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User Guide - Care Management Plus

1. Home Care Equipment Company Name Phone TF 02 stationary portable FT 02 oximeter SAT TF Apnea monitor TT Suction machine supplies TT Trach tube type size Cuff Y N Vent type E Formula I Feeding pump supplies I N G Tube M GT GJ type size I Carseat Wheelchair TBP Monitor Other Home Care Comments Developmental Rehab Company Name Phone mm a mo A MT Speech AAA Vision as Developmental Rehab Comments a A O o aa A School NA Phone Community Resources Applied Accepted Denied DSPD Caseworker Phone SSI Waiver Program J Technology Dependent Children TBI DDMR E WorkForce Service Food Stamps Child Care El WIC E r r m m Housing Assistance Medicaid Caseworker Phone edic A Community Resources Comments Mental Health Phone Other Last revision date gt New Ped Save Ped Print Ped Delete Ped Assessment Assessment Assessment Assessment gt Record 14 4 2 gt gt I gt of 2 Filtered A n n jn jon jo Jm mn n n jj Ln a v NS 4 Figure 8 Diabetes History o Assess Date Page 12 of 33 Clicking this button will bring up the following Diabetes Assessment screen Fig 9 Enter the Diabetes Assessment information Default values for checkboxes are No and defaults for drop downs are Never None or Not At All as indicated in Figure 9 Please note that you may also print a
2. Page 4 of 18 Care Manager Tracking Database Data Dictionary General Use Severity Score Textbox Numeric No Severity Score based on the personal health questionnaire nine symptom checklist PHQ 9 calculated by totaling the values for each severity question Functional Difficulty Not at all Somewhat Very Level of difficulty or degree to which depression Extreme impacts daily activities ex doing work taking care of things at home or getting along with other people Dysthymia Checkbox Yes No No Does Patient have Dysthymia Steadman s defn A chronic mood disorder manifested as depression for most of the day more days than not accompanied by some of the following symptoms poor appetite or overeating insomnia or hypersomnia low energy or fatigue low self esteem poor concentration difficulty making decisions and feelings of hopelessness PHQ Suicide Q9 Drop down 0 1 2 3 Suicide Score based on the personal health questionnaire nine symptom checklist PHQ 9 calculated by totaling the values for each suicide question Suicide State Drop down 1 Thoughts Only 2 The state of risk for Suicide for the Patient Thoughts and Plans 3 Thoughts Plans Actions Suicide Risk Drop down No Risk Low Risk Medium Potential Patient has in taking his her own life Risk High Risk Mood and Anxiety Sleep Score 40 100 Page 5 of 18 Care Manager Tracking Database Data Dictionary General Use Data Element Type Control
3. 1 Johnson John Record nen 1 gt Lot gt of 1 Figure 36 CM Total Encounters by Enc Type Clicking on the CM Total Encounters by Enc Type button will bring up the following query screen Fig 37 This query displays the number of Care Manager Patient Encounters falling within the entered date range sorted by Type of Encounter E CMT Eile Edit View Insert Format Records Tools Window Help CM Total Pat Encounters by Enc Type Select Query 1 Johnson Home Visit 1 Johnson Telephone Contact 2 Thomsen Class 2 Thomsen CM Office Visit 2 Thornsen Non Encounter Related 2 Thomsen Telephone Contact Figure 37 CM Total Encounters by Insurance Clicking on the CM Total Encounters by Insurance button will bring up the following query screen Fig 38 This query displays the number of Care Manager Patient Encounters falling within the entered date range sorted by Insurance Provider and Patient Status E CMT Eile Edit View Insert Format Records Tools Window Help CM Total Pat Encounters by Insurance Select Query _ Care Mgr ID CM Last Name CM FirstName Insurance Status Total Pat Encounters O 1 Johnson IHC Health Plans Active 1 Johnson Mailhandlers Active 2 Thomsen IHC Access Active 2 Thomsen 1X Only 2 Thomsen i Active Record 14 4 1 gt Lot gt of 5 Page 30 of 33 CM Total New Patients Referred Clicking on the CM Total New Patients Referred button wi
4. D C Yes and No Fields Does Patient smoke Checkbox Yes and No Fields Does Patient drink alcohol C gt Does Patient have a history of Hypertension High Cholesterol pee e and No Fields Does Patient have a history of High Cholesterol Family Hx Diabetes Yes and No Fields Does Patient have a family history of Diabetes How Tong have you had Diabetes No No i No i Heart Attack Heart Disease Checkbox Yes and No Fields Ba Does Patient have a history of Heart Attack Heart Disease rop down heckbox i Checkbox Yes and No Fields heckbox i heckbox How long has Patient had Diabetes extbox If Yes Hospitalized Explain T Free Text If Patient has been hospitalized for Diabetes in the last year details Height Weight Height ft Patient Height in feet Patient Height in inches Height in extbox extbox Free Text Patient Weight in Ibs No No No Weight Change in last 6 months Checkbox A AE Any Patient Weight change in the last 6 months NS Do you want to lose weight Yes and No Fields Does Patient want to lose weight At what weight have you felt healthy Textbox Weight in lbs at which Patient felt most healthy Are you experiencing any of the following now lurred vision Checkbox Yes and No Fields No Patient now experiencing blurred vision Numbness tingling pain in hands and Checkbox Yes and No Fields No Patient now experiencing numbness tingling or feet pain in hands
5. amp Diabetes Education Assessment 3 xi Diabetes Education Assessment Patient Mame Person s Instructed Assessment Date gt Key 1 Poor No knowledge Not at all 3 Good Adequate knowledge Most of the time 2 Fair Some knowledge Sometimes O N A Not applicable Before Education After Education Instruct Date Instructor Follow Up Plan a Do you understand how diabetes affects you a A E a Do you understand your meal plan a AAA a Do you understand the benefit of exercise physical activity 3 od Do you understand how your medications work Ca 5 E a Do you understand the benefits of blood glucose monitoring NA IE nm Do you understand how to detect treat and prevent hypoglycemia a OSA 2 E Do you understand how to detect treat and prevent hyperglycemia of 5 IS Do you understand how to prevent and or reduce chronic complications a A O Do you understand how reaching your goals will help you w your diabetes caro i Do you understand that the diabetes team is available to help you problem solve a Do you understand how diabetes affects emotional health A E a Do you understand that your blood glucose needs to be in control before and E A during pregnancy Instructors Instructors RN x RD x Collaborate Date gt RN D x 7 RD New Assessment Save Assessment Print Assessment Delete Assessment Record 14
6. sx 40 4100 20 60 Suicide State J Imp 10 720 1020 Suicide Risk z Mood Anx Mood Comments Anxiety Comments Sleep Assessment Difficulty Severity 0 10 Only if ADHD Parent Yanderbilt An 3 E An a A fg 24 A 1 9 10 18 19 26 27 40 41 47 48 55 Teacher Vanderbilt Only if ADHD NENE Vanderbilt Comments e Symptom Rating Scales Sx 140 A0 YOQ Youth 7 Imp 220 220 Score Dew Dep Developmental Pediatric Intake Only Depression Develop Comments Depress Comments Save Instrument Data Record 14 4 I 710 lal gt of 7 Filtered Figure 7 Delete Instrument Data xi Page 11 of 33 Pediatric Assess Clicking this button will bring up the following Individual Health Plan Pediatric Assessment screen Fig 8 Enter the Pediatric Assessment information Please note that you may also print a copy of this screen form by clicking the Print Ped Assessment button on the bottom left of the screen Required fields are in blue Omitting these fields will generate a pop up error message when you save the form o Ped Assess Date Click the Save Ped Assessment Button to save the record and close the window to return to the main Patient Information screen 10 x Eile Edit View Insert Format Records Tools Window Help S Pediatric Assessment as Home Care Nursing Agency Name Contact Phone Services Ordered
7. 4 I 11109 of 1 Filtered Figure 10 Page 14 of 33 e Patient Goals Clicking this button will bring up the following Patient Goals screen Fig 11 Enter the Patient Goals information Default values for scores are zero Please note The Patient ID field at the top right of the screen will be automatically populated from the Patient record you are currently viewing Also you may print a copy of this screen form by clicking the Print Goals button on the bottom left of the screen Required fields are in blue Omitting these fields will generate a pop up error message when you save the form o Goals Assess Date Click the Save Goals Button to save the record and close the window to return to the main Patient Information screen amp Patient Goals x Patient Goals Goals Assess Date 5 Patient ID oo Goals T Nutrition Management F U Date Score fo T Physical Activity F U Date LO gt Score fo D Meds F U Date Lo Score p z I Monitoring A F U Date li gt Score lb gt T Preventing Acute Complications a F U Date 2 Score fo T Risk Reduction AA F U Date L gt Score fo I Psychosocial Adj Ft Dates Score fo gt Other AAA F U Date E gt Score pP Notes New Goals Save Goals Print Goals Delete Goals Record 14 4 Ii 215 gt t gt of 2 Filtered Figure 11 Page 15 of 33 HF Follow Up Cli
8. No 4o D Q g D o lt D 2 D D ey pe A vie cn on 112124 jojolo w v v v olololjlo III OJOJO O maS o ll ioe lt lt lt lt v g e y je y ye ajajaja jojojo jm Ga oe V oe A r a toa fea fon AJNj gt gt N oOo oO ABI dM gt NIOJ mptom Rating Scales Sx Dev ymptom Rating Scales Sx Dep mptom Rating Scales Imp Dev ymptom Rating Scales Imp Dep YOQ Youth YOQ Youth Score Textbox Free Tet No Comments relating to Depression PEDIATRIC ASSESSMENT Individual Health Plan Ped Assess Date Date field Date MM DD YYYY Date of Patient s Pediatric Assessment Score 40 Developmental Intake Onl Score 100 Pediatric Depression S PIKOA lt D 3 o O gt D O O 3 3 O n io core 20 Pediatric Depression core 20 Developmental Intake Onl S YOQ Youth administered O O O O O O O O O O O O O O O O O O O O O O O O O No O No ojo 0p o o HE l 8 S OIO o o 3 3 3 3 a 212 aja Page 6 of 18 Care Manager Tracking Database Data Dictionary General Use Consultants Specialty Phone 6 Textbox Free Text No Consultants working with the Patient includes fields Consultant specialty and phone Home Care Nursing Services Ordered Services ordered from Home Care Nursing Agenc Home Care Equipment Home Care Equipment Company Home Care Equipment Company Name Name Trach Tube type size Textbox Fr
