User Guide - Care Management Plus
Contents
1. Resource Time fin minutes Total Call Time For Day fin minutes Clinic Visit Time fin minutes Number of Phone Calls Home Visit Time fin minutes Motes Mew Encounter Save Encounter Delete Encounter Record I4 4 1 F Hi of 1 Filtered Figure 5 Page 9 of 26 e Meds Clicking this button will bring up the following Patient Medication screen Fig 6 Enter the Medication information Required fields are in blue Omitting these fields will generate a pop up error message when you save the form o Medication Click the Save Med Button to save the record and close the window to return to the main Patient Information screen amp Patient Medication E x Patient Medication Medication Start Date x Medication End Date o x Medication PRN Dose Poo Motes i Save Med Delete Med Record lA 4 b kl gt of z Filte e 6 Page 10 of 26 e MH Instruments Clicking this button will bring up the following Mental Health Instruments screen Fig 7 Enter the Mental Health Instruments information Scores entered on this screen originate from corresponding instruments such as the PHQ 9 Patient Health Questionnaire which are available for download with the CMT database Data entered on this screen will display on the Care Conference List Report from the Main Menu Mental Health version of the CMT database only Required fields are in2. Care Manager Tracking Database Data Dictionary Heart Failure TyperControl Require Checkbox No Checkbox No Checkbox No Checkbox No Checkbox No No Checkbox No Patient practicing self management No Patient Identified Goal Numeric NO oeverity of Patient validated standard measure of impairment over time Checkbox No Include Patient at next MH Care Conference Checkbox No Was Patient referred to MH off site No General MH Comments for Patient Definition Patient unwilling to use available support Patient exhausted available support Patient has available support actively using Data Element Unwilling to use available support Exhausted available support Has available support actively using Check Adherence ollowing recommendations Patient following recommendations Patient taking medications oeeing therapist Patient seeing therapist Management dentified Goal Global Severity 1 7 4 a 1M 4 7 O mM zh I 5 O 3 O Q O Q ct O D O D olo gt x lt x x D oa oe O Olo O O O o ra x Xx x 3 x Care Conf Referred to MH Off site General Comments Plan PHQ 9 Depression Symptom Count 0 1 2 3 4 5 6 7 8 9 Z Z O O O Depression Symptoms Score based on the personal health questionnaire nine symptom checklist PHQ 9 calculated by totaling the values for each depression symptom question Textbox Numeric Severity Score based on the personal health qu
3. Teohnical Proeratirmer A da icon 26 Page 3 of 26 Care Manager Tracking CMT Software Installing the Database To install the database for a single user download and save the CMT mdb file to the desired folder on a local drive computer For multiple users install the database on a network drive Users can be given access rights permissions to that drive map the drive to their computer and create a shortcut on their desktop to access the live database Opening the Database To open the database double click the Shortcut to CMT mdb icon on your desktop The CMT Care Management Menu will appear Fig 1 CMT nml xl Eile Edit View Insert Format Records Tools Window Help amp CMT Care Management Menu X EI Care Management Tracking Record Entry and Modification General Reports Queries Patient List View Queries Encounter Tickler Care Manager Table Entry Admin Time Encounter Summar Diagnosis Table Entry Encounter Summary Administrative Time Information Facility Table Entry Mental Health Reports Administrative Time List PHOS List Insurance Provider Table Entry V Medication Table Entry Physician Table Entry Figure 1 The CMT Care Management Menu The Care Management Tracking Database Main Menu is composed of 6 sections Record Entry and Modification General Reports Mental Health Reports Diabetes Reports Queries and Admin Time Page 4 of 26 Record Entry and Modification
4. zio 5 5 Date Diagnosis Management began Patient s Active Problem from Problem List Physician managing the Diagnosis Yes Yes O Yes Yes O N N 0 O D Q m 0 P O Page 1 of 9 Care Manager Tracking Database Data Dictionary Heart Failure Data Element Type Control Required A F Definition ctive Resolved No Status of the Diagnosis No Notes relating to the Diagnosis PATIENT ENCOUNTER al LS ME ol Oo o X O 2 Scheduled Date Date field Date MM DD YYYY Date for Patient s scheduled phone call visit Scheduled Time Time field Time HH MM AM PM Time for Patient s scheduled phone call visit Encounter Type Drop down CM Office Visit Class MD Yes Type of Care Manager Patient Encounter Office Visit Home Visit Telephone Contact Group Visit MHI Conference Email Non Encounter Related Diab Initial Diab Followup Diab Class 1 Diab Class 2 Diab Class 3 Diab Class 4 Diab Class 5 Diab Class 6 Diab Additional Class Diab Inpatient Diab Insulin Start pClass Patient Education Non Encounter Related A Filling out forms admin other charting etc Enc Reason Drop down DEA Screen PHQ 9 F U No Reason for the Care Manager Patient Encounter MHI F U DM F U Depression F U DM Depression F U Med Assist Medication Mgmt Agreement Status Check Resource Management New Patient Med Assist Medication Assistance Medication Mgmt Agreement Resource M
