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OFFICE ALLY EHR

1. _ These two buttons take you to correspondingly named screens e Progress Notes Encounters Enables you to view a list of past Encounter Progress Notes e Add Progress Notes Encounter Enables you to CREATE a new encounter Very important functionality blot Clicking on these links take you to lists of cumulative info such as a list of all lab orders or lists of all medications in use by the patient he gt ALERTS Clicking on this link will enable you to view a list of alerts that you set for the patient Once you enter the Alerts list clicking ADD ALERT will allow you to add new ones NOTE Alerts appear as pop ups when you access a patient through the EHR hill Use this drop down menu to RETREIVE AND ATTACH saved documents or ADD new ones Reminder Drop down menus in the brown section of your screen make attachments to the PATIENT e View All Documents enables you to VIEW documents letters and templates that are attached at the patient level Notice how they are sorted by categories such as letters images Progress Note forms etc e Add Documents allows you to ADD documents letters and templates i e an interactive form that has been previously saved in the Manage Office tab gt Templates profile E Templates User Templates G Consultation Letters Progress Notes
2. 2 The Superbill form appears fill out the following info Superbill Name South Side Medical Page Header Information Top Center South Central Medical Con Name TaxlD License ape T144 Pico Ave Los Angeles CA 92414 Page Header Information Left Tax ID 5684125 4 State Lic 654321 Page Header Information ight OO 3 Superbill Name enter the name that you would like the system to store Superbill ID is auto created 4 Page Header Information Top Center Enter the info that you would like to show in the top center of the Superbill form This could be text such as the Practice Physician or Company name tax ID amp License 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 5 Page Header Information Left Like the previous step this field is also user defined It will appear in the top left portion of the Superbill Suggestions for these fields include address phone etc If you wish leave this section blank 6 Page Header Information Right These optional fields are again user defined and might be used for information such as mailing address if different from office location If you wish leave this section blank 7 Provider From the drop down list choose the name of the physician s that will be using the bill 8 Scroll down until you see the following text on your screen Instructions on How to Edit a Superbill Just below this is wh
3. This helpful page provides an at a glance view of a patient s medical history 3 Encounter Date Blood Pressure Pulse Tem Encounter ESRT S View Edit hief Compla Provider Note Note 0812302007 11075 ae gall loss 08211007 veel 09 24 2007 49070 08 21 2007 Nexk Pain PETER Provideri PAIN BACK Debris in ear canal Field Name Valle Date Of Birth 10 25 1960 Age 46 yrs old FirstName Kit Date Created NOTE The panels seen here are determined by you in the Manage Office tab 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 gt Clicking on Edit Note takes you to the Progress Notes screen 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 PROGRESS NOTE SCREEN This page allows a physician to type patient notes by hand or by using a growing number of exciting shortcut options i Update i Cancel Spell Check History Progress Note Medical History Subjective Surgical History Objective Family History Assessment amp Plan Ja Social History x Diagnosis Codes i Alergy History an pannes BBa Immunization History S A N i d Oo o B OO Medication History P JHE Encounters EE Assessment Notes SA P gt Clicking takes you to Progress Note summary screen PROGRESS NOTE SUMMARY SCREEN From this page you can Note
4. THE NEXT STEP From the Nurse Note screen click to go to the Progress Note screen 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 PATIENT CHARTS TAB PROGRESS NOTE SCREEN Overview History Progress Note Medical History IE Subjective Chief Complaints i Nexk Pain PAIN BACK 9 Surgical History Family History Social History s Debris in ear canal Allergy History Immunization History 4 History Of Present Illness Started when Patient was working in back yard Pain first felt on 8 10 Pain is severe Medication History Encounters Documents Past History Nurse s Note iE EE BBBRRBnBnEE Reason For Visit New Vist Nurse s Note N agian wom x The Progress Note screen allows a Provider to type patient notes by hand or by using a growing number of exciting shortcut options This screen is grouped into several sections each made up of panels that relate to that section TIP to expand panels Click on the arrows located to next to the appropriate section REMINDER The Progress Note screen is accessed a number of different ways e From the PATIENT list screen e Or from the Encounter Navigator EncounteriD Date Visit Type Provider Enc Status 100000411 9 17 2007 Progress Notes 32356 S Coast Highway
5. LL OBGYN FORM Form 1 To add a document DOUBLE Sample SOAP Form Form MS Se Gee intel Bee H Transcription Notes e Upload Documents permits you to UPLOAD scanned images from your computer s desktop i e an insurance card or a MRI report Document Type Consultation To attach a pre scanned Coa document click on BROWSE and search for the folder on your computer where the file is stored 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 Encounter Menu Section Encounter Information The next main subdivision that you probably will notice is the ENCOUNTER section In brief encounter drop down menu items see box allows you to 1 Upload and view documents attached to the encounter that you are currently viewing 2 Sign off route or print a Progress Note Lab Order or Prescription _5ign Off_ This menu item allows you to SIGN OFF the progress note that appears on the screen Click Sign Off and follow the prompts that appear __Route enables you to SEND the encounter to another Office Ally user Mew Prt allows you to PRINT the progress note that is currently seen in the Progress note summary screen It also allows you to PRINT a lab order or prescription REVISE Cd ionali Revise Allows you to append a Progress Note future functionality Bocuments This menu works the same as it does at the Patient Level EXCEPT that documents vi
6. pe Status Edit Afternoon Sleepy 10 25 1960 M 555665555 P Active g M Te at P Active y X Patient List one of the Patient Charts screens How you get to a particular Patient Charts screen is primarily determined by what icon you previously click on Key icons are Edit Edit Patient and Insurance demographics 6 Search e _5 uMMAFY Go to the Summary Screen e pols R Go to the Patient List As an alternative you can JUMP to other screens by e clicking on a name in a list Patient Hame Barker Georgegyam e using a drop down list 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 THE FIVE MAIN PATIENT CHART SUB SCREENS As previously stated the Patient Charts tab is primarily made up of a series of several key sub screens Below is a Summary snapshot of each of them THE PATIENT LIST SUB SCREEN enables you to navigate between patients Search For Last Name Starts Witt fs wen w E Display Filter Account Type Al zi Status Actve w 537621112 10 25 1960 10424843 Pasquale Nicholas 40 19 1993 M 555655555 10424829 Pasquale Peter 10 25 1970 M idis Red Gr MW 10 25 1966 M 537621113 10423971 preen e 10425421 Tuesday Patien 07257 532665598 9 11 2007 Cold FRANK Cold extremities Shoulder Pain Provider2 Normal nRa1eNO Call Patiant ta riin raas ANNI Note You can crea
7. w3 org 1999 xhtml gt lt title gt PM160 lt title gt lt meta content HTML Tidy for Windows vers 14 February 2000 name generator gt oom TD 2 Click on Manage Office gt ERE Add New Show All Category Description Source Consultation Back Image Consultation well child PM160 3 Click Wea 4 The following form appears Template Type HTML Form v gooo Hls X oa aara a wanani Pee a a a ae ee a 5 Define the features of your Template by filling out the fields in the sample seen above 6 Scroll to the bottom of the form 7 Click HTML Cd Normal E HTML S Preview 8 Scroll back up to the top of the form 9 HIGHLIGHT the default HTML code that you see and press DELETE on your keyboard das anya a 10 Open the Microsoft Word document 11 Highlight and copy all Codes seen in Microsoft Word 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 12 Paste the code in the HTML form 13 Click 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 SOAP GUIDELINES The SOAP Guidelines profile allows you to create shortcuts that appear as links in Progress Notes Intro to Soap Shortcuts A certain breath mint advertised for years that it was two mints in one So SOAP Guidelines can be used for multiple purposes For example you can think of them as
8. 100072 Virginia test Mungia THIS IS ATEST NOTE 08 10 2007 x Barker George9am he E 100068 VirginiatestMungia Test 08 07 2007 x Pasquale Peter 08 13 2007 Virginia test Mungia Peter Pasquale ppasquale Able Arden virginiam Peter Tech Document 1000000143 Office Ally For Consultation Virginia test Mungia Peter Pasquale ppasquale Able Arden virginiam Peter Tech Document 1000000139 Office Ally For Consultation We Patient Channels Patient Ally to Go Last 100 Entries ee Senevan vy OO O From the Desktop tab the user can view four handy panels which contain Physician Schedules for each Provider in the office Messages secure inter system emails Routed Documents attachments sent to and from other users within your office or any other Office Ally physician Patient Channel Documents forms received from Patient Ally a new patient history system 1 2 3 4 5 The following page will contain more detailed descriptions of each of the Desktop panels 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 THE APPOINTMENTS PANEL The Appointments panel allows a Provider to view his or her schedule for the day Primarily a Provider will use this tab to view his or her schedule and to access patients that need to be seen In order to access a patient so that you can write in
9. 6951 Medications 2 Next direct your attention to the large box on the RIGHT side of your screen labeled CPT s 27275 e ion MANIPULATION OF HIP JOINT 3 Click on the search button amp 4 From the pop up box that appears a Choose Description b Enter a desired CPT code in the rectangular search box c Click Search Click Select the large CPT box will re appear 5 Inthe CPT Box enter the fee for the procedure F 6 Click Add 7 Repeat steps 16 20 to add more CPT codes Adding ICD9 Codes 1 To add ICD 9 codes direct your attention to the large box at the BOTTOM of your screen labeled Diagnosis Symptom Codes Diagnosis Symptom Codes Diagnosis Code JB lt 2 Click on the search button amp 3 From the pop up box that appears a Choose Description b Enter a desired CPT code in the rectangular search box c Click Search d Click Select the large Diagnosis Symptom Codes box will re appear 4 Click Add 5 TOCHECK YOUR WORK Scroll half way up the screen and click on Preview 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 6 Asample Superbill will appear Preview it and click Update to save your changes 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 REASON FOR VISIT Reason for Visit Seon Laboratories eT emplates A click
10. Fi ACUTE CARE VISIT ALLERGY URI Name PatientFirstName PatientLastn IM OF DOB PatientDOB Age F p lt of 1 Click REE 2 Define the features of your Template by filling out the form seen below CC Patient presents with Days L Weeks of g L_1Goughing nonpiogipctiye or Cl Coughing productive P Fever ep pal 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 HTML Form 3 Enter free text at will Css Class Inline style Normal Times New Romar Just type anywhere in the document to enter free t 4 If desired click Iv to create a check box list a The following will appear CheckBox1 b With your keyboard overwrite Checkbox1 with desired text such as Shortcut 1 Copy and paste the just created check box data over and over to save time 2 Then type over undesired text Jltchy eyes Itchy eval ClItchy eves Red eyes i Itchy eyes U Itchy eyes C Watery eyes Visene A gt an S i EN se 5 Click ir to create a radio button Follow the same steps as with a check box 6 To insert a text box a Click the textboxicon gt gt gt gt gt gt gt gt St box f An INPUT pop up box appears CLOSE it for now flies b c Click once on your screen in the desired location to insert the textbox d Drag text box to desired length and if needed desired location e
11. History Immunization History Medication History Encounters Documents Nurse s Note 6 Fill out needed Progress Note panels for details see user manual section on Patient Charts T Superbill e XXXXX XE e Be sure to fill out the Dx and Px manually or click Superbill Click CRS ch Templates and Documents to the encounter e Don t forget your Progress Note shortcuts see earlier sections of the manual for details Personal Shortcut Lists Pop Up 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 SOAP Guidelines Complaints eck Pain Shoulder Pain Nexk Pain PAIN BACK Debris in ear canal Templates TEXT Future functionality coming soon 1 After you click the Progress Note Summary screen appears 9 4 2007 Encounter Type oe Peter Tech No of Attached Doc ar Progress Visit Type sae Provider Enc Status Note for Green Red 9 4 2007 Patient ID 10423971 ae SUBJECTIVE OBJECTIVE i Route Vital Signs Blood Pressure emperature Waist V Circum 2 Click Sign to sign the note 7 3 k 3 Click View Print to Print Lab orders Prescriptions or the note 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 Don t forget Patient ID 10423966 DOB
12. Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 PROGRESS NOTE SCREEN SUB SECTIONS Below is a list of the main groupings of Progress Note panels which can be seen on the LEFT side of your computer screen History Medical History Surgical History Family History Social History Allergy History Immunization History Medication History Encounters Documents Nurse s Note Reason For Visit e The History panels keep a running record of Patient history including Medical Surgical Family Social Allergy Immunization and Medication history e The Encounters panel contains a list of previous encounters Click VIEW I to go to a previous encounter e The Documents panel contains a list of documents and Templates attached to the encounter Coming soon you will be able to attach Templates to the encounter from this panel e The Nurse s Note panel reveals info typed in by the nurse prior to the encounter Below is a sample of Progress Note panels which can be seen on the RIGHT side of your computer screen Progress Note Subjective Chief Complaints History Of Present Illness e Progress Notes panels are used for data entry Type your progress notes in them or use shortcuts listed below IMPORTANT TIP Click to see additional panels FYI Clicking on takes you to PATIENT CHARTS gt the Progress Note summary screen 32356 S Coast Highway Laguna Beach CA 92651 P
13. New Patient List Show All Top 100 Records e Follow steps for adding a new patient as outlined in Chapter Manage Patients Add Edit For the sake of speed you may choose to only add the required information at this time to the New Patient record name only required Other patient information such as employer insurance etc can be entered at the time the patient arrives for the visit Once the patient has been added e Return to the Appointment module to continue with scheduling the appointment e Repeat Steps 1 through 7 discussed earlier in this Chapter e Click on Update 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 The new patient is now scheduled for an appointment This appointment can be edited by clicking on the or deleted by clicking on the while in Daily view In the Edit Appointment screen the user is able to change the appointment status as shown below pic Patient Last Name a aie 3 Pe QFE Patient First lame Kely Oi O lt The Patient Home Phone 77 777 rrr A rM A 18 wa BS ofice Name f YPEY ip s it tn rarm SS TD arlo Resource Machine k r visit Length Color Code MN M Reason For Visit g Hotes Cancelled by Office Cancelled by Patient Udate Cancel Cancelled by Provider Completed Patient Did Not Come Shortcut Keys Alt F1 Help F2 Add New Appoint Add New Vist renon new Paymen
14. O NA ES 93 Apon ES A 4 clo EE EE EE E EEEE AEE A EA AEE O ee 94 WO SC aue ain Ex NE PE aE E E E E 94 oea e Ne O E aa A E EEE ATEA OEE OTO 95 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 CC VII N E EEA EAE eo ET ela arctan ceive ears A E cea al EE A E ceca mate dn ascetic E EA mete eas atleast nie ane EE 98 BILLING STATUS VAD vise ccecaiccucasacscinwieie seciniawaacencanneesnwscauwtacecadseuesceaweassauuniinhcansbtaa N 99 INTRODUCTION TO THE BILLING SATs TAB czcsaonatoauncwrccaadeansarevaaesmacaadansacndscnneaiiolroccusanedan quand sanaucandatiensngunonsdoasaoutsennunsannessnenesnedeneaaaies 99 How to use the Billing Status Screen s lt cc isvasssessnvsnvesvedensnanadseassy cawboausossenesseatwoneansddanbsanveoseeasnd an wesn ees vanwbeanvessieecseesnesvessne gt saeunsanwedsweerseaneedaveavendsiies 99 REFRENCES TAD core ceeveen cae ducsccncvecentavcesccusucecwssewmesascmeneucctustaunvavpdsueeces scan E 100 INTRODUCTION TO THE REFERENCE TA Brinsssssscnavesrtecaiesepnintenasasevindinatararasaitseseibacieniateanien via OaE n TRESS EN Oaa RECA Na ai 100 WORKFLOWS TO ENABLE YOU TO USE THE EHR seessessesesscosscosscescescescescscssescosseesosseesossosssesccscescescescessescesssesessesssssesssssessesscsseese 101 NERO DUC HON e A E E cuesstuaausontaacueaqnlas 101 Font Oce Sta Work OW ereere e nE E E E EE E RN 102 Office Staff Schedule an Appointment Using Practice Mate eeeesseeessrer
