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1. Searching Date range searched Aug 22 1999 Aug 04 2004 Number of records searched 9189 Number of records found 570 Elapsed time 0 minute s 3 second s Current user TIUPROVIDER SEVEN Current date Aug 04 2004 10 20 57 TIU REASSIGNMENT DOCUMENT REPORT DOCUMENT NAME INITIAL PATIENT FINAL PATIENT REASSIGNMENT DATE TIME Addendum TIUPATIENT EIGHT TIUPATIENT SIX Aug 23 1999 08 46 41 Addendum TIUPATIENT EIGHT TIUPATIENT SIX Aug 23 1999 08 46 42 Discharge Summa TIUPATIENT SEVEN TIUPATIENT SEVEN Aug 25 1999 11 51 47 PULMONARY CS CO TIUPATIENT EIGHT TIUPATIENT NINE Aug 25 1999 15 41 40 PULMONARY CS CO TIUPATIENT NINE TIUPATIENT EIGHT Aug 25 1999 16 03 24 PULMONARY CS CO TIUPATIENT EIGHT TIUPATIENT NINE Aug 25 1999 16 16 32 PULMONARY CS CO TIUPATIENT EIGHT TIUPATIENT EIGHT Aug 25 1999 16 36 05 PULMONARY CS CO TIUPATIENT EIGHT TIUPATIENT EIGHT Aug 25 1999 16 36 06 PULMONARY CS CO TIUPATIENT EIGHT TIUPATIENT FIVE Aug 27 1999 10 47 49 PULMONARY CS CO TIUPATIENT EIGHT TIUPATIENT NINE Aug 27 1999 15 56 28 PULMONARY
2. Patient TIUPATIENT ONE SSN 666 23 3456 Sex MALE Race MEXICAN AMERICAN Age 52 Claim UNKNOWN Adm Date 12 22 96 Ward 1A Dis Date 02 12 97 Adm Dx Stage IV non Hodgkin s Lymphoma Correct VISIT YES lt Enter gt The attending must not be a provider that URGENCY routine lt Enter gt routine A AUTHOR DICTATOR TIUPROVIDER ONE requires a cosignature DICTATION DATE lt Enter gt FEB 12 19 and must be in User ATTENDING PHYSICIAN TIUPROVIDER ONE Ot Calling text editor please wait Class PROVIDER or a 1 gt DIAGNOSIS subclass 2 gt 162 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Enter Edit Discharge Summary cont d 3 gt 4 gt 5 gt 6 gt OPERATIONS PROCEDURES EDIT Option 1 Edit line 6 1 gt DIAGNOSIS Replace With Lymphoma Replace DIAGNOSIS Lymphoma 6 gt OPERATIONS PROCEDURES Chemotherapy Replace EDURES Chemotherapy Replace With OPERATIONS PROC Edit line lt Enter gt Save changes YES EDIT Option lt Enter gt lt Enter gt Saving Discharge Summary with changes Is this NOT RELEASED You may enter anot Discharge Summary ready to release from DRAFT YES n her Discharge Summary Press RETURN to exit Select PATIENT NAM E lt Enter gt
3. Progress Notes Feb 14 2001 16 05 36 Page 1 of 6 lt DA gt PROGRESS NOTES 74 note s TIUPATIENT FOUR 666 55 2384 MAR 3 1960 40 Title Author Date Time 1 ID PARENT NINE TIUPROVIDER 02 14 01 08 15 compl 2 _ID CHILD OCCUPATIONAL THER TIUPROVIDER 02 14 01 08 16 compl 3 ER NOTE TIUPROVIDER 02 14 01 08 14 compl 4 ID PARENT REHAB TREATMENT PL TIUPROVIDER 02 08 01 08 26 compl 5 _ ID CHILD REHAB INITIAL A TIUPROVIDER 02 08 01 13 29 compl 6 _ID CHILD REHAB PSYCHOLOGY TIUPROVIDER 02 09 01 09 13 compl 7 _ID CHILD REHAB PHYSICAL TH TIUPROVIDER 02 14 01 16 02 compl 8 ANGIOPLASTY NOTE TIUPROVIDER 01 08 01 13 16 compl 9 _Addendum to ANGIOPLASTY NO TIUPROVIDER 02 14 01 08 13 compl 10 ID CHILD ONE TIUPROVIDER 01 08 01 13 14 compl 11 ID ANY CHILD NOTE TIUPROVIDER 01 02 01 07 52 compl 12 SEVEN S CHILD SIX TIUPROVIDER 12 28 00 13 49 compl 13 SEVEN S CHILD FIVE TIUPROVIDER 12 28 00 13 48 compl 14 lt SEVEN S ID NOTE TIUPROVIDER 12 28 00 13 31 compl NW New Note SS Select Search IN Interdiscipl ry Note B Browse RS Reset to All Signed EE Expand Collapse Entry PC Print Copy AD Make Addendum Q Quit SP Select New Patient S Complete Note s Select Action Next Screen 58 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Discharge Summary Clinicians can review enter print and sign discharge summaries either by individual patient or by multiple pat
4. 194 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Patient Print Progress Notes Example cont d TIUPATIENT TWENTY 666 77 6641 Progress Notes 11 08 95 15 20 CONTINUED FROM PREVIOUS SCREEN NOTE DATED 03 20 96 08 30 Diabetes Education Glucose Monitoring VISIT 03 19 96 08 00 DIABETES EDUCATION SUBJECT TESTING MULTIPLE COPY Date of Class Class Advantage Blood Glucose Monitor Process Lecture Demonstration and Return Demonstration Issued Advantage monitor Level I and II glucose control solutions and 3 boxes 50 each Advantage test strips Subjective Patient states Tests his BG times day Has not received previous directions Objective Patient attended class With Significant Other No Yes Any observed barriers to learning No Yes Concepts 1 Location of batteries 2 Using memory 3 Coding machine 4 Using glucose control These expire 3 mo after opening Dia Performing a blood glucose test A Clean fingertip only with warm soap and water B Use side of any or all fingertips unless there is sore or other damage present 6 Proper care and storage of machine and strips 7 Disposal of lancets in puncture proof container Label A Knowledge deficit r t Advantage SBGM P If no previous directions received recommend
5. 2 Select a Patient Select Progress Notes User Menu Option Search by Patient AND Title Select PATIENT NAME TIUPATIENT ONE TIUPATIENT ONE 09 12 44 666233456 YES SC VETERAN 1 note C 07 22 91 11 27 1 note W 07 22 91 11 34 A Known allergies 1 note D 04 01 92 10 58 3 Type in one or more Progress Note Titles to search for Please Select the PROGRESS NOTE TITLES to search for 1 Lipid CLINIC TITLE 2 Diabetes EDUCATION TITLE 3 lt Enter gt Start Reference Date Time T 2 lt Enter gt SEP 10 1996 Ending Reference Date Time NOW lt Enter gt SEP 12 1996 11 06 Searching for the documents 4 A list is displayed of all notes that meet the criteria you specified ALL Progress Notes Sep 12 1996 11 06 24 Page Patient 1 TIUPATIENT 2 TIUPATIENT Next S Find Add Document Edit ake Addendum Link Select Action by PATIENT from 07 14 96 to 09 12 96 Document Diabetes Addendum D3456 D3456 creen Prev Screen Sign Cosign Detailed Display Browse Print Identify Signers Quit lt Enter gt Ref Date Education 09 12 96 to Diabetes Edu 09 09 96 More Actions Change View Copy Delete Document Quit 1 of 1 2 documents Status completed unsigned gt gt gt Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 49 Progress Notes
6. Document List Management This option lets you specify which types Titles of documents you wish to choose from when asked to select from a given Class e g Discharge Summary or Progress Notes Then when you create a Progress Note you will be prompted to select from the specified list of Titles say Lipid Clinic Note History amp Physical Interservice Transfer Note and Discharge Planning in that order This option also lets you specify a default title for the selected Class Steps to use option 1 Select Document List Management from your Personal Preferences Menu on your TIU menu Select Personal Preferences Option 2 Document List Management Personal Document Lists This option allows you to create and maintain lists of TITLES for any of the active CLASSES of documents supported by TIU at your site Explain Details NO y YES When you use the option to enter a document belonging to a given class you will be asked to select a TITLE belonging to that class Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual Document List Management cont d For any particular class you may find that you only wish to choose from among a few highly specific titles e g if you are a Pulmonologist entering a PROGRESS NOTE you may wish to choose from a short list of three or four titles related to Pulmonary Function or Pul
7. Patient PATIENT FOUR J0222 IU Parent Title OPERATION REPORT IEN 1734321 Parent Entry DT FEB 03 2006 12 43 49 Parent Author TIUAUTHOR THREE Child Title NURSE INTRAOPERATIVE REPORT IEN 1734320 Patient TIUPATIENT FOUR J0222 Parent Title EPHONE CONTACT IEN 1734512 Parent Entry DT JUN 26 2006 10 42 25 Parent Author TIUAUTHOR FOUR Child Title ECU ADL SELF CARE PERFORMANCE SUMMARY IEN 1734511 Rev January 2012 Text Integration Utilities V 1 0 147 Clinical Coordinator amp User Manual TOTAL COUNTS FOR MISMATC ED ID NOTES 1173 CROSS REFERENC 1 MISS MATCHED NOT 1 NON EXISTENT PAR 2 PARENT MAY NOT BE T ti Example of Report and Fix mode MISMATCHED INTERDISCIPLINARY NOTES CHILD DOCUMENT PARENT DOCUMENT Patient TIUPATIENT ONE P1234 TIUPATIENT TWO P5678 Title INTERDISCIPLINARY PATIENT EDUCATI PM amp R KT Entry DT JAN 21 1998 15 28 27 FEB 01 1996 14 16 10 Author TIUAUTHOR ONE TIUAUTHOR ONE Note IEN 345678 123456 SE Removed pointer from child to parent Patie
8. 4 05 28 96 12 37 Crisis Note SEVEN TIUPROVIDER Visit 02 20 96 5 05 28 96 12 37 Crisis Note SEVEN TIUPROVIDER Visit 02 20 96 4 Choose a document from the list Choose documents 1 6 1 Opening Diabetes Education record for review 68 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Individual Patient Document cont d Browse Document Jun 26 1996 17 08 45 Page 1 of 1 Diabetes Education TIUPATIENT 666 23 3456 Visit Date 07 22 91 11 06 DATE OF NOTE JAN 09 1996 17 51 04 ENTRY DATE JAN 09 1996 17 51 04 AUTHOR TIUPROVIDER THREE EXP COSIGNER TIUPROVIDER SIX URGENCY STATUS COMPLETED Provided Mr TIUPatient with Diabetes diet pamphlet and explained areas h especially needed to be concerned about es TIUPROVIDER THREE MD for TIUPROVER SIX MS3 Medical Student III Next Screen Prev Screen More actions Find Make Addendum Identify Signers Print Sign Cosign Delete Edit Copy Link Quit Select Action Quit 5 Select one of the actions to perform on the document e g edit sign make addendum Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 69 All MY UNSIGNED Documents When you choose this option from the Integrated Document Management Menu all your unsigned
9. TIUPATIENT ONE 666 23 3456 Progress Notes NOTE DATED 04 24 96 15 41 LIPID CLINIC VISIT 04 24 96 15 40 DIABETIC EDUCATION INDIV MOD B SUBJECTIVE 51 year old MEXICAN AMERICAN MALE here for initial evaluation of his DYSLIPIDEMIA PMH Significant negative medical history pertinent to the evaluation and treatment of DYSLIPIDEMIA FH SH MEDICATION HISTORY CURRENT MEDICATIONS DIET Counseled on AHA Step I diet today by NINE TIUPROVIDER See her evaluation ACTIVITY OBJECTIVE HT 72 08 23 95 11 45 WT 190 08 23 95 11 45 TSH T4 FBG 89 HEMOGLOBIN AIC SGOT URIC ACID ASSESSMENT Ta MALE with without documented CAD 2y CV Risk factors 34 Lipid pattern PLAN iL fe Implement recommendations to lower fat intake SCH Repeat FBG and HBG Al on Sy Return to review lab on Signed by es Three TIUProvider MD Internist 04 24 96 15 41 Analog Pager 555 1213 Digital Pager 555 1215 Enter RETURN to continue or to exit lt Enter gt iL Discharge Summary Print 2 Progress Note Print 3 Clinical Document Print Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 103 Released Unverified Report Use this option to produce a list of released documents which haven t been verified Steps to use option 1 Select Released Unverified Report from the MRT menu 2 Enter the starting and
10. Beware this patient bites Signed by es NINE TIUPROVIDER VERIFIER 09 06 95 21 53 NOTE DATED 11 08 95 15 20 History amp Physical Ex VISIT 09 05 95 11 00 DIABETES CLINIC SUBJECT TESTING THE GLUCOSE LEVEL 1 Chief Complaint Numbness in legs Reason for Admission if different from 1 2 History of Present Illness Type 2 onset 1993 Medication Allergies Penicillin causes rash Current Medications Oral insulin Enter RETURN to continue or to exit lt Enter gt Rev January 2012 Text Integration Utilities V 1 0 191 Clinical Coordinator amp User Manual Patient Print Progress Notes Example cont d TIUPATIENT EIGHT 666 77 6641 Progress Notes 11 08 95 15 20 CONTINUED FROM PREVIOUS SCREEN PAST HISTORY 1 Hospitalizations 6 10 93 Surgeries Injuries Illness Disabilities Transfusion s Yes X No If Yes give date s 2 Unusual Childhood Illnesses Immunizations X DT last booster 1 90 Pneumonia Flu Hep B Other 3 Habits x Smoking x Alcohol Drugs Caffeine Use x Coffee Tea Cola Suicide Attempts OTHER 4 SOCIAL MILITARY HISTORY Occupations WWI WWII KOREAN x VIETNAM GULF WAR Travel Lives with Source of Income Job Retired x Pension Other 5 REVIEW OF SYSTEMS 6
11. Select REPORT TYPE DISCHARGE SUMMARY lt Enter gt Discharge Summary SHDR DISCHARGE SUMMARY SOC SEC NUMBER 666 12 1212 ADMISSION DATE 02 21 96 DISCHARGE DATE 02 25 96 DICTATED BY TIUPROVIDER TWO DICTATION DATE 02 26 96 ATTENDING TIUPROVIDER SEVEN TRANSCRIPTIONIST ID T1212 URGENCY PRIORITY S TXT DISCHARGE SUMMARY Text END xxx File should be ASCII with width no greater than 80 columns kkk Use for BLANKS word or phrase in dictation that isn t understood Press RETURN to continue lt Enter gt 174 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Chapter 7 TIU for Remote Users Individual Patient Document Multiple Patient Documents Rev January 2012 Text Integration Utilities V 1 0 175 Clinical Coordinator amp User Manual Chapter 7 TIU for Remote Users The options on this menu allow remote users e g VBA RO personnel to access documents which have been completed i e legally authenticated by signature or cosignature if necessary to facilitate processing of claims Remote User Menu Option Description Individual Patient This option allows remote users e g VBA RO personnel to Document access individual documents which have been completed Multiple Patient Documents This option allows remote users e g VBA RO personnel to review and print multiple documents which have been completed
12. The text editor brought up a boilerplate template used for Discharge Summaries entries NO Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 163 Enter Edit Document This option allows the transcriptionist to enter a new document using a document title from the TIU document definition hierarchy or to review verify send back to transcription reassign or print an existing document The option produces a list of document definition types using search criteria such as status search category and reference date range from which you select a document Steps to use option 1 Select Enter Edit Document from the Transcriptionist Menu Select Text Integration Utilities Transcriptionist Option 2 Enter Edit Document Select AUTHOR TIUPROVIDER THREE TIUPROVIDER THREE TT 2 Enter a patient s name and choose the admission from the choices offered Select Patient TIUPATIENT SEVEN TIUPATIENT SEVEN 04 25 31 666042591P NO MILITARY RETIREE 1 note C 11 30 95 17 36 2 notes W 09 16 96 15 12 addendum 09 18 96 09 53 A D Known allergies 1 note 11 30 95 17 38 For Patient TIUPATIENT SEVEN Select DOCUMENT TYPE discharge summary TITLE The following ADMISSION S are available 1 gt MAY 28 1996 15 58 A C TO 1A 2 gt MAY 28 1996 15 51 DIRECT
13. TRANSCRIPTIONIST bs DIAGNOSIS 1 Status post head trauma with brain contusion 2 Status post cerebrovascular accident 3 End stage renal disease on hemodialysis 4 Coronary artery disease 5 Congestive heart failure 6 Hypertension 7 Non insulin dependent diabetes mellitus 8 Peripheral vascular disease status post thrombectomies 9 Diabetic retinopathy OPERATIONS PROCEDURES 1 MRI 2 CT SCAN OF HEAD HISTORY OF PRESENT ILLNESS Patient is a 49 year old white male with past medical history of end stage renal disease peripheral vascular disease status post BKA coronary artery disease hypertension non insulin dependent diabetes mellitus diabetic retinopathy congestive heart failure status post CVA status post thrombectomy admitted from Anytown VA after a fall from his wheelchair in the hospital He had questionable short lasting loss of consciousness but patient is not very sure what has happened He denies headache vomiting vertigo DRAFT Press RETURN to continue or to exit SALT LAKE CITY priority 06 26 96 14 24 Page 2 PATIENT NAME AGE SEX RACE SSN CLAIM NUMBER TIUPATIENT ONE Eck MEXI 666 23 3456 On admission patient had CT scan which showed a small area of parenchymal hemorrhage in the right temporal lobe which is most likely consistent with hemorrhagic contusion without mid line shift or incoordina
14. 193 Patient Print Progress Notes Example cont d TIUPATIENT EIGHT 666 77 6641 Progress Notes 11 08 95 15 20 CONTINUED FROM PREVIOUS SCREEN Last Pap Results Previous Gyn Surgery Birth Control Method Number of Pregnancies iscarriages Stillbirths Live Births Menopause Onset What effect Hormones Prior STD History Last Mammogram Results Number of sexual partners in the past six months Y N SYMPTOMS DESCRIPTION Stress Incontinence Vaginal Discharge Itching Rash Sores Lower Abdominal Pain Dyspareunia Breast Lumps Pain Breast Rash Nipple Discharge Abnormal Bleeding Other PHYSICAL EXAMINATION NOTE Ohio State Law requires that every female inpatient receive a breast and pelvic exam unless one was performed within the preceding 12 months or the patient refuses th xamination in writing Patient must sign below BREASTS dal DESCRIPTION QUADRANT I I Vi 1 I 1 1 LoL L Lo 0 s ss 1 1 l I 1 1 L L GENITALIA Vulva Urethra Vagina Cervix Fundus Adnexa PATIENT REFUSAL OF EXAMINATION I do not wish to receive a breast or pelvic exam at this time I would like to be scheduled for an outpatient breast and pelvic exam at the Women s Health Clinic Patient s Signature 8 INITIAL IMPRESSION ASSESSMENT 9 WORKING DIAGNOSIS 10 PLAN Enter RETURN to continue or to exit lt Enter gt
15. Answer with MEDICAL CENTER DIVISION NUM or NAME or FACILITY NUMBER or TREATING SPECIALTY Choose from 1 SALT LAKE OEX 660 2 ISC SLC A4 660HA 3 SALT LAKE CIOFO 660GC Select division ALL lt Enter gt 3 Select one or more of the following statuses 1 undictated 6 uncosigned 2 untranscribed 7 completed 3 unreleased 8 amended 4 unverified 9 purged 5 unsigned 10 deleted Enter selection s by typing the name s number s or abbreviation s Select Status UNSIGNED 4 UNVERIFIED Multiple Patient Documents cont d 4 Select one of the following types these may be different at your site Addendum Discharge Summary Progress Notes Select Clinical Documents Type s All Addendum Discharge Summary Progress Notes 5 Enter a date range Start Entry Date Time T 7 t 30 May 02 1997 Ending Entry Date Time NOW lt Enter gt JUN 02 1997 14 31 Searching for the documents Rev January 2012 Text Integration Utilities V 1 0 91 Clinical Coordinator amp User Manual 6 All the documents for the criteria selected are displayed Choose an action to perform then the document Verify action example UNVERIFIED Documents Jun 02 1997 14 31 12 Page 1 of 1 from 05 02 97 to 06 02 97 9 documents Patient Document Admitted Disch d 1
16. Enter RETURN to continue or to exit 1 Discharge Summary Print 2 Progress Note Print 3 Clinical Document Print Select Print Document Menu Option lt Enter gt 122 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Clinical Document Print Use this option to print chart or work copies of all clinical documents available through TIU Steps to use option 1 Select Clinical Document Print from the Print Document Menu and then enter a patient name Select Print Document Menu Option 3 Clinical Document Print Select PATIENT NAME TIUPATIENT ONE TIUPATIENT ONE 09 12 44 666233456 YES SC VETERAN 2 notes C 05 28 96 12 37 2 notes W 05 28 96 12 33 A Known allergies 2 notes D 05 28 96 12 36 Available documents 02 17 92 thru 06 21 96 34 2 Enter a date range that documents will be chosen from Please specify a date range from which to select documents List documents Beginning 02 17 92 6 1 96 JUN 01 1996 Thru 06 21 96 6 8 96 JUN 08 1996 1 06 07 96 00 00 Diabetes Education One TIUProvider Visit 04 18 96 2 06 05 96 17 23 Lipid Clinic Three TIUProvider Visit 04 18 96 3 06 05 96 11 10 Addendum to Lipid Clinic Three TIUProvider Visit 04 24 96 Choose the document or documents you would like printed and whether you want work or chart copies Choose doc
17. Most common Enter the ending date NOW Safest Do you wish to delete the entire entry NO Last entered Enter the Provider Name TTUPROVIDER THREE 14 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual List Manager Screen Display of pages Screen Title te Jun IT 1997 99 37 17 Page indicated here by AUTHOR TUPROVIDERONE or EXPECTED COSIGNER Document Ref Date Status 06572 Raverce React Allergy 95 31 97 unsigned ONE H2591 Adverse React llergy 057 31 97 unsigned Message window screen d ore Sign Cosign Detailed Display Dr ng Print Identify Signere TIU uses the List Manager utility which enables TIU and other applications to display a list of items in a screen format Screen title The screen title changes according to what type of information List Manager is displaying e g Progress Notes Discharge Summary etc Header area The header area is a fixed non scrollable area that displays patient information List area scrolling region This area scrolls if there are more items than will fit on one page It displays a list of items such as Unsigned Progress Notes that you can take action on If there s more than one page of items it s listed in the upper right hand corner of the screen Page 1 of Message window This section displays a plus sign minus or gt gt sign or informational text i e
18. pieces of documents such as Subjective Objective Assessment and Plan in a SOAP Progress Note Components may have sub Compon ents as items They may have Boilerplate Text Components may be designated as Shared 238 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Glossary cont d CPRS Computerized Patient Record System A comprehensive VISTA program which allows clinicians and others to enter and view orders Progress Notes and Discharge Summaries through a link with TIU Problem List view results reports including health summaries etc CWAD Cautions Warnings Adverse Reactions Directives a type of Progress Note Discharge Summary Discharge summaries are summaries of a patient s medical care during a single hospitalization including the pertinent diagnostic and therapeutic tests and procedures as well as the conclusions generated by those tests They are required for all discharges and transfers from a VA medical center domiciliary or nursing home care The automated Discharge Summary module of TIU provides an efficient and immediate mechanism for clinicians to capture transcribed patient discharge summaries online where they re available for review signing adding addendum etc Document Class Document Classes are categories that group documents Titles with similar characteristics together For example Nursing Progress Notes might be a Docum
19. Enter for more actions If you enter a plus sign at the action prompt List Manager jumps forward a page If a minus sign is displayed and you enter it at the action prompt List Manager jumps back a screen The plus minus and gt signs are only valid actions if they are displayed in the message window Rev January 2012 Text Integration Utilities V 1 0 15 Clinical Coordinator amp User Manual List Manager Screen Display cont d Action area A list of actions display in this area of the screen If you enter a double question mark at the Select Item s prompt you are shown a hidden list of additional actions that are available to use Entering Actions The List Manager utility lets you browse through the list select items that need action take action against those items select other actions without leaving the option Actions are entered by typing the name or abbreviation at the Select Action prompt Shortcut Actions may also be preselected by typing the action abbreviation then the number of the document on the list Example ED 1 will let you edit entry 1 Consult Report Besides the actions specific to the option you are working in List Manager provides generic actions applicable to any List Manager screen Enter a double question mark 2 at the Select Action prompt for a list of all actions available The abbreviation for each action is shown in brackets following the
20. OK YES lt Enter gt Calling text editor please wait ED E 1 gt Treatment for aller 2 gt lt Enter gt IT Option lt Enter gt gic reaction to injury Saving Adverse React Allergy with changes Is this Adverse React Allergy ready to release from DRAFT YES lt Enter gt Adverse React Allergy Released Se CR Please Indicate the Diagnoses for which TIUPATI lect PRIMARY PROVIDER S PHYSICIAN Enter your Current Signature Code lt Enter Signature gt SIGNATURE TIUPROVIDER S EVEN lt Enter gt TIUPROVIDER S ENT or OUTPATIENT care OUTPATIENT lt Enter gt ONCOLOGY ONCOLOGY ONCOLOGY C G ARDIOLOGY ENERA 1 MEDICINE or lt N gt EW VISIT 2000 09 21 24 AMBULATORY WALK IN VERIFIED EVEN ENT FOUR was Seen 18 Ascites 34 Shoulder 1 Abdominal Pain 19 ASHD MISC 2 2 Abnormal EKG 20 Asthma 35 DIETARY SURVEIL COUN 3 Abrasion 21 Atrial Fibrillation 3 R S 4 Abscess 22 Atypical Chest Pain 3 A list of diagnoses EE Reactio see EN Fingernail 3 relating to the clinic as 7 Alcoholic intoxicat 24 Animal 4 defined using the AICS 8 Alcoholism Chronic 25 Insect Bite 4 package is presented 9 Allergic Reaction MISC 4 10 Anemia 26 Bleeding GI a for you to choose from ANGINA 27 Blurred Vision 4 een 11 Stable 28 BPH 45 Cirrhosis 12 Unstable 29 Bronchitis acute 46 Conjunctivitis
21. Q Close Patient Chart Select Chart Contents Example Writing a note Select Chart Contents NW Write New Note Available note s 11 22 96 thru 02 24 97 9 Do you wish to review any of these notes NO YES Select note s to review Please specify a date range from which to select note s List Notes Beginning 11 22 96 lt Enter gt NOV 22 1996 Thru 02 24 97 lt Enter gt FEB 24 1997 1 02 24 97 08 28 CRISIS NOTE Two TIUProvider Adm 09 21 95 2 02 21 97 09 16 CLINICAL WARNING Sixteen TIUProvider Adm 09 21 95 3 01 24 97 14 18 General Note Three TIUProvider Adm 09 21 95 SUBJECT TEST 4 01 15 97 00 00 CLINICAL WARNING One TIUProvider MD Visit 08 14 95 5 12 04 96 14 39 SOAP GENERAL NOTE Three TIUProvider Adm 09 21 95 Choose Notes 1 5 lt Enter gt Nothing selected 26 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Example Writing a note cont d Personal PROGRESS NOTES Title List for NINE TIUPROVIDER 1 Crisis Note 2 Advance Directive 3 Adverse Reactions 4 Other Title TITLE 1 4 3 Adverse React Allergy Creating new progress note Patient Location 2B Date time of Admission 09 21 95 10 00 Date time of Note NOW Author of Note TIUPROVIER NINE OK YES lt Enter gt SUBJECT OPTIONAL description Calling text editor ple
22. Use this option to review verify print or other actions an MRT can perform on clinical documents for a selected patient Steps to use option 1 Select Individual Patient Document from the TIU MRT menu and then enter a patient name to view documents for Select Text Integration Utilities MRT Option 1 Individual Patient Document Select PATIENT NAME TIUPATIENT ONE TIUPATIENT ONE 666 23 3456 1A SC VETERAN If the patient 2 notes W 05 28 96 12 33 S Available documents 10 24 96 thru 10 28 96 3 has Cautions Enter a date range then choose a document from the list Please specify a date range from which to select documents List documents Beginning 02 17 96 lt Enter gt FEB 17 1992 Thru 10 28 96 lt Enter gt OCT 28 1996 i 1 10 28 96 17 11 BP TEST One TIUProvider mp here In this Adm 07 22 91 Dis 02 12 96 case the patient 2 10 25 96 11 32 Psychology Crisis Four TIUProvider h e Adm 10 25 96 as a Warning Choose documents 1 6 1 W Rev January 2012 Text Integration Utilities V 1 0 89 Clinical Coordinator amp User Manual Individual Patient Document cont d 3 The selected document is displayed You may press Enter to see the remaining two pages or choose an action to perform Browse Document Oct 30 1996 10 33 54 Page L of 3 BP TEST TIUPATIENT O
23. to exit lt Enter gt Detailed Display Apr 17 1997 16 44 31 Page LL et 1 Se Basics Name Abbreviation Print Name Type National Standard Status Owner In Use Items Boilerplate Text Help Try lect Action N Hp pe Quit ORK Title ADVANCE DIRECTIVE n inherited ote Values preceded by have b DVANCE DIRECTIVE DIR DVANCE DIRECTIVE ITLE ES CTIVE LINICAL COORDINATOR ES Next Previous Screen Find PS PL Quit 84 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual Rev January 2012 View Objects This option displays Objects in alphabetical order by Name You can print all available Objects from your site or specific ones Clinician Document Definition Menu Edit Document Definitions Sort Document Definitions View Objects Select Document Definitions Clinician Option 3 View Objects START WITH OBJECT FIRST peter an ENT ETC peed wane ea ede E grid alae REN ae wee Objects Apr 17 1997 11 57 57 Page 1 of 3 Name Status ACTIVE EDICATIONS RGIES ADR BLOOD PRESSURE ENT ADMISSION OW PATIENT AGE PATIENT DATE OF BIRTH PATIENT DATE OF DEATH PATIENT PATI PATIENT RACE PATIE X PATIE PATI PULSI RESPIRATIO TEMPERATURE TODAY S DATE VI
24. 08 27 09 Discharge Summary FIVEH aaa UNDREDELEV TAT Enter RETURN to continue or to exit TRANSCRIPTION BI CAMP MASTE 01 01 2009 to 01 e for Documents Transcribed Tran Date itle Patie E B LLING R 31 2010 R PORT Printed 05 05 2010 11 18 nt Aut VBC Lines 12 03 09 OPERATION REPORT BCMA TO TAT ETURN to continue or to exit EIGHT 0008 JI Ia D tal for Transcriber tlc Total for Division TRANSCRIPTION B I CINCINNAT 01 01 2009 to 01 for Documents Transcribed Tran Date Title Patie Co B LLING I 31 2010 R PORT Printed 05 05 2010 nt Aut VBC tle 07 24 09 Discharge Summary BCMA TO EIGHTYSIX PATI 0086 BA tal for Transcriber tlc Total for Division Rev January 2012 Text Integration Utili ties V 1 0 157 Clinical Coordinator amp User Manual Press RETURN to continue or to exit TRANSCRIPTION BILLING REPORT SUMMARY for ZZ ALBANY PRRTP for Documents Transcribed 01 01 2009 to 01 31 2010 Printed 05 05 2010 11 18 Category Documents VBC Lines Division Totals CAMP MASTER 450 82 CINCINNATI 56 54 Transcriber Totals mti 113 22 ELG 281 58 Station Totals ZZ ALBANY PRRTP 10 507 36 Press RETURN to continue or to exit lt Enter gt 158 Text Integration Utilities V 1 0 Rev
25. 13 Anorexia BURN 47 Constipation 14 Appendicitis Acute 30 First Degree 48 Contusion 15 Arthralgia 31 Second Degree 49 COPD ARTHRITIS 32 Third Degree 50 Costochodritis 16 Osteo BURSITIS 51 CVA 17 Rheumatoid 33 Elbow 52 Cyst Pilonidal 234 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Example Entry of Progress Note cont d A list of procedures Select Diagnoses lt RETURN gt to see next page of choi S 1 52 relating to the clinic as defined using the AICS package is presented for you to choose from P Please Indicate the Procedure s E d on TIUPATIENT EIGHT NEW PATIENT 1 Brief Visit Cardioversion 29 Small Joint 17 EKG DISLOCATION RH 2 Limited Exam 18 Pericardiocentesis 30 Elbow 3 Intermediate Exam 19 Thoracotomy 31 Nasal 4 Extended Exam ENT 32 Phalanx 5 Comprehensive Exam 20 Removal Impacted Cer 33 Radial Head ESTABLISHED PATIENT NASAL CAUTERING AND 34 Shoulder 6 Brief Exam 21 Anterior Simple 35 Temporomandibular 7 Limited Exam 22 Anterior complex 36 Finger Splint 8 Intermediate Exam 23 Posterior 37 Forearm Splint 9 Extended Exam EYE 38 Injection Tendon She 10 Comprehensive Exam 24 Foreign Body Removal IGAMENT TRIGGER CONSULTATIONS 26 PROFESSIONAL C PULMONARY 11 Brief Visit 32 MANDATED SER
26. 176 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Individual Patient Document Steps to use option 1 Select Individual Patient Document from your TIU menu Select Integrated Document Management Option Individual Patient Document 2 Select a patient Select PATIENT NAME TIUPATIENT ONE 09 12 44 666233456 YES SC VETERAN 2 notes C 05 28 96 12 37 addendum 08 12 96 16 04 2 notes W 05 28 96 12 33 A Known allergies 3 notes D 07 08 96 14 14 Available documents 02 17 92 thru 10 28 96 54 3 Enter a date range to display documents for Please specify a date range from which to select documents List documents Beginning 02 17 96 lt Enter gt FEB 17 1992 Thru 10 28 96 lt Enter gt OCT 28 1996 Adm 12 22 94 1 01 09 96 17 51 Diabetes Education FOUR TIUPROVIDER MS3 Adm 07 22 91 SUBJECT Diet etc 2 09 29 95 16 54 Lipid Clinic FIVE TIUPROVIDER Adm 08 14 95 SUBJECT Dyslipidosis 3 04 24 96 08 28 Lipid Clinic ONE TIUPROVIDER MD Visit 04 24 92 SUBJECT Lipid test 4 02 17 96 08 00 Arterial Evaluation THREE TIUPROVIDER Visit 02 17 92 SUBJECT Rule out embolus lower extremity TAL TO STOP 2 Rev January 2012 Text Integration Utilities V 1 0 177 Clinical Coordinator amp User Manual Individual Patient Document cont d
27. Document Definitions Clinician 1 Edit Document Definitions 2 Sort Document Definitions 3 View Objects MAS Options to Print Progress Notes Admission Prints all PNs for Current Admission Batch Print Outpt PNs by Division Outpatient Location Print Progress Notes Ward Print Progress Notes 202 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual Rev January 2012 TIU Menus and Options cont d TIU Maintenance Menu L TIU Parameters Menu 1 Basic TIU Parameters 2 Modify Upload Parameters 3 Document Parameter Edit 4 Progress Notes Batch Print Locations 5 Division Progress Notes Print Params 2 Document Definitions Manager 1 Edit Document Definitions 2 Sort Document Definitions Objects 3 Create Document Definitions 4 Create Objects 5 Create TIU Health Summary Objects 3 User Class Management 1 User Class Definition 2 List Membership by User 3 List Membership by Class 4 Manage Business Rules 4 TIU Template Mgmt Functions 1 Delete TIU templates for selected user 2 Edit auto template cleanup parameter 3 Delete templates for ALL terminated users 5 TIU Alert Tools 6 Unsigned Uncosigned Report 7 TIUHL7 Message Manager TIU Conversion Clean up Menu GMRP TIU This menu comes with Patch GMRP 2 5 44 which is distributed prior to TIU to help clean up the Generic Progress Notes File 121 and the Generic Progress Notes Title File 121 2 I
28. MAY 20 1997 10 51 18 ENTRY DATE MAY 20 1997 10 51 18 AUTHOR TIUPROVIDER ONE EXP COSIGNER URGENCY STATUS UNSIGNED MORE TESTS ORDERED Next Screen Prev Screen More actions Print No Ready for Signature NO y Yes Item 3 Added to signature list 70 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual All MY UNSIGNED Documents cont d Opening General Note record for review SIGN COSIGN Jun 06 1997 12 04 59 Page 1 of 1 General Note TIUPATIENT FIVE 666 04 3779P 2B Visit Date 05 28 96 15 58 DATE OF NOTE APR 07 1997 15 50 26 ENTRY DATE APR 07 1997 15 37 25 AUTHOR TIUPROVIDER ONE EXP COSIGNER URGENCY STATUS UNSIGNED general malaise Next Screen Prev Screen More actions Print No Ready for Signature NO y Yes Item 4 Added to signature list Opening Adverse React Allergy record for review SIGN COSIGN Jun 06 1997 12 04 10 Page 1 of 1 Adverse React Allergy TIUPATIENT ONE 666 23 3456 Visit Date 07 22 91 11 06 DATE OF NOTE MAR 24 1997 11 03 39 ENTRY DATE MAR 24 1997 11 03 39 AUTHOR TIUPROVIDER FIVE EXP COSIGNER URGENCY STATUS UNSIGNED Hay fever reactions severe antihistamines not working Prescribed new medication Next Screen Prev Screen More actions Print No R
29. OPTION for help text Select TIU Maintenance Menu Option 5 TIU Alert Tools Select DOCUMENT STATUS UNSIGNED 1 undictated 5 unsigned 9 purged 2 untranscribed 6 uncosigned 10 deleted 3 unreleased 7 completed 11 retracted 4 unverified 8 amended Enter selection s by typing the name s number s or abbreviation s Select STATUS UNSIGNED ALL undictated untranscribed unreleased unverified unsigned uncosigned completed amended purged deleted retracted Select SEARCH CATEGORY AUTHOR i Author 3 Expected Cosigner 5 Additional Signer 2 Dictator 4 Attending Physician Enter selection s by typing the name s number s or abbreviation s Select SEARCH CATEGORY AUTHOR ALL Author Dictator Expected Cosigner Attending Physician Additional Signer Select NEW PERSON TIUPROVIDER SEVEN CRS PHYSICIAN Start Reference Date Time T 7 t 365 JUN 04 2002 Ending Reference Date Time Jun 04 2003 lt Enter gt JUN 04 2003 Searching for the documents TIU Alert Tools Jun 04 2003 14 01 48 Page 1 of 1 216 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Clinical Documents 5 Documents by ADD L SIGNER AUTHOR DICTATOR EXPECTED COSIGNER ATTENDING PHYSICIAN for TIU
30. author has signed and in this case the EXPECTED COSIGNER would have never received the alerts initially or even after using RESEND However with TIU 1 151 a new document parameter was added that could be set so that the EXPECTED COSIGNER could receive the alert IMMEDIATELY even if the AUTHOR has not signed This parameter is shown below SEND COSIGNATURE ALERT After Author has SIGNED Specify when the alert for cosignature should be sent Choose from After Author has SIGNED 1 Immediately If you have NOT specifically set this parameter or have it set to After Author has SIGNED you ll need to use a 3rd Party Alert to the EXPECTED COSIGNER or change the parameter s setting to Immediately before using RESEND If you HAVE set this parameter to Immediately you can use RESEND 218 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Q I used RESEND ALERT and the EXPECTED COSIGNER didn t get alerted Why A Two possible reasons The first please see the question just before this one The second the EXPECTED COSIGNER may be inactivated or DIUSER d Currently kernel does not alert these individuals who are inactive or terminated TIU 1 0 158 will inform the user that an individual entered as a 3rd Party Alert recipient is inactive DIUSER d However it does not verify every individual attached to a document since this would be too system int
31. for actions protocols on List Manager screens partly because it s difficult to make them consistent with other packages and what users expect Sites however can feel free to add whatever their users would like to have e g for Sign Shortcuts At any Select Action prompt you can type the action abbreviation then the sign and the entry number e g E 4 Jump to Document Def in the Edit Document Definition option takes you directly to a document definition Class Document Class or Title if you know the name When reviewing several notes the up arrow entry takes you to the next note To exit from the review enter two up arrows Visit Information When you enter a Progress Note for an outpatient this Progress Note now needs to be associated with a visit For the majority of Progress Notes this visit association is done in the background based on Scheduling or Encounter Form data If a visit has already been recorded for the date your Progress Note refers to but the Progress Notes wasn t linked e g for standalone visits such as telephone or walk in visits you can select a visit from the choices presented to you during the PN dialogue If no visit has been recorded you must create a new visit See the example below Example Entry of Progress Note which needs Visit Information Select PATIENT NAME TIUPATIENT FIVE TIUPATIENT FIVE 4 9 46 666668829 YES SC VETERAN
32. 02 12 96 thru 02 12 96 1 displayed here 2 Enter a date range to select summaries from then select a summary from the ones displayed The selected summary is displayed Then select an action Browse Document Jun 26 1996 14 21 22 Page 1 of 7 Discharge Summary TIUPATIENT O 666 23 3456 1A Adm 07 22 91 Dis 02 12 96 DICT DATE JUN 09 1996 ENTRY DATE JUN 12 1996 15 07 2 DICTATED BY TIUPROVIDER ONE ATTENDING TIUPROVIDER THREE URGENCY priority STATUS UNSIGNED DIAGNOSIS 1 Status post head trauma with brain contusion 2 Status post cerebrovascular accident 3 Coronary artery disease 4 Hypertension Next Screen Prev Screen More actions Find Make Addendum Identify Signers Print Sign Cosign Delete Edit Copy Link Quit Select Action Quit p Print DEVICE HOME lt Enter gt VAX 60 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Printed Discharge Summary Example SALT LAKE CITY priority 06 26 96 14 24 Page 1 PATIENT NAME AGE SEX RACE SSN CLAIM NUMBER TIUPATIENT ONE Eck Il MEXI 666 23 3456 ADM DATE DISC DATE TYPE OF RELEASE INP ABS WARD NO JUL 22 1991 FEB 12 1996 REGULAR 11666 O 1A DICTATION DATE JUN 09 1996 TRANSCRIPTION DATE JUN 12 1996
33. 08 23 95 11 45 Next Screen Prev Screen More actions Find Make Addendum Identify Signers Print Sign Cosign Delete Edit Copy Link Select Action Next Screen lt Enter gt Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 37 Review Progress Notes by Patient cont d Browse Document Jun 26 1996 10 56 43 Page 3 of 4 Lipid Clinic TIUPATIENT O 666 23 3456 Visit Date 04 18 96 10 00 TSH T4 1 7 1 1 FBG 200 HEMOGLOBIN A1C 15 2 SGOT 44 URIC ACID 4 7 ASSESSMENT Le MALE with without documented CAD Ze CV Risk factors SC Lipid pattern PLAN lee Implement recommendations to lower fat intake Se Repeat FBG and HBG AIC on Si Return to review lab on Next Screen Prev Screen More actions Find Make Addendum Identify Signers Print Sign Cosign Delete Edit Copy Link Quit Select Action Next Screen lt Enter gt Browse Document Jun 26 1996 10 57 04 Page 4 of 4 Lipid Clinic TIUPATIENT O 666 23 3456 Visit Date 04 18 96 10 00 es Three TIUProvider MD Medical Intern Next Screen Prev Screen More actions Find Make Addendum Identify Signers Print Sign Cosign Delete Edit Copy Link Quit Select Action Quit 5 You can then select an action to perform on the note Select Action Quit m Make Addendum Adding ADDENDUM DATE TIME OF NOTE 10 25 96 11 21 lt Enter gt
34. 1 Do you want WORK copies or CHART copies CHART WORK DEVICE HOME lt Enter gt VAX Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 117 Discharge Summary Print Example SALT LAKE CITY priority 06 27 96 08 45 Page 1 PATIENT NAME AGE SEX RACE SSN CLAIM NUMBER TIUPATIENT ONE 51 EXI 666 23 3456 ADM DATE DISC DATE TYPE OF RELEASE INP ABS WARD NO JUL 22 1991 FEB 12 1996 REGULAR 1666 O 1A DICTATION DATE JUN 09 1996 TRANSCRIPTION DATE JUN 12 1996 TRANSCRIPTIONIST bs DIAGNOSIS 1 Status post head trauma with brain contusion 2 Status post cerebrovascular accident 3 End stage renal disease on hemodialysis 4 Coronary artery disease 5 Congestive heart failure 6 Hypertension 7 Non insulin dependent diabetes mellitus 8 Peripheral vascular disease status post thrombectomies 9 Diabetic retinopathy 10 Below knee amputation 11 Chronic anemia OPERATIONS PROCEDURES bh MRI 2 CT SCAN OF HEAD HISTORY OF PRESENT ILLNESS Patient is a 49 year old white male with past medical history of end stage renal disease peripheral vascular disease status post BKA coronary artery disease hypertension non insulin dependent diabetes mellitus diabetic retinopathy congestive heart failure status
35. 1 2 X day test and prn any signs low blood sugar RX 1 Advantage glucose monitor kit To pharmacy 2 Advantage glucose control solutions Disp 1 box Q 3 mo Refill X3 To pharmacy 3 Mo Advantage Test Strips Disp 0 Boxes Q 3 mo Refill X3 ___No Monojector Only one No Refill No Lancets 100 Q 3 mo Refill X3 Evidence of Learning Patient coded used glucose controls and checked his own blood sugar during class When mistakes were made they were acknowledged by patient and corrective action stated Signed by es TIUPROVIDER THREE PGY3 MEDICAL RESIDENT 03 20 96 08 31 T Rev January 2012 Text Integration Utilities V 1 0 195 Clinical Coordinator amp User Manual Word Print Progress Notes Example This option is usually used by the night ward clerk The output is in RM BED order to facilitate filing It prints all notes after the last time they were printed and for ALL current inpatients on the ward regardless of whether the location of the note is that ward a nice feature for transferred patients or patients with outpatient clinic appointment notes This print option requires that you specify a printer you can t print to the screen Print by Ward is designed to support batch printing It has the unique ability to determine when the last note was printed so that sites can now capture the infamous orphan note which was a problem under Progress Notes 2 5 A
36. 45 Page 1 PATIENT NAME AGE SEX RACE SSN CLAIM NUMBER TIUPATIENT ONE 51 EXI 666 23 3456 ADM DATE DISC DATE TYPE OF RELEASE INP ABS WARD NO JUL 22 1991 FEB 12 1996 REGULAR 1666 O 1A DICTATION DATE JUN 09 1996 TRANSCRIPTION DATE JUN 12 1996 TRANSCRIPTIONIST bs DIAGNOSIS 1 Status post head trauma with brain contusion 2 Status post cerebrovascular accident 3 End stage renal disease on hemodialysis 4 Coronary artery disease 5 Congestive heart failure 6 Hypertension 7 Non insulin dependent diabetes mellitus 8 Peripheral vascular disease status post thrombectomies 9 Diabetic retinopathy 10 Below knee amputation 11 Chronic anemia OPERATIONS PROCEDURES bh MRI 2 CT SCAN OF HEAD HISTORY OF PRESENT ILLNESS Patient is a 49 year old white male with past medical history of end stage renal disease peripheral vascular disease status post BKA coronary artery disease hypertension non insulin dependent diabetes mellitus diabetic retinopathy congestive heart failure status post CVA status post thrombectomy admitted from Anytown VA after a fall from his wheelchair in the hospital He had questionable short lasting loss of consciousness but patient is not very sure what has happened He denies headache vomiting vertigo On admission patient had CT scan which showed a small area of parenchymal hemorrhage in the right temporal lobe which is most likely consisten
