphic Displays...32 Allergy Graphics (From GE Centricity Physician Office Help Files)...32 Removing an Allergy or Adverse Reaction - Unsigned...33 Removing a Signed Allergy or Adverse Reaction...33 UpdatingChart2005.doc Rev. Date: 11/21/ MSU HealthTeam

3 Changing an Allergy or Adverse Reaction...34 A Note On Allergy Options In Different Centricity Versions...34 Directives...35 Adding a Directive...35 Removing an Unsigned Directive...35 Removing a Signed Directive...36 Changing a Signed Directive...36 Appending Signed Documents...37 Appending a Signed Note Straight Text...37 Appending a Signed Note Full Update...38 An Appended Document Displayed...39 Getting Help...40 Centricity Help Online...40 HealthTeam Information Systems...40 EMR Implementation Team...40 APPENDIX A...41 Sample workflow of an Office Visit (without Resident/Fellow Contributions)...41 Sample workflow of an Office Visit with Services (without Resident/Fellow Contributions)...41 Sample workflow of an Office Visit with Resident/Fellow Contributions...41 UpdatingChart2005.doc Rev. Date: 11/21/ MSU HealthTeam

4 Introduction Designed for use in conjunction with the HealthTeam s Getting Started training materials, the intent of this training module is to provide assistance in the documentation of clinical content in HealthTeam patient charts. Because HealthTeam clinics have their own workflows and processes, the information provided herein is at a global level; someone in your clinic, or your clinic s Electronic Medical Records (EMR) support person, will guide you through steps specific to your location of care. Additionally, please utilize the training resources available online at a few of the topics addressed in the training materials are: the login process, navigation, and accessing patient information in Centricity EMR The Chart Update In Centricity EMR 2005, you must have a chart update in progress to change information documented in a patient s chart. Such an update might be, but is not limited to, an Office Visit, a Clinical List Update, or a Phone Note. Additionally, the location of care under which you log into the program determines how the system responds, so be sure to login under the location appropriate for the work that you will be doing during the current Centricity session. The Process A chart update frequently requires input from only one or two Centricity users. For example, a basic phone message documented in a patient s chart that requires no further attention may simply be documented in the chart, then signed by the individual entering that information. Sometimes, though, additional HealthTeam staff and/or Providers need to review or contribute to the note, in which case the person documenting would need to route the note to other Centricity users for review or further processing. Options and scenarios for routing and signing documents are discussed in detail later in this section. Also, basic Office Visit workflows are available in Appendix A of this document. Staff member begins phone note in the patient s chart and documents message Staff member Ends the Update and fills in fields of the End Update window Staff member asks: Does this phone note require further processing? Yes No Physician Ends the Update, confirms routing recipients, when applicable, and Signs the Document Physician opens the phone note and performs the requisite task(s) Staff member puts the document On Hold and routes it to the Physician Staff member Signs the Document Basic Phone Note Workflow NOTE: If further processing is necessary in a phone note or other chart update, or if you are uncertain about when to place the update On Hold or to Sign the Document, do NOT Sign it. Verify that a routing recipient has been identified in the End Update window, then put the document On Hold. UpdatingChart2005.doc 1

5 Accessing a Chart Update via your Desktop Summary Page When someone else in your clinic begins a chart update for a patient that requires your attention, that individual completes his or her portion of the note, then routes it to your Desktop. To access that chart update, double-click directly on the document; this takes you to the patient s chart, with that specific chart update open. In that note, then, you can make the requisite changes to the clinical content of that patient s chart. Double-click on a chart update on your Desktop to modify clinical content in the patient s chart. Make sure that the Status of a Document is On Hold not In Progress - before accessing it. Accessing a Chart Update via your Desktop Documents Page If your clinic uses the Comments field of the Routing window when routing documents, open chart updates from your Desktop Documents page, rather than from your Summary page. Comments are only visible on your Documents page, and they are not saved with the document when it is signed. Routing Comments are displayed on the Documents page of your Centricity Desktop UpdatingChart2005.doc 2

6 Starting a Phone Note 1. In an active Centricity session, navigate to the patient s chart. 2. Click the Phone Note button, located on the Charting toolbar. The phone note opens, where you can document the communication and make any necessary changes to the patient s medications, allergies, problems, etc. Click the Phone Note button to document patient-specific communication over the telephone, secure , and similar venues. Use the Update button to begin a full chart update with varied form components. Starting a Full Chart Update (Example: Office Visit) 1. In an active Centricity session, navigate to the patient s chart. 2. Now in the patient s chart, click the Update button of the Charting toolbar. 3. The Update Chart window opens. Click to select the encounter type as is appropriate from those displayed in the left column, or use the binoculars to see an extended list of encounter options. 4. Unless you are the Provider responsible for the update, use the drop-down arrow of the Provider field to locate and select the correct Provider for the current update. 5. Type something descriptive, yet brief, in the Summary: field. 6. Click OK, or use the [Enter] key of your keyboard. Type of update Provider responsible for the update Summary of reason for update ENCOUNTERS What is an Encounter? An Encounter is a set of components, such as forms and blocks of text, that are loaded into a chart update, in a predefined order. The content of an Encounter may vary, depending upon the age and gender of the patient, and the current Location of Care of the person starting that Encounter. UpdatingChart2005.doc 3

