Seamless flow. Medical Assistant & Nurse Training Guide. Rachel J. Cohen PhD DOHMH Training Manager Rcohen5@health.nyc.

Transcription

1 Seamless flow 2 eclinicalworks EMR Medical Assistant & Nurse Training Guide Rachel J. Cohen PhD DOHMH Training Manager Rcohen5@health.nyc.gov

2 Contents Introduction... 3 Log In to eclinicalworks... 4 Taskbar Quick Links (Generally referred to as jelly beans ) Patient Lookup Button... Error! Bookmark not defined. Patient Hub... 7 Create a Telephone Encounter... 8 Access the Office Visits Screen...14 Update Patient Room and Visit Status...17 Access the Progress Note...18 Progress Notes Templates...21 Vitals...24 Chief Complaints...29 Document Chief Complaints...29 Current Medication...32 Enter Current Medication...32 Review Medication History...34 Add a Medication to the Patient s Record...35 Adding or Changing the Pharmacy on Record...39 View Physician Orders...40 Immunizations...43 Document Immunizations...43 Update a Given Immunization...49 Billing...50 Add or Remove the TC Modifier

3 Introduction As part of New York City s Take Care New York initiative, the PCIP Project is a multifaceted program to support the adoption and use of Ambulatory Health Records (AHRs) among primary care providers in NYC's underserved communities. Its mission is to improve population health through appropriate technology and health information exchange. The eclinicalworks system was chosen by New York City s Department of Health and Mental Hygiene as their vendor of choice to accomplish their goals. The Medical Assistant and Nursing staff at doctor s offices, clinics, outpatient, ambulatory facilities will be performing their routine tasks in the AHR (ambulatory health record) system eclinicalworks. The following pages document and demonstrate the system functions necessary for completing common medical assistant and nursing tasks. 3

4 Log In to eclinicalworks After logging into the network using your user name and password, you will notice the ecw icon Click this icon. on the desktop. The logon window appears. Enter your first initial and last name (example, jandrilli) in the Login ID field and initially your password will be password1 (there will be subsequent instructions on how to change your password). 4

5 Display of who is logged in This screen defaults to today s date and the first provider listed in your default clinic. Click the S jelly bean to view your patients. 5

6 Taskbar Quick Links (Generally referred to as jelly beans ). S Menu: Links to the Office Visits window which displays the patients that have arrived for their visit. The number in the S jelly bean indicates the number of patients arrived and displays only in the providers view. Staff will always see a 0. D Menu: Provides the option of going directly to the Fax Inbox or Fax Outbox windows. The number next to D indicates the number of documents assigned to the logged by another staff member. Click the button to open the Review Document window. R Menu: Provides links to the Incoming Referrals or Outgoing Referrals windows. The total number of referrals assigned to the logged on user displays in parentheses next to each link. The number next to R indicates the combined total number of incoming and outgoing referrals. Click the button that has the number to open the Outgoing Referrals window or click on the R itself to select Incoming Referrals or Outgoing Referrals from a drop down list. T Menu: Provides links to the Telephone/Web Encounters window, which includes new telephone and web encounters as well as Actions and a link to Claims. The total number of encounters assigned to the user who is logged in will be displayed in parentheses next to each category. The number next to T indicates the combined number of open telephone and web encounters assigned. Click the button to open the Telephone/Web Encounters window. L Menu: Opens the window directly to the To Be Reviewed tab. The total number of labs and imaging assigned to the logged on user displays in parentheses next to each category. The number next to the L indicates the combined number of labs and imaging. The tabbed sections include Outstanding, To be reviewed, Reviewed, Future, By patient, and All. M Menu: Provides links to messages in the Inbox, Outbox, or Deleted Messages windows, and includes a link to the Create New Message window. The number next to M indicates the number of new messages in the Inbox for the logged in user. Click on the letter M to view the Inbox, Outbox, Deleted Messages or Create New Messages. 6

