Seamless flow

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eClinicalWorksEMRMedicalAssistant&Nurse

TrainingGuideRachelJ.CohenPhDDOHMHTrainingManager

Rcohen5@health.nyc.gov2127885718

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ContentsIntroduction..................................................................................................................................................3LogIntoeClinicalWorks...............................................................................................................................4TaskbarQuickLinks(Generallyreferredtoasjellybeans).......................................................................6PatientLookupButton...................................................................................Error!Bookmarknotdefined.PatientHub...................................................................................................................................................7CreateaTelephoneEncounter.....................................................................................................................8AccesstheOfficeVisitsScreen....................................................................................................................14UpdatePatientRoomandVisitStatus........................................................................................................17AccesstheProgressNote............................................................................................................................18ProgressNotesTemplates..........................................................................................................................21Vitals............................................................................................................................................................24ChiefComplaints.........................................................................................................................................29DocumentChiefComplaints....................................................................................................................29

CurrentMedication.....................................................................................................................................32EnterCurrentMedication........................................................................................................................32ReviewMedicationHistory......................................................................................................................34AddaMedicationtothePatientsRecord...............................................................................................35

AddingorChangingthePharmacyonRecord............................................................................................39ViewPhysicianOrders.................................................................................................................................40Immunizations.............................................................................................................................................43DocumentImmunizations.......................................................................................................................43UpdateaGivenImmunization.................................................................................................................49

Billing...........................................................................................................................................................50AddorRemovetheTCModifier..............................................................................................................51

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IntroductionAspartofNewYorkCitysTakeCareNewYorkinitiative,thePCIPProjectisamultifacetedprogramtosupporttheadoptionanduseofAmbulatoryHealthRecords(AHRs)amongprimarycareprovidersinNYC'sunderservedcommunities.Itsmissionistoimprovepopulationhealththroughappropriatetechnologyandhealthinformationexchange.TheeClinicalWorkssystemwaschosenbyNewYorkCitysDepartmentofHealthandMentalHygieneastheirvendorofchoicetoaccomplishtheirgoals.TheMedicalAssistantandNursingstaffatdoctorsoffices,clinics,outpatient,ambulatoryfacilitieswillbeperformingtheirroutinetasksintheAHR(ambulatoryhealthrecord)systemeClinicalWorks.Thefollowingpagesdocumentanddemonstratethesystemfunctionsnecessaryforcompletingcommonmedicalassistantandnursingtasks.

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LogIntoeClinicalWorks

Afterloggingintothenetworkusingyourusernameandpassword,youwillnoticetheeCWicon

onthedesktop.

Clickthisicon.Thelogonwindowappears.

Enteryourfirstinitialandlastname(example,jandrilli)intheLoginIDfieldandinitiallyyourpasswordwillbepassword1(therewillbesubsequentinstructionsonhowtochangeyourpassword).

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Displayofwhoisloggedin

Thisscreendefaultstotodaysdateandthefirstproviderlistedinyourdefaultclinic.ClicktheSjellybeantoviewyourpatients.

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TaskbarQuickLinks(Generallyreferredtoasjellybeans).SMenu:LinkstotheOfficeVisitswindowwhichdisplaysthepatientsthathavearrivedfortheirvisit.ThenumberintheSjellybeanindicatesthenumberofpatientsarrivedanddisplaysonlyintheprovidersview.Staffwillalwaysseea0.DMenu:ProvidestheoptionofgoingdirectlytotheFaxInboxorFaxOutboxwindows.ThenumbernexttoDindicatesthenumberofdocumentsassignedtotheloggedbyanotherstaffmember.ClickthebuttontoopentheReviewDocumentwindow.RMenu:ProvideslinkstotheIncomingReferralsorOutgoingReferralswindows.Thetotalnumberofreferralsassignedtotheloggedonuserdisplaysinparenthesesnexttoeachlink.ThenumbernexttoRindicatesthecombinedtotalnumberofincomingandoutgoingreferrals.ClickthebuttonthathasthenumbertoopentheOutgoingReferralswindoworclickontheRitselftoselectIncomingReferralsorOutgoingReferralsfromadropdownlist.TMenu:ProvideslinkstotheTelephone/WebEncounterswindow,whichincludesnewtelephoneandwebencountersaswellasActionsandalinktoClaims.Thetotalnumberofencountersassignedtotheuserwhoisloggedinwillbedisplayedinparenthesesnexttoeachcategory.ThenumbernexttoTindicatesthecombinednumberofopentelephoneandwebencountersassigned.ClickthebuttontoopentheTelephone/WebEncounterswindow.LMenu:OpensthewindowdirectlytotheToBeReviewedtab.Thetotalnumberoflabsandimagingassignedtotheloggedonuserdisplaysinparenthesesnexttoeachcategory.ThenumbernexttotheLindicatesthecombinednumberoflabsandimaging.ThetabbedsectionsincludeOutstanding,Tobereviewed,Reviewed,Future,Bypatient,andAll.MMenu:ProvideslinkstomessagesintheInbox,Outbox,orDeletedMessageswindows,andincludesalinktotheCreateNewMessagewindow.ThenumbernexttoMindicatesthenumberofnewmessagesintheInboxfortheloggedinuser.ClickontheletterMtoviewtheInbox,Outbox,DeletedMessagesorCreateNewMessages.

