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