Documenting a Progress Note Template Training Module

Transcription

1 Documenting a Progress Note Template Training Module 70 Royal Little Drive Providence, RI Copyright Optum. All rights reserved. Updated: 3/6/13

2 Table Of Contents Table of Contents 1 About Templates Managing Templates Searching for a Template Saving a Template as a Favorite Sorting the List of Templates Removing a Template from the List Set a Template as a Default Using Quick Text (Clinical Macros) About Quick Text Creating Quick Text Selecting Quick Text Managing Quick Text Entries Edit a Quick Text Entry Delete a Quick Text Entry Sort the List of Quick Text Entries Working with Quick Text Entries Inserting Quick Text Using Shortcut Keys Dictating a Note About Point and Click Templates Inserting Documents and Images Optional Progress Note Template Features Default Progress Note Template Features Selecting and Managing Diagnoses Documenting a Patient Encounter Documenting a Pregnancy Encounter Pregnancy Case Obstetrics and Gynecology (OB/GYN) and Antenatal Record (ACOG) Templates ACOG Antepartum Report Estimate Date of Delivery (EDD) Calculators EDD by Quickening Calculator EDD by Fundal Ht at Umbil Calculator Printing a Template Accessing the Progress Notes Application Filtering Progress Note Templates Managing Progress Note Templates Editing a Progress Note Overriding Edits Deleting a Progress Note Adding an Addendum Signing a Progress Note Unsigning a Progress Note Printing a Progress Note Creating a PDF of the Progress Note ii

3 Table Of Contents 15.9 Sending a ToDo Managing Narratives Viewing a Narrative Searching for a Narrative Adding a Narrative to Favorites Pinning and Unpinning a Narrative to a Progress Note Display a Company Logo in a Narrative Viewing the Activity Log of a Progress Note Template Evaluation and Management (E&M) Accessing the E&M Evaluator Application Chart Based E&M Code Calculation Manual E&M Code Calculation Time Based E&M Code Calculation Visit Capturing Open Encounters Viewing a List of Open Encounters Filtering the Encounters List Resolving Open Encounters Unsigned Notes Viewing a List of Unsigned Notes Filtering Unsigned Notes Signing Notes Untranscribed Notes Viewing a List of Untranscribed Notes Filtering Untranscribed Notes Transcribing Dictations iii

4 About Templates 1 About Templates Each pre-defined specialty and condition specific template available in Optum PM and Physician EMR simplifies the process of documenting a patient encounter at the point of care. Optum PM and Physician EMR provides several template types, each offering a specific layout and custom options. These options allow you to select the template that best suits your documenting needs. You can also pull sections of a prior note and populate information, and insert document and images into templates if necessary. STANDARD TEMPLATES Template Option 1 Option 2 Option 3 Option 4 Description The template consists of 2 tabs and is recommended for providers that prefer using a simple version of a template with quick text or dictation. One tab consists of text boxes for Chief Complaint and History of Present Illness (CC/HPI), History (HX), Review Of Systems (ROS), Physical Exam (PE), Tests, Procedures (Proc), and Assessment and Plan (A&P). The second tab consists of structured data elements that link to the Quality Measure reports in Optum PM and Physician EMR. The template consists of 8 tabs and is recommended for providers that prefer using a simple version of a template with quick text or dictation. Seven tabs consist of text boxes to document the Chief Complaint and History of Present Illness (CC/HPI), History (HX), Review Of Systems (ROS), Physical Exam (PE), Tests, Procedures (Proc), and Assessment and Plan (A&P) in each tab. The last tab consists of structured data elements that link to the Quality Measure reports in Optum PM and Physician EMR. The template consists of 8 tabs and is recommended for providers who are using the structured option or combination of structure and quick text to document a note. Provides data elements in one screen and additional elements in a pop up window to be used as necessary. This option allows for no scrolling within the template. Recommended for providers who are using the structured option or combination of structure and quick text to document a note. All data elements are organized in one screen enabling you to scroll through to document patient information. Optum PM and Physician EMR supports the following date entry methods when documenting a patient encounter: Free Text (Free text mechanism works as a basic text editor enabling you to document simple statements such as Chief Complaint (CC). The text box supports only very basic formatting such as bold, underline and italics that must be applied using keyboard shortcuts.) Quick Text Dictation 1

5 About Templates Note: Third party voice recognition software is compatible with Optum PM and Physician EMR and can be used to document a patient encounter. Point and Click To access the Templates application: 1. Access the Medical Record module using one of the following methods: Pull the patient into context, and click the Medical Record module. (Recommended) If the patient has an appointment, click the patient name in the Appointments application of the Clinical Today module. 2. In the Clinical toolbar, click Progress Notes. The Progress Notes Template window displays. Note: The Progress Notes Template window launches only if an encounter is in context. If documenting a progress note that is not based on an appointment, the encounter dialog box displays enabling you to create a new "visit" type encounter. 2

6 Managing Templates 2 Managing Templates The Templates application enables you to manage templates used on a regular basis by saving as favorites, sorting the template list, or removing templates that are not required. In addition, you can set a template as a default for each operator. This will prevent the need to select a template from the Template list or search for a template each time you have to document a patient note. 2.1 Searching for a Template To search for a template: 1. Access the Medical Record module using one of the following methods: Pull the patient into context, and click the Medical Record module. (Recommended) If the patient has an appointment, click the patient name in the Appointments application of the Clinical Today module. 2. In the Clinical toolbar, click Progress Notes. Optum PM and Physician EMR displays the Progress Notes Template window. Note: The Progress Notes Template window launches only if an encounter is in context. If documenting a progress note that is not based on an appointment, the Encounter dialog box displays enabling you to create a new encounter. 3. By default, the View list is set to Template. 4. Click the Search icon to search for the required template. Optum PM and Physician EMR displays the Template tree dialog box. 5. Click through the specialty tree to search for a template. An alternative method is to enter the name of the template in the Template box, and click Search. Note: Each template is associated with a specialty. For diagnosis specific templates, browse through the specialty where the diagnosis is most common. 6. Click the required template. The selected template launches in the right-hand pane of the Templates window with the associated narrative on the left-hand pane. 2.2 Saving a Template as a Favorite To save a template as a favorite: 1. Access the Medical Record module using one of the following methods: Pull the patient into context, and click the Medical Record module. (Recommended) If the patient has an appointment, click the patient name in the Appointments application of the Clinical Today module. 3

7 Managing Templates 2. In the Clinical toolbar, click Progress Notes. Optum PM and Physician EMR displays the Progress Notes Template window. Note: The Progress Notes Template window launches only if an encounter is in context. If documenting a progress note that is not based on an appointment, the Encounter dialog box displays for you to create a new "visit" type encounter. 3. By default, the View list is set to Template. 4. Search for the required template and click the Favorites icon. A message prompts confirming the action. 5. Click OK. The template is added to the favorite list of templates. 2.3 Sorting the List of Templates To sort the list of templates: 1. Access the Medical Record module using one of the following methods: Pull the patient into context, and click the Medical Record module. (Recommended) If the patient has an appointment, click the patient name in the Appointments application of the Clinical Today module. 2. In the Clinical toolbar, click Progress Notes. Optum PM and Physician EMR displays the Progress Notes Template window.. Note: The Progress Notes Template window launches only if an encounter is in context. If documenting a progress note that is not based on an appointment, the Encounter dialog box displays for you to create a new "visit" type encounter. 3. By default, the View list is set to Template. 4. Click the Manage Templates icon. Optum PM and Physician EMR displays the Templates List dialog box. 5. In the Specialty list, click the required specialty. A list of templates saved as favorites for the selected specialty displays. 6. Click the Up and Down arrow icons to sort the list of templates in the required order. 2.4 Removing a Template from the List To remove a template from the list: 1. Access the Medical Record module using one of the following methods: Pull the patient into context, and click the Medical Record module. (Recommended) If the patient has an appointment, click the patient name in the Appointments application of the Clinical Today module. 4

8 Managing Templates 2. In the Clinical toolbar, click Progress Notes. Optum PM and Physician EMR displays the Progress Notes Template window. Note: The Progress Notes Template window launches only if an encounter is in context. If documenting a progress note that is not based on an appointment, the Encounter dialog box displays for you to create a new "visit" type encounter. 3. By default, the View list is set to Template. 4. Click the Manage Templates icon. Optum PM and Physician EMR displays the Templates List dialog box. 5. In the Specialty list, click the required specialty. Optum PM and Physician EMR displays a list of favorite templates for the selected specialty. 6. Click the Remove icon pertaining to the template to remove from the list. The template is removed from the list. 2.5 Set a Template as a Default To set a template as a default: 1. Access the Medical Record module using one of the following methods: Pull the patient into context, and click the Medical Record module. (Recommended) If the patient has an appointment, click the patient name in the Appointments application of the Clinical Today module. 2. In the Clinical toolbar, click Progress Notes. Optum PM and Physician EMR displays the Progress Notes Template window. Note: The Progress Notes Template window launches only if an encounter is in context. If documenting a progress note that is not based on an appointment, the Encounter dialog box displays for you to create a new "visit" type encounter. 3. By default, the View list is set to Template. 4. Click the Manage Templates icon. Optum PM and Physician EMR displays the Templates List dialog box. 5. In the Specialty list, click the required specialty. Optum PM and Physician EMR displays a list of favorite templates for the selected specialty. 6. Click the Favorites icon for the template you want to set as the default guideline. 5

9 Using Quick Text (Clinical Macros) 3 Using Quick Text (Clinical Macros) 3.1 About Quick Text Optum PM and Physician EMR provides a library of standard quick text that you can use to document information for different specialties. Quick text is a series of common words or phrases that helps document a progress note quickly. Quick text entries contain both standard phrases and tab stop entries or a combination of both. Rich text boxes that support the quick text method enables editing block(s) of text for each patient note. You can add as many quick text entries to the note, use existing entries from the quick text library and add text entries to the library to use when documenting future notes. Note: It is recommended to create quick text entries for templates in order to increase efficiency when documenting a note. The rich text box associated with the quick text mechanism supports a three-row tool bar. By default, all templates display a one row toolbar. You can set to display two or all three rows on the toolbar for each template that has a rich text box. However, if the rich text toolbar is set to minimize, the other rows in the toolbar does not display until the Drop arrow icon is clicked. Support: To customize the view of the rich text toolbar, log a To Do to the Support entity. The rich text toolbar helps create quick text, apply format changes, and include quick text into templates. The toolbar contains many buttons found in a word processor and are used the same way. The additional tool buttons used in the quick text method are described below. TOOL BUTTONS Tool Button Name Description Insert Quick Text Save Text Notation (ipad Only) The tool button displays the Quick text dialog box that helps select blocks of text to incorporate in the template. You can also sort and delete quick text items, replace the current content in the text box, edit quick text and more. Note: You cannot edit global quick text items provided by Optum PM and Physician EMR. The tool button helps create a "dictionary" of standard phrases you use. Quick text can be blocks of text or text with tab stops enabling quick modifications to the phrases. In addition, you can assign shortcut keys for each entry. The tool button changes the rich text box from a read-only mode 6

10 Using Quick Text (Clinical Macros) TOOL BUTTONS Tool Button Name Description to an edit mode enabling you to insert quick text by typing or using shortcut keys. To use shortcut keys, you must have existing quick text items with assigned shortcut keys (For more information on inserting quick text using shortcut keys, see Medical Record module > Progress Note Templates > Using Quick Text (Clinical Macros) > Inserting Quick Text Using Shortcut Keys). (ipad Only) The tool button enables you to enter quick text using shortcut keys. However, you must have existing quick text items with assigned shortcut keys (For more information on inserting quick text using shortcut keys, see Health Record module > Progress Note Templates > Using Quick Text (Clinical Macros) > Inserting Quick Text Using Shortcut Keys). Only) (ipad The tool button helps to move backwards (left arrow tool button) or forward (front arrow tool button) in a note that includes quick text with tab stops. To access a template with a rich text box: 1. Access the Medical Record module using one of the following methods: Pull the patient into context, and click the Medical record module. (Recommended) If the patient has an appointment, click the patient name in the Appointments application of the Clinical Today module. 2. In the Clinical toolbar, click Progress Notes. The Progress Notes Template window displays. Note: The Progress Notes Template window launches only if an encounter is in context. The encounter launches into context when accessing the patient health record via the Appointments application of the Clinical Today module. If documenting a progress note that is not based on an appointment, the encounter dialog box displays enabling you to create a new "visit" type encounter. 3. Access the template section with a rich text box to create quick text entries or manage existing entries. 3.2 Creating Quick Text Quick Text is a combination of both standard phrases and tab stop entries. You can assign a keyboard shortcut for an entry to improve the efficiency of the data entry mechanism. The usage of quick text entry is controlled by assigning company, group or provider access levels. In addition, you can assign a quick text entry to a specific specialty and a quick text group to store and organize the entries in a systematic manner. Optum PM and Physician EMR provides two methods of creating quick text: 7

