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CCC v. 8.3 User Manual - MSU Electronic Medical Records Home

1. C present bilaterally RIGHT Normal Prior Clear LEFT Normal Prior Clear Lying Straight Leg Raise neg pos C back only neg pos C back only Sitting Straight Leg Raise neg C pos C back only neg C pos C pos back only Reverse Straight Leg Raise neg C pos C pos back only 6 neg C pos C pos back only Toe Walking normal C abnormal normal C abnormal Heel Walking normal C abnormal normal C abnormal Patrick s Maneuver neg C pos neg C pos Fabere Test neg C pos 211 44 Prev Form Next Form Ctri PgDn 1 The following may be customized by specialty normal default values observation terms that are populated and the items in the two list boxes 2 The list box values may contain either normal or abnormal values 3 Charting by exception allows the provider to rapidly document a detailed PE as well as capture structured data which can be used for reporting or clinical decision support 4 The provider can use voice recognition CCC VRI Dragon 8 Medical to dictate into structured data fields Page 44 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Neurologic Exam CCC Motor Neurologic Exam CCC Don C Bassett Neuro Cervical US Motor sensory Reflexes Measure Special Motor Exam _Alliormal Lower
2. General Eyes ENT cv Resp Gl GU e C CV Complains of Denies See HPI chest pains chest pains All Hegative palpitations palpitations syncope syncope Clear dyspnea exertion dyspnea exertion orthopnea orthopnea PND PND peripheral edema peripheral edema Comments zl Ohbytheway vj Enter WP PMH _FH SH RiskFactors Ros Problems InstructionsPlan Copyright Prev Form Ctrl PgUp Next Form Ctrl PgDn 25 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example ROS Cardiology ROS CCC Bassett Page 1 2 Templates Patient Entered Hx View Insert REVIEW SYSTEMS Select Specialty Cardiology vi View Positive ROS Clear View See HPI Show Brief Version of Negative Values in Note General Resp Neuro Endo Gl GU o e CV Complains of Denies See HPI chest pain at rest chest pain at rest chest pain with exercise chest pain with exercise All Hegative palpitations palpitations Clear peripheral edema peripheral edema PND PND orthopnea orthopnea shortness of breath dyspnea on exertion syncope claudication
3. 1 The order and the value of radio button headings can be customized by specialty 2 The List box values can be customized add subtract or modify values 3 Clicking a value in the denies column or complains of column automatically un checks the values in the opposite list box 4 Customization designates which body systems are populated by clicking the 1 NEG 2 NEG or 3 NEG action buttons 5 The super buttons All Negative or 1 NEG 2 NEG or 3 NEG action buttons may be hidden or not visible for sites that want to turn off those features through customization 6 problem oriented ROS ESRD Prenatal etc may be created through customization 7 Patient entered history from PatientLink amp or Kryptiq may be automatically inserted or the user may be prompted that patient entered history exists Page 23 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example ROS Family Practice with PatientLink Entered History Option Page 1 Page 2 Templates Viewnsert Patient Entered Hx View Insert Refresh Family Practice wj 1 Heg 2 Heg 3 Heg Clear ALL View Positive ROS Clear View See HPI Show Brief Version of Negative Values in Note General Eyes ENT Resp Gl GU EJ Oh by the way xd 7 Enter FH SH Ris