37. 7 notes D 07 11 00 08 41 A Known allergies Enter RETURN to continue or to exit lt Enter gt Enrollment Priority GROUP 3 Category IN PROCESS End Date Available notes 11 25 1998 thru 07 13 2000 71 Do you wish to see any of these notes NO lt Enter gt TITLE ADVERSE 11 12 ADVERSE REACTION ALLERGY TITLE Rev January 2012 Text Integration Utilities V 1 0 233 Clinical Coordinator amp User Manual Example Entry of Progress Note cont d This patient is not currently admitted to the facility Is Th CH lt U lt R OR PA this note for INPATI e following SCHEDULED 1 gt JUN 29 1999 08 2 gt JUN 24 1999 11 3 gt JUN 24 1999 10 4 gt JUN 24 1999 09 5 gt JUN 24 1999 08 OOSE 1 5 or gt NSCHEDULED VISITS lt ETURN gt TO CONTINUE TO QUIT N VISITS are available 00 00 NO ACTION TAKEN 00 NO ACTION TAKEN 00 NO ACTION TAKEN 00 FUTURE VISITS TIENT LOCATION GENERAL MEDICINE lt Enter gt Enter Visit Date Time NOW lt Enter gt JUL 13 TYPE OF VISIT AMBULATORY lt Enter gt WALK IN Enter Edit PROGRESS NOTE Patient Location GENERAL MEDICINE Date time of Visit 07 13 00 09 21 Date time of Note NOW Author of Note TIUPROVIDER SEVEN
38. ASCII file transfer from your computer NOTE If you have problems consult your local IRM Service to see if the Terminal and Protocol Set up parameters have been set up as shown in the Implementation and Maintenance Section of the TIU Technical Manual or check the user manual for your terminal emulator Initiate upload procedure SHDR DISCHARGE SUMMARY gt PATIENT NAME TIUPATIENT ONE gt SOC SEC NUMBER 666 12 1212 gt ADMISSION DATE 02 20 93 gt DISCHARGE DATE 02 25 93 gt DICTATED BY TIUPROVIDER TWO gt DICTATION DATE 02 26 93 gt ATTENDING PHYSICIAN TIUPROVIDER TEN gt TRANSCRIPTIONIST ID T1212 168 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual gt URGENCY PRIORITY gt DIAGNOSIS gt 1 Acute pericarditis gt 2 Status post transmetatarsal amputation left foot gt 3 Diabetes mellitus requiring insulin gt 4 Diabetic neuropathy gt gt Operations Procedures performed during current admission gt 1 Status post transmetatarsal amputation of left foot on 3 17 93 gt 2 Echocardiogram done 3 17 93 SEND Filer Router Queued Press RETURN to continue lt Enter gt Handling upload errors ASCH PROTOCOL UPLOAD WITH ALERT iL Upload Documents 2 Help for Upload Utility UPLOAD PROCESS 555972453 Failed L
39. All Errors Select Resolution Status UNRESOLVED lt Enter gt Unresolved Errors Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual Review Upload Filing Events cont d 5 Enter the range of dates Start Event Date Time T 30 lt Enter gt MAY 27 1996 Ending Event Date Time NOW lt Enter gt Searching for the events 6 All the documents for the criteria selected are displayed Choose an action to perform then the document to perform it on Filing Events Jun 26 1996 09 07 53 Page 1 of il RESOLVED FILING EVENTS from 05 27 96 to 06 26 96 Document Type Event Type Event Date time 1 DISCHARGE SUMMARY Filing Error 06 06 96 13 29 FILING ERROR STAT DISCHARGE SUMMARY Record could not be found or created 2 PROGRESS NOTES Filing Error 06 06 96 14 39 Next Screen Prev Screen More Actions Find Print event Quit Display Fix Change view Select Action Next Screen Display Fix 1 2 94 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Print Document Menu This menu contains options that print chart or work copies of discharge summaries progress notes or mixed documents 1 Discharge Summary Print 2 Progress Note Print 3 Clinical Document Print Discharge Summary Print Use this opt
40. CONSULTS 27968 CPRSPROVIDER T 0OC324321 com 01 29 05 13 50 35 CRISIS NOTE 28840 CPRSPROVIDER T OC668847 com 01 28 05 11 16 37 ACUTE PAIN NOTE 29362 Totals for Service EDICINE 9 Totals for Division ELY 9 Enter RETURN to continue or to exit 110 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual This page included for two sided copying Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 111 Chapter 5 TIU for MIS HIMS Managers e Individual Patient Document e Multiple Patient Documents e Print Documents Menu e Search for Selected Documents e Statistical Reports e Unsigned Uncosigned Report e Missing Text Report e Missing Text Cleanup e UNKNOWN Addenda Cleanup e Missing Expected Cosigner Report e Mark Document as Signed by Surrogate e Mismatched ID Notes e TIU 215 ANALYSIS e Transcription Billing Verification Report 112 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Chapter 5 TIU for MIS HIMS Managers The Medical Information Section MIS also called Health Information Management Section HIMS maintains and manages records of clinical documents including copies of statistical reports and chart or work copies of discharge summaries and progress notes MIS Manager s Menu Option Description Individual Patient Document
41. Conversion Clean up Menu IOGMRP TIUT cee eeecceeeecceceeeeeceeeeeceeeeeceneeeeeeeeees 203 Suggested Clinical Coordinator Menn en dees eege dee SE ee 204 Meni ASST OIE ee 205 Chapter 11 Setting up TIU Parameter ccssccssssccssssscsssscsssssccssssscsscssssssssssessees 206 TIU Parameters E E 206 Chapter 12 Document Definitions ccccscsscscscscscscssscssccssccessesssssssscsescesseesenees 207 Example of Document Definition Hierarchie 207 Chapter 13 Defining User Classes cccsssssssssssssssssssssssessssssssssssssssssssssssssssssasecees 209 Chapter 14 National Document Titles cssccssssccsssscssssccssssccssssccssssscsssscsssssssoess 210 Rev January 2012 Text Integration Utilities V 1 0 7 Clinical Coordinator amp User Manual Natonal e EE E 210 National Document Classes 211 National Titles sco ges eieiei Ee EE ee EA 212 Chapter 15 TI Alert Tools saciicascssccssvisunisnansvavesinsnasouicenseveusoassesaatece sevavsceveasevecosvivucssnaee 215 Alert TOONS BAO etetdee dee dE ee Rsk bose OE 217 Chapter 16 HL7 Generic Interface sssccssssssssscssssscsssssssscsssessssssssscsessesssesecees 220 Message HE eege Beet Beete eeneg AOE EA EAS E ESS 220 Chapter 17 Helpful Hints Troubleshooting cccsccssssscessscssssccssssccsssscsssesseess 222 Questions about Document Debnpon cc ccccesssssscececececeesessececeeeeseeesenseaeees 229 Classes Document Classes Titles Boilerp
42. D 03 25 97 08 57 Searching for the progress notes 2 A screen with a list of notes for your patient is displayed Items with the plus symbol have addenda You can look at details of any of the notes shown by selecting the Browse or Detailed Display action create a new note make an addendum sign a note or perform any of the other actions listed below as well as hidden actions Progress Notes May 31 1997 14 20 10 Page 1 of 1 lt CWAD gt PROGRESS NOTES Last 15 note s TIUPATIENT O 666 23 3456 SEP 12 1944 52 Title Author Date Time 1 Adverse React Allergy TIUPROVIDER FIV 05 27 97 00 00 compl 2 Adverse React Allergy TIUPROVIDER ONE 05 20 97 17 18 compl 3 CRISIS NOTE TIUPROVIDER THR 05 20 97 17 01 compl 4 Adverse React Allergy TIUPROVIDER SEV 05 20 97 11 23 compl 5 GENERAL NOTE TIUPROVIDER SEV 05 20 97 11 21 comp 1 6 CARDIOLOGY NOTE TIUPROVIDER SEV 05 20 97 10 56 compl 7 Adverse React Allergy TIUPROVIDER FIV 04 21 97 16 02 compl 8 Adverse React Allergy TIUPROVIDER FIV 04 15 97 06 23 compl 9 CARDIOLOGY NOTE TIUPROVIDER FIV 04 11 97 12 09 compl 10 CRISIS NOTE TIUPROVIDER FIV 04 11 97 09 09 compl Next Screen Prev Scree More Actions NW New Note SS Select Search IN Interdiscipl ry Note B Browse RS Reset to All Signed EE Expand Collapse Entry PC Print Copy AD Make Addendum Q Quit SP Sel
43. For the NIR once the cases that need fixing are restored to their original data set see examples one and two one of the circulating nurses listed in the case with the assistance of the Surgery ADPAC should use the Surgery package to put the changes back into the cases and sign the addenda see Options used to reenter the data in Surgery Similarly for the Anesthesia Report once the cases that need fixing are restored to their original data set see examples one and two the anesthetist with the assistance of the Surgery ADPAC should use the Surgery package to put the changes back into the cases and sign the addenda see Options used to reenter the data in Surgery Example ONE using FileMan Step One Select OPTION 1 ENTER OR EDIT FILE ENTRIES INPUT TO WHAT FILE SURGERY EDIT WHICH FIELD ALL ANESTHESIA TECHNIQUE multiple EDIT WHICH ANESTHESIA TECHNIQUE SUB FIELD ALL THEN EDIT FIELD Y PATIENT 30536 GLTLPLN TJXSS HAIXY 08 18 07 Select SURGER TOE X XX XX XXXXXXXX YES SC VETERAN GJ Select ANESTHESIA TECHNIQUE GENERAL SURE YOU WANT TO DELETE THE ENTIRE G ANESTHESIA TECHNIQUE Y Yes Select ANESTHESIA TECHNIQUE Step Two THEN IN SURGERY ADD THE GENERAL ANESTHESIA TECHNIQUE BACK IN USING ONE
44. LAST admission if the patient has been discharged Batch Print Outpt PNs by This option batch prints outpatient progress notes in Division terminal digit order by division Locations that the site would like excluded from this job may edit field 3 in file 8925 93 If the location is not entered in file 8925 93 it WILL be included Outpatient Location Print This option is designed to be used primarily by MAS It Progress Notes produces CHARTABLE notes and tracks the last note printed for the selected outpatient location Output is sorted in alphabetical order by patient Ward Print Progress Notes This option allows the printing of Progress Notes for ALL patients on the ward at the time the job is queued to print All of the notes for a selected date range regardless of the location of the note will print This option is only for WARD locations NOTE Copies can only be printed to a printer not to a computer screen Rev January 2012 Text Integration Utilities V 1 0 185 Clinical Coordinator amp User Manual Author Print Progress Notes Example Print Progress Notes PNPA Author Print Progress Notes PNPL Location Print Progress Notes PNPT Patient Print Progress Notes PNPW Ward Print Progress Notes Select Progress Notes Print Options Option author Print Progress Notes Print Progress Notes for a Selected AUTHOR AUTHOR TIUPROVIDER THREE TT MD Available notes Aug 24 1995 thru
45. Line Count Statistics by AUTHOR ISC SLC A4 JUN 27 1996 09 53 PAGE 1 Line Author Count Ref Date Patient Disch Dict Dict Transcr Transcr Sign Sign Cosign TIUPROVIDER T 0 FEB 12 1996 TIUPATIENT ONE 97 0 Addendum SUBTOTAL 97 0 0 0 SUBCOUNT 1 1 1 0 0 SUBMEAN 97 00 TIUPROVIDER O 0 JUN 19 1996 TIUPATIENT SEV 0 Discharg KK JUN 11 1996 TIUPATIENT TWO J Discharg 78 MAY 31 1996 TIUPATIENT SEV 7 ak Discharg 72 MAR 25 1996 TIUPATIENT NIN 1 0 0 Discharg 78 MAR 24 1996 TIUPATIENT SEV 1 1 0 0 Discharg 73 MAR 23 1996 TIUPATIENT ELE 1 0 0 Discharg 73 FEB 12 1996 TIUPATIENT ONE 84 2 Discharg SUBTOTAL 447 90 7 0 0 SUBCOUNT 7 3 7 3 3 SUBMEAN 63 86 30 00 1 00 TIUPROVIDER S 80 FEB 8 1995 TIUPATIENT TWE 0 44 0 Discharg 96 FEB 8 1995 TIUPATIENT THI 0 44 0 Discharg SUBTOTAL 176 0 0 88 0 SUBCOUNT 2 0 2 2 2 SUBMEA 88 00 44 00 TIUPROVIDER F 1 JAN 10 1996 TIUPATIENT ONE1004 0 0 0 Discharg SUBTOTAL 1 1004 0 0 0 SUBCOUNT 1 1 1 SUBMEA 1 00 1004 00 TIUPROVIDER E 0 MAY 25 1996 TIUPATIENT EIG 1 Discharg SUBTOTAL 0 1 0 0 SUBCOUNT 1 0 T 0 0 SUBMEA 1 00 TOTAL 624 1191 8 88 0 COUNT 12 5 12 6 6 MEAN 52 00 238 20 0 67 14 67 0 00 Rev January 2012 Text Integration Utilities V 1 0 133 Clinical Coordinator amp User Manual Line Count Statistics by SERVICE DISCHARGE SUMMARY Line Count Statistics by SERVICE ISC SLC A4 JUN 27 1996 09 42 PAGE 1 Line Service Count Ref Date Patient Disch Dict Dict Transcr Transcr Sign
46. OCT 25 1996 11 21 00 AUTHOR OF NOTE TIUPROVIDER ELEVEN lt Enter gt jg Calling text editor please wait 1 gt Should say 55 year old 2 gt lt Enter gt EDIT Option lt Enter gt Saving Addendum with changes Addendum Released Enter your Current Signature Code xxxxxxx code hidden SIGNATURE VERIFIED Press RETURN to continue lt Enter gt 38 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Review Progress Notes This option lets clinicians get immediately to a patient s list of notes without preliminary prompts for selection criteria It s particularly useful for when physicians are seeing patients in clinics and want to pull up their records quickly as they are able to do with Progress Notes 2 5 frequently accessed through OE RR 2 5 Note that the actions below the black bar look more like OE RR and CPRS actions than the ones you ll see in other TIU options 1 Select Review Progress Notes from your Progress Notes or OE RR menu whichever one you commonly use Then enter the name of the patient you are seeing Select Progress Notes User Menu Option 2b Review Progress Notes Select PATIENT NAME TIUPATIENT ONE TIUPATIENT ONE 09 12 44 666233456 YES SC VETERAN 2 notes C 02 24 97 08 44 1 note W 02 21 97 09 19 A Known allergies 2 notes
47. OF THE SURGERY OPTIONS LISTED IN THE SECTION OPTIONS USED TO RE ENTER DATA IN SURGERY 152 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Example TWO using FileMan TIU HAS CLEAN FOR WOUND CLASSIFICATION BUT SURGERY HAS CONTAMINATED STEP ONE Select OPTION 1 ENTER OR EDIT FILE ENTRIES INPUT TO WHAT FILE SURGERY EDIT WHICH FIELD ALL WOUND CLASSIFICATION THEN EDIT FIELD Select SURGERY PATIENT 30506 NANNIE ETHAN HAIXY 12 31 06 BAD FINGER X XX XX XXXXXXX YES SC VETERAN GJ WOUND CLASSIFICATION CONTAMINATED CLEAN 1 CLEAN 2 CLEAN CONTAMINATED Choose 1 2 1 CLEAN STEP TWO NOW REENTER CONTAMINATED IN SURGERY USING ONE OF THE OPTIONS USED TO RE ENTER DATA INTO SURGERY AND IT WILL GENERATE AN ADDENDUM FORTIU Options used to reenter the data in Surgery NIR REPORT OSS Operation Short Screen NR Nurse Intraoperative Report ANESTHESIA REPORT AR Anesthesia Report PAC Enter PAC U Information M edications Enter Edit For those sites that use the Anesthesia Report the following list of fields create an addendum to the NIR Sub file Field Other Scrubbed Assistant s Other Scrubbed Assistant Other Scrubbed Assistant s Comments O R Circulating Nurse s O R C
48. ONLY 56 PREOPERATIVE MANAGEMENT ONLY 57 DECISION FOR SURGERY Rev January 2012 Text Integration Utilities V 1 0 235 Clinical Coordinator amp User Manual Example Entry of Progress Note cont d 58 STAGED OR RELATED PROC BY SAME PHYS DURING POSTOP PERIOD 59 DISTINCT PROCEDURAL SERVICE 62 TWO SURGEONS 66 SURGICAL TEAM 73 DISC O P HOSP AMB SURG CENTER ASC PROC PRIOR ADMIN ANESTH 74 DISC O P HOSP AMB SURG CENTER ASC PROC AFTER ADMIN ANESTH 76 REPEAT PROCEDURE BY SAME PHYSICIAN TT REPEAT PROCEDURE BY ANOTHER PHYSICIAN 78 RETURN TO OP ROOM FOR RELATED PROC DURING POSTOP PERIOD 79 UNRELATED PROC OR SERVICE BY SAME PHYS DURING POSTOP PERIOD 80 ASSISTANT SURGEON 81 INIMUM ASSISTANT SURGEON 82 ASSISTANT SURGEON WHEN QUAL RES SURGEON NOT AVAIL 90 REFERENCE OUTSIDE LABORATORY 99 ULTIPLE MODIFIERS AA ANESTHESIA PERF BY ANESGST AS PA NP CN ASSIST SURG QX CRNA SVC W MD MED DIRECTION OZ CRNA SVC W O MED DIR BY MD SG ASC FACILITY SERVICE TG TECHNICAL COMPONENT Select another CPT MODIFIER 47 ANESTHESIA BY SURGEON Select another CPT MODIFIER lt Enter gt DRESSINGS MEDIUM How many times was the procedure performed 1 lt Enter gt Select CPT MODIF
49. Oct 03 1996 Print Notes Beginning t 100 MAY 01 1996 Thru t 60 JUL 10 1996 Searching for the notes gt gt 8 notes found for TIUProvider Three Do you want WORK copies or CHART copies CHART lt Enter gt DEVICE HOME PRINTER A NOTE DATED 05 08 96 11 01 DIABETES EDUCATION ADMITTED 04 21 96 10 00 2B SUBJECTIVE 45 year old AMERICAN INDIAN here for initial evaluation of his DYSLIPIDEMIA COPIED FROM TIUCLIENT TO TIUPATIENT PMH Significant negative medical history pertinent to the evaluation and treatment of DYSLIPIDEMIA FH SH MEDICATION HISTORY CURRENT MEDICATIONS DIET Counseled on AHA Step I diet today by NINE TIUPROVIDER See her evaluation ACTIVITY OBJECTIVE HT 70 08 23 95 11 45 WT 207 08 23 95 11 45 TSH T4 1 7 1 1 FBG 200 HEMOGLOBIN A1C 15 2 SGOT 44 URIC ACID 4 7 Enter RETURN to continue or to exit lt Enter gt 186 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Author Print Progress Notes Example cont d PLAN MALE w CV Ris Repeat Return WNHRWNHE Signed by Enter RETURN to continue or NOTE DATED ADMITTED Follow up Enter RETU 06 21 96 11 38 06 01 96 10 00 2B to 6 1 96 visit Signe
50. Options MAS Options to Print Progress Notes Document Definitions TIU Parameters Menu User Class Management Upload Menu 204 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Menu Assignment We recommend assigning menus as follows Option Name Menu Text Description Assign to TIU MAIN MENU Text Integration Main Text Integration Utilities Transcrip TRANSCRIP TION Utilities menu for transcriptionists tionists Transcriptionist TIU MAIN MENU Text Integration Main Text Integration Utilities Medical MRT Utilities MRT menu for Medical Records Records Technicians Technicians TIU MAIN MENU Text Integration Main Text Integration Utilities MIS Managers MGR Utilities MIS menu for MIS Managers Manager TIU MAIN MENU Progress Notes s Main Text Integration Utilities Clinicians CLINICIAN Discharge Summary menu for Clinicians TIU TIU MAIN MENU Text Integration This option allows remote users VBA RO REMOTE USER Utilities Remote e g VBA RO personnel to personnel etc User access only those documents that have been completed to facilitate processing of claims on a need to know basis TIU PRINT PN USER Progress Notes Print Menu for printing Progress Notes ADPACs MENU Options managers TIU MAS PRINT PN MAS Options to Menu of options for printing MAS ADPACs MENU Print Progress N
51. PHYSICAL 1 Ht HEIGHT Wt WEIGHT Temp Resp BP Lying Sitting Standing 2 General x Well Obese Thin Malnourished Neat Chronically Ill Toxic Acute Distress Head Eyes ENT Enter RETURN to continue or to exit lt Enter gt 192 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Patien t Print Progress Notes Example cont d TIUPATIENT EIGHT 666 77 6641 Progress Notes 11 08 95 15 20 CONTINUED FROM PREVIOUS SCREEN 6 Neck 7 Chest and Breasts 8 Lungs 9 Lymphatics Cervical Epitrocholear Axillary Inguinal Popliteal 10 Heart 11 Abdomen 12 Pelvic Genitalia Penis Scrotum Testicles 13 Rectal 14 Neurological Cranial Nerves Peripheral Neurological exam Reflexes 0 No reflex C 1 Hyporeflexia on 2 Average 1 V 3 Brisk 1 4 Hypereflexia 1 1 15 Musculoskeletal Upper Extremities Lower Extremities Spine 16 Psychiatric a Are any cognitive impairments noted Yes No b Are any communication impairments noted Yes No 17 Skin 7 WOMEN S GYNECOLOGICAL HISTORY AND PHYSICAL EXAM HISTORY Menarche Yes None Interval Duration Characteristics Enter RETURN to continue or to exit lt Enter gt Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual
52. Patient AD Make Addendum B Browse SS Select Search Complete Note s PC Print Copy RS Reset to All Signed Q Quit Select Action Quit ss Select Search Valid selections are L signed notes all 2 unsigned notes 3 uncosigned notes 4 signed notes author 5 signed notes dates Select context 1 2 UNSIGNED NOTES Progress Notes May 31 1997 14 20 10 Page 1 of 1 lt CWAD gt PROGRESS NOTES 1 note s TIUPATIENT O 666 23 3456 1A A 2 SEP 12 1944 52 Title Author Date Time 1 Adverse React Allergy TIUPROVIDER N 05 31 97 15 51 unsig Next Screen Prev Screen More Actions NW New Note SP Select New Patient AD Make Addendum B Browse SS Select Search Complete Note s PC Print Copy RS Reset to All Signed Q Quit Select Action Quit 42 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual All MY UNSIGNED Progress Notes When you select this option the program retrieves all your unsigned progress notes for review edit or signature Steps to use option 1 Select All My Unsigned Progress Notes from the Clinician s Progress Notes Menu 2 The list is then displayed from which you can choose any of the listed actions My UNSIGNED Progress Notes Oct 25 1996 11333352 Page 1 of 1 by AUTHOR TIUPROVIDER ONE or EXPECTED COSIGNER 2 documents Patient Document Ref Date Status L TIUPATIENT D3456 Psychology Crisis 10 25 96 unsigned 2 TIUPATIENT D3456 A
53. Select Integrated Document Management Option Multiple Patient Documents 2 Select one or more of the following statuses 1 undictated 6 uncosigned 2 untranscribed 7 completed 3 unreleased 8 amended 4 unverified 9 purged 5 unsigned 10 deleted Enter selection s by typing the name s number s or abbreviation s Select Status UNSIGNED lt Enter gt 3 Select a document type from whatever you have set up at your site Select Clinical Documents Type s 1 3 Addendum Discharge Summary Progress Notes 4 Select one of the following search categories 1 All Categories 6 Patient LL Transcriptionist 2 Author 7 Problem 12 Treating Specialty 3 Division 8 Service 13 Visit 4 Expected Cosigner 9 Subject 5 Hospital Location 10 Title Enter selection s by typing the name s number s or abbreviation s 72 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Multiple Patient Documents cont d 5 Enter a date range Start Reference Date Time T 7 T 60 APR 01 1997 Ending Reference Date Time NOW lt Enter gt MAY 31 1997 15 42 Searching for the documents 6 All the documents for the criteria selected are displayed Choose an action to perform then the document to perform it on UNSIGNED Documents May 31 1997 15 42 40 Page 1 of 1 by AUTHOR TIU
54. Selected Documents Unsigned Uncosigned Report Reassignment Document Report Review unsigned additional signatures VO OO JO 0 Rev January 2012 Text Integration Utilities V 1 0 201 Clinical Coordinator amp User Manual TIU Menus and Options cont d Text Integration Utilities MIS Manager HE Individual Patient Document 2 Multiple Patient Documents 3 Print Document Menu 1 Discharge Summary Print 2 Progress Note Print 3 Clinical Document Print Search for Selected Documents Statistical Reports Unsigned Uncosigned Report Missing Text Report Missing Text Cleanup Signed unsigned PN report and update UNKNOWN Addenda Cleanup Missing Expected Cosigner Report Mark Document as Signed by Surrogate Mismatched ID Notes TIU 215 ANALYSIS Transcription Billing Verification Report eg VO OO JO us DG LAACH Text Integration Utilities Transcriptionist 1 Enter Edit Discharge Summary 2 Enter Edit Document 3 Upload Menu 1 Upload Documents 2 Help for Upload Utility 4 List Documents for Transcription 5 Review Edit Documents 6 Transcription Billing Verification Report Text Integration Utilities Remote User 1 Individual Patient Document 2 Multiple Patient Documents Progress Notes Print Options PNPA Author Print Progress Notes PNPL Location Print Progress Notes PNPT Patient Print Progress Notes PNPW Ward Print Progress Notes
55. TO 1A 3 gt MAY 22 1996 17 41 DIRECT TO 1A 4 gt DEC 22 1994 17 27 DIRECT TO 1A 5 gt DEC 22 1994 17 22 DIRECT TO 2B CHOOSE 1 5 lt RETURN gt TO CONTINUE OR TO QUIT 1 AY 28 1996 15 58 Patient TIUPATIENT SIX SSN 666 04 2591P Sex MALE Race AMERICAN INDIAN OR ALASKA NA Age 65 Claim UNKNOWN Adm Date 05 28 96 Ward 1A Adm Dx TEST Correct VISIT YES lt Enter gt 164 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Enter Edit Document cont d 3 Enter the urgency if routine press Enter author dictator dictation date and attending physician URGENCY routine lt Enter gt routine AUTHOR DICTATOR TIUPROVIDER THREE TIUPROVIDER THREE TT DICTATION DATE 9 30 SEP 30 1996 ATTENDING PHYSICIAN TIUPROVIDER ONE TIUPROVIDER ONE TO PGY2 RESIDENT 4 Your preferred editor appears with boilerplate if any has been set up for this title and you can now enter the text for this discharge summary Calling text editor please wait 1 gt DIAGNOSIS 2 gt 3 gt 4 gt 5 gt 6 gt OPERATIONS PROCEDURES EDIT Option 2 2 gt Replace lt space gt With diabetes retinopathy Replace diabetes retinopathy Edit line lt Enter gt EDIT Option lt Enter gt Save changes YES lt Enter gt Saving Discharge Summary with changes Is
56. The entry point for this is NITE TIU189 This task will look for notes missing an expected cosigner and send an email to the mail group TIU MIS ALERTS This email will include Patient Name initials and last 4 of SSN Entry Date Time Author Title Author s Service Section Author s Job Title Note IEN and if the note is an addendum the parent s Document Type Entry Date Time and Expected Cosigner Example 80 column report Select Text Integration Utilities MIS Manager Option 11 Missing Expected Cosigner Report START WITH REFERENCE DATE Jan 01 2003 1 1 2005 JAN 01 2005 GO TO REFERENCE DATE Jun 28 2005 JUN 28 2005 DEVICE HOME TCP NOTES WITH UNCOSIGNED STATUS THAT DON T HAVE AN EXPECTED COSIGNER Patient Entry Date Time Title Author Note IEN XXX1234 JUN 28 2005 09 24 44 UROLOGY NO SHOW TIUAUTHOR ONE 4957352 XXX1235 JUN 28 2005 09 36 20 Addendum TIUAUTHOR TWO 4957353 Parent Document Type UROLOGY NO SHOW NOTE Parent Document Date JUN 28 2005 09 24 44 Parent Document Cosigner XXX1236 JUN 28 2005 10 16 21 PROGRESS NOTE TIUAUTHOR THREE 4957355 Enter RETURN to continue or to exit 144 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Example 132 column report Select Text Integration Utilities MIS M
57. Utilities V 1 0 Clinical Coordinator amp User Manual Document Definitions Clinician TIU uses a structure called Document Definitions to organize Progress Notes Discharge Summaries and other documents It contains the Document Definition Hierarchy which allows documents Titles to inherit characteristics of the higher levels Class and Document Class such as signature requirements and print characteristics This structure creates the capability for better integration shared use of boilerplate text components and objects and a more manageable organization of documents End users clinical administrative and MIS staff need not be aware of the hierarchy They work at the Title level with the actual documents The Document Definitions menu for Clinicians may be assigned to those clinicians who are interested in creating and editing boilerplate text or in viewing or editing Document Definition entries Class Document Class or Title You can also view available Objects that can be embedded in boilerplate text See your Clinical Coordinator or the TIU Implementation Guide if you need further information about these options or descriptions of Document Definition concepts Option Description Edit Document This option lets you view and edit entries Entries are presented in Definitions hierarchy order Items of an entry are in Sequence order or if they have no Sequence in alphabetic order by Menu Text and are indented below the
58. all recipients 170 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Avoiding Upload Errors TIU uses header information to file uploaded notes in the TIU Document File 8925 Naturally if this information is inaccurate then either a filing error is generated or the note is filed incorrectly L Note Certain errors in the upload header can cause the upload routine to file the note incorrectly This is a patient safety issue so the accuracy of captions should be verified where possible Each type of document has a different set of upload captions and in some cases a different upload routine Each routine tries to avoid incorrect filing of notes by cross checking the patient information and dates with other information such as the consult number or surgery case number Some types of documents have unique fields to assist the upload program in accomplishing these cross checks and or to file the document A missing field error is generated either when a required field is missing or a field does not match the example data given in the Upload Help Display see Display Upload Help below The following table gives information on required fields and the cross checks performed on fields for several document classes Type of Document Caption Use PROGRESS NOTES SSN Required by filing routine VISIT EVENT DATE Required by filing
59. appear on selection lists You can also specify the way documents are displayed on your review screens by patient by author by type in chronological or reverse chronological order etc If you require cosignatures on your documents for example because you re a medical student PA or some other category that your site has designated as needing cosignature you can designate your Default Cosigner and then this person will be the default when you re prompted for the Expected Cosigner Option Description Personal Preferences Specify defaults that you want in TIU e g Default Location Sort Order Display Menus Patient Selection Preference etc Document List Management Specify your pick lists for document selection when composing or editing documents Personal Preferences Steps to use option 1 Select Personal Preferences from your TIU menu Select Progress Notes Discharge Summary TIU Option Personal Preferences HE Personal Preferences 2 Document List Management Select Personal Preferences Option 1 Personal Preferences 2 Select Personal Preferences from your Personal Preferences menu Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 77 Personal Preferences cont d 3 Answer the following prompts as appropriate Select Personal Preferences Option Personal Preferences Enter edit Personal Preferences for TI
60. bone in the temporal lobe which most likely represents a hemorrhagic contusion Repeated CT scan on 5 13 94 didn t show any progressive changes Patient remained in stable condition He had hemodialysis q o d He restarted treatment with Coumadin His last PT was 11 9 PTT 31 Patient refused before hemodialysis new blood tests His condition remained stable DISCHARGE MEDICATIONS Isordil 20 mgs p o t i d Ferrous sulfate 325 mgs p o b i d Ativan 0 5 mgs p o b i d Lactulose 15 ccs p o b i d Calcium carbonate 650 mgs p o b i d Compazine 10 mgs p o t i d prn nausea Betoptic 0 5 OU b i d Nephrocaps 1 p o qd Pilocarpine 4 solution 1 gtt OU b i d Coumadin 2 5 mgs p o qd Tylenol 650 mgs p o q6 hours prn pain DISPOSITION FOLLOW UP Recommend follow PT PTT Patient is on coumadin and CBC with differential because patient has chronic anemia and thrombocytopenia Patient will be transferred to Anytown VA in stable condition on 5 19 94 WORK COPY UNOFFICIAL NOT FOR MEDICAL RECORD DO NOT FILE SIGNATURE PHYSICIAN DENTIST SIGNATURE APPROVING PHYSICIAN DENTIST One TIUProvider MD Three TIUProvider MS PGY2 Resident Medical Internist CONFIDENTIAL INFORMATION DRAFT JUN 26 1996 17 36 02 ADDENDUM Routine visit today no change to condition SIGNATURE PHYSICIAN DENTIST SIGNATURE APPROVING PHYSICIAN DENTIST Three TIUPr
61. can we clean up these files A You can use the Individual Patient Document option on the GMRD MAIN MENU MGR menu along with VA FileMan to clean up the Discharge Summary files Questions about Document Definition Classes Document Classes Titles Boilerplate text Objects Q After the initial document definition hierarchy is built and used can we modify the hierarchy structure if we feel it is incorrectly built How flexible is this file A Once entries in the hierarchy are in use you can t move them around It would be wise to think your hierarchy through before installation Don t rush the process If necessary create new classes document classes and titles the Copy function streamlines creating new titles and deactivate the old ones The users won t be aware of the change if the Print Name is the same but the 01 Name is new Rev January 2012 Text Integration Utilities V 1 0 229 Clinical Coordinator amp User Manual FAQs cont d Q Who creates titles and boilerplates at a site A Many test sites restrict the creation of titles and boilerplates as much as possible At one site users submit a request for a title or boilerplate IRMS or the clinical coordinator create the boilerplate and or title and forward it to the Chairman of the Medical Records Committee for approval Once approved it is made available for use Titles are name spaced by service and the use of titles is restricted by user class With the a
62. details of a note Enter DT for Detailed Display Detailed Display is a hidden action an action that appears when you enter two question marks Select Action Next Screen det Detailed Display Select Progress Note s 1 25 2 2 Reviewing 1 Opening Adverse React Allergy record for review Detailed Display May 31 1997 13 36 09 Page 1 of 2 Adverse React Allergy TIUPATIENT O 666 23 3456 Visit Date 04 18 96 10 00 Reference Date MAY 27 1997 10 44 19 Author TIUPROVIDER ONE Entry Date MAY 27 1997 10 44 19 Entered By jg Expected Signer TIUPROVIDER EIGHT Expected Cosigner None Urgency None Document Status COMPLETED Line Count 46 TIU Document 1132 Division ISC SLC A4 VBC Line Count 56 25 Subject None Associated Proble No linked problems BEOit Information Edit Date JAN 17 1997 10 45 08 Edited By TIUPROVIDER EIGHT IEEE SMe peli veh EE ment Never Reassigned Next Screen Prev Screen More actions Find Print Quit Select Action Next Screen lt Enter gt Detailed Display May 31 1997 13 37 40 Page 2 of 2 Adverse React Allergy TIUPATIENT O 666 23 3456 Visit Date 04 18 96 10 00 Signed Date MAY 27 1997 10 45 17 Signed By TIUPROVIDER ONE Signature Mode ELECTRONIC Cosigned Date None Cosigned By None Cosignature Mode None Document Body Mr TIUPATIEN e T S alle
63. document may be displayed As of TIU 1 234 documents of these statuses 1 e signed documents cannot be edited regardless of business rules NOTE areport has addenda priority STAT document 50 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Progress Note Actions Find Sign Cosign Change View Add Document Detailed Display Copy Edit Browse Delete Document Make Addendum Print Quit Link Identify Signers Action Description Find Allows you to search a list of documents for a text string word or partial word from the current position to the end of the list Add Document Lets you add a new Progress Note New Note Same as Add Document used in CPRS contexts Edit Allows authorized users to edit selected documents online Make Addendum Allows authorized users to add addenda to selected documents online Physicians will be prompted for their signatures upon exit Link Allows you to link documents to either problems visits or other documents Such associations permit a variety of clinically useful views of the online record Sign Cosign Allows clinicians to electronically sign selected discharge summaries or addenda NOTE Electronic signature carries the same legal ramifications that wet signature of a hard copy discharge summary carries You are advised to carefully review each discharge summary fo
64. documents are displayed to review edit or sign Steps to use option 1 Select All MY UNSIGNED Documents from your Integrated Document Management menu on your TIU menu Select Integrated Document Management Option All MY UNSIGNED Documents Searching for the documents 2 After all your unsigned documents are displayed you can select an action such as add edit or sign cosign etc MY UNSIGNED Documents June 31 1997 15 38 13 Page 1 of 1 by AUTHOR TIUPROVIDER ONE or EXPECTED COSIGNER 4 documents Patient Document Ref Date Status Complete Auth 1 50501050 ONE PER VISIT NOTE 12 18 02 com 12 24 02 TIUP 2 TB668832 Cardiology Note 09 23 02 uns CPRS 3 FW120870 CARDIOLOGY CS CONSULT 11 11 01 uns CPRS 4 CPRSPATI Discharge Summary 10 12 01 com 01 16 01 ARTP 5 CPRSPA Addendum to Discharge Summ 02 09 01 comple 02 12 01 LUPR Next Screen Prev Screen More actions Add Document Detailed Display Delete Document Edit Browse Interdiscipl ry Note Make Addendum Print Expand Collapse Entry Link Identify Signers Encounter Edit Sign Cosign Change View Quit Select Action Quit s Sign Cosign Select Document s 1 5 3 5 Opening Adverse React Allergy record for review SIGN COSIGN Jun 06 1997 12 03 52 Page 1 of T Adverse React Allergy TIUPATIENT TWO 666 12 3243 2B Visit Date 09 21 95 10 00 DATE OF NOTE
65. each with 25 cases per file weee M PORTA NT eeek MPORTA NT tk NOTE The host files created in option T contains Patient Information and should only be sent to a server within the system boundary of the VA The directory must be password protected If you are going to download to a pc and use the Microsoft Word Compare feature for analysis it must be a VA approved encrypted PC Both the host files and the files downloaded to the pc must be destroyed by an approved means when analysis correction is complete When the files are destroyed the systems manager official or the ISO should be notified they have been destroyed de r 202128 M PORTA NT eeek M POR TA NTH tk CORRECTION PROCESS The following manual fix process is provided by the Surgery Enterprise Product Support EPS personnel The Surgery ADPAC should review the reports Health Information Management HIM personnel should also be involved in this process If the programmer feels comfortable in restoring the data in the Surgery package to what it was originally then the programmer can with the help of the Surgery ADPAC do it but we would encourage the site to enter a Surgery Remedy ticket and we will step the site through the process Rev January 2012 Text Integration Utilities V 1 0 151 Clinical Coordinator amp User Manual The programmer would edit the fields in the Surgery Case file 130 that should be restored to their original data using FileMan enter edit
66. ending divisions for the report 3 Enter the starting day for the report 4 Specify a printer If necessary set the margin width to 132 Select Text Integration Utilities MRT Option Released Unverified Report START WITH DIVISION FIRST 660 GO TO DIVISION LAST START WITH RELEASE DATE TIME FIRST lt Enter gt DEVICE PRINTER MARGIN WIDTH IS NORMALLY AT LEAST 132 ARE YOU SURE No YES Released Unverified Report ELY OCT 15 1996 11 59 PAGE 1 PATIENT SSN ADM DATE DIS DATE LINE DICTATED BY URGENCY COUNT RELEASE DATE TIME JAN 10 1996 TIUPATIENT THREE 666042591P 02 27 92 03 05 92 TIUPROVIDER FOUR routine 1 Discharg SUBTOTAL 1 RELEASE DATE TIME SEP 10 1996 TRANSCRIPTIONIST BS TIUPATIENT FOUR 666123456 09 21 95 TIUPROVIDER ONE routine 72 Addendum TIUPATIENT FIVE 666451462 05 04 92 05 31 96 TIUPROVIDER ONE priority 78 Addendum SUBTOTAL 150 Discharge Summary Released Unverified Report OCT 15 1996 11 59 PAGE 2 PATIENT SSN ADM DATE DIS DATE LINE TRANSCRIPTIONIST jg TIUPATIENT ONE 666233456 07 22 91 02 12 96 TIUPROVIDER THRE routine 1 Discharg SUBTOTAL TOTAL 152 Press RETURN to continue lt Enter gt 104 Text Integra
67. for Transcription 160 Printed Discharge Summary 60 List Manager utility 15 PRIVACY ACT OFFICER 49 64 List Notes by Title 46 Problem 231 LM Considerations Procedure 34 Interdisciplinary Notes 55 Progress Note Print 97 119 Location Print Progress Notes 45 183 Progress Notes 29 240 LOOKUP METHOD 228 Upload 170 Maintenance Menu 197 Progress Notes Menu 29 Make Addendum 50 65 Progress Notes Print Menu 183 Managing TIU 196 Progress Notes Print Options 45 181 Manual organization 12 Progress Notes Statuses 49 MAS Options to Print Progress Notes 184 Progress Notes User Menu 22 Meaning of Icons 54 Progress Notes V 2 5 222 Medical Record Technicians 87 Rev January 2012 Text Integration Utilities V 1 0 243 Clinical Coordinator amp User Manual Progress Notes Discharge Summary TIU Menu 22 Titles 206 229 23 TIU and VISTA Conventions 14 prohibits editing 73 TIU Conversion Clean up Menu 202 Provider Class 221 TIU for Clinicians 21 Purpose of Text Integration Utilities 10 TIU for MIS HIIMS Managers 111 Quit 50 65 TIU Maintenance Menu 202 Radiology reports 228 TIU SET UP MENU 197 Reassign action 125 TIU 1 158 214 Reassignment Document Report 87 107 TIUF 207 Reassignment Document Report 200 TIUHL7 197 Release from transcription 225 Transcription Billing Verification Report 160 Released Unverified Report 87 103 Transcription Billing Verification Report 155 Remote User Menu 175 TRANSCRIPTIONIST Line Count Statistics 131 Remote Users 174
68. for sites to share objects they create locally A As sites develop their own Objects they can be shared with other sites through a mailbox entitled TIU OBJECTS in SHOP ALL reached via FORUM NOTE Object routines used from SHOP ALL are not supported by the CIO Field Offices formerly known as ISCs or IRMFOs Use at your own risk Rev January 2012 Text Integration Utilities V 1 0 231 Clinical Coordinator amp User Manual Helpful Hints Troubleshooting cont d Q Is there any way to change the Title of a Progress Note For example if I want to change one of my CWAD notes to a Nursing Psychology note is that possible A Yes Use the hidden action Change Title Q Is there a way to access progress notes that have been linked to a problem I can t seem to find how this is done A Assuming that notes are being linked to problems you can use the Show Progress Notes Across Patients option to search for notes by Problem When prompted to Select SEARCH CATEGORIES enter Problem Select Progress Notes User Menu Option Show Progress Notes Across Patients Select Status COMPLETED ALL undictated untranscribed unreleased unverified unsigned uncosigned completed amended purged deleted Select Progress Notes Type s ALL Advance Directive Adv React Allergy Crisis Note Clinical Warning Historical Titles Select SEARCH CATEGORIES AUTHOR PROB Problem Select PROBLEM ANGINA PECTORIS UNS 2 matches found A
69. have any TEXT Document must NOT have any addenda DAD cross reference Document must NOT have any components ADI cross reference An informational alert is sent once the cleanup process is finished In the following example the cleanup process is run for documents in a one month period Select Text Integration Utilities MIS Manager Option 138 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Individual Patient Document ultiple Patient Documents Print Document Menu Search for Selected Documents Statistical Reports Unsigned Uncosigned Report issing Text Report issing Text Cleanup Signed unsigned PN report and update 0 UNKNOWN Addenda Cleanup 1 issing Expected Cosigner Report m H Hw OD ai GaU e wU NH Enter for more options for brief descriptions OPTION for help text Select Text Integration Utilities MIS Manager Option 8 Missing Text Cleanup START WITH REFERENCE DATE Jan 01 2003 jun1 2004 JUN 01 2004 GO TO REFERENCE DATE Mar 04 2005 jull 2004 JUL 01 2004 Requested Start Time NOW MAR 04 2005 16 02 37 Your task is 165564 Fl Press RETURN to continue Rev January 2012 Text Integration Utilities V 1 0 139 Clinical Coordinator amp User Manual UNKNOWN Addenda Cleanup Prior to the release of TIU 1 187 it was possible to leave surgery addenda
70. information about using the Document Definition system see the TIU ASU Implementation Guide or the TIU Technical Manual 208 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Chapter 13 Defining User Classes The Authorization Subscription Utility ASU which is distributed with TIU provides a mechanism for sites to associate users with User Classes allowing them to specify the level of authorization needed to sign or order specific document types and orderables It also allows privileges to be inherited through its use of a hierarchical structure A set of Business Rules which can be modified or added to by sites further strengthens the Utility s ability to define roles and responsibilities for clinical documents See the ASU Clinical Coordinator Manual or the TIU ASU Implementation Guide for more information about ASU its relationship to TIU and its implementation User Class Management Menu User Class Definition USR CLASS This option allows review addition editing DEFINITION and removal of User Classes List Membership by USR LIST This option allows review addition editing User MEMBERSHIP BY and removal of individual members to and USER from User Classes List Membership by USR LIST This option allows review addition editing Class MEMBERSHIP BY and removal of individual members to and CLASS from User Classes Edit Business Rules USR EDIT This option allows the