11 Using Quick Text (Clinical Macros) Quick Text Library application of the Administration module (For more information on creating quick text via the Administration module, see Administration Module > Clinical > Daily Administration > Quick Text Library in the Help system.) Quick Text application accessed via the progress note template used for documenting the patient encounter The quick text created via the Administration module allows users with access to Administration functions to create quick text without accessing the Medical Record module. However, quick text created via the Medical Record module can be set to populate automatically for a specific section within a template based on the Scope settings. To create quick text entries: 1. Access the Medical Record module using one of the following methods: Pull the patient into context, and click the Medical Record module. (Recommended) If the patient has an appointment, click the patient name in the Appointments application of the Clinical Today module. 2. In the Clinical toolbar, click Progress Notes. The Progress Notes Template window displays. Note: The Progress Notes Template window launches only if an encounter is in context. The encounter launches into context when accessing the patient medical record via the Appointments application of the Clinical Today module. If documenting a progress note that is not based on an appointment, the Encounter dialog box displays enabling you to create a new encounter. 3. Access the template section with a rich text box to create quick text entries. Quick Text entries are created using the following methods: Create quick text entries with standard phrases To create quick text entries with standard phrases: a. Enter text and apply necessary format changes such as bold or underline. Note: To avoid additional data entry, you can import phrases created using the Word application by copying and pasting into the text box. b. Click Text Notation to insert all the text as a single quick text entry or select parts of the text to create multiple quick text entries. The Save Quick Text dialog box displays. 8

12 Using Quick Text (Clinical Macros) Create quick text entries with tab stops To create quick text entries with tab stops: Tab stops are locations within a quick text entry that enables you to navigate through text to enter data by pressing [TAB]. a. Enter numeric values and text. Apply format changes such as bold or underline as necessary. Follow the guidelines listed below. To create tab stop entries, enter <[ ]>. A tab stop entry with no options must have a space between [ ]. Therefore, the format of a tab stop entry with no options is entered in the following format: <[space]>. To create multiple options within a tab stop entry, enter <[option1, option2, option 3]>. There is no limit on the number options for an entry. Each option is represented by a number in ascending order. Selecting the corresponding number populates the text in the template. : If <[number]> <[days, weeks, years]> is entered, you can tab through to complete the information. Tab to <[number]> to enter a number, and press [1], [2] or [3] to make a selection from <[days, weeks, years]>. If [2] is pressed, the text weeks populates in the template. To enter numeric values within a tab strop entry, enter <[1, 2, 3.9]>. The number pressed populates in the template regardless of its position within <[ ]>. b. Click Text Notation icon. The Save Quick Text dialog box displays. 4. In the Caption box, enter a name for the auto text entry. 9

13 Using Quick Text (Clinical Macros) 5. In the Autocomplete Abbreviation box, enter a shortcut key for the quick text entry. Note: The shortcut key assigned is case sensitive. You can auto populate the text by pressing the key assigned, and then pressing CTRL+SPACE BAR to populate the text. Therefore, ensure that the exact case assigned for the entry is used. 6. In the Quick Text Group list, click the template section to assign to the quick text. This helps to store quick text entries in an organized manner. Note: It is strongly recommended you consider using quick text groups as template sections of a progress note. To create quick text groups: a. Click the Pencil icon next to the Quick Text Groups list. The Quick Text Groups dialog box displays. b. Click Add a New Group. 10

14 Using Quick Text (Clinical Macros) c. Enter the group caption and click OK. The group created is added to the list and displays in the quick text tree as a folder. All quick text items for each group are organized under the relevant folder. Note: To edit an existing group, click the Pencil icon next to the quick text group name. 7. In the Scope list, click the access level of the text entry. Quick text items are Company (available only to the company), Group (available only to the group) or Provider (available only to the provider) specific. 8. By default, the Add to Quick Text check box is selected. This provides you the option of adding the quick text to the Quick Text tree. If you do not want to add the quick text entry to the quick text tree, click to clear the Add to Quick Text check box. 9. (Optional) Select the Set as Default check box to assign the quick text entry as the default for the section. This automatically displays the quick text item within the section without having to insert. 10. (Optional) Select the Guideline Specific check box to make the quick text entry available only to the specific template that is in context. 11. (Optional) Select the Add To Library check box to add the quick text entry to the Quick Text library. 12. (Optional) In the Specialty list, click the specialty to assign the quick text entry. 13. Click Save. The quick text entry created is added to the Quick Text library under the selected specialty and quick text group. 3.3 Selecting Quick Text The Quick Text application provides the ability to retrieve global quick text entries and save as company, group or provider specific quick text or provides the ability to insert a global quick text only for the template in context. To select a quick text entry from the quick text library: 1. Access the Medical Record module using one of the following methods: Pull the patient into context, and click the Medical Record module. (Recommended) If the patient has an appointment, click the patient name in the Appointments application of the Clinical Today module. 2. In the Clinical toolbar, click Progress Notes. The Progress Notes Template window displays. Note: The Progress Notes Template window launches only if an encounter is in context. The encounter launches into context when accessing the patient medical record via the Appointments application of the Clinical Today module. If documenting a progress note that is not based on an appointment, the Encounter dialog box displays enabling you to create a new encounter. 3. Browse to the template section you want to enter the quick text. 11

15 Using Quick Text (Clinical Macros) 4. Click Insert Quick Text. The Quick Text dialog box displays with the quick text tree structure expanded enabling you to view all quick text items under each group at once. However, you can click Collapse All to view the quick text tree structure in a collapsed view to show only the quick text groups. 5. Click Load From Library. The Select Quick Text(s) from Library dialog box displays. 6. Search for the required quick text entry or navigate the quick text tree to select the check box for the required entry. You can select multiple check boxes to save more than one quick text entry at a time. It is recommended to first read and review each quick text entry prior to making multiple selections. 7. In the Into Scope list, select the scope level to assign the quick text entry. 8. Click Select. This loads the selected entries from the library to the assigned scope level. If you want to insert the quick text entry into the current template only, click Insert Once. The text associated with the quick text entry populates in the rich text box. Note: To replace all existing text in a rich text box with a quick text entry, select the check box for the entry, select the Replace Current Content check box and then click Insert Quick Text. 12

16 Using Quick Text (Clinical Macros) However, to replace a part of the text in the template, you must select the text before selecting the Replace Current Content check box. 3.4 Managing Quick Text Entries It is important to maintain an updated list of quick text entries to make the documentation process fast and efficient. You can manage the list of entries by editing, deleting or sorting Edit a Quick Text Entry To edit a quick text entry: 1. Access the Medical Record module using one of the following methods: Pull the patient into context, and click the Medical Record module. (Recommended) If the patient has an appointment, click the patient name in the Appointments application of the Clinical Today module. 2. In the Clinical toolbar, click Progress Notes. The Progress Notes Template window displays. Note: The New Progress Note window launches only if an encounter is in context. The encounter launches into context when accessing the patient medical record via the Appointments application of the Clinical Today module. If documenting a progress note that is not based on an appointment, the Encounter dialog box displays enabling you to create a new encounter. 3. Browse to the template section you want. 4. Click Insert Quick Text. The Quick Text dialog box displays with the quick text tree structure expanded enabling you to view all quick text items under each group at once. However, you can click Collapse All to view the quick text tree structure in a collapsed view. 5. Browse the quick text tree to select the quick text entry you want. If the required quick text item is not available, enter the name of the quick text in the box and click the Search icon. Optum PM and Physician EMR displays all quick text items that begins and contains the keyword entered. To clear the search item entered in the box, click the Delete icon. Note: Quick text entries can be made available to all providers for viewing and retrieving based on the scope settings. Only the provider who created the entry can make changes such as edit, delete or reorder the entry in the list. 13

17 Using Quick Text (Clinical Macros) 6. Select the quick text entry to edit and click Edit. The Edit Quick Text dialog box displays. 7. Make necessary changes such as edit the scope, group, formatting and click Save Delete a Quick Text Entry To delete a quick text entry: 1. Access the Medical Record module using one of the following methods: Pull the patient into context, and click the Medical Record module. (Recommended) If the patient has an appointment, click the patient name in the Appointments application of the Clinical Today module. 2. In the Clinical toolbar, click Progress Notes. The Progress Notes Template window displays. Note: The New Progress Note window launches only if an encounter is in context. The encounter launches into context when accessing the patient medical record via the Appointments application of the Clinical Today module. If documenting a progress note that is not based on an appointment, the Encounter dialog box displays enabling you to create a new encounter. 3. Browse to the template section you want. 4. Click Insert Quick Text. The Quick Text dialog box displays with the quick text tree structure expanded enabling you to view all quick text items under each group at once. However, you can click Collapse All to view the quick text tree structure in a collapsed view. 5. Browse the quick text tree to select the quick text entry you want. If the required quick text item is not available, enter the name of the quick text in the box and click the Search icon. Optum PM and Physician EMR displays all quick text items that begins and contains the keyword entered. To clear the search item entered in the box, click the Delete icon. 14

18 Using Quick Text (Clinical Macros) Note: Quick text entries can be made available to all providers for viewing and retrieving based on the scope settings. Only the provider who created the entry can make changes such as edit, delete or sort the entry. 6. Select the quick text entry to remove and click Delete. A message prompts to confirm the delete action. 7. Click OK Sort the List of Quick Text Entries To sort the list of quick text entries: 1. Access the Medical Record module using one of the following methods: Pull the patient into context, and click the Medical Record module. (Recommended) If the patient has an appointment, click the patient name in the Appointments application of the Clinical Today module. 2. In the Clinical toolbar, click Progress Notes. The Progress Notes Template window displays. Note: The New Progress Note window launches only if an encounter is in context. The encounter launches into context when accessing the patient medical record via the Appointments application of the Clinical Today module. If documenting a progress note that is not based on an appointment, the Encounter dialog box displays enabling you to create a new encounter. 3. Browse to the template section you want. 4. Click Insert Quick Text. The Quick Text dialog box displays with the quick text tree structure expanded enabling you to view all quick text items under each group at once. However, you can click Collapse All to view the quick text tree structure in a collapsed view to show only the quick text groups. 5. Browse the quick text tree to select the quick text entry you want. If the required quick text item is not available, enter the name of the quick text in the box and click the Search icon. Optum PM and Physician EMR displays all quick text items that begins and contains the keyword entered. To clear the search item entered in the box, click the Delete icon. Note: Quick text entries can be made available to all providers for viewing and retrieving based on the scope settings. Only the provider who created the entry can make changes such as edit, delete or sort the entry. 6. Select the folder to reorder from the Quick Text tree and click Reorder. The Reorder Quick Text dialog box displays. 7. Click the Up and Down Arrow icons to reorder items in the required order. The sorting of quick text is based on the operator, therefore, the quick text displays in the order that you set in the Quick Text tree. However, new quick text entries that are added to the Quick Text library displays at the bottom of the tree until it is sorted by the operator. 15

19 Using Quick Text (Clinical Macros) Note: You can also move the pointer over the Call out icon to view the text pertaining to the quick text entry. 3.5 Working with Quick Text Entries Quick text entries help document a progress note quickly by creating common phrases that includes text and tab stops. To work with quick text entries: 1. Access the Medical Record module using one of the following methods: Pull the patient into context, and click the Medical Record module. (Recommended) If the patient has an appointment, click the patient name in the Appointments application of the Clinical Today module. 2. In the Clinical toolbar, click Progress Notes. The Progress Notes Template window displays. Note: The New Progress Note window launches only if an encounter is in context. The encounter launches into context when accessing the patient medical record via the Appointments application of the Clinical Today module. If documenting a progress note that is not based on an appointment, the Encounter dialog box displays enabling you to create a new encounter. 3. Click in the section of the template to insert the quick text entry. 4. Click Insert Quick Text. The Quick Text dialog box displays with the quick text tree structure expanded enabling you to view all quick text items under each group at once. However, you can click Collapse All to view the quick text tree structure in a collapsed view to show only the quick text groups. Note: To replace all existing text in a rich text box with a quick text entry, select the check box for the entry, select the Replace Current Content check box and then click Insert Quick Text. 16

20 Using Quick Text (Clinical Macros) However, to replace a part of the text in the template, you must select the text before selecting the Replace Current Content check box. 5. Browse the Quick Text tree to retrieve text entry for a specific group or click Load From Library to retrieve quick text entry saved in the Quick Text library. 6. Continue documenting the note by entering free text or quick text entries. Enter free text in the tab stops or select the appropriate number to populate text for the specific selection. Note: If the quick text consists of tab stops, the cursor will be positioned at the beginning of the paragraph enabling you to press [TAB] to navigate to each tab stop. However, if the quick text does not include any tab stops, the cursor is placed at the end of the sentence. Note: Press the [SPACE BAR] to delete items within <[ ]> if necessary. 3.6 Inserting Quick Text Using Shortcut Keys Optum PM and Physician EMR allows you to assign shortcut keys to quick text entries (see Medical Record Module > Templates > Using Quick Text (Clinical Macros) > Creating Quick Text) and use the shortcut keys to include the text in rich text boxes to document a patient note. 17

