Resident Training Manual Allscripts Version 10.2

Transcription

1 Resident Training Manual Allscripts Version 10.2

2 Allscripts Resident Training Manual 1 Table of Contents Table of Contents... 1 Acknowledgments... 3 Document History... 3 Accessing Allscripts EMR... 4 The Login Page...4 Allscripts Framework...5 Locking, Resuming, and Exiting a Session...6 Tasks... 8 Task List...8 The Task List Workspace:... 8 Buttons in Task Workspace Processing Tasks...11 Sign Note, Co-Sign Note, or Review CC Tasks Batch Signing/Reviewing Go To, Review, Respond To, and other Tasks Creating and Sending a Task...14 Tasks and Screens in Which They are Available...16 Schedule Patients - Accessing Patients Patient Banner...22 Select Patient...23 ChartViewer ChartViewer Workspace...24 ChartViewer Default View...26 Searching for Specific Items...28 Printing A Single Item or Document...29 Printing/Faxing Multiple Documents...30 Faxing a Single Item or Document...32 Snapshot Overview of Snapshot Workspace...33 Allergens...34 Problems... 37

3 Allscripts Resident Training Manual 2 Problems Workspace...37 Editing a Problem Resolving a Problem Medications Medications Workspace...42 Adding Medication History...45 Editing Medications...47 Rx History...49 Printing Drug Education Information for Patients...50 Renewing/Refilling Medications...52 Tasking Med Renewal Med Renewal Task Completion Renewing a Medication Listed in the EMR Editing Medications...60 New Rx Prescribing New Medications in Allscripts...62 Vitals Vitals Workspace...65 Correcting a Vital Entered in Error...67 Results Results Workspace...69 Flowing Results Graphing Results Flowsheets Entering Flowsheet Data...75 Notes Creating Structured Notes...76 Editing Information in a Structured Note... 78

4 Allscripts Resident Training Manual 3 Acknowledgments To submit changes or corrections, please contact UMPhysicians Help Desk at or [email protected] Document History CREATED BY: EMR Project team LAST UPDATED: 05/05/2007 VERSION NUMBER: 1.0

5 Allscripts Resident Training Manual 4 Accessing Allscripts EMR The Login Page Access Allscripts using the URL: Login and Passwords are case-sensitive. Passwords must be a minimum of six characters two of these must be numeric. The New Session button will open a new session for the user. The Last Session button will take the user to the last page in the application viewed by the last user, depending on security access.

6 Allscripts Resident Training Manual 5 Allscripts Framework The primary sections of Allscripts are as follows and are indicated above: Workplace: Workplaces are role-based depending on the user roles. User security and level of access is determined by the workplace. Vertical Toolbar (VTB): This is the menu on the left-hand side of the page. Based on the user s workplace, the selection will vary. Horizontal Toolbar (HTB): This is the series of tabs across the top of the page. A separate series of tabs corresponds to each menu item in the VTB. Based on the user workplace, the tabs will vary. Workspace: The Workspace is the primary area of the window. This is where most chart work and other functionality is done.

7 Allscripts Resident Training Manual 6 Locking, Resuming, and Exiting a Session In order to comply with HIPAA Regulations, users must either Lock or Exit their session when they move away from their PC. Locking a session will allow the user to return to the exact screen they were on when they enter their password to resume their session. Logoff closes the current session for that user. Lock Logoff To Lock a session: Click Lock in upper right-hand corner of the page. A Session Locked dialog box will display. To re-enter this session, Type in the Password. Click Resume. Click Change to change users when signing in.

8 Allscripts Resident Training Manual 7 Enter User Name Enter Password Click Resume. This allows another user to log into the last page that the previous user had displayed prior to locking their session. To Logoff: Click Logoff in upper right-hand of the page. The system will prompt the user to confirm that they wish to log out of their session. Click OK This will close your session and protect your password.

9 Allscripts Resident Training Manual 8 Tasks Task List A task is a request or reminder for action. Tasking can also be used as a means of communication regarding patients within a HIPAA secure site. Tasks are not included as part of the medical record unless they are copied to a note. The Task List Workspace: The Task List is the default view that displays when users log in. Task View Task List Buttons Personalize Total Active Tasks All Tasks can be viewed and accessed from the Task List screen. To view a task list: Click Tasks on the vertical toolbar. Click Task List on the horizontal toolbar. The system will default to display My Active Tasks list these are the requests or reminders that need to be reviewed and/or completed. Tasks Task List

10 Allscripts Resident Training Manual 9 Users can personalize their tasks by clicking on Personalize in the upper right side of the screen. Complete the Personalize Dialog Box. Personalize allows user to set up a default user or team for assigning tasks and it allows the user to determine the number of minutes between automatic refresh of tasks. Choose either User or team Set the # of minutes for refreshing data. Click here to Personalize Check to show Note Selector Task List Field Definitions: P (Priority): A priority is assigned to every task to loosely indicate the expected turnaround time. Task (Type): The type of task generally indicates what is expected from the user. Patient: Patient name that task is related to. Assigned To: The user or team that owns this task. Created By: Indicates who created the task. Tasks can be generated by the users or by the system. Created On: The date and time the task was created. Status: Only Active or In Progress tasks display on My Active Tasks view. Due: The system displays a red frown face as an indicator that the task is past due as defined by the Priority times.

