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EMR Reference Manual

1. fe Current Batch Chief Complaint Mrs Irene Innis Terry Manning MD 04 05 06 System Manage fo Ready to Transcribe Review of Syst Mr Fred Finley Terry Manning MD 04 05 06 A Ready bo Transcribe Physical Exam Mrs Irene Innis Terry Manning MD 04 05 06 You can click secondary toolbar icons to do any of the following PEHLCLIONEMUTCICIIIC NNNM Refresh list F5 Pulls into the view any data that changed recently 3 Use any of the following filters to locate dictation e Click Dictated By to view dictation for a specific caregiver e Click F Fiter to use a quick filter to search for dictation based on pre set filters see Quick Filters on page 98 At Patient click to search for a specific patient otherwise click All e To view dictation sent to individual transcriptionist click the Transcribed By down arrow and select the transcriptionist otherwise select lt All Grantors gt e Click the Dates search button to select a date range for the dictation e Click the Status down arrow and select a status 4 Click any column heading to sort items Statuses include the following lt All Requiring Action lt All Statuses gt Current Batch Ready to Transcribe Submitted Rejected Approved or Others Dictation Type Name of contact screen on which voice note was dictated 135 Internal Transcription see mere Dictated by Dictating caregiver D
2. SP gt Right Lung Field DJ TEES C n Right Upper Lobe Anterior E ES Decreased Right Upper Lobe Anterior Absent Right Upper Lobe Anterior v Reduced vesicular Right Upper Lobe Anterior Right Upper Lobe T T BronchowesicularfRight Upper Lobe Anterior dl Bronchial Right Upper Lobe Anterior Chest and Lung Exam Amphoric Right Upper Lobe Anterior Auscultation 5 Stertorous Right Upper Lobe Anterior Breath sounds Rech Rattling Right Upper Lobe Anterior Stridor Right Upper Lobe Anterior Hsing sound Rignt Upper Lobe Anterior Prolonged expiration Right Upper Lobe Anterior e Click items to document details for the area selected The following things happen gt On the image the selected area turns blue gt Inthe menu box the item is checked and additional icons display on the left for a note and on the right to indicate the finding was significant gt Inthe preview pane below text related to the detail selected appears gt Inthe Physical Exam navigation pane the detail displays in bold e To indicate data for a detail is significant click the exclamation point icon to the right of the menu item The following things happen gt Inthe image the selected area turns red gt The icons to the right of the detail in the drop down menu and in the Physical Exam navigation pane turn red gt Inthe preview pane the text describing the affected area turns red
3. General Mental Status Alert Very present amart nervous Detail flavae nore General Appearance Mot in acute distress Hed a characteristics A nota 5 Click the link to navigate to the selected item Using the documentation pane in ROS and PE For instructions for navigating in the ROS and PE views see ROS and PE Navigation on page 266 Document characteristics and details of body systems in the documentation pane near the upper right side of both Review of Systems and Physical Exam during a patient visit 1 Open a patient chart and from the left pane or the toolbar click Review of Systems or amp Physical Exam 2 Under Review of Systems or Physical Exam click a body system to display its characteristics in the documentation pane to the right In the example below the system General is selected Physical Exam aiem AALE Carene ue Epania Colapse a aj EE emplabes Encounters Apply Preview E clear F4 gt F ew Current Encounter res Mental Status r I General i s General Appearance 53 Orientation Didnot examine ak f Neurological Anatomy ee ee Build amp Nutrition cEjMentalstatus Posture v EJ Alert fa Gait Appears nervous agtated E Hydration ie Inattentive T e Delirious s General E o Skin Surface Stuporous E 3 Problem 1 k Comatose Ba
4. Combine the current selections with the information in combine i the Template or Encounter R amp the current selections wih the information in the p0 Espace ee Eara Tp Skip and dont apply any selechions Apply to al Cancel Use the table below to determine which Operation to select for each system Template Displays the name of the template selected Displays the name of the first system that contains previously entered values When you click one of the three Operation buttons the next system containing values displays after Apply to unless you select Apply to all prior to clicking the operation button Combine Click to combine the values previously entered with the template or encounter information for the system indicated in Apply to Replace Click to replace the values previously entered with those contained in the selected template or encounter Skip Click to avoid adding the selected template or encounter values to those previously entered for the Apply to system shown Apply to all Select to indicate that the operation button selected Combine Replace or Skip should apply to all systems NOTE In the left pane of Review of Systems those systems containing values applied display in bold and the documentation generated displays in the lower right pane 6 Edit template values by doing the following e Inthe Review of Systems pane select a bolded system e Inthe documentation pane on the right
5. 0 00 0 ce eee 329 To edit pregnancy record review of SySteEMS 6 ee 329 To edit pregnancy record maternal fetal data 0 0 0 0 ccc ee 330 To edit pregnancy record cervix 0 cc eee eee ene 331 To edit pregnancy record medical Hx 0 0 cc a 332 To edit pregnancy record OB history nannan naaa ee eee 333 To edit pregnancy record pelvimetry llle 334 To edit pregnancy record next appointment llle 335 Including unsolicited test results in pregnancy records 336 Printing the pregnancy record lllllllllel e 336 immunization HecoFdS usa d ees orco e A de ie eoe Qe Re e cw REOR A e 338 Accessing viewing Immunization Record 000 eee eee 338 HealthMatics EMR Application Reference Manual Editing immunization history 0 0 eee eens 339 To edit existing immunization history llle 339 To add historical immunizations s accused dob ue t EE Rn Ed b pDE d eM 340 Printing immunization record 0 teens 341 Ordering and documenting immunizations 0 0 00 cee ee eee 342 Documenting immunization statuS 0 0 0 ces 342 To enter other free text immunization history 0 0 cece eee eee 342 To document immunizations using previously entered free text LLL 343 ir f c rc cheer late ta oes saad out aware 344 Using TEX III OS a eoe s eda uris A ata het aoc due e Saha MP E Wid a oe pet Gnom
6. E NOTE This is the same dialog that displays from Office Orders where you select a patient lab order double click it and Create Requisition displays 301 Assessment Plan Ordering on behalf of another caregiver You can order labs and procedures on behalf of another caregiver in A P The primary benefit of this option is that when lab orders print at Signoff or from the Output Queue the labs will display as ordered on behalf of the Ordered For Caregiver if one was specified in Caregiver Options To set order on behalf of caregiver option for A P Based on the caregiver option when a lab or procedure is ordered in A P the Ordered For field on the edit Lab Order or Procedure dialog defaults to the appropriate caregiver If Preferred or Appointment Caregiver is the caregiver option the caregiver that represents the caregiver must be one of the caregiver s grantors for the Ordered For field to default properly 1 From HealthMatics EMR menu click Options gt Edit Options gt General gt Assessment and Plan gt Orders 8 Caregiver Options for Manager System General Assessment and Plan Desktop Toolbar Notes Face Sheet Do you want the Comments field ta be deared when you add an Yes Patient Manager existing problem to the current ARP No Reason For Visit Medications Review of Systems Do you always want the Medication Dialog bo open when you add C Yes vtak a medication to the current ARP No
7. gt Click Send and Yes to confirm e To save the message as a file on your computer click Save to File on a tab to save the message to a directory on your computer Viewing patient messages saved to charts 1 Pull the patient s chart and in the Encounters pane click lt 4 View Encounter 2 Sort F the items By Type 3 Expand the Messages folder and select the message to display it in the preview pane to the right E Encounter Explorer Encounters By Type Newest to Oldest ar pA Encounters i 3 Definitive Diagnosis Pending yy Office visit H E Phone Encounter ag Zy Messages E Patient Message be E EE Patient A Patient dre ix Refill Chart Atbachmenbs i3 Consultation Report ly Diagnostic Imaging Report icy Forms Letkers icy Other Unknown i Pathology Report Biel E3 Expand view i Print H Email Hote Patient called with questions Finley Mr Fred To Manager System From Manager System Sent 3 8 2006 4 27 PM Phone 555 555 1212 gt From Manager System gt To Manager System gt Sent 3 8 2006 1 52 PM gt Patient has question about lab result Please call after 5 pm 4 Click the X in the upper right corner to close the Explorer window 1 Office Functions Web Messages Web Messages are patient generated messages sent to you by patients from the practice website using the Internet You can open them reply to them
8. 3 Growth Charts Weight Months weight vears LengthyMonths HeightyYears weightjLength Boys Body Mass Index by Age Fred Findiey as of 11 17 2005 ERETTE 1 z d G uod d m ds d Em Ge m m4 4 D b o e 4o e RS GR e Gb A G G Gb Um OU B S Ue m m d d 3 4 4 A S ws e e n T ae x ws me d e i m m omm Emm mmba x z od us ox ou pmo i t mmmmmmAmmmmmipmmRRRRmmmmp a umm Prt tess Spe ee ee ee ee gee ee epee Growth Charts display the third to ninety seventh percentile lines You can chart the following 1 36 months Weight length e Weight months Length months e Head circumference 2 10 years e Weight height 2 20 years Weight years Height years Body mass index To zoom in on a chart click at the upper left edge of the area that you wish to enlarge and holding the left mouse button down drag a box around the area from left to right NOTE To return the chart to its original view click the upper right edge of the chart and holding the left mouse button down drag a box from right to left 245 Vitals 4 To print a growth chart click Print on the toolbar to display Print Growth Charts Print Growth Charts x Select which growth charts to print e weight Manths v Weight Years J Length Months v Height Years v Length Weight Months vw Lengthy Weight Years J Head Circumference v Body Mass Index Select an orientation For the output f Landscap
9. E Print Preview declmmg dimi m emm BG meme 700 a 0000 B mermere Customize choice drop down list Close Close window 4 Optional Click g to refresh data on the Main Window Editing pregnancy record screens Edit add information for each pregnancy record screen as needed When a caregiver selects 4 the first screen Vital UA default tab displays Pregnancy Record screens include e Vitals UA Data bidirectional between Pregnancy Record Vital Signs Lab results and Allergy History e Pregnancy Labs Includes tab results available in the EMR Results can be filtered based on LMP date e ROS Data bidirectional between Pregnancy Record and ROS e Maternal fetal data Data bidirectional with Pregnancy Record and 59400 Procedure Rule View Procedure Results e Cervix Data bidirectional with Pregnancy Record and 59400 Procedure Rule View Procedure Results 326 3 Patient Contact Functions e Medical Hx Data writes to Pregnancy History in the History window and is bidirectional with Medical HX in the patient encounter e OB history Data writes to Pregnancy History in the History window and is bidirectional with OB History in the Pregnancy Record e Pelvimetry Data bidirectional between the Pregnancy Record and the 59400 Procedure Rule View Procedure Results e Next appt Data bidirectional between the Pregnancy Record and the 59400 Procedure Rule View Procedure Results To
10. Hematology CaF Cramps Black Tarry Stool Claudications Bloody Stool Difficuly Breathing On Change in Bowel Habits Exertion Constipation Fainting f Backing Out Diarrhea Edema Difficulty Suiallosang irregular Heart Beat Dysphagia nm nd Pressure Fond Trieler inea General Present Weight Loss Dietary Changes amd Fatigue Mot Presents Anorexia Neck fresan Meck Soffness Cardiovascular Frese Chest Pain 2 Click the Templates down arrow and select an item NOTE You can Preview template values prior to applying them to the current encounter or Apply the values directly without previewing 3 To view the values to ensure you have selected the appropriate template click Preview NOTE In the Preview pane click the template down arrow and view templates until you find the one most appropriate then click Apply 4 To apply template values to the current encounter click Apply from either the preview dialog box or from the secondary toolbar in the Review of Systems view 5 IF you previously entered values on any of the systems before applying template values and your On Apply default is set to Prompt in Options Edit Options Review of Systems the following dialog displays 278 3 Patient Contact Functions Confirmation Ea You are about to apply a Template or a past Encounter over existing selections How would you like to apply the changes Details Template CARDIAC ROS Apply bx Cardiovascular
11. Option menu ee that a menu of options displays when the icon is clicked mpe pe Delete or archives a selected item or archives a selected item Open F2 and a selected item Ctrl O edt FP Edita selected item 0000 Edita selected item 00 a selected item af emm meses BE A B n a poom reeteseasenonnne penen A ITI Move to the Left Move the selected item to the pane on the left Windows Panes and Other Tools Shortcut Key La Move to the Top _ Move the selected item to the top of the list Move the selected item to the Move the selected item to the top of the list of the list Fr Move to the Bottom I Move the selected item to the bottom of the list M Spell Check Start spell check v Spell Check Options DEM Select spell check dictionaries and other options Include new information in the view Right clicking for pop up menus Right clicking in most panes produces a pop up menu of options SE Procedure Tasks rat Options with chevrons F to the right include secondary menu options To 24 Chart Tasks Ctrl F Sieh TE display them hover the cursor over the E Messages Ctrl M Send Patient Message primary option Send Web Message J Expand All Chri4 X XLI jr right of an options Example Ctrl M Refresh F5 Entering dates Many contact screens require entering dates In most cases the current date displays by default Yo
12. Record and begin speaking into your computer s microphone NOTES When you first enter the Voice tab to record a new note only the red record button is enabled All other buttons are grayed out As soon as you click Record the black field displays lapsed recording time and all buttons other than the stop button are grayed out 3 When finished click Bl Stop to stop recording the voice or sound and enable all the other buttons 4 Click Play to play back the recording 350 3 Patient Contact Functions Click I Stop EI Rewind and d Fast Forward as needed Click a Erase to delete the entire voice note Click Reset to reset the recording to the original file Click Remove All at the bottom of the screen to delete data from all tabs o O NO o To save the recording click OK at the bottom of the screen The recording is stored for transcription NOTES exists onthattab vm e All notes can be reviewed on the H amp P Report screen Importing files as chart attachments 1 With a patient chart open from the HealthMatics EMR toolbar click is E Chart Attachments Chart Attachments Pp 37 Open 3 Mark Erroneous Show Erroneous Attachment Type Subject Updated B Attachment Date ED Other Unknown Your meeting has been cancelled Manning Terry 422006 S Pathology Report Result review Manning Terry az 2006 ED Referral Letter Referral Manning Te
13. agi Undefined NOTE When adding patient demographics required fields are preceded by red asterisks 2 Complete fields as required desired 3 Click the Referred By search button to search for the referring caregiver Click the Specialty down arrow and select a specialty and or at Name enter a few characters of the referring provider name and click Search Double click the appropriate provider from the list or highlight it and click OK to assign that physician as the referring caregiver NOTES Clear resets Specialty back to lt All Specialties gt and clears the Name field If the referral caregiver is not in the database click 4p to add the caregiver 4 Click the Preferred Caregiver down arrow and select the patient primary caregiver for the practice To control access to a single patient chart click the Privacy Level down arrow and select additional privacy controls gt Any caregiver Any caregiver with access to the location can pull the chart gt Any caregiver reason required if not preferred Any caregiver with access to the location can pull the chart however if you are not the patient Preferred Caregiver of record than you must first enter a reason for pulling the chart Otherwise it is locked 163 Demographics 164 gt Preferred caregiver group and referral Only the Preferred Caregiver and referred to caregivers can access the chart
14. e MDM Medical Decision Making Displays in the H amp P Report 369 Evaluation amp Management Calculator Management options Management Options Data Risk Over the counter medicine Physicalloccupational therapy Prescription IM medication Closed treatment of fracture or dislocation Iv fluids Minor surgery without risk Factors Iv fluids with additives Minor surgery with risk Factors High risk medication Major surgery without risk Factors Telemetry Major surgery with risk Factors Respiratory treatments Emergency major surgery Nuclear medicine Risk is based on a combination of diagnosis codes and your Management Options selection Data risk Management Options Data Risk E Lab Testis Independent visualization of Lab best CPT Medicine Test s Independent visualization of CPT Medicine test Radiology Test s Independent visualization of Radiology test Decision to obtain old records Decision to obtain history from someone other than patient Summary of old records Discussion with another health care provider Discussion with MD performing teskis Checkbox Items in Data Risk indicate the amount and complexity of the data reviewed during the encounter Check any all items that apply Summarizing the service level A summary of service level credit received for the documentation is available Time for Visit Based On 50 counseling Service Office or
15. 0 cc eee rn 236 3 Patient Contact Functions 00 0 eee eee 237 Data LIDFabl8S ura ed ER GOES C raat ya am eh a RS rn See cee te ge 238 My SIMON EISIS x3 ood ura E en ee ae ee Rura dtd quud See eee tae 239 Specifying my short lists for assessment plan 0 0 cc 239 Specifying my short lists for reason for visit llle 239 Specifying my short lists in history llle 240 Setting caregiver options for my shortlists llle 240 Adding my short list items to current encounters llli 242 MICI RETE RETREAT 242 DoOCUmenting VIEalSa 3 sa ie kone Oe ruo Eo oa ce i LE aeo at aba E Asie i 242 Documenting printing growth chartS 0 0 0 0 ee eee 245 Viewing vitals in physical exam 1 1 ees 246 PLISFOLY tee adden cuins Aen quud herent da xia ee Ee eunt oe a ney 247 Viewing history during an encounter llle 247 Documenting adding history from previously entered history 248 Editing current encounter history items llle 249 Removing history items from current encounters llli els 250 Indicating no history is available or exists 0 0 0 000 cee 251 Including past medical history in current encounters 000 eae 251 Indicating history is non contributory to current problem 505 252 Documenting history using short listS 0 0 0 0 0 cee ee ee 252 Documenting histo
16. 3 Toattach multiple diagnoses to it do any of the following e Double click the procedure or lab or Select it and click amp or e Right click it and select Edit 4 n the Procedure or Laboratory dialog that displays click the Additional Diagnoses tab Procedure Properties Additional Diagnoses Primary Diagnosis ASTHMA NOS 493 90 Fd SYMPTOMS INVOLVING RESPIRATORY SYST 5 ROUTINE GENERAL MEDICAL EXAMINATIO Additional diagnoses that can be attached to the selected procedure 5 Inthe left pane attach additional diagnosis codes to the selected procedure or lab test using one of the following methods Double click the code or e Click and drag it to the Selected box or Select it and click The additional code moves to the Selected box 6 Use the up down arrows to sort the diagnosis codes in the appropriate order with the primary at the top of the list 7 Click OK to return to Assessment Plan 298 3 Patient Contact Functions To edit diagnoses in A P You can update change diagnoses and see that change in the Problems list on the patient face sheet 1 Open a patient chart and from the left pane or the toolbar click A P Assessment Plan Select the Patient Problem List tab and add the diagnosis you want to upgrade or change to the documentation bottom pane To upgrade and track changes to the diagnosis in the patient problem list in the documentation bottom pane se
17. Live Births Number of Fetuses M Fetal demise Complications _ Fetal distress LI Fetopelvic disproportion LJ Amnionitis Maternal Fever Depression Placental problems _ Eclampsia Precipitate labor Excessive vomiting Prolonged labor _ Excessive weight gain C Uterine atony L Failed vacuum extraction Uterine rupture Fetal distress before labor _ Gestational diabetes Hemorrhage 4 Complete the data screens as required NOTES Pregnancy birth history is available for multiple pregnancies 1 10 Two tabs are available from this screen Pregnancy Labor Tab Details information about the Pregnancy Labor Delivery Tab Details Delivery information This information can be documented also in Pregnancy Birth History gt Maternal Past Medical History 1 0 5 Click OK to save and validate all data in the edit windows or go to the next tab to continue documenting data is not automatically saved 6 Optional Click Cancel if you do not want any data saved from the edit To edit pregnancy record pelvimetry NOTE This information is bidirectional with the 59400 Routine Obstetric Care Procedure Rule View Procedure Results Also responses documented in PE Female Genitourinary Obstetric Exam Pelvimetry will populate this screen 1 Access the Pregnancy Record see Accessing the pregnancy record on page 322 2 Select a visit date and press F2 or click 6 Edit Rec
18. The application sends a message to the reviewer s inbox under Received Charts with the subject Chart Review or Review Received Charts 34 from the status bar 8 Access received charts as described in Received Charts on page 80 9 Double click the Chart Review item to display the message 357 H amp P Report 10 Click Pull Chart then Yes to delete the transmittal chart message and open the patient chart Mr Fred Finfey 3 17 2006 11 45 AM Location Family Medicine Clinic Patient ID 1212 DOE 7 24 1964 Married Language English Ethnicity Caucasian Male History of Present Illness nn Hastings 3 7 772006 17 45 AN The patient is a 41 year old male who presents with a complaint of chest pain The onset ofthe pain has been gradual and has been occurring in an episodic pattern Each episode laste seconds Immunization History System Manager 328 2006 11 27 AM Immunizations up to date This ie a fest fo sea cans enabled Review of Systems Sini Hastings 3 T7 72006 11 45 ANT General Mol Present Fatigue Fever Might Sweats Weight Gain 10Ibs and Weight Loss 10lbs Skin Mot Present Change in Wartl Mole itching New Lesions and Rash Boat ia Nn doom e mon dom m omi m m n wm s hg imrim m iim mom a mom P md Fiom m mon Fm moi imo omm m ET You can conduct an Overall or Detailed section by section chart review Overall chart reviews At Overall Chart Review check the appropr
19. To create requisitions 1 Access Lab Order Entry see Accessing lab order entry on page 214 215 Lab Order Entry 2 Click Order 3 Select an encounter or an order then double click it or click p Create Requisition Create Requisition Name fi FredFinley jf ee p fizi Birth Date 7 24 1964 Plan Type Private insurance SSM 30 30 3131 Gender Male EE Worker s Comp Requisition Performing Lab Bill Type a Ordering Caregiver Manager Systen ass Attending Caregiver Manager System gt Account Number o Storage Type New OnHold Plan type Click the Plan Type down arrow to select the patient insurance type Medicare Medicaid Private Insurance HMO Managed Care BCBS Other Self Pay Workers Comp e Some laboratories require plan type information to process requisitions for orders Refer to the Clinical Customization manual for information on Ins Plan Type Required checkbox The Worker s Comp checkbox automatically selects if Worker s Comp is the Plan Type or if the correct information is provided over the interface from your Practice Management System Requisition Performing lab Select the laboratory to receive the requisition Bill type Informs laboratory who should be billed for the lab work Client Laboratory bills client EMR site who ordered the lab work based on the Account Number specified on the requisition Patient Laborator
20. Vitals hemoglobin Hb that is saturated with oxygen with each pulse beat It is measured using a probe that is attached to the patient s finger or earlobe An oximeter detects hypoxia before the patient becomes clinically cyanosed Pulse Ox is always displayed on the H amp P if data are provided It has also been added in Results Summary 10 To record additional vitals taken such as bilateral or orthostatic blood pressures click amp P as many times as needed NOTE The time vitals were taken displays on the H amp P 11 Click the Comments tab to enter comments about the vitals if needed 12 Click OK to accept the data entered 13 Use the icons on the secondary toolbar to do any of the following tasks Add Vitals Click to add vitals data to the current encounter Delete Vitals Click to delete vitals for the current encounter or mark a selected entry erroneous Edit Vitals Click to edit vitals for the encounter or mark a selected entry erroneous a iz Click to delete all vitals data entered Click to delete all vitals data entered during the encounter the encounter T ULLAM Click to enter a vitals note for the current encounter Growth Charts Click to view or print growth charts 244 3 Patient Contact Functions Documenting printing growth charts 1 In HealthMatics EMR pull a patient s chart and from the left pane or toolbar click 4 Vitals 2 On the secondary toolbar click Growth Charts
21. i d Additional Rents Locsin u Loc abiens gt Shah et eu 5 Sh pee pe Results Us Lab Corm d Carmgrver E Cmegvers iG work Log Account amp cA l Account gu Dares past year a ET Gili reconciliation i i _ Pati Date Aude Open Encounters Finley Fred 1212 zis 28 0024 Complete eM nd Qul Lab Order Entry LL Fred i212 34 XX Fa Complete MAGAT Ty E Orders Frdey Mr Fred 1212 MINE 0018 Complete pene System rir Galespie Mrs COH Allziz006 3 33 Oo0z1 Complete Hastings Lynn ue enm sm Hayes Cynthia CHAYES IZIDS 3 56 DODZ Complete HAYES CYNTHIA Location All Locations is the default Click down arrow to select a location for which the user has access All Statuses is the default Click down arrow to select a status On hold Requisitions incomplete and not ready to be sent across the Interface Complete Completed Requisitions only Ready to send Requisitions ready to send across the interface Wait for resend Requisitions waiting to be resent across Interface Sent OK Requisitions sent across Interface Error Requisitions received errors when sent across the Interface Click down arrow to select Laboratory Caregiver lt All Caregivers is the default Click down arrow to select a specific caregiver lt All Account s gt is the default Click down arrow to select Dates Default is The past year Click search button to select a
22. 0 0 IBI 56 Manually matching eRefill requests 1 0 0 0 0 eee 57 TO match OAM SUAS J 59 9 4 afia o E a eee a est 58 To3natc PHARMACIES 2201 sedate rat dedo atts i ad diia Rule dal aw ates eet der 59 To match maintenance medications not previously recorded LLL 60 Approving matched eRefill requests llle 60 Rejecting eRefill requests lille Ine 62 Rejecting eRefills and sending new prescriptions 0000 eee eee 63 Sending new prescriptions electronically llle 63 Setting up electronic prescribing in administration 0 00 ee eee 66 To assign prescribing agents for caregivers l l 66 To set refill request password prompts 0 ccc ee eee 66 To run ePrescribe synchronization immediately llssnn 67 Setting up electronic prescription pharmacies 0 0 00 eee 67 Using biometric authentication with electronic prescriptions 68 HealthMatics EMR Application Reference Manual To add biometric authentication system options 0 0 cee ee 68 To use biometric authentication with electronic prescriptions ls 69 DOCUMEN Secara EOS II Ea ru DU LEE EIU M a 70 Viewing the list of documents 000 ccc eens 70 Approving or rejecting documents 0 00 ccc eee ee ee 71 To approve or reject external transcriptions 0 0 0 eee 71 To approve or rejec
23. 8 Continue entering results for this lab or panel by clicking or press Alt N on your keyboard When all results for the selected lab test or panel are entered the Next button will display grayed out 9 Click OK NOTE To enter next lab test result without exiting this window click for the next lab to display or click the Next down arrow to select a test from the drop down list Reviewing lab results You can view lab results when you receive a Review Results notification mark results Reviewed and send messages to other caregivers who may need to review results To review lab results from review results 1 From the HealthMatics EMR Status bar click amp amp Review Results then double click the patient name on the list displayed or select it and click E Open amp Lab Tasks Chart Tasks Messages Caregiver Manager System Patent o Neal Mrs Olivia ean Abnormals Only Name Status Mrs Olivia O Neal OBSTETRIC PANEL 80055 URINALYSIS AUTOMATED W O MI Preliminary Partially Reviewed m Ner Dates The past 2 years T Status NeedsReview Sort Newest to Oldest Value Units Collect 3 29 2006 8 57 AM Collect 3 15 2006 2 27PM 2 Double click the test to view results 3 To mark results Reviewed see To review lab results on page 178 To review lab results 1 With a patient chart open from the HealthMatics
24. Administration Module Site Settings 2 On the secondary toolbar click 4 gt Edit 3 Under General Settings do one of the following Site Properties eneral Settings Allow Demographics Entry Require Signature Password v Allow Schedule Entry Jw Require Sign Off Password Change Complaints Text e Select Save Password for eRefills to allow caregivers to enter their password one time and then approve disapprove multiple eRefills without leaving the 66 4 1 Office Functions screen Upon leaving the screen the password is cleared and must be entered again the next time the screen is accessed or Deselect the box to require caregivers to enter a password for each eRefill approval rejection Click OK to save the setting To run ePrescribe synchronization immediately 1 2 3 From the menu bar select Launch gt Administration Module gt Scheduled Tasks Select ePrescribe Synchronization from the list On the secondary toolbar click Run Now and then OK Setting up electronic prescription pharmacies NOTE You can send electronic prescriptions only to pharmacies with a unique NCPDP ID set up 1 From the HealthMatics EMR menu bar select Tools gt Edit Pharmacies Mame er s Phone P p Street P EDI Id City Fax E Stake Hl Zip Cade Search Clear qp 6 EDI Id Fax Kerr Drug i 1919 At Name enter a few characters for the pharmacy name and cl
25. Save As Save inc E bd Documents e crf E3 POF fies pd zl Eze 5 Select the document and click Save to export the file and open the application associated with the file type Previewing documents from any view 1 On the toolbar click FJ Print Information and select the template you need for the document you want to generate 2 Click the Preview tab to view the selected document i Print Encounter Procedure Orders OW x Bernt og Fax S QUEUE Save fo Log fey Export Preview F3 Print Preview Qar bB n i Family Practice Chimc 1111 Mori Street Cry NC 2511 Fhone 585 333 0006 M HEALTH S TETEME EMWICLEABERLTHETAITTIARB LIM Procedure Order Ur dering Site Family mados clinic 11131 Worthyaest re Cary NC 27311 So 555 0000 Report Gabe Cog 2006 Patient Inftunmaton Mr Frog Finkey 200 South Sree Cary NC 27311 3555 333 3212 ganga Mae Late of Birth 0024 7 S54 SzW 290 9019 Page 1 af 1 5575 383 Output Defaults Output Defaults Set site location and caregiver defaults for printers and layouts for each output category 1 On the application menu bar select Launch gt Administration Module then access Output Defaults by doing one of the following e To set personal defaults On the Administration Module toolbar click My Output Defaults To set site defaults In the left pane select Site Settings gt 4
26. You can select a message and click toolbar icons or right click for a drop down menu to do any of the following E Delete Del Delete the selected chart message Open Ctrl O Once opened click either tab or double click Message To view requested action e Report To view the results of the report i Reply Ctrl R Reply to the chart message or any other caregiver to the chart Reply to the chart message or any other caregiver or any other caregiver Forward Forward the chart to another caregiver Ctrl F fg Refresh F5 Display new action items sent to you recently if you cannot wait until the screen refreshes itself automatically NOTE To set the Refresh default time see To set desktop defaults on page 109 2 Open an item and on the Message tab read the instructions for action needed P Report Results Message Flo Reply Ve Forward From Manager System Subject Schedule Cardio stress test Pests another Cardio stress test 6 months 1 Office Functions 3 Click the Report tab to display report results on the following tabs e Summary Graph and Totals of the report results Details List of patients included in the report Diagram Diagram of report parameters Exclude list List of patients excluded from requested action Performing mail merges 1 From the inbox select Reports and double click a message to open it 2 Click the Report tab
27. contact screens become enabled These include Quick Assessment Plan Reason for Visit Review of Systems History Vitals Physical Exam Assessment Plan and History amp Physical All of these and more are used to document patient visits in the Electronic Medical Record NOTE The arrangement of toolbar icons can be customized to suit caregiver preferences see Editing options on page 108 LE Fred Finley Male 41 years old 1712 Insurance Carrier Unknown Session Charts Office Patient Explore Options Tools Launch Help amp m ar4Bu 6dg si amu mW g3fgjio s xs swL Quick Assessment Plan p Reason for Visit Review of Systems History Vitals Physical Exam Assessment Plan H amp P Report 237 Data Libraries 238 Data Libraries While customizing your EMR see the Clinical Customization manual and when documenting patient encounters you will use the following purchased databases ICD 9 The International Classification of Diseases is a classification system for diagnoses published by the American Medical Association AMA used in billing statements and Medicare claims SNOMED The Systematized Nomenclature of Medicine is a classification system for human and veterinary medicine The SNOMED database is broader than the ICD 9 database and other purchased databases Caution Please test billing accuracy when using a SNOMED code CPT The Current Procedural Terminology database is a cl
28. definition of 77 inbox messages 25 28 responding to 79 status bar review from 5 toolbar icon 110 113 using 78 addenda H amp P reports adding notes to 156 procedure results adding notes to 311 additional results in patient manager 174 overview 195 addresses entering in demographics 164 administration electronic prescribing 66 encounter packs creating 388 output defaults 384 templates selecting for views 386 security for refaxing reprinting 391 AFP specimen collection screen 221 anatomical images purchased database 238 annotating lab results 183 antepartum date selection 324 appointments billing information displaying 21 colors 7 16 locations viewing by 16 Ntierprise accessing 17 138 patient manager 174 pregnancy record editing 335 schedules printing daiy 20 scheduling in EMR 17 searching for 19 status bar review from 5 status entering time 16 time entered correcting 16 toolbar icon 110 worklogs tracking patients 104 ask on entry questions answering 222 assessment plan authored text setting default for 320 defaults setting 122 diagnoses adding 294 free text adding 296 Index history viewing 291 medications ordering 303 patient education for 307 using previously recorded 293 viewing history 292 methods of recording data 292 my short lists specifying 239 overview 291 problem history viewing 291 problem search accessing 299 procedure entry rules using 309
29. ACUTE PHARYNGITIS 462 System Manager P E 2 16 2006 Office Visit Unspecfied Diagnosis System Manager sal Patients aje Jaf 4712 2002 to 4 13 2006 H Location Click down arrow and select location where test was ordered NOTE Only orders not yet placed on a requisition for the selected location display The default is the user default location To view orders for all patients accept the lt All Patients gt default To search for a patient click E to display the search dialog To view all orders click All Caregiver Accept the default A Caregivers or click the down arrow to select the caregiver who orders the test s NOTE Only orders not yet placed on requisitions display Dates Click E to search and select a date range that includes the orders to process Current range select date range to view orders e Specific dates enter the dates MM DD Y YYY format or select dates from the calendar Creating requisitions Use requisitions to send lab orders from HealthMatics EMR to external laboratories for processing Requisitions can contain one or many lab orders depending on laboratory preference Create a requisition for all orders within an encounter on the A P screen or on the Requisitions screen in Lab Order Entry or create a requisition for just one lab test If an individual test is selected only that test appears on the requisition for the Lab Order Entry screen
30. Ao Asa 4 5 11 0 10 x 9 celsi 14 4 16 6 42 9 49 1 76 100 2 Chart Functions Order CBC PLATELETS AUTO 85027 Result Details Test Mange MCHC MEAN CORPUSCULAR HEMOGLOBIN CO Status Pending Range 33 37 Reason for Chag e Note amp Ua CR c OY Bl on EJ 7 At Value enter results A Note can be added if desired using conventional word processing tools NOTE Value selection lists can be created in the Lab Catalog See the HealthMatics EMR Clinical Customization manual e IENNENMMN Value Value reported for the test result If abnormal results are entered the Profile Panel Test on the left displays in red Severity If a normal Hange has been specified the field defaults automatically to Normal or Abnormal if the value is outside the normal range specified You can also click the down arrow to select the appropriate severity of the result value for the selected test If appropriate click the down arrow to select units for the result value Displays the normal range for that item Reason for Change If you are changing a lab results entry click the down arrow to select a reason for the change or enter a free text reason Enter a note for the lab test if desired NOTE If your practice receives results over a bi directional lab interface result values automatically populate the Result Details as they are received and matched by the Lab Reconciler 177 Lab Results 178
31. Assessment Plan e Yes Problem dialog opens automatically for entering details 122 1 Office Functions e No Double click the diagnosis or select it and click Edit after adding it to the current encounter to enter medication details 5 Orders Click the down arrow to select the caregiver you want to default in the Ordered For field Appointment Caregiver Preferred Caregiver blank the default and a list of grantors so that you can select an individual caregiver 6 General Click the down arrow to select the Assessment Plan tab you want to display by default Patient Problem List Patient Medications My Short Lists Short Lists Search or Free Text 7 Click OK to exit or select other items in the left pane to set additional defaults To set electronic prescription defaults 1 From the HealthMatics EMR menu bar select Options Edit Options Electronic Presriptions P Caregiver Options for Manager System o x Electronic Prescriptions Auto Transmit Mew Prescription Do vou want to automatically transmit to the patients default Yes Patient Manager pharmacy if it supports electronic prescribing Results Note Selecting Yes will alleviate being prompted Far a pharmacy each time an electronic prescription is transmitted History Lists Quick Lists My Short Lists ced 2 At Auto Transmit New Prescription select one of the following e Yes Automatically transm
32. Cardiomyopathies Pregnancy Birth SS Chest Pain x 4 Click as needed to expand folders to locate the item you want to document 5 Double click the item or select it and click Include or drag it from the upper to the 252 lower pane to display History 3 Patient Contact Functions 6 Access the properties box by highlighting the item then clicking Edit or by double clicking the item and then complete the fields General Modifiers Pe Sy Test Result p e Diagnostic tests Sy Diagnostic test results F ey Tests Renamed Leave this field blank to accept the Knowledge Term description or Rename the term by entered a new name Dae Enter a Date See Entering dates on page 10 Click down arrow to select a status for the history item Active Inactive Resolved Erroneous Entry or Undefined Optional Enter free text about the history item 7 Inthe right pane click signs to expand the folders as needed to locate history details 8 Add as many history detail items as needed to the Comments box by doing any of the following e Double click the appropriate detail for the Knowledge Term selected e Select the leaf level item and click the nclude button at the top of the box e Click and drag the leaf level item to the Comments box on the left NOTE Only items that display in the Comments box are included in the history note for the current encounter 9 Click OK to save the new informati
33. Click the Free Text Diagnosis tab Assessr j t Pl i C P T Curent Encounter Patient Problem List Patient Medications My Short Lists Short Lists Search Cp Include Description 3 At Description enter a free text diagnosis or treatment that you cannot find on a short list or using Search and click Include 4 Ifyou select a diagnosis or treatment from the Free Text tab that was documented in a previous encounter the system displays a message indicating that it was previously used e Yes or Enter The system adds the current encounter information to the history of that problem or medication e No The system creates a new instance of that problem or medication on the Patient Problem List or the Patient Medications List 296 3 Patient Contact Functions NOTE In most cases you will click Yes to attach the problem to the history to prevent duplicate entries 5 Double click the item in the documentation bottom pane to enter additional details and click OK 6 Drag and drop plan items beneath the free text diagnosis you created in the documentation bottom pane To indicate primary secondary and tertiary diagnoses 1 Open a patient chart and from the left pane or the toolbar click A P Assessment Plan 2 Select multiple diagnoses for the current encounter using any method see To specify assessments and plans using short lists on page 294 To search for assessments and plans using database
34. Click to select tests to include on the requisition 1B Check Al B Uncheck all Clea cucrueg ores 306 Wistar Sota 29 2006 4 19 PM 462 Py steer OUE TEST 864035 Meir Sysbem Ajursog 4 p9 pe 462 NOTE Tests checked depend on selection from previous screen If an encounter was selected all tests are checked However if a single test was selected only that test is checked on the requisition by default To include a test or exclude it check or uncheck the box Toinclude all tests on the requisition click Check All Click OK to exit Click for ABN reason Medicare may not cover the service LEITIODO X Select the reason s why amy of the tests below might be denied by Medicare Then click OF to print the ABN Cordon Medcae does not pay For thers beets for you cordon Frequency Medicans does mot pay for there bests as offen as thet derwed ot too frequent E xpenrmeni al Medicae doe nol pay for expenmeni al or research une berii FINAL SIS Ww MICROSOF 81000 URINE BAC CULTLURE QUAM COL COUNT 370 D ALLERGEN SPECIFIC IGE GLUALITATIVE surf E NOTE Each Medicare patient must sign an Advance Beneficiary Notice ABN form for laboratory tests Medicare does not cover The ABN includes the reason Medicare may not cover the laboratory test On the ABN patients indicate they will pay for the test themselves or choose not to have the test performed Condition Medicare does not pay for the te
35. Ensure appropriate encryption prior to emailing patient information 318 3 Patient Contact Functions Option 3 Select referral letter from patient chart 1 With a patient chart open from the HealthMatics EMR Menu bar click Print gt All Templates gt Forms and Letters gt Referral Letter after documenting the pertinent encounter information or select a template from your customized list Select Parameters for Referral Letter 2 Select items to include in the letter from the available tabs 3 Click OK 4 Complete the Print Referral Letter selections and preview as necessary B Print Referral Letter Gert eax i Queue usavetolog emo preview F9 US Letter 83 8 11 imn 5 Click Print Fax Queue Save to Log or Export to complete the process 319 Assessment Plan Using authored text in assessment plan You can use authored text to create standard documentation such as counseling post op or procedure instruction discharge plans and so forth Refer to the HealthMatics EMR Clinical Customization manual for information on how to create practice specific Authored text 1 Open a patient chart and from the left pane or the toolbar click A P Assessment Plan 2 Fromashort list or the Search tab locate the Authored text item 3 Double click it to add it to the encounter lower pane 4 Authored text unless marked with a status of complete displays as pending and appears on the A
36. For prescriptions it s on the Prescription tab Printing no documents at sign off Create an Encounter packs that contains no templates see Creating encounter packs on page 388 Regenerating documents from output queue 1 Set filters select patient and set Status to lt All Statuses gt 2 Right click document and select action Print Fax Save to Log Export NOTE For prescriptions enter a reason for regenerating 392 4 Printing and Faxing Generating queued documents 1 From desktop select Output Queue 2 Set filters and set Status to lt All Requiring Action to list all Queued documents 3 Note Destination Comment if any entered when document was queued 4 Right click document and select action Print Fax Save to Log Export Document Stages Stage 1 Output Manager Stage 2 Administration Module Build the template Assign Output Defaults a Layout and a Printer to each Output Category Assign the template to an Output Category These are best assigned at the Site level when possible Stage 3 EMR Stage 4 Customize Click the printer icon and generate the Add the template to an EMR screen print template from the assigned Output Category list and or to an encounter pack in the in the All Templates Menu Administration Module under Output Settings 393 Document Stages 394 Index A access for refaxing reprinting prescriptions 391 action history output queue 96 action items
37. Gravidity Parity of pregnancies of live births Click Edit to access the Pregnancy Record seePregnancy Record on page 322 174 2 Chart Functions See also To set patient manager defaults on page 116 Lab Results You can enter lab results submit results to providers for approval and save results to patient charts Lab Results features are similar to Procedure Results You can send messages about results to caregivers and you can attach them to patient charts Entering lab results To manually enter lab results into HealthMatics EMR take the following steps 1 With a patient chart open from the HealthMatics EMR toolbar click e View Lab Results or from the menu bar select Office gt Lab Results or from the left navigation pane click i Lab Results E Mr Fred Finley Male 41 years old 7 24 1964 Preferred Caregiver Family Practice E Insurance Company A 1 Miel E3 Session Charts Office Patient Explore Options Tools Launch Help ame FE un Additional Results STREP QUICK TEST 26405 Ordered Collect 3 28 2006 4 19 PM Z Rue il Summaries BAC CULTURE OTHER E7070 Ordered Collect 3 29 2006 4 19 PM IM Contact LIRIMALYSIS WO MIOROSCOPY 81 Ordered Collect 3 6 00 10 31 AM 12 Reason For Visit LAINALYSIS WiO MDOROSCOPY 31 Ordered Collect 3 6 2006 10 30 AM
38. Inform your doctor of av other medical zondions includi kidney problems stomach problems such s u cere throat problems cach as trouble ewallcwing or gactroecophagea rofux dicoaco allongios pea3nancy or breast Teedmng Use OF IFTE MEDICINE IS HOT FECOMMERLEL IT you have ThUdI2 amp wallowinc a narr w orblockac esophagus low levels of calciurr in vourb ood severe kidney prcblems Qr i you canno stand or S uprignt Tor a 1251 30 ines Contec your docio cr or acrmacistif you have ay questions or concems boui taking this medic na HO TO LESE THIS MEDICINE Fol ow the directos forusinc this medicine provided byyour doctor This Patient 41 year oldmale Weight 177 Ib 6 oz 80 53 kg as of 9 26 2004 Cancel 307 Assessment Plan 4 To print the information click g NOTE If Spanish was the language selected in Demographics for this patient patient education displays and prints in Spanish 5 Click OK to close To use formularies 1 Open a patient chart and from the left pane or the toolbar click A P Assessment Plan 2 Inthe preview lower pane double click an ordered medication or select it then click g Click the Formularies tab p a View information related to how the patient formulary classifies the medication and the estimated cost if available 5 Click OK to save Medication Properties and exit Using protocols Protocols are groups of orders associated with one ICD 9 code the equ
39. Me Reply SE Forward Cd Print ET From Manager System Subject Zithromax check lt Previous E Web Co Delete Gg Print Hn IS Export k f Location Healthmatics summary Report C Caregiver salCaregwerss Phanej Address List Summary Details Diagram Exclude List Address Labels Patients iz raskstaus Mail Merge 3 Click Mail Merge Print Mail Merge rinter Mame ae METorint MM Properties Status Type hp LaserJet 1300 PCL 6 Where Rm 1109 Comment Rm 1109 roperties Location Healthmatics Template Diagnostic Tests Letter Description Diagnostic Tests Letter Far Mail Merge Preview F9 Cancel Optionally click Preview to view the merge letter and Close to return to Print Mail Merge Select a Printer Location and Template and click OK to print the letters for the patients listed in the report results For detailed instructions for using the Report tab refer to Report Results in the Reporting Module manual 83 Internet from Inside HealthMatics EMR 84 Internet from Inside HealthMatics EMR HealthMatics EMR provides the ability to access the Internet from within the product and bookmark favorite sites If your computer has access to the Internet via a network connection do the following On the HealthMatics EMR toolbar click i8 oronthe menu bar select Launch Internet Browser Z Electronic Me
40. Move Item Out Move the selected item out of the primary item s drop down menu see above 4 To separate groups of related icons such as Pull Chart File Chart s Send Chart click the arrow icons to place them consecutively in the list on the right and then insert a Separator separator before the first and after the last icon in the group 5 Click OK to exit or select another item in the left pane to set more defaults To set face sheet defaults You can filter information and set the sort order for each of the five panes on face sheets The system remembers each caregiver s preferences 1 From the HealthMatics EMR menu bar select Options gt Edit Options gt Face Sheet p Caregiver Options for Manager System Miel Ed General Face Sheet Problems Viel Active Sark oldest to Newest Encounters YEW Ey Type Sark Newest to Oldest Medications View Al Sark Newest to Oldest Orders View ordered m 2 Physical Exam z Assessment and Plan B Electronic Prescriptions Sign OFF Title Bar jew Common Sark Newest to Oldest SIRO Newest to Oldest Lists Quick Lists My Short Lists cm 2 Problems e Click the View drop down arrow to select the view you want the patient s problems to display by default A Active Inactive or Resolved 114 1 Office Functions e Click the Sort drop down arrow to select the way you
41. P HIET OMHEDATETS Folow ws H TALUS Scacle TSTORY OP PESSENT ILLHEZS 3 Verify that the patient and indexing information on the left is correct revising if needed 4 n the middle pane click thumbnails to display the pages of the document in the preview pane on the right NOTES IF an image needs to be rotated click 4 and select a rotation option IF the pages are in the wrong order click a thumbnail and then click 4 or 4 to move the page up or down respectively 1 Office Functions 5 Use the icons over the preview pane on the right to do the following Print Document Print Document Ctrl P Displays a Print Document dialog Message e Send Patient Message to another caregiver about the document e Send Reminder to the chart Zoom Cursor Click the icon and then click the image to magnify it im Move Cursor Click the icon and then click and drag the image to move it up down and left right Navigate to First Page Return to the first page of a multi page Ctrl Home document Navigate to Previous Move to the previous page of a multi page Page document b Navigate to Next Page Move to the next page of a multi page document Navigate to Last Page Move to the last page of a multi page Ctrl End document jZeomo 00 Enlarge the document to 100 the document to 100 B Zener wan Ereet senene Remar E oe eroe neamono nne waero Fte E Select zoom Click the down arrow to select
42. Patient ID 1212 Pref Caregiver Family Practice E Birth Date 7 24 1964 Subject Patient called with questions 3 Text image Voice Import atient has question about lab result Please call after 5 pm gt Delete Delete the message by clicking Delete and Yes to confirm gt Face sheet Click to open the patient s face sheet in a separate dialog box When you are through viewing the face sheet close it to return to the message for further action 1 Office Functions gt Pull chart Click to close the message and go to the patient s chart A dialog box asks if you want to delete the message on your desktop Click No if you want to be able to view the message again after you pull the chart The Messages view closes and the patient s face sheet displays gt Save to chart Click to save the message to the patient s chart Type a comment or response at the top of the text box if desired and click Save to Chart again and Yes to delete the original message NOTE If neither you nor the recipient is the patient s primary caregiver a message displays asking if you want to notify the primary caregiver that a message was saved to the patients chart gt Reply Click to reply to the message gt Forward Click to forward the message to another caregiver gt Print Click to display the message in Print Preview click amp to print To reply to the sender From the secondary toolbar in the Messag
43. Practice Clinic Billing Level amp DEF Ste De suit Billing Status Cannot bill electronically Digne DA 35000 389 9 HEARING LOSS NOS 3559 53 o dL NE Patient Finley Fir Fred 1212 Billing Provider Mo Eng Provider Encounber Dabe 4 3 2006 12 20 FIR Lacan Fany Prackica Chic Billing Level oan COFFICEPOUTPT VISIT NEW PROB FEC Billing Status Mot fillable Dhage 3 4 DAPACTED CERLIMEM 390 41 EPT 3210 REMOVE IMPACTED EAR WAW 53210 Lir pescihued Daye jing asocio ec pir Ordered 413 2006 by System Manager Waiting Details display in table form from the selected item on down NOTES Cannot bill electronically Encounters documented on charts that were not pulled from the Appointments schedule cannot be billed electronically Billing information for those encounters must be manually entered into the Practice Management System Billable Billable items that aren t pulled from the schedule appear in red since they cannot be billed electronically Not billable Items may be non billable if a non billable encounter type such as Historical Summary was selected at Sign Off Waiting Items marked Waiting in blue result from clicking Bill from H amp P Report on an encounter that has not yet been signed off To print the report do any of the following From Billing Details press Ctrl P or click amp or From Billing Reconciliation click amp or press Ctrl P and select Billing Reconciliation Repo
44. Quick Printing Reference 5 vea ua WR EE eon es DER Ya ad ecd EE 392 Printing from open encounters llli 392 Printing ente Chall s cu ose doen at RE e o C CE oa ntn ee d Moe a c d Pd 392 Printing from appointments llle 392 Printing documents without signing off chart 0 0 ees 392 Printing forms letters and prescriptions from A P 0 cee ee 392 Printing no documents at sign Off 0 eee ees 392 Regenerating documents from output QUEUE 2 0 2c es 392 Generating queued documents 0 ccc eee eee eee ees 393 Document Slages o sibs ce cet ewe a ee a Eu care 393 lue eer PME eee ee oe owe ee ane eee eas 395 Xi HealthMatics EMR Application Reference Manual xii 1 Office Functions 1 Office Functions Before using HealthMatics EMR become familiar with the functions available on the HealthMatics EMR desktop and how they can be used to monitor the workflow in your practice and to access the Internet Login The Login screen displays the name of the application and the version level HealthMatics EMR Cinical Module esc You can log in to HealthMatics EMR in either of two ways e Login name and password gt Login name Login names must be at least five characters A mixture of alpha and numeric characters provides maximum security Privileges are attached to login names gt Password All users must have passwords They must be changed per
45. Show all Immunizations Default This view displays all possible checkbox immunizations and date fields Deselect the checkbox to view immunizations specific to this patient Include In H amp P Select to include the Immunization Record in History and Physical NOTES Immunizations ordered in Assessment Plan are automatically recorded in the immunization table according to the data on record Example If a record shows the date of DTP 1 on 12 28 2004 and another DTP is ordered on 3 28 2005 it automatically populates in the DTP 2 slot You can change this information through editing in A P or from the Edit Immunizations tab If the immunization record entered into HealthMatics EMR is incomplete Example Earlier immunizations were given but not recorded in EMR when an immunization is ordered it will populate the first available slot for the series If this occurs the record can be edited see Editing immunization history on page 339 2 Click the Edit Immunizations tab to edit immunizations 3 Patient Contact Functions Editing immunization history To edit existing immunization history 1 Access Immunizations see Accessing viewing Immunization Record on page 338 2 Click the Edit Immunizations tab Op Add Historical E irre Default view Deselected Click checkbox to display erroneous immunization entries NOTE Erroneous entries appear grayed out with a line through t
46. accessing 227 batches sending in 228 creating 214 215 creating from A P 300 deleting 226 printing 226 processing 227 resending 228 toolbar icon 112 reset list in A P 294 resizing panes columns 8 Index result notifications blocking 31 determining who is notified 30 inbox messages 25 27 toolbar icon 112 viewing 29 result summaries graphs 203 graphs viewing 203 overview 199 spreadsheets viewing 202 toolbar icon 112 viewing 199 results additional in patient manager 174 awaiting review in patient manager 174 defaults setting 117 entering using procedure rules 310 face sheet reviewing from 159 lab entering 175 reviewing 178 procedure attaching to charts 192 changing performance dates 193 entering 189 locating 193 reviewing 191 referrals entering 195 reviewing 197 report in patient manager 174 status bar review from 5 summary graphs creating 203 unsolicited including in pregnancy record 336 review of systems accessing 278 adding notes 282 defaults setting 119 documenting 272 from scratch 281 measurements and sizes 276 quick search 274 using previous encounters 280 navigation map 267 methods 266 my ROS lists 268 269 ROS 266 search 271 selected 268 navigation pane 266 notes 405 Index characteristics level adding 283 review of systems level adding 282 systems level adding 283 pregnancy record editing 329 preview pane 271 templates using 278 toolbar icon 112
47. follow the steps below 1 Open a patient chart and from the left pane or the toolbar click 9 Reason for Visit 2 Click the Previous Complaints tab to display the patient s Past complaints list CC HPI and click a complaint to select it for the current encounter It displays in the Exams Complaints pane at the bottom of the screen 3 To enter complaint details select the item in the Exams Complaints pane and do one of the following e Press F2 on your keyboard or e Double click the item or Click amp Describe selected item to display Complaint Details or 3 Patient Contact Functions e Right click and select Describe 4 To document Complaint Details see Documenting complaint characteristics and details on page 262 NOTE If you select a previous complaint that includes free text comments a message displays when you begin to update the documentation stating the free text comments will be removed This message does not refer to text entered in Note fields Click Yes to continue with your documentation If you do not want to answer this question for subsequent previous complaint documentation click the Don t show this message again checkbox before clicking Yes Repeat the steps above if necessary to document additional previous complaints for the current encounter To document reason for visit using my short lists or short lists The process for documenting reason for visit using My Short Lists or Short
48. or Check Out or 18 1 Office Functions To perform other tasks relating to patient appointments on the secondary toolbar click Appointment for a drop down menu i Ntierprise IF you have the Ntierprise Practice Management System access any of the following Appointment Scheduling Registration Financial Inquiry a Se eeeeemeemensee n B ornare View the H amp P View the H amp P Report for the selected appointment for the selected appointment Bg cd Information appointment a hn View the labs for the selected View the labs for the selected patient s appointment S appointment NOTE Most of these functions can also be accessed by right clicking anywhere in the right pane of the Appointments view to access a pop up menu Searching for patient appointments 1 From the HealthMatics EMR desktop toolbar or status bar click rj Appointments Press F3 on your keypad or on the secondary toolbar click d Search Appointment Select a patient by doing one of the following e Ifthe patient s chart is open click e Use Current Chart e Ifthe patient s chart is not open click the Patient search button For instructions see Patient Search on page 14 To view an appointment select it and click Go to The program scrolls to that date with the selected patient s appointment highlighted 19 Appointments 20 Changing or editing appointment information 1 3 From the HealthMati
49. or reassign them to other caregivers for action For general instructions for using HealthMatics EMR windows see Windows Panes and Other Tools on page 8 To list web messages on your desktop in the left pane of the Healthmatics EMR desktop click Web Messages Web Messages Open e Repe Gt Reassign Caregiver Manager System Type ea Message Types gt is Location Family Practice Clinic Frome Subject Patient Sent See also Messages on page 32 for additional information about processing messages and Viewing other caregivers inboxes on page 28 Use the secondary toolbar icons or right click for a drop down menu to manipulate your messages For a description of those functions see Performing inbox tasks on page 26 e To locate messages click the Caregiver and Location down arrows to filter the list To open a web message select it and do one of the following gt Double click it or gt Press Ctrl O or gt Click Open on the secondary toolbar or gt Right click and select Open e To reply to a web message select it and click Reply on the secondary toolbar For additional instructions see Responding to patient messages on page 40 e To reassign a web message select it and click Reassign on the secondary toolbar 43 Refill Requests Refill Requests Refill Requests are caregiver created messages alerting you to a patient s request for a medi
50. screen refreshes itself automatically To view other caregiver outboxes If you have been granted access by other caregivers see Editing grants on page 129 click the Caregiver down arrow and select the caregiver s name 1 Office Functions NOTE You are now viewing the outbox of that caregiver and can perform the same tasks that you can in your own outbox Be sure to change the name back to your own when you are done Batch Refill Batch Refill displays a list of all approved or rejected refill requests awaiting processing The Rx Manager prints calls faxes or transmits approved refills to pharmacies and then clicks the appropriate button to indicate the action taken The refills are then saved to the chart which documents the action taken in the Encounters pane of the patient s face sheet Processing refill requests in batch refill 1 To access Batch Refill from the HealthMatics EMR menu bar select Office gt Batch Refill or in the left pane of the HealthMatics EMR desktop click Batch Refill Batch Refill d ca OREN Caregiver Manager System Patent L Pharmacy Medication Sent wv Parrot Peter Pharmacy One 101 Childrens Tylenol Sinus 4 20 2006 3 10 PM X Finley Mr Fred Pharmacy One 101 Albuterol 417012006 3 11 PM X Finley Mr Fred Pharmacy One 101 Amoxicillin 4 20 2006 3 11 PM wv Finley Mr Fred Pharmacy One 101 X FA 8 4127012006 3 00 PM wv Gales
51. xe Patient Name Mr Fred Finley Patient DOB Tf 241964 Encounter Date 3 15 2006 am referring the above patient to you in relation to his last Assessmen Flan ca eec If needed edit the letter in the editor pane Optional Click Print Preview L amp to view finished letter 9 Referral Referral di After editing the letter if necessary print or email it Print To print the letter click amp Print gt Select the printer and print properties gt 3 Patient Contact Functions Click OK again to close Review window Email To email the letter via Microsoft Outlook Email IF MS Outlook is set up for emailing from HealthMatics EMR click KB Email gt Select a Profile Name and click OK An email is created with the subject line appropriately completed and the letter attached Choose Profile Profile Mame Waaa Cancel Help Options gt gt Click OK to close the Review window NOTE Ensure appropriate encryption prior to emailing patient information Option 2 Make referrals using letters associated with caregivers You can pre enter frequently used referral caregivers and caregiver associated properties into a short list to generate a referral letter For details about creating referring caregiver short lists see the HealthMatics EMR Clinical Customization manual 1 Open a patient chart and from the left pane or the toolbar click A P Ass
52. 1 Access Output Queue and locate and select the document you want to export see Viewing documents from the output queue on page 92 2 On the secondary toolbar click lt Output Tasks to display a drop down menu and select Export 3 Inthe Export Dialog click the Filename search button to navigate to the directory where you want to store the document enter a File Name and click Save to return to Export Dialog Export Filename ciDocuments and Sakti badiy Documents Frin HiPOSOSOS pof Preview _ a NOTE To view the document in an Acrobat Reader window select Preview and click OK 4 Click OK to export the document to a file The document appears in Output Queue with a status of Exported Viewing output queue action history 1 Access Output Queue locate and select the document see Viewing documents from the output queue on page 92 2 Open the document by doing one of the following e Double click it or e Select it and click z Open or e Right click it and select Open 96 1 Office Functions 3 Click the Action History tab to see the following Output Properties m x System Manager OS 29 06 01 42 pm NETprint2 on rpri Terry Manning MD 04 03 06 3 03 pm Test Rx pdr Terry Manning MD O4 O3 D6 03 07 pm Tast Rx pdf e Action taken e Caregiver who took the action e Date and time action was taken Destination Printer or other output device used e Comment if any was
53. 1212 Office Visit billable Encounber started 3 23 2006 3 38 FM and completed 4 3 2006 10 40 AM Location Family Practice Clinic Biling Level amp DEF SITE DEFAULT Billing Status Cannot be billed electronically Billing Provider 7856 50 CHEST PAIN UNSPECIFIED 786 50 33015 CARDIOVASCULAR STRESS TEST 93015 NO Billed 94010 BREATHING CAPACITY TEST 94010 E 94665 ma INHALATIONS ADDED nn 85031 CBC MANUAL 85031 id d zl e Click Print to print the H amp P Report or other items Template Pack eal Available Templates gt amp Check All Patient Active Medication List Patient Education Uncheck All z C Patient Immunization Record Referral Letter cea Click the Template Pack down arrow to select lt All Available Templates gt or Typical Printouts then select the items to print and click OK to return to Encounter Details e Back in the Encounter Explorer click Rebill to rebill the encounter e Click the X in the upper right corner to return to the face sheet To view approved SOAP and general transcription external transcription SOAP transcription displays on patient History amp Physical Report for the respective office visit To view transcription on the H amp P follow the steps below 1 From the HealthMatics EMR toolbar click L Pull Chart search for a patient with transcription and double click it to display the face sheet 2 Chart Funct
54. 139 PUDO CAIUS Serie DD 139 To pull patient charts for billing lll ee eens 139 To pull charts for concurrent encounters n sasaaa aaee 140 To pull patient charts for non billable contact llli 140 To review open encounters 0 0 cee hn 141 To enter reason Kept ODer i cae s a SA dom Sie eA d AC dX ea e 142 Sending charts to other caregivers lille 142 Reviewing received charts llle 143 mao et Uc RON ERENETRARTLNS TERTII NITET 143 HealthMatics EMR Application Reference Manual To file an open chart from the toolbar 2 2 0 0 ee eee 143 To file charts from the desktop or status bar 0 0 cc eee 143 Frinting ente CHANTS ty do ac obti di obo 9 89h a Cotto e 9 a ie me Rn e ee 144 Face Sheets s cos vr sd XE EE Paquet pg dada vehau i e dace ee ders 145 Viewing and revising problems from face sheetS 00000 eee eee 147 TO VIEW PIODICMS nc a actos m do E ED RU cie oen C al e dm RE UN OR iore a s 147 To revise problem status lllllleee eee eens 148 To revise diagnoses from face sheets 0 00 cece eee 150 TO DIODIGITIS eut nog irte eig tone a E ED anos hed a RUE Pe ER de RR REE E 150 Viewing and revising history from face sheetS 0000 eee eee 151 Qoxur Aio ch Gees adic a a aa Rican Pla tae arate ei eter Sanna aye acer 151 To view edit immunization history from face sheets llli 15
55. 2 From the menu bar select Tools Patient Merge Click the Merge History tab 8 Patient Merge l Es Merge Queue Manual Merge Merge History Reverse Merge Current Patient Merges Original Patient ID Merged Patient ID C 9 30 2005 3 23PM Mr Fred Finley 123456 Mr Fred Finley 12345678 System Manager A separate line item displays for each chart that has been merged into a group Information saved includes the following e Merge date Date the merge was made e Original patient ID The original name and ID number of the patient that was merged into another e Merged patient ID The target chart name and ID into which the patient was merged e Merging provider The user who performed approved the merge To reverse a merge select it and click Reverse Merge e To see the reversal select the Show all merges check box in the bottom left corner of the screen c ars re ns 3 23 PM Mr Fred Finley 123456 Mr Fred Finley 123458678 System Manager The merge icon changes from blue to green for merges that have been reversed To close Patient Merge click the X in the upper right corner 3 Patient Contact Functions 3 Patient Contact Functions HealthMatics EMR provides a point and click method of documenting patient visits and recording immediate legible documentation measurements and results in patient charts When you pull a patient chart the toolbar icons for
56. 2006 Pathology Report Result review 4S One Week Ago 499 3 23 2006 Office Visk CHEST PAIN 3 23 2006 Refill Augmentin rr L 3 23 2006 Refil Augmentin LL EJ Tuc Meals A55 NOTE Sorting By Type groups items by Encounters Messages Chart Attachments Scanned Documents and Correspondence 4 Click to display the contents of the Office Visit folder 5 Select an encounter date to view the H amp P Report for that visit in the right pane History amp Physical Report giling Information Mes 49 RETENE Mr Fred Finley 3 23 2005 3 38 PM Location Family Practice Clinic Patient ID 1212 DOB 7 24 1954 Married Language English Ethnicity Caucasian Male The patient is a 41 year old Male Immunization History Sten Manager 3 24 2006 3 31 PN Immuniations up to date 02 05 1995 Historical entry Assessment amp Plan System Manager 3 31 2005 2 49 Or CHEST PAIN UNSPECIFIED 786 50 Plans Accutane 10MG Capsule 1 PO No Refill 03 31 2006 Ordered CARDIOVASCULAR STRESS TEST 83015 Routine BREATHING CAPACITY TEST 84010 Routine AEROSOL VAPOR INHALATIONS ADDED 94665 Routine CBC MANUAL 85031 Routine 153 Face Sheets 154 Click the Billing Information tab to see the billing level status and provider as well as the items billed and not billed Encounter Details History amp Physical Report Bing Information Mr Fred Finley
57. 25 2004 Office Vist HEALTH MAINTENA Lu em 4 Inthe left pane locate the document and select it to view 155 Face Sheets 156 5 6 In the center pane click the thumbnail sketch to display the image on the right Click the icons above the image to move through the pages NOTE You can also view approved scanned documents by sorting the encounters By Date and then selecting the appropriate item To move attachments messages to other encounters 1 2 3 4 Open a patient chart and on the toolbar click E Face Sheet Click mi to maximize the Encounters pane and Sf Toggle Filter to sort items By Date Click to open an office visit with an attachment or patient message f Click and drag the item to a different Office Visit The item displays under the selected office visit on the face sheet To change encounter information or create addenda To include additional information for an encounter after it is completed and signed off you can add notes as an addendum to the H amp P report 1 2 Open a patient chart and from the toolbar click E Face Sheet In the Encounters pane highlight the office visit you want to add notes to and click amp Edit Encounter n Encounter Addendum Addendum Notes 2 1 ve X amp ap 2 Mr Fred Finfey 1 7 2008 1 44 PM Location HealthMatics Patient ID 1212 DOB 7 24 1964 Married Language English f Ethnicity Ca
58. 9 days starting 01 11 2006 Ordered 2 Sy Ferms Letters 8 4 Other Unknown 4 y Pathology Report 4 te F ia iB r NNNM Called In The refill request was approved by the caregiver and marked called in Printed The refill request was approved by the caregiver and printed Faxed The refill request was approved by the caregiver and faxed Transmitted The refill request was approved by the caregiver and transmitted electronically 1 Office Functions pU Rejected The refill request was rejected by the caregiver and saved to the chart The refill request was approved by the caregiver and saved to the chart without being printed faxed transmitted or marked called in NOTES If the caregiver who requested the refill entered text in the Refill Request text box it displays as a Note at the bottom of the Batch Refill screen When printing the prescription template used is for the caregiver who approved the medication By approving requests and sending them to the Rx Manager caregivers implicitly give their consent to use their signatures If a faxed prescription has not yet gone through a Fax Pending status displays in both the Medication pane of the patient s face sheet and in the Output Queue If the fax fails the notice contains the name of the pharmacy along with the medication name patient name and fax number see Output Queue on page 92 You can create a new refill request from Batch Refill b
59. AM 2 To assign a person to process the approved refill request click the Rx Manager down arrow and select that caregiver 3 Double click a refill request or select it and click Open on the secondary toolbar NOTE If the patient has outstanding refill requests the following dialog box displays Outstanding Refill Requests A Please be aware that this Patient has additional outstanding Refill Requests ya Manager System Childrens Tylenol Sinus 4 20 2006 3 10 PM Click OK to continue and display Refill Request Refill Request o end Aysaveto Chart Pulchat H Face sheet amp Demographics S Reminders 39 High Priority Block one click Approve Rx Insurance aer e Text image voice Last Encounter Office Visit 04 05 2006 02 15 PM raga sen Mamm Maumee SoH 23 30 3131 Pharmacy Pharmacy One 1010 Westwood Drive Cary Phone sss 555 2323 d Save as default Pharmacy For this patient z Request vip Anprove V Approve w Ghanges X Reject 7 Output Al gt FA Vitamin B 6 Vitamin B 12 2 2 25 500MG MG MCG Tablet 1 PO No Refill 02 15 2006 Ordered Accutane 10MG Capsule 1 PO No Refill 03 31 2006 Ordered Albuterol SOMCG ACT Aerosol Soin 1 Inhalation 2006 Ordered Amondcillin 200MG Tablet Chewable 1 Tablet Chewable PO No Refill 03 04 2006 Ordered 48 1 Office Functions NOTE In Refill Request you can use the secondary tool
