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CyberMed Electronic Health Record (EHR)

1. LMP Date 1 10 2013 _ ElDefinite Approximate Month Known Unknown El Normal Amount Duration PMP l i Menses Monthly E Yes C No Final Menarche Frequency Q days Duration Flow Pain Intermenstrul Bleeding hCG On BCP AT CONCEPT El Yes E No Comments _ Ve www www ewww wwe ewww eee eee eee Encounter Form DATE EA WEEKS LENTGH OF LABORBIRTH WEIGHT SEX TYPE DELIVERY Anes PLACEOF DELIVERY PRETERM LABORICOMMENTS COMPLICATIONS mwn E E E T S ee C EO ee ee E T Y O OS Lab Order Entry E Prescribing Medical Charting Dental Charting OBGYN Charting MU Menu Neg Pos Detail For Positive Neg Pos Detail For Positive 1 DIABETES a 16 D Rh SENSITIZED E a 2 HYPERTENSION E 17 PULMONARY TB ASTHMA i 3 HEART DISEASE x 18 ALLERGIES DRUGS 4 AUTOIMMUNE DISORDER E 19 BREAST yl 7 n 5 KIDNEY DISEASE UTI zl 20 GYN SURGERY 6 NEUROLOGIC EPILEPSY x 21 OPERATION HOSPITALIZATIONS x 7 PSYCHIATRIC WH 22 ANESTHETIC COMPLICATIONS o En 8 HEPATITIS LIVER DISEASE el 23 HISTORY OF ABNORMAL PAP x 9 VARICOSITIES PHLEBITIS zl 24 UTERINE ANOMALY DES a a To view the patient s History Summary click on the View Hx History icon Here you will see a summary of the patient s history Figure 8 41 JOSEPH P ADDABEO FAMILY HLTH CNTR Patient History DOB CB
2. lt 8 20 gt CESES Figure 8 18 lt 8 19 gt EHR Getting Started Guide 36 Accessing the EHR CyberMed EHR v1 00 To make it easier for the user to enter notes into the notes box simply click on the Smart Notes Tool button A series of questions will appear fill out the appropriate sections and click on the Generate SmartNotes button JOSEPH P ADDABBO FAMILY HLTH CNTR rovider a i eski p ng jC l vorts Control Pane Patient History Acct Name Sex DOB Age _PMHx Family Hx Social Hx Birth Hx OBGYN Hx Functional Hx Previous Physician s name Dr Madhavi Date of last exam 11 27 2012 Other SPECIALISTS currently seeing Infections Eyes MINo Ifyes detail Sexually transmitted disease yes VINo If yes detail I oe Blood Transfusions Elves MINo If yes detail asthma Hepatitis Pregnancy EIRA Eca HIV Exp FlProblem w Behavior F Rheumatic Fever EFIcCAD lHospitalizations Problem w Eating Flsmoking ElcopPD ElHyperTension ElProblem w Growth ElSurgery Elcva VIMI Problem w Sleeping W Taking Oral Contraceptives Diabetes WIOA ElProblem w Speech ITB JEtoh amp Drug Abuse Wl Others FlProblem w Toilet Training Trauma Encounter Form Heart Murmur Pneumonia Lab Order Entry E Prescribing Pneumonia Influenza flu Flexible Sigmoidoscopy Colonoscopy Medical Charting Teta
3. 5 10 20 AM_SAM AM_THOMPSON AM_VALEUS AM_VARGHESE CDT_CROSBY CDT_LAMB Figure 21 1 EHR Getting Started Guide 78 Accessing the EHR CyberMed EHR v1 00 Each test result is color coded based on it abnormality in the case of high low lt 21 5 gt You can also view the trend by clicking with the similar previous tests if ordered There is a B symbol which indicates an important message from Quest to the provider regarding the test lt 21 6 gt The provider is advised to put in the comments and when reviewed click on Mark as Reviewed If the provider wishes to check on a pending item or recall the patient click on Flag It to add this patient s lab to the flagged list Click on View Lab Hx to view the patient s previous lab histories lt 21 7 gt Welcome CPETERS Logon JOSEPH P E FAMILY HETH CNTR Pharm 9 Fax 66 Pending 453 Lab Result Detail Acct Name Sex DOB Age MRN Bal_Due 0 00 Rpt On 5 17 2012 9 51 12 PM Specimen Number Rpt Status FINAL Review Comments eT Teame ABN Remit Uns Reerece Ranae Sats Se CAI Adding New Comments Below Providers can add additional comments here 1 CA 27 29 lt 21 7 gt 21 6 gt ese Flot Se ee one a S 2 A E pee pe e e p q ooo pe po o pe mro p fmm e e TE a Sa L nforma fy se spew SC e 13 MONOCYTES N Figure 21 4 1 HER2 ELISA LASA 1 LASA CBC I
4. Provider Front Desk orts Pham Far Pendin Review of System Patient s Chart Acct Name SEX DOB Age MRN Bal_Due Making My Own ROS List Select Group Available My List ERA ERGY Group Item Description Apptite ae 1 GENERAL Apptite Loss F Chills 2 GENERAL Chills O Fatigue ENT 3 GENERAL Fatigue Always tired a Feeling o ae RO 4 GENERAL Fevers F Fevers ejmy ie 5 GENERAL Weight Loss E Sleeping Sweats Laie Remove From MyList lt 14 10 gt Weight a LYMPHATIC Or enter new item for this group Weicht 1 MUSCULOSKELETAL NEURO PSYCH RESPIRATORY SEIN tA lt 14 9 gt EHR Getting Started Guide 60 Accessing the EHR CyberMed EHR v1 00 12 0 Physical Exam The Physical Exam page is used to record providers notes based on physical examination The provider is provided with a text box to freely type his her notes into the system and save it lt 15 2 gt TESA TEVA SS Pharm 9 Fax 66 Pending 445 Physical Exam Acct Name Sex DOB Age MRN Bal_Due 5 00 Select template REGULAR JUSEISmaANGTESiToaIN C Context take Discharge Y Testing patient s physical exam a ncounter Form lt 15 2 gt EHR Getting Started Guide 61 Accessing the EHR CyberMed EHR v1 00 12 1 Use SmartNotes Tool This is a tool generated to help the providers to enter the desired information with minimum typing Click on the button Use Smart Notes Tool to go to the page l
5. This template can be composed at one time and will be available for the patient s PE Any changes add removal of item reflects there on ward In order to remove an item from your list select the item and click on Remove from My list lt 15 10 gt On going back to PE The provider would find the template for smart notes default to the user template In order to view regular templates please select Regular in template JOGAI amii o Wealth aie 1 JOSEPH P ADDABBO FAMILY HLTH CNTR S Bama eee Sareea sees Ee r aa ae e ome rovide rront Desk Bil ng Clerk Reports Control Pane Physical Exam Acct Name Sex DOB Making My Own Exam List lt Back Select Group ABDOMEN intake Discharge Available My List My Current Groups as eal _ Encounter Form BDOMEN Bowel sound present eee ee soars m E T o E Prescribing Remove From MyList Me lt 15 10 gt Or enter new item for this group GENERAL APPEARANCE GENITALIA Great Toe HEAD HEART HEMATOLOGIC LYMPHATIC HIPS EXTREMITIES KNEE ABDOMEN 6 ABDOMEN Soft lt 15 9 gt lt 15 8 gt ibis Figure 15 7 EHR Getting Started Guide 63 Accessing the EHR CyberMed EHR v1 00 13 0 Development Assessment This page is used to record provider s notes of development assessment of children The provider is provided with a text box to freely type his her notes into the system a
6. Intake Discharge Encounter Form TT HEMOGLOBINOPATHY EVAL RPR W TITER CONF RFX lt 1 2 4 gt CA 125 HEPATITIS B SURFACE AB QL RUBELLA AB IGG i CBC INCLUDES DIFF PLT v SEQUENTL INTEGRATED SCR 1 CF CARRIER SCREEN NY V HIV AB HIV1 2 EIA W RFLNY SEQUENTL INTEGRATED SCR 2 lt 1 J 3 gt E Prescribing CHLAMYDIA GC RNA TMA HSV 1 2 IGG HERPESELECT SERUM INTEGRATED SCREEN 1 CMV AB IGG V LEAD BLOOD V SERUM INTEGRATED SCREEN 2 Medical Charting sie CMV AB IGM JLH STREP GROUP B CULTURE Dental Charting COMP METAB PANEL W EGFR MATERNAL SERUM AFP v TESTOSTERONE TOT LC MS MS MU Menu v CULTURE GENITAL MEASLES MUMPS RUBELLA PNL TOXOPLASMA AB IGG IGM v J CULTURE HSV RAPID OVA1 TM 7 URINALYSIS COMPLETE CULTURE URINE ROUTINE OVA1 TM INCLUDES FSH LH VARICELLA ZOSTER AB IGG E FSH E PENTA SCREEN E XSENSE W RFL CHROM NY PROGESTERONE GLUCOSE 1HR PP Figure 12 1 EHR Getting Started Guide 52 Accessing the EHR CyberMed EHR v1 00 9 1 1 Make My Own List To make your own list click on Make My Own List lt 12 2 gt Please select the lab vendor from the dropdown
7. Click on the button Use Smart Notes Tool to go to the page lt 17 3 gt Select an age group from the drop down Select various items from the available list lt 17 4 gt If any additional notes are to be added in any category please add it to the comments box available at the bottom of the page lt 17 5 gt You can overwrite the existing notes or append add to the existing notes by selecting the radio button at the end of the page and click on Generate Smart Notes lt 17 6 gt This will add your selections to the note s text box in a format The provider can add make additional changes to the text if he wishes lt 17 2 gt iia _ Anticipatory Guidance Acct Name Sex DOB Unselect All Select All Select group 2wks 1 month Ability to roll C Breast vs formula feeding V Burns from hot liquids Intake Discharge Burping El Falls Feeding Hiccups Cl Infant car seat Infant sleeping position Encounter Form Comments Testing Anticipatory Guidance Lab Order Entry E Prescribing Medical Charting roolem Figure 1 oblem List lt 17 5 gt 7 4 QO lt 17 6 gt EHR Getting Started Guide 68 Accessing the EHR CyberMed EHR v1 00 14 2 Make Your Own Template In order to make your own Anticipatory Guidance template click on the symbol Oj Select the age group and select the available items from the list and click on Add to My List lt 17 8 gt If desired to add a
8. 493 90 2 8 2012 v74 1 2 6 2012 v70 5 382 9 493 90 368 9 Figure 6 31 Pi lt 6 32 gt EHR Getting Started Guide 19 Accessing the EHR CyberMed EHR v1 00 The provider can also search the diagnosis by keyword or by code and selecting the result from the dropdown list below the search box Enter the risk status and additional information in the detail box and click on the Save to add the problem to the list lt 6 34 gt Click to Select OnSet_Date 6 24 2012 Rusk Type Symptom Status Active Problem HYPERTROPHY OF TONSIL WITH ADENOIDS Detail testing lt 6 34 gt Detail Figure 6 33 EHR Getting Started Guide 20 Accessing the EHR CyberMed EHR v1 00 4 6 Labs This displays the patient s previous lab reports ordered by any provider in Addabbo The provider can print the labs by clicking on the print icon In order to view the labs click on View Report lt 6 36 gt JOSEPH P ADDABBO FAMILY HLTH CNTR WME Provider Front Desk R Order ID Lab Type Request Date Provider Order Status Report Date Reviewed 177157 User Defined 2 16 2012 ALTMAN PRINTED aj22 2012 Y View Repot amp 174887 REGULAR 2 6 2012 NEDELEA PRINTEC 2 13 2012 Y View Repot amp F ea 76298 REGULAR 5 7 2010 NEDELEA Requested No Report G 62803 REGULAR 3 5 2010 NEDELEA Requested No Report lt 6 36 gt 37031 REGULAR 5 30 2009 WONG Reques
9. 6 21 2012 x ret Ei Fina i sa e sh SD rary in na Referral Center Hipaa form sample 2 PDF 6 19 2012 X Vaccine Submit BARNABAS HEALTH Ambulatory Care Center Reminder List PROSTATE SCREENING REGISTRATION FORM Group Close Comments Document Title Prostate form Document Category HIPAA Form v Sane HIPAA Form Referral Report Insurance Card History Form Dental Figure 7 10 EHR Getting Started Guide 29 Accessing the EHR CyberMed EHR v1 00 4 10 Demographics This displays patient s demographic information We can add change the information and click on Save to register saved changes to the system lt 7 12 gt JOSEPH P ADDABBO FAMILY HLTH CNTR Home Provider Front Desk Billing ng Clerk erk Sees Saree k Reports Control Pane Patient Chart Vitals Growth Charts Immunization Allergy Medication Problem Lab Referral Encounters Docs Demographic Notes Account MIRN Contact iox 0 0 20451 00 000000 Home v 5555555555 First Name Mi Last Name PATIENT MEST Primary 7777777777 Adiess Email E eee 7 o wel an PH 7 CoB cee mo SEN OO OOOO 000000000 Figure 7 11 lt 7 12 gt EHR Getting Started Guide 30 Accessing the EHR CyberMed EHR v1 00 4 11 Notes In this section the provider can record send out notes about the patient to the patient by clicking on Add Notes The not
10. 65 Warning Please confirm the notes is completed before signing off Once the notes is signed off you will not be allowed to change the notes Sign Off Cancel Figure 19 5 EHR Getting Started Guide 74 Accessing the EHR CyberMed EHR v1 00 4 0 Provider Tab This section describes the various features available for the provider on the left navigation bar as shown below iSeries Provider BA UARA ae pees 0873072012 AM AKHAND ABDUL 110 AM BARCIA a AM BUNYAVANICH JOSEPH P ADDABBO FAMILY HLTH CNTR AM_DHILLON PFPPP we aly Ge 2m ane J g PE wn zs AM_JACOB AM_KALEPU PS imal F PPE AN MADHURAPANTULA AM_RODRIGUE Z PE 4 TS Os U a CDT_CROSBY CDT LAMB Figure 20 1 4 1 Office Mail This feature gives the provider the opportunity to send a mail message to other Providers Nurses Medical Assistants within the organization or also to Providers or personnel outside the organization provided the provider has the email address to whom he she would like to send the message to lt 20 2 gt There are two tabs in the Office Mail One is to the MailBox where the provider can view the received mails from other personnel Other is the Compose tab where the provider can write a new message to be sent lt 20 4 gt EHR Getting Started Guide 75 Accessing the EHR CyberMed
11. AM_AKHAND Fax Status Open Payor Name Phone Contact AKHAND ABDUL oF IRF_PSYCHIATRY Fax Name Phone Contact Referral Description Accessing the EHR CyberMed EHR v1 00 4 5 Provider Dashboard Please select the provider name from the dropdown list of Provider This will automatically refresh the page with the provider s information 4 5 1 Chart This section displays a chart view of the provider s unsigned off notes unclosed encounters and un reviewed labs The blue bar of the chart displays the average number of the providers of the organization The red bar displays the provider s numbers 4 IADDO F Wealth oat ar ly HLTH CNTR Welcome CP gt 5 2Y gt s Report Control Pane a Pharm 9 Fax 66 Pending 453 erk Provider Dashboard Chart Unsigned Off Notes Open Encounters Lab To Review Flagged Lab MU Measures Office Mail UnSigned Off Notes UnClosed Encounters Lab Reports Patient Search Referral Center Vaccine Submit Reminder List Group Close Figure 22 1 4 5 2 Unsigned off notes This section displays a list of all the notes to be signed off The provider can easily open and review the notes and thus sign off notes by clicking on the Select link of each patient which will redirect to the patients chart and SOAP notes lt 22 4 gt EHR Getting Started Guide 83 Accessing the EHR C