7 Patient Lookup Button The Patient Lookup button is your starting point for almost all eclinicalworks activities. You can search for a patient by using the Patient Lookup button. To Search for a Patient 1: Click the Patient Lookup button. 2 3 The Patient Lookup window opens. Not necessarily true as they will be using office visits screen for everything except telephone encounters 4 2: Type the last name of the patient in the Search Patient field. 3: Click on the name of the patient. 4: Click the Patient Info button to open the Patient Information window OR click OK to open the Patient Hub. Patient Hub The Patient Hub is aptly named because all of the major components of the patient's electronic medical records are accessible directly from the Hub. Like the hub of a wheel, the Patient Hub is the central point of access for important features such as Alerts, Demographics, and Progress Notes. 7

8 The Hub contains navigation buttons, static patient information, and a toolbar that links to common areas of the application. Many of the main windows in the application contain a link or button back to the Hub, making it easy for the user to quickly navigate back and forth to the Hub as part of the workflow. You may easily create new telephone encounters and access the progress notes from the Patient Hub. Telephone Encounters The T quick link in the Status Taskbar and the Telephone Encounters window enables office staff to keep track of information communicated to the practice about a patient that requires action to be taken. When a patient or family member calls in to ask a question or provide a comment, record all relevant information in a telephone encounter. 8

9 The Taskbar quick link also keeps track of the number of telephone encounters assigned to staff for review (by user). High priority messages are noted with a red quick link and a red exclamation mark on the Telephone Encounters window. To Create a Telephone Encounter 1: From the T quick link in the Status Taskbar, open the drop down list and select New Telephone Encounter. 9

10 The Telephone Encounter window opens. The Answered by, Date, Time, and Status (Open) fields are automatically populated. 2: Click the Select button above the Patient field. 2 The Patient Lookup window opens. 3: Search for the patient in the database. Double click on the patient s name. The Patient Lookup window closes and the patient's name is added to the Patient field. 10

11 4: Select the patient s provider from the Provider drop down list. 4 High Priority: If this is an urgent message that needs to be addressed as soon as possible, check the High Priority check box. The T quick link turns red and the encounter is marked with a red exclamation mark on the Telephone Encounters window. 11

12 : Review the Pharmacy information, if filled in, or click the Change button and select a pharmacy from the Pharmacies list if the call is for a prescription or refill. 6: Type the name of the caller into the Caller field. 7: Review the Facility and change, if necessary. 8: Type the reason for the call into the Reason field, or select it from the drop down list. 9: Click the More ( ) button to select the provider, resource or staff person who will handle the call from the Assigned To drop down list. 10: Type the message into the Message field. 11: Click the Complaints button to add primary symptoms or Chief Complaints for the patient, if appropriate. 12: If the patient wishes to know any information on their Labs/DI tests, click on the Labs/DI tab. The Lab section of the encounter opens. Choose between the options Labs or DI from the drop down list. The dates they were ordered, the reason for the tests and the results can be viewed in this section. 12

13 13: If the patient needs a refill or a new medication, click on the Rx tab. The Rx section of the window opens. 14: Click on the Cur Rx button to view the current medications of the patient. Select a medication if needed and click OK. 13

14 You may also use the drop down arrow next to the Cur Rx button to view and select from the Current Rx, Rx History or External Rx History of the patient. 15: Once the medication is added to the Refilled Medicines list, click on the fields to specify the Comments, Name, Strength, Formulation, Take, Route, Frequency, Duration, Dispense, Refill, and Auth. To delete a medication, select a medication from the Refilled Medications list and click Delete. 16: Return to the Message tab and click the Add Action Taken button. The Notes window opens. Type a description of your action taken and click OK. Your name, the current date, and the exact time are automatically populated into the Action Taken field along with your notes. 17: Click OK on the Telephone Encounter window. Open vs. Addressed: Be sure that you leave the encounter marked as Open in the Status section. If it is marked Addressed, this telephone encounter will be locked from future editing and the provider will never be notified of this assigned telephone encounter. The telephone message about the patient is now documented and assigned. Access the Office Visits Screen To access the list of arrived patients, click the S jellybean on the taskbar quick link ( ). 14

15 The Office Visits window opens. Patients displayed in this window are those who have been registered and/or those checked in by the front desk. 15