9. No Unwilling to use available support Checkbox YesiNo No Patient unwilling to use available support No No z lz z O JO O o a 2 OOO DIDNIDO ojojo S 5 5 mid ajg ol U S S Date MH Instruments administered recorded Exhausted available support Checkbox Patient exhausted available support Has available support actively using Checkbox Patient has available support actively using ollowing recommendations Taking medication eeing therapist elf Management Patient practicing self management dentified Goal Patient Identified Goal No No No No No 4 Textbox Numeric Severity of Patient validated standard measure e of impairment over time No No No Q gt D O x gt 2 gt 2 5 fa Patient following recommendations Patient taking medications Patient seeing therapist Q o D n D lt lt _ N Care Conf Include Patient at next MH Care Conference site Was Patient referred to MH off site General MH Comments for Patient PHQ 9 Depression Symptom Count Drop down 0 1 2 3 4 5 6 7 8 9 Depression Symptoms Score based on the personal health questionnaire nine symptom checklist PHQ 9 calculated by totaling the JF 5 gt o 2 le E ens DIO ols ol 3 z 3 lt 3 9 np T o No No es No No No es No No No No No No No No No No No No No No values for each depression symptom question
10. Patient Goal Progress Report button will bring up the following Patient Goal Progress Parameters screen Fig 25 The Patient Goal Progress Report generated is a summary report generated from the Patient Goal screen sorted by Care Manager Diabetes Educator E CMT 0 x Eile Edit View Insert Format Records Tools Window Help CMT Care Management Menu Care Management Tracking Record Entry and Modification General Reports Queries Patient Information Patient List View Queries 4 Blood Glucose Meter T EME e o x Admin Time AE Patient Goal Progress Parameters Start Date 1 1 2005 _ Diagnosis Table E be E ive Time Information End Date 3 31 2005 _ Facility Table Er Sort By Patient Last Namel 5d Insurance Provider Te Run Patient Goal Progress Report Medication Table Pan ae Patient Education Progress Report Figure 25 Click Run Patient Goal Progress Report to run the report Fig 26 E CMT 0 x Elle Edit view Tools Window Help Patient Goal Progress Report Patient Goal Progress Repert For Time Period 1 1 2005 to 3 31 2005 Assess Date ID Num PtLast PtFirst Nutrition Activity Meds Monitor Prevent Compl Risk Psychosocial Educator Ann Thomsen 3117 2005 8 Hansen Sally 317 2005 8 Hansen Sally Educator John Johnson 3 4 2005 7 Stevens Daniel Num Pts Meeting Goal score 3 10 Num Pts Not Meeting Goal score 1 7 page MA 1 gt loi Figure 26 Pag
11. Definition ymptom Rating Scales Sx Anx Textbox Numeric No Score 30 60 mptom Rating Scales Imp Mood_ Textbox Numeric No Score 10 20 ymptom Rating Scales Imp Anx____ Textbox______ Numeric___________ No Score 10 20 Mood Comments Textbox Free Tet No Comments relating to Patient mood Anxiety Comments Textbox FreeText No Comments relating to Patient anxiety Sleep Assessment Sleep Difficulty Checkbox YesNo No Patient having difficulty sleeping Sleep Severit Textbox Numeric No Severity of Sleep Difficulty Scale of 0 10 Pediatric Onl Parent Vanderbilt Only if ADHD Parent Vanderbilt 1 9 Textbox Numeric No Parent reported Vanderbilt Questions 1 9 Parent Vanderbilt 10 18 Textbox Numeric No Parentreported Vanderbilt Questions 10 18 Parent Vanderbilt 19 26 Textbox Numeric No Parent reported Vanderbilt Questions 19 26 No No No Parent Vanderbilt 27 40 Parent reported Vanderbilt Questions 27 40 Parent Vanderbilt 41 47 Parent reported Vanderbilt Questions 41 47 Parent Vanderbilt 48 55 Parent reported Vanderbilt Questions 48 55 N N N N N N N N N N N N N if ADHD N N N N N N N N N N N N N ayo o v El o lo s lt SiS 315 oja Sle 2 ofo 2 i Teacher reported Vanderbilt Questions 1 9 Teacher reported Vanderbilt Questions 48 55 No No No No No No A PA No No No No No No
12. MMSE MMSE 15 Pain Score 0 10 Pain Score 3 Notes New Function Save Function Print Function Assess Assess Assess Record 14 4 I 1 gt gt of 1 Filtered Figure 13 zl Delete Function Assess Page 17 of 33 e MODIFYING PATIENT INFO Search for the Patient first to see if he she exists in the database See above instructions o To change demographic and status information on the main Patient Information form modify fields and click the Save Patient button o On Diagnoses Encounters Mental Health Instruments etc click the Edit button on the corresponding windowpane to get a pop up directly to that specific record and click the Save button before closing the pop up window e GENERATE CLINICAL NOTE BUTTON This tool will save you from copying and pasting back and forth between windows when you need to go to another electronic charting method to enter a Note with results from Encounters Mental Health Instruments Diagnoses etc just entered into the CMT database 1 Choose a date Enter a date in the white text box to the right of the button OR click the asterisk button to the right of the date field to pop up a calendar for reference In case you are looking for Last Friday for example and don t know the date off the top of your head 2 Click the Generate Clinical Note by Date button and a Clinical Note Summary Screen window Fig 14 will po
13. These will need to be entered behind the scenes amp Diagnosis Entry x Diagnosis al Scroll to end of list to enter a new item Trach dependent vent Dependent SY WP shunt E Figure 2 Page 5 of 33 Patient Information The Patient Information button brings you to the main data entry screen Fig 3 Here you will locate enter new Patients record new encounters assessments and diagnoses The top portion of the screen displays Patient demographics as well as information regarding the Patient s status with the Care Manager The middle section of the screen consists of several windowpanes which summarize and provide at a glance data entered via the navigation buttons on the bottom left of the screen Also indicated within a thick black box on the right side of the screen is the Patient Search section The bottom of the screen houses the navigation buttons for entering data for the selected patient creating new patients saving and deleting patients and generating clinical note summaries A MT ll EE Edit Insert Records Window Help Adobe PDF amp Patient Information Form Patient Information ID Number Last Name fest O First Name fest DOB 8 16 1977 gt Age 19 44 Race Black African A z Sex Mo Phone 800 800 8000 Cell Phone el Email _a PCP fallen mitch PCP Phone 800 868 6868 Insurance Mailhanders Facility DEF Hospital a I Diab Collaboration FPP 2 ConfusediChaotic
14. Touch Basic Other Precision Extra Precision QID Precision SofTac Prestige Profile Roche AccuCheck Active Roche AccuCheckAdvantage Roche AccuCheck Compact Therasense Flash Therasense Freestyle Page 11 of 18 No No No No No Financial Concerns Checkbox Yes and No Fields Does Patient have financial concerns No No No No No Care Manager Tracking Database Data Dictionary General Use If Meter Approx how old is it Drop down lt 1 year old 2 years old 3 No Approximate Age of Patient s blood glucose years old gt 5 years old If Meter How often do you test Drop down Not at all 2 or 3 times No Patient Testing Frequency with blood glucose weekly 1 2 times daily 3 4 meter times daily 5 8 times daily gt 8 times daily Date of Last HgbA1C Drop down Never Unknown Within the No Date of Patient s last HgbA1C test last 3 mos Within the last 6 mos Within the last year gt 1 year ago No Result HgbA1C Textbox FreeTet No ResultofPatients last HgbA1C test O What type of Activity do you do Drop down Walking Running Biking No Patient Exercise Activity Swimming Weight Lifting Other Activity Text Notes relating to Exercise Activit Physical Limitations that impact Textbox Free Text activit Meal Plan Do you skip meals Checkbox Yes and No Fields Patient s Physical Limitations that may prevent them from exercising When did the Patient last participate in Diabetes Education Last Di
15. copy of this screen form by clicking the Print Assessment button on the bottom left of the screen Required fields are in blue Omitting these fields will generate a pop up error message when you save the form Click the Save Assessment Button to save the record and close the window to return to the main Patient Information screen Eile Edit View Insert Format Records Tools Window Help Diabetes Assessment Assess Date gt Diabetes Type x Special Needs a PY M N Smoker 7 Y Y N Drinker History FF Y N Hypertension FT YMN Heart Attack Heart Disease TT Y Y N High Cholesterol FT YV N Family Hx Diabetes How long have you had Diabetes FT Y YN Hospitalized for Diabetes in last year Tf Yes Explain AAA Height Weight Height fe im weight bs FT Y UN Weight Change in last 6 months FT M N Do you want to lose weight At what weight have you felt healthy lbs Are you experiencing any of the Following now D YMN Blurred Vision D YM N Stress Py F YM N Sexual Difficulty Bg I MN Increased Thirst N Fatigue N N Ty MN Increased Urination N N N Frequent Infections YM YM Dx Numbness tingling pain in hands feet Sores that won t heal Pain Tightness in Chest Other medical conditions FP Y YN Financial Concerns Monitoring Last Diabetes Foot Exam Peer o Last Dilated Eye Exam Peer o Last Dental Exam Peer o YS M YMN Do you have a blood glucose