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PatientLookupButtonThePatientLookupbuttonisyourstartingpointforalmostalleClinicalWorksactivities.YoucansearchforapatientbyusingthePatientLookupbutton.ToSearchforaPatient Not

necessarily1:ClickthePatientLookupbutton.

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ThePatientLookupwindowopens. trueastheywillbeusingofficevisitsscreenforeverythingexcepttelephone

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encounters

2:TypethelastnameofthepatientintheSearchPatientfield.3:Clickonthenameofthepatient.4:ClickthePatientInfobuttontoopenthePatientInformationwindowORclickOKtoopenthePatientHub.

PatientHubThePatientHubisaptlynamedbecauseallofthemajorcomponentsofthepatient'selectronicmedicalrecordsareaccessibledirectlyfromtheHub.Likethehubofawheel,thePatientHubisthecentralpointofaccessforimportantfeaturessuchasAlerts,Demographics,andProgressNotes.

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TheHubcontainsnavigationbuttons,staticpatientinformation,andatoolbarthatlinkstocommonareasoftheapplication.ManyofthemainwindowsintheapplicationcontainalinkorbuttonbacktotheHub,makingiteasyfortheusertoquicklynavigatebackandforthtotheHubaspartoftheworkflow.YoumayeasilycreatenewtelephoneencountersandaccesstheprogressnotesfromthePatientHub.

TelephoneEncountersTheTquicklinkintheStatusTaskbarandtheTelephoneEncounterswindowenablesofficestafftokeeptrackofinformationcommunicatedtothepracticeaboutapatientthatrequiresactiontobetaken.Whenapatientorfamilymembercallsintoaskaquestionorprovideacomment,recordallrelevantinformationinatelephoneencounter.

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TheTaskbarquicklinkalsokeepstrackofthenumberoftelephoneencountersassignedtostaffforreview(byuser).HighprioritymessagesarenotedwitharedquicklinkandaredexclamationmarkontheTelephoneEncounterswindow.ToCreateaTelephoneEncounter1:FromtheTquicklinkintheStatusTaskbar,openthedropdownlistandselectNewTelephoneEncounter.

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TheTelephoneEncounterwindowopens.TheAnsweredby,Date,Time,andStatus(Open)fieldsareautomaticallypopulated.2:ClicktheSelectbuttonabovethePatientfield.

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ThePatientLookupwindowopens.

3:Searchforthepatientinthedatabase.Doubleclickonthepatientsname.ThePatientLookupwindowclosesandthepatient'snameisaddedtothePatientfield.

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4:SelectthepatientsproviderfromtheProviderdropdownlist.4

HighPriority:Ifthisisanurgentmessagethatneedstobeaddressedassoonaspossible,checktheHighPrioritycheckbox.TheTquicklinkturnsredandtheencounterismarkedwitharedexclamationmarkontheTelephoneEncounterswindow.

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5:ReviewthePharmacyinformation,iffilledin,orclicktheChangebuttonandselectapharmacyfromthePharmacieslistifthecallisforaprescriptionorrefill.6:TypethenameofthecallerintotheCallerfield.7:ReviewtheFacilityandchange,ifnecessary.8:TypethereasonforthecallintotheReasonfield,orselectitfromthedropdownlist.9:ClicktheMore()buttontoselecttheprovider,resourceorstaffpersonwhowillhandlethecallfromtheAssignedTodropdownlist.10:TypethemessageintotheMessagefield.11:ClicktheComplaintsbuttontoaddprimarysymptomsorChiefComplaintsforthepatient,ifappropriate.12:IfthepatientwishestoknowanyinformationontheirLabs/DItests,clickontheLabs/DItab.TheLabsectionoftheencounteropens.ChoosebetweentheoptionsLabsorDIfromthedropdownlist.Thedatestheywereordered,thereasonforthetestsandtheresultscanbeviewedinthissection.

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13:Ifthepatientneedsarefilloranewmedication,clickontheRxtab.TheRxsectionofthewindowopens.