12. EHR v1 00 4 1 1 MailBox Click on Receive to view the updated messages in the inbox You can sort the messages by Date from and Subject by clicking on the column s name Date From Subject lt 20 5 gt To Read a message click on Read the message appears below in the screen We can reply to the sender by clicking on the Reply button or forward the message by clicking on the Forward button lt 20 6 gt JOSEPH P ADDABBO FAMILY HLTH CNTR Office Mail MailBox Compose lt 0 6 Office Mail Date From Lab Reports Patient Search Office Mail Testing Referral Center Vaccine Submit Reminder List lt 20 5 gt Group Close Figure 20 3 EHR Getting Started Guide 76 Accessing the EHR CyberMed EHR v1 00 4 1 2 Compose To send a message internally to a user within the organization please click on the 7o button and select the User ID from the list To send a message to a personnel with an email ID that is outside of the organization type in the text box next to the To button and fill in the remaining parts of the mail click on Send lt 20 8 gt For example username yahoo com A message at the bottom of the page will read Success That means that your mail has been successfully sent lt 20 7 gt JOSEPH P ADDABBO FAMILY HLTH CNTR Office Mail rovider Dashboard MailBox Compose Office Mail To username y
13. For Past 12 ial months include NO SHOW Intake Discharge Appointment s In Past 12 Month s Appt Date Office Chief Complaint Provider SOAP Status Dx1i Dx2 Dx3 Dx4 __ccavitals 4454202 3PA GEN HEDELEA X en i lt 74 gt em Ch History I 342642942 3PA CEN SINGH x Immunization 3 9 2012 JPA CEN F U visit NEDELEA E B 474 10 268 9 493 90 782 1 2 27 2012 JPA CEN SINGH B Referral i 2 24 2012 JPA CEN RUNNY NOSE AND CONGESTION X 2 WEEKS recently completed tx f NEDELEA E B 460 268 9 Screening 2 21 2012 JPA CEN KOPELOWITZ B 367 4 O sor 2 16 2012 JPA CEN asthma ALTMAN B B 493 90 lt 7 5 gt __ Prenatal Log 2 8 2012 JPA CEN ARZADON B v74 1 Figure 7 3 oap m Find Pa vist Seen by ENT congested anc snosng a mge consen t atep baetieg mm Frs wiit seen Dy em for tts om Compiaints cf snoring at night ans congestion moat of te Sme Cevelnsed an Retry rash over R ear Figure 7 6 EHR Getting Started Guide 28 Accessing the EHR CyberMed EHR v1 00 4 9 Docs The provider can view various patient related documents in this section These documents can be either the patient referral report imaging report etc Select the category of the document in the Select Document Category dropdown Click on View to view the document on the left side of the page lt 7 8 gt We can also upload the file by clicking on browse selecting the pdf document and then click on Loa
14. Guide 18 Accessing the EHR CyberMed EHR v1 00 4 5 Problem List This displays patient s active problem list In order to view Resolved and Inactive problems please select the fields and click on Refresh In order to add a new problem click on the Add New Problem button lt 6 30 gt WENS JOSEPH P ADDABBO FAMILY HLTH CNTR Home Provider Front Desk Billing Clerk Reports Control Pane Patient Chart Acct Name Sex F DOB Age MRN Bal_Due 0 00 Vitals Growth Charts Immunization Allergy Medication Problem Lab Referral Encounters Docs Demographic Notes No Active Problem Add New Problem Refresh V Resolved Inactive Intake Discharge Dx Code Problem Name OnSet Date Status Changed On i aeRaic RHINITIS CAUSE UNSPEC 6 26 2012 6 26 2012 E 2 27801 B 6 26 2012 v v 6 26 2012 Figure 6 29 lt 6 30 gt Select the current ongoing diagnosis of the patient from the right side of the page to add the problem the diagnosis is related to lt 6 32 gt JOSEPH P ADDABBO FAMILY HLTH CNTR Home Provider Front Desk Billing Clerk Reports Control Pane Problem List Acct Name Sex DOB Age MRN Bal_Due 74 5 No Active Problem Add New Problem E HI 2 Diagnosis Codes Within 12 months No Data Available 3 9 2012 474 10 268 9 493 90 782 1 2 24 2012 460 268 9 2 21 2012 367 4 2 16 2012
15. Sk Billing Clerk Reports Control Panel Help Patient History Acct Name Sex DOB Social Hx Birth Hx CBGYN Hx Functional Hx Family Hx amh El Show Inactive Items Intake Discharge Figure 8 36 Brief Hx LastUpdated 1 9 2013 General Total Preg 1 9 2013 SKHATRI iE OX Y lt 8 37 gt Weary PTE D a JOSEPH P ADDABBO FAMILY HLTH CNTR Home Provider Front Desk Billing Clerk Repo Co Patient History Acct Name Sex DOB Family Hx Social Hx Birth H CBGYN Hx Functional H y T Fad Live with someone with THR or exposed to TER YES Patient or partner has History of Genital HERPES NO Rash or Viral illness since LHMP NO T Exposed to HEPATITIS B C NHO E Prescribing Medical Charting Intake Discharge 0 ccavitals General os LMP Date 11 032012 Definite i Menarche 15 Frequency 2 MONTHLYdays Duration 3 57 referral Flow REGULAR Past Medical History SE lvocruonacs cre asta l Discharge Current Usage No lt 8 39 gt Infection History Lab Order Entry Cancel ES Figure 8 38 EHR Getting Started Guide 42 Accessing the EHR CyberMed EHR v1 00 PMHx I Family Hx Social Hx Birth Hx OBGYN Hx Functional Hx intake Discharge TOTAL PREG FULL TERM PREMATURE AB INDUCED AB SPONTANEOUS ECTOPICS MULTIPLE BIRTHS
16. containing more information about the medication click on Handouts lt 6 27 gt which redirects to the Medline Plus website from where the provider can print and give the patient more information about their medication See Figure 6 28 amity z Weare TETZA JOSEPH P ADDABBO FAMILY HLTH CNTR Sa pun Patient Chart Acct Name Sex DOB Age MRN Bal_Due Vitals Growth Charts Immunization Allergy Medication Problem Lab Referral Encounters Docs Demographic Notes intake Discharge Show Inactive Medication Last Update 7 31 2012 9 44 12 AM You have to refresh to see the lastest medication list or Patient Takes No Active Medication __ccavitals Active Medication _ Mees ET gt Dosage Route Frea Dsp paw PRN efile archive sre Handouts History 4 28 2012 VELASQUEZ Poly Vi Sol Oral Drops lt 6 26 gt by mouth DALY N N 5 N Immunization 4 3 2012 VELASQUEZ mupirocin 2 Ointment 1 apply on the skin BID 1 N N oO N Referral 4 3 2012 VELASQUEZ hydrocortisone 2 5 Ointment 1 apply on the skin BID 1 N N 0 N Screening 8 4 2011 VELASQUEZ acetaminophen 160 mg 5 mL Elixir 3 by mouth Q4h i N Y o N lt 6 27 gt esor i 11 11 2010 VELASQUEZ acetaminophen 80 mg 0 8 mL Oral Syringe 0 5 half by mouth Q4h 1 N N O0 N _ Prenatal Log Discharge Figure 6 25 EHR Getting Started Guide 17 Accessing the EHR CyberMed EHR
17. f 5 i CT 2 months months O 15 ee Mies aes 6 non ths Holds cup to Epona montp Wks alone well C 7 a Jargons 16 11 gt rasa Remove From MyList g 153 Persistent rocking handflapping months or headbanging 15 9 RE Plays pat a cake 15 months 15 months 12 v Takes lids off containers months an Wa a months Dental Charting Figure 16 8 lt 16 9 gt Or enter new item for this group Scribbles Stoops and recovers lt 16 10 gt AHOROBdghkhSj amp Abtbtooe af EHR Getting Started Guide 66 Accessing the EHR CyberMed EHR v1 00 14 0 Anticipatory Guidance This page is used to record provider s notes of anticipatory guidance of children The provider is provided with a text box to freely type his her notes into the system and save it lt 17 2 gt Pharm 9 Fax 66 Pending 459 Anticipatory Guidance Acct Name Sex DOB Age MRN Bal_Due 0 00 Select template CPETERS JUS SimaniNetesineelly C The following anticipatory guidance is disscussed or provided Group 2wks 1 month 2wks 1 month Ability to roll Burns from hot liquids Burping Feeding Hiccups Infant sleeping position and Testing Anticipatory Guidance T 5 og S X i N k a a SaaS Soe SSD SoEE SEES EHR Getting Started Guide 67 Accessing the EHR CyberMed EHR v1 00 14 1 Use SmartNotes Tool This is a tool generated to help the providers to enter the desired information with minimum typing
18. save a summary page appears of the diagnosis and procedures Please select the primary diagnosis of the visit Figure 11 13 If the patient is being referred from outside select The Visit Is In Coming Transition of Care If the patient is referred to outside select The Visit Is Out Going Transition of Care lt 11 14 gt Once all the selections are made please select Confirm to submit A message appears showing Update Successfully The provider can provide the patients with the education materials regarding their diagnosis by clicking on the handouts button There is an availability to check the Rx Reconciliation by clicking on the button lt 11 15 gt Encounter Submission Date Acct Name Sex Age File COMBO IMMUNIZATION ADMINISTERED 101 V76 10 V76 2 an ce Select Referral Visit Type M The visit is in coming transition of care w __ 8 The visit is out going transition ofcare NN Thank You Update Successfully Patient Eduction Resources for Dx Code SCREENING FOR MALIGNANT NEOPLASMS OF THE CERVIX V76 10 BREAST SCREENING UNSPEC hgrdouts l Rx Reconciliation l Provide Record Summary Lab Order Entry E Prescribing Figure 11 13 lt 11 15 gt EHR Getting Started Guide 51 Accessing the EHR CyberMed EHR v1 00 9 0 Lab Order Entry 9 1 Order Lab This is the place to order labs Click on the dropdown list to select a Te
19. v1 00 Trusted Health Information for You Home About MedlinePlus Site Map FAQs Contact Us Search MediinePus _ O Health Topics Drugs amp Supplements Videos amp Cool Tools Mupirocin TE E z Ay MedlinePlus a od myoo peer oh sin Why is this medication prescribed What side effects can this medication cause How should this medicine be used What storage conditions are needed for this medicine What special precautions should follow What other information should know What should do if forget a dose Brand names Why is this medication prescribed Mupirocin an antibiotic is used to treat impetigo as well as other skin infections caused by bacteria It is not effective against fungal or viral infections This medication is sometimes prescribed for other uses ask your doctor or pharmacist for more information How should this medicine be used Mupirocin comes in an ointment that is applied to the skin Mupirocin usually is applied three times a day for 1 to 2 weeks Follow the directions on your prescription label carefully and ask your doctor or pharmacist to explain any part you do not understand Use mupirocin exactly as directed Do not use more or less of it or use it more often than prescribed by your doctor Wash the affected skin area thoroughly and then gently apply a small amount a thin film of the ointment You may cover the area with a sterile gauze dressing Figure 6 28 EHR Getting Started
20. 00 10 2 1 Use SmartNotes Tool This is a tool generated to help the providers to enter the desired information with minimum typing Click on the button Use Smart Notes Tool to go to the page lt 13 3 gt The patient s age and sex information is pre generated lt 13 5 gt Select various categories like complaint location quality etc Provided are the most common items in each category select various items If any additional notes are to be added in any category please add it to the textbox available in each category lt 13 6 gt You can overwrite the existing notes or append add to the existing notes by selecting the radio button at the end of the page and click on Generate Smart notes This will add your selections to the note s text box in a format The provider can add make additional changes to the text if he wishes lt 13 7 gt JOSEPH P ADDABBO FAMILY HETH CNTR Control Panel History of Present Illness Acct Name Sex DOB Patient is 14 years old female Abdominal Complaints L Eye Complaints Lower Extremity Physical Exam Male ACNE C First Visit Iv Neck amp Back Pain Psychological ADD Evaluation Geriatrics Obesity Skin Rash Lesion ADD Follow up Gynecological Problems Pain Management Upper Extremity 1 C Anorectal Problems Headache Physical Exam Adolescent Upper Respiratory Asthma FlHyperten Hyperlip Physical Exam Child Urinary Tract Inf
21. 00 To add a new referral click on New Referral in the above page lt 6 44 gt This directs to a page where we have a list of internal referring providers external providers Check the box next to the department in which you would like to refer the patient to On the right side of the page enter the appropriate referral description lt 6 46 gt JOSEP H P ADDABBO FAMILY HLTH CNTR Home Provider Front Desk B Patient Referral Acct Name Sex SOB Age MRN Select List REGULAR Q Internal External Referal Description SSS SS E abut E neuroLocy PODIATRY Payor hd ASTHMA ALLERGY E NUTRITION PSYCHIATRY o PA F osevn N Dx Code 474 10 Ref LookUp Date 7 31 2012 DENTAL W OPHTHALMOLOGY RYAN WHITE Diagnosis HYPERTROPHY OF TONSIL WITH ADENOIDS DERMATOLOGY E peos E uroLocy Detail ENDOCRINOLOGY E PHYSICAL THERAPY KN lt 6 46 gt l Figure 6 45 The External tab allows you to refer a patient to a different clinic or hospital outside of Addabbo Check the box next to the name of the clinic hospital as shown below lt 6 48 gt JOSEPH P ADDABBO FAMILY HLTH CNTR ae Patient Referral Acct Name Sex DOB Age MRN Select List REGULAR Q fF Intake Discharge Internal External Referral Description Queens Hosptial St Johns Hospital i 4 Payor v Dx Code 474 10 Z Ref LookUp Da