60. Assessment Plan window see Specifying assessments and plans on page 292 3 Click OK to return to the previous window Pregnancy Record Use the Pregnancy Record to document antepartum records used in both American College of Obstetricians and Gynecologists ACOG and Hollister forms through a single point of entry Information added through the Pregnancy Record is saved and populates appropriate clinical module screens in the HealthMatics EMR Documents entered in HealthMatics EMR that relate to the Pregnancy Record populate the Pregnancy Record You can enter the Pregnancy Record from the HealthMatics EMR menu bar or from Patient Manager When you first enter the Pregnancy Record you re asked for the Last Menstrual Period LMP or Estimated Delivery Date EDD The application uses this date to decide what information to display based on the expected gestational period for the pregnancy The Gestational Age calculates automatically for open encounters by using the EDD by Physician if entered or otherwise the LMP date The calculated Gestational Age appears in Patient Manager the Pregnancy Record main window the Prenatal Record grid and the Maternal Fetal Data tab Accessing the pregnancy record To access the Pregnancy Record both requirements below are needed e A patient chart must be pulled e An active 59400 procedure using the OB Antepartum tool must be selected in Assessment amp Plan A amp P for the encounter 1
61. CARDIAC BLOOD POOL 78472 Routine 1 GANGLION BLOCKING AGENTS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE E942 3 2 n the Problems pane on the left do either of the following Latest occurrence To see the latest occurrence of each patient problem in any category highlight the folder Active Inactive or Resolved to display the most recent occurrence of each on the right Single problem history To view all occurrences of a specific problem highlight the problem to show all occurrences on the right with the most recent occurrence at the top Li Problem Explorer Problems All Newest to oldest Revision History Newest to Oldest v7 E SP 4 d Ehia Active 2 BENIGN ESSENTIAL HYPERTENSION 401 1 E ADULT WELL VISIT MALE 7 7 ELECTROCARDIOGRAM COMPLETE ECG IM EBFNIGN ESSENTIAL HYPERTENSION 401 1 93000 Routine 1 BENIGN ESSENTIAL HYPERTENSION 401 1 e CBC amp PLATELETS ALITO 85027 Routine e CHEST X RAY TWO VIEWS 71020 Routine NOTE You can also double click an item in the Problem pane on the face sheet to display its history in Problem Explorer 147 Face Sheets To revise problem status 1 From the Problems pane of the face sheet select the problem and click lt Edit Problem Diagnosis CHEST PAIN UNSPECIFIED 786 50 tg Description PO Details additional Classified as v Qnset Date Status active Resolution Date Acui
62. Deleting messages from the inbox llle 27 To delete messages without opening them 1 2 ees 27 To delete inbox messages after opening them 0 2 0 ee eee 27 Viewing other caregivers inboxes 0 0 2 eee ees 28 Result Notifications 5 tnu other uere dus ctos eae eee 4 oda eet eee es 29 Viewing notification messages and results 0 0 0 eee 29 Determining who receives message notifications 0 000 eee 30 Blocking result notifications iesca d Yas Low D REM UR EAS Se as 31 MeSSades ccu dli kee a RI IM I ee IE MI E E 32 Viewing the list of messages 0 ccc eee e 32 Entering dala Ol EDS 24 set wea RV E RE chium ed oru Lind act etra E ees 32 Sending mail MESSAGES 6 eee eee tenes 37 Sending patient MESSAGES 6 ee eee ees 39 Responding to patient MESSAGES 1 eee 40 Viewing patient messages saved to charts 0 00 eee eee 42 Web Messad6S ud emm ela eon ed oh deas bh we eee ee ee ee ea ee oe 43 Helill HequesisS oc cew so oan we ee eee a hee E I RE ee ee Ru 44 Sending refill requests e sasama pease a e a aA e Rn 44 Viewing refill requests nnna ccc RII 46 Approving or rejecting refill requests llle 48 Using prescription properties 1 noaa aa cc RII 51 Displaying outstanding refill requests from patients 0 00 eee 54 eRhelill Heduesis xxu ERR can E EXERCERI Rex on EROR ER CR RE Ee os 55 Viewing eRefill requests 0
63. E Study date y Cvy Nud Study date CWV PH IT Exercise C Pre Post Rehab CV Rehahb Education i Cv Rehab Outcomes ub Diabetes Labs DCODODDCDODUCCUCD ove i i Hypertension Lats Immunizations Adukt Immunizations Peds IV Therapy lipid Profile Lipid Profile Peak Flow DEEE 206 2 Chart Functions or Add Custom Flow Sheet Add a custom Flow Sheet for this patient only iz x Cancel 3 IF using a prepared template select a Flow Sheet template from the list or IF adding a new custom Flow Sheet enter a name for the new Flow Sheet and column and row headings clicking amp p after each entry 4 Editthe Flow Sheet template or custom template column and row headings as needed 5 Click OK to save the Flow Sheet to the chart and begin manual entry of data NOTE A flow sheet cell that contains data becomes a locked cell after the encounter is signed off However you can strike through a locked cell and create a new row or column with the correct information To correct erroneous entries on flow sheets 1 Access Flow Sheets See To add flow sheets on page 206 2 Click the Flow Sheet down arrow and select the flow sheet to correct 3 Click the cell containing the data for change 4 Click Erroneous The entry changes to gray font and strikes a line through erroneous text 5 Click Edit 6 Enter a new column or row heading and clic
64. EDD by Physician EDD By FetalDescent Fetal Head Fetal Movement Physician 10 20 2006 in months C wa C Not Examined Absent Not Detected Basis Cydelengh Ultrasound Absent Molding Palpable Presen cic se I Fregan tes ot esent aput Decreased Invitro date Fundal Height cm seb sep reu Sop Father of Baby Preterm Labor Signs 0 C Kl Fetal Lie Longitudinal Transverse WJA Oblique Inconclusive Fetal C Vertex Inconclusive Fetal Heart FetalHeartB FetalHeartC Fetal Heart D Fetal Heart Rate bpm Fetal Heart Tones Fetal Heart Tone Quadrant Not Detected Tuo CRUDO C N A Present by doptone Cuca C RO Complete each data field as required NOTES The LMP date is bi directional with the VS Contact Screen as well as the 59400 Routine Obstetric Care Procedure Entry Rule Fetal Heart allows for multiple fetuses 1 4 Click OK to save and validate all data in the edit window or go to the next tab to continue documenting data is not automatically saved Optional Click Cancel if you do not want any data saved from the edit To edit pregnancy record cervix NOTE This information is bidirectional with the 59400 Routine Obstetric Care Procedure Rule View Procedure Results 1 Access the Pregnancy Record see Accessing the pr
65. EMR EMR Desktop To close a module and return to HealthMatics EMR on the menu bar select Session gt Exit Help e References Click to access reference manuals for your HealthMatics modules in PDF form e About Click to see the current HealthMatics EMR Version and Build and to see License Info Clinical Products version information and System Info including space available Using the toolbar Toolbar icons are located directly below the menu bar Icons are shortcuts for commands You can select icons shortcuts for the commands you use most frequently and place them on the toolbar in your preferred order Some commands are available only when a patient chart is pulled if you have appropriate privileges When commands are not available to you the icons appear grayed out Example In the standard toolbar shown below icons are grouped into four categories Vertical bars separators separate each category m 745lo 8dg izimemlsu B3iuPy o ssXesS Epx Workflow and communication Chart Chart Patient contact handling Management documenting visits e Workflow and communication Commands to manage workflow and send messages to caregivers e Chart handling Commands to pull file and send charts e Chart management Commands to view and manage items in charts not connected to current patient visits Patient contact during visits Commands for contact screens used to document current patient visits For
66. Ec E E e ee Lr e eene e To move the keypad tap the title bar and drag it to another position e To enter information at the location of the cursor tap the appropriate characters e To close the keypad tap the x in the upper right corner To access the numeric keypad The numeric keypad is for pen based users to enter numeric information HealthMatics EMR must be open with the cursor in a field that requires numeric information Patient Search 14 Throughout the HealthMatics EMR application you will need to search for patients When the Patient Search dialog box displays follow these steps to locate the patient you need 1 Enter characters in the search fields near the top of the screen and click Search Last Name i Date of Birth Search Patient Id Address o j SSN Search Training Patients O Neal Olivia Quz 2320 30 3132 Female 6 6 1971 555 555 2345 123 West Street 2 To help locate the patient you need sort the list that displays by clicking any column name NOTE The current sort column is indicated by a chevron going either up or down depending upon the sort direction 3 Select the patient and click OK 1 Office Functions Appointments To display the appointments view in HealthMatics EMR click E Appointments on the toolbar desktop left pane Office Manager status bar or menu bar Office gt Appointments Appointments is highlighted in the left
67. For a list of items and customization instructions see To customize the title bar on page 125 1 Office Functions Using the menu bar The menu bar is located directly beneath the title bar Clicking a word on the menu bar displays drop down menus with task commands Session Charts Office Patient Explore Options Tools Launch Help EJ Logout Ctrl F12 ga Auta Logaff Settings QU Exit Alt F4 Commands are enabled disabled based on security privileges and whether a patient chart is pulled When a command is not available it is disabled and displays in gray font Example If you have not pulled a patient chart the Patient and Explore menu options are disabled gray on the menu bar and are unavailable Also if you do not have privileges for a particular function that menu option is not available to you Session From Session you can control automatic logoff settings If you have the appropriate read write function access in HealthMatics Administration you can set HealthMatics EMR to log off automatically after a set period of time with no activity 1 From the menu bar select Session gt Auto Logoff Settings 2 Select Enable Auto Logoff 3 At Logoff after enter the number of inactive minutes that must pass before the system logs off automatically and click OK Launch From Launch you can access either the Internet or other HealthMatics EMR modules as well as any desk references that you have loaded onto
68. Frawley Order i of i 45 previos eB Qa Binal d Gsm Order Status Final Not Reviewed Ordered 4 10 2006 2 25 PM Completed 9 10 2005 Js atient Susan Frawley COS 11 27 1361 Female Cet TRH Referral Request Please provide referring physician with visit summaries Bartell Barry MO Allergy and Immunalogy Manager System Undefined a een m DD E fram Dilga TA CEonslart Roga 12 fl Ilahntrarn 4 To enter comments click the Comments tab Additional Results LLL Susan k Frawley Order 1 of 1 ER ETE iA 5 You can enter text image voice or import referral results on each specific tab NOTES Use conventional word processing tools to add text comments Use Image to add anatomical images Use Voice to enter a voice note 196 2 Chart Functions Use Import to import a file or report Click Save image to a file to save the file so it is accessible from your workstation outside of the EMR At Completed accept the default date or change it to the date the results were entered When you are finished click Final to save the results Click OK to save the referral results and return to Additional Results To review final referral results Access Additional Results see To access referral results on page 195 At Status click down arrow and select Needs Review Click Review All Additional Results Entry Fred Finley Orde
69. Group includes caregivers given grants to access the preferred caregiver inbox A HReferralincludes caregivers to whom the preferred caregiver referred the patient in the A P screen gt Preferred caregiver and referrals Only the Preferred Caregiver and Referred by caregivers identified as referrals can access the chart gt Preferred caregiver only Only the Preferred Caregiver of record can access the patient chart Address tabs Click the Home Address and or the Work Address tabs and enter all contact information Guarantor tab If the guarantor is not the patient click the Guarantor tab Click the Relation to Guarantor down arrow and select the relationship Click Other to enable Select and access Guarantor Search Enter selection criteria and click Search or click Add to add a new guarantor to the database NOTE To edit guarantor information click Edit In the Search Results select the guarantor and click OK to return to the Guarantor tab Emergency information tab To enter optional emergency information click the Emergency Information tab and enter any of the following Blood type Living will Consent of care agreement Organ donor Patient is Deceased and Date of Death Additional comments 2 Chart Functions 8 Other information To enter other miscellaneous information click the Other Information tab Patient Demographics Ed General Home Address Work Address Guarantor Emergency
70. High Priority Tn Manning Terry MD Medicine 1 Internal Ob Gyn 1 Doctor Sear Nurse Registered Manager System Subject staff meeting postponed C Text Image Voice Import AEE Ea TS E wil be reschedued tomorrow al At High Priority click to make the message high priority if desired High priority messages display in the recipients inboxes in red font At Subject type a subject or click the down arrow to select one from the list NOTE To add subjects to drop down lists refer to Message Subjects in the Administration Module manual Click the appropriate tab and enter text image dictated or imported information see Entering data on tabs on page 32 Click Send The message appears in the recipients inboxes and in your outbox until the recipients open it 1 Office Functions Sending patient messages When a patient calls with questions for a caregiver about a problem treatment or other issue you can document the message and save it to the patient s chart in HealthMatics EMR 1 On the HealthMatics EMR toolbar click e1 Send gt Send Patient Message or from the Inbox or Messages view click 5p gt Patient Message Patient Message Mi x J5end Save bo Chart pe m High Priority To Manning Terry MD Subject Patient called with questions Patient r Fred Finley Phone 5s5 555 1212
71. Information Other Information Pharmacy ckerd Drugs 555 Maynard Road Cary NC 919 555 1212 E Employer Release of Information Perrnitted Occupation HCFA 1500 Signature Undefined 7 Status Works Part Time First Name Frank First Name mE Middle Initial Middle Initial LastName Lastname Nickname O v VIP Indicator e Pharmacy To enter a patient preferred pharmacy click the Pharmacy search button and do the following gt Enter criteria in any of the search fields and click Search select the pharmacy then click OK or gt Click amp to add a new pharmacy to the database complete the fields then click OK e VIP Select the VIP Indicator to indicate the patient is a very important person See also To customize the title bar on page 125 9 Click OK to save and view all patient demographics 165 Demographics Printing patient demographics 1 With a patient chart open click ig Demographics then from the application toolbar click amp P gt Patient Demographics Record Fax Li Fax Patient Demographics Record Berit sgeax d Queue uievetolog G Epot A Preview F9 Fax Preview Fax US Letter 8 5 11 in 2 Select a different output method as needed Print Queue Save to Log Export 3 From Extras click the Layout drop arrow to select a layout to print demographics NOTE These layouts are created
72. LABORATORY HH eg i Doc Reviewed by Family Practice E on 8 27 2004 8 30 AM HHY Color photograph i y Old Chart Note Test Name Result Units iim Status SODIUM SERUM 139 mmol 136 145 Reviewed POTASSIUM SERUM 4 4 mEgiL 3 555 Reviewed CHLORIDE BLOCO 100 mEq 72 Reviewed CARBON DICEDDE 23 0 m BICARB 25 mmol L 29 0 Reviewed BUN BLOOD UREA 50 NITROGEN xg mee 4 Click X in the upper right corner to close window and return to the face sheet 5 Click El to return to the original face sheet view 161 Demographics Demographics IMPORTANT NOTE Patient demographics entered into your Practice Management System PMS always override demographic data entered into HealthMatics EMR Therefore most patient demographic information and all appointment caregiver and insurance carrier information should be entered into your practice PMS if you have one If you enter basic demographic information into HealthMatics EMR it will be overwritten when your PMS interface link to HealthMatics EMR is activated Your site administrator can prevent caregivers from updating demographic information within HealthMatics EMR by deselecting Allow Demographics Entry in Administration Module gt Settings gt Site Settings When this setting is deselected all fields that are overridden by your PMS become disabled gray and the Add button is hidden in Patient Search NOTE If you do not have read write privileges for the Demographics functi
73. Lists is identical except for the tab that you click 1 Open a patient chart and from the left pane or the toolbar click 2 Reason for Visit 2 Click the My Short Lists or Short Lists tab Reason For Visit WEEeseemm ol 33 Previous Complaints E My Short Lists E Short Lists 3 Master List T Free Text Search Term A Add Es My Shark Lists f Starts with Contains Short list tems 7 Body System 2 RVF At Search Term search for the list as follows e Type a few characters of the list for which you are searching The list filters as you type e If you do not find the list click Contains to search for lists that contain the letters you typed When you find the list click the to display the complaints it contains Click a complaint to use it as the reason for visit The item is bolded and also displays in the Exams Complaints box in the bottom pane NOTE Double click the complaint to select it and open the Details box at once To enter complaint details select the item in the Exams Complaints list and do one of the following e Press F2 on your keyboard or e Double click the item or e Click g Describe selected item or 259 Reason for Visit 260 e Right click and select Describe 7 To document Complaint Details see Documenting complaint characteristics and details on page 262 8 Repeat the steps above if necessary to document additional c
74. Module Site Settings 51 Refill Requests e Use license Displays and explains the icon in the checkbox below which you can select to include the approving caregiver s license on the prescription e Preferred pharmacy Displays the patient s default pharmacy from Demographics Click the search button at the end of this field to make changes e Template Select a prescription template for the highlighted medication Licenses are selected as follows gt Ifthe selected prescription template is the System Default which has no state association then the ordering caregiver s default state license is used gt Otherwise the prescription template s associated state is used to select the caregiver s license If the ordering caregiver does not have a license defined for that state then no license information is included in the prescription e Apply to all Click to apply the selected template to all medications 2 Use the icons described in the table below to perform tasks as needed Select all prescriptions to process or click to select individual prescriptions in this column to process NOTE Medications preceded by the icon are locked for editing elsewhere in the application E Apply your DEA license number to all unlocked prescriptions listed or click individual boxes to selectively apply your number A Apply your electronic signature to all unlocked prescriptions listed or click individual boxes to se
75. Mr Fred 2 8 2006 10 57 AM es 4 c Rejected L Finley Mr Fred 2 8 2006 10 44 AM al we Manager System Call about r 1 11 2006 1 39 PM Manager m Seeing bororrow mor L 1 sinis 5 304 PMH wi grr AET techn nei Hie Ra N BE aL N d kN 0 4 H Inbox i SA BO Bi Bu Bz wo Status bar inbox filters The status bar is always visible no matter what screen you are on in the EMR Most caregivers manage their inbox and other workflow from the status bar The numbers to the right of each icon on the status bar and the numbers in the left pane under nbox and the bars in Office Manager indicate the number of items of that type that have not been read NOTE If the Urgent Message Indicator has been set to flash the numbers alternate between the number of items awaiting review and the number of items that contain abnormal results or are designated High Priority See To set desktop defaults on page 109 for instructions on setting the Urgent Message Indicator 24 1 Office Functions You can filter the inbox to view any of the following items eT veo Result Notifications Notification messages that lab and or procedure results have been received and are ready for your review see Result Notifications on page 29 Messages Patient and mail messages sent to you by other staff members see Messages on page 32 Web Messages Messages sent from patients via the practice website see Web Messages on page 43 NOTE Web Messag
76. NOTE To delete documentation at the detail level click the checked item again to deselect it To add a note about the detail click the note icon J in front of the menu item enter text and click OK NOTE The note icon is highlighted and the note text displays in italics in the preview pane e Close the menu window by clicking on the x in the upper right corner or anywhere outside the menu 5 Continue documenting other areas and systems as needed NOTE If you document using an image the text describing the area selected not the image displays in the H amp P Report 290 3 Patient Contact Functions Assessment Plan In the Assessment Plan window you can do the following e Specify diagnoses and treatment e Document patient education discharge plans office procedures and nursing services e Document referrals and generate referral letters e Order medications Viewing problem or medication history from A P From Assessment Plan you can view the history of all problems and or medications for a patient In addition you can inactivate both problems and medications from the Assessment Plan window Open a patient chart and from the left pane or the toolbar click A P Assessment Plan Assessment Plan gt Patient Problem List Patient Medications My Short Lists Short Lists Search Free Text Diagnosis ceg Include A view 7 Inactivate Ce Include Active El 1 Active
77. Ntierprise Practice Management System that travel across the interface and display in HealthMatics EMR They can be added to short lists and to the current encounter Third party library of codes Items may not function as billable codes and should be used with caution with regard to billing Third party library of billable codes that is updated annually NOTE Laboratory tests have a separate database see below Patient education Third party library called Clinical Reference System Items from this database that are edited and saved to the system are classified as Authored Text Tools Edit Authored Texts Office User defined in Tools Edit Authored Texts procedures Discharge plans User defined in Tools Edit Authored Texts User defined in Tools Edit Authored Texts Forms letters User defined in Tools Edit Form Letter Templates NOTE To set the order of these sources go to Options Edit Options Quick Lists and at Lists select A amp P Data Sources see To customize quick lists on page 127 for instructions 4 Selectthe appropriate Data Source to locate the specific assessment medication or plan 5 At Category click the down arrow to select a subcategory to limit the search if desired 6 At Search Term enter the ICD 9 or CPT code or the first few letters of the term and select the appropriate radio button e Starts with To search for entries that begin with the entered
78. Other Outpatient Services ESTABLISHED s Minutes Z Exam General Muli System E oem 370 3 Patient Contact Functions 1 From the bottom of the E amp M window click Summary to view details that produced the current service level F Alpha OE aH IM III T Component Detalls Hitoy 7 Exanmded Haito of Present oes 3 eiprment s found s Rewew of Systems 2 eyeterns found e Past Fam and or Social Hatory 1 hitory areas found T aches a love cf Detailed you will pee te docu m At Bot iy of Present hea pements or eee Hawa of 3 chronic oroe s At Bet 2 teen ri Fue of Syed com Foca w General Multi Sysigemi 5 bullets found To buseo leo of Expanded 5 11 buliets are required Medical Decision Making Low 371 Evaluation amp Management Calculator 2 Click the Elements Found tab to view a breakdown of the three coding levels with scores and how many other service levels are required to reach the next level Alpha TIER Calculator Details Elements found History Expanded History of Present Tilness Duration Quality Signs symptoms Review of Systems Constitubon GU Past Family and or Social History e Medical History Exam Focused Exam Type General MultiSystem Cardiovascular Abdominal aorta Cardiac Autcultatieon heart Cardiovascular Carotid arteries Cardiwatcule Extrimities for ederna varicositues Cardiovascular Femoral arteries Car
79. Physical Exam Assessment and Plan Electronic Prescriptions Diagnoses Sign Off Do you want the Diagnosis Dialog bo open when you add a Yes Title Bar diagnosis to the current ARP from a Data Source Search No Hisbory Lists Orders Quick Lists My Short Lists When placing orders default the Ordered For Field to General Default Tab Patient Problem List 2 Click the Orders down arrow to select the caregiver for the Ordered for field default to HINT Choices include Appointment Caregiver Preferred Caregiver Blank the default for none and a list of grantors to select from 3 Click OK 302 3 Patient Contact Functions Ordering and viewing medications from assessment plan From Assessment Plan you can order new medications view potential medication interactions and print fax or electronically transmit prescriptions To order new medications You can order new medications as part of a treatment plan Notice that refill requests are different from new medication orders 1 2 Open a patient chart and from the toolbar click A P Assessment Plan Select a diagnosis for the current encounter from any of the five tabs see specifying assessments and plans on page 292 To order a medication in the preview lower pane highlight the diagnosis then search for the medication you want to order from any of the four tabs described in Specifying assessments and plans on page 2
80. Print Specialist Letter Print Referral Letter Print Patient Education Print Office Visit Fax Pack gt gt gt gt gt Encounter Procedure Orders Fax Encounter Lab Orders Fax Specialist Letter Fax Referral Letter Fax Patient Education Fax Nurse Visit Print Pack gt gt gt gt Encounter Procedure Orders Print Encounter Lab Orders Print Patient Education Print Encounter H amp P Print Nurse Visit Fax Pack gt gt gt gt Encounter Procedure Orders Fax Encounter Lab Orders Fax Patient Education Fax Encounter H amp P Fax Phone Encounter Print Pack gt Encounter H amp P Print Phone Encounter Fax Pack gt Encounter H amp P Fax Consult Print Pack gt Encounter H amp P Print gt Specialist Letter Print Consult Fax Pack gt Encounter H amp P Fax gt Specialist Letter Fax Admission Note Print Pack gt Encounter Procedure Orders Print gt Encounter Lab Orders Print gt Encounter H amp P Print Admission Note Fax Pack gt Encounter Procedure Orders Fax gt Encounter Lab Orders Fax gt Encounter H amp P Fax Admission Note Print Pack Antepartum Record gt Antepartum Record Detailed by Date Print Admission Note Fax Pack Antepartum Record gt Antepartum Record Detailed by Date Print 4 Printing and Faxing Assigning access for refaxing or reprinting prescriptions I
81. SSN pso3o700 Search Training Patients Search Results LastName FirstName Patent1d ssn Gender Date of Birth Phone Address Values supplied by the pharmacy display in the search fields 2 Change or remove the values as needed and click Search to broaden the search LastName fin ato giths Search e je ma d ue ETE p me 1129 1932 555 555 2233 900 North End 3 Select the correct patient and click OK to display the name in the Patient field in the eRefill Request view 4 Approve the eRefill request see Approving matched eRefill requests on page 60 NOTE When the missing information is reconciled and the medication is selected at the bottom of the eRefill Requests screen the icon in the upper pane changes to e If it does not that means that the pharmacy also needs to be matched see To match pharmacies on page 59 1 Office Functions To match pharmacies 1 With an eRefill request selected click the Pharmacy search button Pharmacy Search Ea Mame Kroger Phone In Street f 12 Western Blvd EDI Id City cary Fax El State MC zip Code 27511 Search Clear an oe Mame Phone Number EDI Id Fax li kroger 112 Western Blyd Cary ME Ooo tet 99968859 ig OK Cancel NOTE If the correct pharmacy name displays select it and click OK Otherwise f ollow the steps below Enter a few characters
82. Span A amp F Search Results Category Jal Medi Span Entries E Md RAMS edis Search Term PENICILLIN v a PENICILLIN v PO fecun som Starts with Contains al PENICILLIN v POTASSIUM SOOMG PO Tab Search 4 Enter a Search Term click Starts With or Contains and click Search 5 n Search Results select the new medication and click OK to display the Medication dialog box 6 Enter medication details as needed and click OK see also Approving or rejecting refill requests on page 48 sending ePrescribe Message displays the transmission progress of the new prescription Sending ePrescribe Message Rejecting and sending new prescription Amoxicillin 200MG Tablet Chewable Sending to pharmacy Pharmacy One 1010 Westwood Drive Cary NC 27511 Sending message po Sending new prescriptions electronically NOTE To prescribe medications electronically your practice must have purchased and enabled in Administration Module System Options ePrescribe and you be set up with a SureScripts Provider SPI ID and password Prescriptions can be transmitted to selected pharmacies via the secure ePrescribe Gateway and on to the SureScripts network for message delivery 1 With a patient s chart open from the left pane or the toolbar click A P Assessment Plan 2 Verify that the medication has not previously been prescribed by clicking the Patient Medications tab and vie
83. T Finley Referral Letter Q4f 3fo6 02 07 pm Terry Manning This queved document is bei Gi Printed Freda T Finley Encounter Proc O4J sf06 01 49 pm Terry Manning HPCLI850 on rprint1 from B 1 Office Functions NOTE Documents in the queue can have any one of five statuses E n The document was printed Faxed The document was faxed 0 document was faxed m The document was saved to the BEN UO Queue Log Only documents with a status of Queued can be Saved to Log Export The document was exported to a file It may or may not have been previously printed faxed or saved to the log Queued The document was sent to the Output Queue and is awaiting further action You can click icons on the secondary toolbar to do any of the following Add document to Open Add Output Template to generate new output queue Insert Delete Delete Delete a selected document NOTE You can only delete a document with the Status of Queued m m Open a selected document Output tasks Open a drop down menu of tasks you can perform for a selected document Electronic Signature Add an electronic signature Print Print or reprint a document Fax Fax or refax a document Save to Log Enter a comment and save a document with a status of Queued to the log Export Export a document to a file e Filter Open a list of quick filters that you ve set up see Quick Filters on page 98 Bc
84. TA Demographics A A Reminders Dates The past 6 months E Flow Sheets a A Ineunzahions Pg Chart tbachments i Lab Results E Procedure Results S Additional Results T Reni Summaries 7 Contact T Reason For visit we Reve of Sysbems a Hist y wiy Vitais e Pra Exam AP AssessmentiPan CY Hae Report O mo m im 2 Click the Template down arrow and select a template from the list If data is available the screen populates in spreadsheet format If data is not available a message displays No data to display 3 View data using either the SpreadSheet or Graph tab Displays data in rows and columns Displays selected data in line graphs 199 Result Summaries 4 Optional For template options click Options Template Options x General se re Set at Defauk Template Show Extended Information Show Procedure Addendums v Show Notes Eont Size 8 Vitals C Show vital measurements as cmko Celsus Show vital measurements as in Ib F ahrenhes GN Select all template options Bo Deselect all template options Set as Default Template Click checkbox to make the spreadsheet tab template the default caregiver view to remain in effect until changed Show Extended Click checkbox to include the order date name of the Information result units of measure along with the results in the template Show Procedure Click checkbox to include additional procedure Addendums info
85. Templates Screen Templates EH Forms and Letters Template Action Referral Letter Referral Letter Prompt gt Specialist Letter A Specialist Letter Ea HeP Reports Diagnostic Tests Letter Y Prompt gay Internal Documents d Print 5 29 Lab Orders EN Preview Landscape Documents E Queue Sq Patient Correspondence u Save toL og ga Patient Handouts if Fax Export 2 293 Report Results Diagnostic Tests Letter Select the templates At A Templates open folders and double click templates that you want to make available from the selected Screen Determine the order Use the up down arrows to put the templates in the desired order Set actions In the Screen Templates box you can set the action to be taken for each template by selecting it by clicking g Edit Action right clicking for a drop down menu or pressing F2 and selecting the appropriate action Otherwise accept the default Prompt which allows you to select the desired action each time NOTES You can add a template more than once and assign different actions Queue and Save to Log both send the document generated to the Output Queue Save to Log is useful for the following items consent forms containing patient signatures documents requiring patient signatures on a hardware device at check in or check out documents that patients do not want a copy of but that you may want to print later After selecting all t
86. To customize your toolbar 1 From the HealthMatics EMR menu bar select Options gt Edit Options gt Toolbar P Caregiver Options for Manager System Miel Toolbar Properties z5eparator gt Back PU Patient Manager si Action Items cy Forward Results x Reason For Visit Z Audit Open Encounters H8 Toggle Tree Review of Systems culBatch Processing za Desktop Vitals E Batch Refil S appointments Physical Exam as BE Billing Reconciliation cia Outbox Assessment and Plan l Electronic Prescriptions E Documents t Outlook Inbox Sign Off 4 eRefill Requests EISend M Title Bar UTE E A Send Action Item Histor Lists j E Messages L3 send Mail Message z Quick Lists Zyopen Encounters f send Patient Message i My Short Lists orders Eh send Refill Request i Output Queue S send Web Message dull Patient Manager a Internet Browser ee ee E rie be Reset Settings oe 2 Inthe Toolbar Properties box select an icon from the list on the left and click gt Add Item to move it to the toolbar list on the right selecting from any of the icons listed below NOTE To remove an icon from the toolbar select it in the right pane and click amp Remove Item i lt Separator gt Insert a vertical bar to separate groups of icons on your toolbar Action Items View items sent to your inbox for action ra Appointments View scheduled appointments om Assessment Plan Access the
87. a drop down menu under Send if desired Send Web Message Create a web message to send to a registered patient NOTE Click E Move Item In to place Send Web Message in a drop down menu under Send if desired ru Toggle Tree Toggle the navigation tree in the left pane on and off the navigation tree in the left pane on and off View Lab Results the current patient s lab results or search for another patient s lab results View Procedure View the current patient s procedure results or search Results for another patient s procedure results Vitals Access the Vital Signs screen during a patient encounter Work Log Access the Work Log screen to view contact made with patient charts by caregivers by patient and or by machine 3 After selecting all the shortcuts that you want on your toolbar sort and organize the icons in the right pane by selecting them and clicking the directional arrow buttons described below 7T Move ltem to Top Move the selected item to the top of the list far left side of the toolbar Move ltem Up Move the selected item up Move Item Down Move the selected item down 113 Options 1 Move Item to Bottom Move the selected item to the bottom of the list far right side of the toolbar 5 Move Item In Move the selected item into a drop down menu under the item above NOTE On the toolbar access the menu list by clicking a down arrow to the right of the primary item
88. al Status Partial Reviewed Onder Note L zi i Results Test Hame Value Severity Units Range Status i WBC 6 0 Normal l XScelsiL 4 5 11 0 Final Revie z REC 5 Normal 10 X 6jul 4 73 5 49 Final Revie ay HGB HEMOGLOBIN 15 Hormal gd 14 4 16 6 Final Revie ij HCT HEMATOCRIT 44 Normal ks 42 9 49 1 Final Revie amp MEY MEAN CORPLISCULAR amp 6 Normal cu um 76 100 Final Fe Pus i E Ha j 6 Double click the test name to view the actual results 181 Lab Results 7 Click g Edit Results Edit Lab Results Ed Order URINALYSIS VZD MICROSCOPY 31 002 Result Details 1 Test Name m SPECIFIC GRAVITY tatus Value Severity Linits Range fi D1 1 035 Reason For Change Note amp Ba c Dy YB wm zl Previous gt Next o ca 8 To mark the lab result reviewed click the Reviewed checkbox 9 Click OK to return to Lab Results Finding lab results In HealthMatics EMR you can locate lab results multiple ways 182 Patient chart With a patient chart open click e Lab Results on the toolbar or left pane The patient is automatically selected in the Lab Results view Review Results To view results awaiting review click Review Results from the status bar then double click a notification message or select it and click Open Search To search for lab results for a patient not on the Lab Result
89. and approve 11 Verify the Caregiver and Subject enter a text Message to the caregiver select High Priority if appropriate and click Send The transcription goes immediately to the Documents Inbox of the designated Caregiver and increases the Documents status bar number by 1 Documents 37 Open QO Forward Caregiver Manning Terry MD From o sujet Information O d Manager System Mrs Irene Innis Transcription Innis Mrs Irene L 4 5 2006 5 22 PM For instructions for approving transcription see Approving or rejecting documents on page 71 137 Practice Management System Interface 138 Practice Management System Interface You can access your Ntierprise Practice Management System without leaving the Clinical Module of HealthMatics EMR For instructions for using the Ntierprise screens that you access refer to it online help Appointments On the Appointments toolbar click Appointment for a drop down menu of Ntierprise options p Clinical Module Appointments Session Charts Office Patient Explore Options Tools Launch Help Wb amp e gt BEOS00 893 S3 aaa 2 Bel Sppointments Appointments ey Open Encounters 2 cil Inbox dp TOME i B CE Appointment FS Caregivers al Result Notifications l l l 6 Messages Location ea Locations Hi Appointment Scheduling Ld Web Messages LU R
90. be sent across the billing interface If this message displays the patient chart was probably not pulled from the appropriate place and therefore not linked to an appointment For electronic billing always pull charts from one of the following gt From the Appointments view or gt If the chart was sent to you by another caregiver during an encounter from the Received Pulled Charts icon on your status bar Don t forget to select a billing provider This message displays when the encounter is associated with an appointment but the caregiver with whom the appointment is scheduled does not have billing responsibilities In that case the Billing Provider must be manually selected from the selection list Billing has already been sent This message displays if the billing information was sent using the Bill button Signing off charts Encounter information can be modified at any time until the chart is signed off However once you sign off on the chart you can only modify it by creating addendum notes see To change encounter information or create addenda on page 156 1 With a patient chart open in HealthMatics EMR and the encounter completed from the left pane or the toolbar click E H amp P Report 2 From the H amp P secondary toolbar click fsg off Sign Off Password Indude Signature Bitmap Encounter Type Office Visit billable Billing Level per SITE DEFAULT Y Billing Modfier 1 Bill
91. box to change the Status of a medication Example to reactivate it or other medication property information See To order new medications on page 303 Inactivate Medication Click to enter an inactivate date and move the medication to the nactive folder Toggle Filter Click to toggle the view to show A Active Inactive or Discontinued medications Toggle Sort Click to toggle the view to sort medications Alphabetically Start date ascending or Start date descending View Interactions Click to display the Drug Interactions dialog box to view detailed warnings about the patient s medication interactions To inactivate medications automatically Medications can be inactivated automatically in the patient chart after the course date range has passed IF the medication order specified e days to take the medication and e Refills O Example A medication such as a course10 day of Amoxicillin prescribed for an ear infection with zero refills will inactive automatically after 10 days pass Before listing the patient medications the application checks for any medication courses that are complete and automatically inactivates them NOTES e The revision history of a medication automatically inactivated displays an Automatically inactivated notation e his feature works only on medications ordered through Assessment Plan and does not apply to historical entries unless the historical entry is managed Viewing orders from
92. changes to the information it contains by creating an addendum see To change encounter information or create addenda on page 156 To edit current H amp P reports To edit the H amp P Report for the current encounter change information on the respective contact screens 1 Open a patient chart and from the left pane or toolbar click the appropriate icon to return to the contact window that contains the data to change Reason for Visit Review of Systems History Vital Signs Physical Exam and or Assessment Plan 2 Change data as needed NOTES As data on the contact screens change text in the H amp P Report changes as does the name of the caregiver date and time stamp Changes to the report that are saved as Notes free text entries cannot be sent to your Practice Management System for electronic billing and must be billed manually 3 Click 4 History amp Physical Report to view changes 355 H amp P Report 356 To change or review notes in current H amp P reports 1 Open a patient chart and from the left pane or toolbar click x H amp P Report NOTE Notes icons at the upper left corner of the H amp P Report T window are enabled when notes have been created in the corresponding section of the current encounter at the highest level Click the icons to view or modify current encounter notes at the Visit ROS History Vitals PE or Assessment Plan level Notes QU Vem do ar EF d Notes
93. current patient s Assessment Plan screen Audit Open Track the process of a patient s visit by viewing Encounters worklogs of open encounters Can be filtered by Caregiver Location or Patient 4 Back Go back to a previously opened view NOTE Click the down arrow to see a list of previously selected views from which to select Batch Processing Process lab requisitions in batches 110 1 Office Functions aa Batch Refill View Batch Refill to process multiple refills at once bor Bill Reconciliation View billing information by date range for a provider location or patient NOTE Caregivers must have function access to view Chart Attachments View the current patient s chart attachments Demographics View the current patient s demographics NOTE Click the down arrow to select Chart Attachments Immunizations Flow Sheets or Reminders a pr emer aC c Forward Go forward to a previously opened view NOTE Click the down arrow to list previously opened views from which to select History 000 View the current patient s history information E HP Report View the current patient s H amp P Report oe View the current patient s immunization record Internet Browser Access the Internet IF your practice has Internet access from within HealthMatics EMR Logout Log out of the Clinical Module before leaving your workstation ce List messages patient and mail sent to your inbox Open Encounters List all yo
94. date range selected including the times logged in and out NOTE If the caregiver is still logged in no logout time displays Level 3 Patients Patient charts the caregiver opened during the date range selected If no charts were accessed during the login a messages states No patients are associated with this login Level 4 Encounters Encounters the caregiver created including the time the chart was pulled and the encounter type Office Visit in parentheses NOTE Selecting an encounter enables View Details on the secondary toolbar Level 5 Contacts Start and stop time a caregiver had the chart open before sending it on to another caregiver or filing it NOTE If contacts did not have associated saved data a message states Chart reviewed without edits Level 6 Contact screens Names of contact screens where values were entered NOTE Screen names display if the caregiver documented on the screen and the values entered were not overwritten by another caregiver in a subsequent contact 102 1 Office Functions Filter by patient Work Log Ez view Details 3 Pull Chart Caregiver show All Erom S17 2006 Machine show Alls To 31172006 Patient Finley Mr Fred BESTS 4 40 K E amp S17 2006 1 26 07 PM 1 52 23 PM System Manager RDIRT T Assessment Plan Description of information Level 1 Patients Patient charts the caregiver opened during
95. display a list of messages announcing lab procedure and additional results awaiting review click 9 Result Notifications on the status bar or left pane of the HealthMatics EMR desktop Result Notifications 37 Open A Review Eie m sf Forward Caregiver Manager System a From i Subject Patient ee os Manager System Lab results 3 Finley Mr Fred 2 24 2006 4 37 PM Icons preceding each item in the list designate its type of results pem M om 0 Sort notification messages by clicking on any column head A carat on the column heading indicates the sort column Patient up or down ome OOO o o From Sort by the caregiver who sent the notification message Place high priority items results containing abnormal values at the top of the list Sort by type of results lab procedure referral waiting for review NOTE The number in parentheses shows the number of results ready for review for that patient Se 0 Sort by date and time the notice was sent Filter results by clicking the Caregiver down arrow to see another caregiver s result notification messages IF you have access to his her inbox see Editing grants on page 129 29 Result Notifications 30 4 Select a notification from the list and on the secondary toolbar click icons or right click to do any of the following Delete Delete Delete the notification if you do not need to
96. e OSTEOARTHROSIS GENERALIZED INVOLVING HAND 715 04 UTI To view problem history from A P 1 In Assessment Plan on the Patient Problem List tab click View e To see alist of all active problems highlight Active in the left pane Problem Explorer D x Problems All Acuity Problem Details E E amp Z SP 4 E Expand View Q Print Ei Chronk VINCENT S ANGINA 101 Status is Inactive CM Inad Problem acuity set as Chronic SEE Oem Recorded 04 17 2006 01 28 PM by Darlene Donkin AP H E Active amp BLISTER OF FOOT AND TOE S iara ANGINA H 01 m qz rabiem acuity Set as tonic iioi Recorded 04 13 2006 01 14 PM by Darlene Donkin NP ely Active Annotation Adaendum MANIC AFFECTIVE DISORDER e To see a history of a single problem highlight it in the left pane The history of the problem displays to the right with the most recent occurrence at the top of the list 2 To close Problem Explorer click X in the upper right corner 291 Assessment Plan To view medication history from A P 1 In Assessment Plan click the Patient Medications tab 2 Select a medication and click L amp View P Medication Explorer Oy x Revision History Newest to Oldest Medications All Start date descending ae S amp l S HE Expand view og Print Aa Ordered Augmentin 500 125M amp G Tablet 1 PO No Refill Ambien SMG Ta
97. eck m Ren Summaries JE Gastromtestina ssania Contact F Male Genitourinary D F Respratory Hr Brent 2 Reason For vist JE Musculekeletal DiE cedema o EA Gastrointestinal F Review of Systems F Neurological MM A Hetory I Peychiatrie E 2 Male Geniourinary t l 2 Musculoskeletal il Vtal SE Endocrine oe 5 B EM Pilier VP ee we Heur okepe al Uc Piradi te peri Documentation pane displays characteristics you Lern Havgation aai can document for each system you select shortcuts to pane displays sections of the systems and paraman patient chart navigation aids Documentation pane displays text i E Lot generated as you document ROS or PE for 3 BH Selected the current encounter e Sweet My RIS Liste Search Review of Systems ROS and Physical Exam PE both contain the same four panes for easy navigation NOTE The ROS and PE screens support resolutions up to 640x480 Using the navigation pane in ROS and PE Open a patient chart and from the left pane or the toolbar click ROS or amp PE See also ROS and PE Navigation on page 266 The ROS PE Navigation pane in both views includes up to five tabs depending on the settings in caregiver options The active tab is highlighted To navigate using the review of systems or physical exam tab Open a patient chart and from the left pane or the toolbar click ROS or amp PE 266 3 Patient Contact Functions The ROS PE navigation
98. edit pregnancy record vitals U A 1 Access the Pregnancy Record see Accessing the pregnancy record on page 322 327 Pregnancy Record 2 Select a visit date and press F2 or click amp Edit Record Antepartum Record Ed Vitals UJA Pregnancy Labs ROS MaternaljFetal Data Cervix Medical Hx OB History Pelvimetry Next Appt Measurements Pulse RatelPattem Res ts zi Respiration RatejPattern lno 7 Blood Type Lab Result Patient Reported O Urinalysis Results Blood Pressure paient Position Sitting Systolic Cuff Location Fight Arm Diaskolic Cuff Size standard Allergies Second Blood Pressure Pollens Pina poten in spring and Fal offen leads fo sinus Systolic Patient Position Sitting Diastolic Cuff Location right orm T Cuff Size standard em Enter weight numeric and select either pounds Ib or kilograms kg Default method can be set up as a Caregiver option NOTES This information can also be documented in Vital Signs 2 e Cumulative Weight Gain calculates from the first weight entered Pulse respiration Enter numeric values Rate and pattern descriptors are caregiver options or selected from drop down menu Temperature Enter numeric value and select either Fahrenheit or Celsius values Default reading and method can be set in caregiver options Drop down menu selection includes Ora
99. entered at lower levels are embedded in the H amp P Report Make changes to them in the associated contact screen Click the appropriate Notes icon View change or insert text image or voice note Click Print and OK to print the note if needed NOTE Click Remove All to delete entire note Click OK to return to H amp P To view attachments from H amp P report You can view attachments directly from the H amp P window if any are attached to the encounter Attachments include items such as forms and letters 1 ae Open a patient chart From HealthMatics EMR toolbar click the Demographics down arrow then click l Chart Attachments e IF no attachments are linked with the encounter the information icon with None displays in the Chart Attachments window e IF attachments are linked the Chart Attachments window displays the attachments linked to the current encounter To view the attachment s double click it or select it and click c Open to view You can Email Print the attachment s or Save Attachment to Chart Click x in right upper corner to return to H amp P Report Finalizing encounters from H amp P At the end of a patient encounter there are several options available from the H amp P Report Sign off Sign off and file the chart locking all documentation for the encounter Printing choices are available from the Sign Off window E amp M calculator Classify diagnoses enter medical decision m
100. folder e Ifon a collapsed folder expands the folder e Ifon an item toggles the value e Ifon a folder navigates the documentation pane to the folder Space If on a item toggles the value 275 ROS and PE Navigation 276 To document measurements and sizes Measurement and size dialog boxes appear when Measurement Size is selected as the Knowledge Flow for a user defined term 1 To document one dimensional measurement values ETETETE E e s e oa HAAN 2 Value Click keypad buttons or use keystrokes to enter a value NOTE Click Clear to clear the Value 3 Preview A graphic to the right shows a proportional presentation of the measurement 4 Significant Click to check the Significant box with a red indicator indicating that the measurement is significant 5 Note Click to include a note with the measurement 6 Expand collapse To expand or collapse the dialog box do either of the following e Click the title Measurement or e Click the icon in either upper corner B or 4 NOTES e To document two dimensional measurement values mi da chs Care up qsiExpand All 73 Collapse all Templates Es x apply EJPreview E clear a s s aks s ef oa Hoem ERE PERRE s s oa Enter Height and Width using the keypad or key strokes Select the units of measurement in centimeters or millimeters e The Preview window sh
101. for the E amp M calculator NOTES For the exams to calculate accurately be certain to always install Quarterly EK Quips as soon as you receive them The EK Quips are necessary to enable and update existing physical exam templates in Knowledge Manager with the latest Physical Exam terms View archived items to make certain the knowledge you want to use is enabled 3 Patient Contact Functions Accessing E amp M calculator With a patient chart open click i H amp P Report then click E amp 3 E amp M Calculator c D Quali None pan Management Options Data Risk Noe Dverthe counter medina I Physkaloccupational therapy History Prescription IM medication Closed treatment of fracture or dislocation Not determined IW Fluids Minor surgery without risk Factors Exam 1v fluids with additives Minor surgery with risk Factors High risk medication Major surgery without risk Factors T Telemetry Major surgery with risk Factors Respiratory treatments Emergency major surgery determined Nuclear medicine Time for Visit 50 counseling Service Office or Other Outpatient Services ESTABLISHED Minutes E Exam General Multi Sysbem Clear Calculate summary OK cancel Field checkbox Section MEE Defaults from H amp P Report Qualifier Click the down arrow to the right to choose one of six diagnosis qualifiers Levels Displays the Evaluation amp Management le
102. for the Search feature in both the navigation pane and the Quick Search function Starts with Select to restrict searches to only items that start with characters entered in the Search field Contains Select to allow searches to show all items that contain the characters entered in the Search field Units default size Select the default unit size mm or cm 119 Options Navigation tabs Select or deselect boxes to show or hide Map Selected My PE Lists and or Search in your navigation pane see ROS and PE Navigation on page 266 Colors Click the down arrows and select colors for the Header Panel and Selection color 3 Templates Past encounter count Select the number of past encounters to list in the Templates drop down list Default to last Select to default the template list to the patient s last encounter encounter if one exists Jump to selected after Select to default the template to jump to the selected apply item after clicking Apply Expand selections Select to expand folders containing selections after after apply clicking Apply Filter by age Select to filter template items available by the age of the patient Filter by gender Select to filter template items available by the gender of the patient On apply When selecting a template and clicking Apply set options to control how the template is applied to the current encounter Prompt When you click Apply a dialog box displays
103. have been merged or have had merges reversed History Manually merging patient charts 232 IF you do not have a Practice Management System PMS you can merge patient charts directly in HealthMatics EMR 1 From the menu bar select Tools Patient Merge to search for patients to merge on the Manual Merge tab Merge Queue Merge History nn Cai i Find Duplicates oO Merge Last Mame Finley 0 First Mame Po Finley Mr Fred 123456 ziz8 19 amp Finley Mr Fred 12345678 ziz8j19 2 Find duplicates by doing one of the following e To search by patient in the Patient Search box enter the last and possibly first name of the patient and click Search All patients with that name display in the box below NOTE Scroll to the right to view date of birth DOB and Sex gt Press Insert on your keyboard or click T Add Merge Group to create a New Merge Group for each set of charts that you want to merge 2 Chart Functions gt Select a New Merge Group on the right and then double click each duplicated patient on the left to add them to the merge group Merge Groups 2 tenen der Finley Mr Fred 1212 dn Add Merge Sroup Ins Right click to I a Finley Fred 1212 CI Delete Merge Entry Del display menu ese i fi Mew Merge Group E Select Target Ctrl T View Demographics Ckrl D View Face Sheet Ctrl F Tosearch for ALL duplicates on the toolbar clic
104. in as Manager System FxeSwe o 7249 Gli 0 3 Goo fi Bu B Go 2 Each face sheet pane has its own toolbar Click any icon to sort and change the view L View Revision History Click to open and enlarge the Explorer window to view revisions history Edit Problem Click to edit a selected problem history encounter or medication inactivate Problem Problem Click to inactivate a selected problem or medication 145 Face Sheets 146 SP Toggle Filter Click to change the way items are grouped within a pane Example By Type or By Date in the Encounter pane amp l Toggle sort Click to change the way items sort within a pane Example Oldest to Newest or Newest to Oldest View Flowsheets In the Encounters pane click to view patient flow sheets amp Immunizations Click to access Immunization Record and edit Immunizations Attachments Click to access attachments View Interactions In the Medications pane click to view interactions Maximize Click to maximize the selected pane Restore Click to restore the maximized pane view and display all five panes NOTE You can do all the following from face sheets View the revision history of any item Inactivate or reactivate patient problems or medications Review H amp P reports from previous encounters in chronological order Update patient history medications and problem information Associate patient messages refill requests or chart attac
105. individual caregivers if needed or e Click Check None and then select individual caregivers if needed 2 Click OK to return to the desktop 129 Options Editing output defaults You can set caregiver preferences for default printers for each document type that you print 1 From the HealthMatics EMR menu bar select Options gt Edit Output Defaults Caregiver Output Defaults Caregiver Manager System Printer a Forms and Letters Office Letter zAlwavys Prompt HOP REDONS ss BANK PAJE aee AAS Prompt s e Internal Documents Blank Page lt Always Prompt gt Lab Orders Blank Page Always Prompt gt e Lab Requisitions Nonez zMonez Landscape Dacuments Mone gt Mone gt e Office Correspondence lt None gt lt None gt a Patient Correspondence lt None gt Mone HE Patient Education Nonez zMone Patient Handouts Patient Handout lt Always Prompt gt a Prescriptions None gt lt None gt e Report Results hone gt lt None gt Transcriptions Mone lt None gt Working Documents Nonez lt None gt gt 2 Highlight an Output Category and do one of the following to display Output Default Properties e Press F2 or e Double click it or Click amp Edit Layout Default 3 Click the Layout down arrow to select the appropriate layout for the output 4 Click the Printer down arrow to select a default printer or select lt Always Prompt gt if you want to be able to select the printer e
106. logged in Level 4 Patients Patient charts the caregiver opened during the date range selected If no charts were accessed during the login a messages states No patients are associated with this login toolbar Level 6 Contacts Start and stop time a caregiver had the chart open before sending it on to another caregiver or filing it NOTE If contacts did not have associated saved data a message states Level 5 Encounters Encounters the caregiver created including the time the chart was pulled and the encounter type Office Visit in parentheses NOTE Selecting an encounter enables View Details on the secondary Chart reviewed without edits Level 7 Contact screens Names of contact screens where values were entered NOTE Screen names display if the caregiver documented on the screen and the values entered were not overwritten by another caregiver in a subsequent contact 101 Worklogs Filter by machine Work Log EE view Details Pull Chart C Caregiver show All Erom 31712006 Machine show All Ta 31172006 Patient show All RDIRT Ez 317 2006 1 12 46 PM System Manager EE Finley Mr Fred CL qmusessscmE INCUN BAB 3 17 2006 1 26 07 PM 1 52 23 PM jug Assessment Plan E 14 2006 4 40 PM COfFice visit Description of information Servers Servers used during the date range selected Logins Caregivers logged in during the
107. mark the results Reviewed NOTE This does not delete the results m Open Ctrl O Open the selected message and view the results Review Ctrl V Review lab results and mark them Reviewed You can also annotate and publish results to the website with comments see Reviewing lab results on page 178 and Reviewing procedure results on page 191 Reply to Notification Send a Patient Message to a caregiver about the selected Ctrl R results Vn Forward Ctrl F Forward the results notification to a caregiver other than the original sender Refresh F5 Display new lab and procedure results sent to you recently if you cannot wait until the screen refreshes automatically To set Refresh default time see To set desktop defaults on page 109 For additional information about Result Notifications see Lab Results on page 175 Processing referrals on page 195 and Procedure Results on page 188 See also Viewing other caregivers inboxes on page 28 Determining who receives message notifications When your lab interface is set up you can configure how result notifications are sent to caregivers Your interface team will discuss this with you and set the parameters you select This is the most common configuration for practices with bi directional lab interfaces 1 Ordering caregiver Result notification messages are sent to the Ordering Caregiver NOTE If someone other than the ordering caregiver documents the order on
108. marked Reviewed highlight the lab result click Annotate to return to the Note for Lab dialog box then click Remove All and Yes to confirm To print the annotation click Print to select the printer and print properties Publishing lab result comments with read receipts 184 In practices that use HealthMatics Access and publish lab results you can request Read Receipts so that caregivers are notified when patients open the published results on the Website to see the values You can also add publishable comments about lab results for patients to view Open a patient chart and on the toolbar click amp Lab Results If necessary click Search to locate the patient then set Status to Reviewed 2 Chart Functions 3 Click Web Publish to display Web Publish Reviewed Labs Web Publish Reviewed Labs ProfilePanel Test Fred Finley Y IRON Collect 03 09 2005 3 53PM IRON 63 ug di 65 175 Y STREF QUICK TEST 86403 Colect 06 17 2004 12 41 PM Yes STREF QUICK TEST g Y METABOLIC PANEL BASIC E Collect 06 17 2004 12 40PM SODIUM SERUM 139 mamnol L 136 145 POTASSIUM SERUM 44 mE q L 355 CHLORIDE BLOOD 100 mE q L 97 0 107 0 CARBON DIOAIDE BICAR 25 mmol L 23 0 29 0 BUN BLOOD UREA NITAI 11 rg al 5 0 20 CREATININE BLOOD 0 8 mg dl 0 1 2 GLUCOSE 80 mao di 75105 Text Value and Notes of highlighted item Reported 06 18 04 8 25 AM by System Manager Reviewed 06 19 04 8 30 AM by Family Practice E el Sele
109. menu option select eRefill Requests to display a list of eRefill Requests for you and for those who have set you up as a prescribing agent eRefill Requests d p Pharmacy Approve Di Reject Delete 34 PatienE Medication Pharmac Caregiver Received mmu Mit E ME Pharmacy is 1010 math ee Me piv a m TE EUER m SOOM Tabl Pod One 1010 m Manning ME a j Innis Irene Triamterene HCTZ 37 5 2 Pharmacy One 1010 Terry Manning MD 04 17 2006 4 Patient Finley Fred 555 555 1212 55M 230 30 3131 DOB 07 24 1964 SEX Male Rx To Refill Amoxicillin 200MG Tablet Chewable 0 Ref x1 Directions 1 Tablet Chewable PO x Motes Pharmacy Pharmacy One 1010 Westwood Drive Cary NC 27511 555 555 2323 Id 9998688 Patient rr Fred Finley l e Pharmacy Pharmacy One 1010 Westwood Drive Cary NC 555 555 2323 E a Select Ehe medication that MATCHES the Rx 45 WRITTEN ABOVE Accutane 10M Capsule 1 PO No Refill 04 10 2006 Ordered an Albuterol a MCa ACT Aerosol Saln 1 Inhalation 2006 Ordered Amoxicillin 200hMG Tablet Chewable 1 Tablet Chewable PO Ma Refill 04 17 2006 Ordered Amoxicillin 200m Tablet Soluble 1 Tablet Soluble PO Ma Refill 02 23 2006 Ordered Amoxicillin 250M3 Tablet Chewable 1 Chew Tab PO BID 20 Chew Tab No Refill 3 days starting 01 1 Augmentin 500 1256 Tablet 1 PO No Refill Ordered 2 Select a patient in the upper pane to display the details o
110. oa ia 2 8 2006 843443 TSH THYROID STIMULATING HORMONE 83443 vee a 2 6 2006 84439 THYROXINE FREE 844397 System Manager 2 In From To select a date range for the items you want to view 3 Filter the items if desired by selecting Provider Location or Patient and then clicking the respective down arrow to make a selection e Provider Filter items by billing provider location patient encounter contact screen detail e Location Filter items by location billing provider patient encounter contact screen detail e Patient Filter items by patient location billing provider encounter contact screen detail 4 Click plus signs to expand the folders to reach the level that you need 105 Billing Reconciliation 106 e To view billing details highlight an item and click View Detail Billing Details IDE XJ g EA cose Patient Finley Freda T 555556 Billing Provider Mo ES Provides Encounber Gabe 4 3 2006 1 45 Pre Loc ation Fandy Prackics Clinic Billing Level ADEF Ste Default Billing Status Cannot bill electronically Dhage T6500 S YHETOPS INVOLVING RESPIRATORY SYSTEM AND OTHER CHEST STHEPTOPMS UNSPECIFIED CHEST PAIN 766 30 Las jasa3i CBC MANUAL 65031 l wdered 4 3 2006 by Terry Manning MG No Bill Patient Finley Mr Fred Patient Pandey Mir Fred 1212 Billing Provider Mo Elling Provider Encounber Dake 4 3 2006 11 01 AM Lect iors Farsi
111. of the pharmacy s name and click Search If no matching pharmacy displays click 42 to display Pharmacy Name Pharmacy Two contact 000000 Epid sess Se a o re a we l1 fo mccum Enter pharmacy information as needed 59 eRefill Requests 60 NOTE At EDI Id copy and paste the pharmacy NCPDP ID found in the Electronic Refill Reconciler Pharmacy information Patient Inis Irene 555 555 2233 55M 230 30 7000 DOB 11 29 1932 5Ex Female Rx To Refill Prednisone SMG Capsule Directions 1 Cap PO BID 30 days x 60 Cap Motes Pharmacy Kroger 112 Western Blvd Cary NC 27511 555 555 2323 A Id 2298888 e Click OK to display the pharmacy information in the Pharmacy field 4 Approve the eRefill request see Approving matched eRefill requests on page 60 NOTE When the missing information is reconciled and the medication is selected at the bottom of the eRefill Requests screen the icon in the upper pane changes to i If it does not that means that the patient also needs to be matched see To match patients on page 58 To match maintenance medications not previously recorded 1 With an eRefill request is selected on the secondary toolbar click Face Sheet and amp in the Medications pane e Click 5 to display A medications including inactive and discontinued e If the eRefill request does not match
112. or from the left navigation panel click Reminders Fred Finley 123456 Male 8 1 1955 Insurance Carrier Unknown Session Charts Office Patient Options Took Launch Help amp 9 mt DI 5e duimmimi o uuxsyEb ze Summary x IM r Current Encounter ch E complete ftysend Message E I Brow Patient Fred Finke Jel L Date Time v Cano Date c ed Chart attachments Call gend B LKDROR Oe ae CV Consuk Reminder Bj1 2005 10 39 AM Manager System Lab Results 8 Procedure Results T Resuk Summaries Sy Contact 1 Reason For Visit Patient Finley Fred Entered By M Review of Systems Subject Consult Reminder Completed By AJ History Priority High Date Completed aa Vitals Remind Alea de Physical Exam AssessmentPlan Mote Cal Dr Peters for a consultation CaP HAP Report NOTE To hide completed reminders click Show Pending Only Select the reminder to display reminder text in the pane below To send the reminder to another caregiver click Send Message and complete the Patient Message dialog box see Sending patient messages on page 39 To inactivate the reminder click Complete The reminder displays grayed out with a line through it and the name of the user 2 Chart Functions who marked the item Complete displays in the Completed By column and the date the item was marked done displays in the Date Completed column NOTES e Reminders are permanent entries in patient char
113. pane and a list of appointments for the day displays to the right in the preview pane Clinical Module Appointments DI X eink a s i rm ca a ev 7j da ry DE 5 ad 7 Ye w Te amp ae cointrenis Appointments Bom ree 3 p Inbox dh g AA JAppointment g caregivers 5 eing ES G Resuk Notifications 1 Trpia Location lt All Locations gt Date 3 1 2006 Today 1 1 i b Messages Time i S00 AM 8 00 Pr B 1B AMD Yes OMNea Mrs Manag Family Pr OB 204M 9 19 AM Yes Finley Mr Manag Family Pr Physical F 10 20 Yes Innis Mrs Manag Famiy Pr Folowup pro Foe No Parrot Pet Manag Family Pr Cough PR nene E coo rm Meeting B Manag k L D6 DO0 PM Meeting E Manag Logged in as Manager System Appointments 7 2 24 3 Gli fO fli Bu m uo NOTES Practice management systems HealthMatics EMR automatically imports appointments that are scheduled in your Practice Management System PMS If you do not have any patients scheduled for today the Appointments bar in Office Manager does not display Default schedule displayed The schedule for the day lists patients to be seen at the selected Location and Date Appointment count The Appointment numbers in the left pane and on the status bar represent the total number of checked in and started appointments Number
114. problem but if added from Past Medical History to the active problem list rather than in A P it will not associate with the ICD 9 code needed for billing unless you have customized otherwise This applies with or without a billing interface To manage a history item to a patient active problem list follow the steps below 1 Open a patient chart and from the left pane or the toolbar click amp j History 2 Inthe History folder tree select the category of the item you want to add to the problem list 3 Inthe current encounter pane at the bottom of the screen click Manage and Yes to confirm A red glow displays around the icon hand indicating you have managed the problem or medication ca 2 it Manag ll ES Past Medical NM C oronar y Artery Disease 255 History 256 To manage the problem history once again select the history item in the current encounter pane and click Manage Problem History Lx Knowledge Term Congestive Heart Failure Description gored ie a owe Acuity Stabity I isl Significance E Severity Intensity Goal oo Reason for Change EE Basis Comments 4 Ba o Ny Uh 8A amp Ba CR c uo V Uh a E cma Change history information or add notes as needed and click OK Changes made or information added display as part of the current encounter in the H amp P Report EF To manage medications from history See also Managing
115. problem and medication history on page 255 When managing medications keep the following in mind If you add a medication from a Short List or a Data Source search it is initially entered as an historical entry and will not display on the Assessment Plan screen As with diagnoses in order to have the medication display on the Assessment Plan Patient Medications tab you must click Manage A red glow surrounds the icon hand to indicate it is being managed Free Text medications cannot be managed If you select a medication already being managed and click Manage a message informs you of that fact You cannot edit the properties of a medication using the Manage button as you can for a diagnosis Once a medication or diagnosis has been managed it immediately becomes part of the chart Even if the associated history item is deleted from the current encounter the item designated as managed will still be part of the chart If a managed item is edited on the History screen but not included on the Assessment Plan screen when the next encounter is started the item that displays on the Previously Entered History tab will have the properties of the Assessment Plan entry not the changes that were entered in History during the 3 Patient Contact Functions previous encounter n other words in the case of managed items the properties of the Assessment Plan entries always override the properties of History entries To vie
116. select a different recipient click the To down arrow 4 At Subject enter a subject or click the down arrow to select one NOTE To add message subjects to drop down lists refer to Message Subjects in the Administration Module manual 5 To change the date enter a new date or click the down arrow to select one see Entering dates on page 10 NOTE If you specify a future date the action item does not display in the recipient s inbox until the date selected 6 To change the time enter a new time or click the scroll arrows NOTE If you specify a future time the action item does not display in the recipient s inbox until the time selected 7 Enter information on any of the four tabs see Entering data on tabs on page 32 and click Send The message appears in your Outbox immediately and the recipient s nbox at the date and time selected T1 Action Items Viewing action Items 1 From the status bar or left pane of the HealthMatics EMR desktop click iA Action Items Action Items an ca Open Oy Reply Forward E Caregiver Manager System E From __ 1 Subject__ _senty__ emm System n Manager System iManager System Call about results Meeting tomorrow m Heetng terighe l EET T i 1 11 2006 1 39 PM 1 10 2006 5 04 PM NOTES The number next to Action Items lt 4 3 on the status bar and in the left pane of your desktop in your nbox and Offic
117. the ability to filter lists of items based on multiple criteria using a single click These filters can be customized for each user Quick filters are available on the secondary toolbar of all the following Clinical Module screens e Lab Results e Procedure Results e Additional Results e Output Queue e nput Manager You can set two different sets of quick filters one set for use when you have a chart pulled and set for use when no charts are pulled The system knows the difference and displays the appropriate set of quick filters that you set for each Creating quick filters To create and use a quick filter on any secondary toolbar where the toggle filter button with down arrow Filter displays do the following with or without a chart pulled 1 Setthe Patient Dates and Status and Sortto one set of commonly used criteria for locating documents Examples All Patients The Past Week All Statuses All Patients All Dates All Requiring Action All Patients All Dates Ready for Indexing All Patients All Dates Needs Review Oldest to Newest 2 On the secondary toolbar click 5 and select Set Filter gt 1 to display Set Quick Filter 1 3 At Name type a name for your filter and click OK 4 To set another auick filter select the new filters in the search fields and on the toolbar click Y again select Set Filter 42 enter a name for the new filter and click OK 5 Repeat this process t
118. the caregiver the H amp P report displays for signoff To file charts from the desktop or status bar 1 From the status bar or left pane of the desktop click Review Open Encounters open d riechst disendchot E Refresh Patient Name Encounter Date v Diag Reason For K dr Pulled gO Neal Mrs Olivia 3 20 2006 3 28 PM Unspecified Diag a Griplana Alan 3rz j2 oe 12 50 PM Gig Gripiano Alan 3 20 2006 12 27 PM ASTHMA UINSPE Gy Galespie Mrs Gail 3 20 2006 11 59 AM amp alInnis Mrs Irene 3 20 2006 10 53 AM OSTEOARTHROS Qo Meal Mrs Olivia 3 16 2006 12 43PM Unspecified Diag Parrot Peter 3 5 2006 1 57 PM oneal Mrs Olivia 2 27 2006 1 56 PM NORMAL PREGN 143 Patient Charts 2 Highlight the patient name and from the secondary toolbar click File Chart or right click the name and select File Chart NOTES e Ifa chart needs to be signed off by the caregiver the H amp P report displays for signoff e You can file charts without signing off on them when any of the following are true gt You opened them for review only gt You made changes from the face sheet view only gt You entered data in Demographics Lab or Procedure Results Reminders or Chart Attachments only e You must sign off on a chart before filing if you entered information in any of the contact windows Reason for Visit Vitals History Review of Systems Physical Exam Assessment amp Plan or on a