11 Allscripts Resident Training Manual 10 Buttons in Task Workspace Go To: Click to go to the page or screen in TouchWorks for that task. In Progress: Users may mark a task as In Progress for a task that is currently being worked. Done: This changes the task status to Complete and removes it from the task list. Undelegate: (Upcoming Feature) New: Click to create a new task. Reply: Click to reply to a task sent to you by another user. Reply tasks are removed from your task list. Reassign: Click to reassign a task to another user. Reassigned tasks are removed from your task list. Copy To Note: Click to copy the comments from a selected task into an unstructured or structured note. **Tasks are only included in a patient s medical record when they are copied into a note. Details: Click to view task details and history of task. Original: For notify tasks, click to return to the original task that generated the notify task. Print List: Click to print the task list includes the comment history. Print Task: Click to print an individual task.

12 Allscripts Resident Training Manual 11 Processing Tasks Sign Note, Co-Sign Note, or Review CC Tasks Batch Signing/Reviewing To complete the Sign Co- Sign Note or and Review CC Tasks in the most efficient manner, click on the Documents tab on the horizontal toolbar. This will display the names of the patients that have sign note or co-sign note tasks attached to a document, as well as the type of task (sign or review) Click on Documents Tab The task type will display here The note displayed on the right side of the screen corresponds with the patient name highlighted on the left. Click Edit to make changes. CC button Click CC: to send a copy via Print, Fax, or Review Task. Click Security to restrict document access at the item level. Click Req Corr to reassign documents requiring corrective action. Req Corr. Security Sign Final Edit Check the Final box. Click Sign Enter Password. Sign button changes to Done for Review tasks While in this screen your password is remembered clicking Sign for subsequent tasks signs the document and removes the task. If you have a Review task selected, Click Done.

13 Go To, Review, Respond To, and other Tasks Allscripts Resident Training Manual 12 Highlight the task. Read any comments displayed in the lower left section of the screen Click on appropriate button on lower portion of the screen. (i.e. Go To will take the user to the note, result, or medication being referenced in the task). Comments Action Buttons A Reply button is available to simply reply to the sender on a task. Highlight the task you wish to reply to. Click Reply Task Reply dialog page appears. Complete the Comments Click OK Comments Click OK Reply button

14 Allscripts Resident Training Manual 13 A Reassign button is available to move this task to another user. Highlight the task you wish to reply to. Click Reassign Task Reassign dialog page appears. Assign To: Select appropriate User or Team Complete the Comments Click OK Reassign button Assign to appropriate User or Team Comments Click OK When a Task is completed or no longer relevant and remains on the task list, it can be removed by clicking Done or Remove. Highlight the appropriate Task Click Done Task automatically removes from the list. If done is not enabled, user can click on Remove Select Reason from drop down menu. Add comments if desired. Click OK Done OK Select Reason for Removing Remove

15 Allscripts Resident Training Manual 14 Creating and Sending a Task Click on Chart on the vertical toolbar. Click on the ChartViewer Tab. Click on ChartViewer The Select Patient dialog box appears. Enter the patient name, MRN or other search criteria in the patient field then select the corresponding search type from the dropdown menu and click the Search button Chart Type in Patient Name or MRN Click on the New Task button in on the lower portion of the screen. The Task Detail dialog box will display. Highlight item Note: To direct the recipient to a specific item, such as a note or result, highlight the item prior to clicking New Task. Select New Task

16 Allscripts Resident Training Manual 15 Complete the Task Detail dialog box: Assign To: Choose appropriate User or Team. Task: Choose the Name of the Task from drop down menu (i.e. Sign Note, Respond to RN, etc...) Priority: If other than Routine, select from the drop down menu. Comment: Add message/reason for task in this box. If you wish to be notified when this task is completed or overdue, check the appropriate box. Click OK. Assign Task to a User or Team Task: Select from drop down menu Add Comments or Messages here. If you wish to be notified when task is complete or over due check one of these boxes. Choose Priority, if desired. From the Task List: Click on Tasks on the vertical Toolbar. Click on Task List Tab Click on Tasks Lists Click on the New button on the bottom of the screen. (Note: In order to link this task to a patient, a patient name must appear in the Banner) Click on Tasks Click on New Click Ok Complete the Task Dialog box as noted above. Click OK.