21 Using Quick Text (Clinical Macros) To Insert Quick Text Using Shortcut Keys: 1. Access the Medical Record module using one of the following methods: Pull the patient into context, and click the Medical Record module. (Recommended) If the patient has an appointment, click the patient name in the Appointments application of the Clinical Today module. 2. In the Clinical toolbar, click Progress Notes. The Progress Notes Template window displays. Note: The New Progress Note window launches only if an encounter is in context. The encounter launches into context when accessing the patient medical record via the Appointments application of the Clinical Today module. If documenting a progress note that is not based on an appointment, the encounter dialog box displays enabling you to create a new encounter. 3. Click in the section of the template to insert the quick text entry. 4. Press the shortcut key assigned, and then press CTRL+SPACE BAR to populate the text. Example: If P was entered in the box when creating a quick text, you can populate the text by pressing the [P] key, and then pressing [CTRL+SPACE BAR] to pull the quick text entry into the template. Note: The shortcut key assigned is case sensitive so it is important that you use the exact case assigned to the entry. 18

22 Dictating a Note 4 Dictating a Note The dictation feature is an alternate method within a template for documenting a patient encounter. You can dictate a medical note into a phone or a recording device. When the note is dictated, the audio file is generated and saved directly into the patient's progress note with the file name. The file name is automatically created by the system, and includes the date and time the recording was completed. You must transcribe the WAV file into a medical note using an in-house, or third party transcription or application service. If using a third party transcription service, you can play and transcribe the audio file directly into Optum PM and Physician EMR. When the audio file is transcribed, the transcribed text is saved into the progress note by replacing the file name. The responsible provider must review, edit and sign the progress note. This vital information becomes a component of the patient's chart and the final legal medical documentation. To dictate a note: 1. Access the Medical Record module using one of the following methods: Pull the patient into context, and click the Medical Record module. (Recommended) If the patient has an appointment, click the patient name in the Appointments application of the Clinical Today module. 2. In the Clinical toolbar, click Progress Notes. The Progress Notes Template window displays. Note: The Progress Notes Template window launches only if an encounter is in context. The encounter launches into context when accessing the patient medical record via the Appointments application of the Clinical Today module. If documenting a progress note that is not based on an appointment, the Encounter dialog box displays enabling you to create a new encounter. 3. Click in the section of the template to enter the dictation. 4. Click Dictation. The Add Attachment dialog box displays. Note: You can record and play audio files only if your computer is equipped with a microphone and a sound card. Contact your practice System Administrator to configure audio settings for your computer. 5. Click Record to begin recording. 6. Click Stop to end the recording. Optum PM and Physician EMR saves the WAV file in the rich text box. 19

23 Dictating a Note Note: You can dictate an entire note or a portion of the note as necessary. 7. Click Save to save the dictated note to the patient's medical record. The WAV file name populates in the narrative on the left-hand pane. Note: A progress note that includes a file that needs transcription cannot be signed until it is transcribed. The progress note is saved in the Encounters and Progress Notes sections in the patient's medical record. It is also saved in the responsible provider's Open Encounters list and the Untranscribed Notes list of the Clinical Today module. When the file is transcribed, the transcribe text is saved in the progress note and the provider can review, edit and sign the note via the Open Encounters application. 20

24 About Point and Click Templates 5 About Point and Click Templates Optum PM and Physician EMR provides the capability to document notes using the point and click mechanism. Point and click mechanism enables you to document a patient note by selecting items from pre-structured templates. You can point and click to select appropriate choices from lists, check boxes and extended pop ups to record a patient encounter. This reduces the chances of medical errors since the data is documented in customized forms. Each control used in the point and click mechanism is described below. CONTROLS Control Function Text Box A data entry field used to enter text, date, time and numeric information. or or Check Box Used for "Yes/No" and "Abnormal/Normal" entries. It is also used as a single check box to select items. Clear All Used as a "Select All" option. Clicking the + symbol, selects all Yes entries. Clicking the - symbol, select all No entries. Note: You can click the Clear All link to clear all selections made on items in a section without having to deselect each item individually. Clicking the Clear All link also deletes entries selected or entered in dropdown lists and text boxes in the section. Button Push A push button that triggers a pre-defined action such as displaying a dialog box to enter additional information. Active Text A link that triggers a Medcin (Medcin: A system of standardized medical terminology intended for use in Electronic Medical Record (EMR) systems. The system includes over 250,000 clinical data elements encompassing symptoms, history, physical examination, tests, diagnoses and therapy. The system was developed by Medicomp Systems, Inc.) compliant dialog box to enter additional information. Find Details Displays a dialog box to enter additional information on a specific data element. The Finding Details dialog box is standard across all templates. If additional data is available or can be recorded for the selected data element 21

25 About Point and Click Templates CONTROLS Control Function in the progress note template, the Finding Details dialog box displays. Pop Up Displays a dialog box to enter additional information on a specific data element. A list box used to select information from preset values. Some drop-down lists provide the option of making multiple selections and clicking Save & Close at the end of the list. 22

26 Inserting Documents and Images 6 Inserting Documents and Images Optum PM and Physician EMR provides the ability to embed patient related documents such as lab and radiology results, flow sheets and more when documenting an encounter. Any changes made to the document, reflect in the document attached to the progress note. In addition, templates provide the ability to insert images from a library of images. This helps to quickly identify and describe the exact location of the condition by annotating images and saving in the note. To insert a document or image in a Progress Note: 1. Access the Medical Record module using one of the following methods: Pull the patient into context, and click the Medical Record module. (Recommended) If the patient has an appointment, click the patient name in the Appointments application of the Clinical Today module. 2. In the Clinical toolbar, click Progress Notes. Optum PM and Physician EMR displays the Progress Notes Template window. Note: The Progress Notes Template window launches only if an encounter is in context. The encounter launches into context when accessing the patient medical record via the Appointments application of the Clinical Today module. If documenting a progress note that is not based on an appointment, the Encounter dialog box displays enabling you to create a new "visit" type encounter. 3. Click the section of the template to insert the document or image. 4. Click Insert Image. The Insert Image dialog box displays images uploaded to the patient s record followed by images from the global image library. 5. Click the required image. Optum PM and Physician EMR embeds the image in the progress note. 6. (Optional) Click the Annotate link beneath the image. Optum PM and Physician EMR displays the Document Management View dialog box. 7. Mark up the image using the annotation tools listed in the table below. 8. Click Annotate and select a markup tool to annotate the image. The table below describes each tool: Example: You can scan or attach a standard growth chart into a patient s medical record and mark measurements such as weight and height to analyze the child s growth progress. Note: You can add multiple annotations on an image. ANNOTATION OPTIONS Icon Tool Description Rectangle Click and drag to draw a rectangular shaped markup with no fill. 23

27 Inserting Documents and Images ANNOTATION OPTIONS Icon Tool Description Ellipse Line Freehand Text Sticky Note Highlight Redaction Click and drag to draw an oval shaped markup with no fill. Click and drag to draw a straight line. Click and drag to draw a freehand line. Click and drag to draw a text box with a white background. Double-click the box to add or edit text. Click and drag to draw a yellow note on the document. Double-click the note to edit the text. Click and drag to highlight an area in yellow. Click and drag to draw a filled shape. Note: You can hide markups to the document by selecting the Hide Annotations check box. 9. (Optional) You can customize the appearance of the annotations, if necessary. To customize annotation properties: a. Right click the annotation, and click Change Annotation Properties. Optum PM and Physician EMR displays the annotation properties dialog box. Note: The fields that display in the Annotation Properties dialog box are based on the type of annotation you want to customize. For example, the text size and text color fields are only available when customizing the appearance of Text type annotations. To change the color of an annotation (outline color, fill color, text color), click the color picker icon and click on a new color. Alternatively, you can type the name of the color in the text box. To change the width of a line or the resize text, use the slider to increase or decrease the size or width. Alternatively you can manually enter a number (1-100) in the box to change the width of the line or size of the text. b. Click Save in the Annotation Properties window. Optum PM and Physician EMR saves the markups on the page and location you drew or added text. 10. Click Save when finished. Optum PM and Physician EMR saves the markups on the page and location you drew or added text. 11. Click Save to display the annotated image in the narrative. 24

28 Optional Progress Note Template Features 7 Optional Progress Note Template Features The templates accessed via the Progress Note Template application consists of several optional features you can use when documenting a patient encounter. Support: To add the following features to your template, log a ToDo to the Support entity. The ability to pull forward height information recorded in a previous visit to the current note, and automatically calculate Body Mass Index (BMI). The ability to display the Home Monitoring form for company specific templates. Additionally, you can display home monitoring data recorded via the Vital Signs application in the narrative. If multiple sequences of vital data are recorded, the progress note displays all sequences with a sequence number, and the date and time of the recording. The ability to include office tests and procedures in a template to capture the CPT codes for visit capture. This allows you to capture visit information via the Visit application when the progress note is saved. When the progress notes is saved, the CPT codes of the tests performed in the office are automatically selected in the Visit application to capture visit information. The ability to automatically update the Visit application with the procedure and diagnosis codes selected when documenting a patient encounter. The ability to cite a patient's lab results in the progress note. You can view the patient's recent lab results while in a progress note and indicate the lab results that were reviewed with the patient. All results marked as reviewed are saved under the Results Reviewed with Patient section in the narrative. The ability to display the patient's Primary Care Physician (PCP) and referring provider information recorded in the Demographics application in the narrative. The ability to display active diagnoses information recorded in the default tab of the Problem List application in the narrative. Example: Typically, the Problem List tab includes problems without 25

29 Optional Progress Note Template Features the V or E ICD-9 codes. Therefore, if the Problem List application defaults to the Problem List tab, the narrative displays problems without the V or E ICD-9 codes. The ability to group plan items and diagnoses in the narrative. For example, if two diagnoses and two plan items are selected, the information lists the two diagnoses first followed by the two plan items indicating that the selected plan items pertain to the two diagnoses. You can click the Diagnosis/Assessment header in the narrative to do the following: Change the order in which the diagnoses display in the narrative. Link multiple plan items with multiple diagnoses. The ability to display ICD-9 codes associated with diagnoses in the narrative. The ability to display medication instructions, quantity, and other medicine information on a single line below the medication name in the progress note narrative. The ability to display detailed information pertaining to the immunization administered in the Immunization Given Today section of the narrative. The information includes lot number, administered date, expiration date, series, Date VIS given to patient, and dosage. The ability to display the growth, height, and head circumference percentiles calculated for children via the Flowsheet application in the narrative. The ability to carry forward height information recorded from a previous visit to the current visit, and automatically calculate Body Mass Index (BMI) information. If you want height information automatically moved from visit to visit, log a ToDo to the Support entity. The ability to display the names of clinical letters attached to a ToDo or printed for the patient during the encounter in the Clinical Letters section of the narrative. The ability to display all operators who created an order, prescription or immunization in the footnote of a narrative. The ability to display before each section in the narrative(narrative: A view of your clinical documentation on the left side of the progress note template) the name, date and time of the operator who documented the information in the section or display all of the contributors in the footnote of the narrative. The ability to display the operator's time zone in the narrative. The time zone is set for each individual operator via the Operators and Roles application in the Administration module. Important: The time zone defaults to Eastern Standard Time (EST) if no time zone is set for the operator. It is important to set the correct time zone if you are not in the EST time zone. 26

30 Default Progress Note Template Features 8 Default Progress Note Template Features The templates accessed via the Progress Note Template application consists of several default features you can use when documenting a patient encounter. Note: The features available are based on the version of the template and the specialty. The progress note template displays a standard toolbar to access applications such as Rx, Orders, Order Sets, Immunizations, Referrals, Patient Education, and more. Additionally, the narrative displays information recorded in the Rx, Orders, Immunizations, Referrals and Patient Education applications for the current encounter. Note: The patient education information that display on the narrative also includes the websites accessed via the Link tab of the Patient Education application. The progress note template displays a check mark in the Problem List Reviewed, Allergy List Reviewed, Medication List Reviewed check boxes when you click Mark Reviewed in the Chart Summary. The progress note template displays a check mark in the Problem List Reviewed check box when you click Confirm No Known Problems or Mark Reviewed in the Problem List application. Additionally, the Problem List section of the narrative displays No Known Problems or Problem List Reviewed with the current date. The progress note template displays a check mark in the Allergy List Reviewed check box when you click Confirm No Known Allergies or Mark Reviewed in the Allergies application. Additionally, the Allergies section of the narrative displays No Known Allergies or Allergies Reviewed with the current date. The progress note template displays a check mark in the Medication List Reviewed check box when you click Confirm No Known Medications or Mark Reviewed in the Medications application. Additionally, the Medications section of the narrative displays No Known Medications or Medications Reviewed with the current date. The narrative displays No Refills when the number of refills in the Rx Writer application is set to 0. The narrative displays the patient's current medications with the renewal date for medications prescribed and the original date for medications manually entered. Support: To remove the date from the narrative, log a ToDo to the Support entity. The Medications Administered Today section of the narrative displays medications recorded via the Administered Medication dialog box. The progress note template helps you easily identify popup buttons with information recorded by displaying in orange. This helps when copying information from a previous note to the current note as reminder that data is recorded in the pop up windows associated with the pop up button. Example: You can record information on each joint of a homunculus in a popup window by clicking the popup button in a Rheumatology template. This displays the popup button in orange to indicate 27