22. 07 13 2012 PPD Mantoux Date 7 13 2012 on 11 00 AM PPD Mantoux placement site Left forearm Expiration date 8 31 2013 Interpretation Date 7 16 2012 PPD Mantoux reading site Left forearm Result Negative lt 9 2 gt Chest X ray date 7 27 2012 PPD Screening Outcome No Treatment needed lt 9 3 gt Encounter Form Figure 9 1 Create New Edit oS ra P ADP ARES eS FAME HLT Pe eas Mant S505 Doe Select Screening Type PPD Screening Patient had TE skin test IE yes when Yes PMI No P Dont KErnrow What s the result Wegative Positive Did you hawe a chest ray after yowur skin test yes NO No O Dont Know IF yes when OF VI 532012 WV eee FS Test Date TF1 372012 Tine 17200 AM Placement Site Lett forearm 9 Right forearm TE lot D 7 o sz Expiration date 8 31 2013 ttt Tate Interpreted Traef2012 Mesatwe F Positive Reactine Site E Let forearm O Right forearm En cou A FE Tneecher atiri Care eee eles a Chest X ray Date FY27 2012 E Prescribing Chest X ray Reading Mia Charting LTBI treatment prescribed Patient beig evahiated as a TB suspect y Wo ITreatmernt needed O Patient refused treatment Den ta es E Whe treatment indicated E Treatment not adwised dhire to high risk of hepatitis E Treatment deferred EO Brewiowsly treated for TE orl TEBI Other S Overwrite Append MESATARE Figure 9 4 EHR Gett
23. 1361 Hylan Blvd PSC E 17 KETOSTEROID FRAC Medical Charting 11194X 14 3 3 PROTEIN CSF T 17 KETOSTEROID FRAC PEDS K10061 1651 Third Ave PSC P4742 17 KETO 24HR UR CORTISOL FREE UR CREAT 24HR UR lt E P15690 17 KETOS 24HRUR CORT FR 24HRUR CREAT 24HRUR 15201X 17 KETOSTEROIDS W CREAT P15922 17 OH PREG PROG ANDROS DHEA UNC SUL TEST CORT ALDOS DEOXY DIHYDRO sox mommo OO oooO O e ani P4826 17 OH PROG 3a DIHYD SHBG ESTRAD COR PROG LH PROL ANDRO DHEA Fj P4701 17 OH PROG ANDROS DHEA UN TESTOST T F 3A ANDRO P21003 17 OH PROG ANDROSTENEDIONE DHEA UNCONJUGATED E EO 8 E Remove From MyList Figure 12 5 a l2 7 gt EHR Getting Started Guide 53 Accessing the EHR CyberMed EHR v1 00 9 2 Order Imaging This is the place to order different types of imaging Select the template from the drop down of the types of imaging lt 12 10 gt Select the lab name and other information with respect to the test and enter the pin code to submit lt 12 11 gt lt 12 12 gt The success page appears which can be printed out to be given to the patient FEUI JOSEPH P ADDABBO FAMILY HLTH CNTR 1a VES MIC Home Provider Front Desk B ng Clerk Reports Control Pane Imaging Lab Order Acct Name pare Sex DOB Age MRN Bal_Due 74 55 a lt 12 10 gt E
24. 2 AKHAND ABDUL C in jen fb jd H CMI CM oy 2012 AKHAND ABDUL OM 4 30 2012 AKHAND ABDUL CM CM A EHR Getting Started Guide 85 Accessing the EHR CyberMed EHR v1 00 Flagged Lab This section displays a list of all the labs that are flagged by the provider to be reviewed for later again or waiting for some action like contact with the patient etc The provider can easily review these labs by clicking on the Select link of each patient which will redirect to the patient s lab result report and can thus view the comments to view about the lab lt 22 10 gt JOSEPH P a FAMILY HETH CNTR seas a aarre ere Ho mi e Pro wider r Front t Desk E ng Clerk Repi orts ic ontre al Panel Provider Dashboard Figure 22 9 lt 22 10 gt 4 5 5 Recall List This section holds a list of all patients whose labs have been marked for recall JOSEPH P ADDABBO FAMILY HETH CNTR Home Provider Front Desk Billing ing g Ch Jerk Repi orts c Control Panel Provider Dashboard Chart Unsigned Notes Open Encounters Lab To Review Flagged Lab Recall List MU Measures Patient Search Figure 22 11 EHR Getting Started Guide 86 Accessing the EHR
25. Age Making My Own Referral Provider List Select Group ORF intake Discharge Available Item List My List Referral Provider Name Referral Provider Name 1 Queens Hosptial E 1 ADULT Edt E 2 St Johns Hospital F 2 ASTHMA ALLERGY Edt E i 3 OBGYN Edt F Add to MyList 4 PHYSICAL THERAPY Edt F Remove From MyList Add new My Current Groups e IRF e ORF lt 7 2 gt Figure 7 1 EHR Getting Started Guide 27 Accessing the EHR CyberMed EHR v1 00 4 8 Encounters This displays the patient s previous encounters over the selected period Please select the time span e g 12 months and click on Show Appointments You can check Include No Show to view the appointments that the patient missed lt 7 4 gt The result list also contains the patient s previous visit SOAP notes if the notes are added to the chart to view Click on the icon to view the SOAP notes of that visit The page also displays the diagnosis of the patient On moving the mouse over the Dx the provider can view the description of the diagnosis code i P T FEYZA p JOSEPH P ADDABBO FAMILY HLTH CNTR Patient Chart Acct Name Sex DOB Age MRN Bal_Due 74 55 Vitals Growth Charts Immunization Allergy Medication Problem Lab Referral Encounters Docs Demographic Notes n
26. CyberMed EHR v1 00 CyberMed Electronic Health Record EHR Version 1 00 August 2010 Office of Information Technology OIT Joseph P Addabbo Family Health Center CyberMed EHR v1 00 DOCUMENT REVISION HISTORY Date of Location of Revision Change Revision The information was updated to reflect Version 4 0 2012 EHR Getting Started Guide 1 Accessing the EHR CyberMed EHR TABLE OF CONTENTS ntroduction eeccesazcuasenea cacocessncisgoeeeasaceeese carsceadegen cacwonasssocsceiwasnausaeceaccer 4 Gr e e l E EEO 4 Features of Available Tabs noeeeeeeeeeeeesesseesseessessressrersressreresessressresseeseeeses 6 A AE E NEE ON EEE AE ne 7 Patient Chart NS I a E itt psbonesaedies 9 EON NAG a E AA 11 hamuni zal O D enera E EAE 12 A O a E E E E E 16 Medi a Oore E N E E 17 PODC I eea E E E AEA 19 LoD o A E 21 Be A E E 23 New Ree mals eeerneniaer nE E T TETTE 23 Create Custom Referring Provider List cc eeecccccceeceessseeeeeeeees 2l P O os aT ee ee 28 DO S E E AE A eee ere 29 DEMO Ot ARIS viereesi nE A 30 NO eene E E E E ee EA 31 Intake Discharge DEAL EIIE E EAEI EE A EAE AE TA 32 History PMHX Patient Medical History ccccccccsssssseeecceeeceeeeseseseeeees 35 FPamily HX Family HIStOry ensinan a 38 Social HX Social HISTON Y sanesna E 39 Birth HX Birth History cccccccssssssseccceeceeeeeesssecccceeeseeeeeseeeeeees 40 OBGYN HX OB GYN History cccccccccccceceeceeee
27. Date Acct Name Sex Age File Procedure Diagnosis ae Pick to add Click to Select Click to Select Abdominal Pa OVARIAN DYSFUNCTION HIV Infection 042 PAIN in Lumbago Lower Back 724 2 ABNL ON Rag HYPERESTROGENISM HTN RENAL DISEASE NO RENAL ee EXAM 793 80 OTH OVARIAN HYPERFUNCTION 403 10 p V76 F POSTABLATIVE OVARIAN FAILURE A E Abnormal Chi OTH OVARIAN FAILURE Hypercholesterolemia 272 0 Pharyngitis 462 aAcne 706 1 OVARIAN DYSFUNCTION PREMATURE MENOPAUSE Hypertension 401 9 PPD Reading V74 1 OVARIAN DYSFUNCTION OTHER OVARIAN FAILURE E RE Ean Albuminuria POLYCYSTIC OVARIES Hyperthyroidism 242 90 z 4 OTH OVARIAN DYSFUNCTION eit i Allergic React UNSPEC OVARIAN DYSFUNCTION Hypertriglyceridenia 272 1 Rash 782 1 Allergic Rhinitis Hay Fever 477 9 Diabetes I Uncontrolled 250 01 Hypothyroidism 244 9 Routine Gen Med Exam V70 0 Amenorrhea 626 0 X Diabetes II Uncontrolled 250 02 IMPAIRED FASTING GLUCOSE 790 21 Seizure Disorder 780 39 Diabetes Mellitus w o Complica 250 00 Anemia 285 9 Issue Medical Letter V68 09 Sinusitis 473 9 Anxiety 300 00 Diarrhea 787 91 Issue Repeat Prescription V68 1 STD Screening V74 5 Art
28. GYN H Functional Hc On 17 97 2013 9 15 00 AM wisit user SHHATRI wrote General Total Preg 1 7 t Date 117 032012 Definite 7 Menses Momthly Yes Menarche 15 Frequency Q MONTHLYdays Duration 3 5 Flow REGULAR Past Medical History BPULMONARY TB ASTHMA Contraceptive History Current Usage Ho Infection History Live with someone with IB or exposed to THR YES 7 Lab Order Entry Patient or partner has History of Genital HERPES Rash or Viral illness since LMP HO Figure 8 41 EHR Getting Started Guide 43 Accessing the EHR CyberMed EHR v1 00 5 9 Functional History On the Functional History tab the patient s history list will appear If the user would like to make any changes to the notes already on the list simply click on the icon to edit the note The user can either choose to use the Smart Notes Tool to edit the note or manually type in the notes in the available box provided for free typing of the text To delete the note click on the x symbol or if the user would like to lock the note simply click on the aS symbol To view inactive items check the Show Inactive Item box and then click on the Refresh icon to refresh the list Patient History Patient s Chart Acct Name Sex DOB PA PMHx Family Hx Social Hx Birth Hx OBGYN Hx Functional Hx IntakeDischarge ie a E J J Kr Items Figure 8 42 lt 8 43 gt EHR Getting Star
29. LUMBER SP C m E BRAN o a lt 12 12 gt E PITUITARY o 0 0 l H acs E mm A Prescribing E ORBITS oH 2A Medical Charting E SINUSES E e bail Chasis E Ty o mjm F BRACHIAL PLEXUS E ME lt 12 11 gt E ABDOMEN M oo E PELVIS o 0 0 E SHOULDER o E ELBOW a G E wrist H 0 0 y E HAND m Do E HIP a m GE E KNEE m o o F ANKLE oH 0 0 z Foor o ala E OTHER aE ajm Figure 12 9 EHR Getting Started Guide 54 Accessing the EHR CyberMed EHR v1 00 10 0 MEDICAL CHARTING 10 1 Problem List Please refer to page 18 for this tutorial 10 2 History of Present Illness HPI This page allows the provider to add in detail the history of present illness The provider is provided with a text box to freely type his her notes into the system and save it lt 13 2 gt JOSEPH P ADDABBO FAMILY HETH CNTR Welcome CPETERS Eozou Ho me Pre ovider Fro nt Desk Billing Clerk Repo orts Co ontrol Panel Pharm 7 Fax 6 Pending 982 History of Present Illness Acct Name Sex DOB Age MRN Bal_Due 74 55 Select template REGULAR bag Use Sin tMotes Tool View 3 9 2012 A F u visit seen by ent for f u om Complaints of snoring at night anc congestion most of the time Developed an itchy rash over R ear View 2 16 2012 daltman a E Prescribing Medical Charting Figure 13 1 EHR Getting Started Guide 55 Accessing the EHR CyberMed EHR v1
30. MISON CLINIC PEDIATRI NIP _ CHART 09 45 APPT 0 MARROQUINGRANADI CLINIC PEDIATRI nif M E CHART 09 45 APPT 0 JONES CLINIC PEDIATRI N E CHART 10 00 APPT 0 SANTIAGO CLINIC PEDIATRI N nH wD CHART 10 30 APPT 0 GARCIA CLINIC PEDIATRI N E E CHART 13 30 APPT 0 KWARTENG CLINIC PEDIATRI fo CHART 14 00 APPT 0 RUBIO CLINIC PEDIATRI wif JT CHART 15 00 APPT 0 LOPEZ CLINIC PEDIATRI nit FF lt 5 4 gt CHART 15 15 APPT 0 GAVILANEZ CLINIC PEDIATRI wif iy m CHART 15 15 APPT 0 GAVILANEZ CLINIC PEDIATRI nif jf CHART 15 30 APPT 0 GAVILANEZ CLINIC PEDIATRI nif 7 CHART 15 45 APPT 0 AKINFENWA CLINIC PEDIATRI y a uE E EE E CyberMed EHR v1 00 lt 5 2 gt bi amil j TENPS JOSEPH P ADDABBO FAMILY HITA CNTR os i Home Provider Front Desk Billing Cierk Reports Control Pane Provider Appointments DE 07 31 2012 Provider Figure 5 1 In the provider s name the provider s department appears first followed by the provider s name followed by the 3 digit provider number e g PD_ lt name gt _000 as shown in figure lt 5 2 gt The displayed appointments are the patients who are scheduled for the day In the patients appointment list the green colored appointments are the patients who have already registered and are in the building waitin
31. NCLUDES DIFF PLT 1 WBC fi se Sn ref Poo E EHR Getting Started Guide 79 Accessing the EHR CyberMed EHR v1 00 4 2 1 Lab Search This section allows the provider to search for labs of a patient based on the patient s account number or name Enter the patient s information in the textbox and click on Find Patient lt 21 9 gt Select the patient from the list result generated If the patient has labs with the organization all his previous labs will appear on the right side of the page Click on View to view the patient s lab lt 21 10 gt Veale VETS ai JOSEPH P ADDABBO FAMILY HLTH CNTR Welcome eP gt u A Provider Front Desk Billing Pharm 9 Fax 66 Pending 453 Pharm Pax 00 tending 435 Lab Data Review Lab Review Lab Search Unmatched Lab 5 z Office Mail Search 10 14 19 by DOB x Find Patient enna mame pos sex Aactve Patient sient Name Patient Search 8 25 2011 BUNYAVANICH Referral Center lt 2 9 gt Figure 21 8 4 2 2 Unmatched Lab This section allows the provider to link an unmatched lab with the account number manually Lab Reports Patient Search view Vetall Referral Center 4 8 2011 1 1 1900 NONE NONE QST Save View Detail Vaccine Submit 4 8 2011 3 6 1926 MANUAL269903 QST Save View Detail Reminder List i 4 9 2011 8 9 1953 F RIGAUD 119870932574 QST iew i 12345678910 Figure 21 11 EHR Ge
32. Pertinent findings for this patient noted a GENERAL Apptite Loss Fatigue Always tired Weight Loss ALLERGY Persistent Infections Ni eate Ne BREASTS Gynecomastia CARDIOVASCULAR Claudications ENDOCRINE Diabetes EYES Diplopia lt 14 3 gt GASTRO Abdominal Bloating GYN Last Period Period Duration NEURO Hyperpathia Sensation of Room Spinning PSYCH Anxiety Delusions Depression Mental Problems RESPIRATORY Chest Discomfort SKIN Cancer lt 14 2 gt save reser EHR Getting Started Guide 58 Accessing the EHR CyberMed EHR v1 00 11 1 Use SmartNotes Tool This is a tool generated to help the providers to enter the desired information with minimum typing Click on the Use Smart notes tool button to go to the page lt 14 3 gt Select various categories like general allergy breast etc Provided are the most common items in each category select various items If any additional notes are to be added in any category please add it to the textbox available in each category lt 14 5 gt You can overwrite the existing notes or append add to the existing notes by selecting the radio button at the end of the page and click on Generate Smart Notes This will add your selections to the note s text box in a format The provider can add make additional changes to the text if he wishes igs pip TENTIN RS JOSEPH P ADDABBO FAMILY HETH CNTR EER ASS YOR jj Home Provider F