119. the correct spelling is not in the list at Replace With type the correct spelling in the field and click Change 4 When spell check is complete click OK in the Information box that appears Configuring spell check 1 Click Spell Check Options to display Spell Check Configuration At Main Spell Check Configuration Ea ain Dictionaries CI American English US American English 115 Stedman s 4 K 2003 Mowe Up Stedman s L Z 2003 Add Move Down Remove Move Up Remove Move Down Add words En default udt default udt Add ew Dictionaries select the boxes of the dictionaries you want your spell checker to use NOTE Select a dictionary and click Move Up or Move Down to determine the order in which the dictionaries are searched 2 At User Dictionaries click default udt for the default NOTES On the Dictionaries tab you can click Add to add main and user dictionaries and then browse to link to the appropriate resource You can also select a dictionary and click Remove to remove main and user dictionaries It is unlikely that you will do either of these You may however add words to User Dictionaries while using spell check in the EMR 12 1 Office Functions 3 Click the Options tab Dictionaries Options Words containing numbers v URLs and e mail addresses eneral Re check replaced wards 4 n gnore select boxes as needed to have spell check ignore
120. the date range selected If no charts were accessed during the login a messages states No patients are associated with this login Level 2 Encounters Encounters the caregiver created including the time the chart was pulled and the encounter type Office Visit in parentheses NOTE Selecting an encounter enables View Details on the secondary toolbar Chart reviewed without edits Level 4 Contact screens Names of contact screens where values were entered NOTE Screen names display if the caregiver documented on the screen and the values entered were not overwritten by another caregiver in a subsequent Level 3 Contacts Start and stop time a caregiver had the chart open before sending it on to another caregiver or filing it NOTE If contacts did not have associated saved data a message states contact Using the worklog toolbar functions e View details Click to view the H amp P Report and Billing Information Patient Message or Refill Request associated with the selected encounter in the worklog e Pull chart With a patient encounter or contact in the worklog selected click to pull the associated chart e Refresh Click to update the tree view without changing any of the Date Range or Filter settings 103 Worklogs Tracking patients during visits To track the progress of a patient s visit without having to leave the Appointments view do the following 1 From the status bar toolbar or left pane of t
121. the items 5 n General to set Spell Check to recheck words that have been replaced select Re check Replaced Words and click OK Using pen based functions You can enter information quickly and easily using functions within HealthMatics EMR many of which are designed specifically for pen based users To set dates You can type in dates or use the calendar function Here is an example 1 On the HealthMatics EMR toolbar tap patient and pull the chart Pull a Chart search for a female 2 On the toolbar tap Vitals 3 On the secondary toolbar click P Add Vitals 4 At LMP Date tap the ellipsis button d Date f Full Date Ea March 7006 74 Month Year Only Sun Mon Tue Wed Thu Fri Sat C Year Only E x se 5 6 7 8 9 10 il Mo Date 12 13 14 15 16 17 18 19 20 21 22 25 24 25 eb 2 z0 29 30 31 C Today 3 1 2006 ceca 5 Tap Full Date to display a calendar 6 Tap the year to display scroll buttons the month to display a drop down menu of months and the date to select it then click OK 13 Patient Search To access the keypad The on screen keypad jg helps pen based users enter information The keypad icon is available in many dialog boxes e To change the format of the keypad from the standard style to alphabetical tap i on the bottom left corner of the on screen keypad ie e alelels eli s s r m on o e a e s e vu viv vlz mo P a s Els TebeTeTo lo EE
122. the size NOTE You can view the patient s Face Sheet in a dialog by clicking Iz on the toolbar and then closing the dialog to return to Send Scanned Document or you can close the Send Scanned Document screen and pull a patient s chart by clicking 3 Pull a Chart 6 After verifying the index information on the left and the quality of the scanned document on the right click toolbar icons to do any of the following Print Printthe document 000000 the document a the document and link it to the patient s chart as an attachment Reject Return the document to the scanner for corrections NOTE When rejecting a scanned document the message text box reopens Enter a reason for the rejection 75 Documents Viewing scanned documents from face sheets 1 Open a patient s face sheet and in the Encounters pane click View Encounters 2 Click F to filter the encounters By Type 3 Expand the Scanned Documents folders as needed to locate the document you want to view and click to select it Encounter Explorer Encounters By Type Newest to Oldest Encounter Details 1 43 Encounters 44 Messages Chart Attachments h N Scanned Documents Sy Color photograph 2 8 2006 Color photograph System Mana Ey Labs 2 16 2006 Labs Job Lab results System 2 3 2006 Labs System Manager J Old Records m Made sce Inst vis E 2 6 2006 Old Records Nursing Home Sys ies C Weds Ej 2 8
123. the subscriber to the patient e Click the Relation to Subscriber down arrow and select the relation to display additional fields e Enter the subscriber s information and click OK To enter insurance carriers into the EMR database To add insurance carriers IF you do not have a PMS you can add carriers to the EMR database by following the steps below 1 From the menu bar select Tools gt Edit Insurance Carriers Insurance Carrier Search Ea l Mame north Search Clear Address Phane Number ne North Sane Insurance CIE 900 Weston aaa j TEE nee 555 3484 169 Demographics 2 Press the Insert key on your keyboard or click Sp Add Insurance Carrier Insurance Carrier Mame North Carolina Insurance Group Formulary North Carolina Health Choice External Id k Contact Street Jao Weston Parkway 0000000000000 City Raleigh 000 0 State Nc Zip 27615 Phone kais 555 3484 E Pager Eg Fax E Mobile E Email P E OK Cancel 3 At Name enter the carrier name 4 Click the Formulary search button Formulary Search Ea North Carolina Heath Choice D Box 30111 Am 27702 3 B00 422 3658 North Carolina Medicaid 2516 Mail Service Center Raleigh 27699 2516 866 246 8505 Search for and select the appropriate formulary for the carrier you are adding then click OK to return to the Insurance Carrier dialog 5 E
124. to select the most common monthly quantities gt Use the third and fourth rows to add additional quantities to the numbers in the first or second rows gt Use the QS key to indicate the prescription should be filled with quantity sufficient based on the amount to be taken per day times the number of days prescribed gt Enter the quantity to be dispensed and click OK Quantity drop down list Type or click the down arrow to enter the form or type of units Example tabs caps drops and so forth Refills Click the down arrow to select the number of refills 3 Patient Contact Functions Refill quantity If refills were specified in the field above click the spin arrows or ellipsis button to indicate the number of refills authorized NOTE Once you document the number of days and the refills are set at 0 a Do Not Auto Inactivate checkbox displays Check the box if you do not want this medication to automatically inactivate when the course is complete If you change refills to a frequency other than 0 the Do Not Auto Inactivate checkbox disappears Status Click the down arrow to select a status for the prescription Le eese Active medication Completed course of medication Erroneous Entry Medication entry was in error NOTE The medication displays in Assessment Plan and Problem History but not on the patient face sheet NOTES When the status Discontinued or Inactive is selected an End Date fiel
125. toolbar click gh Add Emergency Contact Emergency Contact ontact Motes Relationship Father First Mame John Last Mame Finley Street 5501 Dillard Drive 000000 City ary 00000 0 0 State Nc Zip 27511 Phone 319 851 6177 E Pager B Fax E Mobile E Email P ES Cancel Enter information as appropriate and click OK To edit contacts on the Emergency Contacts tab select the contact and click 4 Edit Emergency Contact Edit as needed and click OK 171 Demographics Loading patient pictures NOTE To enter patient pictures into the EMR you must have them stored as files in your database 1 With a patient chart open from the left pane or the toolbar click ik Demographics and select the Patient Picture tab 2 Click amp Edit Picture 3 In Patient Picture press Insert on your keyboard or click qm Load picture from file Open ha Ed Look jn 3 My Pictures m amp ectem Picture 3 Hore Fepme f E Fede Romwe a cw e Click the Look in down arrow and navigate to the patient picture if you have one scanned into your database e Select the picture file and click Open 172 2 Chart Functions Patient Manager To provide a single place to manage patients outstanding medical record items and to view reminders for preventive health maintenance needs HealthMatics EMR provides the Patient Manager vie
126. toolbar or right click for a menu select Procedure Tasks gt Review All Review Procedures B x de A Toggle Review Patient Ob ayn 1 Eg Ask about foot hygiene Patient Patient Ob Gyn 1 OB GYN 1 Patient DOB 10 20 1977 Order Date 312212006 10 10 AM Ordered by Manager System Report Dare 3 2zjz Ue6 10 13 AM Pesformed Dare 3 22 2006 10 10 AM Procedure Final Mot Reviewed Ask about foot Fygene Diagnosis Unspecfied Diagnosis Dah X4 per week X3 per week Less Ehan 223 peer vesek Dah Shoe fit wear k ox cm Review results by highlighting the procedure and reviewing documentation in the lower window Procedure results default to Reviewed e Click Review or Review All if the patient has multiple test results e Click OK The Status of the procedure results changes to Final Heviewed and can no longer be changed However you can add Entry Error notes if needed Click OK to exit and save Use chart tasks to do the following e To attach results to the patient chart click Chart Tasks gt Attach to Chart select the original current or both encounter s to attach it to then click OK e Pull the Chart e View the Face Sheet e Attach results to an encounter NOTE Procedure results appear as attachments in the Encounter pane of the patient face sheet To view the patient face sheet click Face Sheet Chart Tasks Click Close to return to Procedure Results e To pull t
127. transcriptionist NOTE You must have the appropriate Function Access 73 Documents 74 Face Sheet Open the patient s face sheet Click the X in the right corner to close the face sheet and return to Send Transcription a Pull Chart Close Send Close Send Transcription and pull the patients chart and pull the patient s chart Keypad Open the keypad to enter text To approve or reject scanned documents NOTE For instructions for scanning documents refer to the Input Manager manual You can scan paper documents into the HealthMatics EMR database associate them with patient charts and then send them to the caregiver for review or save directly to the chart Scanned documents awaiting review are sent to caregiver inboxes as Documents Scanned documents are distinguished from other documents by the Bi icon 1 Inthe Documents view open a scanned document see Viewing the list of documents on page 70 2 Ifthe Message tab has an icon on it click the tab to read the sender s message and then click the Document tab P Send Scanned Document TIE x Off Forward Approve x Reject Face Sheet C Pull Chart Sb Print mM Message Document Patient wr Fred Finley IE A JL la Index Diagnosis Pages 3BB rs to Page ABDOMINAL ACTINOMNCC EB Lype jPath Reports HE cg Scanner System Manager Submitter System Manager Title Path Reports aant ela
128. view the selections made and click applicable positives checks or negatives Xs to reflect the values for the Current encounter e Click the current encounter documentation details to navigate directly to the item you need to change 7 After documenting pertinent body systems you can document that findings in all other systems are negative 279 Review of Systems e Inthe Review of Systems pane highlight Review of Systems e Select the All other systems negative box in the right pane under Review of Systems 5 x e ITI ER Review of Surtoms Cp Some Ey Up quExpand A E Colspse Al Ug Review of Sysbenis YE General Templates CARDIAC ROS acp E Preview O ear 7 Sn HEENT Zo Neck L Respirstor I 5 ie ci i SE General t 5 7 Shin 2m Cardiovascular E E HEENT UH Sl Neck E Gesbrontestinal alc HIME Dacraratosu HE aac All other systems negative is added to the bottom of your system review Documenting ROS using previous encounters 1 Open a patient chart and from the left pane or the toolbar click Review of oystems 2 Click the Templates down arrow and select a previous visit under Encounters NOTES Encounters displays only if the patient has had Review of Systems documented during previous encounters The number of encounters listed depends upon the selection made in caregiver options See Options Edi
129. was created by the interface and not on a requisition the ordering caregiver is used If not on a requisition and not received via the interface the following occurs gt Ifthe scheduled caregiver for the appointment can be determined that caregiver receives notifications for all labs ordered during the visit gt If the scheduled caregiver cannot be determined the ordering caregiver is used Caregivers do not receive result notifications if Block Result Notifications was checked on the Caregiver Properties window in HealthMatics EMR Administration Settings Caregivers Edit Caregiver Properties 187 Procedure Results Procedure Results Procedure Results window features are similar to those in Lab Results You can also send messages about procedure results to caregivers You can set performance dates for historical procedures define procedures as billable or non billable enter procedure results submit procedures to providers for approval and save them to patient charts Defining procedures as billable or non billable From Assessment Plan you can order procedures performed either within or outside your practice Inside procedures are generally billable while outside procedures are not For complete information to create procedure entry rules see the HealthMatics EMR Clinical Customization manual To mark each procedure billable or non billable follow the steps below 1 188 From the HealthMatics EMR me
130. when the message should be sent to the caregiver s inbox Enter a message on any of the four tabs see Entering data on tabs on page 32 To permanently save the message to the patient chart now click Save to Chart and Yes to confirm NOTES A Confirm message appears if you are not sending the message to the patient s primary caregiver Click Yes to notify the primary caregiver that a message has been saved to their patient s chart You can skip the Save to Chart step and allow the recipient to save the message to the patient s chart once a response is entered Click Send The message displays in recipient s inbox and your outbox until opened by recipient Responding to patient messages When you receive a patient message you can view it reply to it forward it to another caregiver print it pull the patient s face sheet or chart and save the message as a permanent part of the patient s chart 1 On the status bar or left pane of the HealthMatics desktop click Messages NOTE The Messages view displays patient messages 4 and mail messages Select a patient message from the list that displays and do any of the following e To view the message double click it or select it and click Open Patient Message D XJ Ca Delte J FaceSheet jPulChart 4ysavetochart fleReply lForward print From Manager System Sent 3 8 2006 1 52 PM Patient Finley Mr Fred Phone 555 555 1212
131. with a bi directional interface the Batch Processing box on the Add Laboratory or Edit Lab screen must be checked See HealthMatics EMR Clinical Customization manual for laboratory set up information 2 Chart Functions To access batch processing 1 From the HealthMatics EMR Menu bar click Office gt Batch Processing or from the left navigation pane click Lab Order Processing gt Batch Processing Batch ETE eee Bates ihe past year l us Jub corp NN Locations is the default Click down arrow to select a location for which the user has access Click down arrow to select Laboratory 2 Select a batch to process To create lab order batches NOTE You must have requisitions created before you can process them in a batch 1 2 Access Batch Processing see To access batch processing on page 229 Click 4g to display Lab Batch Requisitions showing a list of requisitions with a Completed status not yet included in a batch Lab Batch Requisitions Location Famy Medicine Clinic Created By ger System Laboratory Lab Corp Status ew On Hold DateRange Wepssyem E Transmtted 2 si Check all l Unded Al X Preview Patient Name Patient ID Reg Dat Rasguisiio n ID Status are Location Cl Galespie Mrs 0004 4 12 2006 3 33 OO0021 Complete Hastings Lynn Family Mi Ll Heves Cynthia CHAYES 4 12 2006 3 56 0022 Comp
132. 2 Viewing and revising encounters from face sheets 000 ee eens 153 To view encounters 4 2 29 35 42 54 3 RU a ta ik Se Sim di Capi t ye die re Ein ae veh Bs ed 153 To view approved SOAP and general transcription external transcription 154 To view voice notes internal transcription in the chart llle 155 To view scanned documents in the chart llli 155 To move attachments messages to other encounters 000 eee 156 To change encounter information or create addenda 0000eeee 156 Viewing and revising medications from face sheets Lus 157 To inactivate medications automatically ea 158 Viewing orders from face sheets llllllll ee eee 158 To view results from the orders pane llle 159 To view results from the encounter pane on H amp P reports 00 eee 160 Demographics acceded es ae ae EI eee aie ee EL IE 162 Accessing patient demographics 0 0 0 ccc ee eee 162 Entering editing patient demographics llle 163 Printing patient demographics 0 ccc eee 166 Entering patient insurance information llle 167 To enter insurance carriers into the EMR database 00 0 00 eee 169 Entering emergency contactS 0 ccc eee eens 171 Loading patient pictures 1 0 ee re 172 Patient Manager e sescacaca io oo KC ane wea Ria Qc ap
133. 2006 Old Records Tile Nursing home Ple oo m y Path Reports Rezacaa fir vip i S cda i E 2 8 2006 Path Reports System Manager p HIV Gites vii ient id fN BEN T Haea Dale Feys 3 zik 4 Inthe middle pane click thumbnails to view each page in the preview pane on the right NOTE For additional instructions for using this screen see To approve or reject scanned documents on page 74 76 1 Office Functions Action Items Action Items are user created messages about things to do or personal reminders You can send action items to yourself or to other caregivers For general instructions for using HealthMatics EMR windows see Windows Panes and Other Tools on page 8 Creating action items 1 From the left pane of the HealthMatics EMR desktop select Action Items or from the toolbar select amp i gt Send Action Item P Action Item _ OF Easend day High Priority I Private To Manager System Subject Reset User password Date Time 3 10 2006 7 11 11 AM Cu Text image Voice Import EE X meom A Bs pes reset user password For Dir Thompson aj Your login name and the current date and time display as the default 2 Select checkboxes as desired e High priority Select to display the message in red in the recipient s inbox Private Select to hide the item from other users who may have access to view the recipient s Inbox 3 To
134. 220 H H amp P report accessing 353 attachments viewing 356 editing current 355 encounters finalizing 356 face sheets viewing printing from 153 notes adding 156 356 reason kept open 355 signing off charts 364 toolbar icon 111 HCFA 1500 signature on file entering 165 HCPCS database 238 definition 295 head circumference default settings 121 HealthMatics version where to find 4 high priority red 7 urgent message indicator number 78 history Current encounter clearing items from 250 documenting past history items 251 editing items 249 defaults setting 126 document using Index free text 254 my short lists 240 previously entered history 248 search 254 short lists 252 face sheets customizing view 115 viewing revising 151 general viewing and documenting 247 immunizations documenting 338 editing 339 free text entries 342 previously entered free text using 343 viewing 152 immunizations adding 340 indicating none is on record 251 level E amp M calculator 367 medications managing 255 merge 232 non contributory 252 overview 247 printing problem lists 150 problems managing 255 viewing revising from face sheets 147 problems from A P 291 procedures changing dates of 194 toolbar icon 111 hot keys 10 ICD 9 database 238 definition 295 icons inbox 26 images expanding mapped 119 messages notes adding into 33 physical exam notes adding into 286 physical exam documenting 289 immunization record accessin
135. 239 patient words documenting 262 toolbar icon 112 view purpose of 258 reason kept open for pulled charts 142 H amp P report 355 received charts inbox messages 25 28 list displaying 80 status bar review from 5 taking action on 80 toolbar icon 112 viewing 143 received documents reviewing approving 70 status bar review from 5 reconciliation billing 105 red meaning of 7 refaxing reprinting prescriptions security for 391 references menu option 3 referral caregivers entering in demographics 163 referrals caregiver letters using 315 documenting 311 letters selecting 311 ordering and documenting responses 195 results entering 195 reviewing 1977 refill requests accessing 44 approving rejecting 48 awaiting approval in patient manager 174 batch refill processing in 89 batch refills calling in 89 batch toolbar icon 111 eRefill toolbar icon 111 face sheet documentation 90 inbox messages 25 27 passwords setting prompts 66 recording 44 save to chart 49 send toolbar icon 113 status bar review from 5 toolbar icon 112 viewing approving 46 refreshing inbox view 26 reminders creating on patient charts 211 patient chart 211 patient manager 174 toolbar icon 112 viewing completing 212 report messages processing 82 report results patient manager 174 toolbar icon 112 viewing 198 reports inbox messages 25 28 requests regarding report results 82 toolbar icon 112 reprinting refaxing from output queue 94 requisitions
136. 3 333 2233 Manager Sate Famiy Fractke Clinic Fido pe Bod AM Finieg Wr Fe 333 333 1212 anager ahem Family Fractke Clinic Fos kal E AM Cruea bis Olda 555 333 2343 anager ahem Family Fractke clinic 1 Office Functions Use the toolbar buttons to manipulate the document if desired and then click 4 Print Document In the Print dialog select the printer and other information as needed and click OK Displaying daily billing information 1 From the HealthMatics EMR desktop toolbar or status bar click 4 Appointments On the secondary toolbar click View Batch Billing Report to display billing information available for current day s patients including billing levels diagnoses and plans NOTE If a patient has been selected in the Appointments view prior to clicking F1 the billing details list automatically scrolls to the selected patient 3 Click Print to print a list of all patients with billing data entered for the selected day 21 Open Encounters Open Encounters 1 To display a list of encounters that have not been signed off on the status bar in the left pane of the desktop or in Office Manager click Open Encounters Open Encounters 37 Open ol File Chart Send Chart Refresh Patient Mame Encounter Date v Diagnoses Reason For Keeping Pulled Finley Mr Fred 3 5 2006 1 16 PM E Parrot Peter 3412006 1 34 PM Ex 0 Neal Mrs Oli 227 2006 1
137. 392 documents viewing 92 electronic signatures adding 94 exporting from 96 new creating 97 overview 92 queued documents generating 393 reprinting refaxing 94 toolbar icon 112 output settings selecting 385 templates selecting for each screen 386 outstanding chart messages 22 402 P packing lists printing 231 panes resizing 8 passwords changing 108 login to HealthMatics EMR 1 setting refill request prompts 66 patient charts filing 143 procedure results attaching 192 pulling 139 for billing encounters 139 for non billable contact 140 reason kept open 142 received displaying list of 80 reminders creating 211 overview 211 sending to another caregiver 142 transcription viewing 154 viewing 22 patient contact functions description of 237 patient demographics accessing 162 printing 166 patient education library of 295 purchased database 238 patient manager 173 accessing pregnancy record 323 appointments future 174 defaults setting 116 messages 174 toolbar icon 112 patient merges merge queue 235 patient messages face sheets viewing from 42 forwarding to other caregivers 42 patient manager 174 responding to 40 send toolbar icon 113 use of 39 patient search 14 patient words documenting 262 patients charts merging 232 demographics accessing 162 entering editing 163 emailing printing lab reports for all 186 for one 186 insurance entering editing 167 matching for eRefills 58 medication education p
138. 4 reviewing 178 unsolicited including in pregnancy record 336 view toolbar icon 113 viewing from review results 178 labels printing barcode 228 launch accessing other HealthMatics modules 3 lengths documenting 288 levels E amp M calculator 367 libraries list of data sources available 295 license information where to find 4 LifeART database 238 lists customizing quick lists 127 my short lists setting options for 128 living will entering 164 locations appointments viewing 16 editing defaults 131 login name and password 1 logoff automatic setting controls 3 toolbar icon 111 logs saving documents to 95 machine worklog filter 100 102 mail merges performing 83 mail messages sending and creating 37 toolbar icon 113 management options E amp M calculator 370 managing medications from history 256 problems medications from history 255 manifests printing 230 manipulating windows panes data 8 mapped images in physical exam 289 master lists reason for visit 260 maternal fetal data editing 330 MDM level E amp M calculator 367 measurements documenting 288 two dimensional 276 medical history editing 332 medication explorer accessing 157 medications assessment plan setting defaults 122 edit reactivate 158 eRefills matching unrecorded medications 60 face sheet customizing view 115 viewing changing from 157 history viewing from A P 291 292 inactivating 145 automatically 158 from A P 292 interactions vi
139. 56 PM NORMAL PREGNM Ennis Mrs Irene z 13 2006 12 45 PM e Bold Encounter is from the current date e Black Encounter is from the past week e Red Encounter is more than one week old 2 Select an encounter and on the secondary toolbar click icons to do the following L3 Open Chart F2 Open the selected chart and view the patient s face sheet File Chart File the selected chart NOTE If the History amp Physical Report displays the chart contains new clinical information that must be signed off before it can be filed If you do not have authority to save H amp P reports send the chart to a caregiver who does CE Send Chart Send the selected chart to another caregiver Refresh F5 Display new open encounters if you cannot wait until screen refreshes itself automatically To set Refresh default time see To set desktop defaults on page 109 Outstanding chart messages In Open Encounters the Message column provides a quick view of messages sent when one caregiver sends a chart to another Open Encounters 37 Open H File Chart Send Chart Refresh Patient Mame Encounter Date Diagnoses Finley Mr Fred 423 2006 2 36 Multiple Chart Messages ALLERGIC ARTHRITI em Peter 2 16 2006 3 55 Unspecified Diagnosis If there is more than one chart message associated with the encounter Multiple Chart Messages displays in the Message column 1 Sel
140. 5M Capsule 1 Cap PO BID 60 Cap Ref xz 60 Cap 30 days starting 09 26 2004 Orde zithromax Tri Pak S00MG Tablet 1 PO No Refill 02 14 2006 Ordered _ k 2 To select the patient and verify insurance pharmacy information e At Patient click Use current chart or to search for a patient e Verify the patient s phone number NOTE The home phone from Demographics displays automatically For other phone numbers in the database click the Phone down arrow You can also type the phone number in the field if the correct number is not displayed or click the search button to enter a new one e At Rx Insurance accept the patient s preferred carrier entered in Demographics or click the down arrow to select another e View the following information as needed 44 1 Office Functions gt Last Encounter displays date time and type of the selected patient s last encounter Excludes transcription messages refill requests and chart attachments gt Pref caregiver displays the patient s preferred caregiver from Demographics gt Date of birth displays the patient s date of birth and current age gt SSNdisplays the patient s Social Security number if it is in the database gt Click to view the patient s face sheet amp to view the patient s demographic information gt Click to view Reminders placed on the patient s chart If there are no reminders on the chart this function is disab
141. 6 The Required tab lists questions in the Procedure Entry Rule that are required prior to finalizing the rule My Procedure Lists uses this functionality to focus in on questions within a rule that you are responsible for that is rules that both nurse and physician input data 310 3 Patient Contact Functions 4 Click and enter each value as needed to document result Finalize procedure results Review procedure results Attach results to Original encounter Current encounter e Both encounters e Cancel Add note if desired Use the note and significant icons as needed in your documentation When documentation is complete click Final Review Attach or Addendum as needed NOTE Following your action choice a notification message displays that the selected action was taken Documenting referrals To document a referral select a letter from a short list and then print fax or email the letter Option 1 Select referral letters Referral letter templates determine what encounter information displays in the referral letter For instructions for creating referral letter templates see the HealthMatics EMR Clinical Customization manual 1 Open a patient chart and from the left pane or the toolbar click A P Assessment Plan 2 Click one of the Short Lists tabs and click to open a Forms amp Letters folder under a diagnosis orthe Master Forms and Letters or use the Search tab Le V9 Current Enc
142. 88 system defined list of 389 using 389 templates definition of elements 377 encounter packs creating 388 exporting from any view 382 faxing from any view 381 output selecting for each screen 386 previewing from any view 383 printing from any view 379 queuing saving to log from any view 382 review of systems 278 selecting 378 text tab in messages and notes 33 time appointments correcting 16 for visit E amp M calculator 368 title bar 2 defaults setting 125 toggle tree toolbar icon 113 toolbar customizing 110 icons description of 4 using ROS and PE 277 transcription 154 documents 70 external approving rejecting 71 general 72 internal approving rejecting 73 transcribing 135 patient manager not reviewed 174 SOAP 72 U unsolicited lab results pregnancy record 336 urgent message indicator high priority number 78 turning on off 6 V version where to find 4 VIP entering designation 165 vitals defaults setting 121 documenting 242 entering data 221 growth charts 245 physical exams viewing in 246 toolbar icon 113 voice notes transcribing 135 viewing in charts 155 voice tab in messages and notes 36 W waist default settings 121 web messages 185 inbox messages 25 27 send toolbar icon 113 web publishing lab results 184 workflow monitoring 6 worklogs appointments tracking patients 104 caregiver contact 101 chart contact 100 filters for 100 machine contact 102 patient contact 103 toolbar functio
143. 92 In Search Results double click or drag and drop the medication to the current encounter to order it The Medication dialog appears NOTE If you select a medication from Patient Medications or a short list and the Medication dialog doesn t open automatically double click the medication or click g or press F2 or right click the medication and select Edit from the pop up menu to enter prescribing information Medication X Details Prescription Education 3 Patient Allergies 7 Formularies Asthmahaler 0 16MG ACT Aerosol Soln 1 Aerosol Soln Inhalation No Refill 3 14 2006 Ordered Strength 0 16 AerosolSon T os p Route inhalation O Reik we s gemmy rro z Medically Necessary Samples Given Status Ordered etae 2 14 2006 Today Bl Reason Pf End Date es E Hotes Drug Interactions amp GG c DU Ve Wh 5A 3 A Interaction checking un The Medi Span SOLI zie Patient 41 year old male Weight 177 b 6 oz 80 53 kg as of 9 26 2004 Cancel m NOTES If a patient has allergies reported a Patient Allergies tab displays at the top of the screen Click it to see allergy information If the patient does not have allergies recorded this tab does not appear Patient age and the most recently recorded weight along with the date the 303 Assessment Plan 304 weight was measured display prominently
144. A 1 MI Session Charts Office Patient Explore Options Tools Launch Help Ka CE 34 L Appointments Saly TAF LOR VA kw e gt ea Acpohtme lt 4 Open Encounters Sy Open Enco 5 Inbox ARS oe DEDE Result GB Result Notifications By Messa Th Messages rite B Iv Hide patient reported soia M Web Messages Manager System T Dates The past 3 months eRefil Ed Refil Requests lt All Patients Jela Status Ordered Docum QA eRefil Requests 2 Tee E a Action EA Documents a Receiv al Action Items QI Report d Received Charts Outbox Gh Re t Abnormal Oniy Ordered Date Performed NOTE The Office Procedure Results delivers all patients with ordered procedures At Status select Ordered Set other filters as needed Caregiver Patient Dates Sort to locate the appropriate patient NOTE If the patient chart is open on the desktop at Patient click Use Current Chart If not click the search button to search for the patient or for all patients click All Click to display patient procedures and select the one you want to enter results for Details display in the lower pane 189 Procedure Results 5 Onthe secondary toolbar or right click for a menu click Procedure Tasks gt Result Entry a Procedure Results Entry tre Gail Galespie Oeder 8 2 Bena BijReeee gatah g7 Addendum amp 4opM H ES 4 E gene Tjup gzE
145. A HEALTH SvsrEMs All rights reserved Printed in USA A HEALTH SYSTEMS and HEALTHMarICS are Registered in the US Patent and Trademark Office RSMrefresh Copyright C 2005 A Health Systems HealthMatics EMR Application Reference Manual Table of Contents We OMICS HUNG meet 1 LOO umi ERE oA eis e MENGE AEG ER Era eee Dae Peewee eee eee 1 EMR DeSK erem 2 SING Mele IOAN aia neared ca See cee eee nna a ee aa Bae ee eae A 2 USING the ment Dal seed che teed eee eee ued eee dos b M oed RU s 3 WSING estoDIDAle 2a 40st dut E do o ak e Gb gent Phe eS tee S aet de yeast 4 WSING tne Stats Dal seraient ad RUE ECC wie ec owes de oet d ER 5 Monitoring workflow on the desktop lille 6 Windows Panes and Other Tools esere eee RR 8 R sizing paries and COMAS 5 1 oC OUR TCU DER VE RR EA DR RUE 8 SONO CO BEBIS 2 taginiis s dure e Een d o d a ee ee d RS Pd 8 Understanding table font conventions 0 0 ees 8 SING drop dowWbTISIS sc eu ge Nd Stewie AL Sh So ti ee ee RODA CA Seed 8 USING Scrol DaS tease soto dta UND UAS RS Ee ee ee SENE NEP SU S 9 Using secondary toolbar icons and shortcut keys 0 0 00 cee ees 9 Right clicking for pop up menus slsllel s 10 Eneng dales ascendit iret uet aC S koe Me dake dus REO E GE a rit Bia ee ears 10 Etiterng pons Till IDEls s 1n T pu SR Db eR ec ES ARS PLE PEN 10 Checking Spelling kee iiser eanan he HERR eS How PHAR ERA Bor e
146. Caregivers pp Manning Terry MD eee Medicine 1 Internal Pe Bretlaw Nicholas e n Reason For Visit Donkin Darlene ARNP Pediatrics 1 Doctor Review of Systems Gripiano Dr Arlene Vals MANNING Dr Tatiana T i Medicine 2 Internal E Physical Exam Medicine 3 Internal lt 5 Assessment and Plan Medicine E Internal D Electronic Prescriptions Nurse Registered Sign OFF Ob Gyn 2 Doctor L Title Bar Ob Gvn 3 Doctor Je Ob Gvn E Doctor m History Pediatrics 2 Doctor amp l Lists 00 Pediatrics 3 Doctor me Ouick Lists Pediatrics E Doctor l My Short Lists Practice 1 Family Practice 2 Family Dropdown count 15 review m 2 From left pane under Lists select Quick Lists 3 At Lists click down arrow to select a list type 4 Inlist of items that display double click items or select them and click amp to move them to Quick List NOTE To remove an item from Quick List double click it or select it and click a 5 Continue selecting quick list items as needed 6 Sort quick list using icons below Move to Top Click to move item to the top of the list Click to move item up one Click to move item down one Move to Bottom Click to move item to the bottom of the list Sort Ascending Click to sort list in ascending order Sort Descending Click to sort list in descending order 7 At Dropdown Count limit number of items that display in drop down list without scrolling by clicking spin arrow
147. Date 4 11 2006 a til 1f2006 Nurses Note Patient goals M ap omiiia Pt decided to build stamina through rigorous gym program oy Occupational Therapy Note 8 43 OtherfUnknown By Color photograph Sy Old Chart Note Click X in the right upper corner to exit screen 210 2 Chart Functions Reminders If a reminder is placed on a patient chart it can be set to display immediately whenever the chart is pulled or alternatively on the start date of the reminder as long as it remains active NOTE Reminders become a permanent part of a patient record Once created reminders cannot be changed or deleted although they can be marked done Creating reminders on patient charts 1 With a patient chart open from the HealthMatics EMR Menu bar click Patient gt Reminders or Office Reminders or click Reminder on the left navigation panel Mr Fred Finley Male 41 years old 7 24 1964 Preferred Caregiver Family Practice E Insurance Company A 1712 Session Charts Office Patient Explore Options Took Launch Help es e Current Encounter dh v Show Pending Only Patient Mr Fred Finley e Subject _DatesTime To view only pending reminders click the Show Pending Only checkbox 2 Click gp Add Reminder iof x a Save to Chart gl High Priority Private Patient Fred Finley e Remind Caregiver Subject Consult reminder Remind On Jos
148. E Lesions B Rashes i E y STD Lesions General z Foot Ulcers Mental Status Alert 4ooears nenrvous agtace Hydration E ee Dehydrated JS HEENT e Eye 2 Neck ra L3 Lk exam Selected 2 My PE Lists 1 Search e Characteristics details System characteristics display in boxes Mental Status General Appearance and so forth Details are listed under each characteristic e Columns The number of columns displayed in the documentation pane is controlled in Caregiver Options see To set review of systems and physical exam defaults on page 119 and depends on the space available 3 Patient Contact Functions e Quick navigation tip If the choices displayed in the documentation pane are such that you need to scroll you can move quickly from one place to another in this pane by clicking anywhere in a white space and dragging the list up or down a hand displays with this movement e Quick tabbing through values Select values quickly by doing either of the following gt Click a detail multiple times to tab through its values positive negative deselected or gt Selecta detail then press the space bar key on your keyboard repeatedly to tab through the values 3 Select a detail then do any of the following to document Did not examine This is the first available option for each Did not examine body system Present To indicate the item is present click th
149. EMR toolbar click View Lab Results or from the menu bar select Office gt Lab Results or from the left navigation pane click Lab Results 2 Chart Functions NOTE Office gt Lab Results views all patients Caregiver Manager System Abnormals Only Mr Fred Finley e STREP QUICK TEST 86403 n BAC CULTURE OTHER 87070 d AMYLASE 82150 Patient Mr Fred Finley e jaj Status Ordered URINALYSIS W O MICROSCOPY 81 URINALYSIS W O MICROSCOPY 81 Newest bo Oldest sia Value Units Ordered Collect 3 29 2006 4 19 PM Ordered Collect 3 29 2006 4 19 PM Ordered Collect 3 6 2006 10 31 AM Ordered Collect 3 6 2006 10 30 AM Ordered Collect 1 11 2006 9 00 AM Chart Tasks Click down arrow and select Messages Click down arrow and select Lab Tasks Click down arrow and select i S Review All Displays Review Lab Results dialog Review Patient displays lab results for the selected patient Publish to Web Publish patient test results to the practice website if you purchased and connected HealthMatics EMR Access For detailed instructions refer to the HealthMatics Access Manual Result Entry Enter the results or Result Notes see Entering lab results on page 175 Merge Merge lab results from the Lab Interface with results on the Labs view A dialog box displays where you can select the test and merge it with the result Lab T
150. EMR windows see Windows Panes and Other Tools on page 8 1 To access refill requests sent to you for approval on the status bar or left pane of the HealthMatics EMR desktop click r Refill Requests Refill Requests an 37 Open Approve x Reject Caregiver Manning Terry MO Rx Manager lt None gt From Medications Patient ios Manager Syste FA Vitamin B 5 ViE Finley Mr Fred 4 7 2006 2 33 PM NOTE The number next to refill request icon zl 1 on status bar and in the left pane indicates number of refill requests awaiting action 2 To sort refill requests click column headings From Sorts items by users who sent the messages a Sorts items by importance with refill requests marked High Priority at the top 46 1 Office Functions Sorts items by medication name S Patient Sorts items by patient Sent Sorts items by date and time received 3 To assign a refill manager click the Rx Manager down arrow and select the name of the person assigned to call fax or transmit prescriptions to pharmacies 4 To approve refill requests sent to other caregivers IF you have been granted access click the Caregiver down arrow and select the other caregiver s name 5 To perform other functions click the icons on the secondary toolbar or right click for a drop down menu to perform the following tasks New Refill Request Insert Create a new refill
151. Family No Known Allergies A Past Medical bi Social Immunization History Travel Hep B series 02 05 1995 R Medication j Pregnancy Gath Family History Breast Cancer Matemal Grandmother Essential Hypertension Father still Ining Negatwe Family History of CVA Coronary Artery Disease Insulin Dependent Diabetes Mellitus Past Medical History Asthma Diagnosed in 1975 Social History Living Situation Lives with spouse Current Work Study Status Full time Mon Smoker Ma Tobacco Use Alcohol Use Occasional alcohol use Medication History Albuterol BOMCU AACT Aerosol Soln Inhalation Taken starting 1975 Continued Hx Entry NOTE The folder tree on the left uses colors and fonts to indicate the presence or absence of patient history in previous and current encounters for each category e Yellow Folder contains previously entered history e Gray Folder does not contain previously entered history e Bolded font Folder contains current encounter data 2 To view current encounter history data from the History folder tree highlight History All items documented in the current encounter display to the right 3 To create a general history note for an encounter from the secondary toolbar click Note e Enter general information regarding the patient history on the Text Image or Voice tab e Click OK to return to History view The note displays in italics at the end of the History data 4 To include al
152. Father stil ving No Known Allergies R ahna Diagnosed in 1975 I Non Contributory Past Medical History 1 73 Social Living Situation Lives with spouse P Current Work Study Status Full time Pk Nen Smeker No Tobacco Use blu Alcohol Use Gocasional alcohol use 2 To view details select an item Click the x in the upper right corner to close History Explorer and return to the face sheet 3 To revise a history item select it and click amp Edit History Renamedas Manifestations Status active t Abdominal pain td Anaphylaxis td Anemia Ltomments d Im 3 i na X B om v els tj Blood disorder n d Coagulation disorder 4 Cough td Dermatitis 3 Diarrhea t Difficulty breathing 3 Difficulty swallowing Dizziness d Eczema Edema 3 Headache d Hives El Hypotension 151 Face Sheets 4 Change any of the following history details e Renamed as Type a new name for the history item if desired e Status Click down arrow to select a status Active Inactive Resolved Erroneous Entry or Undefined NOTE Entries marked Erroneous Entry do not appear on the H amp P Report e Include In the pane on the right click to expand folders and double click details to include them in Comments e Comments Selections from the pane on the right display in the Comments text box You can also enter free text and auto expand comments into this box 5 Click OK to save changes and retur
153. Flow Sheet e f you attempt to file a chart requiring sign off the H amp P report displays so that you can sign off on the chart Signing off from the H amp P ends the encounter and automatically files the chart Printing entire charts 1 Open a patient chart to the face sheet p 2 On the toolbar click c amp gt Print Entire Chart Chart Print ate Range jal Dates rinters Ps HPCLI850 on rprint1 From BOT Prin Cancel 3 At Include in chart select or deselect the items you want to print 4 At Date Range click the search button urrent Range C Today The past year The past week The past 2 years The past month f All Dates The past 3 months Specific dates The past 6 months Include in chart Attachments Messages Scanned Documents pecific Dates From I DaT aT a ad a 720086 144 2 Chart Functions 5 n Current Range select the period of time you want to include for the documents NOTE If you select Specific dates enter the dates in the Specific Dates fields below 6 Click OK 7 Click the Printers drop down arrow to select a printer then click Print Face Sheets The face sheet view provides a summary of each patient chart Each of its five panes displays a list of items including Problems History Encounters Medications and Orders 1 To access a patient face sheet in H
154. K to close Output Template Settings Using encounter packs 1 When you are ready to output your documents for an encounter with the chart pulled access the Print Template Packs by doing any of the following e From H amp P Report Click EF Sign Off or click 5 Bill or on the toolbar click amp gt Draft From a Assessment Plan On the toolbar click amp gt Draft At the bottom of Sign Off Chart click the Template Pack down arrow and select a pack to generate the documents you need for the encounter with one click Print Template Pack T Encounter H amp P e Check All Encounter Lab Orders a Encounter Pracedure Orders Uncheck All Patient Education Referral Letter v S amp P Prescriptions v Forms Lekkers Click A amp P Prescriptions and Forms Letter to generate these documents They cannot be included in an encounter pack System defined encounter packs Standard Print Pack all encounter types 389 Encounter packs 390 gt gt Encounter Procedure Orders Print Encounter Lab Orders Print Specialist Letter Print Referral Letter Print Patient Education Print Standard Fax Pack all encounter types gt gt gt gt Encounter Procedure Orders Fax Encounter Lab Orders Fax Specialist Letter Fax Referral Letter Fax Office Visit Print Pack gt gt gt gt gt Encounter Procedure Orders Print Encounter Lab Orders
155. MEEZNM ome pee Filled Circle Draw circles that are filled fn P Text Open a Text Properties dialog and type text that you want to appear on the image click OK and then click on the image where you want the text to appear NOTES To change the color of the lines or the fill color click and select the desired color To undo the last change made to the image click gt To clear the Image tab click tl To save the image to a file click lal Voice If your hardware includes sound cards and microphones and is fat client you can dictate notes of up to 5 minutes in length To do so click the Voice tab and use the buttons as you would on a regular tape recorder see Entering voice messages in notes on page 349 Mote Text Image Voice Import EI Dm noe gru 00 00 000 1 Office Functions Import You can include files in your messages such as scanned or other documenis that have been saved to your hard drive To do so click the Import tab Mate Text Image voice Import gt E a Click t Load from File browse to select the desired file and click Open Sending mail messages Mail messages provide a fast convenient way to communicate with one or more caregivers in your practice about things that do not pertain to patients NOTE You cannot attach mail messages to patient charts Use patient messages for items that need to be documented in charts see Sending patient messages on p
156. N eNew Encounter gt Select an existing encounter to join or click New Encounter to open a new encounter that will be open at the same time as the existing encounter Click OK To pull patient charts for non billable contact You can pull charts for non billable purposes such as reviewing previous encounter information entering lab or procedure test results or entering demographic information 1 From the HealthMatics EMR toolbar click J Pull Chart Last Name Date of Birth Lees sx I Clear Patient Id Address Eo SSN Search Training Patients Search Results LastName FirstName Patientid ssw Gender Date of Birth Phone Address NOTE If your practice has a practice management system Add may not appear on your Patient Search screen In this case enter new patients into your PMS or see your system administrator to change site settings to Allow Demographics Entry Enter data in the fields then click Search NOTES SSN The Social Security number field automatically adds the hyphens once the ninth digit is typed 999999999 becomes 999 99 9999 2 Chart Functions Date of birth To enter a date of birth type the date using the format xx xx xxxx month date year or click the search button to display a quick entry window For instructions see Entering dates on page 10 Phone Enter a telephone number For instructions see Entering phone numbers on
157. OTE If the patient s chart is open for a current encounter when you click amp to select the current patient for the refill request after you click OK in the Warning message stating the patient s chart is currently being changed in an active visit an Outstanding Refill Requests message may also appear Click OK again to open the Refill Request dialog box 1 Office Functions eRefill Requests NOTE eRefill Requests are only available for practices that have installed ePrescribe This product allows you to send new prescriptions and receive refill requests except narcotics electronically over the SureScripts network if it is available in your area eRefill Requests are pharmacy generated messages alerting you to a patient s request to the pharmacy for a medication refill To prescribe electronically you must set a caregiver up as a SureScripts user and enter a SureScripts Provider ID SPI ID in the Administration Module You must also enter a NCPDP ID for each pharmacy Prescribing agents Users granted access to eRefill requests work on behalf of the caregiver that receives an eRefill request from the pharmacy When the eRefill request is returned to the pharmacy the SPI of the original provider along with the caregiver name is placed in the response message Assigning a prescribing agent allows the user as well as the caregiver to see or address the eRefills Once processed by either the eRefill disappears Outgoing messag
158. P HEALTHMATICS SOLUTIONS Now part of ALLSCRIPTS HealthMatics EMR Application Reference Manual May 9 2006 Statement of Confidentiality The information contained herein is proprietary and confidential to A HEALTH SvsrEMs No part of this document may be reproduced or transmitted in any form or by any means electronic written or mechanical including but not limited to photocopying and recording or by any information storage and retrieval system without prior written permission from A HEALTH SYSTEMS Statement of Accuracy This document is thought to be fully consistent with the level of product it describes at the time of printing Information is subject to change without further notification A HEALTH SYSTEMS does not assume any liability or provide any guarantees for the contents of this publication If you have any comments concerning this document contact the Education Specialist at A HEALTH SYSTEMS Statement of Responsibility Client agrees to be fully responsible for the operation of the system as outlined in the HEALTHMATICS User Manual and in accordance with the laws of its state To contact A HEALTH SYSTEMS A HEALTH SYSTEMS Phone 888 672 3282 5501 Dillard Drive 919 851 6177 Cary NC 27511 9234 Fax 919 851 5991 USA Web site http www a4healthsystems com Revision History and Copyright Trademark Information Original Release Date 5 11 06 Revision Release Date 5 11 06 Copyright 2005
159. Patient Greene ae alll Status Needs Review Abnormals Only Sort Newest to Oldest Name l Staus Value Urs O aecGeee B amp GLUCOSE 82947 Final Collect 3 14 2006 3 07 PM GLUCOSE Final g mgjdl From the Lab Results toolbar click Lab Tasks Review Patient a Review Lab Results ux e racesheet G Annotate Toggle Review Hama Value Uni Range Review 4 Alie Gene Yes amp GLUCOSE 82947 Collect 3 14 3 07 PM Yes Aci ua Fam mud 75 17 Teg amp URINALYSIS W O MICRO Collect 2 27 417 PM Yes LIA APPEARANCE clear Yes LIA COLOR ethos Yas LIA CXLLK CISE und Yes LA RE TOES nd Yas LA SPECIFIC GRAVITY iam 1 001 1 035 Yes LIA FH vend 3 6 8 0 Yas UA BLOOD veni Yes LIA BILIRUBIN amd Yes LIA PROTEIN vnd Yes LA NITRITE veni Yes UA REDUCING SUBSTAN vend Yes gt Reported 3 14 2006 3 08 PI Reviewed Reported Ey System Planer Reviewed By cea 3 Select the lab test or result to annotate 183 Lab Results 4 From the Review Lab Results toolbar click Annotate NoteforLab GLUCOSE o EN c EX H m oU S dad Remove All Print OK Cancel Use conventional word processing tools or Auto expand text to enter an annotation for the result then click OK NOTES Annotations display in the bottom pane of the Lab Results screen To remove an annotation from a result before the item is
160. Pulling charts IMPORTANT You can pull charts from multiple locations within HealthMatics EMR However to ensure accurate billing for a visit if you use HealthMatics EMR with a practice management system PMS always pull patient charts from either Appointments 1 or Received Charts 3 in the left pane of the desktop or the status bar To pull patient charts for billing From appointments l From the left pane of the HealthMatics EMR desktop or the office menu click Appointments From the right pane double click the appointment to open the chart to the patient face sheet From received charts 1 During patient visits from the status bar or inbox on the desktop click 4 1 Received Charts From the right pane double click the item to view the Chart Message attached to the chart 139 Patient Charts 140 3 Click Pull Chart then click Yes to delete the message once the chart is pulled To pull charts for concurrent encounters Depending on administration module settings selected by your practice more than one encounter at a time can be open for a patient chart You can select an encounter to join 1 From the HealthMatics EMR Appointment screen double click the patient to pull the chart If an encounter is in progress the following message displays Encounter Selection Encounter Date n By ag 3 23 2006 5 40 PM Manning Terry MO OB G M Clinic Unspecified Diagnosis E
161. Refresh F5 Refresh the screen to Refresh the screen to bring in the most recent data in the most recent data Show only Signed Lectin the box to display only documents with electronic Documents signatures 2 To locate an output document click Site on the secondary toolbar and select a quick filter or do the following e Click the Location and Caregiver down arrows and make selections e Click a Patient button gt fto search for a patient see Patient Search on page 14 or gt amp to select the current patient or 93 Output Queue gt Al to select all patients e Click the Dates search button and select a date range e Click the Status down arrow and select either lt All Requiring Action All Statuses gt Done or Faxing e Click the Category down arrow and select the category of the output for which you are searching dh c GS open output Tasks SZ Fiter S show only Signed Documents Location lt All Locations gt Dates The past week E Caregiver All Caregivers Y Status Done Patient cai Patients gt e all Category Prescriptions X Status Patient Document DatejTime cCaregwer Destination Commen ierinted ss Fred Finley Accutane 10M 03 31 06 02 41 System Manager NETprint2 on rprintl Mr Fred Finley Accutane 10M D4r0 306 10 38 am Terry Manning METpr 3 Select an item to
162. Requisitions See Viewing editing ask on entry questions on requisitions on page 224 2 Select the Requisition to delete then click 3 Click Yes to confirm deletion IMPORTANT Requisitions may not be deleted if e An order s on the requisition has results entered e The requisition is turned over to the interface with a status of Ready to Send Wait for Resend or a status of Sent OK The ordered test on the requisition moves to the Orders page The test is not deleted Printing requisitions 1 Access Requisitions see Viewing editing ask on entry questions on requisitions on page 224 2 Select the Requisition then double click or click amp to view the item to print 3 Click Print Printer hare ae Oce 3165 PCLSe Properties Stabus Ready Type ce 3165 PCLEe Where IP 172 16 11 60 Comment ec ren 4 Click the Name down arrow to select a printer if desired or click Properties to adjust printer properties 5 Click OK 226 2 Chart Functions Processing requisitions To access requisitions 1 From the HealthMatics EMR Menu bar click Office gt Requisitions or from the left navigation pane click Requisitions n Clinical Mioduhe Requisitions Seon Chats Office Fx Options Took Launch Help a TT Ae r T fa c Ba i E n By T do T Batch Petal AL Seeranaders i lt a a Lab Rents TA E Labels P Resend E 8 Procedure Results
163. See Reviewing received charts on page 143 2 Chart Functions Reviewing received charts 1 From the status bar or left pane of the HealthMatics EMR desktop click 1a Review Received Charts 2 Double click a name on the list to view the message attached to the chart Chart Message mf x Capete kPulChat CF wew Har Gerephy wilFonwerd G Print From Manager System To Manager System Sent 4 3 2006 11 13 AM Patient Mr Fred Finley Subject Chart Review Mr Fred Finley E Text image voice import 3 To review the chart click Pull Chart and Yes to remove the message from your inbox NOTE Received chart messages are removed according to these conditions e If the sender did not enter any contact data Reason for Visit through H amp P screens you can remove the message without pulling the chart If the sender did enter data in any of the contact windows you must pull the chart or have the chart on your desktop before removing the message The message can also be removed by forwarding it to another caregiver who is authorized to pull that patient chart and remove the message Filing charts You can file charts from either the toolbar or from the status bar To file an open chart from the toolbar To file the chart for a patient whose name displays on the title bar in HealthMatics EMR click amp File Charts on the toolbar or press F4 NOTE If a chart needs to be signed off by
164. Shortness of breath sens 07 Yes C No V Leg Cramps seseeseen nens C Yes C No ff Abdominal pain eeeeeeee C ves No amp orc TER TET anan asas nananana C Yes No ff Constipation eere ens C Yes No f Depression aree rernm nns C Yes C No All Other Systems Negative NOTE If you have applied a template or documented on the ROS Contact Screen those values populate the ROS tab in the Pregnancy Record 4 Click each radio button for each symptom as required IMPORTANT The third radio button for each item resets the answer to nothing 5 Click OK to save and validate all data in the edit window or go to the next tab to continue documenting data is not automatically saved 6 Optional Click Cancel if you do not want any data saved from the edit To edit pregnancy record maternal fetal data NOTE This information is bidirectional with the 59400 Routine Obstetric Care Procedure Rule View Procedure Results 1 Access the Pregnancy Record see Accessing the pregnancy record on page 322 2 Select a visit date and press F2 or click Edit Record 3 Patient Contact Functions 3 Click Maternal Fetal Data tab Antepartum Record Vitals UJA Pregnancy Labs ROS MaternaliFetal Data Cervix Medical Hx OB History Pelvimetry Next Appt LMP 116 2006 ka months ago m Gestational Age 13 Weeks 6 Days EDD By LMP 10 23 2006 Based on
165. Specific date 3 The Print Properties window displays see Printing patient demographics on page 166 for more print property information 337 Immunization Records 338 Immunization Records When you order immunizations in HealthMatics EMR they are recorded automatically in the Immunization Record In Immunization History you can also record the overall status of patient immunizations Accessing viewing Immunization Record Immunizations entered into HealthMatics EMR are captured in an Immunization Record that can be previewed included in the A P and printed to give to patients Open a patient chart and from the left pane select Immunizations or from the HealthMatics EMR toolbar click the Demographics down arrow ji and select Immunizations Mr Fred Finley Male 41 years old 1212 AT amp T Session Charts Office Patient Explore Options Tools Launch Help e o mus5Bo 9d 3 mapu zesf 5 CH Saar JT 2 core acters Face Sheet l Patient Manager 4 Immunization Record Er Immunization 7 idea 3 i i Demographics l ninmi er Reminders v Show all Immunizations Indude In H amp P E Flow Sheets eT Immunization Immunizations 5 BM us Adenovirus type 4 90476 Tt a Adenovirus type 7 90477 The Immunization Record tab with the Show all Immunizations checkbox selected is the default view Immunization Record tab
166. To facilitate printing during a patient visit and at checkout you can select output templates that you want to have available from each screen and create encounter packs that bundle certain items in a print pack for various types of visits You can select settings either by site location or caregiver in the Administration Module By site Select Site Settings gt 9 gt Output Settings e By location Select Locations gt select a location gt 4 gt Output Settings e By caregiver Select Caregivers gt select a caregiver gt gt Output Settings Output Template Settings Screens Templates Encounter Packs screen P 4j etChart Assessment Plan Chark Attachments Demographics Face Sheet Flow Sheets H amp P Report History Immunizations Physical Exam Reason For Visit Result Summaries Review of Systems Vitals r Office Chark Additional Results r Office Chark Lab Results r Office Chart Procedure Results A EE IT eh Marinda On the Screen Templates tab you can select the output templates that you want to be able to print from each screen see Selecting output settings for each screen on page 386 On the Encounter Packs tab you can create bundles of document templates that can be printed faxed or queued all at once at signoff see Encounter packs on page 388 NOTE When you assign templates to a view the screen name is bolded 385 Output Settin
167. VE Review of Systems APTYLASE 82150 Ordered Collect 1 11 2006 9 00 AM 2 At Status select Ordered 3 Select Caregiver Patient Dates Sort as needed 4 Click or z to expand and display patient labs then select the one you want to Mame Units Mr Fred Finley amp STREP QUICK TEST 86403 Ordered Coleck 3 29 2006 4 19 PM S BAC CULTURE OTHER 87070 Ordered Collect 3 29 2006 4 19 PM 3 URINALYSIS W O MICROSCOPY 81 Ordered Collect 3 6 2006 10 31 AM amp URINALYSIS WIO MICROSCOPY 81 Ordered Collect 3 6 2006 10 30 AM e AMYLASE 82150 Ordered Collect 1 11 2006 9 00 AM 4 Li Ordered 3 29 2006 4 19 PM by System Manager Site LABORATORY Collected S29 2006 4 19 PM Requisition Reported Accession Reviewed Diagnosis ACUTE PHARYNGITIS 462 175 Lab Results 5 On the secondary toolbar or right click for a menu click Lab Tasks gt Result Entry Mame f m Fred Finley A STREP QUICK ES i9 BACCULTURE O1 3 URINALYSIS W O ES chart Tasks URINALYSIS W O AMYLASE 82150 Gl Messages Status Value Units ds Review AL Bui ea Review Patient HMP d Publish to Web Selected Patient us Next cee amp PLATELETS AUTO 85027 T9 Skin Entry Reported 4 5 2006 1 98 PM i Status Partigly Reviewed i HGB HEMOGLOBIN H MCW MEAN CORPUSCULAR 176
168. Visit 5 CC HPI History all eight areas 7 Quick Assessment Plan and A P Assessment Plan all include a My Short Lists tab The My Short Lists tab holds short lists an individual caregiver uses most often on those contact screens In Options Edit Options My Short Lists you can specify defaults and put these favorites in the order you prefer See Setting caregiver options for my short lists on page 240 Specifying my short lists for assessment plan 1 Open a patient chart and from the toolbar or left pane click Quick Assessment Plan or A P Assessment Plan d 12712 Insurance Carrier Unknown Explore Options Tools Launch Help c a 33 x0 m E 6 8 87 20 3X wp Aconcomant lI 5 E gt Current Encounter 4 Information FP Adult IM Laborato Mast Master AGP Adult Well vici Master ABP OB J Gyn Master AGP Pediatric Sick Visit Master AGP Pediatric well Visi 2 Click the Short Lists tab and Collapse All 3 Hight click a short list you commonly use or just select it and click Add to My Short Lists NOTE If the short list can be added the bubble message shown above appears and the list is copied to the My Short Lists tab If a selected item cannot be added usually because you have selected a subfolder under the short list a Warning message tells you to Please select a Short List Specifying m
169. With a patient chart open click A P and order the 59400 Routine Obstetric Care procedure 2 From the HealthMatics EMR menu click Tools gt Pregnancy Record Mrs Mary Jo Young Female 26 years old 2 14 1980 Preferred Caregiver Session Charts Office Patient Explore Options Tools Launch Help m Eg 4 75 35 63 g G EditReferral Caregivers Edit Insurance Carriers Face Sheet urance Car Problems All Acuity eo 4 Edit Institutions 4 Patient Merge Pregnancy Record NOTE If the encounter does not have an active 59400 CPT a warning message displays Click OK then add the 59400 Routine Obstetric Care procedure through A amp P 3 Patient Contact Functions 3 Additional pregnancy record access option available from Patient Manager e From HealthMatics EMR left navigation pane and with a patient chart with an active 59400 rule open click Patient Manager oh Mrs Mary Jo Young Female 26 years old 2 14 1980 Preferred Careg Session Charts Office Patient Explore Options Tools Launch Help c gt hOS0 63 S3 2aa Bu Face Sheet B Patient Manager gud Patent Manager Qd Demographics B Reminders 3 Flow Sheets a Immunizations P Chart Attachments i9 Lab Results Pregnancy Record E3 Record Edt Reminders e needs to be on this med Open needs to be on this med Open LMP 1 1 2006 P Result M Procedure Ress EDO 10 20 2006 by Physici
170. a amp de aneincer AGS SB eS Hike B Sk eS Md CHE SOLOS Rew RA FSi Sees 370 Summarizing the service level 0 0 eee ees 370 Adjusting the service level llle 373 Fast Track Templates 2 a ES hee eae ee s ue ax 374 Cancel CONC i46 99d tee bn ee te eee eee 375 4 Prnnung and Faxing usd xatd eee eee eee Us E 377 PM Feriis ee nudes s aea d oe a eee ae Da ada aa a RON RC RR EROR 377 Templates 2s cocus ooh esese esas hee coe oe eee eee 4 3 8 Fri ron any VIGW scis ioo deu iecore d fier ode E pode dol ecl deo 379 HealthMatics EMR Application Reference Manual Faxing Trom any VIO WE usce Doo 9 Aa ns dle Wate E 2 S 9S RO 381 Queuing and saving to log from any view uuaa 382 Exporting from any View 1 hrs 382 Previewing documents from any View 6 0 eres 383 Output Defaults 5 5 a3 9 32 x23 Io amen ees Red nca a ila sta woes se Seer aes 384 Creating output de dull sels 42342 b Ex p ERROR RE X E ES bod 384 Using output default sets u xis tier e e aves RU doe Ope i pat toon 385 Output SCNINGS 2 452 x counts es et oes a dou ee ben mae ds 385 Selecting output settings for each screen llllllllllllssnn 386 ENCOUN Da KS 2326006 dS PR EOR dc ett ree ine ba eee dae 388 Creating encounter packs 0 ccc eee teens 388 Using encounter DECKS 6s d ac uot dh Deo SC eaten dba b don Pob doR Ad oed ees 389 Assigning access for refaxing or reprinting prescriptions llus 391
171. a Hayes Test Name LEAD 83655 Collected 4 12 2006 4 10 PM C Urine Initial C Yes C venous blood Repeat C No Fingerstick blood Follow up C Unknown County Code In Tyoe and Purpose click radio buttons to select type and purpose of the test In Hispanic indicate whether the patient is Hispanic to meet LabCorp specifications In County Code enter the code for the county in which the specimen was collected must be 2 to 5 characters In Comments enter comments as needed Click OK Answering ask on entry AOE questions for orders 1 2 3 Access Lab Order Entry see Accessing lab order entry on page 214 Click Order Select an encounter or an order that has AOE questions mapped to it then double click it Click OK to display Create Requisition Complete any additional information needed then click OK NOTE If a lab source was defined the Lab Source dialog displays Click OK 2 Chart Functions 6 If AOE questions were defined for the selected test panel the Ask On Entry Responses dialog appears Ask On Entry Responses x T stjPane a ucose 82947 Instructions Tf Yes reschedule lab draw x po Lom en lel 7 At Answer type the answer to the question then click Apply for the answer to display in the Answer column in the top pane 8 Click OK Answer 223 Lab Order Entry Viewing editing ask on entry questions on requisitions After or
172. a Source Referrals Seach Rs Category Alergy and Immunology as Bartels Barry Ni Search Term E H NS F aa NOTE For detailed instructions for ordering referrals see Documenting referrals on page 311 Then enter responses from referring caregivers in the Additional Results view To access referral results When referral results are received from the referral physician enter and mark them Reviewed in Additional Results 1 From the HealthMatics EMR menu bar click Patient gt Additional Results or Office gt Additional Results or from the left navigation pane click Additional Resuks Additional Results 2 Click the Status down arrow and select Ordered E C Summary Additional Results 4 7 Face Sheet F nM d ueResu Tasks C Chat Tasks G3Messages qs Sprite E B Danom anhiis Pi fini ini Caregiver Manager System Bates The past 3 months 3 Flow Sheets Patient Susan Frawley gl an Status heeds Reima A Immunizations Newest to Oldest iP Chart Attachments ee tet 1 i Lab Resuks Palent Procedue Status rdered Date BB Procedure Results X susan Fraley ae Additional Results FH Bartels Barry MD Final Not Revie 4 10 2006 2 25 PM 195 Additional Results 3 To enter results select the referral procedure then click Result Tasks gt Result Entry Additional Results Entry Susan l
173. a list of all available icons and instructions for placing them on your toolbar see To customize your toolbar on page 110 NOTE In addition to the main application toolbar most views also have secondary toolbars that display immediately below the primary toolbar and contain additional icon shortcuts Using the status bar 1 Office Functions The status bar is located at the bottom of the HealthMatics EMR window Logged in as Manager System Appointments 7 o 7 3 Ge 1 foo fbi Bu Gee uo y NOTE The status bar may include other icons if you have purchased and turned on additional functionality such as Web Messages from HealthMatics Access This bar displays no matter which view you are in The user login in appears at the left followed by the name of the view currently displayed Appointments in the example above Shortcut icons for appointments 2 and open encounters 3 are followed by inbox filter icons Appointments Open Encounters Hesult Notifications Messages Refill Requests Documents Action Items Received Charts Accesses the schedule of appointments for the day patients checked in but not out Lists encounters open on the desktop encounters in progress not yet signed off Lists lab and procedure results awaiting review Notifications never opened Flashing red Notifications containing abnormal results Flashing is optional see Urgent message indicator on pag
174. a text note about the selected system then click OK to return to Review of Systems n gt Current Encounter i DRAS 9 e Ello akwend a AON Rewer of Systems MS General Templates Tc ROS Female default fuappy Elpreview a Skin e HEENT E pg Respiratory a ve Neck ell chronic um t Respiratory v E cough aJ JE Breast Patent to bring chest raps fo next vet vt Cardiovascular C Decreased Exercise Tolerance JE Gastrointestinal Male Genitourinary ees Snoring Musculoskeletal XE Difficulty Breathing Neurological Patient requests additonal xrays Aw brother had recently Psychiatric i Respiratory e feces oe 2A Respiratory Fresen Cough Patent to bring chest xays to next vit Mot Frasenc Map i prep Breathing Patent requests additional xrays Ahi brother had recentiy Note Fad Selected 3 asked to bring chast xrays to next visi My ROS Lists Search The note icon displays a colored background and the note text displays after the selected system in the preview pane and the H amp P report NOTE To view the complete text of the note either click the note icon after the system or the note text hyperlink To add ROS notes at the detail level 1 e In the Review of Systems navigation pane select a system such as Respiratory In the documentation pane on the right click a detail such as Chronic Cough either
175. ab Order Entry view tests and panels ordered in Assessment Plan You can generate printed requisitions and labels for specimens Lab Order Entry includes the following e Orders Each single result test or panel result lab is considered one lab order Requisitions A requisition is an electronic form documenting a group of lab orders for one patient and may be associated with specimens e Batch Processing Requisitions grouped together in a printable format processed in a batch Requisitions can be electronically transmitted from this screen Accessing lab order entry 1 From the HealthMatics EMR left navigation panel click Lab Order Entry to expand the folder Clinical Module Lab Order Entry Session Charts Office Patent Explore Options Tools Launch Help t jm au 8 dg s 3 b Reminders al Lab Order Entry tan Lab Results BB Procedure Results x Additional Results Ch La b Ord er Entry Ge Report Results f Output Queue I Work Log Billing Reconcliabion E Audit Open Encounters WIES DAZU 3 Orders Sy Requestions sy Batch Processing 2 Click the subfolder required 214 Viewing lab orders 1 2 Click Orders 2 Chart Functions Access Lab Order Entry see Accessing lab order entry on page 214 dn Location lt All Locations gt Patient Caregiver lt a Caregivers gt Dates 2 Eb Finley Mr Fred E E 3 23 2006 Office Visit
176. ach time you print this document type NOTE If you select Always Prompt the Printer field remains blank 5 Click OK to save the default printer for that layout 6 Select another Output Category to set more printer defaults or click OK to exit NOTES e Any Output Categories without default printers assigned default to Always Prompt e Caregiver output defaults can also be set by clicking My Output Defaults on the toolbar of the Administration Module 130 1 Office Functions Editing default locations The system uses the default location when an encounter is not associated with a scheduled appointment 1 To set the default location from the menu bar select Options gt Edit Default Location Default Location Ea 2 Click the Location down arrow select a location and click OK Editing auto replace text In HealthMatics EMR you can set up automatic corrections for commonly mis typed text as well as create standard statements that auto expand upon typing the first few letters of the statement in all Note Comment and free text fields Auto correct example Ask the system to automatically correct respitory to respiratory or correct hte to the Auto expand example Ask the system to automatically expand cv to cardiovascular or Injury to Injury due to accident on or fu to Patient presents for follow up visit for Both Auto correct and Auto exp
177. added to My Short Lists The list is copied to the My Short Lists tab If the short list cannot be added either because you have selected an item below the short list level or have already added the selected item to My Short Lists a Warning appears Setting caregiver options for my short lists 240 After specifying My Short Lists in Reason for Visit History and Assessment Plan see My Short Lists on page 239 you can set caregiver options for sorting the lists setting default short lists or deleting short lists from your specified favorites 1 From the HealthMatics EMR menu bar select Options Edit Options 2 Inthe left pane click My Short Lists 3 Patient Contact Functions 3 Click the Types down arrow and select the type of list you want to sort Short lists you specified for that type display in the pane below L Caregiver Options for Manager System General My Short Lists Desktop Toolbar My Short List Options Face Sheet Types Patient Manager assessment and Pan tt e Lab Results Short List Reason For Visit TCFP Master f Review of Systems FP Master AGP Adult Well Visi sen vitals FP Aduk JIM Laboratory T Physical Exam Assessment and Plan ir Sign OFF Tithe Bar History a Lists ere LEN amp l at ca 4 Selecta list and click icons to do the following fh Make Default Make selected list the default for My Short Lists tab This is a caregiver default Move to T