7 Ending a Chart Update When you have completed your portion of a chart update, you will need to end that update. Depending on your signing privileges in Centricity, and if the document requires no further attention, you may Sign the document. If, however, further processing is required (such as an incomplete office visit), you will need to identify the next person to contribute to the document in the End Update window, then put the document On Hold. NOTE: When you are ready to leave an unsigned chart update and navigate to another area of Centricity (your Desktop, a different patient s chart, etc.) be sure to go through the End Update process and select Hold Document. Not doing so may prevent others from documenting in the update, and it compromises the stability of that update s content. The End Update Window Verify content of both the Summary: and Provider: fields Indicate routing recipient(s) when applicable When checked, you are automatically navigated back to your Desktop when you Sign or Hold Document; if unchecked, you remain in the current patient s chart Modify routing recipients View clinical list changes made during current chart update Sign clinical list changes made during current chart update Delete the entire note by clicking Discard Document. This function is only available under certain circumstances. * Once Discarded, the information documented in the update cannot be retrieved. Use with caution! Click Sign Document if the update is complete and no further changes to the update are required. Hold Document if you or another Centricity user needs to add or modify the update s content. The Cancel button returns you to the update. Sign clinical list changes If you have the signing privileges necessary to print prescriptions, it is important to understand how the Sign clinical list changes feature in the lower right corner of the End Update window functions. If the chart update contains a prescription or refill that is set to be printed or faxed to a pharmacy, signing clinical list changes causes that prescription or refill to be printed or faxed, respectively. If you are ending the update but do not want the prescription or refill to be printed or faxed, either remove the checkmark ( ) in the Sign clinical list changes field, or return to the update and temporarily set the prescribing method to something other than printing or faxing. UpdatingChart2005.doc 4

8 Ending the Update No Further Action and/or Additional Signature Required 1. Upon completion of a chart update, click the End Update button on the charting toolbar. 2. In the Summary field: of the End Update window, add a brief description of the document s content, if none is already there. 3. Verify that the name listed in the Provider: field is correct, or modify that name as needed. 4. The Provider indicated is the document s default routing recipient; however, if no further action is required, and if your clinics protocols do not require that you route the document to that individual for review, select the name in the lower portion of the End Update window and click Remove. 5. If the chart update is complete and requires no further attention, click Sign Document, and the chart update is saved as a permanent part of the patient s Centricity record. End the Update Further Action and/or Additional Signature Required 1. Upon completion of a chart update, click the End Update button on the charting toolbar. 2. In the Summary field: in the End Update window, add a brief description of the document s content, if none is already there. 3. Verify that the name listed in the Provider: field is correct, or modify that name as needed. If the correct name is not included in the dropdown list of the Provider: field, use the Binoculars button to perform a more extensive Centricity user search. 4. The Provider indicated is the document s default routing recipient; if this is not correct for the specific chart update circumstances, click the New button to locate and select the appropriate recipient. ROUTING DOCUMENTS When might the routing recipient of a chart update not be the assigned Provider? If you have completed your portion of a chart update, yet another individual in your clinic also needs to make contributions to the note before the designated Provider sees the patient, route the update to that other individual not the Provider to minimize the chances of multiple users trying to document in the note at the same time. RESIDENTS/FELLOWS: Follow your clinic-specific workflow for signing and routing documents to your Attending Physician s Desktop. UpdatingChart2005.doc 5