31 Default Progress Note Template Features that data is recorded. The progress note template displays a Finding Details icon next to Medcin nodes. You can click the Finding Details icon to access the Finding Details dialog box to record additional information about the Medcin nodes. 28

32 Default Progress Note Template Features The Finding Details dialog box allows you to do the following: Select answers for each modifier. When more than 11 options are available for a modifier and the remaining options are displayed in additional columns, Optum PM and Physician EMR displays the Next and Previous links to view all options. You can delete options selected for a modifier by deselecting the check box of the associated modifier in the Finding Details section. To delete all information recorded in the Finding Details dialog box, click Delete. Record additional information in the Comments box. You can add quick text from the library by clicking the Insert Quick Text icon or use shortcut keys assigned to quick text to add notes. Note: When you create quick text for a node via the Comments box, Optum PM and Physician EMR makes the quick text available in the Finding Details dialog box of all other nodes enabling you to select text to add as notes. You can save the information recorded in the Finding Details dialog box by clicking X on the top right corner or by clicking outside the Finding Details dialog box. When information is recorded, Optum PM and Physician EMR illuminates the Finding Details icon the left of the node., and selects the check box to Alternatively, you can also update and delete the finding detail information on a node from a narrative after saving the note. You can save the changes made by clicking Save. To delete finding detail information from the narrative, click the link with the finding detail information, and click 29

33 Default Progress Note Template Features Delete in the Finding Details dialog box. This clears the check mark to the left of the Medcin node and displays a dimmed Finding Details icon in the template indicating that additional information is not available for the node. The PE tab of a progress note template displays an alert when vital data recorded for the encounter is out of the normal range and highlights the data in red. The progress note templates displays pop up buttons in orange to identify sections with recorded information. For example, if you copy information from a previous note to the current note, pop up windows with data displays the associated pop up buttons in orange. The vital sign values in the narrative display the same measurement used for recording vital signs. For example, if the vital signs are recorded in Metrics, the narrative displays the values in Metrics instead of converting to Standard measurements. If the vital signs are recorded in Standard, the narrative displays the values in Standard. However, if a template is set up to use both measurement types, the vital values in the narrative display both regardless of the measurement used for entering the data. The History section of the narrative displays updates made via the History application with the date and time. Support: To display the date only, log a ToDo to the Support entity. The ability to delete incorrect patient education information recorded for the patient. To delete patient education information from the narrative, click the patient education entry link recorded in the narrative. Click the Delete Patient Education link in the Education Content window. Note: When you delete the patient education entry from the narrative, Optum PM and Physician EMR removes the same entry recorded in the Correspondence application. 30

34 Selecting and Managing Diagnoses 9 Selecting and Managing Diagnoses Some templates accessed via the Progress Note Template application consists of a form enabling you to select and manage diagnoses associated with the encounter. The diagnoses available for you to select are organized in three tabs enabling you to add diagnoses to the Today s Selected Diagnoses section. The Today's Selected Diagnoses section works as a storage area for all diagnoses associated with the current encounter. DIAGNOSES TABS Tab Assessment tab Problem List tab Description The Assessment tab includes diagnoses linked to the form of the template in context. You can select the check box to the left of the diagnoses to add to the current note. Additionally, you can search for diagnoses that are not in the tab by entering a keyword or ICD-9 code in the Search box and pressing [ENTER]. The Problem List tab enables you to view and manage a patient's problem list recorded in the Problem List application via the progress note template. You can select the check box for the diagnoses you want to add to the Today s Selected Diagnoses section of the current note. However, if more than one Medcin term is associated with the ICD-9 code, Optum PM and Physician EMR displays all Medcin terms for you to select the description that best describes the condition. The Medcin clinical term you select is automatically linked to the ICD-9 code when you save the progress note, and is pulled forward to future progress notes. Therefore, if you are seeing the patient for the same problem, the Medcin clinical term automatically displays without having to browse through a list of Medcin terms. Note: If you want to change the associated Medcin clinical term, deselect the check box to the left of the Medcin description in the Today s Select Diagnoses section. You can then search by the ICD-9 code or description to find a different clinically specific description Additionally, you can deactivate a diagnosis in the Problem List application via the Problem List tab of the Progress Note template by clicking the Deactivate icon along the diagnosis line. Note: If the patient does not have active problems recorded in the Problem List application, the Problem List tab appears unavailable. Favorite Diagnosis tab The Favorite Diagnosis tab displays diagnoses listed on the practice's group encounter form. However, if a practice has more than one encounter form, Optum PM and Physician EMR displays the diagnoses of the encounter form linked to the appointment in the favorite list. You can click a specific category to view the ICD-9 codes linked to the category. If the ICD-9 code is associated with more than one Medcin term, Optum PM and Physician EMR displays the Medcin terms in a third 31

35 Selecting and Managing Diagnoses DIAGNOSES TABS Tab Description column enabling you to select the term that best describes the condition. Note: If a default encounter form is not linked to an appointment or an encounter is not associated with an appointment, Optum PM and Physician EMR displays diagnoses in the group encounter form. If you are in a multi-group company, Optum PM and Physician EMR displays the encounter form linked to the group you are currently logged in. If an encounter form does not have ICD-9 codes, the Favorite Diagnosis tab appears unavailable. You can record additional details for each diagnosis by clicking the Finding Details icon, add notes about diagnoses in the Assessment Notes box. You can manage the diagnoses in the Today s Selected Diagnoses section by: Deselecting the check box of a diagnosis you do not want to associate with the current note. Note: If you deselect a diagnosis that was added from the patient s problem list, Optum PM and Physician EMR maintains the diagnosis in the Problem List application. Recording additional details for diagnoses that are added via the search, patient's problem list, and favorite list. Setting the status of a diagnosis by selecting Acute or Chronic. Note: If you add a diagnosis with an existing status from the Problem List tab, Optum PM and Physician EMR defaults to the same status in the Today s Selected Diagnoses section. However, you can change the status if necessary. Deactivating a diagnosis in the Problem List application by clicking the Deactivate icon. The diagnosis is made inactive and displays when the Show Inactive check box is selected in the Problem List application. The narrative displays the Medcin description, and the Problem List application and the Chart Viewer displays the ICD-9 code and description of all diagnoses selected in the Today s Selected Diagnoses section. Note: If the narrative has a problem list section that displays the patient s current diagnoses, and you add diagnoses via the progress note template for the current encounter, Optum PM and Physician EMR does not display the diagnoses under the problem list section in the narrative. However, the diagnoses display under the narrative section that is associated with the diagnoses form of the progress note template. For example, Assessment section. 32

36 Documenting a Patient Encounter 10 Documenting a Patient Encounter It is important to capture patient encounter data at the point of care in order to provide a complete, accurate, and timely view of patient information. Optum PM and Physician EMR supports electronic documentation of patient encounters via condition or specialty specific templates. Note: To view a list of condition and specialty templates available, see the Optum PM and Physician EMR Templates report under Doc > Support. Additionally, when documenting a patient encounter Optum PM and Physician EMR provides the option of opening progress notes in a new tab. To open the progress note in a new tab, click the Set Defaults icon in the Chart Summary, and select the Open Progress Note in New Tab check box. Note: If the progress note opens in a new tab, and you change the encounter in the Chart Summary window, the progress note window closes after prompting to save changes to the note. If you change the encounter in the progress note window, the Chart Summary window refreshes to match with the new encounter in the progress note window. To document a patient encounter: 1. Access the Medical Record module using one of the following methods: Pull the patient into context, and click the Medical Record module. (Recommended) If the patient has an appointment, click the patient name in the Appointments application of the Clinical Today module. 2. In the Clinical toolbar, click Progress Notes. If an encounter is in context, Optum PM and Physician EMR displays the Progress Notes Template window. If documenting a progress note that is not based on an appointment, the Encounter dialog box displays enabling you to create a new encounter. To create an encounter: a. Click Create a New Encounter. The Optum PM and Physician EMR displays the Create a new Encounter dialog box. b. In the Type list, click the type of encounter you want to create. Note: You can use global encounter types provided by Optum PM and Physician EMR or set up your own custom encounter types via the Encounter Types application. Custom encounters that are flagged as an "Office Visit" are used for calculations in Key Performance Indicator (KPI) reports. To count an encounter towards Meaningful Use Quality Measure reporting, you must either create a visit using the Visit application or save the visit as a charge. However, if you want to use an encounter not counted towards meaningful use, you must select an encounter that is not flagged as an office visit. To access the Encounter Types application, click the Administration module, Clinical tab, and then click the Encounter Types link under the Clinical section. For more information on creating custom encounter types, see Administration Module > Clinical > Daily Administration > Encounter Types in the Help system. 33

37 Documenting a Patient Encounter c. By default, the Service Date list is set to the current date. However, you can enter a different date in MM/DD/YYYY format or click the Calendar icon to select the date of the encounter. d. In the Responsible Provider list, click the name of the provider associated with the encounter. e. By default, the Supervising Provider list displays a provider only if one supervising provider is assigned or a default supervising provider is selected in the Cosignature application. However, you must select a provider if many supervising providers are linked and the provider requires a co-signature when initiating an encounter centric action. Note: The Supervising Provider list is unavailable when a co-signature is not required for the provider initiating the encounter centric action. To access the Cosignature application, click the Administration module, Clinical tab and then click the Cosignature link. f. By default, the Patient Case list is set to Default. However, you can click a different case from the list if necessary. g. In the Location list, click the location of the encounter. h. By default, the Transition of Care list is set to No. i. (Optional) In the Description box, enter a description about the encounter. j. Click OK. Tip: You can also access the patient's progress note via the Appointments application of the Clinical Today module. To open the progress note, click the Arrow icon to the left of the Actions menu and then click Progress Notes. 3. If the patient has previously documented notes, Optum PM and Physician EMR displays the Copy from Prior Note dialog box. Note: Optum PM and Physician EMR automatically displays the Copy from Prior Note dialog box only if the Suppress PriorNote Copying field is set to False in the in the Health Records Settings application. However, you can also access the Copy from Prior Note dialog box by clicking Copy next to the View list. The Copy button is active only if the patient has previously documented notes. 4. (Optional) Copy information from sections of a note associated with a previous encounter. To copy information from previous notes: a. In the Select Note list, click the encounter information you want to copy. b. Select the check box in front of each section you want to copy to the new note, or click Select All to copy all sections. Note: You can click Clear All to deselect all sections, or click to clear the check boxes of sections you do not want to copy. You can also click Set As Defaults to set the sections you want to copy each time you create a new note. 34

38 Documenting a Patient Encounter c. Click Insert Selections. The information from the selected sections is copied to the new progress note template. 5. By default, the View list displays Template. 6. In the Template list, select a template. The Template list includes the provider's favorite templates. You can also search for the required template. To search for a template: a. Click the Search icon. Optum PM and Physician EMR displays the Template tree dialog box. b. Click on the specialty name or the plus signs (+) to expand the list. Note: You can move the pointer over the name of the template to view a description of the template. c. Click the template you want to document the patient encounter. Optum PM and Physician EMR launches the selected template on the right pane and the narrative on the left pane of the Progress Note Template window. Tip: An alternate search method is to enter the name of the template in the Template box, and click Search. Note: If you select a chief complaint when booking an appointment and a template is linked to the complaint, the corresponding template displays by default with the complaint in the CC/HPI tab. You can create a list of complaints and associate with templates using the Chief Complaint Maintenance application in the Administration module. If the chief complaint is not linked to a template, but a template is linked to an appointment type, the template associated with the appointment type displays by default. If you type a chief complaint in the Complaint box when booking the appointment, the complaint displays in the Other Complaints section of the CC/HPI tab. You can link a template to an appointment type via the Appointment Types application in the Administration module. 35