33. about aches and pains enter it into Pain Assessment then select on a scale of 1 to 10 to register the measure of pain the patient is in lt 8 4 gt Once all the information is entered selected please click on the Save button to save this information into the system We can also review the vital summary and the growth chart from this page by selecting the tabs in the page lt 8 5 gt lt 8 6 gt lt 8 7 gt EHR Getting Started Guide 32 Accessing the EHR CyberMed EHR v1 00 JOSEPH P ADDABBO FAMILY HLTH CNTR YALE Acct Name Sex DOB Age MRN Bal_Due 0 00 New Vitals Vitals Summary Growth Charts Physical Therapy v Chief Complaint Y This visit is Follow up test lt 8 5 gt lt 8 2 gt Complaint Detail 1 Patient complaints pain at Head Lower Back Wrist Hand L Hip Thigh L Knee R and 2 Patient feels Numbness Tingling Stiffness Tremors Weakness and 3 Patient says Test Complaints intake Discharge English Metric RR 16 min 187 mg dL Sa 02 10 150 inch Pulse 43 min 255 WIRA lo2 16 140 tb 2240 oz BP 120 150 Positive Peak Flow 10 L min cm Temp 99 F Mouth v 06 20 2012 HIV Test Accepted v BSA 56 m2 06 25 2012 Captured on 10 00 AM Encounter Form Lab Order Entry E Prescribing Urine Dipstick Smoke Medical Charting Dental Charting Pain Assessment Location Knee Pain Scale MU Menu Duratio
34. ahoo com Subject Testing Office Mail Attachment Browse Lab Reports Patient Search Testing Sending email to an external account outside of Addabbo Referral Center Vaccine Submit Reminder List lt 20 8 gt Group Close Option Patient Account Submission Content Type History and Physical Status Figure 20 6 EHR Getting Started Guide 77 Accessing the EHR CyberMed EHR v1 00 4 2 Lab Reports This section allows the providers to check the pending lab lab result reports Select the provider name and click on Go to view the pending lab reports lt 21 2 gt Select the patient and click on View Detail to open the lab result lt 21 3 gt Tai A la e Health retin s JOSEPH P ADDABBO FAMILY HLTH CNTR Gitte ome Provider Front Desk Billing Clerk Reports Control Pan lt 21 gt Lab Data Review Lab Review Lab Search Unmatched Lab Provider AM _AKHAND AM AKHAND a z M N 5 18 20 ae sola 1965 4 10 2012 AKHAND c View Det AM_CHAKOTE 1945 5 17 2012 akHand fem n Mie Detail 18 20 5 17 2012 CM Referral Center aiai er iieri i 17 Se aE oer sasaaa oom fon wove lt 1 3 AM DHILLON AN FER D AM KALEPU AM_MADHURAPANTULA AM PATEL ANPATTUGALAN j1967 s s0 2012__fakvano jen n View Dota AM_RIGAUD AM_RODRIGUEZ 12345678 Patient Search PP m Ps o Oo Cc es 5 11 20
35. ame Sex DOB Functional Hx jit gt if lt lt 8 28 gt E Show Inactive Items Bret For LastUpdated 11 19 2012 Patient States his 11 19 2012 EFULGENCIO a Ratient States his her social history as below Drinking Status YES lt 8 26 gt Smoking status Never smoker Patient does not caffeine currently Exercising regularly No Illegal drugs use Not Currently Patient is Single Patient has education with Some School Sexual active NO Birth control usage No Interesting in STD Current housing is APARTMENT Living with MOTHER in household Figure 8 25 EHR Getting Started Guide 39 Accessing the EHR CyberMed EHR v1 00 5 Birth History To view inactive items under the history tab check the Inactive Items check box and click on gt the refresh button to refresh the list lt 8 30 gt To see more details about the patient s history click on the button to view comments that the provider entered lt 8 31 gt To view the patient s history list click on the View Hx List A list of the patient s birth history will appear Click on View Hx Summary to view the summary of the patient s history Figure 8 33 JOSEPH P ADDABBO FAMILY HLTH CNTR Home Provider Front Desk Billing Clerk Reports Control Panel Help Patient History Acct Name Sex DOB oss PMHx Family Hx Social Hx Birth Hx OBGYN Hx Functional Hx pen g
36. ation Described in the previous section Click here to view 5 11 Referral Described in the previous section Click here to view 6 0 Screening and Intervention In order to add the Screening and Intervention select the type of screening from the drop down and click on the Create new button lt 9 2 gt There is a text box available for free typing of the text If the provider wishes to use SmartNotes Tool click on the button and add information regarding the social history Select Generate SmartNotes to add the selected notes lt 9 3 gt If a previous history already exists and the provider wishes to overwrite select Overwrite and then click on Generate SmartNotes lt 9 5 gt Once this is done click on the Save button to save the notes to the system If the patient has screening notes from previous visits it can be found on the left side of the page The provider can click on the lock symbol to lock the history notes from further changes TETA ESYA JOSEPH P ADDABBO FAMILY HLTH CNTR re a ea Dalit Acct Name Sex DOB Age MRN Bal_Due 74 55 Select Screening Type PPD Screening PPD Screening Vision Hearing Screening Alcohol Abuse Screening Drug Abuse Screenin View 8 1 2012 CPETERS X Use SmartNotes Tool intake Discharge PPD Screening On 8 1 2012 10 18 53 AM Patient had TB skin test Yes Result Negative Patient had chest X ray after skin test Yes On
37. d File Please add more comments regarding the document the document title and selecting the category and then click Save to save the document into the system in the right category lt 7 9 gt r SENSES b Peary Mics F JOSEPH P ADDABBO FAMILY HLTH CNTR _ b P F D B Clerk Reports Control Pane Home Provider Front Desk Billing rly UII IJl WW Acct Name Sex DOB Age MRN Bal_Due 0 00 Vitals Growth Charts Immunization Allergy Medication Problem Lab Referral Encounters Docs Demographic Notes Office Mail Select Document Category HIPAA Form Upload File Browse Load File Reset Lab Reports Title Type Updated Display PDF Control Prostate form PDF 6 21 2012 Xx Hipaa form sample 2 PDF 6 19 2012 X i lt 7 8 gt lt 7 9 gt Patient Search Referral Center Vaccine Submit Reminder List Group Close Comments Document Title Document Category HIPAA Form Save Figure 7 7 PEAT FeV PAN JOSEPH P ADDABBO FAMILY HLTH CNTR gl Chart Acct Name Sex DOB Age MRN Bal_Due 0 C Vitals Growth Charts Immunization Allergy Medication Problem Lab Referral Encounters Docs Demographic Notes Office Mail Select Document Category HIPAA Form 7 Upload File Reset Lab Reports Updated 4 Patient Search z Prostate form PDF
38. der Front Des History of Present Illness Acct Name Sex DOB Age lt 13 9 gt Making My Own HPI List ra My List aS 1 iar sa Abdominal Complaints 3 Complaint Anorectal Problems a Complaint Chest Pain 5 Complaint Eve Complaints S Complaint Gynecological Problems Select Group Complaint intake Discharge Available p Complaint My Current Groups Encounter Foo Complaint 1 Bias aaa Abdomini ocation Modifying Factors g Severity Lab Order Entry E Prescribing lt 13 12 gt 10 First Visit Coop Seis Remove From Ni Complaint Gynecological Cecilia Or enter new item for this group 2 14 Hyperten Hyperlip 15 Ingrown Toenail 123 lt 13 11 gt Figure 13 8 lt 13 10 gt EHR Getting Started Guide 57 Accessing the EHR CyberMed EHR v1 00 11 0 REVIEW OF SYSTEM This page allows the provider to add summary of a patient s main and general body system for basic functioning purposes The provider is provided with a text box to freely type his her notes into the system and save it lt 14 2 gt The provider can also use the SmartNotes Tool to help generate the note lt 14 3 gt Pharm 7 Fax 6 Pending 982 Review of System Name Sex DOB Age MRN Bal_Due 0 00 Cres Select template REGULAR iUS SmantNetesireaiy C EEEH as ummary Y 8 23 2012 CPETERS f
39. e Your Own Tenip late senner ie 69 Treatment Pla tvicpiscciwseiachahebs aceite tak las NE 70 Use Smart NOtes TOO lerinen aa a 71 Make Your Own Template ccccccccccccccessseeeeeeeeeeeeeaeeeeees 12 SOAP NO Seann E EEN 73 Provider Tab omes M iaon E 75 Ma DO an E E A 76 COMIDO aape a 77 LAD REPONS sack sanesaereiaanta i eustanelucarete E O 78 TAD SCAT Dieren 80 Umu Wed LiD errreni a 80 PESC E a a A E Sl PROTO aC Ci ore a E T ites eed oa 82 Provider Dashboard CRU Funar AA ie adeiter deh asdaeae ite 83 Unsigned OIT NOS neriie laiaanrtantadtiateaaadees 83 Open ENCOUN eie ee steal racuta dental seueretue ied eae 85 TAD 1O sIRCVICW saree rae E E E AA denuded Slee hiias 85 PIAS Ge OA aie denna nee ta anadaewncham cpus dantnetiatesoanus 86 for 61 II UB arene reste enter a re re 86 EHR Getting Started Guide 3 Accessing the EHR CyberMed EHR v1 00 1 0 Introduction CyberMed EHR application is based on a component framework This means that the application the user sees is actually composed of functional components most suited to the user s role in patient care Thus the application used by a front desk clerk will look much different from that used by a physician This User Manual is organized into chapters where each chapter is devoted to a particular functional component Depending on a user s role some chapters will be valid while others will not 2 0 Accessing the EHR This section provides information abou
40. e providers are provided with the most common diagnosis code for quick adding into the system If the patient is diagnosed with a condition not in the list we can add by going to diagnosis tab 8 3 Diagnosis There is a list of the most common diagnosis available for the provider s convenience If a diagnosis code is not available in the list the provider can search either by the ICD 9 code or by keyword The result appears in the dropdown below Make a selection to add to the list of diagnosis lt 11 11 gt If the provider still cannot find the diagnosis they are looking for from the dropdown list there is a provision to search from Google on the right side of the page Enter the code diagnosis and click Google search This opens a new tab showing the result in description regarding the diagnosis lt 11 12 gt The provider is expected to copy the right diagnosis code and add it to the search box in the diagnosis by code in order to enter it into the encounter form The description for a code available in the EHR system could be different from the description the provider is looking for So the Google search gives the capability to search for the right code based on various descriptions available i N Dit PEPEE E A met A E S EAS 5 amp f as Home CETE Front Desk Billing Clerk Reports Control Panel Pharm 7 Fax 6 Pendine 982 lt 1 1 l 12 gt lt 1 1 1 gt Adult Medicine Encounter Form
41. e up to date immunization information JOSEPH P ADDABBO FAMILY HLTH CNTR Immunizations Acct Name Sex DOB Vaccine Route H Given Date VIS Site Lot Manufacturer Expired On premem vain wnsios renam cmsaa PMC 2201 amv OO se_ afan onsas renien ioman uso e820 5 Iam seen ese peserivetee IM Ho7av202 orasanu teDewwd Patient s CIR ID 709363563 Refresh Patient s Record After Submission Mother s Maiden Name test_maiden Mother s First Name test2_maiden ntake Discharge lt 6 18 gt i i Figure 6 17 EHR Getting Started Guide 15 Accessing the EHR CyberMed EHR v1 00 4 3 Allergy This displays the patient s active and inactive allergies Please select Show Inactive Allergy and refresh to view the inactive allergies lt 6 20 gt We can add new allergies by searching the name at least 3 letters in the textbox on the right side The result is displayed below lt 6 21 gt The most common allergies are already provided in the list on the right side of the page Select the checkbox next to the name of the allergy and click on Add Allergy lt 6 22 gt LERA I EYO ariji Patient Ch Acct Name Sex DOB Age MRN Bal_Due 74 Vitals Growth Charts Immunization Allergy Medication Problem Lab Referral Encounters Docs Demographic Notes Office Mail Refresh_ X Show Inactive Allergy _ ae Add New Allergi
42. eaeeeeeeeeeseeeees 42 Functional HX Functional History ccccccssssssseecceceeeeeeeeeeeeees 44 Screening and Intervention essessoeeeessssssseeeeerssssssesseersssssssseeeressssssseeeereo 46 Pre N aa TO a S 47 Encounter Form PTO O e N EAE EAN 49 Quick Diagnosis Code sesira ieoa o a 50 RA MO eoan E gee a sctes eeee cee cassanss 50 Lab Order Entry OT o E E A A EE E AA E E 52 Make My Own LSU sis cceesorcnceeastenadsnnrcnctasebensunenseetesabeaudorensevabeessanes 53 Order Ta aeee E E A E E EE 54 Medical Charting History of Present Uiness HPI scisicccencnnsnssananatecnnbetatwacanasexnnnesdawusnies 55 Use SmartNotes Tool ccccccscccesecceseceessceeseceeesseeneees 56 Make Your Own Template ccccccccceccccesseeeeeeeeeeeeeeeeeeeees 57 Review of System ROS J dcstisecsacasoncvossianeraenaddawenoraeshessvoleneeedtovecsian 58 Use SmarnNotes TOO vai dsccesanocsnsnasasadionaniesenensencaniacstiesoesasnonen 59 v1 00 EHR Getting Started Guide 2 Accessing the EHR CyberMed EHR v1 00 Make Your Own Template ccccccccccccccesseseeeeeeeeeeeeeeeeees 60 BES eane S rae lo aay A E 6l Use Smart NOs TOO lren ae A 62 Make Your Own Pemplatesccietiiiwucuinentiiwntctiakiveied 63 Development Assessment Dev AsSeSSMeNf cccccccesseeeeeeeees 64 UseSmanNotes Too lrunen aenea 65 Make Your Own Template sann 66 ADUCPaOry GUIC ANIC Eei A ileal naeias 67 Use SMlartINOles FOO airenit tides tt eek 68 Mak
43. ection Chest Pain W Ingrown Toenail woren Exam Female aa Male Cl Diabetes Laceration Physical Exam Infant Location lt 13 6 gt Severity Duration Context Modifying Factors Overwrite Append C SEISHER NEST Figure 13 4 lt 13 7 gt EHR Getting Started Guide 56 Accessing the EHR CyberMed EHR v1 00 10 2 2 Make Your Own Template In order to make your own History of Present Illness template click on the symbol Figure 13 1 Select the group of category and select the available items phrase from the list and click on Add to My List lt 13 9 gt lt 13 10 gt If desired to add an item that is not available in the list there is a text box saying Or Enter New Item for This Group Type the new item and click on Add to add the item to the list lt 13 11 gt This template can be composed at one time and will be available for the patient s History of Present Illness Any changes add removal of items reflects there on ward In order to remove an item from your list select the item and click on Remove from My List lt 13 12 gt On going back to History of Present Illness the provider would find the template for Smart Notes default to the user template In order to view regular template please select regular in template invpoFamil _ eaii TENZA JOSEPH P copiers FAMILY HETH CNTR ng Clerk Reports Control Pane Home Provi