9 Signing Documents When you sign a Centricity document your electronic signature, the date, and time are attached to that document. Signing privileges in Centricity are determined by the document type (Office Visit, Phone Note, Lab Results, etc.) and user profile (Support Staff, Provider, Resident/Fellow, etc.). Clinic-specific workflows and protocols also define when individuals should or should not sign documents. If you are uncertain about the process, use the table below as a guide, ask someone in your clinic, or contact your clinic s EMR support person. Signing Options and Situations Signing the document Placing the document On Hold The Sign Document button is grayed out When I click Sign Document I get a message about not having full signing privileges. What does that mean? I usually can sign office visits, but this time I can t. What does the term dot sign mean, and when is it used? And what about soft sign? Someone else signed the note before I could complete my portion of the document. Your electronic signature and the clinical date are attached to the document which in turn becomes a permanent part of the patient record. Select Hold Document in the End Update window if the document requires further input/modification, and you are ready to navigate to another area of Centricity. The Sign Document button of the End Update window is not available if you do not have the necessary privileges to sign the update s particular document type. Identify a routing recipient of the document, then click Hold Document. If your signing privileges require a second signature and you click the Sign Document button, a pop-up message prompts you to route the document to another Centricity user for signing. For example, this will be the case if you are a resident, fellow, or physician s assistant, and the chart update is an Office Visit. You cannot sign a chart update if someone else is also working in the document. Wait for the other person to put the update On Hold, and then you should be able to complete the signing process. The term dot sign is used inter-changeably with soft sign, and they both refer to quick text that is used to enter your name and clinical date to a chart update. This captures the name of a contributor (you) to the document, while leaving that document available for further processing. For example: a nurse starts an office visit and documents the patient s vitals, allergies, and medications. Before Ending the Update, the nurse types,.sign and presses the Enter key of the keyboard. This causes Centricity to add the nurse s name and clinical date to the note. The nurse then Ends the Update and routes it to the physician. Once a document has been signed, you cannot add or modify the content of that document, so use the Append tool to make the requisite changes in a separate document that is attached to the original. An example: if a physician orders the influenza immunization during a visit, but then signs the document containing the order before the nurse can document the administration of that immunization. The nurse would need to select the document that contains the immunization order, click the Append button, and do a full-update append to access and complete the Influenza form. UpdatingChart2005.doc 6

10 Problems Updating the Patient s Problem List When updating a patient s problem list, first check to make sure that the problem you intend to add is not already on the Active list; if it is, you ll want to update the documentation directly related to the existing occurrence of the problem, rather than add a new occurrence of the problem. Also check for any Inactive occurrences of the same problem; if there is such an occurrence, you may want to either reactivate that entry, or document a new occurrence of the original. (See Reactivate an Inactive Problem, page 12.) Checking the Patient s Documented Problems You can view the patient s problem list on the Problem tab of his or her Centricity chart. Select Active Only to see the patient s current problems, or click All to see problems previously recorded that are no longer active. Additionally, click on a problem in the upper portion of the window to see associated Assessments in the lower portion. View Active and Inactive problems, and associated Assessments, on the Problems tab Checking the Patient s Documented Problems in a Chart Update While in a chart update you can also view the patient s documented problems in the Update Problems window. Although you can access the Update Problems window in various ways, for training purposes, we ll do using the Probs button of the Charting toolbar. 1. Click the Probs button of the Charting toolbar; this opens the Update Problem window. UpdatingChart2005.doc 7

11 2. In the Update Problem window, use the Active and Inactive radio buttons to switch between seeing only the patient s Active problems and those which have been resolved. Patient s Active Problem List Displayed Patient s Inactive Problem List Displayed NOTE: If the Update Problems window doesn t open, you may have clicked on the Problems tab, and not the Problems toolbar button. If this is the case, return to the Update tab of the patient s chart, then click on the Probs toolbar button. Adding a New Problem to the Patient Chart using a Custom Problem List To make a change to the patient s problem list, you ll do so during a chart update. Prior to adding a new problem, though, verify that an instance of that problem is not already on the patient s problem list; if it is not, use the steps defined below. If, however, a problem is already on the patient s problem list, you will need to consider other documentation options, also included in the following pages. 1. With a chart update already in progress, click the Probs button of the Charting toolbar. 2. In the Update Problems window, click the New button, in the lower left corner of that window. Problems already documented in the patient chart Click New to add a new Problem to the list UpdatingChart2005.doc 8

12 3. The New Problem window opens; in the upper left corner of that window, click to select the appropriate Type of Problem. By default, Diagnosis of is highlighted, but you can choose one of the other options, when applicable. 4. The entry displayed in the Using Custom List: field may reflect a problem list created for your clinic. Also, several of the forms used in HealthTeam clinics lead you to specific custom lists. Use the dropdown arrow in the field directly below the Using Custom List: field to access the problems contained in the currently displayed list. Problem Type Custom Problem List Content of Selected List 5. (Optional) Type additional information related to the new diagnosis in the Comments: field. 6. Designate a new Onset Date in the Onset Date: field, if other than what is already displayed there. If you have only a general idea of the Onset date, first click Approximate, just to the right of the Onset Date: field, then enter a date that best reflects the start of the problem. 7. When applicable, enter an End Date for the problem. As with the Onset Date, if you have only a general idea of the end date, first click Approximate, then enter the date that most closely represents that date. 8. Enter the Duration, if applicable, including the units of measurement (Days, Weeks, or Months). 9. Click the Save & Continue button if you need to document further in the New Problem window. Or, if you are done working in the New Problem window and are ready to proceed to a different screen, click OK. 10. (Optional) Make further changes, such as adding an assessment to a problem already on the patient s problem list, or removing problems from the list that have since been resolved. 11. Click OK. NOTE: Whether you add a problem using a custom list, or you locate and choose one via the Reference List button, only change a problem s Description with extreme caution. Problems in Centricity are linked to billing codes, and changing what appears in the Description field could compromise billing integrity. UpdatingChart2005.doc 9

