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ORB 3.0 User Manual

1. 4 Y Standard Normal turgor well hydrated no rashes noted Hide To modify the default normal text SNES click in the exam text box and 2 Standard Regular rate and rhythm No clicks rubs update as needed murmurs or gallops noted No peripheral Hide edema noted Respiratory _ Standard and custom exams have eme ee n a Hide option Selecting Hide Abdominal AA removes that exam category from ee a your My Exam List noted 3 M Standard Clear to auscultation bilaterally without Head Neck 5 Standard Head Normocephalic Face symmetrical Eyes PERRLA EOMI Ears External normal ear Hide Hearing normal Mouth Lips and mucosa normal v os Use the dropdowns next to the VY Standard Alert and oriented x3 Cranial nerves 2 through 12 intact grossly No focal Hide exam text to reorder the exam neurological deficits noted 3 Musculoskeletal categ O ri es 7 I Standard Full range of motion of all extremities No joint edema Hide Eyes 8 Standard Pupils round and reactive to light A bilaterally Extraocular muscles intact Hide bilaterally Conjunctiva sclera clear v 4 The Lab Microbiology Pathology Radiology and Cardiology Tabs allow you to review n the tab s associated results and enter comments regarding the tests into the note These tabs will all function in the same manner as below A
2. oO XR PORTABLE CHEST ONE VIEW 09 25 2012 07 03 Finalized tiome MAA hove oO XR PORTABLE CHEST ONE VIEW 09 25 2012 02 00 Canceled Fj XR PORTABLE CHEST ONE VIEW 09 24 2012 07 04 Finalized Impression 1 No significant change since yesterday s exam p g ry verified and dictated View Image Icons Physician Education and Technology Services 614 566 3646 14 ORB 3 0 User Manual 4 Cardiology a Click the name of the exam to view the interpretation r es s Time Frame One Year All a Test Report Name Date Status o EKG 09 22 2012 20 30 Final oO 09 21 2012 05 45 Final o EKG 09 16 2012 14 01 Final oO EKG 09 16 2012 13 45 Final O Catheterization Report 09 11 2012 11 12 Corrected 0O Cath Procedure Log 09 11 2012 11 12 Final d Trans Thoracic Echocardiogram 09 05 2012 09 57 Final b Click on the image icon to view the actual exam image View Image Icons 5 PVL Peripheral Vascular Lab a Click the name of the exam to view the interpretation Time Frame Current Admission All E Test Report Name Date Status oO Peripheral Vascular Lab 08 24 2012 08 22 Final 6 Pathology a Click the name of the exam to view the interpretation Time Frame One Year All Test Report Name NONGYN Cytology Test Code Cancel Reason 09 18 2012 15 30 Final result verified Physician Education and Technology Services 614 566 3646 15 ORB 3 0 User Manual Clinical Views 3 Cl
3. Continue Change Delete Start Taking Edit Discharge Med Delete Start Taking Edit Discharge Med Delete Start Taking DOB 04 18 1949 Admit Date 11 22 2010 Add Discharge Medication Medications To Reconcile ADVIL 100 MG Oral daily IBUPROFEN Charted By Anne M Rhodes COUMADIN 2 MG 1 Tablet Oral daily WARFARIN Charted By Thomas J Gavin MD KEFLEX 500 MG 1 Capsule Oral four times a day Stop CEPHALEXIN Charted By Sarah L Liegl PA NASAL amp SINUS DECONGESTANT 30 MG 2 Tablets Oral Stop two times a day PSEUDOePHEDrine HCL Charted By Bradley A Bryan MD Discontinued Resolved Edit PERCOCET 5 325 MG half tablet Oral every 6 hours As Needed OXYCODONE ACETAMINOPHEN Charted By Thomas K Hunt A POSSIBLE DUPLICATE MEDICATION VICODIN 5 500 MG 1 Tablet Oral daily As Needed top HYDROCODONE ACETAMINOPHEN Charted By Karen L Hall Ay POSSIBLE DUPLICATE MEDICATION PLAVIX 75 MG 1 Tablet Oral daily Age 63 Acct 21032640001 Print Preview bes Refresh Screen Matched Hospital Medications ORB A 6 The Follow Up tab allows you to enter follow up instructions with the physicians contact information Click Search Add to add additional physicians Note The patients Primary Care Physician PCP is automatically selected if assigned by STAR To remove the patient s PCP another physician must be selected f WED 24 OCT Zzztest ZZZip PATS Time Fram
4. IV Interventions Site Reassessmnt home w family home hospice stretcher ambulance family staff discontinued unchanged observed discontinued catheter intact pressure applied dressing applied unchanged observed unchanged in bed unchanged except in bed right side observed 614 566 3646 ORB 3 0 User Manual c Select the Edit button to modify the default flow sheet at all campuses under Display Options 4 Back to ORB Admit Date 09 25 2012 fT ext View last refresh 9 56 Ce Report Eas Meee NEELS be Sort By Time M Report for Amim Ml Start On 10 19 2012 Go Back 25 Days Significant Only Hotlinks Diabetes Documentation Pain Documentation Review Critical Care Graph View SNAPSHOT D C Communication review 09 28 12 13 30 8 09 28 12 13 30 Back to Top 09 28 12 12 50 i i pi lo 47 40 E Special Events Nrsna Note Pa 1 a packet a squad personnel tot d Once updated click Save at the bottom of the page The newly selected default flow sheets will be displayed for subsequent logins Personalize CM DocView Module tule Support Name CM DocView Module vermo HPP 13 0 Code 7200851 9 EmSTAT a EmSTAT is a link into the emergency room documentation system from Westerville Riverside and Grant b If you need access please call 614 566 HELP 4357 10 ED Viewer a Provides a link to Horizon Emergency Care documentation from Dublin and Doctors Hos
5. a d OH Surgery Viewer e DH Surgery Viewer Directories amp Contact Info Medical Staff Communications Continuing Education Transfer Center Contact Info amp Directories Find a Doc On call Directory Impersonate User f Charge Capture Medical Education Riverside Medical Education Doctors Medical Education Grant Medical Education a Applications links to the following 4 Help i Charge Capture li CDI Templates iii Pharmacy Templates 5 Log Out a To close your session of ORB click the Logout button Logout How to Get Help Physician Education and Technology Services can be reached at 614 566 3646 or physiciantechnology ohiohealth com Immediate assistance is available by calling 614 566 EDOC Physician Education and Technology Services 614 566 3646 52
6. Enter the plan or click Use Previous and update the previous plan ij Diagnoses At least one codified diagnosis is required Selected Diagnoses 1 Zz PROPHYLAXIS v V Abridged Previous Some plan text Plan Step 6 aia mgp i E Add to My Dx Plan Use Previous wo Delete Physician Education and Technology Services 614 566 3646 34 Physician Education and Technology Services 614 566 3646 ORB 3 0 User Manual The ZZZ code will NOT display on the report e DOB Test Brian Arrival Date ES CEES sie Daily Progr Brief Progress Note Preview urrent Service Line is Surgery OHIOHEAL TH DUBLIN METHODIST HOSPITAL 7500 HOSPITAL DRIVE DUBLIN OHIO 43016 TEST BRIAN ACCT MR 1963213 DOB ATTENDING IMM AMY A MD ADMIT DISCHARGE Daily Progress Note Date of Service 01 23 2014 Clinician LAS Header for Progress Notes Serice Line Surgery This report is to be considered preliminary and subject to revision until electronically authentica Assessment and Plan 1 PROPHYLAXIS Some plan text updated today t Step 7 Objective 35 ORB 3 0 User Manual Appending a Note 1 When logged into ORB and in the patient s record select note that you would like to Append _ Time Frame One Year All Note Type M ED ADM Consult Daily DC Completed By O Consult 06 30 2010 14 16 Final Matt P Simpson AIC MHP Surgery O 06 30 2010 14 15 Matt P Simpson AIC MHP O
7. a Quick FRR CA 19 9 Pancreatic Cyst Fluid 06 12 2009 10 33 Canceled Charge Capture g Quick EBM CEA Pancreatic Cyst Fluid 06 12 2009 10 32 Canceled eForms ePrescribing Clinical Navigation Patient Profile Orders r Medications gt Phys Reports gt Studies gt Result View Clinical Views gt Microbiology ae Order canceled by LIS Order canceled by LIS View Print Fax b Click on the trend icon to view serial values for the selected lab result S c Quick View Click the quick link to open pop up a window with a hover feature mn ew _Time Frame SUEN CBC without Diff Status Final result verified 3 Results View a This filtered view gives the ability to view and trend analytes Cell Count W Diff CSF D Dimer Ferritin Collection 09 27 2012 05 14 Accn 12270001155 a Item Value Range Units go WBC 14 17H 4 50 11 00 K meL RBC 3 35L 4 00 5 20 M meL 0 Hemoglobin 9 2L 12 0 16 0 g dL Fi Quik View Hematocrit 28 1L 36 0 46 0 pm MCV 83 9 80 0 100 0 fL s MCH 27 5 26 0 34 0 PG f MCHC 32 7 31 0 37 0 g dL RDW CV 13 2 11 6 14 8 Platelets 181 150 400 K mcL MPV 10 9 90 155 fL The above 10 analytes were performed by Riverside Methodist Hospital 3535 Olentangy River Rd Columbus OH 43214 Source Blood 06 01 2011 13 53 C Tube Tube 3 C Color CSF Straw C Appearanc e CSF Slightly Hazy C Xanthrochr
8. iPad iPod Touch Apple dev ices If you do not yet have an ORB ID submit an d 4 application using one of the forms to the right They are issued per user according to need and Request an ORB ID are randomly audited to confirm eligibility Android HIPAA Regulations require OhioHealth to limit Complete form s and fax to OhioHealth at papagi z access depending on the user s job 614 544 6918 responsibilities Because of the sensitive nature of ORB data your office cannot share an ORB ID i pplicatior gt and access should be terminated when no longer click to Download Blackberry Windows amp Other Biackberry Windows and all other needed smartphones click to launch Have questions Physicians and their staff Terminate an ORB ID should call 614 566 EDOC 3362 All others call 614 566 HELP 4357 If an employee no longer requires access iPhone iPod touch and iPad are to ORB termination changes in job registered trademarks of Apple Inc Android is a responsibilities or leaves of absence please trademark of Google Inc Use of this tradernark call 614 566 EDOC 3362 to place a user is subject to Google Permissions Portions of this termination ticket routed to Information page are reproduced from work created and Security Access Management shared by Google and used according to terms described in the Creative Commons 3 0 Attribution License This platform does not include Synapse images E
9. 09 27 2012 06 48 Finalized Radiology O 09 26 2012 23 00 Finalized Radiology Fi za ee 09 25 2012 07 03 Finalized Radiology Fi XR PORTABLE CHEST ONE VIEW 09 25 2012 02 00 Canceled Radiology Fi XR PORTABLE CHEST ONE VIEW 09 24 2012 07 04 Finalized Radiology c Click on the image icon if listed to view the exam image f Pag 4 Test Report Name Date Status Result Type oO XR PORTABLE CHEST ONE VIEW 09 27 2012 06 48 Finalized Radiology 0O XR ABDOMEN KUB FLAT PLATE 1 VIEW 09 26 2012 23 00 Finalized Radiology O0 E XR PORTABLE CHEST ONE VIEW 09 25 2012 07 03 Finalized Radiology 3 Radiology a Click the name of the exam to view the interpretation Click on the image icon to view the actual exam image The impression for that study will appear next to the status column Note if you do not see an impression verify the status of the study Time Frame One Year All d Test Report Name IMPRESSION 1 Slight interval decrease in size of the right pleural effusion 2 No pneumothorax 3 Impro F 09 27 2012 06 48 Finalized aeration in the right upper lobe There is relatively stable right basilar atelectasis or consolidation and ther left midlung atelectasis 3 Right diaphragmatic elevation 4 Increasing small left pleural effusion SAY sm Fi 09 26 2012 23 00 Finalized RESSION No acute process identified 2 2 gs IMPRESSION Persistent large effusion on the right with right upper and lower lobe airspace disease Stabli f