15. Patient Information FirstName Kit Insurance ALLIED ADMINISTRATORS Mid Initial Universal ID e Anytime you see a BLUE list of menu options you are looking at ENCOUNTER LEVEL menus Encounter Information _Etmote Documents p Delete _Sign Off Route View Print gt 6B 8 A EPLi Important To create a new Progress Note click on Phone 949 464 9129 www officeally com Fax 949 376 6951 32356 S Coast Highway Laguna Beach CA 92651 APPOINTMENTS TAB FFICE SATE APPOINTMENTS OVERVIEW The Appointment module has been designed to meet the needs of both single office single provider practices and those with multiple providers and or multiple offices With a single click of the mouse the appointment calendar can be viewed in daily weekly or monthly mode as well as by provider or office The ability to toggle back and forth allows for quick and easy scheduling You can view the calendar by Office Provider Staff Time Interval and multiple Daily View modes Office South Side Medical Providers Staffs Provider Frank Stokes v Time Interval 15 minutes _Daily View Modes p Detail View Providers Staffs Resources View sa bs a aeea eae a a wwa cE a m K as ee Office If the practice schedules for multiple offices use the drop down box to select the office to view Or select All to view all office at the same time Provider If the practice has mult
16. Phone 949 464 9129 www officeally com Fax 949 376 6951 WORKFLOWS TO ENABLE YOU DEFICE TO USE THE EHR INTRODUCTION The following sections will show you how to use Office Ally s EHR in your everyday practice Wewill start with demonstrating how your front office staff can schedule and check in an appointment e Next we will explain the Nurse s role skip this if your clinic does not have a nurse e Finally we will show you how a Provider can use the program 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 FRONT OFFICE STAFF WORKFLOW Office Staff Schedule an Appointment Using Practice Mate Front Office staff will typically use Practice Mate to schedule a patient appointment If your user profile in the Manage Office gt System Preferences is set to NO the appointments tab only appears in Practice Mate To get to Practice Mate from the EHR click this link at the top of your screen akii To schedule an appointment follow these steps 1 Click the Appointments Tab 2 Click Add New Appointment or Add Daily View Weekly View Monthly View Office Redlands Office Providers Staffs All Time Interval 15 minutes a a eS toma pame pos emer SS meni nt oe ow E e 3 The Add Appointment form appears patient Last ame J Paton First kame Patient Home Phone sd Office Nam
17. SNOMED CT Concept Body structure Clinical finding Environment or geographical location Event Ga Abuse Ga Accidental event Bioterrorism related event G Death bu Accidental death Death expected Death by asphyxiation Death by electrocution A little background information on SNOMED SNOMED is a terminology infrastructure that was developed by the College of American Pathologists SNOMED CT Systematized Nomenclature of Medicine Clinical Terms is considered to be the most comprehensive multilingual clinical healthcare terminology in the world SNOMED CT was a joint development between the NHS in England and the College of American Pathologists CAP to develop an international clinical terminology and was formed in 1999 by the convergence of SNOMED RT and the United Kingdom s Clinical Terms Version 3 formerly known as the Read Codes It has greater depth and coverage of healthcare than the versions of Clinical Terms Read Codes that it replaces SNOMED CT provides the core general terminology for the electronic health record EHR and contains more than 357 000 concepts with unique meanings and formal logic based definitions organized into hierarchies When implemented in computer applications SNOMED CT represents clinically relevant information consistently reliably and comprehensively as an integral part of producing electronic health records 32356 S Coast Highway Laguna Beach CA 92651
18. Statfs Provider PETER Provider 5 Click Edit Schedule 6 A blank schedule appears at the bottom of the screen Schedule for Provider PETER Provider1 Enabled Check to enable this schedule Please note that the hour settings must be within the boundary of Office s operating hours above Days Hours 2nd Hours Session LI Sunday 12 00 am IE 12 00 a z Monday 08 00 am _ 12 00 pm F a Tuesday 08 00 am _ 12 00pm o wednesday 06 00 am 12 00 pm 0 i M Thursday 08 00 am 12 00 pm d a Ll Friday 12 00 am 12 00 an 12 00 am T 12 00 an L Saturday 12 00 am 2 12 00 an 12 00 an 5 12 00 an EMR Login Name PETE 7 Click on the boxes for each day of the week that appointments will be scheduled 8 Monday thru Tuesday etc 9 From the drop down menu for each day select the hours of operation 08 00 am _ 12 00 pm 10 You can block out lunch hours by using the 2nd session option 11 Enter the doctors exact EMR name EMR Login Name PETE 12 Click Update NOTE to Edit a schedule later on highlight the doctor s name and click 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 SPECIAL DATES Click on the Special Dates profile and the administrator or user can block out certain dates from the calendar when the office is closed This prevents the inadvertent scheduling of appointments To Edit Special Dates Please specif
19. T This displays the Add Appointment screen 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 Patient ID 10104819 Patient First Name K Patient Home Phone Office Name South Side Medical Appointment With s t Frank Stokes Appointment Date mmiddjyyy ee FH 00 Resource Machine i MRI Room Visit Length m g Reason For Visit Checkup sss s up Checkup B Hotes Repeat optional Days Between Visits 7 Enter the patient ID or browse for it by clicking on Browse to search the Patient database If there is more than one office select office from the drop down list Choose who the appointment is with Provider Lab Technician Nurse or Therapist and select name from the drop down list Confirm appointment date and time shown or change if necessary If you created Resource Rooms in Manage Office you may select the room Select the number of minutes to allow for appointment from the drop down list if other than that displayed You have the option of selecting a color code to distinguish between different types of appointments Choose reason for visit by clicking on search button or typing in the box provided 2 eS eS eo i Type in any desired notes If the patient will be coming in for treatment that requires regularly scheduled appointments you have the option of entering how many times to return and at what interval Doing so will automatic
20. Visit N 100000340 0905 2007 FRANK Provider2 Peter Tech Barker Georgedam Office Visit 100000324 09 04 2007 FRANK Provider Peter Tech Red Green Office Visit 100000276 08 29 2007 FRANK Provider2 Peter Tech Pasquale Peter Office Visit 7 100000270 08 29 2007 PETER Provideri Peter Tech Barker GeorgeSam Office Visit qooogozs7 08242007 PETER Providert Peter Tech Barker George9am Office Visit 1400000249 08 24 2007 PETER Providert Peter Tech Barker Georgegam Office Visit 100000248 O8 24 2007 PETER Provideri Peter Tech Barker Georgegam Office Visit Pa Pa Ca Ca Ca How to use the Billing Status Screen 1 Identify the patients that you saw today Notice that the list is pre sorted by date 2 Check off any patients that are ready to be billed 3 Send checked off encounters to Practice Mate by clicking BEGAL E EE Sort Options o To sort the list by any other criteria just click on a header item i e Encounter ID Provider Location of Service Patient Name etc o Use the search box to search sort by Encounter Date Or click to load all patients from Office Ally servers to your system 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 REFRENCES TAB 4p F FICE INTRODUCTION TO THE REFERENCE TAB en The References tab contains SNOMED terminology ICD 9 and CPT Codebook links as well as links to other health related websites B
21. hardware is required nor is there a need to purchase expensive software upgrades to take advantage of the latest program features All you need is a unique username and password assigned at the time of enrollment and good broadband internet connectivity You are able to access your account from anywhere 24 hours a day and 7 days a week Feel at ease because your data is safe All records are securely stored and backed up on our network servers leaving it protected and your hard drive available for other uses On top of that you have total control over local office security because you can select who will or will not have access to patient s medical records Keep in mind that Office Ally EHR is also fully integrated with Practice Mate Office Ally s FREE practice management system This gives you further flexibility to oversee scheduling patient management accounting and reporting In addition to this Office Ally EHR also works in conjunction with Office Ally s electronic claims submission service providing you with full access to our claims service menu All of the pieces of Office Ally s suite of programs are fully integrated allowing information to flow seamlessly from one application to another reducing user input time and freeing up valuable office resources You are in complete control free to use whatever application works best for your office 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeal
22. his chart all you need to do is click on the name of the desired patient Note that you cannot set an appointment from this panel Appointments are set in the Appointments tab Pasquale Nicholas Pasquale Peter Red Green M e Click on the Office Drop down button to choose an office The schedule for the office you select will appear below NOTE At this time the default office is determined only in Practice Mate Go to Practice Mate gt the Manage Office tab gt Company Settings gt Preferences Provider e The default Provider is based on the user s log in name If needed click on the Provider Staff button to see someone else s schedule Date Selection e Clickon or b or 41 to select a new date NOTE To go to the Patient Chart tab click on a Patient s Name or click on the Patient Chart tab 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 THE MESSAGES INBOX PANEL The Messages panel works much like any other email application Keep in mind that emails that you send to other people in your office or to other Office Ally users are secure and HIPAA compliant NOTE Presently front office staff must check the EHR to view email but in the future they will be able to see them from Practice Mate Attachments cannot be sent from this panel however they can be sent as Routed Documents The screenshot below demonstrates inbox functionality a
23. list To view inactive patient s select Driving Directions hs EDIT allows you to view and edit a patient s insurance record and demographics e 2 DEL removes a patient from the Patient list E OPEN CHART takes you to the Patient Summary screen e _Add New Patient Allows you to add a new patient to your practice complete with demographic information Data entered here feeds into both Practice Mate and the EHR at once Use the Search Bar arch For Last Name or Next Page Bar 1234 to search for patients not viewed on the first Patient List page FYI From the Desktop tab clicking on a patient s name opens the Patient Summary screen FYI From Patient List clicking on a patient s name also opens the Patient Summary screen PATIENTS CHARTS TAB PATIENT SUMMARY SCREEN PATIENT SUMMARY screen a synopsis of vital patient information This is your patient dashboard and it contains a snapshot of the patient s chart From here you can see historical lists of medications encounters vital signs alerts and more Remember you determined what panels are seen here from the Manage Office tab gt Patient Summary Screen Settings profile There are no data records to display Provider Date Created Alert Message Status 08 21 2007 Nexk Pain PETER Provider4 08 31 2007 Call Patientto discuss abnormal Labs 909 555 1234 ON Z BA i 08 31 2007 Researh treatments for Thalassemia Minor ON seach z Encounter Date Bloo
24. on Reason for Visit allows the administrator to create a pre built list of the most common visit descriptions for an encounter The Reason for Visit list will display on the Nurse Notes screen the Progress Note screen and in Practice Mate NOTE Reasons selected by the physician or nurse will automatically feed into Practice Mate To Create a New Reasons for Visit List Please enter Reason For Visit This list will be used as popup list in your appointment edit Reason For Visit TYPE A REASON HERE Blood Test Sm Follow up visit ness New Visit Physical Exam Preventive Shot 1 Type a reason into the box labeled Reason for Visit 2 Click 3 Your choices will appear in the panel labeled Current Entries LABORATORIES bees Templates SOAP Guidelines A click on the Laboratories profile allows the administrator to create lists of labs to use in user Progress Notes as well as lists of tests that can be ordered To Create New Laboratories 1 Click Gel A oo Add Hew 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 2 Fill out the form that appears Lab 10 Tn Laboratorylame O OE Address Line 1 fF Of Address Line cy State zie Phon DO D Contactame Cd 3 Click 4 The Laboratory List screen re appears Delete 91103 STOTT FE 5 Select the desired lab by clicking k Edit 6 The Current Test Entries screen re app
25. the EHR e Click k Edit to change the user s login and security settings e Click 2 Delete to delete the user e Click i Change Password to change the user s login password How to Add a User 1 Click E a 2 Fill out the demographic details form that appears and then click 3 The next image that you see is the security screen 4 When the security screen appears check off appropriate security levels for the user and then click and Desktop Read Access Desktop Read Write Access V Patient Charts Read Access C Patient Charts Read Write Access V Appointments Read Access C Appointments Read Write Access C Billing Status Read Access 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 Tips 1 The Administrator does not need to check off his or her own security because the administrator automatically has full access 2 The system will prompt you when you made a data entry error As seen below LastName Faroo mone PO 1 __ cenphone p J _ emait Baroo yaoocon User Type Assistant Practice Mate User _ EHRUser Please select at least one system Practice Mate or EHR for this user 3 Be sure to read security settings carefully For example know that you must first GRANT ACCESS to a module see red arrow below in order to define access details WITHIN that module see short blue arrows below Patient Charts Ac
26. 10 25 1960 Age 46 yrs old LastName Carson Gender M FirstName Kit Insurance ALLIED ADMINISTRATORS Mid Initial Universal ID Patient Menus are Found Here Encounter ID 100000214 Encounter Date 8 21 2007 Provider Staff PETER Provider1 Location of Service Peter Tech Patient Menus are Found Here Status Unsigned Signed By Edit Note Documents gt Encounte nD Date Visit Type Prowider Enc status Progress Hotes View sep The Del XxX E t Sign a er Route kad Navigator IS ew Here 100000214 View 2 8 21 2007 Edit Oce Wisit l PETER UA Provider1 sign Ye Unsigned Route gt 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 FINAL WORKFLOW Provider Office Staff or Nurse Send the Encounter to Practice Mate for Billing 1 Click on the Billing Status tab 2 Check off Encounters to send to Practice Mate 3 Click Create Practice Mate Visits Office Ally EHR pach eee Company Peter T Home Service Menu Practice Mate lt lt LOGOUT HIPAA Privacy PayerLists Forms FAQ Contact He Billing Status Reports p a EJ assoc EENT Oos Oo EZ SR baler Pover C agus Encounter i W Change Select Encounter ID Epeei Provider Location of Service Patient Name ype Billing Status 9 Status 100000115 08 14 2007 Dr_Pete Service_Provider Peter Tech Pasquale Peter Office Visit New 40000008
27. 14 eM TAOS ana E ATE E EA A E EO AEE E EETA 14 VE Da ea E E A E E ccm eatauisiecneadel tanavesounseneavaceas 14 EACE D a NE AE EE E O E E E E E T N OEE E NTO OE T 14 EE 2 DEE a E E E pnces sasnauaiantrauekarensmencdsstananenacevmasaieeceseas 14 Cony greece PaE Da n anne ren ene aN A E E E E ee oe ee eee eee rere 15 BS MCh E E EAS E E E E O E E EE A E O O 15 Searching for Data Within Long Pop up Lists wcccasbiscadishusanccsparsdedselexsuapitasbiaan assented e aeaiaioe 15 Searching Tor Data Via TONS sariaren ai a aa E aa a A AE ES 16 PVA INS Search BUTTONS reisiirceni ieenens soar enters iaer KESESATAN ONAA EEREN EAEE ANE AEE ERAN AE EREA 16 Se E LOM DVS LINKS a E TE E N 17 Eaa RE A HON TIO AEE EET AE E E E ET anc ays A pastas E E EA A T E E ER T 18 Drop Down Search Far FIRE gaan ene RRR ane aa EE a iaia AEAT TEETE EET 18 DIG OAV DY F Ee a E E tsacrawssiaeme mnenseauaetsserinmensec anes 19 OES F e T EO A E EEE E AA A E E T EA E 19 Diplayine Fidder Biche penemnee mee tree n T O EESE 19 Navigating the Appointment LiSt cccccccssssccccceesececcaesececcaeseceesaeseeeeeeseeeceesaeseeeesaeseeeesaesseeeeseaesecessueecessuasecesseaa saaseeeesauaseeesauasceesauassesessugees 20 AICS EE AEE EEN EA E EE A A EEA E SA N N E A A TT 21 aA E i PN EEE PEENE E EE N A A EN N N E EEN E AEE E A E EN A EEE 21 rs EEEN AA E E A AOE O E AE A EE E naceeuneecamien 21 TIME GIT MP eae E E T E E E A E A E A 22 MANAGE OFFICE erosia NE E O 23 MANAGE OFF