5. The Encounter Summary report generated is a summary of Encounters by date range for Patients assigned to the selected Care Manager Diabetes Educator This report can be sorted by first name last name encounter date encounter type or encounter outcome Start Data aA Edosa uis Care Manager Poe Sort By ast Mame z Figure 15 Click Run Encounter Summary to run the report Fig 16 fie Edit wew Took Window Help Pathent Encounter Scumnmimny Care Manager Patient Encounter Summary Far Time Period L1 2004m 1 1 2008 Care Manager Ann Thomsen ID Humber Lari Hama Era Name Phea Humbe Encounber Deb Enceuniee Type Dung aces SG Ww MD Oaia vist Pilar Bate POEL MDH Telepi Cor n Biling Date Bondt An 572004 Telephone Contact Hrs ET n BD la iaa c ond et Hare Taly 800 222 2220 1100004 CM Oe Visit Vl inniti Sy Bae TMA CH Dres wia Hare Sally As 1H MD Obes val Redman Potent Finiti 101004 Teiepane onimi Erde eee Box Trop dm Redman Protest FONSI ATTN Tatephone Contact i aiai GS A Teepe Contact Rese an Fone 800 999 9900 1004 2004 Teteprone Conbadt Total Patient Encounter 12 mw mar epe x TOTO Figure 16 Cubs AG om pieles m ded exi Let Henog X certi ped ret Con peeled e om pied is en peeled Conpleled Lr bru Let Menaje Cel Ae Ma Sree Page 18 of 26 Mental Health Reports PHQ9 List e Clicking on the PHQO List button will bring up the following PHQ9 List
6. Save Instrument Delete Instrument E Data Data Record I4 4 7 F gt of 7 Filtered Figure 7 e HF Follow Up Page 11 of 26 Clicking this button will bring up the following Heart Failure Follow Up screen Fig 8 Enter the Follow Up information Please note that you may also print a copy of this screen form by clicking the Print Follow Up button on the bottom left of the screen Required fields are in blue Omitting these fields will generate a pop up error message when you save the form o Call Date o Discharge Date o Hospital Click the Save Follow Up Button to save the record and close the window to return to the main Patient Information screen amp HF Follow Up Heart Failure Follow Up Call Date _ Discharge Date Ta Talked To Medication Review Are vau Following your discharge medications IF rat which ones are you not Following m Why are vou nat Following your discharge meds Reviewed Ehe importance of compliance mot running aut refilling meds E Reminded patient to take all medications to Follow up appointment E Activity Are vau trying to stay active daily T How are vou tolerating activity since discharge Weights Is there any change in weight Motes Mew Follow Up Save Follow Up Print Follow Up Record I4 4 e I gt of 2 Filtered Hospital v Diet Fluid Restriction D
7. Here you will locate enter new Patients record new encounters assessments and diagnoses The top portion of the screen displays Patient demographics as well as information regarding the Patient s status with the Care Manager The middle section of the screen consists of several windowpanes which summarize and provide at a glance data entered via the navigation buttons on the bottom left of the screen Also indicated within a thick black box on the right side of the screen 1s the Patient Search section The bottom of the screen houses the navigation buttons for entering data for the selected patient creating new patients saving and deleting patients and generating clinical note summaries al x Eile Edit Insert Records Window Help Adobe PDF amp Patient Information Form Patient Information ID Number TP 7 Last Mame ET First Mame eT DOB 8 16 1977 Sex n Phone t800 800 8000 Cell Phone NEN Email PCP fallen mth Y PCP Phone 800 888 8888 Insurance Mailhandlers J Facility fac Clinic ef HEER z ConfusediChaetic Patient Search Date of Referral afaojz004 Care Mgr pon Status active ID Number NEN Diag Date Diagnosis Status Sched Date Sched Time Encounter Type Status Last Mame ss edit 2 28 2005 CHF fictive edit 4 30 2005 f Telephone Contact Pending First Mame Edit 3 30 2004 Depression Active Edit 1126 2005 Telephone Contact Resolved Search For P
8. Name CM First Name Total Pat Encounters 1 Johnson IHC Health Plans Active 1 Johnson Malhandlers Active 2 Thomsen IHC Access Active 2 Thomsen Other 1 Only 2 Thomsen Private Pay Active Record I4 4 1 gt ot p of 5 eee El Figure 27 CM Total New Patients Referred Clicking on the CM Total New Patients Referred button will bring up the following query screen Fig 28 This query displays the number of New Patients referred to the Care Manager with a Date of Referral within the entered date range Eile Edit View Insert Format Records Tools Window Help CM Total New Patients Referred Select Query Care Manager Care Manager Last Name Care Manager First Name Total New Patients Exam 2 Thomsen Ann Record 14 4 I i of 1 4 Figure 28 Page 23 of 26 CM Total New Patients Referred by MD Clicking on the CM Total New Patients Referred by MD button will bring up the following query screen Fig 29 This query displays the number of New Patients referred to the Care Manager with a Date of Referral within the entered date range sorted by Patient s Primary Care Physician Eile Edit view Insert Format Records Tools Window Help i CM Total New Patients Referred by MD Select Query Thomsen 1 Durham Terry Thamsen 1 Carmen Julie Record I4 4 f l F pI gt of 2 Figure 29 CM Resource Time Clicking on the CM Resource Time button will bring up the
9. Section This section includes buttons to access the main Patient Information screen as well as table information for Care Managers Physicians Diagnoses etc which appear as selections in the drop down fields throughout the database Entering Values on Main Menu for Care Managers Diagnoses Facilities Insurance Providers Medications and Physicians e Click on the Diagnosis Table Entry button or other Table Entry button from the main menu A pop up window Fig 2 will appear with all of the values for that category currently in the database table available in the drop down menus To add a new one scroll down the window to the blank line Type in the new value and close the window It will now automatically save to that table and appear as an alphabetized choice in the drop downs within the database Please note If you are looking to add an entry for another category other than those listed on the Main Menu please contact your database administrator programmer These will need to be entered behind the scenes amp Diagnosis Entry x Diagnosis al Scroll to end of list to enter a new item Tortocolis Trach dependent Traumatic Brain Injury Traumatic Fractures WATER Syndrome vent Dependent vision problems eP Shunt welness crop 5 Figure 2 Page 5 of 26 Patient Information The Patient Information button brings you to the main data entry screen Fig 3
