EMR CLINICAL TRAINING MANUAL INTER TRIBAL HEALTH AUTHORITY ELECTRONIC MEDICAL RECORD (EMR) CLERICAL TRAINING MANUAL PROFILE VERSION 7 July 1, 2014
TABLE OF CONTENTS Module 1: Sign On 1.1 Purpose 1.2 Icons and Definitions 1.3 Key Fields 1.4 Connection 1.5 Set Defaults for Work Centre Window 1.6 Scenarios Module 2: Client 2.1 Purpose 2.2 Icons and Definitions 2.3 Key Fields 2.4 Insert New Client 2.5 Search for a Client 2.6 Alter Client Information 2.7 Creating a Family Group 2.8 Scenarios Module 3: Scheduling 3.1 Purpose 3.2 Icons and Definitions 3.3 Key Fields 3.4 View Appointments by Provider 3.5 New Appointment 3.6 Reoccurring Appointment 3.7 Editing an Appointment 3.8 Managing an Appointment 3.9 Walk-In Client 3.10 Block Out Provider s Scheduling 3.11 Staff Meeting 3.12 Client Group Session 3.13 Tasks 3.14 Messenger 3.15 Scenarios TABLE OF CONTENTS Page 1
Module 1: Sign on 1.1 Purpose The sign on will allow to connect to the EMR servers that are located in the Harbor Tower at the Vancouver Data Center (VDC) and then on to Profile, so you will need to enter two user names and passwords. It is a two step sign on process: 1. Sign on to the server at VDC 2. Sign on to Profile 1.2 Icons and definitions 1.2.1 Definitions a) Server: a computer that provides services used by other computers b) EMR: Electronic Medical Record c) VDC: Vancouver Data Centre d) RDC: Remote Desktop Connection e) End Point: Band Number (Snuneymuxw = 648) f) Training Server (vdc.train.intertribalhealth.ca): This set up used for training purposes and does not contain any sensitive information g) Production Server (vdc.intertribalhealth.ca): This is to be used for day-to-day operations, should not be confused with the training server, and is to be treated with the upmost concern for security and privacy of the sensitive patient information 1.2.2 Icons a) RDC Icon b) Maximize 1.3 Key Fields Not applicable to this module. MODULE 1: SIGN ON Page 2
1.4 Connection 1.4.1 Remote Desktop Connection 1) Open the Start menu > All Programs > Accessories > Remote Desktop Connection 2) In Computer: You type the name of the computer you are trying to connect to or the IP address. Training = vdc.train.intertribalhealth.ca Production = vdc.intertribalhealth.ca 3) Click connect Step 2 1.4.2 Logon to server IMPORTANT!! Make sure that Caps lock is turned off. 1) Enter your Windows username 2) Enter your Windows password 3) Click OK Step 1 Step 2 MODULE 1: SIGN ON Page 3
1.4.3 Logon to Profile 1) Enter your Profile username 2) Enter your Profile password 3) Click Show Details 4) Check that the information is correct a. Server: i. Training: Local ii. Production: VDCIHS01 b. Protocol: Connection Orientated TCP/IP c. End Point: 554(Band Number) 5) Click OK Step 1 Step 2 Step 4 Step 5 Tip Usually the information in step 4 won t need to be changed after the first logon 1.5 Set Defaults for the Work Centre widow 1) Change the size of the window by a. Click and drag window edge with b. Or using the Maximize icon 2) Change the size of the panes within the window with 3) Add or remove toolbar icons by right click and selecting or De-selecting icon 4) Save the changes by Window Menu > Workspace > Save Workspace Tip To show/hide the Main Toolbar use: Window Menu > Show > Toolbar IMPORTANT!! After 10 minutes the system will locked and you will have to enter your password again. To show the login screen you will need to press CTRL + F3 MODULE 1: SIGN ON Page 4
1.6 Scenarios Scenario 1 Create a short cut to the RDC on the desktop a) Open the RDC connection b) Enter the computer name that you want to connect to c) Click Options d) Click Save As e) Select Desktop f) Enter the shortcut name ex// Profile g) Click Save h) Click Cancel i) Check that the shortcut is on the desktop and opens the connection j) Optional: Give yourself a pat on the back and high five the person next to you Scenario 2 Hide and then show the main toolbar. How do you do this? Scenario 3 a) Open the RDC connection and change the server name and then connect. What happens? b) Change the End point to Snuneymuxw band number (648) and try to login. What happens? MODULE 1: SIGN ON Page 5
1.7 Frequently Asked Questions/ Problems a) What do I do if I forget my password or username? b) Why wouldn t the RDC connection be working? c) Who do I contact if my RDC connection isn t working? d) What do I do if I can t find my profile RDC icon? e) What are some common reasons for an incorrect password? f) Why does my Password have to be so complicated? g) I am getting a new PC do I need to do anything MODULE 1: SIGN ON Page 6