178. age 39 You can also attach Microsoft Outlook emails to patient charts see Outlook Inbox on page 85 1 Tocreate a new mail message do one of the following e From the HealthMatics EMR toolbar click Send gt Send Mail Message or Click f amp Messages on the status bar or the left pane of the HealthMatics EMR desktop to access the Messages view and then press Insert on your keyboard or click 5 New Message gt Mail Message Select Recipients Ea f Donkin Darlene ARMP Gripiano Dr Arlene 5 Manager System MANNING Dr Tatiana Manning Terry MO 5 Medicine 1 Internal f Medicine z Internal Medicine 3 Internal 5 Medicine E Internal 5 Murse Registered Ob Gvn 1 Doctor e Ob Gvn 2 Doctor 5 Ob Gyn 3 Doctor Ob iGvn E Doctor cma 2 Click the Filter By down arrow and select a filter to narrow choices if desired and then select message recipients by doing one of the following e Double click each recipient s name in the Caregivers list or e Select the recipients name and click amp next to the To or Cc box or e Click amp to send the message to all caregivers 37 38 Messages NOTES Select multiple names by pressing Ctrl or Shift keys while clicking names To remove names from the recipient list select a name and click m To clear all names from the To or cc list click 4a After selecting all recipients click OK 9 Mail Message _ OF EJ Send a Ir
179. age tab click Load Image from Library 6 Use the Chart Attachment toolbar icons to do any of the following e To save to chart click Save to Chart To preview print click amp amp Print Chart Attachment To email click Email Chart Attachment 7 Click X in the upper right corner to close window 208 2 Chart Functions Linking chart attachments to office visits 1 With the patient chart open in HealthMatics EMR from the left pane or the toolbar click Face Sheet 2 If encounters are not already sorted by date click S Toggle Filter to sort the encounter By Date 3 Click on the Encounters title bar to maximize the pane ROMBoO SG BSHaa Pw Fier De VHewMDS Ly Summary Face Sheet il Patient Manager i Bf Demographics A f F 4 El B Reminders co One Week Agel EE Flow Sheets SETT A Immunizations Z9 Chart Attachments o Lab Results EB Procedure Ress 4 2006 Office Visit Unspecified Diagnosis Darlene Donkin NP 9 26 2004 METABOLIC PANEL BASIC 80048 Sy 3 31 2006 Office Visit System Manager P 4 4 2006 Occupational Therapy Note Waking on daily basis Manager System ig 3 29 2006 Office Visit ACUTE PHARYNGITIS 462 5ystem Manager 4 Locate both the attachment and the office visit you want to link it to 5 Click and drag the attachment with the paper clip to the appropriate office visit The attachment can now be viewed from the H amp P Re
180. aking and verify the billing level Bill Bill the encounter with or without signing off the chart Printing choices are available from the Sign Off window 3 Patient Contact Functions e Submit Send the chart for review by another caregiver To conduct chart reviews The chart review functionality is designed for use with residents physician assistants and nurse practitioners who must have attending physicians review and sign off on their work 1 With a patient chart open in HealthMatics EMR and the encounter documentation complete from the left pane or the toolbar click i H amp P Report 2 Click fg Submit to display Submit for Review Submit for Review GI 4 Please select a Caregiver to Review the Chart Caregiver aser MT Es Save as Defauk Review Caregiver oma 3 At Caregiver click down arrow and select a reviewing caregiver from the list NOTE To make a caregiver the default reviewer for the caregiver logged in select the Save as Default Review Caregiver checkbox then click OK 4 The To and Subject fields of the chart message fill automatically E Chart Message EJSend iy High Priority Subject Chart Review Mr Fred Finks Patient Mr Fred Finley Text image voice Import Saji Hac o Dp im 5 If required click to select the High Priority chart review checkbox 6 If desired include a Text or other note 7 Click Send
181. althMatics EMR menu bar click Charts gt Cancel Contact 2 Inthe Warning box click Yes IMPORTANT Cancel Contact cancels changes you made along with any other caregiver unless you used Send Chart between entries during that contact only If you enter data for the encounter send the chart to another caregiver who returns it to you and then you enter additional data Cancel Contact only deletes items added in the second contact not the first If you made more than one contact with the patient chart and click Cancel Contact verify that all pertinent data was cleared If not go to each contact screen and click Clear 375 Cancel Contact 376 4 Printing and Faxing 4 Printing and Faxing All output functions are fully integrated into the Clinical Module providing the ability to quickly generate documents that have been user defined location defined or site defined from the point of care You can queue print fax save to log export and preview system defined and customized documents without leaving the current screen in the Clinical Module NOTE Output Queue allows you to print later and still track the documents generated from within the EMR Print Terms Document Template created in Output Manager Template Built in Output Manager by combining output blocks and assigning an Output Category Output blocks Text and data elements with their associated formatting that are used to build templates in Ou
182. ame as in Review of Systems see Adding review of systems notes on page 282 and Using text in notes on page 344 To add an image note At both the Physical exam and System level you can add an image note in addition to a text note see Notes on page 344 and Using images in notes on page 345 3 Patient Contact Functions 1 Click 5 then the Image tab Nabe for Chest and Lung Exam Load image Click down arrow to select image source t File System Library e amp Import Photo Save image to file wl c Pencil drawing tool Click down arrow to select from pencil line rectangle filled rectangle circle filled circle or text tools t Clear 2 Loadthe image from the image source 3 Click OK 287 Physical Exams Documenting measurements and sizes in PE 1 With a patient chart open in HealthMatics EMR from the left pane or the toolbar click Physical Exam 2 Inthe Physical Exam navigation pane click as needed to locate a measurement item and click Size i Ta JITA e 9 grae tup anbosda Colapse a for m Voice Templates Cffice Visit 09 25 2004 SINUSITIS ACUTE S App Preview d Skin ru a 8 C Genera BEA size c4 Shin Surface Se y Problem 1 Haight 5 Dy Lesions ety 7 8 3 Bksp z Sy Lesson First type value 5 sl Del UU Lesion second tyg Uts omm C mm Lesion third type ES aJ 2 3 vu
183. an lt gt Additional Results Blood Type O T Result Summaries Gestational Age 9 Weeks 5 Days Ei Contact Gravidity Farity Patient Manager Pregnancy Record Edit LMP Last Menstrual Period date displays once value is populated Estimated Delivery Date based on LMP or entered by physician Blood type Populates from Pregnancy Record until lab confirms then from Lab data Gestational age Calculated value from EDD By Physician if entered or LMP If the Gestational Age changes on the Maternal Fetal Data tab the change is immediately reflected on the Pregnancy Record main window the Prenatal Record grid and the Maternal Fetal Data tab Gravidity parity Number of pregnancies Number of live births 4 The first time you enter the Pregnancy Record with an active 59400 rule it checks for either an Estimated Delivery Date EDD or Last Menstrual Period LMP date 323 Pregnancy Record If neither date is found the Antepartum Date Selection dialog appears Antepartum Date Selection x Please enter a date For the patient s LMP or the EDD Date Options eee ee Date options Enter either an LMP or EDD date See below Data displays within a particular time frame namely the gestational period for the current pregnancy A valid date generates the text representation of the date such as 7 weeks ago Click ellipse icon to display a calendar to allow full or partial date selection Last Menst
184. anatory performing test s Service Click down arrow to select a service level NOTE Defaults for the Service level can be set at the caregiver level in Options Edit Options Sign Off Exam Click down arrow to select an exam type NOTE Defaults for the Exam type can be set at the caregiver level in Options Edit Options Sign Off Time for Visit 5096 counseling Click checkbox to indicate over 50 of the visit was spent counseling and or coordinating care 368 3 Patient Contact Functions Field checkbox Section Indicate the total duration of the visit Button Functions Resets all checkboxes Calculate Generates the E amp M visit level Summary View details that produced the service visit level when calculated See Summarizing the service level on page 370 Additional information from AlphallClaimmaker to assist coding Understanding the E amp M calculator E amp M level Displays the Evaluation amp Management level that results when you click Calculate and is based on the data documented and the items selected in the calculator Levels E amp M 99715 History Expanded Exam Expanded MOM Moderate e History The E amp M Level of service is calculated from the documentation provided for History Problem focused Detailed and Comprehensive e Exam The calculated levels of E amp M services are also based on Vitals and Physical Exam documentation
185. ancy C Single C Twins Gestational Age Calculation Method Multiple Indications Insulin Dependent Other Indications Routine Screening Advanced Maternal Age C Last Menstrual Period Previous Neural Tube Defects Ultrasound History of Down Syndrome C Estimated Date of Delivery History of Cystic Fibrosis Date M AFP Info Gestational Age Reason For Repeat Weeks b Days b bin T a Elevated Vitals Data Patient Weight ae X At Type of Pregnancy click appropriate type At Gestational Age Calculation Method do the following e Click to indicate the gestational age calculation method At Date enter the date that corresponds to the option selected Last _ Menstrual Period Ultrasound or Estimated Date of Delivery or click to search icon or click to default LMP from vitals At Gestational Age use spin arrows to enter gestational age in weeks and days At Indications click checkboxes as needed and enter AFP information as needed NOTE A maximum of 20 characters can be entered At Reason for Repeat click to indicate the reason for repeating the test if necessary Required At Vitals Data enter patient current weight in the field click either b or kg or click to default weight from vitals At Comments enter a comment if needed Click OK 221 Lab Order Entry 222 Specimen Collection Prompt Blood Lead Lab Specimen Patient ynthi
186. ancy record on page 322 2 Select a visit date and press F2 or click amp Edit Record 335 Pregnancy Record 336 3 Click Next Appt tab vitals UJA Pregnancy Labs ROS Matemal Fetal Data Cervix Medical Hx OB History Pelvimetry Ne Next Appt Tomorrow InZdays C Ini week on pi C InSdays In2 weeks C In4days In3weeks C InSdays In4 weeks C In days Initials Comments Y Te o i v4 a aA 4 Complete Next Appt as required 5 Enter initials NOTE This field can hold initials of multiple caregivers 6 At Comments use conventional word processing tools to add information as desired Comments are dated and display below the Pregnancy date grid 7 Click OK to save and validate all data in the edit window 8 Optional Click Cancel if you do not want any data saved from the edit Including unsolicited test results in pregnancy records To ensure unsolicited reflex tests a secondary test performed by the lab based on the results of the initially ordered test are included in pregnancy records print the record before staff merges the unsolicited test with results from the original order The unsolicited test results are automatically included in the record Printing the pregnancy record Output Manager provides a template of output blocks by Date to ensure all test and procedure results related to the pregnancy are included in the Pregnancy Record For de
187. and PE Navigation 268 3 Navigate the map as follows Click the black box and Documentation pane scrolls according to the box position drag it up and down With the mouse outside The target characteristic under the cursor displays in the the black box click on a target box beneath the map target Click the item in the target box to display it in the documentation pane To navigate using the selected tab 1 Open a patient chart and from the left pane or the toolbar click ROS or amp PE Apply a template or document items in ROS or PE In the navigation pane click Selected to navigate through the exam using a selection list of body systems which have documentation Map Selected My ROS Lists Search All characteristics with documentation display in the Selected list If any selected items are marked significant the characteristic icon changes to a red exclamation point Selected 3 4 5 Months T Developmental Milestones This characteristic ae General Appearance contains a detail that was tenera ae H Ha orientation marked significant General Click a characteristic in the list to display it in the documentation pane on the right and make any necessary updates To navigate using the my ROS PE lists tab 1 Open a patient chart and from the left pane or the toolbar click ROS or X PE NOTE If you frequently use templates for documentation setting the car
188. and are linked to the user s login name so they are available at each workstation 1 To access Auto Replace do one of the following e From the menu bar select Options gt Edit Auto Replace Text or 131 Options e From any text or comment box that displays the icon click 44 Auto Replace Auto Replace A Injury Injury due to accident on 2 Add To add new items press Insert on your keypad or click 5p Add e Auto correct To correct common typing errors automatically select the Auto Correct tab Auto Replace Text Ea Auto Correct Auto Expand From hte To the ana gt At From enter the word as you commonly mis type it gt At To enter the word spelled correctly up to 200 characters gt Click OK to return to Auto Replace 132 1 Office Functions Auto expand To add auto expanding items in Auto Replace click 5p Add and select the Auto Expand tab Auto Replace Text Auta Correct Auto Expand From mm amp Rag og Y 4 Injury due to accident on gt At From type the short text that you want to expand gt At To type the expanded text up to 2 000 characters gt Click OK to return to Auto Replace The replacement items that you entered are listed Whenever you type the text items in the From field the system automatically changes them to the text items in the 7o field Edit To edit Auto Replace items in the Auto Replace dialog box selec
189. and edited via Output Manager 4 Select a font Style if your practice has more than one defined 166 2 Chart Functions 5 Click the Preview tab or the L amp Preview icon from the secondary toolbar to preview the output L Print Patient Demographics Record em Bea Fauve APswvetotog Epot Prenen F9 Print Preview asma gt oog krere Family Practice Clinic 1111 Morthraest Street Cary HC 275 11 Heres Phone 313 665 0000 Mr Fred Finley 1212 rr 230 30 3131 Pad tad Status Birth Dare Oral 15854 Ethnicity Hz 27511 Cary H227511 ccup ation rot aai Laban Phone E55 55 Phone SSS C55 States Works Full Time bile 1i m cr a EX mom RR dem RR Rma Rlead caiman i Fir in Linie Em ile LII T xs R4 acm ma d mom amem o 6 Click the action button Fax Print Queue Save to Log Export 7 Refer to Printing chapter Entering patient insurance information If you have a Practice Management System PMS enter all patient insurance information into the PMS If you do not have a PMS enter patient insurance information into Demographics 1 Open a patient chart and from the left pane or the toolbar click i Demographics 2 Click the Insurance Policies tab Demographics CDF Jecrentmane a hal Patient Demographics Insurance Policies E Emergency Contacts Patient Picture Paj 2 ty 22 1 20 2006 NOTES f the patient has multiple insurance pol
190. and select the template you need for the document you want to generate 2 Click the Queue or Save to Log tab 8 Queue Encounter Lab Orders Sg Print 4 Fax n Queue save En Lag By Export amp Preview FO Queue preview Queue Comment amp Ba ovS Queue comments show in the Output Queue view accessible from the Clinical Module Desktop 3 Enter a Comment if desired Examples Please send additional copy of this document to Dr X or Patient will pick up after 3 PM 4 Click either Queue or Save to Log at the bottom of the screen NOTE If you print an historical document from the Face Sheet Explorer or Output Queue the document is printed based on the template as it existed in Output Manager at the time the document was originally generated If you make changes to the template in Output Manager you must regenerate the document in order for the changes to be reflected Exporting from any view 1 Onthe toolbar click d Print Information and select the template you need for the document you want to generate 2 Click the Export tab 9 Export Encounter Lab Orders of x og Print 4 Fax i QUEUE save to Log fe Export Preview Fo Export Preview Aport Filename fal Preview 3 Click to open the Save As dialog box 382 4 Printing and Faxing 4 Click the Save in down arrow and navigate to the appropriate directory to locate the document Tx
191. any medication in the patient s Medication list order it in Assessment Plan enter a Historical Entry comment and assign a non billable visit code see Ordering and viewing medications from assessment plan on page 303 or reject the request see Rejecting eRefill requests on page 62 e Click Close to return to eRefill Requests 2 To add a maintenance medication to the patient chart click Quick Assessment Plan add the medication see Assessment Plan on page 291 and sign off on the chart see Signing off charts on page 364 3 Return to eRefill Requests and select the newly added medication 4 Approve the eRefill request see Approving matched eRefill requests on page 60 Approving matched eRefill requests IMPORTANT The eRefill response message returned by the practice to the pharmacy always contains the original prescription sent by the pharmacy An approval message approves the original prescription sent a rejected message rejects the original prescription sent Caregivers must manually match the medication so documentation in HealthMatics EMR matches the pharmacy information NOTE eRefill requests can only be approved by caregivers who have privileges for approving electronic prescriptions and also have access to the patient s chart 1 Access eRefill Requests see Viewing eRefill requests on page 56 2 Select a matched ej eRefill request 1 Office Functions In the reconciler pane at the bottom of the sc
192. appropriate information and click OK for detailed instructions see Printing and Faxing on page 377 The document displays in the Output Queue with a Status of Faxed NOTE You can assign access for refaxing or reprinting prescriptions either by individual caregiver or by caregiver type refer to the Administration Module manual for instructions Saving to log To provide an audit trail for documents that don t necessarily have to be printed faxed or transmitted you can save them directly to the Output Queue log To save a document to the log it must have a status of Queued 1 Access Output Queue and locate and select a document with a status of Queued 8 see Viewing documents from the output queue on page 92 2 On the secondary toolbar click 8 Output Tasks to display a drop down menu and select 1 Save to Log TLoneent tonon eu 3 In the Save Dialog enter an optional Comment and click OK 95 Output Queue The document displays in the Output Queue as Saved You can double click it and then click the Action History tab to view the comment added HE GE Open Moapa Tasks Primer E I show ony Signed Documents location lt Al Locations gt Dates Today H Caregiver cM Caregivers Status lt All Statuses gt J Patient RE zj epu Cabegory E Categories al Status EP 5aved TIT ES cae TUTUP oe Caled soda to set up appt Exporting from output queue
193. approving rejecting 71 F face sheets accessing viewing 145 defaults setting 114 diagnoses editing 299 revising 150 emailing from 86 encounters viewing printing 153 flow sheets viewing 146 history viewing revising 151 viewing revising problems 147 medications inactivating 145 interactions viewing 146 viewing changing 157 messages viewing 42 orders list 158 problems inactivating 145 revising 148 viewing 147 refill request documentation 90 scanned documents viewing 76 toolbar icon 111 faxing backup for approvals 62 from output queue 94 overview 377 faxing templates from any view 381 fetal maternal data editing 330 file chart toolbar icon 111 filters status bar icons 5 finalize procedure results 311 financial inquiry accessing from the EMR 138 fingerprint authentification biometric 68 flow sheets erroneous entries correcting 207 face sheets viewing from 146 toolbar icon 111 fonts uses for 8 former name entering 165 forms letters data source 295 formularies using 308 forward toolbar icon 111 free text assessments plans adding 296 previously entered immunization history 343 reason for visit using as 261 using for history documentation 254 G general transcription saving as attachment 72 granting access to messages 129 graphics purchased image databases 238 graphs for result summaries 203 growth charts documenting 242 vitals 245 guarantors entering in demographics 164 GYN cytology screen
194. assification system for medical procedures and treatments used for billing HCPCS The Health Care Financing Administration HCFA Common Procedure Coding Systems HCPCS Level ll database is used to document supplies medical equipment injectables and non physician services The system is used in patient billing if used in conjunction with a PMSLink and a PMS Medi Span The Medi Span database contains currently available medications along with codes for manufacturer product and packaging identification This database is updated quarterly It includes the following gt Patient education including a medication s purpose use precautions side effects and other useful information gt Medication allergy medication medication and medication drug alcohol interaction information CRS The Clinical Reference System database contains printable patient health care advisory information The database contains three modules NOTE Sports Medicine and Cardiology modules can replace one of the standard three by request gt Adult Health Advisor gt Pediatric Advisor gt Women s Health Advisor LifeART Anatomical images are available in all contact screens You can select an image from the Image tab after selecting Notes You can then make notations on the image as part of your documentation These images can also be included in exam templates during customization 3 Patient Contact Functions My Short Lists Reason for
195. at the bottom of the screen If the patient does not have a weight on record the weight field displays not available On the Details tab enter information in the following fields Strength Click the down arrow to select a different strength from available strengths Dosage Clicking the down arrows in the first field select or enter the dosage and in the second field select the form Route Medi Span fills in this field Frequency Type or click the down arrow to enter how often the medication should be taken Medically necessary Select to indicate medication is medically necessary and should be dispensed as written without substitutions Medically Necessary prints on the prescription Samples given Select to indicate the patient received medication samples When checked Samples given displays in the Assessment Plan and the H amp P report NOTE You might want to include a Note with the number of samples dispensed Days Type a number or click the spin arrows to display the number of days the patient should take the medication Quantity Type the quantity in the field click the spin arrows to indicate the number or click the ellipsis button to display the prescription quantity writer s table E pepe Ta T on Eo so se ran sof vo me adn sensa a er 0 30 Use the rows of numbers on the table as follows gt Use the first row to select the most common quantities gt Use the second row
196. ate 9 26 2004 Value qaj 6 Expand view Toggles between full window viewing and navigation panel split screen view 7 To print To print results click select a printer and click OK 9 Email click to select the email provider you want to use to send results NOTE Make certain you meet HIPPA encryption requirements prior to emailing patient data 9 Toattach to encounter To attach results to an encounter click Attach to Encounter and choose from either the Original Current or Both encounter s lal 4 10 Click X in the upper right corner to close window and return to the face sheet To view results from the encounter pane on H amp P reports 1 On the Encounter pane right corner click m to maximize it 2 Expand the Chart attachments folder 160 2 Chart Functions 3 Expand the Labs Procedures folder then double click the results you want to view 2 Encounter Explorer Encounters By Type Newest to Oldest Y SE Sy Encounters a y Historical Summary METABOLIC PANEL BASIC 80048 L Office Visit E3 E Chart attachments Mr Fred Finley Forms Letters EY Labs Procedures Final Reviewed E a6 a04 ME TA BOLIC PANEL BASIC ac i Diagnosis SINUSITIS ACUTE Bi UNSPECIFIED 461 9 FH Nutritionist z Note Dum m Ordered by Family Practice E on 3 26 2004 Routine E3 G3 Occupational Therapy Note Collected on 3 26 2004 12 40 PM h i g Other Unknown Reported on 9 27 2004 8 23 AM
197. bar icons to do any of the following 3 Send Send refill request to another caregiver for approval or to the Rx Manager for processing Save to Chart Document the refill request in the Encounters pane on the patient s face sheet Also add it to history in the Medications pane NOTES e Ifa caregiver approves the refill and clicks Save to Chart without first printing faxing or marking it called in in Batch Refill on the Encounters pane of the patient s face sheet the refill request displays a status of Filed If an approved refill is sent to output but the caregiver does not click Save to Chart on the patient s face sheet the refill is noted under the Revision History in the Medications pane but it is not listed under Hefills in the Encounters pane sheet and the refill message remains in the caregiver s inbox To remove the message open the Refill Request select the medication preceded by the outline of a green check and click Save to Chart Pull Chart Close Refill Request without saving any changes and open the patient s chart Face Sheet Open the patient s face sheet to view the patient s problem list or medication history Click the X in the upper right corner of the face sheet to return to the refill request Demographics Open the Demographics dialog to view or edit the patient s demographics insurance policies emergency contacts or picture Click the X in the upper right corner of the dialog to return to the r
198. blet 1 PO No Refil 4 17 2008 gg 17 2006 Ordered See ETA Recorded 04 777 7006 G20 PM by Dariene Donki AP is Dilantin 125MG 5ML Suspension 1 Suspension r 8 amp eguest E MIFEdipine 30M Tablet ER 24HR 1 PO Mo Ref MiCARdipine HCI 30MG Capsule ER 12HR 1 PO Augmentin 500 125MG Tablet 1 PO No Refill e 04 17 2006 Ordered t zithromax SOOMG Tablet 1 PO No Refill 04 04 u Recorded 04 17 2006 07 09 PM by Darlene Donkin NE E Inderal 10MG Tablet 1 Tablet PO No Refill 04 reine ving p dicii DOM BS Active E NM 5 Mo Known Medications Hx Entry E E Inactive e Medications The left pane displays a list of all patient medications e Revision history The right pane displays the history of the medication selected in the Medications pane with the most recent order at the top e Icons The icons in Medication Explorer are the same as those on the face sheet see Face Sheets on page 145 3 Click the X in the upper right corner to close Medication Explorer To inactivate problems medications from assessment plan 1 In Assessment Plan click either the Patient Problem List or the Patient Medications tab 2 Right click an item or select it and click Inactivate 3 he item moves to the Inactive folder Specifying assessments and plans HealthMatics EMR provides several methods for selecting assessments and plans e Using patient problem or medications lists fo
199. cates a note is present Click to view the whole note see Adding review of systems notes on page 282 You can display notes automatically in caregiver options ru Significant Indicates the finding is significant NOTES As icons are clicked values are documented at the bottom of the screen To deselect an item click the icon again The icon turns gray and the documentation is removed 4 Inthe Review of Systems pane on the left select another system and repeat the process until all systems are documented as needed NOTE Systems in the left pane display in bold as they are documented The significant findings icon displays in front of the system in the left pane and also on the system and detail in the right pane when selected 281 Review of Systems Adding review of systems notes You can add system review notes at three levels e Review of Systems e System e Detail To access Review of Systems open a patient chart and from the left pane or the toolbar click Review of Systems Document the review of systems adding notes as needed To add ROS notes at the review of systems level 1 In the Review of Systems navigation pane on the left highlight the Heview of Systems folder 2 In the documentation pane on the right click the note icon to the right of Review of Systems 3 Onany ofthe three tabs enter information and click OK to return to Review of Systems Mr Fred Finley Ma
200. cation refill Sending refill requests 1 Access the refill request dialog box from any of the following places e Desktop gt Inbox or Outbox gt a down arrow gt Refill Request e Desktop gt Batch Refill gt Ga New Refill Request e Toolbar amp 1 Send gt Send Refill Request Desktop gt Refill Requests or status bar 4 Refill Request gt 4h New Refill Hequest 9 Refill Request Iof x EJ Send A Save to Chart C Pull Chart Face Sheet Fram Manager System Patient Mrs Irene Innis 2 e Ta Medicine E Internal Phone ese 555 2233 fr High Priority v Block one click Approve Rx Insurance Insurance Company B Demographics Reminders Text Image Ot Last Encounter Office Visit 04 05 2006 02 07 PM Pref Caregiver Internal Medicine E om 3x g E Y da 25 Date af Birkh 11 29 1932 73 year old Female Patient asked if dosage could be increased SSH 20 30 7000 Pharmacy Pharmacy Two 2000 South Hills Cary MC ss Rm Phone 555 555 1010 E B Save as default Pharmacy For this patient Atrovent 18MCGIACT Aerosol Soln 2 puffs Inhalation GID 1998 Continued Cromolyn Sodium SO00MCG 4ACT Aerosol Soln 2 puffs Aerosol Soln Inhalation QID Mo Refill 1938 Continued Metformin HCI SOOMG Tablet 1 Tab PO BID 60 Tab Ref xz 60 Tab 30 days starting 09 27 2004 Ordered Prednisone SMG Tablet 3 PO OID 1967 Continued TriamEerene HCTZ 37 5 2
201. ch allows you to edit the Status of a problem Indicating history is non contributory to current problem If in a History category no previously entered history contributed to the current problem indicate that by clicking Non Contrib R amp Allergy Irma Mone Cg Include Ce Include All Non Contrib 2 Ae Medication Pregnancy Birth cee Current Encounter Previously Entered History my Short Lists Short Lists Search Free Text Ey Active Actinic keratosis 2 i iL Manage EE Past Medical al Mon Contributory Past Medical History NOTE You can add other items in the same history category However the Non Contributory statement pertains to the category and applies to all items in the category Documenting history using short lists 1 Open a patient chart and from the left pane or the toolbar click l History 2 From the History folder tree select any category except mmunization to display the tabs for selecting information 3 Click the My Short Lists or Short Lists tab History EuEEeseeeee al History es Allergy E iunea cag Include g Add To My Short Lists t Reset List 3 Collapse All Family 2 EJ Past Medical i 2 Social A Aortic Valve Disorder Previously Entered History My Short Lists Short Lists search Free Text E j CY Past Medical v05 3 SY Angina m Travel pg Arrhythmias Medication 2 H
202. ck 8 and select a different date At Time accept the default current time or click the spin arrows to set a different time or click to highlight and then type a different time At Measurements select the appropriate unit measurement and do the following e Enter the Weight and Height NOTE When Weight and Height have been filled in Body surface area and Body mass index display e Ifa patient is physically unable to use the scale check Patient reported if height weight was not actually measured during the visit e Click to copy the measurements from the previous visit into the fields You can then compare the current weight and height to the previous weight and height and enter the current weight and height instead if desired At Waist Circumference enter the numeric measurement Use the down arrow to choose units in either cm or in At Pain Level click the down arrow and select the level of pain on a 0 10 scale If the patient is a female at LMP Date enter the date of the Last Menstrual Period in mm dd yyyy format or click the ellipsis button to select the date NOTE The Last Menstrual Period Date field displays only if the patient is female and age 6 or older If the patient is under 3 years of age the Head Circ circumference field displays instead Enter Temperature Pulse Respiration and Blood Pressure data as desired NOTE The pulse oximeter reading is a measurement of the percentage of 243
203. cof Delivery i Date 3 8 2006 Patient ID 1212 Pref Caregiver Family Practice E Time Birth Date 7 24 1964 Note GQ Text image voice import CER X Samo T S53 Patient has question about lab result Please call after 5 pm NOTE When a patient is selected Patient ID Preferred Caregiver and Birth Date are pulled from the database 2 Ifthe message is urgent select High Priority 3 Click the To down arrow and select one caregiver from the list 4 Enter a Subject or click the down arrow to select one NOTE To add additional subjects to drop down lists go to Launch Administration Module Message Subjects For instructions refer to the Administration Module manual 5 At Patient do one of the following e If the message is about the current patient that you have open on your desktop name on the title bar click zi Use Current Chart or e Click the search button and select one see Patient Search on page 14 6 At Phone the patient s home phone number displays If the caregiver needs to call the patient at a different number do one of the following e Type the correct phone number or e Click the Phone down arrow to select the number from those on file or 39 Messages 40 10 e Click the ellipsis button __ to enter a phone number and click OK At Delivery accept the defaults to have the message delivered immediately or change the Date and or Time to indicate
204. criptions administration 66 assigning agents for 66 defaults setting 123 matching manually 57 overview 55 patients matching 58 pharmacies matching 59 sending new 63 electronic signatures output queue adding from 94 setting default for 124 emailing from face sheet 86 from HealthMatics EMR 85 from lab reports for all patients 186 for one patient 186 emails creating in EMR 85 emergency information contacts 171 entering 164 employment information entering 165 encounter packs creating 388 overview 388 system defined list of 389 using 389 encounters attachments messages moving 156 billing 363 drafts printing 361 face sheets customizing view 115 viewing printing from 153 finalizing 356 history clearing current 250 editing items 249 open auditing 107 toolbar icon 111 procedure results attaching 311 review of systems 280 ePrescribe prescriptions transmitting electronically 306 synchronization running immediately 67 eRefill requests administration setting up 66 approving 60 biometric authentication 55 inbox messages 25 27 matching manually 57 398 matching unrecorded maintenance medica tions 60 rejecting 62 rejecting sending new 63 toolbar icon 111 erroneous entries correcting flowsheets 207 immunization marking 339 exam default E amp M calculator setting 124 exam level E amp M calculator 367 exit toolbar icon 111 exporting documents from any view 382 from output queue 96 external transcription
205. cs EMR desktop toolbar or status bar click Appointments Select the appointment and do one of the following to display the Appointment dialog box e Press F2 on your keypad or e Right click and select Edit Appointment or e Click amp Edit on the secondary toolbar Make changes as needed and click OK NOTE Clearing the Started field also clears Check Out Clearing Check In clears all three fields Blocking time on schedules If you do not have a Practice Management System you can block time on your schedule directly in HealthMatics EMR 1 From the HealthMatics EMR desktop toolbar or status bar click Appointments On your keyboard press Cirl Insert or on the secondary toolbar click 52 gt Add Blocked Time In Appointment Block fill in the fields and click OK The beginning and ending time for the block display in the schedule Printing daily schedules 1 From the HealthMatics EMR desktop toolbar or status bar click E Appointments If you are printing schedules for multiple locations click the Location down arrow to select the location Click the Date down arrow to select the appropriate date On the toolbar select gt Daily Schedule to open Print Preview E Print Preview g a e 0 m Daily Schedule Wednesday March 1 2006 Chet In check out Pa deat Caregiver Lasathn Famct Peter 555 555 030 anager Sate Famiy Fractioe Clinic Cough 10200 Md Imis bs rane 33
206. ct Caregivers 2 Select the caregiver name and press F2 or click g gt Properties 3 Inthe Classification box select Block Result Notifications and click OK 31 Messages 32 Messages Messages are user generated messages either personal or patient related sent to you by other caregivers For general instructions for using HealthMatics EMR windows see Windows Panes and Other Tools on page 8 Viewing the list of messages 1 a ir To list patient and mail messages on your desktop click amp Messages on the status bar or in the left pane of the HealthMatics EMR desktop NOTE The number next to the icon 1 on the status bar and stack shows the number of unopened messages Unopened messages appear in bold Messages an Co 37 Open P Reply wf Forward Caregiver Manager System Y From Subjet Patient iManager S Labresults O Neal Mrs 3 18 2006 10 14 AM s Manager Syse Patient caled Finley Mr Fred 3 3 2006 3 SUUM EJ Manager Svs Call daughter 2 76 2006 3 01 PM f Indicates a Patient message containing patient information that can be saved to the chart g Indicates a Mail message that does not contain patient information These are messages that can be sent from one caregiver to another similar to email They cannot be saved to a patient s chart Use the secondary toolbar icons or right click for a drop down menu to ma
207. ct the Save button to set all selected results to Published gt Save Cancel 4 Select a result and click any of the buttons described in the following table Click if you do not want the results published on the website Publish Click if you do want the results published on the website Read Receipt Click if you want to be notified when the patient opens the test result on the website Yes w RR displays in the Published column When the patient opens the lab results on the website an automated message goes to your HealthMatics EMR Inbox automatically Comment Click to attach a comment to results that will be published on the website Type a comment to attach to the results and select Read Receipt if you want to be notified when the patient opens the results Web Message Click to place a message to the patient on the website The message displays in the Messages section of My Health Portfolio 5 Click OK Results with comments attached display with an asterisk Yes w RH in the Published column 6 Click Save to save all published values and comments made to the database NOTES The Web Publish button is not available if any of the following is true e Your practice is not connected to HealthMatics Access 185 Lab Results 186 e You do not have the security privilege to publish labs which is the same as the privilege to review labs e You have selected Show Referrals on the Lab Results scree
208. ct to overall health Major Moderate Minor or Undefined Severity Intensity Use the drop down list to describe the problem s seriousness Mild Moderate Severe Incapacitating or Undefined Stability Describe the problem stability Stable Unstable or Undefined Enter the goal regarding treatment or resolution of the problem Disability Enter a description of the patient disability associated with the problem Reason for Change Enter a reason for making the change Enter the reason for choosing the treatment or method for resolving the problem 3 Click OK Changes to elements other than diagnosis classification are internal only View the complete history including changes by double clicking the problem on the patient face sheet or returning to the Problem Explorer 149 Face Sheets To revise diagnoses from face sheets 1 Inthe Problems pane of the face sheet select the problem and click a Edit Problem 2 Click the Diagnosis search button dap in the upper right corner Datasource Search Data Source icp s Search Results Category arcos HYPER TENSION SECONDARY TO RENAL DISEASE COMP LA HYPERTENSION SECONDARY TO RENAL DISEASE COMP Search Term HYPERTENSION HIPERTENSION SECONDARY TO RENAL DISEASE COMP Starts With C Contains NirrreRTENSION SECONDARY TO RENAL DISEASE COMP mms HYPERTENSION SECONDARY TO RENAL DISEASE COMP 3 At Search Term en
209. ctice E ERE Patient Message saved ko Finley Mr Fred s6f2006 4 27 PM E Practice E Family Patient Message savedto Finlew Mr Fred 3 6 2006 3 58 PM t Medicine 3 Internal Lab results Finley Mr Fred Sf6 2006 3 58 PM f Manager System Patient called Finley Mr Fred 3 5 2006 3 30 PM amp Manager System Lab results 3 Far Mr Fred Finley Mr Fred er2412006 4 37 PM eL Manager System Amoxicillin Albuterol F Vi Finlev Mr Fred 2 23 2006 3 48 PM A Manager System Rejected Mr Fred Finley Finley Mr Fred 2f2212006 1 51 PM NOTE Your outbox can contain copies of the following types of items that you sent to yourself or others Lab procedure or referral result notifications Chart messages accompanying charts Mail or patient messages Action items Refill requests Documents transcription and scanned Click secondary toolbar icons or right click for a drop down menu to perform the following tasks du New Insert Create new Patient Message Refill Request Mail Message Action ltem or Web Messages Delete Message Delete a selected message from your outbox and the Del recipient s inbox NOTE You cannot delete refill requests Open Message View a selected message and reply forward print delete Ctrl O or forward it to other caregivers Forward Message Forward a selected message to another caregiver Ctrl F Refresh Outbox Display new items received if you cannot wait until the F5
210. cton skin e Ukin Palpalticn skin m 5 BP P P B BP 2 9 5 BP G P B9 c shaded bullet tair f peface Unshaded bullet regular typeface Dooummiesd bullet bold typetace Overall Pbi ad Danskin taking Lewel Low Cds ali Pech Dsscaaon Mair wel i bad on fe hag feo of Tees Tres ements Suber of diagnoses or management options Minimal Straightlorward lt 1 e Amount and or complexity of data to be reviewed Limited Low 7 o independent veualcaton of Lab west 2 pore e Risk of complications and or morbidity or mortality MIoderate o6 Presxrp5cryT4 maedcateon Moderate 372 3 Patient Contact Functions Adjusting the service level The E amp M Level on the left side of the window displays the calculated level of service based on data you entered for the encounter You cannot change the information in the left pane directly However you can adjust the level of service 1 Return to the contact screens Reason for Visit Review of Systems and or History Family Social and continue documenting to accurately reflect the items discussed and evaluated during the patient visit 2 Return to the E amp M calculator and recalculate NOTE For well visits and procedure only visits omit the use of the E amp M Calculator 373 Fast Track Templates 374 Fast Track Templates Fast Track templates can be created using a series of customized short lists to allow quick movement through all contact scre
211. ctronic prescription fails to transmit you can print or fax it from the queue NOTE Electronic prescriptions generated immediately by clicking an ePrescribe button do not pass through Output Manager and therefore are not listed in the Output Queue This is also true for Web messages and eRefills Viewing documents from the output queue 1 From the left pane of the HealthMatics desktop or from the Office menu bar select Output Queue dh c open Gouput tess Priter E show only Signed Documents Location at Locations Dates uox Caregiver lt All Caregivers Status EAN Statuses o e Patient Eai Patiess E Iz all Category al Categories e Status Patient Document v Car Comment x Freda T Finley Encounter Hie O4f04f06 01 59 pm System Manager FFinley H amp PO40406 pdr 92 ylsaved Mr Fred Finley Referral Letter O4f04 06 01 52 pm System Manager Called specialist bo set up app e Exported Mr Fred Finley Specialist Letter O4 03 06 03 34 pm Terry Manring Specialist letter pdf E Queved Freda T Finley Encounter HEP 04 03 06 03 32 pm Terry Manning a Exported Freda T Finley Encounter HEP 04 03 06 03 08 pm Termy Manring Test Rx pdf iw Exporbed Freda T Finley Encounter H amp P 0403 06 03 07 pm Terry Manning Test Rx pdf f Exported Freda T Finley Encounter H amp P O4f 3 06 03 03 pm Terry Manning Test Rx pdF saved Freda
212. d 4 Sf2006 1 58 PM Diagnosis ACUTE PHARYNGITIS 462 Click to Expand All and view values for each test 2 Click to collapse all and view only patient names Click to display the selected patient face sheet NOTE To return to Lab Result Review click the X in the upper right corner Click to create a patient message web message or reminder on the patient chart See Reviewing lab results on page 178 and Creating reminders on patient charts on page 211 180 2 Chart Functions Annotate Click to enter interpretive comments while reviewing Lab results in a Note for the selected lab See Annotating lab results during review on page 183 Toggle Click to toggle Review from Yes to no entry Review Toggle HealthMatics Access option Click to toggle the Published selected results from Published to Not Published HealthMatics Access option Click to publish a Hi comment about the results to the web and or request a Read Receipt for notification when the patient opens the test result from the website Yes w RHH displays in the Published column An automated message gets delivered to your HealthMatics EMR Inbox when the patient opens the lab results from the website 5 Click OK to save the Reviewed Status Lab Result Entry Fred Finley Order 1 of 18 xs ext cec amp PLATELETS AUTO 85027 Note Collected 371672006 339PM A Un A ecd We aA Reported 4 5 2006 1 53PM
213. d displays and defaults to current date and the Prescription and Education tabs disappear Only active continued and ordered medications are checked for interactions when a new prescription is written Therefore it is recommended caregivers consider all medications active until they change the status of the medication Medications added as authored text are not checked for interactions Reason If you changed the Status click the Reason down arrow to select the reason for the change Start date If the prescription status is Active Ordered or Continued enter a date for instructions see Entering dates on page 10 End date If the prescription status is changed to Discontinued or Inactive enter the date the prescription ends Drug interactions To view interaction information double click the medication in the nteraction box or select it and click ry Preview Drug drug drug food or drug allergy interactions display in the Drug Interaction Report NOTE The latency period is built into the check for medication interactions and is calculated from the prescription end date 305 Assessment Plan 306 To view medication interactions An Interactions button displays on both the Face Sheet k and the Assessment Plan 14 views The icon color represents the following interaction severity Ayinteractions e Red Major interactions e Yellow Moderate interactions e White Mild interactions Click the
214. d on the secondary toolbar click Open 141 Patient Charts 142 To enter reason kept open When you keep a chart open on your desktop rather than signing off and or filing it enter a Reason Kept Open so you and other caregivers know why it remains open 1 Open a patient chart and from the toolbar click 4 H amp P Report JI f Current Encounter Submit Reason Kept Open History amp Physical Report 2 Click the Reason Kept Open down arrow and select a reason Sending charts to other caregivers 1 With a chart open in HealthMatics EMR from the toolbar click 1 Send Chart B Chart Message Gasend jg High Priority To Manning Terry Subject Patient Ready EXAM ROOM Patient Mr Fred Finley c a X a oT ea Mr Finley is ready For the test Select High Priority if desired to display the item in red on the caregiver desktop Click the To down arrow to select the caregiver to receive the chart At Subject type a subject or click the down arrow to select one re Sf If desired select a tab Text Image Voice or Import and enter information to accompany the chart NOTE Information entered on tabs is not saved to the patient chart 6 Click Send NOTE When you send a chart to another caregiver the chart message displays in the Received Charts view of the recipient inbox and in your outbox until the chart is pulled
215. d high priority To turn the urgent message indicator on off follow the steps below 1 From the HealthMatics EMR toolbar select Options gt Edit Options 2 Inthe left pane select Desktop and in the Status Bar box select Yes or No for Do you want the status bar icons to blink when you receive a High Priority item 3 Click OK Monitoring workflow on the desktop From the HealthMatics EMR desktop you can see in one view how your work is flowing From both the Office Manager and the status bar numbers lists stacks bars and urgency indicators all let you know where you are in terms of managing your appointments messages refill requests documents scanned and transcription action items charts and reports The HealthMatics EMR desktop displays a dynamic Summary of your changing workload all in one window 1 Office Functions To access the HealthMatics EMR desktop on the toolbar click ET Desktop 8 Clinical Module Appointments Session Charts Office Patent Expore Options Tes Launch Help CL acc a c1 45 E EF d HOO Pea d Hj IL o w M amp wel Appointments 2 Appointments Tuesday Feb 28 2006 Open Encounters 3 Tih Inbox dh g dA appointment fli Caregivers E piling S Result Notifications 1 Messages 1 Location lt All Locations gt Date 2 26 2006 Today 1 1 68 Web Messag
216. d in green started red or checked out purple Desktop information updates are based on your display preferences For details see To set desktop defaults on page 109 If you do not want to wait for the automatic update manually update your desktop by clicking Refresh available on most secondary toolbars Windows Panes and Other Tools Windows Panes and Other Tools Many views in HealthMatics EMR include tools to resize search and manipulate most views to ease your ability to locate and review the items they contain Resizing panes and columns e Panes 4 Web Messages zx Refil Requests 1 1 eRefill Requests Ed Documents 11 Hover the cursor over the bar between panes until it changes to a double bar double arrow shown in this example Then click and drag it to resize the two panes Bars may be vertical or horizontal e Columns Hover the cursor over the bar between columns until it changes to a heavy line with a double bar through it Then click and drag it left or right to resize the two adjacent columns Patient Name eb Encounter Date Sorting columns Sort items in any column by clicking its heading An arrow displays indicating that its items are sorted in ascending order Patient Name or descending order patient Mame v Click the heading a second time to reverse the order Understanding table font conventions The table of items in views such as Resu
217. d instructions NOTES e The performance review will not display after signing off on the chart e Once the encounter is signed off you cannot retrieve the performance review To print patient information documents without signing off on chart Within HealthMatics EMR if you complete patient contact but not the encounter documentation you can print items the patient may need as they leave your office without signing off on the chart To use this function fully be certain to complete the Assessment Plan so all prescriptions referrals orders and forms letters are available for printing 1 With the patient chart open in HealthMatics EMR from the left pane orthe toolbar click H amp P Report 361 H amp P Report 2 From the HealthMatics EMR toolbar click the gt Draft Print Plans Ea Check the items veu would like Eo print Template Pack Typical Printouts Check All C Encounter H amp P Encounter Lab Orders Encounter Pracedure Orders Uncheck All Patient Education Referral Letter Wi Patient Active Medication List Field Checkbox Template pack Click down arrow to make different selection if desired NOTE Choices include fax print packs as well as non print options Template Packs are created in the Administration Module Check all Click to choose all options Click to deselect all options 3 From the Print Plans window select print items and click OK Each item d
218. d to be saved to a chart or 85 86 Outlook Inbox Click Yes to save the message to a chart as an attachment r Chart Attachment Susavetochat C Pret em ay Patient Freda T Firley E Attachment Type Referral Letter Subject Referral to Dr 5mith Hote CH l ahon VG u In an email sent on 4 3 2006 to Manrang Teny Cmertage bety In Chart Attachment click to use the current chart or to search for another patient Click the Attachment Type down arrow to select the appropriate designation how it is filed or stored in the patient s chart Enter additional information on any of the Note tabs if desired and click Save to Chart Emailing H amp P reports from face sheets From the Encounters pane you can email H amp P reports 1 2 Open a chart and from the patient s face sheet 3 click C View Encounter In the left pane select the appropriate office visit to view the H amp P Report Encounters By Type Newest to Oldest PIPA Encounter Explorer EHEJ Encounters History amp Physical Report Bing Information Sy Office Visit Zu 3 14 2006 Office Visit CHEST PAIN UNSE vc omo a E e 223 3 14 Office Notes Bve Ha FF S 3 5 2006 Office Vest CHEST PAIN UNSPE E 3 5 2006 Office Vist CHEST PAIN UINSPE el E eee E 3 5 2006 Office Vist CHEST PAIN UNSPE aida Tw Se m penas Location Fam
219. date des Revision History Newest to Oldest 4 Ordered s Childrens Tylenol Sinus 15 160MG 5ML Liquid 5 Milliliter s PO Q amp hr Mo f Amoxicillin 125MG SML Fo Refill 04 20 2005 Ordered m M IE iiM Comments prn pain and fever Recorded 04 21 2006 03 06 PM by Terry Manning MD Refill Reg quest Printed to HPCLJ850 on rprint From BDIXON in session 4 04 21 2006 03 07 Pm Displaying outstanding refill requests from patients To see all outstanding refill requests for a patient follow the steps below 1 From the HealthMatics EMR toolbar click se Send gt Send Refill Request 2 Click the Patient search button and double click a patient If the selected patient has any outstanding refill requests Outstanding Refill Requests displays the medication Outstanding Refill Requests Ea Eh Please be aware that this Patient has addtional outstanding Refill Requests FL Manager amp yskeni Accu ane eh Manager System Fuecoxicilin Albuterol FA Viramin B 6 vitamin B 12 Fas Eel Manager System Albuterol 3 23 2006 1 36 PM 3 22 2006 10 38 AM 1 5 2066 10 40 AM This is a read only box 3 Click OK to close the box and do one of the following IF the refill has not already been requested continue creating the request and send it to the caregiver IF the refill has already been requested click the X in the upper right corner of the Refill Request dialog box to cancel N
220. dditional Results tab for follow up Setting patient authored text templates to completed in A P You can set the default status for patient authored text templates to Completed and therefore not have to open each item in Assessment Plan to mark it complete 1 From the HealthMatics EMR menu select Launch gt Clinical Customization Module 2 Click Templates then select one of the patient authored text template categories Discharge Plans Patient Education Office Procedures or Nursing Services to display the authored text templates on the right ra Clinical Customization Module Office m SAogout West Lig Knowledge Office Procedures 8j Short Lists p Exam Templates re NS Cony x P Catalogs 7 2 3 Templates Caregiver Manager System i Fast Track TH Created B PROCEDURE STOP COUMADIN 6 DAYS PRIOR Mansger i PROCEDURE STOP COUMADIN 7 DAYS PRIOR Manager Systa W PROCEUDRE STOP ASP TBU 6 DAYS PRIOR Manager Sysbem S REQUESTED TIME 30 M Manager System EJ REQUESTED TIME 45M Manager System E REQUESTED TIME 60M Manager System Flow Sheet Templates REQUESTED TIME 90f4 Manager Sysbem id Lab Order Entry Setup Stop taking Coumadin 6 days prior to procedure 320 3 Patient Contact Functions 3 Double click an authored text item or select it and click amp
221. der a medication ordered previously for the patient click the Patient Medications tab 4 With the diagnosis highlighted in the documentation pane select the medication from the Patient Medications list using any of the methods described in step 2 NOTES If you link a medication or other item to the wrong diagnosis in the documentation pane click and drag it from the incorrect diagnosis to the correct one If you search for a medication using Medi Span as the Data Source and you select a medication that was prescribed previously a message asks if you want to use the existing medication Click Yes or Enter to attach the medication to the patient s history for that medication The system displays the most recent order for that medication in the preview pane 293 Assessment Plan To specify assessments and plans using short lists 1 Open a patient chart and from the left pane or the toolbar click A P Assessment Plan 2 Click the My Short Lists tab or the Short Lists tab Assessment Plan lt b Curent Encounter Patient Problem List Patient Medications Mv Short Lists short Lists Search Eree Text Diagnosis Ee TH Collapse All Ei c3 Diagnostic Procedures ADULT FEMALE E COLONOSCOPY DTAGNMOSTIC 44588 of k KJ mee 3 Click as needed to expand the appropriate short list and locate assessments diagnoses 4 Select a leaf level 3 it
222. ders are placed for labs that include Ask on Entry AOE questions and the requisition created you can view the AOE questions on the requisition 1 224 From the HealthMatics EMR Menu bar click Office gt Requisitions or from the left pane click Requisitions Clinical Module Requisitions sila ard Session Charts Office Patent Espo M E em3d 3 mmmumv5 839775 EwUdq c Pas sii ly eas e Options Tools Launch Help e AP E habek resena E Location ea Location Stans Ali Statuses gt LIS Lab corp Caregiver lt All Caregivers j andi ed account 455 Dates The past year Firley Pr Fred 1212 4 12 2006 3 20 00018 Complete Manager System Galespie Mrs 0004 4 12 2006 3 33 00021 Complete Hastings Lynn Hayes Cynthia CHAYES 4 12 2006 3 56 00022 Complete HAYES CYNTHIA Hayes Cynthia CHAYES 4 12 2006 4 10 00023 Complete Manager System Secondary Toolbar Delete a requisition when you delete a requisition the ordered labs are placed back on the Orders page 2 Chart Functions 2 Select the patient requisition that includes an AOE question then double click or click amp Edit Edit Requisition 00047 Name FredFiley Insurance E D 1212 Birth Date 4 14 1964 Plan Type Private Insurance T SSN 220 20 3131 Gender Male Worker s Comp Requisition Collection Performi
223. dical Record Software A4 Health Systems Microsoft Internet Explorer imi x Ger O X 2 45 seme serovars Or amp a D address http jiwww atheathsystems cony Joo ws fi HOME BconTacTus ZR CLIENT SITE LOGIN D Authorized Access An F r i bu i ur lj F A HEALTH SYSTEMS Now PART OF ALLSCRIPTS i COMPANY SOLUTIONS CLIENT SUPPORT RESOURCES SPECIALTIES NEWS amp EVENTS CONTACT US About A Health Systems Solutions Allzeripts Completes Acquisition of Af A represents Authorized Access HealthMati ffi Health Systems Anywhere Anytime Electronic Medical Record Solution EMR Tteakt gortarE Led by its HealthMatics Canopy and and Practice Management System PMS Releases New Fully EmSTAT solutions A provides Integrated EMR amp healthcare IT solutions for physician HealthMatics EMR discus practices and hospitals to streamline the Electronic Medical Record Solution Management i System delivery of patient care and to improve bottom line results HealthMatics Ntierprise Leading Hospitals Practice Management System PMS B nN mem 1 Office Functions Outlook Inbox 1 To access Outlook mail from within HealthMatics EMR do one of the following e From the toolbar or the left pane on HealthMatics EMR desktop click or e From the menu bar select Office gt Outlook Mailbox If you are set up to access Outlook from Heal
224. diovascular Palpation heart Cardiovascular Pedal pulses Chest Breast Inspection breasts Cheat Breast Palpation breasts axillae Constitutional Ability to communicate quality of voice Constitutional General appearance Constitutional Measure three vital signs Ear Nose Mouth and Throat Ext auditory canals tympanic maernbr ares Ear Nose Mouth and Throat External nspecbon ears nose Ear Hose Mouth and Throat Hearing general Ear Hose Mouth and Throat Lips teeth guma Ear Hose Mouth and Throat Nasal mucosa septum turbines Ear Hose Mouth and Throat Orophanym general e Musculoskeimtal PUE Statebty dioc aen subir aten fy e Musculoskeletal Spana Rba Pelis Inepecten and or palpation e Musculoskeletal Spann R bs Pelit Moton pan cnepitatioan e Husculossietal Spina R bsPeleis Tuscis strengm and tore e Musculiskeletal Spine P EnPalis St b dalcation subluxatien ay e heck PFack e hu ck Thyroid e heurologicalPeschiric Deep tendon refleaes e heurological Psychiatric Sensation Hourological Peych vric Test cranial nerves Psychiatric Briel mental status SMood and affect e Psychiatric Grief mental status Debent atkon time place person e Peychiatric Brief mortal status Facent and remote memory e Prychiatric Judgment right e Rospratory Auscultation irwy e Respratory Palpation chest e Reipratory Percusion chest e Respratory Fespratory effort amp Skin Inspe
225. e Portrait cea 5 Check or uncheck boxes as needed to indicate which growth charts you want to print 6 Click OK Viewing vitals in physical exam Vital signs height and weight entered during an encounter also display in the Physical Exam window below other findings Physical Exam Physical Exam Physical Exam A EB amp 9 ca Templates remplates s Apply Ez Preview UT Clear E General H g HEENT E Physical Exam one E Chest and Lung Exam f cerdovecnier 1 17 2005 4 62 PM a 32 Abd Weight 160 b 2 oz Height 70 in Waist 32 in ar HMM Weight and Height were reported by patient H e Male Genitourinary a Rectal Body Surface Area 1 3 m Body Mass Index 23 kg m s iss Temp 98 2 F Tympanic e Peripheral Vascular BP 120 80 Sitting Left Arm Standard 246 3 Patient Contact Functions History Use the History view to document allergies immunizations and family past medical social travel medications and pregnancy and birth history Viewing history during an encounter At the History level in the History view you can see all items documented during the current encounter 1 Open a patient chart and from the left pane or the toolbar click l History History C gt gt Current Encounter Allergy lt b 4 RJ Immunization Allergy History
226. e checkbox on the left lw Eil Alert The check mark changes colors and the item is bolded Ef Mental status Text displays in the bottom documentation pane Not present To indicate an item is not present click the EXJI I In acute distress E X box his option is not available for all details Significant If the presence or absence of an item is significant click the exclamation point box p seeneral C 8Significant i Did not examine indicator to the far right of the item Sie Mental Status The icon turns red and a red exclamation Alert point displays in the characteristic and body Huy micant NUNT system boxes The item is indicated as mane significant in all views including the H amp P Drowey bw R eport iiiu Detail level Note port Stuporous NOTE The exclamation mark only displays once the item is selected To deselect an item Click v or 3x To change detail status from Click the item caption The item toggles h xt or no detail selection between the possible statuses NOTES e The text of any note entered displays beneath the detail e Click the note text to open a dialog box to view the entire note e All notes are saved in the H amp P Report and display as follows 273 ROS and PE Navigation ROS or PE level note The entire note displays talicized at the top of the preview pane Characteristics note The word Note displays before the note and the ent
227. e nlc z es oos ize s s eloa 19 Appearance ahal sha H 7 Dermatologe Patt Ds Margin MG Grouping Shiny Lescione fLesion third typene D Tenderness Size 5 crm Height x 2 em Width Ss Color 3 In the Height and or Width boxes in the measurement pane on the right do the following e At Value type or use the key pad to enter a value for the height NOTE To clear the Value click t3 Clear on the secondary toolbar or click Clear on the window keypad e At Units select either cm or mm e At Significant select the box if the measurement is significant NOTE If selected the dimension marked Significant and text in the preview pane displays in red and the Size icons are replaced with red exclamation points e Inthe Preview box view the graphic to see a proportional representation of the values selected NOTES f a value is entered for only the Height or the Width than the Preview graphic is linear rather than two dimensional The preview graphic is proportional but is not drawn to scale 4 Inthe preview pane at the bottom of the screen view the documentation generated NOTE To collapse the Size box click either amp or xJ in the corner of the upper pane 5 To include a note about the size click the note icon type a text note and click OK 288 3 Patient Contact Functions The note icon displays with a colored background and the note text displays as an italiciz
228. e other 4 Click OK to exit or select another item in the left pane to set more defaults NOTE Click Reset Settings to return the view to the original default settings all selected two columns 116 1 Office Functions To set results defaults 1 From the HealthMatics EMR menu bar select Options gt Edit Options gt Results p Caregiver Options for Manager System Patient Manager MESE z Reason For visit 2 Review of Systems Vitals ie Physical Exam z Assessment and Plan Electronic Prescriptions Results ate Range Patient When entering Ehe Results screen For a specific patient default the date range to The past amp months I ate Range All When entering the Results screen For all patients default the date range ta The past amp months s PSI Es Sign OFF Title Bar T History ublish to HM Access Lists IF you have HM Access do vou want to publish lab results by Quick Lists default when reviewing them My Short Lists Yes Mo ced 2 Date range patient Click search to select default date range for viewing lab results for one specific patient 3 Date range all Click search to select default date range for viewing lab results for all patients 4 Publish to HM Access IF you bought and installed HealthMatics Access select option for publishing reviewed results by default Yes or No If you select Yes Published column sets t
229. e 6 NOTE The increases each time a caregiver records a lab or procedure result marked Preliminary Final or Canceled and decreases when you mark results Reviewed Lists messages in your inbox Total patient mail messages never opened Lists refill eRefill requests awaiting approval Total refill and eRefill requests in inbox both read and unread Lists transcription and scanned documents awaiting review or revision if you are the transcriptionist Total documents awaiting action Lists action items Incomplete action items NOTE Action items even if marked Done remain in your inbox until deleted Action items marked Done display in gray with a line through them Lists charts sent to you for review Number of charts awaiting review NOTE Charts received could be for patients waiting in exam rooms charts sent by other caregivers for review and sign off or charts sent to you by other caregivers EMR Desktop Urgent message indicator A flashing red glow over the icon indicates the item was sent to you with urgency All status bar icons except Open Encounters and Patients can flash for urgent messages Urgent is defined below for each icon leon for Urgent Description Number of labs or procedures awaiting review containing abnormal results Number of messages received marked high priority Number of refill requests received marked high priority Note eRefill requests cannot be marke
230. e Manager is the number of action items not yet marked Complete If the urgent message indicator is turned on the number that flashes in red indicates the number of items designated High Priority see Urgent message indicator on page 6 To view another caregivers action items for whom you ve been granted access click the Caregiver down arrow to select the caregiver s name Their Action Items display Set grants in Administration Module gt Caregivers gt select caregiver gt F gt Grants Select an action item and click toolbar icons or right click for a drop down menu to do any of the following New Ins Create a new action item See Action Items on page 77 Delete Del Delete the selected message Open Ctrl O Once opened click any of the tabs with icons on them Text or double click mage Voice or Import to view the message Reply Ctrl R Reply to the sender or any other caregiver Forward Ctrl F a igen Forward the action item to another caregiver Complete Ctrl C Refresh F5 78 Mark the selected item Complete NOTE The item displays in your inbox grayed out with a line through Display new action items sent to you recently if you cannot wait until the screen refreshes itself automatically NOTE To set the Refresh default time see To set desktop defaults on page 109 1 Office Functions See also Viewing other caregivers inboxes on page 28 Responding
231. e bottom pane and click 9 To exit without saving changes click Cancel 10 When Historical Immunization entry is complete click OK to exit and save 11 Edit entries as needed see Editing immunization history on page 339 340 3 Patient Contact Functions Printing immunization record 1 Access Immunization Record see Accessing viewing Immunization Record on page 338 2 From the HealthMatics EMR toolbar click 4 3 1 29 3 3 N Site Templates Potent immer Recte Patient Immunization Record Queue Patient Immunization Record Preview Customize 3 Click Patient Immunization Record Print Patient Immunization Record denne E Queue Asavetolog Exot 2 Preview F9 Print Preview US Letter 8 3 x 11 in m 4 Select Printer Layout and Style as needed 5 Optional Click the Preview tab to review how the Immunization Record will print For information about Preview tools see Documenting with the pregnancy record on page 325 step 3 6 Click Print 341 Immunization Records 342 Ordering and documenting immunizations 1 Open a patient chart and from the left pane or the toolbar click A P Assessment Plan 2 Search for and select an immunization and do one of the following e Double click it or e Click Include or e Right click and select Include or e Drag and drop it to the preview bottom pane 3 Dothe same for the appropriate i
232. e view or the open message click Reply Patient Message OR X E Send SB Save to Chart d T High Priority To Manager Sysbem Subject fe new note save method Patient ffest Righteous aE Phone koi 555 1254 z envoy Date 7j28 2005 Patient ID RIGHTONE Pref Caregiver System Manager Time nz 5s PM Birth Date 1 1 1978 Note By Text image voice import Gd Xn olg 3 gt Sent 1 28 2005 807 AM tome forwarding message gt From Manager System Sent 1 28 2005 B U7 AM gt anolher patient message gt At To accept the original sender s name or click the down arrow to change it gt Enter a reply on the Text Image Voice or Import tab NOTE On the Text tab space is made for the reply at the top of the text box and the original message displays below it gt To permanently save the message and response to the chart click Save to Chart and Yes to confirm 41 Messages 42 NOTE If you are not the patient s primary caregiver another Confirmation message may appear If you would like to notify the primary caregiver about action taken click Yes otherwise click No gt Click Send and Yes to confirm e To forward the message to another caregiver from the secondary toolbar or the open message click Forward gt Click the To down arrow to select the recipient gt Enter a message on any tab Text Image Voice or Import
233. ealthMatics EMR do one of the following Pull a patient chart see Pulling charts on page 139 or If you have a chart open from the left pane or the toolbar click 2 Face Sheet ey Fred Finley Male 41 years old 1212 AT amp T Session Charts Office Patient Explore Options Tools Launch Help e o mudggs8o s dg 3 aaa i Z amp i J D zE I S ae lE Z Summary 7 Face Sheet l hd Patient Manager Problems All Newest to oldest al Encounters By Type Newest to Oldest ij nora 12 wl ea E os um Reminders are E cw Active a 4 Encounters P c Fw Sheets EJ HEARING LOSS MOS 389 9 fy Office Visit E Q Immunizations E CHEST PAIN UNSPECIFIED 781 EHEJ Phone Encounter P Chart Attachments E ABDOMINAL ACTINOMYCOTIC I EL Messages aM ue Ey TRAUMATIC AGENT NOS Medications All Start date descending uie iron Besides z pacified Liag z E T E ACQUIRED HYPOTHYROIDISM S Lingpecified Diagnosis slm eee z S SEBORRHEIC DERMATITIS UNE Accutane 10MG Capsule 1 PO ai E ARfWMINMAI BAT ATAA 0 wll in 500 ei amp 1 po WEIT 2 mm N History Common Newest to oldest ol Orders Ordered Newest to Oldest O el Role als I AA E amp B pe y Less Than a Week Ago A No Known Allergies E CARDIOVASCULAR STRESS TES E LB me ES i oie Ze BREATHING CAPACITY TEST ce 0 5 th 15 4 alo o Cid b Logged
234. ect the item and click Open to see if any of the chart messages associated with the encounter have content other than a Subject 22 1 Office Functions e fthe message has no content other than a Subject the chart message deletes automatically when the chart is pulled e If the message does have content the Outstanding Chart Messages dialog appears Outstanding Chart Messages A Please be aware that this Encounter has related Chart Messages i Manager system Exam Pum 4 24 2006 12 17 PM Manning Terry MD Lab results 4 24 2006 12 04 PM Exam Rm Finley Mr Fred T Manning Terry MD From Manager Sysbem Sent 4 24 2006 12 17 PM in Exam Rm 5 2 After reading the message click or press Delete on your keyboard to delete the message and close the dialog or click OK to close the dialog without deleting the message Chart Reminders if any and the patient s face sheet NOTES Only messages with content appear in the dialog so even if you saw the Multiple Chart Messages subject in your list of open encounters you may only see one message here The dialog displays all messages associated with the encounter not just those sent to you 23 Inbox Inbox Access your HealthMatics EMR Inbox from the left pane on the desktop or from the menu bar by selecting Office gt Inbox Filtering inbox items Filter items in your inbox by clicking any of the following e Icons under nbox in the
235. ed link in the preview pane at the bottom of the screen Documenting physical exam using mapped images 1 Open a patient chart and from the left pane or the toolbar click Physical Exam In the Physical Exam navigation pane select a system such as Chest and Lung Exam Auscultation Breath sounds Click to expand items and locate a mapped image NOTES A mapped image exists if the button displays to the right f you want mapped images to always display expanded you can select that as a caregiver option e Select the item and click the button to open the image iia p DAS e hre Eup Giepend AE 23 Colp Al eq Posture a iv Templates Office visit 09 25 2004 SINUSITIS ACUTE Apply Lz Prevew fo VYolce Auscultation H Cl Breath sounds I E E Meck E amp r Chest and Lung Exam E 3 Inspection Pa H 3 Percussion L f Righi Lung Field H X Palpason zy Breath sounds 3 Decreased ES Absent I Reduced vesic es Bronchovesicular 9 Bronchial Right Middle Lobe Anterior Status area e Hover over the mapped areas in the image to see the following gt Boundaries of the mapped area are outlined in black gt The name of the area appears in the status area below the image 289 Physical Exams 4 To display mapped details click an area on the diagram to display a menu of details mapped to that area H Breath sounds t u Lungs
236. edication or select it and click L View Revision History to display the Medication Explorer J Medication Explorer B E Medications All Start date descending Revision History Newest to Oldest Suns E zy Ordered Asthmahaler 0 15546 ACT Aerosol Soln 1 Aerosol Soln Inhalation No Refill es 03 21 2005 Ordered P Zantac 15005 Capsule 1 one Capsule PO Re Recorded OO 07 11 PN by System Manager Ref Request eo Imuran 50M Tablet 1 Tablet PO No Refill 03 Connectel Extra Gentle 10005 Capsule 1 Capa Asthmahaler 0 164G ACT Aerosol soln 1 Aerosol soln Inhalation No Refill Be Amoxicillin 250MG Tablet Chewable 3 theres 03 14 2005 Ordered fe Albuterol S0MCGIACT Aerosol Soin 1 Aerosol 5 Recorded CPS URL MI P by 5ygtem MAJE Office eet CM Actes 4 Aspirin Buffered PO Specific dose unknown Ada Allergy Sinus 2 30 2000 Tablet PO Acti All the patient medication displays in a list on the left To view the history of a medication select it on the left to display the details on the right with the most current information at the top of the Revision History pane NOTE To view all medications with current orders active or inactive highlight the respective folder in the Medications pane on the left 157 Face Sheets 4 Inthe Medications list on the left select a medication and click the toolbar icons to do the following Edit Medication Click to display the Medication dialog