16. how to detect treat and prevent hypoglycemia Do you understand how to detect treat and prevent hyperglycemia Do you understand how to prevent and or reduce chronic complications Do you understand how reaching your goals will help you w your diabetes Do you understand that the diabetes team is available to help you problem solve Do you understand how diabetes affects emotional health Do you understand that your blood glucose needs to be in control before and during pregnancy pod Figure 28 Page 26 of 33 Queries View Queries Clicking on the View Queries button will bring up the following Queries screen Fig 29 e Generate queries by entering a date range Start and End Date and choosing the button corresponding to the query you wish to run If a button has red text no date entry is required to run the query e These listed Queries are canned queries Any queries not listed here are not available to the users unless this screen is customized by a programmer Ed CMT o x Eile Edit View Insert Format Records Tools Window Help amp CMT Queries lol x CMT Queries Start Date 1 1 2005 EndDate 1 31 2005 _ CM Completed Calls CM Total CM Total Encounters by Encounters by Diagnosis Diab Type CM Total CM Clinic Visits Encounters by MD CM Total CM Home Visits Encounters by Enc Type CM Total CM Total New Encounters by Patients Insurance Referred CM Tot
17. of fields such as a first and last name to further narrow the search Please note that once you have searched you will be seeing a subset of the records in the database For example you may search on Brown as a last name There may be several Browns in the database Check the record indicator number at the bottom left of the main Patient Information form to see which record you are on and how many records you are viewing You may see Record 1 of 4 if 4 Browns have been found If the current record displayed isn t the record you are looking for you can use the VCR like 4 back and 21 forward buttons to move to the previous and next records respectively until you find the record you are looking for Please note To get back to viewing ALL Patients click on the Show All Patients button in the Patient Search area You are now viewing ALL records in the database instead of just the subset of Browns If nothing comes up the Patient has not yet been entered into the database so click the New Patient button on the bottom of the screen to clear the screen fields and enter the Patient information Required fields are in blue Omitting these fields will generate a pop up error message when you save the form o Full Name Last and First Names o ID Number Number unique to a Patient in your organization o Care Manager Diabetes Educator o Date of Referral Click the Save Patient button on the bottom of the
18. screen You must save the record before any other data can be entered on pop up screens ADDING DIAGNOSES ENCOUNTERS MH INSTRUMENTS ASSESSMENTS ETC Click the Diagnosis Encounter or MH Instruments etc button at the bottom left of the screen This will pop up an entry screen All records entered of that type for the Patient you are currently viewing will be retrieved Once this screen appears you will see the latest most recent date entry record of that type for the current patient Be sure to click the New button to clear the screen or you will overwrite an existing record If you wish to you can navigate through these records using the navigation arrows next to the Record number on the bottom of the pop up screen if necessary Page 7 of 33 Click the Save button and close the window to return to the main Patient Information screen You will notice that the record you just entered will now automatically appear in the corresponding windowpane on the main Patient Information screen for that Patient if your database has that specific windowpane e Diagnosis Clicking this button will bring up the following Patient Diagnosis screen Fig 4 Enter the Diagnosis information Status has a default value of Active To enter multiple Diagnoses enter them separately even though they may have the same date instead of combining using the Notes field That way if one Diagnosis has a Status of R
19. y Patient Search Date of Referral 1 2 2006 gt Care Mgr pm o Status active z ID Number O Diag Date Diagnosis Status Sched Date SchedTime Encounter Type Status Last Name edt 2328 2008 hF factive edt 3 9 2006 frelephone Contact Resolved First Name a Edit 3 30 2004 Depression active Edit 3 2 2006 Telephone Contact Resolved Search for Patients zl eair IT anina 1 Telenhane Contact Pendina zl Show All Patients MH Packet Date Symp Severity Fetnal Diff Dysth Q9 Suicide State Suicide Risk Mood 1 23 Moodlmp MoodSx nxImp AnxSx a Diab Assess Date l e fr PO OO lar al os farsa PR fer IT sf apa E al pl UA SC A 0 10 100 A IU me gt Pediatric Generate Diagnosis Encounter Meds EAN A New Save Delete Clinical Note Patient Patient Patient by Date Diabetes Diab Pre Post Patient ECHEN History Knowledge Assess Goals ee Record 14 4 1 gt gt I gt of 1 Figure 3 Page 6 of 33 ADDING A NEW PATIENT Search for the Patient to see if he she exists in the database Go to the Patient Search section on the right side of the Patient Information screen Enter in an ID Number Last Name First Name or Care Manager Diabetes Educator from the drop down lists to search Typing the first letter of a name will bring you to the right place in the list quickly Click the Search for Patients button You may search using a combination
20. 00 0000 Patient s Medicaid Caseworker Phone Has Patient Family applied for Medicaid Checkbox Has Patient Family been accepted for Medicaid Checkbox Checkbox Yes No Has Patient Family been denied Medicaid O a gt D Q Se o O x Se sae SpE SRE 3 Q 2 jajoja OJOO 2181215 o olo O 3 8 S 8 9 8 WSS o o jo m amha j mit an mn DN ur 18 Poe S O ajaizja 5 19 9 3131813 D ADIs O re 7 D olojolsS Ola D o a SI5 5 p Zia lTi lt 2 2 lt ope jaj l3 olala Z 9 ojo o QO O gt lo n 9 OD bm Le n TIS o alol 3 DS 3 o 3 D 5 5 17 2 D Textbox Free Text No _ Comments relating to Community Resources Comments relating to Mental Health Mental Health Professional Phone D 5 sp 2 I O D 5 Phone Numeric 000 000 0000 Other text Other Comments ast Revision Date Date MM DD YYYY Date Pediatric Assessment last revised DIABETES HX ASSESSMENT Assess Date Date field Date MM DD YYYY Date of the Diabetes Assessment Diabetes Type Drop down Type 1 Type 2 Diet Type 2 Patient s Diabetes Type Oral Type 2 Oral Insulin Type 2 Insulin GDM Pre Diabetes IGT D 3 2 y I D D gt O O O O O O O O O O O O O O O O O O O No O No Page 9 of 18 Care Manager Tracking Database Data Dictionary General Use TypelContrl Visual Impairment Hearing Patient Special Needs Impairment Low Literacy Eng 2nd Language Checkbox Does Patient smoke
21. 04 CM Office Visit Completed Hansen Sally 800 222 2222 1117 2004 CM Office Visit Completed Hansen Sally 800 222 2222 12 3 2004 MD Office Visit Completed Redman Robert 800 999 9999 1 31 2004 Telephone Contact Completed Redman Robert 800 999 9999 8 23 2004 Telephone Contact Lett Message Redman Robert 800 999 9999 9 7 2004 Telephone Contact Left Message Redman Robert 800 999 9999 9 24 2004 Telephone Contact Lett Message Redman Robert 800 999 9999 10 4 2004 Telephone Contact No Answer Total Patient Encounters 12 Page IAI A 4 EEE Figure 20 Page 22 of 33 Mental Health Reports PHQ9 List e Clicking on the PHQ9 List button will bring up the following PHQ9 List Parameters screen Fig 21 The PHQ9 List report generated is a list of PHQ9 scores for Patients assigned to the selected Care Manager Diabetes Educator This report can be sorted by date first name last name or suicide risk The report is especially helpful for viewing progress over time CMT Elle Edit View Insert Format Records Tools Window Help CMT Care Management Menu p Care Management Tracking Record Entry and Modification General Reports Queries Blood Glucose Meter Table Entry OO Ercatermales ne Care Manager Table Entry Encounter summary Administrative Time Information Diagnosis Table Entry Mental Health Reports Administrative Time List Facility Table Entry Insurance Provider Table entry EE lo lx Medication Table Ent
22. 9 No _ Score for Goal of Meds 2 3 4 5 6 7 8 9 No Score for Goal of Monitoring Preventing Acute Complications Drop down 2 3 4 5 6 7 8 9 No Score for Goal of Preventing Acute Complications Psychosocial Ad 23 4 5 6 7 89 HF FOLLOW UP HEART FAILURE Hospital Discharge Date this Call followed from To Drop down Home Assisted Living No Place Patient is at time of Call Deceased ECF SNF LTCF Hospital From Location Table Values Hospital Discharged From o Talked To Drop down Patient Spouse Significant Person Actually spoke with on Call Other Health Care Provider Other Page 15 of 18 Care Manager Tracking Database Data Dictionary General Use Medication Review medications following which ones is the Patient not following Why are you not following your Textbox Free Text No If Patient not following discharge medications medications Reviewed the importance of Drop down Yes No Unknown No Did Care Manager review with the Patient the compliance not running out refilling importance of compliance not running meds out refilling meds Reminded patient to take all Drop down Yes No Unknown No Did Care Manager remind the Patient to take all appointment appointment Activity Are you trying to stay active daily Drop down Yes No Unknown N Is Patient trying to stay active daily o i i ily How are you tolerating activity since Drop down Stable Better Worse o How is the Patient toler
23. Care Management Tracking CMT Software User Manual General Use A la Eile Edit View Insert Format Records Tools Window Help E CMT Care Management Menu Care Management Tracking Record Entry and Modification General Reports Queries il i Patient List View Queries Blood Glucose Meter Table Entry Encouhtar tkir Admin Time Care Manager Table Entry mirad Administrative Time Information Diagnosis Table Entry Mental Health Reports Administrative Time List Facility Table Entry PHQS List Insurance Provider Table Entry Diabetes Reports Medication Table Entry ADA Report Physician Table Entry Patient Goal Progress Report Patient Education Progress Report Page 2 of 33 Care Manager Tracking CMT Software Table of Contents Installing the Database ela eo e e al e lo 3 Openine the Database a tt a le aa cae 3 The CMT Care Management MIA A 3 Record Entry and Modification Section edi id rico 4 Entering Values on Main Menu for Blood Glucose Meters Care Managers Diagnoses Facilities Insurance Providers Medications and Physicians iia 4 Patient Intormation di I N 5 General Repo iii cita 19 Pan s e e AS iS toi 19 Encounter el ssi she wala ice gel cs E RER E ls 20 ISIC OM PER SUMA o ds 21 Mental HARIAS a e te dea Das 22 PHA QO Tita a 22 Diabetes Reports A O A 23 ADA REPO sd A A A A A E A AA A EA A ed Med 23 Patient Goal Progress Report viii dirias 24 Patient Education Pr gress REP OO O AiO a