44. ee a P aii aii Given Here Historic Record af eC Date_Given 07 31 2012 VIS 07 26 2011 Admin Site Left Deltoid Route IM Reaction JOSEPH P ADDA Home Prowider Front Desk Existing Lots E CFA Code Vaccine Name Lot Expired On Manufacturer Source OFT 20135 sanofi pasteur Supported by Private Insurance or Other Private Funds Delete T Hib IPW Supported by Private Insurance or Other Private Funds Delete mev Hib l w EEH mle I C4158A4 87 2013 Federally supported eae Drar nav 3 COS OA A 7757 2013 anofi pasteur Federally supported Hab IPV C3917 AA 6 amp O 201 sanofi pasteur Federally supported ete C4130 6 9 2013 Federally supported Del 5 18 2013 Supported by Private Insurance or Other Private Funds 1234 Medical Charting HE m l Dental Chanting Figure 6 15 EHR Getting Started Guide 14 Accessing the EHR Acct Name Sex DOB Age MRN Select_Lot m Date_Given 07 31 2012 vS 12 16 1998 Admin Site T cr lt 6 13 gt CyberMed EHR v1 00 In case there is no CIR number enter the patient mother s maiden name first name to assign retrieve a number from the CIR On checking the option Refresh Patient s Records after Submission lt 6 18 gt submit the immunization information is bidirectional updated and retrieve from the CIR and the two places hav
45. ent s treatment plan Any changes add removal of item reflects there on wards In order to remove an item from your list select the item and click on Remove from MyList lt 18 7 gt On going back to treatment plan the provider would find the template for smart notes default to the user template In order to view regular template please select Regular in Template JOSEPH P ADDABBO FAMILY HLTH CNTR Home Provider Front Desk Billing Clerk Reports Control Panel Treatment Plan Acct Name Sex DOB l Ag Making My Own TxPlan List Select Group CTScan My List eman M E E T Encounter Form e 1 CTScan Abdomen E CTScan s eseas Chet eee SH 3 cron ke S d a 7 Scan frontar Spe ros CTScan Head sid Or enter new item for this group eel mm lt gt pS orsa ee o a B OO oee omberspine G E lt 18 6 gt SOAP Notes Figure 18 6 lt 18 5 gt EHR Getting Started Guide 72 Accessing the EHR CyberMed EHR v1 00 16 0 Soap Notes SOAP notes are basically a summary of all the providers assessment of the patient s visit If the provider has completed various charting encounter ERx labs etc the auto notes items are already highlighted on the right side of the page lt 19 2 gt To add the SOAP notes select the items of notes to be added on the right side of the page and click on Add Refresh lt 19 3 gt This would update the
46. erral Status drop down allows choosing open closed in process or reviewed referrals lt 6 41 gt JOSEPH P ADDABBO FAMILY HLTH CNTR Vitals Growth Charts Immunization Allergy Medication Problem Lab Referral Encounters Docs Demographic Notes r tos Account Referral Date Referred From Referred To Show referral status Open Intake Discharge Status Lookup Date po pasame perimwaumerjonen vrascia e a xia jpe pese opmiuoroerjoven asraon gal a New Referal Sore lt 6 40 gt Figure 6 40 EHR Getting Started Guide 23 Accessing the EHR CyberMed EHR v1 00 Home Provider Front Desk B eports Control Pane Patient Reterral 3 Gex DOB z Ref Date 7 26 2012 Ref Status Open v LookUp 7 26 2012 Ins ID Pavor COMPUTERSCIENCECORP Refemmnge From Physician Neme AM AKHAND 7 Phone 666 666 6666 Fax Email Centact AN_AKHAND lt 6 43 gt Neme IRF_ASTHMA JALLERGY k Phone 000 000 0000 Fax Email Refsrral Description a Encounter Fonm Lab Order Entry E Prescribing Medical Charting Dx Code te Dental Charting Figure 6 42 The picture above shows the details of the referral Click on Details on the referral page lt 6 40 gt Select a provider from the drop down list lt 6 43 gt EHR Getting Started Guide 24 Accessing the EHR CyberMed EHR 4 7 1 New Referral v1
47. es Hep B Hep B Hep B adolescent or adolescent or adolescent or HepB pediatric pediatric pediatric Completed Vaccine Series saa DTaP IPV Hib DTaP IPV Hib DTaP IPV Hib Pentacel Pentacel Pentacel Hib PRP T Encounter Form Hib Completed Vaccine Series ET ava Lab Order Entry Human Papillomavirus 07 29 2021 HPV E Prescribin z Influenza 09 01 2011 influenza NOS E Meningococcal 07 29 2021 meningococcal MCV4 Recommended for high risk groups Dental Charting MMR MMR 07 29 2014 MMR 8 4 2011 Pneumococcal Pneumococcal Pneumococcal Pneumococcal PCV 13 PCV 13 PCV 13 PCV 13 Pneumo Conjugate Completed Vaccine Series aiuto TET DTaP IPV Hib DTaP IPV Hib DTaP IPV Hib Polio Pentacel Pentacel Pentacel 07 29 2014 IPV sina Figure 6 8 EHR Getting Started Guide 12 Accessing the EHR CyberMed EHR v1 00 JOSEPH P ADDABBO FAMILY HLTH CNTR pebathe tisha a ar Home Treated op Erant Meck A aE Clerk Reports li antrol Pane i at i i a N M o C rG La ai i s Immunizations Vaccine Name HepB Choose Vaccine r DTP Choose Vaccine Hib DTaP Hib IPV Ts Polio Choose Vaccine Pneumo Conjugate Choose Vaccine ad Rotavirus Choose Vaccine MME Choose Vaccine MMRV we Choose Vaccine sits Choose Vaccine F Choose Vaccine Encounter Form Influenza seasonal injectable preservative free Y Lab Order Entry Cho
48. es Patient Exisiting aiftcgies ee Search Jat least 3 letters Lab Reports Allergy Severity status Lastupdated a kli Ace Inhibitors Mild Active 7 30 2012 Edit Delete Referral Center Bee Sting Moderate Active 7 30 2012 Edit Delete Jaare SobmiE House Dust Moderate Active 7 30 2012 Edit Delete lt 6 21 gt No Known Allergies Unspecified Inactive 7 30 2012 Edit Delete Severe Active 7 30 2012 Edit Delete Moderate Active 7 30 2012 Edit Delete Severe Active 7 30 2012 Edit Delete Reminder List Group Close Ace Inhibitors Hay Fever 0 Sulfas Bebe amp ClBee Sting Cl Pennicillins House Dust Latex CI Codeine CI Nuts CI Seafood M Peanuts CINo Known Allergies Figure 6 19 lt 6 22 gt This displays a window to select the severity of the allergy and a textbox to add reaction or any additional information Click on Save to save the allergy to the patient s chart lt 6 24 gt Bee Sting Figure 6 23 lt 6 24 gt EHR Getting Started Guide 16 Accessing the EHR CyberMed EHR v1 00 4 4 Medication This displays patient s active medications Click on Refresh to update the medication list to the latest To view inactive medication select Show Inactive Medication and click Refresh If the patient takes no active medication please select the Patient Takes No Active Medication button lt 6 26 gt If the provider wishes to give the patient handouts
49. es can be either the phone communication notes or the letter communication notes You can delete the notes by clicking on the X on the right side of the page or you can lock your notes by clicking on the lock icon lt 7 14 gt Once a note is locked the provider won t be able to make any other changes to it Click on Read to read notes lt 7 15 gt JOSEPH P ADDABBO FAMILY HLTH CNTR Vitals Growth Charts Immunization Allergy Medication Problem Lab Referral Encounters Docs Demographic Notes ntake Discharge Date Created Category Message Created By 7 31 2012 3 09 12 PM Letter Communication Letter communication test notes CPETERS ead 7 31 2012 3 06 53 PM Phone Communication Phone communication test notes CPETERS Figure 7 13 EHR Getting Started Guide 31 Accessing the EHR CyberMed EHR v1 00 category Letter Communication Letter communication test motes gt Figure 7 16 5 0 Intake Discharge 5 1 CC amp VITALS This page is to record patient s chief complains and vital information You can also use SmartNotes Tool to select the information regarding the patient lt 8 2 gt lt 8 9 gt On clicking on Save this information is added to the chief complaints This page also contains various tabs to register Pain Assessment Urine Dipstick and Smoke Cessation lt 8 3 gt If the patient has any complaints
50. etting Started Guide 10 Accessing the EHR CyberMed EHR v1 00 4 1 2 Growth Chart In the cases where the patient is below 18 years old we can select the patient s weight length stature H C or BMI charts by clicking each button lt 6 4 gt JOSEPH P ADDABBO FAMILY HLTH CNTR a a a Encounter Fonm Lab Order Entry E Prescribing Medical Charting E Dental Charting MU Menu Figure 6 5 EHR Getting Started Guide 11 Accessing the EHR CyberMed EHR v1 00 4 2 Immunization This tab displays the patient s immunization information In case the patient s CIR ID is present please enter in the text box below and click on Retrieve from CIR to get the patients updated immunization information In order to add new immunization information click on the Add New button lt 6 7 gt Patient Chart Acct Name Sex DOB Age MRN Bal_Due 187 47 Vitals Growth Charts Immunization Allergy Medication Problem Lab Referral Encounters Docs Demographic Notes PEDS ADULT lt 6 6 gt pisaia The record was last updated on 2 20 2012 10 35 16 AM Enter patient s CIR ID Retrieve from CIR Vaccine D4 wait Hale DTaP IPV Hib DTaP IPV Hib DTaP IPV Hib oa DTP Pentacel Pentacel Pentacel 07 29 2014 DTaP sn H1N1 Influenza No longer recommended Hep A ped adol Hep A ped adol HepA sei fis Completed Vaccine Seri
51. evious section Click here to view 5 3 History This page allows you to view the patient s Medical History PMHX patient s Family History Family Hx Social History Birth History OBGYN History and Functional History lt 8 11 gt JOSEPH P ADDABEO FAMILY HLTH CNTR lt Reports Control Panel Help Patient History Sex DOB O os PMH Family Hx Social Hx Birth Hx OBGYN Hx Functional Hx Intake Discharge Visit Brief Hx LastUpdated User 12 17 2012 Others THYROID PROB 12 17 2012 SDHOLAKIA rY E Figure 8 10 lt 8 13 gt Show Inactive Items EHR Getting Started Guide 34 Accessing the EHR CyberMed EHR v1 00 5 4 Patient Medical History PMHX To view inactive items under the history tab check the Inactive Items check box and click on gt the refresh button to refresh the list lt 8 12 gt To see more details about the patient s history click on the button to view comments that the provider entered lt 8 13 gt Click on View Hx History icon to view the patient s notes history lt 8 15 gt ee c aFamily mR W mapa ica JOSEPH P ADDABEO FAMILY HLTH CNTR Sm Home Provider Front Desk Billing Clerk Reports Control Pane Help Patient History Sex DOB Intake Discharge 12 17 2012 2 00 00 PM visit user SDHOLAKIA wrote Others THYROID PROBLEM THYROXIN NKDA Lab Order Entry E Presc
52. g for the provider lt 5 3 gt The grey colored lists are the patients who have already seen the provider and finished their encounters lt 5 4 gt We can also view the patient s wait time The normal green color shows patients who are waiting for less than 60 minutes The yellow color shows that the patient has been waiting between 60 to 90 minutes Red shows patients waiting over 90 minutes This gives the provider an idea of how long the patients are waiting at a glance The Enct Lab SOAP are also color coded The red color means the notes are not done ordered in case of lab Blue means the following module has been completed Once you get the list of patients select the patient whose information you want to review change lt 5 5 gt Click on Chart to get the patient s chart information lt 5 4 gt EHR Getting Started Guide 8 Accessing the EHR lt 5 5 gt CyberMed EHR v1 00 4 1 Patient Chart The image below displays the different tabs that are available for the provider in order for them to view the patient s chart information when clicked on Char in the appointment page Figure 6 1 I ee ee SS E g E A i Docs Demographic Notes Vitals Growth Charts Immunization Allergy Medication Problem Lab Referral Encounters Figure 6 1 4 1 1 Vitals Summary This displays a list of vitals taken in all the previous visits Click on vital trend to view the height weigh
53. he provider can easily review these labs by clicking on the Select link of each patient which will redirect to the patients lab result report mI k AKHAND AUB WIL C s as aoaz i AKHAND ABDUL EM Sellact Patient Search 5 18 2012 5 14 2012 AKHAND ABDUL CM Select on fon itn In en mj ffm ff i ll la Wi HERE H lec m i 317 2012 m fo i A 5187 2012 5 17 2012 AKHAND ABDUL Selec Referral Center 5 9 2012 AKHAND ABDUL C A 1 12 AKHAND ABDUL CM Vaccine Submit 5 10 2012 AKHAND ABDUL 511 2012 5 8 2012 AKHAND ABDUL CM Reminder List 5 11 2012 5 10 2012 5 10 2012 S o 2012 5 6 2012 SS 2012 Sf 2 2012 lt 22 8 gt M lL i H Seleri 5 11 20 a Select EEFE 5 87 2012 AKHAND ABDUL CM 5 7 2012 AKHAND ABDUL CM 3 ae Selec 5 10 2012 AKHAND ABDUL CM it cM 4 26 2012 cM Sele 4 25 2012 a x 3 21 2012 HAND 3 8 2012 i 35 2012 S S 2012 3 2 2012 Figure 207 em Sele cm cm em eu ta ul un en on ul te pa LISTIS N N Hl H I i Bl sd ctl a H an a Bl a Bl Ra Ba Bl o jai o o A N Ble B m W ha fa N CEFET m ea len ita in Iia fen Ita i f f e e M fia i ib j it Select i a H o pas fl o H MN Di E i in Le ib fh 5 2 2012 AKHAND ABDUL cm Sele 2 25 2012 AKHAND ABDUL cm 3 1 2012 AKHAND ABDUL cM Selec 3 1 2012 AKHAND ABDUL cm Sele S 3 201
54. hritis 716 90 Dizziness 780 4 Mammogram Screening V76 10 Tonsillitis 463 ASTHMA WITH ACUTE EXACERBATIO 493 02 Asthma 493 90 Follow Up V67 9 Need for prophylactic vaccinat VO5 3 Upper Respiratory Infection 465 9 Benign Prostate Hypertrophy 600 00 Gastritis 535 50 OBESITY MORBID 278 01 Urinary Tract Infection 599 0 ELEVATED BLOOD PRESSURE 796 2 Muscle Strain Sprain Unspec 848 9 Trauma Injury 959 9 Breast Mass 611 72 Gastroenteritis 558 9 Obesity 278 00 VACCINE AGAINST INFLUENZA V04 81 VACCINE AGAINST EUMONIAE V03 82 Bronchitis 490 Gastroenteritis Viral 008 8 Osteoarthritis 715 90 Cellulitis 682 9 GERD 530 11 Osteoporosis 733 00 VACCINE AGAINST VARICELLA V05 4 Chest Pain Unspecified 786 50 Headach 784 0 Otits Media Acute 382 9 VACCINE MMR V06 4 Chlamydia 099 53 Heart Murmur 785 2 PAIN IN JOINT 719 40 Viral Syndrome 079 99 Conjunctivitis 372 30 HEP C w o HEPATIC COMA 070 70 PAIN IN LIMB 729 5 Vision Disturbance 368 9 Figure 11 10 EHR Getting Started Guide 50 Accessing the EHR CyberMed EHR v1 00 Once the procedure code diagnosis codes are selected please click on Submit to save in the system On