237. eed with the merge determine who has the chart pulled and have the caregiver file it Then proceed with the merge Alternately you can deselect the box in front of the Merge Group that includes the locked chart or patient and continue the merge process for other merge groups Review patient charts To review the charts before deciding whether to merge them and to determine which one to make the target usually the one with the most data in it select a chart in a merge group and do the following e Face sheet Press Ctrl F on your keyboard or on the toolbar or right click menu click 2 Face Sheet e Demographics Press Ctrl D on your keyboard or on the toolbar or right click menu click Demographics Select target charts Select a target for the group by highlighting the appropriate chart in the Merge Group and pressing Ctrl T on your keyboard or by clicking gt Select Target on the pop up menu or toolbar Merge Groups Slee EE Fred Finley eS Finley Fred 12 dn Add Merge Group Ins NOTE Right click for F a Finley Fred 1 Delete Merge Entry Del the pop up menu G E Irene Innis N S F7 a Innis Irene t Select Target Ctrl T PO de es Innis Irene 00 pa Bee zi f Peter Parrot View Demographics Ctrl D M F m Parrot Peter View Face Sheet Ctrl F gan ea Parrot Peter 1 Remove patients or groups To remove a patient from a merge group or a complete merge group
238. efill request Reminders Open the Reminders dialog to view or add chart reminders for the patient Click the X in the upper right corner of the dialog to return to the refill request 4 From the list of medications at the bottom of the screen select a medication that has been requested 3 and then click one of the following Approve Change the status and icon from Requested to Approved 49 Refill Requests Approve w Changes Change the status from Requested to Approved and open the Medication dialog box to view and or edit details for the prescription or to access the Prescription Education and or Patient Allergies tabs Mark the refill rejected If desired enter instructions to the Rx Manager in the Text box Example Please ask patient to come in and then click Reject to change the status from Requested to Rejected X NOTE A Warning box may display interaction information If so review the information and click OK 5 If the Medication detail dialog box displays you can do any of the following Medication Details prescription Education 32 Patient Allergies Childrens Tylenol Sinus 15 160MG 5ML Liquid 5 Milliiter s PO Q 6 hr No Refill 4 20 2006 Ordered Srengh i i liquid Das m Dosage Mililiter s Quantity b je rj Route po Refills None Frequency Q 6 hr T Refil Quantity P a z Medically Necessary Samples Given Status Ordered orj Star
239. efill request see Refill Requests on page 44 Lab results Results with the status of Final or Needs Review in red if abnormal Click Review to open the Review Lab Results dialog Click Trend to open the Lab Trends dialog See Reviewing lab results on page 178 Procedure results Results marked Finalor Needs Review in red if abnormal Click Review to review the results see Reviewing procedure results on page 191 Additional results Referrals authored text and patient education not marked complete Final Click Review to finalize the document see Additional Results on page 195 Report results Health maintenance and disease management reports that include an action item for the patient Click Edit to view task details e Task tab Click the Task down arrow to indicate what was done Examples Called Patient Ordered Send Letter and enter comments in the text box then select Completed Contact values tab Patient contact information such as address phone numbers age and gender History tab History of actions taken Click Quick A amp P to document orders plan or treatment without closing the Patient Manager view see Report Results on page 198 Pregnancy Record Displays for patients with an active procedure of 59400 routine for female patients Obstetric Care Patient LMP last menstrual period date EDD of child bearing estimated delivery date Blood Type Gestational Age and age only
240. egistration s Refill Requests 3 LJ eRefil RenniesFs i Financial Inquiry Demographics On the Demographics secondary toolbar click Ntierprise Registration Demographics SS current Er al Patient Demographics E Insurance Policies Emergency Contacts Patient Picture 2 eg Patient With a patient chart pulled on the application menu bar select Patient gt Ntierprise for a drop down menu of Ntierprise options P Mr Fred Finley Male 41 years old 1212 AT amp T Session Charts Office Patient Explore Options Tools Launch Help im s al f Mtierprise k Appointment Scheduling Ao Summary aoea i Registration a p E i Financial Inquiry 2 Chart Functions 2 Chart Functions Electronic patient charts are similar to paper charts They include all of the following Patient Charts on page 139 Demographics on page 162 Face Sheets on page 145 Patient Manager on page 173 Lab Results on page 175 Procedure Results on page 188 Additional Results on page 195 Report Results on page 198 Hesult Summaries on page 199 Flow Sheets on page 206 Chart Attachments on page 208 Heminders on page 211 Patient Charts HealthMatics EMR stores patient information in patient charts similar to paper charts You can pull charts enter information in them send charts to other caregivers and file charts You can also print information from charts
241. egiver option Jump to Selected after Apply will help quickly make changes to your template to document your patient s current condition In the navigation pane click My ROS PE Lists to navigate through the exam using a selection list you can create with the body systems or characteristics that you 3 Patient Contact Functions typically document NOTE My ROS PE Lists are helpful to ensure you document necessary exam bullets for the E amp M billing level calculation for the encounter To add exam lists to the my ROS PE lists tab 1 From the navigation pane click My ROS PE Lists PIE u Edit Delete Copy Test m b ail Orientation TETTTFTTTTETEEEETEETTTTETTTETTYTTTTTITETTTTTEETTTT General amp gPosture General NOTE Information in the documentation pane does not change until a body system characteristic in the ROS PE list is selected 2 Click New to display List Properties List Properties 4 No Information Newborn Exam Developmental Mileshones General a 5 Chest and Lung Exam Breast Cardiovascular Abdomen Female Genibourinary ale Genitourinary Rectal Peripheral Vascular Neurologic Neuropsychiatric Peli reri lack ela al Ie 3 c5 xe EAHA e At Title enter a name for your personal physical exam list From the list on the left select folders or characteristic you want to add to your ROS or physical exam l
242. egiver Options for Manager System em z Toolbar z Face Sheet Patient Manager B Results 2 Reason For visit 2 Review of Systems Vitals Physical Exam z Assessment and Plan in Electronic Prescriptions Sign OFF Title Bar I History Lists z Quick Lists My Short Lists lel Es Desktop tacks Refresh Desktop every 60 seconds tatus Bar Do you want Ehe status bar icons to blink when vou receive a High Priority ikem Stack Bar Orientation Horizontal f Yes No Vertical isible Stacks and Status Bar Buttons e Uncheck All Se Check All Patients Open Encounters Results Messages Web Messages Refill Requests Dacuments Action Items Received Charts ced Stacks To set defaults for stacks that display in Office Manager do the following e At Refresh Desktop every click the down arrow and select number of seconds to set frequency for updating stacks and status bar with new data entered e At Stack Bar Orientation click either Horizontal or Vertical Status bar Click either Yes or No to indicate whether you want the status bar icons to blink red when you receive a message marked High Priority or results that contain abnormal values Visible stacks and status bar buttons Deselect any stacks or status bar buttons you do not wish to display Click OK to save changes and exit or select another item in the left pane to set more defaults 109 Options
243. egnancy record on page 322 2 Select a visit date and press F2 or click amp Edit Record 331 Pregnancy Record 332 3 Click Cervix tab Antepartum Record Vitals UJA Pregnancy Labs ROS Matemal Fetal Data Medical Hx O8 History Pelvimetry Next Appt Dilatation Not examined C 1cm amp cm Station Floating C C 1 C Closed C 2cm C 7cm Out of pelvis C 2 C 2 Finger tip C 3m C 8em i O C 3 3 C Open C 4cm C acm NA Ca CH C Sem C 10cm C 5 C 5 Effacement Not examined 50 effaced Length Not examined 2cm Uneffaced 509 effaced zo C 2on C 10 effaced C 60 effaced Position Not examined C Mid C 30 effaced 80 effaced C 40 effaced C 90 effaced Membranes i Notexamined Ruptured C Intact Gross ROM C Bulging Patient reported pH nitrazine Vagna exam Feming Vaginal pooling Bishop Score 4 Complete each data field as required 5 Click OK to save and validate all data in the edit window 6 Optional Click Cancel if you do not want any data saved from the edit NOTE The Bishop Score does not calculate automatically To edit pregnancy record medical Hx NOTE The two screens of Information documented here are bidirectional with the History amp Contact Screen Pregnancy Birth History 1 Access the Pregnancy Record see Accessing the pregnancy record on page 322 2 Se
244. el Delete a selected appointment LM Edit F2 Edit a selected appointment B Search Search for a patient s appointments Appointment F3 F5 Appointment Access Ntierprise Appointment Scheduling Registration or Financial Inquiry Enter appointment status times see Checking patients in and out on page 18 Pull charts View H amp P Reports Billing Information Labs Reminders or Worklogs View Batch Billing Display billing information for all of the current day s Report scheduled patients see Displaying daily billing information on page 21 Refresh Display new information entered into the Appointments F5 HealthMatics EMR recently if you cannot wait until the screen refreshes itself automatically see To set desktop defaults on page 109 Scheduling appointments in HealthMatics EMR IMPORTANT NOTE If you have a Practice Management System PMS appointment information entered in the PMS overwrites appointment information in HealthMatics EMR Therefore make appointments and check patients in and out in your PMS instead of in HealthMatics EMR If you do not have a PMS follow the steps below 1 From the HealthMatics EMR desktop toolbar or status bar click 3 Appointments 17 Appointments 2 Press Insert or on the secondary toolbar click 4p gt Add Appointment Appointment Patient Mr Fred Finley BE Date 3 1 2006 Caregiver Manning Terry MD Time En PM Location Famil
245. em from the short list and add it to the preview pane by doing one of the following e Double click it or e Click and drag it to the preview lower pane or e Right click it and select Include or e Select it and click Include on the secondary toolbar e Select it and click Enter NOTES Resetlist To collapse the current short list to the first level click Reset List e Collapse all To collapse all short lists completely click Collapse All e My short lists To add a short list you use frequently to your personal set of short lists on the Short Lists tab highlight the frequently used short list and click Add to My Short Lists or right click it and select Add to My Short Lists To search for assessments and plans using database libraries 1 Open a patient chart and from the left pane or the toolbar click A P Assessment Plan 2 Click the Search tab Assessment Plan CD ew current encounter z Patient Problem List Patient Medications My Short Lists Short Lists Search Free Text Diagnosis Data Source IAEE Search Results Category aos dS J Please enter a Search Term Search Term Starts With Contains mae 294 3 Patient Contact Functions 3 At Data Source click the down arrow to display source libraries available ICD 9 Third party library that is updated annually PMS service codes CPT current procedural terminology User defined codes entered in the
246. em in your inbox is preceded by one of the following icons LONE ZEN Rem ooo Patient education Transcription Voice transcription s Scanned document Performing inbox tasks 1 On the toolbar or left pane of the HealthMatics EMR desktop click Inbox 2 Click secondary toolbar icons to do any of the following mm mm Delete a selected message see Deleting messages Delete from the inbox on page 27 m erenn ievoa E Forward Ctrl F Forward a selected message to another caregiver Review Ctrl V Review a selected document or result Approve Ctrl A Approve a selected refill request Complete Ctrl C L3 Reject Ctrl R Reject a selected refill request Refresh F5 Display new items sent recently if you cannot wait until the screen refreshes itself automatically see To set desktop defaults on page 109 26 1 Office Functions Deleting messages from the inbox To delete messages without opening them Many but not all items can be deleted from your inbox without opening them To do so select the item click amp on the secondary toolbar and Yes to confirm You can delete the following types of messages this way e Result notifications messages attached to lab and procedure results e Messages both mail and patient e Action items e Received charts You must open and take additional action before you can delete Refill Requests eRefill Requests and Documents transcription and sca
247. emplates and setting actions click OK NOTE In Output Template Settings screens with user selected templates display in bold 387 Encounter packs 388 6 To see the templates you selected for each view in the Clinical Module access the view and click Print on the toolbar falanja w Print Entire Chart Site Templates Encounter Procedure Orders Print Encounter Procedure Orders Fax Encounter Lab Orders Print Encounter Lab Orders Fax Patient Active Medication List Print Encounter H amp P Print Encounter H amp P Fax Location Templates Referral Letter Prompt Specialist Letter lt Frompt My Templates Encounter Lab Orders lt Frompt Encounter Procedure Orders t lt Prompt Customize Encounter packs To facilitate printing at checkout create bundles of output templates called Encounter or Template Packs for various encounter types and set the action for each template Creating encounter packs 1 2 Access Output Template Settings see Output Settings on page 385 Click the Encounter Packs tab and press Insert on your keyboard or click 4P Add Encounter Set to display Encounter Pack Sa N QQ Forms and Letters Template Mame Acti ga H amp P Reports Encounter Lab Orders Print amp a Internal Documents Encounter Procedure Orders Print 2 3 Lab Orders Sab
248. ems face sheet viewing from 147 face sheets customizing view 114 inactivating from 145 reviewing revising from 147 history viewing from A P 291 status revising 148 procedure entry rules using in A P 309 procedure results charts attaching to 192 encounters attaching to 311 entering 189 entry dialog box 310 face sheets viewing from 159 locating 193 overview 188 patient manager awaiting review in 174 performance dates changing 193 reviewing 191 view toolbar icon 113 viewing final 193 procedure rules entering results 310 procedures defining billable nonbillable 188 historical changing order dates 194 ordering using procedure rules 309 protocols using 308 publishing lab results with read receipts 184 pulled charts status bar icon 5 pulling charts 139 toolbar icon 112 pulse ox definition of 244 purchased libraries description of 238 404 Q qualifier E amp M calculator 367 queue definition of toolbar icon 380 documents from any view 382 merge charts 232 queued documents generating 393 merges approving rejecting 235 quick assessment plan toolbar icon 112 using 321 quick filters creating 98 overview 98 user defaults setting 98 using 99 quick lists customizing 127 quick search documenting in ROS or PE 274 R read receipts 185 publishing lab results 184 reason for visit defaults setting 118 details documenting 262 documenting 258 free text using 261 master lists 260 my short lists specifying
249. enable the toolbar icons Adding electronic signatures from output queue 1 Access Output Queue and locate and select a document that requires an electronic signature see Viewing documents from the output queue on page 92 2 On the secondary toolbar click 4 Output Tasks and select Electronic Signature Output Queue cp c 27 Open gl output Tasks Electronic Signature Printing from the output queue 1 Access Output Queue and locate and select the document you want to print see Viewing documents from the output queue on page 92 2 On the secondary toolbar click lt 4 Output Tasks to display a drop down menu and select Print NOTE If reprinting a prescription enter a reason and click OK 3 Click the Name down arrow and select a printer then click OK An entry displays for the regenerated document in the Output Queue Faxing from the output queue 1 Access Output Queue and locate and select the document you want to fax see Viewing documents from the output queue on page 92 2 On the secondary toolbar click 8 Output Tasks to display a drop down menu and select Fax 94 1 Office Functions NOTE If refaxing a prescription enter a reason and click OK Fax Dialog Fa aH Search cep Institution e Patient Humber 919 851 5991 T 4 Common Numbers Description Pharmacy One 1010 Westwood Drive Cary NC 27511 Speed Dial 1 OK Cancel 3 Enter the
250. ens recommended for specific complaints For instructions for building customized Fast Tracks refer to the HealthMatics EMR Clinical Customization manual To document a patient visit using a customized Fast Track template follow these steps 1 Open a patient chart and click the Current Encounter down arrow to display a list of Fast Track templates mee Current Encounter Current Encounter Cardiac VAGINAL DISCHARGE FT Click the template name to automatically go to the first contact screen in the template Document patient information as you normally would in that screen then from the Fast Track toolbar click IE Forward in Current Fast Track to proceed to the next contact screen for the selected template NOTES To move to the previous contact screen for the template click i Back in Current Fast Track To see the systems and short lists included in the selected Fast Track click Show Details of Fast Track Vitals Reason for isit Review of Systems Allergy History Immunization History Family History Past Medical History Social History Travel History Medication History Pregnancy Birth History Physical Exam Assessment and Plan 3 Patient Contact Functions Cancel Contact If you are documenting and do not want to save the information entered Example you discover you are in the wrong patient chart you can cancel contact with that chart 1 With a patient chart open from the He
251. ent Merge Messages on Bob Thorson BT1 Debra Tucker 1255485654 2 Toreview queued merges e Click in front of a merge message to list the patients that were merged E Patient Merge Merge Queue Manual Merge Merge History A pg E pen Bob Thorson BT1 Debra Tucker 1255485654 e With a chart selected press Ctrl F on your keyboard or on the toolbar click Face Sheet and press Ctrl D on your keyboard or on the toolbar click ji Demographics to review the two patient charts before deciding whether to approve or deny the merge in HealthMatics EMR 3 To approve the merge in the EMR e Highlight the Queued Patient Merge Message that you wish to approve 235 Patient Merge 236 4 5 e Press Ctrl A on your keyboard or click W1 Approve Merge The merge message is removed from the queue and all the checked merges are processed in HealthMatics EMR To reject a merge in the EMR e Highlight the Queued Patient Merge Message that you wish to reject Press Ctrl R on your keyboard or click W Reject Merge The highlighted merge is rejected and the message is removed from the queue IMPORTANT Rejecting a merge in the EMR does not reverse it in the Practice Management System To do that you must go through your PMS To close Patient Merge click the X in the upper right corner Reviewing merge history HealthMatics EMR keeps a record of all patient merges 1
252. entered Creating new output from the output queue 1 In the Output Queue view press Insert on your keyboard or click an Add Document to Queue to display a list of all available output templates E Add Output Template ojx Location Encounter Location Family Practice Clinic Patient wr Fred Finley e Recent Patients Encounter Jo3 23 2008 Current Encounter anteparkum Record by Date Prenatal Record of Patient Patient Correspondence Antepartum Record Detailed by D Detailed Prenatal Record of Patient Patient Correspondence 4 Caregiver Schedule 4ppainkment Schedule of Caregiver Internal Documents Diagnostic Tests Letter Diagnostic Tests Letter For Mail M Report Results 2 At Patient select a patient by doing one of the following e Click to search for a patient e Click e Use Current Chart to select the current patient or e Click e Recent Patients to view a list of patient charts recently accessed or 3 Click the Encounter down arrow and select an encounter to which to attach the document 4 Select the Template from the list and click OK to open the Print dialog box NOTE If a dialog box displays make the appropriate selections and click OK to access the Print screen 5 From the Print dialog Print Fax Queue Save to Log Export or Preview the document for instructions see Printing and Faxing on page 377 97 Quick Filters Quick Filters Quick filters provide
253. es Outgoing messages such as new prescriptions and refill responses transmit from HealthMatics EMR to pharmacies through the ePrescribe Gateway across secure confidential networks directly to the SureScripts server Incoming messages Incoming messages such as refill requests queue up on the Gateway and are polled periodically by ePrescribe Synchronization which can be run from HealthMatics EMR Administration either as a scheduled task or manually run on demand Matching Caregivers then match patient and pharmacy if needed and manually match the medication in the refill request to a medication in the patient chart Caregivers with the appropriate passwords can approve or reject refill requests NOTE No values need to be reconciled for requests you are rejecting Biometric authentication The ability to send electronic messages can be further regulated through the use of a biometric authentication fingerprint scanner device A third party vendor provides this software solution 55 eRefill Requests Viewing eRefill requests Providers with SureScripts SPI IDs and caregivers granted access to a SureScripts provider inbox can access eHefill Requests A caregiver can assign one or more other caregivers as their Prescribing Agents who can approve and reject eRefill requests on their behalf see To assign prescribing agents for caregivers on page 66 1 In the left pane of the HealthMatics EMR desktop or from the Office
254. es 344 USING Images I NOES e acc b POE OG Deo T HEX Ve eee EV Ed 345 Todda images to NOLES 2 2 3 ewe dde nb eda ce ue A a deat e o ded 346 Entering voice messages in NOteS 1 eee 349 Importing files as chart attachments llle 351 HAP MCDM e PE Eres 353 Viewing billing information 0 0 00 cc eee eee 354 Indicating reason charts are kept open 2 ee 355 Editing current H amp P reports a sib Ue x dha aia hoe ew and os ibo walk wa ERR 355 To edit current H amp P reports 1 0 eee eens 355 To change or review notes in current H amp P reports 0 0 ce eee 356 To view attachments from H amp P report 0 eee 356 Finalizing encounters from H amp P 1 teens 356 To conduct chart reVvieWS 6 eee ee ee eee 357 To conduct performance reVieWS 6 ee ee ees 360 To print patient information documents without signing off on chart 361 To send encounter billing information without signing off 0000 363 SOMATO CHAN Scc cocq V oaa rau CN i ORE Ced dC Mon Be oe a cq 364 Evaluation amp Management Calculator l llllr es 366 Accessing E amp M calculator s tre OS dvd A dnote de oe e tale ew i io ed 367 Understanding the E amp M calculator 0 0 ee 369 ECU MCD si tripea Sets qe a ee Sloan dial dose dp aee a Gd fu ad aret Sr iniecta walt 369 Managemerntoplors 3x 2o odi eee ptor p e Ra XN OR he maU easi Me pde 370 ALA VIS anre
255. es SS Time CheckIn Started Check Gut Labs PatientiEvent Caregiv Location Comments 8S iliiionaM 245PM 245PM 2 47PM No Parrot Pet Manag FamdyPr Followup 09 00 AM 2 46 PI 2 47 PM Yes Innis Mrs Manag Family Pr 10 00 AM 2 47 PM Yes O Neal Mrs Manag Family Pr Es os oo PM Yes Finley Mr Manag Family Pr Chest pair d Action Items 2 d Received Charts Web Messages and eRefill Requests 7t Batch Refi appear only if you have purchased that V Reminders functionality g i is x H Logged in as Manager System Appointments 2 1 Ei H Abi Bu Bz wo ye e Office manager From the desktop view Office Manager shows a bar graph that indicates the number of items awaiting caregiver action in each category The size of each bar and the number beside it change as work flows Clicking a bar displays the list of items in that category to the right in the preview pane e Lists The table that appears in the preview pane lists the items comprising each bar or view selected e Pop up menus for daily tasks You can right click in the preview pane of all desktop views to display a menu of the most common associated tasks for each view e Priority items In many views items marked high priority urgent or labs with abnormal values display in red e Appointment colors In the Appointments view colors indicate whether the patients are scheduled black checke
256. es only displays if the practice has purchased HealthMatics Access and it has been set up and synchronized refer to the Access Manual Refill Requests Refill requests received from patients by phone see Refill Requests on page 44 eRefill Requests Refill requests sent to you electronically from pharmacies see eRefill Requests on page 55 NOTE eRefill Requests only displays if the practice has purchased ePrescribe and it has been enabled Launch gt Administration Module gt System Options gt ePrescribe Documents ee DUE or scanned documents sent to you for approval see Documents on page 70 Action Items Reminders set for yourself or received from other caregivers see Action Items on page 77 Received Charts Charts sent to you for review prior to a patient encounter or received from a PA or other caregiver requesting review see Received Charts on page 80 Reports Messages sent to you about report results that require your action Example patients who need to be called to set up screening tests NOTES e High priority items display in red when not selected have a red exclamation point in the priority column e Scroll to see all of the columns in your inbox or manipulate column size by grabbing and moving the bars between column headings e tems that have been marked done but have not been deleted from your inbox display in gray with a line through them 25 Inbox Inbox item icons Each it
257. essment Plan Click the Search tab and search for the referral caregiver At Data Source select Referrals At Category select a category to narrow the search if desired At Search Term enter the first few letters of the caregiver last name if desired and click Search 315 Assessment Plan 316 3 Double click the caregiver name to send the referral to ordrag and drop or select and click Include to display Referral Referral X Danmar Caregiver Endocrine Doc Can be referred elsewhere Speciaky Clinic Consultation r Reason for Consultation Referral Please refer patient back for follow up and treatment Advise as to diagnosis Suggest medication or treatment Ba Goo D Wh Referral Please provide referring physician wath visit summaries Assume management For this problem return to primary caregiver at conclusion of care Signature Use my Signature Bitmap Password El Please call me notify me when you have seen patient I would like to receive periodic status reports on this patient Please call me potiry me if any procedures surgery or admission is planned NOTES Under Signature if you select the Use my Signature Bitmap box and enter your Password if required the electronic signature you have on file in the database appends to the referral letter when you click OK Print Fax or Email If Use my Signature Bitmap is checked when screen date saves t
258. eted and ali Fequisitions vll be available bo incdude in another Batch Do you wish to continue 3 Click Yes to delete the batch and to make all requisitions in the batch available for other batches otherwise click No To preview and print batch manifests packing lists There are two ways to print the Manifest Packing List for a batch from the Batch Processing screen e Select the batch and click d gt Lab Batch Preview to print the Manifest Packing List for the batch e Select the batch double click or click Edit then OK e Complete printing options then click OK 231 Patient Merge Patient Merge The Patient Merge function in HealthMatics EMR makes it quick and easy for a Caregiver or system administrator to merge two or more charts into one In addition you can review the merge history and reverse a merge if it was performed in error In Patient Merge you can do all of the following e Manual merge If your practice does not have a PMS you can merge charts directly in the HealthMatics EMR application Manual Merge e Merge queue If your practice uses the HealthMatics Ntierprise Practice Management System PMS when a patient chart is inactivated in the PMS Ntierprise sends a message to the HealthMatics EMR Merge Queue From there you can review the face sheets and demographics of the duplicate charts before approving or rejecting the merge e Merge history Review the merge history of any charts that
259. ewing 306 managing from history 255 256 Medi Span database 238 new ordering 303 overview ordering viewing 303 patient education printing 307 patient manager 174 previously recorded using in A P 293 refills viewing approving 46 Medi Span database 238 definition 295 menu bar using 3 merge charts history of 236 overview 232 merge queue using 235 messages chart outstanding 22 entering data on tabs 32 forwarding to other caregivers 42 granting access to others 129 inbox messages 25 inbox removing from 27 mail creating and sending 37 toolbar icon 113 moving to other encounters 156 overview 32 patient face sheet viewing saved messages 42 toolbar icon 113 use of 39 patient manager 174 procedure results about 193 replying to 40 status bar review from 5 toolbar icon 111 urgent indicator turning on off 6 viewing 32 Microsoft Outlook using to email from EMR 85 modules launching from the desktop 3 my ROS PE lists tab copying 270 Index deleting 270 editing 270 my short lists adding to 294 assessment plan specifying 239 defaults setting 240 deleting 129 history 240 overview of 239 reason for visit specifying for 239 sorting and deleting 128 using 242 N names entering preferred former 165 navigation in ROS PE 266 map 267 my ROS PE lists 268 269 ROS PE 266 search 271 selected 268 next appt editing 335 nickname entering 165 non contributory history entering 252 notes assessment plan sett
260. ewing data 22 chief complaints documenting 258 documenting details 262 clinical information 221 clinical products where to find 4 Clinical Reference System database 238 definition 295 collapse all in A P 294 collection information entering 218 colors on appointments 7 desktop stacks 7 columns resizing 8 concurrent encounters pulling charts for 140 consent of care agreement entering 164 contacts entering emergency information 171 counseling E amp M calculator 368 CPT database 238 definition of 295 D daily schedules printing 20 data elements definition of 377 data source libraries list of 295 data manipulating 8 data risk E amp M calculator 370 databases description of purchased libraries 238 date of birth field format 141 dates entering 10 historical procedures editing 194 pen based 13 deceased date entering 164 defaults for authored text 320 caregivers 108 locations 131 printers 130 quick filters 98 demographics accessing 162 addresses phone numbers entering 164 data entry disallowed 171 emergency information entering 164 entering editing 163 guarantors entering 164 insurance entering editing 167 Ntierprise accessing from the EMR 138 pictures loading 172 printing 166 privacy level setting 163 referral caregivers entering 163 toolbar icon 111 desk references menu option 3 desktop audit open encounters 107 defaults setting 109 launching other HealthMatics modules 3 login 1 orientati
261. ewing final not reviewed procedure results In HealthMatics EMR if procedure results were entered and marked Final but were not reviewed by the caregiver you can locate them in the following places e From the Orders pane of the patient face sheet double click the order or select the order and click View e From the desktop click 48 Result Notifications in the inbox or the stack e From the status bar in any view click 48 Result Notifications e Go to the Procedure Results screen and choose All patients Needs Review set other filters as desired Viewing final reviewed procedure results If procedure results are finalized and marked Reviewed by the caregiver you can locate them in the following places e From the Orders pane of the patient face sheet double click the order or select it and click L amp View 193 Procedure Results From the left pane or toolbar click ll Procedure Results click the Status down arrow and select Reviewed e Setthe remaining filters Caregiver Patient Dates Sort as needed to locate the patient e Click or Expand all to view the tests Select the test to view the values Setting performance dates for historical procedures To enter historical procedures those ordered on one date and scheduled for a future date or those ordered on one date but performed previously order the historical procedure s in Assessment Plan Set the performance dates in Procedure Resul
262. exam using mapped images llus 289 ASSESSMENY Pla a6 2102s dub ERES ESSERE equ aei s eee nad 291 Viewing problem or medication history from A P llle 291 To view problem history from A P eu orte e PE EET de qud er dake ee 291 To view medication history from A P 0 eee 292 To inactivate problems medications from assessment plan 292 Specifying assessments and plans llli ee es 292 viii HealthMatics EMR Application Reference Manual To specify assessments and medications using previous lists 293 To specify assessments and plans using shortlists 0 00000 e eee 294 To search for assessments and plans using database libraries 294 To enter free text diagnoses n eee ee ees 296 To indicate primary secondary and tertiary diagnoses ss 297 To link multiple diagnoses to a procedure code 0 00 cee eee eee 298 To edit diagGnOSeS IN Al P lt unite ede eee keke nb Re ten dba s Ca mb ae 299 TO Classily GlaQnOSes a9 mad acis ee ake eee a a Ses Gao boa PER Hie 299 Creating lab requisitions from assessment plan 0 000 eee 300 Ordering on behalf of another caregiver 0 ccc eee 302 To set order on behalf of caregiver option for A P n n 2 2 0 ce eee 302 Ordering and viewing medications from assessment plan 303 To order new medication
263. f the eRefill request in the pane below NOTES 56 Sort items by clicking column headings Icons display before each request eee INNEN The request must be matched with a patient and or pharmacy in the reconciler pane at the bottom of the screen before it can be approved The patient and pharmacy are matched Select the medication in the pane at the bottom of the screen to approve the eRefill 1 Office Functions In the eRefill Request screen you can use secondary toolbar icons to do any of the following A Pharmacy Insert Add a pharmacy for the selected refill request Approve Ctrl A Approve a selected eRefill request e Approve Approve the refill as is e Approve with changes Display Approve With Changes dialog box in which you can indicate the number of approved refills and insert a Note to pharmacy Reject Ctrl R Reject a selected eRefill e Reject Reject the selected eRefill Reject Send New Prescription Reject the selected eRefill and display Medication Search dialog box to select a new medication HN ae Delete a selected eRefill Face Sheet Ctrl F Display a selected patient s face sheet Click the X in the upper right corner to close the face sheet and return to eRefill Request kl Pull Chart Ctrl P Close eRefill Request and pull the selected patient s chart Refresh Refill Update the screen with the most current eRefills if you Requests F5 cannot wait for the screen to
264. face is enabled for the selected laboratory the Status for the batch and all requisitions in it will be set to Ready to Send This tells the interface it is ready to be sent to the laboratory for processing and no longer editable 2 Chart Functions To edit lab order batches If the batch does not have a Status of Ready to Send you can edit a batch to remove lab test requisitions before transmitting the batch NOTE You cannot add a test to an already created batch The batch would have to be deleted and a new batch started 1 Access Batch Processing See To access batch processing on page 229 2 n Batch Processing select a batch and click a Lab Batch Requisitions Location Rarity Medicine Clinic Crested By er System Laboratory Lab Corp Status Complete On Hold E Gaspa Mrs 0004 4 12 2006 3 33 00021 Complete Hastings Lynn Family Ni EA Hayes Cynthia CHAYES 4 12 2006 3 56 O0022 Complete HAYES CYNTHIA Fami M El Finley Fred 1212 4 12 2006 4 28 D004 Compete Hanger Swsbem Family MH 3 Click to deselect the Patient Name box to the left of any requisition s you do not want to include in the batch 4 Click OK The Print dialog displays to print the Manifest To delete lab order batches 1 Access Batch Processing see To access batch processing on page 229 2 Select a batch and click to display the following message ee N This Batch will be del
265. face sheets 158 You can view face sheet order results from two places Orders pane e Encounters pane on a visit H amp P Report The Orders pane on the face sheet displays information about procedure and lab tests referrals and other orders The system displays orders that are ordered pending need review and are reviewed 2 Chart Functions From the Encounters pane you can access the H amp P Report from a visit To view order results pull a patient chart in HealthMatics EMR and from the left pane or the toolbar click L Face Sheet and do one of the following To view results from the orders pane 1 On the Orders pane toolbar click L View Order 2 Click Toggle Filter to toggle the view to either All or Reviewed Pending or Needs Review 3 Double click an order that is Preliminary Partially Reviewed or Reviewed to display order information and results F Order Explorer Orders All Newest to Oldest Order Details ETY E Expand wiew Print KO Emai EEJ Two Weeks Ago Details Trend La Angina overview Final Not Reviewed a pk ending ordered CBC MANUAL 85031 EHEJ Less Than a Month Ago STREP QUICK TEST 86403 Ordered Ier Fred Finley BAC CULTURE OTHER 87070 Ordered Z8 SPECIMEN HNDUNG TRNSPRT OFFC gt LAB 29000 Preliminary Partially Reviewed La Sore throat diagnosis and treatment Ordered Diagnosis SINUSITIS ACUTE amp UNSPECIFIED 461 9 EHZ One Month Ag
266. g viewing 338 printing 338 341 immunizations adding historical 340 erroneous entries marking 339 free text using in history 342 history documenting 338 editing 339 using previously entered free text 343 history viewing 152 399 Index ordering 342 toolbar icon 111 import tab in messages and notes 37 importing files into notes 351 inactivating medications automatically 158 problems medications from A P 292 from face sheets 145 inbox contents of 24 item icons definition of 26 messages removing 27 other caregivers viewing 28 status bar filters 5 views refreshing 26 insurance adding to EMR database 169 editing in EMR database 170 entering editing 167 interactions face sheets viewing from 146 medication warnings 306 internal transcription 135 viewing in charts 155 internal transcription approving rejecting 73 Internet bookmarking favorites 84 toolbar icon 111 K keypad numeric 14 on screen 14 L lab order entry accessing 214 creating requisitions 215 overview 214 viewing lab orders 215 lab orders batches creating 229 editing 231 lab reports emailing printing for all patients 186 for one patient 186 lab requisitions creating from A P 300 lab results annotating during review 183 date selections 187 entering 175 400 face sheets viewing from 159 finding 182 notification messages rules 187 overview 175 patient manager reviewing in 174 publishing with read receipts 18
267. gs 386 Selecting output settings for each screen Access Screen Templates to select templates available for a screen from any of the following depending upon the level at which you want to set them Site Administration Module gt Site Settings gt gP gt Output Settings These templates display under Site Templates in the drop down list Location Administration Module gt Locations gt select a location gt 9 gt Output Settings These templates display under Location Templates in the drop down list Caregiver Clinical Module gt from the toolbar on any view gt Customize These templates display under My Templates in the drop down list NOTE You can also customize caregiver output settings from the Administration Module Output Template Settings Ea Screens Templates Encounter Packs Screen C Chart Assessment Plan Chart Chart Attachments Chart Demographics C Chart Face Sheet C Chart Flow Sheets C Chart H amp P Report Chart History C Chart Immunizations C Chart Physical Exam Chart Reason For Visit T Chart Result Summaries C Chart Review of Systems T Chart vitals Cal Office Chark Additional Results __ OFfice Chart Lab Results C Office Chart Procedure Results El EN EE Ib E Daria 1 4 Printing and Faxing In Output Settings double click the screen you want to customize a O Screen Chart Chart Attachments All
268. gt Output Defaults e To set location defaults In the left pane select Locations gt select a location gt 9 gt Output Defaults To set caregiver defaults In the left pane select Caregivers gt select a caregiver gt 9 gt Output Defaults 2 Inthe Output Defaults dialog box select an Output Category and click g Edit Layout Default or press F2 Output Default Properties x Please select the default Far category HP Reports efault Output Category HE Reports Layout Patient Letter E Printer US Letter 64 11 in LJ 3 Click the Layout and Printer down arrows and select the appropriate items then click OK Creating output default sets A caregiver can have more than one Output Default set to accommodate default setting for different hallways or wings of a facility 1 Access caregiver Output Defaults either in the Administration Module see Output Defaults on page 384 or from the Clinical Module menu bar Options Edit Output Defaults 384 4 Printing and Faxing 2 Select Output Defaults for each Output Category and click ey Save Set 3 Enter a name for the Printer Set Example Hall A and click OK Using output default sets 1 From the Clinical Module menu bar select Options gt Edit Output Defaults 2 Click the Set down arrow to select the set you want to use 3 Click Apply Set and OK at the bottom of the screen to exit Output Settings
269. he HealthMatics EMR desktop click Z Appointments 2 Right click any appointment and click 8l View Worklog to view contact made with the patient s chart for that visit dew mE p Appointment Worklog Appointment Worklog Encounter 3 5 2006 1 16 PM Review Contact 3 5 2006 1 16 54 PM System Manager RDOIRT Detail Reason For visit Detail Vitals 3 To check the progress of the visit look at Details to see where documentation has been entered then click Close to return to Appointments 104 1 Office Functions Billing Reconciliation Billing Reconciliation provides a quick way to access billing information for a selected period You can filter the data by Provider Location or Patient 1 To access Billing Reconciliation do one of the following e Inthe left pane of the desktop click Billing Reconciliation or e From the application menu bar select Office gt Billing Reconciliation Billing Reconciliation Ez View Details Pull Chart Provider show All From zi 1if2006 Location lt show All Ta 3 31 2006 Patient Finley Mr Fred a Family Practice Clinic E No Billing Provider E du elzl2006 amp DEF Site Default System Manager Cannot bill electronically EF B 706 50 CHEST PAIN UNSPECIFIED 786 50 d 2 3 2008 85031 CBC MANUAL 850313 System Manager B H 244 3 ACQUIRED HYPOTHYROIDISM UNSPECIFIED 244 9 j
270. he anatomical picture library or from the photo import dialog Click the icon to open a browse window Click the arrow to select the source for the image e File System e Library e Import Photo Drawing tools Click arrow to select a drawing tool Pencil Draw a free form line Line Draw a straight line Rectangle Draw an empty rectangle Filled rectangle Draw a filled rectangle Circle Draw an empty circle Filled circle Draw a filled circle Text Enter text Enter text in the text box click OK then click the image where you want to insert the text Remove all Click to remove all data entered on the mage tab Print Click to print the image data To add images to notes 1 In any HealthMatics EMR Note dialog box click the Image tab 2 Click Ey Load down arrow to display a menu of sources for the image 3 Select one of the following sources and then follow the appropriate instructions 3 Patient Contact Functions File system Browse to locate the appropriate image on your computer or network JPEG jpg and Bitmap bmp images are supported cerebral cortex jpg Heart worksheet jpg Respiretory system jpg My Network P Library Scroll to locate or search for the appropriate image in the Anatomical Pictures library contained within HealthMatics EMR NOTE Custom pictures can be added to the library using HealthMatics EMR Clinical Customization Module see the HealthMatics EMR Cli
271. he bottom of the screen Type the note and click OK A paper clip displays on the Note button and the text displays in the bottom pane at the end of the complaint details The onset of the pain has been gradual Patient states that the pain feels like a gradual tightening around the chest and has been occuring in an episodic pattem for 3 days Each episode lasts 15 minutes The pain is described as mild to moderate Chest pain nates Patient repart episodic chest pain associated with stress lt Ne Detail level note Complaint level note ok gt Detail level To add a note about the detail click next to the selected item When a note is entered the note icon is highlighted and the text of the note displays in parentheses in the bottom pane beside the detail the note applies to Review sort documentation The tools in the lower left corner of the Reason for Visit screen allow you to review edit delete or sort the text of your documentation for the encounter at any time before signing off on the patient H amp P Report A Preview Note JO tide Patient Words T ces on Ol 4r mimo 4 Name Recheck E Chast pain ho 3 Patient Contact Functions Use the icons to do any of the following Preview Show HP Click to show all complaint text generated for Reason for text Visit Add or edit reason Click to insert a Reason for el note When a note is for visit note added icon changes co
272. he patient chart click Pull Chart NOTE Pulling a patient chart takes you out of Procedure Results 2 Chart Functions 10 Use messages to do the following To send a message to another caregiver about the results click Messages gt Send Patient Message Create and send the message as you would any Patient Message See Sending patient messages on page 39 NOTE The application does not attach the procedure results to these messages Send a Web message To print results click Print gt Procedure Results The results print automatically To set the date the procedure was performed for historical procedures select the correct date when entering the results by clicking the drop down arrow to display a calendar See Setting performance dates for historical procedures on page 194 Procedure Results Entry Susan L Frawley Order 1 of 3 xus gt Next Joe ANTEPARTUM TOOL 59400 guia E Review d Attach 4 march 2008 A AN Son Mon Tus Wed Thu Fri pa l z 3 O6 ANTEPARTUM TOOL 59400 E S MATERNAL FETAL DATA Gestational Age by Initial Ex 5 6 7 8 9 WW I mi2 13 14 15 16 17 18 Fundal Height LDMLUELADAMESSEA 1 3 20 21 22 23 24 25 Fetal Heart 25 23 29 30 3 Zy Fetal Heart B Fetal Heart C To bring in procedure result data over an interface such as MidMark if you purchased and connected it click Procedure Tasks Acquire data from Vi
273. hem 3 Select the immunization you want to edit and do one of the following e Press F2 or e Double click the immunization or Click 45 Edit Immunizations or e Right click and choose Edit Edit Immunization w BENE pena Erroneous Entry Comments Laos ala 4 Make any of the following changes e Change the date e Mark the immunization Erroneous Entry e Add a comment using conventional word processing tools 339 Immunization Records To add historical immunizations 1 Access Immunization see Accessing viewing Immunization Record on page 338 2 Click the Edit Immunizations tab 3 Click Add Historical Add Historical Immunizations Irrnanization Date Given m Comments me Ga o p Y BH E Immunization Name Date Given Comments DTP 3 90701 Jee 4 Click the Immunization name and CPT code from the Immunization window in the left upper pane NOTE You can multi select by using Ctrl Click 5 At Date Given select a date NOTE This date is entered for all immunizations selected but can be edited later 6 At Comments enter any comments NOTE Comments will be entered for all immunizations selected 7 Click Add for selected immunizations to display in the bottom pane 8 If necessary to remove an immunization highlight the immunization in th
274. hentication is not required and third party software is not installed on the client machine no biometric authentication occurs To use biometric authentication the practice must do the following e Install SAFSolution client software e Add caregiver login names to domain and enroll the users with the SAFSolution client software e Add biometric authentication system options in the Administration Module To add biometric authentication system options Biometric authentication functionality uses three system options To set them go to Launch gt Administration Module gt System Options and follow the steps below 1 Click the Display Section down arrow and select Biometric Authentication 2 To enable biometric authentication double click Key word Disabled and enter a Value of 1 Click OK NOTE To disable biometric authentication change the Value back to 0 3 Double click Key word Domain at Value and enter the name of your Windows domain Click OK 4 Double click Key word Required and either enter a Value of 1 to require the use of biometric authentication for electronic prescriptions or leave it at 0 to make it optional Click OK 1 Office Functions To use biometric authentication with electronic prescriptions 1 Approve an eRefill request by following the steps in Approving matched eRefill requests on page 60 On the screen that requires a password leave the Password field blank e IF the password is b
275. hments with specific encounters View and email laboratory and procedure test results You can view some information problems history medications currently being entered in an encounter not yet saved to the database 2 Chart Functions Viewing and revising problems from face sheets To view problems 1 Open a patient chart and in the Problems pane click View Revision History to display Problem Explorer 8 Problem Explorer Problems All Newest to oldest Revision History Newest to Oldest E 1 HYPERPARATHYROIDISM UNSPECIFIED 252 00 e CONSULTATION WITH FAMILY 90887 Routine e DRAINAGE OF BLADDER EY CATHETER 51010 Routine e LIPID PANEL 80061 Routine S HYPERPARATHYROIDISM UNSPECIFIED 252 0 ANGINA NOS 413 9 CONGESTIVE HEART FAILURE UNSPECIFIED 4 5 GANGLION BLOCKING AGENTS CAUSING ADVER 5 CORONARY ATHEROSCLEROSIS 414 0 Inactive E AFTERCARE FOLLOWTMG SURGERY OF THE CI S ALCOHOL ABUSE UNSPECIFIED DRINKING BEH 2 ANGINA NOS 413 9 1 CONGESTIVE HEART FAILURE UNSPECIFIED 428 0 ARTERIAL BLOOD GAS 82803 Routine CALCIUM SERUM 82310 Routine CBC MANUAL 85031 Routine PTT ACTIVATED PARTIAL THROMBOPLASTIN TIME 85730 Routine VENIPUNCTURE gt AGE 3 NOT ROUTINE 36410 Routine e WITHDRAW ARTERIAL BLOOD DIAGNOSTIC 36600 Routine e SPECIMEN HNDLNG TRMSPRT OFFC gt LAB 99000 Routine e NUCLEAR SCAN
276. ian _ Patient Education Print Encounter Lab Orders Encounter Procedure Orders 29 Landscape Documents QQ Office Correspondence gg Patient Correspondence 2 453 Patient Handouts Patient Active Medication List Patient Demographics Record Patient Education Patient Immunization Flow Sheet Patient Immunization Record W zum 6 9 m ow em 4 Printing and Faxing At Encounter Pack Title enter a descriptive name for your template pack Click the Encounter Type down arrow and select the type of encounter for which you ll use this template pack At All Templates open folders and double click the templates that you want to bundle for the encounter pack Use the arrows to manipulate the order that the templates should appear In the Templates in Pack box if desired you can select template actions by clicking 4 Edit Action or pressing F2 and selecting the appropriate action Otherwise accept Print When you have selected all the templates for the encounter pack and their default actions click OK The new encounter pack is listed on the Encounter Packs tab by Title and Encounter Type Output Template Settings Screens Templates Encounter Packs up c P Title Encounter Tvpe Admission Mote Print Pack Admission Mote i amp ntepartumRecord 0 Admission Mote 7 Office Visit T HINT If you do not print documents at sign off create an empty encounter pack Click O
277. iate box es e Reviewed Check this box to indicate you reviewed the chart e Present Check this box to indicate you were present during the encounter e Note Check this box to enter a Chart Review Note for History and Physical 358 3 Patient Contact Functions Detailed chart reviews 1 Click E switeh te Detaled to go to a detailed chart review by section Ae Performance EE Switch to Summary Reviewed Present Note Reviewed Present Note Reason for Visit B E A Physical Exam E gg History T C LC Aseman I TF o Review of Systems oS op Review Al History amp Physical Report notes ve Ty x ae Y JP Mr Fred Finley 7 3i 7 2006 11 45 AM Location Family Medicine Clinic Patient ID 1212 DOB 7 24 1954 Married Language English Ethnicity Caucasian Male 2 To document your review of the chart do one of the following Review sections individually For each of the five sections of the chart click the appropriate checkbox to indicate whether you Reviewed or were Present for that part of the encounter or both Click the Note box to include a note for that part of the encounter and enter a note using any of the tabs available then click OK to return to the H amp P Report review screen A check mark displays in the Note box on the H amp P Report screen Review all Select the Review All box if you want to indicate with one click that you reviewed all sectio
278. ic set to accept numeric entries when you select an increment such as hours a search icon El displays in the Value column Complaint Details Chest pain C Characteristics Onset seconds minutes Pattern hours Severity Click El to display a number field Type a number or click spin arrows to document the number NOTE Minimum and maximum values for the number are preset in complaint 263 Reason for Visit 264 editor See the HealthMatics EMR Clinical Customization Manual if these need to be changed Episodic pattern Complaint Details Chest pain Onset z g recurrent Bl Duration Patten id EE ersistent Severity E S Characterized As P Location arano E adiaktior Ale S minutes To document an episodic pattern click on the episodic descriptor Examples seconds minutes hours then click E to display a number field Type a number or click spin arrows to document the episodic pattern H amp P report The text in the Text box changes as you document characteristics and details This text is automatically added to the H amp P Report If the complaint is the only complaint or is the first complaint documented an additional sentence documenting this is added to H amp P Add notes You can add additional text to the documentation at both the complaint and detail levels gt Complaint level Click Note at t
279. ically to the pharmacy You can not prescribe controlled substances electronically which includes faxing and eRefills The Approve button is disabled on the eRefill Request screen if a controlled substance is selected You must enter a password to approve or reject all eRefill requests as well as new requests CAUTION Pressing Approve immediately sends a Refill Approved eRefill Response message back to the pharmacy via the SureScripts and ePrescribe Gateway This eRefill Response message contains the original prescription sent by the pharmacy and not the medication selected from the patient medication list If the wrong medication is selected from the medication list the pharmacy still receives the medication originally sent in the eRefill Request but whatever medication is selected from the patient medication list is the medication documented and automatically saved to the patient chart 61 eRefill Requests If the approval does not transmit properly send a fax to the pharmacy in the Fax dialog box that displays IF faxing is enabled at your practice e When faxing the medication approval to the pharmacy the selected medication in the patient medication list is faxed to the pharmacy and not the original prescription sent by the pharmacy If the fax does not go through a failure message contains the name of the pharmacy along with the medication name patient name and fax number Rejecting eRefill requests Any author
280. icies the number in the Rank column indicates whether the policy is primary 1 secondary 2 or tertiary 3 To change policy priorities select a policy and on the secondary toolbar click the up or down arrow 167 Demographics For a description of the secondary toolbar icons see Using secondary toolbar icons and shortcut keys on page 9 3 To add anew policy press the Insert key or from the secondary toolbar click dh Add Policy 4 On the Policy Information tab click the Carrier search button and search for the patient carrier Insurance Carrier Search Mame b Search Clear rg Address Phone Number ceca NOTE If the patient carrier is not in the database enter it into your PMS or if you do not have a PMS follow the instructions in To add insurance carriers on page 169 168 2 Chart Functions 5 Click OK to return to Insurance Policy properties Insurance Policy Policy Information Subscriber Information Carrier BlueCross Blue Shield El Group Mumber 111 Plan Mumber 2 Enrollment Date ssizone med E Termination Date El Plan Type Eces Formulary Blue Cross Blue Shield of North Carolina Blue Care E otes amp FS e E OK Cancel 6 Enter the Group Number Plan Number Enrollment Date and Plan Type 7 IF the policy subscriber is not the patient click the Subscriber Information tab to enter the relationship of
281. ick Search Select a pharmacy and press F2 or click amp Edit Selected Item Pharmacy x Mame Contac EDI Id Street ee City State Zip 0 Phone g19 855 6111 E senes NT El Fac 919 852 4444 Mobile e E Email a oma 67 eRefill Requests 68 e At EDI Id enter a unique NCPDPD ID for this pharmacy and click OK e In Pharmacy Search click Close at the bottom right corner to exit Using biometric authentication with electronic prescriptions As an option to practices that require biometric authentication HealthMatics ePrescribe supports the use of fingerprint verification when sending an electronic message Biometric authentication is implemented by third party software that is integrated into HealthMatics EMR HealthMatics ePrescribe can be set up to require the use of biometric authentication by setting a system option requirement in HealthMatics Administration IF biometric authentication is required the caregiver is always prompted for a fingerprint immediately before the new prescription or refill response is transmitted If the third party software is not installed correctly on the client machine an error message displays and the message will not transmit IF biometric authentication is not required but third party software is installed on the client machine the caregiver is prompted for their fingerprint when sending a new prescription or a refill response IF biometric aut
282. ictated date Date dictated Transcribed by Transcriptionist 5 Select an item and do one of the following to open it e Press F2 on your keyboard or e Double click or Click Edit Selected Item or e Right click and select Edit d Transcription Ioi x d ad di suben E approve Index Patient Mirs Irene Innis Subenithed By Dictation Audia D amp ctation Type Chief Complaint ll Dictated By Terry Manning MD Dictation Date 4 5 2008 I mm Rl Transcription TE c uo B a Internal Transcription Ready to Trarexcribe 6 Click Play to listen to the voice note as you enter the transcription text in the large free text field at the bottom of the dialog box 7 Click Audio buttons as needed to move to the beginning of a dictation rewind play stop pause fast forward and to move to the end of the dictation as needed 8 When you have completed the transcription click Save The Status in the Internal Transcription view changes to Current Batch 9 Click to preview the transcription or click 3 from the Transcription or Preview dialog boxes to print it for review 136 1 Office Functions 10 Click Submit to send the transcription to the dictating caregiver for approval d Send Transcription Iof x EJ Send High Priority Caregiver Manning Terry MD Subject Mrs Irene Innis Transcription Document Message tS Bo Y hls Please review
283. id include saved data display the message Edited screen name 1 2 From the left pane or the Office menu select i amp Worklog Click the From and To down arrows to select a date range for the activity you would like to view Select a filter e Caregiver Displays contact made to patient charts by caregiver e Machine Displays contact made to patient charts at a workstation 1 Office Functions e Patient Displays all contact made to a selected patient s chart 4 Inthe preview pane click signs as needed to view the areas of the worklog 5 Select an item at the encounter level 1 4 Senn SNC and click isl View Details to display it in an Explorer window Filter by caregiver EE View Details Pull Chart Caregiver lt Show All Erom 317 2006 Machine show all gt To 317 2006 E a Manager System El RDIRT ci 28 3 17 2006 1 12 46 PM EE Finley Mr Fred EHE 3 17 2006 1 26 07 PM 1 52 23 PM Assessment Plan Patient Show All 3 14 2006 4 40 PM Office visit Description of information Level 1 Logins Caregivers logged in during the date range selected including the times logged in and out NOTE If the caregiver is still logged in no logout time displays Servers Servers used during the date range selected Level 3 Dates Dates and times caregiver logged Includes log out times unless the caregiver is still
284. if previous data exist which allows you to decide how to apply template data Combine existing with template When you click Apply template data are automatically combined with previously selected data Replace existing with template When you click Apply previously selected data are replaced with template data Reload knowledge Use this button when customizing only Reset settings Click to restore Review of Systems Physical Exam caregiver options to the factory settings 4 Click OK to exit or select another item in the left pane to set additional defaults 120 1 Office Functions To set vitals defaults 1 From the HealthMatics EMR menu bar select Options gt Edit Options gt Vitals P Caregiver Options for Manager System le General Vitals i Desktop Pasurements lood Pressure Be Toolbar Face Sheet Units Ib c2fin Patient position sitting e E aa Waist cm F Cuff location Left Arm hd x Results Cuff size standard Head circ cm NES 2 Physical Exam 2 Assessment and Plan 2 Electronic Prescriptions Sign OFF Title Bar s History Lists z Quick Lists My Short Lists Temperature Reading F Method espiration Pattern JUnlabored id ced 2 Set defaults as follow Default temperature Units Select the usual notation for temperature units settings Fahrenheit or Centigrade Method Select the us
285. ily Practice Clinic 1 Office Functions 3 Click Email H amp P Report H amp P Report Mr Fred Finley 3 5 2006 Message HTML Fie Edit View Insert Format Tools Actions Help Subject Hae Report Mr Fred Finley 3 5 2006 attach pese Report 4 ken Altached is a H amp P Report for Mr Fred Finley The system generate the Subject line and text message and attaches the H amp P Report automatically 4 At To enter the recipient for the email add additional text to the message if desired and click Send 5 Inthe Confirm box that displays click No if you do not want to save the message to the patient s chart otherwise click Yes to display Chart Attachment For additional information see Creating Outlook emails in the EMR on page 85 87 Outbox 88 Outbox ltems in your outbox reflect messages you have sent to other caregivers that have not yet been opened When a recipient opens a message it automatically deletes from your outbox Use this feature to determine if others have read your messages Deleting a message still in your outbox also deletes it from the recipient s inbox 1 To access your outbox in the left pane of the HealthMatics EMR desktop click amp Outbox or from the menu bar select Office gt Outbox Outbox OP cu Open Vf Forward Caregiver Manager System ee Sent v d Manager System 3 10 2006 11 11 AM s Pra
286. in the title bar il Move item to bottom of the title bar list By Refresh default title bar data 125 Options 3 At Separator click the down arrow and select the separator that you want between each item on title bar 4 At Preview review items and Separator selected for customized title bar and make changes if desired 5 Click OK to save the selections and exit or select other items to set additional defaults To set history defaults 1 From the HealthMatics EMR menu bar select Options gt Edit Options gt History P Caregiver Options for Manager System Miel x General History Psr Desktop be Toolbar eneral Pace Sheet Default Tab Previously Entered History Patient Manager Previnusiv Entered History Results Physical Exam z Assessment and Plan z Electronic Prescriptions Sign Off Title Bar History Lists Quick Lists fly Short Lists canal 2 Click the Default Tab down arrow to select the tab that you want to default to open when you click amp History on the toolbar Previously Entered History My Short Lists Short Lists Search or Free Text 126 1 Office Functions To customize quick lists 1 From the HealthMatics EMR menu bar select Options gt Edit Options gt Quick Lists P Caregiver Options for Manager System Io eneral Quick Lists ee Desktop Toolbar uick List Properties es Face Sheet Lists Quick List Patient Manager
287. include with the letter in the upper left corner do the following Click to check or uncheck the sections of the H amp P as wanted or Click Check All and then uncheck sections you don t want included or Click Uncheck All and then check sections you want to include if any NOTE This box populates with the documentation available in the patient chart To send the referral do one of the following Print or fax To print or fax the letter click Print then OK in the Print dialog NOTE To fax the printer must be set to Always prompt so you can select the fax printer See Editing output defaults on page 130 317 Assessment Plan 8 To email the referral letter via Outlook Email IF MS Outlook is set up for emailing out of HealthMatics EMR click Email to display Choose Profile Choose Profile Profile Name ursus ue Mew Cancel Help Options gt gt e At Profile Name select a profile and click OK to display the email form Referral Mr Fred Finley Message HTML File Edt View Insert Format Tods Actions Help Type a question for help E TF Paragraph Aria gt A Bz u E Ea j EE LC QI Subject Referral Mr FredFinley 000 Attachi E bafera Lettered OOO Attached is a referral letter for Mr Fred Finley e Send the email as you would any other from Outlook The subject is provided and the referral letter shows as an attachment NOTE
288. ing Modfier 2 Billing Provider Fe Billing Details A This encounter cannot be billed electronically Unspecified Diagnosis ROUTINE OBSTETRIC CARE 59400 Print l Template Pack otfice Visit Print Pack z 7 Encounter Procedure Orders z e Check All Encounter Lab Orders Specialist Letter s Uncheck Al Referral Letter Patient Education IY AGP Prescriptions v FormsjLetters E e 3 Patient Contact Functions 3 At Sign Off Password enter your password NOTE If the application is set to require biometric authentication it ignores the password and prompts for a fingerprint 4 Select Include Signature Bitmap if you have a signature bitmap on file and want to use it NOTE The rest of this dialog box is the same as the Send Billing Information dialog box see Viewing billing information on page 354 5 Inthe Billing Details pane select or deselect each item that should be sent to the Practice Management System for billing NOTE Selected billable items display bolded preceded by a green sign 6 Click OK 7 Type your sign off password again if necessary to electronically sign any prescriptions written NOTE If an electronic signature was entered into the HealthMatics EMR database you can sign lab orders electronically If a digital signature was not placed in the database the Add Signature check box does not display The chart is automatically filed and the encounte
289. ing defaults 122 entering data on tabs 32 H amp P report viewing from 356 images adding in physical exam 286 loading into 346 using 345 importing files into 351 overview 344 physical exam adding 286 review of systems adding to 282 characteristics level adding 283 review of systems level adding 282 systems level adding 283 text 344 voice entering 349 transcribing 135 notification messages rules for routing 187 viewing 29 Ntierprise accessing from the EMR 138 nursing services data source 295 O OB history editing 333 office manager description of 7 401 Index office procedures data source 295 one dimension measurements documenting 276 open encounters report 107 toolbar icon 111 options editing 108 overview 108 ordering on behalf of another caregiver 302 orders assessment plan setting defaults 123 batches creating 229 face sheet customizing view 115 viewing from 158 viewing results from 159 medications 303 procedure rules using 309 toolbar icon 111 organ donor entering 164 outbox accessing 88 other caregivers viewing 88 toolbar icon 111 Outlook emails within the EMR creating 85 inbox toolbar icon 112 using to email from EMR 85 output defaults setting in administration 384 encounter packs creating 388 output all prescription properties dialog 51 output blocks definition of 377 output default sets creating 384 using 385 output queue action history viewing 96 documents regenerating
290. ing referrals meats aoo oer Re a coca o d Chae dees earth d 195 To access referral results naaa 195 To review final referral results llli 197 Processing authored Text cu x etd oo E E oT OH be CR eee ee 197 PROD ONE OS UES eraan esc eur de eh ens E aues xm Gites ie rd Fee 198 Result Summaries 2 bv4 2e RUP RR Eee nea pda iqe xu et hes 199 Viewing result summaries l l 199 To view spreadsheets default view llle 202 TO VIEW GRADES sinks wuts itt deus ade ta dele oun cde De str ae modis acude ive s atas Se Now acad 203 Creating new result summary graphs 0 ce ee eee 203 Flow SheelS 9 teagan esa eee eae ee ae eae eee ees 206 TO a3dd TloWESTIee S duri os ued be dices bh tale carton ee nts rede eie brat Deas o cedat 206 To correct erroneous entries on flow sheets 0 000 eee eee 207 Chart Atltachmenls 92 606 EXER EROR ED a dM du 208 Adding chart attachments 0 0 eee eee 208 Linking chart attachments to office visits 0 0 0 00 ce ees 209 Viewing chart attachments from face sheet 000000 210 HemiligerS aue oh wee Oo eh eee ee bee idee be ed iba quie 211 Creating reminders on patient chartS 2 2 0 0 cee ee eee 211 Viewing and completing reminders 0 000 eee eee 212 Lab Order ENUY canero aka wae ae bee Pi eae ee ee ee ease 214 ACCESSING lab order eny a asa cd wide wee eee obe ER 8 wee 214 VIEWING lab Order
291. interaction button to see expanded information about the interactions and the severity These are provided by the Medi Span database To print fax or electronically transmit prescriptions 1 With a patient chart open in HealthMatics EMR from the left pane or the toolbar click A P Assessment Plan 2 Order a medication for the current encounter see Specifying assessments and plans on page 292 3 In the preview lower pane double click the medication or select it and click g 4 Click the Prescription tab Detads Prescription Education 3 Patient Allergies 7 Formularies v Use Signature Bitmap Password ae Print Family Medicine Clinic Cary NC 27511 Phone 888 672 3282 Fax 819 651 9551 System Manager DEA License ET CM Patient 41 year oki male Weight 177 Ib 6 oz 80 53 kg as of 9 26 2004 5 At Template click the down arrow and select the appropriate template for the prescription 6 If you are using an electronic signature enter your Password 7 Click Print then click OK in the Print box that displays 3 Patient Contact Functions NOTE You can also print prescriptions when you sign off from an encounter on the H amp P window To do so click the A amp P Prescriptions checkbox and then click OK 8 Prescription Properties e Ifthe Preferred Pharmacy displayed is not the correct one click to search for the correct one using the Phar
292. iodically as determined by the policy of your practice Passwords are required for some application functions including prescription signatures and chart sign offs Biometric authentication At the login screen leave the password field blank and click OK gt IF the password is blank the biometric authentication hardware and software are installed and your system administrator has enabled the Biometric Authentication system options you receive a prompt for a fingerprint gt IF any of the above conditions are not met a message instructs Enter a valid password EMR Desktop EMR Desktop 1 Log in to HealthMatics EMR Clinical Module 2 On the toolbar click z View Desktop 3 On the title bar click Gj Maximize if needed Title bar Menu bar Toolbar Secondary toolbar Filters Minimize Maximize EN X OW N i Clinical Module PEDES Inbox Action Items 2 siiis Office Manager bars Inbox filters User o s5 ww 145 H Derren AE a EA logged in ga 5 jo Gy 1 B fo Eli Bu Gz Gols Urgent message indicators flashing red glow The HealthMatics EMR window has four bars to facilitate navigation and provide patient chart or work information Using the title bar The title bar is located at the top of all views You can customize the title bar to display the information most important to your practice P Mr Fred Finley Male 41 years old 21212 AT amp T
293. ion erae Job bite Review e Calcium in diet Review ide Review 3 3na Rejected Labs Review Rejected Oncology Review e Path Reports Review a fh NI LH SC M Patient Manager bar In the Patient Manager view the bars in the lower left corner reflect the number of items awaiting action for the selected patient Items that are overdue high priority or include abnormal results display in red in both the Patient Manager bars and the preview pane to the right 173 Patient Manager The following types of messages may appear in the Patient Manager view Appointments Future scheduled appointments Click Open to view appointment and edit details see Appointments on page 15 Patient messages Patient messages not Saved to Chart or deleted plus high priority red items Click Open to view see Hesponding to patient messages on page 40 Transcriptions Transcriptions not yet reviewed Click Review to mark item Reviewed seeApproving or rejecting documents on page 71 Pending messages Scanned documents Scanned documents not reviewed Click Review to mark item Reviewed seeTo approve or reject scanned documents on page 74 Reminders Health maintenance disease management and other chart reminders such as reminders for flu shots or immunizations Click Open to view see Reminders on page 211 Medications Pending refill requests in red if high priority Click Open to view and approve a r
294. ion is divided into eight categories see 1 in the graphic Enter history information in any of these categories as needed by selecting the category in the left pane and documenting in the right Each category view has five tabs and two panes the top pane for displaying previously entered data see 2 and the lower pane for history added during the current encounter see 3 Exceptions Allergy History does not have a Free text tab because this would interfere with drug interaction checks and Immunization History only has two tabs due to the implementation of the Immunization Record 3 Patient Contact Functions In the History folder tree select a category and click the Previously Entered History tab To add individual items to the current encounter do any of the following e Double click an item or e Highlight an item and click Enter or e Select an item and click Include or e Right click and choose Include or e Click and drag an item from the upper pane to the lower pane To add all active items to the current encounter highlight Active and click Include All or Shift Enter or click and drag the Active folder from the upper pane to the lower current encounter pane or highlight Active and click Enter Editing current encounter history items 1 2 3 Open a patient chart and from the left pane or the toolbar click amp j History In the History folder tree select the category of the item Enter a histo
