GeeseMed Patient Chart Manual-2018

Transcription

1 GeeseMed Patient Chart Manual v7.0.5

2 Patient Chart Path: Patient Hub>>Patient Chart [Need to Select Patient First] Patient Chart Screen is divided into five sections as shown below. 1. Summary 1. Click on Print to print the details of the particular section. 2. Click on icon to add the details. 3. Click on Patient Document Hyperlink to download the document. 4. Click on More to display more information. 5. Click on Show Historical link to show past history. 6. Click on icon to print multiple sections from multiple charts as shown below. 2

3 A. Click on All to select all the sections. B. Click on None to deselect the selected sections. C. Select the checkbox to select the particular section. D. Select the checkbox to select all the charts. Note: Maximum of 25 charts can be selected. E. Select the checkbox to select the chart. F. Click on Print to print multiple sections as well as multiple charts as shown below 3

4 2. Chart The chart is the written conversation between the Provider and the Patient. 1. Click on New Chart to create a new chart for the selected date. 2. Select the chart and click on Save As to save the same chart details under a different Provider or DOS as shown below A. Select the Template. B. Select the Titles that you want to copy to the new chart. C. Click on Save as New Chart to save the chart as a copy with the selected details. Different Scenario For Save as New Chart: Save As SrNo Patient Location Provider Chart Date New Chart Attending Provider New Chart Fellow Provider 1 Same Same Same Same Will Show Data In Plan Will Show Data In Plan(Att+Fel) 2 Same Same Same Different Will Show Data in Medication Title Will Show Data in Medication Title(Att+Fel) Based on Base Chart 3 Same Same Different Same Will show data in Medication Title without selection Will show data in Medication Title without selection(att+fel) 4

5 4 Same Same Different Different 5 Same Diff Same Same 6 Same Diff Same Diff 7 Same Diff Diff Same 8 Same Diff Diff Diff Will Show Data to Medication Title Will Fetch Only Free text Data in Medication Title Will Fetch Only Free text Data in Medication Title Will Fetch Only Free text Data in Medication Title Will Fetch Only Free text Data in Medication Title Will show data in Medication Title(Att+Fel) based on Base Chart Will Fetch Only Free text Data in Medication Title Will Fetch Only Free text Data in Medication Title Will Fetch Only Free text Data in Medication Title Will Fetch Only Free text Data in Medication Title Note: Vitals, Family History, etc are not copied from the source chart. 3. Select the Type of Visit. 4. Select the Template Name. 5. Select the Fellow Provider if needed. 6. Select the Status of the Chart. 7. Searches for the words from the selected chart. 8. Click on Save to save the Chart. 9. Click on Cancel to cancel. 10. Click on Referral to refer the chart to any other Provider as shown below A. Select the checkbox to refer this chart to other Provider. B. Select Referral type from drop down Referral/Clinical Summary Request/Document Request. C. The Providers name will appear in the box. D. Write an Introduction for the chart if needed. E. Write the Conclusion if needed. F. Choose the file to upload. G. Write the Chart Note if needed. H. Click on icon to select the charts from the list which have been signed off. 5

6 I. Select Referral Note Check Box. J. Click on Send to send the Referral. After sending the referral as direct message the document will be displayed in Transition of Care>>InBound menu on the home page of the particular provider as below Click on the subject name and you will be able to see the below screen 1. Select the type of document. 2. Click on to download the document. 3. Click on to send the document to Patient Doc. Note: It will be disabled if the document is already sent. After sending the document from Transition of Care; it will be displayed in Patient Doc>>Unmapped Doc menu from the Home Page 6

7 1. Click on View to view/verify the document. 2. Click on Map and enter the mandatory details to map the document to the Patient. Note: Map option will be disabled in case of CCD and Referral; in that case you need to view the document first. Enter the mandatory fields and click on Update to map the document to the Patient. K. Click on Cancel to cancel the Referral. L. Click on Add New Connection to add or search Provider and you will get below Screen. A. Search for the details of the Provider or Organization that you want to search and you will get below screen when you click on Search. [Note: Provider and Organization list will come from Kno2 (Third Party Tool)]. 7

8 Click on Save to save the Provider/Organization and you will get below screen. Select the name of the Provider/Organization that you saved and you will get the details of the provider in the below Screen and then click on Save to save the details. Enter the details for the new Provider/Organization and click on Save. We can also check the referrals that were send to the Providers from Transition of Care>>OutBound as shown in the below screen 8

9 11. Click on Print to print the chart. A. Click on icon to print the CCD Report. B. Click on icon save the chart in PDF Format. C. Click on icon to print the chart. 12. Click on Superbill to create a Superbill for that chart. A. Click on Add New to add a new Superbill. a. Select Office CPT or Master. b. Search and Select the CPT. c. Search and Select the Modifier. d. Select Patient or Master ICD radio button. e. Search and Select the ICD. f. Enter the Notes if needed. g. Select the Start Date. h. Select the End Date i. Enter the Quantity. j. Enter the Rate. k. Click on Save to save the Superbill. 9