39 Documenting a Patient Encounter 7. Complete the note by navigating through each tab and section using the various data entry methods such as quick text, point and click, and dictation. Additionally, you can use the optional and default features available in templates to document the patient encounter. 8. Click Save. The patient information documented in the template populates in the narrative on the left pane. Optum PM and Physician EMR saves the note in the Encounters and Progress Note applications. Note: If the note contains a file that requires transcription, it is saved in the Untranscribed Notes application and Open Encounters application of the Home and Clinical Today modules. You cannot sign a note that contains an untranscribed file. When the file is transcribed, the responsible provider must review and sign the note. When the transcribed file is signed, Optum PM and Physician EMR updates the encounter in the Encounters application and the note in the Progress Notes applications. 9. When the note is complete, you can sign the documented note using the provider s digital signature. To sign the note, click the Sign icon. Optum PM and Physician EMR displays the signature of the provider associated with the operator who documented the note. If a provider is not linked to the operator, Optum PM and Physician EMR displays the signature associated with the provider in the batch. Note: If the provider signing the progress note is not the responsible provider on the encounter and requires a co-signature, Optum PM and Physician EMR displays a message. The message is a reminder to change the responsible provider on the encounter. Example: The message displays when a Non-Physician Provider(NPP) sees the patient and documents the progress note instead of the provider on the appointment. Additionally, if two providers sign the note and have a digital signature linked, both signatures display in the note. Note: You can only include a digital signature in the progress note, if you activate the Progress Note option in the Provider Signature application in the Administration module. 10. When the note is signed, you can prompt or automatically print the note, visit summary or generate and send a CCD to the Health Information Exchange (HIE). The actions that occur are based on the On Note Signing and the On Note Signing - CCD to HIE fields in the Health Record Settings application in the Administration module. Note: Your Optum HIE must have Open Access(Open Access: Open Access Service Oriented Architecture (SOA) is the core of Optum Health Information Exchange that enables HIEs to connect new and existing third party applications to the Exchange via exposed web services). and the XDS outbound interface activated to post the CCD. If you are connected to an Optum HIE and want to activate the XDS outbound interface, log a ToDo to the Support entity. When a CCD is posted to the HIE, Optum PM and Physician EMR updates the patient s clinical log with the CCD Sent to HIE entry. A copy of the CCD posted to the HIE is also saved in the Documents application of the Medical Record module. 36

40 Documenting a Patient Encounter Additionally, you can do any of the following based on your requirements: To expand the view of the narrative: Click the Expand icon Note: Click the Expand icon again to collapse the view of the narrative. To print a documented note: Click the Print icon, and then click Print on the Narrative Template dialog box. To create a PDF of the documented note: Click the Print icon, and then click PDF on the Narrative Template dialog box. To add an addendum to a note: Click the Add Addendum icon, and enter additional notes in the Add Addendum dialog box. For more information on adding an addendum, see Medical Record module > Progress Note Templates > Managing Progress Note Templates. To lock and unlock a narrative to a progress note: Click the Pin icon to lock in a narrative to a progress note template. This results in displaying the same narrative each time you access the progress note template. If you want to select a different narrative each time you access the progress note template, you can unlock the pinned narrative by clicking the Unpin icon. To attach the documented note to a ToDo: 37

41 Documenting a Patient Encounter Click ToDo. Optum PM and Physician EMR displays the New ToDo dialog box for you to enter the required information and click OK. A record of the ToDo is saved in the Open Activities section and the Documents application of the Medical Records module. Note: By default, the Type list displays EHR and the Reason list displays Other in the ToDo dialog box. To send a Progress Note via MDM Outbound Interface: To sign and send the note electronically to the HIE via the Medical Document Management (MDM) interface, click the sign and send note icon. Optum PM and Physician EMR displays a message to confirm the action. Support: The sign and send note icon is only available if the Document Export or HIE Document Export interface is activated for your company. To activate the interfaces, log a ToDo to the Support entity. To return to the Chart Summary: Click the Return to Chart Summary link. 38

42 Documenting a Pregnancy Encounter 11 Documenting a Pregnancy Encounter OB/GYN practices can document a pregnancy using the case logic, OB templates and the Antenatal Record (ACOG) template available in Optum PM and Physician EMR. Additionally, you can use the patient education material, flow sheets, alerts with Estimated Gestational Age (EGA), ultrasound orders and results, ACOG Antepartum Reports, EDD Calculators and more to facilitate pregnancy related appointments. Support: You must log a ToDo to the Support entity to display the EGA in alerts for your practice Pregnancy Case Prior to documenting a patient encounter for a pregnancy, you must ensure that the appointment and the associated encounter is linked to a pregnancy case. This is important to ensure that pregnancy information is carried from note to note for the active case, and charges and claims are filed correctly. For example, when you enter the Last Menstrual Period (LMP) and Clinical EDD once, the information is automatically carried through the notes linked to the active pregnancy case. Tip: You do not have to use the Copy Forward feature when documenting a pregnancy related encounter as the Episode logic automatically carries the information forward from note to note. When you create a new encounter for a specific case, Optum PM and Physician EMR automatically pulls information forward from the last encounter associated with the same case. It is also important to create a pregnancy case for the patient in addition to being set up as an OB/GYN practice in order to populate and view data in the prenatal flowsheet report. The prenatal flowsheet report is generated by clicking Print on the Clinical toolbar. Note: If documenting a note for a patient who had prior pregnancies, you must make sure to close the previous pregnancy case and re-open a new case to link the appointment and encounter. In order to use a pregnancy case, you must create a new case and set it as the preferred default case for the patient. To create a case: a. Click the Patient module and then click the Other tab. Optum PM and Physician EMR opens the Other application. b. In the Active Patient Cases section, click Add. The Other application opens a new case record. c. In the Patient Case section of the form, enter the case information in the fields provided: a. In the Description box, enter a description of the case, such as Pregnancy. b. (if applicable) In the Case Number box, enter a reference number for the case. c. In the Primary Dx list, click the diagnosis to associated with the case. You can also click Search to search for a diagnosis by ICD9 code or keyword. d. In the Start Date and End Date boxes, enter the dates in MM/DD/YYYY format or click the Calendar to select a date from the calendar. 39

43 Documenting a Pregnancy Encounter Tip: You can enter start date when the case is created and update the end date at a later time. e. In the Insurer list, click the insurance company to bill for all charges linked to the patient's case. f. In the Dunning Msg list, click Yes or No to indicate whether to print overdue balance notices on the patient's statements. Note: This option is set to Yes by default. g. In the Hold Claim list, click Yes or No to indicate if claims must be held for charges incurred from this case. h. In the Notes box, enter additional notes regarding the case. 4. In the Patient Case Detail section, enter additional details if applicable. 5. Click Save Detail Template to save the case. Note: Assigning a case as a "Preferred" case automatically links the case to the patient s next appointment, regardless of the number of open active cases saved in the patient's active case list. You will still have the ability to link the patient s appointment to any other active case when booking an appointment. The last case added to the patient's record is set as the preferred case by default and the preferred case name appears in italics in the Active Patient Cases list. To set a preferred case, click Edit next to the case, click Set as Preferred in the Patient Case section the Patient Case dialog box, and click Save Detail Template. For more information on cases, see Patient Module > Other > Cases in the Help system Obstetrics and Gynecology (OB/GYN) and Antenatal Record (ACOG) Templates The Optum PM and Physician EMR provides a variety of templates to document a pregnancy related encounter. All templates use the patient case logic. You can use a combination of OB templates based on the type of visit during the pregnancy or use only the Antenatal Record (ACOG) template to document the entire pregnancy (from initial OB visit to confirm pregnancy until completion of the pregnancy). Note: You must carefully select between the OB/GYN templates OR the Antenatal Record (ACOG) template, and avoid using both templates together or switching between templates to document a pregnancy. Using both templates to document a pregnancy can result in hidden data in the narrative and reports ACOG Antepartum Report The ACOG Antepartum report is linked to the Antenatal Record (ACOG) template, and closely resembles the forms from American College of Obstetrics and Gynecology (ACOG). The report displays information recorded in the Antenatal Record (ACOG) template during obstetrical visits. Note: The ACOG Antepartum reports are activated for your group by selecting the Allow access to ACOG Antepartum Reports check box in the Health Record Settings application. To access the Health Record 40

44 Documenting a Pregnancy Encounter Settings application, click the Administration module, Clinical tab, and then click the Health Record Settings link. You can print the ACOG Antepartum report as a single document to include all forms (Form A to Form E) or print each form as an individual report. To print ACOG reports, open the Chart Summary, and then click the arrow next to Print on the Clinical toolbar. From the drop-down menu, click the report you want to print. Note: Any information recorded in the Finding Details sections of the Antenatal Record (ACOG) template displays in the Comments section of the report Estimate Date of Delivery (EDD) Calculators The Antenatal Record (ACOG) template and ACOG Antepartum reports are supported with two calculators to auto calculate the Estimate Date of Delivery (EDD). The two calculation methods are listed below EDD by Quickening Calculator The quickening date is the first date the patient feels the baby move. The quickening date is entered into the template based on the response provided by the patient. The EDD by Quickening Calculator adds 22 weeks to the quickening date to calculate the EDD EDD by Fundal Ht at Umbil Calculator The fundal height at Umbilicus date is entered into the template based on the measurement of the patient s fundal height. The EDD by Fundal Ht at Umbil Calculator adds 20 weeks to calculate the EDD. Note: The calculators display on the Form C Flowsheet tab of the Antenatal Record (ACOG) template and on Form C of the ACOG Antepartum Record report. 41

45 Printing Templates 12 Printing a Template Optum PM and Physician EMR provides the ability to print templates used for documenting patient encounters. This is important for practices that require the provider to review data recorded by the Medical Assistants prior to entering it into the system. The template also prints the information that is pulled into the patient's note from previous visits. 1. Access the Medical Record module using one of the following methods: Pull the patient into context, and click the Medical Record module. (Recommended) If the patient has an appointment, click the patient name in the Appointments application of the Clinical Today module. 2. In the Clinical toolbar, click Progress Notes. Optum PM and Physician EMR displays the Progress Notes Template window. Note: The Progress Notes Template window launches only if an encounter is in context. The encounter launches into context when accessing the patient health record via the Appointments application of the Clinical Today module. If documenting a progress note that is not based on an appointment, the Encounter dialog box displays for you to create a new encounter. 3. (Optional) If the patient has previously documented notes, the Copy from Prior Note dialog box displays for you to copy information from sections of a note associated with a previous encounter. Note: To have the above feature activated for your company, log a ToDo to the Support Entity. 4. (Optional) Select the encounter and the check boxes for the sections you want to copy to the new note, and click Insert Selections. Previously recorded information is copied from each category to the specific sections of the new template. 5. By default, the View list displays Template. 42

46 Printing Templates 6. If a template is saved as a favorite in the Template list, click the template you want to use to document the encounter. If the required template is not available, click the Search icon to search for the required template. Optum PM and Physician EMR displays the Template Tree dialog box. 7. Click through the specialty tree to browse the list of templates. An alternative method is to enter the name of the template in the Template box, and click Search. 8. Click the required template. The selected template launches in the right-hand pane of the Progress Notes Template window with the narrative on the left-hand pane. 9. Click the arrow next to Print on the Clinical toolbar and then click Print Template to print the selected template. This replicates the same layout displayed in the right side of the window. 43

47 Accessing the Progress Notes Application 13 Accessing the Progress Notes Application The Progress Notes application displays a list of notes recorded during each patient appointment and is required for medical, legal, and billing purposes. The note includes information such as the patient s history, medications, allergies as well as a complete record of all that happened during the visit. The application provides a quick and easy way to review and sign notes, and helps identify notes that must be signed by a co-signer: A co-signer is a provider who has the final signatory authority that must sign the note. In addition, the application displays the patient's primary diagnosis selected in the Visit application and other associated diagnoses selected in the A&P tab of the progress note when documenting the patient encounter. This provides the flexibility of reviewing previous notes for a recurring problem or similar symptoms, and helps reduce time to issue orders. To access the Progress Notes application: 1. Access the Medical Record module using one of the following methods: Pull the patient into context, and click the Medical Record module. If the patient has an appointment, click the patient name in the Appointments application of the Clinical Today module. 2. In the Patient Health History pane, click Progress Notes. The Progress Notes window displays with a list of signed and unsigned notes for the patient. Click Next and Previous on the bottom right of the Progress Note window to move to the next or previous progress note in the list recorded for the patient. Tip: You can also access the Progress Note application by clicking the Encounters & Progress Notes section title in the Chart Summary. 44