55. ing Started Guide 46 Accessing the EHR CyberMed EHR v1 00 7 0 Pre Natal Log This page displays the patient s pregnancy information Click on Add New and add the appropriate information and then click on Save to save the information to the system lt 10 2 gt Weary eS EN JOSEPH P ADDABBO FAMILY HLTH CNTR QanprtEe antrol Pane lant ham a Prenatal Care Log Acct Name Sex DOB Ist Visit Trimester Current Status 1 3 2012 3 In Care Y sdoscetatasteta tthe EDC Date HIV PreTest Date HIV Test Result _____ lt 10 2 gt 1242012 Negative Last Visit HIV PostTest_ Date Add New T 26 2012 1 25 2012 Ist Visit Provider GYN CARLENE Delivery Provider EN CARLENE Delivery Date 9 21 20 2 Birth Weight New Borm Visit Date 9 24 2012 Post Partum Visit Date Figure 101 EHR Getting Started Guide 47 Accessing the EHR lt 11 2 gt CyberMed EHR v1 00 8 0 Encounter Form This is the main form for the providers Please select the department if present in the left navigation bar lt 11 2 gt The providers are expected to fill the form with procedure diagnosis code and close the encounter for each patient they see There are two tabs in the encounter form The Procedure and Diagnosis tab these tabs can be found at the top of the page lt 11 3 gt If any Immunization Vaccines Injection Medication Injection Procedure Vaccine Administrati
56. list In order to search for the labs to add to your list you can use Quick filter and enter either the test code or the test name and filter for results or if this 1s not successful for the desired result you can manually search the lab from the list page by page lt 12 6 gt Click the lab test names and click on Add to My List lt 12 7 gt In order to remove lab tests from your list select the test names on the right side of the page your list and click on Remove from MyList lt 12 8 gt lt 12 6 gt My Lab Order List Select Lab Vendor QUEST __ Available List My List Quick filter All fields x Advanced options Quick filter All fields Intake Discharge TestName TestName Encounter Form P11120 N Y VPROTH GENE FACTOR V MTHEFR CARDIO LIP G M TSH Lab Order Entry P9707 NY CF CARRIER SCR CBD ABO ABS RUB RPR HBsAG HgBEVL SICKLE 7 NY CF DNAwRFX CBD ABO HgBEVL HCG TSH RPRHBsAG RUB P9711 NY CF SCN CBD ABO ABS RPR HBsAG RUB TOXO SICKLE HCG HgBEVL E 0 P STOOL CHARCOT LEYDEN CULT SALM SHIG CAMPY STL LEUK STL P11180 NY GENETIC DISEASE SCRFAMILIAR DYS MUCOLIPID IV FRAGILE X DNA vi 10 DRUG W CONF THC 50 ALCOHOL UR CONF NON COC F SPOS SOLUS i P7704 NY MUCOLIPIDOSIS FAMILIAL DYSAUT ASHKENAZIPNL HEX A LEUK E 36637P 10 HYDROXYCARBAZEPINE 30543X 11 DEOXYCORTISOL LC MS MS ed K10490 15 01 BROADWAY E Prescribing K10085
57. mplate this can either be Regular Pre Natal Pap smear RW Drug Screen or Urology or User own list lt 12 2 gt Select the labs needed to be ordered lt 12 3 gt The provider can also search for lab orders either by keyword or by code The result will appear in the dropdown next to the By Code button Select the appropriate lab and it will be highlighted in your list Once all the labs are entered enter the pin which is typically followed by the provider number and click on submit lt 12 4 gt A review page appears which a provision to add notes to order the lab and click on Confirm to order the labs A page confirming successful ordering of the lab appears which the provider can print and give it to the patient The following image shows how your template of lab order appears every time you click on Order lab by default If you would like to use regular template select it from the drop down of templates lt 12 2 gt H Jey CEU PEN JOSEPH P AODASBO FAMILY HLTH CNT Welcome CPETERS Logout S y Ay MS b Home Provider Front Des Billing Clerk Reports Control Pane Fax 6 Pendins 982 i Medical Lab Order Acct ame Sex DOB Age MRN Bal_Due 74 55 Sect Temple STE a AEE Search REGULAR By Keyword By Code Click to Select v PRENATAL iag SMEAR GTT 3 SPEC 75G 7 DRUG SCREEN HB S AG W REFLEX CONF Lab Order Entry UROLOGY HCG TOTAL QN
58. n 2 weeks Frequency 3 w 4 6 7 8 9 10 i Moderate Severe e Worst What helps i ai Pain Pain Severe Possible Figure 8 1 Comments Encounter Form Testing Comments Lab Order Entry E Prescribing Pain Assessment Urine Dipstick Smoke Cessation Leukocytes Trace Blood Medical Charting Dental Charting Nitrite Positive v SpcG Uro 1 0 mg dL v Ketone Trace Bilirubin MU Menu 6 0 v Glucose Figure 8 6 Comments Encounter Form Testing Comments Lab Order Entry E Prescribing Pain Assessment Urine Dipstick Smoke Cessation Smoking Status Smoking Cessation Medical Charting Dental Charting Figure 8 7 EHR Getting Started Guide 33 Accessing the EHR CyberMed EHR v1 00 JOSEPH P eet FAMILY HLTH CNTR Vital Intake Acct Name Sex DOB a Visit type ntake Discharge b Patient s pain on jHead Pelvis Groin E Shoulder R V Wrist Hand L Knee L Face Upper Back JArm L Wrist Hand R Knee R FNeck MLowerBack Arm R MlHip Thigh L Ankle Foot L 1Chest Sacrum Elbow L Hip Thigh R Ankle Foot R A pdomer Shoulde L E Elbow R c Patient feels Y Numbness F Swelling F Stifness F Rigidity F Weakness d Other complamts Testing Vital Comaplaint z a Figure 8 9 5 2 Allergies Described in the pr
59. n item that is not available in the list there is a text box saying Or Enter New Item for This Group Type the new item and click on Add to add the item to the list lt 17 9 gt This template can be composed at one time and will be available for the patient s anticipatory guidance Any changes add removal of item reflects there on wards In order to remove an item from your list select the item and click on Remove from My list lt 17 10 gt On going back to anticipatory guidance the provider would find the template for smart notes default to the user template In order to view regular template please select regular in Template JOSEPH P ADDABBO FAMILY HETH CHTR Welkome EPETE Home Provider Front Desk Billing Clerk Reports Control Pane Pharm Fax 6 Pendin Anticipatory Guidance Acct Name Sex DOB Age MRN Bal Due Making My Own Exam List Select Group Available FANSA My List My Current Groups hie me 12 months EE ere Encounter Form 1 Jwks l month Ability ZE o a 1 2wks 1 month Ability to roll F lws month 2 2wks 1 month Breast 49 months a 2 2wks 1 month Breast vs formula feeding aaa ellen ee 3 2wks 1 month Burns 12 months 3 3wks 1l month Burns from hot liquids C E Prescribing 4 Iwks 1 month a Oo 4 2wks 1 month Burping Oo Medical Charting 5 Dwks 1 month Call a se O 3 Iwks 1 month Falls C 6 2wks 1 month Circ Ca E B Years C 2wks l month Feeding C 2wks 1 m
60. nal template with the selected categories and text from those categories will appear You can Undo Delete or Erase All by clicking on the respective button on the right side of the page lt 19 3 gt Once the notes are reviewed and the respective changes have been made click on Save SOAP to save the soap notes lt 19 4 gt Please Note Save SOAP does not mean the provider has signed off It just saves the provider s notes This can be modified afterwards However the button Sign Co Sign off is used only when the provider has finished all review and finalized to sign it off and lock from further changes Please Note Once the notes are sign co sign off additional changes cannot be added This is the reason the system asks for the provider to enter their pin number Fix Errors in Signed SOAP Notes If a provider for any reason wishes to record an important change to a SOAP note which is already signed off he can record the change only by clicking again on Sign Co Sign Off and adding his text to additional notes For Example The provider has entered the wrong diagnosis and signed off the SOAP notes Later he realizes it and wants to correct it He she can do that by clicking on Sign Co Sign Off and adding the changes to Additional Notes lt 19 6 gt Sign Off Confirmation Enter PIN 111 Confidential PEA The provider can enter additional notes before he she sign off Add l Note 19
61. nd save it lt 16 2 gt Development Assessment Sex DOB J MRN Bal_Due 5 00 Select template REGULAR E 7 Context Testing patient s development assessment EHR Getting Started Guide 64 Accessing the EHR CyberMed EHR v1 00 13 1 Use SmartNotes Tool This is a tool generated to help the providers to enter the desired information with minimum typing Click on the button Use Smart Notes Tool to go to the page lt 16 3 gt Select various age groups from the drop down lt 16 5 gt Provided are the most common items select various items If any additional notes are to be added in any category please add it to the comments box available next to each item lt 16 6 gt You can overwrite the existing notes or append add to the existing notes by selecting the radio button at the end of the page and click on Generate Smart Notes This will add your selections to the note s text box in a format The provider can add make additional changes to the text if he wishes lt 16 7 gt CNTR Home me Pro vider Front Desk Billi Clerk Reports ntrol Panel Development Assessment Acct Name Sex DOB Select group 15 months Fission o re Overwrite Append MOSRSAESMEANEES Figure 16 4 ee lt 16 7 gt EHR Getting Started Guide 65 Accessing the EHR CyberMed EHR v1 00 13 2 Make Your Own Template In order to make your own Development A
62. ns _ i O 2 Birth Date 05 25 1991 Birth Place Skeldon Guyana No Yes e g diabetes high blood pressure if yes detail 3 Prenatal Problems 4 Labor Delivery Normal Vaginal Birth C section Other Problems if others detail No Yes 5 Newborn Problems fe g premature jaundice infection if yes detail 6 Hearing Screen Pass Fail Newborn Screening ID Po Normal Abnormal Encounter Form Lab Order Entry 7 Newborn Screen E Prescribing Medical Charting Overwrite Append Dental Charting Figure 8 34 EHR Getting Started Guide 41 Accessing the EHR CyberMed EHR v1 00 5 8 OBGYN History On the OBGYN History tab the patient s history list will appear If the user would like to make any changes to the notes already on the list simply click on the icon to edit the note A page as displayed in figure Figure 8 36 will appear The user can either choose to use the Smart Notes Tool to edit the note or manually type in the notes in the available box provided for free typing of the text lt 8 39 gt To delete the note click on the x symbol Or if the user would like to lock the note simply click on the symbol To view inactive items check the Show Inactive ab me Item box and then click on the Refresh icon to refresh the list lt 8 37 gt JOSEPH P ADDABBO FAMILY HLTH CNTR Provider Fro
63. nus Booster Zoster Shingles Bone Densitometry Hepatitis Last Tuberculosis TB Screening Result of TB screening Positive VlNegative OBGYN Charting If positive TB screen date of last chest x ray Result of chest x ray Positive VlNegative Dental Charting MU Menu Have you ever been hospitalized Eyes MINo _ if yes what for Operations Injuries without Hospitalization lyes VINo _ if yes what for How many times have you been pregnant 0 Date of last Pap Smear Have you had an abnormal Pap smear Elves INo If yes what was treatment Date of last mammogram Have you ever had an abnormal mammogram yes ElNo Have you ever had a breast biopsy Eyes VINo If yes results Overwrite Append Figure 8 21 EHR Getting Started Guide 37 Accessing the EHR CyberMed EHR v1 00 5 5 Family History Select the family member from the drop down list and check the checkbox next to the problem Click on the Add to Family History button to add the problem to the list lt 8 23 gt In case of more problems or comments description click on the l icon to add more comments lt 8 24 gt Ls ey ha wien gt JOSEPH P ADDABBO FAMILY HLTH CNTR T j eine I Repare Gortrol Pane Provider Front Desk B Patient History Acct Name Sex DOB Age MRN PMHx Family Hx Social Hx Birth Hx Special Hx F Show Inac
64. o check on a pending item or recall the patient click on Flag It to add this patient s lab to the flagged list lt 6 38 gt Click on View Lab Hx to view previous lab histories Figure 6 39 JOSEPH P ADDABBO FAMILY HLTH CNTR Welcome CPETERS Logout E Lab Result Detail Acct 30481 S Sex M DOB Age 11 MRN Bal_Due 74 55 Selected Lab Detail Li Analyte name A FUMIGATUS MS IGE i BERMUDA GRASS G2 IGE BERMUDA GRASS G2 IGE _ f BIRCH 13 IGE Lab Order Entry E Prescribing Medical Charting Dental Charting COMMON PIGWEED W14 IGE COMMON RAGWEED W1 IGE COMMON RAGWEED W1 IGE COTTONWOOD T14 IGE gt D FARINAE D2 gt Figure 6 39 EHR Getting Started Guide 22 Accessing the EHR CyberMed EHR v1 00 4 7 Referrals This displays the referral from one provider to another Click on Detail to view the referral request description and information about the referring provider and the referred provider Figure 6 42 Click on the Print icon to print the referral If you would like to view the referral report once the patient has seen the provider then click on the Note icon which redirects to a page that allows you to view the report or even upload the referral report To delete a referral click on the icon If you would like to lock the details of the referral then click on A the lock conf lt 6 40 gt Show Ref
65. on or Other Procedure is done please select from the list of that section lt 11 4 If there is a vaccine lab injection or other procedures done to the patient are missing from the list it can be searched in the other procedures box on the right side of the page lt 11 5 gt The search box can search either by the CPT code or by keyword If a keyword is used please use 3 letters minimum and then click on Search The result of the search appears in the dropdown Please select the procedure you are looking for lt 11 6 gt lt 11 3 gt Adult Medicine Encounter Form Acct Name Sex Age File Submit gt Oo intake Discharge ther Procedures Click to Select v Chlamydia Amp Probe V Throat Culture _ PAP Smear Venipucture lt l 1 6 gt y Issue Medical Letter v68 09 Mammogram Screening V76 10 Pap Smear V76 2 W E Aspiration Cyst Nail Removal Encounter Form J BMI not calculated Patient not eligible Nebulizer A _ BMI high Follov up plan documented Peak Flow __Adult Medicine E BMI low Follow up plan documented PPD Mantoux Pediatrics Garda