13 Adding a Problem to the Patient Chart Using the Reference List Problems can be added to patient problem lists using the Reference List button of the New Problem window. This allows you to search Centricity s comprehensive table of diagnoses and procedures. Prior to adding a new problem to a patient s problem list, though, be sure to verify that the problem isn t already documented in that patient s record, as an Active or Inactive problem. Then, after having confirmed that the problem is not already there, follow the steps provided below. 1. With a chart update in progress, click the Probs button of the Charting toolbar. 2. In the Update Problems window, verify that the problem you wish to add isn t already on the patient s problem list, then click the New button, in the lower left corner of that window. 3. In the upper left corner of New Problem window, click to select the appropriate Type of Problem. 4. Click the Reference List button, in the upper right corner of the New Problem window. 5. The Find Problem window opens; type the complete or partial name of the problem, or its ICD-9 code, in the Search for: field. 6. Click Search. 7. Locate and select the appropriate problem. If you don t see the one you re searching for, enter new criteria and click Search again. The Find Problem window UpdatingChart2005.doc 10

14 8. Having located and selected the appropriate problem, click OK. The Find Problem window closes. Now back in the New Problem window, the problem you selected is displayed in the Description: field. Below the Description: field is the Comments: field, where you can add a comment, when applicable. 9. The Onset Date: defaults to the current date. If this is correct, leave it as is; however, if you are documenting a problem that was diagnosed in the past, enter the correct date. Problem Description and Comment Problem Onset Date, End Date, Duration Save & Continue, or OK 10. When applicable, enter an End Date for the problem in the End Date: field. 11. Enter the Duration, if applicable, including the units of measurement (Days, Weeks, or Months). 12. Click the Save & Continue button if you need to add another new problem. If you are done working in the New Problem window, click OK. 13. (Optional) Back in the Update Problems window, make further problem changes to the patient chart. 14. Click OK. Additional Ways to Add a Problem to the Patient Chart There are several forms used in HealthTeam clinics that facilitate the addition of problems using methods other than those described above. For example, the Problems-CCC form allows you to place a checkmark in front of a specified problem, and that problem is automatically added to the patient s problem list. On that same form, some of the checkbox options are programmed to open problem-specific custom problem lists. The illustration on the right shows both straight problems and links to custom problem lists (Ex: Ataxia and Asthma-LIST, respectively). If you have questions about using the Problems-CCC form, or about other forms that facilitate the addition of problems to patient problem lists, ask someone in your clinic, or contact your EMR Implementation team member. SEARCH TIPS When searching for a Problem Type a descriptive keyword or short phrase, such as back pain. Enter only a portion of an ICD-9 code, such as 493, omitting qualifiers. Combine two or more words or abbreviations. Ex: hx v lists most of the V-coded Historical problems, without including all diagnoses that have the letter v in them. UpdatingChart2005.doc 11

15 Reactivating an Inactive Problem You can reactivate a problem that is on a patient s Inactive problem list. When you reactivate a problem, the original End Date recorded for that problem is automatically deleted and the problem is returned to the active problem list. The Onset Date remains as originally documented. Once the chart update has been signed, the reactivated problem appears as a typical problem when Active Only is selected on the Problem tab, but the historical information about that problem is displayed if you select All. A Reactivated Problem on the Patient Problem List 1. With a chart update in progress, click on the Probs button of the charting toolbar. 2. Select Inactive, in the upper right corner of the window. 3. Click directly on the problem that you want returned to the active problem list. This, in turn, activates the Reactivate button, located in the lower portion of the Update Problems window. 4. Click Reactivate. 5. Click OK. Select the problem from the Inactive list Click Inactive Click Reactivate Reactivating an Inactive Problem UpdatingChart2005.doc 12