10. View Insert Format Records Tools window Help CMT Care Management Menu Care Management Tracking Record Entry and Modification General Reports Queries Patient Information Patient List View Queries Encounter Tickler Blood Glucose Meter Table Entry Xd iol wl Care Manager Table Entry ES amp Encounter Titi lolx ative Time Information Tickler List Parameters Diagnosis Table Entry nistrative Time List Start Date 412005 Facility Table Entry End Date 4 30 2005 Care Manager John v Insurance Provider Table Entry Run Encounter Tickler Medication Table Entry Physician Table Entry Patient Goal Progress Report Patient Education Progress Report Figure 13 Click Run Encounter Tickler to run the report Fig 14 Eile Edit View Took Window Hep Encounter Tickler Care Manager Encounter Tickler List Care Manager John Johnson Sched Da amd Time Encourier Tyee Ammon iD Aer Firzt Hammie Lad Hama iPhone Numer PLF Cnmmeni Aman Mond ncouwter abus Cac 14 J Viri on 200 4 4484 S Mich check On DL Appt Da JO AO MD Cikas Seed 10 Horii Teran 500 444 4404 Durham Terry EIER LH Telephone Cent Cras Creek ul Daniel earn 00 200000 en Mich pue lapa iT wm sl dad 4 I a Figure 14 Page 17 of 26 Encounter Summary e Clicking on the Encounter Summary button will bring up the following Encounter Summary List Parameters screen Fig 15
11. following query screen Fig 30 This query displays the Total Care Manager Patient Encounter Resource Time within the entered date range and the Average Resource Time for those Encounters Bie Edit view Insert Format Ejcords Tools Window Hep eu Resource Time Select Query _ Care Mgr 1D CM Last Name CM First Name Total Encounter Resource Time mins 1 J hnz an 2 Thomsen record If aif e biel ota El Figure 30 Page 24 of 26 Admin Time Administrative Time Information Module to enter Care Manager time not spent on Patient Encounters such as meeting times education and vacation Fig 31 Enter the Administrative Time Information The total time for the day will be automatically calculated Each day should be entered separately Click the Save Day s Time Button to save the record and close the window to return to the CMT Care Management Menu Main Menu amp Administrative Time l x Administrative Time Daily Entry Date EN Care Manager Meetings Time in minutes Medical Staff Meeting Staff Clinic Meeting Mental Health Integration Diabetes Education Case Management Meeting Geriatric Education SelF Development Teaching Drug Rep Meeting Team Building Meeting TILT TTT Paid Time Off Total Meet Time for Day mins Save Day s Time Record I4 4 12 F e rs of 19 Filtered Figure 31 Administrative Time List Page 25 of 26 Clicking on the Adminis
12. ADL score is the number of Functions Ehe individual is able to do independently 6 Full Function 4 moderate impairment 2 severe impairment Mini Mental Status Exam Score MMSE Pain Score 0 10 MIMSE 15 Pain Score a Motes Es Mew Function Save Function Print Function Delete Function Assess Assess Assess Assess Record lA 4 1 NE kl k of 1 Filtered Figure 9 Page 13 of 26 e MODIFYING PATIENT INFO Search for the Patient first to see if he she exists in the database See above instructions o Tochange demographic and status information on the main Patient Information form modify fields and click the Save Patient button o On Diagnoses Encounters Mental Health Instruments etc click the Edit button on the corresponding windowpane to get a pop up directly to that specific record and click the Save button before closing the pop up window e GENERATE CLINICAL NOTE BUTTON This tool will save you from copying and pasting back and forth between windows when you need to go to another electronic charting method to enter a Note with results from Encounters Mental Health Instruments Diagnoses etc just entered into the CMT database 1 Choose a date Enter a date in the white text box to the right of the button OR click the asterisk button to the right of the date field to pop up a calendar for reference In case you are looking for Last Friday for example and don t know the dat
13. Care Management Tracking CMT Software User Manual Heart Failure lol xl Eile Edit View Insert Format Records Tools Window Help 5 CMT Care Management Menu x El Care Management Tracking Record Entry and Modification General Reports Queries Patient List View Queries Encounter Tickler Care Manager Table Entry Admin Time Encounter Summar Diagnosis Table Entry Emoten Summary Administrative Time Information Facility Table Entry Mental Health Reports Administrative Time List PHO List Insurance Provider Table Entry 2 Medication Table Entry Physician Table Entry Page 2 of 26 Care Manager Tracking CMT Software Table of Contents Instaliiae the Database erica aed mantis 3 Opening the Database sc utram an derat teu mM EL te 3 The CMT Care Manaeement Men A AN 3 Record Entry and ModiHeatton ECON xoci uiuat ein A oiedu sd tb ned tee da 4 Entering Values on Main Menu for Care Managers Diagnoses Facilities Insurance Providers Medications dnd Phy sStelalis e is 4 Patient MONO ati 5 General Repo ecran Iun oi 15 Lan BEL PP ARTO 15 Encounter Lie lets itecto rs ada aida 16 Encounter SWIMM ALY oce s aarti ERR uie am teat ere ROCA he usta nce eeu eet 17 Mental Health REPON Sonica 18 PHOS ESen aa a a a a A a a 18 HL UU E E AAA AAA AE AAA AAA a 19 RAM V ES EEE A mmm 19 A MIN E E E RM IN IA E EI 24 Admite Line OLOT E a Am Qt 24 PTOI S ADV Ce Lime LEIS tarna AA 25 Tips cor Entry Datar iia 26