24. Patients assigned to the selected Care Manager Diabetes Educator This report can be sorted by first name last name encounter date encounter type or encounter outcome Eile Edit View Insert Format Records Tools Window Help CMT Care Management Menu Care Management Tracking Record Entry and Modification General Reports Queries Patient Information Patient List View Queries Blood Glucose Meter Table Entry ___reouterteter a Care Manager Table Entry Administrative Time Information Dare Table Entry 8 Encounter Summary lol x Encounter Summary List Facteyrableenoy Parameters Insurance Provider Table Entry Start Date 1712004 gt End Date 1 1 2005 _ Medication Table Entry o m Care Manager famn o Physician Table Entry Sort By Last Name 3 Run Encounter Summary Figure 19 Click Run Encounter Summary to run the report Fig 20 CMT Elle Edit view Tools Window Help Patient Encounter Scummary Care Manager Patient Encounter Summary For Time Period 1 1 2004 to 1 1 2005 Care Manager Ann Thomsen ID Number Last Name First Name Phone Number Encounter Date Encounter Type Outcome Billings Barbie 800 663 3333 14 2004 MD Office Visit Completed Billings Barbie 800 663 3333 2 23 2004 Telephone Contact Completed Billings Barbie 800 663 3333 35 2004 Telephone Contact Lett Message Hansen Sally 800 222 2222 11 8 2004 Telephone Contact Completed Hansen Sally 800 222 2222 11 0 20
25. abetes Education Drop down None Within the last year 1 5 years ago gt 5 years ago Have you seen a Dietitian Checkbox Yes and No Fields Food Allergies Checkbox Yes and No Fields Does Patient have any food allergies Has Patient seen a Dietitian No i How often do you eat out Drop down lt 1 time a week 1 2 times a How often does Patient eat outside the home Co ode ee cian as l week No f Yes Food Allergies What Textbox If Patient Allergies list them What is the most difficult part of living Textbox Free Text What is the most difficult thing for the Patient in with Diabetes living with Diabetes Sad Blue Checkbox Yes and No Fields No Is Patient sad blue Depression Screening What s your insulin to carbohydrate Textbox Free Text No Patient s insulin to carb ratio ratio No No No No No No Page 12 of 18 Care Manager Tracking Database Data Dictionary General Use Checkbox Yes and No Fields Has Patient lost interest Depression Screening Checkbox Yes and No Fields No Does Patient have someone to talk to Depression Screening FPP PRE POST KNOWLEDGE ASSESSMENT Diabetes Education Assessment Patient Name Patient Name automatically populated from Patient record currently selected Person s Instructed Name of Person s given Diabetes Education Patient family members etc Date field Date MM DD YYYY Date of Diabetes Education Assessment UA E Score BEFORE diabetes educ
26. al New Pts Referred Keni by MD CM Tot Pts wiNo Collaboration No Start and End Dates needed to run query Record 14 4 111 gt t gt of 1 4 LA Figure 29 Page 27 of 33 CM Total Encounters Clicking on the CMT Total Encounters button will bring up the following query screen Fig 30 This query displays the number of Care Manager Patient Encounters falling within the entered date range E CMT lolx Eile Edit View Insert Format Records Tools Window Help 1 Johnson John 2 Thomsen Ann Record 1 gt ot p of 2 Figure 30 CM Completed Calls Clicking on the CM Completed Calls button will bring up the following query screen Fig 31 This query displays the number of Care Manager Telephone Calls and Average Call Length for Care Manager Patient Encounters falling within the entered date range CM Completed Calls Select Query Care Mgr ID CM Last Name CM First Name Total Completed Calls Average Call Length mins Per Encounter gt 1 Johnson John 2 11 El 2 Thomsen Ann 1 Record 14 4 1 gt Lou lp of 2 Figure 31 CM Total Encounters by Diagnosis Clicking on the CM Total Encounters by Diagnosis button will bring up the following query screen Fig 32 This query displays the number of Care Manager Patient Encounters falling within the entered date range sorted by Diagnosis Please note In the CMT database encounters are not linked wi
27. ating activity since discharge Unknown discharge Is there any change in weight Drop down Unchanged Stable Any change in Patient weight Moderate Gain Up to 2 Ibs in one day up to 5 Ibs over optimum Significant Gain gt 5 Ibs in one day Weight Loss Down gt 5 Ibs since discharge Not Checked Weight has not been Diet Fluid Restriction Do you understand your low salt diet Drop down Yes No Unknown Are you following a low salt diet Drop down Yes No Unknown Does Patient understand his her low salt diet Is Patient following a low salt diet No No Are you limiting fluids to lt 2 liters day poe alee No Unknown N A No Is Patient limiting fluids to less than 2 liters a day No E How is your breathing Drop down Better Stable Worse Severe Unknown How is Patient s breathing Page 16 of 18 Instructed to contact provider non urgent Instructed to seek immediate treatment urgent Teaching seminars schedule offered Next phone call scheduled None Other Notes FUNCTION Assessment Date Activities of Daily Living Question 1 Activities of Daily Living Question 2 Activities of Daily Living Question 3 Activities of Daily Living Question 4 Activities of Daily Living Question 5 Activities of Daily Living Question 6 Care Manager Tracking Database Data Dictionary General Use is Patient lightheaded Does Patient have swelling in the feet abdomen Severe Unknown
28. ation Se ll 1 Poor 2 Fair 3 Good No Score Does Patient understand how diabetes 0 N A affects him her Score Does Patient understand his her meal plan Score Does Patient understand the benefit of exercise physical activity Score Does Patient understand how his her medications work Score Does Patient understand the benefit of blood glucose monitoring Score Does Patient understand how to detect treat and prevent hypoglycemia Score Does Patient understand how to detect treat and prevent hyperglycemia Score Does Patient understand how to prevent and or reduce chronic complications Poor 2 Fair 3 Good o Score Does Patient understand how reaching N A his her goals will help with diabetes Drop down 1 Poor 2 Fair 3 Good No Score Does Patient understand that the diabetes 0 N A team is available to help him her problem solve Do you understand how diabetes Drop down 1 Poor 2 Fair 3 Good No Score Does Patient understand how diabetes affects emotional health 0 N A affects emotional health Page 13 of 18 Data Element Do you understand that your blood glucose needs to be in control before and during pregnancy After Education Instruct Date Instructor ollow up Plan nstructors 1 nstructors 2 nstructors 3 Nutrition Management text Physical Activit Physical Activity text Meds Meds text Monitoring Monitoring text Preventi
29. cking this button will bring up the following Heart Failure Follow Up screen Fig 12 Enter the Follow Up information Please note that you may also print a copy of this screen form by clicking the Print Follow Up button on the bottom left of the screen Required fields are in blue Omitting these fields will generate a pop up error message when you save the form o Call Date o Discharge Date o Hospital Click the Save Follow Up Button to save the record and close the window to return to the main Patient Information screen x Heart Failure Follow Up Call Date gt Discharge Date gt To z Hospital Y Talked To bd Medication Review Diet Fluid Restriction Are you Following your discharge medications bd Do you understand your low salt diet If not which ones are you not Following 4re you Following a low salt diet Are you limiting Fluids to lt 2 liters day Why are you not Following your discharge meds Symptoms How is your breathing Reviewed the importance of compliance not Are voullohtheaded running out refilling meds E Reminded patient to take all medications to m a del Swelling in the feet abdomen or ankles Follow up appointment Follow Up Activity T Instructed to contact provider non urgent 4re you trying to stay active daily hm I Instructed to seek immediate treatment urgent How are you tolerating activity since discharg
30. e a Teaching seminars schedule offered Weights T Next phone call scheduled Is there any change in weight O None othr o Notes New Follow Up Save Follow Up Print Follow Up Delete Follow Up Record 14 4 2 5 gt i gt of 2 Filtered Figure 12 Function o Assessment Date Page 16 of 33 Clicking this button will bring up the following Function screen Fig 13 Enter the Function information Required fields are in blue Omitting these fields will generate a pop up error message when you save the form Click the Save Function Assess Button to save the record and close the window to return to the main Patient Information screen amp Function xX Function Assessment Date 9 5 2006 Activities of Daily Living Score ADL Instrumental Activities Score IADL Able to do without help 1 Get out of bed or chair Y Y 2 Walk 3 Take a bath or shower 4 Get Dressed 5 Go to the toilet 6 Feed self a meal 144 71 lt lt lt lt lt ADL 4 Able to do without help 1 Shop VY N 2 Use a telephone E am 3 Cook VY N 4 Travel outside the home pP Y JN 5 Bills Checkbook Finances 7 Y N 6 Housekeeping o a 7 Take medications ao mo TADL 3 Total ADL or IADL score is the number of functions the individual is able to do independently 6 full function 4 moderate impairment 2 severe impairment Mini Mental Status Exam Score