28. 2356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 Patient Summary Settings consist of several set up boxes that establish default preferences such as 1 Which panels will appear on the summary page 2 What order the panels will appear 3 What fields will populate inside key panels For example if you are an acupuncturist and Vital Signs are not needed for your practice you can leave the Vital Signs history panel completely out of your Patient Summary screen Choosing Panels to Display on the Patient Summary Screen Please select the Panels you would like to display on Patient Chart Summary Page Available Panels Selected Panels Left Selected Panels Right Allergies Progress Notes Encounter History of Present liness Alerts Lab Orders Select L gt gt Past Medical History Past Surgical History Select R gt gt lt lt Unselect 1 Highlight a Panel from the Available Panels section 2 Click Kiinid oot if you want the item to appear on the left side of the summary screen 3 Click if you want the item to appear on the right side of the summary screen 4 Move field order up or down using the up and down arrows Choosing Arrangement of Fields Within a Panel individual Panel Settings Panel Available Panel Fields Selected Fields Vital Signs Blood Pressure ffl Choose a Panel using the drop down menu on the far left Highlight a desired field in th
29. 29 www officeally com Fax 949 376 6951 To Create a Specialized Schedule for a Provider cccccsecccsecccsssccecanececeececsececauececsuecseseuecsceuecetsuecesaneceteneceesenecetsueceteuecetsuecetsueceesseagsetanerenea 62 SCC EE crasiesccsnctncace nestennnncsgi E E E E E E E SE 63 TOEA pece a T E E E O uinsiacesunutessncnaieeaieos 63 DESKTOP TAD oa OEE E E E SEE EEEE EOE EN 64 INTRODUCTION TO THE DESKTOP TAB cccseccsssccssccescccseeceneccnsccuecenscesecceusesaesceuscensecseeseuscenseceusesaeeteuecenseeaeeseessensesenssesegseeaeeneesees 64 TIO FOALS PANE aratri iaai ct calc NEAR EENE EN ects an tla seals tse dea aan sea cacti soca ode tla AOA 65 The Messages ON T ONE arcsec nascent AEE E AE EEE EE EE A pene EEEE 66 TheRoued DOUNE PONO aE EE A E A E E E EE E E T oe ee 66 The Patient Channels PONE l erereinnein eanan AE E OA AE EAE R 67 PATIENT CHARTS TAB iiircinasncinnniish n aaa 68 INTRODUCTION TO PATIENT CHARTS conreen E T E EE E E OA E 68 THe Five MainPauent Chart SUD SCI CONS soirracrr an en aa E E A EEE AE EA E TA 69 Patient Charts Tab Patient List Screen eeisnssaiccspasaninsvnasdiwanniiedsvan caucus E A EAN OAE EENE AE TAE E AR 70 Patients Charts Tab Patient Summary SCOCN cccccsesecccsesecccceseseccuescscsusecsecuseseseuecsesuusecscsusesssueecsseusecsseueeesesuecsssusecessesesssegecssseenees 71 Patients Charts Tab Nurse Note Screen vcs cco sna haces nn Teana EAA OA TE AN OO A EEAO eevaaiiees 72 Potent Charts Tab Pr
30. 356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 Congratulations Now when you are working on your Progress Notes you can access CPT codes from the list that you just created by clicking on the first search button in each row 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 Select Multiple Tips TIP ANY TIME you choose the following pop up screen appears C A0021 OUTSIDE STATE AMBULANCE SERV Yes A0080 NONINTEREST ESCORT IN NON ER Yes A0090 INTEREST ESCORT IN NON ER Yes A0100 NONEMERGENCY TRANSPORT TAXI Yes O A0110 NONEMERGENCY TRANSPORT BUS Yes A0120 NONER TRANSPORT MIN BUS Yes A0130 NONER TRANSPORT WHEELCH VAN Yes A0140 NONEMERGENCY TRANSPORT AIR Yes A0160 NONER TRANSPORT CASE WORKER Yes A0170 TRANSPORT PARKING FEES TOLLS Yes A0180 NONER TRANSPORT LODGNG RECIP Yes A0190 NONER TRANSPORT MEALS RECIP Yes A0200 NONER TRANSPORT LODGNG ESCRT Yes A0210 NONER TRANSPORT MEALS ESCORT Yes 123456789 10 gt gt e Only 100 500 records display at once Show All Top 100 Records e As appropriate change the Code Description drop down setting from Description to Code or vice versa e Click here to go to another page 142345678910 gt e Check off multiple codes NOTE You can only select multiple checkboxes for one page at a time 32356 S Coast Highway La
31. 4 2007 PETER Provider 08 08 2007 EMR Doc Pasquale Jr Os 0r 2007 EMR Doc Pasquale Jr Location of Serice Peter Tech Peter Tech Peter Tech Peter Tech Peter Tech Peter Tech Peter Tech Peter Tech Peter Tech Peter Tech Peter Tech Peter Tech Patient Name Pasquale Peter Barker Georgeyam Barker Georgegam Barker Georgegam Carson Kit Red Green Carson Kit Pasquale Peter Afternoon Sleepy Tuesday Patient Office Visit Office Visit Office Visit Office Visit Office Visit Office Visit Office Visit Office Visit Office Visit Office Visit Office Visit The next main module appears when you click on the References tab This screen enables you to look up SNOMED medical hierarchies as well as ICD 9 and Procedure codes E SNOMED CT Concept Body structure Acquired body structure amp Amputation stump Application site Donor site Injection site Operative site NOTE SNOMED is a terminology infrastructure that was developed by the College of American Pathologists Phone 949 464 9129 Fax 949 376 6951 32356 S Coast Highway Laguna Beach CA 92651 www officeally com MANAGE OFFICE OVERVIEW The Manage Office tab is the final main module and it allows you to set up your office build individualized user Templates and create favorites lists amp Main Admin Section Company information Reset Admin Password Import Data Wi
32. 6 08 08 2007 EMR Doc Pasquale Jr Peter Tech Afternoon Sleepy Office Visit New 400000084 08 07 2007 EMR Doc Pasquale Jr Peter Tech Tuesday Patient Office Visit New 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951
33. 6 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 NOTE The schedule tab enables your office to set new appointments without having to use Practice Mate to do so To see how the appointments screen works consult the Appointments section of the Practice Mate manual found at OfficeAlly com Tip You can still send out your claims through Office Ally 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 USER SECTION Each user should set up his or her own User Section Settings will El User Section automatically apply to the person that is logged in at the time User Preferences Patient Summary Page Settings The purpose of the User Section is threefold Patient Demographic Settings 1 It allows each user to determine key default functionality such as the User Defined Diagnosis Codes ability to send prescriptions electronically User Defined CPT Codes 2 It allows each user to set up a unique look and feel for the Patient User Defined Medications Summary screen User Defined Chief Complaint Phrases User Defined HP Phrases a User Defined Medical History Phrases a User Defined Surgical History Phrases User Defined Family History Phrases User Defined Social History Phrases Seep aes A EEN User Defined Allergy Phrases 3 It allows each user to create personal Progress Note po
34. 651 Phone 949 464 9129 www officeally com Fax 949 376 6951 FRANK Provider2 111 Smith Tustin CA CA a Certificate To Return To Workischogy o Whom It May Concern t i Carson has been under my care from to ad ith the following restrictions N en O S T T O ef D ee 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 MORE PROGRESS NOTE PANELS FEATURES AND INSTRUCTIONS Some of the current Progress Note panels require navigation information which is explained below Vital Signs Panel Vital signs that were entered by your nurse for an encounter will display in the VITAL SIGNS panel Objective Vital Signs View History amp Graph Head Blood Pressure BMI Circum Height Fuke Resp Rate Temperature Waist Weight C C e e O C ms e You can add to or change anything listed here at will e To view a summary of previous vital signs click on MUERTE and a chart will appear raph temia Blood Pressure Digstolic Bi ood F Graph Data Date Range Select All Unselect All 100000217 Oaf21 2007 100000214 Oaf21 2007 120 70 The Vital Signs chart above includes a historical list of all vitals by encounter You can see each history in graphical form by e checking off desired encounters e checking off desired graph items e then clicking Show Graph When you do this a vital sign graph appears Blood Pressur
35. 949 376 6951 TIME OUT TIP If at any time you see this message Click OK or follow steps 1 through 5 below System Message Access denied Your session is expired because there is no browser activity over a long period of time please login again If this problem persists please contact Office Ally technical support 2 Type over the expired web address by writing OfficeAlly com OO Emana a 3 Press Enter on your keyboard 4 Click gt gt LOGIN roe gt gt LOGIN Register 5 You will auto logon to the EHR If you ever see this message Server Error in pm Application Cannot open database OASession requested Login failed for user OF FICEALLY oawebfiles Description An unhandied exception occured dunng the execubon of the cumenti s information about the error and where it onginaked in the coche Exception Details System Data Sachen Sqixcepton Cannot open database Login failed for use OF FICEALLYwawebhileshare Source Error An unhapdled ekbsapticon WAR QERETATES during the ewecution cf ERe current nd JOcanion of Ene exc ptio can De Ldeati ped Geieg CBE SROBpELOn star Try clicking on the Back button at the top left of your screen or follow the steps found above at the top of this section 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 MANAGE OFFICE MANAGE OFFICE OVERVIE
36. A A A A E ENE A A E ENEA N A E EEA T 44 AOP AICI EC OOE a E E E E anbrmetaieeccesen 45 REASON FOR VIS Monceau E A E S A E A T 47 TO Create a NEW Reasons Tor Visit LIST vcs snsecaycracnnassensienasnnaticewenscetucawagsansennpnuasesanbaeatunanansauseasebinwesaracnceseuuaqetetaaanmeuhasatauetehaaansaseaunnercesiweasarsunsendotes 47 lo alear E 1 AEP IAEA A E EE O E T eee E E E E E E AE E E E E E E 47 Hete Tea ic ONS A A E A N T A A EN A A E A E A A E N A A 47 TEMPLATE eE E E E E EE EA E E E 49 Da I EE EE E E T N E E AAT EE E EEA ET E E AT AAT EE E es 49 TEM TNA ae E T N EAE A EAA E ANA AA A A 50 TOT eo E cS GS Wy r E E T A A E 50 WO Create Ol E a FOI ra E E E E E E 51 Manua TOKET ES varten T E A E E EA E T trer eer ey oer 54 lImporing Templates Fron Other PEOpIE arrieiro a E EN T E a E 54 SOAP EINE a eoe E E E E E TT 56 To Create S0ap S110 a cape ee mre eR E EEE ENT 56 BRIEF OVERVIEW OF OTHER PROGRESS NOTE SHORTCUTS sississssssasssvcadssasseeianawiavesanssusedseadsvonudavsadaaiesdaalnneddesdavasaddnwadsriasesedadedaordseccnns 58 Parsona Pon up NOn a LSS arseen E A EE E E 58 Auto Complete SIC Caras eagccient rca eat ia EN atone ace vue Ee E Saf Oa e AEE E E N 58 Voe RECO NI O era A E E E EE EE ATE R E A E EE E E EOE E E EAE E EN EEE EE E T 58 Text Shortcut Future functionality sssrssecrsiirirsrirstr renerne nenene r EEEE EEEE EIEEE EPEE NENEN ENEAN EIEN AEVO EEE ER EEEE ERENS 59 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 91
37. ALL THE PATIENTS IN YOUR EHR Depending on what icon you previously clicked the Patient List is normally the first screen that you see in the Patient Charts tab The purpose of the Patient List is to enable you to view all of your patients at a glance so that you can navigate between them For example You think of something later in the day that you would like to add to a Patient s unsigned chart To get to that Patient s medical records you SEARCH for him from the PATIENT LIST screen and then choose Open Chart E TIP Normally the Patient List is the first screen that you see when you click on the Patient Charts tab however whether or not it appears first can depend on what icon or button you previously clicked 10423931 Flinstone Fred 10 25 1958 M 537621111 p Adve O UM X r 10461323 Barker Georaedam 10 2511958 M 555669989 Pp Adve A X i 10423971 Green 10125966 M 537621113 Po aie A Xx 10423966 en DDE L xX BF X Als 10424843 Pasquale Nicholas WEL Patient List Screen T a f k N aa a ae Notes 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 e Type P means that the Patient is the guarantor Primary Insured e D means Dependant Status An Active status means that the patient demographic information is active To change a patient to inactive click on Xe EDIT and select Inactive TIP By default only active patients appear on the above
38. Erase default text inside the box Symptoms are Improving Worsening Patient a ee ee ae oe ee 7 To edit a text box a Double click on the text box PILLLLLPEELALEEELS PPE EE PEPE EEP EEE b The INPUT box appears 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 we fed Name texti vau Patient Name Size Max Length ID text1 Access Key Tab Index Disabled F Readonly c Insert text into the value field If you want to pull in system data such as patient name manually type token data Token Data must be in this format Scroll to next page of the manual to get a list of Tokens that are available at this time d If desired click on the General button to format the textbox appearance INPUT Attributes Css Class Width Alignment Text align Font Color E I Highlight SFFFFFF e Click the Font color box to change font color f Click the Highlight box to give the text box a shadow g Click OK h Cut and paste to create more textboxes and save time Edit the text of the copied textboxes at will 8 If desired insert a merge token anywhere you want in the document a Merge tokens pull in data from Office Ally such as a patient s name or account number b To insert a merge token into the document place your curser on the document where you want the token field to go c Click Mikki If th
39. ICE OVERVIEW aaa se octane ages iss r EEEE EAIA ONREINE EEE EEE T AEE ATE OE O EOE 23 ADMI ECHO N arn E E E A E A E E A E E E E E E E E E 24 ON TE E A A A E E A AE ic ta E tea gece baat E AE E EE A 24 Eea o A Ee EE A E OEE E TEE EA EAE AEE E nes ents AEE E E E E T E E EE 24 MONOC U E A E AA OAE AVOA ONEA EE EAO EEA E EA A OEA 25 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 How to Add a USer sersrsrsissrssisivercresissrsareresideves tsis tre kenis NECE ENESES KEA ENSANSE aewetastynaubae vas ooatwoadareidectdyetueadunatee DEN NESTON SAEN NNSA NEEN ANE TONSA Srna r Erisan 25 Impor Data Wizard serisinin e i EE E E E a 26 VEE T TET S a T R A A ANAA O AE ARO A E A A OOE 27 GER ECTO N a OEE E EEA NEEE EEEE EAE EA EES 29 OL ae cd eg cd od S a AEE E EAA NEA PTE N AN ey A A E A AE P E A AE A E A A E E T 30 Patient Summary Page SETTINGS esiscei aaeiroa niwacenaine sian e a a a a E a Ea E E a aR 30 Choosing Panels to Display on the Patient Summary Screen esssssssssensssseressrsrrressrrressrrressrrressrrerssssrerossreressrerossreressreresssseressseressseressereesseeee 31 Choosing Arrangement of Fields Within a Panel cccccseseccccssseeeccceeeececeeeeeeeeseseeeeeseaeeceesaeseeeeeaaeeeeesauaeeeeeseaseceesueseeeesuaneceesaeaseee eeeesaaaeeesegs 31 POUCHE Demographie SETTING Soraia aE EONA aa Panalocaameaclouanavaa vananceaaievtlewatasesivasaivarieesteevsntecatentiastaiatooaamsieel 32
40. IVISIONS The Main Tabs ina sa At the top of the Progress Note Summary screen you will see the main EHR tabs Patient Menu Section The section immediately below the menu tabs is the PATIENT MENU section see arrow located inside the Patient Information box above Patient ID 10423966 DOB 10 25 1960 Age 46 yrs old Last Name Carson Gender M First Name Kit Insurance ALLIED ADMINISTRATORS Mid Initial Universal ID Patient Information In a nutshell Patient Menus allow you to 1 Go to other screens 2 Attach and view documents that are linked to the Patient s overall medical record and 3 View lists of information from Progress Note panels such as the Medications panel 4 Create New Encounters NOTE Itis IMPORTANT to understand that anything accessed from PATIENT LEVEL DROP DOWN MENUS are connected to the chart at the Patient level as opposed to the encounter level which is explained in the next main section Think of files viewed here as you do when you see them in a paper hospital chart Just as items in a hospital chart data acquired during the entire history of the patient s hospital stay so items acquired with these tabs documents acquired during the patient s entire history with your office 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 Below is a description of each of the Patient Level drop down menus
41. OFFICE ALLY EH FFICE OFFICE ALLY EHR ecamsuesscccdesescescastcencunscsecanebwacaccenessaccuceescstcoensuecebesnceneeesccecusetpaduapeotessnnovactavunccatassundausiensbesauansuaccaneonsucsueteessdeeuteuesteuGs 1 OVERVIEW siensa A A E E A E E E E AA 6 INTRODUCTION TO EAR MODULE Ssss a N i 7 MO TOS e AA casters EATE A A TEA E AA OE EE A NAE 7 SCO CIS E ENNE O A APEE E AA P E EAE A AA AIA AA AA AEN E A A A EET 7 LINKS to other Office Ally SYStENIS eisrirosrireisin inii E E EER NEE AAIR EEREN EE S E EESE A EISER 7 DESKTOP TA D eane ean E E E EE E ENE E EE cedures 8 UY TE T EN E E A oe EE E T EE AEA AE EE A nine A E ere etd aa A E E T 8 PATIENT CHARTS aoa aici won E E EA E E OAE AEA E AI EE E EEE EA A A A AE 9 COV ET VIEW EE E E E E E E E 9 POT EE E a A ANEN OENE A O A N A EE A E E AO A E E E EE E weeeee 9 Faen SUIT S OE oee enia E RT EEA NA TEE E E R 9 Oe E NOE TEE E E E E E E 11 Progress Note SUMMAI SCS sarene ENE E EE EE A 11 BILLING STATU Senn a A A E A E E E E E EAE 12 DU IVY E A ate ete E A E E EE E EE E A E E T E E E at ace canes 12 REFERENCE reanna E T EEA AE EE EAE E E E AS A EA A EE AEN 12 VET a E A E E AE T E E A E A E A A A N 12 MANAGE OFFICE orerar a E N E E A A E A N 13 OU VW EENE E E E E E E EE E EE EE E E E E E E E E A EA 13 NAVIGATING THE ERIR isc casas SE E NE AA EE E voce T T E EE AO E AE 14 NAVIGA TON OVERVIEW sccccasaccnacocetoscntdamcsuacis pata secaeacueaincanactaauatenant NEEN OE ENEE ANEA ETENEE ESTEE RESE ANE AEREE EAER
42. OTS S59 625 0009 Or Michele Seah Enes ate A SH ff tSmwna Byer Mis TOR0OO 85 9289 Dr Michele Smith ners ate W A oS ning Fence Aano o Cv Robert Greene Sport Pryecd lactis wo E bban Wara Sydney Cosinfo GNI SabeEeee Or Miche Sein PymcoExem ate 4 W Ko p Iana SararaTayke SMS SEO fe RebertGreene Picaa Ade E X OEE Haas Sna Daa doren TAGS PS0 Sari Or Mche cah linens Aie X B tena Endy Ronen AGS Ce Michele Sah linens ae wW S SH Time Intervals This allows the user to override the time intervals set up in Manage Office Appointment Settings VIEWING MODES Once the above filters have been selected the calendar can be viewed in Daily Weekly or Monthly view e Click on one of these choices Time Interval 15 minutes Ries B 3 Bie hs BF Daily View Modes P Daily View When the appointment module is launched the calendar for the current date will appear In this view appointments can be added deleted or edited You also have four Daily View Modes to customize your Daily view Detail View Provider Staff Resource View Provider Staff View and Resource View 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 Daily View Weekly View Monthly View Reports Providers Staffs All Time Interval 15 minutes T 24 25 B ae pi i202 4 Daily View Modes gt Detail View Providers Staffs Resources View Ta Pete a ti a