14. D Vanderbilt Comments Comments relating to Patient Vanderbilt Scores HF FOLLOW UP HEART FAILURE Call Date Date Field Date MM DD YYYY Date of Discharge Follow up Call Discharge Date Date Field Date MM DD YYYY Yes Hospital Discharge Date this Call followed from To Drop down Home Assisted Living No Place Patient is at time of Call Deceased ECF SNF LTCF Hospital From Location Table Values Yes Hospital Discharged From Talked To Drop down Patient Spouse Significant No Other Health Care Provider Other TH MT Person Actually spoke with on Call Page 6 of 9 Care Manager Tracking Database Data Dictionary Heart Failure Medication Review medications which ones is the Patient not following N If Patient not following discharge medications why is Patient not following discharge medications Did Care Manager review with the Patient the Yes No Unknown If not which ones are you not following Why are you not following your discharge meds O Reviewed the importance of No compliance not running out refilling meds Reminded patient to take all medications to follow up appointment Activity Are you trying to stay active daily Drop down Yes No Unknown No O How are you tolerating activity since Drop down Stable Better Worse discharge Unknown Is there any change in weight importance of compliance not running out refilling meds Did Care Manager remind the Patient t
15. Diag Delete Diag Record I4 4 1 F I gt of 1 Filte Figure 4 Page 8 of 26 Encounter Clicking this button will bring up the following Patient Encounter screen Fig 5 Enter the Encounter information Please note that Scheduled Time must be entered in the format HH MM AM or HH MM PM For a future Encounter to appear on the Encounter Tickler Report accessed from the database Main Menu you MUST enter the top half above the line of the Encounter pop up entry screen This portion drives the report Required fields are in blue Omitting these fields will generate a pop up error message when you save the form o Scheduled Date Click the Save Encounter Button to save the record and close the window to return to the main Patient Information screen You will notice that the windowpane for Encounters on the Patient Information screen will display that Encounter as Pending Once the Encounter has been completed go back to the Encounter screen for the Patient to fill in the bottom portion below the line of the Encounter record Filling in an Actual Date will cause the windowpane on the Patient Information screen to display Completed and the Encounter to drop off the Encounter Tickler to do List 83 Patient Encounter f x Encounter Information Scheduled Date sE Scheduled Time Encounter Type E Enc Reason m Actual Date Outcome E Call Attempts to Fts
16. Parameters screen Fig 17 The PHQO List report generated is a list of PHQ9 scores for Patients assigned to the selected Care Manager Diabetes Educator This report can be sorted by date first name last name or suicide risk The report 1s especially helpful for viewing progress over time PHOS List HQ9 List Parameters Figure 17 Click Run Patient PHQ9 List to run the report Fig 18 Care Manager Patient PHOS List Care Manager John Johnson mange Law Fa aa Fhe Um Fiki Wi ob fare Da eel y Pim fee m Dana La ae Lac B e GBngPM r He o Dem mt 7 mardi Abuse Desrem PD Y i 1 ima El m i Err Drai nia FO 0 dben i iaa ds Es Pa i 1 Tomas Wt i 325 8 ma EFi brs kam j Ae F Mad A Es Bii 3 rta E o p onmi Pa 2 Aero Ms LL aus Wa a imine E Mj Fm F ear Dorem mm FO Aen Mier daa D Ba TH A has E i arn br F isr Deum mt q M wr Mab eno Apod mii a E UTE e g A L I f ee p OE e MER Ha hoa iiri Li T le Di io 2 em M ded beiee Dew rri O F b Damm nian po men MER LIE XM ii Li a F Brp ina 2 Aen Mich A TACNIM i hee E 2 Apt Le F ire DFF hia 2 dan iiich Haas dr tit hee E E L agro Le r iri oem Maa 7 dies adit Maa AP oer a 5 hara E d Pagan See Lata F Dee onum A bee Mis imas USE As O F Team Dame aa TO jams ii bebede Depas Adi Li F A A pen i Mae Aiie a a fs Darum A
17. RLSROILAEL Aer MeF ieee Deer DADA A E a a E San Era Denm Dre LA ih tae imi FHH if IB ary E i LII r A Md mi ia oe ods 18 E AT 1 Papas Hami fle e Enn a Jiu Li i w a s ede al i af ols ag Figure 18 Page 19 of 26 Queries View Queries Clicking on the View Queries button will bring up the following Queries screen Fig 19 e Generate queries by entering a date range Start and End Date and choosing the button corresponding to the query you wish to run e These listed Queries are canned queries Any queries not listed here are not available to the users unless this screen is customized by a programmer E CMT loj x Eile Edit view Insert Format Records Tools Window Help amp CMT Queries CMT Queries Start Date End Date CM Total CM Completed Encounters Calls CM Total Encounters by Diagnosis CM Clinic Visits CM Total Encounters by MO CM Home Visits CM Total CM Total Encounters by Enc Tvpe CM Total Wew Patients Referred CM Resource Time Encounters by Insurance CM Total New Pts Referred by MD Record I4 4 I Hi gt oF 1 4 A Figure 19 Page 20 of 26 CM Total Encounters Clicking on the CMT Total Encounters button will bring up the following query screen Fig 20 This query displays the number of Care Manager Patient Encounters falling within the entered date range Eile Edit View Insert Format Records Too
