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EMR Features of the Clinical Records System - Hi

1. Date Time User Type Pg Cmpit Text 03 26 2010 14 04 HTS Progress ADL Issues 03 26 2010 14 04 HTS Progress ADL Progress 03 26 2010 14 04 HTS Progress ADL Outcomes G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 60 Hi Tech Software Solutions EMR Features of the Clinical Records System Document Storage Electronic Document Storage System Release 11 06 This process provides the following advantages over the existing Documents process Specify where you want to store the documents files Achieve greater HIPAA compliance through our encryption process Access the documents with our application only Apply additional security options for who can view documents Clinical and or Resident Accounting Classify documents by type such as Doctor s Orders Insurance POA Advance Directives etc Inactivate a document and view inactivated documents Read the instructions on the following pages to learn how Electronic Document Storage works To activate this feature set up a phone appointment with Hi Tech Support at 207 474 7122 or email Support Hi TechSoftware com IMPORTANT This is an optional process however it will eventually replace the existing Documents feature that is part of the Electronic Medical Record described on the previous page If you are using the existing Document feature we encourage you to transition to the new Electronic Document
2. Activities Access Access Access Access Access Access Access Access Access C No Access C No Access C No Access C No Access C No Access C No Access C No Access C No Access C No Access C Inquiry Only C Inquiry Only C Inquiry Only C Inquiry Only C Inquiry Only C Inquiry Only C Inquiry Only C Inquiry Only C Inquiry Only Calendar Notes Documents Stay Tables Patient Liability Data Balances Events Access Access Access Access Access Access C Access C No Access C No Access C No Access C No Access C No Access C No Access No Access C Inquiry Only C Inquiry Only C Inquiry Only C Inquiry Only C Inquiry Only C Inquiry Only Aa cares a ers This user Claire Bourque has access to Activities OAccess but not Events ONo Access If Claire clicks the Activities Event button in Edit Medical Record the Edit Activity Detail screen will display She will not be able to Edit Events NOTE A third option lnquiry Only allows a user to view but not add or change records G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 15 Hi Tech Software Solutions EMR Features of the Clinical Records System Libraries gt Documentation gt Activities Library How to Use the Activities and Events Programs IMPORTANT When you installed Release 12 03 a
3. The resident requires the use of ___ due to list symptoms and medical condition In an effort to attain or maintain the highest practicable physical mental and psychosocial well being of the resident The resident is on a trial for restraint reduction list devices to be tried G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 41 Hi Tech Software Solutions EMR Features of the Clinical Records System D2 93 54 TE 99 62 65 68 71 14 75 18 fo 82 83 84 87 90 Reduction is being attempted in an effort to attain or maintain the highest practicable physical mental and psychological well being of the resident Resident is at risk for decreased ambulation related to unsteady gait personal alarm restraint use Surgical procedure fracture decreased strength and endurance Resident is at risk for falls and needs assistance to ambulate related to unsteady gait inability to independently bear weight cognitive deficit general weakness Resident has decreased lack of motivation to ambulate related to pain specify depression difficulty ambulating fear of falling fatigue Resident is at risk for decreased active range of motion related to decreased mobility diagnosis of Resident is at risk for decreased active range of motion related to decreased mobility diagnosis of Resident is unable to independently move self in bed related
4. 0002 Attended and participated 0005 Attended and participated as cheerleader 0003 Attended with encouragement 0004 Attended but left early 0001 Attended did not participate 0020 No transport required family notified Comment Code o Description Example Event Comments 0003 ER visit admitted for observation 0004 ER visit returned to facility Edit Event Comment Library 0002 Fall with injury 0001 Fall without injury Comment Code E Description G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 18 Hi Tech Software Solutions EMR Features of the Clinical Records System Documentation gt Activities Document Activities Clinical Assessments Edit Resident Activities Vitals Edit by Activity Print Activity Report Notes Inactivate Resident Activities Hi Tech suggests that you use Activities to record items such as bingo birthday party music hour etc After you define an activity in the library record the residents who were offered and participated in the activity e To record individual resident s activities use Edit Detail by Resident e o record the activity for several or all residents use Edit Detail by Activity Edit Detail by Resident MD84 Edit Activity Detail by Resident Enter or select a Resident ID Resident ID 1132 ADAMS HANNAH Date 03 06 2012 EEN Enter Date and Time of activity Activity ID Enter or lookup the Activity ID assigned throug
5. Reset All Selections Resident Select All or Individual and provide the ID Selections will be listed under Residents Selected Dates Select All or a Range of records by date Activity Select All or Individual activities Click the binoculars to select multiple items Selections will be listed under Activities Selected Units If you select lndividual select the Unit Sample All residents Dates and Activities ATE 03 07 2012 RESIDENT ACTIVITIES REPORT HTS MD86 PAGE 1 ID NAME DATE TIME LNGTH ACTIVITY INSTRUCTOR 0068 AXELROD LORNA 09 22 2011 15 32 00 30 0008 Friday Night Social MBM 0575 GREENE JULIANNE 09 22 2011 10 00 00 00 0003 Morning Stretch Activities Staff Sit and Get Fit 05965 SAMPSON SAMANTHA 09 22 2011 10 00 00 00 0003 Morning Stretch Activities Staff Y Sit and Get Fit 1132 ADAMS HANNAH 09 20 2011 00 00 00 00 0011 Individual Activity Y Puzzle 1132 ADAMS HANNAH 09 20 2011 10 00 00 30 0003 Morning Stretch Activities Staff Y Attended and participated 1132 ADAMS HANNAH 09 22 2011 10 00 00 00 0003 Morning Stretch Activities Staff Y G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 21 Hi Tech Software Solutions EMR Features of the Clinical Records System Documentation gt Activities Inactivate Resident Activities MD96 You cannot delete activities that have been recorded however you can inactivate them Inactivate Activity Detail Resident ID 1132 ADAMS wee Date
6. 03 07 2012 Ea Activity ID o Previous Detail as of 03 07 2012 Date ID Time Description Date 03 06 201 2 03 06 2012 0004 15 02 Movie amp Popcorn Time 15 02 03 06 2012 0001 14 56 Bingo Activity Movie amp Popcorn 09 22 201 1 0011 13 34 individual Activity xl 09 22 2011 oo03 10 00 Morning Stretch Instructor Activities Coordinator 09 20 2011 0003 10 00 Morning Stretch 09 20 2011 oo11 Individual Activity Reason for Inactivation 12 16 2010 0003 09 00 Morning Stretch SS EE 09 15 2010 0003 09 00 Morning Stretch 07 01 2010 0003 08 15 Morning Stretch Inactivate 10 22 2009 0025 15 00 Community Event 02 25 2009 0007 13 00 Monthly Lunch Outing 02 01 2009 0004 18 00 Movie amp Popcorn 01 21 2009 0003 10 00 Morning Stretch 01 05 2009 ooo9 17 00 Holiday Party End Print Select the Resident ID to display all the recorded activities for that resident You can also select a specific Activity ID to display just those Activity ID 0004 Movie amp Popcorn activities as shown on the right OS i A L O l O U A O hud Select the specific occurrence to be inactivated and complete the Previo information on the right side of the screen see below ID Time Description You must enter a Reason for Inactivation m 03 06 2012 0004 15 02 Movie amp Popcorn E 02 01 2009 0004 18 00 Movie amp Popcorn Click the button This activity will no longer be d
7. 5 Re add the document using the Add Documents to a Resident s EMR instructions on Page64 Select the document from the location used in Step 3 How to Move a Document added to a Wrong Resident 1 Open Electronic Document Storage in the wrong resident s EMR 2 Select and View the document Select Save As and to a name and location that you will remember 3 Inactivate the document in the wrong resident s record See How to Inactivate a Document on Page 65 Open Electronic Document Storage in the correct resident s EMR 5 Add the document using the Add Documents to a Resident s EMR instructions on Page64 Select the document from the location used in Step 2 Remember When you add a document to a resident s EMR the program removes it from the original location G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 66 Hi Tech Software Solutions EMR Features of the Clinical Records System The IMAR Electronic Medication System IMAR is a complete medication management application for long term care including skilled nursing assisted living and other healthcare settings IMAR directs medication management administration and documentation workflow IMAR helps ensure the Five Rights Right Resident Right Medication Right Dosage Right Route and Right Time during every med pass Log in and select the icon in the Application tool bar at the top of the screen This displays t
8. e Risk for Falls e Risk for Dehydration e BIMS Brief Interview Mental Status e Bowel amp Bladder Training e Nutritional Risk e PHQ 9 Mood Interview e Contracture Risk e Skin Risk e AIMS Abnormal Involuntary Movement Scale G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 46 Hi Tech Software Solutions EMR Features of the Clinical Records System Edit Assessment NRE6 Edit Resident Clinical Assessments DOB 06 10 1936 View Assessments on File Ranges User HTS ID not on File User IMPORTANT lf this is not your User ID log out and log back in under your User ID The User ID is attached to the Assessment record An assessment created by one User cannot be edited by another user You cannot change the User ID from this program 1 Enter or select the Resident ID 2 Click View Assessments on File fo view a list of current assessments Assessment Date User Status 015 Norton Plus Pressure Ulcer Sca 01 23 2012 SALLY 050 Pressure Ulcer Risk Assessment 01 13 2012 SALLY 100 Assessment of Urinary Incontin 08 25 2011 HTS 100 Assessment of Urinary Incontin 08 25 2011 SALLY 001 Risk for Falls 01 05 2010 CRB 001 Risk for Falls 01 10 2009 CRB Locked You can select an assessment from this list to view the details of the assessment G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 47 Hi Tech Software Solutions EMR Features of the Clin
9. pain Chewing difficulties Resident is at risk for urinary incontinence or has incontinent episodes related to cognitive deficit inability to feel urge to void chronic UTIs decreased ability to get to and from toilet commode bedpan frequent dribbling Resident is unable to independently transfer self related to weakness confusion restraint use G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 42 Hi Tech Software Solutions EMR Features of the Clinical Records System fracture hemiparesis 92 Alteration in comfort related to episodes of breakthrough pain 95 End of Life OR _ End of Life non terminal 97 Resident needs cognitive stimulation and socialization 98 Resident is not comfortable attending or participating in large group activities 99 Resident often falls asleep closes eyes and doses off during activity programs 101 Resident often suffers discomfort due to pain Residential Care and Assisted Living Problem List Using Care Plan Language Assist with ADL IADL 300 My memory is not what it used to be and sometimes need your help with personal hygiene 305 need your help to keep clean to get dressed to eat and to meet my bathroom needs because cannot physically or cognitively do it myself 310 cannot get around without your help because have had a stroke social amp Emotional Issues amp Behavioral Symptoms 325 will need your support as transition into my
10. Asmnt Date 08 04 2014 HI TECH NURSING amp REHAB 000 006 Resident is low risk 007 018 Resident is high risk Follow falls protocol document in CF Total Score se E Locked Cognitive Status History of Falls G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 55 Hi Tech Software Solutions EMR Features of the Clinical Records System Minclude Assessment Key to print an additional page that explains the items on an assessment including the Acuity Range and Questions and Answers from the Assessment Library DATE O68 f22 2011 CLINICAL ASSESIHENT LIBRARY ASSESSMENT 101 Risk for Falls RANGE l O0 0D RANGE 2 07 18 QUESTION 01 ANSWER ANSWER ANSWER QUESTION 02 ANSWER ANSWER ANSWER QUESTION 03 ANSWER ANSWER ANSWER QUESTION 04 ANSWER ANSWER ANSWER QUESTION 05 ANSWER ANSWER ANSWER QUESTION 06 ANSWER ANSWER ANSWER ANSWER Resident is low risk Resident is high risk Follow falls protocol Cognitive Jtatus 01 Intact O2 Mild Moderate Impairment 03 evere Impairment General Health 01 3table 02 Declining 03 Terminal Mobility DI Independent 02 With Assist 02 Immobile Transfer Ability m om 01 Independent Failure to Thrive m m 02 Minimum Assist 03 Maximum Assist Weight Bearing Jtatus O1 Full Weight Hearing O02 Partial Weight Bearing 02 Hon Weight Hearing Appliance in use at this time 01 Ho equipment ne
