INTER TRIBAL HEALTH AUTHORITY ELECTRONIC MEDICAL RECORD (EMR) CASE MANAGEMENT TRAINING MANUAL

Transcription

1 EMR CLINICAL TRAINING MANUAL INTER TRIBAL HEALTH AUTHORITY ELECTRONIC MEDICAL RECORD (EMR) CASE MANAGEMENT TRAINING MANUAL PROFILE VERSION 7 July 1, 2014

2 TABLE OF CONTENTS Module 1: Case Management - Administration 1.1 Purpose 1.2 Icons and Definitions 1.3 Key Fields 1.4 Case Admin Tab 1.5 Security Settings 1.6 Creating a New Case without a Referral 1.7 New Case Generated from a Referral 1.8 Initiating Referral Form 1.9 Creating Outward Referral 1.10 Coding the Case 1.11 Adding a Client Associate 1.12 Create an Appointment for Cases Module 2: Case Management - Clinical 2.1 Purpose 2.2 Icons 2.3 Key Fields 2.4 Case Clinical Tab 2.5 Creating an Encounter TABLE OF CONTENTS Page 1

3 Module 1: Case Management - Administration 1.1 Purpose The Case Management System in EMR Profile is for use by Mental Health clinicians. It is used to track client care for specific issues or cases. When a resolution, transfer or alternate care is met, then the case is closed. Providers in mental health departments such as Traditional Wellness will be granted access to case by their role in Profile. A variety of case functionality is exposed. 1.2 Icons and definitions Definitions a) Association: A category for the associate. Must be created before an associate can be added b) Associate: A client in the system can be linked to a particular case using this feature Icons a) Case Icon b) New Icon c) Referral d) Simple Icon 1.3 Key Fields a) Initial Dx: Uses ICD-9 codes, which facilitates reporting b) Privacy: It is paramount that the privacy settings are filled in for each case to limit access to other clinicians 1.4 Case Admin Tab a) General: Used record initial case information such as title, date opened, initial diagnosis, provider. Also, importantly controls the privacy settings and the status of the case. Can create sub-referrals, Administrative encounters, interventions, letters, forms from this window. b) Initiating Referral : Cases can be linked to referrals when creating the case or the initiating referral information can be entered here after the case has been created c) Referrals: This is a listing of referrals associated with the case. To create a new referral, security settings need to be changed. d) Case Sub-Referrals: This is a listing of inter-health centre referrals. To utilize this function we would need to set up the department within the health centre as service units. e) Documents: A list of all documents created for this case including, letters, s, faxes, etc. You have the ability to create these documents from this window. MODULE 1: CASE MANAGEMENT - ADMINISTRATIVE Page 2

4 f) Coding: Allows for diagnosis and service codes to be added to the case in addition to the initial diagnosis. g) Audit: Tracks user access to the case. h) Organizations: Listing of organizations associated to the case. i) Associations: Can create associations, which groups where we can list clients that are associated to the case client. If we want to use this we need to add entries to the necessary short codes j) Tasks: List of all tasks associated to the case. Tasks are only visible to those with appropriate security level for the case k) Notes: Enter free-text notes about the case. Icon will turn red when notes have been entered and saved. l) Registry: Record multiple patient identifiers and the source of these identifiers. For example, if the client has multiple PHNs or status numbers. m) Care Team: Listing of the Care Team for the client. To make this private to the case, you must change the security settings using the Align button. n) Time: Listing of appointments and time spent of the client with regards to the case. Importantly, you can create an appointment from this section that will be set to the cases level of security o) Whiteboard: Display of patients and cases that are being handled on a team basis. FN Counsellor currently does have sufficient privileges to access add a new item 1.5 Security Settings Default security setting is Level 1 If the security setting is changed ALL previous items will be changed to the new setting Changes that are made by the counsellor in the medical record are NOT visible when the counsellor is in the case view When an appointment is booked within a case and the Admin security setting is set to on, then only a blocked out area is visible, NOT the client or the type Case = Controls the case encounter notes MODULE 1: CASE MANAGEMENT - ADMINISTRATIVE Page 3