66. onth Cord Cag_49 years O 2wks 1l month Hiccups a 2wks 1 month Crib saf 13 16 Years F 2wks 1 month Infant car seat C 9 Iwks 1 month Crying oie C 9 Iwks 1 month Infant sleeping position P 10 2wks 1 month Diaper rash O 11 2wks 1 month Falls O lt 17 10 gt 12 2wks month Feeding P Or enter new item for this group 13 2wks 1 month Hiccups a 14 2wks 1 month Infant car seat F 15 2wks 1 month Infant sleeping position 12 lt 17 9 gt SOAP Notes Figure 17 7 s lt 17 8 gt EHR Getting Started Guide 69 Accessing the EHR CyberMed EHR v1 00 15 0 Treatment Plan This page is used to record provider s plan of treatment for the patient The provider is provided with a text box to freely type his her notes into the system and save it lt 18 2 gt EESAVI Pharm 9 Fax 66 Pending 453 Treatment Plan Name Sex DOB f Age MRN 01 059918 Bal_Due 0 Create New Select Template CPETERS _ Use SmartNotes Toc ee cons REGULAR DIABETES Recommended the following treatment plan HYPERTENSION CTScan Abdomen Elbow L Knee R Lumbar Spine and Patient treatment plan testing S lt 18 3 gt lt 18 2 gt Figure 18 1 EHR Getting Started Guide 70 Accessing the EHR CyberMed EHR v1 00 15 1 Use SmartNotes Tool The provider can select predefined templates for diagnosis like regular hypertension diabetes and asthma from the Select Template dropdown lt 18 3 gt For the
67. ose Vaccine E Prescribing Today Cl Another Date gt Dental Charting Fl None enter individually MU Menu Medical Charting Medicaid h Figure 6 9 Please select the vaccine to be given lt 6 10 gt The default date is today In case the date given is not today then select the date and then indicate the patient s VFC eligibility lt 6 11 gt EHR Getting Started Guide 13 Accessing the EHR CyberMed EHR v1 00 Select the lot number from the drop down list Admin Site Route and Reaction In case the lot number is not available in the list please add the new lot by clicking the New Lor button lt 6 13 gt In the next page Figure 6 14 enter the lot information Manufacturer Source etc and save it to select again from the list in the previous page lt 6 16 gt In case the vaccine given elsewhere needs to be recorded into the system please select Historic Record to enter into the system lt 6 14 gt JOSEPH P ADDABBO FAMILY HLTH CNTR Home P rovider Front Desk B ng Clerk Reports Control Pane Immunizations Selected Vaccine Name DTaP Hib IPV ae Se ete ae Given Here Historic Record 6 1 4 gt Reaction 2 MMRV B B Given Here Historic Record Select Lot T004AA_MSD_Expred On 06282013 Date Given 07 2012 vis 03 192008 Admin Sie Let Thigh Route SC Reaction 3 Influenza seaso injectable preservative fr
68. regular template SmartNotes Tool is a tool generated to help the providers to enter the desired information with minimum typing Click on the button Use SmartNotes Tool to go to the page lt 18 3 gt You can overwrite the existing notes or append add to the existing notes by selecting the radio button at the end of the page and click on Generate Smart Notes lt 18 5 gt This will add your selections to the note s text box in a format The provider can add make additional changes if he wishes JOSEPH P ADDABBO FAMILY HETH CNTR ome Provider Front Desk Billing c erk Reports Co ntrol Panel Treatment Plan Acct Name Sex Reset All Selections VlAbdomen Chest Knee L Vl Lumbar Spine Cervical Ml Elbow L F Knee R Patient treatment plan testing oak O Overwrite Figure 18 4 lt 18 5 gt EHR Getting Started Guide 71 Accessing the EHR CyberMed EHR v1 00 15 2 Make Your Own Template In order to make your own treatment plan template click on the symbol OF Select the group of category and select the available items from the list and click on Add to My List lt 18 5 gt If desired to add an item that is not available in the list there is a text box saying Or Enter New Item for This Group Type the new item and click on Add to add the item to the list lt 18 6 gt This template can be composed at one time and will be available for the pati
69. ribing Figure 8 14 EHR Getting Started Guide 35 Accessing the EHR CyberMed EHR v1 00 Click on the Create New Hx to create a new medical history lt 8 15 gt A list of the most common problems is on the right side of the page if the problem is not present on the list select Others and click on the Select and Edit Comments lt 8 17 gt _ A pop up box will appear where the user can add more comments about the problem Figure 8 18 Simply click the Insert button to save the problem lt 8 19 gt The user can also manually type in their notes in the blank space box that is available for free typing lt 8 20 gt 19 Fax 284 Pending 6 6 Patient History Acct Name Sex DOB Age MRN Bal_Due 3 PMHx Family Hx Social Hx Birth Hx OBGYN Hx Functional Hx ego F ouic Pick List REGULAR _Use SmartNots F I a Asthma El Pneumonia CA Pregnancy CAD Problem w Behavior COPD El Problem w Eating CVA Problem w Growth Diabetes Problem w Sleeping Etoh amp Drug Abuse El Problem w Speech Heart Murmur Problem w Toilet Training Hepatitis RA HIV Exp E Rheumatic Fever El Hospitalizations E Smoking Encounter Form HyperTension o Surgery MI El Taking Oral Contraceptives Hoa EITB Others El Trauma Lab Order Entry E Prescribing Medical Charting Dental Charting og x X Co ka ON Froblem Name
70. ront Desk Bil ing Clerk Control Panel Review of System Acct Name Sex DOB Apptite Loss Feeling of Sick L Sleeping problems Weight gain C Chills Fevers T Sweats Weight Loss Fatigue Always tired ALLERGY BREASTS CARDIOVASCULAR ENDOCRINE ENT GYN HEAD_NECK HEMATO LYMPHATIC MUSCULOSKELETAL PSYCH RESPIRATORY SKIN Overwrite Append CHES SHEANGEST Figure 14 4 lt 14 6 gt EHR Getting Started Guide 59 Accessing the EHR CyberMed EHR v1 00 11 2 Make Your Own Template In order to make your own Review of System template click on the symbol Select the group of category and select the available items phrase from the list and click on Add to My List lt 14 8 gt If desired to add an item that is not available in the list there is a text box saying Or Enter New Item for This Group Type the new item and click on Add to add the item to the list lt 14 9 gt This template can be composed at one time and will be available for the patient s ROS Any changes add removal of item reflects there on ward In order to remove an item from your list select the item and click on Remove from My List lt 14 10 gt On going back to ROS the provider would find the template for Smart Notes default to the user template In order to view regular templates please select Regular in template ANNO
71. sh lt 21 16 gt The list appears on Refresh Click on Detail to view the patient s referral The referral can be printed by clicking onl 2l You can also view the referral report by clicking on lt H gt In order to delete the referral click on x The referral can be locked from any further changes by clicking on af Referral Center lt 21 17 gt A FERO LELLLI Peary rey PA JOSEPH P ADDABBO FAMILY Ao _ Re eras Pe Se eee Fer ar Desk E lling Clerk Provider AM_AKHAND Incoming Outgoing To Review Show referral status Open y Refresh New Referral Lab Reports Account Patient Name a Referred To Status Lookup Datel Patient Search Reported ASTHMA ALLERGY Open 8 3 2012 8 x ef Reviewed Referral Center ____Closed foemiaumorosv foren ers 2o12 Detail Deleted FF a ALL PSYCHIATRY Open 8 3 2012 Detail hh Se he AAi 7 27 2012 PSYCHOLOGY Open 8 3 2012 Detail x af S __ Zane frmnieronn esa ooa felada Group Close E er pooner pero oem lala da O 6 paan arsaa fsa owen ea O fom feon fom arma oat x O p en pr o pan oe Jelfa O bem foom fom oes oo a Figure 21 15 EHR Getting Started Guide 82 Welcome Pharm 9 Fax 66 Pending 4 Account Q Ref Date 7 27 2012 Ref 2 LookUp 8 3 2012 Ins_ ID COMPUTER SCIENCE CORP Referring From Physician
72. sil F Tdap BMI normal v PPD Reading ocr H1N1 Influenza Vaccine E Varicella LIEKG Pulse Oximetry Ryan white Hep A Zoster _ Finger Stick Rapid Strep Test E Foreign Body Removal Removal Impact Cerumen went Ceftriaxone Sodium Removal of Skin Tags Urology Depo Provera E Incision amp Drainage Spirometry Pre amp Post lt 1 1 5 gt Asthma Influenza not ordered reasons documented Suture Removal Ophthalmology Ast Vace Admin T H1N1 immunization administration Influenza not ordered reasons not specified Ucg 2nd Vacc Admin Therapeutic Diagnosis Injection Admin F Medical Clearance Urine Dip Podiatry _ Combo Vacc Admin penn By Keyword CPT Code _ Mental Heath or ent __ Phys therapy Acupuncture e Figure 11 1 EHR Getting Started Guide 48 Accessing the EHR CyberMed EHR v1 00 8 1 Procedure If you would like to overwrite the billing rule please select Yes for Overwrite Billing Rule lt 11 8 gt For an office visit please check the duration of time spent with the patient in the visit For preventive visit please select the Preventive Visit tab and then the age of the patient lt 11 9 gt lt 11 8 gt Procedure Diagnosis Ove i illi 7 ES verwrite Billing Rule ETETTTETETE Office Visit Preventive Visit Figure 11 7 EHR Getting Started Guide 49 Accessing the EHR CyberMed EHR v1 00 8 2 Quick Diag Code Th
73. ssessment template click on the symbol Select the age group and select the available items from the list and click on Add to My List lt 16 9 gt If desired to add an item that is not available in the list there is a text box saying Or Enter New Item For This Group Type the new item and click on Add to add the item to the list lt 16 10 gt This template can be composed at one time and will be available for the patient s Development Assessment Any changes add removal of item reflects there on ward In order to remove an item from your list select the item and click on Remove from My list lt 16 11 gt On going back to Development Assessment The provider would find the template for Smart notes default to the user template In order to view regular template please select regular in Template SHED 1G a i ome Provider Front Desk Billing Clerk Reports Control Panel Development Assessment Acct Name SEX DOB Age MRN Bal_Due Making My Own Exam List Select Group i My List My C t Groups Intake Discharge iv Current sroups 2 Group Item Description Encounter Form 15 6 ada Mama 13 months l onih 1 aont D345 Mama specfic al Seas Lab Order Entry a D5 4 5 ane months months iiias O E Prescribing 3 15 3 15s Persistent rocking handflapping Fi months months orheadbanging Medical Charting F 15 i 15 RL E i months months Phys patai O x 15 15
74. t F le Show Inactive Items amp IntakeDischarge lt 8 32 gt l Visit Brief Hx LastUpdated User 6 12 2012 FT 39 weeker C sect 6 12 2012 RGUILLEN A cewa zo Figure 8 29 HNS lt 8 31 gt JOSEPH P ADDABBO FAMILY HLTH CNTR Home Provider Front Desk Billing Clerk Reports Control Panel Help Patient History Acct Xi DOB Family Hx Social Hx Birth Hx OBGYN Hx Functional Hx Om 6 12 2012 1 30 00 PM visit user RGUILLEN wrote FT 39 weeker C section secondary to failure to progress 61b loz Born at St Johns Hospital no complications Figure 8 33 EHR Getting Started Guide 40 Accessing the EHR CyberMed EHR v1 00 Click on Create New Hx to create a new history summary for the patient There is a text box available for free typing of the text If the provider wishes to use SmartNotes Tools click on the button and add the information regarding the birth Select Generate SmartNotes to add the selected notes lt 8 35 gt If a previous history exists and the provider wishes to overwrite select Overwrite and click on Generate SmartNotes Once this is done click on the Save button to save the notes to the system JOSEPH P ADDABBO FAMILY HLTH CNTR esk Billing Clerk Reports Control Panel Help Patient History Name Sex DOB Functional Hx Intake Discharge 6 Birthiength 11 Jobstetricia
75. t temp BP Pulse and BMI trend Figure 6 3 Bic JOSEPH P ADDABBO FAMILY HLTH CNTR w Patient Chart Acct Name Sex DOB Age MRN Bal_Due 368 6 Vitals Growth Charts Immunization Allergy Medication Problem Lab Referral Encounters Docs Demographic Notes Show vitals in 1 year s Vitals Summa 68 1 29 2013 i 1 10 2013 lt 6 2 gt TER i 12 19 2012 i 40 16 2012 10 15 2012 Intake Discharge Figure 6 1 JOSEPH P ADDABBO FAMILY HLTH CNTR Home Prc ne lF OnREDAk a erk Reports ontrol F Patient Vital Trend Acct Name Sex DOB Height finch Weight Ib Temperature F BP mmHg Lab Order Entry Figure 6 3 EHR Getting Started Guide 9 Accessing the EHR CyberMed EHR v1 00 Select your encounter form Adult Medicine e Adult Medicine Pediatrics OBGYN Dental Physical Theraphy Infection Disease Urology Asthma Ophthalmology Podiatry Acupuncture Ryan White Mental Health Child Day Treatr Transition Care Figure 6 4 To customize your own encounter form menu click on the g icon lt 6 2 gt The above page will be displayed Select the department associated with you and then click on the Save button By doing so the department that the user selected will be displayed when clicked on the Encounter tab on the left side of the page eliminating the other departments encounter forms EHR G