48 Filtering Progress Note Templates 14 Filtering Progress Note Templates The Progress Notes application helps filter a list of notes documented during a patient encounter. You can filter the list of notes based on the approval status, the documented date or the diagnoses associated with the note. It is important that a provider sign the note after reviewing the accuracy and completeness of the note. When a note is created, the system automatically moves the note to the specific tab based on the approval workflow set up for your practice. The application also allows you to filter the list based on other diagnoses selected in the A&P tab of the progress note when documenting the patient encounter. To filter the list of notes: 1. Access the Medical Record module using one of the following methods: Pull the patient into context, and click the Medical Record module. If the patient has an appointment, click the patient name in the Appointments application of the Clinical Today module. 2. In the Patient Health History pane, click Progress Notes. The Progress Notes window displays with a list of signed and unsigned notes for the patient. 3. Do one of the following: To filter the list of notes by approval status, click the Signed, Un-signed or Requires Co-Sign tab. To filter the list of notes by documented date, click the Last Encounter, Past 6 months, or Past year tabs. To filter the list of notes by case, click the Case tab. Select the check boxes next to each case you want included in the list and then click Select. To filter the list of notes by diagnoses selected in the A&P tab of a progress note, click the Diag.Filter tab. The Select Diagnosis dialog box displays for you to select one or more diagnoses and click Select. Optum PM and Physician EMR displays the notes associated with the selected diagnoses. Note: The Diag.Filter tab displays all diagnoses selected in the A&P tab of a progress note when documenting a patient encounter. It does not display the primary diagnosis selected via the Visit application. 45

49 Managing Progress Note Templates 15 Managing Progress Note Templates The Progress Notes application helps maximize the view of a progress note for readability, unsign a signed note, edit an unsigned note, add an addendum to a note, send a ToDo, sign or print a note, and create a PDF of the note. Important: It is important to complete and sign all progress notes before any billing information is submitted to the payers Editing a Progress Note When a note is signed, the template is unavailable to prevent you from making any changes to the note. However, you can unsign a note to make changes if necessary. To edit the progress note: 1. Access the Medical Record module using one of the following methods: Pull the patient into context, and click the Medical Record module. If the patient has an appointment, click the patient name in the Appointments application of the Clinical Today module. 2. In the Patient Health History pane, click Progress Notes. Optum PM and Physician EMR displays the Progress Notes window. 3. Click the progress note to edit. The progress note displays on the right pane of the window. 4. Click Edit. The Progress Note window launches enabling you to edit the unsigned note. 5. Make necessary changes, and click Save Overriding Edits Optum PM and Physician EMR provides a notification if the content of a progress note changes before the operator has a chance to save their edits. To override edits: If Optum PM and Physician EMR displays the Override Edits box when the progress note is saved, review the options and select the edits you want to save, and then click Apply. 46

50 Managing Progress Note Templates 15.3 Deleting a Progress Note You can only delete unsigned notes. When a note is signed, Delete Note appears dimmed. To delete a progress note: 1. Access the Medical Record module using one of the following methods: Pull the patient into context, and click the Medical Record module. If the patient has an appointment, click the patient name in the Appointments application of the Clinical Today module. 2. In the Patient Health History pane, click Progress Notes. Optum PM and Physician EMR displays the Progress Notes window. 3. Click the progress note you want to delete. The progress note displays on the right pane of the window. 4. Click Delete Note. Optum PM and Physician EMR displays the Delete Reason dialog box. 5. Click the reason for deleting the note from the Delete Reason list. If the reason is not in the list, click Other, and then enter the reason in the Other Reason box. 6. Click Save. Note: A record of the deleted note is maintained in the Clinical log. To access the Clinical log, click the arrow next to View on the Clinical toolbar, and then click View Clinical Log Adding an Addendum The Progress Notes application enables you to add an addendum to both a signed and unsigned note to accommodate any clinical workflow your practice follows. An addendum helps track any updates made to a note by logging a date and time stamp to the entry as well as the operator s name. The words Addended By will follow any addendum to indicate the text was added after the progress note was signed. To add an addendum to a progress note: 1. Access the Medical Record module using one of the following methods: Pull the patient into context, and click the Medical Record module. 47

51 Managing Progress Note Templates If the patient has an appointment, click the patient name in the Appointments application of the Clinical Today module. 2. In the Patient Health History pane, click Progress Notes. Optum PM and Physician EMR displays the Progress Notes window displays the Progress Notes window. 3. Click the progress note you want to addend. The progress note displays on the right pane of the window. 4. Click the Add Addendum icon. Optum PM and Physician EMR displays the Progress Notes window displays the Add Addendum dialog box. 5. Enter the additional notes, and then click Save. You can also choose to dictate the addendum or use the quick text feature to enter additional notes. 6. Click Save. Optum PM and Physician EMR attaches the addendum to the bottom of the original note with an electronically signed by stamp. This helps track changes made to the note and the person responsible for the change Signing a Progress Note When a note is signed, the provider's name displays at the bottom of the progress note as the servicing provider, with a signature and date stamp. If the note requires a co-signature, the Signed column displays "CS" until signed off by the supervising provider. In addition, the provider can make changes to the signed note until it is signed by the supervising provider. Note: The Cosignature maintenance application allows practices to setup providers requiring a cosignature on progress notes. You can assign one or more supervising providers who are authorized to provide a cosignature. For more information on the Cosignature application, see Administration Module > Clinical > Daily Administration > Cosignature. When the supervising provider signs the note, the signature is appended to the end of the note. In addition, the Signed column changes to Y and the supervising provider name displays under the Signer column. This locks the note by making Edit unavailable to prevent from making changes. However, either provider can add an addendum to the locked note if necessary. To sign a progress note: 1. Access the Medical Record module using one of the following methods: Pull the patient into context, and click the Medical Record module. If the patient has an appointment, click the patient name in the Appointments application of the Clinical Today module. 2. In the Patient Health History pane, click Progress Notes. Optum PM and Physician EMR displays the Progress Notes window. 3. Click the progress note you want to sign and click Edit. Optum PM and Physician EMR displays the progress note on the right pane of the window. Tip: An alternative method is to view the progress note on the right pane of the window and click the Sign icon to sign the note. 48

52 Managing Progress Note Templates 4. (Optional) Click the Expand icon to maximize the view of a progress note prior to signing a note. You can click the icon again to collapse the narrative. 5. Click the Sign icon to sign the note. Optum PM and Physician EMR displays a confirmation message. 6. Click OK to sign the note. The Signed column changes to Y indicating that the note is signed Unsigning a Progress Note You can unsign a signed note if necessary. However, only the operator who signed the note is allowed to unsign a note based on the operator s role. You must enter a reason for unsigning the note to complete the action. For audit purposes a copy of the original note is maintained in the patient s clinical log. To access the clinical log, click the arrow next to View on the Clinical toolbar, and then click View Clinical Log. To unsign a progress note: 1. Access the Medical Record module using one of the following methods: Pull the patient into context, and click the Medical Record module. If the patient has an appointment, click the patient name in the Appointments application of the Clinical Today module. 2. In the Patient Health History pane, click Progress Notes. Optum PM and Physician EMR displays the Progress Notes window. 3. Click the progress note you want to unsign. The progress note displays on the right pane of the window. 4. Click the Unsign icon. Optum PM and Physician EMR displays a confirmation message. 5. Click OK to unsign the note Printing a Progress Note To print the progress note: 1. Access the Medical Record module using one of the following methods: Pull the patient into context, and click the Medical Record module. If the patient has an appointment, click the patient name in the Appointments application of the Clinical Today module. 2. In the Patient Health History pane, click Progress Notes. Optum PM and Physician EMR displays the Progress Notes window. 3. Click the progress note you want to print. The progress note displays on the right pane of the window. 4. Click the Print icon. Optum PM and Physician EMR displays the Progress Notes window displays the Narrative Preview dialog box. 5. Click Print. A copy of the note prints to the printer attached to your computer. 49

53 Managing Progress Note Templates 15.8 Creating a PDF of the Progress Note To create a PDF of the progress note: 1. Access the Medical Record module using one of the following methods: Pull the patient into context, and click the Medical Record module. If the patient has an appointment, click the patient name in the Appointments application of the Clinical Today module. 2. In the Patient Health History pane, click Progress Notes. Optum PM and Physician EMR displays the Progress Notes window. 3. Click the progress note you want to convert to PDF. The progress note displays on the right pane of the window. 4. Click PDF. Optum PM and Physician EMR creates a PDF version of the documented progress note. Note: An alternative method is to click the Print icon Preview dialog box., and then click PDF in the Narrative 15.9 Sending a ToDo To send a ToDo: 1. Access the Medical Record module using one of the following methods: Pull the patient into context, and click the Medical Record module. If the patient has an appointment, click the patient name in the Appointments application of the Clinical Today module. 2. In the Patient Health History pane, click Progress Notes. Optum PM and Physician EMR displays the Progress Notes window. 3. Click the ToDo icon next to the progress note you want to attach to the ToDo. Optum PM and Physician EMR attaches a PDF version of the note attached to the ToDo dialog box. You can enter the required information to send the ToDo. Note: By default, the Type list displays EHR and the Reason list displays Others in the ToDo dialog box. 50

54 Managing Narratives 16 Managing Narratives A narrative defines the output of a progress note. You can change the output display of the progress note by switching narratives or choosing a specific narrative for a progress note by pinning the narrative to the progress note. The application provides the capability to manage narratives by creating a list of favorite narratives, removing a narrative from the list or by sorting the list in the order required Viewing a Narrative To view a narrative: 1. Access the Medical Record module using one of the following methods: Pull the patient into context, and click the Medical Record module. If the patient has an appointment, click the patient name in the Appointments application of the Clinical Today module. 2. In the Patient Health History pane, click Progress Notes. The Progress Notes window displays with a list of signed and unsigned notes for the patient. 3. Click the progress note to view. The progress note details display in the right pane of the Progress Notes window. 4. Click the Printer icon. The Narrative Preview dialog box displays the narrative Searching for a Narrative To search for a narrative: 1. Access the Medical Record module using one of the following methods: Pull the patient into context, and click the Medical Record module. If the patient has an appointment, click the patient name in the Appointments application of the Clinical Today module. 2. In the Patient Health History pane, click Progress Notes. The Progress Notes window displays with a list of signed and unsigned notes for the patient. 3. Click the progress note to view. The progress note details display in the right pane of the Progress Notes window. 4. Click the Printer icon. The Narrative Preview dialog box displays the narrative. 5. Click the Search icon. The Search Narrative dialog box displays. 6. In the Search For box, enter the name of the narrative, if known. 7. Select the Include Global Elements check box, and then click Search. Optum PM and Physician EMR displays a list of available narratives. 51

55 Managing Narratives 8. Click Select next to the narrative you want to use. The progress note displays in the selected narrative Adding a Narrative to Favorites To add the narrative as a favorite: 1. Access the Medical Record module using one of the following methods: Pull the patient into context, and click the Medical Record module. If the patient has an appointment, click the patient name in the Appointments application of the Clinical Today module. 2. In the Patient Health History pane, click Progress Notes. The Progress Notes window displays with a list of signed and unsigned notes for the patient. 3. Click the progress note you want to view. The progress note details display in the right pane of the Progress Notes window. 4. Click the Printer icon. The Narrative Preview dialog box displays the narrative. 5. Click the Favorites icon. Optum PM and Physician EMR adds the narrative to the Narratives list Pinning and Unpinning a Narrative to a Progress Note Pinning a narrative displays the progress note in the selected format each time the specific template is used. Unpinning a narrative unlocks the progress note and allows you to select a different narrative template. To pin a narrative: 1. Access the Medical Record module using one of the following methods: Pull the patient into context, and click the Medical Record module. If the patient has an appointment, click the patient name in the Appointments application of the Clinical Today module. 2. In the Patient Health History pane, click Progress Notes. The Progress Notes window displays with a list of signed and unsigned notes for the patient. 3. Click the progress note you want to view. The progress note details display in the right pane of the Progress Notes window. 4. Click the Printer icon. The Narrative Preview dialog box displays the narrative. 5. Click the Pin icon to lock the narrative template into the progress note. To unpin a narrative: 1. Access the Medical Record module using one of the following methods: Pull the patient into context, and click the Medical Record module. If the patient has an appointment, click the patient name in the Appointments application of the Clinical Today module. 52

56 Managing Narratives 2. In the Patient Health History pane, click Progress Notes. The Progress Notes window displays with a list of signed and unsigned notes for the patient. 3. Click the progress note you want to view. The progress note details display in the right pane of the Progress Notes window. 4. Click the Printer icon. The Narrative Preview dialog box displays the narrative. 5. Click the Unpin icon Display a Company Logo in a Narrative You can display the company logo in a narrative by uploading a logo via the Company Logo application. To access the Company Logo application, click the Administration module, Setup tab, and then click the Company Logo link. Note: For more information on the Company Logo application, see Administration Module > Setup > Practice Management > Company Logo in the Help system. 53