14:ClickontheCurRxbuttontoviewthecurrentmedicationsofthepatient.SelectamedicationifneededandclickOK.

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YoumayalsousethedropdownarrownexttotheCurRxbuttontoviewandselectfromtheCurrentRx,RxHistoryorExternalRxHistoryofthepatient. 15:OncethemedicationisaddedtotheRefilledMedicineslist,clickonthefieldstospecifytheComments,Name,Strength,Formulation,Take,Route,Frequency,Duration,Dispense,Refill,andAuth.Todeleteamedication,selectamedicationfromtheRefilledMedicationslistandclickDelete.16:ReturntotheMessagetabandclicktheAddActionTakenbutton.TheNoteswindowopens.TypeadescriptionofyouractiontakenandclickOK.Yourname,thecurrentdate,andtheexacttimeareautomaticallypopulatedintotheActionTakenfieldalongwithyournotes.17:ClickOKontheTelephoneEncounterwindow.Openvs.Addressed:BesurethatyouleavetheencountermarkedasOpenintheStatussection.IfitismarkedAddressed,thistelephoneencounterwillbelockedfromfutureeditingandtheproviderwillneverbenotifiedofthisassignedtelephoneencounter.Thetelephonemessageaboutthepatientisnowdocumentedandassigned.

AccesstheOfficeVisitsScreen

Toaccessthelistofarrivedpatients,clicktheSjellybeanonthetaskbarquicklink(

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TheOfficeVisitswindowopens.

Patientsdisplayedinthiswindowarethosewhohavebeenregisteredand/orthosecheckedinbythefrontdesk.

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Note:Ifyouareinaclinicwhereyouservicemultipleclinicspatients,usetheFacilityGroupselectiondropdownforthemostefficientviewofyourpatients.Ifnot,useFacilityastheselectioncriteriawhichwillprovidealistofallpatientsinthatclinic.

ClickthedropdownandchooseFacilityGroup

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or,clickthedropdownandchooseFacility

UpdatePatientRoomandVisitStatusToroomapatient:

1:ClickintheRoomfieldforthepatient.TheRoomNo.windowopens.2:Typeorclickthenumbersonthekeypadtoenterthetriageroomnumber.3:ClicktheOKbuttton.YouarereturnedtotheOfficeVisitswindow.Toupdateapatientsstatus:1:ClickintheStatusfieldforthepatient.TheStatusCodeswindowopens.

Tip:Scrolldowntoseeallavailablestatuscodes.

2:ClickTRI.YouarereturnedtotheOfficeVisitswindow.

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AccesstheProgressNoteTherearemultiplewaystoaccessapatient'sProgressNotesfromwithintheeCWapplication.PatientcareworkflowvariesgreatlyamongstaffmemberswithdifferentjobtaskssotheProgressNoteisreadilyaccessiblefromanumberofworkareas.Thefollowinglistdescribesthevariousmethodsofaccessingapatient'sProgressNote:

1.FromtheOfficeVisitswindow:Doubleclickthepatient'snameintheOfficeVisitswindowtolaunchtheProgressNotesforthepatient.Alternatively,checkthecheckboxnexttothepatientsnameandclickViewProgressNotes.

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2.Fromtheleftnavigationbar:ClickthePracticeband,andthenclicktheProgressNotesicon.

3.FromthePatientHub:ClicktheProgressNotesbutton.

4.FromtheCentralResourceSchedulewindowortheProviderSchedulewindow:

Rightclickthemousebuttononanappointmentslot.ClickViewProgressNotesinthedropdownlist.

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CentralResourceScheduleWindow: ProviderSchedulewindow:

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ProgressNotesTemplatesAProgressNotestemplateprovidesdetailsaboutobservationsandtreatmentstrategies.Usingatemplatecanmaximizeapatientvisitbyfocusingonlyonthepertinentinformation.TheusageoftemplatesassistsindocumentingtheProgressNotefasterforcommonanddiscreteproblems.ToCopyandMergeaGenericTemplateAgenerictemplateismostusefulbecauseitcanbeusedforanypatient.Thereisnopatientspecificinformationinit.Physicians,nurses,andotherauthorizedstaffwithaccesstoProgressNotescancopyormergetheselectedtemplateintothepatient'sProgressNotes.1.OntheProgressNoteswindow,clickthegreenarrownexttotheTemplatesbuttoninthebottomtoolbar(or,fromtheFilemenu,selectTemplates)andselectCopyandMergefromTemplatesfromthedropdownlist.

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TheProgressNotesTemplatewindowopens.