16 New Occurrences of Old Problems You can use an Inactive problem on the patient s problem list as a template of sorts, upon which you build documentation of a new problem added to that patient s chart. When you begin a new occurrence of an old problem, that new occurrence will have a history entirely independent of the original. 1. With a chart update in progress, either click the Probs button. 2. Select Inactive. 3. Click on the appropriate problem in the upper portion of the Problem list. Select the problem from the Inactive list Select Inactive Click New Occurrence 4. Click New Occurrence, located in the lower portion of the Update Problems window. 5. The New Occurrence of Problem window opens. There you determine the Type of Problem, then define the Problem as applicable to that instance. 6. Click OK, then OK again. TIP Use the New Occurrence tool to document a new diagnosis of an Inactive problem with a new onset date. This might be a discrete instance of a recurring problem, such as UTI or Otitis Media. Reactivate a problem when the new diagnosis of the problem is directly related to the original diagnosis and onset date. The clinical history of this reactivation is grouped with the original problem. UpdatingChart2005.doc 13

17 Duplicate Problem Notices The Duplicate Problem(s) Found feature helps reduce the number of duplicate entries on patient problem lists. When you go to add a problem, the program checks to see if it already resides on either the patient s Active or Inactive problem list. If it does, the Duplicate Problem(s) Found window opens. There you can opt to add a New Assessment to the existing problem, view the Details. of that problem, or actually add a duplicate of that problem by clicking the Continue Adding Problem button. If you choose to add a new instance of a problem already on the list, that new instance will be independent of the original entry. Removing a Problem from the Patient s Problem List - Unsigned If you ve added a problem to the patient s problem list during the current chart update, then decide that it should not remain on that list, click on the Probs button of the Charting toolbar. The problem should be displayed in the lower portion of the Update Problems window, labeled Effect of this update. Click to select the problem; this, in turn, activates the Change Back button. Click Change Back, and the problem will be removed from the patient s problem list. NOTE: The Change Back option will not be available if the problem you want to remove is from a previously signed chart update. Select the problem Click Change Back UpdatingChart2005.doc 14

18 Removing a Problem from the Patient s Problem List - Signed Occasionally a problem on the patient s problem list does not accurately reflect the patient s current diagnoses. An example of this would be an illness from which the patient has recovered since his or her last visit. To remove a problem from a patient s problem list that was part of previously signed chart update, follow these steps: 1. With a chart update in progress, click the Probs button of the Charting toolbar. 2. In the Update Problems window, click to select the problem in the upper portion of the window. 3. Click Remove. 4. The Remove Problem window opens, where you can record the problem s End Date, if known. If you have only a general idea of the date, first check Approximate, and then a general date in the End Date: field. 5. The default Reason for Removal: is Resolved, but you can use the drop-down arrow to select one of the other options, when appropriate. 6. Click OK, and then OK again. Changing a Problem on the Patient s Problem List At some point you may need to change a problem on the patient s problem list, without actually removing it. For example, originally an unspecified diagnosis may added, but subsequent testing helps to refine that diagnosis, in which case its entry on the problem list should be refined, as well. 1. Click the Probs button of the Charting toolbar. 2. In the Update Problems window, click to select the problem that you wish to change. 3. Then click the Change button, in the lower portion of the Update Problems window. 4. In the Change Problem window, locate and select the correct problem. 5. Select the reason for the change form the options in the drop-down Reason for Change: field. 6. If you wish to enter more problems on the patient s list, click the Save & Continue button; otherwise, simply click OK. UpdatingChart2005.doc 15

19 Assessing a Problem on the Patient s Problem List If you want to document an assessment of a problem that already resides on the patient s problem list, you should not add another instance of that problem; rather, you add the new assessment to the existing problem. 1. With a chart update in progress, click the Probs button of the Charting toolbar. 2. Click to select that problem to be assessed in the upper portion of the window 3. Indicate the assessment in the Assessment / Comment: field, choosing from Improved, Unchanged, Deteriorated, or Comment Only. 4. (Optional) Type additional information regarding the new assessment of the problem in the free-text area directly below the Assessment / Comment: field. 5. Click OK. 1. Select the Problem 2. Assess the Problem 3. Add Comment 4. Click OK Assessed Problems and their associated details are displayed on the Problems tab of the patient chart. Problem assessments are displayed in the lower pane of the problem window when the actual problem is selected in the upper window pane. The Problem List and Associated Assessments UpdatingChart2005.doc 16

20 Medications Medications documented for a patient are displayed on the Medication tab of the patient s chart. To make changes to the patient s medication list, a chart update must be in progress, such as an Office Visit or Phone Note. The task of updating a patient s medications will be easiest if you first familiarize yourself with the New Medication window. The features of the New Medication window, as well as the tasks performed in that window, are similar to those in the Change Medication window. The New Medication Window Custom Medication List Content of Custom Med List Full Medication List Patient Information (age, weight, height, insurance, etc.) Insurance Formularies Patient s Current Medication list Patient s documented Allergies, Adverse Reactions, and associated alerts Medication selected in Find Medication field or via Reference List; associated Instructions, Duration, and Comments Quantity, number of Refills, Pharmacy and prescribing physician information Patient Information, Current Medications, and Allergies/Adverse Reactions The patient information displayed in the New Medication window helps the physician determine which medication and dose to prescribe. Medications already on the patient s medication list are displayed, so as to reduce the likelihood of duplicate entries. This also helps the physician prescribing a medication to recognize potential interactions between medications the patient is currently taking and what is being prescribed. Allergies and adverse reactions documented in the patient chart are displayed, so as to prevent the prescribing of medications that should actually be avoided. (See Allergy and Adverse Reaction Graphic Displays, page 32.) UpdatingChart2005.doc 17