17 Allscripts Resident Training Manual 16 Tasks and Screens in Which They are Available The name or type of task that can be selected varies by page or screen that the user has open. The Tasks shown at the right are task names available at the following screens: Task/Task List Screen Schedule/Daily or Provider Schedules Chart/ChartViewer screen when a Document is NOT selected (highlighted) on left panel Chart/Results when a result is NOT selected (highlighted). Call Back Call Floor/Hospital Call Patient Call Referring Physician Follow Up Help Desk Question Hospital Calls Miscellaneous Onc TX New/Change Order Order New Int Other Pedneuro RX Refil Personal Please Respond Orders Needed Result Request Scheduling Issue Treatment Plan Due

18 Allscripts Resident Training Manual 17 The Tasks shown at the right are task names available at the following screens: Chart/ChartViewer Screen when a Document is selected (highlighted) If a Scanned Document is selected the task below will also be an option: Review Scan Document Bariatric Team CorrectNote User CoSign Note Derm Team epat Med Ques epat Med Renew epat Message epat Visit Go to Note Infusion Room Order Invalidate Note Medical Problem or Complaint Medication Refill Referral Follow Up Review CC Review Date of Service Review Document Review, Sign, File Route To Help Desk Sign Edited Note Sign Note Unfinished Call Call Back Call Floor/Hospital Call Patient Call Referring Physician Follow Up Help Desk Question Hospital Call Miscellaneous Onc Tx New/Change Order Order New Int Other Pedneuro Rx Refill Personal Please Respond Orders Needed Result Request Scheduling Issue Treatment Plan Due

19 Allscripts Resident Training Manual 18 The Tasks shown at the right are task names available at the following screens: Chart/Results screen when a Result is selected (highlighted). Go To Result Print Result Result Follow Up Result Invalid Review Results Route To Help Desk Sign Edited Note Sign Note Unfinished Call Call Back Call Floor/Hospital Call Patient Call Referring Physician Follow Up Help Desk Question Hospital Call Miscellaneous Onc Tx New/Change Order Order New Int Other Pedneuro Rx Refill Personal Please Respond Orders Needed Result Request Scheduling Issue Treatment Plan Due

20 Allscripts Resident Training Manual 19 Schedule Personalize to set up your schedule one time only: Click on Personalize Automatic Refresh can be changed to 1 minute if desired. Change Double Click Action to Chart. Choose desired schedule contents. The Provider Schedules tab allows users to view up to 4 provider schedules on one page the defaults for these providers can be set on the personalize if desired. Change Double Click Action to Chart. Automatic Refresh can be set to 1 minute Change Double Click Action to: Chart Defaults can be chosen for the Providers Schedules Click Personalize Select Schedule from menu Schedule Real-time IDX interface Click All to search for provider All Type name/partial name in Search for: field; click GO Highlight desired provider from list; click OK Schedule for current day will be displayed Type name Ok Highlight desired name

21 Allscripts Resident Training Manual 20 To navigate to schedule for another day: Click on day of the week Click back arrow for previous week Click forward arrow for next week Click calendar icon select month, year, date in Calendar Calendar icon Day of Week Back/Forward arrows Calendar Once selected, names remain in Provider: drop down list as favorites Options buttons. FYI: some enabled only when patient name highlighted Demographics patient demographics display Appt Details - additional appointment details display Patient Appts - other outpatient appointments with UMP providers display Print - print the schedule New Task - send a task to another user Favorites list Options buttons

22 Appointment Status from IDX displayed in column labeled A (Arr, Pen, RSC) Note Status (icon) displayed in column labeled N if note for that visit is in patient Chart Green check mark appears on Note icon if in Final status Navigate to patient s chart from schedule by double clicking on the desired patient To view a note attached to the visit, click once to open the note. Note Status Click once on note icon to open the note Allscripts Resident Training Manual 21 Appointment Status

23 Allscripts Resident Training Manual 22 Patients - Accessing Patients Patient Banner The Patient Banner tells you what patient you have selected. This is very important to make sure you are manipulating the correct data for the correct patient. Note Selector. Search for a Patient Shortcut to Patient Demographics FYI: Highlighted if filled out. Patient Directives FYI If a note is open, Different options appear. Patient Name

24 Allscripts Resident Training Manual 23 Select Patient Allows you to search for a patient using various information, including Name, Medical Record Number, Social Security Number, Date of Birth, and Phone Number. Click Select Patient. Click Search. Choose a search parameter. Enter a search. Select a search result. Click OK.

25 Allscripts Resident Training Manual 24 ChartViewer ChartViewer Workspace From the menu on the left side of the screen, click the Chart button In Select Patient dialog box, enter patient name, MRN or other search criteria in Patient field; select the corresponding search type from the dropdown menu; click Search button If MRN search is used, that patient name will appear by itself OR if a Name search is done, a list of patients will appear. Select the correct patient by double-clicking on the name or highlight the name Click OK On the Horizontal Tool Bar, select the ChartViewer tab. In the View filter drop down, select desired view. Four additional filters are available on the left side of the screen. Within each of these filters is the option to limit the search to date ranges. Type in Pt. identifying information Choose appropriate type. Choose desired view from drop down menu Four sub-filters to sort/search for information.