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2.Thepatient'snameandtheencounterdateappearintheTemplateForsectionatthetopofthewindow.3.UnderChooseTemplate,clickGeneric.4.ClickontheCategorydropdownlistandselecttheAllcategory.Alistoftemplatesdisplaysonthebottom.

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5.IntheFindfield,typeNursingtofilterthetemplateslist.IntheFacilityfield,selectafacilityforwhichthetemplatewassavedfromthefacilitydropdownlist.Atemplateis(oralistoftemplatesare)displayed.6.Clickonthedesiredtemplate.7.UnderAllOptions,clickthecheckboxforthetemplateinformationtobeincluded.Ifallinformationisdesiredtobeincluded,clickAllOptions.8.SelectCopyTemplateorMergeTemplate.CopyTemplateremovestheinformationfromthepatient'sProgressNotes,andsubstitutesthetemplatevalues.MergeTemplateleavestheexistinginformationinthepatient'sProgressNotes,andappendstheadditionalinformationfromthetemplate.CopyingtemplateinformationwilloverwritetheexistinginformationintheProgressNote:Ifunsureaboutoverwritinginformation,chooseMergetoaddthenewtemplateinformationtotheexistingProgressNote.ThePatientsProgressNoteispopulatedwiththeinformationcopiedormergedfromtheTemplate.9.ClickClosetoexitthescreen.

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VitalsTheVitalswindowiswhereapatientsvitalsignsatthetimeoftheencounterarerecorded.Vitalsignswillgenerallybetakenbyamedicalassistant.DocumentVitals

1.OntheOfficeVisitsscreen,clickonthepatientsnametoopentheProgressNoteswindow.2.ClicktheVitalslinkintheprogressnote.TheVitalswindowopens.Thecurrentvisitishighlightedin

yellow.

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3.Checkthepopupcheckboxtoenableapopupwindowtoenterinformationforeachvitalitem.

4.Chooseavitalitemwhichneedstoberecordedbyclickingonthevitalspecificfieldintherowhighlightedinyellow.Awindowcontainingthevitalspecificinformationappears.ThefollowingvitalswindowappearswhentheHeightfieldisclicked.

5.Iftheheightistoberecordedinfeetandinches(e.g.5feet4inches),enterthevaluesintheFtandInfieldsrespectively.IftheHeightistoberecordedinmeterandcentimeter,enterthevaluesinmandcmfieldsrespectively.

TheHeightisautomaticallyconvertedintoinchesiftheunitofmeasurementissetasinchesforheightintheVitalsAdminSettings.Iftheheighthasbeenenteredinapreviousencounter,clickCopyHeighttoimporttheheightfromthepreviousvisit.

6.ThefollowingwindowappearswhentheWeightfieldisclicked.IftheweightistoberecordedinKilogramsandGrams,enterthevaluesinKgandgmfieldsrespectively.Ifthevaluesaretoberecordedinpoundsandounces,enterthevaluesinthelbandozfieldsrespectively.TheweightisautomaticallyconvertedtopoundsiftheunitofmeasurementissetaspoundsforweightintheVitalsAdminSettings.

Thenumberbuttonscanalsobeusedtoenterthevaluesintherespectivefields.

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7.Clickthe>buttontodisplaythevitalsontheright.ClickDeletetodeletethevitals.

8.ClickApplytoimportthepatientsvitalsintheVitalswindowandexitthevitalspecificwindow.Or,clickNextinthevitalspecificwindowtogoontothenextvitaltype.TheinformationprovidedisautomaticallyimportedintothepatientsVitalswindow.

WhenHeightandWeightareentered,theBMIisautomaticallycalculated.

9.UsethepagearrowtopageforwardorbackwardandviewtheotherVitalItemsonthelist.ClicktheHearingfieldtoentertheHearingTestdata.TheHearingwindowopens.

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a.AdefaultdecibellevelappearsintheDecibelscolumnbutitcanbechangedtorecordthe

actualdecibellevelduringthetest.RefertotheSettingssectionformoreinformationonsettingadefaultdecibellevel.

b.ClickinacellforasideandafrequencyandthenclickPforpassorFforfail.ClickPforallorFforalltorecordpassorfailforalltests.ClickClearalltoclearallcellsandreenterdata.

c.ClickontheappropriateRadiobuttonunderComments.EnternotesintheOtherfieldifOtherisselected.

d.ClickApplytodocumentthedataintotheVitalswindowandtoexitthewindow.Or,clickNexttomovetotheentrywindowfornextdataitem.