10. Brief Daily Note 06 30 2010 14 15 Final Matt P Simpson AIC MHP Surgery O Daily Progress Note 06 30 2010 13 40 Final Matt P Simpson AIC MHP Surgery O H amp P 06 30 2010 13 30 Final Matt P Simpson AIC MHP Surgery F Discharge Instruction 06 29 2010 14 30 Final F Discharge Summary 06 29 2010 14 30 Final John L Binkhorst MD F Consult 02 25 2010 13 12 Final Janell D Harvey Crowl ORB QA Hospitalist Fi H amp P 02 25 2010 13 11 Final Janell D Harvey Crowl ORB QA Hospitalist 1 The note will open Click the Append button Anne M Rhodes JE ORB Report Cose Zzztest ZZZiP MRN 21963352 DOB 04 18 1949 63 Fax Bee 1100 0 E BIBS BB l commen al g 9 1 am Daily Progress Note gress Date of Service 10 15 2012 Page1 of 1 Clinician gress gress Eai Service Line Womens Health 7 gress lote Assessment and Plan END abdominal pain fe s p exploratory laparotomy 2 Click on Manage User Defined Text p ed Anne M Rhodes ORD Report o o Zzzte st Zzzip swe z1063392 04 18 1949 3 C vas a amp E ja om by B e Connenent oss alert and ononmiod x3 jor Extremities No chubieng Cyanoss of edeme noted Physician Education and Technology Services 614 566 3646 36 ORB 3 0 User Manual 3 Create your user defined text This is where you can create your multiple phrases for the type of notes you will be appending Q wo2Goc 9CV s o Advan
11. Click here for additional help My Exam head Skin Get Most Recent Exam dated 11 4 2011 2 04 04 PM Cardiovascular Pont Previous 3 Exam Neurological Musculoskeletal 1 Sof nontender nondistended normal bowel e ee a ay sounds No palpable organomegaly or masses a Today s noted Exam w Delete Comment c The My Exam List can be customized to meet your preferences by clicking Manage Current Physical Exam New exam categories can be added and or existing categories can be modified Click here for additional help Get Most Recent Exam dated 11 4 2011 2 04 04 PM Abdominal Previous Exa 1 v f Soft nontender nondistended normal bowel Be Normal sounds No palpable organomegaly or masses 6 dee Today s noted Woun Exam iw Delete Extremities Fa eal Physician Education and Technology Services 614 566 3646 26 ORB 3 0 User Manual Close Manage My Custom Exam List Click Add New Exam Category to Use this page to manage your preferences for My Exam You may add new edit reorder hide and unhide exam j 5 add an exam category to yo ur My ied by ORB Iti the first time you have accessed this page this list will include all standard exam categories w help i Exam List Upp include any custom exam categories that you have ad wick here for additional a Add New Exam Category head was successfully deleted Skin
12. Patient Education ePPO References ppetatens Maps amp Directions Up To Date ePrescribing Natural Standards Chart Completion atura andar Laboratory Test GE Centricity EMR pram es Efillable Forms EAA PE Ep DynaMed OH Surgery Viewer ynalvie DH Surgery Viewer Directories amp Contact Info Medical Staff Communications Continuing Education Transfer Center Contact Info amp Directories Find a Doc Physician Education and Technology Services 614 566 3646 20 ORB 3 0 User Manual Queries 1 Onthe ORB 3 home page the CDI and Pharmacy queries assigned to either you or your groups folders will appear under My Work Click one of the links to view the queries a Queries Assigned to Me are queries assigned specifically to you b Queries Assigned to My Group Folders are queries assigned to one of your physician groups OR is associated with a patient in one of your folders You can edit your shared folders through this icon on the ORB home page My Patients My Work 186 General Patient Search con Medical Record Deficiencies T My Watch List a Signatures Needed 8 Queries Assigned to Me E Queries Assigned to My Groups Folders 2 Select the Review button next to the query you want to review For the queries in the My Group Folders category only respond to the ones associated with your patients Queries Assigned to Me Ode Jr Brad P Nutrition Abnormalities 420 4203 01 M S 09 17 2008 0826140003 Od
13. SHORTNESS OF BREATH 03 14 Mec SWRNOANMF AIP AM OVWNCAnr mam rewvneas ALLL 4 amp 4 LUJLUH UVUL Procedure Details Procedure s Performed Required Add Procedure Specimens Removed Required L Operative Findings Refer to Pathology Report for Final Diagnosis Required Composite List Comprehensive Plan View Previous Encounters EBL Required Diagnoses Previous Diagnoses My Diagnoses List for Anne M Rhodes and Medicine Dx SORE THROAT 11 04 2011 Dx 786 05 SHORTNESS OF BREATH 03 1 Dx SYNCOPE NEAR SYNCOPE PRESYNCC 03 14 2011 Dx 784 0 HEADACHE 01 17 2011 Composite List Dx 692 9 CONTACT DERMATITIS 09 05 Mw 277 4 OTHED ANN LINGDECTETEN Physician Education and Technology Services 614 566 3646 ORB 3 0 User Manual 3 Complete Diagnosis field by choosing a documented diagnosis on the right or by typing a codified diagnosis code or description 4 Check mark type of anesthesia utilized for procedure 5 Intra and Immediate Post Op Complications and Post Operative Note are free text fields 6 Complete operative report should be dictated EBL Required Diagnoses Select Diagnosis r a v M Abridged Type of Anesthesia C General Mask ETT LMA Cl Local with Sedation J Intravenous Sedation Dx 784 0 HEADACHE 01 17 2011 Composite List Dx 692 9 CONTACT DERMATITIS 09 05 2012 Dx 272 4 OTHER AND UNSPECIFIED HYPERLI
14. Signatures needed on ORB notes and unsigned orders iii CDI queries or review v Draft notes v Pharmacy queries b Click on the line to process item 10 Fax Status Physician Education and Technology Services 614 566 3646 ORB 3 0 User Manual a By clicking on fax status a screen will appear with a list of all faxes sent in the past 5 days ORB Report o 0 Close Fax Status 7 EB de allij ty T List G hie OhioHealth Fax Status Patient Name Med Rec Type of Fax Date of Fax Fax Status 11 Patient Management folder Gg icon will attach the patient to your census folders watch list and or detach the patient Once a patient is attached or detached a popup will appear letting you know the patient was either added or detached from your census Patient was added to your Census 12 Printer icon a i View reports sign out memos patient list facesheets Fi 13 Paper Pencil icon i Batch print view of the Pre Anesthesia Evaluation eForm 7 Note The Help button is available throughout ORB 3 Click on the Help button to get information about the current section Search Options 1 Click inside the Patient Search box A Mon oct Paares tees Seer en er 2 Using the Advance search option type in the patient name and click Search sity ws E t lernt ote a Fasiliti ine cstectecd 3 From the search results cl
15. amp SINUS DECONGESTANT 30 MG 2 Tablets Oral two times a day Patient Cough Bradley A Bryan M PSEUDOePHEDrine HCL 9 23 2011 1248 Last verified by Bradley A Bryan MD on 9 23 2011 12 48 b Type in the name of the medication dose form quantity frequency last taken 200 MG Tablet Unknown Tablet Chewable Unknown Tablet jose im lt lt 4 To highlight beta blockers on the home medications a Click on the gear next to Create Medication Order button Current Home Medications Home Medications Audit Trail af Pharmacy Express Edit Create Medication Order This is an active admission m gt z Ra b Select the Show Beta Blocker option Close Beta Blocker Beta Blocker Show Beta Blocker c Select the Save and Close button Physician Education and Technology Services 614 566 3646 10 ORB 3 0 User Manual Physician Reports 1 Click Physician Reports on the toolbar This will provide links to physician reports including history and physicals consults operative reports and emergency room reports plan view and rounding report Click on the report name to view the full text The time frame will default to current admission on reports Note if the patient is not currently an inpatient All Notes will default to ALL 2 All Notes List of all transcriptions and ORB created documentation EDO List of all ED reports from OhioHealth facilities H amp
16. by clicking on the name of the note or delete the note completely Physician Education and Technology Services 614 566 3646 32 ORB 3 0 User Manual My Diagnosis Codified Diagnosis Tool 1 Create a Daily Progress Note Brief Daily H amp P or Consult note in ORB 2 Select the A amp P Tab 3 Select the My Diagnosis tab 4 Select Manage 5 Enter the desired Codified Diagnosis in that field You may enter text and select a provided diagnosis or you may enter the ICD 9 code E Daily Progress Note Ea Pilzen soa g Disagree C Daily Progress Note 564 9 ACUTE RENAL FAILURE SYNDROME Ml Abridged iy Pe E Daily Progress Note Disposition Or Comm 7 Whew CJ Pre Op Note Plan i Abridged a oses sasa Procedure Note Angina 413 9 Ci Fimme Atypical chest pain 786 59 PAIN Quick Not v 7 _ Total adsida Fii AVNRT Chest discomfort bid G Quick Ne PI ome tc C ty 786 50 t cuet rolitis 123 9 E Daily P N f y Pr o 7 ee Select Diagnosis Chest pain on a ee CI Brief Daily No gt j che Zl Abridged a mr Brief Daily Note hest pal bak og g Briet Daly Ne aza Brief Daily No A aa Brief Daily N 6 Once a codified diagnosis has been entered you may also modify the description and or enter a plan that will be saved with that diagnosis 7 Once you have created a codified diagnosis and plan click Dx Plan to enter it in any subsequent note gt AGMINE VALS Lisa ea Daily Progress Note ra
17. clicking the red Delete link A weo DM oct DOB 04 18 1949 Age 63 Close Zzztest Zzzip Admit Date 11 22 2010 Acct 21032640001 E Zzztest Zzzip Jolan Dx Meds F U Diet Instr Disp Addi Allergies DCiReview DCS Review Daily Progress Note Add Procedures Selected Procedures Entered from Progress Notes Studies Primary MAn Soe slid dues Edit Delete Time Frame One Yea s in proper postion lumbar discectomy View z 2 v 10 13 11 cardioversion Edit Delete n ee et se abdominoplasty View a ee ET Total Knee Arthroplasty View v 3 10 11 11 TAVR Edit Delete a Report Type oO Daily Progress Note d Daily Progress Note oO Daily Progress Note O Daily Progress Note F Daily Progress Note 0O Pre Op Note Procedure Not a TE Add your own procedure edit selected procedure s ia Quick Note go Quick Note Quick Note a Fi Driant Naikhe Mata 4 The Meds tab contains home and hospital medications that must be reconciled prior to discharge Click Reconcile to create the patient s discharge medications DOB 04 18 1949 Age 63 Close Zzztest Zzzip Admit Date 11 22 2010 Acct 21032640001 L Dx Proc Meds F U Diet Instr Disp Addi _ Allergies DCiReview DCS Review Medications Name Dose Route Frequency Please continue taking these medications per your pr
18. i Meds F U Diet _ Instr _ Disp i Addl Allergies DCi Review DCS Review Add Diets Selected Diets Select from the following 2 gram sodium Edit Delete No restrictions a Home Diet a Diabetic 8 The Instructions tab allows for entry of standard and custom care instructions Select the service line then procedure to add standard instructions Additional instructions can be entered using the text box You can create custom instructions for future use by selecting Save as Custom red Delete link A WED 24 OCT Zzztest ZZZip Hx OPA DS Time Frame KETENE lacie 1 2 3 AS67858 9 0 Report Type Daily Progress Note Daily Progress Note Daily Progress Note Daily Progress hlo Daily Progress Note Pre Op Note Procedure Note Quick Note Quick Note Quick Note Daily Progress Note me fee em m img eee fee fee m Brief Daily Note One Yea after entering your text Remove unwanted instructions by selecting the DOB 04 18 1949 Age 63 Admit Date 11 22 2010 L Acct 21032640001 Addi Allergies DCi Review DCS Review Next select Procedure CHF Heart Failure Close Zzztest Zzzip Dx Proc Meds F U Diet Disp Add Instructions Select Service Cardiac be stem Data DataRowView Add your own instructions s or edit the selected instruction s Add Manage Custom Instructions Selected Instructions If you smo