26 Allscripts Resident Training Manual 25 1 Choose from the drop down list available After choosing the initial filter, choose next filter from drop down list. 3 Once the initial filters have been identified, users can select a Quick Filter by clicking on the icon If desired, an addition Quick Filter for dates can be created After selecting the desired filters to search for information: Highlight the desired note on the left. The Note will display on the right side of the screen. Previous and Next buttons are available above the note to move to the next or previous available note. The number of available documents for desired filter selections displays above the note. Click on desired note Click Previous or Next to move to another note Note displays here Number of available documents

27 Allscripts Resident Training Manual 26 ChartViewer Default View The Default View is set to 90 days. The Total number of chart items will display in the upper right-hand corner of the page. The Total number of items in this View are displayed in red text in just above the Item Viewer Section. Default View is 90 Days The # of items in the chart The # of items currently displayed To view more items: Click on the drop-down menu at the View prompt. Select the desired View. Additional views have been added for: 6 Months 12 Months 18 Months Select desired View from list

28 Allscripts Resident Training Manual 27 To change the default view: Click Located in the upper-righthand portion of the screen. Click on Manage Personal Tab. Highlight the desired view. Highlight desired Default Click on Set as Default Click on Manage Personal Click Click Close Close

29 Allscripts Resident Training Manual 28 Searching for Specific Items Users can search a chart for a specific item (notes, scanned documents, results, etc ) by clicking on the magnifying glass in the upper right-hand-side of the ChartViewer page. Magnifying Glass Partial or full name of item Go Click on the Magnifying Glass At the Search Prompt type in a partial or full name of the item or document Click on Go.

30 Allscripts Resident Training Manual 29 Printing A Single Item or Document Click Chart (Vertical Tool Bar) and ChartViewer (Horizontal Tool Bar) Click on drop down menu to change View Select desired view. Select desired filters. Click here to set up filters Highlight appropriate note on the left. Click Print. Click Print Print Dialog Box appears Choose printer from Printer: drop-down list (Printers located primarily in clinics) Check box next to Save as Default Printer Printer Tray(s) and Document type can be selected for this document. If printing to local printer is necessary, click Print Preview button. Note: If using Print Preview, Document type must be Document. Print Preview Select Printer

31 Allscripts Resident Training Manual 30 Print Preview Dialog Box appears System recognizes the default or local printer associated with your PC to allow printing there if necessary Click Print button Note: You may receive an Allscripts Error Message box when Print Preview is accessed. This is simply an indication that the number of users has reached the maximum allowed. Close this box and try again later. Click Print Printing/Faxing Multiple Documents Multiple documents can be sent to print or fax at one time from the ChartViewer Screen. Select desired View Click on Chart Click on ChartViewer Additional Filters for sorting In the View filter drop down, select desired view. Four additional filters are available on the left side of the screen. Within each of these filters is the option to limit the search to specified parameters.

32 Allscripts Resident Training Manual 31 1 Choose from the drop down list available After choosing the initial filter, choose next filter from drop down list. 3 Once the initial filters have been identified, users can select a Quick Filter by clicking on the icon If desired, an addition Quick Filter for dates can be created. After selecting the desired filters: Click Print Chart Only the items that show in the left side of the ChartViewer page will print or fax. Only these items will print or fax Click Print Chart

33 Allscripts Resident Training Manual 32 To Print the documents: Click on the Print Tab Complete the required fields in yellow. Click OK To Fax the documents: Click on the Fax Tab Complete the required fields in yellow. Click OK Enter the 10-digit fax number only. The system will auto-format the number. Faxing a Single Item or Document Click Chart (Vertical Tool Bar) and ChartViewer (Horizontal Tool Bar) Select desired view. Select desired filters. Highlight appropriate note on the left. Highlight desired note Fax button Click Fax

34 Allscripts Resident Training Manual 33 Snapshot Overview of Snapshot Workspace Located within Chart, SnapShot allows the user to view Active Problems, Active Medications, Allergens, Encounters, and Tasks on a specific patient all on one screen. Allergens is the only field that can be edited on this screen. Active Problems Displays the active diagnosis or procedures for a patient. Active Problems FYI FYI allows the user to add notes for patients that are not included in the medical record. If notes are recorded here, the button color changes from Blue to Gold. (See instructions for adding notes on next page) FYI Medications Active Medications Displays the active medications (if any) for a patient Printing Options: Choose desired printing option from the drop down menu next to the Print Button. Options include: Allergy List Medication List Snapshot Worksheet Problem List Click Print Choose or verify printer. Click OK Print Printing Options

35 Allscripts Resident Training Manual 34 Allergens Allergens displays any known allergies for a patient. New allergies are added at this screen. (See instructions on next page). Encounters Allergens Displays the Encounters for the patient Tasks Tasks Displays outstanding tasks related to the patient Encounters Print Print A drop down list gives the user different options to print from this screen To add notes in FYI: Click on FYI. Click on FYI Type note in gold text box that displays. Click on FYI when note is complete. The FYI button is now displayed in Gold. Type in notes here

36 Allscripts Resident Training Manual 35 Adding Allergens: Click on New Dialog box displays Click appropriate radio button Medication or Allergy Hx Select NKA or NKDA buttons if appropriate Click on All to search for Allergen or Medication. Once you have added one or searched for one, it will save to your favorites under the drop down menu Click OK. Complete the Allergens Dialog Box as below. Choose Medication or Allergy History Click New NKA or NKDA Choose Status from the drop down menu Enter other information as appropriate. Click Apply and Close or if you have more that one to add, click Apply and Add New. If Encounter Selector dialog box appears, highlight appropriate encounter and click OK button. Click All to Search Click Apply and Close or Apply and Add New

37 Allscripts Resident Training Manual 36 If an allergen was entered in error: Highlight the Medication or Allergen. Click Details Change the Status from Active to Entered in Error and click Ok. Details

38 Allscripts Resident Training Manual 37 Problems Problems Workspace Access patient: Chart/Problems Tab; Problems screen displays Click corresponding radio button to view the following Problem lists: Active PMH (Past Medical History) PSH (Past Social History) Family Hx Pers Hx (Personal History) All Click Problems Tab Choose desired view of problems Adding a Problem: Select appropriate radio button (Active, PMH ) Click on New Problem button Problem Detail dialog box appears Complete fields as necessary then click Apply and Close or Apply and Add New (see complete instructions on following pages) Status Click on All to search for Problems Note: Only two fields are required Name and Status Click Apply and Close or Apply and Add New.