43. Pasquale Peter There are a number of options for navigation within the main Appointments tab Provider Schedule Click on the Office dropdown button T O to choose a different Provider Staff schedule Note Default physican is set in the Manage Office tab Click on EI or to change the date one day at a time or click on EE to select a date from a calendar Click on a Patient s name i e Red Green M to open Patient Summary information Encounter Chief Complaint Provider 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 GENERAL LINKS Office Ally EHR Provides links that enable you to move back and forth between screens For instance clicking on the above link will move you to the Patient List screen NOTE Generally it is best to move from screen to screen in the system by using appropriate Links buttons and drop down lists However if all you need to do is go back one screen then you can click on the Internet Explorer back arrow PRINTING Progress Note Prescription Laboratory Orders Several of the modules have screens or reports which can be printed as well as viewed Look for the View Print or Print button to print GETTING HELP Office Ally EHR s online manual can be accessed by clicking on Help from the Manage Office module 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax
44. Phrases you are building short cuts that can be accessed in the User Defined Family History Phrases Progress Note panel shown below User Defined Social History Phrases User Defined Allergy Phrases User Defined Immunization Phrases User Defined Review Of system Phrases User Defined Physical Exam Phrases User Defined Assessment Phrases User Defined Procedure Phrases User Defined Plan Phrases User Defined Patient Instruction Phrases Profile Tree The set up step actions for each of the profiles listed above are the same Therefore a generic set of instructions are provided below Listis empty Please click Add to add data to this list pescripton lt e io Figure 3 Sample Set up Screen Click on the desired profile link in the User Section under the Manage Office tab Click on the Search button Mo click EERE Select an item or multiple items from the master list that populates Click Repeat as necessary So i 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 LIST MAINTENANCE List Maintenance Providers Referring Providers Facilities Insurances Superbills Foon Reason for Visit Aa boratories feos Templates Been SOAP Guidelines List Maintenance allows the administrator to create and store business information that will be used throughout the program Only the System Administrator can c
45. Security No Patient ID Patient Account No Peter User Field 1 Peter User Field 2 To use a Drop Down search menu click on the down arrow m and select an item from the list that appears If nothing happens look for additional buttons such as or Show All 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 Display By Filter Additional filters allow you to search and display lists by a specific date or date range In the example at left enter the date and then click on the button to begin your search Sort By Filter Patient ID Last Name First Name 10423931 Flinstone 10423971 Red 10423966 Carson Sorting functionality enables you to sort lists by column header For example click once on the underlined column heading to sort by that column Double clicking sorts by ascending or descending order Diplaying Hidden Data 3 History Medical History Surgical History Family History Social History 5 5 ah awh ES A a D a Allergy History 5 ad Eat ES ie a Immunization History 5 oh ES E a Medication History i r To keep certain screens clean some data is hidden from view To display hidden data simply click on or El 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 Navigating the Appointment List Pasquale Nicholas
46. User Defined Diagnosis COGES iismsiscatsnincatarntasenniGannantacaeacniransanecaanaaedunsiatois bis Gaarnbesndacabaisasananetaiebuanndaanteinandeaesusaandbauvauapdoudoiebieiansendoadhe 32 TO Setup a Diagnosis Code Shortcut List cc ccsteadacevacectoenecudacenecartacesusasectuspcaui bcuseae csecsdeapisnisnitees senate ia eased and ee 32 Bol an Beg hi clo lO od Me OL 6 0 S eee A ee ete or enc one oe me en nee een ene De ee ne A oe eee ne ner 33 to Set p a CPT Cade Shortcut St oeseri eee en ee ee ee 33 Ue ITE Be T e A A E E E A N 35 er Dna N 6107 O E E E A EE EE E E E EA 36 WOE MEd ON oaae E E E E E E E E N 36 More User Da ned oel Wy Sei Ce 1S inte sei ran AT E E TAE E OEA 37 T VAIN IE IAING E orae E E E E E E E E E E E E E 38 OC OS ce EAEE A AE A NE EA P A E A AE A TE A ET ANE AA ATA NE E E A E E A ET 39 Wi EST a ISI Se NENV O E A E naaeiemess eeu aanancnaue ns covaucaaieuenes ceesaasauacsmauousnnieneanh ees 39 Te Create New Referring Providers oorsssirrensorens tibia tier ir SeNi SE EUA EE ENE TREE TENE EINTE OE TE EE E E dais vensaancaneatas ENa STES 40 FA S E E E E E A E A A E E A A E E teeaee 41 TOCE ae NEN EE en E E E E 41 MU OS E A E AE E E E E A 42 to create New Mourne S eraa e E EA TE T A e A A ATN S 42 SUPEO E ET AA NE EAE AAA E E A AA EE A E A E E EE EA E A AE 43 TO Create New SUpErDIIS sorcrenien sinsdien inani eE ENEN E OT E ENE EAEE ER 43 Eepe ek Ecje 1e i EE E A E E E E E A A A E E E 44 e ay 4a cad Ia Ore e E wv me E EE EE EEE or eer E
47. Virginia test Mungia Peter Pasquale ppasquale Able Arden virginiam Peter Tech Document 1000000139 Office Ally For Consultation 2 DELETES a routed attachment VIEW allows you to see an attachment e Once you open an attachment you can Print it or Save it TIP Within an open document you will see various icons that allow you to do more than Print or Save To see what an icon does just hover your mouse pointer above the icon and a description will appear THE PATIENT CHANNELS PANEL This panel is under development Date Received From immisdiywy sl To sl Go Last 400 Entries Search For Patient Last Name Y Starts with Display Filter Status New V Reason Al The Next Step To go to the Patient Charts tab click on the Patient Charts tab Also you can click on a Patients Name 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 PATIENT CHARTS TAB FFICE SATE INTRODUCTION TO PATIENT CHARTS The Patient Charts tab is the gateway for viewing or creating Progress Notes and Templates as well as viewing scanned Documents There are 5 main Patient Charts sub screens Since the system is context based the screen that appears depends on your previous choice Search For Last Name Starts With X Display Filter Account Type Status Last Name First Name MI Soc Sec No Patient Acct No
48. W The Manage Office module is the place where you set up your Health Record system mon J rrenen Apso S Main System Preferences User Section User Preferences Patient Summary Page Settings Patient Demographic Settings User Defined Diagnosis Codes User Defined CPT Codes User Defined Medications User Defined Chief Complaint Phrases l User Defined HPI Phrases User Defined Medical History Phrases 3 User Defined Surgical History Phrases User Defined Family History Phrases User Defined Social History Phrases User Defined Allergy Phrases User Defined Immunization Phrases User Defined Review Of System Phrases User Defined Physical Exam Phrases User Defined Assessment Phrases 3 User Defined Procedure Phrases User Defined Plan Phrases User Defined Patientinstruction Phrases amp List Maintenance Offices Providers 3 Referring Providers Facilities 3 Insurances superbills 3 Reason for Visit Laboratories Templates The Mange Office tab provides the foundation from which all other modules are built Decisions made here will affect the overall functionality of the application so this tab needs your attention before doing anything else NOTE Data entered in Manage Office will affect both the HER system as well as the Practice Mate practice management system The left hand side of the Manage Office screen will display a PROFILE TREE that is composed
49. a favorites list of your most used words or phrases Also they can be used to store treatment reminders that are categorized by specialty Once created SOAP Guideline shortcuts appear as links in Progress Note panels You can create and save a different set of SOAP Guidelines for virtually every specialty that there is and these guidelines will be right at your fingertips when you are entering Progress Note data Below is a brief example of the how to access SOAP guidelines while you are typing Progress Note text If you look to the top of the Progress Note screen you will see a drop down icon a this drop down icon is located next to the field entitled Guideline Name A screenshot of what you should look for is shown directly below Guideline Name Dr Pete Chiropractor Choose a specialty from the down list If this specialty contains any of your pre built SOAP Guideline words or phrases then these words or phrases will appear as links within appropriate Progress Note panels as seen below Chief Complaints P E E Al S0ap Note Links Create these links to do whatever you want For example you can access a phrase or word that you use over and over in your practice or you can access a treatment reminder paragraph To Create a Soap Guideline Search For Guideline Name Starts With lt Add New Show All 1 From the profile tree click on the SOAP Guidelines profile Manage Off
50. a a jozooam Co T meS ac a soam CS EC T T S T sa fT o T T O OS T ooa ooo o T T O S T sam ooo PE T T S O OAST T soan fT o T T T O ATS T SSS eS SSS pM eS e i SS Weekly View Weekly view allows the user to view a full week s calendar on the screen Click on a date to toggle to the calendar for that particular date Providers Staffs All Time Interval 15 minutes i 08 15 am es 06 30 o E E _ West Adam H ca x G x 08 45 am HK R x o Co EE OO jose UT O wt o E tld ld TEE eee tim o EO OK Monthly View 0 a Monthly view will display the current month s calendar as illustrated below The number of bookings currently scheduled for each day of the month will be indicated Click on a date to toggle to the calendar for that date 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 Office South Side Medical Providers Staffs All Ea A4 CLOSED 8 X CLOSED X CLOSED 71 X CLOSED X CLOSED 28 X CLOSED X CLOSED SEARCH To search for a particular patient in the calendar e Click on Search at the top of the menu e Type in patient s name or phone number or use the browse function to find the patient in Patient List e You can search for all appointments last 30 days or upcoming appointments e Click on Search Y ae ae E Pat
51. ach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 SYSTEM PREFERENCES Admin Section Company Information Manage Users Impor Data Wizard System Preferences From this profile you tell the system whether or not you want to show Practice Mate profiles and tabs in the HER Preferences Choose YES until Show Practice Mate modules ves Se t_u is complete YES will cause the PROFILE TREE to expand because it will temporarily display profiles and tabs normally only seen in Practice Mate When initially building your EHR office you will want to see all possible profile options in order to do a complete set up Company Information Manage Users Import Data Wizard system Preferences The Profile Tree If You Choose YES the Following Things Will Happen in your EHR system 1 Most of the Practice Mate profiles will also appear in the EHR PROFILE TREE olan Palen Summary Page dating Taa Dermigtaehes hi F 2 The Practice Mate appointments tab will appear in the EHR Add New Appointment Search Daily View lt September 2007 gt 2 J f z l amp cry Office Redlands Office 4 Sun Mon Tue Wed Thu Fri Sat Providers Staffs All _ Time Interval 15 minutes v A 10 11 12 13 1415 p 46 17 19 20 2122 3 23 24 25 26 27 2829 l Wi 23458 e Patient Name DOB Home Phone Provider Reason for Visit Status 3235
52. ad these Templates and use them as is or modify them to suit your needs Note Templates are accessed anywhere in the system that you see a drop down list similar to the one shown below Documents P Add Document Upload Document OVERVIEW Here s a general OVERVIEW on how to set up a Template Specific instructions are found on the following page Add New Show All Category Description Type Source Edit Delete Consultation Back Image Consultation well child PM160 1 Click iee 2 The following form appears Template Type HTML Form v tepee Document Type 3 Click to select Template Type a Letter Word Document that you can use to send mail merged letters Can also be a written lab or MRI report b HTML Form Allows you to create a fill in form with checkboxes c Image Allows you to import a scanned image such as an silhouette of a body 4 Type a Personalized Name for your Template 9 P te Description 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 5 Click to select a Document Type Document Type is important determines what category your document will be organized under i e Letter Progress Note Consultation Image etc 6 Build your Letter on the form 7 Click There are 3 types of Templates Each Template type will dictate the documents appearance and each one uses a different method of editing Tex
53. aguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 NURSE WORKFLOW Nurse Create an Encounter from the EHR Office Ally EHR Home Service Menu Practice Mate To Create an Encounter 1 If you are in Practice Mate click on the EHR link at the top of the screen 2 Click on the Desktop tab 3 Click on the Patient s name Home Service Menu EHR 4 The Patient Summary Form appears a 5 di Ls sO e FS Recent Charts _Patient List_ Patient ID 10423971 LastName Red FirstName Green Mid Initial M i Insurance ALLIED ADMINISTRATORS Universal ID Blood Pressure Value 10 25 1966 Age 40 yrs old Green Red Display Fiter From Date E E To pm Last 100 Entries KES cO zt View ae ee Provider ga peel Note Note There are no data records to display There are no data records to display 5 Click Progress Notes gt Add Progress Note Encounter 6 Fill out the form that displays with as much or as little information that you desire 22 2319 085 Coast Highway Laguna Beach CAS 92 651 www officeally com Phone 949 464 9129 Fax 949 376 6951 Encounter Date Ea Encounter Type Office Provider statt Location of Service Reason For Visit E a all ead Height Pulse Resp Temperature Waist Weight COo Ee TICO TEO TMEO TMEO JOCO JEO JIo Allergi
54. ally add these appointments to the calendar Using this option however will schedule the patient at the same time of day as the original visit It is advisable that the user first check those future dates for availability as the system does not prevent double booking e Click on Update Patient visit has now been scheduled and will appear in the calendar as illustrated below WAWIE PrP Freire TO SCHEDULE A NEW PATIENT A patient must first exist in the database in order to schedule an appointment The patient can be added by clicking on the Manage Patient module and following the steps previously outlined A faster method for scheduling a new patient is as follows 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 e Click on hi in the Add column corresponding to the date and time on the calendar that you want to schedule coe ee nar oh men tS i a a fesse REE sasam fF T T S ASS U joxcoamf FE D T OO ONESTE E S The Add Appointment screen will display e Click on the Browse patient patient Lastam patient Home Phone South Side Medical FrankStokes 9 Frank Stokes Stokes ka Appointment pato crt E 17 u na Time 08 0 Visit Length 15 minutes E Color Code reasonrorvise OB Notes Repeat optional Days Between Visits The Patient List in Manage Patient module will display e Click on Add
55. am by contacting Office Ally because it is used to contact you regarding the status of your claims Maximum EMR Users Bso ncludes this user 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 MANAGE USERS Admin Section Company Information Manage Users impor Data Wizard System Preferences The Manage Users screen allows the Administrator to create user profiles for employees who will have access to the program Typically an office will be set up with one or two physicians a receptionist a biller or an office manager and perhaps a nurse Each person can have a different level of security NOTE Any Provider added as a user must ALSO have a Provider Profile with a USERNAME that exactly matches the one entered here The Provider Profile is located near the bottom of the Profile Tree MAKING CHANGES IN THE USER SECTION Add New Show All ppasquale Admin Peter Pasquale a i Biller_Peter Assistant Biller Peter Y t x E EMR_User_1 Assistant EMR_Userl One YA X i Recptionist_Peter Assistant Receptionist Peter s x i FRANK Provider Frank Provider2 Y A X i a X i PETE Provider Peter Provider Y Screen Definitions e A Y inthe PM column means that this user has basic security that enables him or her to use Practice Mate e A Y onthe EHR column means that this user has basic security that enables him or her to use