295. ions 2 Inthe Encounters pane click to sort By Type and expand the Encounters and Office Visit folders 3 Double click the office visit for which notes were transcribed to view the History amp Physical Report Items pertaining to transcription are marked Transcription text in the respective section s of the report To view voice notes internal transcription in the chart Voice notes display on the patient History amp Physical Report for the respective office visit To view the voice notes follow the steps below 1 On the HealthMatics EMR toolbar click 4 Pull Chart search for a patient with transcription and double click it to display the face sheet 2 n the Encounters pane click S to sort By Type and expand the Encounters and Office Visit folders 3 Double click the office visit for which notes were transcribed to view the History amp Physical Report Contact screens with notes display as active icons at the tope of the window Click the corresponding icon to read or listen to notes Items pertaining to transcription are marked Transcription text in the respective section s of the report To view scanned documents in the chart 1 From the HealthMatics EMR toolbar click l Pull Chart search for a patient with scanned documents and double click it to display the face sheet 2 Click View Encounter to display Encounter Explorer 3 Click S Toggle Filter to sort By Type E brecou
296. ions Options In HealthMatics EMR you can tailor the way information displays to suit your preferences and needs From the Options menu you can do all of the following e Changing passwords on page 108 e Editing options on page 108 e Editing grants on page 129 e Editing output defaults on page 130 e Editing default locations on page 131 e Editing auto replace text on page 131 Changing passwords You can change your password at any time In addition your system may be set to require password changes at selected intervals Laregiver Password Ea Login Mame SYSTEM Old Password puse 0 0 0 0 O O Mew Password pee verify New Password a o 1 To change your password from the menu bar select Options gt Change Password 2 Enter the requested password information and click OK Editing options You can edit display preferences for many areas of your desktop toolbar patient face sheets Patient Manager lab results reason for visit review of systems vitals physical exam assessment and plan electronic prescriptions sign off title bar history quick lists and My Short Lists NOTE The system or practice administrator can also set defaults for all caregivers in the Administration Module For instructions refer to the HealthMatics EMR Administration Module manual 108 1 Office Functions To set desktop defaults 1 From the HealthMatics EMR menu bar select Options gt Edit Options gt Desktop P Car
297. ire note is italicized at the end of the characteristic documentation Detail note The entire note displays within parentheses and is italicized next to the detail term To document using quick search 1 Begin to type a few characters of the item you need with the focus on the top documentation pane Ly Physical Exam on General Templates Encounters F Apply El Preview ET Clear Skin l EY General E Skin Surface SkinfSkin SurfacejChest Cindoding bred and eine diae amp j y Head Including hair dudo CX Neck No Information Sy Chest Including brea lt gt gt Current Encounter z zi ga 3 SP LgHome X Up elExpand all Cola Physical Exam Tal S G Alae is a Eh n a Color et T 4 Moisture Right Axila ES Temperature d Left Axilla t D Texture rs Thickness pum I5 Mob ity amp Turgor sie o P Body Hair e riter 4 hier E ty Chest H Sy Breasts Sk w YJ Right Axilla af 2 When the desired item displays in a yellow box click Enter on your keyboard to automatically scroll to the selected item 3 Use the following keystroke conventions with Quick Search Type any letter in the documentation pane to start Quick Search and open a yellow box with the item that fits the criteria you entered De
298. isplays individually e To use biometric authentication leave the password on the screen blank gt IF the password is blank and the Biometric Authentication hardware and software are installed and the system administrator has enabled Biometric Authentication system options you will receive a prompt for a fingerprint gt IF any of the above conditions are not met Enter a valid password displays gt IF a password is entered and the application is set to require biometric authentication the application ignores the password and prompts for a fingerprint e For Referrals click H amp P Sections to select the sections of the H amp P you want to include in the referral letter e Continue completing information on the screens for each item you want to print 4 Click OK to print all items and return to the H amp P Report NOTES e When all items are printed or sent you return to the H amp P Report Continue documenting and or sign off on the encounter 362 3 Patient Contact Functions Drafting does not bill the encounter or sign off the chart Therefore you can go back afterward and complete all other contact screens before going to the E amp M Calculator and signing off on the chart To send encounter billing information without signing off If you use a billing interface you can send billing information to your Practice Management System PMS without signing off on the chart h 4 With a patient chart open i
299. ist then click c or right click repeating as needed to add all body system folders characteristics that you want 269 ROS and PE Navigation 270 4 To sort the items in your list select an item and click the icons located in the o middle of the screen as needed Deselects item Deletes all items from the selected list Moves item to the top of the list Moves item up one position Moves item down one position Moves item to the bottom of the list Click OK To edit exam lists on the my ROS PE lists tab P 2 3 Select the list then click Edit Use left arrow icon to deselect and move unwanted items out of your list use the appropriate arrow to sort rearrange items as desired Click OK To delete exam lists on the my ROS PE lists tab 1 2 Select the list Click Delete and Yes to confirm TO copy lists on the my ROS PE exam lists tab 1 2 Click Copy oelect a caregiver list to copy and click OK NOTES You can copy multiple caregiver lists by pressing down and holding the Ctrl key on your keypad and clicking desired lists The copied lists are named for example copy of Cold If the list name exists a new one is created and 2 displays following the original list name Edit the copied list s as needed 3 Patient Contact Functions To navigate using the search tab 1 Open a patient chart and from the left pane or the toolbar click ROS o
300. its to the patient s default pharmacy if it supports electronic prescribing thus avoiding being prompted for a pharmacy each time an electronic prescription is transmitted e No Prompts you to select a pharmacy 3 Click OK to exit or select other items in the left pane to set additional defaults 123 Options To set sign off defaults 124 1 From the HealthMatics EMR menu bar select Options gt Edit Options gt Sign Off p Caregiver Options for Manager System Miel x General Sign Off il Desktop Toolbar ignature B Face Sheet Do you want Ehe Use my Signature Bitmap checkbox to be Patient Manager checked by default on the Sign OFF screen Results C Yes f Mo D Reason Far visit Review of Systems MiEals m Physical Exam Default Service office or Other Qutpatient Services MEW H Assessment and Plan ervice xar Default Exam General Multi System i Hiskarv Lists j Quick Lists i My Short Lists ced Signature e Yes Automatically selects nclude Signature Bitmap in Sign Off Chart and appends your electronic signature to every H amp P Report when you sign off H Sign Off Chart _ Of x Encounter Type office visit billable e No Leaves nclude Signature Bitmap deselected The caregiver s signature line does not display on the H amp P Report unless the caregiver manually checks the box Service Click the down arrow to select most common service t
301. ivalent of standard treatment plans By selecting a protocol the diagnosis and all the standard orders become part of the current encounter NOTE For protocol details see the HealthMatics EMR Clinical Customization manual 1 Open a patient chart and from the left pane or the toolbar click A P Assessment Plan 2 Click one of the Short List tabs that contains a customized protocol Patient Problem List Patient Medications My Short Lists Short Lists Search Free Text Diagnosis mgndude TyAddtoMy Short Lists E Reset List Colapse Al EL Protocols PR ACQUIRED HYPOTHYROIDISM UNSPECIFIED 244 9 EHS ACUTE PHARYNGITIS 462 fey ANEMIA UNSPECIFIED 285 9 fog CONTACT WITH OR EXPOSURE TO TUBERCULOSIS V01 1 URINALYSIS W MICROSCOPY 81000 i URINE BAC CULTUR E QUIAM COL COUNT 87085 E SPECIMEN HANDLING TRANSPORT ero k Water in diet brief version c gb rib Proe Cte mi J Interactions Sp isabel A ABN Check amp CALCULUS OF KIDNEY 592 0 3 Click signs as needed to locate and select a protocol from the upper pane then do one of the following e Drag it to the lower pane or e Select the protocol and click Include or e Right click the protocol and select Include 308 3 Patient Contact Functions NOTES To remove any unwanted orders select the order in the preview bottom pane and click Delete Ite
302. ized caregiver can reject an eRefill request No reconciliation or matching is required to do so Rejecting an eRefill Request prompts the caregiver for a rejection reason and password and immediately sends an eRefill Response Refill Denied message back to the pharmacy 1 Inthe left pane of the HealthMatics EMR desktop or from the Office menu option select eRefill Requests 2 Select an eRefill request click Reject gt Reject 3 Enter a password and click OK Electronic Refill Rejection Ea Reason For rejection e Click the Reason for rejection down arrow and select a reason for the rejection or e At Other enter a custom reason up to 70 characters in length 4 Click OK Sending ePrescribe Message Rejecting Metformin HCl SOOMG Tablet Sending to pharmacy Pharmacy One 1010 Westwood Drive Cary NC 27511 Sending message E The Sending ePrescribe Message box displays briefly NOTE A Refill Denied refill response message goes immediately to the pharmacy 62 1 Office Functions Rejecting eRefills and sending new prescriptions NOTE See also Rejecting eRefill requests on page 62 1 Inthe left pane of the HealthMatics EMR desktop or from the Office menu option select eRefill Requests 2 Select a pending eRefill request and click Reject gt Reject Send New Prescription 3 Enter your password and click OK to display Medication Search Medication Search x Data Source Medications Medi
303. jo2 05 10 28 AM um Always Remind Gd X5 eig TS Call Dr Peters for consultatian 3 Select checkboxes if desired e High priority Click to make the reminder display in red Private Click to make the reminder visible only to the user who created it 4 At Patient do one of the following e To place the reminder on the current open chart click e or 211 Reminders e To place the reminder on another patient chart click E and search for the patient At Remind Caregiver do one of the following e To remind one caregiver only select the box and click the down arrow to select the caregiver to receive the reminder or e To remind all caregivers deselect the Remind Caregiver box At Subject enter a description for the reminder At Remind On do one of the following e To create a reminder that displays every time the patient chart is pulled select Always Remind To create a reminder for a specific date time deselect Always Remind and click the date and time arrows to select the Date and Time you want the caregiver to receive the reminder An Action Item displays on the caregiver desktop at the designated date and time NOTE You can also type the date time in the respective fields Type the reminder text in the text box Click Save to Chart Viewing and completing reminders 1 212 With a patient chart open from the HealthMatics EMR Menu bar click Patient gt Reminders Office gt Reminders
304. k Find Duplicates to display Matching Criteria Matching Criteria First Mame Last Name Sex OF Cancel gt Double click a search criterion in the left pane or select it and click 2 NOTES To deselect a criterion double click it in the right pane or select it and click lt To select or deselect all criteria click gt or respectively WARNING Finding all duplicates using matching criteria may be time consuming if your database is large and you have much duplication During the time that the system is searching for duplicates you will not be able to access HealthMatics EMR for other work A progress bar for the search displays in the lower right corner of the Manual Merge tab 233 Patient Merge 234 gt After selecting criteria click OK Merge Groups E kA Fred Finley e n Finlev Fred 1212 Mall Finley Fred 1212 El Rt TE Irene Innis Isl Innis Irene 0005 amp es5 Innis Irene 0005 If needed in the Merge Groups pane on the right click to display all duplicate patients B nm i Peter Parrot onion M m Parrot Peter 0003 ES Parrot Peter 1113 Groups of charts that fit the selected criteria display in the Merge Groups pane Search criteria and order selected are represented by the data in brackets NOTES Patient names preceded by lock icons i have charts pulled on a caregiver s desktop To proc
305. k qp 7 Click OK 8 Enter the corrected data in the appropriate cell 9 Click and drag the new column or row to the appropriate position in the flow sheet 207 Chart Attachments Chart Attachments You can add attachments such as copies of letters EKG reports and laboratory reports to an encounter The attachments can be viewed from the patient face sheet either in an attachments folder or from an H amp P Report if you attached them to an office visit Adding chart attachments 1 Open a patient chart and do one of the following e From the menu bar select Patient gt Chart Attachments or e From the toolbar click the Demographics down arrow and select Chart Attachments to display Chart Attachments 2 From your keyboard press Insert or click qm Add Attachment l Chart Attachment Jhsmetochwt pent Kimi gay Pglisti Feier Mr Fred Attachment Type ether uckreoem Subject es Text image voice import SCH X Hac co mq Vom 5 3 Click the Attachment Type down arrow and select the Attachment Type from the drop down list NOTE Types can be added in the Administration Module Dictionary 4 At Subject enter a subject for the attachment 5 Selecta tab to enter text upload an image dictate a voice note or import a file as needed e To attach a document from a file from the Text tab click ge Load from File e To attach an image from a library on the Im
306. k to move the item to the top of the list Click to move the item up one MweDon Click to move the item down one Move to Bottom Click to move the item to the bottom of the list 128 1 Office Functions Sort Ascending Click to sort the items in ascending order Sort Descending Click to sort the items in descending order jee Delete Click to delete item from My Short Lists 4 Click OK to save changes and exit or select other items to set additional defaults Editing grants You can grant permission for other caregivers in your practice to access your inbox outbox and worklog This is particularly useful if another caregiver is going to cover for you in your absence Caregivers with grants to your message can view any items other than Action Items marked Private 1 On the HealthMatics EMR menu bar select Options gt Edit Grants to display Caregiver Grants Do one of the following Caregiver Grants x Manager System Grantor Grantees Check All Check None Manning Terry MD Medicine 1 Internal Medicine 2 Internal Medicine 3 Internal Medicine E Internal Nurse Registered Ob Gyn 1 Doctor Ob Gyn z Doctor Ob Gyn 3 Doctor Ob Gyn E Doctor Pediatrics 1 Doctor Pediatrics 2 Doctor Pediatrics 3 Doctor Pediatrics E Doctor Practice 1 Family Practice 2 Family Practice 3 Family W Practice E Family MANNING Dr Tatiana E emen e Click Check All and then deselect
307. kena AE He aa RS a a 173 Bab RESUS essre ad i daher Aide hoses a Ou Dau uL gaude dob 175 Entering lab results aee LAS EA eevee REDIERE se koe oe Ake eS 175 Reviewing eb Tesullss ena bec eoe aao aa aaa SCR ao ENa 178 To review lab results from review results llle 178 TOTOVIGW lab resul irc a mdi da mp RUP SCIEN ER RUE ER ER else er Ncc e 178 Finding lab Tesis uoto pde aora tbe d EE Ro E Beg Soe eid EOS de aco eet e d 182 Annotating lab results during review llle 183 Publishing lab result comments with read receipts 00 00 eee 184 Emailing printing lab reports for one patient 0 20 cee eee 186 Emailing printing lab reports for all patients llli 186 HealthMatics EMR Application Reference Manual vi Rules controlling date selections in lab results 0 0 0 187 Routing lab result notificationS 0 ees 187 Procedure Resulls 552 24 0 dade d aed ewe hn aes d dex cu m uc pale icc o uns 188 Defining procedures as billable or non billable llle 188 Entering procedure results llle 189 Reviewing procedure results 1 0 ee eee eee 191 Viewing final not reviewed procedure results 0 0000 eee eee 193 Viewing final reviewed procedure results 0 0 0 ee ee 193 Setting performance dates for historical procedures 0005 194 Additional Results 5 2 3m x oo rai aaa eae ae ee aaa Se 195 Process
308. l Tympanic Rectal and Axillary 328 3 4 o 3 Patient Contact Functions Blood type Data is bidirectional between Demographics and Patient Reported Drop down default is Undefined Other selections include all other blood types Lab RH Blood Typing 86901 and ABO Blood Typing 86900 but both have to be ordered These are included in the Obstetric Panel Once resulted the lab data populates the Pregnancy Record Blood pressure Enter blood pressure Descriptors are caregiver options or selected from drop down menu Second blood Enter second blood pressure reading if indicated pressure Urinalysis results Reports urinalysis results from any of the following 81000 81002 81001 81003 80055 Allergies Reports from History Allergies Complete fields as necessary Click OK to save and validate all data in the edit window Optional Click Cancel if you do not want any data saved from the edit To access pregnancy record pregnancy labs l Access the Pregnancy Record see Accessing the pregnancy record on page 322 2 Select a visit date and press F2 or click amp Edit Record 3 Click Pregnancy Labs tab Antepartum Record vw Filter results based on LMP date Test Name vawe unts rer Date Status None NOTES Labs resulted in the EMR display on this tab Click any header tab to sort the lab Check Filter results based on LMP date to view
309. l previously entered active history items in an encounter e Inthe left pane of the History view highlight History 247 History 248 e Click Include Active All active history items in all eight categories from previous encounters are added to the current encounter NOTE A medication is considered active if its status is Active Ordered or Continued 5 To clear all history items and general notes added to a current encounter do the following e Inthe left pane of the History view highlight History Click to Clear All and Yes to confirm History items are cleared from the current encounter as well as any general note indicated by the paper clip on the Note button Documenting adding history from previously entered history 1 Open a patient chart and from the left pane or the toolbar click amp j History dw Current Encounter x History Previously Entered History my Short Lists Short Lists Search Free Text oo EJ Allergy m Imrnunizatian Mone cag Include Ce Include All ln Familv EJ Past Medical le Social pe Travel B Medication bee PregnancyJBirkh l Fosamax Plus D 7 za ma LINIT Tablet 1 Tablet PO No Refill C 2 Previously entered history Categories cag i JL Manage UI ES Medication AS Fosamax Plus D 70 2800MG UNIT Tablet PO Ordered Hx Entry 3 History entered into the current encounter In the History view patient informat
310. l reports that were created in the Reporting Module the last run time and the number of patients who met the search criteria when the report was last run You can open a report in the Clinical Module to view the details 1 To access Report Results from the left pane on the desktop or from the Office menu select Report Results Report Results 37 Open gA Send Message Report Title Last Run Patient Count Result Access 4 S SU mammogram us call Us SACHE SEE 3 11 47 PM Mormal NOTE Access to open report results can be restricted in Administration Module gt Function Access To restrict viewing when building the report in the Reporting Module Report Properties check the Restricted Access box For detailed instructions refer to the Reporting Module manual 2 Select a report with Result Access Normal or Restricted if you have the appropriate privilege and click Open or just double click the report 9 Report Results _ Oy X pa Previous P Mext Co Delete grint fy Export Hide Criteria Location Healthmatics Result Mar zn 06 03 11pm 2 Pt System Manager Caregiver eal Caregivers gt Date rhe past year E Summary Detail Diagram Exclude List Trend Locations 1 Heathmatics 17 H Total 2 0 1200 PM 12 30PM 1 00PM 1 30PM Zz DPM Zz30PM 3 00 PM Total Totals S SA Segment Females 40 En 65 F Count 2 Runat Mar 20 06 11 47a
311. labs pertinent only to this pregnancy To edit pregnancy record review of systems NOTE This information is bidirectional between Review of Systems s and Pregnancy Record 329 Pregnancy Record 330 1 Access the Pregnancy Record see Accessing the pregnancy record on page 322 2 Select a visit date and press F2 or click Edit Record 3 Click the ROS tab Vitals UJA Pregnancy Labs ROS MaternatiFetai Data Cervix Medical Hic 08 History Pelvimetry Next Appt Review of Systems Pair cscrccnisisri e C ves C No EJ Nasen seen C Yes C No f Weight Gain scere C Yes C No Vonmlingscseeeseneeees C Yes Cho C e E eere C Yes No Contractions regular C Yes No ft Rash rece A UE C Yes No ft ErGQUMDICY eec rr nr rrr C Yes Wo Blurred vision iens C Yes ho Decreased fetal movement C Yes C No Headache EIS C ves No Painful urinsbion seien ee Yes No Bleeding gums eren C Yes C No Pelvic pains C Yes C No C Difficuky breathing eese C ves C No Urinary complaints C Yes No ff Breast MASS Leere nans C Yes C No Vaginal bleeding of Yes C No G Chest pain iem Hee Yes C No fe Vaginal discharge cc cc 0 UC Yes C No ff Fainting OOOO 4 C Yes C No Vaginal Ma T a eene C Yes No v Elevated blood pressure C Yes Wo C Bak OS sss 0 OS C NO Goe
312. lank the biometric authentication hardware and software has been installed and the system administrator has enabled the Biometric Authentication system options you receive a prompt for a fingerprint e IF any of the above conditions are not met you receive the message Enter a valid password e Fapassword is entered and the system has been set to require biometric authentication the system ignores the password and prompts for a fingerprint When sending a prescription electronically if you have not entered a password on the screen the following happens e You are prompted for the password via a pop up authentication dialog e If you leave the password in this dialog blank you are asked for your fingerprint If biometric authentication is required the dialog does not display and you are prompted for your fingerprint 69 Documents 70 Documents Documents are system generated messages that accompany documents sent to you for review and approval including scanned documents and internal and external transcription For general instructions for using HealthMatics EMR windows see Windows Panes and Other Tools on page 8 After a user scans or transcribes dictation and submits it regardless of whether it is new or changed the system sends a message to the appropriate caregiver that it is awaiting review and approval before being filed in the patient s chart Viewing the list of documents The Documents view o
313. le 41 years old 7 24 1964 Preferred Caregiver Family Practice E Insurance Compa ID Session Charts Office Patient Explore Options Tools Launch Help t gt G 4O40 69 S3 aaa Ba d amp ee VERA Rowe D Review of Systems S current Encounter ilg o SAHome jup Expand All Collapse all Templates TC ROS Female defauk happy Epreview Ditch F pt k 7 d Review of 5y ot A All other systems m gative Respiratory F i ius Tie Breast LE 1 C S r Cardiovascular mi _ Feeling well Lac Gastrointestinal vl Weight Gain Fr va Male Genitourinary IE Weight Loss Musculoskeletal emi Neurological m SE Psychiatric Nole n d End uh General Present Feeling well and Weight Gain s All other systems negative Lal mnn mbala a Map M The note icon displays a colored background and the note text displays at the end of the ROS documentation in the preview pane and on the H amp P report NOTE To view the complete text of the note either click the note icon after Review of Systems or view the note in the documentation pane 282 3 Patient Contact Functions To add ROS notes at the system level 1 2 3 In the Review of Systems navigation pane select a system such as Respiratory In the documentation pane on the right click the note icon to the right of the system Enter
314. lear all history entries from the current encounter select the History folder click 1 then at confirm click Yes to clear all history items added for the current encounter 3 To remove history items from a history category for the current encounter bottom pane do one of the following e Select the History category and item click amp Delete selected item then Yes to confirm or e Click lj Clear all items and Yes to confirm to clear all history items from the encounter NOTE If you select the top level folder Allergy for instance and click e it performs the same functions as iJ and removes all items from the current encounter 250 3 Patient Contact Functions Indicating no history is available or exists 1 2 Open a patient chart and from the left pane or the toolbar click amp j History In the History folder tree select a category that is not bolded indicating it has no history documented in it E ee Current Encounter m al Previously Entered History my Short Lists Short Lists Search Free Text i ert Allergy m imiinien ag include cH Include Al Mon Contrib x Family 3 Active m Fa Past Medical No active items oo Fd Social 2 P Et E i Pregnancy Birth ca it S manage M ES Travel tll No Travel History items have been added to the current Encounter NOTE Informational messages lt display in both the history
315. lect a visit date and press F2 or click amp Edit Record 3 Patient Contact Functions 3 Click Medical Hx tab Vitals UJA Pregnancy Labs ROS Matemal Fetal Data Cervix Medical Hx oe History Pelvimetry Next Appt Page 1 Pace 2 4 Congenital heart defect Cystic Fibrosis Depression Taaa S d 1 133 13 3 1 3 1 3173 11 a 4 Complete each of the two data screens as required 5 Click OK to save and validate all data in the edit windows 6 Optional Click Cancel if you do not want any data saved from the edit NOTE If you choose to document on the History Contact Screen access Pregnancy Birth History and use the selection Maternal Past Medical History and Family History selections To edit pregnancy record OB history NOTE Information documented here is bidirectional with and writes to Pregnancy history in History 1 Access the Pregnancy Record see Accessing the pregnancy record on page 322 2 Select a visit date and press F2 or click amp Edit Record 333 Pregnancy Record 3 Click OB History tab Vitals LJA Pregnancy Labs ROS MaternalfFetal Data Cervix Medical Hx O8 History Pelvimetry Next Appt OB History Gravidty f Term Abortions spontaneous Ectopic Preterm Stilbirth Abortions induced
316. lect it and do one of the following e Double click or Click amp Edit Item or e Right click it and select Edit In the Problem dialog click the Diagnosis search button to display Problem Search Datasource Search Ea Data Source fico s Search Results P E Category lali ICDs AJ Please enter Search Term Search Term Starts With Conkains Search for the new diagnosis using Data Source Category and Search Term see To search for assessments and plans using database libraries on page 294 In Search Results select the new diagnosis and click OK In the Problem dialog box fill in other fields as needed and click OK again The diagnosis in the Assessment Plan preview pane reflects the change made To classify diagnoses In Assessment Plan you can enter a diagnosis with a specific classification such as Aamitting Preliminary Probable Definitive Diagnosis Pending and many others 1 Open a patient chart and from the left pane or the toolbar click A P Assessment Plan 2 Select one of the tabs and add a diagnosis to the documentation bottom pane 299 Assessment Plan 3 To enter a classification for a diagnosis in the documentation bottom pane select it and do one of the following e Double click or Click or e Right click it and select Edit Diagnosis ACUTE PHARYNGITIS 462 4 At Classified As click the down arrow and select a clas
317. lectively apply your signature NOTE Bitmap signatures must be loaded for each caregiver in Administration Module gt Caregivers gt Signature Medication List all of the patient s prescriptions awaiting refills NOTE When accessing Prescription Properties from the patient s face sheet a search button displays after the medication Click this to open the Medication dialog if you need to make changes Select all unlocked prescriptions for printing or click individual boxes to selectively print NOTE If the default printer does not display or needs to be changed click the search button at the right of the Destination field and select a printer Select all unlocked prescriptions for faxing or click individual boxes to selectively fax prescriptions to pharmacies NOTE This only works if the prescription is not for a controlled substance and you have purchased Faxpress 52 1 Office Functions renee a Select all unlocked prescriptions for electronic transmittal or click individual boxes to selectively transmit prescriptions to pharmacies NOTE This only works if it is not a controlled substance and ePrescribe is installed Destination Display printer pharmacy etc where prescription will be sent If the information does not display or needs to be changed click the drop down arrow or search button to the right Select your printers in Administration My Output Defaults on toolbar Prescriptions
318. led 3 To verify select pharmacy information At Pharmacy verity that the pharmacy displayed is the correct one or click Bi to search for a pharmacy and if not in the database click dh to create it for the current refill At Phone verify that the number displayed is correct or if it is not in the database enter a phone number for the current refill or click to look up the pharmacy number NOTES Changes made in the Pharmacy and Phone fields are for the current refill request only To change the data in Demographics select Save as default Pharmacy for this patient The medications listed in the bottom pane display the complete sig for the patient s most recent active and inactive medications 4 Torequest the medication s From the list at the bottom of the screen select the medication and click Request A purple arrow displays in front of the medication Select additional medications as appropriate clicking Request for each one individually NOTE Active medications are prioritized and sorted alphabetically on the Refill Request screen First Medications that have been Requested Approved or Rejected display first in the list Next The remaining active medications that have not been requested display next in the list sorted alphabetically by name Medications with a status of either Ordered or Continued are considered active Last Inactive and discontinued medications that have not been req
319. left pane e Bars in Office Manager e cons on the status bar Peter Parrot Male 30 months old 1113 Insurance Carrier Unknown EX NI IUE que pr ung e mta 5B8gu s d zj i 01 D w sU Oe IA ew GB Appointments 1 Zs Open Encounters 4 ixl 25 Inbox dh F open fl Repty W Foward E Gill Resuk Notifications 1 regiver Manager System m Messages 1 Pe Web Messages From Subject l Patient sem A Refil Requests 1 anager System Call daughter 4 2 28 2006 3 01 PM eRefil Requests m stem Lab results 3 for Mr Fr Finley Mr Fr 2 24 2006 4 37 PM 25 Documents 11 Amoxicillin Albuterol F Finley Mr Fr 2 23 2006 3 48 PM A eee iz tem Rejected Mr Fred Finley Finley Mr Fr 2 22 2006 1 51 PM aim charts Mr Fred Finley Finley Mr Frae 2 22 2005 12 06 PM E cn Mr Fred Finley Finley Mr Fr 2 22 2006 11 10 AM dics TON NDOX aces Firley Mr Fred 2 16 2006 12 01 PM amp Batch Refil ACCESS tr Fred Finley Finley Mr Fra 2 15 2006 10 50 AM Rarmindars inley Fred Finley Fred 2 16 2006 10 48 AM 1 Lah Rasuk Fred Finley Finley Mr Fr 2 16 2006 10 43 AM 4 we cted job title Finley Mr Fr 2 13 2005 3 47 PM _Office Manager die Oncology Finley Pr Fred 28 2006 11 03 AM Eg i g Rejected Path Reports Finley
320. lete HAYES CYNTHIA F mnib Mk D Friey Fred 1212 aizizoDe 4 28 00024 Complete Manager Sysbem Family Ii Maniests to Print a caca gt At Location and Laboratory Batch Processing selected items display but can be changed from the drop down list boxes 229 Lab Order Entry 230 At Date Range click the El search button to set the date range for requisitions NOTES Information displayed includes patient names and IDs requisition dates and IDs statuses caregivers and location To view a requisition before including it in the batch select it then click Preview Print Laboratory Requisitions joy Gorn Eae f Queue SPsavetolog Emot O Preview F9 Prig Preview at DB ld 4 Cole thee Dabei 5 12 2008 IN NN Ti mas 43 33 Fey rib DET heute Reg 3 001 alza NE 007511 Acami B 122145 Dede vmm Phy an nascere lps Check the box for those patient requisitions you want to include in the batch or click Check All to select all requisitions in the batch or click Uncheck All to remove all requisitions from the batch At Manifests to Print indicate the number of packing lists to print Click On Hold IF the batch is not complete and should not be sent across the interface Click OK The newly created batch displays in Batch Processing Print box displays for you to select a printer to send the packing list NOTE If the batch is not on hold and an inter
321. letters or numbers This search is quick but may be limited 295 Assessment Plan e Contains To search for all entries that contain the entered letters This search method is slower but more inclusive 7 Click Search to begin the search and display results to the right NOTE If the results of your search includes more than 100 items only the first 100 display in the Search Results pane on the right At Search Term enter additional characters and click Search again if needed to limit the results 8 In Search Results double click an item or drag and drop it to the documentation bottom pane NOTE If you select a diagnosis or treatment from the Search tab that was documented in a previous encounter the system displays a message indicating that it was previously used Yes or Enter The system adds the current encounter information to the history of that problem or medication No The system creates a new instance of that problem or medication on the Patient Problem List or the Patient Medications List In most cases you will click Yes to attach the problem to the history to prevent duplicate entries To enter free text diagnoses You can associate free text diagnoses with plans However plans based on free text diagnoses do not contain the associated ICD 9 codes and are not electronically billable 1 Open a patient chart and from the left pane or the toolbar click A P Assessment Plan 2
322. libraries on page 294 To enter free text diagnoses on page 296 og 4r db AP move note DE Ay interactions G Isabel D ABN check 5 6 Unspecified Diagnosis i 7 Diabeta 2 5MG Tablet 1 one Tablet PO daily Ref Q 30 Days x1 Year 03 13 2006 Ordered E DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION TYPE II OR UNSPECIFIED TYPE NOT STATED AS UNCC TE CHEST X RAY COMPLETE 71030 Routine 3 Indicate the hierarchy of the diagnoses by clicking icons in the preview bottom pane to move them up or down in the list DE e T M 8 eo uem memememum Clear All Items Clear all items from the preview pane Isabel Access Isabel a web based decision support system purchased module i ABN Check Advance Beneficiary Notice check includes reason Medicare may not cover a laboratory test Billing Level Select a billing level and add modifiers 297 Assessment Plan To link multiple diagnoses to a procedure code In HealthMatics EMR you can send multiple diagnosis codes ICD 9s to your practice management system to explain the need for a procedure or lab test Diagnosis codes available for selection are those already included in Assessment Plan 1 With a patient chart open from the left pane or the toolbar click A P Assessment Plan and select multiple diagnoses for the current encounter 2 Inthe preview bottom pane highlight the primary diagnosis and order a procedure or lab
323. ll results are entered for a procedure click Final NOTE A message displays indicating results are ready for review by the provider The application sends a message that results are ready for review to the caregiver inbox The caregiver Result Notifications stack and numbers on the inbox and status bar increase by one 8 Click OK Reviewing procedure results When you receive a Result Notification you can view the results mark them Reviewed and send messages to other caregivers who may need to review them NOTE Messages sent to other caregivers from Procedure Results do not include the results They are just notifications that results are available for review When you receive a Result Notification review the results accordingly 1 On the HealthMatics EMR status bar or left pane of the desktop click H Result Notifications Double click a procedure notification message gj or select it and click Open to display Procedure Results NOTE Status defaults to Need Review Set filters as needed Caregiver Patient Dates Sort to locate the appropriate patient NOTE If the patient chart is open on the desktop at Patient click E Use Current Chart or click the search button I to search for the patient then click OK or click the All Patients checkbox Click to display the patient procedures and values or click Expand All 191 Procedure Results 192 5 Select a patient or procedure and on the secondary
324. llapsed except the last level Templates Templates Click the down arrow to select a template exam list from the drop down list see To set review of systems n physical exam defaults on page 119 to set Template options E Apply Click to apply the selected template to the current encounter see To set review of systems and physical exam defaults on page 119 to set Apply options Click to preview the values of the applied template i Clear After a confirmation all the values are cleared from the selected folder down 277 Review of Systems Review of Systems To document Review of Systems ROS findings click items for each system You can document ROS based on templates previous encounters or from scratch Documenting ROS using templates 1 Open a patient chart and from the left pane or the toolbar click X amp Review of Systems C Waviow ol Spotancs II ease ea Hp i z a i atl i j Collapse All S Review of Systems 4 7 zr General Templates CARDIAC ROS apply L Prevew T Gear san HEENT E Review of Systems zt Meck All cttver systems negative 4 Respratory E Breast sit General EAE Sn ot 1 Cardiovascular E HeENT Hi He BIf Meck H Gastrointestinal 7 f Male Genitcurinary Sif Respiratory HOH Ze Breast HOH i El cardiovascular Ef Gastrointestinal et ae Fainting Abdominal Mass zt Psychiatric E Endocrine v Chest Pain Abdominal Pain
325. lling in all note comment boxes and free text fields using either a standard English dictionary as well as the Stedman s Medical Dictionary Dictionaries are stored in files on each workstation consequently Spell Check is saved per workstation 1 From any note or comment box where Spell Check icons are displayed click 57 Knowledge Term Edema Renamed as Date E Status Active Spell check icons Comments NOTE If you have not previously configured your spell check program a Confirm message appears Click Yes to select the main dictionary and follow the instructions for Configuring spell check on page 12 2 IF Spell Check does not find any misspelled words click OK in the message box that displays the number of words checked 3 IF misspelled words are found Spell Check displays possible corrections Spell Check x Mot Found Replace Wikh Change All Change Ignore All Ignore Add Suggest m JE Start ET Undo Last Cancel Unrecognized spelling displays at Not Found e IF the spelling is correct as is do one of the following gt To skip over it and continue the spell check click Ignore or 11 Windows Panes and Other Tools gt To add it to the system s dictionary click Add e IF the word needs to be corrected do one of the following gt Select the correctly spelled word from the list and click Change or just double click it or gt If
326. lor to Ell Hide show patient Click to Hide Patient Words text and box from the H amp P words Click again to Show Patient Words m Clear all items Click to clear all items in Reason for Visit Isabel Click to access Isabel a web based decision support system purchased module In the Exams Complaints box select a complaint and right click for a menu or click an icon to do any of the following tasks Remove selected Click to remove selected complaint item Del Describe selected Click to describe the characteristics and details of the item F2 selected complaint e Click to move Click to move complaint to the primary spot to the Click to move complaint to the primary spot spot DELENITI CDI SN NN 265 ROS and PE Navigation ROS and PE Navigation To access the Review of Systems screen or the Physical Exam screen open a patient chart and from the left pane or the toolbar click either ROS or amp PE I Al Review of Systems Pisce Sheet ESSE hi Patient Manager MI Hus o naon DA 49 amp Hm iju quExpandAB Collapse A bd Demographics 3 Review of Systemes D Beards SE General ait Adult Male Linder 50 ROS Maiy erede E Cen 3 Flow Sheets JE Shin 7 s 2 bemunizations vi HEENT E GRU Review of Systems ME P Chart Attachments vE Meck l other systems negative Lab Fressut C Respratory AI ED n iais JL Breast yt General gers ae ira ne a E Candewasculer E gt HEENT i E
327. lt Notifications Messages Refill Requests and others follow these font conventions e Red Items are marked High Priority or contain abnormal results e Bold Items have never been opened e Regular Items have been opened but are still in the inbox e Strike through Completed items display grayed out with lines through them Using drop down lists Many screens have fields that provide the ability to select an item to limit or filter the information that displays When filters are available click the down arrow to select an item from the list that displays dp c 3 Open Pe Reply Ve Forwar Caregiver Manager System ad 1 Office Functions Using scroll bars If a scroll bar displays either vertically or horizontally view additional information by clicking and dragging the scroll bar to display the rest of the data Iu Appointments 2 A IN _ Scroll bars fe E sein xj Ac Beo Items 2 sd k Using secondary toolbar icons and shortcut keys Most views have secondary toolbars with icons that are specific to that view Secondary toolbars are located below the main application toolbar and generally but not always on the right side of the screen above the preview pane Standard secondary toolbar icons along with their shortcut keys if any include the following Shortcut Key CE Insert Add Create Add or create Add or create something new new
328. ly SPI IDs are required to initiate new prescriptions but not to respond to a eRefill requests 65 eRefill Requests Setting up electronic prescribing in administration To set up and manage the ability to use electronic prescribing in the HealthMatics Administration Module you can do the following Jo assign prescribing agents for caregivers on page 66 e To set refill request password prompts on page 66 e To run ePrescribe synchronization immediately on page 67 e Setting up electronic prescription pharmacies on page 67 To assign prescribing agents for caregivers 1 From the menu bar select Launch Administration Module Caregivers 2 Select a caregiver and click amp gt Prescriber Agents Prescriber Agents Caregiver Manning Terry MO Cl Donkin Darlene SRNP Gripiana Dr Arlene Manager System MANNING Dr Tatiana Agents Medicine 3 Internal C Medicine E Internal Nurse Registered Qb Gyn 1 Doctor O Ob Gyn 2 Doctor O Ob Gyn 3 Doctor 1 Ob Gyn E Doctor Pediatrics 1 Dockor a Pediatrics 2 Doctor C Pediatrics 3 Doctor L Pediatrics E Doctor C Practice 1 Family Practice 2 Family El cana 3 Click to select the boxes in front of all caregivers authorized to respond to eRefill Requests sent to your inbox and click OK Check All Check Mone To set refill request password prompts 1 From the menu bar select Launch
329. m Example Edited Previously used ree text 343 Notes 6 Click the Date search button select Full Date then to accept today s date circled in red on the calendar click OK 7 Click OK to return to Immunization History Notes Add notes on multiple levels throughout all patient contact screens Notes can contain multiple images drawings and images selected from a library You can create voice recordings and use auto expand text The Note dialog box contains up to four tabs Text Image Voice and Import depending upon the location of the note in HealthMatics EMR Using text in notes NoteforAssessment amp Plan Text Image Voice Gg 83181 V oW A E Remove All Print 344 3 Patient Contact Functions Icons Enter and manipulate text using the Text toolbar icons LN CNN NN NNNM stom Resse 000 ee a NN Auto Replace Options Adds edits deletes or copies auto replace text Remove all Click to remove all data entered on the Text tab Print Click to print text data Using images in notes You can enter multiple images into a note From a Note dialog click the Image tab to enter view or edit image data NOTE Due to file size two images maximum per note is recommended Moke for HEENT B tet B imag ERE Xe S m 345 Notes 346 Icons Manipulate the image using the mage toolbar icons EX Load Loads image from a file from t
330. m or right click the order and select Delete You can also add additional orders to the treatment plan Using procedure entry rules In the Clinical Customization Module create procedure entry rules to assist with the documentation process For instructions refer to the HealthMatics EMR Clinical Customization manual To order procedures with rules attached ju With a patient chart open in the HealthMatics Clinical Module from the left pane or the toolbar click A P Assessment Plan Select an assessment and search for a procedure with a rule attached see specifying assessments and plans on page 292 lt PF gt Current Encounter Patient Problem List Patient Medications My Short Lists Short Lists Search Free Text Diagnosis Data Source er sz Category uc Tq EXCISE ORAL MUCOSA FOR GRAFT DONOR 40818 V EXCISE SKIN WEDGE INGROWN TOENAIL 11765 Search Term bxc S excrse SKULL LESION EXTRADURAL 61615 Procedure Rules _ select the Procedure Rule that should be used to document the results EP Ask about Foot hygiene Ingrown Toenal NOTE If the CPT code you select has more than one rule attached to it select the correct rule for the patient from the Procedure Rules dialog box then click OK 309 Assessment Plan To enter results of procedures with rules attached 1 With the patient chart open from the left pane o
331. m Execution Time 00 00 0 Report Annual mammogra Count 2 Runat Mar ZU 06 03 11pm Execution Time 00 00 0 3 Fora detailed description of the Report Results screen refer to Viewing Report Results in the Reporting Module manual 198 2 Chart Functions Result Summaries Result Summaries allow tracking of patient data over time Use HealthMatics EMR flow sheets to create spreadsheets and enter data manually Use Result Summary templates to automatically extract and pull together result data entered elsewhere in HealthMatics EMR into a spreadsheet or graph format Choose from CPT HCPCS Procedure Entry Rules Laboratories Medicines Physical Exam elements and Vital Signs NOTE Imported information can include data from internal laboratory tests as well as results transmitted from external labs IF the external labs are cross referenced to the CPT codes in the HealthMatics EMR Lab Catalog See the HealthMatics EMR Clinical Customization manual to set up Result Summary templates Viewing result summaries The default Result Summary display is soreadsheet format You can also choose to display data in graph format by clicking the Graph tab 1 With a patient chart open in HealthMatics EMR and from the Menu bar select Patient gt Result Summaries or from the left pane or toolbar click Result Summaries Exi gal Result Summaries c Face Sheet DEED Patient Miaria Template hypertension Tloptions S Ej
332. m in the left pane to set more defaults 115 Options To set patient manager defaults 1 From the HealthMatics EMR menu bar select Options gt Edit Options gt Patient Manager P Caregiver Options for Manager System Mi Ea General Patient Manager Desktop Toolbar ate Range z Face Sheet rhe past 6 months Ee Results anels Reason For Visit Left Side Right Side Review of Systems Appointments D Medications vitals Pending Messages Lab Results Physical Exam em ee eee E Reminders Procedure Results A Electronic Prescriptions Report Results iP Additional Results T Sign Off Pregnancy Record Title Bar is History Lists Quick Lists My Short Lists Reset Settings oa The Panels box displays the list of items that can be included in the Patient Manager view Selected items will be included The default view includes all items in a two column format 2 Click the Date Range search button and select a range of dates or specific transaction dates for the information you want to display in Patient Manager 3 Determine the items that you want to include in the view and how they are displayed by doing the following Deselect check boxes preceding items that you do not want to include in the Patient Manager view Position each item in the order you want to view it by highlighting the item and clicking the arrows to move it up or down in the list or from one side to th
333. macy Search dialog box e Then do one of the following gt Fax To fax the prescription click the medication radio button beneath the Fax icon and click OK gt Electronically transmit To electronically transmit the prescription available only to pharmacies that have EDI IDs click the medication radio button beneath the Electronic Prescribe icon J and click OK gt Print To print the prescription click the medication radio button beneath the print icon amp and click OK To print medication patient education information 1 Open a patient chart and from the left pane or the toolbar click A P Assessment Plan In the preview lower pane double click an ordered medication or select it then click g Click the Education tab to display the Patient Drug Education Report Medication ation 2 Patient Allergies E Formularies Patient Drug Education Report Pationt Brancy Dixon Date 0609 2005 10 49 Drug Fosamzx Generic Marre ALENDRONATE ia LEH droe nabe COWON SES Thig medicine is a 2isphaspnhonate sped to prevent and teat osteoporosis t may also be used io treat other conditoris s determined by you doctor BEFORE USING THAS MEDICINE INFORM YOJR DOCTOR CR PHARMAC ST of al prescription and over the coumer medicine that you are taking ADDITIONAL MONITORING OF TOUR DOSE OR CONDITION rry be needed M you art Taking nonste oidal att ifammstory medicines such as ibuarafen cr naproxen
334. ment you want to generate NOTE If the template requires more information before it can print a message tells you what additional information it needs Example Encounter location or date Supply the information and click OK to display the Print screen Print Encounter Procedure Orders of x Bernt 3 Fax 8 QUEUE Save to Log fey Export Preview Fo Print Preview rinter Mame x METprintz Properties Status Type hp LaserJet 1300 PCL amp Where Rm 1109 Comment Rr 1109 Bras Category Lab Orders Lavaut Blank Page M Style Defaut Style US Letter 64 11 in g NOTE If the template contains Dialog data elements a pop up window displays with tabs corresponding to each dialog data element Choose the applicable information on each tab and click OK to continue to the Print screen In the Printer and Extras boxes click down arrows if needed to select the appropriate items Optional Click Preview to view the item before printing Click Print 379 Templates Print toolbar icons Use toolbar icons to do any of the following Print a document from the view Click Properties to select Layout and Paper Quality NOTE Printer and Layout defaults can be assigned in Output Defaults Fax Fax a document fromthe view 0 a document from the view queue comment if desired Fill in information in the dialog that displays and click the app
335. mp P Print Encounter H amp P Fax Location Templates Referral Letter Prompt Specialist Letter Prampk Location Templates are templates specific to each location within the practice My Templates My Templates are additional templates defaults Encounter Lab Orders lt Prompt gt selected by the specific caregiver logged in Encounter Procedure Orders i lt Prompt All Templates All Templates provide access to all templates Forms and Letters available listed by Outout Category H amp P Reports Internal Documents Lab Orders Lab Requisitions Landscape Documents Office Carrespandence Patient Correspondence Patient Handouts Report Results i i i J wa F wa wan ow F e uai Click Customize to add more default templates to Customize the view They will display under My Templates NOTE You can also select output templates for each view from the Administration Module By caregiver Select Caregiver gt select the caregiver gt amp gt Output Defaults By location Select Locations gt 6 gt Output Defaults By site Select Site Settings gt Output Defaults Whenever possible select Output Defaults at the Site Settings level For additional instructions see Selecting output settings for each screen on page 386 4 Printing and Faxing Printing from any view 1 3 4 On the toolbar click FJ Print Information and select the template you need for the docu
336. n Emailing printing lab reports for one patient 1 Open a patient chart and from the toolbar click a Lab Results 2 Select a lab report to print or to print all lab reports highlight the patient name rather than a specific report Click the di Print down arrow then Lab Results Print or to preview the report before printing click Lab Results Preview sana Lab Tas Print Lab Results Preview All Templates Farms and Letters d HAD Damark k Lab Report Patient Fradfinley Ordered X 15 2005 3 36 FM by Sytem Manager Patient Tel pn Collected 315 2006 3 26 FM Patient DOR 4 14 1564 Reported 4 5 2006 1 58 PM Beshewed 46 2006 1 29 PM Eg System Marie Di acgnosis ACUTE PHARYNGITIS 852 Site LABOR ATOR Y Checker Name CEL amp PLATELETS AUTO BSE For chi sitios Status Reviewed AATE RN Test Name Result Units Normal Range Status WE 6 0 10 X 8 cell iv 45 110 Ried Bere REC 10 x f 473549 Pitre eval HG HEMOGLOBIN 15 Qr H 4 166 Fund gere HET HEMATOCRIT a4 Ta 42 3421 Riera Berea MEV MEAN CORPLECLILAR VOLLE m cu um J5 100 Rund Geta MCH MEAN CORPUSCULAR HEMCOLOBIN 29 pJ z7 3 Pega gere MCHC MEAN CCRFLIGOUL AR HEMOGL OBI MERC RON ees ene gi ay nsii ROW RED CELL DISTRIBUTION WIDTH n Rand owed BLOC COUNT PLATELET AUTOMATED m Rare wena CBC COMMENTS n C Rara oved 3 Click Close to exit Print Preview or amp to print lab report Emailing printing lab reports for all
337. n HealthMatics EMR from the left pane or the toolbar click E H amp P Report From the H amp P secondary toolbar click I Bi Y Send Billing Information Billing Details A This encounter cannot be billed electronically Unspecified Diagnosis 33 ROUTINE OBSTETRIC CARE 59400 Template Pack office Visit Print Pack T 3 a heck Al Encounter Procedure Orders Encounter Lab Orders a Uncheck Specialist Letter MEE in LI Referral Letter I Patient Frliiatinn x v ASP Prescriptions M FormsjLetters Cx cm See Viewing billing information on page 354 for field explanation See To print patient information documents without signing off on chart on page 361 for print choices if desired In Billing Details click labs and procedures to select deselect them for billing e Billable items display in bold preceded by green dollar signs e Non billable items display in regular font preceded by gray dollar signs Labs procedures not bolded are not sent to your PMS for billing Click OK to send the billing information to your PMS NOTE You may see any of the following three messages on your Send Billing Information screen displayed under the Billing Provider This encounter cannot be billed electronically The encounter billing information must be manually entered into your PMS Only encounters associated 363 H amp P Report 364 with a scheduled appointment can
338. n HealthMatics EMR pull a patient chart and from the left pane or toolbar click 4 Vitals Vitals ae ae ae ee ee ee ee ee ee RARE a Rma a Rm Date T a T a a I 3 7 2006 99 2 F 58 18 110 70 158lb 4 oz 66 in 32 cm 12 19 2005 JF 70 20 132 68 130b amp 6 in 9 26 2004 96 3 F 72 18 125 70 130b 66 in aj 3 7 2006 11 26 AM Weight 158 Ib 4 oz Height 66 in Waist 32 cm Weight and Height mere reported by patient Body Surface Area 1 81 m Body Mass Index 25 57 kg m Temp 99 2 F Oral Pulse 65 Regular Resp 18 Inlabored BP 110 70 Sitting Right Arm Standard 2 In a child s chart this will be Head Circumference Other Blood Pressure Pain level M pain scale 0 10 Systolic Patient position sitting 3 Patient Contact Functions From the Vitals secondary toolbar click qm to display Vitals Entry Vitals Entry Ea Date 4 18 2006 Time 4 23PM Vitis Comments Measurements f gt Temperature Pulse a 3 ERE fF gt Rate mm Weight b m 3 Method Pattern Regular Height in Patient reported Respiration Walst cm Bate Neck in Pattern unlabored Pulse Cr Y Room air LMP Date Diastolic Cuff location Left Arm Pertinent Hx Palpated cuff size Standard dij Save amp Add Another x cs At Date accept the default current date or cli
339. n internal transcription 4 amp document see a Viewing the list of documents on page 70 and read the message if any on the Message tab Send Transcription _ OF x tS Forward Approve X Reject Face Sheet Pull Chart C Print E From Manning Terry M Subject Mrs Irene Innis Transcription Physical Exam Voice Mate for Irene Innis Dictated 4 5 2006 2 Click the Document tab B Send Transcription lel F3 OG Forward 7 Approve Di Reject ij Face sheet G Pull chart agerint ay This document was sent with High Priority From Manager System Subject Mrs Irene Innis Transcription Index Audio R Patient Mrs Irene Innis Dictation Type Chief Complaint 00 00 000 Dictated By Terry Manning M Fae a r xi Dictation Date 4 5 2006 Transcription RH Be MPM ABs uL sample transcribed voice note for Review of Systems 3 Review the Transcription text clicking Audio buttons if needed to review your dictation see Internal Transcription on page 135 4 Click the toolbar icons to do any of the following Forward Open Send Transcription to forward the document to another caregiver You can enter an additional text message before clicking Send Approve Approve the transcription The transcription is saved in the appropriate section of the H amp P Report NOTE You must have the appropriate Function Access Reject the transcription and return it to the
340. n the Administration Module assign access for refaxing or reprinting prescriptions either by individual caregiver or by caregiver type Caregiver Select Caregivers gt highlight the caregiver gt 6 gt Access gt Clinical Module gt Office Functions gt Output Queue select Refax Reprint Prescriptions Caregiver type Select Function Access gt Clinical Module gt Office Functions gt Output Queue select Refax Reprint Prescriptions 391 Quick Printing Reference Quick Printing Reference Printing from open encounters 1 Open chart and click printer icon on toolbar 2 Select document from list of templates or from one of the template categories Example Forms amp Letters H amp P reports 3 Provide additional information if prompted to do so 4 Select printer defaults if dialog opens Printing entire chart 1 Open patient s face sheet and click printer icon on toolbar 2 Select Print Entire Chart 3 Select items to include from chart and click Print Printing from appointments Print the same way you would from an open encounter but if you want patient specific documents highlight the patient s appointment first Printing documents without signing off chart 1 From A P click printer icon on toolbar 2 Select Draft 3 Select Template Pack and click Print Printing forms letters and prescriptions from A P 1 From A P order referral medication etc 2 Click Print or printer icon
341. n to the face sheet To view edit immunization history from face sheets See Immunization Records on page 3368 for full information and details 1 From the History pane click 8 Edit Assessment Plan Show al mmunizations Include In H amp P Immunzation Date HIB HbOC 1 30645 2 o view all immunizations select the Show all Immunizations checkbox 3 To include the Immunization Record in H amp P select the Include in H amp P checkbox 4 To edit immunization history click Edit Immunizations tab GP Add Historical a Show Erroneous Immunization DaeGwven You can add historical immunizations here also See To add historical 152 2 Chart Functions immunizations on page 340 and Editing immunization history on page 339 for more information about editing immunization options from the face sheet Viewing and revising encounters from face sheets To view encounters 1 Pull a patient chart or click El Face Sheet on the toolbar 2 Inthe Encounters pane click View Encounter 3 Click S Toggle Filter to sort By Type See Face Sheets on page 145 Encounters By Date Newest to Oldest FAEX Sy Today ap 4 S 2006 Office Vis HEARING LOSS NiCr Yesterday 4 4 2 2006 Referral Letter Referral Mannin P 4 2 2006 Referral Letter Referral Mannin 4 2 2006 Other Unknown Your meeting hi PP 422006 Other Unknown Procedure rasul 4 2
342. n your desktop lists documents that have been sent to you for review and or approval 1 From the status bar or the left pane of the HealthMatics EMR desktop or the Office menu bar option click e Documents 37 Open af Forward Caregiver Manager System From Subject Information Set O 3 Manager System Rejected Mr Finley Mr Fred SOAP Transc 2 22 2006 1 51 PM Manager System Mr Fred Finley Finley Mr Fred SOAP Transc 2 22 2006 17 06 ae Manager System Mr Fred Finley Finley Mr Fred General Tran 2 22 2006 11 10 i3 Manager System Path Reports Finley Mr Fred 1 Page 2 16 2006 12 01 PM NOTE The following icons precede the various document types Li Document Type External transcription Soap or General a Internal transcription Note from Voice tab ra Scanned document x Rejected document 2 Open a document for viewing by using any of the following methods e On your keyboard press Ctrl O or e Double click the document or e On the toolbar click pen or e Right click and select Open 1 Office Functions NOTE Secondary toolbar icons Open Ad the selected document for review and approval see To Ctrl O rove or reject scanned documents on page 74 Forward the selected document Enter comments in Edit Transcription and forward it back to the transcriber or scanner See Documents on page 70 Forward Ctrl F Refresh F5 Display ne
343. need to edit 5 To view PE documentation text highlight Physical Exam PE documentation displays in the lower right pane Documenting physical exams using previous encounters 1 With a patient chart open in HealthMatics EMR from the left pane or the toolbar click amp Physical Exam Physical Exam Ay Physical Exam er General Templates office Visi 0925 2004 SINUSI v Apply C Preview LI Clear m Al some X Up Expand AB Collapse Al I Mental Status rj General Appearance D Orientation D Neurological Anatomy D Build amp Nutrition Physical Exam Lisl HH F General Did not examine Posture De Gait Hydration Voice H ej Skin General t es HEENT Mental Status Alert Appears nervous agtatec General Appearance HF e Eye Cooperative Gait Normal Hydration Well hydrated Voice Normal b 22 Neck B 22 Chest and Lung Exam Skin A i Brat Lesions UR C E n Lesion second type Size 1 5 mm Height x 5 mm Width Click the Templates down arrow select the appropriate office visit displayed under the Encounters section then click Preview if you want to view it first or Apply Use hyperlinks from the current encounter documentation pane bottom right to navigate directly to any item you need to edit Click to expand folders and view template documentation as needed to review the systems and values documented Documenting physical exams f
344. nformation 4 Click OK 219 Lab Order Entry Specimen Collection Prompt GYN Cytology screen Lab Specimen Patient fa 5 Gail Galespie Test Mame fa INICAL PATH CONSULT LIMITED WiO RECORDS AND HISTOR Collected 4 24 2006 2 45 PM Gyn Cytology Gyn Source PLMP Menopause Cervical Labia Vulva endocervical Endometrial Date Bi Vaginal Collection Technique i Previous Cytology Brush f Spatula Swab Spatula Negative Censu Spatula Only Brush Only Atypical Invasive Cervix Broom Only other Dysplasia Other Other Patient Information Previous Treatment Pregnant Menopausal None Laser Vaporization Lactating Estrogen Rx Hysterectomy Cryotherapy Postpartum PMP Bleeding Conization Radiation Oral Contraceptives Other Colposcopy amp Biopsy Dakes R mf 1 Click to select check boxes as appropriate 2 Required At LMP last menstrual period Menopause enter a date Use the Search button if desired At Previous Treatment and Dates Results enter information as needed At Previous Cytology check boxes as needed At Comments enter comments as needed Click OK OX Oo Se Ie 220 2 Chart Functions Specimen Collection Prompt AFP screen Patient Ewanwes Test Name ALPHA FETOPROTEIN SERUM 82105 Collected 4 12 2006 3 56 PM Are Type of Pregn
345. ng Lab Lab Corp Date Time 4 24 2006 i 3 11 PM EE Gal Type Third Party Drawn By Mamager System 7 Location Heakthmatis m orama 8 rz Ordering Caregiver Manager System X Specimens E H Fasting Attending Caregiver Manager System Pi Routines c Account Humber i345 active Comments Storage Type Status Complete On Hold amp GLUCOSE 82947 Routine Manager System 4 24 2006 3 07 PM 790 6 amp oe c 3 Select the test if more than one test is listed and click AskonEntry to display the AOE questions and answers in Lab Ask On Entry Ask On Entry Responses NOTE If the requisition does not include an AOE question when the Ask on Entry button is selected a warning note displays that the requisition does not include an AOE question 4 Do one ofthe following e IF you are viewing the requisition view the AOE answers and click OK to exit e IF you want to edit the test change the Answer as needed and click OK and OK again to exit Edit Requisition 225 Lab Order Entry IMPORTANT Requisitions may not be edited if e Anorder s on the requisition has results entered e The requisition is turned over to the interface with a status of Ready to Send Wait for Resend or a status of Sent OK e When a requisition with Ask on Entry questions prints the questions and answers provided print on the requisition Deleting requisitions 1 Access
346. nical Customization manual 347 Notes Import photo At Directory click the search button to browse to the directory containing the photos F Import Photo el EG ntes JE E Es cm 3 Ja2zx253 22 03 kB 3 t Sort by Iu Date Time 2 aire 5 Heart worksheet jpg 2 ba 6 14 2005 4 53 30 PM Dimension Large 800x600 a 356x378 22 32 KB j 2 i cerebral cortex jpg 6 14 2005 4 57 42 PM 409x340 34 25 KB ETT e NOTE Import Photo remembers all settings for each caregiver It scans for bitmap and jpeg format files in the selected directory gt Locate the image you need Directory Search for the directory holding jpeg and bitmap images Icon size Set size in pixels to display thumbnails in the list Sort by Sort files in directory by Date Name Type or Size Files are scanned in this order Order Select ascending or descending order to list files Files list in descending date order by default Dimension Set maximum size of the image after import or for preview The original image is scaled proportionally to fit the selection gt Edit the image 348 3 Patient Contact Functions Click the Preview tab at the top of screen or the Preview button at the bottom of the screen to preview and edit the image T Import Photo Bel Ea Efl Rotate Left Manipulate Rotate mirror flip resize or crop image as needed Changes are applied to
347. nipulate your messages For a description of those functions see Performing inbox tasks on page 26 See also Viewing other caregivers inboxes on page 28 Entering data on tabs NOTE See also Notes on page 344 Both Mail and Patient Messages include four tabs for entering the message Text Image Voice and Import The tab containing the message displays an icon X Text to indicate that it contains data 1 Office Functions Text Text is the most commonly used method of entering a message On the Text tab type the text of the message All Text message boxes include a toolbar with icons similar to those available in Microsoft Word LBS EE REN lg eere onone eao ansans oone FRCNNNNLIIIICILICLICIII gH Highlight text and click to copy it to clipboard text and click to copy it to clipboard Click to undo last action taken LEN Click to clear selected text Spell Check Click to open Spell Check Configuration dialog to set up spell Options checker Select one or more dictionaries including American and Stedman and select options to ignore such as words in upper case Auto Replace Click to Add Edit Delete Print or Copy auto replace entries Options see Editing auto replace text on page 131 Image You can add images to your messages Click the Image tab and do the following 1 On the toolbar click the E down arrow and select the repository for the image File System Library or Imp
348. njection administration code 4 From the left pane orthe toolbar click Procedure Results to complete the clinical administration that is location lot and so forth 5 The Immunization name and administration date transfers to the Immunization Record automatically Documenting immunization status You can now enter the patient immunization status using one click entry of Up to Date or Not up to Date in Immunization History To enter other free text immunization history 1 Open a patient chart and from the left pane or toolbar click amp History 2 Inthe History folder tree select Immunization and click the Free Text tab Mr Fred Finley Male 41 years old 7 24 1964 Preferred Caregiver Family Practice E Insurance Company A 1212 CIE E3 Sesdon Chats Office Patient Explre Options Took Launch Help moimBoe dg sumxauDi z msby 9xXs seBge o Summary History P E Current Encounter Face Sheet z Patient Manager Previoutly Entered History Erea Text ii Demographics diis A Reminders ES Flow Sheets J Immunizations Description P Chart Attachments Lat Rente E Procedure Results a Addons Resuks 2 Resuk Summaries 4 Contact 1 Reason For Visit TE Review of Systeme 5 Hy 3 At Description enter the immunization text 4 Click Include and OK to return to the Immunization History screen 3 Patient Contact Functions To document immunizations using previo
349. nned items from your inbox Therefore you do not need to worry about deleting them by mistake To delete inbox messages after opening them After opening a message in HealthMatics EMR you can delete it by doing any of the following depending upon the type of message fey tee Result Notifications Mark the patient s test results Reviewed to delete the message from your desktop automatically and place a note in the patient s chart see Reviewing lab results on page 178 and Reviewing procedure results on page 191 Mail Messages Take action on the item if necessary click Delete and Yes to confirm see Viewing the list of messages on page 32 Patient Messages Take action on the item click Delete If you choose to save the patient message to the chart you are prompted to confirm the delete see Responding to patient messages on page 40 Web Messages Take action on the item click Delete If you choose to save Displays if you have the patient message to the chart you are prompted to HealthMatics Access Confirm the delete see Web Messages on page 43 Refill Requests Approve the refill and either file the chart or send it to the refill manager The message deletes from your desktop automatically and a note is placed in the patient s chart see Approving or rejecting refill requests on page 48 eRefill Requests Approve the refill and either file the chart or send it to the refill Displays if you have Manager The mes
350. ns using 103 toolbar icon 113 Index 407
351. ns of the H amp P Report NOTE All chart sections that contain information which are bolded and preceded by check marks are marked Reviewed You can still check individual Note boxes and add notes as appropriate 3 Click f switchto summary to return to H amp P 359 H amp P Report To conduct performance reviews 1 To access the chart review window see To conduct chart reviews on page 357 2 From the chart review H amp P Report click Performance Performance Review x tamany ala 3 Rate the caregiver performance e Use the Evaluation tab to add performance review comments if desired Use the Ratings tab to indicate performance in each selected area Performance Review E Evaluation Ratings Category fy accuracy of Physical Exam Excelent S Thoroughness of History Excellent Tr Logical Thought Process Excellent r Appropriate and Effective Use of Laboratory Good v Demonstration of Good Pt Rapport and Respect For Dactor Patienk Relationship lt No Entry Category Appropriate propriate and Effective Use of Laboratory Rating C lt No Entry gt 4 Click Print to display Print Preview Use the preview buttons as needed and then click to print review Click Close to return to Performance Review NOTE You must print the Performance Review to have a record of it The Review is not saved in the EMR 360 3 Patient Contact Functions 5 Click OK to return to the H amp P Rep
352. nt words 1 Open a patient chart and from the left pane or the toolbar click 3 Reason for Visit lt p lS Yeecurentenccunter z fo Previous Complaints amp my Short Lists E short Lists Masher List T Free Text Description Patient requested a confidential discussion with the doctor Preview tote D cear Exams Complaints Patient Words Preview amp Ba o IN Y haa Name Recheck My chest feels tight and hurts periodically Patient requested a confidential disc 2 Click anywhere in the Patient Words text box and type the patient description of the complaint NOTES Standard word processing functions including Cut Copy Paste Undo Clear Spell Check Spell Check Options and Auto Replace Options all work in this dialog box If the Patient Words box is not visible click show Patient words in the center of the Reason for Visit view This is also a caregiver option setting Documenting complaint characteristics and details 1 With a patient chart open in HealthMatics EMR from the left pane or the toolbar click 4 Reason for Visit Select one or more complaints pulling from any of the five tabs For instructions see the following e Jo document reason for visit using previous complaints on page 258 lo document reason for visit using my short lists or short lists on page 259 e To documen
353. nter Explorer Encounters Ey Dabe Newest bo Oldest Encounter Drtadls P TY e s dic Al n 4 bM fag 211642006 Office Visit system Manager Pages gy 2 15 2006 Office Visit System Manager c zILA f 2006 Office Visit ABDOMINAL ACTIN 59 z 13 2006 Phone Ercounter Darker Dor 23 z IBI2006 Office Visit Terry Manning WE 2h 5006 Other Unknown Manning Terry l Laboratory Cofporation of America r socer rien Research Trage Pat NZ 27709 goia bo me Ajadi Diagnostic Imaging Report Manni na A zo Atai Conuitstion Report Hanri Te LA i Za 2006 Other Unknown Manning Terry d Kame Dane of fern Dac 2812006 Old Records Nursing Home Syst Paien IC fec ul SSS Labs Sy sbem Manager Gah gai NENNEN 2 8 2006 Color photograph System Manag l A cy Two Months Ago haar 2TR TOL LLE Ac Dead SHIT iy 21212006 Office Visit CHEST PAIN UNSPE Dau j ing UST Oe Office Viet CHEST PAIN USPI ay 1119 2006 Office Vie System Manager 23 1 11 2006 Office Velit Urerpeseified Diagnee E LIT LI2006 Refill Amcoicilin 23 1 4 2006 Office visit CHEST PAIN UNSPE cy Three Months Ago e L221 2006 Office Visit ABDOMINAL PAIN bess Than a Year Ago H D 28 2005 Office Visit CHEST PAIN UNSPI Mere Than a Year Ago ag 9 25 2004 Office Visit SINUSITIS ACUTE eg 9
354. nter the remaining information in the appropriate fields and click OK to display the new carrier in the Insurance Carrier Search 6 Click Close To edit insurance carrier information IF you do not have a PMS you can edit carrier information in the EMR database by following the steps below 1 From the menu bar select Tools Edit Insurance Carriers 2 In Insurance Carrier Search search for the insurance carrier select it and click 3 In Insurance Carrier edit information as needed and click OK 4 Click Close 170 2 Chart Functions IMPORTANT NOTE If Allow Demographics Entry in Launch gt Administration Module gt Settings gt Site Settings is Off secondary toolbars on the Insurance Policies and Emergency Contacts tabs do not display since that information cannot be edited from HealthMatics EMR The 4 Edit Patient Demographics button on the Demographics screen still displays but when you click it fields updated by the PMS interface are disabled gray and you will only be able to modify fields that are not updated by your PMS Entering emergency contacts 1 Open a patient chart and from the left pane or the toolbar click id Demographics then click the Emergency Contacts tab Demographics 4 P F Se curent Encounter x A Patient Demographics Insurance Policies Emergency Contacts E Fatient Picture Relationship 2 To add emergency contacts press the Insert key or from the secondary
355. nu bar click Launch gt Clinical Customization Module Click Catalogs gt Procedure Entry Rules Select the procedure and click i Click the Search tab then at Billing Codes select the Procedure Code Billing Codes ca Led L Type Descipton E Owners Statu CPT 11765 EXCISE SKIN WEDGE INGROWN TOENAIL System Mana Enabled NOTE A green dollar sign precedes CPT codes that are billable If the CPT code you are looking for is not on the list check the Show Archived box If you still do not find the CPT code see the HealthMatics EMR Clinical Customization manual How to Create Procedure Entry Rules Click amp a EXCISE SKIN WEDGE INGROWN TOENAIL properties General Mare xc ISE SEIN WEDGE INGROWN TOENAIL pede Billable Medicare Limited Coverage Bibl Condition Freguency Experimental Comment amp 83 BoD Y Bl 4A EHE OK Cen e For procedures that should be billed by the practice click to select the Billable checkbox 2 Chart Functions e For procedures that should not be billed by the practice the Billable checkbox should be left deselected 5 Click OK Entering procedure results From the HealthMatics EMR menu bar select Office Procedure Results or with the patient chart open click ig Procedure Results in the left pane or toolbar Mr Fred Finley Male 41 years old 7 24 1964 Preferred Caregiver Family Practice E Insurance Company