71. is closed or a new search is initiated via the CHANGE VIEW option Rev January 2012 Text Integration Utilities V 1 0 143 Clinical Coordinator amp User Manual Missing Expected Cosigner Report List detailed document information for notes that have a status of uncosigned where the expected cosigner field is either null O or 1 Users will have a choice of 3 different report formats an 80 column standard report a 132 column extended report and a delimited report for use in exporting the data to Excel The 80 column report will include Patient Name initials and last 4 of SSN Entry Date Time Author Title and the Note IEN The 132 column report and the delimited report will include Patient Name initials and last 4 of SSN Entry Date Time Author Title Author s Service Section Author s Job Title and the Note IEN In either case if the document is an Addendum then the parent s Document Type Entry Date Time and Expected Cosigner will also be displayed The cause of the problem is being fixed in CPRS patch OR 3 0 215 Users should review the notes displayed on this report to determine who should be the expected cosigner and then enter the expected cosigner Once a note is signed the software doesn t permit editing so they will need to use FileMan The author of the note may need to be contacted to determine who should be the expected cosigner In addition this report may be setup in Taskman to be run nightly
72. may be Enter 23 for more actions outside the Browse Charge View original date Detailed Di 1 j etaile isplay range Select Action Quit F Find Pant Select Document s 1 3 3 START WITH REFERENCE DATE Jan 01 2003 lt Enter gt JAN 01 2003 GO TO REFERENCE DATE Apr 04 2005 lt Enter gt APR 04 2005 Searching for the documents 140 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Rev January 2012 Text Integration Utilities V 1 0 141 Clinical Coordinator amp User Manual Operation Reports Apr 04 2005 08 49 04 Page 1 of 1 OPERATION REPORTS from Jan 01 2003 to Apr 04 2005 Patient Doc IEN Entry DT Status Case 1 CPRSPATIENT T C5525 2181 09 17 04 RETRACTED 90 2 CPRSPATIENT T C5525 2182 09 20 04 RETRACTED 89 3 CPRSPATIENT T C5525 2192 09 28 04 RETRACTED 90 4 CPRSPATIENT T C5525 2195 09 29 04 COMPLETED 89 5 CPRSPATIENT T C5525 2237 10 14 04 RETRACTED 90 6 CPRSPATIENT T C5525 2284 01 20 05 UNVERIFIED 90 7 CPRSPATIENT T C5525 2292 01 28 05 UNDICTATED 109 Enter for more actions Attaching 2238 to 2195 Press lt RETURN gt to continue Do you wish to begin attaching NO Y YES success Browse Change View Detailed Display Attach to Parent S
73. note for a 56 year old patient would be presented with the text Patient is a healthy 56 year old male where the age for this specific patient is pulled from the patient database The Progress Notes module of TIU is used by health care givers to enter and sign online patient progress notes and by transcriptionists to enter notes to be signed by caregivers at a later date Caregivers may review progress notes online or print progress notes in chart format for filing in the patient s record Text Integration Utilities Titles are definitions for documents They store the behavior of the documents which use them User Classes are the basic components of the User Class hierarchy of ASU Authorization Subscription Utility which allows sites to designate who is authorized to do what to documents or other clinical entities Rev January 2012 Text Integration Utilities V 1 0 241 Clinical Coordinator amp User Manual Index lt Enter gt 13 Clinicians 22 121 2 202 Completed 49 64 8925 170 Component 237 8925 1 202 Computerized Patient Record System 23 Action 237 Consults Action abbreviations 232 Upload 171 Actions 16 50 65 Conversion Clean up Menu 202 Add Document 50 65 Copy 50 65 Additional Signature 75 200 Correcting Documents 125 Additional Signatures 108 Cosigning privilege 62 Admission Prints all PNs for Current Admission 184 COTS 219 Alert Tools 214 CPRS 23 28 39 199 219 238 Alert Tools FAQ 2
74. notes on these titles are auto generated by the Medicine Conversion patch MD 1 5 Note The TIU document classes user class category I note title and category I business rule installed by patches TIU 1 165 and USR 1 24 must not be modified in any way or Patient Record Flags may not work properly Rev January 2012 Text Integration Utilities V 1 0 213 Clinical Coordinator amp User Manual Patch TIU 1 159 implements the War Related Illness and Injury Study Centers WRIUSC pronounced risk note title and template The associated note title is WRIISC ASSESSMENT NOTE This note is described in the memo Description of WRITSC Programs and Associated Referral Process accompanying the patch To get it to work properly a Clinical Coordinator authorized to edit shared templates must perform the following steps from the CPRS GUI Go to the Notes tab From the Options menu select Edit Shared Templates In the Shared Templates pane highlight document Titles From the Tools menu select Import Template Select WRHISCASSESSMENT TXML and press Open Highlight the WRIISC ASSESSMENT template In the Associated Title list box select WRIISC ASSESSMENT NOTE Press OK RAO Oe NS Once these steps have been performed the template and note title will work for all CPRS users Further information about setting up shared templates is available in the Computerized Patient Record System CPRS User Guide in the section on Creating Personal Do
75. on a single menu but as individual menus intended for categories of users These are described in earlier sections of this manual and also here Sites may rearrange these as needed Recommended assignments are also listed on the following pages We ve also included an example of a potential Clinical Coordinator Menu Progress Notes s Discharge Summary TIU 1 Progress Notes User nu Entry of Progress Note Review Progress Notes by Patient Review Progress Notes All MY UNSIGNED Progress Notes Show Progress Notes Across Patients Progress Notes Print Options List Notes By Title Search by Patient AND Title Personal Preferences ALL Documents requiring my Additional Signature ischarge Summary User Menu Individual Patient Discharge Summary All MY UNSIGNED Discharge Summaries Multiple Patient Discharge Summaries ntegrated Document Management Individual Patient Document All MY UNSIGNED Documents All MY UNDICTATED Documents ultiple Patient Documents Enter edit Document ALL Documents requiring my Additional Signature ersonal Preferences Personal Preferences Document List Management ion NOPWAOBWNHRHWNEFUOUODMDANAUOBWNHNE Text Integration Utilities MRT 1 Individual Patient Document 2 Multiple Patient Documents 3 Review Upload Filing Events 4 Print Document Menu z 1 Discharge Summary Print 2 Progress Note Print 3 Clinical Document Print Released Unverified Report Search for
76. post CVA status post thrombectomy admitted from Anytown VA after a fall from his wheelchair in the hospital He had questionable short lasting loss of consciousness but patient is not very sure what has happened He denies headache vomiting vertigo On admission patient had CT scan which showed a small area of parenchymal hemorrhage in the right temporal lobe which is most likely consistent with hemorrhagic contusion without mid line shift or incoordination ACTIVE MEDICATIONS Isordil 20 mgs p o t i d Coumadin 2 5 mgs p o qd ferrous sulfate 325 mgs p o b i d Ativan 0 5 mgs p o b i d Lactulose 15 ccs p o b i d Calcium carbonate 650 mgs p o b i d with food Betoptic 0 5 ophthalmologic solution gtt OU b i d Nephrocaps 1 tablet p o qd Pilocarpine 4 solution 1 gtt OU b i d Compazine 10 mgs p o t i d prn nausea Tylenol 650 mgs p o q4 hours prn Patient is on hemodialysis no known drug allergies PHYSICAL EXAMINATION Patient had stable vital signs his blood pressure was 160 85 pulse 84 respiratory rate 20 temperature 98 degrees Patient was alert oriented times three cooperative His speech was fluent understanding of spoken language was good Attention span was good He had DRAFT Press RETURN to continue or to exit lt Enter gt 118 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Discharge Summary Print Exampl
77. progress notes or mixed Documents Released Unverified Report This report gives information on documents for a specified time period that have been released from transcription but still aren t verified This menu action can be eliminated if Transcription Release or MAS Verification parameters are not enabled Search for Selected Documents Allows MRT s to generate lists of selected documents by extended search criteria e g status search category and reference date range These can then be reviewed individually or by groups verified sent back to transcription reassigned or printed Unsigned Uncosigned Report Provides information on unsigned uncosigned documents for one multiple or all divisions The report can be either Summary or Full The summary report lists the number of documents by the service or section of the author The full report lists detailed document information such as author patient patient SSN etc by the service or section of the author Reassignment Document Report Provides a list of reassigned notes based on date range 88 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Description Review unsigned additional signatures Gives a list of documents that require additional signatures Provides either a detailed report listing each document that requires an additional signature or a summary report Individual Patient Document
78. routine The patient record indicated by the SSN is checked for a matching visit or event TITLE Required by filing routine LOCATION Required by filing routine AUTHOR Generates missing field error DATE TIME OF DICT Generates missing field error DISCHARGE SUMMARY PATIENT SSN Required by filing routine DATE OF ADMISSION Required by filing routine The patient record indicated by the SSN is checked for a matching admission date DICTATED BY Generates missing field error DICTATION DATE Generates missing field error ATTENDING PHYSICIAN Generates missing field error URGENCY Generates missing field error Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 171 Type of Document Caption Use CLINICAL PROCEDURES SSN Required by filing routine TITLE Required by filing routine This is the name of the procedure The patient record indicated by the SSN is checked for a matching procedure VISIT EVENT DATE Required by filing routine The patient record indicated by the SSN is checked for a matching visit or event CONSULT REQUEST NUMBER Required by filing routine The patient record indicated by the SSN is checked for a matching consult that the consult is a clinical procedure and that results are available for interpretation TIU DOCUMENT NUMBER Only required by filing routine when an incomplete CP document has been attached by the CPUse
79. s you chose is displayed Choose an action to perform Browse Document Oct 15 1996 12 23 42 Page 1 of 1 Diabetes Education TIUPATIENT SEVEN 666 04 2591P 1A Visit Date 09 28 96 15 58 DATE OF NOTE SEP 05 1996 13 51 03 ENTRY DATE SEP 05 1996 13 51 03 AUTHOR TIUPROVIDER SIX EXP COSIGNER TIUPROVIDER THREE URGENCY STATUS COMPLETED TEST DRUG EFFICACY es Six TIUProvider MS3 es Three TIUProvider MD Medical Student III Signed 10 05 96 13 51 Cosigned 10 05 96 14 11 Next Screen Prev Screen More Actions gt gt gt Find On Chart Reassign Print Amend Send Back Edit Delete Quit Verify Unverify Select Action Quit Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 115 Multiple Patient Documents Use this option to display TIU documents of specified types which can then be reviewed verified sent back to transcription reassigned or printed K Caution Avoid making your requests too broad in statuses search categories and date ranges because these searches can use a lot of system resources slowing the computer system down for everyone The example below would probably be too broad in a large hospital Steps to use option 1 Select Multiple Patient Documents from the MIS Manager menu Answer the prompts that follow Select Text Integration
80. site where participation is optional It took a test site with a million notes about 2 5 weeks to run their Progress Notes conversion 222 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual FAQs cont d Q Will the Discharge Summary and Progress Notes packages be gone once files are converted to TIU A Discharge Summary V 1 0 and Progress Notes V 2 5 should be made Out of Order once the conversions have been run staff trained and the cut over started The data in files 121 and 128 will remain until your site decides to purge these files We suggest that they remain intact until you re sure the conversions have run correctly and the implementation is going smoothly Q Can TIU be used without converting the Discharge Summaries until much later A TIU can be used without converting Discharge Summary but we strongly recommend that Progress Notes and Discharge Summary both be converted to TIU at the same time to avoid complications r NOTE You cannot run dual implementations of Discharge Summary that is Discharge Summary 1 0 and Discharge Summary through TIU Q Is it possible to load ASU in production and start populating the groups before we load TIU A Yes you can The Business Rules will not be functional because they are tied to the Document Definition File but you will be able to populate the Class memberships Q Do we have to delete or sign unsigned notes before we c
81. the Person Class A The Provider Class in ASU fulfills a different function and therefore its database design is a different kind of hierarchy A patch to ASU in the near future will help assure that your efforts in populating the Person Class Membership at your site are not lost or repeated We are developing a mapping between a subset of the exported User Classes and the Person Class File i e for each Person Class there will be a corresponding User Class which will help you autopopulate User Class Membership assure that future changes to an individual s Person Class Membership are reflected automatically in his User Class Membership and allow resolution of privileges for inter facility access to data We recommend that you initially implement TIU and ASU by populating only the most essential User Classes Oe Provider MRT Chief MIS and Transcriptionist and use the forthcoming patch to assist you in autopopulating more specific User Classes when you have become acquainted with the two products Q We ve heard that implementation of TIU is very complex and time consuming How long does is take A TIU implementation is complex but the amount of time it takes to implement has to do with the complexity of the site how many users how big the database is how extensive the hierarchy is the level of users how dependent the site is on the package obviously a site that is totally electronic has very different issues than a
82. this Discharge Summary ready to release from DRAFT YES lt Enter gt Discharge Summary Released Chart copy queued You may enter another Discharge Summary Press RETURN to exit Select PATIENT NAME lt Enter gt Rev January 2012 Text Integration Utilities V 1 0 165 Clinical Coordinator amp User Manual Upload Menu The Upload Menu contains options that allow the transcriptionist to upload a batch of clinical documents Option Name Description Upload Documents This option lets transcriptionists upload transcribed ASCII documents in batch mode either from remote microcomputers using ASCII or KERMIT protocol upload or from Host Files Ge DOS or VMS ASCII files on the host system Your site may define the preferred file transfer protocol and the destination within VISTA to which each report type e g discharge summary progress notes Operative Report etc should be routed Help for Upload Utility This option displays information on the formats of headers for dictated documents that are transcribed off line and uploaded into VZSTA It also displays blank character major delimiter and end of message signal as defined by your site The upload utility permits mixed report types within a single batch This allows the transcriptionist to enter each report in arrival sequence into a single ASCII file on the remote computer e g using a proprietary word processing program a
83. you enter the parameters that apply to specific documents i e Titles or groups of documents i e Classes or Document Classes Print Params Division Progress Notes TIU PRINT PN DIV PARAM These parameters are used by the TIU PRINT PN BATCH INTERACTIVE and TIU PRINT PN BATCH SCHEDULED options If the site desires a header other than what is returned by SITE VASITE the 02 field of the Ist entry in this file will be used For example Waco Temple Marlin can have the institution of their progress notes as CENTRAL TEXAS HCF Locations Progress Notes Batch Print TIU PRINT PN LOC PARAMS Option for entering hospital locations used for TIU PRINT PN OUTPT LOC and TIU PRINT PN WARD options If locations are not entered in this file they will not be selectable from these options L NOTE The TIU Implementation Guide and TIU Technical Manual contain instructions and examples for using these options 206 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Chapter 12 Document Definitions TIU uses a document storage database called the Document Definition hierarchy This hierarchy provides the building blocks for Text Integration Utilities TIU It allows documents Titles to inherit characteristics of the higher levels Class and Document Class such as signature requirements and print characteristics This structur
84. 06 07 96 00 00 DIABETES EDUCATION VISIT 04 18 96 10 00 GENERAL MEDICINE Routine diabetes education given as follow up to lipid clinic visit Signed by es One TIUProvider MD PGY2 Resident 06 07 96 10 22 NOTE DATED 06 05 96 17 23 LIPID CLINIC VISIT 04 18 96 10 00 GENERAL MEDICINE SUBJECTIVE 51 year old MEXICAN AMERICAN MALE here for initial evaluation of his DYSLIPIDEMIA T PMH Significant negative medical history pertinent to the evaluation and treatment of DYSLIPIDEMIA FH SH MEDICATION HISTORY CURRENT MEDICATIONS DIET Counseled on AHA Step I diet today by Nine CPRSProvider See her evaluation ACTIVITY OBJECTIVE HT 72 08 23 95 11 45 WT 190 08 23 95 11 45 TSH T4 FBG 89 HEMOGLOBIN AIC SGOT URIC ACID ASSESSMENT Ls MALE with without documented CAD Zhe CV Risk factors ES Lipid pattern PLAN Ls Implement recommendations to lower fat intake 2 Repeat FBG and HBG A1C on 3 Return to review lab on Signed by es Three TIUProvider MD Internist 06 05 96 17 23 Analog Pager 555 1213 Digital Pager 555 1215 Enter RETURN to continue or to exit lt Enter gt 102 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Clinical Document Print Example cont d
85. 1 06 1A SUBJECT Routine diabetes education Patient understanding good Three TIUProvider MD edical Internist 06 23 96 08 34 Analog Pager 555 1213 Digital Pager 555 1215 Cosigned by es TIUProvider Three 06 23 96 08 34 Analog Pager 555 1213 Digital Pager 555 1215 Signed by es NOTE DATED 04 24 96 08 00 ARTERIAL EVALUATION LOWER EXTREMITY VISIT 04 17 92 08 00 FOURTEEN S CLINIC SUBJECT Rule out embolus lower extremity AGE 50 UNIT General Medicin REFERRING MD Eight CPRSProvider DIAGNOSIS Rule out embolus HISTORY severe pedal edema foot ulcers OTHER cyanosis SYMPTOMS RESTING SYMPTOMS EXERTIONAL SYMPTOMS SIONS MEDICATIONS RECORDED RECORDED AUDIBLE DOPPLER SIGNAL RIGHT EFT DOPPLER WAVEFORM RIGHT LEFT COMMON FEMORAL COMMON FEMORAL SUPERFICIAL FEMORAL PRE EXERCISE POPLITEAL POST EXERCISE POSTERIOR TIBIAL OTHE DORSALIS PEDIS N NORMAL ABN ABNORMAL O ABSENT B BIPHASIC TRANSCUTANEOUS PO2 VALUES RIGHT LEFT SUBCLAVICULAR A0 A0 ABOVE KNEE 3g An HIGH BK A8 A0 CALF ote 29 ANKLE 36 WG GE DORSUM OF FOOT a 3s OTHER aig 28 Enter RETURN to continue or to exit lt Enter g
86. 16 Create Document Definitions 207 ALL Documents requiring my Additional Signature 66 CWAD 238 All MY UNSIGNED Discharge Summaries 62 CWAD components 85 All MY UNSIGNED Documents 66 69 Data repositorie 236 All MY UNSIGNED Progress Notes 43 Defaults 14 allow edit 18 Defining User Classes 208 Ambulatory Care Data Capture 236 Delete Document 50 65 Amended 49 64 Deleted 49 64 ANATOMIC PATHOLOGY AP 210 Detailed Display 41 50 65 ASCII 10 Diagnosis 33 ASCII characters 225 Discharge Summaries 18 ASCII file transfer 167 Discharge Summary 58 238 ASCII Protocol Upload 167 168 Upload 170 ASU 208 237 Discharge Summary Menu 58 ATTENDING 161 Discharge Summary Print 94 116 Author Print Progress Notes 45 183 Discharge Summary Statuses and Actions 64 Batch printing 195 224 Discharge Summary User Menu 22 Batch upload 227 Discharge Summary V 1 0 222 Batch upload of Progress Notes 227 Display Upload Help 173 Batch Upload Reports 166 division 87 92 103 106 134 143 144 145 146 Benefits 10 11 147 148 166 167 Boilerplate 11 Division 184 Boilerplate Text 237 Document Class 206 238 Boilerplates 229 Document Definition 238 Business Rule 237 Document Definition File 202 Business Rules 222 224 Document Definition Hierarchy 11 81 206 228 C amp P EXAM 227 Document Definition Options 207 C amp P exams 226 Document Definitions 206 Captioned headers 173 Document Definitions Clinician 81 Care Episode 236 Document Definitions printing 230 Change T
87. 2 gt lt Enter gt EDIT Option lt Enter gt Save changes YES lt Enter gt Saving General Note with changes Enter your Current Signature Code HIDDEN CODE SIGNATURE VERIFIED 7 Enter the Diagnosis associated with this Progress Note NOTE To receive workload credit VAMCs must now capture Provider Diagnosis and Procedure for all outpatient visits Please Indicate the Diagnoses for which the Patient was Seen Abdominal Pain Abnormal EKG Abrasion A list of diagnoses Abscess lt _ _ V Adverse Drug Reaction relating to the type ATDS ARC POO of Progress Note is Alcoholic intoxication Alcoholism Chronic presented for you to Allergic Reaction choose from 10 Anemia ANGINA VO OO JO 0 Ai t Stable Unstable Anorexia Appendicitis Acute Arthralgia THRITIS Osteo Rheumatoid Ascites 19 ASHD 20 OTHER Diagnosis Select Diagnoses 1 20 9 A oO Jon 0 UD vs AA Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 33 Entry of Progress Note cont d 8 Enter the Procedure associated with this Progress Note Please Indicate the Procedure s Performed A list of procedures relating to the type of Progress Note is presented for you to choose from CARDIOVASCULAR a Cardioversion 2 EKG 3 Pericardiocentesis 4 Thoracotomy MISCELLANEO
88. 4 Choose a document from the list Choose documents 1 4 1 Opening Diabetes Education record for review Browse Document Jun 26 1996 17 08 45 Page 1 of iL Diabetes Education TIUPATIENT ONE 666 23 3456 Visit Date 01 09 96 17 06 DATE OF NOTE JAN 09 1996 17 51 04 ENTRY DATE JAN 09 1996 17 51 0 AUTHOR TIUPROVIDER ONE EXP COSIGNER TIUPROVIDER THREE URGENCY STATUS COMPLETED Provided Mr TIUPatient with Diabetes diet pamphlet and explained areas h especially needed to be concerned about es Three TIUProvider MD for Five TIUProvider MS3 Medical Student III Next Screen Prev Screen More actions Find Print Quit Select Action Quit Print 5 The document is printed at the device you specified NOTE DATED 01 09 96 17 51 DIABETES EDUCATION ADMITTED 07 22 91 11 06 1A SUBJECT Lipid TEST Provided Mr TIUPatient with Diabetes diet pamphlet and explained areas h especially needed to be concerned about Signed by es TIUPROVIDER FIVE MD Medical Student III 01 23 96 08 34 Analog Pager 1 900 555 8398 Digital Pager 1 900 555 7883 Cosigned by es TIUPROVIDER THREE 01 23 96 08 34 Analog Pager 1 900 555 8398 Digital Pager 1 900 555 7883 178 Text Integration Utilities V 1 0 Rev Ja
89. 43 Doc Entry Date Time Title Missing Reference Date Tim Patient Status Signature Date Time Author Dictator 28476 Jun 04 2004 13 09 06 RS TEST NOTE 0 Text Jun 04 2004 13 08 CPRS PATIENT TWO 3213 COMPLETED Jun 04 2004 13 12 08 CPRSPROVIDER FIVE 28481 Jun 04 2004 13 54 45 H amp P GENERAL MEDICINE 0 Text Jun 04 2004 13 54 CPRS PATIENT FIVE 8828 COMPLETED Jun 04 2004 13 57 22 CPRSPROVIDER FIVE 28520 Jun 04 2004 13 54 47 GENERAL MEDICINE 0 Text Jun 04 2004 13 54 CPRS PATIENT ONE 8846 COMPLETED Jun 04 2004 13 57 23 CPRSPROVIDER SEVEN 28522 Jun 04 2004 14 02 49 H amp P GENERAL MEDICINE Text Jun 04 2004 14 02 CPRSPATIENTFEMALE EIGHT 8662 COMPLETED Jun 04 2004 14 03 43 CPRSPROVIDER FIVE 29498 Jan 18 2005 11 34 16 PRIMARY CARE NOTE 0 Text Jan 18 2005 11 33 CPRS PATIENT THREE 6626 COMPLETED Jan 18 2005 11 37 34 CPRSPROVIDER TWO Press RETURN to continue Rev January 2012 Text Integration Utilities V 1 0 137 Clinical Coordinator amp User Manual Missing Text Cleanup Note The TIU MISSING TEXT REPORT should be run prior to running the cleanup Refer to the documentation on the previous page for TIU MISSING TEXT REP
90. 44 666233456 YES SC VETERAN A Known allergies Select the Document type Select TITLE Choose from ADVANCE DIRECTIVE TITLE ADVERSE REACTION ALLERGY TITLE CLINICAL WARNING TITLE CRISIS NOTE TITLE DISCHARGE SUMMARY TITLE Select TITLE ADVERSE REACTION ALLERGY TITLE 3 If the patient is an outpatient choose the Visit admission from the list displayed that you wish to associate with the Adverse Reaction Allergy note This patient is not currently admitted to the facility Is this note for INPATIENT or OUTPATIENT care OUTPATII The following VISITS are available 1 gt APR 18 1996 10 00 2 gt FEB 21 1996 08 40 3 gt FEB 20 1996 10 00 4 gt F CHOOSE 1 4 or lt N gt EW lt RETURN gt TO CONTINUE OR TO QUIT 1 EB 20 1996 08 00 VISIT D ENT lt Enter gt ERAL MEDICINE ONARY CLINIC GEN PUL ONCOLOGY GEN ERAL MEDICINE All outpatient TIU data has to be associated with a visit If a visit related to TIU documents already exists you only need to confirm it otherwise you ll have to enter a new visit 74 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual Rev January 2012 Enter Edit Document cont d Creating new progress note Patient Location GEN Date time of Visit 04 18 96 10 00 Dat
91. 666 23 3456 1A Visit Date 07 22 91 11 06 DATE OF NOTE OCT 28 1996 17 11 51 ENTRY DATE OCT 28 1996 17 11 51 AUTHOR TIUPROVIDER ONE EXP COSIGNER URGENCY STATUS COMPLETED NAME TIUPATIENT ONE SEX MALE DOB SEP 12 1944 ALLERGIES Amoxicillin Aspirin MILK LABS WBC 8 7 RBC 5 1 HGB 16 HCT 47 MCV 91 MCH 29 MCHC 34 Plt 320 Next Screen Prev Screen More Actions Se Find Edit Copy Verify Unverify Send Back Print On Chart Reassign Quit Select Action Next Screen Multiple Patient Documents Use this option to display TIU documents of selected types which can then be individually or multiply reviewed verified sent back to transcription reassigned or printed Ve Caution Avoid making your requests too broad in statuses search categories and date ranges because these searches can use a lot of system resources slowing the computer system down for everyone Steps to use option 1 Select Multiple Patient Documents from your TIU menu 90 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Multiple Patient Documents cont d 2 Select one or more divisions Select division ALL ENTER Return for all divisions or A division and return when all divisions have been selected limit 20 Imprecise selections will yield an additional prompt e g When a user enters A all items beginning with A are displayed
92. 666090934 NO NON SERVICE CONNECTED CHOOSE 1 4 2 TIUPATIENT TWENTY 4 1 48 666090934 NO NON SERVICE CO 126 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Correcting Documents that are Entered in Error cont d NNECTED THIS IS A TEST 1 note C 03 16 99 10 20 Available documents 11 23 1998 thru 01 19 2001 19 Please specify a date range from which to select documents List documents Beginning 11 23 1998 lt Enter gt NOV 23 1998 Thru 01 19 2001 lt Enter gt JAN 19 2001 01 19 2001 10 27 Infection Control TIUPROVIDER O Visit 01 26 1999 2 12 30 2000 16 00 Discharge Summary TIUPROVIDER T Adm 12 25 2000 Dis 12 30 2000 3 11 01 2000 14 00 Discharge Summary TIUPROVIDER T Adm 04 19 2000 Dis 11 01 2000 4 04 24 2000 00 00 Discharge Summary TIUPROVIDER T Choose one or more documents 1 4 1 Browse Document Jan 19 2001 10 33 50 Page 1 et 1 lt Infection Control TIUPATIENT NINE 666 09 2591 AUDIOLOGY AND SPE Visit Date 01 26 1999 17 50 lt DATE OF NOTE JAN 19 2001 10 27 57 ENTRY DATE JAN 19 2001 10 27 58 AUTHOR TIUPROVIDER SEVEN EXP COSIGNER URGENCY STATUS UNSIGNED Pt is very sick Next Screen Prev Screen More actions Find On Chart Reassign Print Amend Send Back Edit Delete Quit Verify Unverify Select Action Quit R Reassign Ar
93. ATIENT H2591 Adverse React Allergy 03 05 97 unsigned 2 TIUPATIENT D3456 Adverse React Allergy 03 05 97 completed 3 TIUPATIENT R1239 CLINICAL WARNING 03 05 97 completed 4 TIUPATIENT H2591 Adverse React Allergy 03 11 97 completed Next Screen Prev Screen More Actions gt gt gt Find Sign Cosign Change View Add Document Detailed Display Copy Edit Browse Delete Document ake Addendum Print Quit Link Identify Signers Select Action Quit Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 47 List Notes by Title cont d 3 You may now choose an action such as Edit Sign Cosign Make Addendum or Detailed Display Progress Notes by Title Mar 11 1997 09 10 09 Page 1 of I from 03 01 97 to 03 11 97 8 documents Patient Document Ref Date Status 1 TIUPATIENT H2591 Adverse React Allergy 03 05 97 unsigned 2 TIUPATIENT D3456 Adverse React Allergy 03 05 97 completed 3 TIUPATIENT R1239 CLINICAL WARNING 03 05 97 completed 4 TIUPATIENT H2591 Adverse React Allergy 03 11 97 completed 5 TIUPATIENT H2591 Adverse React Allergy 03 10 97 completed 6 TIUPATIENT S1462 CLINICAL WARNING 03 04 97 uncosigned 7 TIUPATIENT P4365 Adverse React Allergy 03 04 97 completed 8 TIUPATIENT N1234 Adverse React Allergy 03 06 97 completed Next Screen Prev Screen More Actions 222 Find Sign Cosign Change View Add Document Detailed Display Copy Edit Browse Del
94. Allows you to review or print patient Clinical Documents Multiple Patient Documents This option lets MIS Managers see any of the available TIU documents on the Text Integration Utilities Review Screen Print Document Menu This menu gives MAS personnel access to options which print CHART or WORK copies of discharge summaries progress notes or mixed Documents on demand Search for Selected Allows MIS Managers to generate a list of selected Documents documents based on extended search criteria e g STATUS SEARCH CATEGORY and REFERENCE DATE RANGE Statistical Reports This menu allows you to view or print statistical reports for line counts and timeliness by Author Transcriptionist and Service Unsigned Uncosigned Report Provides information on unsigned and uncosigned documents for one multiple or all divisions The report can be either Summary or Full The summary report lists the number of documents by the service or section of the author The full report lists detailed document information such as author patient patient SSN etc by the service or section of the author Missing Text Report Reports which TIU Documents that do not have any report text are missing the 0 node of the text node or both cases Documents may be of any type including addenda but not notes with components or addenda attached to them Missing Text Cleanup This is a utility for assisting with the cleanup of documents without r
95. CS CO TIUPATIENT EIGHT TIUPATIENT SIX Aug 27 1999 16 18 45 PULMONARY CS CO TIUPATIENT EIGHT TIUPATIENT SIX Aug 27 1999 16 41 45 PULMONARY CS CO TIUPATIENT EIGHT TIUPATIENT SIX Aug 27 1999 16 41 46 PULMONARY CS CO TIUPATIENT EIGHT TIUPATIENT SIX Aug 31 1999 16 14 29 Addendum TIUPATIENT EIGHT TIUPATIENT SIX Aug 31 1999 17 01 15 Addendum TIUPATIENT EIGHT TIUPATIENT SIX Aug 31 1999 17 01 16 Enter RETURN to continue or to exit 108 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Review Unsigned Additional Signatures This option prints either a detailed or summary report of documents requiring additional signatures In the detailed report the patient name is abbreviated to the patient initials followed by the last six digits of the social security number to save space In the following example a detailed report is run covering a four month period Select VO OO JO 0 a o r Tex ultipl t Integra tion Individual Pa e Pati Review Upload Print Documen Utilities MRT S Option tient Document ent Documents Filing Events t Menu Releas Unsigne d Unv d Unco Reassignment Review unsigned additional signatures Enter for more options rified Report Search for Selected Documents signed Report Document Report 2 for brief des
96. ERFICIAL FEMORAL PRE EXERCISE POPLITEAL POST EXERCISE POSTERIOR TIBIAL OTHE DORSALIS PEDIS N NORMAL ABN ABNORMAL O ABSENT B BIPHASIC TRANSCUTANEOUS PO2 VALUES RIGHT LEFT SUBCLAVICULAR An An ABOVE KNEE EES An HIGH BK o 39 A0 CALF E cae EES ANKLE o 36 ee DORSUM OF FOOT EE 28 OTHER Ip 38 Enter RETURN to continue or to exit lt Enter gt Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 121 Progress Notes Print Example cont d TIUPATIENT ONE 666 23 3456 Progress Notes 04 24 92 08 00 CONTINUED FROM PREVIOUS SCREEN 40 ADEQUATE FOR HEALING 39 30 EQUIVOCAL FOR HEALING 29 0 INADEQUATE FOR HEALING SEGMENTAL SYSTOLIC BLOOD PRESSURE RIGHT INDEX LEFT INDEX ARM HIGH THIGH ABOVE KNEE BELOW KNEE ANKLE PT DP EXERCISE RESPONSE PH 5 mph AAXIMUM WALKING TIME 10 MIN 20 SEC SYMPTOMS Pedal edema cyanosis AXIMUM HEART RATE ACHIEVED TIME RIGHT INDEX LEFT INDEX ARM 1 MINUTE 3 MINUTES 5 MINUTES 10 MINUTES 15 MINUTES 20 MINUTES POST EXERCISE IMPRESSIONS Signed by es Three TIUProvider MD Medical Internist 04 24 96 14 19 Analog Pager 555 1213 Digital Pager 555 1215 A
97. GE MEDICATIONS Isordil 20 mgs p o t i d Ferrous sulfate 325 mgs DOs b i d Ativan 0 5 mgs p o b i d Lactulose 15 ccs p o b i d Calcium carbonate 650 mgs p o b i d Compazine 10 mgs p o t i d prn nausea Betoptic 0 5 OU b i d Nephrocaps 1 p o qd Pilocarpine 4 solution 1 gtt OU b i d Coumadin 2 5 mgs p o qd Tylenol 650 mgs p o q6 hours prn pain DISPOSITION FOLLOW UP Recommend follow PT PTT Patient is on coumadin and CBC with differential because patient has chronic anemia and thrombocytopenia Patient will be transferred to Anytown VA in stable condition on 5 19 94 WORK COPY UNOFFICIAL NOT FOR MEDICAL RECORD DO NOT FILE SIGNATURE PHYSICIAN DENTIST SIGNATURE APPROVING PHYSICIAN DENTIST TIUPROVIDER ONE MD THREE TIUPROVIDER MS PGY2 Resident Medical Internist CONFIDENTIAL INFORMATION DRAFT JUN 26 1996 17 36 02 ADDENDUM Routine visit today no change to condition SIGNATURE PHYSICIAN DENTIST SIGNATURE APPROVING PHYSICIAN DENTIST Three TIUProvider MD Medical Internist Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 97 Progress Note Print Use this option to print chart or work copies of progress notes Steps to use option 1 Select Progress Note Print from the Print Document Menu 2 Enter a patient name Select Print Document Menu Opt
98. IENT ONE 666 12 3456 2B JAN 1 1951 46 Title Author Date Time 1 Psychology Notes TIUPROVIDER ONE 04 08 97 15 49 compl 2 CRISIS NOTE TIUPROVIDER THR 04 08 97 00 00 compl 3 Adverse React Allergy TIUPROVIDER NIN 04 07 97 16 28 compl 6 Adverse React Allergy TIUPROVIDER NIN 04 03 97 19 31 compl 7 Adverse React Allergy TIUPROVIDER NIN 03 17 97 17 15 compl 8 CRISIS NOTE TIUPROVIDER NIN 02 24 97 08 28 compl Next Screen Prev Screen More Actions NW New Note SP Select New Patient AD Make Addendum B Browse SS Select Search Complete Note s PC Print Copy RS Reset to All Signed Q Quit Select Action Quit SS Select Search Valid selections are L signed notes all 2 unsigned notes 3 uncosigned notes 4 signed notes author 5 signed notes dates Select context 1 4 AUTHOR Select AUTHOR TIUPROVIDER TWO lt Enter gt jg Please Specify Sort Order descending Enter a code from the list Select one of the following A ascending OLDEST FIRST D descending NEWEST FIRST Please Specify Sort Order descending A ascending OLDEST FIRST Searching for the progress notes Progress Notes Apr 09 1997 14 42 50 Page L of L lt CWA gt PROGRESS NOTES 4 note s TIUPATIENT ONE 666 12 3456 2B JAN 1 1951 46 Title Author Date Time 1 CRISIS NOTE TIUPROVIDER 02 24 97 08 28 compl 2 Adverse React Allergy TIUPROVIDER 03 17 97 17 15 compl 3 Adve
99. IER lt Enter gt Was this encounter related to any of the following Service Connected Condition Y YES You have indicated the following data apply to this visit DIAGNOSES 995 23 Allergic Reaction lt lt lt PRIMARY PROCEDURES 65205 Foreign Body Removal W Mod w mod x 2 CPT Modifier s 26 PROFESSIONAL COMPONENT 32 MANDATED SERVICES 47 ANESTHESIA BY SURGEON 16015 Dressings Medium SERVICE CONNECTION Service Connected YES OK YES lt Enter gt Posting Workload Credit Done Print this note No lt Enter gt NO You may enter another Progress Note Press RETURN to exit Select PATIENT NAME 236 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Visit Orientation Why associate Progress Notes with Visits Database design An event clinical or otherwise may be fully described by five key attributes or parameters Who what when where and why Three of these i e who when and where are all encoded in the Visit File entry itself The remaining two parameters what and why are generally included in the content of the document The VHA Operations Manual M 1 Chapter 5 requires that every ambulatory visit have at least one Progress Note Deficiencies with respect to this requirement can only be identified if Progress Notes are associated with their cor
100. IUProvider MD 10 02 96 10 34 Analog Pager 1 900 555 8398 Digital Pager 1 900 555 7883 ETURN to continue or to exit HOSPITAL LOCATION NAME Patient Print Progress Notes Example T 190 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual Rev January 2012 Location Print Progress Notes Example cont d Select Progress Notes Print Options Option p Patient Print Progress Notes Print Progress Notes for a Selected PATIENT Select PATIENT NAME TIUPATIENT THIRTEEN 04 01 44 666776641 YES SC VETERAN 1 note W 09 02 95 09 00 Available notes Sep 06 1995 thru Mar 21 1996 Print Notes Beginning t 360 APR 08 1995 Thru t APR 02 1996 Searching for the notes gt gt 5 notes found for TIUPATIENT THIRTEEN Do you want WORK copies or CHART copies CHART lt Enter gt T Do you want to start each note on a new page NO lt Enter gt DEVICE HOME lt Enter gt LAT TERMINALS TIUPATIENT EIGHT 666 77 6641 Progress Notes NOTE DATED 09 01 95 12 00 General Note VISIT CARDIOLOGY This is a very sad situation It is also a general progress note We hope the patient does better in the future She is quite nice clean and nice Signed by es NINE TIUPROVIDER VERIFIER 09 06 95 21 51 NOTE DATED 09 02 95 09 00 Clinical Warning VISIT CARDIOLOGY
101. Integration Utilities TIU for expressing notes from different care givers as a single episode of care They always start with a single note by the initial contact person e g triage nurse attending and continue with separate notes created and signed by other providers and attached to the original note To accomplish this your facility must 1 Set up note titles for the initiating note and the attachment notes also called parent note and child notes 2 Use version 15 of the CPRS Windows GUI interface or later The Text Integration Utilities TIU Implementation Guide contains a new appendix Appendix C that describes in detail the technical aspects of setting up Interdisciplinary Notes The rest of this section shows the actions Interdisciplinary Notes using Version 15 of the CPRS Windows interface The Parent Note You start any interdisciplinary note with a parent note A parent is a note title that includes an ASU Authorization Subscription Utility rule allowing attachments Your facility should have set up these titles with unique names that allow you to easily identify them Only certain members of your team should start Interdisciplinary Notes To establish a parent note for a patient and a specific episode of care all they do is create a note with the proper title and sign it The Child Note s Continue an interdisciplinary note by attaching one or more child notes to the parent note The intention is for each c
102. Intensive Care Units they may have a very long complicated summary to describe the care while in the unit This should be an interward transfer note but some of our physicians feel that due to the complexity of care delivered in the unit this should be included in their Discharge Summary BUT should have its own date episode of care I realize that the interward transfer note is a progress note and very few of our physicians are using progress notes Our physicians seem to want to have that interward transfer information in these complex cases attached to the Discharge Summary My question is will TIU offer us anything different that will satisfy our physicians I still do not have a mental picture of what it will look like when I go to look up a DCS or PN from the TIU package Will the documents be intermingled and arranged by date Iam a firm believer in calling things what they are and putting them where they belong when it comes to organizing our electronic record I hate to see the DSC and interward transfers go together now in the DCS package as it does create a problem when the patient is actually discharged and Incomplete Record Tracking IRT thinks he was discharged when the interim was written Does anyone have any thoughts and can someone show me how it looks when I get TIU and look up documents on a patient A From TIU Developer Interim Summaries may be easily defined in TIU and linked with the corresponding IRT deficiency Parame
103. January 2012 Clinical Coordinator amp User Manual Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 159 Chapter 6 TIU for Transcriptionists e Enter Edit Discharge Summary e Enter Document e Upload Menu e List Documents for Transcription e Review Edit Document e Transcription Billing Verification Report 160 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Chapter 6 TIU for Transcriptionists Transcriptionists typically enter Providers discharge summaries progress notes or other documents 1 directly from dictation or 2 from uploaded transcribed ASCII documents in batch mode a from remote microcomputers using ASCII or KERMIT protocol upload or b from Host Files Ge DOS or VMS ASCII files on the host system Options on this menu can be assigned accordingly Transcriptionist Menu Option Name Description Enter Edit Discharge Summary This option lets you enter or edit discharge summaries and progress notes directly online If the transcriptionist holds the AUTOVERIFY security key each discharge summary will be verified automatically when the transcriptionist releases it Enter Edit Document This option lets you enter edit clinical documents directly online Upload Menu This menu includes options to upload batches of documents and to get help on the header formats for the various documents w
104. January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 87 Chapter 4 TIU for Medical Record Technicians Medical Record Technicians in the MIS or HIMS of Medical Administration Service complete the tasks of assuring that all discharge summaries placed in a patient s medical record have been verified for accuracy and completion They are also responsible for assuring that a permanent chart copy has been placed in a patient s medical record for each separate admission to the hospital MRT Menu This is the main TIU menu for Medical Record Technicians MRTs It includes all of the options necessary for MRTs to review edit sign and print documents print reports on TIU documents search for documents and review upload filing events Option Description Individual Patient Document This option allows MRTs to review edit or sign patient Documents Multiple Patient Documents Text Integration Utilities review screen of all types of TIU documents available for MRTs Review Upload Filing Events This option lets MRTs generate a list of all upload filing events i e successes filing errors or missing field errors by division by status by date range and to print the corresponding error records or resolve the error e g correct the Patient SSN or Admission date and retry the filer Print Document Menu This menu lets MAS personnel print chart or work copies of discharge summaries