10.IntheVitalswindow,clicktheVisionfieldtoentertheVisionTestdata.TheVisionwindowopens.

a.Selectresultsforleft,rightorbotheyesfromtheirrespectivedropdownlistormanuallyenter

theresultsintothefields.b.RecordtheFusiontestresultsintotheFusionfieldandthecolorperceptiontestresultsintothe

Colorfield.c.ClickonanappropriateradiobuttonunderCommentstorecordwhetherachildwastooyoung

totestorthepatientworeglassesforthetest.d.SelectOthertorecordadditionalcommentsintotheOtherfield.e.ClickApplytodocumentthedataintotheVitalswindowandtoexitthewindow.Or,clickNext

tomovetotheentrywindowfornextdataitem.

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11.IntheVitalswindow,clickonthePainScalecelltorecordapatientsassessmentofpain.

Enteranumberbetween0and10thatrepresentsthelevelofpainthatthepatientisexperiencing.ClickApplytodocumentthedataintotheVitalswindowandtoexitthewindow.Or,clickNexttomovetotheentrywindowfornextdataitem.

12.ChecktheVitalsTakencheckboxtodocumentthatvitalsweretakenduringthevisit.Thisfieldisforindicationpurposesonly,anditdoesnotdisplayonthechart.ItinsertsastethoscopeindicatoronNotesStatusfieldintheOfficeVisitswindowtoinformtheproviderthatthevitalshavebeenrecordedandthepatientisreadytobeseen.

13.ForthisWalkthrough,exittheVitalswindowtoviewthevitalsinthePatientsProgressNote.

ExerciseYourpatientTestEMR##vitalsignshavebeingtakenbythenurse.Thefollowingvitalswererecorded:Temperature98.4F,Weight155lbs,Height54,BP130/84,HR60perminute.DocumentTestEMR##vitalsinthepatientsprogressnotes.ExerciseOncethevitalshavebeendocumentedintotheprogressnotes,notifytheproviderthroughthesystemthatthevitalsignsforTestEMR##havebeentaken.

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ChiefComplaintsTheChiefComplaintswindowiswheretheprimarysymptomsorcomplaintsforthecurrentencounterarerecorded.DocumentChiefComplaints1.FromthepatientsProgressNotes,clickChiefComplaint(s).

TheChiefComplaintswindowopens.AnytextenteredintotheReasonfieldontheappointmentwindowbythefrontofficestaffappearshereasthefirstChiefComplaint.

2.ClickBrowsetoselectacomplaintfromapredefinedlistofmedicalconditions.TheChiefComplaintsKeywordswindowopens.Toselectacomplaint,clickthecomplaintintheleftpane.Theselectedcomplaintdisplaysintherightpane.Tolookupachiefcomplaint,enterthefirstfewlettersofthecomplaintintheFindfield.Alistofcomplaintsdisplay.

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Theleftpanedisplaysalistofgeneralcomplaintstochoosefrom.Therightpanedisplaysthelistofcomplaintschosenfromtheleftpane.Clickthe

6.Toenterachiefcomplaintmanually,clickAddintheChiefComplaintssectionoftheChiefComplaints

window.AblankrowappearsintheChiefComplaintswindow.7.Clickontheblankrowandenteranotherreasonforthevisit.

8.Toremoveachiefcomplaint,clickontherowandclickRemove.Todeletetextinsidearow,placethe

cursorinsidetherowandmanuallydeletethem.9.Toarrangetheorderofthechiefcomplaints,usetheupanddownarrows.10.ForthisWalkthrough,exitthewindowtoviewthechiefcomplaintsinthepatientsProgressNotes.

ExerciseYourpatientTestEMR##complainsoffatigueanddepression.Documentthesecomplaintsintothepatientsprogressnotes.

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CurrentMedicationsTheCurrentMedicationswindowiswherecurrentlyprescribedmedicationsandapatient'sprescriptionhistoryarerecorded.Thisfeatureletstheprovidertrackthecurrentmedicationsapatientistakingandreviewtheirprescriptionhistory.CurrentMedicationscanbecarriedforwardvisittovisitbyusingthefollowingsteps.Failuretodocumentthepatient'scurrentmedicationsonanyProgressNotewillcausethemedicationsonthatProgressNotetomovetotheRxhistoryinsteadofCurrentRx.AlthoughalloftheinformationisretainedintheRxHistorysection,theprovider'sworkflowisfasterandsimplerifthepatient'sCurrentMedicationsectionisupdatedoneachvisit.ToEnterCurrentMedications

1.FromtheProgressNotes,clickCurrentMedication.

TheChiefComplaintswindowopens. Todisplaythedrugnameonly,withoutanydosageinformation,checkRxNameOnlycheckboxintheCurrentMedicationSectionoftheTreatmentScreen.Todisplaymedicationsalongwithdosageinformation,leavethisboxunchecked.Dosageinformationcanbealteredoncethemedicationhasbeenselected.