18. anagement Assisting Patients in obtaining Medications Financial Assistance Agreement between Physician and Patient re Narcotic use Assisting Patient with Referrals Procurement Research etc ex finding MDs or Nursing Home obtaining equipment Page 2 of 9 Care Manager Tracking Database Data Dictionary Heart Failure Actual Date Date field Date MM DD YYYY Date Patient Encounter Actually took place Outcome Drop down Completed No Show Outcome of Care Manager Patient phone Cancelled Reschedule call visit Wrong Number No Answer Left Message Letter Sent Disconnected Deceased No Answer Includes Busy Signal Call Attempts to Pts 1 2 3 4 5 Number of tries to reach Patient by Phone Total Call Time for Day Textbox Numeric No Total Length of time on phone in minutes for the day for the Encounter Resource Time Textbox Numeric No Total Time spent on any preparatory work charting travel research admin etc in minutes for the Encounter Face to face Face to face Encounter PATIENT MEDICATION Medication Start Date Date Field Date MM DD YYYY Date Medication Started Medication End Date Date Field Date MM DD YYYY Date Medication Ended Table Values MH MENTAL HEALTH INSTRUMENTS Date field Date MM DD YYYY Date MH Instruments administered recorded Check Support EM Relational Isolation Assess Isolated from available support Checkbox Patient isolated from available support Page 3 of 9
19. atients E hansen Telenhnne Contact Resnlved Show All Patients HF FI Discharge Following Reviewd Remnded Active Activity Low Salt Undrstnd Limit Light Call Date Date Meds Comp Meds Daily Talernce Weight Change Diet Diet Fluids Breathing headed Swelling Edit 3 4 2005 3 3 2005 ves res ves res Stable Moderate Gain No ves res Stable No Stable MH HF Generate isos Encounter Meds mu m Function New save Delete Clinical Nate Patient Patient Patient by Date Record I4 4 1 b I ve of 1 Figure 3 Page 6 of 26 ADDING A NEW PATIENT Search for the Patient to see if he she exists in the database Go to the Patient Search section on the right side of the Patient Information screen Enter in an ID Number Last Name First Name or Care Manager Diabetes Educator from the drop down lists to search Typing the first letter of a name will bring you to the right place in the list quickly Click the Search for Patients button You may search using a combination of fields such as a first and last name to further narrow the search Please note that once you have searched you will be seeing a subset of the records in the database For example you may search on Brown as a last name There may be several Browns in the database Check the record indicator number at the bottom left of the main Patient Information form to see which record you are on and how many records you are viewing You may see Record 1 o
20. blue Omitting these fields will generate a pop up error message when you save the form o Date Click the Save Instrument Data Button to save the record and close the window to return to the main Patient Information screen 83 MH Instruments x Mental Health Instruments Date Check Support Check Adherence Global Severity Isolated from available support Following Recommendations 1 7 4 Care Conf Unwilling to use available support Taking Medication Referred To MH Off Site Exhausted available support Seeing Therapist General Comments Plan Has available support actively using self Management Identified Goal PHO 9 Depression Mood and Anxiety Sleep Pediatric Only Symptom Coun Mood Screen Parent VanderbilE Only iF ADHD 5 E 4 3 3 H Severity Score cus vw A A everity Score 5 z P n a 1 3 10 16 19 26 27 40 41 47 46 55 Functional Difficulty Dysthymia Symptom Rating Scales Teacher Vanderbilt Only if ADHE PHO Suicide Q9 T Sx 4011010 30460 A A A A A n Suicide State Y I 10 20 10 20 n hood I Vanderbilt Comments Suicide Risk Clinician Aware 7 Mood Comments Symptom Rating Scales Follow Up Required 3x rau 100 vOO Youth 7 I 20 20 Suicide Comments ji Score Dev Dep Anxiety Comments LE Developmental Pediatric Intake Only Depression Develop Sleep Assessment
21. e off the top of your head 2 Click the Generate Clinical Note by Date button and a Clinical Note Summary Screen window Fig 10 will pop up which will summarize all events for the day you selected for that patient the record you are currently viewing Any Encounters matching that date Any HF Follow Ups recorded matching that date and ALL Diagnoses for that Patient regardless of date will appear We included all Diagnoses for an at a glance reference you may not wish to copy and paste an earlier Diagnosis that doesn t relate to the date with which you are concerned Page 14 of 26 amp Clinical Note Summary x Summary for Stevens Daniel ID Number pl HF Discharge Follow up 34 2005 Talked to Patient Discharged 3 3 2005 From DEF Hospital to Home Following Meds Yes Reviewed Compliance Yes Reminded Meds Yes Active Daily Yes Activity Tolerance Stable weight Moderate Gain Following Diet Ma Understand Diet Yes Limiting Fluid Yes Breathing Stable Lightheaded Mo Swelling Stable Instructed to Contact Provider Diagnosis 2 28 2005 CHF Specialist Benson George Status Active Diagnosis 3 30 2004 Depression Status Active Diagnosis 3 30 2004 Anxiety Status Active Record 14 4 1i F r gt oF 1 Figure 10 3 To copy the text as much as you need to transfer to another program Click inside the box where the summary appears Highlight the text you want to copy Right click a
22. elp CM Total Pat Ens aes by Diagnosis Select Query A ON OS 1 Johnson Anxiaty 1 Johnson CHF 1 Johnson Depres son 2 Thomson Deprisa J Thorn Diahat s 2 Thomsen Crhar pem Majo c renes uen Figure 22 Page 21 of 26 CM Clinic Visits Clicking on the CM Clinic Visits button will bring up the following query screen Fig 23 This query displays the number of Care Manager Patient Encounters of type Clinic Visit falling within the entered date range and the Average Clinic Visit Time with those Patients Ed CMT ETSI Eile Edit view Insert Format Records Tools Window Help CM Clinic Visits Select Query Care Mgr ID CM Last Name CM First Name Total Clinic m A Thomsen Ann Record I4 4 lk i gt oF 1 4 Figure 23 CM Total Encounters by MD Clicking on the CM Total Encounters by MD button will bring up the following query screen Fig 24 This query displays the number of Care Manager Patient Encounters falling within the entered date range sorted by Primary Care Physician Eile Edit View Insert Format Records Tools Window Help CM Total Pat Encounters E MD Select Query Hl Johnson Allen Mitch 2 Thomsen Benson George 2 Thomsen Carmen Julie 2 Thomsen Durham Terry Figure 24 CM Home Visits Clicking on the CM Home Visits button will bring up the following query screen Fig 25 This query displays the number of Care Manager Patien