21 The Reference List Use the Reference List to access Centricity s comprehensive medication list. This list contains both trade names and generic names, includes an equivalent look-up utility, and displays average wholesale prices. Durable medical supplies are included on the reference list, as well. Custom Medication Lists A custom medication list lets the provider enter a few matching characters and select from a pre-defined medication list, rather than going through the full medication list. Some of the benefits of a custom medication list are: Medications on a custom medication list can include associated Instructions, Quantities, number of Refills, and End Dates/Durations. Using a custom medication list facilitates thorough and accurate documentation of medications prescribed. This is especially true with medications that have hyphenated names or irregular spelling. Custom lists can be assigned to individual Centricity users. Lists can also be specialty/diagnosis-specific, which helps the users document medications quickly and accurately. End Dates and Durations help keep patient medication lists current. A medication with an End Date or Duration automatically moves from the Active to Inactive medication list once that amount of time has elapsed. Formularies The GE Centricity 2005 online help description of a formulary: A formulary is a list of medications that an insurance company has determined to be most cost-effective for a given therapeutic use. Considering formularies when prescribing medications helps reduce the number of prescriptions that are not approved under a specific plan. Options for the Prescribing Method Choose Handwritten if the prescription was written out on paper and given to the patient. (Ex: the original prescription wouldn t print, so the physician used a traditional prescription pad.) Use Historical if the medication was given in the past, or by a non-healthteam provider. Select Fax to Pharmacy to send the prescription via fax to the pharmacy indicated. If the prescription is to be printed and given or mailed to the patient, or mailed to a Pharmacy, choose Print then Give to Patient, Print then Mail to Patient, or Print then Mail to Pharmacy, respectively. Samples Given records that the medication was given directly to the patient; subsequent refills can be generated from this original entry. Select Telephone if the prescription is being called in to a pharmacy. Prescribing Methods Use Reprint or Re-Fax if the originally printed or faxed prescription needs to be replaced. (Ex: the original prescription was destroyed due to a paper jam in the printer.) UpdatingChart2005.doc 18

22 Adding a Medication using a Custom Medication List 1. With a chart update in progress, click on the Meds button of the Charting toolbar. 2. The Update Medications window opens. Verify that the medication to be added does not already appear in the medication list, in the upper portion of the window, then click the New button. Medications already documented in the patient chart Click New to add a medication to the patient chart 3. In the New Medication window, use the Custom List and the field directly below the Custom List: field to locate and select the medication and any associated instruction set, quantity, and/or number of refills. NOTE: If you don t find the medication you re looking for in the drop-down list, do a complete medication look-up using the Reference List. 4. The medication you ve selected in the Find Medication field is automatically displayed under Define Medication, in the middle of the window. Modify the Instructions, if necessary. 5. (Optional) Type additional information specifically related to the prescription in the Comments: field. 6. (Optional) The Start Date: field is automatically set to the current date; change it, if applicable. 7. When applicable, enter either a Stop Date in the Stop Date: field, or indicate the Duration. Using one of these features will send a message to Centricity to automatically move the medication from the patient s Active to the Inactive medication list, once the designated time has elapsed. UpdatingChart2005.doc 19

23 8. Indicate the quantity in the Quantity: field. (If this field remains blank, you will not be able to print the prescription.) 9. Enter the number of Refills in the Refills: field. 10. Change the entry in the Authorized By: field, if what is displayed is incorrect. 11. Choose the Prescribing Method from those available in the drop-down list. 12. Selecting a Pharmacy is not required if the prescription is to be printed and given to the patient; however, if the patient indicates that he or she would like the prescription faxed directly to a particular pharmacy, you will need to locate and select that pharmacy in the Pharmacy: field. 13. If you need to add additional medications, click Save & Continue, then repeat the process. If you are finished entering medications in the current chart update, simply click OK. This closes the New Medication window and returns you to the Update Medications screen. Medication Pending Details of the new prescription Click Print RX, when applicable 14. If you d indicated in the New Medication window that the prescription was to be printed and given to the patient, the Print Rx button is activated. Click Print Rx. 15. Click OK to close out of the Update Medication window. IT WON T PRINT! Three of the most common reasons you may be unable to print a medication: 1. In the New or Change Medication window, one of the Print then. options is not selected. 2. There must be a number in the New/Change Medication Quantity field. 3. There s a problem with your network connection; reboot your computer, then try again. If you still can t print, call HIT at UpdatingChart2005.doc 20