10 1. Click on icon to edit the changes of Superbill. 2. Click on icon to delete the Superbill. 3. Click on icon to view the Superbill. 4. On click of send, HL7 DFT message will be sent to configured profile. l. Click on Cancel to clear the data. B. Click on Print to print the Superbill a. Click on to save the Superbill in PDF Format. b. Click on to print the Superbill. 13. Click on Sign-Off to sign off the chart. Note: Providers can only Sign-Off their own charts. 14. Click on Co-Sign to assign the chart to a cosigner. 15. Click on FAX to send selected chart as FAX. 10

11 A. Select the checkbox to whom you want to send Fax to. B. Click on Send FAX button to send selected chart through Fax. 16. Click on Plan to see details such as Lab, Prescribed Medication, Implant Device and Diagnostic Imaging as Structured entry added for same DOS as well as Lab Result will also appear in this section as below Note: Future Appointments will be displayed in plan title. Note: Lab, Prescribed/reported Medication, and Diagnostic Imaging created before DOS of the chart, it will be displayed in its own title. You can also add future appointment directly by the below button 17. Click on Addendum to make any changes and you can Sign-Off it as well. Note: You can addendum only after the chart is Signed-Off. A. Add Addendum. B. Click on Accept to accept the Addendum. C. Click on Deny to deny the Addendum. D. Click on SignOff to SignOff the Addendum and it will be shown as shown below 11

12 18. Click on Clinical to view the Clinical Summary as shown below Select the titles that you want to view and then click on View Summary or View XML and you will see the format as below 19. Click on Delete to delete the chart. 20. Click on CCM Care Plan to create a Care Plan. 21. Syndromic Surveillance applies to surveillance using health-related data that precede diagnosis and signal a sufficient probability of a case or an outbreak to warrant further public health response. 22. Click on Forms / Templates to attach the form in the chart as shown below 12

13 1. Click on the template name to add/edit the details. 2. icon will display that the template is signed-off. 3. Add the necessary details. 4. Click on Update to update the details. 5. Click on Sign-off to sign-off the details. 6. Click on Clear to clear the details. After adding the form in the chart you can see the Form under Entry Form title as shown below Click on icon to print the Form details as shown below 23. Color indicates the chart has been created by different Provider. 24. Color indicates the chart has been co-signed by the selected Provider. 25. Color indicates the chart has been created in different Location. 26. Symbol indicates the chart is signed off by the Fellow Provider. 27. Symbol indicates the chart is signed off by the Attending Provider. 28. Symbol indicates the chart is signed off by the Cosigner. 29. Click on Icon to view help File. 13

14 Types of Data Entry 1. Free Text Free Text allows you to enter free text and also check for errors in the field as shown below Spell Check Feature: Hold Ctrl Key and right click on the wrong word to get the suggestions as in the below screenshot 2. Macro Macros help the user quickly complete entries for common responses A. Select the radio button and search in the search box. B. Select the Macro to open it in the Chart Editor Screen. C. Click on Add/Edit Macro to add the macro. 14

15 A. Select the Chart Title you want to add/edit macro. B. Select the checkbox to select the macro. C. Click on macro name to edit the macro. D. Click on Delete to delete selected macro. E. Enter the name for the Macro that you want to keep. F. Select the Speciality from the dropdown menu. G. Select the checkbox to share the macro with all locations. H. Enter the information for the macro. I. Click on Save to save the macro. J. Click on Cancel to cancel the details added. 3. History There are two types of History in chart A. Past Medical History 1. Enter the details and click on Submit and Close to save the data for particular chart only. 2. Click on Save To Central History to save the data for all the charts. 15

16 B. Family History 1. Select the checkbox if patient has no known Family History. 2. Select the Relation of the Patient. 3. Search and Select for the diagnosis. 4. The diagnosis selected will be displayed in the grid. 5. Enter the death age of the Patient. 6. Enter the Free text if any. 7. Click on Save to save the details. 8. Click on Clear to clear the details. 9. Click on Save To Central History to save the data for all the charts. 4. Vitals Vitals allow us to enter vital details for the patient. 1. Enter the temperature in Fahrenheit and it will be automatically be converted in Celsius. 2. Click on Save to save the details. 16

17 5. Structured Entry Some Titles allow us to select a Structured Entry. A. This button allows us to void RX. B. This button allows us to DC RX. C. This button gives information when the Refill Request has been generated. Click on icon to you will get below Screen Note: Details will depend on the title of the chart. Select the entries by selecting the checkbox that you want to add in the respective title of the chart. 6. Geesemed Forms A. Click on the Form name and details will be shown. Note: Only forms that are filled will be appeared over here. B. Click on the respecticve checkbox to add those details as Free Text. 17

18 7. Review of System / Physical Exam Click on icon to you will get below Screen A. Select the option. B. Select the answer from the dropdown. C. Click on icon to add new option in the dropdown. D. Enter the text that you want to display in the dropdown. E. Click on Save to save the details. F. Click on Clear to clear the details. G. Select the option and the respective option will be selected in all the fields for that particular group. 8. Import Functionality Import functionality can be used to import data from other Location for the same Patient. A. Select the checkbox that you want to import. B. Click on to import the data. 9. Lab Order Lab results for current DOS will display in the Plan, however, for future DOS charts, the lab order will be displayed in the Lab Order title as shown below 18