16 Note: If you are in a clinic where you service multiple clinic s patients, use the Facility Group selection dropdown for the most efficient view of your patients. If not, use Facility as the selection criteria which will provide a list of all patients in that clinic. Click the dropdown and choose Facility Group or, click the drop down and choose Facility 16

17 Update Patient Room and Visit Status To room a patient: 1: Click in the Room field for the patient. The Room No. window opens. 2: Type or click the numbers on the keypad to enter the triage room number. 3: Click the OK buttton. You are returned to the Office Visits window. To update a patient s status: 1: Click in the Status field for the patient. The Status Codes window opens. Tip: Scroll down to see all available status codes. 2: Click TRI. You are returned to the Office Visits window. 17

18 Access the Progress Note There are multiple ways to access a patient's Progress Notes from within the ecw application. Patient care workflow varies greatly among staff members with different job tasks so the Progress Note is readily accessible from a number of work areas. The following list describes the various methods of accessing a patient's Progress Note: 1. From the Office Visits window: Double click the patient's name in the Office Visits window to launch the Progress Notes for the patient. Alternatively, check the check box next to the patient s name and click View Progress Notes. 18

19 2. From the left navigation bar: Click the Practice band, and then click the Progress Notes icon. 3. From the Patient Hub: Click the Progress Notes button. 4. From the Central Resource Schedule window or the Provider Schedule window: Right click the mouse button on an appointment slot. Click View Progress Notes in the drop down list. 19

20 Central Resource Schedule Window: Provider Schedule window: 20

21 Progress Notes Templates A Progress Notes template provides details about observations and treatment strategies. Using a template can maximize a patient visit by focusing only on the pertinent information. The usage of templates assists in documenting the Progress Note faster for common and discrete problems. To Copy and Merge a Generic Template A generic template is most useful because it can be used for any patient. There is no patient specific information in it. Physicians, nurses, and other authorized staff with access to Progress Notes can copy or merge the selected template into the patient's Progress Notes. 1. On the Progress Notes window, click the green arrow next to the Templates button in the bottom toolbar (or, from the File menu, select Templates) and select Copy and Merge from Templates from the drop down list. 21

22 7 The Progress Notes Template window opens The patient's name and the encounter date appear in the Template For section at the top of the window. 3. Under Choose Template, click Generic. 4. Click on the Category drop down list and select the All category. A list of templates displays on the bottom. 22

23 5. In the Find field, type Nursing to filter the templates list. In the Facility field, select a facility for which the template was saved from the facility drop down list. A template is (or a list of templates are) displayed. 6. Click on the desired template. 7. Under All Options, click the check box for the template information to be included. If all information is desired to be included, click All Options. 8. Select Copy Template or Merge Template. Copy Template removes the information from the patient's Progress Notes, and substitutes the template values. Merge Template leaves the existing information in the patient's Progress Notes, and appends the additional information from the template. Copying template information will overwrite the existing information in the Progress Note: If unsure about overwriting information, choose Merge to add the new template information to the existing Progress Note. The Patient s Progress Note is populated with the information copied or merged from the Template. 9. Click Close to exit the screen. 23

24 Vitals The Vitals window is where a patient s vital signs at the time of the encounter are recorded. Vital signs will generally be taken by a medical assistant. Document Vitals 1. On the Office Visits screen, click on the patient s name to open the Progress Notes window. 2. Click the Vitals link in the progress note. The Vitals window opens. The current visit is highlighted in yellow. 24

25 3. Check the pop up check box to enable a pop up window to enter information for each vital item. 4. Choose a vital item which needs to be recorded by clicking on the vital specific field in the row highlighted in yellow. A window containing the vital specific information appears. The following vitals window appears when the Height field is clicked. 5. If the height is to be recorded in feet and inches (e.g. 5 feet 4 inches), enter the values in the Ft and In fields respectively. If the Height is to be recorded in meter and centimeter, enter the values in m and cm fields respectively. The Height is automatically converted into inches if the unit of measurement is set as inches for height in the Vitals Admin Settings. If the height has been entered in a previous encounter, click Copy Height to import the height from the previous visit. 6. The following window appears when the Weight field is clicked. If the weight is to be recorded in Kilograms and Grams, enter the values in Kg and gm fields respectively. If the values are to be recorded in pounds and ounces, enter the values in the lb and oz fields respectively. The weight is automatically converted to pounds if the unit of measurement is set as pounds for weight in the Vitals Admin Settings. The number buttons can also be used to enter the values in the respective fields. 25