4. 5 Template Replace w Prior sH Problems Flowsheet El Medications Allergies HPI FH SH RiskFactors Ros PE Problems InstructionsPlan Copyright Prev Form Ctri PgUip Next Form Ctrl PgDn 1 Note the Pediatric specific list box values 2 The Social History list boxes can also be customized to capture important basic Risk Factor information Values may be linked to the Risk Factors form to automatically populate the data captured such as immunization status and passive smoke exposure Update Flowsheet E Potential Observation list for Debbie Diabetes 04 15 2004 12 02 2003 08 01 2003 WEIGHT 188 180 182 186 BP SYSTOLIC 144 144 148 150 BP DIASTOLIC 84 80 88 88 CHOLESTEROL 278 277 256 280 TRIGLYCERIDE 232 226 222 256 HDL 40 33 38 40 LDL 178 180 180 188 JP 4 gt Effects of this update Added new observation of IMMUNIZ UTD no 03 20 2005 19 03 Added new observation of PAS CIG 5 03 20 2005 19 03 New Change Remove Change Back New to add or select an observation to change or remove Cancel 20 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Risk Factors CCC The Risk Factors CCC form is designed to allow for rapid point and click entry of t
5. 0 LeftTriceps 7 Rt Brachioradialis Lt Brachioradialis Right Adductors 3 LeftAdductors Right Knee LeftKnee Right Anke LeftAnde x RightFingers vi LeftFingers Ei Toes Normal Prior Clear Right Left Toes are downgoing bilaterally upgoing right upgoing left downgoing right downgoing left equivocal right equivocal left Clonus Normal Clear Right Left Clonus is absent non sustained clonus right non sustained clonus left sustained clonus right sustained clonus left Normal Clear Inconsistent behavioral responses are positive for Inconsistent behavioral responses are absent Prev Form Ctri PgUp Next Form Ctri PgDn 1 The following may be customized by specialty normal default values observation terms that are populated and the items in the two list boxes 2 The list box values may contain either normal or abnormal values 3 Charting by exception allows the provider to rapidly document a detailed PE as well as capture structured data which can be used for reporting or clinical decision support 4 The provider can use voice recognition CCC VRI Dragon 8 Medical to dictate into structured data fields Page 47 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Neuro
6. EXT Don C Bassett CHECK PROTOCOLS 59 Year Old Male DOB 11 25 1945 Patient ID 80 TEST011 x BH 9 OA Find Pt em Graph Handouts Probs Meds Refills Allergies Directives Flowsheet Orders End Up Summary Problems Medications Alerts Orders Documents Update DocD 126 Properties Office Visit at SOUTH 06 15 2005 6 07 by Harry S Winston MD Summary Change Properties HPI CCC PMH CCC FH SH CCC Risk Factors CCC ROS CCC Neck Adult Vital Signs CCC Carotids Carotids full and equal bilaterally without bruits PE CCC Neck Veins Normal no JVD Neurologic Exam CCC CV Exam CCC Heart GU Exam CCC Inspection no deformities or lifts noted Problems CCC Palpation normal PMI with no thrills palpable CPOE A amp P CCC Auscultation regular rate and rhythm S1 S2 without murmurs rubs gallops or clicks Patient Instructions C Detailed Cardiovascular Exam Vascular Abdominal Aorta no palpable masses pulsations or audible bruits Femoral Pulses normal femoral pulses bilaterally Pedal Pulses normal pedal pulses bilaterally Radial Pulses normal radial pulses bilaterally Peripheral Circulation no clubbing cyanosis or edema noted with normal capillary refill Detailed Genitourinary Exam ij Urethra No lesions or discharge noted Urethral Meatus Normal size and location no lesions or discharge Penis Normal without
7. Chart Go Actions Options Help VEsDesktop Chart Appts Reports ew intenet Hep EXT Custom Cardiology CHECK PROTOCOLS Home None Work None 55 Year Old Female DOB 04 14 1950 Patient ID 72 0563001 Insurance Group a Ow RM x EB d Find Pt Protocols Graph Handouts Probs Meds Refills Allergies Directives Flowsheet Orders End Up Summary Problems Medications Alerts Flowsheet Documents Update Doc 6 Properties CCC Text File Editing at SOUTH on 04 15 2005 2 19 PM by Harry S Winston MD Summary Change Properties CCC Text File Editor Bl z ul S S 9 g El For Help press F1 inm Click the Open Text File to Edit action button which will automatically open the CCCQE User Edit TFE text file CCCQE User Edit HPI Card TFE Notepad File Edit Format View Help Page 113 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved To paste the CCCQE MEL functions into the CCCQE User Edit TFE text file do the following e Press CTRL V this inserts the selected text into the TFE text file Press CTRL S this saves the TFE text file Close the TFE text file Open the Text File Editor form component Click the Remove from Text action button to remove the CCCQE MEL functions from the chart note