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2.IntheCurrentMedicationssection,clicktheCurRxbuttontoselectamedicationthatthepatientiscurrentlytakingfromthepatientsmedicationhistoryasofthelastvisit.

TheSelectMedicationwindowopens.

Thiswindowdisplaysallmedicationsthepatientwasonorhadstartedtakingduringtheirlastvisit.ThiswouldincludethemedicationsthatweredocumentedintheCurrentMedicationSectionaswellasthemedicationsthatwereprescribedtothemintheTreatmentsectionoftheprogressnotesduringtheirlastvisit.3.Clickonalinecontainingthemedicationtoselectit.Theselectedmedicationisnowhighlightedin

yellow.

4.Toselectallmedication,clickSelectAll.Toremoveallselections,clickDeselectAll.

5.ClickOK.ThemedicationisnowlistedontheCurrentMedicationSectionoftheprogressnotes.

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TheCurrentMedicationlistingletsthephysicianalterStrength,Take,FrequencyandStartDateasappropriateforthepatient.Clickinthecelltoactivatethefreetextfunctionalityandtoalterdosageinformation.

ToReviewMedicationHistoryThissectiondisplaysahistoryofmedicationsthatthepatienthasbeentakingorhadtakeninthepast.

1.FromtheCurrentMedicationsectionoftheChiefComplaintswindow,clickthegreenarrowbesideCurRx,andthenselectRxHistory.

TheSelectMedicationwindowopens.

2.Choosefromoneofthefollowingoptionstosortthemedicationhistoryofthepatient. Thepatientencountersarelistedbydate,startingwiththemostrecent.Anydateinboldhasmedicationinformation.3.CurRxliststhemedicationsthatweredocumentedintheCurrentMedicationsectionoftheProgress

Notefortheencounterdatethatslisted.ClickontheCurRxradiobutton.Alistofencountersdisplaybydatesontheleftpane.Clickonadatetoviewthemedicationsontherightpane.ToaddthatmedicationtotodaysCurrentMedication,clickonthemedication.Theselectedmedicationishighlightedinyellow.ClickOK.

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4.RxbyDatelistsanymedicationprescribedtothepatientwithineachencounter.ClickontheRxBy

Dateradiobutton.Alistofencountersdisplaybydatesontheleftpane.Clickonadatetoviewthemedicationsontherightpane.ToaddthatmedicationtotodaysCurrentMedication,clickonthemedication.Theselectedmedicationishighlightedinyellow.ClickOK.

5.RxbyNameliststhenameofanyprescriptioneverprescribedtothepatient,sortedbyname.ClickontheRxByNameradiobutton.Alistofmedicationsdisplayontheleftpane.Clickonamedicationtoviewdosageinformationontherightpane.ToaddthatmedicationtotodaysCurrentMedication,clickonthemedication.Theselectedmedicationishighlightedinyellow.ClickOK.

6.ThemedicationsselectedintheRxHistorysectionareaddedtotheCurrentMedicationSection.ToAddaMedicationtothePatientsRecordIfapatientiscurrentlyonamedicationthatisnotlistedintheirpastrecords,thenthemedicationneedstobemanuallyaddedfromthedrugdatabasetothepatientsCurrentMedicationSection.

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1.FromtheCurrentMedicationsectionoftheChiefComplaintswindow,clicktheAddbutton.

TheSelectRxwindowopens.

2.FromtheTypedropdownlistselectthedrugdatabase.TheoptionsintheTypedropdownlistare:AllRx,CustomRx,MedispanRx,andEquip/SuppliesRx.MedispanRxisadatabaseforawidelyusedlistofmedications.Thiswillbeusedinthemajorityofcasestochooseamedication.CustomRxisacustomizablelistofmedicationsmanagedandusedbytheProvidertomakemodificationstoandaddtomedications.Equip/Suppliesisanonpharmaceuticallistofitemsrecommendedfortreatment.

3.Alistofmedicationsdisplay.UsetheRxdropdownoptions:StartsWith,ContainsandAllWordstofacilitatethesearch.EnterthenameofthemedicationintheFindfieldtonarrowdownthesearch.Selectfromthelistofmedications.

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4.Theavailableformulationsanddosagesaredisplayedhere.Clickthedosethatneedstobeprescribed.5.ThemedicationanddosageareaddedtotheSelectedRxlist.

6.Selectthemedication.ToremovetheselectedmedicationfromtheSelectedRxpanel,clickRemove.7.ClickOKtosavetheselectionandreturntotheCurrentMedicationsectionoftheChiefComplaints

window.ThenewmedicationisnowincludedontheCurrentMedicationlist.8.ClickontheDatefieldtospecifyadatewhenthepatientstartedtakingthemedication.