105. L 00T5 VAWW VITERION CC MED VA GOV DNS TIUHL7 68 9 ANONYMOUS MED V A GOV DNS 20060731092708 0700 MDM T02 MDM_ T02 99953046 T 2 4 AL AL USA EVN TO2 PID USVHA NI USSSA SS 290 USVHA PI TIUPATIENT FIVE PVL gt AAGL WALK IN MASA SARDARANEAAMAAASAABAAANHAADAAANAAR ZOO EE LOS TXA TEXT 200607311621 33271 TIUPROVI DER THREE USVHA USVHA PROGR SS NOTES AA AA A wia n nn nn nn wn wenn en nn nn nnn nnn OBX 1 TX SUBJECT This is the subject NEW TEST TODAY NEW Location NEW TEST n ew REF date for GI WALK IN Enter for more actions Delete Message Reprocess Messag Select Item s Quit The messages displayed by the Message Manager are from the XTEMP Global which is set to delete messages after seven 7 days In other words VistA discards HL7 messages that are more than seven 7 days old Rev January 2012 Text Integration Utilities V 1 0 221 Clinical Coordinator amp User Manual Chapter 17 Helpful Hints Troubleshooting FAQs Frequently Asked Questions Ve NOTE Most of these questions were received from TIU ASU test sites Thanks to everyone who contributed Q We just entered all of our Providers into the Person Class file when the Ambulatory Care Reporting Project came out Do we have to do this all over again for the User Class file in ASU Why can t TIU and ASU just use
106. MENT PLAN Please select a ti TITLE Choose from ER NURSE NOTE ER PHYSICIAN OCCUPATIONAL EHAB HI LD EHAB HI LD EHAB HI LD EHAB HI LD EHAB HILD EHAB HILD tle for your entry TITLE NOTE TITLE THERAPY CHILD NOTE DISCHARGE PLANNING NOT INITIAL ASSESSMENT NOT NURSE NOTE TITL PHARMACY NOTE TITLE PHYSICAL THERAPY NOTE PSYCHOLOGY NOTE TITL A REHAB CHILD PHYSICAL T H a Gl TITLI 1 TITL ab bi TITLE D DDAA C C C C C C Fl TITLE HERAPY NOT Fl TITLI Fl Edit PROGRESS NOTE Patient Location PULMONARY CLINIC Date time of Visit 02 08 01 08 26 Date time of Note NOW Author of Note TIUPROVID OK YES lt Enter gt Calling text editor please wait 1 gt The Pt is doing very well 2 gt EDIT Op Enter ER TWENTY ONE tion lt Enter gt Saving ID CHIL Enter your Current Signature Code Rev January 2012 D REHAB PHYSICAL THERAPY NOTE KaKKKK KKK with changes Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual
107. MY UNDICTATED Documents ultiple Patient Documents Enter edit Document ALL Documents requiring my Additional Signature On UG GA b i Enter for more options for brief descriptions OPTION for help text Select Integrated Document Management Option 6 ALL Documents requiring my Additional Signature Searching for the documents My Identified Signer Docs Feb 21 2005 19 00 32 Page L of 1 ALL DOCUMENTS Requiring My Additional Signature Patient Document Ref Date Status L CPRSPATIENT S C1050 ONE PER VISIT NOTE 12 18 02 completed 2 CPRSPATIENT T C6572 PATIENT EDUCATION 06 19 98 completed 3 CPRSPATIENT T C6572 MEDICINE CS CONSULT 06 09 98 completed Next Screen Prev Screen More Actions Edit Browse Expand Collapse Entry ake Addendum Print Encounter Edit EE o ENEE Identify Signers Quit Sign Cosign Delete Document Detailed Display Interdiscipl ry Note Select Action Quit 76 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Personal Preferences The two options on this menu let you customize the way TIU operates for you that is which prompts will appear what lists you will see to select from etc Thus if you only work with Discharge Summaries or Progress Notes or only a specific set within these categories you can set your preferences so that only these documents
108. OOKUP FAILED Enter VA VIEW ALERTS to review alerts Select Upload menu Option VA View Alerts dle UPLOAD PROCESS 555972453 Select from 1 to 1 or Enter A I Failed LOOKUP FAILED Aa P M R or to exit 1 The header of the failed record looks like this SHDR DISCHARGE PATIENT NAME TIUPATIENT ONE SOCIA ECURITY NUMBER 666 09 1244P DAT ISSION 11 17 95 DAT DISCHARGE DICTATED BY TIUPROVIDER TW DICTATION DATE 4 16 96 ATTENDING PHYSICIAN TIUPROVID PTIONIST C7689 PRIORITY SUMMARY Gs ENTY ER ONE ENCY TXT Inquire to patient record YES lt Enter gt Select PATIENT TIUPATIENT ONE 09 12 44 666091244P TO ERAN The following admissions are available dcs indicates a Discharge Summary exists 12 44 1 TIUPATI 2 TIUPATI 3 TIUPATI O 812091244P ENT ONE Adm ENT ONE Adm ENT ONE Adm SC VET 07 22 95 10 28 95 11 16 92 ERAN Dis Dis Dis 10 28 92 10 28 92 Open Open Open Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 169 ASCII PROTOCOL UPLOAD WITH ALERT cont d Patient TIUPATIENT ONE SSN 666 09 1244P Sex MALE Ward 1A Race Age 48 Att Phys TIUPROVIDER EIGHT Prim Phy
109. ORT for cause and frequency to run that report This is a utility designed to help clean up TIU documents with no text Before using this utility a number of other things should be tried They are e NO TEXT in DOCUMENT body with no attached addendum or image document may or may not have the TEXT 0 node as indicated by the report Delete or retract the document based upon status no disclaimer is needed e Ifthe TEXT 0 node is missing as indicated by the report and the document has text o For direct entry documents contact author to make an addendum to the note and add the missing information Sites may determine the allowable timeframe to permit the author entering the addendum with the missing information If the author is no longer at the site or the timeframe has passed the HIMS Manager or designee should enter an addendum with the following disclaimer DISCLAIMER This completed document contains missing text that was electronically deleted in error o For uploaded documents contact the transcription company to re upload if possible or contact the author to make an addendum to the note and add the missing information The cleanup utility retracts documents within a date range that meet certain criteria The criteria are e Document may be of any type including ADDENDUM with a STATUS of UNCOSIGNED COMPLETED AMENDED Document must fall within user entered date range Document must NOT have the TEXT O node Document must NOT
110. PROVIDER ONE ATTENDING TIUPROVIDER THREE URGENCY routine STATUS UNVERIFIED DIAGNOSIS 1 Status post head trauma with brain contusion 2 Status post cerebrovascular accident 3 End stage renal disease on hemodialysis 4 Coronary artery disease 5 Congestive heart failure 6 Hypertension 7 Non insulin dependent diabetes mellitus Find Verify Unverify Print Quit Select Action Next Screen v Verify Unverify Do you want to edit this Discharge Summary NO lt Enter gt VERIFY this Discharge Summary NO y YES Discharge Summary VERIFIED Refreshing the list Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 125 Correcting Documents that are Entered in Error Reassigning signed documents is restricted to the Chief MIS User Class This includes notes that are awaiting a co signature If the document is completely unsigned users who are Author Dictator or users with proper authorization may reassign it Besides reassigning a note to a different patient admission or visit the reassign action may be used to promote an Addendum as an Original swap the Addendum and the Original change a discharge summary to an Addendum The basic reassign process includes the following steps 1 Electronic signature challenge If the document is already signed TIU asks for the electronic signature of the Chief of MIS 2 Retract If the document is mov
111. PROVIDER ONE from 04 01 97 to 05 31 97 3 documents Patient Document Ref Date Status 1 TIUPATIENT FIVE T3779 Discharge Summary 06 02 97 unsigned 2 TIUPATIENT ONE T3456 Adverse React Allergy 05 31 97 unsigned 3 TIUPATIENT TWO T3243 Adverse React Allergy 05 20 97 unsigned Next Screen Prev Screen More actions Find Sign Cosign Change View Add Document Detailed Display Copy Edit Browse Delete Document ake Addendum Print Quit Link Identify Signers Select Action Quit Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 73 Enter Edit Document This option lets you enter and edit clinical documents directly online L NOTE L NOTE Steps to use option All documents for outpatients must be associated with a Visit or Admission in order to receive workload credit Signed notes may not be edited even if there is a business rule allowing them to be Hard code within TIU prevents editing of signed documents The following categories are considered signed Un cosigned completed amended and retracted 1 Select Enter Edit Document from your Integrated Document Management menu on your TIU menu and enter a patient name Select Integrated Document Management Option Enter edit Document Select PATIENT NAME TIUPATIENT ONE TIUPATIENT ONE 09 12
112. PROVIDER SEVEN from 06 04 02 to 06 04 03 Patient Document Ref Date Status 1 TIUPATIENT FO T8832 OT ASSESSMENT NOTE 09 09 02 completed 2 TIUPATIENT FO T8832 Cardiology Note 09 23 02 unsigned 3 TIUPATIENT FI T0150 ONE PER VISIT NOTE 12 18 02 completed 4 TIUPATIENT SI T3323 Discharge Summary 02 27 03 unreleased 5 TIUPATIENT SE T6351 H amp P GENERAL MEDICINE 02 27 03 completed Enter for more actions gt gt Browse Edit Change View Identify Signers Combo Alert s Resend Alert s Delete Alert s Third Party Alert s Detailed Display Select Action Quit R Resend Alert s Select Document s 1 5 2 Resend Alerts for the following documents 2 TIUPATIENT FOUR T8832 Cardiology Note 09 23 02 unsigned Send these alerts as OVERDUE NO Y YES Is this correct YES lt Enter gt Sending Alerts Finished ETURN to continue or to exit Enter R Alert Tools FAQ Q My search results by an ADDITIONAL SIGNER and UNSIGNED documents aren t showing any matches but I know they exist What s wrong A Additional signers are usually added AFTER a document has been signed or co signed Add UNCOSIGNED and COMPLETED documents to your search criteria I want to regenerate alerts for an UNCOSIGNED document but I don t want the AUTHOR to get alerted Should I just send a 3rd Party Alert to the EXPECTED COSIGNER You could but if you select RESEND ALERTS the regenerated ale
113. R 84 Example email message Subj MISSING EXPECTED COSIGNER 440685 02 08 06 13 14 11 lines From XXXX In IN basket Page 1 PATIENT ABC1234 ENTRY DATE TIME JAN 10 2006 15 34 21 NOTE TITLE Addendum AUTHOR TIUAUTHOR ONE AUTHOR S SERVICE SECTION CHIEF OF STAFF AUTHOR S TITLE SUPERVISOR PHYSICAL MEDICINE NOTE IEN 1234567 PARENT DOCUMENT TYPE ANESTHESTA POST OP NOTE PARENT DOCUMENT ENTRY DATE JAN 09 2006 16 25 47 PARENT DOCUMENT COSIGNER Enter message action in IN basket Rev January 2012 Text Integration Utilities V 1 0 145 Clinical Coordinator amp User Manual Mark Documents Signed by Surrogate This option allows documents needing an Additional Signer where the additional signature was signed by a surrogate of the Additional Signer to be marked as Signed By Surrogate This should not be needed for documents signed after patch TIU 1 0 199 is installed Example Select OPTION NAME TIU MAIN MENU MGR Text Integration Utilities MIS Manager MIS Managers Menu 1 Individual Patient Document 2 ultiple Patient Documents 3 Print Document Menu 4 Search for Selected Documents 5 Statistical Reports 6 Unsigned Uncosigned Report 7 issing Text Report 8 issing Text Cleanup 9 Signed unsigned PN report and update 10 UNKNOWN Addenda Cleanup 11 issing Expected Cosigner Report 12 ark Document as Signed by Surrogate 13 ismat
114. R or Dictating practitioner Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 131 TRANSCRIPTIONIST Line Count Statistics DISCHARGE SUMMARY Line Count Statistics by TRANSCRIPTIONIST ISC SLC A4 JUN 27 1996 09 51 PAGE 1 Line Transcriber Count Ref Date Patient Disch Dict Dict Transcr Transcr Sign Sign Cosign BS 0 JUN 19 1996 TIUPAT T SEVEN 0 Discharg 73 JUN 11 1996 TIUPAT T FIVE 1 Discharg 78 AY 31 1996 TIUPAT T SEVEN 7 1 Discharg 72 AR 25 1996 TIUPAT T EIGHT 1 0 0 Discharg 78 AR 24 1996 TIUPAT T NINE 1 1 0 0 Discharg 73 AR 23 1996 TIUPAT T ELEVE 1 0 0 Discharg 73 FEB 12 1996 TIUPAT T ONE 84 2 Discharg 80 FEB 8 1995 TIUPAT T TWELV 0 44 0 Discharg 96 FEB 8 1995 TIUPAT T ELEVE 0 44 0 Discharg SUBTOTAL 623 90 a 88 0 SUBCOUNT 9 3 9 5 5 SUBMEAN 69 22 30 00 0 78 17 60 DP 1 JAN 10 1996 TIUPATIENT FIVE 1004 0 0 0 Discharg SUBTOTAL 1 1004 0 0 0 SUBCOUNT 1 J 1 1 T SUBMEAN 1 00 1004 00 SBW 0 MAY 25 1996 TIUPATIENT SEVEN As Discharg SUBTOTAL 0 4 0 0 SUBCOUNT 1 0 1 0 0 SUBMEAN 1 00 jg 0 FEB 12 1996 TIUPATIENT ONE 97 0 Addendum SUBTOTAL 97 0 0 0 SUBCOUNT 1 1 1 0 0 SUBMEAN 97 00 TOTAL 624 1191 8 88 0 COUNT 12 5 12 6 6 MEAN 52 00 238 20 0 67 14 67 0 00 132 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Line Count Statistics by AUTHOR DISCHARGE SUMMARY
115. RESS NOTE OK YES Patient Location Date time of Visit Date time of Note Author of Note 1999 09 00 NINE CLINIC 07 30 99 09 00 01 19 01 10 27 TIUPROVIDER SEVEN AUTHOR DICTATOR TIUPROVIDER SEVEN Infection Control Reassign Press RETURN to continue Select PATIENT NAME ed 128 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual Rev January 2012 Rescinding Advance Directives Patch TIU 1 261 supports Imaging patch MAG 3 0 121 The two patches are being released in a combined release with TIU 1 261 requiring MAG 3 0 121 Patch MAG 3 0 121 provides the ability to watermark images RESCINDED Patch TIU 1 261 permits an authorized user to rescind an Advance Directive document by changing the title to RESCINDED ADVANCE DIRECTIVE MAG 3 0 121 takes it from there and watermarks any linked images RESCINDED NOTE Exact title names are required Exact title names are required The title of the Advance Directive to be rescinded must be ADVANCE DIRECTIVE The title it is changed to when it is being rescinded must be RESCINDED ADVANCE DIRECTIVE Both LOCAL and National Standard titles must be as above Variations on either title will cause the Change Title action to fail to watermark images as rescinded These exact titles are required by policy See the VHA HANDBOOK 1004 02 section on Advance Directi
116. RS Computerized Patient Record System access to and operations on Progress notes is streamlined Here we give an example of reviewing Notes through the List Manager version of CPRS The GUI version has a different sequence of steps but should seem even easier to most people Example Reviewing and signing Notes through CPRS 1 Select the Clinician Menu from your CPRS menu OE CPRS Cl RR Results AD Add New RO Act On PP Persona Select Clinician inician Menu Reporting Menu Orders Existing Orders 1 Preferences enu Option OE CPRS Clinician Menu 2 The Patient Selection screen is displayed If you have a patient or team list defined the patients are on this display Ward 2B Mar 17 1997 17 07 09 Page i o T Current patient No patient selected Patient Name ID DOB Room Bed L TIUPATIENT ONE 3456 Jan 01 1951 2 TIUPATIENT THREE 1996 Mar 05 1949 3 TIUPATIENT FIVE 3779 Nov 19 1991 4 TIUPATIENT SEVEN 3234 Mar 03 1966 5 TIUPATIENT TE 2432 Apr 04 1932 6 TIUPATIENT NINE 2591 Apr 25 1931 9 B If you have a 7 TIUPATIENT ELEVEN 8910 Jan 01 1934 A 4 8 TIUPATIENT TWO 3243 Apr 04 1954 patient list 9 TIUPATIENT FOURTEEN 4723 Oct 23 1927 A 2 defined in your personak Next Screen CG Change List FD Find Patient preferences it is D Previous Screen
117. RY IEN 1734555 TOTAL COUNTS FOR MISMATCHED ID NOTES 148 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual 1173 CROSS REFERENCES CHECKED 2 MISS MATCHED NOTE S FOUND 2 NON EXISTENT PARENT NOTE S 2 PARENT MAY NOT BE AN ID NOTE 1 POINTER S FIXED FOR MISMATCHED NOTES 1 XREF S FIXED FOR MISMATCHED NOTES 1 POINTER S FIXED FOR MISSING NOTES 1 XREF S FIXED FOR MISSING NOTES Example of email sent to G PSI 06 030 in report only mode Site Number Site Nam AUG 31 2006 15 24 09 1173 CROSS REFERENCES CHECKED 9 MISMATCHED NOTE S FOUND 7 NON EXISTENT PARENT NOTE S MODE REPORT ONLY Example of email sent to G PSI 06 030 in report and fix mode Site Number Site Nam AUG 31 2006 15 24 09 1173 CROSS REFERENCES CHECKED 9 MISMATCHED NOTE S FOUND 7 NON EXISTENT PARENT NOTE S MODE REPORT AND FIX 5 POINTER S FIXED FOR MISMATCHED NOTES 4 XREF S FIXED FOR MISMATCHED NOTES 3 POINTER S FIXED FOR MISSING NOTES 4 XREF S FIXED FOR MISSING NOTES Rev January 2012 Text Integration Utilities V 1 0 149 Clinical Coordinator amp User Manual TIU 215 ANALYSIS A probl
118. S YES Enter YES if you want to be prompted for a SUBJECT when entering or editing a Progress Note Subject is a freetext indexed field which may help you to find notes about a given topic etc Choose from 1 YES 0 NO ASK SUBJECT FOR PROGRESS NOTES YES lt Enter gt NUMBER OF NOTES ON REV SCREEN This determines the number of notes that will be included in your initial list when reviewing progress notes by patient 78 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Personal Preferences cont d NUMBER OF NOTES ON REV SCREEN 5 Type a Number between 15 and 100 NUMBER OF NOTES ON REV SCREEN 15 SUPPRESS REVIEW NOTES PROMPT Allows user to specify whether to suppress the prompt to Review Existing Notes on entry of a Progress Note YES will SUPPRESS the prompt while NO or no entry will allow the site s default setting to take precedence Choose from 1 YES 0 NO SUPPRESS REVIEW NOTES PROMPT 0 Select DAY OF WEEK Monday Are you adding Monday as a new DAY OF WEEK the 1ST for this TIU PERSONAL PREFERENCES Y Yes HOSPITAL LOCATION GENERAL MEDICINE TIUPATIENT TWO Select DAY OF WEEK lt Enter gt 1 Personal Preferences 2 Document List Management
119. SIT DATE A A A A A I A A H A ENT NAME A A A A A A A A A A gt ScrollRight PS PL PrintScrn List Find Detailed Display Quit Change View Select Action Next Screen Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual TIU and Health Summary A new Health Summary component is available through Patch GMTS 2 7 12 Selected Progress Notes which allows selection of specific Progress Notes Titles for display on Health Summaries Patch GMTS 2 7 45 Interdisciplinary Progress Notes expands this functionality to include Interdisciplinary Notes All Progress Notes Discharge Summary and CWAD components now extract data from TIU rather than Progress Notes GMRP or Discharge Summary GMRD Care has been taken to assure that the formatting and content of the components have remained the same except that the signature block information will now reflect the author s and cosigner s name and title at the time of signature rather than displaying their current values at the time of output 86 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Chapter 4 TIU for MRTs Individual Patient Document Multiple Patient Documents Review Upload Filing Events Print Document Menu Released Unverified Report Search for Selected Documents Unsigned Uncosigned Report Rev
120. SV Save as Default List Q Close displayed here Select Patient Close 1 TIUPATIENT ONE Searching for the patient s chart MH 3 Select a patient by e Entering a name from a list if you have one defined and set as your default e Entering a patient s name or last initial last 4 letters of SSN e Entering FD Find Patient entering a ward or clinic name then selecting a patient name from the list that appears If not just enter a patient name Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 23 Example Reviewing Notes cont d 4 The Cover Sheet for the patient s record is displayed Select Chart Contents Cover Sheet Mar 17 1997 17 07 50 Page 1 of 2 TIUPATIENT ONE 666 12 3456 2B JAN 1 1951 46 lt CW gt Item Entered Allergies Adverse Reactions 1 PENICILLIN 1 rash nausea vomiting 01 03 97 Patient Postings 2 CRISIS NOTE 02 24 97 08 28 3 CRISIS NOTE 12 03 96 10 44 4 CLINICAL WARNING 02 21 97 09 16 5 CLINICAL WARNING 01 15 97 Recent Vitals No data available Immunizations No immunizations found Enter the numbers of the items you wish to act on gt gt gt NW Document New Allergy CG Change List SP Select New Patient Next Screen CC Chart Contents Q Close Patient Chart Select Next Screen ce CHART CONTENTS Shortcut Enter CC N to bypa
121. Sign Cosign MEDICINE 0 JUN 19 1996 TIUPATIENT SEV 0 Discharg PS JUN 11 1996 TIUPATIENT TWO 1 Discharg 78 MAY 31 1996 TIUPATIENT SEV 7 1 Discharg 80 FEB 8 1995 TIUPATIENT ELE 0 44 0 Discharg 96 FEB 8 1995 TIUPATIENT TWE 0 44 0 Discharg SUBTOTAL 327 7 2 88 0 SUBCOUNT 5 1 5 2 2 SUBMEAN 65 40 7 00 0 40 44 00 SURGERY 0 FEB 12 1996 TIUPATIENT ONE97 0 Addendum 1 JAN 10 1996 TIUPATIENT S1004 0 0 0 Discharg SUBTOTAL 1 1101 0 0 0 SUBCOUNT 2 2 2 1 1 SUBMEAN 0 50 550 50 TOTAL 328 1108 2 88 0 COUNT 7 3 7 3 3 MEAN 46 86 369 33 0 29 29 33 0 00 134 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Unsigned Uncosigned Report Lists detailed document information such as author patient patient SSN etc for notes with no signature and or cosignature Optionally a summary report can be generated showing the number of unsigned and uncosigned documents in each service In the following example a summary report is generated for all divisions Select Text Integration Utilities MIS Manager Option 6 Unsigned Uncosigned Report Select division ALL lt Enter gt Select service Please specify an Entry Date Range Start Entry Date T 180 AUG 08 2003 Ending Entry Date T FEB 04 2004 ALL lt Enter gt Select one of the following D FULL S SUMMARY Type of Report S SUMMARY DEVICE HOME lt Enter gt ANYWHERE
122. Statistical Reports 130 Word processing program 225 Statuses 64 Word processors 173 Template 237 Workload Capture 236 Terminal settings 223 WRIISC 212 213 Title 240 XTEMP Global 220 244 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual
123. Statuses and Actions Statuses Status Description Amended The document has been completed and a privacy act issue has required its amendment By design only the following user classes are allowed to amend a note CHIEF MIS CHIEF HIM PRIVACY ACT OFFICER Completed The document has acquired all necessary signatures and is legally authenticated deleted Status DELETED is no longer operable Before status RETRACTED was introduced deleting a document removed the text of the document leaving a stub with status DELETED Retracted When a signed document is reassigned amended or deleted a retracted copy of the original is kept for audit purposes Uncosigned The document is complete with the exception of cosignature e g by a supervisor undictated The document is required and a record has been created in anticipation of dictation and transcription but the system has not yet been informed of its dictation unreleased The document is in the process of being entered into the system but has not yet been released by the originator i e the person who entered the text directly online unsigned The document is online in a draft state but the author hasn t signed untranscribed The document is required and the system has been informed of its dictation but the transcription hasn t been entered or received by upload unverified The document has been released or uploaded but must be verified before the
124. TIU 1 182 in support of the Medicine Package Conversion patch MD 1 5 This document class must be left with status INACTIVE Rev January 2012 Text Integration Utilities V 1 0 211 Clinical Coordinator amp User Manual The complete list of national document classes is ADDENDUM ADDICTION SEVERITY INDEX ADVANCE DIRECTIVE ADVERSE REACTION ALLERGY C amp PEXAMINATION REPORTS CLINICAL WARNING CRISIS NOTE DISCHARGE SUMMARIES HISTORICAL PROCEDURES LR ANATOMIC PATHOLOGY PATIENT RECORD FLAG CAT I PATIENT RECORD FLAG CAT II OPERATION REPORTS NURSE INTEROPERATIVE REPORTS ANESTHESIA REPORTS PROCEDURE REPORT NON O R SCI OUTCOMES Note Although CONSULTS was not exported as National the same cautions apply If you make explicit changes to CONSULTS then the Consults tab of CPRS may not work properly TIU 1 169 supports patch DVBA 2 7 53 C amp P WORKSHEET MODULE PHASE These patches together allow users to create C amp P Examination documents and store them in TIU The advantage to this is that providers are allowed to view the C amp P exams in CPRS along with the rest of a patient s medical record C amp P documents are entered through the C amp P Worksheet Module using a title in the C amp P EXAMINATION REPORTS Document Class Upon signing the C amp P Exams are retained in AMIE and stored in TIU Further information on this can be found in the AMIE Regional Office User Manual National Titles The
125. TIUPATIENT ONE T1255 Adverse React Allergy 05 03 97 05 31 97 2 TIUPATIENT TWO T3456 ADVANCE DIRECTIVE 05 18 96 3 TIUPATIENT FIV T3456 ADVANCE DIRECTIVE 08 14 95 4 TIUPATIENT T1462 Discharge Summary 05 04 92 05 31 97 5 TIUPATIENT F T3456 Discharge Summary 09 21 95 6 TIUPATIENT O T3456 Discharge Summary 07 22 91 05 12 97 Next Screen Prev Screen More Actions gt gt gt Verify Unverify Link with Request Print On Chart Send Back Interdiscipl ry Note Edit Detailed Display Change View Reassign Browse Quit Select Action Quit V Verify Unverify Select Document s 1 3 4 Opening Discharge Summary record for review 7 The selected document is displayed for you to verify Verify Document Jun 02 1997 14 38 22 Page 1 of 20 Discharge Summary TIUPATIENT SEVEN 666 45 3234 1A Adm 05 04 92 Dis 05 31 97 DICT DATE MAY 25 1997 ENTRY DATE MAY 26 1997 08 54 19 DICTATED BY TIUPROVIDER THREE ATTENDING TIUPROVIDER ONE URGENCY priority STATUS UNVERIFIED xx Discharge Summary Has ADDENDA DIAGNOSIS 1 Status post head trauma with brain contusion 2 Status post cerebrovascular accident 3 End stage renal disease on hemodialysis 4 Coronary artery disease Next Screen Prev Screen More actions Find Verify Unverify Print Quit Select Action Next Screen v Verify Unverify Do you want to edit this Dischar
126. TIUProvider Visit 02 21 96 Choose notes 1 6 3 5 Do you want WORK copies or CHART copies CHART lt Enter gt DEVICE HOME lt Enter gt VAX 120 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Progress Notes Print Example NOTE DATED 06 07 96 17 51 DIABETES EDUCATION ADMITTED 07 22 95 11 06 1A SUBJECT Routine diabetes education Patient understanding good Signed by es One TIUProvider MD edical Internist 06 23 96 08 34 Analog Pager 555 1213 Digital Pager 555 1215 Cosigned by es TIUProvider Six 06 23 96 08 34 Analog Pager 555 1213 Digital Pager 555 1215 NOTE DATED 04 24 96 08 00 ARTERIAL EVALUATION LOWER EXTREMITY VISIT 04 17 92 08 00 FOURTEEN S CLINIC SUBJECT Rule out embolus lower extremity AGE 50 UNIT General Medicin REFERRING MD Six TIUProvider DIAGNOSIS Rule out embolus HISTORY severe pedal edema foot ulcers OTHER cyanosis SYMPTOMS RESTING SYMPTOMS EXERTIONAL SYMPTOMS LESIONS EDICATIONS RECORDED RECORDED AUDIBLE DOPPLER SIGNAL RIGHT LEFT DOPPLER WAVEFORM RIGHT LEFT COMMON FEMORAL COMMON FEMORAL SUP
127. Transcriptionist Menu 160 Reports and Upload 226 Transcriptionists 159 resend alerts 215 216 Troubleshooting 221 Resolution Status 92 Uncosigned 49 64 Review Progress Notes 39 Undictated 49 64 Review Progress Notes by Patient 36 Unreleased 49 64 Review unsigned additional signatures 88 113 Unresolved Errors 92 Review Upload Filing Events 87 unsigned 49 Review Edit Document 160 Unsigned 64 69 Reviewing Notes 23 Unsigned Uncosigned Report 105 134 Rotating residents 227 Untranscribed 49 64 Router filer 165 Unverified 49 64 Screen Display 15 17 Up arrow 29 37 232 Screen Editor 225 Upload Documents 165 Scrolling region 15 Upload errors Search 28 42 Avoiding 170 Search by Patient AND Title 48 Correcting 168 Search categories 63 71 231 Upload Filing Events 92 93 Search for notes by Problem 231 Upload Menu 160 165 Search for Selected Documents 87 104 112 123 User Class 240 Share objects 230 User Class file 221 SHOP ALL 230 User Class Management Menu 208 Shortcut 16 User responses 13 Shortcuts 232 Using TIU 19 Show Progress Notes Across Patients 44 VBA RO 175 Sign Cosign 50 65 VBC Line Count 113 155 signatures 214 Verify action 91 signing privilege 62 View Objects 81 84 SOAP 237 Visit Information 232 Sort Document Definitions 81 207 Visit Orientation 236 Special Instructions for the First Time Computer User Visit Tracking 199 12 Ward Print Progress Notes 45 183 Standardized user interface 10 Ward Print Progress Notes 184
128. UPROVIDER ONE OT Are you adding TIUPROVIDER ONE as a new TIU PERSONAL PREFERENCES the 5TH y Yes DEFAULT LOCATION Cardiology Clinic REVIEW SCREEN SORT FIELD Specify the attribute by which the document list should be sorted Choose from P patient D document type R reference date S status e completion date A author expected cosigner REVIEW SCREEN SORT FIELD p patient REVIEW SCREEN SORT ORDER Please specify the order in which you want the list sorted Choose from A ascending D descending REVIEW SCREEN SORT ORDER a ascending DISPLAY MENUS Indicate whether menus for document selection etc should be displayed Choose from 0 N 1 YES DISPLAY MENUS 1 YES PATIENT SELECTION PREFERENCE Please indicate your patient selection preference Choose from S single M multiple PATIENT SELECTION PREFERENCE m multiple DEFAULT COSIGNER Indicate which person will usually cosign your Progress Notes FO Answer with NEW PERSON NAME or INITIAL or SSN or NICK NAME or DEA or VA Do you want the entire 66 Entry NEW PERSON List N DEFAULT COSIGNER TIUPATIENT TWO TIUPATIENT TWO CA PHYSICIAN ASK Save changes AFTER EDIT y YES ASK SUBJECT FOR PROGRESS NOTE
129. URSING NOTES ENCOUNTER GROUP Now Specify the TITLE you d like as your DEFAULT for PROGRESS NOTES DEFAULT TITLE This determines what TITLE will be offered by default when selecting from a given parent class eg when entering a PROGRESS NOTE you may want the DEFAULT TITLE to be DIABETES EDUCATION etc 80 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Document List Management cont d el EFAULT TITLE PSYCHOLOGY PSYCHOLOGY BEHAV MED TITLE PSYCHOLOGY BIOFEEDBACK TITLE PSYCHOLOGY CRISIS TITLE F I PSYCHOLOGY FAMILY THERAPY TITL PSYCHOLOGY P SATC TITLE TI TO STOP OR Leos 3 Fl OBBWNE TYPE CHOOSI Fl Select PERSONAL DOCUMENT LIST Name SUBSTANCE ABUSE SUBSTANCE ABUSE TITLE UBSTANCE ABUSE COMMITTEE TITLE S SUBSTANCE ABUSE TLC TITLE S 4 Sl 1 2 3 4 3 UBSTANCE ABUSE TREATMENT CENTER CONSULT TITLE CHOOSE 1 4 Are you adding SUBSTANCE ABUSE as H a new PERSONAL DOCUMENT LIST the 1ST for this TIU PERSONAL DOCUMENT TYP LIST Y Yes SEQUENCE 1 DISPLAY NAME SUBSTANCE ABUSE Rev January 2012 Text Integration
130. US 5 Abscess 6 Less than 2 5 cm 7 2 6 7 5 cm 8 Greater than 7 5 cm 9 Burns 1 Local Treatment 10 Dressings Medium 11 Dressings Small 12 Transfusion L3 Venipuncture UROLOGY 14 Foley Catheter ENT 15 Removal Impacted Cerumen 16 Anterior Simple 17 Anterior complex 18 Posterior EYE 19 Foreign Body Removal 20 OTHER Procedure Select Procedure 1 20 19 You have indicated the following data apply to this visit DIAGNOSES BE 2 Allergic Reaction lt lt lt PRIMARY PROCEDURES 65205 Foreign Body Removal OK YES lt Enter gt Posting Workload Credit 34 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual 8 If you wish you can print the note now Print this note No y YES Do you want WORK copies or CHART copies CHART work DEVICE HOME lt Enter gt VAX NOTE DATED 02 24 97 08 30 ADVERSE REACT ALLERGY VISIT 02 24 97 08 30 GENERAL MEDICINE new tests Signed by es THREE TIUPROVIDER THREE TIUPROVIDER 02 24 97 08 30 Enter RETURN to continue or to exit You may enter another CLINICAL DOCUMENT Press RETURN to exit Select PATIENT NAME lt Enter gt Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 35 Review Progress Notes by Patient This option
131. Unsigned and Uncosigned Documents Aug 08 2003 thru Feb 04 2 004 23 59 59Page 1 PRINTED for SALT LAKE CITY HCS FEB 04 2004 09 16 Totals for Service IRM UNSIGNED 1 UNCOSIGNED 0 Totals for Division SALT LAKE CITY HCS UNSIGNED 1 UNCOSIGNED 0 Enter RETURN to continue or to exit Rev January 2012 Text Integration Utilities V 1 0 135 Clinical Coordinator amp User Manual Missing Text Report This report lists TIU Documents that do not have any report text are missing the 0 node of the text node or both cases The report results have the following categories Missing Text Only This means the note has a 0 TEXT node but no text and this can be fine depending on the status of the document such as undictated Missing 0 Node Only This means the note has text but no 0 TEXT node Missing 0 node amp Text This means the note doesn t have a 0 TEXT node or text This cause of this condition is unknown and has only been reported from a few sites Nevertheless this report should be run by all sights If any missing text documents are found refer to the discussion under Missing Text Cleanup below for guidance The report can be run as often as needed to track the occurrences of documents without text and missing the 0 text node It is advised to run the report on a regular interval once per week or month to track an increase or decrease of reported documents missing text or
132. Utilities MIS MANAGER Option Multiple Patient Documents Select division ALL lt Enter gt These may Select Status UNSIGNED lt Enter gt Unsigned differ at your Select Clinical Documents Type s 1 Progress Notes 2 Discharge Summary 3 Addendum site Enter selection s by typing the name s number s or abbreviatio Select Clinical Documents Type s 1 3 Addendum Discharge Summary Progress Notes Start Reference Date Time T 7 t 15 MAR 19 1997 Ending Reference Date Time NOW lt Enter gt APR 18 1997 15 21 Searching for the documents 2 When the documents that fit the criteria you entered are displayed choose an action and a document s UNSIGNED Documents Apr 18 1996 15 21 44 Page l1 of 1 by ALL CATEGORIES from 03 19 96 to 04 18 96 15 documents Patient Document Admitted Disch d 1 TIUPATIENT T8101 Nursing Note 04 15 96 2 TIUPATIENT T T2760 Addendum 03 22 96 3 TIUPATIENT T T2760 Addendum 03 22 96 4 TIUPATIENT F T6641 Ambul Outp Care 04 18 96 5 TIUPATIENT F T6641 General Note 04 18 96 6 TIUPATIENT F T6641 Diabetes Ed 03 20 96 7 TIUPATIENT S T0482 Diabetes Edu 03 25 96 8 TIUPATIENT S T0482 Addendum 03 25 96 Next Screen Prev Screen More Actions o gt Verify Unverify Link with Request Print On Chart Send Back Interdiscipl ry Note Edit Detailed Display Change View Reassign Browse QuitSel
133. VI 39 Admin Oxygen 12 Limited Visit 25 Air ambulance servic 40 Inhalation Therapy 13 Intermediate Visit 26 PET follow SPECT 41 Peak Flow Spirometry 14 Extended Visit ORTHOPEDIC UROLOGY 15 Comprehensive Visit ARTHROCENTESIS 42 Foley Catherter 27 Intermediate ISCELLANEOUS CARDIOVASCULAR 28 Major Joint shoulde I amp D Select Procedures lt RETURN gt to see next page of choices 1 42 24 43 Abcess SIMPLE REPAIR WOUND 44 Less than 2 5 cm 45 2 6 7 5 cm 46 Greater than 7 5 cm SOFT TISSUE 47 Burns 1 Local Trea 48 Dressings Medium 49 Dressings Small 50 Transfusion 51 Venipuncture 52 OTHER Procedure Select Procedures 1 52 48 FOREIGN BODY REMOVAL W MOD W MOD X 2 How many times was the procedure performed 1 lt Enter gt Current CPT Modifiers 26 PROFESSIONAL COMPONENT 32 MANDATED SERVICES Select another CPT MODIFIER E A list of CPT Modifiers Choose from can be printed out by 22 UNUSUAL PROCEDURAL SERVICES E INUSUAL ANFSTHESTA entering two question 26 PROFESSIONAL COMPONENT marks at the 32 ANDATED SERVICES prompt 47 ANESTHESIA BY SURGEON 50 BILATERAL PROCEDURE 51 ULTIPLE PROCEDURES 52 REDUCED SERVICES 53 DISCONTINUED PROCEDURE 54 SURGICAL CARE ONLY 55 POSTOPERATIVE MANAGEMENT
134. Vista TEXT INTEGRATION UTILITIES TIU CLINICAL COORDINATOR amp USER MANUAL Version 1 0 July 1997 Updated January 2012 Department of Veterans Affairs Product Development Revision History Patch TIU 1 261 Page 129 214 January 212 J Green Rescinding an Advance Directive document Patch 248 Security For Page 135 June 2011 C Arceneaux T Downing The Tiu Option Missing Text Cleanup Patch 250 Line Count Page 113 152 158 June 2010 C Arceneaux T Downing Patch 219 DS Attending Requirements June 2008 C Arceneaux A Ebert Patch 231 Analyze potential Surgery TIU January 2008 G Werner A Scott problems Patch 234 Expected Cosigner Edit and Disallow December 2007 C Arceneaux S Madsen Signed Document Edit Patch 215 Disallow Edit June 2007 C Arceneaux S Madsen Patch USR 1 31 Informational on Business Rules June 2007 C Arceneaux S Madsen Patch 220 December 2006 C Arceneaux S Madsen Patch 200 TUI HL7 Generic Interface October 2006 C Arceneaux D Rickard Patch 214 Mismatched ID Notes September 2006 T Dawson C Greening Patch 199 May 2006 T Dawson C Greening Patch 189 Expected Cosigner March 2006 T Dawson C Greening Patch 191 Disclosure of Adverse Event Note May 2005 C Arceneaux G Smith Patch 182 Medicine Conversion June 2005 C Arceneaux G Smith Patch 173 Unknown Addenda Cleanup April 2005 C Ar
135. action name These actions are described on the next page 16 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual List Manager Screen Display cont d The following actions are available enter to see these Next screen GO Go to Page DD Detailed Display Previous Screen RD Re Display Screen EC Edit Cosigner FS First Screen ADPL Auto Display On Off CT Change Title LS Last Screen Q Quit CWAD CWAD Display UP Up a Line gt Shift View to Right DN Down a Line lt Shift View to Left Generic hidden actions Action Description Next Screen Move to the next screen may be shown as a default Previous Screen Move to the previous screen Up a Line UP Move up one line Down a Line DN Move down one line Shift View to Right gt Move the screen to the right if the screen width is more than 80 characters Shift View to Left lt Move the screen to the left if the screen width is more than 80 characters First Screen FS Move to the first screen Last Screen LS Move to the last screen Go to Page GO Move to any selected page in the list Re Display Screen RD Redisplay the current screen Print Screen PS Prints the header and the portion of the list currently displayed Print List PL Prints the list of entries currently displayed Search List SL Finds sel
136. ager 1 900 555 8398 Digital Pager 1 900 555 7883 Enter RETURN to continue or to exit lt Enter gt TIUPATIENT SEVEN 666 04 2591P Progress Notes NOTE DATED 09 17 96 13 37 LIPID CLINIC VISIT 08 18 96 08 00 GENERAL MEDICINE SUBJECTIVE 55 year old AMERICAN INDIAN OR ALASKA NATIVE MALE here for initial evaluation of his DYSLIPIDEMIA PMH Significant negative medical history pertinent to the evaluation and treatment of DYSLIPIDEMIA FH SH MEDICATION HISTORY CURRENT MEDICATIONS DIET Counseled on AHA Step I diet today by NINE TIUPROVIDER Enter RETURN to continue or to exit lt Enter gt Rev January 2012 Text Integration Utilities V 1 0 189 Clinical Coordinator amp User Manual Location Print Progress Notes Example cont d 09 17 96 13 37 ACTIVITY OBJECTIVE ASSESSM ENT PLAN Enter R Select HT TS N N CONTINUED FROM PREVIOUS SCREEN H T4 FBG SGOT TO 08 23 96 11 45 WT 207 08 23 96 11 45 Leis tof Lied 200 HEMOGLOBIN A1C 15 2 44 URIC ACID 4 7 MALE with without documented CAD CV Risk factors Lipid pattern Implement recommendations to lower fat intake Repeat FBG and HBG AIC on Return to review lab on Signed by es Three T
137. an convert them A No you don t have to delete or sign the unsigned notes The conversion will move them as is However you probably don t want to be moving old irrelevant notes from one package to the other By the way notes for test patients are NOT moved they are ignored Rev January 2012 Text Integration Utilities V 1 0 223 Clinical Coordinator amp User Manual FAQs cont d Q Can we require a Cosignature for a particular note A Yes you can set Cosignature requirements for document classes or titles Use the option Document Parameter Edit as described in the TIU Implementation Guide Individual clinicians can designate an expected Cosigner through their Personal Preferences option described on page 64 of this manual Q Why do we have to enter Visits and encounter data for Progress Notes What are Historical Visits A Visit data is now required for every outpatient encounter The vast majority of Progress Notes are already linked to an admission and don t require additional visit information to be added A historical visit or encounter is a visit that occurred at some time in the past or at some other location possibly non VA Although these are not used for workload credit they can be used for setting up the PCE reminder maintenance system or for other non workload related reasons NOTE If month or day aren t known historical encounters will appear on encounter screens or reports with zeroes fo
138. anager START WITH REFERENCE DATE GO TO REFERENCE DATE Option 11 Missing Expected Cosigner Report Jan 01 2003 1 1 2005 JAN 01 2005 Jun 28 2005 JUN 28 2005 DEVICE HOME TCP NOTES WITH UNCOSIGNED STATUS THAT DON T HAVE AN EXPECTED COSIGNER Patient Entry Date Time Title Author Service Section Job Title Note IEN XXX1234 JUN 28 2005 09 24 44 UROLOGY NO SHOW TIUAUTHOR ONE CHIEF OF STAFF SUPERVISOR PHYS 4957352 XXX1235 JUN 28 2005 09 36 20 Addendum TIUAUTHOR TWO CHIEF OF STAFF SUPERVISOR PHYS 4957353 Parent Document Type UROLOGY NO SHOW NOTE Parent Document Date JUN 28 2005 09 24 44 Parent Document Cosigner Enter RETURN to continue or to exit Example delimited report lines are truncated for this example Select Text Integration Utilities MIS Manager Option 11 Missing Expected Cosigner Report START WITH REFERENCE DATE Jan 01 2003 1 1 2005 JAN 01 2005 GO TO REFERENCE DATE Jun 28 2005 JUN 28 2005 DEVICE HOME TCP Patient Name Entr y Date Time Title Author Service Section Job Title Note XXX1234 JUN 28 2005 09 24 UROLOGY NO SHOW TIUPROVIDER ONE PHYSICIAN SUPERV YYY5678 JUL 01 2005 19 14 PROGRESS NOTE TIUPROVIDER TWO NURSE SUPERIVO
139. arge Summary TIU menu also includes a Personal Preferences menu that lets clinicians change their own parameters for viewing clinical documents Option Name Description Progress Notes User Menu This menu includes options for reviewing entering printing and signing progress notes either by individual patient or by multiple patients Discharge Summary User This menu includes options for reviewing entering Menu printing and signing discharge summaries either by individual patient or by multiple patients Integrated Document This menu lets clinicians perform actions on progress notes Management discharge summaries and other clinical documents from a single menu For example a clinician may want to bring up all his unsigned documents Personal Preferences This menu allows users to 1 enter preferences about the behavior of the TIU Package These preferences include DEFAULT LOCATION REVIEW SCREEN SORT FIELD SORT ORDER DISPLAY MENUS PATIENT SELECTION PREFERENCE 2 specify pick lists for document selection when composing or editing documents e g when choosing documents from the class Progress Notes Let me see these three specific titles 22 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Using Progress Notes through OE RR 2 5 or CPRS Clinicians who enter and review Progress Notes through OE RR 2 5 will also be able to do so with TIU CP
140. ase wait 1 gt TEST 2 gt lt Enter gt EDIT Option Save changes YES lt Enter gt Saving Adverse React Allergy with changes Enter your Current Signature Code XXX SIGNATURE VERIFIED Print this note No YES Do you want WORK copies or CHART copies CHART lt Enter gt DEVICE HOME lt Enter gt VAX NOTE DATED 03 17 97 17 15 ADVERSE REACT ALLERGY ADMITTED 09 21 95 10 00 2B Signed by es NINE TIUPROVIDE NINE TIUPROVIDER 03 17 97 17 15 Enter RETURN to continue or to exit lt Enter gt PI EI You may enter another Progress Note Press RETURN to exit Select PATIENT NAME lt Enter gt Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 27 Select Search through CPRS You can narrow your view to signed notes by author unsigned notes etc You can also specify the date order your notes will appear in ascending oldest first or descending most recent first order Ve Caution Avoid selecting too large a date range or too general a category as big searches are very system intensive This means that not only might it slow down your work but everyone else s as well Progress Notes Apr 09 1997 14 42 58 Page 1 of 1 lt CWA gt PROGRESS NOTES Last 15 note s TIUPAT