8. Surgical Medical Medical Medical Unremarkable Asthma Appy Atrial Fibrillation Choly Anemia Abd Surg type Anxiety Autoimmune Disorder Cerebrovascular Disease C A Stroke copp Coronary Heart Disease Crohn s Disease CRF Depression Diabetes Type 1 Diabetes Type 2 Diverticulitis GIBleed GERD Heart Disease Hyperlipidemia Hypertension Hypothyroidism Hyperthyroidism Kidney Disease Tonsillectomy Carotid Endarterectomy Hip Replacement Knee Replacement Rheumatoid Arthritis Seizure Disorder Knee Arthroscopy Colon Cancer Hepatitis Thyroid Disorder Rotator Cuff Repair Cataract Extraction Hepatitis Tuberculosis Carpal Tunnel Anesthesia Complications Hepatitis C Valvular Heart Disease LA F Bypass Blood Transfusions Infertility UT l Recurrent x _FH SH RiskFactors Ros PE Problems InstructionsPlan Copyright Prev Form Ctrl PgLp Next Form 9 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example PMH CCC for Family Practice Internal Medicine Past Medical History Last update Kidney Stone Hx of Osteoarthritis Select Specialty Family Practice E
9. Go Actions Options EsDesktop C chart new internet Hep CHECK PROTOCOLS Home None Work None 55 Year Old Female DOB 04 atient ID 72 0563001 Insurance Group Z amp HR x amp x B 9 A cx 5 uos Be i eis Gem Summary Problems Medications Flwsheet Orders Documents Update 6 Properties Text File Editing at SOUTH on 04 15 2005 2 19 PM by Harry 5 Winston MD summary Change Properties CCC Text File Editor us Be ccc_Card_HPl_exec Acute Visit Form Enterprise CC C Adult ACV CCC 2 ccc_Card_HPI_exec Anticoagualtion Form Enterprise CCC CPOE Anticoagulation C C C 2 ccc Card exec Chest Pain Hx Form Enterprise C CC Cardiology Cardiology Chest Pain Hx CCC 2 ccc Card exec CHF Form Enterprise C CC CHF Q amp E CCC 2 ccc Card exec Diabetes Form Enterprise CCC Diabetes Q amp E CCC 2 ccc Card Form Enterprise CC C Hypertension Q amp E CCC 2 ccc Card exec Lipid NCEP Ill Form Enterprise CCC Lipid Q amp E CCC 2 ccc Card exec Prior Treatment Form EnterpriseCCC Prior Treatment Review CC C 2 ccc Card exec Cardiovascular Risk Form Enterprise CCC Cardiovascular Risk CC C 2 ccc Card exec Cardiovascular Reports Enterprise
10. HRT Postmenopausal Hyperprolactinemia Hypertension Benign Hypothyroidism 100 Removal Check Infertility Female Unsp Infertiity Male irregular Menses irritable Bowel Syndrome UD Insertion Leiomyoma Uterus Lesion Cervix Unsp Low Back Pain Mastalgia Mastisis Menopause Perimenopause Menorrhagia Menometrorrhagie Menstrual Disorder Pap Only CA Screen Cervix Pelvic Mass Pelvic Pain Pelvic Relaxation Perimenopausal Bleeding Periodic GYN Exam Pers Hx Breast CA Physical Exam PMS Polycystic Ovary Disease Postcoital Bleeding Postmenopausal Bleeding Postmenopausal Status Natura Post op Wound Infection Postpartum Care Prenatal Care Procidentia Uterine Prolapse Pt w Health Hx Risk Vaginitis Monilia Candida Vaginitis Trichomonas Vaginosis Bacterial NOS Vulva Lesion Vulvitis Vulvovaginitis Pyelonephritis amp cute Problems Medications Skin Rash Allergies Orders Sterilization Syncope Add Text to Note Th _ Select Specialty Tubal Occlusion Ureteral Syndrome Urethral Syndrome Urinary Frequency Obstetrics Gynecology Cursor must be blinking Yellow Field for CCC VRI Diaphragm Cervical Cap Fitting Metrorrhagia Urinary Incontinence NOS Dysfunctional Uterine Bleeding Mittelschmerz Urinary Incontinence Stress d Dyspare