31. e 25 of 33 Patient Education Progress Report e Clicking on the Patient Education Progress Report button will bring up the following Patient Education Progress Report Parameters screen Fig 27 The Patient Education Progress Report generated is a summary report generated from the Patient Diabetes Education Assessment screen for the selected Care Manager Diabetes Educator E CMT loj xi Eile Edit View Insert Format Records Tools Window Help Care Management Tracking Record Entry and Modification General Reports Patient Information Patient List Blood Glucose Meter Table Entry OO Eromen EE Care Manager Table Fntrw I Patient Education Report 5 5 dministrative Time List Patient Education Progress Report Parameters PORRES R Diabetes Educator ann Medication Table Er Run Patient Education Progress Report Physician Table En Patient Education Progress Report Figure 27 Click Run Patient Education Progress Report to run the report Fig 28 E CMT 10 x Elle Edit view Tools Window Help Patient Education Progress Report lol x a Patient Education Progress Report Educator Ann Thomsen Pre Educ Score Avg Do you understand how diabetes affects you Do you understand your meal plan Do you understand the benefit of exercise physical activity Do you understand how your medications work Do you understand the benefits of blood glucose monitoring Do you understand
32. ee Text No If Patient has trach tube what is the type and or size of the tube Checkbox Is Patient using a cuff Checkbox Is Patient NOT using a cuff Checkbox Is Patient on formula Formula text If Patient is on formula formula name and or notes is Patient using Feeding Purp supples Page 7 of 18 Data Element Other text Home Care Comments Developmental Rehab Company Name Company Phone PT PT text peech peech text OT OT text Vision Vision text Developmental Rehab Comments chool School Phone Community Resources DSPD Case Worker DSPD Case Worker Phone DSPD Applied DSPD Accepted DSPD Denied SI Applied SI Accepted SI Denied Waiver Program Technology Dependent Children Waiver Program TBI Waiver Program DDMR Waiver Program Applied Waiver Program Accepted Waiver Program Denied Care Manager Tracking Database Data Dictionary General Use Other Home Care Equipment items notes Comments relating to Home Care Developmental Rehab Company Name Numeric 000 000 0000 Developmental Rehab Company Phone Checkbox Yes No Patient in Physical Therapy extbox ree Text Comments relating to Physical Therapy Checkbox Yes No Patient in Speech Therapy extbox ree Text Comments relating to Speech Therapy Checkbox Yes No Patient in Occupational Therapy extbox ree Text Comments relating to Occupational Therapy Checkbox Yes No Patient in Vision Therapy extbox ree Text Comments relating to Vision T
33. esdaemeaeye dad etaatinbaeceseni aes 25 COUNT Saeed th canon Sheahan lh eS S madam A E A A E oda die tien A a A 26 BS oa JU A E E A A scl 8 ER IE Re OR OPEN CEI E IR AUT 26 Admin MATES i 31 Administrative Time Information sici n i n li dd dd cani 31 Administrative AS ER 32 Tips for Entry Data INEST A E E E 33 Technical Programmer Use Dn RnR Dee A RR seent 33 Page 3 of 33 Care Manager Tracking CMT Software Installing the Database To install the database for a single user download and save the CMT mdb file to the desired folder on a local drive computer For multiple users install the database on a network drive Users can be given access rights permissions to that drive map the drive to their computer and create a shortcut on their desktop to access the live database Opening the Database To open the database double click the Shortcut to CMT mdb icon on your desktop The CMT Care Management Menu will appear Fig 1 Ed CMT Oj xj Eile Edit View Insert Format Records Tools Window Help E CMT Care Management Menu Care Management Tracking Record Entry and Modification General Reports Queries Patient Information Patient List ise hale Encounter Tickler Blood Glucose Meter Table Entry Admin Time Care Manager Table Entry Ee Sane Administrative Time Information Diagnosis Table Entry Mental Health Reports Administrative Time List Facility Table Entry PHQS List Insurance Provide
34. esolved and another Active they can be tracked separately Required fields are in blue Omitting these fields will generate a pop up error message when you save the form o Diagnosis Date o Diagnosis Click the Save Diag Button to save the record and close the window to return to the main Patient Information screen amp Patient Diagnosis x Patient Diagnosis Diag Date a gt Diagnosis CY Specialist IO Status active F Notes New Diag Save Diag Delete Diag Record 14 4 1 gt of 1 Filte Figure 4 Page 8 of 33 Encounter Clicking this button will bring up the following Patient Encounter screen Fig 5 Enter the Encounter information Please note that Scheduled Time must be entered in the format HH MM AM or HH MM PM For a future Encounter to appear on the Encounter Tickler Report accessed from the database Main Menu you MUST enter the top half above the line of the Encounter pop up entry screen This portion drives the report Required fields are in blue Omitting these fields will generate a pop up error message when you save the form o Scheduled Date Click the Save Encounter Button to save the record and close the window to return to the main Patient Information screen You will notice that the windowpane for Encounters on the Patient Information screen will display that Encounter as Pending Once the Encounter has been compl
35. eted go back to the Encounter screen for the Patient to fill in the bottom portion below the line of the Encounter record Filling in an Actual Date will cause the windowpane on the Patient Information screen to display Completed and the Encounter to drop off the Encounter Tickler to do List amp Patient Encounter i x Encounter Information Scheduled Date l Scheduled Time Encounter Type Enc Reason v Actual Date Outcome Call Attempts to Pts Resource Time in minutes Total Call Time for Day in minutes Clinic Visit Time in minutes Number of Phone Calls Home Visit Time in minutes Notes New Encounter Save Encounter Delete Encounter Record 14 4 1 P px of 1 Filtered Figure 5 Page 9 of 33 e Meds Clicking this button will bring up the following Patient Medication screen Fig 6 Enter the Medication information Required fields are in blue Omitting these fields will generate a pop up error message when you save the form o Medication Click the Save Med Button to save the record and close the window to return to the main Patient Information screen ES Patient Medication x Patient Medication Medication Start Date gt Medication End Date HA gt Medication CY T PRN Dose Notes i ji Save Med Delete Med Record 14 4 gt bl gt of 2 Filter om 6 MH Instr
36. feet Page 10 of 18 No No No No No No No No Hospitalized for Diabetes in last year Checkbox Yes and No Fields No Has Patient been hospitalized for the Problem of Diabetes in the last year No No No No No No No No Care Manager Tracking Database Data Dictionary General Use Sores that won t heal Checkbox Yes and No Fields Patient now experiencing sores that won t heal Pain Tightness in Chest Checkbox Yes and No Fields Patient now experiencing pain tightness in chest Checkbox Yes and No Fields No Patient now experiencing Stress Sexual Difficult Checkbox Yes and No Fields No Patient now experiencing Sexual Difficulty Other Medical Conditions Free Text Patient s Other Medical Conditions not listed above Last Diabetes Foot Exam Never Within the last year Time frame for Patient s last Diabetes Foot Exam Within the last 2 years gt 2 years ago Last Dilated Eye Exam Never Within the last year Time frame for Patient s last Dilated Eye Exam Within the last 2 years gt 2 months Within the last year Within the last 2 years gt 2 Never Within the last 6 ar frame for Patient s last Dental Exam Do you have a Blood Glucose Meter Checkbox Yes and No Fields weet Does Patient have a blood glucose meter If Meter Type Drop down None Bayer Ascensia Bayer Type Brand of Patient s blood glucose meter Dex Bayer Glucometer Elite Chronimed Lifescan SureStep Lifescan Ultra Lifescan Ultra Smart One
37. ght click again on the title bar of the CMT Care Management Menu 4 Choose Properties 5 Scroll down to the Form s On Load property and click on the words Event Procedure Click the button with the 3 dots 6 Change all the False booleans to True 7 Close out of the database all the way 8 Open it again 2 more times The 3rd time you should see the database window After you make your changes Please go to Tools on the main Access toolbar Choose Database Utilities and Compact and Repair Database It may take a few moments but then your windows will pop back up Repeat the earlier steps to get to the code window or in Design view of the Main Menu choose View and Code from the main Access toolbar In the SetStartUp Properties change all of the True s back to False Close out of the database and go back in 2 more times 3rd time s a charm to make sure the database window is no longer visible Care Manager Tracking Database Data Dictionary General Use PATIENT INFORMATION ID Number Textbox Numeric Yes Unique Number specific to a Patient in your organization Patient s Last Name Patents Fist Name 8 Made ital aested Date field Date MM DD YYYY Patient s Date of Birth lt 19 19 44 45 64 gt 65 Automatically calculated from Patient s DOB Race Drop down White Caucasian Am Patient s Race Classification Indian Alaskan Native Black African Am Asian Chinese Japanese Kor ean Pacific Islander Hispanic C
38. he text into the other electronic charting location Open the program into which you wish to paste your Note Once you choose your Patient in that system go to where you normally enter a Note to type in or copy in information and do a Control V sequence Hold down the Cntrl key in the bottom left of the keyboard and then press the V letter key on the keyboard This is a shortcut to the Paste command Your electronic charting system may not let you Right click and choose Paste as we did with Copy Please Note You may also print from this screen by clicking the printer icon on the top right of the screen Page 19 of 33 General Reports Patient List Clicking on the Patient List button will bring up the following Patient List Parameters screen Fig 15 The Patient List report generated is a list of Patients assigned to the selected Care Manager Diabetes Educator This report can be sorted by first name last name diagnosis insurance PCP Primary Care Physician or status E CMT Of x Eile Edit View Insert Format Records Tools Window Help CMT Care Management Menu Care Management Tracking Record Entry and Modification General Reports Queries Patient Information Patient List View Queries F F Blood Glucose Meter Table Entry EEES xi Admin Time Patient List Parameters Care Manager ohn z rater Information Blood Glucose Meter Table Entry Care Manager Tale try ___FectyTableere
