omr transcription options & features click mouse to advance

OMR Transcription Options & Features

CAREGROUP H E A L T H C A R E S Y S T E M

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OMR Transcription Overview

The purpose of this presentation is to provide an overview of basic OMR transcription functions.

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• Keystrokes & conventions

• Accessing OMR & Transcription options

• Entering a note in Transcription• Using free text• Using a template• Pasting from Word

• Saving a transcribed note & forwardingit for signature

• Editing a transcribed note • Printing unsigned notes

• Establishing margin & printing defaults

Topics Included

Click on a topic to go directly to the topic information or click on

Continue to review all topics sequentially. Continue

OMR Keystrokes & Conventions

To move back one level Type an underscore (Shift hyphen) To exit Type a ^ (Shift 6) or

if in a word processor window press <ESC>

To view help Enter a ? or if in a word processor window press < F1 >

To select a menu option Enter either the first letter of the item or

the number associated with the item

Default values At certain prompts, the system provides default values. Default values always follow // . To accept the default value, press <ENTER>.

To delete a previously Enter an * (Shift 8). filed entry without replacing the data

ContinueReturn to Table of Contents

Use these keystrokes & conventions when you work in OMR.For this overview, only mouse clicking is required.

Accessing OMR & Transcription Options


Accessing OMR & Transcription Options

The Online Medical Record (OMR) is part of BIDMC’sClinical Computing System (CCC).

To obtain OMR access contact the IS Support Center at (617) 754-8080.

Hospital computers provide direct access to OMR for authorized users.

External transcription services can access OMR remotely.

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Users can access OMR remotely using one of the following methods:

• via the Meditech emulator program through a dial-up connection using a modem• via Metaframe using an Internet connection

To install the Meditech emulator use the following link:http://home.caregroup.org/portal.asp?category=emulator

To install Metaframe use the following link & follow the directions provided: http://home.caregroup.org/metaframe/

To obtain remote access help using any of these methods, contact the IS Support Center at (617) 754-8080.

Remote Access

http://home.caregroup.org/portal.asp?category=emulator

http://home.caregroup.org/metaframe/

To access OMR, sign onto CCC. Use the up & down arrow keys on your keyboard to select Online Medical Record.

SystemO

Appointments/SchedulingClinical InformationOnline Medical RecordOPD Reg (Outpatient Admitting)Online Medical Record

NextPage PrevPage DoneSelectSelect

Beth Israel DeaconessMedical Center

Clinical Computing – CCC System

Mary Smith Port: TS3.421

Continue

You have OMR messages.

Transcription Option

1 Clinical Information options 2 Display/Edit Transcription 3 Enter Transcription 4 Hard Copies - Unsigned 5 Insert test enter/edit 6 Letter/Notes Defaults 7 OMR Messages (Notes for printing) 8 Online Medical Record 9 Providers’ Schedules10 Transcription Report11 Utilities

Transcription Option: 3

Continue

The Transcription Option menu includes options for:

• Displaying & editing transcriptions

Return to Table of Contents

• Entering transcriptions• Printing copies of unsigned notes• Establishing defaults

Entering a Transcription


You have OMR messages.




Enter 3 at the Transcription Option prompt to enter a transcription.

Continue

At the Provider prompt, enter the provider’s name using the format Last Name, First Name. Enter the first few letters of the name & OMR will display matches.

OMR displays the provider’s default Service & Location. Press <ENTER> to accept this information or type in the Service & Location specified in the dictation.

PROVIDER: SMIT, MAR

1. SMITH, MARY 11- 111 PSYCHIATRY PAGE: 99999OK? Y / /

Service and Location: 1. Psychiatry, Beth Israel Hospital Outpatient DepartmentOk? Y / /

PATIENT: FROG,KERMIT

There are several test patients in OMR to use for training. They include: Kermit Frog, MRN 0901910 Kermit Frog, MRN 1213367

0901910123-12-1234

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OMR displays matches to the name you entered. Press <ENTER> to accept the name displayed.

At the Patient prompt, you can identify the patient in a variety of ways: Last name, first name 7 digit CCC medical record number Social security number Room number for hospitalized patients Last name for patients currently or recently hospitalized or in ED

After you enter the patient’s identifying information,OMR displays a list of patients to choose from.