76. t 15 3 gt Select various categories for example general appearance abdomen back etc Provided are the most common items in each category select various items If any additional notes are to be added in any category please add it to the textbox available in each category lt 15 5 gt You can overwrite the existing notes or append add to the existing notes by selecting the radio button at the end of the page and click on Generate Smart Notes This will add your selections to the note s text box in a format The provider can add make additional changes to the text if he wishes lt 15 6 gt Home Prowider 4 ske H Cle i Front Desk Clerk he pec Lab Order Entry E Prescribing GENITALIA HEMATOLOGIC LY MPHATIC SOAP Notes HIPS EXTREMITIES Dental Charting RESPIRATORY Shoawlder TEETH ROUTH Overwrite Append SGSis SMEHINS Ey SPINE I Figure 15 4 lt 15 6 gt EHR Getting Started Guide 62 Accessing the EHR CyberMed EHR v1 00 12 2 Make Your Own Template In order to make your own Physical Exam template click on the symbol Select the group of category and select the available items phrase from the list and click on Add to My List lt 15 8 gt If desired to add an item that is not available in the list there is a text box saying Or Enter New Item for This Group Type the new item and click on Add to add the item to the list lt 15 9 gt
77. t how to access the Electronic Health Record EHR application Double click the EHR application icon on your desktop or open Internet Explorer ig Sla item in the start menu and type https appserver addabbo org in the Internet Explorer and click Go or enter key Once you clicked on the Enter Key a page may be displayed as shown below a Certificate Error Navigatio x Google S Search E Share More 3 gt There is a problem with this website s security certificate The security certificate presented by this website was not issued by a trusted certificate authority The security certificate presented by this website was issued for a different website s address Security certificate problems may Indicate an attempt to fool you or intercept any data you send to the Server We recommend that you close this webpage and do not continue to this website Click here to close this webpage Continue to this website not recommended More information Click Here Figure 1 1 Click on Continue to this website not recommended Next the logon screen displays asking you to enter your Username ID and Password EHR Getting Started Guide 4 Accessing the EHR CyberMed EHR v1 00 JOSEPH P ADDABBO FAMILY HLTH CNTR Welcome Lo Ha f j Lo g In User Name Password Remember me next time lt 22 gt Figure 2 1 Logon Window
78. t of the patients that have appointments with that provider for the day AgcaAgporami ii Wealth FEP JOSEPH P ADDABBO FAMILY HLTH CNTR Welcome CPETE lt A r4 Te ae ee EET gt BE baz me Provider ont Desk Billing Clerk Reports Control Panel Help Pharm 15 Fax 287 Pending 679 Provider Appointments Provider Office Mail 146_AM BARCIA 157_AM_BECKERLY 143_AM_BUNYAVANICH 144_AM_BURGOS 147_AM_CARMENATE 11_AM_CHAKOTE 4_AM CHAN Reminder List 101_AM_CHEN 149 AM DHILLON 142_AM_FERDOUS 19 AM GO 133_AM_HILL MARK All rig 17_AM_HOLALKERE R a 107_AM_JACOB 134_AM_KALEPU Lab Reports Patient Search Referral Center Vaccine Submit Group Close 123_AM PATEL 30_AM PATTUGALAN 153_AM_PIERRO 32_AM_RIGAUD 136 AM_ RODRIGUEZ 150_AM_SAM 155_AM_VALEUS 156_AM_ VARGHESE 764_CDT_CROSBY L 722_CDT_LAMB 402 DEN BENEDICTO Figure 4 1 EHR Getting Started Guide 7 Contact Information lt 5 3 gt Office Mail EE DOB Chart _ Service Name S Enct Lab SOAP CHART 0 CASTILL CLINIC PEDIATRI A CHART Q CASTILLO CLINIC PEDIATRI oe T e a CHART 0 4 MARTINEZ WALK IN PEDS al M CHART 0 44 ANDRADE WALK IN PEDS al L JL F yane submit CHART 0 9 FABIAN WALK IN PEDS a M i IN Reminder List PERON 0 APPT 29 KELLY CLINIC PEDIATRI 1 m a 45 APPT 8 ENEDA THE cma W E CHART 09 15 APPT 0 JA
79. te 7 31 2012 lt 6 48 gt Diagnosis HYPERTROPHY OF TONSIL WITH ADENOIDS a Detail a EHR Getting Started Guide 25 Accessing the EHR CyberMed EHR v1 00 In order to add more external referring providers to the list click on the icon Fill in the appropriate information The referring provider can have names like Queens Hospital or Queens Hospital Radiology etc Make sure the Provider Is Active checkbox is checked in order to appear in the list We can also link this referring provider to an internal Addabbo provider by selecting the provider s name from the dropdown of Link to Internal Provider lt 6 50 gt Referred Provider Name rovider lt 6 50 gt Email Provider Class es Contact Tels Link to Internal Provider Figure 6 49 EHR Getting Started Guide 26 Accessing the EHR CyberMed EHR v1 00 4 7 2 Create Custom Referring Provider List Click on the icon to add custom referring provider We can create both internal by selecting IRF group and outside providers by selecting the ORF group Check the provider in the list to add to the group and click on Add to my list We can also remove the provider from the list select the provider and click on Remove from My List Click on Add new to add new referring provider to IRF ORF list lt 7 2 gt JOSEPH P ADDABBO FAMILY HLTH CNTR Patient Referral Acct Name Sex DOB
80. ted Mo Repor 29268 REGULAR 2 28 2009 NEDELEA Requested No Report 28162 REGULAR 2 12 2009 NEDELEA Requested No Report Figure 6 35 EHR Getting Started Guide 21 Accessing the EHR CyberMed EHR v1 00 TEFA EEVA JOSEPH P ADDABBO FAMILY HLTH CNTR Home Pro rk Reports Control Pane Lab Result Detail Acct Name Sex DOB Age MRN Bal_Due 74 55 Rpt On 2 22 2012 2 03 41 PM Specimen Number Rpt Review Comments Status FINAL _ vider Front Desk E ng c Test Name ABN Result Units Reference_Range Status im A FUMIGATUS M3 IGE Adding New Comments Below a ca ALLERGEN A ALTERNATA T al Encounter Form BIRCH T3 IGE maoa f es onas e O e e Fo lt 6 38 gt C HERBARUM M2 IGE Camano fs asana D e e Fo CAT EPITH DANDER E1 IGE Vewoworane fs as onas il e e Fo COCKROACH 16 IGE masose s as weas e O Class N a F m Lab Order Entry E Prescribing Medical Charting Dental Charting Figure 6 37 Each test result is color coded based on its abnormality in case of high low You can also view the trend by clicking the icon with the similar previous tests if ordered There is a Ei symbol which indicates as an important message from Quest to the provider regarding the test The provider is advised to put in the comments and when reviewed click on Mark as Reviewed If the provider wishes t
81. ted Guide 44 Accessing the EHR CyberMed EHR v1 00 Click on Create New Hx to create a new history summary for the patient There is a text box available for free typing of the text lt 8 45 gt If the provider wishes to use SmartNotes Tools click on the button and add the appropriate information needed Select Generate SmartNotes to add the selected notes If a previous history exists and the provider wishes to overwrite select Overwrite and click on Generate SmartNotes lt 8 47 gt Once this is done click on the Save button to save the notes to the system bs reds tic JOSEPH P ADDABBO FAMILY HLTH CNTR Billing Clerk Reports Control Panel Gar Patient History Sex DOB Functional Hx Intake Discharge Encounter Form Lab Order Entry F Prescnbing Medical Charting Help Patient History Acct Name Sex DOB HEEL SECS Full Independence Full dependence in locomotion Modefied independence Full dependence in social cognition Distant supervision Full dependence in communication Close supervision Assistive device wheelchair Needs assistance Assistive device walker Full dependence in self care El Assistive device crutches Full dependence in sphincter control L Assistive device cane Full dependence in mobility Overwrite Append Figure 8 46 EHR Getting Started Guide 45 Accessing the EHR CyberMed EHR v1 00 5 10 Immuniz
82. text area with a pre designed template of SOAP notes with your various notes from the different categories already embedded into each category If the provider has not recorded any category he can still add his notes by typing in that part of SOAP notes Select the category on the right side and click on Add Refresh This would allow a blank slot for the provider to type his her notes ESYA JOSEPH P ADDABBO FAMILY HLTH CNTR EER SS Home Provider Front D rts Contro eae ts Billing Clerk Reports Control Pane Pharm 9 Fax 66 Pending 453 Progress Notes Bal_Due 0 OUGSF7is4aBxl9e MO NQ9 Bz Se Vital Progress Notes Ecc UserName CPETERS Logged in user is NOT registered as Provider Problems Allergy PMH Family Hx Social Hx Birth Hx Func Hx Screening HPI SLON E PE Dx Dev Assess Current Medication pP i Centrum Jr Extra C Chewable Tab by mouth DAILY Dispense 30 R M Rx E Lab aaa F i E Immunizat al Charting Normal Q Preview lt table gt lt tr gt lt td gt lt pre gt E twee enu Print Sign Co Sign Off E Peen Add Refrest Undo Delete Erase All Figure 19 1 lt 19 4 gt lt 19 3 gt EHR Getting Started Guide 73 Accessing the EHR CyberMed EHR v1 00 Please Note If a provider types in text SOAP notes and then for any reason clicks on Add Refresh the notes that were typed will be erased and the origi
83. tive Items Add New History Family Medical History Select a member GrandParents v ES oS oi FATHER Allergy 8 2 2012 X W Allergy V High Blood Pressure E Jaundice Peat i n i Save V Asthma E No Known Family History VIC v Obesi FATHER Asthma 8 2 2012 Wi cancer a omy SaD ears TEG F Diabetes NOthers i _ lt 8 24 gt E Easy Bleeding E PXychiatric Illness GRANDPARENTS Cancer 8 2 2012 E Gout E syfoke Heart Trouble Tuberculosis V High Blood Fats Comments l GRANDPARENTS Heart Trouble 8 2 2012 a MOTHER High Blood Pressure 8 2 2012 MOTHER Obesity 8 2 2012 MOTHER Stroke 8 2 2012 E E Encounter Form Lab Order Entry __Add To Family History _ Figure 8 22 EHR Getting Started Guide 38 Accessing the EHR CyberMed EHR v1 00 5 6 Social History To view inactive items under the history tab check the Inactive Items check box and click on a the refresh button to refresh the list lt 8 26 gt To see more details about the patient s history click on the button to view comments that the provider entered lt 8 27 gt Click on View Hx History icon to view the patient s notes history To add new social information about the patient click on the Create New Hx lt 8 28 gt JOSEPH P ADDABBO FAMILY HLTH CNTR rovider Front Desk Billing Clerk Reports Control Pane Help Patient History N
84. to the EHR system Type your User Name and Password and press either the enter key or click on Log in lt 2 2 gt The IT Department assigns your Username ID and Password Please request your paper work from your supervisor and submit it at the HR office at Site 1 3 floor to request access Once you type in the assigned Username ID and Password Click on the Login button to enter into the system You are now directed to the welcome page as shown below lt 3 gt EHR Getting Started Guide 5 Accessing the EHR CyberMed EHR v1 00 JOSEPH P ADDABBO FAMILY HLTH CNTR Welcome CPETERS Logout Home Prov Front Desk B ne erk Re ts ntr Pane 6 358 Welcome To Electronic Health Record System Figure 3 1 3 0 Features of Available Tabs The following tool bar appears in every page within the CyberMed EHR This tool bar provides the needed information for you to know when you are using the software gt Control Panel Figure 3 2 EHR Getting Started Guide 6 Accessing the EHR CyberMed EHR v1 00 4 0 Provider Guide Once you click on the Provider tab at the top of the page a page as displayed below will appear You can either click on the drop down list and select a provider or enter the provider s number and the name of the provider will appear lt 4 2 gt Select the date and then click on Go lt 4 3 gt The appointment list for that provider will appear with the lis
85. tting Started Guide 80 Accessing the EHR CyberMed EHR v1 00 4 3 Patient Search This feature allows the user to search for a patient based on their account number name date of birth or MRN Enter the appropriate number text in the search field and make a selection from the In Field drop down Click on the Search button to search for the patient lt 21 14 gt If multiple results appear in the list as shown below select the right patient based on other information Click on Demographics to view the patient s demographics or Show Visits to view the patient s past visits or Patient Chart to be redirected to the patient s chart information lt 21 13 gt JOSEPH P ADDABBO FAMILY HLTH CNTR Clerk Reports Control Panel Patient Search Search 10 21 1998 InField DOB lt lt 2 14 gt Total Return Rows 3 a ae ae M Y Referral Center lt 21 13 gt EHR Getting Started Guide 81 Accessing the EHR CyberMed EHR 4 4 Referral Center v1 00 This section is for the provider to view the incoming outgoing and referrals waiting for the provider to review Click on each tab to view the sections Select the provider s name from the drop down list The page is then automatically refreshed By default the page displays all open referrals To view other status referrals select from the dropdown list of Show Referral Status and click on Refre
86. yberMed EHR v1 00 1 r ry oa i Home Provider Front Desk Billing rk Reports Control Panel i i I i 23 l I EUA eee eek JOSEPH P ADDABBO FAMILY HLTH CNTR Provider Dashboard idk M AKHAND aaa l Chart Unsigned Off Notes Open Encounters Lab To Review Flagged Lab MU Measures Account Location Patient Name __ 7 9 2012 JPA MAIN Select sji4 20i2 JPA CEN Se a Sate 5 8 2012 3PA MAIN soa macen Selec s202 acen Jseea JPA MAIM Se arama let a nozo paman SSC i et foramen seega Pei z202 ___pea cen Telec s 7 aoi2 paman selec s a 2oi2 maman Select srao framan raroa paman Teea sao paman O Tselea ar02 paman Vselect sao raman elec Figure 22 2 EHR Getting Started Guide 84 Accessing the EHR CyberMed EHR v1 00 4 5 3 Open Encounters This section displays a list of all the encounters that are not closed The provider can easily review these encounters by clicking on the Select link of each patient which will redirect to the patients chart and encounter form lt 22 6 gt Provider Dashboard ARAR AM_AKHAND z Account Location Patient Name 3 l i JPA MAIN Select s 1e 2o12 ara maIN Select s is 2oi2 apa main Select Figure 22 5 4 5 4 Lab to Review This section displays a list of all the labs waiting to be reviewed T

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