EMR Setup and Data Entry Best Practices to Optimize EMR Reporting

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1 EMR Setup and Data Entry Best Practices to Optimize EMR Reporting Last updated 8/12/2013

2 The information presented in this document is subject to change. Please direct any questions or comments to or call Document Objective The purpose of this document is to guide you through best practices of entering data and properly documenting lab and imaging test results in eclinicalworks. Imaging and lab tests are frequently done outside the office. There are tests that are ordered by the clinic and tests ordered by external providers. When results and reports are made available to you in the form of a document that needs added into the patient chart. However, just adding the document to the patient s Documents area is not enough when it comes to reporting needs. The process of accurately documenting a test and its results are very similar whether the test is a lab or a diagnostic imaging. Disclaimer: Due to data collection variances and eclinicalworks software version updates, the instructions in this document are subject to change and may not be suitable for all eclinicalworks operations. In the event that your site is collecting data in a way that differs from the assumptions in this manual, please call our Client Services Manager at x 701 or [email protected] to schedule customization assistance from one of our consultants. Page 2 of 26

3 eclinicalworks is a registered trademark of eclinicalworks, LLC. BridgeIT is a trademark of Vision Data Technologies Inc. Table of Contents Disclaimer:... 2 Data Entry in eclinicalworks... 4 Date Values... 4 Numeric Values... 4 Blood Pressures... 4 Immunizations... 5 Lab and Imaging Reports... 5 Adding New External Reports to a Patient Chart... 6 Attaching a Report to an Order... 8 Attaching a Lab Order... 9 Attaching Imaging Orders Updating an Existing Document to Include the Order Defining Test Patient Accounts Setting up Patient Structured Demographics field to exclude Test Patient Accounts Creating a Rx Group in eclinicalworks Page 3 of 26

4 Data Entry in eclinicalworks Date Values Date values should be entered as mm/dd/yyyy or m/d/yyyy Correct Incorrect 2/4/ /10/ /04/ /31/0947 2/4/13 Numeric Values Do not use text or special characters in fields that are numeric results Special Characters = %, $, >, <, =, +, - Correct Incorrect % H >=14.0 Blood Pressures Page 4 of 26

5 BP start the field with the number any additional notes should be added after the BP Usage of a qualifier for sitting, standing etc... before the BP must end with a : Correct sitting:106/66 Incorrect sitting123/77 170/95 RA manually 128\67 142/73, 112/ /78 Out of Bp med x 4 days 160/62 at 12:20 p.m. Immunizations Immunization data must be entered in the Immunizations Detail Window. Scanned documents or entries flagging a patient as Up To Date do not provide the necessary immunization details for reporting. Lab and Imaging Reports All lab and imaging reports must be attached to their related orders. If the order was not created by your providers a virtual order for the Lab or Imaging test must be created. Please NOTE that a virtual order is not the same as a virtual visit. Page 5 of 26

6 Adding New External Reports to a Patient Chart New documents need added to the patient s chart in the Patient Documents section of eclinicalworks. This window is where you can scan documents or get them from the fax inbox and add them to the appropriate folder: After selecting the document and the folder, click the Add button in the lower left area of the window. If you have the Add Description box checked, the next window that allows you to name the document and attach it to an order automatically opens. Otherwise, you will need to click on the document and then Update to open the next window. Page 6 of 26

7 The report must be attached to an order in the system for it to count in the BridgeIT reports. And eclinicalworks will only allow you to attach it when the document is put in the correct folders. All lab results go in the folder named Lab Documents And all Diagnostic Imaging results go in the folder named X-ray Documents Page 7 of 26

8 Attaching a Report to an Order Once you add the document to the appropriate folder, the window that allows you to name the document and put any notes pops up. This is also where you will attach the document to an order by clicking on the button: ***Note*** The Document must be put in either the lab or x-ray documents folders for the next steps to work. Page 8 of 26