19 10. Quality of Care This title is located in every chart at the bottom. The description of all the titles are as follows 1. Medication Reconcillation:- This checkbox is used to indicate when you have reconciled a patient s medication during an office visit. This checkbox is used to meet the requirements of the Stage 1 Medication Reconciliation menu measure and the Stage 2 Medication Reconciliation core measure. 2. Documentation of Current Medications:- This checkbox allows a provider to indicate that they have updated the patient s medication record or can attest that the patient s medication record is up to date for each particular encounter. This checkbox is used as part of the clinical quality measure requirements for the Documentation of Current Medications (CMS68v3/NQF 0419). 3. Transfer of Care - Incoming:- This checkbox is used to indicate that a particular encounter is an incoming transition of care, meaning this patient was transferred to you from another facility or provider. This checkbox is used as part of the calculations for the Stage 1 Medication Reconciliation menu measure and the Stage 2 Medication Reconciliation core measures. 4. Transfer of Care - Outgoing:- This checkbox is used to indicate that a particular encounter is an outgoing transition of care, meaning you are transferring this patient to another facility or referring them to another provider. This checkbox is used as part of the calculations for the Stage 1 Menu Transition of Care Summary measure and the Stage 2 Core Summary of Care Measures. 5. The Patient declined to receive a clinical summary:- This checkbox can be used to indicate that a patient has declined to receive a clinical summary at the conclusion of their visit. Clinical summaries are offered to patients in order to meet the requirements of the Stage 1 Clinical Summaries core measure and the Stage 2 Clinical Summaries core measure, but not all patients will accept the offered documents. Using this checkbox provider can achieve credit for Meaningful Use even if the patient declines to receive the offered clinical summary. 6. Patient Decision Aids:- This checkbox can be used to indicate that you have given a patient educational material outside of the EHR. This checkbox can be used to meet the requirements of the Stage 1 Patient-Specific Education Resources menu measure and the Stage 2 Patient-Specific Education Resources core measure. 19

20 3. Past Encounter Past Encounter is used to search encounters by type as shown below 4. Tel. Encounter Telephonic Encounter describes a patient remote encounter by phone. 1. The non-editable username will appear in this tab. 2. Select the date for Telephonic Encounter. 3. By default, the System s time will be taken. 4. Enter the name of the caller. 5. Enter the phone number of the caller. 6. Select the checkbox if encounter is to be set for higher priority. 7. Enter the reason for calling. 8. Select the user to whom this encounter is to be assigned. 9. Select the status as Open or Addressed. 10. Enter the notes as needed. 11. Enter Action Taken. 12. Click on Save to save the encounter and it will appear in Summary and Chart Page as below 13. Click on Clear to clear the details entered in the above grid. 20

21 Click on FAX to fax the telephone encounter as shown below 5. Documents Documents allows uploading of patient documents shown below 1. Click on Document Name to select the Document and click on Print to print the document. 2. Click on Upload Document to upload the Document of the Patient. A. Click on Choose File to choose the file. B. Enter the Description. C. Select the Document Type. D. Select the Priority of the Document. E. Select the User who uploaded the file for the Patient. F. Click on Upload to upload the file. 3. Select the Document and click on Delete to delete the Document. 4. Click on Edit to edit the details. 5. Click on Document Name to preview. 21

22 Version Change Log Version Release Date Updated By Change Details V /14/2017 Gary 1. Added Plan Button in Chart. 2. Lab Result will be displayed in Lab Order. V /11/2017 Gary Attending and Fellow Provider s Medication, Lab, and Diagnostics data will display in Plan section & Respected Title. V /30/2017 Gary 1. Medication entry screen will be open From Chart s Medication Title for Medication Entry. 2. Refills Status will be display in Chart s Medication and Plan Title. V /29/2018 Gary 1. Appointments created before DOS of chart will appear in Plan Title. 2. GUI of FAX title has been changed. V /09/2018 Gary Spell Check Feature added V /23/2018 Gary New titles for Vitals added V /21/2018 Gary 1. Added Appointment button besides Plan button. 2. Added ROS and PE title. 3. Entry Form implemented. 4. Added Fax button in Telephonic Encounter. V /06/2018 Gary 1. Added Telephonic Encounter Search option from Past Encounter. 2. Added Geesemed Forms tab under each title. 3. Added Save as Functionality for Forms /Template. 4. Added Auto Score Functionality. 5. Added select all functionality Drop Down in ROS Structured Entry. 6. Change display format of Appointment in chart. 7. Added Created By Label in Chart which will be reflected in Print as well. V /02/2018 Gary 1. Disabled CDS alert from Telephonic Encounter. 2. Added Colums in Transition Of Care. 3. Added Addendum SignOff Functionality. 4. ICD-CPT code will not display in chart print and Fax. 22