57 Viewing the Activity Log of a Progress Note Template 17 Viewing the Activity Log of a Progress Note Template The Activity Log displays a history of events such as accessing and modifying the specific progress note. This provides protection to patients and helps ensure and demonstrate compliance with the privacy and security provisions of the Health Insurance Portability and Accountability Act (HIPAA), and other privacy laws and regulations. To view the Progress Note Template Activity Log: 1. Access the Medical Record module using one of the following methods: Pull the patient into context, and click the Medical Record module. If the patient has an appointment, click the patient name in the Appointments application of the Clinical Today module. 2. In the Patient Health History pane, click Progress Notes. The Progress Notes window displays with a list of signed and unsigned notes for the patient. 3. Click the Log icon for the progress note. The Activity Log dialog box displays the date and time for each action associated to the progress note, and the operator responsible for the action. 54

58 Evaluation and Management (E&M) 18 Evaluation and Management (E&M) 18.1 Accessing the E&M Evaluator Application The E&M Evaluator application helps you identify the most appropriate E&M procedure (CPT) code to use when billing for office visits and consultations. The code is evaluated based on the information documented during the visit. Additionally, you can apply either the 1995 or 1997 E&M Documentation Guidelines issued by the Centers for Medicare and Medicaid Services (CMS), to identify the correct code for the level of service provided. Note: For more information on E&M Documentation Guidelines, go to the CMS website: Careful reading and understanding of the rules and guidelines is essential for correct E&M code assignment or validation. The application enables you to determine the appropriate E&M CPT code using three different methods as listed below: Chart Based Manual Time Note: If a patient record is marked as VIP, the patient name display as **VIP** in the appointment list unless you have the VIP overrides (VIP Patient Access Break Glass or VIP Patient Access) assigned to your profile. VIP status is set in the Demographic application of the Patient module and overrides in the Operators and Roles application of the Administration module. To access the E&M Evaluator application: 1. Access the Medical Record module using one of the following methods: Pull the patient into context, and click the Medical Record module. If the patient has an appointment, click the patient name in the Appointments application of the Clinical Today module. 2. In the Clinical toolbar, click E&M Evaluator. 3. If an encounter is in context, Optum PM and Physician EMR displays the E&M Evaluator dialog box. If an encounter is not in context, Optum PM and Physician EMR displays the Select Encounter dialog to create an encounter Chart Based E&M Code Calculation The Chart based mechanism enables you to calculate the most appropriate E&M CPT code based on the information documented for the patient during the encounter. Note: You must use a structured template for this method of calculation. Free text elements are not recognized. 55

59 Evaluation and Management (E&M) The Chart based method takes the following factors into consideration when determining the E&M CPT code: Chief Complaint (CC): Reason for the encounter in the patient s words. History of Present Illness (HPI): Location, quality, severity, duration, timing, context, modifying factors, associated signs and symptoms. Review of Systems (ROS): Constitutional symptoms (e.g., fever, weight loss) Eyes Ears, Nose, Mouth, Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary (skin and/or breast) Neurological Psychiatric Endocrine Hematologic/Lymphatic Allergic/Immunologic Past, Family, and/or Social History (PFSH): Past illnesses, operations, injuries, and treatments; family medical history for heredity and risk; social activities, both past and current. To calculate the code based on the chart based mechanism: 1. Access the Medical Record module using one of the following methods: Pull the patient into context, and click the Medical Record module. If the patient has an appointment, click the patient name in the Appointments application of the Clinical Today module. 2. In the Clinical toolbar, click E&M Evaluator. 3. If an encounter is in context, Optum PM and Physician EMR displays the E&M Evaluator dialog box. If an encounter is not in context, Optum PM and Physician EMR displays the Select Encounter dialog to create an encounter. 4. By default, the Calculation Method is set to Chart Based. 5. From the Patient Type list, click the appropriate type based on the patient status. 56

60 Evaluation and Management (E&M) 6. By default, the Guideline is set to However, you can click 1995 if necessary. 7. From the Managed 3 + chronic conditions this visit, click the correct option based on the service provided. Note: The Managed 3 + chronic conditions this visit only applies to the 1997 guidelines and is a required field. 8. From the Medical Decision Making Level list, click the appropriate option based on the complexity of medical decision making involved. Note: Optum PM and Physician EMR determines the history and exam level based on the information documented in the progress note after the medical decision making level is selected. 9. Click Calculate. Optum PM and Physician EMR calculates and display the recommended code based on the selections made and the information recorded for the patient during the current encounter. 10. In the Selected Code list, click the E&M CPT code you want. Note: The code recommended by Optum PM and Physician EMR is marked with an asterisk (*) sign. 57

61 Evaluation and Management (E&M) Note: You can recalculate the E&M CPT code if necessary. However, you can submit an E&M CPT code only once. Therefore, it is important that you verify the selected E&M CPT code prior to submitting the code. 11. Click Submit. A message displays asking you to confirm that the E&M CPT code is successfully submitted. The E&M CPT code automatically updates the Visit application for the encounter. 12. Click OK. The E&M CPT code automatically updates the Visit application for the encounter. Note: You can submit an E&M CPT code for billing only once. Therefore, it is important that you verify your CPT code selection prior to submitting the code. If the E&M Evaluator application is closed without submitting a CPT code, you can review or update the progress note and reevaluate your documentation as necessary Manual E&M Code Calculation The Manual based calculation method enables you to calculate the E&M CPT code based on the selections you make on the key components of a service, including history, examination and medical decision making. To calculate the code using the Manual mechanism: 58

62 Evaluation and Management (E&M) 1. Access the Medical Record module using one of the following methods: Pull the patient into context, and click the Medical Record module. If the patient has an appointment, click the patient name in the Appointments application of the Clinical Today module. 2. In the Clinical toolbar, click E&M Evaluator. 3. If an encounter is in context, Optum PM and Physician EMR displays the E&M Evaluator dialog box. If an encounter is not in context, Optum PM and Physician EMR displays the Select Encounter dialog to create an encounter. Important: You must have an appointment based visit type encounter in context to access the E&M Evaluator application. 4. From the Calculation Method section, click Manual. 5. From the Patient Type list, click the appropriate type based on the patient status. 6. By default, the Guideline is set to However, you can click 1995 if necessary. 7. From the Managed 3 + chronic conditions this visit, click the appropriate option based on the service provided. Note: The Managed 3 + chronic conditions this visit only applies to the 1997 guidelines and is a required field. 8. From the History Level list, click the appropriate option based on the extent of history obtained. 9. From the Exam Level list, click the appropriate option based on the extent of the exam performed. 10. From the Medical Decision Making Level list, click the appropriate option based on the complexity of medical decision making involved. 11. Click Calculate. Optum PM and Physician EMR calculates and display the recommended code based on the selections made and the information recorded for the patient during the current encounter. 12. In the Selected Code list, click the E&M CPT code you want. Note: The code recommended by Optum PM and Physician EMR is marked with an asterisk (*) sign. 59

63 Evaluation and Management (E&M) Note: You can recalculate the E&M CPT code if necessary. However, you can submit an E&M CPT code only once. Therefore, it is important that you verify the selected E&M CPT code prior to submitting the code. 13. Click Submit. A message displays asking you to confirm that the E&M CPT code is successfully submitted. 14. Click OK. The E&M CPT code automatically updates the Visit application for the encounter. Note: You can submit an E&M CPT code for billing only once. Therefore, it is important that you verify your CPT code selection prior to submitting the code. If you close the E&M Evaluator application without submitting a CPT code, you can review or update the progress note and reevaluate your documentation as necessary Time Based E&M Code Calculation The Time based calculation method enables you to calculate the E&M CPT code based on the patient type and the time spent with the patient. The use of time as a component for determining the level of service pertains to visits where the majority of time is spent on counseling or coordination of care. If counseling or coordination of care accounted for more than 50% of the time spent face-to-face with the patient, then time 60

64 Evaluation and Management (E&M) may be used as the determining factor to select a CPT code. However, the total visit time, the time spent counseling and brief description of the discussion must be documented in the medical record. To calculate the code based on time: 1. Access the Medical Record module using one of the following methods: Pull the patient into context, and click the Medical Record module. If the patient has an appointment, click the patient name in the Appointments application of the Clinical Today module. 2. In the Clinical toolbar, click E&M Evaluator. 3. If an encounter is in context, Optum PM and Physician EMR displays the E&M Evaluator dialog box. If an encounter is not in context, Optum PM and Physician EMR displays the Select Encounter dialog to create an encounter. Important: You must have an appointment based visit type encounter in context to access the E&M Evaluator application. 4. From the Calculation Method section, click the last option with time information. 5. From the Patient Type list, click the appropriate type based on the patient status. 6. From the Time for Visit list, click the time spent face-to-face with the patient. 7. Click Calculate. Optum PM and Physician EMR calculates and display the recommended code based on the selections made. 8. In the Selected Code list, click the E&M CPT code you want. Note: The code recommended by Optum PM and Physician EMR is marked with an asterisk (*) sign. 61

65 Evaluation and Management (E&M) Note: You can recalculate the E&M CPT code if necessary. However, you can submit an E&M CPT code only once. Therefore, it is important that you verify the selected E&M CPT code prior to submitting the code. 9. Click Submit. A message displays asking you to confirm that the E&M CPT code is successfully submitted. 10. Click OK. The E&M CPT code automatically updates the Visit application for the encounter. Note: You can submit an E&M CPT code for billing only once. Therefore, it is important that you verify your CPT code selection prior to submitting the code. If you close the E&M Evaluator application without submitting a CPT code, you can review or update the progress note and reevaluate your documentation as necessary. 62

66 Visit Capturing 19 Visit Capturing The Visit application helps capture procedure (CPT) and diagnosis (ICD-9) codes in an electronic encounter form directly via the patient's medical record. It is important to capture visit information pertaining to a patient encounter to submit claims. The electronic encounter form supports a search feature to find CPT and ICD-9 codes. Additionally, you can use ClaimsManager to reduce denial rates and improve the practice cash flow, and EncoderPro to verify code information on-line. If CPT and ICD-9 codes are entered in the Progress Note application when documenting a note or if an E&M CPT code is selected in the E&M Evaluator application, the Visit application is updated with the selected codes. This enables you to move to the Save link of the Visit application directly and enter other information such as modifiers and units to complete the visit. Support: Optum PM and Physician EMR supports automatic updates to the Visit application based on the codes selected when documenting a patient encounter. To activate the feature, log a ToDo to the Support entity. The visit recorded within an appointment is billable and is listed under the Encounters application in the Medical Record module. This encounter is also listed under the Open Encounters application in the Clinical Today module until the progress note is signed and reviewed. To capture visit information: 1. Access the Visit application using one of the following methods: The Appointments application in the Clinical Today module. Click the Arrow icon next to the Actions menu along the appointment row, and then click Visit. The patient's chart summary. a. Click the Clinical Today module. Optum PM and Physician EMR displays the Appointments window with a list of appointments scheduled for the day. b. From the list of appointments, click the patient name to access the Chart Summary. Optum PM and Physician EMR displays the patient's medical record. c. In the Clinical toolbar, click Visit. If an encounter is in context, Optum PM and Physician EMR displays the Visit dialog box. Important: You must have an appointment based visit type encounter in context to access the Visit application via the Medical Record module. 63

67 Visit Capturing 2. Select the CPT and ICD-9 codes for the patient visit, review, enter modifiers and units, and click Save under the Save link to capture visit information. When visit information is captured, a check mark displays in the appointment slot of the Clinical Today and the Scheduling modules as a visual indication. This helps to track and work on appointments that require visit information, and helps front office or billing staff to continue with the billing process. Visit information entered for all "visit" type encounters are saved under the Procedures & Diagnoses tab of the Encounters application in the Medical Record module. Additionally, the ICD-9 code selected displays as the primary diagnosis under the Primary Diag/Complaint column for the associated note in the Progress Notes application. Note: Visit information cannot be edited after it is converted to a charge in Optum PM and Physician EMR. Therefore, it is important to ensure that visit information is accurate before the charge is saved. When a charge is captured, the Visit link in the Clinical Today module is unavailable preventing edits to the visit information. 64

68 Open Encounters 20 Open Encounters 20.1 Viewing a List of Open Encounters An encounter is an interaction with a patient on a specific date and time. Encounter types include visits, phone calls, referrals, results of a test, and more. The Open Encounters application displays a list of appointment based "visit"' type encounters that do not have a corresponding clinical note and also identifies patients who have a clinical note for a specific date of service, but no encounter billed for that same date. Additionally, the Open Encounters application displays customized encounters that require billing or a signed note. You can resolve encounters by entering visit information, reviewing, transcribing (if the note contains an untranscribed file), signing, and then billing. The Open Encounters application is accessible from the following locations: Home module > Dashboard tab > Open Encounters link (Clinical section) Clinical Today module > Tasks tab > Open Encounters (from the Tasks menu on the right side of the window) Tip: An alternative method is to click the Clinical Today module, Tasks tab and view open encounter tasks in the All Tasks window. You can sort on the Tasks column to easily identify open encounter tasks. Note: If a patient record is marked as VIP, the patient name displays as **VIP** in the open encounter list unless you have the VIP overrides (VIP Patient Access Break Glass or VIP Patient Access) assigned to your profile. VIP status is set in the Demographic application of the Patient module and overrides in the Operators and Roles application of the Administration module. The table below describes the information displaying in the columns of the Open Encounters window. OPEN ENCOUNTERS COLUMNS Column Patient Name Encounter Date Encounter Type Provider Description The name of the patient with an open encounter. The date of the encounter. The type of encounter. The name of the billing provider associated with the encounter. 65