Module 2: Client 2.1 Purpose The purpose of this module is to enable the user to add clients, search for existing clients and update client information, such as address. Most of this information in this section will not change (i.e. Name, date of birth, Status Number), but very occasionally this information will need to be changed. 2.2 Icons and Definitions 2.2.1 Icons a) New Client d) Find Client b) Alter Client e) Social Tab c) Expand icon f) Family Tab 2.2.2 Definitions a) Demographics: Commonly-used demographics include sex, race, age, etc. b) PHN: Personal Health Number c) NoK: Next of Kin 2.3 Key Fields 2.3.1 Mandatory a) Last name b) First Name c) Sex d) Date of birth e) Status number- This will be auto generated if not entered f) Health Centre Use default value IMPORTANT!! If possible, an accurate status number must be taken as it is used to uniquely identify clients 2.3.2 Important a) PHN b) On/Off Reserve Located in the social tab c) FN Status Located in the social tab d) Band Located in the social tab 2.4 Insert New Client MODULE 2: CLIENT Page 7
IMPORTANT!! You should ALWAYS search for a client using Find Clients before you add a new client. 1) If the client s record is not found, Select the New Client icon or use (Ctrl +N) 2) Enter Last Name, First Name, Sex, DOB 3) Enter the Status Number and PHN Tip To enter DOB, Use the calendar to select the client s birth day and month and then change year using the keyboard 4) Enter additional information Address and Phone numbers 5) Select Social Tab Step 2 Step 4 Step 5 MODULE 2: CLIENT Page 8
6) Enter On/Off Reserve and FN Status 7) Enter Band Name and Number 8) Click OK Step 6 Step 7 Step 8 MODULE 2: CLIENT Page 9
2.5 Search for a Client IMPORTANT!! When searching for clients it is better and quicker to provide less detailed information. Normally, the first 3 letters of the last name is sufficient. 1) Select Find Client icon from the toolbar or use (Ctrl+F) 2) Type the first three letters of the clients last name 3) Click Find Step 2 4) Select the correct client from the produced list 5) Click Display 6) Verify that the client s address and phone number hasn t changed Step 4 Step 5 Tip If searching a common last name (i.e. White), add the first initial of the first name (i.e. White, J) MODULE 2: CLIENT Page 10
2.6 Alter Client Information IMPORTANT!! Do not use this function to search for clients 1) Select the Alter Client icon from the toolbar or use (Ctrl + A ) 2) Type the first three letters of the clients Last name 3) Click Search Step 2 4) Select the correct client from the list 5) Click OK Step 4 Step 5 MODULE 2: CLIENT Page 11
6) Change contact information (Address, Phone, etc) Step 6 2.7 Creating a family group 1) Select Alter Client 2) Type the first three letters of the head of the family s last name 3) Click search 4) Select the correct Client from list 5) Click OK Tip 2.7 Steps 1-5 are demonstrated in 2.6 above 6) Select the Family icon and 7) Type the family name 8) Click the Family Head check box 9) Click Apply Step 7 Step 6 Step 8 Step 9 MODULE 2: CLIENT Page 12
Tip If the family contains members then it already exists, so the family name needs to be changed and it is suggested to add a number to it (ex// White01) 10) Search for the NoK and if not already created, Create the NoK client See Section 2.4 11) Click the family icon 12) Type or search for the family name 13) Check that the Family Head is correct 14) Click Apply Step 12 Step 13 Step 14 2.8 Scenarios Scenario 1 Create a client with the following information: a) {Your First Name and initial} Seward b) {Your DOB and Sex} c) {Any Status Number with 10 digits} d) Any 10 digit PHN starting with 9020 (i.e. 9020xxxxxx) e) 877 Berry Point Road, Gabriola, BC, V0r 1x1 f) 250-247-8900, 778-628-1111 g) Family is Seward{Your Address} h) They are Status First Nations that are living off reserve from the Esquimalt band MODULE 2: CLIENT Page 13