39 Allscripts Resident Training Manual 38 Choose the problem from drop down menu (your favorites) or click on All to search; Click All to search Search by Name or ICD-9 or CPT for Procedures. Note: Check the box to limit your search to problems with ICD-9 or CPT codes. Highlight the problem or diagnosis; for most efficient workflow Add this to your favorites. Click on the folder icon to add to favorites. Favorites icon Click OK Select the Doctor that identified the problem Highlight desired problem Click OK

40 Allscripts Resident Training Manual 39 Choose the appropriate Status from the drop down menu: Active Assumed Resolved Denied Entered in Error Resolved If this is the only problem or diagnosis that needs to be added, Click Apply and Close. If you want to add another diagnosis click Apply and Add New Click Apply & Close or Apply & Add New Verify Status After choosing Apply & Close you are returned to the Problems Screen. Highlight the problem and click Save (If multiple problems have been entered, highlight one and click Save All will be saved.)

41 Allscripts Resident Training Manual 40 Editing a Problem If a problem is listed and is not correct: Highlight the problem. Click on Details. Change the Status to: Entered in Error Click Apply and Close. Click Save. Details Status Apply and Close If a problem has not been Saved yet (it still shows as magenta), the entry can be cancelled. Highlight the problem. Click Cancel Entry The entry returns to its previous state (Active, Resolved, etc ) Cancel Entry

42 Allscripts Resident Training Manual 41 Resolving a Problem Highlight the problem you wish to Resolve. Click Resolve. Choose the appropriate encounter if the Encounter Selector box appears. The selected problem appears as Magenta. You may continue to make any other changes if needed. When done, click Save, and the problem will be removed from the Active Problems list. Select the problem to resolve. Click Resolve. Selected Problem appears Magenta. Click Save.

43 Allscripts Resident Training Manual 42 Medications Medications Workspace Personalize View Allergens listed here Patient s Pharmacy In the Medications Workspace, there are three Views available: Active Medications, Past Medications (Meds that have been D/C or completed), and All Medications. The columns display the following: * - An asterisk (*) in the first column indicates that there is an Annotation on that medication. To view that note, double click on the medication and click on the Annotations Tab. - The Green Smiley Face that appears in the second column is an indicator that this medication meets a generic formulary. Please Note: This feature is not currently capturing the patient s medication coverage information.

44 Allscripts Resident Training Manual 43 Name: Name of the Medication including dose and form (i.e. Tablets, Capsules, etc.) SIG: Directions on how this medication is to be taken/given. DS:QTY:REF : This is the Days Supply, Quantity, and number of refills that was last given to this patient for that medication.. Dates of Therapy: The first date listed is the date that this med was initially recorded in the patient s electronic record, or the first date this medication was given. Dates shown in parenthesis represent the most recent date filled. The first date listed will always remain constant, the date in parenthesis will change. Rx By: The name of the provider or nurse that last filled the selected medication. Type: Two types are listed: HX- indicates that the medication was entered as part of the patient s medication History. RX indicates that this medication was a prescription that was given to this patient. Status: The statuses are as follows: U/A Unauthorized indicates this medication was tasked to a provider to approve. This could be a refill or a new prescription. ACT Active The patient is currently taking this medication. VOID A prescription or a refill that required an authorization was denied or voided by the provider. COMP Completed The medication therapy ran its course. D/C Discontinued This medication was discontinued. EIE Entered in Error The patient was never on this medication. DocA Administration of this medication has been documented. ReqA Administration of this medication is required. The buttons on the lower portion of the screen allow the user to do the following: New Rx Create a new prescription for the selected patient. New Hx Enter a medication that patient is currently taking. Renew Renews the medication as it currently is written Same dose, same SIG, same number days supply, quantity, and refills. Change Allows a change in the SIG, days supply, quantity, refills, and provider on a medication. Please note you cannot change the DOSE you need to D/C the medication and enter the new dose as a New Rx. D/C Discontinue This allows the user to discontinue a prescribed medication. Cite Selected Allows the uses to cite one or more medications into a note.

45 Allscripts Resident Training Manual 44 Continue This indicates on the audit tab of the medication detail that this med has been reviewed with the patient. Details Allows the user to view details of the selected medication. New Task Allows the user to create a new task. Drug Ed Allows the user to print a copy of the drug education sheet for the selected medication. Rx History Displays the medication history detail screen. Print List Print a list of the patient s active medications. Reprint Rx Allows the user to reprint the select prescription. Cite View Allows the user to cite the selected view of the patient s medications into the note. (i.e. Active, Past, All) Save - Allows the user to save any changes. Cancel Entry Allows the user to cancel the action taken on the selected prescription. (Undo Button).