5 Admin = Controls the appointments, alerts and tasks Clinical = Controls the clinical encounters, notes, and interventions FNC = Counsellor Security Setting Level 1 Level 2 Level 3 Level 4 Level 5 Case FNC X X FNC X X Admin FNC FNC X X FNC X Clinical FNC FNC FNC X X X Level 6 Case Counsellor View = What is viewed by the counsellor in the case Clinical Counsellor View = What is viewed by the counsellor in the medical record Clinical Nurse View = What is viewed by the Nurse in the medical record Function Created By Visible By Case Counsellor Clinical Counsellor Clinical Nurse L1 L2 L3 L4 L5 L6 1) Charting Notes Counsellor view in Case X X Counsellor View in MR Nurse view in MR X X X X 2) Appointment Counsellor Nurse X X X 3) Tasks Counsellor view in Case X X Counsellor View in MR Nurse view in MR X X X 4) Medications Counsellor view in Case Counsellor View in MR Nurse view in MR 5) Notes Counsellor view in Case X X Counsellor View in MR Nurse view in MR X X X MODULE 1: CASE MANAGEMENT - ADMINISTRATIVE Page 4

6 1.6 Creating a New Case without a Referral 1) Click the Case Icon 2) Click the New Icon Step 2 2=1 Step 1 2=1 MODULE 1: CASE MANAGEMENT - ADMINISTRATIVE Page 5

7 3) Select the Client from the search screen 4) Enter the Case Title Should allow for easy identification 5) Select the Case Type from the drop down menu 6) Enter the Initial diagnosis Use the first 3 or 4 letters and then select from list 7) Enter Priority, Case Setting, First Visit and Referrer 8) Enter Referral Source Internal or External 9) Enter Care team Information 10) Set the Privacy information See Section 1.5 for privacy settings 11) Click Align the privacy Settings for further privacy detail (Can remove this step) 12) Enter the progress condition 13) Click Apply Step 4 2=1 Step 5 Step 10 Step 6 Step 7 Step 8 Step 11 Step 9 Step 12 MODULE 1: CASE MANAGEMENT - ADMINISTRATIVE Page 6

8 1.7 New Case Generated from a Referral IMPORTANT!! Referring Clinician must create an Outward Referral to initiate the process 1) Select Referral Icon From the Work Centre 2) Open the Referral from the referring clinician Step 2 2=1 Step 1 2=1 MODULE 1: CASE MANAGEMENT - ADMINISTRATIVE Page 7

9 3) Click Make Case Icon Step 3 4) Follow the steps 3-12 in Section 1.6 MODULE 1: CASE MANAGEMENT - ADMINISTRATIVE Page 8

10 1.8 Initiating Referral Form IMPORTANT!! This section will only need to be filled in if the case was created without a referral 1) Click Initiating Referral Icon 2) Enter source, and presentation of the case. Initial diagnosis should be entered in the General Tab. 3) Click From tab 4) Enter the referring provider information. Provider = Internal referral and Ext. Prov. = External Referral 5) Enter the reason (i.e. diagnosis) for the referral and the treatment if applicable Step 1 Step 2 Step 3 Step 4 Step 5 MODULE 1: CASE MANAGEMENT - ADMINISTRATIVE Page 9

11 6) Click the To tab 7) Enter the provider information Likely this would be your information 8) Click apply Step 6 Step 7 Step 8 MODULE 1: CASE MANAGEMENT - ADMINISTRATIVE Page 10

12 1.9 Create an Outward Referral Tip Use the Simple Icon to switch to simple mode that will allow you to reduce the amount of additional information needed for the referral. 1) Open the New Referral menu using the drop down icon and select New Referral Out Step 8 MODULE 1: CASE MANAGEMENT - ADMINISTRATIVE Page 11