56. anual Prescription Data Entry DINECtlONS sx icccscesscnceeenceadseusscurteconepacucaeaneceaseepecueseanceancnsdaudicesdsereeesiavaccuslioiaateieadiaveiwaiensedeanseredesdepedsencpedactiarades 82 Electronic Medication Data Entry Directions cccccssssccccsececesececeececeeccecsececsuececauecesaueccetsuececseecessuececsueecetsnecesseecetsuecescetegecetsuecetsgecetseecenea 82 Here s how the electronic process WORKS sassccsicesiascnnnserade inaedvsnnwncsasunendaaededauededhaaweaninsinenasdndacensdedseriedeceetonwiasedaaieyads tua wpadbeutedaabaad AEE N eieiei 82 Patients Charts Tab Progress Note Summary SCION scccccsesecsesesececeeseesccunecscsusecsccusescsusecsecsuseseseueesssusecsseusesssuueessssessseesestseseeees 85 MVS VN ANIA WMS ea E T E ae aaa oe sae oes 85 POMC VEMMO SECTION ccseneananetsctcannanteusseaseratinatssiaataaeccsaneaescieamentcbawaienadntieanteaareuncetsaseunuaneds Mounties wtreameda sung tne E T NN 85 Encounter Meni S CC CON enere EEEE EEE EEE EE E EE OIE AEAEE OENE ERE 87 The Encounter Navieator Secon esseci rnan T A EE EEE E EEA E 88 Wie Curent Progress Note Section errre n ENE EE EAE E E NE NN TOES NEE 88 Nole kegordaind FAR TOP DOWN LI TS srona E E TE E ER 89 APPOINTMENTS TAG ceirar E E E EO 90 APPOINTMENTS OVER VIEN setessoniiE nE EI TE EEEREN EOE EA EEEE O ONORE 90 VAC WO MOGO aar rriar EAE E E E 91 SCC 1 NA E N E EE PE A EE dae A A E O I E E A E E E A E E N A E evees 93 OO T C E N a E A EEA ease EA ina ance TOA
57. by clicking on the first search button in the panel clea a BA Below is a sample of a pop up list shortcut Each panel has its own unique list Select Select Debris in ear canal Select DEPRESSION Select PAIN BACK Select PAIN NECK Select SORE THROAT Phone 949 464 9129 51273735 0 6 5 Coast Highway Laguna Beach CAS 92 651 www officeally com Fax 949 376 6951 TIP You can create shortcut lists on the fly by highlighting the desired word or phrase then clicking the Add EY button Also shortcut lists are created and maintained in numerous Manage Office tab profiles How Add O Works 1 Highlight the word or phrase ioe 2 Click 3 Click Update select Dust Mite Select Food Allergies 4 The word appears on your personal Shortcut list Select Hay Select Mold Text Shortcut Future Functionality coming soon TEXT provides an alternative for you to access phrases from your Personal Shortcut List or from elsewhere in the system Here s how it works e Set up for your TEXT directory occurs when you click on the ADD button Once you click on this button you will be allowed to correlate key words or phrases from your shortcut list with a dot and a one to five letter association e For example Mold can be related to M e Usage Once a particular TEXT association is set up you can access a desired word or phrase by typing the appropriate TEXT shortcut fr
58. cess e gt Patient Charts Progress Notes Encounters Read Access Patient Charts Progress Notes Encounters Add _ Patient Charts P rogress Notes Encounters Edit IMPORT DATA WIZARD Admin Section Company Information Manage Users import Data Wizard System Preferences A click on the Import Data Wizard profile allows the administrator to import Provider Insurance and Patient data from a CSV file saved from an outside program Import Data Wizard will assist you import data from data sources such as HCFA Stored Info Office Ally web service application and other file types into Practice Mate You will have choices to select one or more data records from source tables Billing Providers Providers Facilities Payers etc and import into corresponding tables in Practice Mate Data Source Office Ally Stored info HCFA Records Per Please select a data source then click Next to continue or Cancel to exit If you use Practice Mate your Provider Insurance and Patient information is already stored in the EHR If you have been using an outside billing program you may be able to import Provider Insurance and Patient data depending on the export capabilities of your application This will save you the time of re entering this information manually For complete import instructions locate the Practice Mate manual at OfficeAlly com 32356 S Coast Highway Laguna Be
59. ch through lists that you have previously created or ones that Office Ally provides such as CPT and ICD 9 code lists Here are the varous ways to search for information within Office Ally s programs The Search Button Diagnosis Tiagnosis Symptom Codes 034 0 Strep Throat f3o 1 Dyawia 1789 00 Abdominal Pain YS Weccare Admin Diagnosis Coda a Descriptio l e The search button B indicates that there is a search list available in the background e Simply click on the B button and select an item from the list that populates Searching for Data Within Long Pop up Lists When a click on a search button B causes a long list to populate the list will be capped and categorized alphabetically This allows the screen to lload faster 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 System Allergy Phrases Show All Top 100 Records Select Description select 8 HOUR BAYER Select MOP select Select select YOROCORT A METHAPRED H STANNOUS AGGREGATED ALBUMIN A POXIDE Select Select select select CAVIR AACAVIR SULFATE JABOKINASE HELCET select select Select 123456789 To search for Allergies beginning with B type B in the blank box and click Search Searching for Data via Icons Encounte nD Visit Type Provider Enc Status Progresa Hotes e Allows you to View info such as a chart Allo
60. cholas 10 19 1993 M Patient List Underlined data such as patient names in the Patient List are shortcuts to other screens In the example above clicking on the name Fred or Flinstone in the Patient List will display Fred s patient summary screen Fred s Patient Summary Screen 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 FILTERING LISTS OF INFORMATION Patient ID Last Name First Name Soc Sec ho 10423931 Flinstone Fred 40 25 1958 M 537621111 40423971 Red Green M 10 25 1966 M 537621113 10423966 Carson Kit 10 25 1960 M 537621112 10424843 Pasquale Nicholas 40 19 1993 M 555665555 Patient List as seen under the Patient Charts tab Because your data is maintained on Office Ally s web servers you can create and maintain an unlimited amount of it Thus there are no restrictions on the number of patients your database can manage However to optimize system performance we have limited the number of records that will display when the user accesses certain tabs or search buttons For instance the Patient List screen shown above will display only the most recent patient records unless you tell it otherwise Therefore to find a particular record that does not display automatically you must use filter or sort functions Drop Down Search For Filter Search For LastName Last Name First Name Date Of Birth soc
61. create their visit The visit is where you will add the codes and charges for the claim e From the appointment schedule Click on the Create Visit button d IE a aea ea ied eter ese lanl E 08 00 am 15 mins Clark Kelly 6 21 1975 777 777 7777 Frank Stokes Check up Bess ix vv a jostsam T T OS AT SYS joszoam T T Y OT AS OS oO Ei ee Oe eS a eR Se a l e This will bring you to the Patient Visit screen where you can add the codes and charges for the claim Note If you have created a template for the patient you are creating a visit for the template information will appear in the visit e Patient Visit will be discussed in detail in the next chapter Patient Visits 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 BILLING STATUS TAB INTRODUCTION TO THE BILLING STATUS TAB The Billing Status tab is where Providers manage their visits for the day and send them to Practice Mate for billing fa Encounter Date From B To B Go Last 100 Entries Show All Create Practice Mate Visits View Encounter E i Change e Provider Location of Service Patient Name ype Billing Status Billng Sta fe Info 09 06 2007 FRANK Provider2 Peter Tech Pasquale Nicholas Office Visit Oo 06 2007 FRANK Provider Peter Tech Barker Geargegam Office Visit 100000345 09 06 2007 FRANK Provider2 Peter Tech Barker Georgedam Office
62. d Pressure Field Name 10 25 1960 Age 46 yrs old Kit Summary Screen DRIVING DIRECTIONS 1 Click k to edit a Progress Note 2 Click to view a Progress Note 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 3 Also you can use the Progress Notes Drop down menu toeither view a note or create a new note Other Info e A neat feature you can left click on a panel and drag it to a new location on the fly THE NEXT STEP To create a new Progress note click on Progress Notes Add Progress Note Encounter Progress Notes P gt Add Progress Note Encounter PATIENTS CHARTS TAB NURSE NOTE SCREEN When you create a new encounter by clicking Notes Add Progress Note Encounter you will see the Nurse Note screen appear Progress Notes p gt Add Progress Note Encounter Encounter Date Encounter Type Outpatient Office Visit ka Redlands Office Provider Staff Provider FRANK Provider2 Location of Service Peter Tech ReasonForvisity OOo o OD Vital Signs Head Blood Pressure BMI Circum Height Pulee Resp Temperature Waist Weight E sR nO Allergies BESO urrent Medications a a A Nurse s Note s 4 aA hts MIE es e This screen will only appear ONE TIME only after you click on Progress Notes gt Add New Progress Note Encounter e Fill out this screen and click update or leave blank
63. d under the Facilities profile Office names and locations set up in this area of the program will display in a drop down box in the Desktop tab where it can be selected for appointment viewing Office Redlands Office To Establish a New Office 1 Click NOTE Click b to Edit and to Delete existing data ssw Contact Hame Search For Office Name we Office Name Delete Redlands Office San Bernardino Office Contact Title Phone 2 Office ID will be automatically assigned office 10 Office Name Address Line 2 City San Bernardino State Zip contact Tite J ContactFirstName ContactLastName si mone pL rox 6 S 3 Fill out the form that appears Click 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 REFERRING PROVIDERS A click on Referring Providers allows the administrator to create physician referral profiles including the doctor s name address specialty state License and NPI number This information will feed into Practice Mate and when needed go out on a claim To Create New Referring Providers 1 Click Bibi SearchFor tsstName Sterts wen Hf a Specialty x 3 Click 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 FACILITIES iF ACES jue insurances bee superbills A click on the Fac
64. e Redlands Office v appoinment it Appointment Date mm ddiyyyyk a i 4 2007 Time 08 00 rowel Visit Length color cove A O E Notes Repeat optional Days Between Visits 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 4 Click Browse to select a patient from the office Patient list 5 Fill out the form at left be sure to select a reason for the visit 6 Click Update 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 Office Staff Check in the Patient Using Practice Mate 1 From the appointments tab click the Check In icon 2 The Check In form appears Add New Appointment Search Daily View Weekly View Monthly View DE Py Office Redlands Offee m providers statts Time intervat ERRER E Aa GA eRBER BE enge REE CRB EP Ey agren 3 Fill out the form Patient ID 10423971 LastName Reg Feston Ge e tig 10 Js 1966 _ gy Sender SSN 537621113 usta siatus ares 7 Emmet Empoy enuas CEO Addresstine2 oo cy oma je ca z p Home Phone d hO Work Phone d bi lt WorkExt came A e o insurance Co D 131275 insurance Name ALLED ADMINISTRATORS Subscroero zs O crown veue D oi Resource 4 Don t forget to check the Check in box 5 Optional Click Print Superbill 6 Click Update 32356 S Coast Highway L
65. e Dia stolle Bisco Pr etsaure aE 40 O21 2007 Ona eboT Diagnosis and Procedure Panels Diagnosis and procedure codes can be auto entered into the appropriate panels by either clicking the first search button your Personal Shortcut List E or the second button the appropriate code book ll Another option for entering codes is to click on the Superbill Et button Clicking this button enables you to enter ICD 9 and CPT codes from a form that you previously created in Manage Office gt Superbills 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 Superbill NOTE Data entered from the Superbill will feed into Practice Mate Lab Orders Lab Order lists are pre built by you in the Manage Office tab gt Laboratories profile Test Name ema a Here is how to use Lab Order lists while typing your Progress Notes e From the Lab Orders Progress Notes Panels you choose the desired lab by clicking w e Access your pre built list of tests by clicking the Test Code search button B e Repeat for each test al View Print e To print the order click and then click ON gt Lab orders on the following screen Medications The MEDICATIONS panel allows the user to submit prescriptions electronically or print them manually NOTE You choose whether you want to do prescriptions manually or electronically in the Manage O
66. e Insert Fields button is not seen manually insert a token token list is on the next page d An inserted token will result in something like this PatientFirstName e Tip Merge token data can be inserted anywhere even inside of text boxes 9 Format the form as needed NOTE The formatting icons are the same as in Microsoft Word If you hover your mouse over an icon a description will appear 10 When finished click TIP OPTIONAL CREATING A TABLE FOR YOUR FORM 1 Optional Click on to create a table that will provide a graphical guideline for your form 2 Atable wizard will appear Define the number of columns for your table by highlighting them with your mouse Draw Table DENN 2x3 Table Table Wizard 3 Click anywhere within the table to type free text or insert checkboxes radio buttons bullet points etc 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 Manual Token List PatientCity PatientDOB PatientFirstName PatientGender PatientID PatientLastName PatientPhone PatientState PatientZip ProviderAddress ProviderCity ProviderDEA ProviderFirstName ProviderlD ProviderLastName ProviderState ProviderZip IMPORTING TEMPLATES FROM OTHER PEOPLE 1 Have the person trying to send you the Template that you want to import first copy the HTML Code from that Template and paste it into a Word document See sree 4 11 for details html amlas http www
67. e middle section called Available Panel Fields Click to add the field to the Selected Fields section on the far right Move field order up or down using the up and down arrows a tS ae 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 PATIENT DEMOGRAPHIC SETTINGS Patient Demographic Settings User Defined Diagnosis Codes fe User Defined CPT Codes This set up option is in the process of being moved to Patient Summary Settings USER DEFINED DIAGNOSIS CODES User Defined Diagnosis Codes User Defined CPT Codes User Defined Medications A click on User Defined Diagnosis Codes allows each user to build a personal Dx code shortcuts list which make taking Progress Notes easier and more efficient To Setup a Diagnosis Code Shortcut List Current Entries Diagnosis Code 2980 Depressive type psychosis T241 Fain inthe Back Click on the search box for B Description A pop up box of codes from the Internet will appear After searching click select to choose a code Click Mias m eR Repeat if necessary DRIVING TIP Office Ally s set up screens are fairly intuitive When preparing to enter data into a profile your most common starting points are one of these two buttons Add New BECCLGYA or Search B THE RESULT Snapshot of the Progress Notes screen as seen in the Patient Charts tab Congratulations Now when you are working on your P
68. ears 7 Fill out the additional fields shown above 8 Click 9 Repeat as necessary THE RESULT The above screenshot is a snapshot the Lab Orders panel that the physician will see when doing his or her Progress Note for a patient If a Lab has been previously set up the Provider will click on the down arrow to select a lab Next he or she can click on the search button to choose a test Eventually the choices will be sent to the lab electronically However at this time they must be printed manually 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 TEMPLATES Templates SOAP Guidelines Templates are documents that you 1 Upload as is such as an image or silhouette of a body that a Chiropractor would write notes on 2 Create from scratch i e a form used to make assessment and prognosis go more quickly 3 Or adapt for example a previously used mail merge letter Templates can be attached to the Patient s overall chart or to a specific Encounter For example items such as a collection letter are useful if attached to the PATIENT S chart because a collection letter deals with guarantor issues In contrast an HTML form designed to aid Progress note taking might be best used if attached to a specific ENCOUNTER In the near future Office Ally will be uploading a Template library of forms commonly used within various specialties You can uplo
69. ere you will be adding CPT and ICD 9 codes and categories to your Superbill To Add Categories _Procedure Service Categories Medications Pregnancy Related Category CPT _ Fee PY a er rr see Procedure Service Categories The large box seen above left is where you define and add Procedure categories that will show up on the Superbill as a header Headers divide the bill into sections so that CPT codes can be grouped by service i e Office Procedures Vaccinations Medications etc The large box shown above right is where you add CPT codes to be associated with categories Here is what to do 1 Direct your attention to the large box on the LEFT side of your screen that is labeled Procedure Service Categories Procedure Service Categories Category Medications 2 Underneath the large box click in the small rectangular box labeled Category Enter a name This is the header under which you will add related CPT codes 3 Click Add 4 The Category header will appear in the large box on the Left onto the Procedure Service Categories Procedure Service Categories _ Medications 5 Repeat Steps 11 14 to add more CPT categories Adding CPT Codes 1 First highlight a category from the Procedure Service Categories box on the LEFT side of your screen 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376