141. ategories Rev January 2012 Text Integration Utilities V 1 0 179 Clinical Coordinator amp User Manual Multiple Patient Documents cont d 5 Enter a date range Start Reference Date Time T 7 lt Enter gt JUN 02 Date Time NOW lt Enter gt JUN 09 Ending Referenc Searching for the documents 1997 1997 11 19 6 All the documents for the criteria selected are displayed Choose an action to perform then the document to perform it on ALL Documents Jun 09 1997 11 20 01 Page 1 of 1 by ALL CATEGORIES from 06 02 97 to 06 09 97 14 documents Patient Document Ref Date Status 1 TIUPATIE T1965 ADVANCE DIRECTIVE 06 06 97 completed 2 TIUPATIE T1255 Addendum to CLINICAL WARNING 06 05 97 completed 3 TIUPATIE T1239 Adverse React Allergy 06 05 97 completed 4 TIUPATIE T1239 CRISIS NOTE 06 05 97 completed 5 TIUPATIE T1255 FANCY RAT NOTES 06 04 97 completed 6 TIUPATIE T1255 Addendum to Adverse React Aller 06 04 97 completed 7 TIUPATIE T1255 Addendum to Adverse React Aller 06 04 97 completed 8 TIUPATIE T3456 FANCY RAT NOTES 06 04 97 completed 9 TIUPATIE T1255 Addendum to Adverse React Aller 06 03 97 completed 10 TIUPATIE T2591 FANCY RAT NOTES 06 03 97 completed 11 TIUPATIE T1462 Addendum to FANCY RAT NOTES 06 03 97 completed 12 TIUPATI T1462 FANCY RAT NOTES 06 03 97 compl
142. ave a patient list set up through Personal Preferences it is displayed here Loading Ward Patient List 2B ward list 1 TIUPATIENT ONE 3456 8 TIUPATIENT TWO 3243 A 4 2 TIUPATIENT NINE 2591 9 TIUPATIENT EIGHT 3242 3 TIUPATIENT FOUR 2384 10 TIUPATIENT TEN 2432 A 2 4 TIUPATIENT SEVEN 3234 11 TIUPATIENT TWELV 3213 A 1 5 TIUPATIENT THREE 1996 12 TIUPATIENT FOURT 4723 6 TIUPATIENT FIVE 3779 13 TIUPATIENT SIXTE 1321 A 3 7 TIUPATIENT SIX 2476 9 B 14 TIUPATIENT ELEVE 1414 2 Type in a patient name or a number from the list Demographic data and CWAD Cautions Warnings Adverse Reactions and Directives notes are displayed You are prompted to choose if you want to see any of the previous Progress Notes for this patient Select Patient s 7 TIUPATIENT TWO 04 25 31 666043243P NO MILITARY RETIREE 6 notes W 01 27 97 15 17 addendum 02 08 97 17 19 A Known allergies 1 note D 03 26 97 13 02 Available notes 11 11 96 thru 04 15 97 27 Do you wish to see any of these notes NO nter gt This indicates that there are 27 notes for this patient 30 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Entry of Progress Note cont d 3 Select a Title If you ha
143. bility to search by title keeping the number of titles small and their use specific can be very useful e g patient medication education is documented on an electronic progress note and can be reviewed easily Some of the other sites allow the ADPACs to create boilerplates without going through such a formal review process Another site restricts this function to the Clinical Coordinator It was designed so that sites can do whatever they are most comfortable with Q The root Class supplied with the package is CLINICAL DOCUMENTS Can a peer class level be made using our configuration options Ex ADMINISTRATIVE DOCUMENTS A You cannot enter a class on the same level as Clinical Documents In TIU Version 1 0 entries can only be created under Clinical Documents Q I ve changed the technical and print names for a Document Class but it doesn t seem to have changed when I select documents across patients What am I doing wrong A When you select documents across patients you are presented with a three column menu The entries in this menu are from the Menu Text subfield of the Item Multiple To make a consistent change you must update Menu Text as well as Print Name when you change a Document Definition name 230 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual FAQs cont d Q How can I print when I m in Document Definitions options A All Document Definitions printing is done usi
144. but not fixed When this report is run in Report Only mode the report looks like the first example When this report is run in Report and Fix mode the report looks like the second example When this report is run in either Report Only mode or in Report and Fix mode an email will be sent to the PSI 06 030 mail group on Forum This email will contain ONLY the site the date the report mode and the result totals No patient data of any kind is sent The purpose of this is to track the extent of this problem Note that the emails do not report the count of CHILD ID NOTES POINTING TO A PARENT THAT MAY NOT BE AN ID NOTE Example of Report Only mode MISMATCHED INTERDISCIPLINARY NOTES CHILD DOCUMENT PARENT DOCUMENT Patient TIUPATIENT ONE P1234 TIUPATIENT TWO P5678 Title INTERDISCIPLINARY PATIENT EDUCATI PM amp R KT Entry DT JAN 21 1998 15 28 27 FEB 01 1996 14 16 10 Author TIUAUTHOR ONE TIUAUTHOR ONE Note IEN 345678 123456 CHILD ID NOTES POINTING TO A NON EXISTENT PARENT ID NOTE Patient TIUPATIENT THREE P9876 Title CARDIAC REHAB DAILY Entry DT APR 28 2003 07 43 49 Author TIUAUTHOR TWO Child IEN 3300852 Parent IEN 3200408 CHILD ID NOTES POINTING TO A PARENT THAT MAY NOT BE AN ID NOTE NOTE THIS IS AN INFORMATIONAL LIST FOR INVESTIGATION NOTHING WILL BE FIXED
145. c sisvess ccisvcisssievesnesydvececgausadedss svesscadunsdaeen aces aateeesdueaeantenes 12 Special Instructions for the new VISTA Computer User 12 Graphic Conventions Used in This Manual 13 LW and NEE 14 Sechon 2 Using A EE 19 Chapter 3 TIU for Clinicians ssesssecesocesooecsocssocessecssocesooesoosssocessocesocesooessosessesssecssoses 21 Progress Notes Discharge Summary Menu sssesseseseseesesseseresresseseresressessresressersresreeseeee 22 Using Progress Notes through OE RR 2 5 or CDR 23 Select Search Oooh e a E len A R A A 28 Progress Notes RL Ee 29 Entryof Ee 30 Review Progress Notes by Patient s c 2csccsscievssaccaseacacsassavaceaseosnccsssnceatasdevedeadoonaceesacenes 36 Review Progress E 39 All MY UNSIGNED Progress Notes cccsscccssscecsseceesseceessccecssccecsscceesseceessceseacens 43 Show Progress Notes Across Patients je 55 cc5 deeg 44 Progress Notes Print HDD scssi isiin gst dee SEENEN 46 Last Notes Dy Terre 47 Search Dy Patient AND Title ciir aasgier i ages beet ect 49 Progress Notes Statuses and EE 50 Interdisciplinary Notesi iiinn rre Eed a Ea aE ET E E a ia 52 The Parent EE 52 The C ul Wee CG 52 Me AEOS mesa caro ee 54 The Display EE 55 Meaning Of EE 55 EM COms Oral Ons geet 56 E 56 RRE 56 Discharge Summaya nerens Ae EE 59 Individual Patient Discharge Summary ssseesseseeseeseseseereeseessesreeseeseseresresseseresressesee 60 Rev January 2012 Text Integration Utilities V 1 0 v Clinica
146. ceneaux G Smith Patch 157 Additional Signer Changes March 2005 C Arceneaux G Smith Patches 174 amp 177 Blank Note Nov 2004 C Arceneaux G Smith Patch 171 SCI Document Definitions February 2005 C Arceneaux G Smith 192 352 applied Patient Privacy Document December 2004 C Arceneaux amp S Wellman P Scrubbing Landy Patch 169 C amp P Document Definitions December 2004 C Arceneaux G Smith Patch 177 Missing Text October 2004 Patch 185 Reassign Report August 2004 Patch 112 Surgery February 2004 Patch 113 Multidivision February 2004 Patch 159 WRIISC October 2003 Patch 165 Patient Record Flags September 2003 Patch 137 Anatomic Pathology June 2003 Patch 158 Alert Tools June 2003 Patch 109 Clinical Procedures June 2002 Patches 61 95 100 amp 105 April 2001 Miscellaneous patches July 2000 Originally released July 1997 Text Integration Utilities V 1 0 Rev May 2011 Clinical Coor Preface Purpose of Text Integration Utilities Text Integration Utilities TIU simplifies the access and use of clinical documents for both clinical and administrative VAMC personnel by standardizing the way clinical documents are managed In connection with Authorization Subscription Utility ASU a hospital can set up policies and practices for determining who is responsible or has the privilege for performing various actions on required VHA documents The initial release of Version 1 0 includes D
147. ched ID Notes 14 TIU 215 ANALYSIS 15 Transcription Billing Verification Report Select Text Integration Utilities MIS Manager Option 12 Mark Document as Signed by Surrogate Select ADDITIONAL SIGNER PAGETT OTTIS OAP 116 HEALTH TECHNICIAN START WITH REFERENCE DATE Jan 01 2003 3 1 1998 MAR 01 1998 GO TO REFERENCE DATE Jul 18 2005 4 1 1998 APR 01 1998 SEQ PATIENT DOCUMENT TYPE REFERENCE DATE 1 BIGBEE DARREN L B0181 DOMICILIARY CARE n ECTION MAR 12 1998 09 52 21 ENTER SEQUENCE TO MARK AS SIGNED BY SURROGATE NEW FOR A NEW SEARCH OR TO QUIT 146 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Mismatched ID Notes The option TIU MISMATCHED ID NOTES is under the TIU MAIN MENU MGR and it runs a routine that will report fix mismatched interdisciplinary ID notes There are cases where a child ID note points to a parent ID note and that parent ID note is for a different patient There are also cases where the GDAD cross reference links a child ID note to a parent ID note when in fact the child does not point to the parent In these cases the situation will be reported fixed If it is found that there is a child ID note pointing to a parent that may not be an ID note this will be reported
148. complete list of national note titles in alphabetical order is ADDENDUM ADVANCE DIRECTIVE ADVERSE REACTION ALLERGY ANESTHESIA REPORT ASI ADDICTION SEVERITY INDEX CLINICAL WARNING DISCLOSURE OF ADVERSE EVENT NOTE CRISIS NOTE 212 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual DISCHARGE SUMMARY HISTORICAL CARDIAC CATHETERIZATION PROCEDURE HISTORICAL ECHOCARDIOGRAM PROCEDURE HISTORICAL ELECTROCARDIOGRAM PROCEDURE HISTORICAL ELECTROPHYSIOLOGY PROCEDURE HISTORICAL ENDOSCOPIC PROCEDURE HISTORICAL EXERCISE TOLERANCE TEST PROCEDURE HISTORICAL HEMATOLOGY PROCEDURE HISTORICAL HOLTER PROCEDURE HISTORICAL PACEMAKER IMPLANTATION PROCEDURE HISTORICAL PRE POST SURGERY RISK NOTE HISTORICAL PULMONARY FUNCTION TEST PROCEDURE HISTORICAL RHEUMATOLOGY PROCEDURE LR AUTOPSY REPORT LR CYTOPATHOLOGY REPORT LR ELECTRON MICROSCOPY REPORT LR SURGICAL PATHOLOGY REPORT NURSE INTERPRETATIVE REPORT OPERATION REPORTS PATIENT RECORD FLAG CATEGORY I RISK OF CJD SCI CRAIG HANDICAP ASSESSMENT amp REPORTING TECHNIQUE SHORT FORM SCI DIENER SATISFACTION WITH LIFE SCALE SCI GENERAL NOTE SCI FUNCTIONAL INDEPENDENCE MEASURE WRISC ASSESSMENT NOTE PROCEDURE REPORT Note The HISTORICAL titles in document class HISTORICAL PROCEDURES were created by patch TIU 1 182 with status INACTIVE The status of these titles MUST REMAIN inactive in order to prevent users from entering notes on these titles All
149. criptions OPTION for help text You have PENDING ALERTS Enter VA to jump to VIEW ALERTS option Select Text Integration Utilities MRT Option 9 Review unsigned additional signatures Select division ALL Please specify an Entry Date Range Start Entry Date t 90 NOV 09 2004 Ending Entry Date t FEB 07 2005 Select service ALL Select one of the following F FULL S SUMMARY Type of Report f FULL This report should be sent to a 132 Column Device DEVICE HOME ANYWHERE Pending Additional Signature Documents for ELY on Feb 07 2005 14 39 49 Oct 10 2004 thru Feb 07 2005 23 59 59 Page 1 IDENT SIGNER PATIENT STATUS ENTRY DATE DOCUMENT TITLE DOCUMENT IEN SERVICE MEDICINE CPRSPROVIDER E EB111148 com 10 15 04 07 58 50 ACUTE PAIN NOTE 29303 CPRSPROVIDER F BH224567 com 11 26 04 14 39 48 SURGERY CS CONSULT 28002 CPRSPROVIDER F FC781990 com 11 30 04 07 39 31 CARDIOLOGY NOTE 29008 CPRSPROVIDER N FC781990 com 10 20 04 12 30 10 MEDICINE NOTE 29079 Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 109 CPRSPROVIDER O SH345377 com 10 30 04 12 40 24 AB ID PARENT BARRY TEST 29019 CPRSPROVIDER O TH345377 com 12 30 04 12 40 24 AB ID PARENT BARRY TEST 29019 CPRSPROVIDER S NC448661 com 12 20 04 13 08 40 PODIATRY CS
150. cument Templates 214 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Chapter 15 TIU Alert Tools Starting with patch TIU 1 158 there is a new option in the TIU Management Menu that allows refresh and manipulation of TIU alerts especially with respect to signatures These tools are designed to assist CACs and other users with TIU management responsibilities to help control the backlog of unsigned notes It accomplishes this by providing flexible control over alert generation The following actions are available BROWSE DOCUMENT TIf authorized presents a read only view of a selected document CHANGE VIEW Allows entry new search criteria COMBINATION ALERTS Allows the sending of new alerts for single or multiple documents to the expected signers AUTHOR DICTATOR EXPECTED COSIGNER ATTENDING PHYSICIAN and ADDITIONAL SIGNER S and one or more third parties RESEND rules outlined below apply for a document s expected signers DELETE ALERTS Allows deletion of all the alerts for a single or multiple documents DETAILED DISPLA Y TIf authorized allows the viewing of document details EDIT DOCUMENT TIf authorized allows the editing a selected TIU document IDENTIFY SIGNERS TIf authorized allows the editing of the expected signers of a TIU document and removal of additional signers RESEND ALERTS Allows the regeneration of alerts for a single document or multi
151. cuments to either problems visits or other documents Such associations permit a variety of clinically useful views of the online record Make Addendum Allows authorized users to add an addendum to the current document online When electronic signature is enabled physicians are prompted for their signatures upon exit thereby allowing doctors to review edit and sign as a one step process Print Allows you to print copies of selected documents on your corresponding VA Standard Forms to a specified device Quit Allows you to quit the current menu level Sign Cosign Allows clinicians to electronically sign the current summary NOTE Electronic signature carries the same legal ramifications that wet signature of a hard copy discharge summary carries Carefully review each discharge summary for content and accuracy before exercising this option Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual Rev January 2012 Integrated Document Management The options on this menu allow clinicians to review edit or sign progress notes discharge summaries and any other documents set up at your site This menu is especially useful for clinicians who wish to see an integrated view of documents to be able to edit or sign many types in one session without changing applications Option Name Description Individual Patient Document Allows you to interactively review edit or s
152. d business rules is in the TIU ASU Implementation Guide Exported Business Rules section L Note The TIU class document class user class note titles and business rules installed by patch TIU 1 137 and USR 1 23 must not be modified in any way or the Anatomic Pathology enhancements to the Lab Package will not work properly An exception exists in the case of USR 1 31 which directed medical centers to change these rules to refer to CHIEF MIS or CHIEF HIM rather than the LR ANATOMIC PATHOLOGY EMPTY CLASS The VA Office of Inspector General OIG determined that these rules are not in harmony with VHA Handbook 1907 1 See the section USR 1 31 Impact on Business Rules in the TIU Implementation Guide for details For document class PATIENT RECORD FLAG CAT I a business rule was exported by patch USR 1 24 the companion patch to TIU 1 165 that limits the writing of notes in this document class to a select group This select group is made up of members of the user class DGPF PATIENT RECORD FLAGS MGR Circumventing this rule violates the intent of keeping the flag documentation process in the hands of qualified domain experts Patch TIU 1 171 installed document titles and objects to support Spinal Cord Injury It also creates the Document Class SCI OUTCOMES The objects are listed on the TIU Web Page at http vista med va gov tiu html objects html HISTORICAL PROCEDURES contains medicine procedures that were converted to TIU notes by
153. d by RN to continue or EDICATION ISTORY DIET ACTIVITY 07 03 96 14 18 05 28 96 15 58 1A 65 year old AM initial evalua MORE STUFF Significant ne evaluation and CURRENT MEDICA 15 18 CONTINUED FROM PREVIOUS SCREEN ith without documented CAD k factors Lipid pattern Implement recommendations to lower fat intake FBG and HBG AIC on to review lab on es Three TIUProvider MS Physician Assistant 06 21 96 07 47 Analog Pager 555 1213 Digital Pager 555 1215 to exit lt Enter gt SOCIAL WORK SERVICE es Three TIUProvider MS Physician Assistant 06 21 96 07 47 Analog Pager 555 1213 Digital Pager 555 1215 to exit lt Enter gt LIPID CLINIC ERICAN INDIAN OR ALASKA NATIVE MALE here for tion of his DYSLIPIDEMIA gative medical history pertinent to the treatment of DYSLIPIDEMIA TIONS Counseled on AHA Step I diet today by NINE TIUPROVIDER Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 187 Author Print Progress Notes Example cont d OBJECTIVE HT 70 08 23 95 11 45 WT 178 07 01 96 17 15 TSH T4 1 7 1 1 FBG 223 HEMOGLOBIN A1C 15 2 SGOT 44 URIC ACID 4 7 ASSESSMENT Lis MALE with without documented CAD 2 CV Risk facto
154. ddendum to Lipid Clinic 10 25 96 unsigned Next Screen Prev Screen More Actions Find Sign Cosign Change View Add Document Detailed Display Copy Edit Browse Delete Document ake Addendum Print Quit Link Identify Signers Select Action Quit s Sign Cosign Select Progress Note s 1 2 1 Opening Psychology Crisis record for review SIGN COSIGN Oct 25 1996 11 34 21 Page 1 of 1 Psychology Crisis TIUPATIENT ONE 666 23 3456 2B Visit Date 10 25 96 11 32 DATE OF NOTE OCT 25 1996 11 32 55 ENTRY DATE OCT 25 1996 11 32 55 AUTHOR TIUPROVIDER ONE EXP COSIGNER URGENCY STATUS UNSIGNED Six month follow up visit Patient continues to improve no change in treatment required Next Screen Print Ready for Signature NO y Item Prev Screen Enter your Current Signature Code Yes 1 Added to signature list XXXXXXX code hidden 2 More Actions SIGNATURE VERIFIED Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 43 Show Progress Notes Across Patients This option lets you search for and review progress notes by many different criteria status type date range and cateogory By different combinations of these criteria you can see almost any view of your progress notes you could want SF NOTE Use caution in how broad your search is da
155. different criteria status type date range and category Caution Avoid selecting too large a date range or too general a category as big searches are very system intensive This means that not only might it slow down your work but everyone else s as well Progress Notes Print Options The options on this menu support the printing of chart or work copies by author location patient or ward These options are described in Chapter 8 List Notes By Title This option lets you look up progress notes by title within a specified date range Search by Patient AND Title This option lets you search for and review progress notes by patient as well as many other criteria status type date range and category Personal Preferences The two options on this menu let you customize the way TIU operates for you that is which prompts will appear what lists you will see to select from etc You can also specify the way documents are displayed on your review screens by patient by author by type in chronological or reverse chronological order etc Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 29 Entry of Progress Note This is the main option for entering a new progress note You can also edit patient progress notes Example 1 Inpatient progress note Steps to use option 1 Select Entry of Progress Note from your Progress Notes Menu If you h
156. ditor and will then be allowed to edit the buffer e g correct a bad social security number admission date etc and retry the filer With each attempt to correct the buffered data and retry the filer all alerts associated with that batch will be deleted and if the condition remains uncorrected re sent until all records in the batch are successfully filed Batch Upload Reports Kermit Protocol Upload If your site is using the upload option to transfer batches of discharge summaries from a remote computer using the Kermit transfer protocol start the upload process by following the sequence below 1 Choose UP from your Upload Menu You are currently logged into DIVISION SALT LAKE CITY HCS If a hospital location cannot be determined for an uploaded document the document s division may be loaded with your log in division 1 Upload Documents 2 Help for Upload Utility Select Upload Menu Option UP Batch upload reports KERMIT UPLOAD Now start a KERMIT send from your system Starting KERMIT receive N3 L Note When entering the Upload Menu you receive a warning which specifies which division you are logged into If division information is not explicitly available in the header then it uses division information from your most current login To change this division without re logging in you can use the XUSER DIV CHG option from the TBOX menu 2 When you see the N3 prompt initiate the Ker
157. e while complex to set up creates the capability for better integration shared use of boilerplate text components and objects and a more manageable organization of documents End users clinical administrative and MIS staff need not be aware of the hierarchy They work at the Title level with the actual documents Plan the Document Definition Hierarchy your site or service will use before installation of TIU and conversion of progress notes This step is critical to the organization of existing and future documents in each site s implementation of TIU A worksheet is provided in Appendix A of the TIU Implementation Guide to help build the three basic levels Example of Document Definition Hierarchy CLASS Clinical Documents Progress Discharge CLASSES Notes Summary Nursing Dietitian Psychologist DOCUMEN Notes Notes T CLASSES Notes Cardiology Eye Clinic TITLES Nursing Nursing Notes Notes Rev January 2012 Text Integration Utilities V 1 0 207 Clinical Coordinator amp User Manual Document Definition Options Option Option Description Text Name Edit Document TIUFH EDIT This option lets you view and edit entries Entries are Definitions DDEFS presented in hierarchy order Items of an entry are in sequence order or if they have no sequence in alphabetic order by menu text and are indented below the entry Since Objects don t belong to the hierarchy they can t be view
158. e cont d SALT LAKE CITY priority 06 27 96 08 46 Page 4 PATIENT NAME AGE SEX RACE SSN CLAIM NUMBER TIUPATIENT ONE 51 MEXI 666 23 3456 moderate memory impairment no apraxia noted Cranial nerves patient was blind pupils are not reactive to light face was asymmetric tongue and palate are mid line Motor examination showed muscle tone and bulk without significant changes Muscle strength in upper extremities 5 5 bilaterally sensory examination revealed intact light touch pinprick and vibratory sensation Reflexes 1 in upper extremities coordination finger to nose test within normal limits bilaterally Alternating movements without significant changes bilaterally Neck was supple LABORATORY Showed sodium level 135 potassium 4 6 chloride 96 CO2 26 BUN 39 creatinine 5 3 glucose level 138 White blood cell count was 7 hemoglobin 11 hematocrit 34 platelet count 77 Fl HOSPITAL COURSE Patient was admitted after head trauma with multiple medical problems His coumadin was held Patient had cervical spine x rays which showed definite narrowing of C5 C6 interspace slight retrolisthesis at this level prominent spurs at this level as well as above and below CT scan on admission showed a moderate amount of scalp thinning with subcutaneous air overlying the left frontal lobe A small area of left parenchymal hemorrhage adjacent to the right petros
159. e is a comprehensive handbook for first time users of any V STA application to help you become familiar with 12 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual basic computer terms and the components of a computer It is reproduced and distributed periodically by the Kernel Development Group To request a copy contact your local Information Resources Management Service IRMS staff Graphic Conventions Used in This Manual lt Enter gt The Enter or Return key It is pressed after every response you enter or when you wish to bypass a prompt accept a default or return to a previous action In this manual it is only included in examples when it might be unclear that such a keystroke must be entered Option examples Menus and examples of computer dialogue that you see on the screen are shown in boxes Select Menu Option User responses User responses are shown in boldface Select PATIENT NAME TIUPATIENT ONE NOTE The pointing finger with a NOTE is used to call your attention to something especially significant Example SZ NOTE You can respond to many prompts by typing the first few letters of a name option or action Select PATIENT NAME TIUPATIENT O TIUPATIENT ONE Rev January 2012 Text Integration Utilities V 1 0 13 Clinical Coordinator amp User Manual TIU and VISTA Conventions A AA AANA Enter the up arrow also known as a caret or circumflex at a pr
160. e time of Note NOW Author of Note TIU OK YES lt Enter gt SUBJ Call 1 gt 2 gt ECT ing Mr OPTIONAL description text editor please wait ERAL MEDICINE PROVIDER NINE lt Enter gt TIUPatient s allergies improved with medication EDIT Option lt Enter gt Save changes YES lt Enter gt Saving Adverse React Allergy with changes You may enter another CLINICAL DOCUMENT Press RETURN to exit Enter your Current Signature Code xxx SIGNATURE VERIFIED Print this note No lt Enter gt NO Select PATIENT NAME lt Enter gt VG G r Clinician s Menu Individual Patient Document All MY UNSIGNED Documents Enter edit Document ultiple Patient Documents Select Integrated Document Management Option lt Enter gt Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 75 Documents Requiring Additional Signature A report is available that will give you all documents requiring your additional signature This report is available from the Integrated Document Management Menu and the Progress Notes User Menu To run this report 1 From a menu select ALL Documents requiring my Additional Signature 2 The following report is displayed Select Integrated Document Management Option Individual Patient Document All MY UNSIGNED Documents All
161. e you sure you want to REASSIGN this Infection Control NO Y YES Please choose the correct PATIENT and CARE EPISODE Select PATIENT NAME TIUPATIENT N i TIUPATIENT NINE SENSITIVE SENSITIVE NO EMPLOYEE THIS Is A TEST 2 TIUPATIENT NINE 1 1 65 666344321 YES SC VETERAN THIS Is A TEST CHOOSE 1 2 2 TIUPATIENT NINE 1 1 65 666344321 YES SC VETERAN THIS IS A TEST 1 note W 09 15 98 08 29 A Known allergies Enrollment Priority GROUP 1 Category IN PROCESS End Date This patient is not currently admitted to the facility Is this note for INPATIENT or OUTPATIENT care OUTPATIENT lt Enter gt Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 127 Correcting Documents that are Entered in Error cont d The following SCHEDULED VI 1 gt AUG 20 1999 08 00 2 gt JUL 30 1999 09 00 3 gt JUL 29 1999 09 15 4 gt JUN 03 1999 13 00 5 gt JUL 22 1997 09 00 CHOOSE 1 5 or SITS are available NINE CLINIC NINE CLINIC NINE CLINIC NINE CLINIC INPATIENT APPOINTMENT SIX CLINIC D lt U gt NSCHEDULED VISITS lt F gt UTURE VISITS or lt N gt EW VISIT lt RETURN gt TO CONTINUE OR TO QUIT 2 JUL 30 Enter Edit PROG
162. eady for Signature NO y Yes Item 5 Added to signature list Enter your Current Signature Code XXX SIGNATURE VERIFIED MY UNSIGNED Documents Jun 06 1997 12 04 27 Page 1 of T by AUTHOR TIUPROVIDER FIVE or EXPECTED COSIGNER 5 documents Patient Document Ref Date Status 1 TIUPATIENT FIVE T3779 Discharge Summary 06 02 97 UNSIGNED 2 TIUPATIENT ONE T3456 Adverse React Allergy 05 31 97 completed 3 TIUPATIENT TWO T3243 Adverse React Allergy 05 20 97 completed 4 TIUPATIENT FIVE T3779 General Note 04 07 97 completed 5 TIUPATIENT SIX T3476 Adverse React Allergy 03 24 97 completed Items 3 4 5 Signed gt gt gt Find Sign Cosign Change View Add Document Detailed Display Copy Edit Browse Delete Document Make Addendum Print Quit Tank was Identify Signers Select Action Quit Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual Multiple Patient Documents Use this option to see an integrated Review Screen of all TIU documents Caution Avoid making your requests too broad in statuses search categories and date ranges because these searches can use a lot of system resources slowing the computer system down for everyone Steps to use option 1 Select Multiple Patient Documents from your Integrated Document Management menu on your TIU menu
163. ect Action Quit ON CHART 116 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Print Document Menu This menu contains options which print chart or work copies of discharge summaries progress notes or mixed documents 1 Discharge Summary Print 2 Progress Note Print 3 Clinical Document Print Discharge Summary Print Use this option to print chart or work copies of discharge summaries Steps to use this option 1 Select Discharge Summary Print from the MIS Manager s Print Document Menu 2 Enter the name of the patient whose discharge summary you want to print il Discharge Summary Print 2 Progress Note Print 3 Clinical Document Print Select Print Document Menu Option 1 Discharge Summary Print Select PATIENT NAME TIUPATIENT ONE TIUPATIENT ONE 09 12 44 666233456 YES SC VETERAN 2 notes 05 28 96 12 37 Known allergies G 2 notes W 05 28 96 12 33 A D 05 28 96 12 36 2 notes Available summaries 02 12 96 thru 02 12 96 1 3 Enter the range of dates to choose the discharge summary or summaries you want to print Please specify a date range from which to select summaries List summaries Beginning 02 12 96 lt Enter gt FEB 12 1996 Thru 02 12 96 lt Enter gt 1 02 12 96 13 56 Discharge Summary One TIUProvider MD Adm 07 22 91 Dis 02 12 96 Choose summaries 1 1
164. ect New Patient Complete Note s Select Action Quit B BROWSE Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 39 Review Progress Notes cont d 3 If you select the action Browse you can see more details of a note Select Action Next Screen b Browse Select Progress Note s 1 15 1 Reviewing Item 1 Opening Adverse React Allergy record for review Browse Document May 31 1997 14 29 07 Page 1 of 1 Adverse React Allergy TIUPATIENT O 666 23 3456 GENERAL MEDICINE Visit Date 04 18 96 10 00 DATE OF NOTE MAY 27 1997 ENTRY DATE MAY 27 1997 12 15 13 AUTHOR TIUPROVIDER ONE EXP COSIGNER URGENCY STATUS COMPLETED Another test is the antibiotic working es ONE TIUPROVIDER MD PGY2 Resident Signed 05 27 97 12 21 Next Screen Prev Screen More actions Find Sign Cosign Link Print Copy Encounter Edit Edit Identify Signers Interdiscipl ry Note ake Addendum Delete Quit Select Action Quit NOTE When reviewing several notes sequentially the up arrow entry takes you to the next note To exit from the review enter two up arrows 40 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Review Progress Notes cont d 4 If you select the action Detailed Display you can see even more
165. ected text in list of entries Auto Display On Off ADPL Toggles the menu of actions to be displayed not displayed automatically Change Title CT Lets you change the Title of a note from e g a CWAD note to a Nursing Note CWAD Display CWAD Displays details of any CWAD notes available Rev January 2012 Text Integration Utilities V 1 0 17 Clinical Coordinator amp User Manual List Manager Screen Display cont d Edit Cosigner EC Allows authorized users to modify the Expected Cosigner Attending Physician for Discharge Summaries of documents without having access to the text of the document It is intended for Clinical Coordinators when they need to change the Expected Cosigner of a document whose Expected Cosigner cannot be otherwise changed because it is already signed It permits the Expected Cosigner field to be edited for unsigned or uncosigned documents of type Progress Notes Consults Clinical Procedures or Discharge Summaries Note Recent changes enforce limits on cosigning privileges No provider may be a cosigner on Discharge Summaries if the provider requires a cosignature To correct expected cosigners who were erroneously assigned before this restriction went into effect perform a search on uncosigned notes then use the hidden Edit Cosigner EC action to correct any problems Quit QU Exits the screen may be shown as a default Text Integr at
166. ed edited using the Edit Options Create TIUFC This option lets you create new entries of any type Class Document CREATE Document Class Title Component except Object placing Definitions DDEFS them where they belong in the hierarchy Although entries can be created using the Edit and Sort options the Create option streamlines the process This option presents entries in hierarchy order traversing ONE line of descent starting with Clinical Documents at the top The Create option permits you to view edit and create entries but only from within the current line of descent The Create Option doesn t let you copy an entry Sort Document TIUFA SORT This option lets you view parts of the hierarchy by selected Definitions DDEFS sort criteria It displays the selected entries in alphabetic order by Name rather than in hierarchy order Depending on sort criteria entries can include Objects The Sort option lets you view and edit entries Create Objects TIUFJ This option lets you create new objects or edit existing CREATE objects First you select Start With and Go To values and the OBJECTS existing Objects within those values are displayed in MGR alphabetical order View Objects TIUFJ VIEW This option lets you look at or edit existing objects First you OBJECTS select Start With and Go To values and the existing Objects MGR within those values are displayed in alphabetical order NOTE For further
167. ed to a different patient TIU retracts the document 3 Re edit original visit If necessary the PCE information is updated for the original visit 4 Edit destination visit If necessary PCE information is collected or revised for the new visit 5 Sign The original provider needs to sign the document If the document was moved to a different patient TIU removes the original signature In the following example an unsigned note is transferred from one patient to another Select OPTION NAME TIU MAIN MENU MGR Text Integration Utilities MIS Manager MIS Managers Menu 1 Individual Patient Document 2 ultiple Patient Documents 3 Print Document Menu 4 Search for Selected Documents 5 Statistical Reports 6 Unsigned Uncosigned Report 7 issing Text Report 8 issing Text Cleanup 9 Signed unsigned PN report and update 10 UNKNOWN Addenda Cleanup 11 issing Expected Cosigner Report LI issing Expected Cosigner Report 12 ark Document as Signed by Surrogate 13 ismatched ID Notes 14 TIU 215 ANALYSIS 15 Transcription Billing Verification Report Select Text Integration Utilities MIS Manager Option 1 Individual Patient Do cument Select PATIENT NAME TIUPATIENT E HE TIUPATIENT ELEVEN 4 2 44 666568765 YES NON SERVICE CONNEC TED THIS IS A TEST 2 TIUPATIENT TWENTY 4 1 48
168. elect Item s Quit 4 Select Action Attach to Parent lt Enter gt Attach the following UNKNOWN Addenda TIU Doc No Patient Entry DT Time Status Parent 2238 CPRSPATIENT T C5525 10 14 04 11 56 14 UNSIGNED None to the following OPERATION REPORT TIU Surgical Doc No Patient Entry DT Time Status Case No 2195 CPRSPATIENT T C5525 09 29 04 08 18 39 COMPLETED 89 L Note Be sure to verify any addenda before attaching to a parent document Many addenda are duplicates of the original Operation Report and may be deleted once they are verified as UNSIGNED copies Only one document may be selected as the potential parent to the previously selected addenda Users may NOT attach addenda to a parent OPERATION REPORT with a different patient or an OPERATION REPORT whose ENTRY DATE TIME falls after the addenda 142 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual Rev January 2012 Once a parent document has been selected a confirmation screen will display the selected addenda and parent information and prompt the user to begin attaching the documents After the utility attempts to associate the addenda with a parent Operation Report the user will be returned to the initial List Manager display with successful associations being listed under the Parent column showing the TIU Document number of the parent that has been assigned These documents will no longer appear once the current session
169. em Sterility Checked Sterility Expiration Date RN Verifier Vendor Model Lot Serial Number Sterile Resp Size Quantity Medication Time Administered Route Dose Ordered By Administered By Comments Irrigation Solution Time Utilized Amount Provider Replacement Fluid Type Quantity ml Source Identification VA Identification Comments 154 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual Rev January 2012 Laser Unit s Laser Unit s Laser Unit s Laser Unit s Laser Unit s Laser Unit s Cell Saver s Cell Saver s Cell Saver s Cell Saver s Cell Saver s Cell Saver s Cell Saver s Cell Saver s Anesthesia Technique s Anesthesia Technique s Anesthesia Technique s Anesthesia Technique s Laser Unit ID Duration Wattage Operator Plume Evacuator Comments Cell Saver ID Operator Amount Salvaged ml Amount Reinfused ml Comments Disposables Name Lot Number Quantity Anesthesia Technique Principal Technique Anesthesia Agent Dose mg Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 155 Transcription Billing Verification Report This report can be run by division and provides information on all transcriptionists or one or more selected transcriptionists It reports based on an entered date range Since the VBC Line Count is only calculated for transcribed reports it does not report on any docume
170. em has been found with VistA patch TIU 1 0 215 released June 28 2007 One of the intents of this patch was to only allow editing amending etc from the Surgery package to keep the Surgery file 130 and TIU files in sync This was for the Nurse Intraoperative Report NIR and the Anesthesia Report only However if surgery personnel made changes to a surgery case using one of the case editors such as OSS Operation Short Screen SROMEN OUT they were asked if they wanted to create an addendum After installation of TIU 1 0 215 the addendum was not created for viewing via the Surgery Tab in CPRS however the data was being updated in the Surgery application files A new option TIU 215 ANALYSIS is set up with installation of patch TIU 1 0 231 and is being added as sequence 14 to the TIU MAIN MENU MGR option TIU MAIN MENU MGR Text Integration Utilities MIS Manager TIU 215 ANALYSIS A ANALYZE POTENTIAL SURGERY TIU PROBLEMS V VIEW SINGLE SURGERY CASE USING CASE T SEND ANALYSIS OUTPUT TO TEXT FILE Option A Analyze Potential Surgery TIU Problems Allows for the analysis process which was run during the installation of this patch to be run again Surgery cases will be analyzed within a particular date range and the information from NIR and or Anesthesia reports will be compared to their corresponding TIU notes If the information does not match the case number w
171. ensive and time consuming on a batch send of alerts Q I used RESEND ALERT and no alerts were resent to anyone even though it appeared that alerts were being re generated Why A While TIU may create and attempt to regenerate the alerts this will always happen if TIU Alerts attempts to fulfill a user s request it has no way of actually confirming whether or not kernel will send an alert to an individual associated with a document See 7 The important rule to remember is that kernel will not actually send alerts to inactivated or terminated users Additionally TIU sends alerts based on the current status of the document and whether or not the recipient still needs to sign the document If an individual has already signed they should not receive an alert However if a user associated with a document has already signed and they are sent a 3RD PARTY ALERT they will receive another alert Q Isent the AUTHOR who has already signed a 3RD PARTY ALERT and now they can t process it What should I do Just RESEND ALERTs for that document All alerts will be deleted and regenerated 3RD PARTY ALERTS that had been manually generated will have to be re entered See 3 Rev January 2012 Text Integration Utilities V 1 0 219 Clinical Coordinator amp User Manual Chapter 16 HL7 Generic Interface The purpose of the HL7 Generic Interface is to create a Health Level Seven HL7 line to Text Integration Utilities TIU that will
172. ent Class with Nursing Dialysis Progress Notes Nursing psychology Progress Notes etc as Titles under it Or maybe the Document Class would be Psychology Notes with Psychology Nursing Notes Psychology Social Worker Notes Psychology Patient Education Notes etc under that Document Class Document Definition Document Definition is a subset of TIU that provides the building blocks for TIU by organizing the elements of documents into a hierarchy structure This structure allows documents Titles to inherit characteristics such as signature requirements and print characteristics of the higher levels Class and Document Class It also allows the creation and use of boilerplate text and embedded objects Rev January 2012 Text Integration Utilities V 1 0 239 Clinical Coordinator amp User Manual Glossary cont d HIMS Hospital Information Management System common abbreviation synonym used at VA site facilities also known as MIS see below IRT Incomplete Record Tracking a package TIU can interface with to transmit incomplete progress notes and discharge summaries Interdisciplinary Note A new feature of Text Integration Utilities TIU for expressing notes from different care givers as a single episode of care They always start with a single note by the initial contact person e g triage nurse case manager attending and continue with separate notes created and signed by other providers then attached to the origi
173. entry Since Objects don t belong to the hierarchy they can t be viewed edited using the Edit Option Sort Document The Sort option lets you view and edit entries by sort criteria It Definitions then displays selected entries in alphabetic order by Name rather than in hierarchy order Depending on sort criteria entries can include Objects View Objects The option displays Objects within selected Start With and Go To values in alphabetic order by Name 82 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Edit Document Definitions This example shows you how to traverse the hierarchy to see details about a Title in Document Definitions in this case an Advance Directive The first screen shows just the top level of document types A indicates that there are items under that document type To see these select Expand Collapse then enter the number of the document type to be expanded Select Document Definitions Clinician Option 1 Edit Document Definitions Edit Document Definitions Apr 17 1997 16 42 53 Page 1 of iL BASICS Name Type 1 CLINICAL DOCUMENTS CL 2 DISCHARGE SUMMARY CL 3 PROGRESS NOTES CL 4 ADDENDUM DC Help gt ScroLllRight PS PL PrintScrn List gt gt gt Expand Collapse Detailed Display Quit Jump to Document Def Try B