NextPage PrevPage DoneSelectSelect

Choose Patient:

Frog,Kermit 41 M 000-00-0000 21 Sep 1959 OUTPT 0901910 123 Main Street Anywhere 12345Frogger Frogette Frogge

Frog,Kermit 79 M 000-00-0000 2 Feb 1922 OUTPT 0078199 (ACCESS RESTRICTED) Ziggy Phyllis Nancy

Frog, Kermit 36 M 000-00-0000 28 Jul 1964 OUTPT 1058295 (ACCESS RESTRICTED)Joseph Donna Fanny Frog

Frog,Kermit 25 M 000-00-0000 1 Jan 1976 OUTPT 1117257 11 Glendale St Everett 02149Richard Mary Linda

4

1

2

3

44 Frog,Kermit 25 M 000-00-0000 1 Jan 1976 OUTPT 1117257 11 Glendale St Everett 02149Richard Mary Linda

Use the up and down arrow keys on your keyboard tohighlight the correct patient and press <ENTER>.

Continue

At the Date of Service prompt, enter the date using the formatMM/DD/YY or enter T-X. For example for yesterday, enter T-1.

There are 4 dictation types: initial note, letter, progress note, telephonecontact. Enter the type of dictation you want to create.

You can enter a dictation even if the patient did not have a visit recorded in the system on the date of service entered.

DATE OF SERVICE:

Continue

T-1

Initial note Letter Progress note Telephone contact

WHICH TYPE OF DICTATION?: PROGRESS NOTE

No visit recorded for FROG,KERMITWith SANDS,DANIEL Z. on 07/22/01Enter dictation anyway? N / / Y

--------------------------- ----------------------------- -------------------------- -------------------------Medications before July 22, 2001

PROZAC 20MG—One by mouth at bedtime

No medications DC’d on July 22, 2001.

No medications prescribed on July 22, 2001.--------------------------- ----------------------------- -------------------------- -------------------------

For help info press <F1> To exit press <ESC>

111-72-57 FROG,KERMIT M25

Provider: Smith, MaryDate: July 22, 2001 Type of dictation: Progress note

OMR includes the patient’s medications as established by the clinician’sdefault settings.

Continue to View HelpFor HELP press <F1>

To escape the notes screen: Press <ESC> at any time.







Provider: Smith, Mary Date: July 22, 2001

Top of Document F9

Additional Help F1Select Text F2Paste F3Delete Word F4 & Shift F4Text Inserts F6Set Up Search F7Search F8Top of Document F9End of Document F9Page Up Shift Up Arrow Page Down Shift Down ArrowWord Back Shift Left ArrowWord Forward Shift Right ArrowExit <ESC>

Top of Document F9

OMR Help: Use the up & down arrow keys on your keyboard to highlight a Help option.

To Exit Help: Press <ESC>.Continue

: Progress Note

Options for Creating Notes

• Type in freeform text

• Use a personal text insert • Use a public text insert

When you create any note type you can:

Continue

• Combine freeform text & text inserts in a single note

• Paste in text from a word processing file

Transcription with Text from a Word Processing File


To Paste Text into OMR

• Create the note in Word or other word processing software program

• Highlight or select the text and click on Copy

• Initiate note or letter in OMR

• Click on Edit

• Click on Paste

• OMR pastes the Word text into the OMR note

MEDITECH Remote WorkstationOptions Edit HelpEdit

Copy Alt+C Paste Alt+V Paste Alt+V



Transcription with Freeform Text









Type in freeform text.

You can combine freeform text with insert text in a single note.

Press <F6> to access text inserts.

Continue

25 year old male with history of depression


Transcription with a Template


----------------------------------------------------------------------------------------------------------------

Medi

Pro

No m

No m---------------------------------------------------------------------------------------------------------------

Select Topic

NameExamNorm{Antepartu{Complianc{Dermatolo{Discharge{Endocrine{HCA}{Psychia

GENERAL: Well appearing in no distress***(Index Term)******(Index Term)******(Index Term)******(Index Term)******(Index Term)******(Index Term)******(Index Term)***

NextPage PrevPage Done

111-72-57 FROG.KERMIT M25



SelectSelect

{Psychiatr

{Psychia *** (Index Term)****

When you press <F6>, OMR displays personal text inserts first, followed by public text inserts organized by service. You can use any service’s text inserts. Use the arrow keysto select the Service from the list or enter the first few letters of the Service name. Press <ENTER>.