70. es Current Medications B B Nurse s Note m l G Update i 7 Click Update Note f your office does not use a nurse this screen should be filled out by the doctor Any data entered here auto feeds into all other appropriate HER screens 32356 S Coast Highway Laguna Beach CA 92651 www officeally com Phone 949 464 9129 Fax 949 376 6951 PROVIDER WORKFLOW Provider Chart the Encounter in the EHR 1 Click on the Desktop tab 2 Click on the Patient s name Office Ally EHR Home Service Menu Practice Mate Deskto Patient ID 10423971 DOB 10 25 1966 Age 40 yrs old Display Fiter Frompate G to S LastName Red Gender M i Go FirstName Green Insurance ALLIED ADMINISTRATORS Last 100 Entries ERJ Mid Initial M Universal ID Blood Pressure gt Encounter Date 09 04 2007 08 22 2007 Back Pain PETER Provider1 Chief Complaint 10 25 1966 Age 40 yrs old There are no data records to display 4 Click Edit Note 5 The Progress Note screen appears 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 Encounter Date Provider FRANK Provider2 Location of Service a SOAP Guidelines gt Specialty all Guideline Name none History Progress Note Medical History g Subjective Surgical History lt lt ease Family History Social History Allergy
71. ewed and attached here are attached to the specific encounter Progress Note that you see on the screen e View All Documents enables you to VIEW encounter level documents letters and templates Doc Tithe Type Status View Of die007 Edit i Back Image Del X Consultation Sign AS Route e Add Documents allows you to ADD documents letters and templates that have been previously saved in the Manage Office tab gt Templates profile Encounter level document management works just like the Patient Level therefore for instructions see Textbox on previous page Upload Documents permits you to UPLOAD scanned images from your computer s desktop such as an insurance card or a MRI report Encounter level document management works just like the Patient Level therefore for instructions see Textbox on previous page 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 The Encounter Navigator Section On the far right of your screen you will notice the Encounter Navigator From here you can jump to the following EncounterlD Visit Type Provider Enc Status Progress Notes Route e Click View to see a different note e Click Edit hs to re edit a note e Click Del amp to delete a note e Click Route td to Route a note to another user e IMPORTANT To sign a Progress note click Sin 4 and follow the prompts l i Horiz View e Click t
72. ffice tab gt User Preferences profile Seen below ee Ii s_ x 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 Manual Prescription Data Entry Directions l View Print NOTE To print prescriptions click and click on e Select a drug ID B gt Prescriptions on the following screen e Click Directions B and on the form that populates enter quantity dispense directions and number of refills The Electronic Prescription Data Entry panel looks like this Mcicationt Drug ID Drug Name 1 105966 NEXIUM EQ 40MG BASE CAP 30 Take 1 tab by mouth once a day Electronic Medication Data Entry Directions TIP Don t hit Enter from your keyboard when entering electronic prescriptions Here is what you do the FIRST time you click on the Online Prescription button Click on MEQ Click Add E Pick a Licensed Prescriber First Name Last Name Middle Name Opret Osu DEA confirm uPIN confirm License Number confirm License State Select a State Save Cancel Delete 4 Fill it out and click Save Here s how the electronic process works 1 Click on Online Prescription The COMPOSE RX SCREEN appears 2 Search for the Drug Click on the Drug that you want to prescribe 32356 S Coast Highway Laguna Beach CA 92651 www officeally com Phone 949 464 9129 Fax 949 376 6951 3 Add SIG info into the Comp
73. for Kit Carson 8 21 2007 Patient ID 10423966 t SUBJECTIVE f Chief Complaint Nexk Pain PAIN BACK Debris in ear canal History Of Started when Patient was working in back veh Present Illness Medical History Auto accident 1 1 07 No apparent connection Surgical History Tonsils 1980 Family History Depression Mother Lung Cancer Father P Social History Pt has normal social history Allergies Hay Mold e View a Progress Note e Print the Note e Securely route send the note to another user e Print orders i e labs meds etc e Attach scanned documents to a patient s general record or to a specific encounter 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 BILLING STATUS OVERVIEW The Billing Status tab is your next main module It enables your office manager nurse or P A to send the Dx Px and cost of service to Practice Mate for billing Desktop Select Be eee ee ee oa o REFERENCES Encounter ID 100000276 100000270 100000257 100000249 100000248 100000247 100000235 100000224 100000214 100000115 100000086 OVERVIEW Encounter Date Provider 08292007 FRANK Provider2 08292007 PETER Provideri 08 24 2007 PETER Providert 08 24 2007 PETER Provideri 08 24 2007 PETER Provider 08 24 2007 PETER Provider 08 23 2007 PETER Providert 08 22 2007 PETER Provideri 08 21 2007 PETER Provider 08 1
74. go to the Service Menu To understand how the service menu or Practice Mate works call Office Ally at 949 464 9129 and ask for a FREE appointment or go to officeally com 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 OVERVIEW The Desktop tab controls scheduling email routed attachments and documents from Patient Ally ra From a alnbox J 100072 Virginia test Mungia THISISATESTNOTE 08 10 2007 x Sent items 100068 VirginiatestMungia_ Test 08 07 2007 x 8 13 2007 Virginia test Mungia virginiam Peter Tech Document 1000000143 x Office Aly For Consultation Virginia test Mungia virginiam Office Ally Peter Pasquale ppasquale Able Arden Peter Tech Document 1000000139 x For Consultation Patient Channels Patient Ally to Go Last 100 Entries e Schedule Here you can view daily schedules for every Provider in the office e Messages Inbox panel displays inter system secure email Routed Documents panel displays attachments and documents i e letters Progress Notes that have been routed sent to you by other Office Ally users e Patient Channels panel displays Patient Ally forms that have previously been filled out by a patient Patient Ally is under development and it focuses on new patient enrollment info and medical his
75. guna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 USER DEFINED MEDICATIONS fee User Defined Chief Complaint Phrases User Defined HP Phrases A click on User Defined Medications allows each user to build personal Medication shortcuts which are used to make taking Progress Notes easier and more efficient To Set up Medications Drug Name Dosage Form Ingredient Select Multiple Click on the Drug Name Search button M or click EEE Select a Medication or multiple Medications from the master list that appears 3 Fill out the rest of the form Units Dosage Form Ingredient PFC CC CsdS 4 Click 5 Repeat if necessary THE RESULT Allegra D ASorin Snapshot of the Progress Notes screen as seen in the Patient Charts tab Congratulations Now when you are working on your Progress Notes you can access your personal medication list by clicking on the first search button from the Current Medications Panel shown above 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 MORE USER DEFINED SET UP SCREENS User Defined Chief Complaint Phrases Each set up profile on the list on the left corresponds to a panel in ees Defined HFI Phrases the Progress Notes that has the same name User Defined Medical History Phrases For example when you set up User Defined Chief Complaint bi Defined Surgical History Phrases
76. hange settings in List Maintenance Creating List Maintenance profiles reduces data entry time and supports reporting functions REMINDER Preferences gt lt Choose YES until Show Practice Mate modules Yes w set up is complete Many of the List Maintenance screens and forms will have already been filled out if you are a Practice Mate user Nonetheless you will want to check on them while you are initially putting together your EHR Therefore we recommend that the Manage Office gt System Preferences profile be set to YES at first Once you are Satisfied with your Manage office settings change System Preferences to NO and unnecessary Practice Mate profiles will only be seen in that application Keeping this in mind know that some of the following profiles will only be seen in Practice Mate once your initial build is complete 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 OFFICES Providers jne Referring Providers A click on the Offices profile allows the administrator to create multiple office locations In the easy to use screen that appears you will enter the office information where the Provider typically performs services such as Redlands Office and or Rialto Office TIP Do not enter facilities such as a hospital outpatient clinic or other places where the Provider may see a patient These are to be create
77. he Update and or Add buttons Entering Data _ Data entry has been designed to be as easy and intuitive Text is entered into fields boxes and the tab key moves the cursor from one field to another Editing and Deleting Left Click and drag your mouse over the To edit previously entered data click in the desired field and move your mouse so that it selects highlights the info to be changed Once the highlighted text turns blue simply type over it 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 To delete highlight desired text and press Delete from your keyboard Note Some data cannot be deleted once entered A dialogue box similar to that shown below will alert the user and these fields will be grayed out Here are a couple of shortcuts e To select all data in a field click multiple times anywhere within the field e A double click will highlight an entire sentence Copying and Pasting Data Copy and paste functions common to Windows applications are also available e Using your mouse highlight data to be copied mis Text e Right click and select copy from the drop down list that appears e Click inside a new field e Right click and select paste from the drop down list that appears Or use the Edit function in the Windows Menu Bar to cut and paste Searching Within many areas of the program you are offered the ability to sear
78. his link to change the navigator to a list See Below Encounter ID Encounter Date 100000411 9 17 2007 Chief Complaint 100000375 9 11 2007 Cold Cold extremities Shoulder Pain Normal f 100000235 8 23 2007 g Ade re ET age t nenetnnnnh ia The Current Progress Note Section The last and most prominent sector to the Progress Note Summary Screen is a print view of the most recent progress note that has been viewed or edited SUBJECTIVE Chief Complaint Nexk Pain PAIN BACK Debris in ear c anal oN History Of Started when Patient was working Present Illness Medical History Auto accident 1 1 07 No appar e Family History Depression Mother Lung Cancer Father Social History Pt has normal social history g Allergies Hay Mold Eoaea a een Surgical History Tonsils 1980 1 e TIP Use the Encounter navigator to go to a different note 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 NOTE REGARDING EHR DROP DOWN LISTS As you become familiar with Office Ally EHR you will realize that drop down lists appear on other screens besides the Progress Note Summary screen As you move about the system know that e Anytime you see a BROWN list of menu options you are looking at PATIENT LEVEL menus Patient ID 10423966 DOB 10 25 1960 Age 46 yrs old LastName Carson Gender m
79. hone 949 464 9129 www officeally com Fax 949 376 6951 PROGRESS NOTE PANEL SHORTCUTS You can always choose to hand type your progress notes much as you did in paper charts However Office Allys HER offers you a multitude of shortcuts to minimize your charting efforts Below is a description of these shortcuts So before explaining the LAST of the Patient Charts screens The progress Note Summary screen we are going to highlight a number of shortcuts and features available to you while you type a Progress Note Also we will demonstrate key Progress Note Panel features History Section Copy Shortcut You can always choose to hang type patient histories however in a couple of clicks you can copy and paste any word or phrase from the panels located in the HISTORY section to a corresponding current info Progress Note panel Note The past history section is on the left side of your screen while current panels are on the right Here is how you do it History Medical History Surgical History Family History Social History Allergy History Immunization History Medication History e e Highlight a word or phrase in a panel on the left side of your screen e Click Copy e The word or phrase will automatically copy to the appropriate progress note panel for the CURRENT encounter Personal Shortcut Lists There are exciting user created pop up lists available on virtually every Progress Note panel You access them
80. hree types of Templates 1 HTML documents that contain checklists and text boxes that can be edited 2 Letters or written lab reports that can be merged with Patient chart data 3 Images such as a silhouette of a back that a chiropractor or acupuncturist can mark up with notes In the future Templates will be available that will auto feed data into appropriate Progress Note panels e f you prefer to type your Progress Notes into Microsoft Word you can attach the Word document to the encounter with just a couple of clicks e Template Forms are set up in the Manage Office tab gt Templates For set up instructions see the Manage Office template section of this manual Sample Templates San Jose Family Practice Dr Khae V ia 1569 Lexann Dr Suite 128 San Jose CA of Phone 408 274 3200 Fax 408 274 8021 a ACUTE CARE VISIT ALLERGY URI Name Kit Carson Cm Clr oos 10 25 1960 Age J CC Patient presents with Cl Days _ Weeks of F Coughing nonproductive or d Coughing productive spitum d Fever Fi Itchy eyes Fi Watery eyes CI Red eyes F Itchy scratchy throat d Plugged Ear CJ Headache A Runny nose d Sneezing O Sinus pressure or pain F Chest pai C sos O Wheezing Clother Symptopms are improving Ll Worsening gt OTC or home remedies tried g Triggers a Unknown CJ Trees 0O Pollen F Grass F Dust Cl Animals A s a eS _ a S a DOO a T 32356 S Coast Highway Laguna Beach CA 92
81. ice gt SOAP Guidelines 2 Click EeNNN 3 The following set up form appears 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 Guigetine w Guideline Name Specialty Chiropractic a Guideline ID is assigned by the system b Enter a Guideline Name of your choosing c Choose a Specialty from the list Each specialty acts as a separate bucket to hold different sets of SOAP notes Chief Complaints Neck Pain Shoulder Pain Type desired words or phrases d Chief Complaints G insert Link ie astm shoulder Pain e Highlight one word or phrase at a time f Click g Repeat as necessary h Click 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 BRIEF OVERVIEW OF OTHER PROGRESS NOTE SHORTCUTS SOAP Notes are NOT the only shortcuts available to you Here are a few others Personal Pop up Shortcut Lists These are user created pop up directories available on virtually every Progress Note panel BEED You access them by clicking on the first search button Bin the panel Select oelect Debris in ear canal Select PAIN BACK Select PAIN NECK Select SORE THROAT TIP You can create these lists in Manage Office or create them on the fly by clicking the Add E button NOTE Click on the second search button and a large and appropriate list of terms from the internet w
82. ient Last Name Browse aa E 3 maw f Ie f Patient Home Phone p Starts With w SVE AE All E r Last 30 Days DDO i Set PRINTING THE CALENDARS To print or export a calendar e Highlight Reports and click on Daily Appointment Report 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 e Youcan print the report or export it to excel APPOINTMENTS ADD EDIT Appointments can be scheduled added in the Appointment module or in the Manage Patient module In either case a patient must first exist in the database before an appointment can be scheduled This chapter describes how to schedule an appointment through the Appointment module Refer to the Chapter Manage Patients for scheduling through that module To Schedule an Existing Patient If the patient to be scheduled already exists in the Patient List he or she can quickly be scheduled in the Appointment module e Click on Appointments tab An appointment calendar will appear for the current day Find the day and time for which you want to schedule an appointment or use navigation tools to find the correct date Office South Side Medical Providers Staffs All Daily View Modes P 8 SS eo Sa ae S osa5am TE CE T C S TST O aS es S e click on the te in the Add column to the date and time of the appointment to be scheduled
83. ilities profile allows the administrator to create a location from which services or supplies are rendered l e hospital outpatient clinic lab office etc The facility used for the encounter will populate into Box 32 of the CMS 1500 claim form and will include name and address and facility ID To Create New Facilities 1 Click Bie Search For Facity Name Starts win WHI ELS Facility Name City i Delete 2 Fill out the form that appears state o M ze nore P J rex pi nee 3 Click 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 INSURANCES bees Superbills bee Reason for Visit A click the Insurances profile allows the administrator to set up and maintain a list of all insurance companies that will be billed By clicking you can easily import an insurance carrier s electronic data including Company name and Insurance type such as Blue Cross from Office Ally s database of 1800 carriers If a payer is not in our database you can hand type data into the form that you see in this profile and Office Ally will send the claim out for a minimal fee To Create New Insurances 1 Click Bae Search For Sorts wih Gy Add New Y Show All Insurance Name Payer ID State Contact Name Phone Billing Type Edit Delete ALLIED ADMINISTRATORS 94177 CA MrAllied A SA Blue Cross California BCOOT CA EDI h x Kaiser Pe