24 Adding a Medication using the Reference List 1. With a chart update in progress, click on the Meds button of the Charting toolbar. 2. The Update Medications window opens; verify in that window that the medication to be added does not already appear in the medication list, then click the New button. 3. In the upper right corner of the New Medication window, click on the Reference List button. 4. Type a portion of the medication name for which you are looking in the Search for: field of the Find Medication window. 5. Click Search. 6. All medications that match your search criteria are displayed in the lower portion of the Find Medication window, both by brand and generic names. Locate and select the appropriate medication. NOTE: If the medication that you were searching for does not appear in the list, check the spelling of the search criteria that you initially entered; you may want to try a different spelling, or just enter the first few characters of the medication name, then click Search again. 7. Once you ve located and selected the correct medication, click OK. Type a medication name, then click Search Click to select from the displayed medications in the Search results Click OK, or do a cross-lookup via the Equivalent Meds button TIP You can search for and add medication to a patient chart that doesn t have a specific strength. This is useful when documenting historical medications when the strength is unknown. However, you should never actually prescribe a medication without a specified strength. UpdatingChart2005.doc 21

25 8. Now back in the New Medication window, the medication you ve selected is displayed in the middle of the window, under Define Medication. Type the instructions in the Instructions: field. 1. Medication selected 2. Enter usage instructions, comments, Start and End Dates, and/or Duration 3. Enter quantity, number of refills, and prescribing method information 4. Click OK 9. (Optional) Enter a comment for the medication in the Comments: field. 10. Add a Start Date and Stop Date, when applicable. 11. Enter a Duration and the correct unit of time, when applicable. 12. Use the drop-down arrow, if necessary, to indicate the correct individual in the Authorized By: field. 13. Choose the correct method for this instance of the medication s use in the Prescribing Method: field. 14. Click Save & Continue if you need to add more medications. If there are no more medications to add at this time, just click OK. 15. Back in the Update Medications window, the medication you just added appears under Effects of this update. If you indicated that you would be printing the prescription, the Print Rx button should be activated, as well. If that is the case, click the Print Rx button, then OK ; otherwise, you ll just click OK. The medication you just added UpdatingChart2005.doc 22

26 Removing Medications from the Patient s Medication List If you ve added a medication to the patient s medication list during the current chart update, but then determine that the new entry is incorrect, you may remove it during that same update. If, however, you ve already signed the prescription (i.e.: printed, faxed, etc.) the process for removing the medication is slightly different. Removing a Medication not yet Signed A prescription that has been entered during the current chart update but has not been printed, faxed, or otherwise signed can be removed in that same update, and that prescription will not be added to the patient s medication list. A new medication with this status can be identified by the word Pending in the Last Refill column in the upper portion of the Update Medication window. 1. Click on the Medication button of the Charting toolbar. 2. In the lower portion of the Update Medications window, under Effects of this update, click to select the medication you wish to remove. This activates the Change Back button. 3. Click Change Back. 4. Click OK to close out of the Update Medication window, or remain there to make further changes to the patient s medication list. A Pending medication can be removed using the Change Back button. Select the Added new medication entry, then click Change Back Removing an unsigned medication NOTE: You cannot retrieve a prescription once the Change Back feature has removed it from the patient s medication list. If you remove the wrong medication from the list via Change Back, you will need to return to the New Medication and add it again. UpdatingChart2005.doc 23

27 Removing a Medication from the Patient s Medication List Previously Signed Update To remove a medication from the patient s medication list that was added during an earlier chart update, follow these steps: 1. With a chart update in progress, click on the Charting toolbar s Medication button. 2. Select the medication to be removed from those listed in the upper portion of the Update Medication window. 3. Near the bottom of the window, click the Remove button. 4. In the Remove Medication window, type when the patient discontinued the medication s use in the Stop Date: field, if known. 5. Indicate the reason the patient quit taking the medication in the Reason for Removal: field. 6. (Optional) Enter a comment in the Comment: field. 7. Click OK. 8. Back in the Update Medications window, click OK to move on to another aspect of the chart update, or make further changes in the Update Medication window. Changing a Medication on the Patient s Medication List 1. With a chart update in progress, click the Medications button of the Charting toolbar. 2. In the upper portion of the Update Medications window, click to select the medication that requires modification. 3. Click Change, in the lower left corner of the window. 4. The Change Medication window opens. This window is almost identical to the New Medication window, and you document the changes to the existing medication as you would when entering a new medication to the patient s medication list. UpdatingChart2005.doc 24