11. Cirrhosis Patellofemoral Syndrome 5 Colitis Hormone Replacement Therapy Pharyngitis Acute Conjunctivitis HEADACHE List Plantar Fasciitis Internal Medicine Constipation Heart Murmur Pneumonia bam CONTRACEPTION List Hematuria Polymyalgia Rheumatica Cursor must be blinking in Coronary Atherosclerosis HEMORRHOIDS List Postmenopausal Status EE RS EEE Costochondritis HERNIA List PROSTATE List y Cough Herpes Simplex Renal Stone New Pibbicins Crohn s Disease Herpes Zoster Rheumatoid Arthritis 2 Croup HYPERLIPIDEMIA List RHINITIS List eee DVT HYPERTENSION List Sebaceous cyst 2 Degenerative Disc Disease Hyperthyroidism Seborrheic Keratosis DEGENERATIVE JOINT DISEAS Hypothyroidism SEIZURE DISORDER List DERMATITIS List INCONTINENCE List SINUSITIS List zl Acv FH SH RiskFactors Ros vs Problems Instructions Plan Copyright Prev Form CtrisPgUp Next Form Ctri PgDn Page 55 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Problem CCC Form Customized for Pediatrics Problems CCC Custom Adult Add Problems Form Note Unchecking a Problem from this form will NOT remove it from the Problem List ABDOMINAL PAIN COLIC List ACCID
12. Dexa Scan View Glucose cPK B X o9192000 Pap Smear view HGBA1C d Troponin Urinalysis View Calcium B3 X 09 20 2000 Myoglobin Sa Urine 85 View 4 ERE BMP View Mirosbunm vicaxpHo View Mammogram View ptH intact 00 LFTs view PSA Magnesium 09 20 2000 Hepatitis View E Colonoscopy View _Commit Orders Diagnosis Specific Orders View Schedule Schedule New Orders Committed v HGBA1C v Cholesterol HGBA1C Lipid Profile v Creat JV Microalb Urn TSH DRE Pneumovax Flu Shot HPI PMH FH SH Risk Factors Ros vs Problems CPOE Instructions Plan Copyright Prev Form Ctrl PgUp Next Form Ctrl PgDn Note the list box that automatically appears lower left with Diagnosis Specific Orders Clicking the View Schedule action button shows guideline indication NOTE Many evidence based guidelines come within the CCCQE application and are updated quarterly but the latest release also allows sites to create their own protocols and recommendation alerts Page 120 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Diagnosis Diabetes Mellitus ICD 250 Age specific Between 0 1000 months HGBA1C Due every 90 days Last done
13. Evaluation Form enterprise ccc cardiology cardiology Pre op Eval CCC 2 Ccc Card HPI exec Stress Test FormAenterprise ccc cardiology cardiology ETT CCC AT_ENDA ccc card HPI exec Renal Evaluation FormAEnterprise ccc Renal Renal Evaluation CCC 2 Card HPI exec New Patient Template card HPI exec Acute Visit Template ccc Card HPI exec Pacemaker Template Card HPI Template ccc card HPI exec Another template ccc card HPI exec Template 22 ccc card exec Template 23 Card HPI exec Template 24 Card HPI exec Template 254A Ccc Card HPI exec Template 26 3 2 2 2 ccc_Card_HPI_exec Template 274A ccc_Card_HPI_exec Template 28 ccc_Card_HPI_exec Template 29 4 ccc_Card_HPI_exec Template 30AA ccc card HPI vis typ 1 Consult Follow up Evaluation Pacemaker check ccc_Card_HPI_vis_typ_vis yes ccc_Card_HPI_vis_typ_add_to_text yes ccc card HPI cc abdominal pain chest pain headache palpitations syncope near syncope dizzir ccc_Card_HPI_cc_vis yes ccc_Card_HPI_cc_add_to_text yes card HPI Dr Smith Dr Jones 114 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Formatted Text of Customizations CHECK PROTOCOLS No
14. FH Thyroid Dz v FH Aortic Aneurysm FHAAA v FH Marfan s iv NEGFHx ASCVD NEG FHx Diabetes NEG FHx HTN NEG FHx DM HTN CAD Insert FH Template Remove FH Template Replace w Prior FH Social History Insert Selected Values Last updated reviewed no changes required Check to insert into SH Edit Field Patient is currently smoking Patient admits to alcohol use Hx Domestic Abuse Religion Affecting Care Current Smoker Quit Smoking Never Smoked Alcohol Use No Alcohol Use Insert SH Template Remove SH Template Replace w Prior su Problems Flowsheet Medications Allergies HPI FHSH RiskFactors Ros PE Problems InstructionsPlan Copyright Prev Form Ctrl PgUp Next Form 1 Note the Cardiology specific list box values Marfan s Sudden Death etc 2 The Social History list boxes can also be customized to capture important basic Risk Factor information Values may be linked to the Risk Factors form to automatically populate the data captured Use the Risk Factors form to document additional risk factor information Page 19 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example FH SH CCC for Pediatrics Family History Select Specialty Pediatrics