174. eport text In some cases you may choose to correct documents manually such as when the author is still available or when the document was originally an upload document Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual Option Description UNKNOWN Addenda Cleanup Gives a list of surgery addenda that are not connected to an Operations Report and provides options for reviewing assistance in finding the parent and attaching to the parent Missing Expected Cosigner Report Provides a list of documents that have a status of Uncosigned where the Expected Cosigner field is null 0 or 1 Mark Document as Signed by Surrogate Provides a way to mark a document as Signed by Surrogate This will set the 09 field of file 8925 7 to 1 meaning that the signing for an Additional Signer was done by a surrogate of that Additional Signer Mismatched ID Notes This option runs a routine that will report fix mismatched interdisciplinary ID notes TIU 215 ANALYSIS Surgery cases will be analyzed within a particular date range and information from Nurse Intraoperative Report NIR and or Anesthesia reports will be compared to their corresponding TIU notes If the information does not match the case number will be recorded as one that needs to be reviewed Transcription Billing Verification Report This report can be run by division and provides
175. eral Note 01 24 97 14 18 completed 4 CLINICAL WARNING 01 15 97 completed 5 SOAP GENERAL NOTE 12 04 96 14 39 completed 6 SOAP GENERAL NOTE 12 04 96 11 32 completed 7 CRISIS NOTE 12 03 96 10 44 completed 8 SOAP GENERAL NOTE 12 03 96 10 31 completed 9 SOAP GENERAL NOTE 11 22 96 12 37 completed Enter the numbers of the items you wish to act on gt gt gt NW Write New Note CG Change List SP Select New Patient Next Screen CC Chart Contents Q Close Patient Chart Select Chart Contents CG CHANGE LIST Date range Status Select attribute s to change S STATUS Select Signature Status completed Enter the signature status you would like to screen on Choose from amended completed deleted purged uncosigned undictated unreleased unsigned untranscribed unverified Select Signature Status completed UNSigned Searching for the patient s chart Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual Example Reviewing Notes cont d 7 The patient s unsigned notes are displayed Unsigned Progress Notes Mar 17 1997 17 13 22 Page 1 of 1 TIUPATIENT ONE 666 12 3456 2B JAN 1 1951 46 lt CW gt Title Written Sig Status T Addendum to CLINICAL WARNING 01 28 97 unsigned Enter the numbers of the items you wish to act on gt gt gt NW Write New Note CG Change List SP Select New Patient Next Screen CC Chart Contents
176. ete Document ake Addendum Print Quit Link Identify Signers Select Action Quit DET 3 4 A detailed display of the note you chose appears on your screen Detailed Display Mar 11 1997 09 21 40 Page 1 of 2 CLINICAL WARNING TIUPATIENT NINE 666 12 1239 Visit Date 02 04 97 13 00 Reference Date MAR 05 1997 14 50 17 Author TIUPROVIDER ONE Entry Date MAR 05 1997 14 50 18 Entered By DP Expected Signer TIUPROVIDER FIFTEEN Expected Cosigner None Urgency None Document Status COMPLETED Line Count 46 TIU Document 27752 Division ISC SLC A4 VBC Line Count 56 25 Subject None Associated Problems No linked problems Edit Information Edit Date MAR 05 1997 14 50 41 Edited By TIUPROVIDER FIFTEEN Signature Information Next Screen Prev Screen More actions Find Print Quit Select Action Next Screen 48 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Search by Patient AND Title This option lets you search for and review progress notes by patient as well as many other criteria status type date range and category You can then take any of the usual actions on these notes Steps to use option 1 Select the Search by Patient AND Title option from the Progress Notes User Menu
177. eted 13 TIUPATI T2591 Discharge Summary 06 02 97 completed 14 TIUPATIE T2591 Addendum to Discharge Summary 06 02 97 unsigned Next Screen Prev Screen More Actions gt gt gt Find Browse Change View Detailed Display Print Quit Select Action Quit DEVICE HOME PRI P 13 NTER 180 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual Rev January 2012 Multiple Patient Documents cont d SALT LAKE CITY 06 09 97 11 29 Page 1 PATIENT NAME AGE SEX RACE SSN CLAIM NUMBER TIUPATIENT SEVEN 66 M AMER 666 04 2591P ADM DATE DISC DATE TYPE OF RELEASE INP ABS WARD NO MAY 30 1997 l DICTATION DATE JUN 02 1997 TRANSCRIPTION DATE JUN 02 1997 TRANSCRIPTIONIST jg DIAGNOSIS toe injury OPERATIONS PROCEDURES evaluated for prosthesis COPY SIGNATURE APPROVING PHYSICIAN DENTIST es NINE TIUPROVIDER e NINE TIUPROVIDER NINE TIUPROVIDER JUN 02 1997 16 55 56 ADDENDUM In remission SIGNATURE APPROVING PHYSICIAN DENTIST Three TIUProvider MS Rev January 2012 Text Integration Utilities V 1 0 181 Clinical Coordinator amp User Manual Chapter 8 Progress Notes Print Options Admission Prints all PNs for Current Admission Author Print Progress Notes Batch Print Outpt PNs by D
178. ge Summary NO lt Enter gt VERIFY this Discharge Summary NO y YES Discharge Summary VERIFIED Chart copy queued Refreshing the list 92 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Review Upload Filing Events Steps to use option 1 Select Review Upload Filing Events from the TIU MRT menu Select Text Integration Utilities MRT Option Review Upload Filing Events Select division displayed Select division ALL SALT 1 SALT LAKE CIOFO 660GC 2 SALT LAKE OEX 660 CHOOSE 1 2 2 SALT LAKE OEX 660 Select another division lt Enter gt a Note This prompt is only displayed if you are at a multi division medical center In other words if the MULTIDIVISION MED CENTER field of the MAS PARAMETERS file is set to YES 3 Select the event type to be displayed Select Event Type FILING ERRORS Enter a code from the list Select one of the following Filing Errors Missing Field Errors Successes All Events DUKH Select Event Type FILING ERRORS lt Enter gt Filing Errors 4 Select the Resolution Status Unresolved Errors Resolved Errors or All Errors Select Resolution Status UNRESOLVED Enter a code from the list Select one of the following U Unresolved Errors R Resolved Errors A
179. he following is an example of using the HL7 message Manager to check an error message Select TIU Maintenance Menu Option TIU Parameters Menu Document Definitions Manager User Class Management TIU Template Mgmt Functions TIU Alert Tools Active Title Cleanup Report TIUHL7 Message Manager ANH PWNE Select TIU Maintenance Menu Option 7 TIUHL7 Message Manager Searching for messages Refresh Message List 220 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual TIUHL7 Message Manager Aug 04 2006 15 47 19 Page 1 of 1 TIUHL7 Received Messages Receiving Sending Message Message ID Date Time Processed Application Application Status 1 99953044 Jul 31 2006 11 24 53 TIUHL7 HTAPPL Rejected 2 99953046 Jul 31 2006 11 27 14 TIUHL7 HTAPPL Rejected 3 99953048 Jul 31 2006 11 28 44 TIUHL7 HTAPPL Accepted 4 200T40029200608 Aug 02 2006 11 35 11 TIUHL7 HTAPPL Accepted 5 200T40003200608 Aug 02 2006 14 28 14 TIUHL7 HTAPPL Accepted 6 99953050 Aug 02 2006 15 45 41 TIUHL7 HTAPPL Accepted Enter for more actions View Message Delete Message s Refresh Message Lis Note Error Select Action Quit 2 message TIUHL7 Message Viewer Aug 04 2006 15 47 22 SA AR 99953046 TIUHL7 HTAPPL ERR PV1 44 0000 00 Could not find a visit for Jul 3 Page 1 of L 2006 16 21 rd SH amp HTAPP
180. hen displayed Opening Lipid Clinic record for review Browse Document Jun 26 1996 10 55 18 TIUPATIENT O DATE OF NOTE AUTHOR URGENCY SUBJECTIVE 5 year old AMERICAN INDIAN OR ALASKA NATIVE MALE here for Lipid Clinic 666 23 3456 Visit Da JUN 21 1996 07 47 47 ENTRY DATE JUN TIUPROVIDER ONE EXP COSIGNER Page 1 of 4 te 06 18 96 10 00 21 1996 07 47 47 STATUS COMPLETE initial evaluation of his DYSLIPIDEMIA COPIED FROM TIUCLIENT TO TIUPATIENT PMH Significant negative medical history pertinent to the evaluation and treatment of DYSLIPIDEMIA FH Next Screen Prev Screen More actions Find Make Addendum Identify Signers Print Sign Cosign Delete Edit Copy Link Quit Select Action Next Screen lt Enter gt NOTE The screen indicates that this is Page 1 of 4 press Enter after each screen to see all the pages of this note When reviewing several notes the up arrow entry takes you to the next note To exit from the review enter two up arrows Browse Document Jun 26 1996 10 56 09 Page 2 of 4 Lipid Clinic TIUPATIENT O 666 23 3456 Visit Date 04 18 96 10 00 SH MEDICATION HISTORY CURRENT MEDICATIONS DIET Counseled on AHA Step I diet today by NINE TIUPROVIDER See her evaluation ACTIVITY OBJECTIVE HT 70 08 23 95 11 45 WT 207
181. hich have been defined for upload by your site List Documents for Gets all UNDICTATED and UNTRANSCRIBED Transcription Documents for review edit and signature Review Edit Document Allows the user to interactively review edit and or print documents Transcription Billing This option produces a report for the verification of Verification Report transcription bills using the Visible Black Character counting method described in VHA Directive 2008 042 Rev January 2012 Text Integration Utilities V 1 0 161 Clinical Coordinator amp User Manual Enter Edit Discharge Summary Use this option to enter and edit discharge summaries directly online Steps to use option 1 Select Enter Edit Discharge Summary from the Transcriptionist Menu Transcriptionist Menu Enter Edit Discharge Summary Enter Edit Document Upload Menu List Documents for Transcription Review Edit Documents Transcription Billing Verification Report On UG GA b i Select Text Integration Utilities Transcriptionist Option 1 Enter Edit Discharge Summary 2 Enter a patient s name and choose an Admission from the choices offered Select Patient TIUPATIENT ONE TIUPATIENT ONE 09 12 44 666233456 YES Sc VETERAN For Patient TIUPATIENT ONE The following ADMISSION is available 1 gt JUL 22 1995 11 06 DIRECT TO 1A CHOOSE 1 1 1 JUL 22 1991 11 06
182. hild note to be by a different provider involved in this episode of care Again your facility has established a number of notes with unique titles to act as child notes 52 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Interdisciplinary Notes cont d Previously created note attachments are made to the parent node by dragging and dropping Dragging and dropping may be a new concept to you To drag and drop 1 Point the cursor at the child note 2 Hold down the left mouse button 3 Move the cursor over the parent note A ghost of the child note title will follow the cursor 4 Release the left mouse button Gi VistA CPRS in use by TUProvider Seven File Edit View Action Options Tools Help NT FC CARD Oct 26 00 11 22 Default List Visit 10 26 00 ID CHIL ER TITLE ID DATE OF NOTE NOY oe 1700 EADENT EE le ACHAUTHORSE pr Nov 17 00 ERR URGENCY E Nov 17 00 ER NOTE PULMC Nov 17 00 SUSAN S CHILDA fr recieved the i When dragging an outline of the item follows the cursor The following dialog appears to confirm the attachment Confirm attachment 2 2 ATTACH Nov 17 00 ID CHILD REHAB NURSE NOTE CARDIOLOGY TIUPROVIDER SEVE TO Nov 17 00 ID PARENT REHAB TREATMENT PLAN CARDIOLOGY TIUPROVIDER 0O Are you sure Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 53 Interdisciplinary Notes cont d Men
183. hor 6 Problem 10 Transcriptionist 3 Expected Cosigner 7 Service 11 Treating Specialty 4 Hospital Location 8 Subject 12 Visit Enter selection s by typing the name s number s or abbreviation s Select SEARCH CATEGORIES AUTHOR lt Enter gt Author Select AUTHOR TIUPROVIDER ONE JG Rev January 2012 Text Integration Utilities V 1 0 105 Clinical Coordinator amp User Manual Search for Selected Documents cont d 5 Enter the range of dates you want displayed Start Reference Date Time T 7 lt Enter gt MAY 26 1997 Ending Reference Date Time NOW lt Enter gt JUN 02 1997 15 46 Searching for the documents 6 The documents fitting the search criteria you selected are displayed Choose an action to perform on the relevant documents UNSIGNED Documents Jun 02 1997 15 46 28 Page 1 of 1 by AUTHOR TIUPROVIDER ONE from 05 26 97 to 06 02 97 2 documents Patient Document Ref Date Status 1 TIUPATIENT ONE T3456 Adverse React Allergy 05 31 97 unsigned 2 TIUPATIENT FIV T2591 Adverse React Allergy 05 31 97 unsigned Next Screen Prev Screen More Actions SSS Find Reassign Print Verify Unverify Send Back Change View On Chart Detailed Display Quit Edit Browse Select Action Quit Unsigned Uncosigned Report Lists detailed document information such as author patient patient SSN etc for notes with no signature and or cosignat
184. icant changes bilaterally Neck was supple LABORATORY Showed sodium level 135 potassium 4 6 chloride 96 CO2 26 BUN 39 creatinine 5 3 glucose level 138 White blood cell count was 7 hemoglobin 11 hematocrit 34 platelet count 77 HOSPITAL COURSE Patient was admitted after head trauma with multiple medical problems His coumadin was held Patient had cervical spine x rays which showed definite narrowing of C5 C6 interspace slight retrolisthesis at this level prominent spurs at this level as well as above and below CT scan on admission showed a moderate amount of scalp thinning with subcutaneous air overlying the left frontal lobe The basal cisterns are patent and there is no mid line shift or uncal herniation Patient has also a remote left posterior border zone infarct with hydrocephalus ex vaccuo of the left occipital horn a rather large remote infarct in the inferior portion of the left cerebellar hemisphere He had hemodialysis q o d He restarted treatment with Coumadin His last PT was 11 9 PTT 31 Patient refused befor hemodialysis new blood tests His condition remained stable DISCHARGE MEDICATIONS Isordil 20 mgs p o t i d Ferrous sulfate 325 mgs p o b i d Ativan 0 5 mgs p o b i d Lactulose 15 ccs p o b i d Calcium carbonate 650 mgs p o b i d Compazine 10 mgs p o t i d prn nausea Betoptic 0 5 OU b i d Nephrocaps 1 p o qd Pilocarpine 4 solution 1 gtt OU b i d Coumadin 2 5 mgs p o
185. ients Clinician s Discharge Summary Menu Individual Patient Discharge Summary This option lets you review edit or sign a patient s discharge summaries All MY UNSIGNED Discharge Summaries This option shows you all unsigned discharge summaries for you to review edit or sign You must have signing or cosigning privileges to sign or cosign based on your document definition user class status and business rules governing these actions See your Clinical Coordinator if you have any problems or questions Multiple Patient Discharge This option shows you discharge summaries for selected Summaries statuses types and categories which you can then review edit and or sign Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 59 Individual Patient Discharge Summary This option lets you review edit or sign a patient s discharge summaries Steps to use option 1 Select Individual Patient Discharge Summary from your TIU menu then select a patient Select Discharge Summary User Menu Option Individual Patient Discharge Summary Select PATIENT NAME TIUPATIENT ONE TIUPATIENT ONE 09 12 44 666233456 YES SC VETERAN 2 notes C 05 28 96 12 37 we If the patient has any CWAD 2 notes W 05 28 96 12 33 i p Crisis Warning Allergies A Known allergies and Directives notes they are Available summaries
186. iew Start Reference Date Time T 7 T 30 Ending Reference Date Time NOW lt Enter gt Searching for the documents 124 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Search for Selected Documents cont d 6 After the documents are displayed you can choose one of the actions listed below amend browse delete etc to perform on one or more of the documents UNVERIFIED Documents Jun 09 1997 LO LLsL1 Page 1 of 1 by ALL CATEGORIES from 04 10 97 to 06 09 97 4 documents Patient Document Ref Date Status 1 TIUPATIENT T3456 Addendum to Discharge Summary 06 05 97 unverified 2 TIUPATIENT T3456 Addendum to Discharge Summary 06 05 97 unverified 3 TIUPATIENT T3456 Addendum to Discharge Summary 06 04 97 unverified 4 TIUPATIEN T3456 Discharge Summary 05 25 97 unverified Next Screen Prev Screen More Actions gt gt gt Find Delete Document Browse On Chart Reassign Print Edit Send Back Change View Verify Unverify Detailed Display Quit Amend Document Select Action Quit v 3 Verify Unverify Opening Addendum record for review Verify Document Jun 09 1997 10 11 46 Page 1 of 33 Addendum TIUPATIENT ONE 666 122 3456 2B Visit Date 09 21 95 10 00 DICT DATE JUN 04 1997 ENTRY DATE JUN 05 1997 16 10 02 DICTATED BY TIU
187. ign a designated clinical document for a designated patient All MY UNSIGNED Documents Gets all unsigned documents for review edit and signature Multiple Patient Documents Provides an integrated Review Screen of all TIU documents Enter edit Document Allows you to enter and edit clinical documents directly online ALL Documents requiring my Prints a report showing all documents that Additional Signature require an additional signature Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 67 Individual Patient Document Use this option to review an individual document for a patient You can then edit sign delete or perform other actions as appropriate on the document Steps to use option 1 Select Individual Patient Document from your Integrated Document Management menu on your TIU menu 2 Select a patient 3 Enter a date range to display documents for A list is displayed of that patient s documents for the specified time period Please specify a date range from which to select documents List documents Beginning 02 17 92 1 96 JAN 1996 Thru 06 07 96 lt Enter gt JUN 07 1996 1 06 07 96 00 00 Diabetes Education ONE TIUPROVIDER MD Visit 04 18 96 2 06 05 96 17 23 Lipid Clinic THREE TIUPROVIDER Visit 04 18 96 3 06 05 96 11 10 Addendum to Lipid Clinic THREE TIUPROVIDER Visit 04 24 96
188. ill be recorded as one that needs to be reviewed The information generated by this option should be printed either by cutting and pasting the results into a text file or you can simply print the MM that was generated during installation It can be used to identify which TIU records have addenda and which do not This is extremely important as how a comparison is handled depends directly on if the TIU record has addenda It can also be used as a checklist to make sure that every record in question is examined Option V View the Contents of a Surgery Case Using Case Views the content of a Surgery Case file 130 NIR data will be displayed followed by the Anesthesia data Option T Send Output To Text File Sends output to a Host text file on your production account s server This will be very useful for sites that have a large number of cases to review Microsoft Word can then be used to compare the text files which is extremely helpful because discrepancies are automatically highlighted thus expediting the comparison process 150 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Option T Overview Option T will send data from both Surgery and TIU to respective output files First the user is prompted for a path to send output files to which should look something like this USERS lt directory name gt You may need to coordinate with your local IRM VistA system administrator to dete
189. information on all transcriptionists or one or more selected transcriptionist It reports based on an entered date range Since the VBC Line Count is only calculated for transcribed reports it does not report on any document transcribed before the line count patch was installed 114 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Individual Patient Document Use this option to review or print TIU documents for a patient Steps to use option 1 Select Individual Patient Document from the MIS Manager Menu and then enter the patient name Select Text Integration Utilities MIS Manager Option Individual Patient Document Select PATIENT NAME TIUPATIENT SEVEN TIUPATIENT SEVEN 04 25 31 666042591P NO MILITARY RETIREE 2 notes W 09 16 96 15 12 addendum 09 18 96 09 53 A Known allergies Available documents 08 11 95 thru 10 10 96 131 2 Select a date range for the documents you wish to review and then choose one or more of the documents displayed Please specify a date range from which to select documents List documents Beginning 08 11 95 t 15 SEP 30 1996 Thru 10 10 96 lt Enter gt OCT 10 1996 1 10 06 96 14 11 Addendum to Diabetes Education Three TIUProvider Adm 09 28 96 2 10 05 96 13 56 Diabetes Education Six TIUProvder Adm 09 28 96 Choose documents 1 3 2 3 The document
190. ion 2 Progress Note Print Select PATIENT NAME TIUPATIENT ONE TIUPATIENT ONE 09 12 44 666233456 YES SC VETERAN 2 notes C 05 28 96 12 37 2 notes W 05 28 96 12 33 A Known allergies D 2 notes 05 28 96 12 36 Available notes 02 17 96 thru 06 21 96 31 3 Enter the range of dates for progress notes you want to print 4 Choose a note from those listed Please specify a date range from which to select notes List notes Beginning 02 17 96 lt Enter gt FEB 17 1996 Thru 06 21 96 lt Enter gt JUN 21 1996 1 06 21 96 11 40 Lipid Clinic FIVE TIUPROVIDER Visit 02 21 96 2 06 21 96 11 38 Social Work Service FIVE TIUPROVIDER Visit 04 18 96 3 06 07 96 00 00 Diabetes Education ONE TIUPROVIDER MD Visit 04 18 96 4 05 15 96 13 10 Addendum to Diabetes Education SEVEN TIUPROVIDER Visit 02 21 96 5 04 24 96 15 41 Lipid Clinic THREE TIUPROVIDER Visit 04 24 96 6 02 23 96 14 08 Diabetes Education THREE TIUPROVIDER Visit 02 21 9 Choose notes 1 6 3 5 Do you want WORK copies or CHART copies CHART lt Enter gt DEVICE HOME lt Enter gt VAX 98 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Progress Notes Print Example NOTE DATED 06 07 96 17 51 DIABETES EDUCATION ADMITTED 07 22 95 1
191. ion Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Section 2 Using TIU Chapter 3 TIU for Clinicians Chapter 4 TIU for MRTs Chapter 5 TIU for MIS Managers Chapter 6 TIU for Transcriptionists Chapter 7 TIU for Remote Users Chapter 8 Progress Notes Print Options 20 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual Rev January 2012 Chapter 3 TIU for Clinicians Progress Notes Discharge Summary Menu Using Progress Notes through OE RR 2 5 or CPRS 1 0 Progress Notes Options Progress Notes Actions and Statuses Interdisciplinary Notes Actions Discharge Summary Options Discharge Summary Actions and Statuses Integrated Document Management Options Personal Preferences Document Definitions TIU and Health Summary Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 21 Chapter 3 TIU for Clinicians Progress Notes Discharge Summary Menu This is the main TIU menu for clinicians It includes all of the options necessary for clinicians to manage their Progress Notes Discharge Summaries and other clinical documents which may be set up locally either separately or in an integrated fashion TIU also lets you continue to access Progress Notes and Discharge Summaries through OE RR menus CPRS allows point and click access to all Progress Notes Discharge Summaries and Consults TIU documents The Progress Notes Disch
192. ion to print chart or work copies of discharge summaries Steps to use this option 1 Select Discharge Summary Print from the MIS Manager s Print Document Menu 2 Enter the name of the patient whose discharge summary you want to print 1 Discharge Summary Print 2 Progress Note Print 3 Clinical Document Print Select Print Document Menu Option 1 Discharge Summary Print Select PATIENT NAME TIUPATIENT ONE TIUPATIENT ONE 09 12 44 666233456 YES SC VETERAN 2 notes 05 28 96 12 37 Known allergies Gi 2 notes W 05 28 96 12 33 A D 05 28 96 12 36 2 notes Available summaries 02 12 96 thru 02 12 96 1 3 Enter the range of dates from which to choose the discharge summary or summaries you want to print Please specify a date range from which to select summaries List summaries Beginning 02 12 96 lt Enter gt FEB 12 1996 Thru 02 12 96 lt Enter gt ab 02 12 96 13 56 Discharge Summary ONE TIUPROVIDER MD Adm 07 22 91 Dis 02 12 96 Choose summaries l 1 1 Do you want WORK copies or CHART copies CHART WORK DEVICE HOME lt Enter gt VAX Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 95 Discharge Summary Print Example SALT LAKE CITY priority 06 27 96 08
193. irculating Nurse O R Circulating Nurse s Educational Status O R Scrub Nurse s O R Scrub Nurse O R Scrub Nurse s Educational Status Rev January 2012 Text Integration Utilities V 1 0 153 Clinical Coordinator amp User Manual Other Persons in O R Other Persons in O R Position s Position s Restraints and Position Aids Restraints and Position Aids Restraints and Position Aids Principal CPT Modifier Other Procedures Performed Other Procedures Performed Other Procedures Performed Tourniquet Tourniquet Tourniquet Tourniquet Tourniquet Thermal Unit Thermal Unit Thermal Unit Thermal Unit Prosthesis Installed Prosthesis Installed Prosthesis Installed Prosthesis Installed Prosthesis Installed Prosthesis Installed Prosthesis Installed Prosthesis Installed Prosthesis Installed Prosthesis Installed Medications Medications Medications Medications Medications Medications Medications Irrigation Solution s Irrigation Solution s Irrigation Solution s Irrigation Solution s Blood Replacement Fluids Blood Replacement Fluids Blood Replacement Fluids Blood Replacement Fluids Blood Replacement Fluids Other Person in O R Title Organization Position Placed Restraint Position Aid Applied By Comment CPT Modifier Other Procedure CPT Code CPT Modifier Time Applied Time Released Site Applied Pressure Applied in TORR Applied By Thermal Unit Temperature Time On Time Off It
194. ischarge Summary and Progress Notes TIU replaces and upgrades the previous versions of these VISTA packages Scope of Manual This manual provides descriptions of menus and options as well as other information required to effectively use the Text Integration Utilities package Audience Information in this manual is intended for Clinical Coordinators Automated Data Processing Application Coordinators ADPACs and end users clinicians MIS Managers Medical Record Technicians and transcriptionists Related Manuals Text Integration Utilities TIU Implementation Guide Text Integration Utilities amp Authorization Subscription Utility Installation Guide Text Integration Utilities TIU Technical Manual Authorization Subscription Utility ASU User Manual Rev January 2012 Text Integration Utilities V 1 0 iii Clinical Coordinator amp User Manual Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual Rev January 2012 Table of Contents Revisi n FISIOFY saci ccssiwiranedvciesdocvusiscaceussasborstecwsd vcheatncucsdeusadets eteusei ened ectendavevaiensiontschoseuvenslestaass ii EE iii Section I Introduct n EE 9 Chapter 1 Introduction to TIU ssesssecsesocesocecsocssscessocssocesooesoosssoccssecesocesoossoosssoessseessosee 10 Purpose of Text Integration Elplttee e Mere dE dee eer e 10 TEE 10 Chapter 2 CPIM E TE 12 Ma n al COT ANA AUN Oa so eeh AA 12 Online documentation Intranet
195. itle 50 231 Document List Management 78 Change View 50 65 Documents Requiring Additional Signature 75 CHIFF HIM 49 64 Edit 65 CHIFF MIS 49 64 Edit Cosigner EC 18 CIRN 236 Edit Document Definitions 81 82 207 Class 206 237 Electronic Signature Code 198 Clean up the Discharge Summary file 228 Enter Edit Discharge Summary 160 161 Clinical Coordinator Menu 203 Enter edit Document 66 Clinical data repositories 236 Enter Edit Document 73 160 163 Clinical Document Print 100 122 Entered in Error CLINICAL DOCUMENTS 229 Correcting 125 Clinical Procedures Entry of Progress Note 30 Upload 171 error code 219 Clinician 237 error message 219 242 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Exit 232 Medicine Conversion 210 212 Expected Cosigner 143 Menu Actions FAQs 221 Interdisciplinary Notes 53 File transfer 166 Menus and Option Assignment 200 FILING ERROR 93 Message window 15 Find 50 65 Minus sign 15 Find Patient 23 MIS 239 Frequently Asked Questions 221 MIS Manager 239 Generic Progress Notes Title File 202 MIS Manager s Menu 112 Glossary 237 Mismatched ID Notes 146 GMRP TIU 202 Missing Expected Cosigner Report 143 Graphic Conventions 13 Missing Text Cleanup 137 Header 226 Missing Text Report 135 Health Information Management Section 112 Mnemonics 232 Health Summary 85 modify the Expected Cosigner 18 Health Summary component 85 Modify the hierarchy 228 Help for Upload Utilit
196. itle Author Date Time 1 ID PARENT NINE TIUPROVIDER 02 14 01 08 15 compl 2 _ID CHILD OCCUPATIONAL THER TIUPROVIDER 02 14 01 08 16 compl 3 ER NOTE TIUPROVIDER 02 14 01 08 14 compl 4 ID PARENT REHAB TREATMENT PL TIUPROVIDER 02 08 01 08 26 compl 5 ID CHILD REHAB INITIAL A TIUPROVIDER 02 08 01 13 29 compl 6 _Addendum to ID CHILD R TIUPROVIDER 02 14 01 08 11 compl 7 _ID CHILD REHAB PSYCHOLOGY TIUPROVIDER 02 09 01 09 13 compl 8 ANGIOPLASTY NOTE TIUPROVIDER 01 08 01 13 16 compl 9 _Addendum to ANGIOPLASTY NO TIUPROVIDER 02 14 01 08 13 compl 10 ID CHILD AMY TIUPROVIDER 01 08 01 13 14 compl 11 ID ANY CHILD NOTE TIUPROVIDER 01 02 01 07 52 compl 12 SEVEN S CHILD SIX TIUPROVIDER 12 28 00 13 49 compl 13 SEVEN S CHILD FIVE TIUPROVIDER 12 28 00 13 48 compl 14 lt SEVEN S ID NOTE TIUPROVIDER 12 28 00 13 31 compl Next Screen Prev Screen More Actions NW New Note SS Select Search IN Interdiscipl ry Note B Browse RS Reset to All Signed EE Expand Collapse Entry PC Print Copy AD Make Addendum Q Quit SP Select New Patient Complete Note s Select Action Next Screen IN To ADD a new entry to an interdisciplinary note please select th interdisciplinary note To ATTACH an existing stand alone note to an interdisciplinary note please select the note you want to attach Select Progress Note 1 14 4 Are you adding a new interdisciplinary entry to this note YES lt Enter gt Adding a new interdisciplinary entry to ID PARENT REHAB TREAT
197. ivision Location Print Progress Notes Outpatient Location Print Progress Notes Patient Print Progress Notes Ward Print Progress Notes 182 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual Rev January 2012 Chapter 8 Progress Notes Print Options Clinicians can print progress notes but most printing is geared towards MAS and managing this function on a medical center level TIU offers two methods of printing documents 1 Print actions on option screens Clinicians may print all types of documents using a variety of methods from the List Manager interface for TIU including Progress Notes Discharge Summaries Consults etc Work and chart copies are possible Chart copies are the recommended type of printed copy but many sites still want to print work copies For example you may want to print work copies of unsigned notes Other than the above List Manager printing all other print options are on print menus Only signed notes are available from these options 2 Progress Notes Print Menus Progress Notes Print Menu For many types of users clinical administrative management MAS Options to Print Progress Notes For printing at the Wards and Clinics both by individual patient and batch printing Rev January 2012 Text Integration Utilities V 1 0 183 Clinical Coordinator amp User Manual Progress Notes Print Menu All of the options on this menu support the printing of char
198. l Coordinator amp User Manual All MY UNSIGNED Discharge Summartes 63 Steps to use SO ET 63 Multiple Patient Discharge Summaries ssnssessesseeessetesseesserssessseeesseeessresseesseesseeesseee 64 Discharge Summary Statuses and ACtionS ssseseeseseseesesseseresresstseresressessresrensersresrerseese 65 Integrated Document Management 67 Individual Patient eege 68 All MY UNSIGNED Documents ss ssesessseesseesseesseeeseeessseesseessersseresseesseessresseeeseeesseee 70 M ltiple Eerad 12 E ter Edit tee 14 Documents Requiring Additional Signature e eeeeseseeseeseesseeeresressrreresresseseresressesees 76 Personal Preferences nns inos in a EE E A EE 11 Document List Manareme nt ees a ate a age E a a a 79 Document Definitions Chnean cccccsessscececcceceesesssececeeeceesesesseceeeeeeseeeeenseaeees 82 Edit D c ment Definit ns niinen nanna a a i a ia 83 View Objects ericsson asin erea a A E T KEA O EENT e 85 Wand Health Summary ee hee tena i o Bae Neh Bae de 86 Chapter 4 TIU for RTS 87 MRE Men NEE 88 Individual Patient Re 89 Multiple Patient Documents st iere cesastaesvicdissscadeaspavaddasavsaecasnaveavasdeveaeadoasaccesavens 90 Review Upload Piling Events 20 6 6 acetate Sa eel iach eee E Nota Bae ele 93 Print Document eier Eed 95 Disebar S ay EE dee ege 95 Progress Note pt nunnu gesitt edd ESA E E A EEES 98 Clanical Document EE heeten 101 Released Unverified Report imsite esee ee e e aoti laeiki et 104 Sea
199. l clinical documents available through TIU Steps to use option 1 Select Clinical Document Print from the Print Document Menu and then enter a patient name Select Print Document Menu Option 3 Clinical Document P rint Select PATIENT NAME TIUPATIONE ONE TIUPATIENT ONE 09 12 44 666233456 YES SC VETERAN 2 notes C 05 28 96 12 37 2 notes W 05 28 96 12 33 A Known allergies 2 notes D 05 28 96 12 36 Available documents 02 17 92 thru 06 21 96 34 2 Enter a date range that documents will be chosen from Please specify a date range from which to select documents List documents Beginning 02 17 92 6 1 96 JUN 01 1996 Thru 06 21 96 6 8 96 JUN 08 1996 1 06 07 96 00 00 Diabetes Education One TIUProvider MD Visit 04 18 96 2 06 05 96 17 23 Lipid Clinic Three TIUProvider Visit 04 18 96 3 06 05 96 11 10 Addendum to Lipid Clinic Three TIUProvider Visit 04 24 96 3 Choose the document or documents you would like printed and whether you want work or chart copies Choose documents 1 3 1 3 Do you want WORK copies or CHART copies CHART lt Enter gt DEVICE HOME PRINTER Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 101 Clinical Document Print Example 4 The document s will then be printed at the device you specify NOTE DATED
200. late text Objects cee eeeeeeseeeeeeteeeeeees 229 Action abbreviations on List Manager screens cceesseeceeececeeeeeceeceeceteeecneeeeeneeeees 233 Killer e CN 233 Misit INfOrMAtlOn EEN 233 Kg E rent EE 237 QI OSS ANY AE E EAEE E OEA E A 238 AID OX AREE EE EAE E EA E E ES 242 8 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Section I Introduction Chapter 1 Introduction to TIU Chapter 2 Orientation Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual Chapter 1 Introduction to TIU Purpose of Text Integration Utilities The purpose of Text Integration Utilities TIU is to simplify the access and use of clinical documents for both clinical and administrative VAMC personnel by standardizing the way clinical documents are managed In connection with Authorization Subscription Utility ASU a hospital can set up policies and practices for determining who is responsible or has the privilege for performing various actions on required VHA documents The initial release of Version 1 0 includes Discharge Summary and Progress Notes Consult Reports was added with the release of Computerized Patient Record System CPRS TIU replaces and upgrades the previous versions of these V STA packages It has also been designed to meet the needs of other clinical applications that address document handling TIU lets you continue to access Progre
201. lect division ALL lt Enter gt 1 Choose from INCORPORATED ASCOTT TRANSCRIPTION AT TRANSCRIPTION SI MEDTRAN INC M1 TRANSCRIPTION SI Please choose a KNOWN Transcriptionist Duplicates not allowed 1 ASCOTT INCORPORATED ASCOTT TRANSCRIPTION ATI TRANSCRIPTION SERVICE 2 MEDTRAN INC MTI TRANSCRIPTION SERVICE 3 lt Enter gt Start Transcription Date Time Jan 01 2010 1 1 09 JAN 01 2009 Ending Transcription Date Time Jan 31 2010 23 59 lt Enter gt JAN 31 2010 23 59 156 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual E lt Enter gt T These are the initials TRANSCRIP ON CAMP MASTE 01 01 2009 to 01 for Documents Transcri Tran Date itle Patie BI of the transcriptionist as taken from the New Person file VBC Lines R 3 n 07 31 09 07 31 09 Discharge Discharge Summary Summary BCMA BCMA To 07 23 09 07 23 09 EIGHT BCMA Discharge Discharge To 08 13 09 Discharge Summary BCMA F EVEN DATT ONE PATIENT tal for Transcriber ati o DI ENT PAT Y INPATI FIFTEEN bi Di AW m tal for EIGHTYTHR LG H 08 27 09 Discharge Summary NINET YEIGHT OUTPATI 08 27 09 Discharge Summary CPRS COMBATVET
202. lets you review edit or sign a selected patient s progress notes Steps to use option 1 Select Review Progress Notes by Patient from the Progress Notes menu then enter the name of the patient Select Progress Notes User Menu Option 2 Review Progress Notes by Patient If the patient PATIENT NAME TIUPATIENT ONE TIUPATIENT ONE 09 12 44 666233456 has ERAN 2 notes C 05 28 96 12 37 Cautions 2 naes We 05 28 96 12 33 Warnings A Known allergies Allergies or 2 notes D 05 28 96 12 36 3 i i e notes thru Directives lo L 02 17 95 th 06 21 96 31 CWAD they are displayed Pr the date range of notes you wish to review here specify a date range from which to select notes List notes Beginning 12 01 96 DEC 01 1994 Thru 05 01 96 lt Enter gt MAY 01 1997 3 From the selection displayed choose the notes you wish to review 1 04 18 97 2 06 21 96 3 06 07 96 4 01 19 96 Choose notes 11 38 Social Work Service Three TIUProvider MD Visit 04 18 97 07 47 Lipid Clinic Three TIUProvider MD Visit 06 18 96 00 00 Diabetes Education One TIUProvider MD Visit 04 18 96 10 37 SOAP General Note Three TIUProvider MD Visit 1 10 96 1 8 2 36 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual Rev January 2012 Review Progress Notes by Patient cont d 4 The note you selected is t
203. lly Filed 06 23 2011 by CPRSPROVIDER ONE Next Screen Prev Screen 3 More actions gt gt gt Find Sign Cosign Link Print Copy Encounter Edit Edit Identify Signers Interdiscipl ry Note Make Addendum Delete Quit Select Action Quit ct CT TITLE ADVANCE DIRECTIVE RESCINDED ADVANCE DIRECTIVE TITLE Std Title RESCINDED ADVANCE DIRECTIVE OK Yes Yes a The title of this note will be changed to RESCINDED ADVANCE DIRECTIVE and linked images will be watermarked RESCINDED OK NO YES Title changed Image queued for watermarking Press RETURN to continue 130 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Statistical Reports Use this menu to produce statistical reports for line counts and timeliness by Author Transcriptionist or Service er NOTE These reports are designed for a margin width of 132 Option Description TRANSCRIPTIONIST Line Count Statistics This option allows generation of statistical reports of line counts and timeliness data by transcriptionist or the person who entered the document SERVICE Line Count Statistics This option allows generation of statistical reports of line counts and timeliness data by SERVICE e g Medical Service Surgical Service Psychiatry Service etc AUTHOR Line Count Statistics This option allows generation of statistical reports of line counts and timeliness data by AUTHO
204. mit file transfer from your computer Try the default settings for the Kermit protocol as provided by your terminal emulation software If you have problems consult your terminal emulator user manual or contact your local IRM Service Rev January 2012 Text Integration Utilities V 1 0 167 Clinical Coordinator amp User Manual 3 When the transfer is complete you ll see this message File transfer was successful 1515 bytes Filer Router Queued Press RETURN to continue lt Enter gt 1 Upload Documents 2 Help for Upload Utility Select Upload menu Option lt Enter gt ASCII Protocol Upload If your site is using the upload option to transfer batches of discharge summaries from a remote computer using the ASCII transfer protocol start the upload process by following the example shown below 1 Choose UP from your Upload Menu 1 Upload Documents 2 Help for Upload Utility Select Upload menu Option UP Batch upload reports ASCII UPLOAD L Note If you are at a site that uses multiple divisions you will receive a warning at this time specifying which division you are logged into If division information is not explicitly available in the header then it uses division information from your most current login To change this division without re logging in you can use the XUSER DIV CHG option from the TBOX menu 2 When the Initiate upload procedure prompt appears initiate the
205. monary Disease Rather than presenting you with a list of hundreds of unrelated titles TIU will present you with the list you name here In the event that you need to select a TITLE which doesn t appear on your list you will always be able to do so NOTE If you expect to enter a single title or would be unduly restricted by use of a short list then we recommend that you bypass the creation of a list and simply enter a DEFAULT TITLE for the class This option will afford you the opportunity to do so 2 Answer the following prompts as appropriate Enter edit Personal Document List for ONE TIUPROVIDER Add a new Personal Document List YES lt Enter gt CLASS Please select the parent group to which the document list belongs You may only pick CLASSES of documents at this prompt Answer with TIU DOCUMENT DEFINITION NAME or ABBREVIATION or PRINT NAME Do you want the entire TIU DOCUMENT DEFINITION List y Yes Choose from DISCHARGE SUMMARY CLASS PROGRESS NOTES CLASS CLASS Progress Notes Edit L ist D efault TITLE or B oth BOTH lt Enter gt both When selecting from this PARENT CLASS which TITLES would you like to be presented with initially Select TITLE PSYCHOLOGY CRISIS Select TITLE PSYCHOLOGY FAMILY THERAPY Select TITLE PSYCHOLOGY NURSING NOTE Select TITLE N
206. naged through use of the following tools Menu assignments Parameter set ups Document Definitions User Class set up See the TIU Implementation Guide for more detailed instructions on performing these various set ups TIU Maintenance Menu Option Name TIU PARAMETERS TIU Parameters This option allows the Clinical Coordinator MENU Menu or IRMS Application Specialist to set up either the Basic or Upload Parameters for TIU TIUF DOCUMENT Document Document Definitions menu which includes DEFINITION Definitions Edit Document Definitions Sort Document Definitions Create Document Definitions Create Objects USR CLASS User Class Menu of options for managing User Class MANAGEMENT Management Definition and Membership MENU TIU IRM TEMPLATE TIU Template Menu options for managing pre defined MGMT Mgmt Functions templates created by your medical center TIUHL7 Message TIUHL7 MSG Utility for viewing message going in and out Manager MGR of the TIU Generic HL7 Interface 198 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Legal Requirements Patient Confidentiality TIU works with patient records and documents All users are reminded to be aware of the confidentiality of these records Electronic Signature TIU uses a combination of menu access User Classes and Electronic Signature codes to maintain security and responsibility Individuals in the system who have a
207. nal note MIS Common abbreviation synonym used at VA site facilities for the Medical Information Section of Medical Administration Service May be called HIMS Health Information Management Section MIS Manager Manager of the Medical Information Section of Medical Administration Service at the site facility who has ultimate responsibility to see that MRTs complete their duties MRT Medical Record Technician in the Medical Information Section of Medical Administration Service at the site facility who completes the tasks of assuring that all discharge summaries placed in a patient s medical record have been verified for accuracy and completion and that a permanent chart copy has been placed in a patient s medical record for each separate admission to the hospital 240 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Object Progress Notes TIU Title User Class Glossary cont d Objects are a device to extract data from other VISTA packages to insert into boilerplate text of progress notes or discharge summaries This is done by having a placeholder name embedded in the predefined boilerplate text of Titles such as PATIENT AGE The creator of the Object types the placeholder name into the boilerplate text of a Title enclosed by Te If a Title has the following boilerplate text Patient is a healthy PATIENT AGE year old male 3 Then a user who enters such a