356. o Ordered by Family Practice E on 9 26 2004 Routine FOLLOW UP AS NEEDED Ordered Collected on 3 26 2004 12 39 PM EXCISE SKIN WEDGE INGROWN TOENAIL 11765 F Reported on 8 27 2004 8 24 AM LABORATORY URINALYSIS W O MICROSCOPY 81002 Ordered Reviewed by Family Practice E on 3 27 2004 8 30 AM URINALYSIS W O MICROSCOPY 81002 Ordered Sy Three Months Ago Ej EXCISE SKIN WEDGE INGROWN TOENAIL 11765 F Test Name Result Units 2 prag Status AEROSOL VAPOR INHALATIONS ADDED 94665 Fir 0x9 45 l AMYLASE 82150 Fina Reviewed WEC 10 2 ces iio evened iB EXCISE SKIN WEDGE INGROWN TOENAIL 11765 F lx 47 2 BB EXCISE SKIN WEDGE INGROWN TOENAIL 11765 F l ahl 549 Reviewed dB EXCISE SKIN WEDGE INGROWN TOENAIL 11765 F E E nad E EXCISE SKIN WEDGE INGROWN TOENAIL 11765 F Hene Sm nae giat 16 6 m EHEH Less Than a Year Ago 43 1 EE HEP A VAC ADULT INTRAMUSCULAR 90632 Orde MCV MEAN a More Than a Year Ago CORPUSCULAR 77 cuum 76 100 Reviewed CELZ HANDAL E5031 Pre nanan Parkia Reve MH i Ras uen Pein i MEAN i MPT AST PBA RAS fla Ne a EB CORPUSCULAR 28 pa 27 31 Rew 4 Details of the reviewed order display 159 Face Sheets 5 Optional Click the Trend tab to graphically represent order results Order Details Frit Jems Detats Trend Dates hepast2yers H Tests Show Graph v Display Values in Graph Table Test Name MCT HEMATOCRIT Collected D
357. o Yes by default when entering Lab Review screen provided the practice has HealthMatics Access 5 Click OK to exit or select another option in the left pane 117 Options To set reason for visit defaults 1 From the HealthMatics EMR menu bar select Options gt Edit Options gt Reason for Visit P Caregiver Options for Manager System Mai Ea General Reason For Visit Sis Desktop Toolbar eneral Face Sheet Default Tab Master List z Patient Manager Results Previous HPIJ CC NE d Date Range 365 days a Review of Systems atient words gt Physical Exam Assessment and Plan Show Patient Words Electronic Prescriptions Hide Patient Words z History Lists Quick Lists My Short Lists Reset Settings comes 2 At General click down arrow to select the Default Tab that you want displayed when you open Reason for Visit Previous Complaints My Short Lists Short Lists Master List or Free Text 3 At Previous HPI CC click down arrow to select the Date Range to constrain the amount of previous HPI CC that you want to display on Previous Complaints tab Choices extend from 30 days to 365 days 4 At Patient words click appropriate radio button to determine whether patient words should be shown or hidden 5 Click OK to exit or select another item in the left pane to set additional defaults NOTE Click Reset Settings to set all defaults in this view back to their o
358. o default on E M Calculator Exam Click the down arrow to select the most common exam to default on E M Calculator Click OK to exit or select other options in the left pane to select additional defaults 1 Office Functions To customize the title bar 1 From the HealthMatics EMR menu bar select Options gt Edit Options gt Title Bar p Caregiver Options for Manager System Io Ed ae Title Bar Title Bar Properties Title Bar e Patient Manager Results z Physical Exam Assessment and Plan Be Electronic Prescriptions Sign Off Preferred Caregiver Title Bar Referring Caregiver History Living Will Indicator Web Account Indicator Lists Quick Lists My Short Lists E Separator Comma Hr Jasper A Wright Jr Male 43 years old 12843 Insurance Ca cm e Fields Lists items that can be selected for title bar including Separator punctuation marks and or spaces e Title bar Lists items selected for customized title bar e Separator Clicking down arrow displays list of punctuation that can be used to separate items selected in title bar display e Preview Displays title bar as it reflects selected fields 2 n Fields list double click or select items and click icons to move and sort them in Title Bar list S ee ee IM i ir Move item up one in the title bar list and to the left in the title bar 4 Move item down one in the title bar list and to the right
359. o npe 11 Configuring spell check llli 12 Using pen based functions anaana aaaea eh DES Sb awe Rt ee eieESE 13 TO SEPdaleS iu cece e E oa eee ec ee as be st ba oe ce bes 13 TG ACCCSS the keypad vies aah ahs alae pee cg SiMe ways e Se nlm dS a Ue ee a dE e t c Re E OR 14 To access the numeric keypad 0 00 cece eee tenes 14 Patient Searchl uns cic cine eam usquc mE a Rcg Nd ee a eae ae 14 ADDOINIMCNIS 62 052 33 owe df Rr dE cdieeienewnes E i cared edie 15 Scheduling appointments in HealthMatics EMR 0 2 ee ee 17 Checking patients in and OUt n naana ee eens 18 Searching for patient appointments 1 0 0 es 19 Changing or editing appointment information 000 02 ce eee eee 20 Blocking time on schedules 0 000 eee teens 20 Panino daly Senedules x28 up qo eee dde icesee Sr br de SD EG ee OPI 20 Displaying daily billing information lll 21 Open EHnCOUIOES oir dut tardive a ERE eI dE EE OU Rudd e Nu 22 Outstanding chart messages llle lees 22 SID OX GNI EDIT ecc 24 E Iterhng IRDOX NEMS c dri ob S ccs Se Se UE Cr I E eO eme Pe dq epe Ed 24 HealthMatics EMR Application Reference Manual odiis Dar IDbDOX tiNCKS s uerus der aed Ro ae e Pra aro fen Dod Ae Lame ce rks 24 IGDOX MSTA NC OMS ouis dog to cde de ed us o e EA e Re Nr uec Mb Sh DG n de CRI b UE EUR Dn e d d up ad 26 Performing INDOX TASKS s uus an ip oH epo e We od BES ae AR Re a Sog t TT 26
360. o set up to eight quick filters Setting user defaults for quick filters 98 You can set two different default quick filters one for the filters you use most often when working in a patient s chart and one for the filters you use most often when no chart is pulled Example you are entering lab results on multiple patients or reviewing results on multiple patients at one time 1 With no chart open set a quick filter see Creating quick filters on page 98 with the search criteria that you use most commonly when not in a patient chart Example All Patients The past month Ordered Oldest to Newest and name the quick filter Results Entry 1 Office Functions 2 To set the no chart user default quick filter click S to display the quick filters you ve set up Sf Filter System Default 1 All Locations All Caregivers All Patients All Dates All Requiring Action All Categories 2 4ll Locations All Caregivers All Patients The Past Week All Statuses All Categories 3 All Locations Terry Manning All Patients The Past Week All Requiring Action All Caregivers 4 s 5 n B Set Filter k Set User Default k NOTE System Default is the original filter settings for Patient Dates Status and Sort oelect Set User Default and the filter that you want as your default when you open the screen Open a patient s chart and repeat the preceding steps to set a quick filter with the search criteria that you
361. o the database the Details tab in the Referral dialog box is only accessible to the caregiver who effectively signed the letter Other caregivers can view the Letter tab but not the Details tab 4 Complete referral dialog screen Caregiver and Specialty Clinic These fields default from Data Search selections Can be referred elsewhere Check to indicate patient can be referred elsewhere Consultation Select appropriate box es to indicate what follow up is desired Referral Select to transfer management of the patient problem to the referral physician and request visit summaries Signature Check Use my Signature Bitmap to use your electronic signature on the letter or form 3 Patient Contact Functions rics RR NR Checkboxes Follow up At the bottom of the screen select as many of the checkboxes as appropriate to indicate follow up reporting desired Reason for consultation referral Enter the reason for the patient referral consultation into the text box using conventional word processing tools 5 Click the Letter tab to view the letter Referral x Detal Letter z Check All Uncheck All wv Assessment amp Plan atient Mr Fred Finley DOB 7 24 1954 Male IDF 1212 Referral Request Ta Endocrine Doctor Endocrinologist 1220 Westwood Place Cary MC 27511 555 555 0005 rom Manager System irratira zj Fm Er RC E Le qp exi To select the items you want to
362. oing one of the following Send Click to send the approved rejected refill s to the Rx Manager or the caregiver who created the request if an Rx Manager has not been designated gt The approved rejected refill messages appear in the Rx Manager s or original sender s inbox and in the Batch Refill window until the Rx Manager or original sender calls faxes or transmits it to the pharmacy or prints it for the patient and files the request in the chart gt he patient s face sheet displays the following message in the Medication History pane Recorded date time by nb di d Office Visit see Using aaa properties on page 51 where all approved prescriptions can be printed faxed or transmitted electronically with electronic signatures if that functionality has been purchased Using prescription properties See also Approving or rejecting refill requests on page 48 1 To process prescription refills for a patient access Prescription Properties from any of the following four places A P gt on toolbar gt Draft gt A amp P Prescriptions checkbox gt OK H amp P Report gt Sign Off gt A amp P Prescriptions gt OK W Prescription Properties Miel Use Signature Patient Mrs Irene Innis c Use License Preferred Pharmacy Two 2000 South E Template lt System Default gt Apply bo All Use signature Enter password for signatures and ePrescribe if required in Administration
363. omatically to the Graphs list box in the far right pane 205 Flow Sheets Flow Sheets Use Flow Sheets to manually enter data in spreadsheet format to the patient record To add flow sheets 1 Open a patient chart and access flow sheets e From the menu bar select Patient gt Flow Sheets or From the toolbar click the down arrow and select Flow Sheets or e From the left pane click Flow Sheets pNNEMESUNS CUTE MONI SODEDERUOC OC SIRE e E Xa C d 3 9 d E39 n n i B2 8 C mI xAy GB Sy Summary 0 PUPS Current Encounter ld d Flow Sheets y E Note E Erromenus Face Sheet T Indude In Hap M erae aa c 2l4 Reminders X Flow Sheets Blow Sheet 2 Click 5P Mrs Gail Galespie Female 61 years old 1 26 1945 Preferres Session Charts Office Patient Explore Options Tools Launch Help BRoOuwmo S3 aaa Bw EHZ Summary Face Shest wl Patient Manager ud Demographics b Reminders TEE Tu Select either Add From Template Add a Flow Sheet from a template either delivered with the application or created in the Customization Module f Select Flow Sheet Template _ Site Templates 3 Audiogram Date iCoumadin Management Coumadin Therapy CV Aden Stress date j Cv CHF Education CV CHF Infusion Cy CHF Mmi h Cv Dobt Stress Echo CV GXT
364. omplaints for the Current encounter NOTES Short lists with hot links to disabled short lists display a warning balloon indicating the linked list is not available Short lists in which the description of the chief complaint was changed use the original description when generating text The original complaint name also displays bolded in the Master list or any other place it is used To prevent this add the changed complaint to your short list Refer to the HealthMatics EMR Clinical Customization manual for assistance To document reason for visit using the master list 1 Open a patient chart and from the left pane or the toolbar click 2 Reason for Visit 2 Click the Master List tab Reason For Visit BuEEese o 5 Previous Complaints E My Short Lists E Short Lists 1 Master List T Free Text Search f Starts with Contains Complaint Master list 20 Abdominal distention E 2 Abdominal distention TM 2 Abdominal mass At Search Term do the following e Type a few characters of the complaint you need for documentation The list filters as you type e f you do not find the item you are looking for click Includes to include items that contain letters you typed When you find the item click it to use it as the reason for visit The item is bolded and also displays in the Exams Complaints list in the lower left corner of the Reason for Visit screen To enter complaint detail
365. on to change the date Review the transcription e General transcription is saved to the patient chart as an attachment Therefore it has an Attachment Type such as Consultation Report or Historical Summary assigned to it General transcription text displays in the Transcription text box e SOAP transcription is not associated with an Attachment Type and will appear as part of the H amp P Report for the selected encounter Read the text by clicking on each of the tabs Subjective Objective Assessment Plan and Misc Click toolbar icons to do any of the following Forward Forward the document to another caregiver If a rejected document is forwarded the status changes back to Submitted Approve Approve the document after checking adjusting the index information and adding a comment if desired save it to the patient s chart Reject Reject the document after entering a reason for the rejection and return it with a message to the indexing caregiver u Face Sheet View the patient s face sheet Pull Chart Pull the patient s chart and leave the document without taking any action on it Print Ctrl P Print the document Access the keypad 1 Office Functions To approve or reject internal voice note transcriptions NOTE For instructions for recording voice notes in HealthMatics EMR see Entering voice messages in notes on page 349 and Internal Transcription on page 135 1 Inthe Documents view open a
366. on when you try to access Demographics a message states Your account does not have the proper privileges to access this function Accessing patient demographics Access Demographics in one of two ways depending upon whether the patient is established or not Demographics 4 P F Se current Encounter al Patient Demographics E Insurance Policies Emergency Contacts Fatient Picture EN e o edit established patient demographics with a patient chart open name is on the title bar from the left pane or the toolbar click ji Demographics and then press F2 or click 4 Edit Patient Demographics e To enter demographics for a new patient from the toolbar click l Pull a Chart then at Patient Search click Add if it is not hidden 162 2 Chart Functions Entering editing patient demographics 1 Access Patient Demographics see Accessing patient demographics on page 162 General Home Address Work Address Guarantor Emergency Information Other Information Legal Name Identification Title e Patient Id la T Training FirstName Fed ss 230 30 3131 7 Active Middle Initial Referred by TEE Last Name Filey 000000 Preferred Caregiver ZEILE NBUCA DL NN cue mele aa Demographics Notes Date of arth 7 24 1964 al yearsago vog om e e EM Martal Status undefined v a m L Language
367. on 2 overview 1 preferences setting 108 Index toolbar icon 111 diagnoses assessment plan setting defaults 122 classifying and adding descriptions 299 300 database libraries searching 294 E amp M calculator 367 face sheets editing on 299 revising from 150 free text using for 296 orders associating with 308 primary secondary tertiary assigning 297 short lists selecting from 294 discharge plans data source 295 display options setting 108 documentation pane in ROS PE 272 documents approving rejecting 71 exporting from any view 382 faxing from any view 381 inbox messages 25 28 output queue viewing from 92 overview 70 previewing from any view 383 printer defaults setting 130 printing from any view 379 queued generating 393 queuing saving to log from any view 382 regenerating from output queue 392 saving to log 95 scanned 76 scanned reviewing approving 74 status bar accessing from 5 toolbar icon 111 transcription reviewing approving 70 drafting encounters 361 drop down lists using 8 drugs Medi Span database 238 duplicate charts merging 232 E E amp M calculator accessing 367 data risk 370 E amp M level 367 369 exam default setting 124 field definitions 369 level of service adjusting 373 management options 370 overview of 366 service type default setting 124 edit desk references menu option 3 electronic charts contents of 139 397 Index electronic pres
368. on to the current encounter NOTES e The items you select display in the current encounter pane at the bottom of the History window 253 History e To see documentation for all categories highlight History in the folder tree on the left Documenting history using search 1 Open a patient chart and from the left pane or the toolbar click History 2 Inthe History folder tree select any category except mmunization to display the tabs for selecting information 3 Click the Search tab At Data Source click the down arrow to select the Dev Current Encounter Em ili Previously Entered History My Short Lists Short Lists Search Free Text B taisietion Data Source Past Medcalvistory x SemthResks P Family Category All Past Medical Histor y hi Na streptococcal Infection Past Medical mn A streptococcal Septicemia Fa Social Search Term STREP IK streptococcal Sore Throat Fy Travel f Starts With Contains L Medication Pregnancy ith de appropriate data library NOTE Data sources available depend upon the category selected in the History folder tree 4 At Category select a category if you want to narrow your search 5 At Search Term type a few letters of the item you want to find and click one of the radio buttons e Starts with To search for items that begin with the letters you specified e Includes To search for items that contain the letters y
369. op Move selected list to top Move selected list up one position Move selected list down one position Move to Bottom Move selected list to the bottom Sort Ascending Sort short lists in ascending order rm Sort Descending Sort short lists in descending order Delete selected list from the My Short Lists tab This does not delete the short list from the system just the tab 5 Click OK to save your changes and exit 241 Vitals Adding my short list items to current encounters Vitals Open a patient chart and from the toolbar click 2 to display Assessment Plan Click the My Short Lists tab 8 Edit Assessment Plan Patient Problem List Patient Medications Mv short Lists short Lists Search ree Text Diagnosis djgindude i ResetLit Collapse Al o AS Diagnostic Imaging al EHEH Diagnostic Procedures 1 3 Therapeutic Proc Sw Patient Educatior a P tt T ABDOMINAL PAIN 789 0 REPAIR SUPERFICIAL WOUNDS FACE 12013 Routine Cecon 8S0MG ML Solution 1 PO Mo Refill Ordered Cedar Leaf Oil 1 No Refill Ordered Reset TCFP Master Ckr R A Collapse All Select an item and do one of the following e Click Include or e Drag the item and drop it in the encounter pane below or e Right click and select Include or e Double click the item Use the Vitals view to document patient vital signs and growth chart data Documenting vitals 242 I
370. or from the menu bar Options Edit Output Defaults Pharmacies default to the preferred pharmacy or the last used pharmacy on the medication 3 Click OK to process the output and return to the Refill Request dialog box NOTE The refills sent to output are preceded by the outline of the green check icons lt to indicate that the refills have been processed 4 Select the medication and click Save to Chart to save the refill request to the patient s face sheet and remove the refill message from your inbox Refill request details are documented on the patient s face sheet in both Refill Requests from the Encounters pane and in Revision History in the Medications pane Encounter Explorer gt Messages gt Refill P Encounter Explorer E eo me Encounter Details Expand View Print CX Email Hote Encounters SS Office Visit Ey Messages Gre 2 Childrens Tylenol Sinus Parrot Peter j LR This message was sent with High Priority a 3 Chart Attachments To Manager System Gy Labs Procedures From Manning Terry MD Sent 421 2006 3 13 PM Pharmacy Pharmacy One 1010 Westwood Drive Cary NC B55 555 2323 Request Medication Status Printed Childrens Tylenol Sinus 15 160MG 5ML Liquid 5 Milliliger s PO Q6 hr No Refill 04 20 2006 Ordered 53 54 Refill Requests Medication Explorer Ordered B Medication Explorer Medications All Start
371. ord 334 3 Click Pelvimetry tab Antepartum Record X Vitals UJA Pregnancy Labs ROS Maternal Fetal Data Cervix Medical Hx OB History Pelvimetry ext apet Pelvic Type Side Walls Diagonal Conjugate Bi ischial Diameter Not examined v Adequate Borderline Contracted Not examined Mot examined C Not examined I Androki Anthropoid Gynecoid Mixed C Convergent C Divergent C Straight C e11 5cm C 11 5cm v eBecm C gt 8cm 3 Patient Contact Functions Sacrum Notexamined Flat Hollow Hooked Supra pubic Not examined lt 90 degrees Arch gt 90 degrees Ischial Spines Not examined Small i Average Prominent Coccyx Not examined C Fixed Mobile Pelvis Proven rs s Ibs 4 az 4 Select each checkbox radio button data field as required 5 At Pelvis Proven to enter pounds and ounces of the largest baby the patient delivered 6 Click OK to save and validate all data in the edit window or go to the next tab to continue documenting data is not automatically saved 7 Optional Click Cancel if you do not want any data saved from the edit To edit pregnancy record next appointment NOTE This information is bidirectional with the 59400 Routine Obstetric Care Procedure Rule View Procedure Result 1 Access the Pregnancy Record see Accessing the pregn
372. ort 6 In Overall Chart Review select the Reviewed checkbox to add an automatic annotation Add a Note if desired Jsoenor EmEsM E ed By send Back sg Performance is Switch to Detaled Reviewed Present 7 Note History amp Physical Report Notes BVM amp aw EY P History and Physical Note Chart Review Mote 5System Manager 3 28 2006 4 29 Pry I have reviewed the histony bna physical note and findings with System Manager You can select both the Present and Reviewed checkboxes to add an automatic annotation that the reviewer was present during the review described History and Physical Note Chart Review Note Syren fanager No0 z006 4 34 Pre Iwas present diving the Alston and physical note and have r eviewedlihe findings with System Manager 7 To finalize the encounter do one of the following e To send the chart back to the original caregiver for sign off click Send Back Enter message information as needed and click Send To print documents for the patient without signing off the chart see To print patient information documents without signing off on chart on page 361 e To bill the encounter without signing off the chart click Bill See To send encounter billing information without signing off on page 363 e To sign off bill the encounter and refile the chart click Sign Off See Signing off charts on page 364 for detaile
373. ort Photo or you can just click E not the arrow to default to the Library 33 Messages 34 File system Open Look inc 8 My Pictures e ctr E 4m Leg Left Anterior Musculoskeletal am Leg Left Anterior Musculoskeletal 4m Leg Left Anterior Skeletal im Leg Musculoskeletal ay Leg Right Anterior Musculoskeletal ay Leg Right Anterior Skeletal ay Leg Veins ay Leg Arterial Left 4m Leg Left Anterior Leg Muscles Left Lateral m Leg Right Anterior 4m Leg Venous Left Preview Scale 100 None Fa Search for the image from the files available on your PC Library leg f Starts with Contains area Type a few characters in the search field to automatically scroll to the appropriate image e Import photo 1 Office Functions Import Photo HRSG preview Directory J E Icon Size ss x 48 pixels sotby Fios z C Ascending Descending Dimension medium 500x500 Preview F9 Le cm Search for the image from the directories available from your workstation Select the image and click OK or Open to include the image in the message The data icon displays on the Image tab 4 image and the image appears on the screen NOTE Scroll down if necessary to view the image 35 Messages 36 3 Click t Drawing Tool to drop down a menu of items you can use to draw on the image es NEEMEMEME
374. ou add a Hx entry to the current encounter the Status is automatically changed to Active 257 Reason for Visit 258 Reason for Visit Use the Reason for Visit view to document a patient chief complaint or reason for visit as the patient reports them Documenting reason for visit Open a patient chart and from the left pane or the toolbar click XY Reason for Visit Reason For Visit BuENgeeemee 1 32 Previous Complaints E My Short Lists E Short Lists 1 Master List T Free Text Search f Starts with Contains Complaint Master list 3 Abdominal distention Bl 8 Abdominal distention TM Complaints can be set up and customized by gender and or the following age groups e Newborn less than one year old e Pediatric less than 18 years old e Maternal females 12 55 years old e Adult 15 years and older e Geriatric 65 years and older To customize complaints by age group refer to your HealthMatics EMR Clinical Customization manual Customization by gender or age will affect the complaints available for selection based on the patient chart pulled To locate the chief complaint or reason for the patient visit select one of the five tabs near the top of the screen To document reason for visit using previous complaints In Reason for Visit Previous Complaints lists the patient s previously reported problems CC HPI To document the reason for visit using Previous Complaints
375. ou specified 6 Click Search to display the first 100 items in the Search Results box NOTE If more than 100 items fit your search criteria a message says Only the first 100 results were returned For better results please refine your search criteria Enter more specific information for your search criteria and search again 7 To include history items in the patient s current encounter do one of the following e Double click the item in the Search Results box or e Click the item you want to include then click Include or e Drag the item from the Search Results pane to the current encounter pane Documenting history using free text You can enter and reuse Free Text entries 1 At Description type the free text entry or 2 Click Include or press Enter key NOTE Free text data is not reportable or billable 254 3 Patient Contact Functions Managing problem and medication history You can add an item from the current history pane to a patient problem or medication list A red glow around the icon indicates the item is managed NOTE If you build your Past Medical History list from commonly used ICD 9 codes Managing a PMH problem in A P will be supported by billing If you do not use ICD 9 codes to build PMH most likely unless you have customized otherwise the problem does not have an associated ICD 9 code needed for billing and could result in rejected claims Example Hypertension may be a historical and an active
376. ounter Patient Problem List Patient Medications My Short Lists Short Lists Search Free Text Diagnosis digindude RpAddto My Short Lists Z Reset list Colapse Al Chee DE interactions P Isabel BENIGN ESSENTIAL HYPERTENSION 401 1 te Correspondence Day Surgery Referral Letter NOTE Create a forms and letters short list folder in the Clinical Customization 311 Assessment Plan 312 Module For instructions see the HealthMatics EMR Clinical Customization manual To select a referral consultation letter double click it or drag it to the preview bottom pane or select it and click Include IF a referring caregiver was entered in patient Demographics ii a confirmation message displays gt Click Yes to send the letter to the patient s referring caregiver on record gt Click No to display Referral Caregiver Search which allows you to select a different caregiver as the recipient IF no referring caregiver was entered for the patient in Demographics Referral Caregiver Search displays Referral Caregiver Search Spedety lt Allspecokies gt Wee Search Clear Po 2 SMendocrine Doctor Endocrinologist E 555 555 0005 gt At Specialty click down arrow to select the referral caregiver specialty if desired gt At Name enter a few characters of the caregiver name and click Search From the list that displays select the ap
377. ows Panes and Other Tools on page 8 1 On the status bar or left pane of the HealthMatics EMR desktop or Office Manager click 4 Received Charts Received Charts 27 Open P e Reply wf Forward Caregiver Manager System w Erom Subject Patient Manning Te ExamRm3 Fries a Fr 3 11 2006 10 35 AM Select a message and click toolbar icons or right click for a drop down menu to do any of the following Li Delete Del Delete the selected chart message Open Ctrl O Once opened click any of the tabs with icons on them Text or double click mage Voice or Import to view the chart message Reply Ctrl R Reply to the chart message or any other caregiver to the chart Reply to the chart message or any other caregiver or any other caregiver Forward Forward the chart to another caregiver Ctrl F fg Refresh F5 Display new action items sent to you recently if you cannot wait until the screen refreshes itself automatically NOTE To set the Refresh default time see To set desktop defaults on page 109 2 Open the chart message and click toolbar icons to do any of the following Delete Del Delete the selected chart message Pull Chart Close the Received Charts view and open the patient s chart for review Click Yes to delete the chart message from your inbox once the chart is pulled View H amp P View the patient s current H amp P Report in a sepa
378. ows the area proportions but is not drawn to scale e Ifa value is entered for only the Height or the Width the Preview graphic is linear rather than two dimensional 3 Patient Contact Functions Using the toolbars in ROS and PE Open a patient chart and from the left pane or the toolbar click Review of Systems or 2 Physical Exam aal ee Templates lEncounters 77 apply E Preview Clear NOTE Most ROS PE toolbar functions can also be accessed by right clicking in the documentation pane and selecting the item from the menu that appears Navigation Toggles the navigation pane on and off The last settings are remembered for each caregiver Preview Toggles the preview pane The last settings are remembered for each caregiver Navigate Back The view navigates back in history Click the down arrow to display a menu with a maximum of 20 entries to navigate back to documented items Navigate Forward The view navigates forward in history Click the down arrow to display a menu with a maximum of 20 entries to navigate forward to documented items The navigation tree switches to the top level that is Review of Systems or Physical Exam All the child folders are visible Ex Up The view navigates to the parent folder of the current selection Expand All From the currently selected folder down all the child folders are expanded Collapse All From the currently selected folder down all the child folders are co
379. page 10 Click to display a quick entry box Add The button displays in Patient Search only if the site setting for Allow Demographics Entry is checked in the Administration Module If not checked Add does not appear and all patients must be entered in the Practice Management System and pulled into the EMR across the interface If the patient name does not display in the list enter other identifying information in the search fields and click Search or press Enter NOTES Search criteria If you enter information in more than one field HealthMatics EMR searches for the chart that meets all of the criteria Search results HealthMatics EMR displays a default list of patients whose charts were pulled by caregivers within the last 15 days Your system administrator can change the number of days in the Administration Module Inactive deceased patients Inactive patients display in gray font Deceased patients display in strikeout font Inactive deceased patients display in gray strikeout font Sort Click any column heading to sort the list by that item To select a patient double click the patient or select the patient from the list and click OK To review open encounters 1 From the HealthMatics EMR desktop status bar or left pane click Open Encounters Review Patient Name Encounter Date v as Reason For K Pulled To open a patient chart double click the patient name or select it an
380. pane and the current encounter pane To document the patient has no history in that category click None to replace the informational message with the word None Example To indicate a patient has not traveled select the category Travel and click None When you then highlight History in the folder tree the documentation shows the following Travel History None Including past medical history in current encounters 1 Open a patient chart and from the left pane or the toolbar click amp 4 History 2 Inthe History folder tree select Past Medical and the Previously Entered History tab 3 To include all Previously Entered History items in the current encounter do either of the following e Select a folder Example Active and drag it to the bottom pane or e Select the Active folder and click Include All NOTES If you plan to manage diagnoses from PMH for use in A P use ICD 9 entries to document PMH This assists billing See Managing problem and medication history on page 255 Erroneous entries Any items previously marked Erroneous Entry will display under a separate folder in the upper pane However this folder is not opened in the History window by default and erroneous items in it are not included in the current encounter if you click Include All Diagnoses 251 History Editing If you select a diagnosis in the current encounter pane and click amp Edit selected item the History dialog box appears whi
381. patients 1 From the toolbar click Lab Results Lab Results a Lab Tasks 3 Chart Tasks EJMessages cS S Filter M s Caregiver Manager System Dates rhe past 3 manths E Patient sal Patients gt T e st Status ordered Abnormals Only Sort Newest ta Oldest 2 Click All in the Patient filter 2 Chart Functions Select the appropriate Dates Status and Sort to display all patients meeting the selected criteria Highlight a patient name then from the Menu bar click the di Print down arrow and Lab Results Print or to preview the report before printing click Lab Results Preview gt Would you like to print For all Patients or only the selected Patient Selected Cancel Click All All results for all patients that meet the selected criteria display consecutively Click Close to exit Print Preview or amp to print lab report Rules controlling date selections in lab results When a caregiver leaves the lab results window the application saves the Results Date Range caregiver option for a single patient or the date range for all patients whichever was selected Routing lab result notifications The following rules determine how labs and result notifications messages to provider inboxes are routed If the order to which the results belong is on a requisition the ordering provider selected on the requisition receives the notification If the order
382. pearance of the spreadsheet click Options to display Template Options See Viewing result summaries on page 199 for information about the options available e Click Print gt Result Summaries to print the spreadsheet The Print dialog box displays Select the Printer Paper Orientation and whether you want to print a spreadsheet or graph e Click OK to print 202 2 Chart Functions To view graphs Click the Graph tab for the selected template to select items you need to view in graphical format Previously created graphs will be available for view Result Summaries _ I COE Dates The past 6 months Date Time Display se s Spreadsheet Graph Blood Pressure Systolc ap 100 thing Right Arm Skandard 3 29 2006 E Elocd Pressure Syla Creating new result summary graphs To create a new graph to view patient data do the following 1 With a patient chart open in HealthMatics EMR from the left panel click X 2 Select a template 3 Click the Graph tab to create add the graph format 4 From the Graph toolbar click dm pc s Graph B a a LI M New Graph v Weight EP 5 At Graph name enter a unique new graph name 6 Double click to choose Template Elements you want or highlight and click amp to add your selection to Graph Elements up to 15 max 203 Result Summaries e To remove a Graph Element select it then click NOTE Non numeric i
383. pending on the caregiver option set Starts with or Contains is used for the search see To set review of systems and physical exam defaults on page 119 Ends the Quick Search with no action Jumps to the folder or item displayed in the white target box under the search string If your search target is a folder quick search locates the folder and presents only folder subfolders and items BO Jumps to the next item matching the search term 274 3 Patient Contact Functions NOTE Quick Search begins searching from the highlighted item down the navigation tree To navigate using key strokes e Z2 e If an item is selected the selection jumps to the folder e Ifa folder is selected selects its parent folder Ctr Home Same as toolbar Home e Ifon an item selects the last item in that list e f on an expanded folder selects the last subfolder e f on a collapsed folder selects the last sibling folder Page Up Moves the focus to physical exam Moves the focus to the last item in list and opens the item Left e Ifon an item moves the selection to its parent folder e f on an expanded folder collapses the folder e If on a collapsed folder moves the selection to the parent folder Alt Left Same as toolbar History Back Ctrl Left If on a folder its the same as on the toolbar Collapse Folder e f on an item moves to the next possible folder e f on an expanded folder moves to the next sibling
384. pie Mrs Gail Pharmacy One 101 Calcium Antacid 4 20 2006 2 59 PM v Innis Mrs Irene Pharmacy Two 200 Triamterene HCTZ 4202006 2 54 P Parrot Peter 555 555 0101 DOB 12 11 2002 Pharmacy Pharmacy One 1010 Westwood Drive Cary MC 555 555 2323 Approved by System Manager Medication Amoxicillin 125MG SML For Suspension 5 Milliliker s PO BID 7 For Susp No Refill 7 Eg days starting 04 20 2006 Ordered NOTES To sort the refills click the column headings To view refills awaiting processing by other refill managers click the Caregiver down arrow Security assures that refills can only be processed by the Rx Manager designated at the time the refill was approved so the list is Read Only Highlight a refill and the prescription details display in the preview pane at the bottom of the screen NOTES Refills marked High Priority display in red with an exclamation mark in the column f the refill request was rejected only the name of the medication displays 89 Batch Refill 90 To view the Refill Request dialog for additional details on the secondary toolbar click Open see Sending refill requests on page 44 Process the refill by doing one of the following Call the prescription in to the pharmacy or the patient if the refill was rejected and click Called In or e Click Output to open the Prescription Properties dialog box from which you can print fax o
385. port see Viewing chart attachments from face sheet on page 210 209 Chart Attachments Viewing chart attachments from face sheet There are two ways to view chart attachments from patient face sheets With a patient chart open in HealthMatics EMR from the left pane orthe toolbar click Bi Face Sheet By type Click S Toggle Filter on the Encounters pane title bar to sort the encounters By Type gt Click El on the Encounters pane to maximize the pane gt Click to open Chart Attachments and other folders as needed to locate the attachment you want to view gt Select the attachment then double click it or click Face Sheet Encounters By Type Newest to Oldest i View Encounter a ETY Encounters amp J Historical Summary SS Office Visi EX Chart Attachments Sy FormsjLetters fy LabsjProcedures 4S Nurse s Note i 4 1 LAG Nur ce Mote Pablent goals Manager System er 4 4 2006 Nutritionis s Note Reduce dietary protein Manager System Occupational Therapy Note Sy OtherfUnknown Ey Scanned Documents Sy Color photograph Sy Old Chart Note Encounter Explorer Encounters By Type fewest to Oldest Vu g E HHZ Encounters fy Historical Summary Patient goals EHE Office Visit B J Chart Attachments FEN Dans EMO oy Feems Letters fy Labs Procedures Caregiver Manager System Eg Nurse s Note
386. positive or negative 3 Click the note E icon enter a text note about the selected detail then click OK to return to Review of Systems Review of Systems DAS e h Eup ax Expand al Colapse Al CO Review of Systems ZE General Templates CARDIAC ROS happy ESlpreview f clear jr Skin 2E HEENT Respiratory peip 7 Neck Chronic Cough 70 Respiratory ml I Cough JE Breast Pabent to bang chest xrays fo next vt E Cardiovascular JE Gastrointestinal SERS 4 Male Genitourinary Respiratory rent Cough Pabeat to bang chest xrays fo next vet Aot Presenc Difficulty a Musculoskeletal Breathing The note icon displays a colored background to alert the caregiver that the M includes a note and the note text displays after the selected detail in the preview pane if selected in caregiver options and the H amp P report 283 Physical Exams NOTE To view the complete text of the note either click the note icon after the system or the note text hyperlink Physical Exams Document Physical Exam PE findings by clicking items for each system You can document PE findings based on templates previous encounters or from scratch Documenting physical exams using templates 1 With a patient chart open in HealthMatics EMR from the left pane or the toolbar click Physical Exam T juris D E3 gt hme Eu ajexmand AE Colapse Al e General fy Men
387. propriate modifier s if you need to link billing modifiers Billing provider If needed click down arrow to select appropriate billing provider NOTE The default billing provider is the caregiver of record Billing details Click labs procedures to select deselect for billing NOTE Billable items display in bold preceded by green dollar bill Non billable items are preceded by gray dollar bills Labs procedures not in bold are not sent to your PMS for billing 3 Patient Contact Functions Indicating reason charts are kept open If you are unable to complete and sign off on a chart immediately at the end of the encounter indicate the reason for keeping the chart pulled on the H amp P Report 1 Open a patient chart and from the toolbar click e History amp Physical Report 2 At Heason Kept Open enter the reason for keeping the chart pulled or click down arrow and select a reason from the list J E 9 Current Encounter Psion off muesm E eil Qsubme Reason Kept Open sr History amp Physical Report NOTE To review a list of open encounters click 4 Open Encounters on your status bar or click l Audit Open Encounters on the left navigation pane to review all open encounters by Caregiver Location or Patient Editing current H amp P reports You can make changes to H amp P reports notes and attachments for open encounters Once the H amp P Report is signed off you can only indicate
388. propriate caregiver and click OK to place that caregiver name in the letter NOTE If the caregiver is not in the database click Add and add the caregiver 3 Patient Contact Functions Depending on the form you select Referral Referral for example if labs were ordered Select Order appears Check the orders you want included in the FormjLetter _f2e 2004 METABOLIC PANEL BASIC 80048 0 19 26 2004 STREP QUICK TEST 86403 O 9 25 2004 OCCULT BLOOD FECES SCREEN 82270 19fesj2004 PSA 84153 10322 Select the orders you want to include in the letter then click OK If procedures were ordered Select Order appears Select Order x Check the orders you want included in the Form Letter 3 15 2006 EXCISE SKIN WEDGE INGROWN TOEMAIL 11765 Select any procedure orders you want to include in the letter If no procedures are ordered a warning message states There are no Procedure orders for this patient 313 Assessment Plan 314 To view the letter double click it in the current encounter bottom pane Referral Referral GH Print E Emal Dee aj 5 Selo 4 Oo c os Merma Asie fo z a z u E a a EE Cc ae hone eh OS ae A A a a FA ee ee Ee ee E HealthMatics Family Practice 5501 Dillard Drve Cary NC 27511 883 672 3282 phone 888 673 3423 fax amp John Smith MD 1220 Westwood Place Cary NC 27511 rom Terry Manning MD
389. ption Send Prescription x Pharmacy jews 1010 Westwood Drive Cary NC 555 555 2323 E TN NOTE If the select pharmacy is not configured to accept electronic prescriptions a warning displays in the Send Prescription dialog box e f Pharmacy is blank or incorrect click Pharmacy to find the correct one in Pharmacy Search and click OK to return to Send Prescription e Select Save as default Pharmacy for this patient if appropriate e Click ePrescribe to display a progress dialog Sending ePrescribe Message Prescribing PredniSONe Pak 10MG Tablet Sending to pharmacy CVS 1010 Westwood Drive Cary MC 27511 Sending message Pe NOTES If the default pharmacy for the patient has a valid Pharmacy ID the ePrescribe message is sent immediately If there is a problem during transmission a warning displays to allow the caregiver to change the pharmacy if possible If a message states The selected pharmacy has not been configured for e Prescriptions you can fax the prescription if you are set up to do so or try updating your pharmacy SureScripts IDs from the A4 Client Website From the website select HealthMatics EMR gt Electronic Prescribing The information on the website is updated at least once a month The ePrescribe button is enabled only if the provider is enrolled and the selected pharmacy has a Pharmacy ID NCPDP ID If it does not an icon and label explain that the pharmacy is not set up correct
390. quick using 321 requisitions creating from 300 short lists using 294 toolbar icon 110 attachments encounters moving to other 156 face sheets viewing from 210 H amp P report viewing from 356 office visits linking to 209 procedures results 192 audit open encounters description of 107 toolbar icon 110 authentification biometric 68 authored text 295 defaults setting 320 processing 197 auto logoff setting disabling 3 automatic inactivation of medications 158 B back toolbar icon 110 barcode labels printing 228 batch processing accessing 228 229 deleting 231 editing 231 lab order batches creating 229 editing 231 manifests printing 231 toolbar icon 110 batch refill overview 89 refill requests processing 89 toolbar icon 111 billing appointments displaying charges for 21 batches 17 encounters 363 information viewing 354 395 Index procedures defining billable status 188 pulling charts for 139 reconciliation 105 toolbar icon 111 biometric authentication eRefill requests 55 362 login 1 overview 68 preparing to use 68 printing faxing 69 System options setting 68 blood lead specimen collection screen 222 blood type entering 164 bookmarking favorite Internet sites 84 browser Internet toolbar icon 111 build where to find 4 C calendars using to enter dates 10 canceling contact 375 caregiver options assessment and plan 122 defaults overview 108 desktop 109 editing 108 electronic p
391. r 1 of 1 jet Bartels Barry MD Ena By Review Order Status Pending Ordered 3 10 2006 3 49PM Completed 10 2006 3 56 pM Document All results needing review default to a status of Reviewed Select a referral result and click Toggle Review to deselect any referrals Click OK To print additional results select the Patient and or the item and from the HealthMatics EMR menu bar click amp Print gt Additional Results The results print instantly Processing authored text Patient Education Office Procedures Discharge Plans and Nursing Services can contain authored text that will require review or follow up 1 2 oF 4 Access Additional Results see To access referral results on page 195 Choose the Ordered status and set other filters as desired Click or Expand All to view items oelect the authored text and Right click or click Result Tasks and choose the needed action e Review all Launches the Review screen allowing you to review all finalized results e Finalizes Finalizes the result without entry of additional comments NOTE You can customize authored text so it is automatically finalized when ordered e Result entry Launches the dialog box allowing entry of additional comments 197 Report Results NOTE You can mark the result Final and Reviewed from this screen see To review final referral results on page 197 Report Results The Report Results view lists al
392. r X PE In the navigation pane click Search to navigate through the exam by searching for items Map Selected My ROS Lists Le Skin Skin E 2 5kin Color Female Genitourinary Extemal Ge Skin tag RectallFectumJExtemal 3 Enter search criteria and click Search Search results contain the search criteria you entered depending on settings you selected in Caregiver Options see To set review of systems and physical exam defaults on page 119 NOTES The last 10 search terms are saved Select an item in the results list and the documentation pane scrolls to the selected item Using the preview pane in ROS and PE For instructions for navigating in the ROS and PE views see ROS and PE Navigation on page 266 1 Open a patient chart and from the left pane or the toolbar click Review of Systems or 42 Physical Exam Document a review of systems or physical exam see Using the documentation pane in ROS and PE on page 272 NOTE Text generated as you document appears in the preview pane the lower pane on the right side of both the ROS and the PE views You can click directly on text in the preview pane to navigate to the item 3 From the left navigation pane click Review of Systems or Physical Exam 271 ROS and PE Navigation 272 4 Move the cursor over text in the preview pane until the cursor changes to a hand and the selected text is underscored or highlighted indicating it is a link
393. r becomes a part of the patient permanent record NOTE At signoff the application checks to see if a managed item was modified in History but not in Assessment Plan If so it edits the Assessment Plan item to match the values of the History entry However medications entered into History but not ordered in Assessment Plan are recorded as Active so that they do not appear as prescribed by the caregiver 365 Evaluation amp Management Calculator 366 Evaluation amp Management Calculator The application automatically calculates billing levels based on information entered in patient contact screens The Evaluation amp Management E amp M calculator serves all nine specialty areas Cardiovascular ENT Genitourinary Hematologic Lymphatic Immunologic Musculoskeletal Neurologic Psychiatric Respiratory Skin and uses Alpha II Unicore Med technology to analyze the procedures documented and suggest an E amp M level for an encounter All exam types are available to caregivers and all possible exam systems body parts and organ parts are within the database The E amp M overall calculation is based on 1997 E amp M Documentation Guidelines that map HealthMatics EMR clinical terms to codes provided by Spring Management After the mapping takes place the application feeds the codes to a dynamic library file where the codes are summarized to generate a score Visit the Spring Management website www springmgmt com to request backup data
394. r diagnoses or medications recorded previously e Using short lists practice and personal favorites e Using database libraries e Entering free text 292 3 Patient Contact Functions To specify assessments and medications using previous lists In Assessment Plan selecting assessments or plans from the Patient Problem List tab or the Patient Medications tab attaches the current encounter assessment and plan to this previously entered information 1 Open a patient chart and from the left pane or the toolbar click A P Assessment Plan Assessment Plan SE Se Current Encounter Patient Problem List Patient Medications My Short Lists Short Lists Search Free Text Diagnosis cag Include ch view 7 Inactivate Ce Include Active MANIC AFFECTIVE DISORDER RECURRENT EPISODE IM PARTIAL OR UNSPECIFIED RE Unspecified Diagnosis BLISTER OF FOOT AMD TOE S INFECTED 817 3 DIABETES INSIPIDUS 253 5 5 ACUTE FRONTAL SINUSITIS 461 11 B 1 Inactive fEl VINCENT S ANGINA 101 Status is Inactive 2 Click the Patient Problem List tab and select a problem and do one of the following e Double click the problem or e Select the problem and click Include or e Right click and select Include or e Select the problem and click Enter on your keypad or e Drag and drop the problem to the bottom pane NOTE You can also click Include All to include all active problems in the current encounter 3 To or
395. r electronically transmit the prescription see Using prescription properties on page 51 Viewing refill documentation on face sheets 1 2 3 4 5 Pull a patient s chart to access the face sheet In the Encounters pane click a View Encounter On the toolbar click 5 to filter By Type Under Messages click the plus sign to open the Refill folder Highlight a refill to view the details and the Request Status to the right 8 Encounter Explorer B x EEN a a Encounter Details i sg a E Expand view Prnt RE Emai EHT Encounters a Nu Sy Definitive Diagnosis Pending Amoxicillin 4 Office Visit a Phone Encounter foie fuii Y Messages 31 73 Patient Message A This message was sent with High Priority Refil Ta Manager System el 4 20 2006 Refill Morphine Sulfate CR Fii Manager System m 4 10 2006 Refill FA Vitamin B 6 Vitani Sent 1 11 2006 11 04 AM Hel 4f 7 2006 Refill Anmcxicilin Augmentin el 3 23 2006 Refill Augmentin Pharmacy eh 3123 2006 Refill Augmentin aL 2 24 2006 Refill Albuterol Pharmacy One 1010 Westwood Drive Cary MC 555 555 eae eh 2 24 2006 Refill Amoxicilin ra nen Medication re praia Called In Albuterol Q0MCG ACT Aerosol Soln 1 Inhalation 2006 Sy Chart Attachments ordered amp J Consultation Report Called in oxicilin 250G Tablet Chewable 1 Chew Tab PO BID 20 Diagnostic Imaging Report Chew Tab No Refill
396. r the toolbar click is Procedure Results Procedure Results Caregiver A1 Grantors Dates The past 3 months gl Patient em Abnormals Only Sort newest to Oldest PalenUPwocedus 0 Status Ordered Date PedomedDae or Fred Finley a Sf ingrown Toenail Ordered L 18 2006 10 01 AM 1118 2008 10 01 AM IR AEROSOLIVAPOR INHALATIONS A Ordered 1 17 2006 1 45 PM 1 17 2006 1 45 PM f Ask about Foot hygiene Ordered 1j 2006 2 18PM 1 9 2006 2 18 PM gt 2 Click the Status down arrow and select Ordered 3 To open the procedure rule select the procedure and do one of the following e Double click it or e From the Procedure Results toolbar click Procedure Tasks gt Result Entry or e Right click it and select Procedure Tasks gt Result Entry Procedure Results Entry Mr Fred Finley Order 3 of 4 Mr Fred Finley BB Ask about foot hygiene leae c Cate u Eranda Colpa Al 0 clear Ask about Foot hygiene Foot hygiene E Daly O x3fweek Less than x3jweek E Shoe fit BOY Bla Required My Procedure Lists Search NOTES The Procedure Results Entry dialog box has three panes similar to the Review of Systems and Physical Exam views For detailed instructions for using the navigation pane on the left see ROS and PE Navigation on page 26
397. rate dialog Close the H amp P Report dialog to return to the Chart Message 1 Office Functions Displays the Chart Message dialog Enter a new message back to the original sender and click Send or Ctrl Enter to return the message and chart Click Yes to delete the original message from your inbox The message and chart are removed from your inbox and returned to the original caregiver s inbox Forward Displays the Chart Message dialog Fill in the Jo and Message Subject fields as needed and click Send or Ctrl Enter to forward the message and chart to a caregiver other than the one who originally sent it to you Click Yes to delete the original message from your Inbox Print the message See also Viewing other caregivers inboxes on page 28 81 Reports Reports Reports are user generated messages accompanying report results that other 82 Caregivers send to you for action For general instructions for using HealthMatics EMR windows see and Other Tools on page 8 Processing report messages Windows Panes 1 On the status bar or left pane of the HealthMatics EMR desktop or Office Manager click amp Reports O ae c Message about Report Re 3 20 2006 3 11 PM Ge Manager 5 Zithromax check 3 20 2006 2 28 PM Manager Ss Message about Report Re 3 20 2006 11 58 AM 37 Open Fe Reply sf Forward Caregiver Manager System X
398. reen select the medication from the HealthMatics EMR database that exactly matches Rx To Refill Patient Innis Irene 555 555 2733 55N z30 30 7000 DOB 11 28 1932 SEX Female Rx To Refill Triamterene HCTz 37 5 25MG Capsule 60 30 Days Ref xz Directions 1 Cap PO BID 30 days x 60 Cap Motes Pharmacy CVS 1010 Westwood Drive Cary NC 27511 555 555 2323 Id 29998888 Patient Mrs Trene Innis M e Pharmacy Pharmacy One 1010 Westwood Drive Cary NC 555 555 2323 E Select the medication that MATCHES Ehe Rx 45 WRITTEN ABOVE Prednisone SMG Tablet 3 PO QID 1967 Continued a Ref x2 60 Cap r Triamberene HOT 37 5 25MG Capsule 1 PO BID 04 20 2006 Ordered 4 On the eRefill Requests secondary toolbar click Approve A screen displays showing that the system is sending an ePrescribe message Sending ePrescribe Message Appraving Amoxicillin 200MG Tablet Chewable Sending to pharmacy Pharmacy One 1010 Westwood Drive Cary NC 27511 Verifying connection pony NOTES The Sending ePrescribe Message displays the progress of the connection to the ePrescribe Gateway The action being taken and the medication being approved displays in the message to provide feedback so that you will know exactly what is being sent to the pharmacy The name of the caregiver who approves the request is added to the saved eRefill Request on the patient face sheet and also is sent electron
399. refresh automatically Manually matching eRefill requests Medication matching must be manually performed for each eRefill request If the prescription from the pharmacy does not match any of the medications in the patient medication list the eRefill Request should be rejected However in a case where a patient new to the practice is on a maintenance drug and the pharmacy sends an eRefill request to the caregiver if the medication is not ordered in the chart yet the caregiver can pull the chart add the medication and then approve the refill 1 2 Access eRefill Requests see Viewing eRefill requests on page 56 oelect an eRefill Request in the upper pane to display the prescriptions details and matching information from the HealthMatics EMR database in the pane below NOTE In most cases the patient name and pharmacy are automatically matched but either one or both may not be 57 eRefill Requests 58 To match patients If a pharmacy misspells the patient name or there are multiple patients with the same name and the pharmacy did not include enough information to distinguish among them the system cannot match the patient name No medications are listed in the bottom pane for unmatched patients 1 With an eRefill request selected click to use the current patient or click the Patient search button Last Name Date of Birth fo Search J First Name irene poms fl de patientId ades
400. rends Display results in a graph or table Pull Chart Pull the patient chart NOTE Closes Lab Results Face Sheet View the patient face sheet NOTE To return to Lab Results click X in the upper right corner Attach to Encounter Attach the lab result to the H amp P for the original encounter current encounter or both Send Patient Message Send a patient message to another caregiver about the lab results Send Web Message Only available if you purchased and connected HealthMatics EMR Access Send a message to the patient via the website Send Reminder Place a reminder on the patient chart Expand All Click to view all lab tests results 179 Lab Results ET Collapse All Click to collapse all the results Select a Filter Click down arrow and select e System Default List of up to eight custom filters Set Filter e Set User Default Refresh F5 Click to refresh the view to include any recent changes 2 Click Expand All 3 At Status click the down arrow and select Needs Review 4 Select the test for review then from the secondary toolbar click Lab Tasks gt Review Patient F Review Lab Results i B x um B 7 Facesheet GJ Annotate Toggle Review Mame s Value Units Range Review Fred Finley Yes CEC amp PLATELETS AUTO 1OXFceisL 4 5 11 0 Ordered 3 16 2006 3 39 PM by System Manager Site LABORATORY Collected S16 2006 3 39 PM Reporte
401. request see Refill Requests on page 44 z Open Ctrl O Select a refill message and click Open to view it Approve Refill Request Ctrl A Reject Refill Request Ctrl R Refresh Refill Requests F5 Select the refill and click to Approve it see Approving or rejecting refill requests on page 48 NOTES The approved refill request goes automatically to the person designated as Rx Manager to be called or faxed to pharmacy or printed e You must have the appropriate Function Access Select and or open a refill request from the list and click to reject it NOTES Rejected requests go automatically to the person designated as the Rx Manager to notify the patient e You must have the appropriate Function Access Display new information entered into the database recently see To set desktop defaults on page 109 NOTES Refill request messages are removed from your inbox when you approve the refill or when the Rx Manager clicks Called In Fax or Print in Batch Refill or clicks File in Chart 47 Refill Requests Approving or rejecting refill requests 1 From the status bar or left pane of the HealthMatics EMR desktop click Refill Requests Refill Requests an 37 Open Approve X Reject Caregiver Manager System Rx Manager zHane From I Medications Patient iManager System Amoxicillin Albuterol FA Vitamin Finley Mr Fred 3 22 2006 10 38
402. rescriptions 123 face sheet 114 history 126 my short lists 128 240 order on behalf of another caregiver 302 patient manager 116 quick lists 127 reason for visit 118 results 117 review of systems physical exam 119 sign off 124 title bar 125 toolbar 110 vitals 121 caregivers display options 108 outbox viewing other s 88 output default sets creating 384 performance reviews conducting 360 scheduled patients viewing 17 worklog filter 100 101 cervix editing pregnancy record 331 charges displaying in the EMR 21 chart attachments adding 208 face sheets viewing from 210 H amp P report viewing from 356 office visits linking to 209 396 overview 208 toolbar icon 111 chart reviews detailed 359 overall 358 charts contact canceling 375 tracking in worklogs 100 electronic contents 139 file toolbar icon 111 filing 143 internal transcription viewing 155 merge 232 history 236 manually merging 232 queue using 235 opening 141 outstanding messages 22 printing entire 144 privacy levels setting 163 procedure results attaching to 192 pulling 139 for billing encounters 139 for concurrent encounters 140 for non billable contact 140 from status bar 5 toolbar icon 112 reason kept open 142 355 received displaying list of 80 viewed from status bar 5 viewing 143 reminders creating 211 overview 211 viewing completing 212 scanned documents viewing 155 send toolbar icon 113 sending to caregivers 142 signing off 364 vi
403. review pane in ROS and PE 0 ec ee 271 Using the documentation pane in ROS and PE 00 000 e eee 272 TO d0CuMeNnt USING QUICK Segrelt i diano tits a pine do oed tet abd eta 274 To navigate using key strokes llli 275 To document measurements and sizes 2 ee ee ee 276 Using the toolbars in ROS and PE 1 ce ens 277 REVIEW Of SVSIOITIS sae crete eae cere 95 1 1902 9 3 ow ese 33 ee eden 278 Documenting ROS using templates 0 0 0 00 eee 278 Documenting ROS using previous encounters 000 llle 280 Documenting review of systems from the beginning 2006 281 Adding review of systems notes 0 0 0 ee eee 282 To add ROS notes at the review of systems level 0 0000 cece eee eee 282 To add ROS notes at the system level 0 0 ccc ee es 283 To add ROS notes at the detail level 0 0 0 0 ccc ees 283 Physical EXAMS 2400224005 6050 0 34 wows ewneie ee di be deseo we weeds ees 284 Documenting physical exams using templates eee eee 284 Documenting physical exams using previous encounters 285 Documenting physical exams from the beginning lll 285 To add physical exam NOS os iac ne roter d aec eere E emilee edlen dnos 286 To add an mage NOE 3 25 duties tow an BOR ARE RE LR ORE ed eRe edis 286 Documenting measurements and sizes in PE 2 0 0 cee eee 288 Documenting physical
404. riginal default settings 118 1 Office Functions To set review of systems and physical exam defaults NOTE The Review of Systems and Physical Exam options are identical 1 From the HealthMatics EMR menu bar select Options gt Edit Options gt Review of Systems or Physical Exam P Caregiver Options for Manager System Mai x Review of Systems eneral gt Face Sheet Maximum Column Count E m Navigation Tabs ag eere get Iv Show Notes I Map Iw My Lists PU Results W Selected W Search Review of Systems Search cz Physical Exam Units Default Size Panel Color RFFFFFF E x Assessment and Plan TIRE ERO ae ma Electronic Prescriptions SEES Coe a Sign Off iie Templates Title Bar Filer by Age A Past Encounter Count E c History T m Filter by Gender Lists Default ta last Encounter On Apply y Quick oe Jump to Selected after Apply Prompt My Short Lists Expand Selections after Apply Combine Existing with Template Replace Existing with Template Reload Knowledge Reset Settings 2 General Maximum column count Click the down arrows to select the number of columns to display across the panel pane in Physical Exam maximum 3 or 4 Select to display notes under the knowledge term in Review of Systems Physical Exam Expand mapped images Select to automatically open images mapped to items selected Select a default Starts with or Contains
405. rinting 307 history viewing from A P 292 merge history reviewing 236 merges manual 232 Ntierprise accessing from the EMR 138 pictures loading 172 problems medications managing 255 reminders viewing completing 212 searching for 140 visits tracking progress 104 worklog 100 103 pelvimetry editing pregnancy record 334 pen based functions list of 13 pending messages patient manager 174 performance dates changing 193 performance reviews conducting 360 pharmacies calling in refills 89 entering NCPDP ID 60 matching 59 preferred entering 165 setting up NCPDP IDs 67 phone numbers entering 10 physical exam accessing 284 defaults setting 119 documenting 272 exam lists using 284 measurements and sizes 276 using quick search 274 documenting from scratch 285 documenting measurements sizes 288 images using to document 289 navigation map 267 my PE lists 268 269 PE 266 search 271 selected 268 navigation methods 266 navigation pane 266 notes adding 286 notes adding images 286 preview pane 271 toolbar icons 112 277 vitals viewing 246 pictures loading patient 172 purchased database of anatomical images 238 practice management system Index entering demographic information in 162 Ntierprise access 138 preferences setting 108 preferred name entering 165 pregnancy record accessing 322 cervix editing in pregnancy record 331 documentation enhancements 322 documenting 325 maternal fetal data editing 330 medical H
406. rmation Show Notes Click checkbox to include notes in view Eo Seefe Click down arrow to choose the font size 8 15 pts for the view Show vital Click radio button to display measurements in metric measurements as cm units kg Celsius Show vital Click radio button to display measurements in non measurements as in lb metric units Fahrenheit 200 2 Chart Functions 5 To change Dates view click f Ellipsis Search button and select a date range for encounter dates to include in your result summary Current Range C Today C The past year C The past week The past 2 years The past month All Dates C The past 3months Specific dates f The past 6 months Specific Dates From T Radio button choices Click one radio button to select a current date range Specific Dates Enter the From and To dates in m d yyyy format or Click the down arrow to select dates from a calendar e Click OK to return to Result Summaries 6 At Date Time Display select how you want to display date and time ia ai Date Time Date time displays in m d yyyy h mm PM format Time displays in h mm PM format 7 Click OK 201 Result Summaries To view spreadsheets default view Result Summaries Template results Here are the results of your template Vitals Dixon Brandy T Blond Pressure Temperature ee mamme J 128 84 105 76 05 17 2003 120 80 Print Options e To change the ap
407. rom the beginning oee also Adding review of systems notes on page 282 and Documenting review of systems from the beginning on page 281 1 With a patient chart open in HealthMatics EMR from the left pane or the toolbar click Physical Exam In the Physical Exam navigation pane for each system you want to document click as needed to expand folders and display the characteristics at the level needed for documentation 285 Physical Exams 286 3 Inthe pane on the right click to document items as needed Physical Exam EA amp Ahome Ejup quExpandAl G Collapse All Ay Physical Exam A do General Templates Office visit 09 25 2004 SINUSI Apply ElPreview H Clear Mental Status 4 General Appearance Orientation Orientation es Neurological Anatomy Jl Orienbed to time ER Build amp Nutrition Oriented to place Dm Posture IE Oriented to ose Gait d 3 Hydration pt Orienbed to person i Voice General Orientation dg Skin Orientation Oriented x4 id i2 LigggRIT e Physical exam notes can be added at all levels NOTE Image notes can be added at the physical exam and system level You can also add an image note in addition to a text note To add physical exam notes You can add notes at all levels in Physical Exam from the physical exam encounter level down to the Detail level The process for adding notes in Physical Exam in the s
408. ropriate button at the bottom of the screen to Print Fax Queue Save to Log Export or Preview 380 4 Printing and Faxing Faxing from any view 1 On the toolbar click EJ Print Information and select the template you need for the document you want to generate Click the Fax tab B Fax Encounter Procedure Orders of x ci Print Bex 8 Queue Save to Log fey Export Preview iFa Fax Preview as Search Humber m a Numbers Description Speed Dial 1 Pharmacy Bras Category Lab Orders Lavaut Blank Page Style Defaut Style US Letter 81x11 in coal Locate the pharmacy number by doing any of the following Search At Search click any of the search buttons Pharmacy Referral Caregiver Institution or Patient to locate the fax number Common numbers Click Common Numbers to display recently faxed numbers specific to the patient Speed dial To save the fax number once you locate it click Set and then click a Speed Dial number 1 through 8 The pharmacy name displays on the selected button and the Number and Description display in the appropriate fields Optional Click the Preview tab to preview the document To transmit the document click Fax 381 Templates Queuing and saving to log from any view NOTE Only documents containing patient data can be queued or saved to log 1 On the toolbar click d Print Information
409. rry az 2006 er Referral Letter Referral Manning Terry 422006 2 Press Insert on your keyboard or click np Add Attachment 3 Click the Import tab 8 Chart Attachment Chseetegen diee Kem a WU EET Attachment Type athen e Subject E ooo Noe Text Image woke Import cg og T a NOTE The Import tab displays only on the Chart Attachment screen 4 Click amp Load from File locate and select to the file and click Open to attach it to the chart 351 Notes Icons Load and save imported files to a patient chart using the mport toolbar icons Click to load from a file W e O Click to save to a file mow Click to launch a file in the associated viewer Click to clear imported data 352 3 Patient Contact Functions H amp P Report You can view the H amp P Report at any time while documenting an encounter This report contains all the information entered in each of the contact screens Reason for Visit Review of Systems History Vital Signs Physical Exam and Assessment Plan Open a patient chart and from the left pane or the toolbar click H amp P Report asign off meem z eit History amp Physical Report Notes f Attachments Mr Fred Finley 10 26 2005 5 11 PM Location HealthMatics Patient ID 123456 DOB 2 28 1950 vires i Language Undefined Ethnicity Undefined The patient is a 55 year old Male Revie
410. rt To view a patient s chart and exit Billing Reconciliation highlight the patient s name and click Pull Chart 1 Office Functions Audit Open Encounters Audit Open Encounters lists all encounters that have not yet been signed off You can sort items by Caregiver Location or Patient and view H amp P reports and or pull charts for the encounters patients listed 1 To access Audit Open Encounters do one of the following e Inthe left pane of the desktop click Audit Open Encounters or e From the application menu bar select Office gt Audit Open Encounters Audit Open Encounters Ef view Hap Pul Chart C Caregiver Show Al C Location show All Patient show all gt E Finley Mr Fred cR Family Practice Clinic EB Manager System EE Es 23 2006 3 38 PM SITE DEFAULT NOTE Encounters open more than one week display in red 2 Filter the items if desired by selecting Caregiver Location or Patient and then clicking the respective down arrow to make a selection e Caregiver Filter items by caregiver location patient encounter e Location Filter items by location caregiver patient encounter e Patient Filter items by patient location caregiver encounter 3 Click plus signs to expand the folders to reach the encounter level 4 To view the H amp P report for the encounter double click the encounter or select it and click View H amp P 107 Opt
411. rual Period date Date entered populates both Vitals in EMR and the Maternal Fetal Data tab Cannot be a future date or Estimated Delivery Date Date entered used to populate the Procedure Rule in EMR and the Maternal Data tab Cannot be a past date NOTE The LMP date is queried from Vitals in the HealthMatics EMR The LMP and or EDD date entered is added to the Pregnancy Record Vital Signs and H amp P Report when you click OK 5 Enter the appropriate date click either LMP Last Menstrual Period or EDD Estimated Date of Delivery then click OK NOTE To access previous encounters once within the Pregnancy Record from the HealthMatics EMR menu click Explore gt Encounters and select the encounter to view 324 3 Patient Contact Functions Documenting with the pregnancy record The Antepartum Record is the main window for the Pregnancy Record and includes a dated list of relevant antepartum visit records in the top pane The LMP or EDD date is used to calculate which records fall within the current pregnancy EDD minus 280 days Previous pregnancies are not displayed those prior to the LMP The lower section of the main window includes a tab selection of summary screens e Prenatal records Displays a row for each 59400 rule documented NOTE Cannot edit the 59400 detail when the encounter is signed off e Active problems Lists all active problems for the patient e Active medications from the EMR Lis
412. ry item into the current encounter see Documenting adding history from previously entered history on page 248 From the current encounter pane at the bottom of the screen double click the item you want to edit or select it and click 4 Edit selected item Right click and choose edit or highlight and press F2 History Knowledge Term Asthma Include Renamed as Date e General Modifiers X Test Resul status EHEJ Diagnostic tests EHS Diagnostic test results amp x Tests History Properties Bax c 249 History NOTE Medication History displays if a medication is selected Medication History Ea Albuterol SOMCG ACT Aerosol Soln Inhalation Taken starting 1975 Continued Hx Entry Status Continued T Start Date 1975 Ka years ago E Reason Nobbes amp G Ho v Sh El E L9 em The Status field allows you to change the status of the medication and then select the Reason and include Notes If you select a Status of Discontinued an End Date field displays for the date the medication ended 5 Edit items as needed and click OK Changes display in the documentation pane at the bottom of the window 6 To view all changes made select History in the folder tree on the left and view the text changes in the pane on the right Removing history items from current encounters 1 Open a patient chart and from the left pane or the toolbar click amp j History 2 To c
413. ry using Search 1 6 ee eee 254 Documenting history using free text 0 0 eee 254 Managing problem and medication history 00000 e eee ee eee 255 To manage medications from history llle 256 To view managed history items on the assessment plan screen 257 vii HealthMatics EMR Application Reference Manual Reason TOF VIS sa 2 acscucti eoi a est each fr uita Dae ace ee he eae aie Dares 258 Documenting reason for visit aaea a eens 258 To document reason for visit using previous complaints 000000 258 To document reason for visit using my short lists or short lists 259 To document reason for visit using the master list llli 260 To document reason for visit using free text llle 261 To document reason for visit using patient words 0c eee eee 262 Documenting complaint characteristics and details lLsn 262 HOS and PE Navigatlon uisi nie fe o eed m Uns oe dlc ee qur 266 Using the navigation pane in ROS and PE 0 cc eee eee 266 To navigate using the review of systems or physical exam tab 266 To navigate using the maptab aaea aae 267 To navigate using the selected tab 0 00 ce eee 268 To navigate using the my ROS PE lists tab 0 00 00 eee eee 268 To navigate using the search tab llli 271 Using the p
414. s 20 6 sn 303 To view medication interactions llle 306 To print fax or electronically transmit prescriptions lllllllllsss 306 To print medication patient education information 00 0000 eee ees 307 MEO LSS TOTO S uerus rara Giada i acts te ten miele ees dd sr ee ence te ae ees eer 308 WISING DEOIDOOIS ros cd ee Ree a ee be Ce ea ee he 308 Using procedure entry ruleS 1 eee ees 309 To order procedures with rules attached 0 0 cee ee eee 309 To enter results of procedures with rules attached 000 cee eeeee 310 Documenting Telerfals u x 3 0 3 deu R9 es ORE e OR n cs Bw ERR UC Wo de 311 Option 1 Select referral letters llle 311 Option 2 Make referrals using letters associated with caregivers 315 Option 3 Select referral letter from patient chart 0 0 0 0 cc eee eee 319 Using authored text in assessment plan llllllsnnn 320 Setting patient authored text templates to completed in A P 320 Displaying quick assessment plans 0 0 0 0 cc eee 321 Pregnancy FHecOFQ ose ni ded ete iouis Qa aes ated a a ea ae eS 322 Accessing the pregnancy record 0 ce eren 322 Documenting with the pregnancy record llle 325 Editing pregnancy record screens 1 cc tees 326 To edit pregnancy record vitals U A 1 eee 327 To access pregnancy record pregnancy labs