46 Allscripts Resident Training Manual 45 Adding Medication History Click Meds Click New Hx button Choose Search, Browse, or Favorites to look up Medication. When you choose a new medication, it will automatically populate your favorites list. New Hx Button Highlight the Medication from the list displayed. Click OK. The Medication Detail (SIG) dialog box appears. Rx Date: This will default to today s date. Click Apply & Close. If you have more than one Rx to add for this patient, you may Click Apply & Add New. This will allow you to choose another medication.

47 Allscripts Resident Training Manual 46 If the Encounter Selector Screen displays. Select New Encounter. Type: Rx History Click OK. Type: Rx History Click Save. The Confirm Rx dialog box displays. Verify information. Click OK. Medication has now been saved. Click OK

48 Allscripts Resident Training Manual 47 Editing Medications To Discontinue, End a Medication, or to Change the Dose or SIG for a Medication: Highlight the desired Medication. Click D/C. Click Save. Click D/C Click Save Confirmation Dialog box displays. Verify Information. Click OK. To record a new dose or SIG, click on New Hx and add. Click OK

49 Allscripts Resident Training Manual 48 If Medication Entered in Error: Highlight desired Medication. Click Details Status: Choose Entered in Error from the drop down menu. Click Apply & Close A line now appears through the Medication. Click Save. The Confirm Dialog box displays. Verify the information. Click OK. Click Details.

50 Allscripts Resident Training Manual 49 Rx History From the patient s chart - Click on the Meds tab. Highlight the Medication. Click Rx History The history of the medication refills including quantity will be displayed.

51 Allscripts Resident Training Manual 50 Printing Drug Education Information for Patients Once a drug has been entered in the EMR, drug education information can be printed for distribution to the patient if desired. From the Patient s Chart Click on the Meds Tab. Highlight the drug/medication that you wish to print information on. Click on the Drug Ed... button on the bottom of the page. Rx History Click Drug Ed button

52 Allscripts Resident Training Manual 51 The Drug Education Information will display with the option to Print. Click on Print. Verify the correct Printer on the Print Dialog Box. Click OK. Click Print Verify correct Printer Click OK

53 Allscripts Resident Training Manual 52 Renewing/Refilling Medications Tasking Med Renewal Remain in Chart or Meds Mgmt menu with Meds tab selected Highlight Medication just entered Highlight Medication Click New Task New Task Choose appropriate user or team (RN or RN Team who will be entering the renewal) under Assign To User or Assign To Team. Click radio button as appropriate by User or Team - task will be sent to this user or team Select Task called Med Renewal User Name Click User or Team Med Renewal Enter Provider name in Comments if applicable for your clinic Ok Click OK

54 Allscripts Resident Training Manual 53 Med Renewal Task Completion Access Tasks menu and Task List tab Select your Team from View: Highlight Med Renewal Task identify if you are responsible for this renewal by noting comments in Comments box when applicable Identify Medication in Task About box Click Chart Comments View Highlight Med Renewal task Task about Click Meds tab Highlight the medication to renew Click Change or Renew button In Encounter Selector box: Existing Encounter Select Radio button for Existing Encounters and choose the correct Rx Refill as Type (Encounter was created by non-rn) Highlight Medication Change Ok Click OK

55 Allscripts Resident Training Manual 54 Medication Detail box is displayed. SIG: Choose Preferred (most commonly used); All (all available SIG s); or New (allows user to free text Rx) Enter Days Supply OR Quantity. Rx By: Authorizing person. Supervised By: Supervising or Authorizing provider. (for use by staff with authorization to fill prescriptions per written protocol or verbal orders). Rx Date: Today s date is default Tip: To renew specific number of tabs and avoid having to specify Days Supply, select SIG of PRN or Other.

56 Allscripts Resident Training Manual 55 If communication needs to be sent to provider: Click Annotations tab Under New Annotations, enter information for the provider such as date of last visit, etc. (nurse name and date of entry will be attached automatically) Click Apply & Close Enter information as required Annotations Apply & Close Clinical Warnings may appear RN: Assess and determine appropriate course of action Click Save & Continue or Return as appropriate Save & Continue or Return

57 Allscripts Resident Training Manual 56 Medication will now display in magenta color font. Click Save button Confirm Rx box appears - verify renewal Verify Action (See Action definitions and uses at the right) Click OK Verify renewal information Select Pharmacy Link Verify Action Ok Save Retail: electronic submission to pharmacy. Pharmacy that was entered by non-rn staff will be listed under blue Select Pharmacy link NOTE: Class 2 Schedule Drugs may NOT be faxed Mail Order: electronic submission to mail order pharmacy. Click blue Select Pharmacy link if correct mail order pharmacy not listed in Confirm Rx box or is missing (Select Pharmacy details below) Print: prints a prescription. Select Print action if necessary (narcotics, etc) Record: records the medication in the chart primarily used for adding medication history Phone: note that this prescription was called in to the pharmacy.