19. patients By hovering on this button a drop Chart Chart Deceased a Test Registration Test Downtime O Testbarcoder Iii Riverside A TNR TN12 01 Test Bloodbank Test I Am Test I Am A Test Centricity1 3 E Test Centricity Two Test Grady Test I Am A Testbarcoded Sr Doctors A TND TN2 01 Playd Heo TND TN3 01 Zzztest Zzzip 777test 777in TNR TNO4 01 M S Patient search can be done from the header by entering the patients name medical record number or account number The advanced search options are still available Name MRA Acct a Advanced el Note If you search on an older account number and the patient also has a current admission in a bed or in the ED you will get a warning that the patient has a current admission and have an option to switch to the current admission 8 Select your service line Set up your signature customization Set up your email notifications Set up your fax for discharge summaries H amp Ps and consult notes allows you to adjust your user preferences aop Physician Education and Technology Services 614 566 3_ ORB 3 0 User Manual 8 My patients a This is your default patient list i To set up a default patient list 1 Select My Folders 2 Select the folder you wish to be your default census O FRIY Avec i Mame MRN Acct Reg Adwanced ES overing Provider 28 See UU Mrunal Shah MD Amb FPT Family Practice Pa
20. required O Yes ONo NA Services Required 7 Home Health Aide Is patient aware of diagnosis Yes No C Medical Social Worker Is patient aware of prognosis Yes No Nursing Occupational Therapy Physical Therapy F Speech Therapy Save or click on any other tab 10 The Addl tab allows for free text entry of any additional information you would like to include on the Discharge Instructions ae 5 DOB 04 18 1949 Age 63 Close Zzztest Zzzip Admit Date 11 22 2010 Acct Z1032640001 ol Dx Proc _ Meds FU Diet A Instr Disp Allergies DCi Review _ DCS Review Add any additional information Additional Information None Add Physician Education and Technology Services 614 566 3646 42 ORB 3 0 User Manual 11 Allergies previously documented will cross over automatically to the Discharge Instructions Additional allergies can added if indicated CI DOB 04 18 1949 Age b3 Close Zzztest Zzzip Admit Date 11 22 2010 Acct Z1032640001 ol Dx _ Proc Meds F U Diet _ Instr j _ Disp Addl S i i ptes Add an Allergy Selected Allergies Allergies Reaction Search on aspirin Rash hives Cy Penicillins Hives Added Allergies Reaction None Added Allergies listed here have been added for the Discharge Instruction report and de Add your own allergy persist in the patient s medical record To associate these allergies with the patient
21. the diagnosis code is selected Diagnosis and Plans entered previously will display in the Diagnosis List for selection Enter Disposition or comments via free text Face to Face counseling and Critical Care time can also be entered via the A amp P Tab 29 ORB 3 0 User Manual 8 The Preview Tab allows you to review and print the note Once you are satisfied with the note you can select Approve to finalize and approve the note Zzztest Zzzip DOB 04 18 1949 Age 63 Admit Date 11 22 2010 Acct 21032640001 Daily Progress Note z Rad Card 0 Meds 13 Trans 9 A amp P Preview Current Service Line is Medicine Y ou can choose to OHIOHEALTH A th t DUBLIN METHODIST HOSPITAL 7500 HOSPITAL DRIVE pprove e No e DUBLIN OHIO 43016 ZZZTEST ZZZIP ACCT Zz1032640001 now or Save as MR 21963352 DOB 04 18 1949 ATTENDING NO PHYSICIAN MD ADMIT 11 22 2010 Draft to complete at DISCHARGE Pending a later time Daily Progress Note Date of Service 10 29 2012 Clinician Anne Rhodes A E cos Approve Note Along with Sign Approving the note You are approving the Daily Progress Note as you can Approve amp Submit Charges This will take you Warnings into Charge Capture Physical Exam has not been completed Please review for the patient after Click Approve to ignore these warnings and approve the note Click Close to return to the note and make changes the note appro
22. 2640001 H amp P History Phys Exam Labs 0 Micro 0 Path 0 Rad 0 Card 0 Meds 13 Trans 18 A amp P Preview Past Surgical History can be entered via the text boxes A reference for prior procedure notes will be shown if available Past Surgical History Past anesthesia history Allergies Enter patient allergies by typing in RS 4 the Allergies selection field e Allergies selections will populate Add your own allergy Add Reaction if known a en as you type If your selection is es ae not available you can add your Comments own allergy to the patient list CII have reviewed the patient s allergies L ee Home Medications 7 Ollowing list of home medications from the report The patients Home Cl Show only home medication names on the report HOME MEDICATIONS Name Dose Quantity Route Freguenc Medications will be listed 1 LISINOPRIL LISINOPRIL 5 MG 1 Tablet Oral daily a 2 OXYCODONE OXYCODONE 15 MG Oral for your review You can 3 SYNTHROID LEVOTHYROXINE 25 MOG 1 Tablet Oral daily 4 XANAX Alprazolam 2 MG Oral Pump daily AS NEEDED also select Express Edit to 5 YELLOW JACKET TREATMENT Yellow Jacket Venom 0 12 MG Injection systemic add Or edit home 6 ZOCOR SIMVASTATIN 40 MG 1 Tablet Oral Pump two times a i r day AS NEEDED medications 7 ZOCOR Simvastatin 20 MG 1 Tablet Oral systemic Changed Comments The Social Hi
23. 9 25 14 50 9 25 22 54 9 26 07 40 9 26 08 26 9 26 11 37 9 26 15 33 9 26 20 00 9 26 22 52 9 27 08 01 9 27 15 08 Vitals 09 24 2012 09 25 2012 09 26 2012 09 27 2012 Temp 99 97 2 97 1 97 101 1 100 8 100 8 99 5 96 9 97 Pulse 2 95 99 84 90 108 96 91 88 a8 Resp i4 16 17 16 i6 i8 i6 16 20 O2 Sat 90 91 93 93 93 89 92 94 93 95 O24 02 142 156 99 137 118 140 155 144 143 B P 71 81 52 70 60 69 66 64 80 Weight 54 800 kg 120 834 Ib Height 61 in 154 94 em 9 25 2012 Intake amp Output 201 201 09 27 2012 DAY NIGHT TOTAL DAY NIG OTA N TAL DAY EVE NIGHT TOTAL Intake 20 200 320 Outpe Net 2 200 320 Gluce el 09 25 2012 21 10 09 1211 6 20 17 26 09 26 2012 2 01 09 27 2012 9 21 TS hoo ener ania A 5 eget eae 6 Chemotherapy a This provides a consolidated view for when and what facility a patient received treatment T Trend View Physician Education and Technology Services 614 566 3646 16 ORB 3 0 User Manual a This link takes you to McKesson Physician Portal to view clinical documentation from Care Organizer and MUSE 4 Back to ORB Admit Date 09 25 2012 ED Trend View last refresh 9 29 Report for ee ea z Report Nursing Documentation b Time Interval Exact Time Significant Only M Start On 10 19 2012 Go Back 20 Days Column Display Max 14 Hotlinks Diabe
24. G ORAL EVERY 4 HOURS AS NEEDED N A Exclusive Acetaminophen g Active Tylenol Equiv 650 MG NG TUBE EVERY 4 HOURS AS NEEDED N A a an tan rr m miee venia seran m mmis a anmannan amn eee nn inr innan 6 The Transcriptions Tab lists results and reports for the selected encounter Add a check mark to indicate results have been reviewed Additional comments on the indicated reports can be entered as well Save As Draft Save amp Continue H amp P History PhysExam Labs 29 Micro Path Rad Card Meds 25 Tas _Re ry Phy Current Service Line is Medicine Results transcriptions Reviewed Additional Comments Report Type Date Status Service Code Dictated By View Emergency Dept Physician Note 09 26 2012 00 38 Transcribed Medicine ROBERT J GRAESSLE DO View Consultation Note 09 25 2012 12 54 Final Medicine Naveen Singn MO View ED Assessment Sheet 09 25 2012 04 22 Final Medicine Robert J Graessle Do View ED Summary 09 25 2017 04 22 Final Medicine Robert J Graessle Do View ED Transition Summary 09 25 2012 04 22 Final Medicine Robert Graessle Do View History and Physical 09 25 2012 03 31 Final Medicine David L Condon MD COPC Physician Education and Technology Services 614 566 3646 28 ORB 3 0 User Manual 7 The Assessment and Plan Tab allows for entry of the patient s diagnosis and treatment plan aes Sa Ses oa Approve Perpetual Assessment Differential Diagnosis Diag
25. GMIt Date e AC EEE Save As Draft H amp P History Phys Exam Labs 29 Micro 3 Path 0 Rad 1 Card 4 Meds 25 Current Service Line is Medicine i 7 Results C Labs Results Reviewed lf all exams in a test tab have Additional Comments been reviewed you can l select Lab Results Reviewed You can also enter additional acai comments via the free text Reverse Chronological default Chronological Test Name Critical t Abnormal Abnormality Reference range unspecified box Collection Date Study Name Item Value Range E 09 27 2012 04 18 Phosphorus added per 61438 Phosphorus 2 2L 2 8 4 1 mg dL The above 1 analytes were performed by Riverside Methodist Hospital 3535 Olentangy River Rd Columbus OH 43214 OOOO Each Test Tab will also allow you to see the reported ee results and select only Chloride 98 8 108 mmol L Bicarbonate 25 21 32 mmol L individual results for review Anion Gap 14 10 20 mmol L Glucose 94 65 99 mg dL documentation BUN 21 8 25 mg dL Creatinine 4 02H 0 60 1 20 ma dL eGFR 11L 61 589 mL min 1 73 m2 E 09 27 2012 04 18 Chem 7 The eGFR should be used for monitoring renal function only and 00000000000 not for medication dosing Physician Education and Technology Services 614 566 3646 2 ORB 3 0 User Manual 5 The Medications Tab lists the patients current hospital medications H amp P History Phys Exam Lab
26. HROMBOSIS lt gt Important Information Edit test Include Anti Coaqulation Flowsheet View lt 8 To approve the Discharge Summary select the DCS Review tab and select Approve Y DCi Review Hosp Course i DCs Review The Discharge Summary is unsigned Allergies Procedures Discharge Medications Anti Coaqulation Flowsheet and Condition at Discharge sections of this report will be updated automatically to ensure cu information FETT T TS N T TTT Physician Education and Technology Services 614 566 3646 44 ORB 3 0 User Manual Editing and Creating Folders in ORB 1 To edit any folders you can hover over the Show Folder icon A list of all your folders will appear in the dropdown There is a pencil icon beside editable folders in the folder hover list clicking on the pencil lets you edit the folder 0 Va Name MRN Acct RON Advanced Q a Add Folder Mrunal Shah MD Amb FPC Family Practice Riverside Family Practice My Watch List 0 Covered Patients C Fovering Provider 29 2 The gear G next to your folder name allows you to edit the folder icc Test Registration 06 03 2009 02 06 1985 27 Joseph Ruan close Manage Folder s Folder Properties Pi ider Name test patients Folder Ic 19042 e Folder Type Public Privata Created By Todd J Grieshop Created Date 09 26 2008 13 43 F C Automatically remove patients when discharged ay F This
27. Jefferis Kristina B Eader Click on the Covering Providers name on this list to bring up their contact information Close Covering Prowiderts Starting 11 28 2012 from 15 50 23 00 Daily Kristina B Eader Medicine 555 5555 This is a test Call main number if you do net recerne a return call frorm me 2 The Covering field in the Patient Header will contain Provider entries depending on whether any coverage is present or currently active Arrival Date Location Attending Melilla Jason MD 11 19 2012 3LD 3200 01 Covering Kristina B Eader The Covered Patients folder will only show your list of covering patients This will appear in your folders list O weo oO R nov EOE My Folders amp E Mrunal Shah MD Amb FPC Family Practice O Testbarcoder River cc 5 OBES Testbarcoded Doctor cc L5 ave Zertest Zzzip Riverside Family Practice Mh Watch List Covered Patients MMedicine Covering Folder 3 If you do not see the Covering column appear on the patient list display click on the gear icon E and add it to the Current Fields list Physician Education and Technology Services 614 566 3646 49 ORB 3 0 User Manual Charge Capture 1 Under Resources select Charge Capture or from the Charge Capture link on the patient s navigation toolbar O Resources w TEST Feedback Resources Nurse Betty DOB 01 0 HOF A erring Physician Too Fax Status Preprin