11. Docs EMR ClinicalRecordsSystem doc 11 2014 Page 62 Hi Tech Software Solutions EMR Features of the Clinical Records System Admission Procedures gt Edit Medical Record gt Access a resident s document by clicking the button on any EMR screen Hea ei Demographics Resident ID 1 132 Prefix i First Name Hannah i sss sC Midde Name J i OO OO OC Last Name Adams i itsi Ss Suffix Nickname Preferred Name MRS A Social Security No 105 37 8545 Canadian SIN Date of Birth 06 10 1938 Phone 207 4747122 Group Id s 101 102 0 Admit Date 01 04 2009 Time 13 00 Source 01 PRIVATE HOME OR APPT City SKOW SKOWHEGAN County SOME i SOMERSET 02 0 1 2006 Original Admission Date HIPAA Consent Authorization Gender M F Female sx h Marital Status Married gt PEE Race 5 White not of Hispanic origin Level of Care 2 ICF Primary Payer 0001 MEDICAID A Unit NF UNIT Room Bed 0351 a gih ROOM amp BOARD Discharge Date Time Status of Demographics Contacts Insurance Physicians Diagnoses Allergies Adv Dir Other Vitals Order Flowsheet Kardex Clinical Assessments Care Plans Activities Events Inoculations Calendar Notes Stay Tables Patient Liability Data Balances This displays the Electronic Document Storage screen and any documents already saved and selected for this resident
12. EMR Features of the Clinical Records System Documentation gt Inoculations Inoculations You can also access Inoculations through Edit Medical Record gt Demographics Demographics Demographics HIPAA ite Contacts Consent Insurance M Authorization Physicians Diagnoses Gender M F Female 1j Allergies Adv Dir Other Marital Status Married Attach Picture Vitals Race 5 White not of Hispanic origin Order Flowsheet Kardex Clinical Assessments Level of Care 2 ICF Primary Payer 0001 Laid MEDICAID ie Goad itt NF UNIT i awn Le nee MDS 3 0 and RCA Records View Inoculations Edit MDS Section O click View Inoculations to display the resident s inoculation record so you can respond to 0250 Influenza Vaccine and O300 Pneumococcal Vaccine Edit RCA 1 When you set up an inoculation code in the library indicate that the inoculation satisfies the RCA Section T 1 e Influenza or RCA Section T 1 f Pneumococcal Care Plans Record those inoculations when given In RCA Section T click Pull T 1 e f responses from Inoculations Detail to update T 1 e and T 1 f automatically from these inoculation records G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 35 Hi Tech Software Solutions EMR Features of the Clinical Records System Edit Resident Inoculation Detail Resident ID 1301 BRYANT Date 05 09 2008 Reference No 1 FLU SHOT Doc
13. G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 14 Hi Tech Software Solutions EMR Features of the Clinical Records System EMR Security for Activities and Events The Release 12 03 conversion process applied previous security settings for Activities Events to the new Activities and Events options From Edit Medical Record e lf you had access to Activities Events when you click the Activities Events button you will have access to both Edit Activities and Edit Events Select the program you want to edit e lf you did not have access to Activities Events you will not have access to the Edit Activities or Edit Events from the EMR record Activities Events button will be grayed out e lf you change the security to allow access to only one of these modules when you click Activities Events the program will display the edit screen for the module you can access See your System Administrator if you do not have access to these security programs Utilities gt System Structure gt Maintenance gt Medical Record Security Select the areas of the EMR this user can access through Edit Medical Record UserID CRB CLAIRE BOURQUE Edit User Medical Record Access Demographics Access C Inquiry Only Inoculations Access C No Access C Inquiry Only Contacts Insurance Physicians Diagnosis Allergies Adv Dir Other Height amp Weights Order Flowsheet Kardex Clinical Assessments Care Plans
14. activity and did not participate Select Residents Select All or By Unit If you select By Unit enter or look up the Unit No Residents names will then be listed on the right side of the screen Use M Select All and M Un Select All to select deselect all the residents listed for the entire facility or the unit You can also M Select All and then deselect individual residents Comments Enter a general comment for the activity To record different Comments for each resident checkM Edit Individual Comments E Edit Individual Resident Comments This will display a Comment entry window for each HANNAH ADAMS resident see window for HANNAH ADAMS on the right Enter comment text or click the binoculars to Comments select from the Comments library Click Add Note to add a Note related to the activity to the Cancel Ok Add Note resident s Progress G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 20 Hi Tech Software Solutions EMR Features of the Clinical Records System Documentation gt Activities Print Activity Report MD86 Print Resident Activity Report Residents Selected Activities Selected 1132 Bingo Report Date 03 07 2012 Birthday Party Community Event Resident C All Individual Dates All C Range From Thru Activity CA Individual Units All C Individual 0000 C Page Break by Resident l Sort by Activity Id l Include Discharged Residents
15. attached to a resident in error or if the information is no longer current You can inactivate them Check mark the record in the Inactivate column The program will ask if you are sure Resident ID 1132 Resident HANNAH ADAMS File Description Type View 1132_MR_SocialSec Hannah Adams SS card Admission Contract View 1132_MR_DOC_2010 registration Admissi View 1132_MR_AdmitOrder Admit DH activate 1132_MR_BCBSinsur BCBS Ins A Are you sure you want to inactivate this record ves No Click Yes to continue the inactivation The inactivated document will no longer be displayed on the resident s document list unless you select Fiter Documents Show Inactive to view inactivated documents Show Inactive W Add Document Click to leave the Electronic Document Storage process and return to Type Al the resident s EMR record G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 65 Hi Tech Software Solutions EMR Features of the Clinical Records System How to Reactivate a Document 1 Select Show Inactive M 2 Select the inactivated document and click button 3 While the document is displayed click Save As and the document under a name you will recognize in a folder you will remember Close the document NOTE Until it is re added to a resident s EMR this document is no longer encrypted and can be accessed outside the Hi Tech System Deselect Show Inactive
16. beat shtta woes aes a 21 inactivate Resident AGIIVINGS acercan a A aaa 22 Pintnactivated ACHVILY REDO annuns eiee re eeeibad ae ne eet ah cena biter te atta 23 Document TFSSSIC SHES EVO IIS sacs sates cies joe ate cote eden a A 24 CIE MeSIG eM Cli orcct ceretiete eta es th tet ett Atte et eet eh Ae tl ete et a ee 24 PUOCEVENGR CDON caei 25 inactivate Resident EVENTS nicieni a ia a meuneieets 26 Pintinelnacuvated Event Repi sssr E ttte aa etc ate aae soe ade nt ets uted 27 FRESIGGNIS Vital Sarran N 28 View Vitals from Edit MDS and Edit RCA ccc ccccceeceeeseeeseeeceeeseeeseeeseeeseeeseeeseeeseeeseesseeseeesaeees 28 FON VALAIS aaen a EE E E RSE 29 MEW Vitals IISIOLY sogea e E E E E TEO 32 PALV S ecn a T 33 Macie IV ILS iiachnauanaa heated ianucauteammtanemametanenasuiauenaaataasrauuiaapranataaniaenuieninalaaen tn pnameuaan cami praanedaseaninle 34 HOCU pein et ene terns cee E tenant eis ee eae et eee ene tee tan me re ee ere 35 Edit Detail OY TAS SIC SIN oe axe ab seers ates hs anlar SN ont ans Shs v aauiaes ea A a a a 36 Edit Detail Dy INOCULATION arene E T EE E E A E T A R 36 OC UIATONS LD AN Y assa a a e a ss 36 care Plans neina a bce Macchi nasi Sanaa ns oka ca carte nae aaa gaa eee nse ae no ac a 37 SME O72 1S Sl ad re ae Renee ete eee ee me Se ee ee Oe ee E ee ree 37 N rsmg CaS oa 0 9 tu lho Geena eet et mn nn ee 41 Residential Care and Assisted Living Problem List c ccccecseccceeeeeceeeeeeeeeeeeeeeseeeesseeees
17. resident to ask for assistance or use call hell Approach 0003 Disciplines N Wa Maintain adequate hydration monitor and document fluid intake Approach 0004 Disciplines N Wa Follow toileting schedule Approach 0005 Disciplines N Wa Use prompting to encourage resident to go to bathroom Do not rush Provide stimulation i e run water in the Zink Provide privacy Approach OOO Disciplines N Wa Give positive reinforcement RESIDENT HAME RESIDENT Ha ROOM HG ADMIT CATE BIRTHDATE AGE PHYSICIAN BARNETT LILLIAN W 1566 IEn METAIS 2 008 Oo 06 1919 J7 BARKLEY WILLIAM DATE PAGE ALL ENTRIES MUST BEIN INK THIS 15 A PERMANENT PART OF THE HEALTH RECORD 140102014 03 G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 39 Hi Tech Software Solutions EMR Features of the Clinical Records System Signature page RESIDENT CARE PLAN HI TECH NURSING amp REHAB INITIAL CARE PLAN Advanced directives status reviewed Date Init _ Current Advanced Directives Status Durable POA for health care Date f Living Will Pate gt fF Do not resuscitate Date Do not Aospitalize Dare f f fF Discharge plan has been discussed as follows __ Indefinite stay indicated Discharge to another Setting is under consideration See social service notes for details Revylew all problems in Tonths UDFATE Advanced directives status reviewed Date Init _ Discharge plan has been discussed as fo
18. residents rooms and becomes agitated Cancel G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 49 Hi Tech Software Solutions EMR Features of the Clinical Records System NOTE Ifthe library template includes Help text you can click the Help button to display that text cancer Hep oe 11 Click OK to save the entries The Question Answer Score and Comment will be displayed Questions Answers E Q Cognitive Status A Mild Moderate Impairment C Wanders into other residents rooms and becomes agitated Q Question A Answer C Comment 12 New Assessments will be in Add mode and the program will automatically display the next Question that has been defined for the Assessment For example after you click to save the Cognitive Status Question the screen displays 02 General Health shown below Q Cognitive Status A Severe Impairment E Select Answer s to Question 02 General Health Answers Score C Stable Declining Terminal Failure to Thrive You can continue through the entire assessment this way selecting Answers to each Question or you can click the button to exit the question on display and then manually select the questions you want to add to the assessment oep Question A nswer C omment Add The program is in Add mode when you start a new assessment The word Add displays in lower left corner If you return to e
19. sheets physicians orders and care plans Several items must be completed manually Print Resident Transfer Form Report Date KPIZ Izp Residents to Print C All Individual Blank Form Resident ID RESIDENTS SELECTED Select Modules to Print Background Information Transfer Forms G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 10 Hi Tech Software Solutions EMR Features of the Clinical Records System Resident Diagnosis List Print Resident Diagnosis List NRO6 Types to Include Resolved Through Edit Medical Record gt Residents to Print All Individual Physician Diagnoses you can checkmark a diagnosis in the Move to History column and enter a Resolved date This MOVES the diagnosis from l Types to Include Current Resolved Both current to history and you can now print a list of these resolved diagnoses sample below Resolved Dates All Range From 00 00 0000 Thru 12 31 2199 Resident ID Include Discharged Residents Resident Resolved Diagnosis List Diag Code Resolve Date Description 401 9 06 11 2009 ESSENTIAL HYPERTENSION UNSPECIFIED ESSENTIAL HYPERTENSION Allergy Phys List Adv Dir NRO7 List the allergies or physicians recorded for a resident through Edit Medical Record gt Physicians Diagnoses Allergies Adv Dir Other Print Resident Allergies Physicians Advance Directives List Residents to Print All C Individual Reside
20. the Clinical Records System Documentation gt Events Print Event Report MDE46 Print Resident Event Report Residents Selected Events Selected Report Date Resident All individual 2 Dates All C Range From Thru eS Events All Individual ee Units All C Individual 0000 l Page Break by Resident l Sort by Event Id l Include Discharged Residents Print End Reset All Selections Resident Select All or Individual and provide the ID Selections will be listed under Residents Selected Dates Select All or a Range of records by date Event Select All or Individual events Click the binoculars to select multiple records selections will be listed under Events Selected Units If you select lndividual select the Unit Sample All residents Dates and Events ATE 03 07 2012 RESIDENT EVENTS REPORT HTS MDE4 PAGE NAME DATE TIME EVENT REPORTED BY ADAMS HANNAH 02 20 2009 15 00 0100 ER Visit Bumped her elbow on the door jamb compl ained of severe pain Xray recommended ADAMS HANNAH 12 16 2010 07 45 0200 Fall Fell in bathroom during morning care Monitored no transport required ADAMS HANNAH 03 07 2012 10 00 0200 Fall Sally O Malley while getting out of bed Fall without injury AKERS HENRY 01 15 2009 10 35 0200 Fall Fell while walking in hallway No transport required G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 25 Hi Tech Software Solutions