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Pleaseaddtheyearandmonthsearchasmostofourpatientshavebeenontheirmedsforyears

9.Themedicationisnowdocumentedalongwithdosageandthestartdateinformation.

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AddingorChangingthePharmacyonRecordYoucanaddorchangeapharmacyonthepatientrecord.1.AccessthePatientInformationwindowinanyoneofthefollowingways:

ClicktheInfobuttonnexttopatientsnamefromtheProgressNotesscreenorthePatientHub.ThePatientInfowindowopens.

Or,clickthePatientInfobuttononthePatientLookupwindow.ThePatientInfowindowopens.

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2.FromthePatientInformationwindow,clicktheAdditionalInfobutton.ThesecondpageofthePatientInformationwindowopens.3.ClicktheSel(Select)button.ThePharmaciesLookupwindowopens.

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4.BegintypingthenameofthepharmacyintheLookupPharmacyfield.5.Selectthepatient'spharmacyfromthelist.6.ClickOK.TheaddressoftheselectedpharmacyappearsinthePharmacywindowonthePatientInformationscreen.7.ClickOKonthePatientInformationwindow.

ViewPhysicianOrdersAsapatientprogressesthroughtheirvisit,thephysicianwillmostprobablyenterlaband/ordiagnosticimagingorders.Someofthelabordersandallimmunizationordersareperformedintheofficeandassucharereferredtoasinhouseorders.TherearemultipleindicatorsthatanurseorMAisneededtoperforminhouseorders:

StatusindicatesNurseneededPhysicianverballyindicatesanorderispresent,orTheorderisnoticedinthetreatmentsectionoftheprogressnote.

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ViewOrdersforaPatient1.FromtheOfficeVisitsscreen,clicktheappointmentforthepatient.2.ClicktheViewOrdersbutton.

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ThePatientOrderswindowopens.

3.Reviewthetabbedsectionforcurrentorders:CurrentLabs,,CurrentDiagnosticImaging,,and.Dependingontheclinic,testswillbeorderedbyproviders.ProcedurescanbeviewedbyhighlightingthedesiredprocedureandclickingtheViewbuttonfortheassociatedprocedure.4.IfInterfacedselectthelabtosentandhitthequicktransmitbuttontosendthelabtotheselectedcompany.5.Ifreferralreviewreferralhitviewandprintorderforpatientsamefordiagnosticimage6.ClickClose.YouarereturnedtotheOfficeVisitswindow.

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ImmunizationsTheImmunizationssectioniswherethenursedocumentsanyimmunizationthatwasorderedforapatient.Thenursecaneasilyrefertothepatient'srecordofpastimmunizations.DocumentImmunizations

FromthepatientsProgressNote,clickImmunizations.

TheImmunizations/Injectionswindowopens.

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2.ClicktheAddbuttontoaddanimmunization.TheImmunizationDetailwindowopens. 3.UsetheFindfieldtolocateanimmunizationfromthelistintheleftpane. 4.Oncelocated,clickthedesiredimmunization.TheselectedimmunizationdisplaysintheImmunizationfieldintheImmunizationDetailsection.

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5.Ifapplicable,selectanencounterdatebyusingtheVisitDatedropdownlistofpatientencounters. Immunizationscanbeassociatedwithaspecificvisitdate.TheVisitDatefielddisplayswhen

thecheckboxforVaccinationGiveninthePastissettoN.IftheVaccinationGiveninthePastischeckedasN,theGivenDatedefaultstotheVisitDateandcannotbeedited.IftheVaccinationGiveninthePastischeckedasY,theGivenDatefieldisactivated.

6.Ifactivated,usetheGivenDatedropdowncalendarfeaturetoselectthedateonwhichtheimmunizationwasgiven.BydefaultthegivendatedefaultstotodaysdateandthesystemautomaticallysavestheexacttimeintheGivenDatefield.

8.Eachimmunizationhasbeensetupwiththecorrectdosagesothisfieldisprepopulated.

9.ClickOK.10.Iftheimmunizationispartofaseries,usetheDoseNumberdropdownlisttoselectthedosenumber.

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11.clicktheMore(...)buttonnexttotheGivenByfield.

TheStaffLookupwindowopens.Selectyournamefromthestafflist.ClickOK.

12.ClickontheLocationdropdownlisttoselecttheareaofthebodythroughwhichtheimmunizationwasadministered.

13.IntheLotNumberfield,clicktheMore()buttontoopentheLotNumberswindow.