28. KGs Order Entry or scanned medical records Questions Please contact the OhioHealth Help Desk at 614 566 EDOC 3362 3 Enter your username OPID 3 letters 3 numbers Example abc123 and password 4 Select the Login button 5 The first time you log into ORB you will need to fill out the Electronic Signature with Credentials Any changes to your electronic signature can be completed in User Preferences Electronic Signature Full Name and Credentials are required and will be used as your electronic signature for documents signed in ORB Full Name Required Required Physician Education and Technology Services 614 566 3646 ORB 3 0 User Manual Home Screen Once you have logged into ORB your home screen will appear Customize your view by selecting the gear next to My Patients Oo on H L7 to donna cy FEB 4 2013 Logout 1 7 The gear next to your name My Patients My Work aA Mrunal Shah MD ES Medical Record Deficiencies a My Watch List B Signatures Needed Queries Assigned to Me C Queries Assigned to My Groups Folders The home icon Q will bring you back to this page The quote icon will take you to your work and show the number of deficiencies you have The folder icon E take you to your folders and folder maintenance T The people icon ae down will appear 27 Pi Ee Close test patients will displays your
29. Lt Dorsal Bespiratory Therapy Resp Fu Respiratory Protocol 09 12 10 50 11 23 12 10 12 50 tesp Basel entilator Flowsheet breath Soum AD Documentation All Fields Ban Review old 92 Saturati toom air2 tesp Patte PT Documentation Text View a By clicking on Trend View this link takes you to McKesson Physician Portal to view clinical documentation from care Organizer 4 Back to ORB 8 09 25 2012 it Dat Poe Te View Inst refresh 9 56 QD C Report Nursing Documentation Review Sort By Time v Report for Start On 10 19 2012 Go Back 25 Days O Significant Only Refresh Hotlinks Diabetes Documentation Pain Documentation Review Critical Care Graph View SNAPSHOT D C Communication review 09 28 12 13 30 Beck to Top 2 212 en SE PERE Special Evente nrang Note Pg 3 A i aaa 09 28 12 11 23 7 home w family home 09 28 12 10 50 Discharged hospice 09 28 12 09 12 Discharged Via stretcher ambulance asi Accompanied By family staff 06 35 09 28 12 12 50 Beck to Top 05 45 Cardiac Function Cardiac Monitor discontinued 09 28 12 04 04 ActivtyExercse09 Activty Baseline unchanged 09 28 12 02 02 Resting Sleeping observed 09 28 12 01 36 discontinued catheter Iv Therapy PeripheralSite 1 IV Interventions intact pressure applied dressing applied 09 28 12 12 10 Beck to Top Activtylixercseo9 Activty Baseline unchanged Resting Sleeping observed IV Therapy PeripheralSite 1 Site Reassessmnt un
30. Note Rad 0 Card 0 Meds 0 Trans 10 A amp P Medicine All Memos Sign Out Memo Pharmacy Query Physician Status Automatic Drug Stop Order Mrunal Shah MD Pending Composite List _ Comprehensive Plan View Previous Encounters eee Previous Diagnoses My Diagnoses c If there is a query on the patient a message will also appear on each tab when composing a note Approve Subj PhysExam Labs 0 Micro 0 Path 0 Rad 0 Card 0 Meds 0 arming Clinical Documentation Query is pending review Cli Pharmacy Quer is pending review Click here to Respon Service Date Service Line Date 04 19 2013 Medicine mm dd yyyy Chief Complaint Reason for Visit Subjective TT Physician Education and Technology Services 614 566 3646 ORB 3 0 User Manual Completing Notes in ORB 1 Under the Create menu select Notes then the type of note you wish to create Murse Betty DOB 01 01 1900 113 Arrival Date Location Attending I MEM L917881 Acct O38 76030045 4T1 4102 01 Covering La Create Clinical Nawiqgation gt Problem List Daily Progress Discharge Orders b Cuick Consult Brief Daily Charge Capture eForms Pre Operative ePrescribing Post Operative DChntical Mawtqgatiom Procedure Patient Profile eForms Select an eon Orders La 2 The first tab in the Progress Note or Consult will be t
31. ORB 3 0 User Manual ORB 3 0 User Manual Physician Education and Technology Services 614 566 3646 ORB 3 0 User Manual Table of Contents Downloading ORB For Remote ACCESS cccssccceececeeeeceeeeceeeeceuceceeeeseeeseeeseeeeseeeenees 3 Logging into the Remote Desktop cccceecceccceeeceeeeneeeceeeeaueeseeeseeeeeueeseeeseeesueeaeeeneess 3 LO CIGD MO O RB ie ccccereteaermcercecrentt erdeeeeiacier EEEE EEEE AEE EES EREA E EEEE EEEE 4 POMES CTO eee ne eee ee ene ee ee ne ee ee ee ee 5 CEOD TONE eee ene ee en ee ee eee ee eee eee 7 Patient Name Bale ls accgeccxcnesecvecnacensiconsvenswensdexenewedexeesxedaveysicetinceesnedatenexeGevewene eusweneeeeeesee 8 PATEROS teas aiceeectatcacs 9 Current Orders cccceccceecccececeececeueecececeueeseueeseueeseceseueessueeseueeseueetausessueesaueessueetneensees 9 MEGI CUON ie esses cece tastes E E E ERT 10 PAYSAN RODO renea RERE RRR 11 EE o e E A A EE 12 SUG SS aserrean A E A A sean 14 ACTON aaa A A AA 16 Medica ROCO arere raresep 19 EE e E E E N ENET 21 Completing Notes in ORB cccccceccccsseeeeeeeeceeeeeseeeeeseeeeeseeseeseeeesseeesseeeessaeeesaaeeesaaes 23 GCOmpleting a Preoperative NOG ai iciriecwsccesusraccmguaranaeaeevardscuasaneenexeawdestewacdeavasarcecewsedneee 31 Completing a Postoperative note ccccccccseecccseeeeceeeeeceeeeeceeceeseeeesseeesseueessaeeesaaeeesaaes 31 My Diagnosis Codified Diagnosis TOOl ccccccccccseececeeeeeee
32. P Progress notes Pre Op and Post Op notes Procedure notes eForms Discharge Discharge Instructions Discharge Summaries CY Create Phys Reports gt All Notes Notes Time Frame One Year All Discharge gt eee Date Status Completed By Appended iuas a Consult 04 19 2011 15 35 EDU MedStudent Test User Only Charge Capture 0 H amp P 04 19 2011 15 28 EDU MedStudent Test User Only eForms Precrrihinn 3 Plan View a This view is broken up by service line displaying perpetual assessment diagnosis and plan and disposition comments Approved Date Type 02 25 2010 i es i sSSS Consule Hospitalist wi ORB QA ime you sit down to cheese Surgery Matt P Simpson AIC MHP t gt e 4 Rounding Report a This PDF report pulls documentation for the past 2 days medications studies for the past 2 days and labs for the last 24 hours and nursing documentation for the past 4 days Physician Education and Technology Services 614 566 3646 11 Labs ORB 3 0 User Manual 1 Click Labs on the toolbar Use the Search functionality to find a specific test The time frame will default to current admission on labs Note The drop down list has all tests that have been completed on the patient 2 All Labs a Click on the name of the test to view the reported result Acie Time Frame One Year All Search type to sec f test Discharge t Test Report Name ie
33. PIDEMIA 08 08 2012 Dx 584 9 ACUTE RENAL FAILURE UNSPECIFIED 08 08 2012 Dx 401 1 BENIGN ESSENTIAL HYPERTENSION 08 08 2012 Dx 799 02 HYPOXEMIA 08 08 2012 Dx 564 00 CONSTIPATION 08 08 2012 El Local Only C Spinal C IV Regional Block Dx 530 81 GASTROESOPHAGEAL REFLUX Fresi E adjuncti l Eleni DISEASE 08 08 2012 Regional Block Adjunctive Epidural Epidural Dx 491 21 ACUTE EXACERBATION OF CHRONIC El Other OBSTRUCTIVE AIRWAYS DISEASE 08 08 2012 Dx 518 81 ACUTE RESPIRATORY FAILURE 08 08 2012 Dx 585 6 END STAGE RENAL DISEASE 08 08 2012 Dx 250 00 DIABETES MELLITUS TYPE 2 Post Operative Note 08 08 2012 Dx 786 59 ATYPICAL CHEST PAIN 08 08 2012 Intra and Immediate Post Op Complications Dx 411 1 ACUTE CORONARY SYNDROME 08 08 2012 Dx 682 9 CELLULITIS 08 08 2012 Dx 453 40 ACUTE DEEP VENOUS THROMBOSIS 08 08 2012 Nv 415 19 PII MONARY FMRANI TSM NA NA 7N1 d If you have chosen to Save as Draft or toggle the unapproved note will show under the Create then Notes Daily Progress 01 30 2013 13 23 H amp P Quick Discharge Orders b Consult Brief Daily Charge Capture eForms Pre Operative ePrescribing Post Operative linical Navigation 9 Procedure Patient Profile eForms Select an eform Current Orders e Select the Notes button to approve or delete the note f From this screen you can choose to edit the existing note
34. S OF BREATH 03 14 20 Da SYNCOPE NEAR SYNCOPE PRESYNCOPE 03 14 2011 Dx 764 0 HEADACHE 01 17 2011 Composite List Dx 692 9 CONTACT DERMATITIS 09 05 2011 Dx 272 4 OTHER ANO UNSPECIFIED HYPERLIPIDEMIA 08 00 2012 4 ACUTE RENAL FAILURE UNSPECIFI 08 08 2012 Dx 401 1 BENIGN ESSENTIAL HYPERTENSIOT 12 Dx 799 02 HYPOXEMIA 08 08 2012 Dx 564 00 CONSTIPATION 08 08 2012 Dx 530 81 GASTROESOPHAGEAL REFLUX DISEASE 08 08 2012 1 Click Add Procedure and enter procedure name in text box aoe ey ep AGMIT VATE LijZZf ZU1U Post Operative Note ACCT Z1LUSZ04UUUL Post Operative Note Preview Service Date Service Line ig Date 10 19 2012 ii Medicine mm dd yyyy Physicians Surgeon Required Anne M Rhodes Assistant Physician Names Only Required if Assistant was present Procedure Details Procedure s Performed Required Add Draza ra Specimens Removed Reg ired Composite List Comprehensive Plan View Previous Encounters Operative dings Refer to Pathology Report for Final Diagnosis Required 2 Complete the Specimens Removed Operative Findings and EBL fields by entering free _ text These fields are required Post Operative Note Preview AUNI Vole LL LL LULU Post Operative Note Previous Diagnoses My Diagnoses List for Anne M Rhodes and Medicine UEET Dx SORE THROAT 11 04 2011 Dx 786 05
35. and pertinent findings noted System Reviewed Comment System Reviewed Comment Constitutional Skin Eyes i ENT cv F Resp ca o cu p Musc Neuro Endo a Heme Lym Allergy Psych Add System Se _ arn Check the applicable All Results Reviewed Ra Results Reviewed C Microbiology Results Reviewed This can be completed C Pathology Results Reviewed on individual tabs as o Radiology Results Reviewed well o Cardiology Results Reviewed C Pertinent Medications Reviewed C Transcriptions Reviewed eS ee Agmit Date 11 22 2U1U ACCT 410326040001 Save As Draft Save amp Continue H amp P History PhysExam Labs 0 Micro Path 0 Rad 0 Card 0 Meds 13 Trans 18 A amp P Preview Past Medical History No Past Medical Problems Past Med ical History can be Prior Diagnoses d b Dx CONTACT DERMATITIS se ecte y Dx OTHER AND UNSPECIFIED I HYPERLIPIDEMIA enteri ng a Dx ACUTE RENAL FAILURE i UNSPECIFIED Diag NOSIS Into the Dx BENIGN ESSENTIAL HYPERTENSION Select Diag nosis Dx HYPOXEMIA Dx CONSTIPATION field or selecting Dx GASTROESOPHAGEAL REFLUX DISEASE from Prior Dx ACUTE EXACERBATION OF CHRONIC OBSTRUCTIVE D i ag noses AIRWAYS DISEASE Physician Education and Technology Services 614 566 3646 24 ORB 3 0 User Manual eh ELLI Admit Date 11 22 2010 Acct Z103
36. ave been added will be displayed on the right side WED OCT DOB 04 18 1949 Age 63 Q 24 Close Zzztest Zzzip Admit Date 11 22 2010 Acct Z1032640001 L Zzztest Zzzip P i a 5 Y i i A D Proc Meds F U Die Instr Disp Addi Allergies DCiReview DCS Review Add Diagnoses Selected Diagnoses BP Diagnoses entered through Progress Notes Primary Heart Failure Edit Delete Time Frame OneYeaq ABDOMINAL PAIN 789 00 F MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRE Mi CHF st 234567809 10 CONTACT DERMATITIS 692 9 3 V HTN Edit Delete p 7 a OTHER AND UNSPECIFIED HYPERLIPIDEMIA 272 4 he o d Report Type Filter by Specialty 4 v DVT Deep Vein Thrombosis Edit Delete F Daily Progress me 5 w Stroke CVA Edit Delete 0O Daily Progress Note iaa a oO Daily Progress Note d Daily Progress Note go Daily Progress Note d Pre Op Note o Procedure TEM your own diagnosis or edit selected diagnosis es F Quick Note Fi Quick Note Add F Quick Note O Daily Progress Note Physician Education and Technology Services 614 566 3646 38 ORB 3 0 User Manual 3 Add Procedures performed during this encounter You can select a procedure from the specialty filters or enter you own Procedures selected will be added to the patient list on the right Procedures can be removed by