Scenario 2 Search for the client Joe Walsh, who is his son? Scenario 3 Create a child for the person created in Scenario 1 with any information and add to the Marley family you created in Scenario 1 Scenario 4 a) Find all male clients in the system that are 19. How many are there? b) Find all female clients that are 65. How many are there? c) You find a piece of paper with an appointment time and the phone number 250-247-8999, who does this belong to? Scenario 5 Find client St. Andrews. What is his first name? 2.9 Reports a) Total Clients on or off reserve b) Total Client with or without status c) Elders list d) All children between 3-9 years old 2.10 Frequently Asked Questions and Problems a) Why can t I find a client when I have entered their last name? b) Should I search for a client using Alter Clients? c) What should I do if I find a duplicate client? MODULE 2: CLIENT Page 14
Module 3: Scheduling 3 Purpose The appointments module is extremely important as many significant reports, program and provider usage statistics are generated from the information captured in this section. This is information may be key in filling out your Health Canada reporting. 3.1 Icons and definitions 3.1.1 Definitions a) Appointment Type = a listing of short codes that focuses on program (i.e. Immunization) that is important for reporting b) Appointment Reason = a listing of service codes that focuses on service (i.e. Flu shot) 3.1.2 Icons a) Work Center f) Walk-in b) New Appointment g) Block Out c) Cancel Appointment h) Move All appointments for a provider d) Tasks i) Cancel All appointments for a provider e) Multiple Providers j) Add Multiple Clients/ Providers 3.2 Key Fields a) Appointment Type = This allows us to create usage reports by program type, which are important for funding purposes b) Provider = This allows us to create reports detailing the number of clients seen by provider, which is important when requesting additional employees MODULE 3: SCHELDULING Page 15
3.3 View Appointments for a single provider 1) Open Work Centre if not already open 2) Select Provider expand icon 3) Type first three letters of providers name 4) Click search 5) Select correct provider 6) Click OK 7) Select the number of days 1 Day, 5 Day, 7 Day, 1 month, 1 year Step 1 Step 2 Step 7 Step 5 Step 6 Step 4 MODULE 3: SCHELDULING Page 16
3.4 View Appointments for multiple providers 1) Open Work Centre 2) Click the multiple provider button 3) Select date Only 1 day can be displayed Step 2 Step 1 3.5 New Appointment 1) Check that provider is visible 2) Click and drag on empty appointment slot to set time and duration Step 2 Tip You can create a copy of an appointment by holding Ctrl button and then click and drag appointment to new timeslot. MODULE 3: SCHELDULING Page 17
3) Type first 3 letters of client s last name and select Client from list 4) Click expand icon 5) Select type of appointment short code 6) Click OK 7) Check start and end time 8) Check provider Step 4 Step 5 Step 7 Step 8 Step 6 IMPORTANT!! Appointment type will facilitate program reporting and allow for usage statistics. Appointment type is selected from a short code list, which can be altered to your centre s specific needs. MODULE 3: SCHELDULING Page 18
3.6 Reoccurring Appointment (WARNING: do not use until further notice) 1) Open a new appointment and enter necessary information See Section 3.6 2) Click the Reoccurrence tab 3) Check first appointment date, time and duration 4) Click Recurrence pattern button 5) Enter recurrence pattern by day (The Last Friday of every month) or by date (The 2 nd of every month) 6) Click OK Step 2 Step 4 Step 5 Step 6 MODULE 3: SCHELDULING Page 19
3.7 Editing Appointments 1) Right Click appointment 2) Select Edit 3) Change where necessary 3.7 Step 2 IMPORTANT!! Appointments have 3 stages of attendance and these should be changed by either a) Click and drag client into appropriate room or b) Right click and select correct status a) Arrived = Client is located in the waiting room b) Seen = Client is with the provider c) Closed = Client has left the health centre 3.8 Managing Appointments 3.8.1 Cancelling an Appointment 1) Right Click the appointment 2) Select Cancelled 3) Click Yes 3.8 Step 2 Tip Appointments should NEVER be deleted. If the client calls because they can t make it then the appointment should be cancelled. If they do not come to the appointment, then open the appointment and then click Did Not Attend check box 3.8.2 Did not attend 1) Right Click the appointment (See Section 3.7) 2) Select Edit from the Menu 3) Check the Did Not Attend box MODULE 3: SCHELDULING Page 20