84. ill pop up Click on g and SNOMED medical terms will pop up Auto Complete Shortcut Po p Up Auto Complete allows you to access a smaller segment of a particular panel s Shortcut List with even less mouse clicks Here s how it works If a word that you type in a Progress Note panel matches something from your Personal Shortcut list that word or phrase will pop up immediately so that you can easily select it Voice Recognition Voice Reckognition 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 If you have Vista or Microsoft Office version 2003 or later loaded into your computer you can use system voice capabilities to auto transcribe your Progress Notes Text Shortcut Future functionality coming soon TEXT provides an alternative for you to access phrases from your Personal Shortcut List or from elsewhere in the system Here s how it works clicking the Add E button will allow you to associate key words or phrases from your shortcut list with dot and a one to five letter association For example Mold can be associated with M Then when typing your Progress Notes you can access Mold by typing M Or type P and the patient name will automatically be entered Template Shortcut PATIENT INFORMATION Last First Ml PatientLastName DOG Age Response Ferson Mame o Po At the click of a bu
85. ink Box Take complete RX to review page this process will review the drugs prescribed and check if there are any drug to drug drug to allergy or drug to disease problems 5 Four rectangular boxes will appear Choose one of the four Select Proceed to Print Transmit takes you to Route RX screen so that you can send the RX electronically Select Approve Leave for Staff this will leave RX for nurse to finish and fax to pharmacy Select Finish Add to Current Meds this will add to favorites list without sending the RX to the pharmacy electronically Select Return Additional RX this will return you to the Compose RX screen 6 Be sure to check off each drug to send ROUTE RX SCREEN 7 The Route RX screen Select Number of Copies How many receipts do you want printed default is one Select Leaflet Language Default is English for any accompanying patient documents Select Print as Singles this prints each prescription on its own page some states require this Select Print RX Add to Current Meds this will print a prescription for the patient to take to the pharmacy Select Transmit RX this takes you to the Transmit RX screen TRANSMIT RX SCREEN 8 The Transmit RX screen Select Click Here will specify mail order home delivery for the RX Select Add Pharmacy this will allow you to add a pharmacy to the patie
86. inting CPT Codes Descriptions in view in View Progress Note Progress Note User Preference Definitions 1 Color Theme Sets the background color Patient Chart Summary Page Appearance This option allows for a multi color or one color view in the Patient Summary screen 3 Edit Medication Method Allows you to choose whether or not to link to New Crop Online Prescription service 4 Skip Printing CPT Codes Descriptions As a part of the Progress Note workflow the physician chooses diagnosis codes and procedure codes usually from a Superbill on his or her screen If you do not want the CPT codes to be included in a printout of the Progress Note indicate it here with a check mark PATIENT SUMMARY PAGE SETTINGS Patient Summary Page Settings Patient Demographic Settings User Defined Diagnosis Codes Patient Summary Page Settings impact the look and feel of the Patient Summary screen The Patient Summary screen appears under the Patient Charts tab Blood Pressure PATIENT SUMMARY SCREEN Provider FRANK Provider2 9 11 2007 Cold FRANK Cold extremities Shoulder Pain Provider2 Normal 8 23 2007 PETER Provider1 Field Name Value Date Of Birth 10 25 1960 Age 46 yrs old FirstName Kit Last Name Carson Actual results of settings seen below Created Alert Message Status 08 31 2007 Researh treatments for Thalassemia Minor ON 08 31 2007 Call Patientto discuss abnormal Labs 909 555 1234 ON 3
87. iple providers choose the provider from the drop down box Or click All to view for all providers The schedule shown below is filtered to just display Dr Greene s daily calendar ET w TET ES C0 ami C2 Mem Sma Cee Coe WAANS Cr Robert Greene linens ide A A Ko g ISmo Diraba cooper SOOO ASR Zee Or Robert Greene Bineri ade x 1000em Imre Nurse Hurter S04997S HEHA Or obert Greene bemurtration ate amp amp M B Dam Marci Basi AARO MEHAMN Cr Robet rene Priced iam Ace x OE ioe mre Pence Dba fy Robert Gvecne Spote Priced Ade W h X h00 on Simin Sanaa Tavke SIMS SAEED Ov Robet Greene PeyskcalEem Adee h kf E eo iy 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 Appointments for both Dr Greene and Dr Smith can also be displayed together by clicking on All from Provider This is displayed below Create ETS hs eb 0 ae ha Coban iiam Harton Comrcy MMPS SSE IO oe Miecha Sewn karmur ave A Xo p nw aace ANS Or bichas Seih murador Acie w w OO inn iia i lt MHaAGTS Dr Robert Greene linens Acre Ty x E timing Cirebem Cooper SLAN MAMAI r Robert Greene iner ade S S x ibian Jims lchedGodels OR Or Michele Sei Pryce Ezam Acie h o amp igma Fustelirte S04nd S SE BNSISS Or Robert Greene emarien Ace OOD Mint Mary Russe GAT SHEH Cr Ackeridreene Pesce Erwe Ache 3 ED Itan Sawa kahere Mir TO
88. ly com Fax 949 376 6951 INTRODUCTION TO EHR MODULES Office Ally EHR consists of 5 modules which define its main functional units Think of each module as a tab on a file folder that you use in your office every day MAIN TABS Each MAIN tab is opened with a single left click of the mouse Office Ally EHR Home Service Menu Practice Mate lt lt LOGOUT HIPAA Privacy PayerLists Forms FAQ Contact He below SECONDARY TABS Add New Patient Recent Charts P Patient List Reports gt Some modules such as the Patient Charts tab have secondary tabs that are available to you so that you can perform additional tasks Secondary options are context sensitive and will vary based on what screen you are looking at For example in the above screenshot secondary tasks available to you are Add New Patient Recent Charts Patient Lists and Reports LINKS TO OTHER OFFICE ALLY SYSTEMS Home Service Menu Practice Mate Practice Mate is Office Ally s FREE practice management system Key features of the system are that it enables you to do scheduling billing take payments and send claims Practice Mate is fully linked to the EHR system See the Practice Mate manual for complete details Note To get to Practice Mate from the EHR click on the link shown above Service Menu is your link to office Ally s electronic claims submission service If you use Practice Mate you usually do not need to
89. nt s pharmacy list 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 9 Select Transmit RX Add to Record this will fax the RX to the pharmacy and print copies of the receipt as well as a leaflet THE NEXT STEP Once you have finished entering your Progress Notes clicking on takes you to the Progress Note summary screen 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 PATIENTS CHARTS TAB PROGRESS NOTE SUMMARY SCREEN VIEWING PROGRESS NOTE SUMMARIES This screen allows you to view current and past progress notes view lists of patient information and attach documents at the encounter AND patient levels The first thing that you will probably notice here is a printable view of the Progress Note for the encounter that you just created Note for Kit Carson 8 21 2007 Patient ID 10423966 SUBJECTIVE Chief Complaint Nexk Pain PAIN BACK Debris in ear canal History Of Started when Patient was working in back y Present Illness Medical History Auto accident 1 1 07 No apparent comnectiodl Surgical History Tonsils 1980 Family History Depression Mother p Lung Cancer Father uf Der ai mth NI a Secondly you will probable notice that overall this screen is divided into 5 sections The following is a description of these segments Overview of the 5 progress note summary screen SUBD
90. of the following main sub sections e Admin Section This section is set up by the system administrator only The primary purpose of the profiles listed here is to establish Company and User Access Who is allowed to log into your office database and what level of security wills each person have e User Section This section is set up by each user who will define his or her own settings The primary purpose of the profiles listed here are to allow you to create and edit Progress Note pop up lists personal shortcuts and the layout of certain Provider screens e List Maintenance This section is set up by the Administrator The primary purpose of this segment is to create and edit company wide lists of Labs to be used SOAP Guidelines and Provider Templates e Appointment Settings This section is set up by either the Administrator or each user The primary purpose of the profiles listed here is to establish the viewable scheduled hours for the office and for each Provider TIP FOR FIRST TIME USERS User and List set up can take some time so try creating just 5 or 6 items for each of the profile screens found in the profile tree This will give you a jump start in learning system functionality in one sitting 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 ADMIN SECTION OVERVIEW The Admin Section allows one person in your office to setup company and user profiles imp
91. ogress Note SCIEN vicsaccesvanausesnwcravetaceduatusnessisacuvencesteseseexacseetaverameadueneesneisbeesdacensemieenadteeestatersanduaensineabnesesatas 73 Progress Note Screen SUD SCCTIONS ccccsesecccsesecsceesececsusecscsusecscsusesscuesesssuseesscsusessseecsssusecsssusesssceneesssusessseuseseseecsssuesecesseseeestsusesenees 74 Poors Noe PONE STOTT OUT S ea E E E E E T E 75 History Section COPY SPONOU scire na NENEA EEE EEEE REAN EEE TE EEEE 75 Ferona MON a E Aa OEE E E O EO AA EEA E E E E O 75 Text Shortcut FUTUFE Functionality aciiacsssadecansseponenedeucnedesussusecnasaaseanas ENNE TAT E TEA E N ETAETA a 76 Completion Matching SNOrtCUl rrssiismeninreess enone Rinrin EERU PETAENT REE TEREN ETENEE ETES E EEEN SE EE EEEE EEIE ARIA 76 SOAP Guidelines ssicinssacdndaitsnssesrsedsscnaebswandantddecdsnaawsedesedlenuadswedddacdsyabsiddancddees suaneilenssuedwaddunnddend dewnsbupaeawaeadewsvaudandddecisbadwsddseassbavacssndddecduvatsiodaneddonts 77 Voer FECENU aeaa T E E E E E A E 77 Tane ON aa E E A A EEA AEA A E A E EAA E E E AAAA EA EO EAA eee 78 SE WM E a E E A EEEE EE EE EEE E E E T A 78 More Progress Note Panels Features and Instructions ccccssesccccssseseecccsnneesecsscauesecssnsunseessuaussseesessuunsesessaussesssauunseecessaussecessaunseseeas 80 Kace aa N E E A AE V O E E E EE E E E AEE D E A EE 80 Diagnosis and Procedure Panele messeenr irn nna A E E E E A 80 LO e A IEA se A AEE EEA AEE A E A A E 81 Modi a e E E I AE E E E E E E E E 81 M
92. om a Progress Note panel For example you could access Mold by typing M e In addition to this you can bring in certain system phrases such as patient name or account number For example typing PAT while editing the chart for Franklin Antonio Smith will cause the system to auto type Franklin Antonio Smith for you e Hereis another TEXT example Type AGE and the age of the patient will automatically appear in the panel that you are typing in e Toseealist of available TEXT shortcuts click on the TEXT link Completion Matching Shortcut Pop Up Completion Matching allows you to access a mini segment of a panel s Shortcut List with even less mouse clicks 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 Here s how it works If a word that you type in a Progress Note panel matches something from your Personal Shortcut list that word will pop up automatically Click on the automatically completed word as shown above SOAP Guidelines SOAP Guidelines are user shortcuts and treatment instructions that are pre set by the user Guideline Name none v E Jr Pete Chiropractor You can select a variety of guidelines each sorted by specialty To choose one click on the Guideline Name icon The Guideline Name icon is located at the top right of the Progress Note screen From each guideline you can choose a different li
93. ort data and to tell the system whether or not to interact with Practice Mate Office Ally s practice management system It is therefore important to note changes made in this section can only be made by the EHR Administrator Main g Admin Section Ook Company Information fe Reset Admin Password fe Imp ont Data Wizard System Preferences EHR DRIVING TIP Office Ally s set up screens are fairly intuitive When preparing to enter data into a profile your most common starting points are one of these two buttons Add New Mentill or Search BS COMPANY INFORMATION Admin Section Company Information Manage Users impor Data Wizard System Preferences Click on Company Information and this screen will display company demographics that were provided to Office Ally at the time of your enrollment Please review them to make sure that all information is correct Company Information e User name is automatically assigned by our system once we establish your account Company M SE e The number of users with access to the program is Company Name Peter Tech Street Address 32356 S5 Coast Highway City Laguna Beach state CA a User Name ppasqua determined at time of enrollment typically the startup number is 5 users Call Office Ally if you need more admin user e NOTE The email field may not be changed or edited except FirstName Peter Last Name Pasqua Phone 949 ase 19129_ m
94. ose RX tab Type in the name of the drug and press Search Drug List From the list that appears select how the patient should take the drug apply take inhale etc Select type of application pills tablets capsules etc Select where to apply the drug mouth ear nose etc Select Frequency that the drug should be taken daily nightly etc Choose PRN to signifyas needed This option will add As Needed to the label Additional Sig Whatever you type here will appear on the label Pharmacist message Type a message to the pharmacist only viewable by pharmacist Select packaging for bottle per bottle not required Select Add to Doc s Drug RX list this will add drug with the Sig to their favorites list Disp will change based on the frequency that you choose DAW Dispense as Written if selected pharmacist can t substitute a generic drug 2nd RX 90 Day generates a 2nd prescription One time No refills allowed Ref select the number of refills Click Save to save the Sig Review Sig data that has populated f needed you can search and select another drug to add to this prescription NOTE lf you click Drug Search List with no search criteria it brings up the Provider s favorites list TIP Watch for any error messages they appear in a brown bold reverse text box TAKE COMPLETE RX TO REVIEW SCREEN REVIEW RX 4 Click the P
95. p up lists User Defined Immunization Phrases Progress Note User Defined Review Of system Phrases User Defined Physical Exam Phrases User Defined Assessment Phrases User Defined Procedure Phrases User Defined Flan Phrases User Defined Patient Instruction Phrases History Of Present Iliness Lacking in ener Lacks confidence Past History Medical History Auto accident 1 1 07 No apparent co Alcohol dependence Figure 2 Progress Notes S O A P Chart TIP FOR FIRST TIME USERS Set up can take some time so try creating just 5 or 6 items for each of the profile screens found on the list above This will give you a jump start in learning system functionality in one sitting 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 USER PREFERENCES G User Section Patient summary Fage Settings Patient Demographic Settings The User Preferences profile allows each user to determine personal defaults such as the color of the Patient Summary screen or background color For example one user might choose a background color theme of gold while another chooses the blue default color User Preferences Color Theme Blue Default Patient Chart Summary Page a e i Appearance Multi Colors in Patient Chart Edit Medication Method Use NewCrop 3rd Party Online Prescription din Edit Mote Skip Pr
96. rmanente Southern California Only 94134 CA MrKP Paper isl 2 Click Browse to select an insurance company for Office Ally s data base of 1800 carriers Insurance Co ID Payer ID Address Line 1 Address Line 2 City Zip Contact Name Email Phone __ Fax _ Insurance Type Other w Billing Type EDI v 3 The Insurance Co ID will auto populate If it does then you don t need to enter an address 4 Ifthe insurance company is not found manually enter the carrier s name and address as you would like it to appear on the CMS 1500 claim form 5 Choose the Insurance Type This corresponds to Box 1 on the CMS 1500 Form 6 Click 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 SUPERBILLS SUperbills Reason for Visit Laboratories A click on the Superbills profile allows the administrator to create and customize superbills for use while writing your Progress Notes You can create any number of superbills such as one for each office or one or more for each Provider Each superbill can be customized to meet the needs of a particular medical specialty by adding CPT and ICD 9 codes used by that specialty To Create New Superbills TIP For starters create a simple Superbill and add to it later on 1 Click Wi ye Add New Show All Delete Preview