15. Ofc Vst New Level Ill Ofc Vst New Level V Minor dx of INFLUENZA Minor dx of FUNGAL DERMAT Minor dx of FEVER Minor dx of COUGH Assay E UV assa UV assa Assay b Urinalysis Assay b Assay Metabolic P Glucose Assay a gt Son orders ox Office Consult Level Office Consult Level II Office Consult Level ill Office Consult Level V Office Consult Level V Telephone Call brief Telephone Call intermediate Telephone Call lengthy Arthritis Screen RBC sedimentation rate automated quest code 809 Antinuclear antibodies titer quest code 249 Rheumatoid factor test quest code 4418 Assay uric acid blood quest code 905 protein quest code 4420 CCP cyclic citrilunated peptide quest code 11173 Med Profile Blood count compl CBC pit w auto diff WBC quest code 26399 Page 76 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Documenting Review of Labs or Diagnostics Using the CPOE A amp P Form Insert Template Using custom templates or the CCC CPOE Templates allows providers to quickly review diagnosis specific labs diagnostics or clinical data while documenting that review in the note NOTE A large part of E amp M coding is contingent on the provider documenting the order
16. orthostatic symptoms shortness of breath dyspnea on exertion syncope claudication orthostatic symptoms Comments Oh by the way sl 7 Enter PMH FH SH Risk Factors ROS PE Problems CPOE Instructions Plan Copyright Prev Form Next Form Ctrl PgDn 1 Note that the list box for CV is more detailed and that the order of body systems is more cardiology specific 2 The Show Brief Version of Negative Values in Note generates an abbreviated text translation see below This may be customized to be the default value that is checked for all patients Page 26 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Abbreviated ROS text translation set by checking Show Brief Version of Negative Values in Note ORTE Harry S Winston MD Southside Clinic CLINIC 5 10 2005 4 05 PM Chart m ni x Go Actions Options Help Jchart ESappts fyRenots Linkoge New view internet ExT Don C Bassett CHECK PROTOCOLS Home 503 629 5541 Work 503 692 8958 59 Year Old Male DOB 11 25 1945 Patient ID 80 TESTO11 Insurance MCR Medicare Part B 3 2 LL mH e amp x E A Find Pt Protocols Graph Handouts Probs Meds Refills Allerg
17. Alerts Flowsheet Doc ID 431 Properties Office Visit at SOUTH on 05 10 2005 2 35 PM by Harry S Winston MD Summary Change Properties 5 Risk Factors CCC ROS CCC Adult Vital Signs ccc General PE CCC well developed well nourished in no acute distress Problems CCC Head Test normocephalic and atraumatic E3 2 yes 222 PERRLA EOM intact fundi benign conjunctiva and sclera clear ars TM s intact and clear with normal canals and hearing Nose no deformity discharge inflammation or lesions Mouth no deformity or lesions with good dentition Neck no masses thyromegally or abnormal cervical nodes Chest Wall Physical Exam Example Text Translation for PE CCC Exam Detailed Neurologic Exam Don C Bassett CHECK PROTOCOLS Home 503 629 5541 Work 503 692 8955 59 Year Old Male DOB 11 25 194 atient ID 80 57011 Insurance BHI Futura Group BHI8654 rig OE Ry amp Protocols Graph Handouts Probs Meds Refis Directives Flowsheet Orders EndUp Summary Problems Medications Flwsheet Orders Documents Update DocD 126 Properties Office Visit at SOUTH on 06 15 2005 6 07 PM by Harry S Winston MD Find Pt Detailed Neurologic Exam Adult Vital Signs ccc General Neurologic Exam Neurologic Exam ccc Speech GU Ex