23. estionnaire nine symptom checklist PHQ 9 Severity Score calculated by totaling the values for each severity question U O b o O 5 Z Level of difficulty or degree to which depression impacts daily activities ex doing work taking care of things at home or getting along with other people Functional Difficulty U s Q E o O 2 Not at all Somewhat Very Extreme Page 4 of 9 Care Manager Tracking Database Data Dictionary Heart Failure Dysthymia Checkbox Yes No No Does Patient have Dysthymia Steadman s defn A chronic mood disorder manifested as depression for most of the day more days than not accompanied by some of the following symptoms poor appetite or overeating insomnia or hypersomnia low energy or fatigue low self esteem poor concentration difficulty making decisions and feelings of hopelessness PHQ Suicide Q9 Drop down 0 1 2 3 Suicide Score based on the personal health questionnaire nine symptom checklist PHQ 9 calculated by totaling the values for each suicide question Suicide State Drop down 1 Thoughts Only 2 The state of risk for Suicide for the Patient Thoughts and Plans 3 Thoughts Plans Actions Risk High Risk Mood and Anxiety Sleep Score 40 100 Score ii 20 Sleep Assessment Pediatric Only Page 5 of 9 Care Manager Tracking Database Data Dictionary Heart Failure Parent Vanderbilt Only if ADHD Teacher Vanderbilt Only if ADH
24. f 4 if 4 Browns have been found If the current record displayed isn t the record you are looking for you can use the VCR like 4 back and forward buttons to move to the previous and next records respectively until you find the record you are looking for Please note To get back to viewing ALL Patients click on the Show AII Patients button in the Patient Search area You are now viewing ALL records in the database instead of just the subset of Browns If nothing comes up the Patient has not yet been entered into the database so click the New Patient button on the bottom of the screen to clear the screen fields and enter the Patient information Required fields are in blue Omitting these fields will generate a pop up error message when you save the form o Full Name Last and First Names o ID Number Number unique to a Patient in your organization o Care Manager Diabetes Educator o Date of Referral Click the Save Patient button on the bottom of the screen You must save the record before any other data can be entered on pop up screens ADDING DIAGNOSES ENCOUNTERS MH INSTRUMENTS ASSESSMENTS ETC Click the Diagnosis Encounter or MH Instruments etc button at the bottom left of the screen This will pop up an entry screen All records entered of that type for the Patient you are currently viewing will be retrieved Once this screen appears you will see the latest most recent date entry record of
25. ime Patient List Parameters Care Manager Table Entry lo i trative Time Information Care Manager pt zl Diagnosis Table Entry Sort By lastname inistrative Time List Facility Table Entry 8 Pan Paentiad Insurance Provider Table Entry Medication Table Entry ADA Report Physician Table Entry Patient Goal Progress Report Patient Education Progress Report Figure 11 Click Run Patient List to run the report Fig 12 aow mix Edt view Took Window Heip Patient List Care Manager Patient List Care Manager John Johnson Il Pur Der Lad Bene Fra Nat ce Phe Mier Piir ae Pe Cee eo I gps T Jere Anson Adie GOTT Carmen Aue Depression IHC Health Pins 7 Stevens Craniel active DODOOUOOD Alen Mitch amiey Madhandiers 7 Gtevent Dari Adie 00 0000 Men Mich Depresi n Halhandiers T XI ee lar Judam EISELE Aer Mich cms J Bad lera Her 10 Tennison Hew Closed BON Durham Terry Hyseligidertia Diher 14 Winston Jess Active BOQ TALAAAA Alem Mitch Depression IHC Head Plies Total Patients 5 Pee Jif aif 1 ofr H a Figure 12 Page 16 of 26 Encounter Tickler e Clicking on the Encounter Tickler button will bring up the following Tickler List Parameters screen Fig 13 The Encounter Tickler report generated is a Tickler To do list for contact by date range for Patients assigned to the selected Care Manager Diabetes Educator Eile Edit
26. ls Window Help E CM Total Pat Encounters Select Query Care Mgr ID CM Last Name CM First Name Total Pat 1 Johnson Jahn E 2 Thomsen Ann Record 14 4 1 k r gt of 2 Figure 20 CM Completed Calls Clicking on the CM Completed Calls button will bring up the following query screen Fig 21 This query displays the number of Care Manager Telephone Calls and Average Call Length for Care Manager Patient Encounters falling within the entered date range Eile Edit View Insert Format Records Tools Window Help E CM Completed Calls Select Query BB MM Care Mgr ID CM Last Name CM First Name Total Completed ak Average Call Length mins Per Encounter 1 Johnson John C 2 Thomsen Ann a Record I4 4 1 F gt I of 2 Figure 21 CM Total Encounters by Diagnosis Clicking on the CM Total Encounters by Diagnosis button will bring up the following query screen Fig 22 This query displays the number of Care Manager Patient Encounters falling within the entered date range sorted by Diagnosis Please note In the CMT database encounters are not linked with specific diagnoses Therefore it cannot be deduced that there were 6 encounters geared specifically for Diabetes management in this time period see Fig 22 Rather it suggests that there were 6 encounters within this time period with Patients who have Diabetes in the Problem List Elle Edit view jnsert Format Eecords Took Window H