208. nd to transmit the text to the VISTA host system as a one step process As this ASCII data arrives at the VISTA host it is read into a buffer file and stored for subsequent filing by a special background process called the Router filer The Router filer is queued upon completion of transmission of a given batch of reports and will proceed to read each line of the buffer file looking for a header When a header is encountered the filer will determine whether the record corresponds to a known report type as defined by your site and if so it will attempt to direct the record to the appropriate file and fields in V STA On occasion the Router filer will not be able to identify the appropriate record in the target file and will therefore be unable to file the record When this happens the process will leave the record in the buffer file and send an alert to the user who invoked the upload utility and to a group of users identified by the site as being able to respond to such filing errors 166 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Upload Menu cont d When any of the alert recipients chooses to act on one of these alerts by entering VA at any menu prompt and choosing the alert on which they wish to act they will be shown the header of the failed record and allowed to inquire to the patient record before being presented with their preferred V sTA e
209. ndum is present lt An Interdisciplinary Note with one or more addendum present The addenda may be in the child note s gt An Interdisciplinary Note child with one or more addendum present LM Considerations CPRS Interdisciplinary Notes are not supported in the List Manager LM interface of CPRS with the following exception Interdisciplinary Notes are viewed and printed just as other notes supported by TIU TIU To access the full range of Interdisciplinary Notes features use the Progress Note User Menu and choose exported option 2b Review Progress Notes The IN Interdiscipl ry Note action is the universal action for operations on Interdisciplinary Notes You should select a note before selecting this menu option If the note selected is a parent note it will prompt you to enter a child of this note If the note selected is an unattached child note it will prompt you to select the parent that goes with it 56 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual In this example a new child note is added to an existing parent note Progress Notes Feb 14 2001 15 09 32 Page 1 of 6 lt DA gt PROGRESS NOTES 74 note s TIUPATIENT FOUR 666 55 2384 MAR 3 1960 40 T
210. new page is started for each patient Print Progress Notes for ALL patients on WARD Select WARD Location 6 1A Print Notes Starting With DATE TIME t 20 MAY 23 1997 gt gt 32 notes found for WARD 1A DEVICE PRINTER MEDICAL RECORD Progress Notes NOTE DATED 05 27 97 12 13 CLINICAL WARNING ADMITTED 04 20 97 15 58 1A Mr TIUPatient is becoming violent and self destructive again Will try a new Prescription Signed by es Ten TIUProvider MD 05 27 97 12 14 05 28 98 09 45 Addendum Mr TIUPatient is more calm and responding to counseling and medication Signed by es Ten TIUProvider MD 05 28 97 10 14 NOTE DATED 04 20 97 12 13 CLINICAL WARNING ADMITTED 04 20 97 15 58 1A Mr TIUPatient is violent and self destructive again Prescribed tranquilizer Signed by es Ten TIUProvider MD 04 20 97 01 20 TIUPATIENT SEVEN REGION 5 Printed 06 09 97 11 50 196 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Section 3 Managing TIU Chapter 9 Introduction Chapter 10 Menu Assignments Chapter 11 Document Definition Set up Chapter 12 User Class Set up Chapter 13 Parameter Set ups Rev January 2012 Text Integration Utilities V 1 0 197 Clinical Coordinator amp User Manual Chapter 9 Managing TIU Introduction TIU is ma
211. newed prescription Signed by es NINE TIUPROVIDER NINE TIUPROVIDER 05 31 97 14 59 Enter RETURN to continue or to exit You may enter another Progress Note Press RETURN to exit Select PATIENT NAME lt Enter gt Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 31 Example 2 Outpatient note Outpatient notes require more information than inpatient notes because every outpatient encounter must now be associated with a visit to get workload credit Most Progress Notes automatically get the visit data from Checkout or a scanned Encounter Form Steps to use option 1 Select Entry of Progress Note from your Progress Notes Menu 2 Type in a patient name Select Patient s TIUPATIENT ONE TIUPATIENT ONE 09 12 44 666233456 YES SC VETERAN 1 note C 11 19 96 addendum 01 28 97 09 55 A Known allergies For Patient TIUPATIENT ONE 3 Type in a Progress Note Title You can use an existing Title or create a new one If you have created a personal document list through the Personal Preferences Document Management option that list is displayed here Personal PROGRESS NOTES Title List for THREE TIUPROVIDER 1 Crisis Note 2 Advance Directive 3 Adverse Reactions 4 Other Title TITLE 1 4 3 Adverse React Allergy 4 Since thi
212. ng the hidden actions Print Screen and Print List First locate the data to be printed so that it shows on the screen and then select either the action PS or PL To locate the appropriate data use the Edit Sort or Create option to list appropriate entries To print a list select the PS or PL action at this point To print information on a single given entry first locate the entry in one of the above lists then select either the Detailed Display action or the Edit Items action Edit View shows all available information for a given entry Edit Items shows the items of a given entry Then select PS or PL Enter PS for Print Screen to print the current display screen It only prints what is currently visible on the screen ignoring information that can be moved to horizontally or vertically pages so you should move left right and up down to the desired information before printing Enter PL for Print List to print more than one visible screen of information Print List prints the entire vertical list of entries and information including entries and information not currently visible but which are displayed when you move up or down If the action is selected from the leftmost position of the screen you re asked whether to print ALL columns or only those columns visible on the current leftmost position of the screen If you select the action after scrolling to the right only the currently visible left right columns are printed Q Is it possible
213. ngina pectoris unstable Other and unspecified angina pectoris Type to STOP or Select 1 2 1 Start Reference Date Time T 2 T 9999 JAN 20 1970 Ending Reference Date Time NOW lt Enter gt JUN 06 1997 09 00 Searching for the documents Of course this query has several limitations Only one problem may be selected at a time e you can t select ANGINA PECTORIS OR AIHD as a search criterion Problems can t be grouped or expressed ambiguously e g a search for ANGINA PECTORIS rather than ANGINA PECTORIS UNSTABLE would not have found this record and The only way for this benefit to be exercised at all is for the clinicians at your facility to be actively using Problem List Still if you re interested in a focused search for all notes about a specific problem and if your facility has committed to the use of the Problem List package this can be a powerful asset for retrospective research utilization review and epidemiological studies With the Preventive Measures for certain chronic diseases being made part of the Director s performance appraisal being able to easily pull notes that document what was done for those problems is of HIGH importance 232 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Facts amp Helpful information Action abbreviations on List Manager screens The TIU and ASU packages don t use mnemonics abbreviations or numbers
214. nt TIUPATIENT THREE P4321 TIUPATIENT FOUR P8746 Title PRIME CARE CLINIC PATIENT FAMILY EDUCATION DOC Entry DT FEB 04 2003 10 33 48 Author TIUAUTHOR TWO Note IEN 3100784 3000597 Child note did not point to parent GDAD cross reference removed CHILD ID NOTES POINTING TO A NON EXISTENT PARENT ID NOTE Patient TIUPATIENT FIVE P2233 Title OTP DOSING NOTE Entry DT APR 28 2003 07 54 47 Author TIUAUTHOR THREE Child IEN 3300864 Parent IEN 3200349 Child note did not point to parent GDAD cross reference removed Patient TIUPATIENT SIX P4567 Title PM amp R PT DISCHARGE Entry DT JAN 29 2004 15 26 57 Author TIUAUTHOR FOUR Child IEN 4000224 Parent IEN 4000522 Removed pointer from child t o parent removed CHILD ID NOTES POINTING TO A PARENT THAT MAY NOT BE AN ID NOTE NOTE THIS IS AN INFORMATIONAL LIST FOR INVESTIGATION NOTHING WILL BE FIXED Patient TIUPATIENT SEVEN J0202 Parent Title OPERATION REPORT IEN 1834321 Parent Entry DT FEB 03 2006 12 43 49 Parent Author TIUAUTHOR FIVE Child Title NURSE INTRAOPERATIVE REPORT IEN 1784320 Patient TIUPATIENT EIGHT P2539 Parent Title TELEPHONE CONTACT IEN 1734552 Parent Entry DT JUN 26 2006 10 42 25 Parent Author TIUAUTHOR SIX Child Title ECU ADL SELF CARE PERFORMANCE SUMMA
215. nt document This is especially useful when composing a note for a group of patients e g therapy group and rapid duplication to all members of the group is appropriate Delete Document Allows the author to delete an unsigned document In rare cases a signed document can be deleted but a copy is kept as a retracted document Detailed Display Displays the report type patient urgency line count VBC line count author attending physician transcriptionist and verifying clerk in addition to the admission discharge dictation transcription signature and amendment dates without showing the narrative report text Edit Allows authorized users to edit the current document online When electronic signature is enabled physicians will be prompted for their signatures upon exit thereby allowing doctors to review edit and sign as a one step process Find Allows you to search for a text string word or partial word from the current position in the summary through its end Upon reaching the end of the document you will be asked whether to continue the search from the beginning of the document through the origin of the search Identify Signers Allows authorized users to identify additional users who are to be alerted for concurrence signature These signers may enter an addendum if they do not concur with the content of the document but they may not edit the document itself Link Allows you to link do
216. nt transcribed before the patch was installed The accuracy of this report depends on the accuracy of the data Specifically it depends on whether transcriptionists are reliably recorded in the header of each document If you choose to use this report you should follow the directions in the Text Integration Utilities TIU Line Count TIU 1 250 Release Notes available from the VA Document Library http www4 va gov vdl to insure that each uploaded document has the needed data This example is a complete report for all facilities on the local VistA system for the month of August MIS Managers Menu Individual Patient Document ultiple Patient Documents Print Document Menu Search for Selected Documents Statistical Reports Unsigned Uncosigned Report issing Text Report issing Text Cleanup Signed unsigned PN report and update UNKNOWN Addenda Cleanup issing Expected Cosigner Report ark Document as Signed by Surrogate ismatched ID Notes IU 215 ANALYSIS Transcription Billing Verification Report e VO OO JO 0 w a r lt CPM gt Select Text Integration Utilities MIS Manager Option 15 Transcription Billing Verification Report e Transcription Billing Verification In this example these company names have been entered into Specific Transcriptionist s NO YZS the New Person file and marked Select Transcriptionist s as belonging to the transcrivtionist user class Se
217. nuary 2012 Clinical Coordinator amp User Manual Multiple Patient Documents Use this option to see a list of clinical documents for more than one patient in TIU You can specify types categories and time range Caution Avoid making your requests too broad in statuses search categories and date ranges because these searches can use a lot of system resources slowing the computer system down for everyone The example below would probably be too broad in a large hospital Steps to use option 1 Select Multiple Patient Documents from your TIU menu Remote User Menu 1 Individual Patient Document 2 Multiple Patient Documents Select Text Integration Utilities Remote User Option 2 Multiple Patient Documents 2 Enter a status Select Status COMPLETED all undictated untranscribed unreleased unverified unsigned uncosigned completed amended purged deleted 3 Select a document type such as Discharge Summary Progress Notes Addendum Select Clinical Documents Type s All Discharge Summary Progress Notes Addendum 4 Select one of the following search categories S All Categories 6 Patient 11 Transcriptionist 2 Author 7 Problem 12 Treating Specialty 3 Division 8 Service 13 Visit 4 Expected Cosigner 9 Subject Hospital Location 10 Title Enter selection s by typing the name s number s or abbreviation s Select SEARCH CATEGORIES AUTHOR all All C
218. oilerplate Text Find Select Action Quit e Expand Collapse Select Entry TAY GENEE Edit Document Definitions Apr 17 1997 16 43 56 Page L of 1 BASICS Name Type 1 CLINICAL DOCUMENTS CL 2 DISCHARGE SUMMARY CL 3 PROGRESS NOTES CL 4 ADVANCE DIRECTIVE DC 5 ADVERSE REACTION ALLERGY DC 6 CRISIS NOTE DC 7 CLINICAL WARNING DC 8 HISTORICAL TITLES DC 9 ADDENDUM DC Help gt ScrollRight PS PL PrintScrn List gt gt gt Expand Collapse Detailed Display Quit Jump to Document Def Try Boilerplate Text Find i Select Action Quit Expand Collapse 4 phorteut Enter action and the item number Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 83 Edit Document Definitions cont d Edit Document Definitions Apr 17 1997 16 44 17 Page 1 of 1 BASICS Name Type 1 CLINICAL DOCUMENTS CL 2 DISCHARGE SUMMARY CL 3 PROGRESS NOTES CL 4 ADVANCE DIRECTIVE DC 5 ADVANCE DIRECTIVE TL 6 ADVERSE REACTION ALLERGY DC J CRISIS NOTE DC 8 CLINICAL WARNING DC 9 HISTORICAL TITLES DC 10 ADDENDUM DC Help gt ScrollRight PS PL PrintScrn List gt gt gt Expand Collapse Detailed Display Quit Jump to Document Def Try Boilerplate Text Find Select Action Quit DET DETAILED DISPLAY Select Entry 1 11 5 Non Owner View Only Press RETURN to continue or or
219. ompt to exit the current option menu sequence of prompts or help To get completely out of your current context and back to your original menu you may need to enter two or three up arrows For example when you re reviewing a list of documents one up arrow takes you to the next document you need to enter two up arrows to get out of the option gt gt TIU screens can contain more information to the right of the main screen display To see this information enter the gt character To return to the main screen enter the lt character NOTE The arrow keys on the keypads of some keyboards can sometimes be used for navigation in List Manager applications but this depends on the operating system So if you get funny characters on your screen when you use those arrows use the gt and lt symbols on the comma and period keys the greater than and less than symbols Online Help Online help is available by entering one two or three question marks at a prompt One question mark elicits a brief statement of what information is appropriate for responding to the prompt two question marks shows a list and sometimes descriptions of more actions and three question marks provide more detailed help including a list of possible answers if appropriate Defaults Defaults are responses provided to speed up your entry process They are either the most common responses the safest responses or the previous response Examples
220. on the Notes tab of CPRS DISCHARGE SUMMARY contains note titles that appear on the D C Summ Discharge Summary tab of CPRS LR LABORATORY REPORTS was released with patch TIU 1 137 in support of Anatomic Pathology You should not add any local document classes to this class CLINICAL PROCEDURES was released with patch TIU 1 109 SURGICAL REPORTS was released with patch TIU 1 112 and is not used until the surgery patch SR 3 100 is installed 210 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual National Document Classes Four of the national document classes are in support of CWAD CRISIS NOTE CLINICAL WARNING ADVERSE REACTION ALLERGY ADVANCE DIRECTIVE If these are changed then CWAD will not function properly The same is true for other document classes such as ADDENDUM DISCHARGE SUMMARIES and ASI ADDICTION SEVERITY INDEX The last of these contains notes pushed from the Psychiatry Package For the LR ANATOMIC PATHOLOGY document class nine 9 business rules were exported by patch USR 1 23 the companion patch to TIU 1 137 These rules help to ensure that the Anatomic Pathology features of the Lab Package function properly All access to the titles in this document class creating editing signing cosigning and printing except viewing takes place through the Lab Package Local sites must not circumvent the rules by adding modifying or overriding the business rules A list of the exporte
221. option 1 Select List Notes by Title from the Clinician s Progress Notes Menu Select the titles one or more of progress notes to search for Select Progress Notes User Menu Option 6 List Notes By Title Please Select the PROGRESS NOTES TITLES to search for 1 Answer with TIU DOCUMENT DEFINITION NAME or ABBREVIATION or PRINT NAME Do you want the entire TIU DOCUMENT DEFINITION List y Yes Choose from ADMISSION ASSESSMENT TITLE DVANCE DIRECTIVE TITLE A ADVERSE REACTION ALLERGY TITLE CLINICAL WARNING TITLE CRISIS NOTE TITLE FINAL DISCHARGE NOTE TITLE G P a ENERAL NOTE TITLE ATIENT EDUCATION TITLE se Select the Progress Notes TITLES to search for ADVERSE REACTION ALLERGY TITLE CLINICAL WARNING TITLE lt Enter gt PL 1 2 3 2 Enter a beginning and ending date range to choose documents from The selected documents are displayed Start Reference Date Time T 2 t 10 MAR 01 1997 Ending Reference Date Time NOW lt Enter gt MAR 11 1997 09 10 Searching for the documents Progress Notes by Title Mar 11 1997 09 10 09 Page L of 1 from 03 01 97 to 03 11 97 8 documents Patient Document Ref Date Status 1 TIUP
222. or example one site wants all users to be able to see all UNSIGNED notes ON the flip side another site doesn t want any users to be able to print or view UNCOSIGNED notes until the cosigner has signed Two very different views Just because you are in the same VISN doesn t mean you would view these issues in the same light Another example is the hospital that wants to restrict the entering viewing printing of every Progress Note by TITLE You can do this but it is not something we would recommend We strongly recommend that you work with the exported business rules for awhile before making any changes Q When I read my Discharge Summaries after they come back from the transcriptionist there are dashes or other funny characters sprinkled throughout what do these mean and what am I supposed to do A These characters your site determines whether they will be dashes hyphens or some other character indicate words or phrases that the transcriptionist was unable to understand You need to replace these with the intended word or phrase before you ll be able to sign the document Rev January 2012 Text Integration Utilities V 1 0 225 Clinical Coordinator amp User Manual Q FAQs cont d What is the best editing word processing program and how can I learn how to use it This is partly a matter of personal preference and partly a matter of what s available at your site Commercial word processors are available at some site
223. otes Progress Notes for specific amp supervisors locations individually or by batch TIUF DOCUMENT Document Document Definition Clinicians DEFINITION Definitions Clinician Document Definition Clinical Manager Coordinator IRM staff TIU IRM IRM Maintenance This option allows IRM staff to IRM maybe MAINTENANCE Menu set modify the various parameters Clinical MENU controlling the behavior of TIU as Coordinators well as the definition of TIU or some of the documents options on the menu GMRP TIU TIU Conversion A menu of options for getting the ADPACs IRM Clean up Menu Progress Notes package ready for or Clinical conversion to TIU Coordinators Limit to few Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 205 Chapter 11 Setting up TIU Parameters TIU Parameters Menu This menu contains options for Clinical Coordinators or IRM Application Specialists to set up the basic parameters including Upload parameters for TIU Basic TIU Parameters Option Name TIU BASIC PARAMETER EDIT This option allows you to enter the basic or general parameters which govern the behavior of the Text Integration Utilities Modify Upload TIU DOCUMENT PARAMETER EDIT Parameters This option allows the definition and modification of parameters for the batch upload of documents into VISTA Document Parameter Edit TIU UPLOAD PARAMETER EDIT This option lets
224. ough Patch GMTS 2 7 12 Selected Progress Notes which allows selection of specific Progress Notes Titles for display on Health Summaries The PN DS and CWAD components now extract data from TIU rather than Progress Notes GMRP or Discharge Summary GMRD Care has been taken to assure that the formatting and content of the components have remained the same except that the signature block information will now reflect the author s and cosigner s name and title at the time of signature rather than displaying their current values at the time of output e Improved management of Documents e TIU has a file structure called the Document Definition Hierarchy for defining elements and parameters of a document It allows e Inheritance of document characteristics such as signing cosigning visit linkage etc Site definition of document characteristics Shared components Ownership personal or class of document definitions Boilerplate text functionality Interdisciplinary Note functionality Embedded Object functionality which can extract data from otherV sTA packages and insert it into boilerplate text Rev January 2012 Text Integration Utilities V 1 0 11 Clinical Coordinator amp User Manual Chapter 2 Orientation Manual organization This manual is divided into four major sections Section Purpose I Introduction Presents overviews of TIU software and the User Manual II Using TIU Describes and demonstrates how to
225. ovider MD Medical Internist Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 119 Progress Note Print Use this option to print chart or work copies of progress notes Steps to use option 1 Select Progress Note Print from the Print Document Menu 2 Enter a patient name Select Print Document Menu Option 2 Progress Note Print Select PATI YES S Available notes C VE TE RAN 2 notes ENT NAME TIUPATIENT ONE TIUPATIENT ONE 09 12 44 666233456 05 28 96 12 37 Known allergies Cs 2 notes W 05 28 96 12 33 A D 2 notes 05 28 96 12 36 02 17 96 thru 06 21 96 31 3 Enter the range of dates for progress notes you want to print 4 Choose a note from those listed Please specify a date range from which to select notes List notes Beginning 02 17 Thru 06 21 96 lt Enter gt FEB 17 1996 96 lt Enter gt JUN 21 1996 1 06 21 96 11 40 Lipid Clinic Three TIUProvider Visit 02 21 96 2 06 21 96 11 38 Social Work Service Three TIUProvider Visit 04 18 96 3 06 07 96 00 00 Diabetes Education One TIUProvider MD Visit 04 18 96 4 05 15 96 13 10 Addendum to Diabetes Education Seven TIUProvider Visit 02 21 96 5 04 24 96 15 41 Lipid Clinic Three TIUProvider Visit 04 24 96 6 02 23 96 14 08 Diabetes Education Three
226. ple documents all alerts associated with each document are deleted before being resent Previously sent 3rd Party Alerts would be deleted and need to be resent Alerts are sent appropriate to the document s status and only to expected signers as follows The Author Dictator amp Expected Co signer Attending only receive alerts if they have not signed Additional Signer s will only receive alerts if the document has been signed THIRD PARTY ALERTS Allows the sending of new alerts for a single document or multiple documents to one or more third parties regardless of the document s status Rev January 2012 Text Integration Utilities V 1 0 215 Clinical Coordinator amp User Manual Business rules are checked and adhered to so while anyone who has access to this option can use it you may be blocked from certain functions such as viewing unsigned notes In the following example TUI Alert Tools are accessed through the TIU Maintenance Menu TIU IRM MAINTENANCE MENU a year of notes are checked for Dr Snow then alerts are resent for an unsigned note Select TIU Maintenance Menu Option TIU Parameters Menu Document Definitions Manager User Class Management TIU Template Mgmt Functions TIU Alert Tools TIU Alert Tools TIU ALERT TOOLS Active Title Cleanup Report TIU ACTIVE TITLE CLEANUP TIUHL7 Message Manager ADM BWNE Enter for more options for brief descriptions
227. qd Tylenol 650 mgs p o q6 hours prn pain T DISPOSITION FOLLOW UP Recommend follow PT PTT Patient is on coumadin and CBC with differential because patient has chronic anemia and thrombocytopenia Patient will be transferred to Anytown VA in stable condition on 5 19 96 WORK COPY UNOFFICIAL NOT FOR MEDICAL RECORD DO NOT FILE SIGNATURE PHYSICIAN DENTIST SIGNATURE APPROVING PHYSICIAN DENTIST THREE TIUPROVIDER MD ONE TIUPROVIDER MS PGY2 Resident Medical Informaticist CONFIDENTIAL INFORMATION 62 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual All MY UNSIGNED Discharge Summaries This option shows you all unsigned discharge summaries for you to review edit or sign You must have signing or cosigning privileges to sign or cosign based on your document definition user class status and business rules governing these actions See your Clinical Coordinator if you have any problems or questions about electronic signature or cosigning Steps to use option 1 Select All MY UNSIGNED Discharge Summaries from your TIU menu 2 Your unsigned discharge summaries are displayed Discharge Summaries Jun 18 1996 10 13 45 Page 1 of 1 by AUTHOR TIUPROVIDER ONE or EXPECTED COSIGNER 0 documents Patient Document Ref Date Status 2 TIUPATIENT S T4831 Di
228. r Enter your signature code Rev January 2012 Text Integration Utilities V 1 0 199 Clinical Coordinator amp User Manual Electronic Signature cont d INITIAL JG SIGNATURE BLOCK PRINTED NAME FIVE TIUPROVIDER SIGNATURE BLOCK TITLE Clinical Coordinator OFFICE PHONE 101 555 5736 Enter your Signature Code xxxxxxx Cosignature Cosignature requirements are determined at local levels Sites or departments can set Cosignature requirements for certain kinds of documents through the Document Parameter Edit option on the TIU Parameters Menu Individual clinicians can designate a default cosigner on their Personal Preferences option Links and Relationships with Other Packages TIU is closely linked to other applications and utilities Authorization Subscription Utility ASU List Manager utility the Computerized Patient Record System CPRS Visit Tracking etc This linkage should remain transparent to users but the IRM Service and Clinical Coordinators will need to coordinate the components Instructions will be provided with a TIU patch for setting up the interface with CPRS See the User and Technical Manuals of the above listed packages for further instructions about interfaces 200 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Chapter 10 Menus and Option Assignment TIU menus and options are not exported
229. r program In this case the consult request is checked for a matching TIU Document Number DATE TIME OF DICTATION Required by filing routine LOCATION Required by filing routine AUTHOR Generates missing field error CONSULTS SSN Required by filing routine TITLE Required by filing routine CONSULT REQUEST NUMBER Required by filing routine The patient record indicated by the SSN is checked for a matching consult VISIT EVENT DATE Required by filing routine The patient record indicated by the SSN is checked for a matching visit AUTHOR Generates missing field error LOCATION Required by filing routine DATE TIME OF DICTATION Generates missing field error Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual Rev January 2012 Type of Document Caption Use PROCEDURE REPORT PATIENT SSN Required by filing routine DOCUMENT NUMBER Required by filing routine If missing the upload routine infers it from the SSN and Operation Date an optional field SURGICAL CASE Required by filing routine If missing the upload routine infers it from the SSN and Operation Date Then if there is more than one matching surgical case it generates a missing field error DICTATION DATE Generates missing field error ATTENDING SURGEON Generates missing field error DICTATED BY Generate
230. r content and accuracy before exercising this option Detailed Display Displays the report type patient urgency line count VBC line count author attending physician transcriptionist and verifying clerk and also admission discharge dictation transcription signature and amendment dates Browse Lets you browse through Documents from the Review Screen by scrolling sequentially through the selected documents and their addenda You can search for a word or phrase or print draft copies Print Allows you to print copies of VAF 10 1000 for selected summaries Identify Signers Allows authorized users to identify additional signers for a document Change View Lets you change the displayed reports to signature status review screen or dictation date range Copy Allows authorized users to copy one or more documents to other patients and encounters This is particularly useful when documenting group sessions etc Delete Document Allows the author to delete an unsigned document In rare cases a signed document can be deleted but a copy is kept as a retracted document Change Title This action on the hidden list lets you change a Title for a Progress Note e g CWAD Notes to another Title Quit Lets you quit the current menu level Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 51 Interdisciplinary Notes Interdisciplinary Notes are a new feature of Text
231. r the missing dates for example 01 00 95 or 00 00 94 Q Are there any terminal settings that we need to be aware of for TIU On the VT400 setting in Smart Term the bottom half of the Create Document Definitions screen was not scrolling properly It was writing over previous lines and got very confusing A Various terminal emulators can affect applications using the List Manager interface The VT220 and 320 work very well with List Manager 224 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual FAQs cont d Q Ihave gotten my 600 clinic and ward locations set up but when I try to print by ward I am only allowed to print to a printer This is not true under the Print by Hospital Location where I can print to the screen What is the difference A Print by Ward is designed to support batch printing It has the unique ability to determine when the last note was printed so that sites can now capture the infamous orphan note which was a problem under Progress Notes 2 5 You might consider adding a message on entry into the option to inform users that they can only print to a printer not on screen Q Can we share business rules with other sites A It isn t yet known how appropriate or desirable it is to share business rules amongst sites The package is exported with all the business rules needed to run the standard package The differences are usually on a medical center basis F
232. rch for Selected MM ee 105 Unsigned Uncosigned Report saisisscccccisccvessactesscedsehsacdsdeasednasdesaceaseasceve Dee 106 Reassignment EIERE ee Eeer 108 Review Unsigned Additional Signatures eecceeseeecssceecseececeeeeecseeeecsteeeeeneeeeeaes 109 Chapter 5 TIU for MIS HIMS Managers scccssscsssssccsssscsssccssssccssssccssscscssssscoess 112 IVINS Manager Ee EE 113 Multiple Patient Documents isi ssscsctasccsaieisicecianeavaasd Gipaecaawnceeeasdevateadeenacesbedceedeanesaaesdens 116 Print GC rie TG E EE 117 Discharge Summary EE jess candid vaghegy aueaeadancee adds eaansadsnss ass akiaeseec owe t 117 PROSTESS IN GUS e EE 120 Clinical Document mt ceisio esn deed NEEN Edge lesceeeseas 123 Search for Selected Documents 5 cci ieisancissseaciaasavelaatejeacaraenseeaasecyadsasvesaceedntesensteavaatereres 124 Correcting Documents that are Entered in Por 126 Rescinding Advance Directives eege Eege EES 129 Statista REDONS E 131 6 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Unsigned Uncosigned Report EEN 135 Missing LexEREPOTt E 136 Missing Text leamup nicio nen eae a a EE EK EEEE 138 UNKNOWN eher episode ee 140 Missing Expected Cosigner Report 144 Mark Documents Signed by Surrogate 0 0 eeccesceeeceeeceeeeceseceeeeeeeeesseecsaeeneenees 146 Mismatched ID Notes siseseid rnos eia soevedeadeonaavesnacs 147 THU 25 ANALY SIS 2h sales mss RE EERE E EERE weg oe 150 Transc
233. responding Visits Inter facility data transfer requires identification of the Facility from which the data originated Because the Facility is an attribute of the Visit file entry it is not necessary to maintain a reference to the facility with every clinical document Workload Capture particularly for telephone and standalone encounters where the only record of the encounter is frequently a Progress Note can be easily accommodated provided that notes are associated with visits Roll up of documentation by Care Episode To allow access to all information pertaining to a given episode of care e g for close out of a hospitalization a visit orientation is essential Integration with PCE Ambulatory Care Data Capture and CIRN The visit orientation provides a useful associative entity for interfaces with other clinical data repositories that allow query and report generation based on the existence of a variety of coded data elements For example a search of PCE to identify all patients with AIHD who were discharged without a prescription for aspirin prophylaxis might identify a cohort of patients for further evaluation The ability to call for all the cardiology notes entered during the corresponding care episodes could revolutionize retrospective chart review Rev January 2012 Text Integration Utilities V 1 0 237 Clinical Coordinator amp User Manual Glossary ASU Action Boilerplate Text Business Rule Cla
234. rgies improved with medication 06 08 97 ADDENDUM Improvement was temporary patient relapsed after a few days SIXTEEN TIUPROVIDER Next Screen Prev Screen More actions Find Print Quit Select Action Quit Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 41 Review Progress Notes cont d 5 If you select the action Select Search you can narrow your view to a specific context of notes signed unsigned by author or by a date or date range Progress Notes May 31 1997 14 20 10 Page 1 of 1 lt CWAD gt PROGRESS NOTES Last 15 note s TIUPATIENT O 666 23 3456 SEP 12 1944 52 Title Author Date Time 1 Adverse React Allergy TIUPROVIDER N 05 27 97 00 00 compl 2 Adverse React Allergy TIUPROVIDER N 05 20 97 17 18 compl 3 CRISIS NOTE TIUPROVIDER N 05 20 97 17 01 compl 4 Adverse React Allergy TIUPROVIDER N 05 20 97 11 23 compl 5 GENERAL NOTE TIUPROVIDER N 05 20 97 11 21 compl 6 CARDIOLOGY NOTE TIUPROVIDER N 05 20 97 10 56 compl 7 Adverse React Allergy TIUPROVIDER T 04 21 97 16 02 compl 8 Adverse React Allergy TIUPROVIDER T 04 15 97 06 23 compl 9 CARDIOLOGY NOTE TIUPROVIDER T 04 11 97 12 09 compl 10 CRISIS NOTE TIUPROVIDER T 04 11 97 09 09 compl Next Screen Prev Screen More actions NW New Note SP Select New
235. ription Billing Verification Report 156 Chapter 6 TIU for Transcriptionists sesssesssecssocesocescosesocessccesocesocsssosesoeessecesooesooseso 160 Transcriptionist Menti EE 161 Enter Edit Discharge Summ ar ysyi5 isisesssccessnsiesascavadeasvonaceadnageevasoavaatisgessccesnavedveseays 162 Ent r Edit Documentos Tree Lait Redacted te daca ce aes a ae ea SL Sal 164 Breil WEEN 166 BACH Brei We ac ek idee eee een Gee ee ea Aedes oe 167 Kermit Protocol Upload cai sncsssinosresn ain eones ENER Eegen 167 ASC Protocol Uplodd EE 168 Handling Up lO AC SCRE E 169 Avoiding Upload Ee 171 Display Upload Help sssrin oins eain a ie ra I E 174 Chapter 7 TIU for Remote Users eeesooessocsssccssecesocesocescosesoesesccesocesoosesocssoecssocesocssoosess 175 Individual Patient erte Eed eegen 177 M ltiple Patient Hotten ete esbed lder ceed Abend s essiensa isi 179 Chapter 8 Progress Notes Print Options esssessseessooescocssoccssccesocesoossoocessccssocesocesooseso 182 Progress Notes Print Ment ree roo e NRE AA vende ate ese 184 MAS Options to Print Progress Notes AAA 185 Section 3 CN NEE 197 Chapter 9 Managing TIU Introduction sessoesoossessoesocesessossoossossoesoossosssessossosssesssse 198 Legal ReguirementS EE 199 Links and Relationships with Other Packages 0 ecccccessseceeneeceeeeeceeneeceeeeeceeeeeenneeeens 200 Chapter 10 Menus and Option Assignment seessccescocssscsssccssocesocssoosesoeessecssocesooesso 201 TIU
236. rmine exactly what the path should be The user is then prompted for three filenames one for Surgery output one for TIU output and one for associated TIU addenda If the path and or filenames are invalid you will be prompted to enter them again Option T will use the same analysis technique as Option A does Instead of just listing cases that need review it will write the contents of the associated reports to text files For each case what is on record in Surgery will be written to one file and what is on record in TIU will be written to another file Also if there are any associated TIU addenda with the case these addendums will be written to a separate file Multiple cases will be written to a single file with the user pre defining the maximum limit When this limit is encountered a new set of output files will be created For instance if there are a total of 50 cases found with possible discrepancies and the user sets a maximum of 25 cases per file then 2 Surgery output files will be created two TIU output files and x number of addenda output files Note The number of Surgery and TIU files will always be the same the number of addenda files may not This is due to the fact not every Surgery case will have an associated TIU addenda Let s say the names Surgery TIU and ADDENDA are used for the output filenames You would then have Surgery1 txt Surgery2 txt TIU1 txt TIU2 txt and ADDENDA txt and possibly ADDENDA2 txt
237. rs 3 Lipid pattern PLAN L Implement recommendations to lower fat intake Zi Repeat FBG and HBG AIC on Sg Return to review lab on Signed by es Three TIUProvider MS Physician Assistant 07 03 96 14 19 Analog Pager 1 900 555 8398 Digital Pager 1 900 555 7883 Enter RETURN to continue or to exit AUTHOR lt Enter gt 188 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual Rev January 2012 Location Print Progress Notes Example Select Progress Notes Print Options Option Location Print Progress Notes Print Progress Notes for a Selected LOCATION Select HOSPITAL LOCATION NAME GENERAL MEDICINE TIUPROVIDER TWENTY Available notes Sep 06 1995 thru Oct 02 1996 Print Notes Beginning t 30 SEP 08 1996 Thru t OCT 08 1996 Searching for the notes gt gt 2 notes found for GENERAL MEDICINE Do you want WORK copies or CHART copies CHART lt Enter gt DEVICE HOME lt Enter gt VAX NOTE DATED 10 01 96 11 59 BP TEST VISIT 04 18 96 10 00 GENERAL MEDICINE NAME TIUPATIENT ONE SEX MALE DOB SEP 12 1944 S ALLERGIES Amoxicillin Aspirin MILK LABS No data available LIPIDS No data available HT 72 08 23 95 11 45 WT 190 08 23 95 11 45 Signed by es Three TIUProvider MS 10 01 96 15 38 Analog P
238. rse React Allergy TIUPROVIDER 04 03 97 19 31 compl 4 Adverse React Allergy TIUPROVIDER 04 07 97 16 05 compl Next Screen Prev Screen More Actions NW New Note SP Select New Patient AD Make Addendum B Browse SS Select Search Complete Note s PC Print Copy RS Reset to All Signed Q Quit Select Action Quit 28 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Progress Notes Options Clinicians can review enter print and sign progress notes either by individual patient or by multiple patients through TIU NOTE When reviewing several notes sequentially the up arrow entry takes you to the next note To exit from the review enter two up arrows Clinician s Progress Notes Menu Option Description Entry of Progress Note This is the main option for entering a new progress note You can also edit patient progress notes Review Progress Notes by Patient This option lets you review edit or sign a selected patient s progress notes by selected criteria Review Progress Notes This option lets clinicians get quickly to a patient s list of notes without preliminary prompts to select criteria for displaying notes All MY UNSIGNED Progress Notes This option retrieves all your unsigned progress notes for review edit or signature Show Progress Notes Across Patients This option lets you search for and review progress notes by many
239. rts are context sensitive and sent only to individuals that have NOT signed the document in this case only the EXPECTED COSIGNER and any ADDITIONAL SIGNERS that have not signed will be alerted Q I selected RESEND ALERTS and my 3rd Party Alerts disappeared What happened Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 217 A A document s alerts are deleted before being regenerated so that they remain accurate regarding the document s status 3rd Party Alerts are deleted as well and must be resent since they are not officially part of the document s record and cannot be automatically regenerated Q I changed the ADDITIONAL SIGNER for a document using IDENTIFY SIGNERS but it didn t update in the display Why not A Because there can be more than one ADDITIONAL SIGNER unless the ADDITIONAL SIGNER matches the search criteria it won t be displayed Q I added an ADDITIONAL SIGNER for a document using IDENTIFY SIGNERS but it didn t update in the display Why not A Because there can be more than one ADDITIONAL SIGNER unless the ADDITIONAL SIGNER matches the search criteria it won t be displayed Q The AUTHOR of several documents requiring co signature is gone and I want to regenerate the alerts for the EXPECTED COSIGNER so they can SIGN and COSIGN these UNSIGNED documents Should I use RESEND A It depends Default alert behavior would be to send the alert AFTER the
240. ry Note reference date order repeating the current note In all other respects the format of the display is the same as a regular note The display of unsigned notes depends upon the business rules in effect at your site These rules may allow you to view the unsigned child notes of other providers in the context of an Interdisciplinary Note This is up to your local authorities Meaning of Icons In the CPRS Windows interface notes are listed in a tree structured arrangement This is intended to graphically show a number of things 1 Signed and Unsigned notes 2 Notes with an addendum attached 3 Interdisciplinary notes 4 Regular notes The meaning of the various icons is E A list of notes either signed or unsigned AG An Interdisciplinary Note The open folder indicates that all the children are listed A child to an Interdisciplinary Note A regular note or a child note that has not yet been attached to a parent amp S HHE The plus sign indicates an addendum is present An addendum Rev January 2012 Text Integration Utilities V 1 0 55 Clinical Coordinator amp User Manual Interdisciplinary Notes cont d In the List Manager interface similar devices are used to indicate the type of note Meaning Nothing A regular note or a child note that has not yet been attached to a parent lt An Interdisciplinary Note parent gt An Interdisciplinary Note child An adde