13 2) Enter the provider information 3) Select the reason for referral, diagnosis and treatment if applicable. 4) Set the Priority of the referral 5) Click Save and Close Step 5 Step 2 Step 3 Step 4 MODULE 1: CASE MANAGEMENT - ADMINISTRATIVE Page 12

14 1.10 Coding the Case 1) Click the Coding Tab 2) Click the New Button Step 2 Step 1 3) Select the Appropriate diagnosis 4) Enter any necessary information 5) Click OK Step 3 Step 4 Step 5 MODULE 1: CASE MANAGEMENT - ADMINISTRATIVE Page 13

15 1.11 Adding a Client Associate 1) Click the Association Icon 2) Click New Associate Step 2 Step 1 3) Select Type of Association and description (We need to populate the list) 4) Add Provider Privacy 5) Click OK Step 3 Step 4 Step 5 MODULE 1: CASE MANAGEMENT - ADMINISTRATIVE Page 14

16 6) Select Association that you want to add the associate client to 7) Click New Associate 8) Select Associated client 9) Select Relationship 10) Select Intensity 11) Click OK 12) Repeat for Additional Clients, if necessary Step 6 Step 8 Step 7 MODULE 1: CASE MANAGEMENT - ADMINISTRATIVE Page 15

17 1.12 Create an Appointment for Cases IMPORTANT!! Details of appointments created within the case are NOT visible to providers who do not share your role - see Section 1.5 1) Click the Time Icon 2) Select New Attendance Step 2 Step 1 MODULE 1: CASE MANAGEMENT - ADMINISTRATIVE Page 16

18 3) Enter Appointment Type 4) Check date and time 5) Click OK Step 3 Step 4 Step 5 MODULE 1: CASE MANAGEMENT - ADMINISTRATIVE Page 17

19 Module 2: Case Management - Clinical 2.1 Purpose The Case Management Clinical is very similar to the clinical section of the medical record. Most sections and actions are the same. For instruction on these sections and the pertaining actions, please refer to the Clinical Training Module. 2.2 Icons a) Case Icon b) New Icon c) Referral 2.2 Key Fields a) Privacy: It is paramount that the privacy settings are filled in for each case to limit access to other clinicians b) Measure: Creates an active record for certain vital statistics, including, but not limited to blood pressure, weight, respiratory. See Module 4 Section 4.8 in the clinical manual for a full description c) ICD 9: Classification of Disease codes that allows clinicians to record and later report diagnosis, procedures, allergies, etc. 2.3 Case Clinical Tab a) Overview: Gives an overview of the case and the client in different views b) Clinical Front Page: Summarizes clinical (Diagnosis, Services and Care Team) and Demographic(Address, Organizations and Social) c) Encounters: Listing of Encounters relating to the case d) Care plans: Care Plans, Interventions and Actions planned or completed e) Forms: Shows forms, including Chronic Disease Management Templates that are linked to the case f) Notes: Listing of client s major issues. Shows Diagnosis, Adverse Reactions, Procedures, Social and Risk factors, and Administrative g) Measures: Displays measures recorded across all cases. Can be displayed in table for or as a graph h) Mental Health: Show Mental Health events and reviews, but I don t know where to add an event???? i) Wait List: Displays the waitlist states and times j) Medications: Listing of all medications currently and previously prescribed for the client k) Alerts: Shows alerts associated with this case MODULE 2: CASE MANAGEMENT - CLINICAL Page 18

20 2.4 Creating an Encounter 1) Click the Clinical Tab Step 1 MODULE 2: CASE MANAGEMENT - CLINICAL Page 19

21 2) Click the Encounters Tab 3) Select the New Encounters Step 3 Step 2 MODULE 2: CASE MANAGEMENT - CLINICAL Page 20

22 4) Check the Header and that the privacy levels are correct 5) Enter the necessary notes and/or measures 6) Click save 7) Close IMPORTANT!! The Encounter will not be visible, but any measures entered will be visible in the Medical Record to all clinicians with access to the client s medical information Step 7 Step 6 Step 4 Step 5 MODULE 2: CASE MANAGEMENT - CLINICAL Page 21