58 Allscripts Resident Training Manual 57 Renewing a Medication Listed in the EMR Clinic contacted by Pharmacy for med renewal staff logs into Allscripts Select Patient Click Meds tab Highlight the medication to refill Click Change or Renew In Encounter Selector box: Highlight Med New Encounter Ok Renew or Change Rx Refill Select Radio button for New Encounter and choose Rx Refill as Type Click OK Medication Detail box is displayed. Complete Medication Detail box as described on Page 63.

59 Allscripts Resident Training Manual 58 If communication needs to be sent to provider: Click Annotations tab Annotations Under New Annotations, enter information for the provider such as date of last visit, etc. (nurse name and date of entry will be attached automatically) Enter information as required Click Apply & Close Apply & Close Clinical Warnings may appear STAFF: If this box appears, consult an RN RN: Assess and determine appropriate course of action After consulting with RN, click Save & Continue or Return as appropriate Save & Continue or Return

60 Allscripts Resident Training Manual 59 Medication will now display in magenta color font Click Save Confirm Rx box appears - verify renewal Verify Action Click OK Verify renewal information Select Pharmacy Link Verify Action Save Ok

61 Allscripts Resident Training Manual 60 Editing Medications To Discontinue, End a Medication, or to Change the Dose or SIG for a Medication: Highlight the desired Medication. Click D/C. Click Save. Confirmation Dialog box displays. Verify Information. Click OK. To record a new dose or SIG, click on New Hx and add.

62 Allscripts Resident Training Manual 61 If Medication Entered in Error: Highlight desired Medication. Click Details Change Status to Entered in Error Click Apply & Close. Click Save Verify the information in the Confirm Dialog box Change Status

63 Allscripts Resident Training Manual 62 New Rx Prescribing New Medications in Allscripts Select Desired Patient. Click New Rx tab Choose Problem-based, My Favorites or Search Master, to find Medication. Problem-based My Favorite Search Master When you select a new medication, it will automatically populate your favorites list. Favorites Highlight desired Medication If medication was previously prescribed your preferred SIG(s) display. Highlight one or click New blue link for new SIG or click Detail button to change details of an existing SIG New

64 Allscripts Resident Training Manual 63 In Medication Detail box: Select or change SIG choose radio button for Preferred, All or New Select SIG Enter or edit Days Supply or Qty. (Only 1 needs to be completed). Refills: # of refills authorized. Rx by: Rx By: Defaults to provider logged into system. Note: If nurse is completing per protocol be sure to complete the Supervised By field. Click Apply & Close Medication displays under Pending Prescriptions in magenta color font. Additional medications may be prescribed for the same patient at this time if appropriate Click Save

65 Allscripts Resident Training Manual 64 Confirm Rx box appears Verify the medication name, dose, and dispensing information. Verify Action change as appropriate. Click OK. Action OK If the Pharmacy needs to be selected or changed: Click on the Retail or Mail Pharmacy Link. Enter full or partial pharmacy identifiers in fields presented. Click the radio button All. Highlight desired pharmacy and click OK Highlight desired pharmacy Click OK

66 Allscripts Resident Training Manual 65 Vitals Vitals Workspace Click on Vitals tab from patient chart Select Patient if necessary To set preferences for Vital Signs content and layout, click the blue hyperlink Personalize in upper right-hand-corner of screen Personalize The Vitals Personalize option allows the user to re-format the page based on their workflow. The left two columns allow the user to select what items display on the page only those items checked will display on the page. In addition, the user may choose to set a default for any of the drop down boxes i.e. set the Height & Weight to Metric instead of US.

67 Allscripts Resident Training Manual 66 The right two columns allow the user to select where the items display on the page. To move an item highlight the item, click on the appropriate arrow (move it to the right or left and up or down). When complete click on Update. Enter patient vitals as appropriate Date/Time will default to today When done, click Apply If the Encounter Selector dialog box appears, highlight the appropriate encounter and click the OK button.

68 Allscripts Resident Training Manual 67 Correcting a Vital Entered in Error If a vital is entered in error on a patient, click on the Flowsheet tab. Highlight an entry on date that the error was made Highlight an entry under the date that the error was made. Click Edit Click Edit User is re-directed to the vitals page. The vitals that were recorded at that time will now appear in the boxes that they were entered in. To correct any entry: Simply re-type the correct entry at the prompt. If the entire entry was made in error (i.e. on wrong patient) Click on Status, click on drop down menu and choose Entered in Error Click Apply Click Apply Change Status

69 Allscripts Resident Training Manual 68 Return to the Flowsheet Verify that the incorrect entry has now been removed or updated. Note Incorrect Entry has been removed or updated.

70 Allscripts Resident Training Manual 69 Results ***IMPORTANT: Allscripts does not interpret or determine results*** Results Workspace The Results Workspace allows the user three Views of the patient s results: 1. View filters Filter results by category (Laboratory, Dx Imaging, Other Results, or Procedures/Tests) and Sub-Category (i.e. Category: Dx Imaging. Sub- Category: MRI) 2. Search for analyte Search for specific test by name. Click Go to begin search 3. Unverified display only results which have not been verified The Option Buttons on this workspace are: Print Allows user to print the selected result Fax Allows user to Fax the selected result (Reminder to fax multiple results to the same number use ChartViewer to filter these to fax). New Task Allows user to create a new task from this screen. Cite Recent The system will prompt the user for the number of days to cite into a structured note. Cite Selected Only the results selected will cite into a structured note. Graph Allows user to graph selected results will graph up to six (6) results. Flow Allows user to flow out the selected results to display any trends.