26 7. Click the > button to display the vitals on the right. Click Delete to delete the vitals. 8. Click Apply to import the patient s vitals in the Vitals window and exit the vital specific window. Or, click Next in the vital specific window to go on to the next vital type. The information provided is automatically imported into the patient s Vitals window. When Height and Weight are entered, the BMI is automatically calculated. 9. Use the page arrow to page forward or backward and view the other Vital Items on the list. Click the Hearing field to enter the Hearing Test data. The Hearing window opens. 26

27 a. A default decibel level appears in the Decibels column but it can be changed to record the actual decibel level during the test. Refer to the Settings section for more information on setting a default decibel level. b. Click in a cell for a side and a frequency and then click P for pass or F for fail. Click P for all or F for all to record pass or fail for all tests. Click Clear all to clear all cells and re enter data. c. Click on the appropriate Radio button under Comments. Enter notes in the Other field if Other is selected. d. Click Apply to document the data into the Vitals window and to exit the window. Or, click Next to move to the entry window for next data item. 10. In the Vitals window, click the Vision field to enter the Vision Test data. The Vision window opens. a. Select results for left, right or both eyes from their respective drop down list or manually enter the results into the fields. b. Record the Fusion test results into the Fusion field and the color perception test results into the Color field. c. Click on an appropriate radio button under Comments to record whether a child was too young to test or the patient wore glasses for the test. d. Select Other to record additional comments into the Other field. e. Click Apply to document the data into the Vitals window and to exit the window. Or, click Next to move to the entry window for next data item. 27

28 11. In the Vitals window, click on the Pain Scale cell to record a patient s assessment of pain. Enter a number between 0 and 10 that represents the level of pain that the patient is experiencing. Click Apply to document the data into the Vitals window and to exit the window. Or, click Next to move to the entry window for next data item. 12. Check the Vitals Taken check box to document that vitals were taken during the visit. This field is for indication purposes only, and it does not display on the chart. It inserts a stethoscope indicator on Notes Status field in the Office Visits window to inform the provider that the vitals have been recorded and the patient is ready to be seen. 13. For this Walkthrough, exit the Vitals window to view the vitals in the Patient s Progress Note. Exercise Your patient Test EMR ## vital signs have being taken by the nurse. The following vitals were recorded: Temperature 98.4 F, Weight 155 lbs, Height 5 4, BP 130/84, HR 60 per minute. Document Test EMR ## vitals in the patient s progress notes. Exercise Once the vitals have been documented into the progress notes, notify the provider through the system that the vital signs for Test EMR ## have been taken. 28

29 Chief Complaints The Chief Complaints window is where the primary symptoms or complaints for the current encounter are recorded. Document Chief Complaints 1. From the patient s Progress Notes, click Chief Complaint(s). The Chief Complaints window opens. Any text entered into the Reason field on the appointment window by the front office staff appears here as the first Chief Complaint. 2. Click Browse to select a complaint from a pre defined list of medical conditions. The Chief Complaints Keywords window opens. To select a complaint, click the complaint in the left pane. The selected complaint displays in the right pane. To look up a chief complaint, enter the first few letters of the complaint in the Find field. A list of complaints display. 29

30 The left pane displays a list of general complaints to choose from. The right pane displays the list of complaints chosen from the left pane. Click the < button to remove a complaint from the selected list. Click the << button to remove all the complaints from the selected list. Click Next to scroll through the list of complaints. 3. To select a complaint from patient s medical history, click the Follow Up tab to see the Medical History. Information that is documented in the Medical History section for the current visit is visible in the Follow Up section. This information can also be added to this visit's Chief Complaints. 4. Click on the medical history information from the Follow Up window. The selected medical history information appears on the right pane. 5. Click OK to close the Chief Complaints keywords window. The complaints selected from the Chief Complaints keywords window are documented in this section. The phrase "Follow up" is appended to the symptoms gathered from the Medical History. 30