39. herapy Free Text Comments relating to Developmental Rehab Patient s School Numeric 000 000 0000 Patient s School Phone Patient s DSPD Case Worker Patient s DSPD Case Worker Phone Has Patient Family Applied for DSPD Has Patient Family been accepted for DSPD Has Patient Family been denied DSPD Has Patient Family Applied for SSI Has Patient Family been accepted for SSI Has Patient Family been denied SSI Checkbox Yes No No Waiver Program Technology Dependent Children Checkbox Waiver Program TBI Checkbox Waiver Program DDMR Checkbox Has Patient Family applied for Waiver Program Checkbox Yes No No Has Patient Family been accepted for Waiver Program Checkbox Yes No No Has Patient Family been denied Waiver Program Care Manager Tracking Database Data Dictionary General Use Checkbox Workforce Service Food Stamps Checkbox Workforce Service Child Care Service Service Service Checkbox Has Patient Family applied for WIC Checkbox Has Patient Family been accepted for WIC Checkbox Has Patient Family been denied WIC Housing Assistance Applied Checkbox Yes No N Has Patient Family applied for Housing Assistance Housing Assistance Accepted Checkbox Yes No N Has Patient Family been accepted for Housing Assistance Housing Assistance Denied Checkbox Yes No N Has Patient Family been denied Housing Assistance N N N N Medicaid Caseworker assigned to Patient Medicaid Caseworker Phone Numeric 000 0
40. hicano Cuban Me xican Puerto Rican Latino Sex Drop down _ M Male F Female Patient s Gender ic Numeric 000 000 0000 Patient s Contact Phone Number Cell Phone Textbox Numeric 000 000 0000 Patient s Cell Phone Number Patient s Email Address From Physician Table Values Patient s Primary Care Physician PCP Phone Numeric 000 000 0000 Patient s Primary Care Physician Phone Number Insurance Drop down From Insurance No Patient s Primary Insurance carrier Defaults to Table Values Yes Yes Unknown if not entered From Facility Table Values Care Manager s Facility Diab Collaboration Checkbox Yes No Has at least 1 RN and 1 RD as Diabetes Education Instructors collaborated on Patient FPP Drop down 1 Disconnected Avoidance N Patient s Family Pattern Profile An assessment 2 Confused Chaotic of the relationship pattern style that is most like 3 Secured Balanced the family of the patient pene Pee PA Managers educator Manager Diabetes Educator Care Mgr Drop down From Care Manager Care Manager assigned to Patient Fa i fee ati Y Page 1 of 18 Care Manager Tracking Database Data Dictionary General Use Data Element Type Control Definition Status Drop down _ Active Closed 1X Only No __ Patient s status with Care Manager po Closed Deceased Moved etc PATIENT DIAGNOSIS Diag Date Date field Date MM DD YYYY Date Diagnosis Management began Drop down From Diagnosis Table Values Patient s Active Problem fro
41. l Date Date field Date MM DD YYYY Date Patient Encounter actually took place Outcome Drop down Completed No Show Outcome of Care Manager Patient phone Cancelled Reschedule call visit Wrong Number No Answer Left Message Letter Sent Disconnected Deceased No Answer VE Includes Busy Signal Call Attempts to Pts 1 2 3 4 5 Number of tries to reach Patient by Phone Total Call Time for Day Textbox Numeric No Total Length of time on phone in minutes for the day for the Encounter Resource Time Textbox Numeric No Total Time spent on any preparatory work minutes for the Encounter Face to face Face to face Notes Textbox Free Text No Notes relating to the Care Manager Patient Encounter Page 3 of 18 Care Manager Tracking Database Data Dictionary General Use TyperControt_atues Require Definition Date Field Date MM DD YYYY Date Medication Started Date Field Date MM DD YYYY Date Medication Ended No Drop down Medications from Y Medication Name Table Values PRN Checkbox Yes No No Medication PRN No Y U S e 5 m D 5 e v gt a m Z m g O gt a O Z Dose Medication Dose Notes Textbox FreeTet No Notes relating to the Patient Medication MH MENTAL HEALTH INSTRUMENTS Date Date field Date MM DD YYYY Check Support ERP e CM Relational Isolation Assess Checkbox Yes No solated from available support Checkbox Yes No Patient isolated from available support Yes i
42. ll bring up the following query screen Fig 39 This query displays the number of New Patients referred to the Care Manager with a Date of Referral within the entered date range fa CMT Ee x Eile Edit View Insert Format Records Tools Window Help i CM Total New Patients Referred Select ques i ne AAA ara A NNT oO E Thomsen Ann Record ni 1 gt AID of 1 Figure 39 CM Total New Patients Referred by MD Clicking on the CM Total New Patients Referred by MD button will bring up the following query screen Fig 40 This query displays the number of New Patients referred to the Care Manager with a Date of Referral within the entered date range sorted by Patient s Primary Care Physician Eile Edit View Insert Format Records Tools Window Help is CM Total New Patients Referred by MD Select Query Record 1 gt JD of 2 Figure 40 CM Resource Time Clicking on the CM Resource Time button will bring up the following query screen Fig 41 This query displays the Total Care Manager Patient Encounter Resource Time within the entered date range and the Average Resource Time for those Encounters CMT Eile Edit View Insert Format Records Tools Window Help ss CM Resource Time Select Query __ Care Mgr ID CM Last Name CM First Name Total Encounter Resource Time mins Average Resource Time mins per Encounter gt 1 Johnson John 2 Thomsen Ann Z Record lt 1 gt o
43. m Problem List tatus Drop down Active Resolved Notes cheduled Date ate field Date MM DD YYYY Yes ate for Patient s scheduled phone call visit cheduled Time ime field Time HH MM AM PM ime for Patient s scheduled phone call visit No Encounter Type rop down CM Office Visit Class MD Type of Care Manager Patient Encounter Office Visit Home Visit Telephone Contact Group Visit MHI Conference Email Non Encounter Related Diab Initial Diab Followup Diab Class 1 Diab Class 2 Diab Class 3 Diab Class 4 Diab Class 5 Diab Class 6 Diab Additional Class Diab Inpatient Diab Insulin Start AA E Class PatientEducation A Non Encounter Related Filling out forms admin other charting etc tatus of the Diagnosis Defaults to Active otes relating to the Diagnosis Drop down From Physician Table Values RT Physician managing the Diagnosis Nos No Yes No Yes No No No No Yes Page 2 of 18 Care Manager Tracking Database Data Dictionary General Use Enc Reason Drop down DEA Screen PHQ 9 F U Reason for the Care Manager Patient Encounter MHI F U DM F U Depression F U DM Depression F U Med Assist Medication Mgmt Agreement Status Check Resource Management New Patient Assistance Financial Assistance E A as cad eee ee Narcotic use Resource Management Assisting Patient with Referrals Procurement Research etc ex finding MDs or Nursing Home obtaining equipment Actua
44. me in minutes Medical Staff Meeting Staff Clinic Meeting Mental Health Integration Diabetes Education Case Management Meeting Geriatric Education Self Development Teaching Drug Rep Meeting Team Building Meeting Paid Time Off Total Meet Time for Day mins Save Day s Time Record 14 4 19 gt bl gt of 19 Filtered Figure 43 Administrative Time List Page 32 of 33 Clicking on the Administrative Time List button will bring up the following Admin Time List Parameters screen Fig 44 The Administrative Time List generated is a summary report for all Care Manager database users generated from the Administrative Time Information module Ed CMT Eile Edit View Insert Format Records Tools Window Help CMT Care Management Menu Y Care Management Tracking Record Entry and Modification Patient Information Blood Glucose Meter Table Entry Care Manager Table Entry Diagnosis Table Entry Facility Table Entry Insurance Provider Table Entry Medication Table Entry Physician Table Entry General Reports Patient List Encounter Tickler Encounter Summary Mental Health Reports Diabetes Reports ADA Report Patient Goal Progress Report Patient Education Progress Report Figure 44 Queries View Queries Admin Time Administrative Time Information PHQ9 List ii Lal xj Admin Time List Parameters Start Date 1 1 2005 _ End Da
45. meter Type fone Approx how old is it as How often do you test not at al gt Date of Last HgbA1C Never y ResutHobAiG What type of activity do you do Potaa Physical limitations that impact activity CASA Meal Plan FT MN Do you skip meals What s your insulin to carbohydrate ratio NA Last Diabetes Education Poe D M N Have you seen a Dietitian How often do you eat out es FF YMN Food Allergies IF Yes What What is the most difficult part of living with Diabetes PY N Sad Blue PY YN Lost interest PY Y N Someone to talk to Save assessment Print Assessment Delete Assessment Record 14 al 2 gt fone of 2 Filtered Figure 9 Page 13 of 33 e Pre Post Knowledge Assess Clicking this button will bring up the following Diabetes Education Assessment screen Fig 10 Enter the Diabetes Education Assessment information Please note The Patient Name field at the top of the screen will be automatically populated from the Patient record you are currently viewing Also you may print a copy of this screen form by clicking the Print Assessment button on the bottom left of the screen Required fields are in blue Omitting these fields will generate a pop up error message when you save the form o Assessment Date Click the Save Assessment Button to save the record and close the window to return to the main Patient Information screen