37. bmitted charges A Close Charge Capture Process m i 1 h Process Enty Manage Group af Manage Group Codes Manage My Codes From Date 91 28 2013 mm dd yyyy Physician Aj To Date 01 28 2013 mm dd yy Patients ay State Unprocessed id Group All Print Report Charg e Patient rge Patient Name Physician E Comments Group Name Location Date gt El asm Tonan er 3EV 316 02 My Group Adm 01 14 2013 Physician Education and Technology Services 614 566 3646 51 ORB 3 0 User Manual Resources 1 Applications links to the following a b OO g Eprescribing i Call Physician IT Services at 614 566 3646 for access and training Chart Completion i See Medical records GE Centricity i Link to GE Centricity EMR eFillable Forms OH Surgery Viewer DH surgery Viewer Transfer Center 2 Resources a Provides links to commonly used physician resources 3 Admin O E ie A oe a Feedback Resources Give FeedBack z aE z z z Referring Physician Tool Krt Patient Safety amp Qualrty Research amp Reference Fax Status Preprinted Orders cy aos OhioHealth Libraries l Practitioner Reports Fax Status Report Printable eForms MicroMedex aiiai Forms Patient Education ePPO References F PP Pane Maps amp Directions Up To Date ePrescribing Matural Standards Chart Completion ees abor sts GE Centricity EMR ania el Efillable Forms a an
38. ce Zzztest Zzzip ORB Report AT Anne M Rhodes close Zzztest ZZZip MAN 21963352 008 04 18 1949 63 4 6 amp 1 103 G zE N amp G PK E Comment Time Frame BU mn a a DOB 04 18 1949 Age 63 Coxe Zzztest Zzzip Admit Date 11 22 2010 Acct 21032640001 bi Addendum Report Daily Progress 0 Off Progress Note User Defined Addendum Text main your custom user defined text for use in the Addendum screen Use this tool to mair Daily Progress Daily Progress Daily Progress Pre Op Note Procedure Nof Quick Note Quick Note his my Consult text Quick Note Daily Progress Brief Daily Not Brief Daily Not Brief Daily Not Brief Daily Not Brief Daily Not Brief Daily Not e pfe fede fee efe fede fede efe Brief Daily Not Canaral hla armita dietenee alert and ariantad w 4 Click Update when ready to save To add additional user define text options select Add New Text 5 Click Select User Defined text to add text 6 Edit text within box A WED 24 OCT p OC Bi Name MRN Aca BBY PR Zzztest Zzzip ORB Report n AL Cose Zzztest ZZZiP MRN 21963352 DOB 04 18 1949 63 LA Compose 1 ag Dle eeh Bel B 6XA GB i Comment Time Frame Current Admissiot ee Close Zzztest Zzzip Admit Date 11 22 2010 Acc 71032640001 d Report Type O Daily Pr
39. changed 09 26 12 11 23 Back to Top ActivtyExercse09 Activity in bed 09 28 12 10 50 beck to Top Activty Baseline Activity unchanged except in bed Activtylxercseo9 b Select the documentation type from the drop down and select refresh CF Cedit Text View Report Sort By Time Report start Days O Significant Only Hotlinks ESSN Wound Review htation Review Critical Care Graph view SNAPSHOT D C Communication revie PSA Review GAJAJ EE npatient PACU eto Top 09 28 09 28 09 28 09 28 09 28 09 28 09 28 09 28 09 28 09 28 09 28 09 28 requent Checks SardioVascular Services rocedure Checklist onitor Sedation Review PAS Dialysis Dialysis Review PRISMA Review D C Communication review Bafety with Checks PICC Insertion Review mmunization Review accination Review emodynamics Review Patient Education Review ransfusion includes vitals ransfusion mo vital signs lan of Care espiratory Review espiratory Protocol Review ENT Review AD Review PT Review PT Review BT Flowsheet Review bpeech Language Cognition Discharged cto Top cto Top cto Top Activity cto Top ctivity urm ischarged via Accompanied By PeripheralSite 1 rsng Note Pg 1 ardiac Monitor ctivty Baseline Resting Sleeping ctivty Baseline esting Sleeping PeripheralSite 1 Activty Baseline Resting Sleeping Physician Education and Technology Services
40. current hospital medication list The time frame will default to today You can pull reports based on administration schedule or the medication list All home medications are documented here 2 Hospital Medications a Click on the name of the medication to view medication administration schedule Encounters 09 16 2008 Inpatient Riverside Reports 1 28 2013 GJ Administrations Schedules List Status Start Date Medication ri Active 09 18 2008 DOPAMINE 400 MG DSW 250 ML PMX INTRAVENOUS INTRAVENOUS 09 18 2008 14 39 Ej Active 09 18 2008 gt SODIUM CHLORIDE 0 9 INTRAVENOUS INTRAVENOUS 09 18 2008 14 39 Co Discontinue 09 18 2008 DOPAMINE 400 MG D5W 250 ML PMX INTRAVENOUS INTRAVENOUS a Discon tinue 09 18 2008 SODIUM CHLORIDE 0 9 INTRAVENOUS INTRAVENOUS Pj Cancelled 01 15 2009 ASPIRIN 325 MG ORAL ONCE A DAY ORAL ASPIRIN co Cancelled 01 15 2009 CLEOCIN IN D5W 600 MG INTRAVENOUS EVERY 8 HOURS INTRAVENOUS CLINDAMYCIN D5W Fi Cancelled 01 15 2009 DIGOXIN 125 MCG ORAL ONCE A DAY ORAL DIGOXIN E Cancelled 01 15 2009 FUROSEMIDE 40 MG ORAL EVERY 24 HOURS ORAL Penne sfdmenmensse FUROSEMIDE Current Home Medications X Home Medications Audit Trail y Pharmac vi Express Edit Quantity Route Frequency Charted By Verified COUMADIN 2 MG 1 Tablet Oral daily Thomas J Gavin MD WARFARIN 7 23 2012 02 55 Last verified by Thomas J Gavin MD on 7 23 2012 09 55 DCi j Verified NASAL
41. e One Yea 2345678 9 10 Report Type Daily Progress Note Daily Progress Note Daily Progress Note Daily Progress Note Daily Progress Note Pre Op Note Procedure Note OOOA0DO0OR Quick Note DOB 04 18 1949 Cl i Age 63 Close Zzztest Zzzip Admit Date 11 22 2010 Acct 21032640001 Dx Proc Meds Diet Instr Disp Addl Allergies DCiReview DCS Review Physicians from ORB Mrunal Shah MD ORB Attached Add Judson Jr Millhon MD ORB Attached Add Karanvir Grewal MD ORB Attached Add Search Add Selected Physicians Name Type Instructions Phone Fax Fax To DMH Foot and Ankle Clinic Clinic Call for appointment 614 544 8102 Edit Delete Orthopedic Foot and Ankle Center Specialty Call for appointment 614 895 8747 Edit Delete Physician Education and Technology Services 614 566 3646 40 ORB 3 0 User Manual 7 Select the Diet indicated for the patient A WED 24 OCT Zzztest ZZZip x OPA DS DOB 04 18 1949 Age 63 Time Frame One Yea 34567 Report Type Daily Progress Note 8 9 10 Nm Daily Progress Note Daily Progress Note Daily Progress Note Daily Progress Note Pre Op Note Procedure Note pee ee ee ee iy Niel Mata Heart Healthy Diabetic and Heart Healthy Add your own diet or edit selected diet Add Close Zzztest Zzzip Admit Date 11 22 2010 Acct 71032640001 Dx Proc
42. e Jr Brad P One for Todd 420 4203 01 M S 09 17 2008 0826140003 Ode Jr Brad P Anemia 420 4203 01 M S 09 17 2008 0826140003 Ordersnsg Dana Automatic Drug Stop Order ICD 382 01 02 20 2009 0905110005 Registration Iii Otis Nancy Test Template 3T 3104 01 06 14 2006 0616530024 Synrrdip One Acute Renal Failure 45 4026 02 08 21 2009 0923330017 Review Test Pharmfive Pneumonia Clarification 5TC 5103 01 05 22 2009 0914230054 p Upghlab Rmhadult Automatic Drug Stop Order 3H 3310 01 09 01 2010 0827530005 3 The query review window will open a Review the query and choose either Agree or Disagree b Be sure to update your response documentation in the progress note regardless of agreement Do not select agree disagree on a patient if you are not providing care for this patient Anemia Mrunal Shah MD Pending 12 20 2012 16 37 lf you believe the patient has anemia or another diagnosis please document the type of O Disagree ee E anemia in the progress notes Agree Hemoglobin Hematocrit Transfusions given Examples Acute blood loss anemia Hemolytic anemia Aplastic anemia Iron deficiency anemia Chronic blood loss anemia Pancytopenia Other Les Mt A ma Oe eee 4 Queries can also be responded to from the following locations in ORB a Clinical Navigation gt Queries tab Physician Education and Technology Services 614 566 3646 21 ORB 3 0 User Manual b Assessment and Plan tab while documenting a note Daily Progress
43. eeeesesesseeeesseeeesseeeesaeeeeeas 33 APDO NGING IN OU atic staat ats teed pad uiataienahaeised iaieen sid brinaaeieens ouelahanoteiauga ets ietoaskeaawee set sinuree ata 36 Completing the Discharge WSIFUCUONS wicccceccccscersceccespsiesosexecasscacasecceanaseceeaiecesersseeaseress 38 Completing the Discharge Summaries ccccseccccseeeeceeeeececeeseeeeseeeesseeeessaeeesaeeesaees 44 Editing and Creating Folders in ORB cccccccccceeceeceeceeeeeceseeeeeseeeeessaseeseeeesaeeesaeess 45 Covering PrOVIGEL cccccccccceecceceeeeeseeeeeseeeeeaeeeeeseeceeaeeeeseeeeeseueeeseeeeesaeessaeeessaeeesaeeesaaes 47 Viewing the Covering Provider TOO c cccccccseccecesceeeeeeesseeeesseeeessaeeeseeeeeseeeesaeeesaaes 49 onare GPU eee nee ee ee ee eer er ee eee eee eee eee 50 RESOUrCeS ira eeareceaeeeatseaacnatiena inne aeenaqemanssaaehineraquniesaneanceeunecahsedaereleataecehoeteanetinnehaacheaunesaneaants 52 FOW TO Gt Hel Deeriin EEEE ee ee 52 Physician Education and Technology Services 614 566 3646 ORB 3 0 User Manual Downloading ORB Remote Access 1 Goto news ohiohealth com to download the OhioHealth desktop 2 Click on the Green download button 3 Enter the server ohconnect ohiohealth com Logging into the Remote Desktop 1 Click on the VM Ware icon on your desktop 2 Ensure the connection server is ohconnect ohiohealth com and select connect YAware View Client vmware E3PColE VMware View 5 Enter the hos
44. escribing physician COUMADIN WARFARIN 2 MG 1 Tablet Oral daily Start taking these medications KEFLEX CEPHALEXIN 500 MG 1 Capsule Oral four times a day PERCOCET OX YCODONE ACETAMINOPHEN 5 325 MG half tablet Oral every 6 hours AS NEEDED Opiavix CLOPIDOGREL 75 MG 1 Tablet Oral daily Ovicopin HYDROCODONE ACETAMINOPHEN 5 500 MG 1 Tablet Oral daily AS NEEDED STOP taking these medications NASAL amp SINUS DECONGESTANT PSEUDOePHEDrine HCL 30 MG 2 Tablets Oral two times a day Resolved Unreconciled medications ADVIL BUPROFEN 100 MG Oral daily One Time Medications No one time medications have been given ee Click to see today s MAR Vaccination Screening Physician Education and Technology Services 614 566 3646 ORB 3 0 User Manual 5 Home medications will show in the top left hand side medication in house the medication will display to the right of the home medication Hospital only medications will display in the bottom right hand side For each medication select the appropriate option Continue Change Stop or Start Taking When complete select Close lf the patient had continued that Close Zzztest Zzzip tj Add Home Medication ontinue Change O Stop Continue Taking Edit Home Med Delete Reset Continue Taking Continue O Change O Stop Edit Home Med Delete Reset Start Taking Edit Discharge Med Delete Stop Taking
45. he History Tab We will walk through completing the history tab in the following steps 4ZZUeSt 4ZZIp l Admit Date 11 22 2010 Acct Z1032640001 Select the Date and a Service Line this can _ be set as a default in E Date 10 11 2012 E2 Medicine User Preferences mm dd yyyy History Phys Exam i Labs 0 i Micro 0 i Rad 0 Selected Physicians Search Add Include Name Type Phone Fax Fax To In Report Fj Karanvir S Grewal ORB 614 262 6772 614 358 8350 F P fw MD Attached Fi Judson S Jr Millhon ORB 614 262 6772 614 358 8350 Fi P fw Attached O Mrunal Shah MD ORB 614 566 5414 614 566 6842 Fj P w Attached Physician No MD Attending P fw 7 amit Enter the P d f PRO nter tne Froceaure Referring Ordering id di d indicated Procedure Name mm dd yyyy iin diene a t Enter the Chief Fa History of Present Illness Complaint Reason for Visit The History of Present Illness can be entered via the free text box Physician Education and Technology Services 614 566 3646 23 ORB 3 0 User Manual Pre rue D DN olof l M G N A ie ee HAP History Phys Exam Labs 0 Micro 0 Path Rad Card Meds 13 Trans 18 A amp P Preview Check the applicable systems reviewed Comments can be entered for each system Review of Systems The ROS section has been updated to meet CMS regulations C unobtainable The following systems were reviewed