Continue

---------------------------------------------------------------------------------------------------------------------------

Medi

PR

No m

No m---------------------------------------------------------------------------------------------------------------------------

Select Topic

Name

ED/AdmitHMFP evalHMFP groupHMFP noteHMFP termHMFP treatNEURO dataNEURO evalOPD eval

BETH ISRAEL DEACONESS MEDICAL CENTERAMBULATORY SERVICES – HMFP PRACTICE GROUAMBULATORY SERVICES – HMFP PRACTICE GROUAMBULATORY SERVICES – HMFP GROUP PRACTICAMBULATORY SERVICES – HMFP PRACTICE GROUAMBULATORY SERVICES – HMFP PRACTICE GROUCONFIDENTIAL – NEUROPSYCHOLOGICAL DATA SCONFIDENTIAL NEUROPSYCHOLOGICAL CONSULTAMBULATORY SERVICES – RESIDENCY TRAINING

NextPage PrevPage Done

111-72-57 FROG.KERMIT M 25



Select

HMFP treat AMBULATORY SERVICES – HMFP PRACTICE GROU

HMFP treat

Select

A list of departmental text inserts appears.

Use the arrow keys to select the template.

Continue to Use a Text Insert

0901910 FROG.KERMIT M41


DSM-IV Diagnosis Codes & Diagnosis DescriptionAxis I [ ] Axis II [ ]Axis III [ ]Axis IV [ ]Axis V: [ ]

TYPE OF TREATMENT: Include relevant modality, frequency and duration of treatment; using the examples below.

Modality: [ ] Psychopharmacology

Frequency: [ ] Weekly [ ] Twice per month [ ] Monthly [ ] Quarterly [ ] Other, please specify:Duration: [ ] Within UR Protocol [ ] Out of Protocol[ ] Long term maintenance [ ] Other, please specify:For help info press <F1> To exit press <ESC>

296.33 Severe Depression

x

xx

Type the appropriate information into the text insert.

After the note is complete, press <ESC>.

Continue to Save NoteReturn to Table of Contents

Save Transcription


111-72-57 FROG.KERMIT M25


Note:DSM-IV Diagnosis Codes & Diagnosis DescriptionAxis I [296.33] Severe DepressionAxis II [Axis III [Axis IV [Axis V: [

TYPE OF TREATMENT: In y, frequency andDuration of treatment; using the examples below.

Modality: [x] Psychopharmacology

Frequency: [ ] Weekly [x] Twice per month [ ] Monthly [ ] Quarterly [ ] Other, please specify:Duration: [x] Within UR Protocol [ ] Out of Protocol[ ] Long term maintenance [ ] Other, please specify:


Save and Exit

Select Choice

Discard and Exit Save and Exit

S

Save and Exit

When you complete data entry, press <ESC>, OMR prompts you to saveor discard your work.

You can save unfinished work & return to it later.Continue

When you choose to Save & File a note, OMR provides options to:

Review the text you entered

Enter a note title

File the note

Notify the provider that the note is ready to sign

If you press <ENTER> to accept the default of Yes, OMR sendsthe note to the provider’s online list of notes requiring signature.

Enter “ N “ if you wish to return later to complete additional work onthe note before you forward it to the provider for signature.

Review the note? N / /Title (I.e. SUMMARY):OK to file this note? Y / /Notify provider to sign note? Y / /


Display/Edit Transcription


Editing Transcribed Notes

Unsigned notes• Transcriptionists can edit any unsigned noteentered via transcription for services for which they authorized

Signed notes• Transcriptionists can not edit signed notes.• Once a note has been signed, OMR permitsproviders to make edits during the 3 hours following signing. After that, providers can add addendumsat any time.

Continue to Display/Edit Transcription

You can display or edit any unsigned note entered via theTranscription Option for services you are authorized to access.

Enter “ 2 “ at the Transcription Option prompt todisplay or edit an unsigned note.




Continue

You can display or edit notes using: Transcription date

Patient ID

Enter the name of the provider whose notesyou want to display or edit.

TRANSCRIPTION DATE OR PATIENT ID: T

Continue

PROVIDER:

1. SMITH, MARY 11-111 PSYCHIATRY PAGE: 99999

SMITH, MARY

U 1. FROG,KERMIT 2. FROG,KERMITU 3. FROG,KERMIT

105829511172571316942

PROGRESS NOTEPROGRESS NOTEPROGRESS NOTE

VISIT DATE: 07/24/01 MVWVISIT DATE: 07/22/01 MVWVISIT DATE: 07/23/01 MVW

PROVIDER: SMITH, MARY

Choose from above list to editor press <ENTER> to continue displaying

CHOOSE: 1

Continue

At the prompt, enter the number associated with the note you wish todisplay or edit.

When you choose to display/edit transcriptions by transcription date& enter the provider whose notes you wish to display/edit, OMR Lists all notes entered via transcription for the transcription date specified.

OMR labels all unsigned Notes with a “ U “. Only the text of unsigned notes can be displayed or edited.

OMR also includes the system initials of the transcriptionist who entered the note.