46. nce Provider Tabh Medication Table Entry ADA Report Physician Table Entry Patient Goal Progress Report Patient Education Progress Report Figure 23 Click Run ADA Report to run the report Fig 24 E CMT Eile Edit view Tools Window Help ADA Report Diabetes Educator ADA Report For Time Period 1 1 2005 to 2131 2005 Page 1 of 1 Facility GHI Clinic Encourter Date Patiert Name Gender ID Number Encounter Type Age Diabetes Type Speda Needs Insurance Collaboration 19 2005 Sampson Josep M CM Office Visit 19 44 Type 2 Visual Impairment Private Pay 1113 2005 Sampson Josep Class 19 44 Type 2 Visual Impairment Private Pay 1112 2005 Sampson Josep Telephone Cont 19 44 Type 2 Visual Impairment Private Pay 1 25 2005 Redman Robert Telephone Cont 19 44 Type1 LowLiteracy IHC Access 1 24 2005 Redman Robert Telephone Cont 19 44 Type 1 LowLiteracy IHC Access 111 2005 Redman Robert Telephone Cont 19 44 Type1 LowLiteracy IHC Access Totals Age lt 19 Sex 19 44 45 64 gt 65 CA White Caucasian Al Am Indian Alaskan Native AA Black African Am PI Asian Chinese JapaneseMoreanP acific Istander HC Total of Patients 2 HispaniciChicano Cuban Mexican P uerto Total of Visits 6 Type 1 Special Needs 1 Visual Type 2 Q Hearing GDM 1 LowLiteracy Pre DiabAGT 0 Eng 2nd Lang Fe por olor ana tal a OT Tien iat Figure 24 Page 24 of 33 Patient Goal Progress Report e Clicking on the
47. ng Acute Complications Preventing Acute Complications text Risk Reduction Risk Reduction text Care Manager Tracking Database Data Dictionary General Use Drop down 1 Poor 2 Fair 3 Good 0 N A Drop down 1 Poor 2 Fair 3 Good 0 N A Date MM DD YYYY Textbox extbox extbox extbox extbox extbox Date field Date Field Date MM DD YYYY Textbox Checkbox extbox Checkbox extbox Checkbox extbox ree Text Checkbox Yes No extbox Free Text Checkbox Yes No Yes No Textbox Checkbox No o No No No No No No No Yes No No No No No No No No No No No No Definition Score Does Patient understand that his her blood glucose needs to be in control before and during pregnancy question above question above Follow up Plan For Each question above For 1st Diab Educ Instructor signature For 2nd Diab Educ Instructor signature For 3rd Diab Educ Instructor signature Date of Collaboration on Patient if not as part of class education above Ex Meeting re Patients Date of Patient Goals Assessment Patient ID Number automatically populated from Patient record currently selected Does Patient have Goal of Nutrition Management Details for Nutrition Management Goal Does Patient have Goal of Physical Activity Details for Physical Activity Goal Does Patient have Goal of Meds Details for Meds Goal Does Patient have Goal of Monitoring Details f
48. nge and the Average Clinic Visit Time with those Patients Eile Edit View Insert Format Records Tools Window Help Y CM Clinic Visits Select Query Care Mgr ID CM Last Name CM First Name Total Clinic Visits Average Clinic Visit Time mins Thomsen a reee 2 Thomsen Ann Record a 1 gt Ln gt of 1 4 Figure 34 CM Total Encounters by MD Clicking on the CM Total Encounters by MD button will bring up the following query screen Fig 35 This query displays the number of Care Manager Patient Encounters falling within the entered date range sorted by Primary Care Physician Eile Edit View Insert Format Records Tools Window Help CM Total Pat Encounters by MD Select Query Care Mgr ID CM Last Name CM First Name Total Pat Encounters Johnson Allen Mitch 2 Thomsen Benson George 2 Thomsen Carmen Julie 2 Thomsen Durham Terry Record 14 4 Il 1 gt gt t gt of 4 Figure 35 Page 29 of 33 CM Home Visits Clicking on the CM Home Visits button will bring up the following query screen Fig 36 This query displays the number of Care Manager Patient Encounters of type Home Visit falling within the entered date range and the Average Clinic Visit Time with those Patients fa CMT Elle Edit View Insert Format Records Tools Window Help E CM Home Visits Select Query __ Care Mgr ID CM Last Name CM First Name Total Home Visits Average Home Visit Time HE C E
49. or Monitoring Goal Does Patient have Goal of Preventing Acute Complications Details for Preventing Acute Complications Goal Does Patient have Goal of Risk Reduction Details for Risk Reduction Goal Page 14 of 18 Care Manager Tracking Database Data Dictionary General Use Data Element Type Control Definition Psychosocial Adj No Does Patient have Goal of Psychosocial Adj Psychosocial Adj text No Details for Psychosocial Adj Goal Other Goal No Does Patient have Other Goal not listed Other text No Details for Other Goal ollow up Dates Nutrition Management Date field Date MM DD YYYY Follow up Date for Goal of Nutrition Management Physical Activit Date field Date MM DD YYYY Follow up Date for Goal of Physical Activit Date field Date MM DD YYYY Follow up Date for Goal of Meds Date field Date MM DD YYYY Follow up Date for Goal of Monitoring Preventing Acute Complications Date field Date MM DD YYYY No Follow up Date for Goal of Preventing Acute Complications Risk Reduction Date field Date MM DD YYYY Follow up Date for Goal of Risk Reduction Psychosocial Adj Date field Date MM DD YYYY No _ Follow up Date for Goal of Psychosocial Adj Other Goal Date field Date MM DD YYYY Follow up Date for Other Goal not listed Nutrition Management 2 3 4 5 6 7 8 9 No Score for Goal of Nutrition Management Physical Activit 2 3 4 5 6 7 8 9 No Score for Goal of Physical Activit 2 3 4 5 6 7 8
50. or ankles Did Care Manager instruct Patient to contact his her Provider non urgent for follow up Checkbox Yes No No Did Care Manager instruct Patient to immediately seek treatment urgent for follow up Did Care Manager offer to Patient a schedule of teaching seminars for follow up Is the next Care Manager phone call scheduled Checkbox Is no Follow up with Patient necessary Other follow up for Patient Specify Comments relating to the Discharge FoTOW Up Date of Function Assessment ADL Question Is Patient able to Get out of bed or chair without help ADL Question Is Patient able to Walk without help ADL Question Is Patient able to Take a Bath or Shower without help ADL Question Is Patient able to Get dressed without help ADL Question Is Patient able to Go to the toilet without help ADL Question Is Patient able to Feed self a meal without help Page 17 of 18 Care Manager Tracking Database Data Dictionary General Use Question 2 telephone without help Question 3 help Question 4 the home without help Question 5 Checkbooks Finances without help Question 6 Housekeeping without help Question 7 Medications without help Values 1 to 7 Pain Score Scale 0 10 Comments relating to Function Page 18 of 18
51. ormat Records Tools Window Help CMT Care Management Menu Care Management Tracking Record Entry and Modification General Reports Queries Patient Information Patient List View Queries hd Grs tr Tt ry AAA EEren oxi A Tickler List Parameters Facility Table Entry Insurance Provider Table Entry Medication Table Entry Physician Table Entry Admin Time Start Date 4 1 2005 End Date 4 30 2005 Care Manager orf x Run Encounter Tickler Patient Goal Progress Report Patient Education Progress Report Figure 17 Click Run Encounter Tickler to run the report Fig 18 El CMT Elle Edit view Tools Window Help Encounter Tickler Care Manager Encounter Tickler List Care Manager John Johnson Last Name Winston Tennison Sched Dt and Time Encounter Type Reason ID Number First Name 4 14 2005 Non Encourter Status Check 14 Joie 4 22 2005 MD Office Visit 10 Herold 4 30 2005 Telephone Cont Status Check ie Daniel Stevens Phone Number _ PCP 800 744 4444 Allen Mitch 800 444 4444 Durham Terry 800 800 8000 Allen Mitch Comments check on fiu appt wDr Jo Page MAYA 1 gt dor 4 ts HZ Figure 18 Page 21 of 33 Encounter Summary e Clicking on the Encounter Summary button will bring up the following Encounter Summary List Parameters screen Fig 19 The Encounter Summary report generated is a summary of Encounters by date range for
52. p up which will summarize all events for the day you selected for that patient the record you are currently viewing Any Encounters matching that date Any MH Instruments recorded matching that date and ALL Diagnoses for that Patient regardless of date will appear We included all Diagnoses for an at a glance reference you may not wish to copy and paste an earlier Diagnosis that doesn t relate to the date with which you are concerned Page 18 of 33 83 Clinical Note Summary xi gt Summary for Btevens Daniel ID Number F 3 Encounter Scheduled Date 1 26 2005 Actual Date 1 26 2005 Telephone Contact Depression F U Completed Call Attempts 2 Call Length 12 min Notes PHQ 9 1 3 Doing much better Not taking Depakote or Klonopin MH Packet 1 26 2005 PHQ 9 Symptom Count 1 PHQ 9 Severity 3 Funct Diff Somewhat Dysthymia Yes PHQ9 Suicide O Suicide Risk No Risk Diagnosis 2 28 2005 CHF Specialist Benson George Status Active Diagnosis 3 30 2004 Depression Status Active Diagnosis 3 30 2004 Anxiety Status Active Record 14 4 I 11109 of 1 Figure 14 3 To copy the text as much as you need to transfer to another program Click inside the box where the summary appears Highlight the text you want to copy Right click and choose Copy from the menu Not highlighting first and just right clicking will highlight everything and save time if that s what you want to do 4 Paste t
53. r Table Entry Diabetes Reports Medication Table Entry ADA Report Physician Table Entry Patient Goal Progress Report Patient Education Progress Report Figure 1 The CMT Care Management Menu The Care Management Tracking Database Main Menu is composed of 6 sections Record Entry and Modification General Reports Mental Health Reports Diabetes Reports Queries and Admin Time Page 4 of 33 Record Entry and Modification Section This section includes buttons to access the main Patient Information screen as well as table information for Care Managers Physicians Diagnoses etc which appear as selections in the drop down fields throughout the database Entering Values on Main Menu for Blood Glucose Meters Care Managers Diagnoses Facilities Insurance Providers Medications and Physicians e Click on the Diagnosis Table Entry button or other Table Entry button from the main menu A pop up window Fig 2 will appear with all of the values for that category currently in the database table available in the drop down menus To add a new one scroll down the window to the blank line Type in the new value and close the window It will now automatically save to that table and appear as an alphabetized choice in the drop downs within the database Please note If you are looking to add an entry for another category other than those listed on the Main Menu please contact your database administrator programmer