31 6. To enter a chief complaint manually, click Add in the Chief Complaints section of the Chief Complaints window. A blank row appears in the Chief Complaints window. 7. Click on the blank row and enter another reason for the visit. 8. To remove a chief complaint, click on the row and click Remove. To delete text inside a row, place the cursor inside the row and manually delete them. 9. To arrange the order of the chief complaints, use the up and down arrows. 10. For this Walkthrough, exit the window to view the chief complaints in the patient s Progress Notes. Exercise Your patient Test EMR ## complains of fatigue and depression. Document these complaints into the patient s progress notes. 31

32 Current Medications The Current Medications window is where currently prescribed medications and a patient's prescription history are recorded. This feature lets the provider track the current medications a patient is taking and review their prescription history. Current Medications can be carried forward visit to visit by using the following steps. Failure to document the patient's current medications on any Progress Note will cause the medications on that Progress Note to move to the Rx history instead of Current Rx. Although all of the information is retained in the Rx History section, the provider's workflow is faster and simpler if the patient's Current Medication section is updated on each visit. To Enter Current Medications 1. From the Progress Notes, click Current Medication. The Chief Complaints window opens. To display the drug name only, without any dosage information, check Rx Name Only check box in the Current Medication Section of the Treatment Screen. To display medications along with dosage information, leave this box unchecked. Dosage information can be altered once the medication has been selected. 32

33 2. In the Current Medications section, click the Cur Rx button to select a medication that the patient is currently taking from the patient s medication history as of the last visit. The Select Medication window opens. This window displays all medications the patient was on or had started taking during their last visit. This would include the medications that were documented in the Current Medication Section as well as the medications that were prescribed to them in the Treatment section of the progress notes during their last visit. 3. Click on a line containing the medication to select it. The selected medication is now highlighted in yellow. 4. To select all medication, click Select All. To remove all selections, click Deselect All. 5. Click OK. The medication is now listed on the Current Medication Section of the progress notes. 33

34 The Current Medication listing lets the physician alter Strength, Take, Frequency and Start Date as appropriate for the patient. Click in the cell to activate the free text functionality and to alter dosage information. To Review Medication History This section displays a history of medications that the patient has been taking or had taken in the past. 1. From the Current Medication section of the Chief Complaints window, click the green arrow beside Cur Rx, and then select Rx History. The Select Medication window opens. 2. Choose from one of the following options to sort the medication history of the patient. The patient encounters are listed by date, starting with the most recent. Any date in bold has medication information. 3. Cur Rx lists the medications that were documented in the Current Medication section of the Progress Note for the encounter date that s listed. Click on the Cur Rx radio button. A list of encounters display by dates on the left pane. Click on a date to view the medications on the right pane. To add that medication to today s Current Medication, click on the medication. The selected medication is highlighted in yellow. Click OK. 34

35 4. Rx by Date lists any medication prescribed to the patient within each encounter. Click on the Rx By Date radio button. A list of encounters display by dates on the left pane. Click on a date to view the medications on the right pane. To add that medication to today s Current Medication, click on the medication. The selected medication is highlighted in yellow. Click OK. 5. Rx by Name lists the name of any prescription ever prescribed to the patient, sorted by name. Click on the Rx By Name radio button. A list of medications display on the left pane. Click on a medication to view dosage information on the right pane. To add that medication to today s Current Medication, click on the medication. The selected medication is highlighted in yellow. Click OK. 6. The medications selected in the Rx History section are added to the Current Medication Section. To Add a Medication to the Patient s Record If a patient is currently on a medication that is not listed in their past records, then the medication needs to be manually added from the drug database to the patient s Current Medication Section. 35