18. CONGESTIVE HEART FAILURE ECHO done 11 26 1998 shows EF 40 with inferior posterior hypokinesis ICD 428 0 2 5 Symptom of HOARSE VOICE QUALITY Hoarse x 3 wks without other symptoms 2 EFFUSION PLEURAL bilateral ICD 511 9 Entered By Harry S Winston MD EDEMA bilateral pedal ICD 782 3 5 Minor Diagnosis of INFLUENZA ICD 487 1 Rescomtle Harry Winston MD Minor Diagnosis of FUNGAL DERIATITIS 1 0 111 9 Minor Diagnosis of FEVER ICD 780 6 View Problem Details Minor Diagnosis of COUGH ICD 786 2 06 24 2005 Comment only Harry S Winston MD Patient will also refer to the diabetes education program and schedule for cardiac stress test with cardiology prior to starting an exercise program Orders 06 15 2005 Comment only Harry S Winston MD Recommended referral to Diabetes Education Program and Cardiology Consult for Stress Test prior to starting exercise program Labs Reviewed HgBA1c 8 4 12 07 2004 Creat 1 0 06 12 2002 His updated medication list for this problem includes For Help press F1 kad 81 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Problem List Assessment for Hyperlipidemia Update Problems Potential problem list for Don Bassett DIABETES MELLITUS TYPE II CO
19. Hemarthrosis Specify Basilar Joint Arthritis Boutonnaire Deformity Hip Pain liotibial Band Syndrome Hip Bunion lliotibial Band Syndrome Knee BURSITIS List impingement Syndrome CDH bilateral Ingrown Nail CDH unilateral Calcaneal Spur Calcific Tendonitis Shoulder Carpal Tunnel Syndrome Interdigital Neuroma JOINT EFFUSION List Specify JOINT PAIN List Specify Knee Pain CELLULITIS ABSCESS List Cerebral Palsy Cervical Radiculitis Cervical Spasm Chondromalacia Patella Clubfoot Equinovarus CONTUSION List Specify Cruciate Sprain Cubital Tunnel Syndrome DEGENERATIVE ARTHRITIS Lis DeQuervain s Derangement meniscus Digital nn Lac Finger Disc Degeneration DISLOCATION List Dupuytren s Contracture Fibromyalgia Fibromyositis FRACTURE List Kyphosis LCL Sprain Lateral Epicondylitis Legnth Discrepancy Legg Perthes Loose Body Knee Low Back Pain Lumbar Spasm MCLSprain Mallet Finger Medial Epicondylitis Metatarsalgia Metatarsus Adductus Muscular Dystrophy Nailbed Laceration Finger Nailbed Laceration Toe Neuropathic Arthropathy Laceration Finger w Tendon In Osgood Schlater Osteochondritis Dessicans OSTEOMYELITIS List Specify Osteonecrosis Hip PAIN List Knee Neck Shoulder Painful Hardware Paronychia Finger Paronychia
20. P 5 Risk Factors ROS P Problems CPOE Instructions Plan Copyright Next Form Ctrl PgDn a Prey Form 1 The Form s Template s list box can be customized to load encounter forms or insert custom text templates In this example the CCCQE OB Prenatal and Disease Management Forms appear in the Form s Template s list box but any forms or Text Templates may be listed 2 To integrate with the E amp M Advisor the provider must check either the brief 1 3 elements or extended 4 or more elements radio button 3 Text can be entered into the multi line edit field using QuickText typing inserting text templates or using voice recognition 4 Navigation buttons at the bottom of the forms allow quick navigation between the Core Forms NOTE All CCC forms are best viewed using display settings of 1024 X 768 5 For certain specialties specialty specific navigation buttons appear at the bottom NOTE Except for the Disease Management action buttons that appear for Family Practice or Internal Medicine these action buttons will LOAD and GO TO the corresponding forms Page 7 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example HPI CCC for Pediatrics HPI CCC Peter Pediatrics HPI Additional Hx History of Present Illness Select Speci
21. VBAC witrial labor VBAC w o trial labor VBAC contraindicated Episiotomy Reviewed Anesthesia No Meds Anesthesia Local Anesthesia Pudendal Anesthesia Epidural Breast Feed Ed Recommend Clear All ClicktoEnter View Insert Prior Print Patient Instructions Diet Activity Instructions Follow up Instructions Apt 2 Weeks F U Apt 1 Month Apt 3 Months F U Apt 6 Months Apt 1 Year Lab Work Before F U Mammogram Scheduled PostPartum High Risk Cord Cutting Discussed Back Pain Cord Cut No Contraception PP Contra No Plans Contra Undecided PP Contra Barrier Contra OCP Norplant Depo Provera Vasectomy Tubal Ligation Sterilization Counseling Informed Consent BTL Intake Prenatal visit Past Preg Hx Genetic Flowsheet Lab Prenatal Ed Ultrasound PAP Entry UP 5 NES The Patient Instructions CCC list boxes be customized by specialty and or provider Customization options include list box headings list box items the obs term that is to be populated by clicking the list box item and the value that gets The provider clicks all of the applicable instructions and clicks the Click to Enter action button to populate the patient instructions field and any specified obs The values populate the patient instructions field the INSTRUCTIONS obs term which po