46. hysician Education and Technology Services 614 566 3646 45 ORB 3 0 User Manual 4 Tocreate a new folder a Select the add folder icon on the top header of the screen then select Add Folder daa F Give Feedback My Patients amp ae Mrunal Shah MD FR KR Aas VAS Ateh I ict b Select the create button under create new folder Close Add Folder Add an existing Folder Add c Enter the name of the folder in Folder Name field d Mark Folder Status public e Enter name of physicians that needs to share folder in Sharing Options and add to Shared User List f Save folder gt ovyv Folder Physician Education and Technology Services 614 566 3646 46 ORB 3 0 User Manual Covering Provider The Covering Provider Tool in ORB 3 allows all users the ability to easily view the Covering Providers for patients that have not yet been discharged The covering provider s for a patient are shown in the patient list display column called Covering and also in the patient header when viewing a single patient When viewing the covering provider you may click on the name of one of the providers to view the details about all providers currently covering the patient These details include the provider s specialty when they are covering contact information and any additional information A folder may have several covering providers such as individuals with different s
47. ick Clinical Views on toolbar This will provide links to Clinical Summary Interdisciplinary Trend View Text View EmSTAT and ED Viewer Click on the report name to view the full text The time frame will default to last 48 hours on reports 4 Clinical Summary a Defaults to the last 48 hours b Clinical Summary Contains All ORB created notes c Transcriptions d Labs e Cardiology f Radiolog DOB 11 12 1954 58 Arrival Date Location A c MRN 1917035 Acct 0826130027 17Z 1110 04 Covering is Orders oO Consult 04 19 2011 15 35 EDU Progress Note MedStudent Test Charge Capture o Consultation Note 04 19 2011 15 35 Final Transcription MedStudent Test eForms Bi H amp P 04 19 2011 15 28 EDU Progress Note MedStudent Test ePrescribing oO History and Physical 04 19 2011 15 28 Final Transcription MedStucent Test Chir I Navigati Patient Profil Orders 5 Interdisciplinary a Select Interdisciplinary b Popup window with graphic view of vital signs and input output c Below the nursing documentation clinical nutrition occupational soeech amp physical therapy social work wound Hospice documentation can be found d Close the window by clicking on the X in the upper right corner Temperatures cl B Farenheit 103 0 102 1 102 0 4 7 0 101 0 4 S 90 8 100 8 100 100 0 99 6 lu 99 b 99 0 4 98 0 4 2 gt 7 2 97 1 9 6 9 87 97 0 4 o o 96 0 t t t t t T t 9 25 03 50 9 25 07 54
48. ick on the patient s name link General Patient Search is Ea Sign Out Physician Education and Technology Services 614 566 3646 ORB 3 0 User Manual Patient Name Banner 1 The patient name banner has quick reference icons eee ee ee ef JAN 31 2013 wp wee INUIDE De ty DOB 01 01 1900 113 Arrival Date ocation Attending Imm Amy A MD Hx A MRN 1917881 Acct 0826030045 4T1 4102 01 Covering a History kezd icon i This will show you a list of encounters Patient History Encounters Merge History Arrival Discharged Facility Class Service Acct MRN Corp ID 09 16 2008 17 07 Admit Riverside Inpatient Medicine 1917881 03958139 08 29 2008 10 14 Admit Riverside Inpatient Medicine 0824230004 1917881 03958139 b Patient indicator icon i The patient indicator will turn red if the patient has tested positive for C Diff CRE ESBL MRSA VRE or if they have been designated a difficult airway patient amp Close Patient Indicators c Allergies A icon i By clicking on the allergies icon shows a quick summary of all the allergies with a detail link Clicking on the details link show the full PDR report Nurse Bett x Allergies View Details Demerol 2 S co aO e Te L mA e Comune pa Allergy Information ore li The Allergy button will appear A if allergies have been documented iii The allergy button will appear NKA if no Known al
49. is a Cov ering Folder w Folder Sharing Search Users 2 h EIR Dolor Kessl s i Ret Murchland PI 3 To move patient from one folder to another folder a Select the box next the patients name you wish to move 7 General Patient Search 449 EB amp View Frais a Sign Out ro Ne Page 1 of 2 results 1 to 350 of 449 NP Accenx Labip 3H 3306 01 06 12 1953 59 CAR Allison Pond 1855227 0722231756 Ainstructor Karen 45 4022 01 11 21 1954 58 Amy Imm 1917067 0826230031 Asoft Testone 4W 4214 01 09 08 1988 24 Donna Diaz 1962751 0916330016 Baddrug Riverside 37 3134 01 01 20 1954 59 Carl Backes 1750336 0616630008 Baldwin Jean W 1Z7Z 1110 01 04 19 1946 66 Xiaomei Gao Hickman 1670614 0520931368 OBS Beckibiller Test 4W 4219 01 06 21 1951 61 SUR Michael Mcshane 1961258 0908630040 O e b Select the Manage Patient icon 7 test patients See Cer eee View EEEN Sign Out a Patient Name Admitted DOB Attending Covering MRN Acct E ce Chart Chart Deceased 08 09 2007 01 01 1900 112 Peter Pema 351583 0722131283 c Select Move to a folder then the folder s name k kh Attach To Census Add to Folder 08 09 2007 01 01 19 test covering 06 03 2009 02 06 1985 27 Joseph Ruane AEE 520553 Move to Folder 08 07 2009 01 01 1932 80 Susan Daab Krzykowski 968768 0921930914 d The patients are now listed in the selected folder P
50. ke it is recommended that you quit If you ora family member would like to quit smoking tobacco cessation counseling and nicotine replacement products are available at NO COST from the Ohio Tobacco Line at 1 800 QUIT NOW Additional outpatient tobacco cessation therapy is also available in Columbus from a Certified Tobacco Treatment Specialist at Sowing Hope For information call 614 505 6040 or e mail drmitchell sowinghope com Physician Education and Technology Services 614 566 3646 41 ORB 3 0 User Manual 9 The Disp tab allows for entry of disposition information Select the location the patient is being discharged to Select the Condition at discharge The Medicare Face to Face Encounter box should be checked for any home health patients Referral to a post acute provider can be entered as indicated H l DOB 04 18 1949 Age 63 Close Zzztest Zzzip Admit Date 11 22 2010 Acct Z1032640001 s Dx Proc Meds F U Diet Instr Addi Allergies DCiReview DCS Review required field Disposition Discharge patient to Home Health ss v C Medicare Face to Face Encounter Certification documentation is required for this patient Condition At Discharge Good v Referral to M Enter your own Phone Fax Level of care v Mental Status Prognosis v Rehabilitation potential Estimated Stay v Medicare certification
51. lergies have been documented Physician Education and Technology Services 614 566 3646 ORB 3 0 User Manual iv The allergy button will appear A if no allergies are documented d Sign out Memo E icon i Provides basic patient information and will be visible once a patient is admitted and until 72 hours post discharge of vetive Merve Memo Hi r Mame taet t zesty DOM 478s ae tan t hwre E li Data entered in the same fields as progress notes will automatically appear in the Sign Out Tools Data in both places is presented based on patient selected and user s service line The shared fields include This was previously known as the Sign out Memo It is shared with progress notes Reason for admission This data is shared with progress notes Perpetual assessment This data is shared with progress notes Disposition This data is shared with progress notes e Mom Baby icon i This allows the toggle between mother and infant Patient Profile 1 Click Patient Profile on the toolbar This link takes you to a list of all OhioHealth encounters 2 Clicking on an encounter will display the facesheet for the encounter Current Orders 1 Click Orders on the toolbar This link takes you to McKesson Physician Portal to view current orders Physician Education and Technology Services 614 566 3646 ORB 3 0 User Manual Medications 1 Click Meds on the toolbar This populates
52. mation for the first time or edit what has already been added a Covering Provider Name and Specialty are defaulted from User Preferences however they can be changed via the dropdown b Once the Contact and Additional Information fields are added they will pre populate when that provider is selected in subsequent fields c Start date and time default to current close Add Covering Provider Covering Provider Kristina B Eader Covered Specialty Contact Information 555 5555 Additional Information This is atest Call main number if you do not receiwe a return call from me Start Date 11 28 2012 FEA Start Time 15 28 D End Time End Date Selecting Daily indicates coverage for each day during the designated Start and End times Physician Education and Technology Services 614 566 3646 48 ORB 3 0 User Manual Viewing the Covering Provider Tool 1 Covering Provider is listed in the Patient View if their coverage is active during the time of the Patient View display The Manage Covering Folder Patient List View EZ Test patients Views Sign Out link is also available in the Gj Manage Covering Folder d E New Cc 3LD 3200 01 11 19 2012 Jason Melillo Kristina B Eader C New cc 5 3NC 3249 10 11 14 2012 Angela Isbel Kristina B Eader E New cc X 3TN 3150 03 11 17 2012 Ann Aring Kristina B Eader EC New CC 4 3TN 3150 10 11 19 2012 Melissa
53. n Quick 7 CA 19 9 Pancreatic Cyst Fluid 06 12 2009 10 33 Canceled 06 23 2009 15 03 Order canceled by LIS Quick 2 CEA Pancreatic Cyst Fluid 06 12 2009 10 32 Canceled 06 23 2009 15 03 Order canceled by LIS c When you select the Print button A PDF of all the selected studies will populate There is also an option to fax from this view MEREN e DOB LOR 10s E a amp amp eZ Test Culture Urine Aerobic Collection 08 31 2012 14 51 Source Urine Cath Indwell Site AC CNS ae Status Final result verified item Range Units URINE AEROBIC Specimenrt Urine Catn Incdweil Collected OoB s73a1ivseoics 14 51 Status rinnal Last Updated o mir torrea Ce ee 1 imina d Select the fax button to fax the report s to a physician Send and stay will allow you to enter additional providers without reopening the fax window Physician Education and Technology Services 61 13 ORB 3 0 User Manual Studies 1 Click Studies on the toolbar Click the name of the exam to view the interpretation Click on the image icon to view the actual exam image The time frame will default to current admission on reports 2 All Studies a This view will list all radiology cardiology PVL and pathology b Click on the name of the exam to view the interpretation Time Frame One Year All 2 Pagel of 2 results 1 to d Test Report Name Date Status Result Type oO XR PORTABLE CHEST ONE VIEW
54. noses At least one codified diagnosis is required Select Diagnosis v Mabridged Disposition Or Comment Time Total time spent with at least half in face to face counseling 7 Direct Critical Care Time f Minutes AUMIL UALS LLZ ZULU Save As Draft Save amp Continue H amp P ALLL 2LU ZU Sign Out Memo 11 04 2011 14 04 Medicine Elaine Dunn Mrunal enan MLE Composite List Comprehensive Plan View Previous Encounters Previous Diagnoses My Diagnoses List for Anne M Rhodes and Medicine Manage Dx Dx Plan SORE THROAT 11 14 Dx Dx Plan dle HORTNESS OF BREATH 03 14 2011 Dx Dx Plan SYNCOPE NEAR SYNCOPI PRESYNCOPE 03 14 2011 Dx Dx Plan 784 0 HEADACHE 01 17 Composite List DX BOSG 19 05 Dx 272 4 OTHER AND UNSPECIFIED HYPERLIPIDEMIA 08 08 2012 Dx 584 9 ACUTE RENAL FAILURE UNSPECIFIED 08 08 2012 Dx 401 1 BENIGN ESSENTIAL HYPERTEN 08 08 2012 Dx eM O XEMIA 08 08 2012 Dx 564 00 CONSTIPATION Smaa Dx 530 81 GASTROESOPHAGEAL REFLUX DISEASE 08 08 2012 Dx 491 21 ACUTE EXACERBATION OF CHRONIC OBSTRUCTIVE AIRWAYS DISEASE 08 08 2012 Dx 516 81 ACUTE RESPIRATORY FAILUR Physician Education and Technology Services 614 566 3646 The Perpetual Assessment is a free text entry box Diagnosis is a required field All diagnoses entered must be codified To search by ICD 9 code select Abridged You may edit a diagnosis description once