21. the Clinical Records System Documentation gt Vitals gt Enter Vitals There are two Vitals entry screens that will list selected residents Use the scroll bar to see more residents Screen 7 User HTS Enter Vitals Date Edit Res ID Time BP BP Pulse Resp 02 Pain Non Glucose Add View Syst Dias Rate Sat Scale Verbal Comment History E 1 132 ADAMS HANNAH 05 1 0 2011 i 1 53 a 1476 AKERS HENRY 05 10 2011 11 53 B 1314 ALLEN IRENE 05 10 2011 11 53 M VT1500 AMIDON LEATRICE 05 10 2011 11 53 tT ttt tl TLE EE TT EP es el cal ad tT ttt tl TT tt tl Ee EP ls Ea Screen 2 Vitals Save amp Exit More Vitals Height Weight Edema Scale Intake Output Click More Vitals lower right to display Screen 2 User HTS Enter Vitals Date 05 10 2011 Edit Res ID Time Height Weight Edema Intake Output Add View Scale Comment History Screen 1 Vitals Print Notes BP Pulse Temp Resp Rate O2 Sat Pain Scale Glucose Click Back lower right to return to Screen 1 LEETE El ele an ls en ELEELE TEEPE tit G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 30 Hi Tech Software Solutions EMR Features of the Clinical Records System Documentation gt Vitals gt Enter Vitals To enter vitals check mark the resident User HTS Enter Vitals Date Edit Res ID Time BP BP Pulse Temp Resp 02 Pain Non Glucose Add View Syst Dias Rate Sat Scale Verb
22. the age RESIDENT LAST MAME FIEST NAME LE 50C SEC NO GEN MS BIRTHDAY amp 1053785545 F LE S0C SEC NO FIRST MAME CE LAST MAME RESIDENT amp 1053785485 Fi 1245 E RYO 07 474 Sidd G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 13 Hi Tech Software Solutions EMR Features of the Clinical Records System Activities and Events Suggested Uses for Activities and Events e Use Activities to record items such as bingo birthday party music hour etc e Use Events to record health related items such as ER visits falls infection flu etc You can assign security to limit access to the more confidential health related Events records For example allow only Nursing and Administration to access Events while all clinical staff can access Activities See the Security instructions that follow Select ACUVINES and Events from Edit Medical Record tivities Events button on the right side of the screen Demographics Demographics HIPAA Contacts 3 ees Insurance M Authorization Physicians Diagnoses Gender M F Female Allergies Adv Dir Other Marital Status Married Attach Picture Vitals Race 5 White not of Hispanic origin Order Flowsheet Kardex Clinical Assessments Level of Care 2 ICF Care Plans Primary Payer 0001 iit MEDICAID a a mee Activities Events i Select Activities and Events from the Documentation Menu
23. to weakness confusion obesity fracture hemiparesis Resident has difficulty communicating with others related to cognitive deficit aphasia hearing loss inability to finish thoughts longer response time slurred speech Resident is unable to independently feed self related to confusion arthritis contractures weakness short attention soan decreased mobility to upper extremities Resident requires assistance with the following tasks bathing upper body dressing lower body dressing hair grooming brush teeth or denture care applying lotion applying deodorant applying makeup shaving other explain Related to cognitive impairment diagnosis _ weakness tremors shortness of breath pain specify Resident is at risk for contractures related to decreased mobility hemiplegia diagnosis Resident has decreased mobility and is unable to actively range joints related to Contractures hemiplegia diagnosis Resident is at risk for contractures related to decreased mobility hemiplegia diagnosis Resident has a contracture of the related to decreased mobility hemiplegia diagnosis Resident is at risk for aspiration related to swallowing problems other explain Resident has difficulty swallowing related to Alzheimer s disease or dementia Cancer of the esophagus CVA Multiple Sclerosis Parkinson s Disease Throat pain Resident pockets food related to Alzheimer s disease or dementia CVA Parkinson s Disease Throat
24. 0 TABLET PROPOXY PRN 05 29 2008 PROMETHAZINE 25 MG ML VIAL PRN 05 29 2008 Facility All B WING All SAM P ass m Ham 3pm a Status Time UnSent Orders 4 Do one of the following Facility All 1 Select orders from the Work to Do status bar El at bottom left B WING All 2 Continue with the displayed resident and administer med 3 Select another resident G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 67
25. 40 Page 1 Discipline ea Margaret became confused during lunch because she thought it was breakfast and she From Library wanted orange juice Aide explained that it was lunch and that she had orange juice at breakfast but Margaret grew agitated Aide gave her juice to calm her After lunch she was assisted to her room but she was confused about its location She asked where her TV was and that she wanted to watch TV She would not go to the l Next P activity room to watch TV She was so agitated that we called daughter Mary Joe who g aoe e Check M Note Complete Locked or M Note Complete Locked amp Signed if users have permission to e sign Notes and save _Note Complete Locked amp Signed the note so you can no longer edit the note e The User ID assigned to a note is the only User ID that can edit lock or inactivate the note e Copy Text On the Note Inquiry screen top right select and display the note to be copied Click the button The text will be copied to Add Note as a new note that you can edit You can also copy text from each page of a multi page note Display the Note Inquiry screen below Each page of the note will be listed Check the box of the note that you want to copy It will be displayed Click the button to copy the text of that note to the Add Note area as a new note that you can edit and save a Note Inquiry A hum Start Date oipo Type All Progress Face Sheet
26. Docs EMR ClinicalRecordsSystem doc 11 2014 Page 19 Hi Tech Software Solutions EMR Features of the Clinical Records System Documentation gt Activities Edit by Activity MD85 Edit Activity Detail by Activity ID Finished Loading Residents Resident Last Name First Name Select Residents All C By Unit 1132 ADAMS HANNAH 1476 AKERS HENRY Unit No 0000 1314 CO ALLEN t C S C IRENE T1500 AMIDON LATICES 1273 ANISTON THERESA 1517 APPLEBEE CLARA 2187 APPLETON THERESA 1200 ARCHER BENAMN 0o68 AXELROD JORA 1523 BALLARD APH 1566 BARNETT WUN 07192011 BENTY u 1514 BoR DORIS 201 BOULDER BRET 1301 BRYANT MARGARET 490 BURKE MLUCENT T Select All M Un Select All x x lt I Date 03 06 2012 Bal Time 15 02 Activity ID 0004 Movie amp Popcorn qd a 9 Length 01 20 Instructor Activities Coordinator M Participated l Edit Individual Comments Comments Singing inthe Rain aN st LLL La lt x Provide the Date and Time of the Activity Select the Activity ID number or enter the Alpha Code that identifies the activity i e BP for Birthday Party The program will translate it Enter the Length of time for the activity MParticipated Leave checked if the residents you are about to select participated in attended the activity Uncheck to build a separate batch of records for residents who were offered the
27. EMR Features of the Clinical Records System Documentation gt Events Inactivate Resident Events MDE8 You cannot delete events that have been recorded however you can inactivate them Inactivate Event Detail Resident ID 1132 ADAMS HANNAH Date ELORE Ed Event ID 0 Previous Detail as of 03 07 2012 ID Time Description Date r 12 16 2010 0200 07 45 Fall Time a r 02 20 2009 0100 15 00 IER Visit Event p Reason for Inactivation ooo oe Select the Resident ID to display all the recorded events for that resident You can also select a specific Event ID to display just those events Select the specific occurrence to be inactivated and complete the information on the right side of the screen see below You must enter a Reason for Inactivation Click the button l PpS Date 03 07 2012 Time Description Ti 10 08 03 07 2012 0300 10 08 Infection si Event Infection 03 07 2012 0200 10 00 Fall 03 07 2012 0200 10 00 Fall imal ma 07 45 Fall Reason for Inactivation inactivate This event will no longer be displayed in the resident s event record To view inactivated events click Print See next page G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 26 Hi Tech Software Solutions EMR Features of the Clinical Records System Documentation gt Events Print the Inactivated Event Report Print Resident Inactivated Event Report R
28. ESIDENTNO ROOMNO ADMITDATE BIRTH DATE AGE PHYSICIAN BARNETT LILLIAN V 1566 046 2 05 04 2008 08081919 92 BARKLEY WILLIAM DATE PAGE ALL ENTRIES MUST BE IN INK THIS IS A PERMANENT PART OF THE HEALTH RECORD 11 01 2011 04 G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 37 Hi Tech Software Solutions EMR Features of the Clinical Records System Problem with two goals and approaches attached to each goal RESIDENT GARE PLAN HI TECH HURSING amp REHAB Review Datel Problem Goal f Approach Signature Problem 0014 Date 08 15 2010 Type Active Lillian requires assist in performing ADLS dw to decreased strength associated with extended illness and hospitalization for prewonia Goal 000l Date 08 15 2010 Lillian will receive assistance with ADLS and present a neat clean odor free appearance daily Thru next review Approach OOO3 Disciplines N NA Provide assistance with ADLS as needed Approach OO04 Disciplines N NA Encourage to participate in ADLS as much as possible Approach 0006 Disciplines N Wa Dress in clothes that are clean and in good repair daily Approach 000g Disciplines N NA Monitor for changes in ADL participation and notify charge nurse of changes for further evaluation and possible physician and responsible party notification Approach OO11 Disciplines N NA Keep call bell within reach Approach OO12 Disciplines N NA Encourage resident to request assistance when
29. Events from Edit Medical R COIrGd ccccccccseccceeeeeeeeseeeeseeeseeeseeeseeesaueeaeeeseees 14 Select Activities and Events from the Documentation MENU cccccscccseeeceeeeseeeeeeeeseeeeeeeesaueeseeeeaees 14 EMR Sec rity TOF Activities ANG EVENS wicteccctcccecatdesenscideivedictecieeeldiele cal eaa 15 From EGIL Medical TAS CONO secs tee cca leet ce deta a ie ach a eae eae eta Mie a nek ces ada 15 How to Use the Activities and Events Programs ccccccccseecseeecsuceceeecseeceueeceeecsuseseueeseeecsueessueseaeessusenaess 16 PACUV IMS SORA Y cerre a E N O nics a kcanaus nana na eioan 16 E VENS EIO Vne a a MeO aases hth Datncy a aka atte oautiate taints st hints head A eed bin Mea aden eee nanan tenn eae 17 Tracking and Reporting Falls in the MDS and RCA ccccccccecccececeeeeeeeeceeeeseeeeeeeeseueesseesanesaeeenaees 17 ACUN COMMONS LIDA tetctecet acct oo dentchteres weet aa cidaneeeetbeciees 18 Events Commens Me Iy epee eared meee reed sneer ee ior ene ee tare ee ere nee ey ee ee nee ey ee ear eee 18 DOCUMENTA CTIVINGS cic Gtouvicih tortesuicotttals Staaubttoneaald Resale tantat als Me tnauhG toner ahs Mel suhG fontele Ml sahG ton tuhe te cuhitane tela tes 19 Git DSTAN OY Residen eeen Siew het anaes Caan absense Saas Sheth aness San abs onstect rans ale canudeeraes sbstees 19 EGIL DV AACUIVINY eegne nE C meld oan pacer sO Sak ehent E RE E EER 20 PIAL ACIIVITY RODO csie sntauore bia ea a baby ahbtia woreda
30. Example D ent M i t ocumern anagemen Resident ID 1132 Resident HANNAH ADAMS File Bacal fetal Lype Added By Inactivate Date Added p Pew GUETB 1132_MR_DOC_2010 e dinette A 5 2 2011 243 PM Admit DR Orders BCBS Insurance 1132_MR_AdmitOrder View 1132 _MR_BCBSInsur Add Document Select File Description Type Admission Contract Doctor Orders HTS Insurance HTS Fiter Documents A Show Inactive C Type All 5 2 2011 9 14 AM 5 2 2011 9 10 AM Click a column heading to sort the documents by that heading criteria alphabetically or chronologically by date To print a document click the button Use the standard print process for the program that displays the document i e Microsoft Word Adobe Reader etc G A HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 63 Hi Tech Software Solutions EMR Features of the Clinical Records System Add Documents to a Resident s EMR Verify that you have selected the correct resident then select and add documents to the EMR Select File Description Type Admission Contract select File click the binoculars at the right end of the field and browse to the folder where you save documents to be i4 Open attached to residents a GJ DATA VMR INFO 1132 Select the document and click mn B Organize nan Views Y Bi New Folder or double click the document file name f gt The selecte
31. Hi Tech Software Solutions EMR Features of the Clinical Records System EMR Features of the Clinical Records System EICCIFOMIC SIGMA TUN CS gotta te hehe cet et ele E ake Mot einen tla siet is ieee as 2 Edit Medical RECOM cascnna a eneadd medeeateeer oc bacaneteiat alder eae a oeeeds 3 VIEW Medical RECO iersieccost aries eee i ae es ee ee 4 CSO mis oye at ale aana ser ener se einer PE et etre ener inn ee PL ER ct REE MOE ety er REE MOP ne eae Cre Fe aE eer renee ee ne reer 5 Design a New Report or Edit an Existing Report Design ccccccceeeceeeceeeeeeeeeeeeeeeeeeeeeeesaeeeeeeeeeenes 6 Oiher Face Sheer REDONS errs a 10 TANS ORRO a ateatente couneete ints athe nquant a tawteaedecuante mie at eiem an aeaes san meeaneet gamely ice ereee 10 Resident Diagnosis WS Usain otra ea htc ha ea han ia aut eat ta ha at at a 11 PICTOY PRYS LIS VAV Di sceatitsecnamals Seco ssictran s ston aaa aaa 11 Reporting Options Print Display Create File 0 0 ccccccccccccccseeceeeeeeeeeeeeceeeeseeeeeseeeessaeeeseesesseeeseeeesaeeeas 12 PACC gcse een ee ee eee heh eer er Seen eek Terenas eee er eee eee ere kere 12 Condense PRN sxastiesieshcie ttaidis Siegen teaaciaatinahdenatsaddan Meadaanateaddos tea ieanot becca aateedcensteadcesendaan st iadeas neds 13 ACUVNGS ANIGHEN CIS oreren E tment tated anc melanin iced antluedanintacedant huceda nip tacedaniluttelenbauntclactabadae 14 Suggested Uses for Activities ANd EVENS senaera iian 14 Select Activities and