241. s The FileMan line editor and Screen Editor are available at all sites Of these two most Discharge Summary users prefer the Screen Editor Your IRM office or ADPACs can help you get set up with the appropriate editor and provide training The Clinician Quick Reference Card summarizes the FileMan Screen Editor functions Q Why should a site require release from transcription A Release from transcription is required to prevent a discharge summary from becoming visible to other users before the person entering the summary has completed the entry For example if a transcriptionist needed to leave the terminal the summary would not be available for anyone else to look at until the summary is released from transcription Q Why can t we use extended ASCII characters e g gt A etc in our documents to be uploaded A These alternate character sets are not standardized across operating systems and your MUMPS system may not be set up to store them 226 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual FAQs cont d Questions about Reports and Upload Q At present we put all discharges in the Discharge Summary package We do allow Spinal Cord Injury to put interim summaries in on their patients every 6 months or annually These reports stack up under the admission date and are all under that one date upon discharge When patients are transferred to the
242. s TIUPROVIDER EIGHT Adm Date 11 16 95 Adm Dx IL Select PATIENT lt Enter gt T You may now edit the buffered upload data Press PF1 then H for help WRAP INSERT lt gt SHDR DISCHARGE SUMMARY PATIENT NAME TIUPATIENT ONE SOCIAL SECURITY NUMBER 666 09 1244P DATE OF ADMISSION 11 16 95 Cursor to this point and change the 7 to a 6 then DATE OF DISCHARGE Enter lt PF1 gt E to exit and save DICTATED BY TIUPROVIDER THREE DICTATION DATE 4 16 96 ATTENDING PHYSICIAN TIUPROVIDER TWO TRANSCRIPTIONIST C7689 URGENCY PRIORITY STXT DIAGNOSES 1 Status post coronary artery bypass graft 2 Unstable angina prior to coronary artery bypass graft 3 End stage renal disease 4 Diabetes mellitus 5 Hypertension 6 History of peptic ulcer disease M T T T T T T T T T Now would you like to retry the filer YES lt Enter gt Filer Router Queued 1 Upload Documents 2 Help for Upload Utility Select Upload menu Option lt Enter gt In th xample above notice that patient One TIUPatient had no admission on 11 17 96 so the filer could not create a record in the target file for this discharge summary record The user acts on the alert to correct the admission date as 11 16 96 and retries the filer which is now able to file the record appropriately and the alerts are removed for
243. s are defined for the upload fields A From a user coordinator OP reports and C amp P exams reside in their appropriate packages You can use the TIU upload utility to put them there As for OP notes we have several titles 1 e Surgeon s Post OP note Do you have TIU in the APPLICATION GROUP field of the Surgery and C amp P file Our FILE File has this for our Surgery file NUMBER 130 NAME SURGERY APPLICATION GROUP GMRD APPLICATION GROUP TIU Q Can we do batch upload of Progress Notes by vendor through TIU A Yes you may now batch upload Progress Notes through TIU See instructions earlier in this manual under Setting Parameters or in the TIU Technical Manual 228 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual FAQs cont d Q Currently our Radiology reports are uploaded by the vendor Can this functionality be built into TIU A You may upload Radiology Reports but it will be necessary to write a LOOKUP METHOD to store several identifying fields in the Radiology Patient File The remainder are stored in the Radiology Reports File along with the Impression and Report Text The TIU and Radiology development teams will work together on a lookup method as development priorities allow Q We have hundreds of entries in files 128 1 and 128 5 to be cleaned up because many duplicate discharge summaries were mistakenly uploaded by the transcriptionists of our vendor How
244. s is a note for an outpatient you may be prompted to select an existing visit or create a new visit to associate the progress note with This patient is not currently admitted to the facility Is this note for INPATIENT or OUTPATIENT care OUTPATIENT lt Enter gt The following VISITS are available 1 gt FEB 24 1997 09 00 DIABETES CLINIC 2 gt SEP 05 1996 10 00 CARDIOLOGY CHOOSE 1 2 or lt N gt EW VISIT lt RETURN gt TO CONTINUE OR TO QUIT N Creating new progress note Patient Location NUR 1A Date time of Visit 02 24 97 14 29 Date time of Note NOW Author of Note TIUPROVIDER THREE OK YES lt Enter gt SERVICE MEDICINE lt Enter gt 111 32 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Entry of Progress Note cont d 5 Enter a subject for your note optional SUBJECT OPTIONAL description Enter a brief description 3 80 characters of the contents of the document SUBJECT OPTIONAL description Blue Note 6 Type in the text of the note If it s a SOAP Note or there s a boilerplate for this you can fill in the blanks or edit existing text You can use the FileMan text editor or full screen editor Sign the Note when you re finished Calling text editor please wait 1 gt Follow up visit to ensure compliance with regimen
245. s missing field error OPERATION REPORT PATIENT SSN Required by filing routine DOCUMENT NUMBER Required by filing routine If missing the upload routine infers it from the SSN and Operation Date an optional field SURGICAL CASE Required by filing routine If missing the upload routine infers it from the SSN and Operation Date Then if there is more than one matching surgical case it generates a missing field error DICTATION DATE Generates missing field error DICTATING SURGEON Generates missing field error ATTENDING SURGEON Generates missing field error STAT or ROUTINE Generates missing field error Rev January 2012 Clinical Coordinator amp User Manual Text Integration Utilities V 1 0 173 Display Upload Help Transcriptionists may select this option in the Upload Menu to display the formats expected by the upload process for the report types defined at your site The captioned headers may be captured as ASCII data and used to build macros using a commercial word processors e g WordPerfect or Microsoft Word thereby avoiding having to retype the captioned headers while minimizing the risk of spelling errors or inconsistencies with the formats expected by the host system UP Batch upload reports HLP Display upload help Select Upload menu Option HLP Display upload help
246. scharge Summary 03 15 96 uncosig Next Screen Prev Screen More Actions ee Find Sign Cosign Change View Add Document Detailed Display Copy Edit Browse Delete Document Make Addendum Print Quit Link Identify Signers Select Action Quit COSIGN 3 Select an action such as Sign Cosign if y NOTE You can enter Cosign cosign ou are authorized to perform these rather than Sign Cosign if you want to Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 63 Multiple Patient Discharge Summaries This option shows you discharge summaries for selected statuses types and categories which you can then review edit and or sign Caution Avoid making your requests too broad in statuses search categories and date ranges because these searches can use a lot of system resources slowing the computer system down for everyone Steps to use option 1 Select Multiple Patient Discharge Summaries from your TIU menu 2 Select one or more of the following statuses untranscribed unreleased e unverified unsigned uncosigned e completed amended purged deleted 3 Select one of the following search categories 1 All Categories 6 Patient 11 Transcriptionist 2 Author 7 Problem 12 Treating Specialty 3 Division 8 Service 13 Visit 4 Expected Cosigner 9 Subject 5 Hospital Location 10 Title 4 Enter a date range 5 A list is di
247. splayed of the summaries that meet your specifications My UNSIGNED Disch Summaries Jun 05 1997 14 02 15 Page 1 of 1 by AUTHOR TIUPROVIDER ONE from 05 06 97 to 06 05 97 1 documents Patient Document Ref Date Status 1 TIUPATIENT T T2591 Discharge Summary 06 02 97 UNSIGNED Next Screen Prev Screen More actions Find Sign Cosign Change View Add Document Detailed Display Copy Edit Browse Delete Document Make Addendum Print Quit ELOK sce Identify Signers Select Action Quit s 6 You can now take an appropriate action on one or all of the summaries 64 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Discharge Summar Statuses Amended y Statuses and Actions The document has been completed and a privacy act issue has required its amendment By design only the following user classes are allowed to amend a Discharge Summary CHIEF MIS CHIEF HIM PRIVACY ACT OFFICER Completed The document has acquired all necessary signatures and is legally authenticated deleted Status DELETED is no longer operable Before status RETRACTED was introduced deleting a document removed the text of the document leaving a stub with status DELETED Retracted When a signed document is reassigned amended or deleted a retracted copy of the original is kept for audit purposes uncosigned The document is complete with
248. ss Clinician Component Authorization Subscription Utility an application that allows sites to associate users with user classes allowing them to specify the level of authorization needed to sign or order specific document types and orderables ASU is distributed with TIU in this version eventually it will probably become independent to be used by many VISTA packages A functional process that a clinician or clerk uses in the TIU computer program For example Edit and Search are actions Protocol is another name for Action A pre defined TIU template that can be filled in for Titles speeding up the entry process TIU exports several Titles with boilerplate text which can be modified to meet specific needs sites can also create their own Part of ASU Business Rules authorize specific users or groups of users to perform specified actions on documents in particular statuses e g an unsigned progress note may be edited by a provider who is also the expected signer of the note Part of Document Definitions Classes group documents For example Progress Notes is a class with many kinds of progress notes under it Classes may be subdivided into other Classes or Document Classes Besides grouping documents Classes also store behavior which is then inherited by lower level entries A doctor or other provider in the medical center who is authorized to provide patient care Components are sections or
249. ss Notes and Discharge Summaries from OE RR menus The CPRS Graphical User Interface GUI allows point and click access to all Progress Notes Discharge Summaries and Consults TIU documents Benefits a Standardized and common user interface Clinicians can go through the same program to enter review and sign discharge summaries progress notes and other clinical documents that may be set up locally for processing through TIU b Integration Clinicians and management can search for and retrieve clinical documents more efficiently because documents reside in a single location within the database This is also a benefit for other uses such as Incomplete Record Tracking quality management results reporting order checking research etc c Data Capture Flexibility TIU accepts document input from a variety of data capture methodologies Those initially supported are transcription and direct entry TIU allows upload of ASCII formatted documents into V STA 10 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Benefits cont d d Links to Other Packages TIU interfaces as appropriate with such applications as Health Summary Problem List Patient Care Encounter Visit Tracking and Incomplete Record Tracking Computerized Patient Record System CPRS further integrates VISTA packages and allows point and click switching between packages A new Health Summary component is available thr
250. ss the next screen 5 A new set of actions is displayed These are the Contents or categories of the Patient Chart also known as Tabs Select the Notes tab Cover Sheet Mar 17 1997 17 07 50 Page 1 of 2 TIUPATIENT ONE 666 12 3456 2B JAN 1 1951 46 lt CW gt Alert Entered Allergies Adverse Reactions d PENICILLIN 1 rash nausea vomiting 01 03 97 Patient Postings 2 CRISIS NOTE 02 24 97 08 28 3 CRISIS NOTE 12 03 96 10 44 4 CLINICAL WARNING 02 21 97 09 16 5 CLINICAL WARNING 01 15 97 Recent Vitals No data available Enter the numbers of the items you wish to act on gt gt gt Cover Sheet Orders Imaging Reports Problems Meds Consults Notes Labs D C Summaries Select chart component N Notes Searching for the patient s chart 24 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Example Reviewing Notes cont d 6 The patient s completed progress notes are displayed This is the default set up through Personal Preferences You can change view to see a different status such as unsigned notes Completed Progress Notes Mar 17 1997 17 10 56 Page 1 of 1 TIUPATIENT ONE 666 12 3456 2B JAN 1 1951 46 lt CW gt Title Written Sig Status 1 CRISIS NOTE 02 24 97 08 28 completed 2 CLINICAL WARNING 02 21 97 09 16 completed 3 Gen
251. support the upload of a wide range of textual documents from Commercial Off the Shelf COTS applications in use now and in the future at Veteran Administration VA Medical Centers Projects that may work with the interface are the Remote Order Entry System ROES software used by the Denver Distribution Center DDC the Precision Data Solutions Transcription Service software and the VA Home Telehealth software The project creates a single COTS application interface specification to allow textual documents to be uploaded and displayed in CPRS This allows clinicians to view information from the COTS package without leaving the patient s electronic medical record Generic HL7 will not work with external software unless it is specifically set up to do so The details of how to do this are contained in the Text Integration Utilities TIU Generic HL7 Handbook This handbook describes the HL7 fields required for each document types and gives additional information on system features and vendor guidelines To retrieve this document go to the VistA Document Library at http www va gov vdl then click on CPRS Text Integration Utility TIU Message Manager The only place where the Generic HI Interface is visible is in the TIU Maintenance Menu The TIUHL7 Message Manager has been added to this menu to assist medical center in setting up the interface If an error message is returned it will be contained in clear text explaining the error T
252. t Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual Progress Notes Print Example cont d TIUPATIENT ONE 666 23 3456 Progress Notes 04 24 92 08 00 CONTINUED FROM PREVIOUS SCREEN 40 ADEQUATE FOR HEALING 39 30 EQUIVOCAL FOR HEALING 29 0 INADEQUATE FOR HEALING SEGMENTAL SYSTOLIC BLOOD PRESSURE RIGHT INDEX LEFT INDEX ARM HIGH THIGH ABOVE KNEE BELOW KNEE ANKLE PT DP EXERCISE RESPONSE PH 5 mph AAXIMUM WALKING TIME 10 MIN 20 SEC SYMPTOMS Pedal edema cyanosis AXIMUM HEART RATE ACHIEVED TIME RIGHT INDEX LEFT INDEX ARM 1 MINUTE 3 MINUTES 5 MINUTES 10 MINUTES 15 MINUTES 20 MINUTES POST EXERCISE IMPRESSIONS Signed by es Three TIUProvider MD Medical Internist 04 24 96 14 19 Analog Pager 555 1213 Digital Pager 555 1215 A Enter RETURN to continue or to exit 1 Discharge Summary Print 2 Progress Note Print 3 Clinical Document Print Select Print Document Menu Option lt Enter gt 100 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Clinical Document Print Use this option to print chart or work copies of al
253. t also contains options to assist in populating the TIU Document Definition File 8925 1 which is roughly equivalent to file 121 2 This menu is NOT exported on any existing menu It should be assigned to the person responsible for getting the Progress Notes package ready for conversion to TIU We suggest that this be limited to one person per site or several people working closely together on these clean up exercises Calculate Number of PNs per TITLE Number of Notes per TITLE Report DELETE a Progress Notes TITLE MOVE Notes to Another TITLE Edit TITLE Enter Edit Doc Class TITLEs Sorted by Document Class Report CONVERT TITLES 121 2 to TIU 8925 1 T Title of Progress Note List Unsigned Progress Notes by AUTHOR Delete a Signed Progress Note DQGQDWADUOABWNHE j zZ D Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 203 Suggested Clinical Coordinator Menu TIU doesn t export a Clinical Coordinator Menu However sites may wish to create one which includes most of the other menus and options except possibly IRM options requiring programmer access Text Integration Utilities Transcriptionist Text Integration Utilities MRT Progress Notes s Discharge Summary TIU Text Integration Utilities MIS Manager Text Integration Utilities Remote User Progress Notes Print
254. t or work copies NOTE The location print option prints for any location that has signed notes entered for it but it doesn t track anything Option Description Author Print Progress Notes This option produces chart or work copies of progress notes for an author for a selected date range Location Print Progress Notes This option prints chart or work copies of progress notes for all patients who were at a specific location when the notes were written The patients whose progress notes are printed on this report may not still be at that location If Chart Copy is selected each note will start on a new page Patient Print Progress Notes This option prints or displays progress notes for a selected patient by a selected date range Ward Print Progress Notes This option lets you print progress notes for all patients who are now on a ward for a selected date range This option is only for ward locations NOTE Copies can only be printed to a printer not to a computer screen 184 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual MAS Options to Print Progress Notes The MAS options are intended for printing at the Wards and Clinics both by individual patient and batch printing Option Description Admission Prints all PNs for This option prints all progress notes for a selected patient Current Admission for the current admission if patient is an inpatient or
255. t with hemorrhagic contusion without mid line shift or incoordination ACTIVE MEDICATIONS Isordil 20 mgs p o t i d Coumadin 2 5 mgs p o qd ferrous sulfate 325 mgs p o b i d Ativan 0 5 mgs p o b i d Lactulose 15 ccs p o b i d Calcium carbonate 650 mgs p o b i d with food Betoptic 0 5 ophthalmologic solution gtt OU b i d Nephrocaps 1 tablet p o qd Pilocarpine 4 solution 1 gtt OU b i d Compazine 10 mgs p o t i d prn nausea Tylenol 650 mgs p o q4 hours prn Patient is on hemodialysis no known drug allergies PHYSICAL EXAMINATION Patient had stable vital signs his blood pressure was 160 85 pulse 84 respiratory rate 20 temperature 98 degrees Patient was alert oriented times three cooperative His speech was fluent understanding of spoken language was good Attention span was good He had DRAFT Press RETURN to continue or to exit lt Enter gt 96 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Discharge Summary Print Example cont d SALT LAKE CITY priority 06 27 96 08 46 Page 4 PATIENT NAME AGE SEX RACE SSN CLAIM NUMBER TIUPATIENT ONE S MEXI 666 23 3456 moderate memory impairment no apraxia noted Cranial nerves patient was blind pupils are not reactive to light face was asymmetric tongue and palate are mid line Motor e
256. te range of patients etc because searches for a lot of documents can be very system intensive slowing down response time for everyone Steps to use option 1 Select Show Progress Notes Across Patients from the Clinician s Progress Notes Menu 2 Select one of the following status es of progress notes undictated uncosigned untranscribed completed unreleased amended unverified retracted unsigned 3 Select one of the following Progress Note Types Advance Directive Crisis Note Historical Titles Adv React Allergy e Clinical Warning 4 Select one or more of the following search categories 1 All Categories 6 Patient 11 Transcriptionist 2 Author 7 Problem 12 Treating Specialty 3 Division 8 Service 13 Visit 4 Expected Cosigner 9 Subject 5 Hospital Location 10 Title 5 Select the range of dates to include 6 The notes meeting the criteria you selected are displayed UNSIGNED Progress Notes Jun 18 1997 09 19 20 Page 1 of 1 by AUTHOR from 06 15 96 to 06 18 97 2 documents Patient Document Ref Date Status 1 TIUPATIENT R0482 Clinical Warning 06 14 97 unsigned 2 TIUPATIENT D4029 Crisis Note 06 14 97 unsigned Next Screen Prev Screen More Actions gt gt gt Find Sign Cosign Change View Add Document Detailed Display Copy Edit Browse Delete Document ake Addendum Print Quit Link Identify Signers 44 Text Integration Utili
257. ters determining their processing requirements as well as the format of a header for uploading them in mixed batches with Discharge Summaries Operative Reports C amp P exams and Progress Notes can all be defined without modifying any code A patch will be necessary to link them to a specific transfer movement and to introduce a chart copy of the appropriate Standard Form This involves a modest programming effort but will have to be prioritized along with a number of other requests Rev January 2012 Text Integration Utilities V 1 0 227 Clinical Coordinator amp User Manual FAQs cont d We need the help of the user community to try to sort out the relative priorities of each of these tasks along with your patience as we work to deliver as many of them as possible as timely as possible A From a user coordinator A possible solution to the problem of rotating residents is to set up your summary package with the author not needing to sign the summary This allows the attending physician to sign the report While the residents may rotate in and out the attending usually remains the same through the course of the patients stay Q What are sites doing with C amp Ps amp op notes It is my understanding that C amp Ps are a type of discharge summary I ve tried creating C amp P EXAM as a title underneath the DISCHARGE SUMMARY document class I get TYPE errors when uploading test documents The document parameter
258. the 0 text node A delimited form of the report can be provided for users who want to put the report into a spreadsheet program In the following example a report is generated starting June 1 2004 Select Text Integration Utilities MIS Manager Option Individual Patient Document ultiple Patient Documents Print Document Menu Search for Selected Documents Statistical Reports Unsigned Uncosigned Report issing Text Report issing Text Cleanup Signed unsigned PN report and update 0 UNKNOWN Addenda Cleanup 1 issing Expected Cosigner Report in H Hassi gG Ue U N Enter for more options for brief descriptions OPTION for help text Select Text Integration Utilities MIS Manager Option 7 Missing Text Report START WITH REFERENCE DATE Jan 01 2003 jun 1 2004 JUN 01 2004 GO TO REFERENCE DATE Mar 04 2005 lt Enter gt MAR 04 2005 Would you like a delimited report NO lt Enter gt DEVICE HOME lt Enter gt ANYWHERE Searching Date range searched Jun 01 2004 Mar 04 2005 of Records Searched 1074 Missing Text Only 1 Missing 0 Node Only 0 Missing 0 node amp Text 4 136 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Total 5 Elapsed Time 0 minute s 0 second s Current User CPRSPROVIDER SEVEN Current Date Mar 04 2005 15 08
259. the exception of cosignature i e by the supervisor undictated The document is required and a record has been created in anticipation of dictation and transcription but the system has not yet been informed of its dictation unreleased The document is in the process of being entered into the system but has not yet been released by the originator i e the person who entered the text directly online unsigned The document is online in a draft state but the author hasn t signed untranscribed The document is required and the system has been informed of its dictation but the transcription hasn t been entered or received by upload unverified The document has been released or uploaded but must be verified before the document may be displayed As of TIU 1 234 documents of these statuses i e signed documents cannot be edited regardless of business rules Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 65 Actions Find Add Document Edit ake Addendum Link Sign Cosign Change View Detailed Display Copy Browse Delete Document Print Quit Identify Signers Actions Description Add Document Enter a new Document Change View Allows you to modify the list of reports by signature status review screen and dictation date range without exiting the review screen Copy Allows authorized users to duplicate the curre
260. ties V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Select Action Quit Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 45 Progress Notes Print Options See Chapter 8 for examples and further descriptions of these options Option Description Author Print Progress Notes This option produces chart or work copies of progress notes for an author for a selected date range Location Print Progress Notes This option prints chart or work copies of progress notes for all patients who were at a specific location when the notes were written The patients whose progress notes are printed on this report may not still be at that location If Chart is selected each note will start on a new page Patient Print Progress Notes This option prints or displays progress notes for a selected patient by selected date range Ward Print Progress Notes This option lets you print progress notes for all patients who are now on a ward for a selected date range This option is only for ward locations NOTE This option only prints to a printer not to your computer screen 46 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual List Notes by Title This option lets you look up progress notes by title within a specified date range You can then take any of the usual actions on these notes Steps to use
261. tion ACTIVE MEDICATIONS Isordil 20 mgs p o t i d Coumadin 2 5 mgs p o qd ferrous sulfate 325 mgs p o b i d Ativan 0 5 mgs p o b i d Lactulose 15 ccs p o b i d Calcium carbonate 650 mgs p o b i d with food Betoptic 0 5 ophthalmologic solution gtt OU b i d Nephrocaps 1 tablet p o qd Pilocarpine 4 solution 1 gtt OU b i d Compazine 10 mgs p o t i d prn nausea Tylenol 650 mgs p o q4 hours prn Patient is on hemodialysis no known drug allergies Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 61 Printed Discharge Summary Example cont d PHYSICAL EXAMINATION Patient had stable vital signs his blood pressure was 160 85 pulse 84 respiratory rate 20 temperature 98 degrees Patient was alert oriented times three cooperative His speech was fluent understanding of spoken language was good Attention span was good He had moderate memory impairment no apraxia noted Cranial nerves patient was blind pupils are not reactive to light face was asymmetric tongue and palate are mid line Motor examination showed muscle tone and bulk without significant changes Muscle strength in upper extremities 5 5 bilaterally sensory examination revealed intact light touch pinprick and vibratory sensation Reflexes 1 in upper extremities coordination finger to nose test within normal limits bilaterally Alternating movements without signif
262. tion Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Search for Selected Documents Use this option to produce a list of selected documents by extended search criteria e g status search category and reference date range These can then be reviewed verified sent back to transcription reassigned or printed Steps to use option 1 Select Search for Selected Documents from the TIU MRT menu 2 Select the status of documents you want displayed Select Text Integration Utilities MRT Option 6 Search for Selected Documents Select Status COMPLETED 1 undictated 5 unsigned 9 purged 2 untranscribed 6 uncosigned 10 deleted 3 unreleased 7 completed 11 retracted 4 unverified 8 amended Enter selection s by typing the name s number s or abbreviation s Select Status COMPLETED lt Enter gt completed 3 Select the document type you want displayed These may be different Select CLINICAL DOCUMENTS Type s Discharge Summaries KK at your site 1 Discharge Summaries 2 Progress Notes 3 Addendum Enter selection s by typing the name s number s or abbreviation s Select CLINICAL DOCUMENTS Type s Progress Notes Progress Notes 4 Select the search category you want displayed Select SEARCH CATEGORIES AUTHOR 1 All Categories 5 Patient 9 Title 2 Aut
263. u Actions There are two Interdisciplinary Note specific menu commands in the CPRS Windows interface They are e Add New Entry to ID Note e Detach from ID Note These commands become active usable when the correct kind of note is selected as in these illustrations m VistA CPRS in use Aula Add New Entry to ID Note Detach from ID Note Changes 4 istA CPRS in use by TUProvider Seven Reload K EE GE Edit View Actio TIUPATIENT FO yenno Tools Help Sooo ew Progress Nate f Make Addendum Nov 17 0 Edt Prog Default List Add Hew Entry toro Note j i E All signed hotes Detach from ID Note S gt SI Change Title Noy S Reload Boilerplate Text Nov Add to Signature List Nov 17 0 Delete Progress Note cs D Nov 170 Edit Progress Note In the first case the parent note has been selected In this case you can add a new note to the Interdisciplinary Note without having to later attach it via drag and drop In the second case one of the child notes has been selected In this case you can detach this note from the parent 54 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual Interdisciplinary Notes cont d The Display CPRS displays all notes in the Interdisciplinary Note reference date order unless one of the child notes is selected In this case CPRS displays the child note then it displays all the notes in the Interdisciplina
264. uments 1 3 1 3 Do you want WORK copies or CHART copies CHART lt Enter gt DEVICE HOME PRINTER 4 The document s will then be printed at the device you specify Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 123 Search for Selected Documents Use this option to generate a list of selected documents based on extended search criteria e g status search category and reference date range Steps to use option 1 Select Search for Selected Documents from the MIS Manager Menu 2 Select the status of the documents you want to view completed unsigned amended etc Select Text Integration Utilities MIS Manager Option Search for Selected Documents Select Status COMPLETED UNV unverified 3 Select the type of documents you want to view progress notes discharge summary etc Select CLINICAL DOCUMENTS Type s All Discharge Summary Progress Notes Addendum 4 To make your search more specific select one or more categories for the documents you want to view All Categories Patient Title Author Problem Transcriptionist Division Expected Cosigner Service Treating Specialty Hospital Location Subject Visit Select SEARCH CATEGORIES AUTHOR SERVICE Select SERVICE MEDICINE 5 To limit the search even further specify a time period for the documents you want to v
265. unconnected to their associated operation report The UNKNOWN addenda Cleanup menu option is provided in TIU 1 173 to assist in cleaning up these unattached addenda In the following example an unknown addenda is attached to a surgery case MIS Managers Menu HE Individual Patient Document 2 ultiple Patient Documents 3 Print Document Menu 4 Search for Selected Documents 5 Statistical Reports 6 Unsigned Uncosigned Report 7 issing Text Report 8 issing Text Cleanup 9 Signed unsigned PN report and update 10 UNKNOWN Addenda Cleanup 11 issing Expected Cosigner Report 12 ark Document as Signed by Surrogate 13 ismatched ID Notes 14 TIU 215 ANALYSIS 15 Transcription Billing Verification Report Select Text Integration Utilities MIS Manager Option 9 UNKNOWN Addenda Cleanup START WITH REFERENCE DATE Jan 01 2003 lt Enter gt JAN 01 2003 GO TO REFERENCE DATE Apr 04 2005 lt Enter gt APR 04 2005 Searching for the documents TIU Surgery Cleanup Apr 04 2005 08 48 53 Page 1 of 1 UNKNOWN ADDENDA from Jan 01 2003 to Apr 04 2005 Patient Doc IEN Entry DT Status Parent 1 CPRSPATIENT T C5525 2194 09 29 04 UNSIGNED NO 2 CPRSPATIENT T C5525 2236 10 14 04 UNSIGNED NO 3 CPRSPATIENT T C5525 2238 10 14 04 UNSIGNED NO You may select more than one document by using or notation The parent document
266. ure Optionally a summary report can be generated showing the number of unsigned and uncosigned documents in each service 106 Text Integration Utilities V 1 0 Rev January 2012 Clinical Coordinator amp User Manual In the following example a summary report is generated for a selected division Select Report Select 1 SALT OPTION run NAME JAKE T routine division ALL SALT CIOFO 2 SALT LAKE OEX SALT JAKE CHOOSE 1 2 1 Select Please specify an Start Ending Entry Date Select service Select on p EN Entry Date t another division try t 365 JAN 28 of the f F S Type of Report S FULL IU UNSIGNED UNCOSIGNED REPORT 660GC 660 CIOFO lt Enter gt 660GC Date Range JAN 28 2003 2004 ALL lt Enter gt ollowing SUMMARY SUMMARY Unsigned Uncosigned DEVICE HOME lt Enter gt ANYWHERE Unsigned and Uncosigned Documents Jan 28 2003 thru Jan 28 2 004 23 59 59Page 1 PRINTED for ELY JAN 28 2004 16 33 Totals for Service IRM UNSIGNED 24 UNCOSIGNED 0 Totals for Service MEDICINE UNSIGNED 112 UNCOSIGNED Totals for Service OTHER UNSIGNED 1 UNCOSIGNED 0 Totals for Service PHARMACY UNSIGNED 6 UNCOSIGNED 0 Totals for Ser
267. use the basic entry and reporting functions of TIU This section is divided into sub sections for the four major users of TIU clinicians MRTs MIS Managers and transcriptionists Ill Managing TIU Describes the options and tools available to coordinators and IRMS for assigning menus setting parameters and other management functions Also includes Troubleshooting and Helpful Hints Glossary and Index Definitions of terms and the index to the manual How each chapter is formatted Each chapter generally follows the format of Brief overview Description of process step by step description of how to use functions if appropriate Examples Online documentation Intranet Online Documentation for this product is available on the intranet at the following address http www va gov vdl This address takes you to the Clinical Products page which has a listing of all the clinical software manuals Click on the Text Integration Utilities link and it will take you to the TIU Homepage You can also get there by going straight to the following address http vista med va gov tiu TRemember to bookmark this site for future reference Special Instructions for the new VistA Computer User If you are unfamiliar with this package or other Veterans Health Information Systems and Technology Architecture VISTA software applications we recommend that you study the DHCP User s Guide to Computing This orientation guid
268. user to enter Business BUSINESS RULES Rules authorizing specific users or groups of users to perform specified actions on documents in particular statuses e g an UNSIGNED PROGRESS NOTE may be EDITED by a PROVIDER who is also the EXPECTED SIGNER of the note etc Manage Business USR BUSINESS This option allows you to list the Business Rules RULE rules defined by ASU and to add edit or MANAGEMENT delete them as appropriate Rev January 2012 Text Integration Utilities V 1 0 209 Clinical Coordinator amp User Manual Chapter 14 National Document Titles Certain entries in the Document Definition file have been exported either with TIU and or with various TIU patches The operation of certain functions in VistA and CPRS depends on these entries being there These entries include certain classes document classes and titles Most exported Document Definitions are marked National Local editing of National Document Definitions is severely restricted e Note You must limit your editing of national Documents Definitions to actions permitted by the exported Document Definition options Other editing will cause certain functions of VistA and CPRS to not work properly National Classes Classes are the most fundamental unit of organization in the Document Definition file CLINICAL DOCUMENTS is the root class for all other classes and document classes PROGRESS NOTES contains note titles that appear
269. uthority to approve actions at whatever level have an electronic signature code Like the access and verify codes used when gaining access to the system the electronic signature code is not visible on the screen These codes are also encrypted so that they are unreadable to other users even when viewed in the user file by those with the highest levels of access Electronic signature codes are required by TIU for every action that currently requires a signature on paper How to Change Your Electronic Signature Code 1 Select User s Toolbox from the Mailman Menu 2 Select Edit Electronic Signature Code from the User s Toolbox menu Select Option User s Toolbox Display User Characteristics Edit Electronic Signature code Edit User Characteristics Menu Templates Spooler Menu TaskMan User User Help Select User s Toolbox Option Edit Electronic Signature code This option is designed to permit you to enter or change your Initials Signature Block Information and Office Phone number In addition you are permitted to enter a new Electronic Signature Code or to change an existing code 3 Enter your initials 4 At the Signature Block Printed Name prompt enter your name as you want it printed on forms that require your signature 5 At the Signature Block Title prompt enter your job title as you want it printed on forms that require your signature 6 Enter your office phone numbe
270. ve a personal Progress Notes title list set up through Personal Preferences that list is displayed for you to choose from Enter a Subject if desired and the text of the Progress Note Personal PROGRESS NOTES Title List for THREE TIUPROVIDER 1 Crisis Note 2 Advance Directive 3 Adverse Reactions 4 Other Title TITLE 1 4 3 lt Enter gt Adverse React Allergy Creating new progress note Patient Location 1A Date time of Admission 05 30 97 10 43 Date time of Note NOW Author of Note TIUPROVIDER NINE OK YES lt Enter gt SUBJECT OPTIONAL description lt Enter gt Calling text editor please wait 1 gt Mr TIUPatient improving renewed prescription 2 gt lt Enter gt EDIT Option Save changes YES lt Enter gt Saving Adverse React Allergy with changes 4 Enter your electronic signature code If you wish to print the note either a Work or Chart copy answer yes to the next prompt and enter a printer device name Enter your Current Signature Code XXX SIGNATURE VERIFIED Print this note No y YES Do you want WORK copies or CHART copies CHART w WORK DEVICE HOME lt Enter gt VAX The note is printed You are prompted to enter another note or to exit NOTE DATED 05 31 97 14 58 ADVERSE REACT ALLERGY TED 05 30 97 10 43 1A r TIUPatient improving re
271. ves http vaww 1 va gov vhapublications ViewPublication asp pub_ID 2042 Example Select OPTION NAME Manager menu Select Text Integration Document Select PATIENT NAME 1 notes D Enrollment Priority GROUP 3 Available documents TIU MAIN MENU MGR CPRSPATIENT TWO 12 20 2002 09 07 12 17 1998 thru 01 10 2012 Category IN PROCESS 231 Please specify a date range from which to select documents List documents Beginning 12 17 1998 01 10 11 Text Integration Utilities End Date JAN 10 2011 MIS Utilities MIS Manager Option 1 Individual Patient Thru 01 10 2012 JAN 10 2012 1 01 10 2012 11 44 ADVANCE DIRECTIVE CPRS PROVIDER ONE Adm 12 20 2002 Dis One document found within date range Opening ADVANCE DIRECTIVE record for review Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 129 Browse Document Jan 10 2012 11 52 57 Page 1 of HE ADVANCE DIRECTIVE CPRSPATIENT TWO 666 54 8668 1A 1 amp 2 Adm 12 20 2002 Dis STANDARD TITLE ADVANCE DIRECTIVE DATE OF NOTE JAN 10 2012 11 44 13 ENTRY DATE JAN 10 2012 11 44 13 AUTHOR CPRSPROVIDER ONE EXP COSIGNER URGENCY STATUS UNSIGNED DNR URGENCY STATUS COMPLETED VistA Imaging Scanned Document SCANNED DOCUMENT SIGNATURE NOT REQUIRED Electronica
272. vice SURGERY UNSIGNED 1 UNCOSIGNED 0 Totals for Service UNKNOWN UNSIGNED 2 UNCOSIGNED 0 Totals for Division ELY UNSIGNED 146 UNCOSIGNED 0 Enter RETURN to continue or to exit Note A full Unsigned Uncosigned Report requires a printer device capable of printing 132 columns Rev January 2012 Text Integration Utilities V 1 0 Clinical Coordinator amp User Manual 107 Reassignment Document Report The reassign action reassigns a note to a different patient admission or visit Besides this the reassign action may be used to promote an Addendum as an Original swap the Addendum and the Original or change a discharge summary to an Addendum This report provides a list of reassigned notes based on date range In the following example TIU displays a report of reassigned documents over the past 6 months Select Text Integration Utilities MRT Option Individual Patient Document ultiple Patient Documents Review Upload Filing Events Print Document Menu Released Unverified Report Search for Selected Documents Unsigned Uncosigned Report Reassignment Document Report OD JO OD U NH Enter for more options for brief descriptions OPTION for help text Select Text Integration Utilities MRT Option 8 Reassignment Document Report ENTER STARTING DATE JAN 01 2003 t 180 AUG 22 1999 ENTER ENDING DATE Aug 04 2004 AUG 04 2004 DEVICE HOME ANYWHERE
273. xamination showed muscle tone and bulk without significant changes Muscle strength in upper extremities 5 5 bilaterally sensory examination revealed intact light touch pinprick and vibratory sensation Reflexes 1 in upper extremities coordination finger to nose test within normal limits bilaterally Alternating movements without significant changes bilaterally Neck was supple LABORATORY Showed sodium level 135 potassium 4 6 chloride 96 CO2 26 BUN 39 creatinine 5 3 glucose level 138 White blood cell count was 7 hemoglobin 11 hematocrit 34 platelet count 77 Fl HOSPITAL COURSE Patient was admitted after head trauma with multiple medical problems His coumadin was held Patient had cervical spine x rays which showed definite narrowing of C5 C6 interspace slight retrolisthesis at this level prominent spurs at this level as well as above and below CT scan on admission showed a moderate amount of scalp thinning with subcutaneous air overlying the left frontal lobe A small area of left parenchymal hemorrhage adjacent to the right petros bone in the temporal lobe which most likely represents a hemorrhagic contusion Repeated CT scan on 5 13 94 didn t show any progressive changes Patient remained in stable condition He had hemodialysis q o d He restarted treatment with Coumadin His last PT was 11 9 PTT 31 Patient refused before hemodialysis new blood tests His condition remained stable DISCHAR
274. y 165 MRT 239 hidden action menu 17 MRT Menu 87 Hidden actions 17 MRTs 86 87 HIMS 112 239 Multiple Patient Discharge Summaries 63 HISTORICAL PROCEDURES 210 211 212 Multiple Patient Documents 66 71 72 87 89 90 Historical Visits 223 115 178 179 180 HL7 Generic Interface 219 national HL7 Troubleshooting 219 document titles 209 Identify Signers 65 New Note 50 Individual Patient Discharge Summary 59 Object 240 Individual Patient Document 66 67 87 88 114 176 Objects 81 84 Integrated Document Management 22 66 OE RR 2 5 23 39 Interdisciplinary Notes 51 Online Help 14 Inter facility data transfer 236 OP reports 227 Interim Summaries 226 Outpatient Location Print Progress Notes 184 Interward transfer note 226 Outpatient note 32 Intranet 12 Parameters 205 Introduction 9 Parameters Menu 205 Introduction to the TIU User Manual 12 Parentless Addenda 139 Introduction to TIU 10 Patch GMTS 2 7 12 85 Introduction Managing TIU 197 Patient Print Progress Notes 45 183 IRT 239 PCE 236 IRT deficiency 226 Person Class file 221 Legal Requirements 198 Personal Preferences 22 76 Line Count 113 155 Plus sign 15 Line Count Statistics by AUTHOR 132 prevents editing 73 Line Count Statistics by SERVICE 133 Print 65 Line editors 225 Print actions 182 Link 50 65 Print by Ward 195 224 Linkages 11 Print Document Menu 94 116 Links and Relationships with Other Packages 199 Print Document Ment 87 List area 15 Print Options 181 182 List Documents

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