28 5. If you need to change the actual medication in terms of strength or name, use the Reference List button to locate and select the appropriate medication. Use Reference List button to change the actual medication or strength. Change Instructions, Comments, Start/Stop dates, Duration as needed. Modify Quantity and/or Refills, as well. 6. Make the requisite change(s) to the medication instruction set or other information previously documented. 7. Click OK to return to the Update Medication window, then click OK once again to return to the main chart update window, or make further changes to the patient s medication list in the Update Medication window. MEDICATION ALERT Why is it so important to select a medication from either a custom medication list or the full reference list? A medication typed directly in the medication field by a Centricity user will not be considered when allergy and drug interaction checks are run. The same applies when changing a medication already on the patient medication list. Do not merely change the medication in the Define Medication Medication field. Select the correct medication from either a custom medication list, or from the full reference list. UpdatingChart2005.doc 25

29 Refilling Prescriptions To refill a prescription that is in the patient s chart, you can do so from within a chart update already in progress, or via the Refill button of the Centricity toolbar. Beginning a Refill Chart Update Refill a prescription independent of other chart updates by first going to the patient s chart, then clicking the Refill toolbar button. This begins a chart update, with the Prescription form in that update. Adding the Prescriptions Form to a Chart Update Many of the encounter types at HealthTeam clinics automatically include the Prescriptions form; however, if the Prescriptions form isn t in the current update and you want to add it to the update, follow these steps: 1. Place the cursor in the chart update where you want the Prescription form to load. 2. Click the Refills button of the toolbar. NOTE: If you neglect to place the cursor in the correct location of the chart update prior to clicking the Refill button, the Prescriptions form will load wherever the cursor was when you clicked the button, which, in turn, can negatively effect the chronological order of the chart note. The Prescriptions Form The Prescriptions form displays a patient s active prescriptions, associated instructions, quantities, number of refills, and the most recent prescribing dates. Also displayed are allergies and other prescribing details. The Prescriptions window displays the patient s active medications, allergies, and adverse reactions UpdatingChart2005.doc 26

30 Using the Prescriptions Form To refill a prescription displayed in the Prescriptions form: 1. Verify that there are no known allergies that conflict with the medication(s) being refilled, then place a checkmark ( ) in the Refill? box of the particular medication(s). This triggers the display of associated Quantity and #Refills fields, with the numbers automatically pulled forward from prior instances. 2. If the Quantity and #Refills values are correct for the current refills, leave them as they appear; otherwise, make the necessary changes. 3. Review any allergies and/or adverse reactions as displayed under Current Allergies. 4. When applicable, use the Select button to change the Pharmacy where the prescription(s) will be filled. 5. If the individual authorizing the prescription is not the person displayed in the Authorized By: field, use the drop-down arrow of that field to locate and select the appropriate person. If his or her name does not appear in the drop-down list, use the Binoculars to launch a full search. 6. If the refill is to be called into a pharmacy, set the Prescribing Method: to Telephone. This choice, in turn, activates a Sign Rx button. Alternatively, choosing Print then Give to Patient or one of the other Print options activates the Print Rx button. 7. Depending upon the workflow in your clinic, click the Sign Rx button, click the Print Rx button, proceed to the next form of the chart update, or close the form, end the update, and route it to the appropriate person for further processing. REFILL TIP A medication s actual dose and instruction set cannot be changed in the Prescriptions form. To make such changes, you ll need to go through the process of Updating Medications. UpdatingChart2005.doc 27

31 Allergies and Adverse Reactions Centricity 2005 enables us to distinguish between allergies and adverse reactions to treatment. It also provides room for detailed reaction descriptions. Access the Change Allergy or Adverse Reaction screen during a chart update by either clicking on the Allergies button of the Charting toolbar, or via an Update Allergy button on an encounter form (such as a Nurse Intake form). Recording No Known Allergies If there are no existing allergies or adverse reactions on record for the patient, and the patient reports having no new allergies or adverse reactions, record that information in the Update Allergies or Adverse Reactions window. This information will then be displayed on the summary page of the patient s chart. 1. While in a chart update, click the charting toolbar s Allergies button. 2. In the Update Allergies or Adverse Reactions window, put a checkmark in This patient has no know allergies or adverse reactions (NKA), in the middle of the window. 3. Click OK. An allergy is a hypersensitivity to some environmental agent, food, or drug that can result in minor reactions or life-threatening emergencies. A critical adverse reaction is any undesirable or unwanted consequence of a preventative, diagnostic, or therapeutic procedure or regimen. UpdatingChart2005.doc 28