32. NT 1490 BURKE 1202 CHASE 2010 CONWAY T SelectAll HENRY IRENE LEATRICE THERESA CLARA THERESA BENJAMIN LORNA RALPH LILLIAN JUDITH DORIS BRENT MARGARET IMILLICENT ALLEN LILLIAN Edit Inoculation Library Inoculation Code BE Frequency Requirement One Time Only Every 00 Months Every 00 Years Optional Recommended Required Satisfies RCA Section T 1 e Influenza Satisfies RCA Section T 1 f Pneumococcal Page 36 Hi Tech Software Solutions EMR Features of the Clinical Records System Care Plans Clinical Nursing Care Clinical Res Care Asstd Lvg 03 16 2012 Sample Care Plan First Page Diagnoses Allergies problem list RESIDENT CARE PLAN HI TECH NURSING amp REHAB DIAGNOSIS SCHIZOPHRENIC DISORDERS OTHER SPECIFIED TYPES OF SCHIZOPHRENIA UNSPECIF DISORDERS OF CONTUNCTIVA CONTUNCTIVITIS UNSPECIFIED EPISODIC MOOD DISORDERS BIPOLAR I DISORDER MOST RECENT EPISODE OR CURR MULTIPLE SCLEROSIS SYMPTOMS INVOLVING HEAD AND NECE OTHER SPEECH DISTURBANCE DEFICIENCY OF B COMPLEX COMPONENTS OTHER E COMPLEX DEFICIENCIES TRIGEMINAL NERVE DISORDERS TRIGEMINAL NEURALGIA ALLERGIES TEGRETOL DISCHARGE PLAN COMFORT CARE Problem List 0014 Lillian requires assist in performing ADLs due to decreased strength associated with exten 0016 Lillian ia incontinent of bladder and is at risk for rash skin breakdown social isolatio RESIDENT NAME R
33. R visits falls infection flu etc You can assign user security to limit access to confidential health related Events records For example allow only Nursing and Administration to access Events while all clinical staff can access Activities Edit Resident Events Edit Event Detail by Resident MDE3 sident ID 1132 Enter or select a Resident ID Enter Diels the Date and Time of event Date 03 07 2012 Event ID Enter or lookup the Event Time 10 00 ID assigned through Events Library or enter the Alpha Code Event ID 0200 created for this event For example ER for Emergency Room Visit Reported By Name of person who Reported By Sally O Malley reported or recorded this event Comments Enter additional Comments MCE Ene EEE comments and or select from the ore ae Event Comments Library Fall without injury Click Add Note to add a Note Previous Detail as of 03 07 2012 related to the event to the resident s Progress Notes Date ID Time Description m 12 16 2010 0200 07 45 Fal m 02 20 2009 0100 15 00 IER Visit Review event records at the bottom of the screen To view or edit the comment for a specific record check it to display it on the screen for editing You cannot delete Event records You can inactivate records See Inactivate Resident Events on Page 26 G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 24 Hi Tech Software Solutions EMR Features of
34. Storage process using the SQL database with file encryption The Hi Tech Electronic Documentation Storage System Your Server 3 Documents folder Any where that users Can access Define location in Clintcal Company header Holds encrypted files Wit hin the Hi Tech System 1 From the resident s EMR Documents screen a Browse and select the document from the Temporary Holding Folder b Provide a description type and security sove the document The Hi Tech System enay pi and renames the document and moves it to the booume specitied under Libraries gt Facility gt Clinical Profile gt Screen 3 gt Medical Records Documents path The K Tech System saves the encrypted file s location D and resident tags to a SOL Database IMPORTANT Users who attach scanned document to residents EMR must have full Read Write rights to alll three locations El Temporary Holding Folder F Documents Folder ESOL Database G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 61 Hi Tech Software Solutions EMR Features of the Clinical Records System Set Up Requirements Hi Tech must set up Electronic Document Storage on your system for it to work as described on the following pages Please work with your IT staff to determine if you meet these requirements e ASQL Server or SQL Server Express free e The users PCs that accesses the database must have 1 The ability to run EXEs 2 a NET frame
35. Tech Software Solutions EMR Features of the Clinical Records System Design a New Report or Edit an Existing Report Design You must complete two screens when designing a report Screen 1 below allows you to select which residents will be included on the report and in what order Resident Reporting Pick Detail Report Select Sort Order Resident ID Active Residents Only Yes No Individual Resident ID Last Name Unit Room Bed Include Zero Admit Dates Religion Physician All Residents Yes No Birth Date Disch Residents Only Yes No Census Date Print Birthday List Birthday Month Primary Payor HIPAA Privacy Disclosure All Units Ea r Thru 9999 Log Non Care Purpose Use All Physicians From a 9999 Skip Residents without Authorization Admit Date Range From Thru Page Break on Resident Discharge Date Range Yes N From Thru All Groups From 1 Thru jog9 Double Space Number of Copies 1 Report Date 1 1 24 2009 Select the Sort Order that you want You will usually sort in Select Sort Order Resident ID alphabetic order by Last Name of in numeric order by resident Last Name ID Choose the other options depending on the type of Unit R Bed information you are printing Please note that selecting Birth eet tas Date sorts by the year born so oldest residents are listed first Religion Physician Birth Date Primary Payor If this is a list that will include protected health information PHI and i
36. al Comment Histo Vv 132 ADAMS HANNAH 05 10 2011 13 04 If necessary change the Date and Time Enter the vitals information Edit Res ID Time BP BP Pulse Temp Resp 02 Pain Non Glucose Add View Syst Dias Rate Sat Scale Verbal Comment Histo MW 1132 ADAMS HANNAH 05 10 2011 13 04 135 89 90 98 6 20 98 01 100 Pain Scale check mark Non Verbal if that is how Enter Vitals Comments level of pain was determined MAdd Comment to display the Enter Vitals ADAMS HANNAH Comments screen on right Enter comments for any Vitals recorded on screen 1 Click Ok to record the comments D Pulse Temp Resp Rate O2 Sat Pain Scale Glucose Height Weight Edema Scale Intake Output Click More Vitals lower right to display screen 2 On Screen 2 checkmark the resident and enter the i Cancel vitals information Ok Edit Res ID Name Date Time Height Weight Edema Intake Output Add View Scale Comment History 1132 ADAMS HANNAH 05 10 2011 13 04 54 128 0 1 oa r MAdd Comment to display the Enter Vitals Comments screen Enter comments for any Vitals Height you have recorded on screen 2 Weight Click Ok to record the comments Edema Scale EE lial intake Output G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 31 Hi Tech Software Solutions EMR Features of the Clinical Records System Documentation gt Vitals gt Enter Vitals View Vitals History Check mark View Hi
37. behavior cognitive decline no family involvement 528 Short term memory impairment resulting in wandering out of facility into others rooms forgetting essential ADL s frustration adverse behavior impaired social interaction 529 Grieving related to Loss of significant person independence home control over life situation functional abilities 530 Resident displays ineffective coping skills 531 Sleep pattern disturbance Poor sleep havits Change in sleep habits 532 Behavior management Resistive to care Diet eating bathing hygiene dressing taking medication ambulation 533 Intimidating behavior Makes others feel unsafe or at risk invades others privacy 534 Easily manipulated by others 535 Evaluation of behavior Monitor for behavioral changes frustration anger verbal abuse physical abuse threats resistance to care change in mental function G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 44 Hi Tech Software Solutions EMR Features of the Clinical Records System 536 Behavior Management__VERBAL ABUSE of others threatens screams at swears at unreasonable demands PHYSICAL ABUSE of others hits shoves scratches sexually abuses 537 Behavior Management Socially inappropriate or disruptive behavior sexual behavior disrobes in public smears throws food or feces rummages in others belongings makes disruptive sounds Activity Needs amp Recreational Issue
38. cordsSystem doc 11 2014 Page 32 Hi Tech Software Solutions EMR Features of the Clinical Records System Documentation gt Vitals Print Vitals NRH5 Select Print Vitals from the menu or by clicking the button on the Enter Vitals screen Print Resident Vitals Sel ao til oo P Do Residents Selected for Printing Print by Unit c 6 HANNAH ADAMS Enter Unit ID Print by Physician E c Enter Physician ID te Dates to Print All C Most Recent C Range From 00 00 0000 Thru 99 99 9999 Vitals to Print M All Vitals n 5 V C By Date e By Vital 7 Sort By Last Name Include Discharged Residents C Unit M Inactivated Vitals Only Select the resident s If you select individual residents each will be listed on the right side of the screen under Residents Selected for Printing Note that you can only select by Unit and Physician if you choose All residents Dates to Print All the Most Recent as of today s date or Range and enter a date range Vitals to Print in sequence By Date or By Vital Select MAII Vitals or uncheck All Vitals and select specific vitals Sort By if printing for multiple residents select Last Name or Unit Minclude Discharged Residents to include residents with a discharge date on EMR Demographics screen MI Inactivated Vitals Only See Page 34 for more information on inactivated vitals DATE TYPE 05 10 2011 Weight 05 10 2011 0 Temp 05 10 2011 Resp Rate 05 10 2011 Pul
39. cored questions within a scored assessment G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 51 Hi Tech Software Solutions EMR Features of the Clinical Records System Complete and Lock an Assessment If you have decided an assessment is complete checkmark MAssessment Complete Locked m Assessment Complete Locked amp Signed or MAssessment Complete Locked amp Signed if you allow electronic signatures and this resident has permission If all Questions are not answered and you select Not all questions have been answered Continue MAssessment Complete Locked or Locked amp Signed the screen will display Not all questions have been answered Continue Click to Continue The screen will display the message Completing this Assessment will Lock It OK e If you click Yes you will not be able to change this assessment l Eas Completing this Assessment will Lock It OK You will be able to view and print it e f you discover errors in a locked assessment you can Inactivate it See Page 56 e If you click Yes the program will allow you to schedule the next assessment of this type and it will be added to the resident s calendar You should understand how to use the Hi Tech Clinical Calendar if you plan to use this feature Buttons at Bottom of Screen cont To Fee Fo ee F Jes Cancel Do not save any of the choices or changes Add mode only OK Save all entri
40. d path and document will be displayed Favorite Links me Date modified AdmitOrders BCBSInsuranceCard mi SocialSecurityCard E Documents Ai Recenth Changed Add Document Select File C DATA WMR INFO 1 132 SocialSecurityCard pdf Enter a Description and select a Type from the drop down Type list Description Type Admission Contract Security Description Hannah Adams 5 card Type Admission Contract Advance Directives l Bills Statements Collection Notes Cost of Care Letters Doctor Notes Doctor Orders H and F Insurance Lab Pathology Nursing Notes Other Outside Comespondence Power of Attomey Receipts G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 64 Hi Tech Software Solutions EMR Features of the Clinical Records System security Select the type of users who should be able to view the Acre document Both Clinical and Financial Click Add The document will be added to this resident s EMR renamed ae using the resident s ID number and encrypted for security 3 Resident ID 1132 Resident HANNAH ADAMS File Description Type Added By Inactvate Date Added 1132_MR_SocialSec _ Hannah Adams SS card Admission Contract HTSt 5 11 20113 21PM NOTE The document will be removed from its original location You can only access it through Hi Tech Document Management How to Inactivate a Document You cannot delete documents that were
41. d selection This will print the most recent assessment date Several assessment dates will be included on the same page O Most recent Date unchecked will print all selected assessments on separate pages This could result in many pages of printed assessments Assessment Date All all assessment dates Range recommended Enter a range of assessment dates See a Detail Assessment sample on the next page See a Summary sample on Page 55 G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 53 Hi Tech Software Solutions EMR Features of the Clinical Records System Sample Detail Assessment Report Date avi0i2011 Risk for Falls Asmat Date ONDADI HI TECH NURSING amp REHAB 000 006 Resident is low risk ce ed Cognitive Status Mild Moderate Impairment Commant Wanders into othar residents r Medications Anti hypertensive Cardiotonic Paychoactiva History of Falis 1 2 falls in the past 3 months Resident ADAMS HANNAH Unit O07 Primary Physician KOK RANDALL Medical Record No 1132 Room Bed O35 17 Weer HTS G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 54 Hi Tech Software Solutions EMR Features of the Clinical Records System Sample Summary Assessment w Most recent Date Assessment Date All Range 7 11 20 thru 08 10 2011 User All C Individual Print Options Summary Include Assessment Key Report Date 08 10 2014 Risk for Falls