71 Allscripts Resident Training Manual 70 Invalidate To be used ONLY if these results were reported in error. (please refer to section on tasking results to lab or radiology teams if reported under wrong provider name). Verify Allows user to verify that the results have been received and reviewed. Select desired patient; access Chart Select Results tab Click radio button of preferred view: Select test or study (highlight) in left panel; result displays in right panel Red = abnormal; Black = verified; Blue = unverified. Desired Result Selected Views View of selected result

72 Allscripts Resident Training Manual 71 Flowing Results Click the Flow Analyte icon - to display any trends. or Check the box in front of results to flow and click Flow. Flow Analyte icon. Flow Results will flow out to display trends that can easily be followed. Note: Results in Red indicate results outside of the reference range for that test/study. Click OK to return to Results page. OK

73 Allscripts Resident Training Manual 72 Graphing Results Select Result Check the desired results to graph. Click Graph. Select results to graph Graph Up to six (6) items will graph on one page. The graph can be printed by Clicking with the right mouse. Choose Export Dialog Under Export Destination Select Printer Click Print.

74 Allscripts Resident Training Manual 73 Flowsheets Flowsheets allows the users to flow out a patient s vitals, lab results, and values attached to Medcin Findings. The default view is set to Vitals and the measurement displays in either US or Metric based on the Personalize selections a user has chosen from the Vitals page. Users can change the measurement displays on this page by clicking U.S. or Metric. The Name field contains a list of all available flowsheets. Buttons: Detail Displays the Result Detail form. Edit Enables the user to edit the flowsheet data. New Column Allows the user to enter new flowsheet data. Edit Column Allows user to edit the whole column of flowsheet data. New Task Allows the user to create a task. Cite Recent Cites recent results to a note. Graph Graphs selected items from the flowsheet. Print Prints the active flowsheet.

75 Allscripts Resident Training Manual 74 Graphing - Flowsheets. To graph items from a flowsheet: Select up to six (6) items. Click Graph. Select Results Graph To Print the Graph: Right mouse click within the graph. Click Export Dialog Choose Printer as Export Destination. Click Print.

76 Allscripts Resident Training Manual 75 Entering Flowsheet Data Users with access to Flowsheets are able to enter Flowsheet data Select a flowsheet from the Name list and then click New Column. If an encounter has not been selected, the Encounter Selector box will display. Choose New encounter and select Outside Results from Type list; click OK. The Select Element to Document page is displayed Check the appropriate elements, then click OK (if this page does not display, highlight the new column and click Edit column OR highlight a specific item and click Edit) The Result Activity page is displayed. Enter appropriate Flowsheet data in Details screen. Then click Results tab and enter appropriate data in this screen. Choose Performing Location as either Outside Labs or Inside Labs Click Apply and Close

77 Allscripts Resident Training Manual 76 Notes Creating Structured Notes Open desired patient s chart Click on New Note in ChartViewer or the Note Tab Select the New Note radio button Select Structured Note Select appropriate Group. Select the Note Type. Select the Note Owner. Select from either an Existing Encounter or a New Encounter. Click OK Note Workspace: Functions Table of Contents

78 Allscripts Resident Training Manual 77 The Table of Contents on the left-hand-side of the page defines the note sections listed in this note. All available note sections can be displayed by clicking on All Note Sections. To access any text in the right-hand side of the screen, click on the blue hyperlinks. Note Functions: Along the top of the note are several function buttons: Go To: Allows user to navigate to another window. Cite: Enables user to Cite information into the note Add: Allows user to Add a new item or incidence from the note. (i.e. problem, med, vital, etc) Text: Allows user to enter text into a note either free text or text templates. Dictation: Inserts a Dictation Marker which acts as a place-holder for dictated sections of the note. Findings: Allows user to enter structured findings using MedCin Templates. Image: Allows user to insert an image into the note. MedCin Findings: Images:

79 Allscripts Resident Training Manual 78 Editing Information in a Structured Note Locate desired note to edit in the ChartViewer. Highlight the note. Click Open or Edit button. If the note has been final signed the Open button will display; if not, the Edit button will display.) Highlight the Note Section on the left that you wish to edit. To Remove the current text in that section Click on Remove Entry Highlight Note section Remove Entry

80 Allscripts Resident Training Manual 79 Check the box in front of the text that you wish to remove. Click OK The Notes Section that you selected remains Highlighted. Text Click on Text to enter corrected information. Note Section

81 Allscripts Resident Training Manual 80 To display the original template, click on the name of the template on the right. Complete/Select updated information. Click OK Complete as desired. Choose template. OK Corrected Information displays in magenta along with a note stating Amended by: with the users name, date, and time. Click Sign (Note has been amended and needs to be re-signed). Changes display Sign