27. mmer e Dates If typing in a date you must use the MM DD Y Y Y Y format 03 instead of 2003 will generate an error or click on the button for a pop up calendar e Consult the Data Dictionary and or Data Manager for your program when in doubt as to what to enter into a field Technical Programmer Use Only Following are instructions for revealing and hiding the tables of the CMT software so that programmers may customize it 1 Right click on the title bar of the CMT Care Management Menu 2 Choose Form Design 3 Right click again on the title bar of the CMT Care Management Menu 4 Choose Properties 5 Scroll down to the Form s On Load property and click on the words Event Procedure Click the button with the 3 dots 6 Change all the False booleans to True 7 Close out of the database all the way 8 Open it again 2 more times The 3rd time you should see the database window After you make your changes Please go to Tools on the main Access toolbar Choose Database Utilities and Compact and Repair Database It may take a few moments but then your windows will pop back up Repeat the earlier steps to get to the code window or in Design view of the Main Menu choose View and Code from the main Access toolbar In the SetStartUp Properties change all of the True s back to False Close out of the database and go back in 2 more times 3rd time s a charm to make sure the database window i
28. nd choose Copy from the menu Not highlighting first and just right clicking will highlight everything and save time if that s what you want to do 4 Paste the text into the other electronic charting location Open the program into which you wish to paste your Note Once you choose your Patient in that system go to where you normally enter a Note to type in or copy in information and do a Control V sequence Hold down the Cntrl key in the bottom left of the keyboard and then press the V letter key on the keyboard This 1s a shortcut to the Paste command Your electronic charting system may not let you Right click and choose Paste as we did with Copy Please Note You may also print from this screen by clicking the printer icon on the top right of the screen Page 15 of 26 General Reports Patient List Clicking on the Patient List button will bring up the following Patient List Parameters screen Fig 11 The Patient List report generated is a list of Patients assigned to the selected Care Manager Diabetes Educator This report can be sorted by first name last name diagnosis insurance PCP Primary Care Physician or status Eile Edit View Insert Format Records Tools Window Help CMT Care Management Menu Care Management Tracking Record Entry and Modification General Reports Queries Patient Information Patient List View Queries E i is Blood Glucose Meter Table Entry Patient List Admin T
29. o take all medications to the Patient s follow up appointment Is Patient trying to stay active daily How is the Patient tolerating activity since discharge Any change in Patient weight Yes No Unknown UO U 3j sg zs E Q O O O O O O x x 3 E EE O L Unchanged Stable Moderate Gain Up to 2 Ibs in one day up to 5 Ibs over optimum Significant Gain gt 5 lbs in one day Weight Loss Down gt 5 lbs since discharge Not Checked Weight has not been tracked os O w O T e O D Diet Fluid Restriction Do you understand your low salt diet Drop down Yes No Unknown Are you following a low salt diet Drop down Yes No Unknown Are you limiting fluids to 2 liters day Drop down Yes No Unknown N A N Does Patient understand his her low salt diet Is Patient following a low salt diet Is Patient limiting fluids to less than 2 liters a day N N O O O Page of 9 Care Manager Tracking Database Data Dictionary Heart Failure How is your breathing Drop down Better Stable Worse No How is Patient s breathing oevere Unknown Are you lightheaded Drop down Yes No Unknown Is Patient lightheaded owelling in the feet abdomen or Drop down Better Stable Worse No Does Patient have swelling in the feet abdomen ankles severe Unknown or ankles Instructed to contact provider non Checkbox Did Care Manager instr
30. o you understand your low salt diet M Are vou Following a low salt diet ia Symptoms How is your breathing Are vau lightheaded Are vou limiting Fluids to lt z litersfday Swelling in the feet abdomen or ankles Follow Up Instructed to contact provider non urgent Instructed to seek immediate treatment urgent Teaching seminars schedule offered Next phone call scheduled Mone other BEI Delete Follow Up Figure 8 Page 12 of 26 Function Clicking this button will bring up the following Function screen Fig 9 Enter the Function information Required fields are in blue Omitting these fields will generate a pop up error message when you save the form o Assessment Date Click the Save Function Assess Button to save the record and close the window to return to the main Patient Information screen amp 3 Function X Function Assessment Date 9 5 2006 Activities of Daily Living Score ADL Instrumental Activities Score IADL Able to da without help Able to do without help 1 Get out of bed or chair fy Y MW 1 5hap e Y M 2 Walk Ie NM 2 Use a telephone f NM 3 Take a bath or shower 7 Y M 3 Cook e Y M 4 Get Dressed e Y M 4 Travel outside the home P Y MN 5 Gn to the toilet WY NM 5 Bills Checkbook Finances Y M 6 Feed self a meal vf N 5 Housekeeping NM 7 Take medications e Y M ADL 4 IADL 3 Total ADL ar I