42. dit an existing assessment Modify will display at the lower left Q uestion A nswer C omment G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 50 Hi Tech Software Solutions EMR Features of the Clinical Records System Scoring As you select Answers for Assessment Fanges Questions the program displays the 0000 0006 Resident is low risk Acuity range score for each answer in the Score 0007 0018 Resident is high risk Follow falls protocol document in CP column The sum of the answer scores are displayed at Total Score right side of Score for each Answer Score for entire assessm ent 10 the screen You can compare the Total Score to the Acuity Ranges listed at the top right corner of the screen For example The Total Score of 10 displayed on the right would fall into the 0007 0018 high risk Override Score 00 range Total Score C Score Override Reason M Score Override Select this item if you want to change the score assigned by the program Provide a Reason For example When you do a BIMS or PHQ 9 assessment the resident might give you four or more nonsensical answers You can enter 99 as the Override Score to reflect the nature of those responses and to reflect the scoring you have also used on the MDS NOTE Define acuity Ranges in the Assessment Library gt Assessment ID gt Scoring Ranges In the library you can also designate non scored assessments and non s
43. doc 11 2014 Page 28 Hi Tech Software Solutions EMR Features of the Clinical Records System Documentation gt Vitals Enter Vitals Enter Vitals NRH3 The Vitals Date and Time will default to the current date and be recorded Vitals Date Eo with the vitals that you enter Time 11 38 You can change the date and time here or on the vitals entry screen for Resident to Edit All C Individual individual residents 7 Report by Unit All Individual Resident to Edit select All to list all E iaat naivicua residents on the Enter Vital screen ane If you select All you can then E select an lndividual Unit and enter vitals for residents on that unit The residents must already be assigned to that unit through the Census program or on the Demographics screen of Edit Medical Record Select lndividual Residents to select the residents for whom you will enter vitals These residents will be listed on the right side of the screen When you click the Edit button only these residents will be listed on the Enter Vitals screen Resident to Edit All C Individual Report by Unit All Individual Enter Unit ID Residents Selected for Editing 05 10 2011 B ADAMS HANNAH AKERS HENRY 11 43 amp Individual ME When you have made your choices click the Edit button G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 29 Hi Tech Software Solutions EMR Features of
44. e vertical scroll bars on the right side of the screen to scroll up and down through the report Click the up or down arrow to move one line at a time or click and hold on the movable button to scroll quickly G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 12 Hi Tech Software Solutions EMR Features of the Clinical Records System Condense Print MCondense Print A wide report with several columns will be condensed to fit on one screen and it might be difficult to read RAH V57 OTHER PHYSICAL THERSPY vaT OCCUPATIONAL THERAPY c70 l UNSPECIFIED AcuTE EDEMA 406 PREMMIONTA ORGANISH UNS Uncheck LICondense Print to expand the text DANIELSON Of544e975 F W 05r 0871918 84 360 C BAPTISTA oo 1 652125895 F W lof2Zl f1l926 76 70 E ERSTWHILE i m ena Condense Print Beginning ot Report Exit End of Report Pagelip PageDn Print Report Print Page larg B Panel Freeze Point Jump to Page 00014 of 004 You won t see the entire report so click at the bottom of the report to display the right side of the report A vertical dashed line indicates the viewing edge of the report RESIDENT LAST MAME FIRST MAME LE 50C SEC WO GEN MS BIRTHDAY AG l 1053795545 F H Oefloyflssd 6 fO 474 S544 oso A Panel Freeze Point To move this edge to see more text adjust using the up 4 and down arrows On the sample below we increased the Panel Freeze Point to display
45. eded 02 Leg brace 02 walker 04 wheel chair ru ci oo ra a Li om oo bho be oo oo G O W hae a a Ho oG ENH a mT i BUESTION OF Vision ANSWER 01 Good AHSWER ANSWER QDUESTION O08 Incontinence ANSWER Ji Hever ANSWER 02 Less than daily ANSWER 02 Daily G g gd bo bo eo ba be contact lenses 02 Wears glasses 02 Poor 7 Hlind D i hae pi Documentation gt Clinical Assessment gt Inactivate Assessments NREO Inactivate assessment that should not be an active part of a resident s EMR IMPORTANT A User can only activate assessments entered under his her User ID Print Assessment Exceptions NRFO Display and or print a list of the assessments that e have been Inactivated e are not yet Locked G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 56 Hi Tech Software Solutions EMR Features of the Clinical Records System Documentation gt Notes Notes The Notes programs allow your staff to record Notes to document residents care status behavior activities etc Print Notes Library NR34 Print Notes Library If you have not used the Notes programs yet print or display Sapori naig the Notes Library to see what it contains You can delete records that you won t use Discipline All Individual If you have already built a library this list could be several pages Y
46. eeeeseeeesseeeess 43 GMC IAS SESSMENT 46 G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 1 Hi Tech Software Solutions EMR Features of the Clinical Records System ECE PASS O SON eree ce co eaticne eet ee eacete ete yeesae cee t deat Pecans E E eta oeekente cet eee tene Se TO NMG cea pe ne pe E A A steno E T E E dose ueadsentmenddesstnsdesstesndseaunndeestianisecemancesatiessasiaiered Complete and EOCKk an ASSESS MEN ipana EENE Print Assessment ccccccceccecceceeeeceeeeeeceeeseeceeesecaeeseeseeesaeeeeesaeeseesaeeseesaeeseeseeeseesaeeseesseeseeeseeseesseeseeeaes WiC IV ANG is SCS SNM CIN Sess cc sca t cas ceeessuatnsccuecrnssSaceceasacecragesunhanecautceasaseoteessspseeusssucesecesuseeanssueaeasecusdeuseas Print Assessment EXCEPtiONS ccccecccececeeeceeecececeeeceeeceueceeeceeecseeceueseueceeeseeeseeeseueteeeseeeteeeseeetseeneeenes IS rece ectce a sect sent aonb a eee Postage e a steed aut e a a a Ea PNMUINOteS CID AI ceas E EENG SLID IY e E tees eteanana decunnebiennanateconneteaanaatecunpayienaen EO I NOUS Ga E E E E E E E E E E E A DOCUMENT StOrage cccccccccsecccsecccceeecceneecceeecceneesceeescesescaecesceaeesanecsceneecseeesounesceneescenesceeeesoueesceaessceaeseeeesoeees Electronic Document Storage SYStOM ccccceececseeeeceeeeseeeeceeeeceeeeesaeeeseeeessaeeeseeessaeeeseeeesaeeesaeeeseeeesaes oy 8 R GUE 10 gt te en ee ee eee Add Documents toa Residents EMR te cicca
47. em and then check it again to add it to the end of the order G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 8 Hi Tech Software Solutions EMR Features of the Clinical Records System To print or display the selected records Does not save the design End To end the program without printing To remove selections from Screen 2 so you can choose again List Choices To print a listing of the items on the screen To save this report design When saving a report design the program first lists the Code 20 existing report designs Enter a Code not yet in use 20 Character Description and the description of the report for example Click Save The program will ask if you want to print the report now f i Penort Saved Do vou want to orint it now The next time you run this program the saved report will be p A T AE available for selection Resident by ID numbe Residents Last Name Residents religions Yes No All birthdays December birthdays PAYMENT NUMBERS G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 9 Hi Tech Software Solutions EMR Features of the Clinical Records System Other Face Sheet Reports Reporting gt Face Sheet Reporting Transfer Form Print this 2 page form and send it with a resident s other records when they transfer to the hospital or other facility The form combines information recorded on MDS and RCA records face
48. ent RCA J7 Accidents a Fell in past 30 days and b Fell in past 31 180 days Tracking and Reporting Falls in the MDS and RCA Define a Falls event through Libraries gt Documentation gt Activities Events Library Check MSatisfies MDS J1800 3 0 or MSatisfies RCA Section J 7 a b 1 Record Falls on dates that they occur Documentation gt Events gt Edit Resident Events 2 Complete resident s MDS 3 0 Edit MDS or MDS RCA Edit RCA 3 In Edit MDS click Pull J1800 Responses from Event Detail View the recorded falls 1800 Any Falls Since Admission or Prior Assessment 0 No OBRA or Scheduled PPS 03 07 2012 Fall 03 07 2012 Fall Pull J1800 response from Events Detail gt 12 16 2010 Fall 4 In Edit RCA click Pull J 7 a b responses from Event Detail button If the program finds Falls records dated within 30 and 31 180 days of the Assessment Start Date it will check mark J7a and or b 7 Accidents a b T Fellin past 31 180 days Pull J 7 a b responses from Events Detail G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 17 Hi Tech Software Solutions EMR Features of the Clinical Records System Libraries gt Documentation gt Activity Comments Library MD89 Events Comments Library MDE5 Create standardized Comments that you can add to Activity and Events records Example Activity C ts Edit Activity Comment Library xample Activity Comments Description
49. ent has difficulty making self understood due to The resident has an alteration in hearing as evidenced by The resident requires up to____ assist in performing ADLs due to list diagnosis amp specifics Decreased independence with ADLs due to The resident is incontinent of bladder due to and is at risk for rash skin breakdown social isolation infection etc The resident requires the use of a Foley catheter due to and is at risk for infection The resident is at risk for signs and symptoms of dehydration due to The resident requires special attention to oral care due to The resident has multiple risk factors for falls such as History of falls The resident requires to be fed via tube due to ___ and is at risk for complications such as dehydration aspiration infection Use of a feeding tube required related to history of impaired nutrition The resident is at risk for the development of pressure ulcers due to list all risks and diagnoses The resident has an open area location Resident unable to perform own dental oral care The resident requires the use of an anti anxiety due to and is at risk for adverse reactions The resident requires the use of an anti depressant due to ____and is at risk for adverse reactions The resident requires the use of an anti psychotic due to and is at risk for adverse reactions The resident requires the use of a sedative hypnotic due to _ and is at risk for adverse reactions
50. eport Date 03 07 2012 Resident All C Individual All Range From Thru Page Break by Resident Select the items you want to review and click Print DATE 03 07 2012 INACTIVATED RESIDENT EVENTS HTS MDE9 PAGE 1 DATE TIME EVENT INACTIVATED BY DATE REASON 03 07 2012 10 08 0300 Infection HTS 03 07 2012 lab negative no UTI G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 27 Hi Tech Software Solutions EMR Features of the Clinical Records System Documentation gt Vitals Residents Vitals You can record residents Vitals through the Documentation menu shown below Clinical Nursing Care Date 03 1 A5 Demographics Resident ID 1132 Demographics HIPAA Contacts p Prefix v Consent Insurance First Name Hannah Authorization gt Physicians Diagnoses Middle Name J Last Name Adams i ss s Gender M F Female E at Neuere Dir Other Suffix Marital Status Married Attach Picture 2 Tane MRSA Race 5 White not of Hispanic origin M Order Flowsheet Kardex Click the button to launch the Enter Vitals program See the next page View Vitals from Edit MDS and Edit RCA Hi Tech has added Wiew Vitals buttons to the following programs e Edit MDS gt Section I J and K e Edit RCA Maine amp Vermont gt Section I J and K and import Height and Weight G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem
51. es on the screen Return to Resident ID for next entry NOTE If the assessment does not have any answered questions it will not be saved End Save all entries on the screen and return to the menu Print Launch Print Assessment The displayed resident and assessment will be selected for printing See Page 53 Notes Launch Edit Notes for this resident to enter a Progress Note related to this assessment TIP To help you organize Assessment Progress Notes you can add the notes under specific Discipline codes Please see instructions in the Clinical Records System User Instruction Manual gt Section A gt Documentation gt Edit Notes G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 52 Hi Tech Software Solutions EMR Features of the Clinical Records System Documentation gt Clinical Assessment gt Print Assessment NRE9 Print Resident Clinical Assessments Repor Date 08 10 2011 Resident All Individual Unit amp All Individual o Assessment All Individual ry w Most recent Date Assessment Date All Range 07 11 2011 thru 08 10 2011 User All Individual Detail w Print Comments Summary NOTE Make selections carefully to avoid printing unwanted pages select the Residents by ID number or by Unit You can click on the Edit Resident Clinical Assessment screen to print the selected resident and Assessment displayed on the edit screen M Most recent Date Recommende