54. ry _ Insurance Provider Table Entry ___Nedeatin Tabie entry __ Physcan Table try Care Manager Table Entry trative Time Information Facility Table Entry Run Patient List Insurance Provider Table Entry Medication Table Entry ADA Report Physician Table Entry Patient Goal Progress Report Patient Education Progress Report Figure 15 Click Run Patient List to run the report Fig 16 E CMT Eile Edit view Tools Window Help Patient List Care Manager Patient List Care Manager John Johnson ID Number Last Name FirstName Status Phone Number Primary Care Physician Diagnosis Insurance 11 Jennings Anson Adive 800 777 7777 Carmen Julie Depression IHC Health Plans Stevens Daniel Adive 800 800 8000 Allen Mitch Anxiety Mailhendlers Stevens Daniel Active 800 800 8000 Allen Mitch Depression Mailhandlers Stevens Daniel Adive 800 800 8000 Allen Mitch CHF Mailhendlers Tennison Harold Closed 800 444 4444 Durham Terry Hyperlipidemia Other Winston Joie Active 800 744 4444 Allen Mitch Depression IHC Health P lans Total Patients 5 pace MIMI AAN Figure 16 Encounter Tickler Page 20 of 33 e Clicking on the Encounter Tickler button will bring up the following Tickler List Parameters screen Fig 17 The Encounter Tickler report generated is a Tickler To do list for contact by date range for Patients assigned to the selected Care Manager Diabetes Educator Eile Edit View Insert F
55. ry PHQ9 List Parameters Care Manager ohn y J ian Tabl Prosen Taen jetne E Run Patient PHQ9 List Figure 21 Click Run Patient PHQ9 List to run the report Fig 22 CMT Df x Elle Edit View Tools Window Help PHQ9 List Care Manager Patient PHQ9 List Care Manager John Johnson 1D Number Last First Patient P hone FPP PCP Insurance Diagnosis PHQDete SympCt Severity Fetni Diff Dysth Q9 Suic Suic State Suicide Risk Stevens Daniel 800 800 8000 Allen Mitch Mailhandiers Depressio 1 26 2005 Somewhat M No Risk Stevens Daniel 800 800 8000 Allen Mitch Mailhandlers de 1 26 2005 Somewhat No Risk Stevens Daniel 800 800 8000 Allen Mitch Mailhandlers CHF 1 26 2005 Somewhat No Risk Stevens Daniel 800 800 8000 Allen Mitch Mailhandiers CHF 9 1 2004 Not at all No Risk Stevens Daniel 800 800 8000 Allen Mitch Mailhandlers Depressio 9 1 2004 Not at all No Risk Stevens Daniel 800 800 8000 Allen Mitch Mailhandlers Anxiety 9 1 2004 Not at all No Risk Stevens Daniel 800 800 8000 Allen Mitch Mailhandlers Anxiety 6 8 2004 Stevens Daniel 800 800 8000 Allen Mitch Mailhandiers CHF 67872004 Stevens Daniel 800 800 8000 Allen Mitch Mailhandiers Depressio 6 8 2004 Stevens Daniel 800 800 8000 Allen Mitch Mailhandiers Depressio 5 4 2004 Somewhat 1 Thoughts Only LowRisk Stevens Daniel 800 800 8000 Allen Mitch Mailhandlers de 5 4 2004 Somewhat 1 Tho
56. t p of 2 KI Figure 41 Page 31 of 33 CM Tot Pts w No Collaboration Clicking on the CM Total Pts w No Collaboration button will bring up the following query screen Fig 42 This query displays the Number of Patients for which there has been no collaboration for Diabetes recorded as evidenced by an unchecked Diab Collaboration checkbox on the main Patient Information form This query is mainly used as a check to identify those Patients who need collaboration which will also be displayed on the ADA Report accessible from the Main Menu A CMT ES Eile Edit View Insert Format Records Tools Window Help lol x CM Last Name CM First Name Pt Last Name Patient First Name Collaborate Jennings Anson Stevens Daniel Tennison Harold Wilcox Terry Winston Joie Billings Barbie Brown Francis Redman Robert Sampson Joseph Record I4 4 LA ru gt of 9 i Figure 42 Admin Time Administrative Time Information Module to enter Care Manager time not spent on Patient Encounters such as meeting times education and vacation Fig 43 Enter the Administrative Time Information The total time for the day will be automatically calculated Each day should be entered separately Click the Save Day s Time Button to save the record and close the window to return to the CMT Care Management Menu Main Menu xl Administrative Time Daily Entry Date e Care Manager z Meetings Ti
57. te 1 31 2005 Care Manager Jann z Click Run Admin Time List to run the report Fig 45 E CMT Eile Edit View Tools Window Help X S OM 88 100 Administrative Time ose 0 a0 Care Manager Administrative Time List For Time Period 1 1 2005 to 1 31 2005 Care Manager Ann Thomsen Date Med Staff Staff Clinic MHI DiabetesEd Case Mgmt GeriatricEd Self Develop Teaching DrugRep Team Build PTO 1 26 2005 1118 2005 1113 2005 1112 2005 1112 2005 1111 2005 1 10 2005 0 90 0 0 o 110 90 0 o 90 120 0 140 30 0 0 0 0 o 0 0 0 0 0 0 0 Totals 290 440 0 o 0 Grand Total Figure 45 Page 33 of 33 Tips for Entry Data Integrity e Using drop downs Always drop down to select NEVER type in an entry If it needs to be added do so in Value List from the Main Menu or request a change from your database administrator programmer e Dates If typing in a date you must use the MM DD YY YY format 03 instead of 2003 will generate an error or click on the button for a pop up calendar e Consult the Data Dictionary and or Data Manager for your program when in doubt as to what to enter into a field Technical Programmer Use Only Following are instructions for revealing and hiding the tables of the CMT software so that programmers may customize it 1 Right click on the title bar of the CMT Care Management Menu 2 Choose Form Design 3 Ri
58. th specific diagnoses Therefore it cannot be deduced that there were 6 encounters geared specifically for Diabetes management in this time period see Fig 32 Rather it suggests that there were 6 encounters within this time period with Patients who have Diabetes in the Problem List E CMT _ O x Eile Edit View Insert Format Records Tools Window Help ss CM Total Pat Encounters by Diagnosis Select Query _ Care Manager ID CM Last Name CM First Name Diagnosis Total Pat Encounters 1 Johnson Anxiety 1 Johnson CHF 1 Johnson Depression 2 Thomsen Diabetes 2 Thomsen Other gt ia O 2 Thomsen Depression O _ Record 1 gt pL of 6 Figure 32 Page 28 of 33 CM Total Encounters by Diab Type Clicking on the CM Total Encounters by Diab Type button will bring up the following query screen Fig 33 This query displays the number of Care Manager Patient Encounters falling within the entered date range sorted by Diabetes Type The Type of Diabetes with which a Patient has been diagnosed is recorded on the Diabetes History Assessment screen Eile Edit View Insert Format Records Tools Window Help Record 14 4 1 gt t gt of 4 4 Figure 33 CM Clinic Visits Clicking on the CM Clinic Visits button will bring up the following query screen Fig 34 This query displays the number of Care Manager Patient Encounters of type Clinic Visit falling within the entered date ra
59. ughts Only LowRisk Stevens Daniel 800 800 8000 Allen Mitch Mailhandiers CHF 5141204 Somewhat 1 Thoughts Only LowRisk Stevens Daniel 800 800 8000 Allen Mitch Mailhandiers CHF 4 6 2004 Stevens Daniel 800 800 8000 Allen Mitch Mailhandiers Depressio 4 6 2004 Stevens Daniel 800 800 8000 Allen Mitch Mailhandlers Anety 4 6 2004 Stevens Daniel 800 800 8000 Allen Mitch Mailhandlers Depressio 3 24 2004 No Risk Stevens Daniel 800 800 8000 Allen Mitch Mailhandlers Anety 3 24 2004 No Risk Stevens Daniel 800 800 8000 Allen Mitch Mailhandiers CHF 3 24 2004 No Risk Ternison Harold 800 444 4444 Durham Terry Other Hypertipid 10 13 2003 page 141 T plot el Figure 22 Page 23 of 33 Diabetes Reports ADA Report e Clicking on the ADA Report button will bring up the following ADA Report Parameters screen Fig 23 The ADA Report generated is a summary report by date range for submission to the American Diabetes Association CMT Eile Edit View Insert Format Records Tools Window Help CMT Care Management Menu Care Management Tracking Record Entry and Modif SPB Mo Tolo Dj x Queries Patient Informatio ADA Report Parameters View Queries Blood Glucose Meter Tab Start Date 1 1 2005 _ End Date 373172005 Admin Time Care Manager Table E Facility GHICinic wd Sort By Patent Nane Diagnosis Table Ent Run ADA Report Facility Table Entr O Punaoa Insura
60. uments Page 10 of 33 Clicking this button will bring up the following Mental Health Instruments screen Fig 7 Enter the Mental Health Instruments information Scores entered on this screen originate from corresponding instruments such as the PHQ 9 Patient Health Questionnaire which are available for download with the CMT database Data entered on this screen will display on the Care Conference List Report from the Main Menu Mental Health version of the CMT database only Required fields are in blue Omitting these fields will generate a pop up error message when you save the form o Date Click the Save Instrument Data Button to save the record and close the window to return to the main Patient Information screen Mental Health Instruments Date Check Support Check Adherence Global Severity ga FF Isolated from available support F Following Recommendations 1 7 4 J Care Conf T Unwilling to use available support FT Taking Medication I Referred To MH Off Site I Exhausted available support Seeing Therapist General Comments Plan F Has available support actively using TT Self Management Identified Goal PHQ 9 Depression Mood and Anxiety Sleep Pediatric Only Symptom Count y Clinician Aware J Follow Up Required J Suicide Comments Mood Screen Severity Score mas Ym i Functional Difficulty y i 2 3 Dysthymia J Symptom Rating Scales PHQ Suicide Q9

User Guide - Care Management Plus

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