31. s no longer visible Care Manager Tracking Database Data Dictionary Heart Failure PATIENT INFORMATION ID Number Textbox Numeric Yes Unique Number specific to a Patient in your organization Patient s Last Name Patients First Name amp Middle Inia i desired M Male F Female PCP Phone Numeric 000 000 0000 Patient s Primary Care Physician Phone Number From Insurance No Patient s Primary Insurance carrier Defaults to Table Values Unknown if not entered From Facility Table Values NO Care Manager s Facility 1 Disconnected Avoidance Patient s Family Pattern Profile An assessment 5 D C c m O D UO A O o Q O 3 U O Q O acility FPP UO E Q e O 2 2 Confused Chaotic 3 Secured Balanced Date MM DD YYYY of the relationship pattern style that is most like the family of the patient Date Patient was Referred Assigned to Care Manager Diabetes Educator Care Manager assigned to Patient Patient s status with Care Manager Care Mgr oj o O cO D zh o o z ax From Care Manager Table Values rop down Active Closed 1X Only Status U TI NY gm D O h A D D v Deceased Moved etc Date MM DD YYYY From Diagnosis Table Values From Physician Table Values gt 4 m Z Q gt G Z O e o g D O U v D gjy Q O si O o o U Jg C0 O O O Oo o o az O o o
32. t Encounters of type Home Visit falling within the entered date range and the Average Clinic Visit Time with those Patients 10 xi Eile Edit View Insert Format Records Tools Window Help E CM Home Visits Select Query w Care Mgr ID CM Last Name CM First Name Total Home Average Home Visit Time ca 1 Johnson Jahn Record I4 4 f 1 F rs of 1 Figure 25 Page 22 of 26 CM Total Encounters by Enc Type Clicking on the CM Total Encounters by Enc Type button will bring up the following query screen Fig 26 This query displays the number of Care Manager Patient Encounters falling within the entered date range sorted by Type of Encounter Ce Sl Edit view Insert Format Recorde Took Window Hel bi IURI Pat En ounters by E Enc um Soe Quer Jihrrisar John IS Mrd 1 Johnson Jab Milenka Cantal z Thomsen A nri Chos z Thomsen A nri CM Other visi 2 Momsen An Mare Encbunlbir Holalee 2 Thomsen Pan leleprhone Conlacl reum jall 1 bir Figure 26 CM Total Encounters by Insurance Clicking on the CM Total Encounters by Insurance button will bring up the following query screen Fig 27 This query displays the number of Care Manager Patient Encounters falling within the entered date range sorted by Insurance Provider and Patient Status Eile Edit View Insert Format Records Tools Window Help E CM Total Pat Encounters by Insurance Select Query Care Mgr ID CM Last
33. that type for the current patient Be sure to click the New button to clear the screen or you will overwrite an existing record If you wish to you can navigate through these records using the navigation arrows next to the Record number on the bottom of the pop up screen if necessary Page 7 of 26 Click the Save button and close the window to return to the main Patient Information screen You will notice that the record you just entered will now automatically appear in the corresponding windowpane on the main Patient Information screen for that Patient if your database has that specific windowpane e Diagnosis Clicking this button will bring up the following Patient Diagnosis screen Fig 4 Enter the Diagnosis information Status has a default value of Active To enter multiple Diagnoses enter them separately even though they may have the same date instead of combining using the Notes field That way if one Diagnosis has a Status of Resolved and another Active they can be tracked separately Required fields are in blue Omitting these fields will generate a pop up error message when you save the form o Diagnosis Date o Diagnosis Click the Save Diag Button to save the record and close the window to return to the main Patient Information screen amp Patient Diagnosis I x Patient Diagnosis Diag Date Diagnosis i Specialist Status factive f Motes Mew Diag Save
34. trative Time List button will bring up the following Admin Time List Parameters screen Fig 32 The Administrative Time List generated is a summary report for all Care Manager database users generated from the Administrative Time Information module E CMT Care Management Menu Click Run Admin Time List to run the report Fig 33 Administrative Time Be Edit view Tools Widow Help a2 DE I 100 nagement Tracking Admin Time List state 11705 i E ndDse Waynes Figure 32 Cos E ae Care Manager Administrative Time List For Teme Period 10 02005 18 1021 2005 Care Manager Ann Thomsen Dae Meist SimtiCiric MHi DimpeterFd Case dgmt Geriatric Ed Sebesen Teaching Crug hep Team Budd PTO IMITA a a ay li u a U a LAA TA o 13 2005 n n 120 n 16212005 n 110 140 il o 1A 272005 n 0 ao a o 1112005 130 10005 ih u Totals 139 pe 200 440 12 D Pops Map 3 n a n cad Toa 1S5 rn L Figure 33 Page 26 of 26 Tips for Entry Data Integrity e Using drop downs Always drop down to select NEVER type in an entry If it needs to be added do so in Value List from the Main Menu or request a change from your database administrator progra
35. uct Patient to contact urgent his her Provider non urgent for follow up Instructed to seek immediate Checkbox Yes No NO Did Care Manager instruct Patient to immediately treatment urgent seek treatment urgent for follow up Teaching seminars schedule offered Checkbox Yes No No Did Care Manager offer to Patient a schedule of teaching seminars for follow up Next phone call scheduled Checkbox Is the next Care Manager phone call scheduled Checkbox Is no Follow up with Patient necessary Other follow up for Patient Specify Comments relating to the Discharge Follow up UNCTION Assessment Date Date Field Date MM DD YYYY Date of Function Assessment or chair without help help Shower without help without help without help meal without help Activities of Daily Living Score Values 1 to 6 Page 8 of 9 Care Manager Tracking Database Data Dictionary Heart Failure Data Element TypelControl Values Required Definition Question 1 help Question 2 telephone without help Question 3 help Question 4 the home without help Question 5 Checkbooks Finances without help Question 6 Housekeeping without help Question 7 Medications without help Values 1 to 7 Pain Score Scale 0 10 Comments relating to Function Page 9 of 9
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