69 Open Encounters OPEN ENCOUNTERS COLUMNS Column Appointment Type/ Complaint Note Description The type of appointment and the complaint information. A note can have three different statuses that include Not Signed, Missing (Required) or Complete. It is important to focus on notes that are in the Not Signed or Missing (Required) statuses, and complete the note by clicking Progress Notes on the Clinical toolbar of the Medical Record module. The application prevents signing notes with untranscribed files so you must transcribe the note prior to signing. When the note is signed the status of the Note column changes to Complete. Visit This column can have two different statuses that include Y or N (Required). It is important to focus on encounters with N (Required) to ensure that visit information is entered in order to bill for services. When the appropriate CPT and ICD-9 codes are saved, the status of the Visit column changes to Y. Transcribed Note This column can have two different statuses that include Y or N. If a file is not attached to the note, the column is left blank. It is important to focus on encounters with an N to ensure that you transcribe all notes with untranscribed files Filtering the Encounters List The Open Encounters application enables you to filter the list of open encounters on the provider or status. To filter the list of open encounters: 1. Access the Open Encounters application from one of the following locations: Home module > Dashboard tab > Open Encounters link (Clinical section) Clinical Today module > Tasks tab > Open Encounters (from the Tasks menu on the right side of the window) Tip: An alternative method is to click the Clinical Today module, Tasks tab and view open encounter tasks in the All Tasks window. You can sort on the Tasks column to easily identify open encounter tasks. Optum PM and Physician EMR displays a list of open encounters for the provider set up in your batch. 2. Filter the list of encounters based on your requirements: To filter the list of to display open encounters for all providers, select All. To display a list for a specific provider, select the provider from the Provider list. 66

70 Open Encounters By default, the Open Encounters application displays all encounters you must work on. Do one of the following: To view encounters that are missing notes or have unsigned notes, click the Missing/Unsigned Notes tab. To view encounters that are missing visit information, click the Missing/Unbilled Procedures tab Resolving Open Encounters The Open Encounters application helps resolve appointment based "visit" type encounters by entering visit information, transcribing (if the note contains an untranscribed file), and signing notes. All tasks related to the note can be completed via the Progress Note application in the Medical Record module. Visit information is captured by entering the appropriate CPT and ICD-9 codes using the Visit application. To resolve an open encounter: 1. Access the Open Encounters application from one of the following locations: Home module > Dashboard tab > Open Encounters link (Clinical section) Clinical Today module > Tasks tab > Open Encounters (from the Tasks menu on the right side of the window) Tip: An alternative method is to click the Clinical Today module, Tasks tab and view open encounter tasks in the All Tasks window. You can sort on the Tasks column to easily identify open encounter tasks. 2. Select the encounter you want to resolve. Note: An open encounter with an unsigned note, untranscribed file is billable if visit information is captured; however, it is recommended to enter, transcribe and sign the note, and then complete the billing. 3. Under the Note column, click the Not Signed or Missing (Required) link. The Progress Notes application displays enabling you to complete and sign the note. When the note is signed, the Note column status changes to Complete. Note: It is important to complete transcription on a note before signing. The application prevents from signing notes with untranscribed files. 67

71 Open Encounters 4. Click N (Required) under the Visit column. Optum PM and Physician EMR displays the Visit application. Enter the appropriate CPT and ICD-9 codes, and click Save. When the visit information is entered, the status of the Visit column changes to Y. After both the note and billing process is complete, the encounter is deleted from the Open Encounters application and is saved under the Encounter section of the patient's medical record for reference. Optum PM and Physician EMR updates the status of the Note, Visit and Transcribed Note columns to Complete, Y and Y. Note: Copies of billable open encounters are saved with other unbillable encounters in the Encounters section of the Medical Record module. Therefore, you can also resolve an open encounter for a patient using the Encounter application in the Medical Record module. 68

72 Unsigned Notes 21 Unsigned Notes 21.1 Viewing a List of Unsigned Notes The Unsigned Notes application displays a list of progress notes that are not signed or require a cosignature. A co-signature is required when a progress note is documented by a non-physician provider such as a Personal Assistant (PA) or a Nurse Practitioner (NP). Co-signing for activities performed by others is used to determine who is responsible for the supervision and quality of care. The list that display is based on the provider in your batch. The Unsigned Notes application is accessible from the following location: Clinical Today module > Tasks tab > Unsigned Notes (from the Tasks menu on the right side of the window) Tip: An alternative method is to click the Clinical Today module, Tasks tab and view unsigned note tasks in the All Tasks window. You can sort on the Tasks column to easily identify unsigned note tasks. Note: If a patient record is marked as VIP, the patient name displays as **VIP** in the unsigned notes list unless you have the VIP overrides (VIP Patient Access Break Glass or VIP Patient Access) assigned to your profile. VIP status is set in the Demographic application of the Patient module and overrides in the Operators and Roles application of the Administration module. The table below describes the information displaying in the columns of the Unsigned Notes window. UNSIGNED NOTES COLUMNS Column Enc Date Enc/Appt Type Patient Primary Description The date of the encounter associated with the note. The type of encounter and appointment type. The patient name associated with the note. The complaint associated with the patient appointment. 69

73 Unsigned Notes UNSIGNED NOTES COLUMNS Column Description Diag/Complaint Signed Provider/Signer Open Indicates that the document requires a signature. The Signed column displays one of two statuses that include 'N' or 'CS'. 'N' indicates that the note is not signed and 'CS' indicates that the note requires a co-signature. The author and the cosigner of the note, if applicable. Enables you to open the note in a new window for review, editing and signing Filtering Unsigned Notes The Unsigned Notes application enables you to filter the list of progress notes on provider and the signed status. To filter the list of unsigned notes: 1. Click the Clinical Today module, Tasks tab, and then click Unsigned Notes from the Tasks menu on the right side of the window. The Unsigned Notes application displays a list of notes requiring a signature or a co-signature. Tip: An alternative method is to click the Clinical Today module, Tasks tab and view unsigned note tasks in the All Tasks window. You can sort on the Tasks column to easily identify unsigned note tasks. 2. Filter the list of unsigned notes based on your requirements: By default, the Unsigned Notes application displays a list of notes that the provider set up in your batch must sign or co-sign. To filter the list to display unsigned notes for all providers, select the All check box. To display unsigned notes for a specific provider, select the check box for the provider from the Provider list. To filter the list to display signed and unsigned notes, click All. To view notes that require your final review and signature, click the Requires Co-Signer Only tab. Note: The notes that display under each tab are based on the provider selected in your list and the set up for your company Signing Notes The Unsigned Notes application lists notes that the treating and supervising provider must review and sign. It is important to review and sign these notes in order to commit to a patient chart. 70

74 Unsigned Notes To sign a note: 1. Click the Clinical Today module, Tasks tab, and then click Unsigned Notes from the Tasks menu on the right side of the window. The Unsigned Notes application displays a list of notes requiring a signature or a co-signature. Tip: An alternative method is to click the Clinical Today module, Tasks tab and view unsigned note tasks in the All Tasks window. You can sort on the Tasks column to easily identify unsigned note tasks. 2. Click the note to sign. The note launches on the right side of the pane. 3. When the note is reviewed, click the Sign icon on the top right side of the window. A message prompts to confirm the action. Tip: An alternative method is to click the Open icon below the Open column. This opens the note in a new window allowing you to review, make changes, and sign or co-sign the note. 4. Click OK. When a note is signed, the provider's name displays at the bottom of the progress note as the servicing provider with the signature and date stamp. Note: A note requiring a co-signature displays under the specific provider's Unsigned Notes list. The provider can make changes to the signed note until it is signed by the supervising provider. When the note is signed by the supervising provider, the signer's signature and the date stamp is appended to the note. 71

75 Untranscribed Notes 22 Untranscribed Notes 22.1 Viewing a List of Untranscribed Notes The Untranscribed Notes application displays a list of patient encounters documented using the dictation feature for an entire note or part of a note. For example, you might use a pen tablet to check off the exam findings, diagnoses, and treatments, and then dictate the remaining narrative text for the subjective section of your note. The files are saved as audio files enabling you to translate into a medical note using an inhouse, or third party transcription or application service. After a file is marked as transcribed, the text automatically replaces the file in the appropriate section of the patient's progress note. The medical note is also saved in the Open Encounters application for the provider to review, edit, and sign. The Untranscribed Notes application is accessible from the following locations: Home module > Dashboard tab >Unstranscribed Notes link (Clinical section) Clinical Today module > Tasks tab > Unstranscribed Notes (from the Tasks menu on the right side of the window) Tip: An alternative method is to click the Clinical Today module, Tasks tab and view untranscribed note tasks in the All Tasks window. You can sort on the Tasks column to easily identify untranscribed note tasks. Note: If a patient record is marked as VIP, the patient name displays as **VIP** in the untranscribed notes list unless you have the VIP overrides (VIP Patient Access Break Glass or VIP Patient Access) assigned to your profile. VIP status is set in the Demographic application of the Patient module and overrides in the Operators and Roles application of the Administration module. The table below describes the information displaying in the columns of the Untranscribed Notes window. UNTRANSCRIBED NOTES COLUMNS Columns Enc Date Enc/Appt Patient Name Description Description The encounter date of the note. The type of the encounter. The name of the patient associated with the audio file. The name of the audio file. Doc. date The date the file is transcribed. 72

76 Untranscribed Notes UNTRANSCRIBED NOTES COLUMNS Columns Transc. Active Dw Description The transcription status of the file. The status of the file. Enables downloading the audio file to your computer to send to a third party Filtering Untranscribed Notes The Untranscribed Notes application enables you to filter the list of encounters on the transcription and active status of the associated audio file. To filter the list of voice attachments: 1. Access the Untranscribed Notes application from one of the following locations: Home module > Dashboard tab > Unstranscribed Notes link (Clinical section) Clinical Today module > Tasks tab > Unstranscribed Notes (from the Tasks menu on the right side of the window) Tip: An alternative method is to click the Clinical Today module, Tasks tab and view untranscribed note tasks in the All Tasks window. You can sort on the Tasks column to easily identify untranscribed note tasks. The Untranscribed Notes application displays a list of untranscribed notes requiring transcription. 2. By default, the Untranscribed Notes application displays all active encounters that have an associated audio file that requires transcription. To filter the list to view encounters with both transcribed and untrasncribed files, click the All tab. To view encounters with both active and inactive files, click the All (Include Inactive) tab Transcribing Dictations The Untranscribed Notes application enables transcribing audio files recorded during a patient encounter into medical notes. The application supports both in-house and third party transcription by enabling to directly transcribe through the application or download the file to the computer to outsource. When a file is marked as transcribed, the text automatically replaces the file in the appropriate section of the patient's progress note. The medical note is also saved in the Open Encounters application for the provider to review, edit and sign. To transcribe a dictation: 1. Access the Untranscribed Notes application from one of the following locations: Home module > Dashboard tab >Unstranscribed Notes link (Clinical section) Clinical Today module > Tasks tab > Unstranscribed Notes (from the Tasks menu on the right side of the window) 73

77 Untranscribed Notes Tip: An alternative method is to click the Clinical Today module, Tasks tab and view untranscribed note tasks in the All Tasks window. You can sort on the Tasks column to easily identify untranscribed note tasks. The Untranscribed Notes application displays a list of untranscribed notes requiring transcription. 2. Click the encounter to transcribe. The audio files for the encounter displays on the right pane. 3. Click the audio file to transcribe. Optum PM and Physician EMR displays the Transcription dialog box. Note: You can send the audio file to a third party transcription service by downloading the file to your computer. Click the Download icon to download the file. 4. Use the following playback controls to play the audio file and draft the note. PLAYBACK CONTROLS Control Description Plays the audio file Pauses the audio file Stops playing the audio file Each click moves the recording forward incrementally 5. Review and edit the text using quick text and standard word processor tools. 6. Do one of the following Click Save and Mark as Transcribed when you complete transcription. The transcribed file is removed from the responsible provider's Untranscribed Notes list and the text replaces the audio file in the specific section of the patient note. Click Save to save an unfinished note. 74