97. rogress Notes you can access Diagnosis s from the list that you just created by clicking on the first search button in each row the second button brings up the entire ICD 9 codebook 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 USER DEFINED CPT CODES A click on User Defined CPT Codes allows each user to build personal Px code shortcuts which are used to make taking Progress Notes easier and more efficient To Setup a CPT Code Shortcut List ae Mod Mod ae TOS Description POS A B D C MBE OUO Select Multiple 1 Click CPT Code Search button M or click BEERS see following page for Select Multiple instructions Code Starts Wit Select CPT Description Terminated hw Select 0001F HEART FAILURE COMPOSITE 0003T CERVICOGRAPHY Select 0005F OSTEOARTHRITIS COMPOSITE 2 Enter a code in the blue box highlighted above Click Search Click Select You can select more than one code per page The main screen re appears The code and description will automatically display on this screen ie Mod Mod Mod See Description POS A B C D a 99215 MBlforricerourratentvisr est O O Pr 4 Fill out the following info POS Place of Service and it must be entered as a numerical value rc ge ee POS A OOU eo 5 Click 6 Repeat as necessary THE RESULT Snapshot of the Progress Notes screen as seen in the Patient Charts tab 32
98. sssreressrerrersserossseresssrcesssrcesssrseeesssecessseressseeessseeessssreressreressseressseresssee 102 Nar eO ON ar A EE E AE EE AE E A EAEN E E ON AO AEE OOE OAE NAN OTEO EANA 105 Nurse Create an Encounter from the EAR nmeeriursisrsiseesissdrnannd ioa ao aa T Aaa a aae 105 Toc eeann E E e E E E E EE EE EEE EE ee eee EE A OETA EEEE AE 105 Prov TAO IO ana AA AAAS AA AN AAE AN NRTA E AAAA EAS AAAA AAE AA EA 107 Provider Chart the Encounter in the EHR ccccssscccccsscccceceseccecaesececceauececseeeeecesseusecessaesecessueseceesauensceesseaseeesaueseeesauaseeeees seuuesecessuneeessuggss 107 PV VO e EEEE E PAE PEE E EA A A PE E P A E EE EE PE TT 111 Provider Office Staff or Nurse Send the Encounter to Practice Mate for Billing cccccssssecccceesseececeeeeceecseeeceeseesecesseaeaeeeeseeeeeeesageeeeesees 111 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 OVERVIEW FFICE ay Vhs Welcome to Office Ally EHR This exciting web based program has been designed to facilitate charting patient records and patient management as well as optimize staff resources It is part of a growing health record management suite that is affordable easy to use and designed by doctors Unlike other EHR systems which are very costly and must be installed on your PC or network server our system is web based and fully accessed via the Office Ally website This means that no special
99. st of SOAP notes SOAP notes are pre typed words or phrases and they appear as links in appropriate Progress Note panels eck Pain Shoulder Paina Nexk Pain PAIN BACK Debris in ear canal Clicking on the link inserts a pre set word or phrase into the Progress Note panel that your are editing SOAP notes can save you lots of time To create your SOAP Guideline shortcuts go to the Manage Office tab gt SOAP Guidelines Voice Recognition If you own Microsoft Office version 2003 or later or Microsoft Vista then you can transcribe your comments into desired Progress Notes panels If you want special medical voice recognition technology consider purchasing Dragon Naturally Speaking as this software is compatible with Windows 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 Template Shortcut At the click of a button you can access a pre made Template that you have imported as is or previously edited or created from scratch Among other uses Templates can provide check lists to enable you to easily select words or phrases as you go Here are some details e Within the Progress Note screen Templates are accessed or added by clicking on this bar gt FYI Templates are attachments to either the Patient Chart or Patient encounter Attachments linked in the Progress Notes screen are automatically associated with the encounter e There are t
100. t F9 Add New Patient F10 Patient List CHECK IN Once you create an appointment for a patient you can now check them in using the Check In button on the appointment calendar e Click the Check in button mme madame ill ented oi ete e 08 00 am 15 mins Clark Kelly G 6 21 1975 777 777 7777 Frank Stokes Check up mw sx oO ee raaa a raua aulai IauluaaaaaaaaaaaaaaaaaiaeaIaIaIasaIi The following screen will appear for Check In 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 car Fst ame ut S pos Gender Ferae v se Ol artar satas sn Empoymen Status pone GT THAT oe yf nent cebProne pf mae Insurance Co ID 101272 Insurance Name Subscriber ID Group No Plan United Payment Method Check Amount e Check Nunber o Appointment With Provider Frank Stokes v Superbill South Side Medical 7 Resource Machine ka MRI Room Check in From this screen you can update the patient s record add a copay print a superbill or change which provider or room the appointment is for e Once you ve made any needed selections put a check mark in the Check in box e Click Update to check the patient in e This will change the Check in button on the appointment schedule from a toa Y meaning the patient is ready for their appointment CREATE VISIT Once you have checked a patient in you are ready to
101. te a new encounter from here by clicking on the File Menu item Progress Notes gt Add Progress Note Encounter More about this later NURSE NOTE SUB SCREEN Encounter Date 8 21 2907 Encounter Type Outpatient Office Visit v Office Redlands Office e Provider Staft Provider FRANK Providers Location of Service Peter Tech i Reason For Visit t B Vital Signs Head Blood Pressure Ghi Cireum aint Puise Resp Temperatore Allergies Current Medications This screen is used by the Nurse in order to prepare the patient for his or her office visit 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 The Nurse Note screen only appears one time It appears after you click on the File Menu item Progress Notes gt Add Progress Notes Encounter PROGRESS NOTE SUB SCREEN Contains blank panels and fields for Progress Note data entry PROGRESS NOTE SUMMARY SUB SCREEN Contains a print version of the encounter s Progress Note as well as links to attachments and other vital patient summary information ee Delete Sign on Note for Peter Pasquale 8 29 2007 Patient ID 10424829 SUBJECTIVE Chief Complaint Cough Chest pam sneezing runny n0s Allergies Dust Mite Now that we have overviewed the PATIENT CHARTS screens we are going to cover each of them in detail PATIENT CHARTS TAB PATIENT LIST SCREEN PATIENT LIST A LIST OF
102. tes t From the Office drop down box select the office for which a calendar is to be customized Office PERME Click on the boxes for each day of the week that appointments will be scheduled W Monday From the drop down menu for each day select the hours of operation 08 00 am _ 12 00 pm You can block out lunch hours by using the 2nd session option Set the Default Time Interval length for physician appointments Click Update In the above screenshot the office is closed for lunch on Monday and Tuesday from 12 2 and it is closed on Wednesday O p oe ee A a 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 To Create a Specialized Schedule for a Provider Please define Providers Staffs Resources available for appointments for this Office below Optionally you may click each Provider or Staff member to define his her work schedule otherwise the Office s schedule will be used Providers Staffs Type Provider Provider m Name Indicates Provider Staff schedule exists E Indicates mapping to real EMR user lt lt Add Remove gt gt Edit Schedule Resources lt Add Remove gt gt From the Type Drop down box select Provider Click on the Provider ID search box BM and choose a Provider from the list that appears Click Add Highlight the Providers name seen in Providers Staffs panel oe a ee Providers
103. tiLetter Template his template is used to create Letters or Reports that when saved can be sent as is merged or edited like any Word document Tokens can be Inserted into any field you want to pullin live data such as Patient Name or Address Hospital imaging Xray MRI etc Insurance Laboratory Order Laboratory Result Legal Letters J Medication Prescription Others Past Medical Records Progress Notes HTML Form Template his template is used to create HTML forms complete with check boxes and drop down lists etc Tokens can be inserted in any filed you Want to pullin live data Image Template This template is used to store predefined image files such as human body silhouettes or other scanned documents Once the document is saved vou Can draw sketch or annotate on top of these images TEMPLATE MANAGER There are a lot of set up icons to choose from in Template Manager The following are instructions for use of the most common icons that are helpful in building or editing a letter To Create or Edit a Letter 1 Click AeA 2 Define the features of your Template by filling out the form seen below Template Template Type Letter Letter Report Mail Merge na Template Description Document Type Consultation 3 Using freehand text type your Company Name or other desired info into the Header see blank area below in Green Text 32356 S Coast High
104. tory It will enable you to import data from electronic New Patient enrollment forms directly into the EHR record 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 PATIENT CHARTS OVERVIEW The Patient Charts tab is your gateway to viewing or creating Progress Notes and Templates as well as viewing scanned Documents It consists of 4 main sub screens Since the system is context based the screen that populates when you click on this tab depends on your previous choice Below are snapshots that represent the FOUR main sub screens that appear under the Patient Charts tab PATIENT LIST SCREEN This is a list of all the patients in your system Gi La a Patient ID Last Name First Name MI DOB en Soc sec No Patient Acct No Type Status Edit 10461323 Barker George2am 10 25 1958 WM 555669989 P Adve A X 0425078 Afternoon Sleepy 10 25 1960 il 555665555 pP Adve A X 10423968 Carson Ki 10 25 1960 Me 537621112 Pp Adve A X 10423931 Flinstone Fred 10 25958 Mo 537621111 p Adve A X 10424843 Pasquale Nicholas 10 19 1993 M 555665555 Do aie A X 10424829 Pasquale Peter 101251958 F 537624458 p Adve A XG 10423971 Red Green M 102571968 Mo 537621113 P Ade A XU 10425421 Tuesday Patient 10 25985 M 532665598 pP Adve A X 10425422 Tuesday Patientil 101254975 M 537889989 Pp Adve A X gt Clicking on a patient s name opens the Patient Summary screen PATIENT SUMMARY SCREEN
105. tton you can access a pre made Template that you have adopted as is or have previously edited or created NOTE For More Information on system shortcuts see the module on Patient Charts 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 APPOINTMENT SETTINGS 3 Appointment Settings Time Schedule a opecial Dates This section applies to administrators or users who wish to create hours of operation or establish Provider schedules Both of the Appointment Settings profiles will have already been set up if you are a Practice Mate user Rest assured that any changes you make in data is reflected equally in both programs 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 TIME SCHEDULES Time Schedule Special Dates Click on Time Schedules and you will be able to customize the appointment calendars to meet specific office needs To Create an Office Time Schedule Please enter your office operating schedule These settings will be applied to your appointment book Days Operating Hours 2nd Operating Hours L_ Sunday 08 00 am 12 00 am E Monday Tuesday 08 00 am 12 15 pm 4 02 00 pm _ Wednesday 08 00 am 05 00 pm 12 00 am V Thursday 08 00 am 12 15 pm F 02 00 pm 5 07 00 pm Friday ri 02 0 07 00 om Saturday 00 a 1200 a Default Time Interval 15 minu
106. vailable to the user i E nbox 100068 Virginia test Mungia Test osor 2007 kai Mew Folder Hew e __ allows you to Create and SEND an email e Click on the appropriate Folder E to VIEW FOLDER CONTENTS e Select an email and click VIEW to read it or click on the name of the person who sent it e DELETES an email _MoveTo PF moves your email to a different folder e New Folder enables you to CREATE personal folders THE ROUTED DOCUMENTS PANEL This Routed Documents panel allows you to send attachments to other Providers in your office or to any other person who is using Office Alley EHR Any type of document or attachment can be viewed as long as you have that particular application loaded in your computer For example Microsoft Word files can be viewed if you have Word loaded Many companies offer free versions of their software that allow you to read documents created with their programs i e Adobe reader is free Obtaining and downloading one of these programs into your computer extends your capabilities greatly 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 Date Received From mmidd ssl To CH Go Last 400 Entries ssw Display Filter Route To Al From Al Patient Name Document T amp 1D Status View ee Remove Reason Virginia test Mungia Able Arden virginiam Document 1000000143 x Office Ally For Consultation
107. way Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 BOGR ASIF 4B 88K 9 S FSH00 OVNI FORE BRST PSP RR GGe ta WO Bee se haa hoses O u aaa zg EA Yo EK i kha ME BBL DRERRHHY Ew Css Class Inline style Normal Times New Roman Size Links Code Snippet Images Zoom IN FREEHAND TEXT TYPE YOUR COMPANY NAME HERE CompanyAddress Dear PatentFirstName Our office is to inform you that Age Ae S A e ae ae a a V oo W ee draa pee pen amp 4 Center the Header by clicking Formatting icons work the same as in Microsoft Word 5 Begin writing your letter 6 Insert a merge token in the document wherever you want to insert system data a Amerge token tells the Template to pull in system data such as a Patient s name or account number b To insert a merge token into the document place your curser on the document where you want the field to go see Red Text c Click Insert Fields d The result will look something like this PatientFirstName 7 Format the letter further as needed If you are taking a long time periodically click EEE 8 When finished click NOTE The formatting icons are the same as in Microsoft Word If you hover your mouse over an icon a description will appear Finsen Table f ail i i z To Create or Edit a Form Vermont Family Practice f 1569 Lexann Dr Suite 128 San Jose CA 95121 Phone 408 274 3200 Fax 408 274 8021
108. ws you Edit info e Allows you to Delete info Allows you to Route a document to another user Multiple Search Buttons When navigating sections with patient Progress Notes you will notice unique search button options that look like this B BE Here is an explanation of these buttons Progress Note 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 e User Defined List The first search button displays a shortcut list that has been previously set up by you Click on the search button and choose an item from the list that poplulates e Office Ally List The second search button displays a large list of pre determined system options that have been set up by Office Ally SnowMed List The third search button displays a list of medical terms from the SnowMed library EEG BEaO Add Button The A button enables you to quickly add words or phrases to your user defined list a k a the first button Here s how to use the button Type a word words or phrase into the chart as seen in the above screenshot or choose previoulsy entered data Highlight the word or phrase with your mouse 3 Click Click Update 5 The word or phrase will now appear under search button 1 Searching for Data via Links Patient ID Last Name 10423931 Flinstone 10 25 1958 M 10423971 Red R M 10 25 1966 M 10423966 Carson kit 40 25 1960 M 10424843 Pasquale Ni
109. y any special dates you want to block or unblock from booking appointments Office San Bernardino Office ka Current Blocking Date s z August 2007 gt Mon Tue Wed Thu Fri Sat i Hi 2 fol eS 14 16 na pean 28 29 30 4 5 Remove gt gt Exception Do Not Block Date s Select Date 2007 eee Description Action Exception Do Not Block This Date Y Remove gt gt Choose an Office If needed change the month by clicking on the calendar arrow August 2007 Click on the desired date in the calendar The Select Date boxes will auto populate Enter a Description such as Yom Kipper Choose the Action Block This Date Us Si 38 i Click Add See Se eS PS NOTE Federally recognized Holidays such as Christmas or New years are already blacked out Therefore if you are open ona Federal Holiday you must 1 Click on the Holidays Button Holidays 2 Choose the desired holiday from the list of federal holidays that appears by clicking Select 3 Choose the Action ton ee eee 4 Click Add 5 Holiday will appear in the Exceptions panel TIP f you are finished with your initial settings change Manage Office Preferences to Yes 32356 S Coast Highway Laguna Beach CA 92651 Phone 949 464 9129 www officeally com Fax 949 376 6951 DESKTOP TAB FFICE SATE INTRODUCTION TO THE DESKTOP TAB 30 2007 1 DI z er
110. zard System Preferences User Section User Preferences Patient Summar Page Settings Patient Demographic Settings User Defined Diagnosis Codes User Defined CPT Codes User Defined Medications User Defined Chief Complaint Phrases User Defined HFI Phrases NOTE Future editions of the program will enable you to set up and manage all your weekly chart related things to do lists from one screen 51273735 0 6 5 User Defined Medical History Phrases pasquale admin user Company 1 Company Name Street Addresa 52258 5 CousiHghway cil annaba State CA Zip First Name Last Name phone 949 Maximum EMR Users includes this user Coast Highway Laguna Beach CA 92651 www officeally com Phone 949 464 9129 Fax 949 376 6951 FFICE ALLY NAVIGATING THE EHR NAVIGATION OVERVIEW THE MAIN TABS Office Ally EHR has been designed using navigational tools familiar to Windows users f Desktop Patient Charts Billing Status References Manage Office The program consists of 5 modules which define the main functional units of Office Ally EHR Think of each module as a tab on a file folder Each tab is opened with a single left click of the mouse Some modules present you with even more options via secondary tabs which are context sensitive For example in the above screen shot the user can open a variety of patient attachments images and letters Saving Data Save data by clicking on t

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