36 1. From the Current Medication section of the Chief Complaints window, click the Add button. The Select Rx window opens. 2. From the Type drop down list select the drug database. The options in the Type drop down list are: All Rx, Custom Rx, Medispan Rx, and Equip/Supplies Rx. Medispan Rx is a database for a widely used list of medications. This will be used in the majority of cases to choose a medication. Custom Rx is a customizable list of medications managed and used by the Provider to make modifications to and add to medications. Equip/Supplies is a non pharmaceutical list of items recommended for treatment. 3. A list of medications display. Use the Rx drop down options: Starts With, Contains and All Words to facilitate the search. Enter the name of the medication in the Find field to narrow down the search. Select from the list of medications. 36

37 4. The available formulations and dosages are displayed here. Click the dose that needs to be prescribed. 5. The medication and dosage are added to the Selected Rx list. 6. Select the medication. To remove the selected medication from the Selected Rx panel, click Remove. 7. Click OK to save the selection and return to the Current Medication section of the Chief Complaints window. The new medication is now included on the Current Medication list. 8. Click on the Date field to specify a date when the patient started taking the medication. 37

38 Please add the year and month search as most of our patients have been on their meds for years 9. The medication is now documented along with dosage and the start date information. 38

39 Adding or Changing the Pharmacy on Record You can add or change a pharmacy on the patient record. 1. Access the Patient Information window in any one of the following ways: Click the Info button next to patient s name from the Progress Notes screen or the Patient Hub. The Patient Info window opens. Or, click the Patient Info button on the Patient Lookup window. The Patient Info window opens. Page 1 Page

40 2. From the Patient Information window, click the Additional Info button. The second page of the Patient Information window opens. 3. Click the Sel (Select) button. The Pharmacies Lookup window opens Begin typing the name of the pharmacy in the Lookup Pharmacy field. 5. Select the patient's pharmacy from the list. 6. Click OK. The address of the selected pharmacy appears in the Pharmacy window on the Patient Information screen. 7. Click OK on the Patient Information window. View Physician Orders As a patient progresses through their visit, the physician will most probably enter lab and/or diagnostic imaging orders. Some of the lab orders and all immunization orders are performed in the office and as such are referred to as in house orders. There are multiple indicators that a nurse or MA is needed to perform inhouse orders: Status indicates Nurse needed Physician verbally indicates an order is present, or The order is noticed in the treatment section of the progress note. 40

41 View Orders for a Patient 1. From the Office Visits screen, click the appointment for the patient. 2. Click the View Orders button

42 The Patient Orders window opens. 3. Review the tabbed section for current orders: Current Labs,, Current Diagnostic Imaging,, and. Depending on the clinic, tests will be ordered by providers. Procedures can be viewed by highlighting the desired procedure and clicking the View button for the associated procedure. 4. If Interfaced select the lab to sent and hit the quick transmit button to send the lab to the selected company. 5. If referral review referral hit view and print order for patient same for diagnostic image 6. Click Close. You are returned to the Office Visits window. 42

43 Immunizations The Immunizations section is where the nurse documents any immunization that was ordered for a patient. The nurse can easily refer to the patient's record of past immunizations. Document Immunizations 1. From the patient s Progress Note, click Immunizations. The Immunizations/Injections window opens. 43

44 2. Click the Add button to add an immunization. The Immunization Detail window opens. 3. Use the Find field to locate an immunization from the list in the left pane. 4. Once located, click the desired immunization. The selected immunization displays in the Immunization field in the Immunization Detail section. 44

45 5. If applicable, select an encounter date by using the Visit Date drop down list of patient encounters. Immunizations can be associated with a specific visit date. The Visit Date field displays when the check box for Vaccination Given in the Past is set to N. If the Vaccination Given in the Past is checked as N, the Given Date defaults to the Visit Date and cannot be edited. If the Vaccination Given in the Past is checked as Y, the Given Date field is activated. 6. If activated, use the Given Date drop down calendar feature to select the date on which the immunization was given. By default the given date defaults to today s date and the system automatically saves the exact time in the Given Date field. 8. Each immunization has been setup with the correct dosage so this field is prepopulated. 9. Click OK. 10. If the immunization is part of a series, use the Dose Number drop down list to select the dose number. 45