PROVIDER: SMITH, MARY / /Service and Location: 1. Psychiatry, Beth Israel Outpatient DepartmentOk? Y / /PATIENT: FROG,KERMIT / /DATE OF SERVICE: 07/21/2001 / / Initial note Letter Progress note Telephone contact

WHICH TYPE OF DICTATION?: PROGRESS NOTE / /

Continue

The edit option allows you to make changes to unsigned notes entered using the transcription option. By typing the new information in at the appropriate prompt you can make edits to the following :

To retain the existing information, press <ENTER> at each prompt.

• Provider name• Service & location• Patient name• Date of service• Type of dictation

Patient called to discuss test results.



Provider: Smith, MaryDate: July 24, 2001 Type of dictation: Telephone contact

Continue

Asked patient to schedule follow-up appointment.

Press <ESC> to exit and file edits.

Edit existing text or enter new text.


Printing Unsigned Notes

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Transcription Option 1 Clinical Information options 2 Display/Edit Transcription 3 Enter Transcription 4 Hard Copies - Unsigned 5 Insert test enter/edit 6 Letter/Notes Defaults 7 OMR Messages (Notes for printing) 8 Online Medical Record 9 Providers’ Schedules10 Transcription Report11 UtilitiesTranscription Option: 4 Hard Copies – UnsignedPROVIDER:

Continue

Select one of the following, or press <Enter> for all: Initial note Letter Progress note Telephone contactWHICH TYPE OF DICTATION?:

To print out copies of unsigned notes for review or manual editing, enter “ 4 “ at the Transcription Option prompt.

SMITH, MARY 1. SMITH, MARY 11-111 PSYCHIATRY PAGE 99999OK? Y / /

Enter the name of the provider whose unsigned notes you wish to print.

Enter the type of unsigned note you wish to print. To print all types, press <ENTER>.


Establishing Margin & Printing Defaults

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Continue

To establish margin & printing defaults, enter “ 6 “ for Letter/Notes Defaultsat the Transcription Option prompt.

Default option

1 Letter printing 2 Notes printing

Default option: 1

Continue

To establish margin defaults, enter “ 1 “ for Letter Printing at the

Default Option prompt.

LETTER PRINTING

L LETTERHEAD: Beth Israel Hospital (2 inch top margin) / /LS SECOND PAGE LETTERHEAD:M MARGINS: Two (2) inch left margin / /B BOTTOM MARGIN: Increased margin (1.25 inch) / /W WINDOWS PAGE BREAK OFF?:PS PRINT SINGLE COPY OF LETTER (ON STATIONARY)?: Y / /ESFL PRINT “ELECTRONIC SIGNATURE ON FILE” ON LETTERS

EDIT:

If you print letters for providers, you can use the Letter Printing Default options to establish margins for provider letters.

Enter “ M “ at the prompt to establish the left margin.

Enter “ B “ at the prompt to establish the bottom margin.

Enter “ PS “ at the prompt to control how many copies OMR prints of each letter.

LMBPS

Continue

Enter “ L “ at the prompt to establish the top margin.

Enter “ ESFL “ at the prompt if you wish “ Electronic Signature on File “ to print on each letter.

ESFL

Default option

1 Letter printing 2 Notes printing

Default option: 2 Notes printing

NOTE PRINTING

PU PRINT UNSIGNED NOTES DOUBLE SPACED?:ESFN PRINT “ELECTRONIC SIGNATURE ON FILE” ON NOTES?:

EDIT:


Enter “ PU “ at the prompt to print all unsigned notes double spaced.

Enter “ ESFN “ at the prompt if you wish to have “ Electronic Signature on File “ printed on all notes.

PUESFN

For Additional Information

Continue to Additional Information about OMR

Click on HELP on the CareGroup portal for detailed CCC/OMR help.

Continue

Click on CCC/OMR Help for OMR Documentation topics.

Continue

OMR documentation topics include: General Information, Medications, Notes, Problem Lists, Management Options, and Transcription Information. Continue

Questions or Problems

For computer & printer problems

• Call the IS Support Center x48080

For questions about how to use OMR

• Email [email protected]• Receive a response within 1 business day

Continue

mailto:[email protected]

…And OMR Overview Training is Complete

Click Here to Return to CCC/OMR Help

OR

Click Here to Return to the CareGroup Portal

http://home/portal.asp?category=CCC%20help

http://www.home.caregroup.org/

omr transcription options & features click mouse to advance

Documents

omr access

access omr

transcription report

displayedit transcription

online medical record

transcription option

utilities transcription

transcription option