9 Attaching a Lab Order From a document in the Lab Documents folder, clicking that button will take you to the lab orders window: In this window, if there is already an order created you can check the box and click on Ok to attach the result to the lab. However if there is not an order already in the system, a new one must be created: Page 9 of 26

10 Fill out the appropriate information about the test, along with the results and any attributes for the test then click Ok to go back to the Lab Orders window. Then check the box next to your new lab and select Ok again to attach. Now you can assign the document to the provider for review. Page 10 of 26

11 There are two types of documents that can be attached to lab results: Interface results and chart documents. The pink paperclip on the left side of the window next to the attributes shows any electronic results that came in through an interface. The grey paper clip on the bottom of the screen shows a document that the attached document is in to the patient s documents. The BridgeIT reports will look for one of these paperclip attachments to determine if the office received an external result report. Page 11 of 26

12 Attaching Imaging Orders The Imaging Orders screen looks very similar to the Lab Orders screen. You can attach an existing order to create a new one then enter the results: Page 12 of 26

13 The grey paperclip on the bottom left corner of the window shows that a report is attached to this order. The BridgeIT reports will look for this paperclip to determine if a result was received for this order. Page 13 of 26

14 Updating an Existing Document to Include the Order For patients having tests that were previously put in their chart and not attached to an order, you will need to attach them. You can do this by going into Patient Documents and selecting the document to edit then clicking on Update. Please NOTE before you can attach a Lab Document to a Lab Order or an Imaging Document to an Imaging order the document must be in the proper folder. Page 14 of 26

15 From this screen, click on the button to open up the appropriate order window and follow the directions for attaching a lab or imaging order. ***Note*** If the document is marked Reviewed the box will need to be unchecked before eclinicalworks will allow you to attach an order. Page 15 of 26

16 Defining Test Patient Accounts OVERVIEW: Many sites have test patient accounts, aka: Tom Test, Fake Patient, Test Test etc that are used to test workflow related to EMR and Practice Management processes. Some of these patients show up on Financial and Clinical reports that may skew statistics. To globally exclude Test Patient Accounts from your reporting, follow the setup instructions below: Setting up Patient Structured Demographics field to exclude Test Patient Accounts A field for Test Patient needs to be defined in Patient Information Structured Data. 1. Open patient demographics and select the Info button 2. Inside the patient information screen, click on Additional Info this will open the General Information tab. 3. On General Information tab, lick on the Structured tab Page 16 of 26

17 4. Click the Custom button to edit fields in the Structured tab 5. Click the Add button to create a new field 6. Enter the name of the structured data field as Test Patient NOTE: Use exact spelling Page 17 of 26

18 7. Use the drop-down in Type, select Boolean 8. Check the box for Is Searchable to allow for searching through the eclinicalworks registry. Click OK to complete the addition of the field. 9. The Test Patient field is available with a drop down for the choices of Yes or No Page 18 of 26

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20 Excluding Test Patients from reporting 1. Open the Data Sources under the Project 2. Right-click on the table Patient Information and select Edit Restrictions 3. In the restrictions window, select the TestPatient field and set it as <> (not equal to) Yes Page 20 of 26

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22 Creating a Rx Group in eclinicalworks 1) From the EMR menu click on Rx Groups 2) From the Rx Groups window click the New button 3) Enter a group name in the Rx Group Name and a description for the group in the Description, then click OK Page 22 of 26

23 4) Your new group will now be displayed in the list of Rx Groups 5) To add medications to a medication group highlight the group and click the Update button. 6) Click on the Associate Rx button Page 23 of 26

24 7) the Select Rx window, you are able to search for the medication in the Find field 8) As you being typing in the medication name, a list of the meds that match the entered text will display in the window below. Page 24 of 26

25 9) Clicking on the medication from the list will add it to the Selected Rx section, then click OK. 10) The selected medication is now a member of the Rx Group. NOTE: Do NOT select more than one medication at a time in the Select Rx window, once you click OK the EMR will saves only the first selection on the list. (see the screen shots below) Page 25 of 26

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