415. s s e su 408 oom Eg LEUR RC eR bee aed Dior S de og 215 Creating requisitions llle rs 215 To create requisitions llle rs 215 To enter specimen collection information llle 218 Answering ask on entry AOE questions for orders lll 222 Viewing editing ask on entry questions on requisitions 005 224 Deleting requisitions 0 0 0 IRI I6 226 F rinthg TedquisillOfiS 3 3 ocio week ead Os bie hee Gtk d 226 HealthMatics EMR Application Reference Manual Processing requisitions et d wc ER eR CR we Ve ee D Re t 227 TO AGCESS reguislllOfiS s cows Decale Be ae dioere qe 6 i etra dose Goto ada cub ad Seri 227 Touesend regulsltlollS aid mca crs amp dem aede bt fetu oat dt de Ec Da cdd de oues 228 TO DHEILIBDGlS sas areas ores Beans dee vb oed ut Docendi S t Na Geen a els ag 228 Processing requisition batches 0 0 ccc ee eee 228 To access batch processing 00 ee eee nets 229 To create lab order batches 1 0 0 ccc eee eee ene 229 TO edit lab Order Dates andai a eve SIC gh t ae i e d at etg Acts 231 To delete lab order batcheS 1 ce ees 231 To preview and print batch manifests packing lists llle 231 Patient Merge iude xen wea SR ew Peete eed xcd x eu eee eed 232 Manually merging patient charts n n anaana 232 Using the merge queue lslleeleeee rn 235 Reviewing merge history
416. s select the item in the Exams Complaints list and do one of the following e Press F2 on your keyboard or e Double click the item or e Click g Describe selected item or e Right click and select Describe 3 Patient Contact Functions 6 To document Complaint Details see Documenting complaint characteristics and details on page 262 7 Repeat the steps above if necessary to document additional complaints for the Current encounter To document reason for visit using free text 1 Open a patient chart and from the left pane or the toolbar click Reason for Visit 2 Click the Free Text tab Reason For Visit x 13 Previous Complaints E My Short Lists E Short Lists 2 Master List T Free Text Description Patient requested a confidential discussin with the doctor Include 3 At Description enter up to 255 characters of free text to describe a complaint and then click Include NOTES An encounter can only have one free text entry If a free text complaint has already been entered in the encounter the Description box displays the name read only and the Include button is disabled If you make an error in the free text entry select the entry in the Exams Complaints box click Delete and then re enter the free text Description 261 Reason for Visit 262 Toggles between Show Patient Words and Hide Patient Words To document reason for visit using patie
417. s change when data are refreshed 13 Appointment time columns gt Time Appointment time scheduled gt Check in Time patient arrived gt Started Time patient was taken to exam room gt Check out Time patient checks out Other appointment information gt Labs Displays Yes or No to indicate if labs were ordered gt Patient Event Displays name and phone number of patient or event 15 Appointments 16 gt Caregiver Displays caregiver scheduled to see patient gt Location Displays location where patient scheduled to be seen gt Comments Displays reason for patient visit or description of event if time was blocked Office manager In Office Manager the bar for the current day s appointments is color coded based on the status of each Appointment colors Office Manager and preview pane gt Black Appointment is scheduled patient has not yet checked in gt Green Patient has checked in gt Red Appointment has started gt Purple Patient has checked out gt Gray Time is blocked Entering appointment status times To enter the current time and change the appointment status select the appointment and do one of the following gt Right click the appointment and click either Check In Start or Check Out or gt Onthe secondary toolbar click Appointment and then either Check In Start or Check Out NOTES Clicking Start when no Check In time is present enters the current
418. s list from the menu bar select Office gt Lab Results or on the toolbar or left pane click Lab Results and search for the patient and results Caregiver Manager System Dates The past 3 months El Patient cal Patients all status ordered Abnormals Only Sort Newest to Oldest gt Click the Caregiver down arrow to select A Grantors gt or the caregiver who ordered the lab test gt At Patient click Use Current Chart or click the search button I to search for a specific patient or select All Patients gt Click the Dates search button l to set a date range for the labs you need to view 2 Chart Functions NOTE Selecting Specific dates enables the Specific Dates fields Click the down arrows to select the specific date or range of dates to view gt Click the Status down arrow and select from Ordered Pending Needs Review Reviewed or All NOTE You cannot select all statuses if All Patients is selected gt Click the Sort down arrow and select Oldest to Newest Newest to Oldest or Alphabetical gt To view only labs that include abnormal test results click to select the Abnormals Only checkbox Annotating lab results during review 1 In HealthMatics EMR access Review Labs see Reviewing lab results on page 178 for instructions Lab Results vr Eychart Tasks Messages cm Z3 Trite 5 amer uersum OOO oz men emuen 7000
419. s to select number between 15 and 50 127 Options 8 Click the Preview down arrow to view the customized list followed by dotted lines and the remaining items 9 Click OK to save the selections and exit or select other items to set additional defaults To sort or delete my short lists Using the Clinical Customization Module each practice creates shorts lists to assist with documentation In Reason for Visit History and Assessment Plan each caregiver can designate the short lists used most often as My Short Lists In Caregiver Options each caregiver can customize the order in which My Short Lists appear or delete them 1 From the HealthMatics EMR menu bar select Options gt Edit Options gt My Short Lists P Caregiver Options for Manager System 0 Ed My Short Lists v Short List Options Quick Lists Types m Patient Manager Assessment and Plan gt Lab Results Short List aR ee lone Wisik FP Master A amp P Adult Sick Visit em Review of Systems IM Master A amp F Sick visit EE Vitals z Physical Exam T x Assessment and Plan iT D Electronic Prescriptions Il Sign Off l Title Bar iL History A Lists amp l z at r3 cm 2 Click the Types down arrow and select the type of short lists to display in the box below 3 Inthe Short List box select items and click icons to rearrange the list Make Default Click to make the item the default P Move to Top Clic
420. sage deletes from your desktop ePrescribe automatically and a note is placed in the patient s chart see eRefill Requests on page 55 27 Inbox a NND Documents Review the document and Approve it which files it in the chart or Reject it which returns it to the transcriber or scanner The message deletes from your inbox automatically see Approving or rejecting documents on page 71 A Action Items Take action on the item click Delete and Yes to confirm see Responding to action items on page 79 Received Charts Click Pull Chart and Yes to confirm see Received Charts on page 80 Gh Reports Take action on the item if necessary click Delete and Yes to confirm refer to the Reporting Module manual for additional information Viewing other caregivers inboxes IF other caregivers have granted you access to their inboxes you can view their inboxes from your desktop see Editing grants on page 129 1 On the toolbar or left pane of the HealthMatics EMR desktop click 4 Inbox 2 Click the Caregiver down arrow and select a caregiver 28 1 Office Functions Result Notifications Result Notifications are system generated messages sent to you when lab procedure or other results are available in the patient s chart and awaiting your review For general instructions for using HealthMatics EMR windows see Windows Panes and Other Tools on page 8 Viewing notification messages and results 1 To
421. select the patient or the group respectively and press Delete on your keyboard or click Delete Merge Entry The removed patient or group of patients return to the Patient Search box on the left Merge To merge the charts in each Merge Group do the following e Verify that all boxes to the left of each patient and group that you wish to merge are checked 2 Chart Functions e Press Ctrl M on your keyboard or click Merge on the toolbar gt Amessage displays the progress of the merge and then closes gt Green checks display in front of the charts that have been merged into the target charts in each group 7 To close Patient Merge click the X in the upper right corner Using the merge queue IF you have the HealthMatics Ntierprise Practice Management System when you inactivate a duplicate patient chart in Ntierprise the system sends a message to the Merge Queue in HealthMatics EMR Messages in this queue list the date and time the chart was inactivated in Ntierprise A caregiver or system administrator with the appropriate security can then review the face sheets and demographics of the duplicate patient charts that are queued for possible merging and either approve or reject the merge 1 From the HealthMatics EMR menu bar select Tools Patient Merge to display queued messages from your PMS if any P Patient Merge Merge Queue Manual Merge Merge History Approve x Reject Queued Pati
422. set date range 2 Double click a requisition to print see Printing requisitions on page 226 227 Lab Order Entry 228 To resend requisitions You can resend requisitions that had errors as well as those previously transmitted successfully 1 Access Requisitions see To access requisitions on page 227 2 Select the requisition to resend then from the secondary toolbar click f NOTE A warning message displays if the Interface is not enabled To print labels 1 Access Requisitions see To access requisitions on page 227 2 From the secondary toolbar click E Print Labels Requisition ID fooozs Patient Fred Finley Printer Labels E cm 3 At Printer select a printer you use for labels 4 At Labels use the spin buttons to indicate how many labels you need 5 Click OK or Cancel to leave the box without printing labels NOTES Once you select a printer and click OK the printer defaults on subsequent returns to this screen If you change workstations the system maintains the same default printer Consequently if the printer is not valid for your new workstation you must pick a different printer The number of labels always defaults to 2 Priority and Ordered By fields print on barcode labels Processing requisition batches Use Batch Processing to send electronic requisitions in batches and to print batch manifests packing lists NOTE In order to use batch processing
423. sification for the selected diagnosis 5 Fill in other fields as needed to further describe the diagnosis then click OK Creating lab requisitions from assessment plan If you collect lab samples you do not have to go to Lab Order Entry to create requisitions and add collection data Instead you can do this dynamically from Assessment Plan 1 Open a patient chart and from the left pane or the toolbar click A P Assessment Plan 2 Click either Short Lists tab or the Search tab and order a lab test 3 In the preview lower pane select the test and do one of the following e Double click it or Click g or e Highlight it and press F2 or 300 e Right click it and select Edit 3 Patient Contact Functions Properes Name cec amp MANUAL DIFF 85022 Notification Routine Requisition Id El ogam yela 4 Click the Requisition id search button Create Requisition Name r Fredin Insurance D feaz BirthDate 7 24 1984 Plan Type Private Insurance ttt ssn 230 30 3131 Gender Mae Worker s Comp E METRUM E Pefomngtab emme 3559206 4 57PM Bil Type el Drawn By Manager System Location Heakhmatks l t amp Ordering Caregiver Manager System Specimens P H T Fasting DISCS SORS Manager System T Priority Routine S 7 Account Number ha Comments
424. st for the specified medical condition Frequency Medicare does not pay due to the time interval since the last test Experimental Medicare does not pay due to the experimental research nature of the test Click to select box indicating patient signed an ABN for the test s ordered 4 Click OK to create the requisition To enter specimen collection information When creating or editing a requisition if specimen collection prompts were designated for any of the tests included Source Gyn Cytology AFP or Blood Lead tests the appropriate Lab Specimen dialog box automatically displays See Lab Order Entry in HealthMatics EMR Clinical Customization manual for detailed information Four example Lab Specimen screens follow below 218 2 Chart Functions NOTE The specimen collection screens display only if an external code with the appropriate Lab Specimen Collection Prompt was designated for one or more lab tests on the requisition Specimen Collection Prompt Source screen Patient Fred Finley Test Name ISOLAT FUNGI CULTURE OTHR 87102 Collected 4 24 2006 2 41 PM sue x7 se a Specimen Requirements and Special Handling Instruction Comments m x em 1 At Source Site and Volume for the specimen enter appropriate information 2 At Specimen Requirements and Special Handling Instructions view any information given 3 At Comments enter any required i
425. t Date 4 20 2006 frestera Reason Ps End Date Le BI Notes rDrugInteractions 34 BoM Y Bla Brey The Medi Sp4n SOL Interaction inter action checking un pm pain and fever gt Patient 3yearoldmale Weight 27 19 b 12 33 kg as of 9 27 2004 Cancel e Details tab Enter or change ordering details if needed e Prescription tab Click to select a template and print fax or transmit if you have these functions the prescription immediately e Education tab Click to print drug information for the patient e Patient allergies tab Click to display patient allergies and manifestations NOTE If no allergies are listed in History for the patient then the Patient Allergy tab does not display 50 1 Office Functions Click OK to return to the Refill Request screen 3 Request Approve A Approve wiChanges 3 Reject f Output All X Amoxicillin 250M Tablet Chewable 1 Chew Tab PO BID 20 Chew Tab Mo Refill 9 days st v Augmentin 600 125 Tablet 1 PO Ma Refill Ordered v Fackrel 100M For Solution 1 For Solution Injection Ref x1 4 07 2005 Ordered NOTE Refill requests remain in the caregiver s inbox until approved rejected sent to output and either the caregiver or Rx manager clicks Save to Chart 6 Process the refill request by d
426. t Options Review of Systems Past Encounter Count 3 Select an encounter from the list and click Preview to preview the values or Apply to apply the values to the current encounter see Documenting ROS using templates on page 278 for details 4 Make changes to the values as needed based on your review of patient systems in the current encounter 280 3 Patient Contact Functions Documenting review of systems from the beginning 1 Open a patient chart and from the left pane or the toolbar click Review of Systems 2 Inthe Review of Systems pane select a system to review AE S Cunert Encounter Review al Systems ra ny ee ie p Home m uiExpand A Collapse All ga Review of Systems 75 General Templates CARDIAC ROS anny preview a E Skin E HEENT El Respiratory Wy Neck Chromic Cough 4 Respiratory Eh Cough MC EAM Decrease Exercise Tolerance 16 Cardiovascular c Gastrointestinal JE Male Genitourinary X Dic Breathing 7 Musculoskeletal Faban reports occanou druty in reatu 2 Neurological t Psychiatric r Endocrine lt E Hematology Respiratory MM Respiratory Frezea Cough Mor Pregent D ficuley Breathing Patent raporte occasio acuity in baai 3 In the documentation pane on the right document details by clicking the icons as described in the table below g Present Indicates the item is present UN Not present Indicates the item is not present Indi
427. t an item and press F2 or click 4 Edit to display Auto Replace Text e At To edit the entry as needed e Click OK to return to Auto Replace NOTE The SQL database is not case sensitive so it sees HL7 and HI7 as the same This helps prevent duplication Delete To delete Auto Replace items in Auto Replace select an item and press Delete on your key pad or click Delete and Yes to confirm 133 Options 5 Copy To copy auto replace entries from other users in Auto Replace click a Copy to display other caregivers entries in Copy Auto Replace Text Copy Auto Replace Text Ea Select Ehe texkisi khak you want to copy Created b a cardiovascular System Manager Patient presents For Follow up v System Manager the System Manager Injury due to accident an System Manager ane gt Select the entry you want to copy and click OK to display the entry in Auto Replace 6 Click OK to close Auto Replace 134 1 Office Functions Internal Transcription Use the Input Manager to transcribe Voice notes recorded throughout the contact screens in HealthMatics EMR 1 From the HealthMatics EMR menu bar select Launch gt Input Manager 2 Inthe left pane select Internal Transcriptions Internal Transcriptions oa fP Dictated By GPriter S Patient a Dates Transcribed By Manager System Status Dictation T Patient aT w I Td Transcribed
428. t face sheet defaults 0 0 ee eens 114 To set patient manager defaults 1 0 0 eens 116 TO set results detaulls 3 123a ord EE Ned Law ER e oaa N Beebe ea Be 117 To set reason for visit defaults nannaa aaa 118 To set review of systems and physical exam defaults liliis 119 TO sebvitals derallliS 222 430 chest a Dec dea ghey at a a edd np ec See aes 121 To set assessment and plan defaults 2 0 0 00 eee 122 To set electronic prescription defaults lille 123 To set sign off defaults lllllllelllele ne 124 To cusiomize the tile Dal ss oteta uo do Ea ee ea de est Gm er Be m aer Tbe eoa 125 TO Set history detaulls ue accom Ge gs wien RU OX uides SR Sole d Roe Enc s 126 To customize QUICK MISTS ds ur hr tad ate pop tee dc adag scd e etn ow qe 127 To sort or delete my short lists x22 dud ver ERO RE edu pn Ee Eg Soe 128 EGUNGO AM Oege ieee Si eld dedit dd eet dh Rea o d web ete Sudden duit dh ees 129 Editi OUIDULOCIAUNS c ac turc oig t eU x opto o EU HOD bays eee ger n aes 130 Editing defaultlocations llle III 131 Ediling altoTepldce teh d 33 ir 9E ht de io teed it dede UHR at ead os 131 Internal Transcription s dus duda de ELE e er bine T x RERPEEE E ERE TE 135 Practice Management System Interface LL 138 2 Chan FUDCHOILIS 245 sete acte nate Shwe wea ied ae ea ee 139 Palle Chan S mu E TTE TCI TT ICLT IST eee eee Oe eae
429. t internal voice note transcriptions 0 00 eee ee 73 To approve or reject scanned documents a anaoa 74 Viewing scanned documents from face sheets 00 0c e eee eee 76 ACUON NEMS 2s ten mm EER twa eee ss Soe ee ee en eases Uae awe Eua S en 77 Creating action tems erista cid iiidid oi ie iia 6056944444 0184804448 77 Viewing action Items 52m ud 5 et cme 70 Dp de E a eR 2e tede Xa dea e e 78 Responding to action items 0 0 aaae eee eee 79 aid CAS ceirar card eae a acne ae nel EDITED 80 REDONS 22 0552 ncntee tome Meee es eee ode ae roa EA 82 Processing report messages 1 ee eens 82 PeMOrMING mail Merges o a aderunt emer ERE EP an EPA Cet ed ws a3 Internet from Inside HealthMatics EMR LLe e 84 Outlook InDOX cece use ade bed wea ORs se EM M dar dq dixe E BE 85 Creating Outlook emails inthe EMR 0 ees 85 Emailing H amp P reports from face sheetS 2 0 2 0 ees 86 OUIBDX vs cs ae tee ey a ee ee ee Pe oe EE 88 zril ee p 89 Processing refill requests in batch refill llle 89 Viewing refill documentation on face sheets 0000 cee ees 90 Output QUOUE 2 554 ocio as deba eub betieetaew eee cede Ghee 92 Viewing documents from the output queue 1 ee 92 Adding electronic signatures from output queue 2 ee ee 94 Printing from the output QUEUE 1 es 94 Faxing from the o
430. t reason for visit using the master list on page 260 e To document reason for visit using free text on page 261 To enter complaint details select the complaint in the Exams Complaints list and do one of the following Complaint Note 3 Patient Contact Functions e Press F2 on your keyboard or e Double click the item or Click g Describe selected item or e Right click and select Describe Lomplaint Details Chest pain C Characteristics Onset Duration sudden Pattern B gradual Severity Se Characterized As Location ES Radiation Detail note Precipitated Bv Aggravated Bv Relieved Bv Associated Features F Y Thema iaae Crash tobias The onset of the pain has been gradual Patient states that the pain feels like a gradual tightening around the chest ij Note e 4 Highlight a Characteristic for the complaint and in the right pane select the detail s that describes tt 5 After documenting the detail s for one characteristic click another Characteristic for the complaint and continue documenting Values are saved automatically 6 Click OK to return to Reason for Visit NOTES Undoing To undo or remove a detail while documenting click the check box again to deselect it The check box grays out and the corresponding text is removed from the documentation Numbers If you document Duration or any other characterist
431. t requisitions that have been created but not yet sent NOTE Click E Move Item In to place Requisitions in a drop down menu under Lab Order Entry if desired as Result Notifications List result notifications sent to you for review Result Summaries Access the Result Summaries for the current patient v Review of Systems Access the Review of Systems screen for the current encounter Send List items that you can create and send Web Message Refill Request Patient Message Mail Message or Action Item NOTE Click Move Item In to place message types in a drop down menu under Send if desired 112 1 Office Functions Create a new action item to send to yourself or to another caregiver Send Action Item NOTE Click Move Item In to place Send Action Item in a drop down menu under Send if desired Send Chart Send the current chart displayed on the title bar to another caregiver Send Mail Message Create a new mail message to send to one or more caregivers NOTE Click E Move Item In to place Send Mail Message in a drop down menu under Send if desired Send Patient Create a new patient message to send to another Message caregiver NOTE Click E Move Item In to place Send Patient Message in a drop down menu under Send if desired Send Refill Request Create a new refill request to send to an approving caregiver NOTE Click E gt Move Item In to place Send Refill Request in
432. tails see the HealthMatics EMR Output Manager manual 1 From the HealthMatics EMR menu click the Print drop down arrow 2 From All Templates gt Patient Correspondence click the version of the Antepartum Record to print You can also customize to make these templates display under 3 Patient Contact Functions the Site Location or My Templates sections aj Daily Schedule Site Templates Location Caregivers Print Caregiver Schedule Print Location Schedule Print All Templates Forms and Letters d H amp P Reports k Internal Documents d Lab Orders j Lab Requisitions k k Landscape Documents Office Correspondence see Antepartum Record by Date Prompt Patient Handouts k Antepartum Record Detailed by Date f lt Prompt gt NOTES When you select the Antepartum template the application prompts for a date and provides two radio button choices Today and Specific date before printing the Pregnancy Record The Today date default subtracts 280 days from today s date Items are pulled to the record based on this time frame The date is not diagnosis specific but date driven f you enter a Specific date this should be the EDD date the application counts back 280 days from the date and includes all test procedure results within that date range Output Manager Parameters Date electDate or EDD date Today 12 08 2005 l2je 2005 Today f
433. tal Status General Appearance es Orientation eq Neurological Anatomy 9 Build amp Nutrition es Posture 3 Hydration nS oce I i Skin General cm imd Mental Status Alert 4ooears nervous agtalec Hydration Dehydrated r Eye ez Meck Skin o Chest and Lung Exam Lesions Lesion second typek Size 1 5 mm Height x 5 mm Width S eh p sei I9 9l cz Breast i E LI Click the Templates down arrow and select one from the list that appears Click Preview or Apply to apply the values to the current encounter without previewing them 8 Template Preview on General well Adult Male Under SOPE General Mental Status Alert General Appearance Cooperative Gait Normal Hydration Well hydrated Voice Normal NOTE In the Preview pane you can click the Template down arrow and preview templates until you find the one most appropriate then click Apply 4 Use one of the following methods to make changes to the template 284 3 Patient Contact Functions e Click as needed or the hyperlinks in the documentation pane to edit items examined during the patient visit e Make changes by selecting and opening the bolded documented systems items and making alternative selections as needed in the upper documentation pane to reflect the patient s current condition e Click the hyperlink in the current encounter documentation pane to navigate directly to the item you
434. tems cannot be added to a graph Blood Pressure systolic 49 l aD Blood Pressure Systolic Diastolic Jp Blood Pressure Disstolic C external hemorrhesds C lacerated perianal inflammation C perirectal abscess C pilonidal cyst Weight BP Blood Pressure Diastolic fe l Skting Left Ann Standard aS 2004 Cr SgBstgscssu Sr25 2004 1227 200 Blood Prezzure Syztolic A Blond Prezsure Diastobc 8 To display data point details click the data point 204 2 Chart Functions 9 To print from the HealthMatics EMR toolbar click amp then Results Summary Select the print options Print Settings Printer Hame es NETprint2 on rprintl Properties Status Ready Type HP LaserJet 1100 M5 Where T5005 Comment Orientation Portrait C Landscape FY Punt Spreadsheet F Print Graphs ze Check All e UncheckAl 10 Click to return to the patient Face Sheet or click Back to return to the previous screen NOTES Graph title names display above each graph A legend displays at the bottom of each graph If more than one graph is created scroll down to see additional graphs Each data element is color coded and indicated by a different shape To view specific information about a particular data point click the point to see extended result information Click again to hide the data Only graph elements that contain data display Graphs save aut
435. ter alpha or numeric characters to search for the revised diagnosis and click Search 4 n Search Results select the correct diagnosis and click OK 5 Inthe Problem dialog box click OK again To see the problem history revision double click the item in the Problems pane of the face sheet P Problem Explorer Oy x Problems All Newest to oldest Revision History Newest to Oldest di PUERPERIUM UNSPECIFIED 45 TO EPISODE OF CARE OR MOT APPLICABLE 542 10 1 Unspecified Diagnosis To print problems 1 Open a patient chart and in the Problems pane click View Revision History to display Problem Explorer 2 Inthe left pane select a folder or problem and in the right pane click amp Print e List To print a problem list select a folder Active Inactive or Resolved e History To print the history of a specific problem select the specific problem 150 2 Chart Functions Viewing and revising history from face sheets To view history 1 Open a patient chart and in the History pane click View Revision History to display History Explorer n History Explorer oy x Revision His Newest Eo Oldest History Common Ni Newest to oldest Mo Known Allergies Recorded GZ 0S Z006 09 24 AM by Ferry Manning MD Ove Viet Sulfa Drugs F Recorded OZ 09 7006 09 24 AM by Terry Manning MD Office Hint Hj Breast Cancer Maternal Grandmother is Essential Hypertension
436. thMatics EMR the email view displays messages if any in your Outlook Inbox Outlook Inbox dn r1 G Open Pe Reply PH Reply All S Forward A Save to Chart View Inbox Received v Manning Terry H amp P Report Mr Fred Finley 3 5 2 422006 1 23 PM bd Manning Terry Referral 4 2 2006 12 03 PM P4 Manning Terry Chart Attachment Please revi 4 2 2006 11 58 AM bd Manning Terry Your meeting has been cancelled 4 2 2006 11 58 4M bd Manning Terry Procedure results available 4 2 2006 11 36 AM bJ Manning Terry Test results 4 2 2006 11 34 4M Double click an item to view it or select it and click Open NOTES To view a list of Outlook emails that you sent click the View down arrow and select Sent Items The Delete Reply Reply All Forward functions are identical to Microsoft Outlook functions Creating Outlook emails in the EMR 1 2 From the Outlook Inbox on the secondary toolbar click np New Mail Message E amp Referral to Dr Smith Message HTML Fle Edt wew Insert Format Tools Actions Hep pe qu ek miad i vo Nermal Arial 0 A B 7 U ES H f EIE To Manning Terry subject Remato sehn SSCS message text gt In the Message dialog box select the recipient and subject enter your message text and click Send A Confirm message asks if you want to save the message to a patient s chart e Click No if the message does not nee
437. the A P screen their name defaults as the Ordering Caregiver To assure that the result notification message goes to the appropriate caregiver on the Create Requisition screen click the Ordering Caregiver down arrow and select the appropriate caregiver who should receive the Result Notification see Creating lab requisitions from assessment plan on page 300 cc caregiver IF the ordering caregiver information is not available then the system looks for a cc caregiver which is designated by the laboratory Example An EMR physician refers a patient to a specialist who orders the test and indicates that the results should also go to the EMR physician who referred the patient 1 Office Functions 3 Default IF no information is available for either the ordering caregiver or a cc caregiver the result notification message goes to the person designated by the practice to be the Default caregiver for message notifications This default caregiver can be the system administrator or any other caregiver that the practice assigns when the interface is set up NOTE The designation Attending Caregiver is not used to determine message notifications Typically Attending Caregiver defaults to the person placing the order on the Create Requisition screen Blocking result notifications You can block result notification messages from your inbox by doing the following 1 Log into the Administration Module and in the left pane sele
438. the imported photo Entering voice messages in notes Throughout the patient contact screens in HealthMatics EMR you can enter voice notes up to 5 minutes in length by clicking any Note button and then selecting the Voice tab to display the voice recorder Reason for Visit Note Text Image Yoke The field displays the recording time elapsed once you click the record button In addition a moving black bar proceeds across the field to the end as the allowed 5 minutes lapses 349 Notes NOTE In order to use the Voice tab the application must be running on a full client and your workstation must have a sound card 1 With a patient chart open in HealthMatics EMR locate a Note with a voice tab Reason for Visit Click l mete on the toolbar in the middle of the screen then click the Voice tab v Review of Systems For a general note in the right pane next to Review of Systems click 1 then click the Voice tab History Click Note near the top of the screen then click the Voice tab M Vitals Click Note near the top of the screen and then click the Voice tab Physical Exam For a general note click after Physical Exam in the right pane and then click the Voice tab Assessment Plan Click Note near the middle of the screen and then click the Voice tab Record using the following recording buttons Go to the beginning of the recording mee ES J m Pecos 0 08 2 Click
439. time in both Check In and Started fields Clicking Check Out when no Check In or Started times are present enters the current time in all three fields To remove a time entered in error highlight the appointment click 4 Edit Appointment and Clear Editing appointments To edit an appointment status time after it has been entered or to change other appointment information select the appointment and do one of the following to display the Appointment dialog gt Press F2 on the keyboard or gt Onthe secondary toolbar click 4 Edit Office manager Appointments remain in the Office Manager stack unless rescheduled from your PMS or checked out When you enter a check out time either in HealthMatics or in your PMS the following things happen gt The check out time appears in the Check Out column gt The appointment item turns purple gt The appointment stack number reduces by one Viewing appointments by location Click the Location down arrow and select the location to view 1 Office Functions e Viewing appointments by date Click the Date down arrow to display a calendar and select the date to view or click 1 or 1 to view the day previous or the day after the selected date Click Today to return to the current date e Use secondary toolbar icons to do any of the following Add Block e Add an appointment Ins or Block time IF you do not have a Practice Management System Ctrl Ins ru Delete D
440. to action items 1 From the status bar or left pane of the HealthMatics EMR desktop or Office Manager click 34 Action Items 2 Openan item see Viewing action Items on page 79 P Action Item 3 C3 Delete Complete Oe Reply QE Forward Cl Print From Manager System To Manager System Date Time 1 11 2006 1 39 PM Subject Call about resulks Cu Text Image Voice Import eminder for patient Mr Fred Finley m 3 Click the toolbar icons to do any of the following Delete Delete the selected message in the inbox NOTE A system generated action Item resulting from a patient reminder remains as a permanent entry in the patient s chart after it is deleted from your inbox see also Heminders on page 211 Complete Mark the selected action item Complete but leave it in the inbox grayed out with a line through it Reply to Sender Send a message back to the person who sent the action item Forward Message Forward the action item to another caregiver Print the action item message 79 Received Charts 80 Received Charts Received Charts are system generated messages accompanying charts that other Caregivers send to you by clicking Send Chart Charts may be for scheduled patients waiting in exam rooms or for charts that require your review such as exams performed by Physician Assistants or other caregivers For general instructions for using HealthMatics EMR windows see Wind
441. to display Authored Text ds Office Procedure Properties MEPPROCEDLURE STOP COUMADIN 6 DAYS PRIOR X daomSBlrluESI GG Stop taking Coumadin 6 days prior to procedure al Ej Print m Mark Completed o Cancel 4 Click Mark Completed and then OK 5 Repeat steps for other patient authored text templates to default them to Completed in Assessment Plan Displaying quick assessment plans Add a quick assessment and plan from any contact window at any time during an encounter without leaving the window you are documenting 1 Open a patient chart and on the toolbar click Quick Assessment Plan to display Edit Assessment Plan on top of other contact windows such as History 7m Assessment Plan Patient Problem List Patient Medications My Short Lists Short Lists Search Free Text Diagnosis dhire dO view A inactivate cipincude Al EHEJ Atie 0 MEM HEALTH MAIMTEMATHC E EXAMINATION v70 0 MALE 18 39 TEARS HIGH RISE El E ACUTE PHAR YHGITIS 462 E ABNORMAL SERUM ENZYME LEVELS OTHER NONSPECIFIC 790 5 Social Hx Ho Caf Peine Lisa cad fp Db fees Cote DEO A teractions P Isabel D ABN check amp 5 ACUTE PHARYNGITIS 462 e CBC amp PLATELETS AUTO 85027 Routine sang eva fepe S 321 Pregnancy Record 322 2 Add assessment and plan data as you would with the full
442. to open when you add a Tithe Bar diagnosis Ea the current A amp P From a Data Source Search i History Lists Orders p Quick Lists When placing orders default the Ordered Far Field to i My Short Lists m eneral Default Tab Patient Problem List ced 2 Notes Caretakers sometimes enter notes in the Comments section of the Assessment Plan for patients with managed diseases On succeeding visits when pulling a problem from the Patient Problem List you may prefer to see previous comments or you may prefer the Comments field to be blank ready for new comments e Yes Comments if any from previous encounter are erased and the Comments field is blank ready for new comments e No Comments if any about the existing problem display and you can add the date and new comments at the end 3 Medications When selecting medications In Assessment Plan e Yes Medication dialog displays automatically for entering medication details when adding a medication to the current encounter from either a Data Source or Short List NOTE Even if Yes is selected the Medication dialog will not open automatically if you select a protocol In this case you will need to double click or click Edit to enter medication details e No Double click the medication or select it and click Edit after adding it to the current encounter to enter medication details 4 Diagnoses When selecting diagnoses from a Data Source search in
443. toolbar using icons 277 reviews conducting performance 360 S save to chart refill requests 49 save to log 95 scanned documents charts viewing in 155 face sheets viewing from 76 not reviewed in patient manager 174 reviewing approving 74 schedules entering appointments in EMR 17 printing daily 20 status bar review from 5 scroll bars using 9 search diagnoses 299 history documenting 254 patients 14 140 security prescriptions refaxing reprinting 391 privacy levels on patient charts 163 send toolbar icon 112 separator toolbar icon 110 service level adjusting in E amp M calculator 373 service E amp M calculator default setting 124 sessions 3 short lists history documenting 252 in assessment plan 294 sign off charts 364 defaults setting 124 from H amp P report 356 signatures include signature bitmap default 124 sizes documenting 288 SNOWMED database 238 definition 295 Social Security number entering 163 Social Security number field format 140 source prompt screen 219 specimen collection entering information 218 promt screens 219 406 specimens collection information entering 218 collection prompts AFP 221 blood lead 222 spell check configuring 12 using 11 spreadsheets viewing esult summaries 202 status bar icon definitions 5 inbox filters description of 5 synchronization running immediately 67 System information where to find 4 T telephone numbers entering 10 template packs creating 3
444. tput Manager Data elements Similar to tokens in Forms and Letters these data elements extract data from the EMR Layout The page setup for a template margins landscape vs portrait page orientation Output categories A filing system for templates Printer and Layout defaults should be assigned to each category Output defaults Screen within the Administration Module where printer and layout assignments are made NOTE This screen is also available within the Clinical Module but default assignments made here are only for the current user Output settings Screens in the Administration Module where you define which documents display from the printer icon drop down list by Site Location or Caregiver for each EMR screen and where Encounter Packs are created Encounter pack Group of documents that will generate at Signoff These can be associated with and then filtered by Encounter type 377 Templates 378 Templates From the toolbar in any view in the Clinical Module clicking J Print displays a list of all default templates selected for the view in the Administration Module g ala aala w Print Entire Chart Site Templates are templates made available as he Templates defaults to all locations within the practice Encounter Procedure Orders Print Encounter Procedure Orders Fax Encounter Lab Orders Print Encounter Lab Orders Fax Patient Active Medication List Print Encounter H a
445. trees both display systems in a ranked order Folders that contain documentation display bolded If a detail within the folder is marked significant the icon turns to a red exclamation point Physical Exam A Physical E am j General Mental Status lt General Appearance DR Orientation r Neurological Anatomy S Build amp Nutrition Blue i indicates information was documented for this encounter Ge Posture Red exclamation point indicates there is a mot oH o finding s for that characteristic which is Hydration significant ee Voice amp 2 Skin J amp HEENT e To expand a folder in PE and show the contents in the documentation pane to the right click the folder e To expand a folder click e To collapse a folder click To navigate using the map tab 1 Open a patient chart and from the left pane or the toolbar click ROS or amp PE 2 Inthe ROS navigation pane click Map to navigate through the exam using an outline format Selected My PE Lists Search The navigation pane changes from the tree view to a map 1 _ Black frame Indicates the area currently visible in the documentation pane to the right Green Indicates characteristics with documentation Red Indicates characteristics with documentation marked significant ae Target box Displays the item the cursor points to So Posture 267 ROS
446. ts all active medications for the patient 1 Access the Pregnancy Record see Accessing the pregnancy record on page 322 2 To document the current encounter select the current date in the top pane and double click or click g then click tabs as needed to document the visit see Editing pregnancy record screens on page 326 EN Preqnancy Record for Mrs Mary Jo Young Procedure Status aie 1 2006 Signed Of endre Ordered URINALYSIS 81005 i3 Weeks amp Days Open Ordered Prenatal Record Active Problems Active Medications Fetal Fetal Fetal PTL Cervical Date Weeks Gest Furdal Ht Pres Heart Mvmt 575 Exam BP Weight Urine Edema Next Appt Initials DIL GUC Hands 03 16 2006 3 Weeks EFF i ALB Feces T wr 2 andis Da Lo EFF Eh ALB Egg 13 weeks E DIL WT GUL Handa nayoaone 13 Week aT Exon Days EA am RE Bx Lominrenls Comments section includes each date if applicable NOTES CPT 59400 procedure can be reviewed and finalized from the Pregnancy Record in the same way as in the Procedure Results screen in the EMR Once the procedure is Final Heviewed status the procedure data in the Pregnancy Record is read only However other tabs not related to the procedure are still editable The CPT 59400 Procedure Entry Rule cannot be customized 325 Pregnancy Record 3 Click d to open the Prenatal Record in the Print Preview window
447. ts and cannot be deleted e Reminders can also be completed from the Action Items view see Responding to patient messages on page 40 213 Lab Order Entry Lab Order Entry Use Lab Order Entry to manage lab orders create requisitions and send lab orders for lab tests and panels from HealthMatics EMR If your lab supports bi directional interfacing you can generate lab requisition forms directly from HealthMatics EMR to external laboratories for processing If you purchased a lab interface you can electronically receive lab results from a lab directly into the patient chart Requisitions can contain one or many lab orders depending on laboratory preference You can create a requisition for all orders within an encounter or for just one lab test either on the A P screen or in Lab Order Entry You can define all items you need in your database to send or print requisitions electronically using Lab Order Entry Setup in the Clinical Customization Module The Clinical Customization Module stores all information needed to generate lab requisitions including practice information patient information and external lab ID codes that may be required by insurance carriers You can set up priority statuses for lab orders and define specimen containers sites and sources You can also create Selection Lists for easy entry of lab results See the HealthMatics EMR Clinical Customization manual for detailed Lab Order Entry setup information From L
448. ts to reflect the date the procedure was actually performed 1 With a patient chart open in HealthMatics EMR from the toolbar or left pane click or from the menu bar select Office gt Procedure Results 2 Accept the current patient or click the Patient search button B to search for and select the correct patient 3 Click the Status down arrow and select Ordered NOTE Performance dates cannot be changed once the procedure is marked Reviewed 4 Set the remaining filters Caregiver Dates Sort as needed to locate the patient with historical procedures entered 5 Click the in front of the name or click Expand All to display the procedures 6 Select a procedure and click Procedure Tasks gt Results Entry then click the Performance down arrow to display a calendar 7 Select a date from the calendar and set the time the procedure was performed then click Close On the patient face sheet the Order History details reflect the accurate Performed date NOTE You can change performance dates only on procedures not linked to an external source such as a Brentwood device 194 2 Chart Functions Additional Results The Additional Results folder contains orders other than labs or procedures such as referral letters and their responses and other authored text items Processing referrals Order referrals in Assessment Plan steps 1 4 on the graphic Hee DH bs ey 22S Patient Problem List Patient Dat
449. ty Acute Comments amp Em Gs y V Sh aa a OK Cancel 2 Forthe Details tab click down arrows or enter information to revise any of the following ee 2NNRN Details tab Diagnosis Displays the name and ICD 9 for the problem selected on the face sheet Click the Diagnosis search button to edit the ICD 9 for the diagnosis see To revise diagnoses from face sheets on page 150 Change the description for the problem if desired Classified As Click the down arrow to select a classification for the nature of the problem Examples Principal Established Admitting and so forth Onset Date Change the date on which the problem began If necessary enter the month day and year the problem began or click the calendar button to select the date when the problem began Click the down arrow to select Active Inactive Resolved Erroneous Entry or Undefined 148 2 Chart Functions ee ee Resolution Date Enter the date the problem resolved or click the ellipsis button to enter the date NOTE This field appears only when you select Resolved in the Status field Enter the month day and year Describe the problem type Acute Chronic or Undefined Comments Use conventional word processing tools or Auto Replace text to enter any general comments about the patient problem condition or progress Additional tab Significance Use the drop down list to describe the problem s significance with respe
450. u can double click the month day or year to highlight it and then type the correct date over the highlighted area or click the search B button to enter the date in a dialog box Date 3 1 2006 Today 1 i n Hal January February March 1 Year Click 2006 to display roll bars to change the year 2 Month Click _4_ Back or Forward to select a different month or click the name of the month to display a drop down menu of months 3 Day The current day is circled in red To select a different date click it 4 Click OK to save the date Sun Mon Te 5 6 iz 13 1 Apel i9 20 2 May eB 2r 2 June July August NOTE In a text field you can press F5 on your keyboard to insert the current date Entering phone numbers To enter a phone number do one of the following e Type the number in the field The system automatically formats a 7 or 10 digit number when you tab off of it Example 9191234567 becomes 919 123 4567 or 10 1 Office Functions e Click the ellipsis button l to display a quick entry box 1 Enter the area code without parentheses 55555 2323 EEC pgr 2 Enter the humpe without Ds or spaces 3 Enter an extension number if any Area Code Ess 4 Click OK Number 555 2323 A correctly formatted number displays in the Phone field Extension Phone S55 555 2323 Cancel Checking spelling HealthMatics EMR spell checker provides the ability to check spe
451. ual method for taking patient temperatures Undefined Oral Tympanic Rectal or Axillary Default respiration Pattern Click the down arrow to select the respiration settings pattern Default measurement Select usual notation for height and weight b oz in kg cm units or Ib oZ ft in NOTE If you select b oz ft in the in field in Vitals changes to two fields ft and in needed to record the data in that format Default blood pressure Select usual position location and size for blood pressure settings readings Default head Select the usual notation for measuring head circumference circumference settings Default waist settings Select the usual notation for measuring head circumference 3 Click OK to exit or select other options in the left pane to set additional defaults 121 Options To set assessment and plan defaults 1 From the HealthMatics EMR menu bar select Options gt Edit Options gt Assessment and Plan P Caregiver Options for Manager System Mii General Assessment and Plan i Desktop PU Toolbar Notes Face Sheet Da you want Ehe Comments Field to be cleared when you add an L Patient Manager existing problem to the current A amp P z Results Medications Do vou always want Ehe Medication Dialog to open when you add a medication to the current A amp P me assessment and Pla Electronic Prescriptions Diagnoses Sign Off Do you want Ehe Diagnosis Dialog
452. ucasian Wale The patientis a 41 year old Male Assessment amp Plan System Manage I T8 2006 TOT AM Unspecified Diagnosis Plans AEROSOUVAPOR INHALATIONS ADDED 94665 Routine EXCISE SKIN WEDGE INGROWN TOENAIL 11755 Routine 2 Chart Functions 3 From the Addendum Notes box at the top of the window click the H amp P section icon you want to insert notes into Addendum Note History ny Text Image SH X Eam o BY Ba This is the third time pt has presented vith thas complaint Enter the note then click OK The information displays as an Addendum Note in the appropriate section of the H amp P Report History Addendum Note priem Manager 5 28 2006 Tio ANTI This is the thard time pt has presented with this complaint In addition the office visit displays in purple font in the Encounters pane on the face sheet and an information symbol displays on the folder icon 1 24 2006 Office Visit System Manager Gp 1 17 2006 Office Visit Unspecified Diagnosis System Manager Viewing and revising medications from face sheets Use the Medication pane on the face sheet to view and update information about patient medications You can view history inactivate reactivate or discontinue medications from the Medication Explorer 1 2 Open a patient chart and from the left pane or the toolbar click E Face Sheet In the Medications pane double click an active m
453. uested display last in the list sorted alphabetically by name 45 Refill Requests 5 To send the refill request to the approving caregiver e Click the To down arrow and select the approving caregiver from the list NOTE The caregiver name defaults to the primary caregiver on the patient s Demographics screen as soon as you add a patient name e Select High Priority for refills that are urgent The refill request will display in red in the caregiver s inbox e Select Block one click Approve to cause the Medication dialog box to open automatically which forces the caregiver to review prescription details before approving the refill NOTE When deselected the caregiver can approve the refill by selecting message and clicking TA Approve on the secondary toolbar without opening the Medication dialog box to view details If Block one click Approve is selected the refill message on the desktop displays in italics e Add an optional message on any tab Text Image Voice and enter information e Click Send to send the refill request to the caregiver for approval NOTE The Save to Chart and Pull Chart buttons are for approving caregiver s use If you Click Pull Chart the Refill Request dialog box closes and the chart opens If you click Save to Chart before the refill has been approved a Warning displays telling you to approve or reject the request Viewing refill requests For general instructions for using HealthMatics
454. ur open encounters x Orders List all patients with orders that have not yet been placed on requisitions NOTE Click E Move Item In to place Orders in a drop down menu under Lab Order Entry if desired View items that you have sent that have not yet been read 111 Options Outlook Inbox Access your Outlook inbox IF your site uses Microsoft Outlook from within HealthMatics EMR Output Queue List all documents that you have printed faxed or transmitted Patient Manager Access the Patient Manager view of the current patient s health reminders and documents orders and refill requests awaiting your review Physical Exam Access the Physical Exam screen for the current encounter gi Print Output a document may include printing faxing or transmitting Pull Chart Open a chart for a patient F Quick Assessment Access the Assessment amp Plan screen for the current Plan encounter T Reason for Visit Access the Reason for Visit screen for the current encounter Received Charts List charts sent to you by other caregivers i Refill Requests List refill requests sent to you for approval d Reminders 0 List reminders on the current patient s chart Report Results List reports that have been enabled at your site along with the last time they have been run and the results Reports Access report results that have been sent to you for action Example Patients that need followup calls T Requisitions Lis
455. use most commonly when you are in a patient s chart Example The past 3 months Needs Review Oldest to Newest and name the quick filter Review When no chart is open on your desktop and you click amp the appropriate filters set by default Using quick filters NOTE For instructions for setting up quick filters see Creating quick filters on page 98 On any screen where you have set up quick filters to search lists of items using multiple criteria do the following 1 On the secondary toolbar click p Fiter S Filter E System Default All Locations All Caregivers All Patients All Dates All Requiring Action All Categories All Locations All Caregivers All Patients The Past Week All Statuses All Categories All Locations Terry Manning All Patients The Past Week All Requiring Action All Caregivers Oo M p Look at the descriptions of the filters and click the one you want to use to locate the item you need NOTE You can also click System Default at any time to return to the original filter settings Caregiver user logged in Patient All Patients Dates The past 6 months Status Ordered Sort Newest to Oldest 99 Worklogs 100 Worklogs In HealthMatics EMR use the worklog to meet HIPAA requirements for auditing and tracking chart contact and caregiver activity The worklog also captures failed logins where a valid Login Name was entered Uses for worklogs gt Revie
456. usly entered free text You can use one free text entry multiple times editing it as needed to reflect the current cond ition This prevents a long list of disconnected free text items from accumulating in the patient history list You can also enter multiple free text items as needed 1 Open a patient chart and from the left pane or the toolbar click amp History 2 t n the History folder tree select Immunization and the Previously Entered History ab aes we Previously Entered History Free Text Cupinclude cJpinclude Active Immunization Record Upto Date Not up to Dake Eg Active a Previously entered free text Pu Immunization Family Past Medical P Social Fal Travel Py Medication FJ Pregnancy Birth wm 2 it manag BI Immunization td Previously entered Free text 3 Add the free text item to the current encounter by doing one of the following Double click it or Select it and click Include or Right click it and select Include or Click and drag it to the preview lower pane 4 To edit the free text item select it in the preview lower pane and click ae Edit Selected Item or double click it Knowledge Term Previously entered free bext Include Ee Edked Previously entered free text 7 TEE ener Status Active M Comments amp Ba Ch oe Dp V Wh a 5 At Renamed as change the text of the ite
457. utput queue seleeeeee 94 SAVING WOOO FERRE EE a T TRO tak oan Weed El bee ele a 95 Exporting from output queue 1 eee eee 96 Viewing output queue action history 2 0 ee 96 Creating new output from the output queue n naana oaa es 97 QUICK FIIIGES cus crib acra x ER aie create ohne are ee eae eee ie in oar en 98 Creating GUCK NOIS cute eaae dne 6 od p eo hed que Ede eu eee 98 Setting user defaults for quick filters llle 98 JSO AUCK ilic CLR TP 99 WOIKIOQS 26 520 3E EVA Chie eben eee EEe a RE xS C142 EEG ES ERE 100 HealthMatics EMR Application Reference Manual Tracking chart contact using worklOgS 00 cee eee eee eee 100 Filler DV CaFOOIVOl amp nuez eases amp e RU DE oda Revere arene OM Auten eh to du Rn ead 101 Fiter DY Machine wc ERES 102 Fier DY Dalle p e P n 103 Using the worklog toolbar functions llle 103 Tracking patients during visits llle 104 Billing Reconciliation erum eden vee s U4 ete eee eee ees GERE EUR 105 Audit Open Encounters cu rais dex ur o ere nom el ie ee kn oe ea 6 cn 107 ODNONS tab ac E Oca deut doe ad ai ee ne Pera Oa Ae eee 108 Changing PasSwoOrdS s 3 ui aco ea RR RP aaa bata deae ewes cia e 108 EGUING ODOM S Scared epos dta hw ay ee luda St ee ea aaa dct a dot a Ae et 108 To Set desktop delallis s saa de hes Be eee o sab Cede o a idR d Gos 109 To customize your toolbar n naana aaaea eee eae 110 To se
458. vel that results when you click Calculate based on data documented and the items selected in the calculator History Problem focused Detailed Comprehensive NOTE History characteristics are mapped to HPI elements used in the calculation Reason for Visit ROS and Past Family and Social History Based on documentation in Vitals and Physical Exam MDM Medical Decision Making Based on diagnosis or Management Options the data reviewed and the risk associated with presenting problems Straight forward Low Moderate or High This shows in the H amp P Report Management Options 367 Evaluation amp Management Calculator Field checkbox Section Click to select items used to determine risk levels for the encounter Risk is based on a combination of your diagnosis codes and management options Data Risk Lab test s Populate directly from A P screen Independent visualization of lab test CPT medicine test s Refers to any diagnostic test in the 90000 range Populates when ordered in A P Independent visualization of CPT medicine test Radiology test s Populates when ordered in A P Independent visualization of radiology test Decision to obtain old Self explanatory records Decision to obtain Self explanatory information from someone other than patient Summary of old records Self explanatory Discussion with another Self explanatory health care provider discussion with MD Self expl
459. w Patient Manager lists all items awaiting review for a selected patient including results documents and transcriptions The Patient Manager view also lists pending messages refill requests and health maintenance and disease management reminders for the patient Patient Manager provides hyperlinks to screens that need review trends schedules orders or refill items To access this view with a patient chart open from the left pane select Patient Manager or click the Patient Manager bar in the lower left corner of the screen Sy Summary Patient Manager Face Sheet el Appointments Medications hie 03 24 2006 09 00 AM Terry Manning MD Refill Requests Open s Albuterol open E Flow Sheets e Amoxicilin Albuterol FA Vitamin B 6 Vitamin 4 Immunizations B 12 FA 8 A Open Chart Attachments otha ee Potent Me BiabResus S Modra fiis e Patient Message saved to Chart Open amp Lab Results nip e Patient Message saved to Chart Open e T 3 RESIN UPTAKE T3RU 84473 Review lt Additional Results e Patient called Open Trend x Result Summaries Transcriptions E EN Contact Mr Fred Finley Review S Procedure Results J Reason For Vist e CARDIOVASCULAR STRESS TEST 93016 Review Mr Fred Finley Review Il Mr Fred Finley Review E Review of Systems Mr Fred Finley Review Rejected Mr Fred Finley Review T C ons erme Labs Review Patient Educat
460. w and manage multiple caregivers patient workloads gt Determine which caregiver last saw a patient on a specified date gt Review the productivity of caregivers gt Track which machine a user logged into as well as which charts were accessed from a specific machine gt Track which contact screens were documented for a specific chart by a specific user gt Print a worklog report gt View encounter information from Appointments Generation The worklog is automatically generated and updated Manipulation Resize the columns or re order them by dragging and dropping the headings You can filter information using any of three methods Caregiver Use the Caregiver worklog to display a list of scheduled and unscheduled events that occur on a specified date for a particular caregiver including charts pulled and or reviewed Machine Use the Machine worklog to display all contact with patient charts made from a specific machine Patient Use the Patient worklog to display all contact made with an individual patient s chart for one date or all dates NOTE Assign the privilege to access worklogs in the Administration Module either by Caregiver or by Function Access Set Access to None or Read Only For instructions refer to the Administration Module manual Tracking chart contact using worklogs Contacts that did not have associated saved data display the message Chart reviewed without edits Contacts that d
461. w documents sent to you recently if you cannot wait until the screen refreshes itself automatically To set the Refresh default time see Io set desktop defaults on page 109 See also Viewing other caregivers inboxes on page 28 Approving or rejecting documents NOTE For information about transcribing external dictation refer to the Input Manager manual To approve or reject external transcriptions External transcription can be general or in the standard SOAP format 1 In the Documents view open an external transcription document see Viewing the list of documents on page 70 Send Transcription PSI OE Forward A Approve G Reject 7 Face Sheet Pull Chart Qf Print ig From Manager System To Manager System Subject Mr Fred Finley NOS HEARING LOSS NOS 389 a Transcription Subjective Objective Assessment Plan misc mom EAnB iuii iiusyXgea Comments o0 Y BH 71 Documents 72 Read the text if any on the Message tab Click the Document tab and check the identifying information in the top half of the Send Transcription screen revising if needed e Click the Patient search button to match the dictation with a different patient or if a patient chart is currently pulled on the desktop click Use Current Chart e Click the Attachment Type down arrow to correct the type of transcription e Click the Dictation Date search butt
462. w managed history items on the assessment plan screen Open a patient chart and from the left pane or the toolbar click A P Assessment Plan Assessment Plan Ds Patient Problem List Patient Medications My Short Lists Short Lists Search Free Text Diagnosis sg Include View Inactivate Mp Include Active Ela Active H E Coronary Artery Disease n i BENIGN HYPERTEMSIVE HEART DISEASE WITHOUT HEART FAILURE 402 10 Principal Diagnosis Managed items added in History display as child nodes indented under the parent entries History entries are expanded initially if any of the following are true e Medications The Strength or Status of the drug differs from the Assessment Plan entry Example The Assessment Plan medication has an Ordered status but the medication was marked Discontinued on the Hx screen or the strength was 500MG in Assessment Plan but the Hx entry was changed to 750MG NOTE Changes in Dose or Frequency do not trigger the node to be expanded initially e Diagnoses The Status was changed Example The Assessment Plan diagnosis is Active but it was marked Resolved in the History screen e History An item was marked Inactive Resolved or Erroneous in History on the Assessment Plan screen It displays the status after the caption Example Asthma Erroneous Entry NOTE You can add the Assessment Plan entry or the Hx entry to the current Assessment Plan encounter but not both When y
463. w of Systems System Manager T0 27 2005 1 25 PM General Aot resent Appetite Loss Fatigue Weight Gain gt 10lbs and Weight Loss gt 10fbs Gastrointeskinal Ao Prezen Constipation Diarrhea Difficulty Swallowing Nausea and Vomiting Male Genitourinary of Sresen Frequency Impotence Urgency and Urinating ak Might Musculoskeletal ot fresean Muscle Pain and Muscle Weakness depart ital Present Decreased Memory Dizziness Headaches Spinning Sensation Visual Changes and Weakness Psychiatric Aresen Anxiety and Depression Endocrine of Present Appetite Changes Cold Intolerance Excessive Thirst Excessive Urination Hair Changes Heat Intolerance and Libido Change F 353 H amp P Report 354 Viewing billing information 1 To view billing information based on the items documented click si or Sign Off Y Send Billing Information Ol X Template Pack office Visit Print Pack d v Encounter Procedure Orders z y Check Al v Encounter Lab Orders 1 Lincheck All vw Specialist Letter w Referral Letter wi Patient Febi akin x ASP Prescriptions Forms Letters Encounter type Click down arrow to select appropriate encounter type and billing status billable or non billable Billing level Click down arrow to select CPT code for the service level provided NOTE Billing level passes from the E amp M Calculator if used Billing modifier Click down arrow to select ap
464. want the patient s problems to sort by default Newest to Oldest Oldest to Newest Alphabetically or by Acuity History e Click the View drop down arrow to select the way you want the patient s history to display by default Full all eight categories Allergies Immunizations or Common allergies family past medical and social history e Click the Sort drop down arrow to select the way you want the patient s history to sort by default Newest to Oldest Oldest to Newest or Alphabetically Encounters e Click the View drop down arrow to select the way you want the patient s encounters to display by default By Date or By Type e Click the Sort drop down arrow to select the way you want the patient s encounters to sort by default Newest to Oldest or Oldest to Newest Medications e Click the View drop down arrow to select the way you want the patient s medications to display by default All Active Inactive or Discontinued e Click the Sort drop down arrow to select the way you want the patient s medications to sort by default Newest to Oldest or Oldest to Newest or Alphabetically Orders e Click the View drop down arrow to select the way you want the patient s orders to display by default A Pending Needs Review Reviewed or Ordered e Click the Sort drop down arrow to select the way you want the patient s orders to sort by default Newest to Oldest or Oldest to Newest Click OK to exit or select another ite
465. wing the medications list 3 Then click the Search tab to order a new prescription 63 eRefill Requests 4 64 Click the Data Source down arrow and select Medications Medi Span At Search Term type a few characters for your search select either Starts With or Contains and click Search In Search Results double click the medication you want to prescribe In the Medication dialog that opens enter details as needed and click the Prescription tab Click the Template down arrow and select a template for the prescription Details Prescription Education 3 Patient Allergies 2 Formularies Template uc RX Template v Use Signature Bitmap Password A HEALTH SYSTEMS WWW AA HERARLTHSYSTEIBS COM Famuly Prachce Clinic Cary NC 27511 Phone 919 555 0000 Fax Terry Manning MD DEA HCTM56789 License UPIN 321321 x Patient 41 year oldmale Weight 177 38 lb 80 46 ka as of 3 11 2006 Cancel NOTES If your system is not set up to send prescriptions electronically the ePrescribe button does not display f your system is set up to fax but not ePrescribe or if the caregiver is not able to use ePrescribe a Fax button displays instead If there is a problem sending the medication electronically you can fax it instead Select or enter other information on the screen as needed and click ePrescribe 1 Office Functions Enter your password and click OK to display Send Prescri
466. x editing 332 next appt editing 335 OB history editing 333 patient manager 174 pelvimetry editing 334 printing 336 review of systems editing 329 unsolicited lab results including 336 prescribing agents assigning 66 prescription properties using 51 prescriptions biometric authentication printing faxing 69 electronic overview 55 sending new 63 setting up 66 history viewing in A P 292 security for refaxing reprinting 391 transmitting electronically 306 viewing approving 46 preview pane in ROS PE using 271 previewing documents from any view 383 previous encounters documenting in ROS 280 printers selecting defaults for documents 130 printing A P forms letters prescriptions 392 at sign off 392 barcode labels 228 batch manifests packing lists 231 charts 144 daily schedules 20 documents without siging off chart 392 encounters 361 entire chart 392 from appointments 392 from open encounters 392 from output queue 94 glossary of terms 377 H amp P reports 153 immunization records 341 output default sets creating 384 using 385 403 Index output queue 92 output settings selecting 385 overview 377 patient demographics 166 patient education for medication 307 pregnancy records 336 problem lists 150 quick reference 392 requisitions 226 templates from any view 379 selecting 378 toolbar icons 112 380 priority items red 7 privacy level setting 163 problem lists diagnoses revising 150 problem search 299 probl
467. xpand Al Colapse Al E Un o m VY a chia Information gt oe e If aprocedure entry rule was created in Tools gt Edit Procedure Entry Rules questions with possible answers display to the right Reason For Procedure Mote Traumatic injury involving laceration Hl Location Reset Face Farehead Face left temporal region Face right temporal region Face left cheek Face right cheek Nose Face left nares IOOOOOOO RI Face right nares gt iud Check boxes and select values to answer questions The word Note displays in gray next to each item as you answer it You can click it to add a comment e For procedures not created in Tools gt Edit Procedure Entry Rules type or use Auto Expand text to enter the results of the procedure in the text box that displays to the right The word Note displays in gray to the right 6 Toenter a free text note associated with an answer do the following e Click the word Note to display Add Modify note Web Page Dialog Enter text or an image and click Save The word Note displays in bold in Procedure Results 190 2 Chart Functions NOTES You cannot enter a note after the results are marked Final Instead click Addendum f you need to change an answer before finalizing it click Reset to clear the fields and start again For information about changing answers after finalizing them see Reviewing procedure results on page 191 After a
468. y Practice Clinic Comments Followup Coverage Type Medical Check In Check In Started Start Check Out Check Gut 3 Select a patient by doing one of the following e IF the patient s chart is open name displays on the application title bar click amp Use Current Chart Fthe patient s chart is not open click the Patient search button to locate the patient you need see Patient Search on page 14 4 At Date and Time accept the defaults type over them or click down arrows to select an appointment date and time Click the Caregiver down arrow to select the provider that the patient wants to see Click the Location down arrow to select the location for the appointment At Comments enter comments about the appointment if desired A X v m Click the Appt Type down arrow and select the type of appointment if desired NOTE You can set a caregiver option to display appointment types on the title bar if desired See To customize the title bar on page 125 9 Click OK to create the appointment Checking patients in and out IF you do not have a Practice Management System to enter check in information from the HealthMatics EMR desktop toolbar or status bar click Appointments e To enter appointment time gt Press Shift on your keyboard and click in the appropriate column on the appointment line or gt Highlight the appropriate appointment right click and select Check In Start
469. y bills patient directly Third party Laboratory bills the patient insurance company An insurance company is required if you select this option 216 2 Chart Functions Location Value defaults to location where order is placed Location information prints on requisition Ordering caregiver Value defaults to caregiver who ordered test in A P Select the caregiver who ordered the test result notifications return to that caregiver Attending caregiver Value defaults to caregiver who ordered test in A P Select the attending caregiver Account Number Defaults to the performing lab account number Select the performing lab ID number Storage type Select a storage type Ambient Refrig Frozen and so forth All tests on the requisition must have the same storage type When Storage Type is required a message displays if one is not selected Displays the requisition status for example New when the requisition is created On Hold Checkbox Click to indicate the requisition is not complete and should not be sent across the interface Collection Date Time Date Click drop down arrow to display calendar to select collection date if other than today e Time Enter the time or click the scroll arrows to select collection time Wenn soe eaen one sooren eo Ee Fane es Comments Add any additional specimen collection comments if desired 217 Lab Order Entry 4 ABN Check ABN Signed Checkbox
470. y clicking Ga New Refill Request or by pressing Insert on your keyboard 91 Output Queue Output Queue To provide efficient workflow and security all output documents excluding Web messages eRefills and other documents outputted immediately at the point of care pass through Output Manager and are recorded in the Output Queue These documents can be printed faxed or transmitted from the Multiple Output dialog box during Sign Off or queued directly to the Output Queue All documents in the Output Queue can be reprinted or refaxed or just saved to the queue log if no paper copy is required The Output Queue provides an audit trail of actions taken on documents From the Output Queue you can do any of the following e Generate new documents that pull information by Location Patient and Encounter e View items that have been printed faxed or transmitted electronically e Reprint or refax failed documents e Save documents that do not have to be printed to the log e Export documents to a file which can then be emailed to another caregiver Security Output Queue security allows you to access documents for patients for whom you have chart access If you try to open an item for which you do not have access an Access Denied message appears Electronic prescriptions IF you have purchased ePrescribe the Output Queue also lists prescriptions transmitted from the Multiple Output dialog at Sign Off Therefore if an ele
471. y short lists for reason for visit 1 Open a patient chart and from the toolbar or left pane click Reason for Visit 1 amp 1212 Insurance Carrier Unknown Explore Options Took Launch Help Search Term Skarts wh C Contains 2 Click the Short Lists tab 3 Right click a short list and then click the popup message Add name of short list to My Short Lists 239 My Short Lists NOTE If the short list can be added a bubble message confirms Name of short list has been added to My Short Lists If the short list cannot be added either because you have selected an item below the short list level or have already added the selected item to My Short Lists a Warning appears Specifying my short lists in history 1 Open a patient chart and from the toolbar or left pane click 54 History 2 Inthe left pane of the History view select any category except mmunization d 212 Insurance Carrier Unknown Explore Options Took Launch Help Past Medical 3 rcp include Enter Social XU Add To My Short Lists Pu Travel Fi Fe Medication 3 Fi amp Reset List Ctrl Me Pregnancy Birth z PED Past Medka 3 Click the Short Lists tab 4 Right click or select a favorite short list and click Add to My Short Lists NOTE If the short list can be added a bubble message confirms Name of the short list has been
472. your computer From the menu bar select Launch gt module you wish to access NOTE If you do not have privileges to access a module the system displays the following message This account does not have the proper privileges to access this application Clicking OK in the message box displays a login window that lets you enter a user name and password with the proper privileges e Access administration If your practice has purchased HealthMatics Access click to set up the module e Administration module Click to set up or change HealthMatics EMR practice settings caregivers system options and interface queues Clinical customization module Click to customize knowledge short lists templates catalogs or to set up Lab Order Entry e ePrescribe administration module If you have purchased ePrescribe functionality click to modify settings for your electronic prescription transmission e Input manager Click to input scanned documents and transcription and to set up document types and scanning qualities e Output manager Click to create templates using styles layouts and building blocks of patient information for all output documents that can be printed faxed or emailed e Reporting module Click to build reports that generate patient reminders that display in Patient Manager e Edit desk references Click to add or edit electronic reference sites that you want to be able to launch from within HealthMatics

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