22. e Click the Insert Formatted Text action button to insert a summary description of customizations into the chart note e Copy and paste the formatted text into a Word document for your records CCCQE User Edit HPI Card TFE Notepad File Edit Format View Help ccc_Card_HPI_exec Acute Visit Form Enterprise CCC Adult ACV CCC 2 ccc Card HPI exec Anticoagualtion Form Enterprise CCC CPOE Anticoagulation CCC 2 P Card HPI exec Chest Pain Hx Form Enterprise ccCcardiology cardiology Chest Pain Hx CCC 2 Card exec CHF Form EnterpriseXCCC CHF Q amp E CCC 2 ccc card HPI exec Diabetes Form EnterpriseXCCC Diabetes Q amp E CCC 2 card exec Hypertension Form EnterpriseXCCC Hypertension Q amp E CCC 2 Card HPI exec Lipid NCEP III FormAEnterprise ccc Lipid Q amp E CCC 2 Ccc Card HPI exec Prior Treatment Form EnterpriseXCCC Prior Treatment Review CCC 2 ccc card HPI exec Ccardiovascular Risk FormAEnterprise ccc Cardiovascular Risk CCC 2 Card HPI exec Ccardiovascular ReportsAenterprise ccc cardiology Cardiovascular Reports CCC AT card HPI exec Data Entry Enterprise XCCC Data Entry CCC AT END card exec Diagnostic Testing Review Form Enterprise CCC Diagnostic Testing Review CCC 2 ccc Card HPI exec Echocardi FormAEnterprise ccc cardiol ENDA 2 ccc Card
23. tender mass g Anus Perineum Normal Prior Clear Normal external exam poor sphincter tone perineal lesion s absent anal wink mass external hemorrhoids abscess Rectal Normal Prior Clear Normal digital exam without masses a l normal digital exam external hemorrhoids hemoccult negative internal hemorrhoids mass B abscess Prostate Normal Prior Clear Normal size prostate without asymmetry masses symmetrically enlarged mass right lobe or tenderness tenderness right lobe mass left lobe tenderness left lobe mass diffuse tenderness HPI ACV PMH 5 Risk Factors ros s _ Problems CPOE Instructions Plan Copyright Prev Form Ctri PgUp Next Form Ctri PgDn 1 The following be customized by specialty normal default values observation terms that are populated and the items in the two list boxes 2 The list box values may contain either normal or abnormal values 3 Charting by exception allows the provider to rapidly document a detailed PE as well as capture structured data which can be used for reporting or clinical decision support 4 The provider can use voice recognition CCC VRI Dragon 8 Medical to dictate into structured data fields Page 37 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example
24. tenderness on the left right epididymal mass left epididymal mass Seminal Vesicles Normal Prior Clear No masses or tenderness tenderness HPI PMH FH SH Risk Factors ros _vs _ Problems CPOE Instructions Plan Copyright Prev Form Ctri PgUp Next Form Close 1 The following may be customized by specialty normal default values observation terms that are populated and the items in the two list boxes 2 The list box values may contain either normal or abnormal values 3 Charting by exception allows the provider to rapidly document a detailed PE as well as capture structured data which can be used for reporting or clinical decision support 4 The provider can use voice recognition CCC VRI Dragon 8 Medical to dictate into structured data fields Page 36 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example GU Exam CCC Male GU 2 GU Exam CCC Don C Bassett GU 1 GU 2 Prior Clear Inguinal no masses right inguinal tenderness No masses tenderness or hernias noted 2 no tenderness left inguinal tenderness right inguinal hernia right inguinal mass left inguinal hernia inguinal mass Bladder Normal Prior Clear Normal size without masses or tenderness f distended