3.9 Walk-In Client 1) Select Provider or multi-provider view 2) Right click calendar 3) Select Walk-in client 4) Search for client Type first 3 letters and Select from list Double Click 5) Create New Client if necessary 6) Change Appointment Type 7) Enter in other necessary information Step 4 Step 5 MODULE 3: SCHELDULING Page 21
3.10 Block out a providers schedule 1) Select Provider or multi-provider view 2) Select Block out icon from toolbar 3) Click and drag on time you want blocked out 4) Enter Rule Name 5) Click OK Step 2 Step 4 Step 5 MODULE 3: SCHELDULING Page 22
Step 1 3.11 Meeting 1) Create a new appointment See Section 3.6 2) Click the meeting check box Step 2 3) Click the Expand icon 4) Select Staff Member from list 5) Click OK and repeat as necessary 6) Repeat the process for Clients if they are attending Step 4 Step 5 MODULE 3: SCHELDULING Page 23
7) Click Appointment Tab 8) Enter the appointment type 9) Check the Time, Date, and Duration 10) Click OK Step 6 Step 7 Step 8 Step 9 MODULE 3: SCHELDULING Page 24
3.12 Client Group session Tip Meeting vs. Group Session a) Meeting: Creates multiple appointments for clients and providers, but is not recorded in the medical record b) Group Session: Creates an entry in the all of the clients medical records. Similar to a Bulk Encounter. Doesn t create an appointment. 1) Create a new appointment See Section 3.6 2) Click the meeting check box B See Section 3.11 3) Click Group Session 4) Click Yes 5) Click Yes again Step 4 MODULE 3: SCHELDULING Page 25
6) Add Multiple Clients 7) Check Date, Time, and Duration 8) Enter the Appointment Type 9) Add other Providers if necessary 10) Click OK 11) Click Yes Step 6 Step 7 Step 8 Step 9 Step 10 MODULE 3: SCHELDULING Page 26
3.13 Tasks 1) Click the Tasks Icon 2) Click New Tasks 3) Enter Subject and Provider 4) Enter Date and Time 5) Enter Client, Priority and Status 6) Click OK Step 2 Step 1 Step 4 Step 5 Step 6 MODULE 3: SCHELDULING Page 27
3.14 Messenger 1) Click on the Messenger Icon 2) Click the Conference Icon 3) Click New Conference 4) Enter the Name 5) Select Health Centre 6) Click OK Step 1 Step 2 Step 4 Step 5 Step 6 7) Select User 8) Click Invite and repeat for all participants Step 8 Step 7 MODULE 3: SCHELDULING Page 28
3.15 Scenarios ***Nurses don t have to complete ALL scenarios in this section*** Scenario 1 Create an appointment a) Client : John Doe b) Date: tomorrow c) Time: 10:00 am d) Duration: 20 min e) Provider: FN Nurse f) Type: Immunization Scenario 2 Create an appointment for a walk-in client who wants a diabetes consult Scenario 3 Create a Family Consult group session for 3 members of the Gump Family for next Tuesday at 09:00 am for 1 hour Scenario 4 Provider Dean Driver is going to Hawaii for three weeks and wants his schedule blocked for while he is away Scenario 5 Heather Tea did not show up to her weekly diabetes consult. What should you do? What if she called and said that she can t make it? Scenario 6 A mother {enter client} enrolls her child {enter client} in the Early Childhood Development (ECD) Program Kolour Kids. The program runs ever 2 nd week on Friday from 10am-2pm Scenario 7 A new program Better Parenting is starting up hosted by the ECD department. Add four members/ clients to group meeting that runs on the first Wednesday of every month at 7pm for 2 hours, ending Jan 2011. Scenario 8 Start a new messenger conference, add users to conferences and have each send at least one comment so everyone can see who sent it and when. Scenario 9 A nurse asks you to make an appointment for a new program at the health centre. You cannot find the program on the appointment type list. What do you do? Scenario 10 A nurse has just called and she is running late and wants one appointment moved back an hour. What if she called in sick and needs to have all her appointments cancelled? MODULE 3: SCHELDULING Page 29
Scenario 11 Send a task to the CHR asking if they can contact {Enter Client} about an upcoming TeleOphthamology clinic on July 15 starting at 9am. Scenario 12 Send a message to your neighbor congratulating on completing Module 3 3.16 Reports a) Number of clients seen by program b) Number of clients seen by provider c) How many times a client has used a service d) How many times a client Did Not Attend appointments 3.17 Frequently Asked Questions and Problems a) Why do I need to fill in appointment type? b) A new program has started, what do we need to do? MODULE 3: SCHELDULING Page 30