55. ocedure Code s EESE Ss User Group Code ke Modifier s Help Me Choose 99234 Admit amp Discharge Same Day 99235 Admit amp Discharge Same Day 99236 Admit amp Discharge Same Day l Diagnosis 36140 Art Line Radial 427 31 Atrial Fibrillation n 75572 Calcium Score with contrast 75571 Calcium Scoring w out contrast 92960 Cardioversion 76937 3655 Central Line Placement with Ultrasound Consultation 99252 Consultation v Select the procedure code by either typing in the number or part of the name or using the drop down Enter any modifiers or use the Help Me Choose feature Process Entry Manage Group Manage Groug Important Charges submitted in the ORB2 version do not transfer stop entering charges in ORB2 If you have an office manager or bil configured Arrival Date 1 14 2013 1 26 00 AM Admit Date Group Name My Group Anne Rhodes l Charge Date 01 28 2013 mm ddiyyyy l E M Code s Tune to Search for a E M Code Help Me Choose Modifiers Help Me Choose a Select the type of modifier by placing a check mark in the box Physician Education and Technology Services 614 566 3646 50 ORB 3 0 User Manual b Once the code type has been selected click on the Select amp Close button CodeType Description Unrelated post op visit or Would need to be controlled by previous CPT charge entry ranges from 1000 to 6000 s or pop up with each entry Qualifies sepa
56. ogress Addendum Report Fi Daily Progress y som ia oO Daily Progress Select User Defined Text Manage User Defined Tex oO Daily Progress men User Defined Text F Daily Progress consult 0O Pre Op Note Fi Procedure Not F Quick Note gog Quick Note E E Quick Note Fi Daily Progress Fi Brief Daily Not oO Brief Daily Not 0O Brief Daily Not E o Brief Daily Not J v F Brief Daily Not a E oO Brief Daily Not M Brief Dailv Not Sblecive PERAE EE AT EE E E DO EEE E iP 7 Click on Approve when finished Physician Education and Technology Services 614 566 3646 37 ORB 3 0 User Manual Completing the Discharge Instructions 1 Under the Create menu select Discharge select Discharge Instructions Nurse Betty DOR 01 01 1900 113 Hx A MEAN 1917881 Acch 0876030045 Ei Create Phys Reports gt All Notes Note Type i Date Tienes One Year All Time Frame Discharge Instructions Order Discharge Summar Orders _ TPO 06 30 2010 14 1 Charge Capture C H amp P 06 30 2010 14 1 eForms Rrief Daile Note NA S0 2010 14d 2 The Dx tab will list any diagnoses completed in ORB documentation Select to adda diagnosis to the patient s discharge instructions by clicking on the diagnosis You can also search for procedures by selecting the filter drop down Finally you can enter additional diagnosis by typing your selection in the bottom text box Diagnosis that h
57. omia Mild CJ RBC CSF 13H C Monocytes CSF OL 06 20 2011 04 11 2011 09 01 13 53 Details Details CO B Dimer 1 90 lt 0 19L 07 11 2011 05 11 2011 09 04 09 04 Physician Education and Technology Services 614 566 3646 Range Unit Colorless Clear Negative o meL 0 5 meLl 0 4 40 80 15 45 A Range Units 0 19 2 00 mg L FEU Range Units 12 ORB 3 0 User Manual 4 Microbiology a Click the name of the exam to view the interpretation mm yg _ y Test Report Name Cancel Reason O Culture Body Fluid Aerobic 09 18 2012 12 35 Final result verified Fj EER MRSA DNA Probe Amplified 08 31 2012 18 59 Final result verified CI Culture Urine Aerobic 08 31 2012 14 51 Final result verified b Click on the trend icon to view serial values for the selected lab result 1 D Trend icon 5 To Print or Fax a study a Select the studies you wish to be printed or faxed by placing a checkmark in the box next to the study s name Labs gt All Labs Time Frame One Year AIl Test Report Name Cancel Reason Quick 7 CA 19 9 Pancreatic Cyst Fluid 06 12 2009 10 33 Canceled 06 23 2009 15 03 Order canceled by LIS Quick 2 CEA Pancreatic Cyst Fluid 06 12 2009 10 32 Canceled 06 23 2009 15 03 Order canceled by LIS b Select the Print or Fax button Labs gt All Labs Time Frame B MiCne Cinisrum One Year All Search type to search fora test View Print Fax Test Report Name i Cancel Reaso
58. pecialties and or different work shifts Creating a Covering Folder E 1 From the ORB Home Page hover on your folders icon Add Folder 2 Click on the Add Folders button 3 Select appropriate option to either create a new folder or edit an existing folder from the list Close Add Folder Create New Folder Add an existing Folder 4 Fill in the fields such as Folder Name and Type Check the box next to This is a Covering Folder Add any users to Folder Sharing and click Save SE Pall amp close Create New Folder Folder Properties Folder Mame Medicine Cowering Folder _ Folder Type Public Private Pi View onby C Automatically remove patients when discharged Folder Sharing Search Users Physician Education and Technology Services 614 566 3646 47 ORB 3 0 User Manual 5 Any folder that is checked as a Covering Folder will have the Manage Covering Folder Manage Covering Folder button when opened Click on 7 cw Name MRN Acct q older to add a covering provider Kristina B Eader Manage Covering Folder 6 Click on Add New Covering Provider to add information on each provider close Manage Covering Folder Add New Covering Provider There are no Covering Providers defined for this folder To add a covering provider click on the Add New Covering Provider link above 7 Fill in the fields to add a provider s infor
59. pital Physician Education and Technology Services 614 566 3646 18 ORB 3 0 User Manual Medical Records 1 8 9 Click Medical Record on the toolbar This link takes you to McKesson Medical Records Portal to view the entire patient s current and past legal medical record Select the back to ORB link to return to ORB Once selected from the left side of the screen you can select to view a patient s medical record grouped by either encounter or document type To bookmark a document a Click on the document in the document tree to be bookmarked b Click the Bookmark button on the toolbar To print click on the Prinf button on the tool bar To personalize how you view groups of documents a Select File then Preferences b Select Personal Record View c Select the documents you want in your personal record view then click Add d To include all of the accessible documents click on Add All To Change your PIN a Select the edit button located in the top left corner of the application screen Note For first time use only OLD PASSWORD is the last four digits of your SSN To Complete Deficiencies a Select Deficiency Type in the top left corner b Select Group worklist or Individual worklist to see those encounters that you need to dictate You will need to dictate this report using the normal process via MedQuist Click on the check box es to select the deficiency Select Process to view and comple
60. rate E M or would need to be controlled with charge entry in CPT code range 1000 6000 same day or pop up with each entr O CPT CPT O cT Decision for Surgery made within 24hrs of this E M or be reflected by previous surgical CPT entry C HCPCS Resident teaching visit C HCPCS Left Side of body indicator needed or Could be listed for specific surgery CPT codes C HCPCS Right Side of body indicator needed or Could be listed for specific surgery CPT codes 6 Enter a diagnosis by placing a check mark in the box next to the diagnosis name You can also make a diagnosis primary and organize the order from this section Diagnosis M Abridged Diagnoses without a code cannot be selected You can include them in the charge by searching for a codified version Code Description Date Primary S P RIGHT KNEE REPLACEMENT 01 16 2013 1 272 2 MIXED HYPERLIPIDEMIA 01 16 2013 O 2 ANXIETY 01 16 2013 3 B E 2859 ANEMIA 01 16 2013 O W O 3051 SMOKER 01 16 2013 O 5 w OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER C 71536 PRIMARY OR SECONDARY LOWER LEG 0116 2013 O 6 m HYPOTHYROIDISM 01 15 2013 7 DVT PROPHYLAXIS 01 15 2013 8 vy E 493 20 CHRONIC OBSTRUCTIVE ASTHMA UNSPECIFIED 01 14 2013 O 9 DYSLIPIDEMIA 01 14 2013 10 DEPRESSION 01 14 2013 1x GERD 01 14 2013 12 Select the Submit New Charge button Charges submitted successfully icon will appear On the Charge Process tab you can review edit or delete your su
61. s 29 Micro 3 Path 0 Rad 1 Card 4 Meds 25 Trans 6 A amp P Preview Current Service Line is Medicine You can select Pertinent Medications Reviewed or select individual medications to include in reviewed notes Additional comments can also be entered for the medications C Pertinent Medications Reviewed Cl Include hospital medication names only in the report Additional Comments Active Medications View Administration Report for Today id Status Drug Name Dosage Route Frequency Last Given r evi ew F Active Ambien Equiv 10 MG ORAL AT BEDTIME 09 26 2012 S Zolpidem 21 13 g Active Heparin porcine 5000 UNIT SUBCUTANEOUS EVERY 8 HOURS 09 27 2012 Heparin 05 19 g Active Midodrine 20 MG ORAL SPECIAL SCHEDULE 09 27 2012 Midodrine 09 27 g Active Midodrine 10 MG ORAL SPECIAL SCHEDULE 09 26 2012 Midodrine 22 49 Active Novolin R Conservative Scale 2 UNIT to 8 UNIT SUBCUTANEOUS THREE TIMES DAILY BEFORE MEALS 09 25 2012 Exclusive insulin Sliding Scale consery 13 30 O Active Novolin R Conservative Scale 2 UNIT to 8 UNIT SUBCUTANEOUS EVERY SIX HOURS N A g Active Novolin R Custom Scale 2 UNIT SUBCUTANEOUS AT BEDTIME N A insulin Sliding Scale custom O Active Plavix Equiv 75 MG ORAL ONCE A DAY 09 27 2012 Clopidogrel 09 27 O Active Protonix Equiv 40 MG ORAL TWICE A DAY 09 27 2012 Pantoprazole 09 27 O Active Synthroid 25 MCG ORAL ONCE A DAY 09 27 2012 Levothyroxine 05 19 Active Acetaminophen 650 M
62. s me record they must be added through Star or Care Manager Add Reaction if known Add 12 The DCi Review tab allows for preview of the final instructions Physicians must approve the DCi by selecting the green Approve button Green DCi Review means the DCi has been approved p DOB 04 18 1949 Age 63 Close Zzztest Zzzip Admit Date 11 22 2010 Acct Z1032640001 ol J Dx Proc Meds F u Diet Instr Disp Addi Allergies DCS Review cs Approved By Elaine Dunn on 10 17 12 12 16 This discharge instruction was edited after being approved Click here to review the edit history Preview Diagnoses Procedures Primary Heart Failure 1 10 11 11 echocardiogram EF 35 valve in proper 2 CHF postion 3 HTN 2 10 13 11 cardioversion 4 DVT Deep Vein Thrombosis 3 10 11 11 TAVR 5 Stroke CVA Diet Allergies 2 gram sodium aspirin Rash hives Penicillins Hives Medications Name Dose Route Frequency Please continue taking these medications per your prescribing physician anvi IBUPROFEN 100 MG Oral daily cOUMADIN WARFA RIN 2 MG 1 Tablet Oral daily Start taking these medications lt a Physician Education and Technology Services 614 566 3646 43 ORB 3 0 User Manual Completing the Discharge Summaries Under the Create menu select Discharge then Discharge Summary 2 Clinical Summary Perpetual Assessment from previous notes can be u