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14.ClickontheSelfieldnexttoFacility.SelecttheFacilityfromtheFacilityListswindow.Immunizationlotnumberwillbeenteredbyfacility.Immunizationsassociatedwiththeselectedfacilitydisplays.ChecktheDisplayLotsforselectedvaccineonlycheckboxtoviewlotnumbersfortheselectedvaccine.

15.TypetheVaccineLotNumberintheFindfield.Theimmunizationwithselectedlotnumberdisplays.16.Clicktherowcontainingthelotnumbertohighlightit,andthenclickOKtoaddittotheLotNumberfield.Ifthelotnumberyouareusingisnotlisted,additbyupdatingthefield.

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17.TheLotNumber,DateonVIS,ExpDate,andManufacturergetspopulatedintheImmunizationDetailwindow.18.Thisdefaultstocurrentdate.19.UsetheRouteofAdministrationdropdownlisttoselectthemethodofdelivery.

20.EnteranycommentsintotheCommentsfield.

21.IfthevaccineisassociatedwiththeCDC'sVFCprogram(VaccinesforChildren),usetheVFCdropdownlisttoselectthestatus.22.UsetheVaccinationGiveninthePastcheckboxtoindicateifthevaccinationwasgiveninthepastandonlyenterthedateiswasgivenasinputforthisindicator.

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23..AllimmunizationsshouldbesetupwiththeappropriateCPTcodeusedforbillingalongwiththeimmunizationadministrationcode.

24.Toquicklyaddmorethanonevaccine,clickSaveandNewtosavethecurrentinformationandkeeptheImmunizationDetailswindowopentoaddanothervaccine.ItwillbenecessarytomanuallyaddthemultiplegivenCPTcodeinthebillingwindow.

WhenSaveandNewisused,informationisclearedfromtheImmunization,Dose,DoseNumber,GivenBy,Manufacturer,DateonVIS,VISGiven,ExpirationDate,andCommentsfields.25.ClickOKtoaddtheselectedimmunizationinformationtothepatientscurrentvisit.TheimmunizationisdocumentedinthepatientsProgressNote.ToUpdateaGivenImmunizationTheselectedimmunizationsarevisiblefromtheImmunizationssectionofthechartlinksinthePatientDashboardorfromtheImmunizationssectionoftheProgressNoteandPatientHub.1.ClickonanyoftheaboveoptionstoopentheImmunizationswindow.

2.Theimmunizationsthatweregiveninthepasttothepatientcanbeviewedinthiswindow.3.SelectanimmunizationandclickUpdate.TheUpdateImmunizationDetailswindowopens.

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4.AllthefieldsareeditableexcepttheImmunizationname.EditanydetailsonthiswindowandclickOK.ExerciseYourpatientTestEMR##wasgivenavaccinationforTetanusToxoide.DocumenttheimmunizationinthepatientsProgressNote,usingtheLotnumberTest123.Therouteofadministrationisintramuscularandthelocationisleftlowerforearm.ThevaccinationwasgivenbyEileenPowell.

BillingThebillingwindowcontainsinformationabouttheICDCodesassociatedwiththecurrentdiagnosis,CPTcodesassociatedwithanyproceduresorderedforthecurrentvisitandEvaluationandManagementCodes(E&MCodes).ThewindowalsohasanoptiontochoosemodifiersandappropriateE&Mcodes.TheEMCodertoolcanbeaccessedfromtheBillingwindow.TheBillingwindowalsoincludesaNotessectionforbillingrelatednotes,aswellasafollowuptooltokeeptrackofbillinginformationforthepatient.AllimmunizationshavetheTC(technicalcomponent)modifieralreadyassignedas90%ofthetimenursesprovidethisservice.Pediatricianswillneedtodeletethatmodifierastheygiveimmunizationstotheirpatients.Thisistrueofanyinhouseproceduresaswell.Wherethenursegenerallyprovidestheservice,theTCmodifierisalreadyassignedtotheCPTcodesointheeventaphysicianprovidestheservice,theTCmodifiermustberemovedforthephysiciantogetcreditfortheservice.

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AddorRemovetheTCModifier1:ClickNextAppointment,VisitCodeorProcedureCodeintheProgressNotetoaccesstheBillingwindow.

TheBillingwindowopens.

2:Clickintheappropriatemodifierfield.TheNoteswindowopens.

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3

4

3:ToaddtheTCmodifier,clickinthemodifierfieldandtypeTCorclicktheSelbuttonandchooseTCfromthelistofoptions.ToremovetheTCmodifier,clickinthemodifierfieldanddeletetheTCentry.4:ClickOKtosaveandreturntotheBillingwindow.

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