52. gies 560 INCONTINENCE requiring scheduled toileting plan due to Urinary incontinence stress incontinence stress functional dementia urge Bowel incontinence 561 Tendency toward DIARRHEA related to Medication Loss of part of intestinal tract Intolerance to certain foods Excessive consumption of lleostomy ___562 Anti Coagulant Therapy Specific observation and prevention of complications ____569 Potential for injury related to TOBACCO abuse and safety related to smoking Miscellaneous Issues ____ 5 0 Health maintenance amp related issues ____571 Discharge planning assist needed for preparations to live independently ____ 574 Supportive Care Comfort measures 575 At high risk for FALLS because of dizziness unsafe habits poor vision confusion dementia balance problem G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 45 Hi Tech Software Solutions EMR Features of the Clinical Records System Clinical Assessments Clinical Nursing Care or Clinical Res Care Asstd Living gt Documentation gt Clinical Assessments qua Clinical Nursing Care Date 08 10 2011 Edit and create Assessment templates Libraries gt Documentation gt Clinical Asmnt Library Hi Tech has defined and provided the following Clinical Assessment areas in the Clinical Assessments Library You can edit and add your own assessments through Libraries gt Documentation gt Clinical Asmnt Library
53. gt Resident Clinical Br es NRPK Pick Detail Screen 1 Resident by ID numbe 2 Residents LastName 3 Residents religions 4 All birthdays 5 December birthdays Custom Reporting NRPK You can design listings of information that you have entered into residents face sheets for example e Resident names and room numbers Birth dates and age Religions Medicare and Medicaid numbers Admit and discharge dates If you have already created and saved report designs the program will first display a list of these reports on right E g F 2 F z p 7 7 2 a i To print a report listed on this screen click the checkbox in front of the report name to check mark it Iw 1 Resident by ID numbe Select Reports from the above list to print You can select more than one Build a New Report Click at bottom of the screen Select Reports from the above list to Delete or End Delete To design and print a new report a an eee click New Report See the next page na i ies Csi A eae To delete an existing report design select report title and click Delete To change an existing report design select that report and click Edit The report will display the existing report design screens for you to change and record See the next page Click End to end the program without printing G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 5 Hi
54. h Time 14 56 Activity ID 0001 Bingo Activities Library or enter the Alpha Code created for this event For example BP for Birthday Party Length 0046 Length amount of time the activity activities stat OSOS S took if it differs from that recorded o akin in the library Participated op Add Note Comments Attended with encouragement Instructor Input from the Activity prm PRETE RSE Library record or manually entered MParticipated Leave checked if resident participated Uncheck if the resident was offered the activity but declined to participate This helps track staff intervention with residents whose care plan goal is increased participation in activities Comments Enter additional comments or select from the Activity Comments Library Add Notei to add a Progress Note related to the activity Previous Detail as of 03 06 2012 Date ID Time Description Review activity records at the bottom of the pozzo 0011 13 34 ndividualActvty S S S S screen on right Select an activity too view 0972272011 0003 10 00 Morning Stretch or edit the record 09 20 2011 0003 10 00 Morning Stretch You cannot delete Activity records You can 09 20 2011 0011 Individual Activity inactivate records through Inactivate 12 16 2010 0003 o9 00 _ Morning Stretch Resident Activities See Page 22 09 15 2010 0003 09 00 Morning Stretch 07 01 2010 0003 08 15 Morning Stretch G HITECH Webinars Webinar
55. he IMAR Medication Administration Screen from which you will perform the med pass IMAR Medication Administration Record Screen The screen will display the resident last displayed before exiting the IMAR system You can select and deselect Show Administered top right of the med list to display or hide meds that have already been administered NOTE When you log in the med pass defaults to the current pass time The Administration screen displays orders scheduled for that med pass If not correct select correct Pass Time from the drop down list at the bottom right IMAR Medication Administrati rkshir r Ow p SAMUEL CLEMONS MARK TWAIN ad Be By m JS Ch Wing B WNG ID 33333 Resident Orders Check In Reports Tools Administer Lock Exit Rm Bed 129 A DOB 11 30 1910 Current User Hitech Hitech i sande ltl l Alerts FULL CODE _ Administrations List Notes WILL WANDER OUT IF NOT WATCHED MAY SIT OUTSIDE IN THE EVENINGS CRUSH MEDS Allergies NO KNOWN ALLERGIES Order Type All Orders C Med Orders Treatments Tasks Show Administered Schedule Status Time Drug Order Start Date 04 19 12 00 PN PP FUROSEMIDE 80 MG TABLET 05 29 2008 04 19 12 00 PN PP RISPERDAL 0 25 MG TABLET RISPEF 05 29 2008 04 19 01 00 PN PP REGLAN 5 MG TABLET METOCLOPR 05 29 2008 04 19 02 00 PN PP DILTIAZEM ER 180 MG CAP SA DILTL 05 29 2008 ACETAMINOPHEN 500 MG TABLET PRN 05 19 2009 DARVOCET N 10
56. ical Records System Sort By Reference Number 3 Enter the Assessment reference Display Favorites Only number Click the binoculars icon to list and select an Assessment shown on right 4 Sort By Reference Number or Assessment Title BIMS Brief Interview Mental Status Bowel and Bladder Training Contractu re Risk Nutritional Risk hile 5 Status l PHQ 9 Mood Interview F Favorites Risk for Dehydration Inactive Risk for Falls Skin Risk Assessment C Reference Number Alpha by Title w Display Favorites Only TETT ME PL LaLa LL Lad D a io kkk 6 Select M Display Favorites Only to display the Assessments flagged Title Status as Favorites in the library BIMS Brief Interview Mental Status F 7 The screen below displays Assessment 001 Risk for Falls O 95 PHQ 9 Mood Interview F Resident ID 1132 ADAMS HANNAH DOB 06 10 1938 View Assessments on File Ranges 000 006 Resident is low risk Assessment 001 Risk for Falls Acuity range defined for this assessment in the Date I amp assessment library Compare to Total Score ona User iis ID noton Fie Complete Assessment Questions Answers Q Cognitive Status Questions defined for this assessment in the library Total Score 00 l Score Override Override Score 00 Reason Q Appliance in use at this time al Q uestion A nswer C omment Assessment Complete Locked G HITECH Webinars Webinar Docs EMR C
57. isplayed in the resident s activity record Date 03 06 2012 To view inactivated activities click Prini See next page Time 15 02 Activity Movie amp Popcorn Instructor Activities Coordinator Reason for Inactivation sleeping did not attend Inactivate G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 22 Hi Tech Software Solutions EMR Features of the Clinical Records System Select through Documentation gt Activities gt Inactivate Resident Activities Print Inactivated Activity Report Print Resident Inactivated Activity Report Report Date 03 07 2012 Resident All C Individual All C Range From Thru Select the items you want to review and click Print DATE 03 07 2012 INACTIVATED RESIDENT ACTIVITIES HTS MD97 PAGE 1 NAME DATE TIME ACTIVITY INACTIVATED BY DATE REASON 09 22 2011 15 29 0004 Movie amp Popcorn CRE 03 01 2012 ill did not attend 02 29 2012 09 36 0001 Bingo CRE 03 01 2012 out of facility did not atten 03 06 2012 15 02 0004 Movie amp Popcorn HTS 03 07 2012 sleeping did not attend G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 23 Hi Tech Software Solutions EMR Features of the Clinical Records System Documentation gt Events gt Document Residents Events Edit Resident Events Print Event Report Inactivate Resident Events Hi Tech suggests that you use Events to record health related items such as E
58. it Break Total on Unit Double Space If you selected another sort order for example Unit Room Bed the screen will display the options to the right Clicking Page Break and Break Total on Unit is a good idea because it will print each Unit on its own page making the report easier to read Number of Copies Report Date 06 07 2012 Click to display Screen 2 On Screen 2 select the columns of information that will be listed on the report Sorted by Last Name Space Left 122 Select up to 10 items for Detail Line 01 RESIDENT ID WARNING Items will be printed on the report in the 02 LAST NAME order shown below 03 FIRST NAME 04 LEVEL OF CARE Selection Order 05 SOC SEC NO 1 RESIDENT ID 06 GENDER 07 MS CODE 08 BIRTHDAY 09 AGE 10 RELIGION 11 PARISH 12 N A 13 IDEAL WEIGHT 14 N A 15 N A 16 N A 17 NIA 18 PRIMARY DR amp 2ND 19 1ST 8 DIAGNOSES 20 1ST 2 ALLERGIES 21 PREV ADDRESS 1 22 PREV ADDRESS 2 _ Run ff enc List Choices Sorted by lists sort order selected on Screen 1 xl z z a E m z 2 z z Space Left indicates how much space is left on the page from left to right margin for information to be printed each time you select an item Click an item to check mark it M 01 Resident ID Selected items will be listed under SAIA iake Cl in the sequence selected Column headings will be printed in this same order To change the order you can uncheck an it
59. line Be Ey selected as Face Sheet in Edit Notes a If the code you want to use does not appear in the Inquiry S list of codes add it to the System through Libraries gt Library Face Sheet gt Disciplines Library Enter a number that will identify this note HTS recommends that you begin with the number 2 or 5 and then number the items by 2s 002 004 006 008 or 5s 005 010 015 020 This will leave space between records so that in the future when you add new records to the library they can be inserted between existing items to keep related items together Discipline FS FACE SHEET The sample on the right is a note template record that can be used to Library 4 document residents emergency room visits In Edit Notes pull this template into a resident s notes records and then completed with the required EMERGENCY ROOM VISTTS information TO WHICH HOSPITAL DY le H When you are satisfied with the content of the note record click OK Scere ee eevee RETURNED TIME EMERGENCY ROOM VISITS TO WHICH HOSPITAL RETURNED DATE RETURNED TIME G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 58 Hi Tech Software Solutions EMR Features of the Clinical Records System Documentation gt Notes Edit Notes NR32 IMPORTANT You cannot delete notes but you can inactive them through Inactivate Notes Use this program to enter and edit the following types of notes on re
60. linicalRecordsSystem doc 11 2014 Page 48 Hi Tech Software Solutions EMR Features of the Clinical Records System 8 Date Enter or select the date for a new assessment or existing assessment that is not yet Complete Click to list and select existing assessment NOTE You can create multiple assessments on the same date Status los 10 2011 HTS 08 04 2011 HTS e You can edit assessments until they have been Locked e You can view but not change Locked assessments e View History will display assessments entered by all Users You can view the answers of another User s assessment but you cannot edit or lock another User s assessment i i ti IA E Select Answer s to Question 9 After you enter or select a Date the screen will display ee each Assessment Question Q so you can select the one you want to answer or edit on the right 10 Checkmark the Answer to that Question m E EE E NOTE In the library you can set up Questions to allow for multiple Answers shown on the right Q Mobility Independent Enter a comment if necessary With Assist The following screens show the selected Question Answer and Comment Immobile Assessment Question E Select Answer s to Question 01 cognitive Status Select One Answer Intact Answers defined for this Severe Impairment Question and the acuity m Mild Moderate Impairment score for each answer Comment Wanders into other
61. ll previous Activities Events records became Activities To transfer Event type records out of Activities into Events please contact Hi Tech Support We will help you transfer both library items and actual detail records into the Events category Activity Comments Library CAUTION Do not Inactivate Event records in the Activities Library and then recreate them in Events Contact Hi Tech for assistance in transferring these records Inoculation Library Event Library Notes Library Event Comments Library Activities Library MD84 Build a library of the Activities that you want to track for your residents When you record an actual activity select the item from the library This helps to keep your activity records organized and standardized for reporting and analytical purposes Edit Activity Library Activity ID 1 Description Alpha Code Length 00 45 Instructor Activities Staff Satisfies RCA Section N 4 a Cards other games Activity ID Assign ID numbers Enter the Description Alpha Code a short hand for an activity Example BP for Birthday Party In Documentation gt Activities enter the Aloha Code and the program will look up and display the event Provide the Length HH MM of time for a typical session of this activity Specify the Instructor satisfies RCA Section N 4 Maine only Select the RCA item matched by this Activity In Edit RCA at N4 General Activity Preferences when you select Impo