63. sed or click Edit to enter additional text Diagnosis Plan Previously documented diagnosis and plans can be utilized by clicking the Dx or Dx Plan on the left Important Information Click Edit to enter any indicated text Diet Click to add the Diet entered in the Discharge Instructions Additional Comments Click Edit to enter indicated text Time Spent on Discharge select 30 minutes or less radio button or slect the 30 minutes or more radio button a oro Dx Proc Meds F U Diet Instr Disp Addl Allergies DCi Review Hosp Course DCS Review required field A Documentation from Progress Notes and DCi Hospital Course Service Line Medicine b Perpetual Assessment Add D Clinical Summary Edit test Diagnosis Plan p Diagnosis Plan Add Service Line Mine is C Bold Edit R t R M Dx Dx Plan 415 19 PULMONARY EMBOLISM A a l i PULMONARY EMBOLISM Dx Dx Plan 282 64 517 3 ACUTE CHEST SYNDROME DUE TO SICKLE CELL HEMOGLOBIN C DISEASE CRISIS test Dx Dx Plan 313 83 ACADEMIC UNDERACHIEVEMENT DISORDER 2 Bold Edit Remove g ACUTE CHEST SYNDROME DUE TO SICKLE CELL HEMOGLOBIN C Composite DISEASE CRISIS Dx Dx Plan 415 19 PULMONARY EMBOLISM Dx Dx Plan 282 64 517 3 ACUTE CHEST SYNDROME DUE TO SICKLE CELL HEMOGLOBIN C DISEASE CRISIS Dx Dx Plan 313 83 ACADEMIC UNDERACHIEVEMENT DISORDER Dx Dx Plan 427 31 ATRIAL FIBRILLATION Dx Dx Plan 453 40 ACUTE DEEP VENOUS T
64. story is completed by selecting the patient s tobacco and alcohol use living situation occupation marital status and functional status Additional comments can be entered via the Comments text box Physician Education and Technology Services 614 566 3646 25 ORB 3 0 User Manual 3 The next tab will be the Physical Exam Tab From this tab you can review patient vitals I O s and the Graphic Record You can also enter free text comments relating to the vital signs History Phys Exam Labs 0 Micro 0 Path 0 Rad 0 Card 0 Current Service Line is Medicine Meds 13 Trans 18 A amp P Preview Vitals Please note that vitals from the ED and HSM systems are not available in ORB Progress Notes Yea s os C There are no vitals for this patient within the last 24 hours LMP Gravida Para Enter additional comments related to vitals b Physical Exam components can be added to the note using the My Exam List i To start an exam make a selection from My Exam on the right side of the page li Click on the name of a specific physical exam category to add it to the note The exam will be added with the default normal text iii Exam text can be edited by clicking in the text box and entering desired text iv To add all listed exam categories select Add All on the My Exam List Current Physical Exam New exam categories can be added and or existing categories can be modified
65. t name or IP address of the view Connection Server Connection Server ohconnect chiohealth corn Log in as current user DSjexd225 Support Information 3 Enter your user name and password 4 Your phone will ring Answer and hit The automated voice will confirm your authentication and you can then end the call 5 The blue remote desktop screen will start to load Select ORB icon on remote desktop and enter your user name and password if prompted 7 To log off select the START button and choose Log Off You will be asked to confirm a 2 Start Zee Physician Education and Technology Services 614 566 3646 ORB 3 0 User Manual Logging Into ORB 1 Select ORB icon on the desktop 2 Click on the Login button in the upper right corner ORB Resources gt TEST FEB 4 2013 About ORB Get ORB Mobile Meaningful Use The OhioHealth Results Browser ORB allows Version 3 12 x 0 ORB Mobile gives OhioHealth providers and physicians and office staff to access patient This EMR is Modular Certified for clinical staff real time access to OhioHealth results data from all inpatient and outpatient use by Hospitals by the patient information viewable over 4 mobile encounters at OhioHealth hospitals and Certification Commission for device ambulatory sites Access requires a computer or Health Information Technology handheld device with a secure Internet CCHIT r connection and an ORB ID Learn More Here a IP hone
66. te a single deficiency or click on Process All to view and complete all of your Signature deficiencies e The PIN Required window will open You will only need to enter your PIN once per chart completion session ap To add or edit text a Click in the document where you want to start typing Be sure to edit BEFORE you sign the deficiency b Click the Sign Button to complete the deficiency Missing Text a Enter the missing text in the yellow text box b Maximum of 240 characters c Your initials date and time are added to the bottom of the page d Once all text is entered in each box click the Complete button to complete the Missing Text deficiency 10 To Decline Deficiency a Click the check box next to the document you wish to decline Physician Education and Technology Services 614 566 3646 19 ORB 3 0 User Manual b Then click the Decline button c Select a standard reason from the drop down menu or enter your own reason with a maximum of 225 characters d Click OK to save your deficiency decline and reason 11 From any ORB screen click on the Resources tab Select Chart Completion TEST ace Name MRN Acct LJ Advanced Feedback Resources Give FeedBack Referring Physician Tool Kit Patient Safety amp Quality Research amp Reference Fax Status Preprinted Orders rt oe OhioHealth Libraries s Practitioner Reports Fax Status Report Printable eForms MicroMedex Pee Forms
67. ted Orders Fax Status Report Pahi Eom L create Clinical Navigation gt Patient Profile A Forms Patient Education Notes Farem Maps amp Directions Discharge Chart Completion i GE Centricity EMR Orders 09 16 2008 17 07 Efillable Forms OH Surgery Viewer DH Surgery Viewer Directories amp Contact Info Admit Ch Capt _ Charge Capture he 29 2008 10 14 eForms Admit Transfer Center Contact Info amp Directories Find a Doc Admin On call Directory Impersonate User Charge Capture Medical Education Riverside Medical Education ePrescribing Clinical Navigation Patient Profile Doctors Medical Education Current Orders Grant Medical Education Medications gt Select group name Select E M code by either typing in the number or part of the name or using the drop down Process Manage Group Manage Group Codes Manage My Codes Important Charges submitted in the ORB2 version do not transfer over to this version Therefore you will need to determine a date to start using this version and stop entering charges in ORB2 If you have an office manager or biller we recommend you coordinate this date with them to ensure your group codes are properly configured Arrival Date 1 14 2013 1 28 00 AM Admit Date 1 14 2013 1 41 00 PM Status INP Group Name yy Group Anne Rhodes X l Charge Date 01 28 2013 E mm dd yyyy E M Code s Help Me Choose l Pr
68. tes Flowsheet Pain Documentation Critical Care Graph View SNAPSHOT Admission Assessment flu season Intake and Output 4 09 28 12 09 10 13 30 MEWS v 53 30 7 09 12 10 50 11 23 12 10 12 50 13 30 MEWS Back to Top HR Hro SBP Sbpo RR Rri Temp decrees F Tempo CNS LOC Loco MEWS Calculation 2 i MEWS Response _ cont monitor L L L Neurocognition SSRIS bag Reverie 09 12 10 50 11 23 12 10 12 50 13 30 Neiurn Raseline Wdlexrc H 1 T T Select the documentation type from the drop down and select refresh Report ursing Documentation Time Interval Exact Time be Only Vursing Documentation V Start Days Column Display 7 Max 14 bpeciality Treatment oncology E Hotlinks ncision and Wounds on Critical Care Graph View SNAPSHOT Admission Assessment flu season I PSA Documentation o9 4 09 28 npatient PACU requent Checks MEWSIEV Services Documentation 09 12 10 50 11 23 12 10 12 50 MEWS Procedure Checklist iR Procedure Monitor Sedation we ialysis DAS Charting temp dea Dialysis Flowsheet 5NS LOC RRT PRISMA Charting AEws Caledi gt C Continuity Review EWS Reseisafety with Checks NeurocokT nurses Documentation 09 12 10 50 11 23 12110 12 50 leuro Base ICC line insertion Documentation Drientation peech Cardiac Feemodynamics 09 12 10 50 11 23 12 10 12 50 ardio Basalt Education Charting f cardiac Mo ransfusion Record includes VS Disctd uleee ransfusion Record no VS Rt Dorsa l bilan of Care
69. th 0 Raci 0 Cara 0 Mecs 3 Trans 19 A amp P Previev l Abridged ew Previous Dost practic ie to update th jay Qu elect Diagnosis Quick Not 4 x n Z abridged Quick Note y ess Note Disposition Or Commenti 8 You can also use the Add to My Dx link to add a codified diagnosis to your list after you have created it in your note Diagnoses d Diag 1 428 0 CONGESTIVE HEART FAILURE V Abridged Previo 1 Plan T today s Diuretics E Add to My Dx an 3 lt 1 Delete Best ice is to update the plan each day 2 w 514 Pulmonary edema bd F Abridged Today s IPPB ael Plan Selart Nianne neice Physician Education and Technology Services 614 566 3646 33 ORB 3 0 User Manual SAVING NON DIAGNOSIS BASED PLANS IN THE MY DIAGNOSES LIST This feature is only to be used for non diagnosis based plans for example e AAOS Statement for VTE Prophylaxis e Critical Care Assessment e Discharge Exam Well e Follow Up Exam Formula Fed e Prophylaxis e Nutrition 1 In Progress Notes go to the My Diagnoses tab and click the Manage button 2 Search for the term ZZZ 3 Click on the Abridged or Standard List entry for ZZZ new plan 2 speg Abridged 7773777 Select Diagnosis E v Abridged My Custom Diagnoses Dx 89 09 AB PAIN MY GROUP EDIT eea Dx Plan ZZZ PROPHYLAXIS Step 5 Dx Plan 789 09 ABDOMINAL WALL 6
70. tient Name Location Riverside Family Practice F cc OBS Test Ricio My Watch List L cc INP Heartlab Rmhfive 6B 6104 02 Cowered Patients C c 5 IWE Registration Mack 6T 6104 01 F cc 5 INP Rpatch Chuckpdr 6T 6104 01 Fj cc INP Meds Susie 6T 6104 02 11 14 1979 33 Amy Imm T ae al Tk yo BAe ee Lele ee aT cao MA A171 NANI PaaS Mo emme o Tomm emm 3 Select the marker next to My Folders 4 Select the green Select Default button l Close My Folders Preferences Default Patient List My Current Default Patient List is Mrunal Shah MD Remove Set My New Default Patient List as Search by Account Patient Lists Show the New icon for patients I have not documented on O Yes No b From the patient list the New button represents a new patient that does not have ORB documentation completed by you c Select the gear to set preferences such as empty beds Charge Capture icon surgery times report preferences double space sign out memos etc and customizing the columns for the Sign Out View 7 Mrunal Shah MD GJ amp Patient Name Location Arrival DOB Attending Covering MBN Acci L ki ct O8S O Testbarcoder TNR TN12 01 02 24 1954 71637820 Riverside A 58 7052693000 E New CC by OBS Testbarcoded TND TH2 01 06 24 1954 D7Z9018686 Doctors A 58 7052691000 9 My Work a This section contains items that require action such as i Medical record deficiencies li
71. val Selecting Approve will Approve and electronically sign this Daily Progress Note Your signature completed datetime and service line of Medicine will be attached to this document Physician Education and Technology Services 614 566 3646 30 ORB 3 0 User Manual Completing a Preoperative note a Enter a Codified Diagnosis on Pre Operative Note by typing in Diagnosis box or selecting a diagnosis by clicking on Dx on the Diagnosis List on the right b The H amp P status attestation will default to No with pre formatted text If there has been a change since the last H amp P select Yes and free text indicated update 4ZZteSt 42ZzZIp Admit Date 11 22 2010 Acct 21032640001 Pre Operative Note Pre Operative Note Preview Service Date 10 19 2012 ne Year Date Service Line Medicine ad Cmin dd yyyy Procedure Details Surgeon Required Anne M Rhodes Diagnoses Select Diagnosis Abridged Has status changed since H amp P No Yes Explain Reason Required When Statue Change is Yes The most recent HEP was reviewed and the patient Was exar enanges noted Procedure t proceed as pianned Surgical Indications If not listed in H amp P or Op Note Completing a Postoperative note Composite List Comprehensive Plan View Previous Encounters Previous Diagnoses My Diagnoses List for Anne M Rhodes and l Manage Manage Medicine Dx SORE THROAT 11 04 2011 Dx 786 05 SHORTNES

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