62. llows __ Indefinite stay indicated Discharge to another Setting is under consideration See social service notes for details Problems goals approaches and discharge plan reviewed Date 7 f and contime to be appropriate The following problems have heen added to the current plan of care f Review all problems in months RESIDENT MAME RESIDENT Ho ROOK HO ADMIT DATE BIRTH DATE AGE PHYSIGCLAH BARMETT LILLIAN W 1566 O46 2 Na 042008 08081919 J7 BARKLEY WILLA M DATE PAGE ALL ENTRIES MUST BE IN INK THISIS A PERMANENT PART OF THE HEALTH RECORD qo Cd G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 40 Hi Tech Software Solutions EMR Features of the Clinical Records System Nursing Care Problem List 1 2 3 4 10 11 12 14 15 16 17 19 21 23 24 28 29 30 31 33 34 35 36 38 41 42 This resident suffers from delusions due to As evidenced by Probable delirium as evidenced by confusion and disorientation The resident has impaired short term memory due to The resident suffers from the progressive cognitive and communicative deficits associated with Alzheimer s Disease Resident has memory problem impaired decision making skills and impaired ability to comprehend The resident has decreased vision specify and is at risk for complications The resident has difficulty making self understood due to dementia difficulty being understood The resid
63. needed Goal oo02 Date 0871572010 Target 1L1 O 2010 Resident will be able to trun self while in bed and call for assistance when needed Approach 0010 Disciplines N MNA Resident ubilizes l a side rails on bed to help position self while in bed Approach 0011 Disciplines N MNA Keep call bell within reach Approach OO12 Disciplines N Wa Encourage resident to request assistance when needed RESIDENT NAME RESIDENT HG ROOM HO ADMIT DATE BIRTHDATE AGE PHYSICIAN BARNETT LILLIAN 1566 046 050412008 080811919 92 BARKLEY WILLIAM DATE FAGE ALL ENTRIES MUST BE IN INK THIS 15 A PERMANENT PART OF THE HEALTH RECORD 1110112011 02 G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 38 Hi Tech Software Solutions EMR Features of the Clinical Records System Problem with two goals and approaches attached to both of the goals HI TECH HURSIH G amp REHAB Review Datel Signature Problem Goal Approach Problem 0016 Date 0871572010 Type Active Lillian is imontinent of bladder and is at risk for rash skin breakdown social isolation infection etc Goal 000l Date 0871572010 Target 11707 2010 The resident will have no skin breakdowms or odors Thru next review Goal 0003 Date 0871572010 Target 11707 2010 Resident will remain free of infection Thru next review Approach 000l Disciplines N Wa Assess for canses of Urinary incontinence Approach 000Z Disciplines N Wa Encourage
64. new living environment am not used to having so many people around or having a roommate and miss my own home 330 prefer self directed activities such as 335 no longer remember things so cannot communicate my needs When this happens become agitated Medical Management Issues 350 have a history of having UTI s due to __ Poor hygiene habits _ Poor fluid intake _ My catheter Diabetes Mellitus ____ 353 have high blood pressure and need your support to follow my Doctor s recommendations ___ 355 do not always tell people when am uncomfortable or in pain _____35 have had some rashes and sore areas in the past ____ 361 1 have a high risk for injury because of my _ dementia __ seizure disorder _ restlessness 362 My mobility is impaired because can not understand or follow instructions Due to _ Stroke Dementia Mental Status 363 am legally blind and I have been told that my decisions are not always safe As a result have fallen a lot and been hurt 375 often refuse to participate in activities and stay in my room because am in pain G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 43 Hi Tech Software Solutions EMR Features of the Clinical Records System Using Traditional Language Assist with ADL IADL 500 Resident needs assist with bathing personal hygiene oral hygiene dressing undressing 501 Resident needs assist with toileting personal hygiene
65. nt ID Types to Print C Allergies C Doctors Advance Directives l Include Discharger G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 11 Hi Tech Software Solutions EMR Features of the Clinical Records System Reporting Options Print Display Create File Most Reporting programs will display in the following format and provide options to print a paper copy DILLINGHAM LORRAINE J DRAPER DELILAH J GENTRY ARIANNA G GILESPIE LILLIAN F GUNDERSON JEREMIAH M JAMES HANNAH P KETCHUM VERNETTA G LANCASTER YVETTE LANDRY CONSTANCE L E c M Condense Print Beginning of Report Ext End of Report PageUp SS S Print Repot Print Page Jump to Page 0001 of 0003 Top Margin PageDn Create File Left Margin Print the Report Make your selections on the program screen Click Ok or Print The report will be displayed For example RITA M EA y lC Condense Print Beginning of Report Exit End of Report PageUp Print Repot Print Page Jump to Page 0001 of 0003 Top Margin PageDn Create File Left Margin File Path Name Click the Print Report or Print Page buttons on left to print to paper all or portions of the displayed report The report will remain on the screen To view other parts of the report Click or to move directly to the top or bottom of the report Click to move up or down one page at a time Use to move to a specific page of the report Use th
66. ou should display the report first to see how long it iS Page Break by Discipline To display or print the entire library accept the default response of All for each item Click You can also select specific items by choosing Individual and then clicking to select that item from the list that is displayed G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 57 Hi Tech Software Solutions EMR Features of the Clinical Records System Libraries gt Face Sheet gt Edit Notes Library NR49 You can write Face Sheet Nursing and Progress Notes through Edit Medical Record gt or through Documentation gt Notes gt Edit Notes Build a Notes Library of frequently used Notes text or formats You can copy these items into individual resident s records and edited to suit that resident Spend time deciding what kind of notes you ll record in your notes library A well designed library will make it easier to write and manage notes Here are some suggestions 1 Begin with the items that will be common to many residents Set these up in the order that you would like to see them on a printed record in the chart 2 Don t put highly individualized items in the library Enter these in residents notes as needed Discipline code is optional You can assign a code for the Edit Note Library staff discipline that will use this kind of note or you can select FS for Face Sheet if note of this type will be Discip
67. rceacadenctccncsenciandenetssaacursuendacanauatuatsunataeametncentosepiaeaoiacersseeite FIOW to Inacivate a Document ssssrissnia nA EAA ANANASA How to Reactivate a DOCUMEDNM cccccccecceecceeceeeceeeeeeceeaeeceeeeeeceeseecaeeseeceeseeseeseesseeseeeeeeseeseeseegaes How to Move a Document added to a Wrong ReSICEN1 cc cecceecceeeeeeeeeeeeeseeeeeeeeseeeeseeseneeseeeneeeeaes The IMAR Electronic Medication System cccccccccssececeececeeeeeceeeeceeeeesueeeseucessaeeeseueessueeeseueesseeeseeeesseeeseas IMAR Medication Administration Record SCreen cccccccccsecceseeeeceeeeeeeeceseeeseeeeeseeeessaeeeseesesseeeseeeesaneeeas Electronic Signatures As you move towards more electronic documentation and signature in Hi Tech be sure that each staff person s User ID record also includes credentials that should be included with the electronic signature Your System Administrator can access to these records through Utilities gt System Structure gt Maintenance gt User Security User ID In the Full Name field add the credentials after the last name as shown on the right Full Name LM regeo aaa Job Title In the IMAR System enter the credentials in the Title field as shown below Login don Last Name DON First Name Ima Initials DON Title RN G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 2 Hi Tech Software Solutions EMR Features of the Clinical Record
68. related to toileting managing incontinent Supplies 502 Resident needs assist with eating 503 Resident needs assist with safe transfer 504 Needs supervision or assist with mobility or locomotion to ensure safety in environment by Improving stability in ambulation Maintaining current status of mobility Reduction of hazards of immobility _____ 505 Needs assist with ADL functions due to limited mobility of arm hand ____511 Needs assist with telephone use ____514 Needs assist with managing finances Handling cash making purchases Banking checkbook amp writing checks reconciling checkbook keeping cash safe _____516 Needs assist with arranging shopping making list obtaining help ____518 Needs assist with transportation making arrangements keeping appointments 519 Needs assist with safe medication procedure preparation administration documentation tracking obtaining securing social amp Emotional Issues amp Behavioral Symptoms 524 Monitor amp evaluate for behavioral symptoms Frustration anger verbal abuse threats physical abuse resistance to care change in mental functioning 525 Support needed to adjust to new environment adjust to change in life situation maintain contact w family amp friends 526 Emotional disturbance which hinders functioning anxiety agitation isolation depression crying calling out fear 527 Social isolation related to depression hearing deficit withdrawn
69. rt General Activities this item under N4 will be checked if the resident participated Note that you should also consider the resident s preferences when answering N 4 Minactive You can no longer delete Activity records from the library You can inactivate them This will retain the residents detail associated with this item G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 16 Hi Tech Software Solutions EMR Features of the Clinical Records System Libraries gt Documentation gt Events Library Edit Event Library MDE1 IMPORTANT if you had established Event records in the Inactive Event ID 100 previous Activities Events library and you want to transfer these records into the Events library call Hi Tech Support for assistance Enter the Event ID and Description This helps to keep your records organized and Standardized for reporting and analytical purposes Description Saauei Alpha Code ER Satisfies MDS Section J 4 a b 2 0 or J1800 3 0 Satisfies RCA Section J 7 a b Alpha Code a short hand for an activity or event record Example ER for ER Visit When you record an event through Edit Resident Events rather than look up the event ID enter the Alpha Code The program will look up and display the event Does this Event satisfy the MDS and RCA questions indicated See Tracking and Reporting Falls below MDS 3 0 J1800 Any Falls Since Admission or Prior Assessm
70. s Delete Cancel Click the binoculars to select a resident You can then edit several parts of a resident s clinical record from the button panel on the right side of the screen Demographics Contacts The top five buttons access parts of the traditional Face Sheet Insurance Physicians Diagnoses Allergies Adv Dir Other Other buttons access information that you can also maintain outside of Edit Medical Record by selecting an edit option on a menu for example Documentation gt Vitals Vitals If you select the button from the Edit Medical Record when you complete processing in that record the program will return you to the resident s Demographics screen Order Flowsheet Kardex Clinical Assessments ad a Care Plans Your System Administrator can limit which users can access certain information Call HTS for assistance Activities Events inoculations For Surveyors or users who can only view Medical Records see the next page Calendar Notes Documents Stay Tables Patient Liability Data G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 3 Hi Tech Software Solutions EMR Features of the Clinical Records System View Medical Record Use this method to provide view only access to Surveyors and users who can view and not change the Medical Record From the Clinical Menu select View Medical Record This will displa
71. s 539 Motivational activities needed to 540 Need for participation in activity program specifically group activity resuming former hobby or interest socialize with peers community involvement motivational activities diversional activities Communication ___545 Impaired hearing vision resulting in ____546 Impaired communication difficulty expressing self understanding others following directions making needs known Medical Management Issues 550 At risk for INFECTIONS UTI URI SKIN UTI risk due to HX of UTI Poor hygiene habits Poor fluid intake Catheter Diabetes Mellitus 551 Impairment of skin integrity Incontinence poor circulation poor hygiene habits 552 Ineffective breathing pattern related to COPD 553 Hypertension med controlled at risk for orthostatic hypotension 554 Seizure disorder at risk for injury 555 Tendency toward constipation Poor fluid intake lack of activity chronic constipation psychological factors medication 556 Pain or discomfort Chronic acute or sporadic Arthritis headache joint pains generalized discomfort phantom pains abdominal discomfort 557 Special care required due to diabetes mellitus Special diet foot care exercise regimen complications of insulin therapy ____558 Recent weight loss Due to medical problem depression ill fitting dentures mouth pain 559 Dietary limitations related to diabetes mellitus gastric problems medications food aller
72. s System Admission Procedures gt Edit Medical Record NRO3 Edit Medical Record accesses traditional face sheet information and parts of a resident s clinical record that can be maintained outside of the Edit Medical Record program Haw Demographics Resident ID Prefix 223020200 Insurance 909S EEES EEEIEI EEE EAEE NENANA First Name a SS IN EEES 505 Gi 28ST Physicians Diagnoses SoS rates x ran BSNS OEE Xx 55 i Demographics SoS ecb tatrtcte es 2 gt Se S52 2 raters O05 es SORES Contacts EREE S550 se estat lt gt S lt gt gt gt S52 S OY 2 2 S555 ae res oe es res res e oS rates lt 5 gt gt 6 SS re S EEA es re S RS 625 res 25 3 lt gt 2 S S55 SSS Middle Name Last Name Gender M F OY SS Allergies Adv Dir Other e Suffix Marital Status Vitals Nickname Race Order Flowsheet Kardex Preferred Name Clinical Assessments Social Security No Level of Care Canadian SIN Care Plans Ey A gt aire i al Activities Events Date of Birth a o Unit Phone Inoculations Group Id s 0 0 0 ees wok Calendar Notes Admit Date Discharge Date Time Time Source Status Patient Liability Data City To County Balances Original Admission Date Documents Stay Table
73. se 05 10 2011 Pain Scale 05 10 2011 0 02 Sat 05 10 2011 Height 05 10 2011 30 Glucose 00 reduce sugar intake 05 10 2011 Edema Scale low salt diet 05 10 2011 BP 135 89 G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 33 Hi Tech Software Solutions EMR Features of the Clinical Records System Documentation gt Vitals gt Inactivate Vitals Inactivate Vitals NRH4 If you enter inaccurate vitals information you cannot change it You must inactivate ResidentID 1132 ADAMS the information Select the Resident Dates All Range From 00 00 0000 Thru Dates select All or Range and enter a date range Vitals M Blood Pressure M Glucose Select the type of Vitals you need to liga Pisa inactivate The selected items will be ol bass ee ne dieolaved C Respiratory Rate C Edema Scale ISplayea T O2 Sat T Intake Pain Scale M Output User HTS inactivate Vitals Resident 1132 HANNAH Pick Date Time User Type Reading Reason for Inactivating m 05 10 2011 13 04 HTS Pain Scale 1 Checkmark the vitals to be inactivated and enter a Reason for Inactivating required Pick Date Time Jse Reading Reason for Inactivating v 05 10 2011 13 04 HTS Pain Scale You can re enter correct information through Enter Vitals to replace the information that you inactivate G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 34 Hi Tech Software Solutions
74. sidents conditions activities behavior etc e Face Sheet Notes previously recorded on Edit Face Sheet gt Notes screen e Nursing and Progress Notes and other types of notes that you define in the Note Library e Secure Notes i e Complete Notes e View MDS 3 0 and CAA Notes recorded through MDS Care Plans gt MDS gt Edit MDS A Edit Resident Notes Resident 1301 MARGARET BRYANT iene HTS as Type Progress 2 Nate Comniete Lacker Face Sheet pe Choose Note Type Select standardized text from library Date ype nme E Time 09 54 Page 1 Discipline Add new notes here Next Page Click binoculars to display Note Inquiry See next page E juice at breakfast but Margaret grew agitated Aide gave her juice to calm her After lunch she was assisted to her room but she was confused about its location She asked where her TV was and that she wanted to watch TV She would not go to the activity room to watch TV She was so agitated that we called daughter Mary Joe who came to visit Margaret After visiting with daughter and napping Margaret was calmer and no longer confused about time of day and where she is Add Note Existing Notes F View Discipline Snly C All Progress C Face Sheet C CAA C MDS EA er ages View All or select a Type of Note I Use scroll bar on right to scan through Notes When you select a Resident if the restaent nas exsmg nores me TIrst More or
75. sidents Only C Yes No C Individual Resident C Include Zero Admit Dates All Residents C Yes No Disch Residents Only C Yes No Census Date adli each This will select only those residents with birthdays in a specific month Enter the birthday month i e 1 for January 12 for December The next part of the screen allows you to be more specific about which residents should be included on the report e lf you do not want to exclude any residents leave the existing selections e f you do want to be more selective click the opposite radio box and enter a selection range at From and Thru All Units All Physicians Admit Date Range Discharge Date Range All Groups Access to these items might depend on previous selections For example if you have selected Active residents only it makes no sense to ask for a discharge date range because Active residents should have no discharge date in their face sheet G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 7 Hi Tech Software Solutions EMR Features of the Clinical Records System Page Break on Resident Page Break on This part of the screen depends on previous selections For example the text at the right will be displayed if you are sorting by Resident ID or Last Name If you select Page Break it will print a separate page for each resident which is not a Number of Copies good idea Report Date Double Space Page Break on Un
76. story to display saved vitals Note Vitals being entered will not yet be included You must return to Screen 1 and click Save amp Exit Reselect the resident and checkmark View History Vitals 30 Day History 1132 ADAMS HANNAH Non Date Time User Type Reading Verb Comment 05 10 2011 13 04 HTS Weight izzo See D5 10 2011 13 04 HTS Temperature i BG a 05 10 2011 13 04 HTS RespRate f o 05 10 2011 13 04 H ts Pulse o f o 05 10 2011 13 04 HTS Pain Seae dt 05 10 2011 13 04 HTS Jozso 98 oo 05 10 2011 13 04 HTS Hegt BK 05 10 2011 13 04 HTS Glucose fo et 05 10 2011 13 04 HTS EdemaScae h ooo 05 10 2011 13 04 HTs Blood Pressure f35s89 Note O ower ot Click to add a Note regarding these Vitals using the existing Hi Tech Notes program Click to launch the Print Vitals program See Page 33 Save amp Exit lower right Save amp Exit will record the information displayed on both screens and then return to the Enter Vitals select residents screen reduce sugar intake low salt diet OS CSi C i O A O O O elu will clear all information on the screen without saving it This choice will ask you WARNING This will clear all vitals entered in this session Are you sure Click Yes to discard all the information without saving it Then click Save amp Exit to close the program G HITECH Webinars Webinar Docs EMR ClinicalRe
77. t will be disclosed to persons outside the facility for HIPAA Privacy Disclosure reasons other than treatment payment or other health care operations TPO click M Log Non Care Purpose Use and complete Log Non Care Purpose Use the HIPAA Discl Inf tion e Isciosure Information Skip Residents without Authorization This record will be added to the HIPAA Disclosure Log which can be printed by selecting from the Master HIPAA Disclosure Information Menu Utilities gt HIPAA Processing gt Print Disclosure Log on right Request Date pierre Requestor Mame FO Fee noo Click User Manual icon on the Utilities Menu for more Address FO information on HIPAA City State Zp O Purpose CT m m What disclosed pick DETAIL REPORT Authorization fp File Pe iriten Request G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 6 Hi Tech Software Solutions EMR Features of the Clinical Records System Decide which residents to list Active All or Individual If Active Resident Only Yes you can select toM Include Zero Admit Dates without Admit Dates in the face sheet because not yet entered into the census Active Residents Only Yes C No C Individual Resident ID C Include Zero Admit Dates All Residents o e Disch Residents Only Z g Census Date If you respond No you can list Active and or Discharged residents and enter a Census Date to list thos in the facility on that date Active Re
78. te selected type will display at Existing Notes At the bottom of the screen Source will identify the program from which you chose to edit notes i e Edit Notes from menu Face Sheets CAA Notes Existing notes converted from previous notes CV Notes G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 Page 59 Hi Tech Software Solutions EMR Features of the Clinical Records System E Note Inquiry gt ae Existing Start Date 02 02 2011 Type All Progress C Face Sheet C CAA Notes Date Time User Type ARD Subset Pg Cmplt Text 06 30 2006 To select a note click the binoculars to display the Note Inquiry screen on right On this screen you select Progress Face Sheet CAA or MDS to list just that type of note Selected Note displays in text box below To edit the note click OK to display note at Modify Note next screen Margaret became confused during lunch because she Select a note to display the full thought it was breakfast and she wanted orange Copy Text note in the text area at the Hag fe E eee era eal bottom of the Inquiry screen an pe Loe nn S n If you want to edit this note click so2 2ss _gbens 2 e tecation See agned where nex 2 and it will be displayed at Marie sa ete as oa GaWe seas ace ae ale Came So Modify Note on the Edit Resident Notes screen below NOTE You cannot edit RAP or CAA notes Date 05 19 2009 Time 11
79. umentation gt Inoculations Edit Detail by Resident Edit Detail by Inoculation below Use if several residents receive the same inoculation on the same day Print or view the inoculation report by clicking from either Edit program or through Print Inoculation Report Administered By MAGGIE MCGEE RN Comments 05 09 2008 Previous Inoculation Detail as of Date Inoculation Administered By Edit Resident Inoculation Info by Library Code Resident Last Name First Name f 132 ADAMS HANNAH Date EMCO PE E Library Code 0 Description Administered By Comments Select Residents by Unit Unit No 0 Libraries gt Documentation gt Inoculations Inoculations Library Create inoculations codes for all inoculations that will be administered to your residents select if an inoculation Satisfies RCA Section T 1 e Influenza or RCA Section T 1 f Pneumococcal Record those inoculations when given When you complete the residents RCA Section T click Pull T 1 e f responses from Inoculations Detail to automatically from the inoculation records linked to the Section T G A HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 11 2014 ae i Oi Oi O C O O O A i S huh l O i 1476 AKERS 1314 ALLEN lvT1500 AMIDON 1273 ANISTON 1517 APPLEBEE 2187 APPLETON 1200 ARCHER 0068 AXELROD 1523 BALLARD 1566 BARNETT 071 92011 BENTLY 1514 BOHR 1201 BOULDER 1301 BRYA
80. work version 4 or higher 3 Permission to access the database 4 Permissions to access the folder that holds the documents e You can store and view scans PDFs MicroSoft Word files etc The program will allow you to view documents in the native file format in which a document was created for example you will need Microsoft Word to open and view Word files and Adobe Acrobat Reader to open and view PDFs These programs must be installed on the PC used to view these types of documents Hi Tech will assist you in setting up the process and the location where you will save all documents to be attached to your residents e You must schedule a phone appointment e You can use 1 Hi Q Point In Clinical or Resident Accounting select Libraries gt Facility gt Clinical Profile Click OK twice to display the screen with the following fields shown on the right Medical record documents storage path mecical ier orm cocuments sorage pall Define where documents will be stored for this facility XADOCUMENTS Medical record documents scanning path Define where facility will scan documents to and where the Medical record documents scaning path program will find the documents to be copied to residents records XASCANDOCUMENTS Hi Tech System Administrator Select Utilities gt System structure gt Maintenance gt Company Profile Database URL MARTIPC SQLEXPRESS Enter the Database URL Example G HITECH Webinars Webinar
81. y Edit Medical Record gt Demographics Select the resident and then select the type of information in the button panel on the right side of the screen You will be able to view but not change the information on that screen Had ale Demographics Resident ID 1132 Prefix First Name Hannah Middle Name lJ Last Name Adams Suffix Nickname Preferred Name MRSA Social Security No f 05 37 8545 HIPAA M Consent M Authorization Gender M F F emale Marital Status Married Canadian SIN Date of Birth 06 10 1938 Phone 2074747122 Group Id s 101 102 0 Unit 10 NF UNIT Primary Payer 0001 MEDICAID Room Bed Discharge Date Time Status Admit Date 01 04 2009 Time 13 00 Source 01 a PRIVATE HOME OR APPT City sKow a SKOWHEGAN County SOME a SOMERSET 0210172006 Original Admission Date G HITECH Webinars Webinar Docs EMR ClinicalRecordsSystem doc 1 Attach Picture Race 5 White not of Hispanic origin Level of Care 2 ICF 035 1 ROOM amp BOARD 1 2014 Demographics Contacts Insurance Physicians Diagnoses Allergies Adv Dir Other Vitals Order Flowsheet Kardex Clinical Assessments Care Plans Activities Events Inoculations Calendar Notes Documents Stay Tables Patient Liability Data Balances Page 4 Hi Tech Software Solutions EMR Features of the Clinical Records System Reporting gt Custom Reporting

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