25. 60 09 10 2001 LDL 100 09 10 2001 TG 210 09 10 2001 SGOT 17 09 20 2000 SGPT 16 09 20 2000 Lipid Goals BBCI For Help press F1 82 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example of CPOE Template and Workflow for Prenatal Visit The nurse MA or provider enters information in the OB Flowsheet CCC form OB Flowsheet 2 CCC Sarah S Oberheim Flowsheet Comments Working EDC Initial Wt Initial BP Wt gain this visit 12 this pregnancy 14 G 3 P2 0 Recommendations 1108 2005 130 100 68 Click HERE or below to copy previous results Date Weeks wt BP E aJ ERE 06 28 2005 21 0 7 144 102 ies N No No 0 GAS 33 573 Een en n n n Es rare pem io med mm f nf peer pe e e e pei m pes pee pea re ee eer prn on pe pif p SS pr pen e een pef pe o pe perf p esu Jom o Tn i a a mai s ig eee aee pn emn ee peri p pf ru pd E rl a p p t a esr n cr pn pac pomi per pen em pon peni pel pef pni qmm p pod pom p p Em pom pem pd p pl Tn on nnn n n n n n Visit Freq 0 28 wks q 4 wks 28 36 wks q 2 wks 36 42 wks q 1 w
26. Conjunctivitis Pulmonary Rehab Referral Clear All ClicktoEnter View Insert Prior Print Patient Instructions Follow up Instructions Apt 2 Weeks F U Apt 1 Month Apt 3 Months Apt 6 Months F U Apt 1 Year Lab Work Before F U Lipid Profile 1 Week Before Lii T Lipid 5 Months HgBA1c amp Lipid 3 Months Mammogram Scheduled v Orthopedic Miscellaneous Ankle Sprain Back Pain Carpal Tunnel Neck Pain Shoulder Pain Outof Work Outof School Out of Phys Ed Return to Work Conjunctivitis Oral Rehydration button to populate the patient instructions field and any specified obs terms 3 The values populate the patient instructions field the INSTRUCTIONS obs term which populate the chart note and the Patient Instruction Handout Instructions action button to select and print the handout 4 The Patient Instructions Handout may be further customized Page 86 Copyright 2005 Clinical Content Consultants LLC All rights reserved Click the Print Patient Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Pediatric Patient Instructions CCC Select Specialty Pediatrics EN Click to Enter View Insert Prior Print Patient Instructions Diet Instructions Follow up Instructions Follow up 1 week Follow up 2 weeks Follow up 1 month Patient Instruct
27. Copyright 2005 Clinical Content Consultants LLC All rights reserved Ordering Tests or Diagnostics Using the CPOE A amp P Form To on Update Orders Don C Bassett 59 Year Old Male DOB 11 25 1945 Orders Thisupdate Open All Primary Coverage BHI Futura Set Coverage Potential Diagnoses date Description Status Diagnoses DIABETES MELLITUS TYPE 1 06 28 2005 Hemoglobin 1 Unsigned DIABETES MELLITUS TYPE II HYPERLIPIDEMIA 06 28 2005 Microalbumin urine Unsigned DIABETES MELLITUS TYPE I eee Remove Reorder Clear Diagnoses New 06 28 2005 Custom List Categories Search Order Details i Use customiit occat gt _ Spirometry AST SGOT Creatinine Hematocrit v Microalbumin urine Spirometry post inhalation Basic Metabolic Panel Digoxin serum Monospot Sterile Set up Lg or Sm Bilirubin direct Electrolyte Panel Hemoccult Medicare Pap Smear 1 slide Trim nails any number BUN ESR Hemoglobin Pap Smear Monolayer Vasectomy Calcium Ferritin v Hemoglobin A1c Pap Liquid w HPV Rfx on ASC INTENSE coc widittplatelet J Folate Folic Acid Hepatic Function Panel Potassium Venipuncture CBC Platelet no diff GGT Hepatitis Panel 4 Pregnancy Test urine Albumin Cholesterol Glucose w Reflex PSA ALT SGPT Comprehensive Metabolic Pane Pylori IgG Abs Iron and TIBC PS
28. Flowsheet Medications Allergies Patient Entered Hx Dated 02 21 2005 Automatically Added to List Boxes Below Onset Procedure Date optional Surgical Medical Medical Medical Kidney Disease v Kidney Stone Liver Disease Abnormal Pap Smear Asthma Atrial Fibrillation Anemia Anxiety Autoimmune Disorder Breast Disease Cerebrovascular Disease CY A Stroke coPD Coronary Heart Disease Crohn s Disease Unremarkable Depression Diabetes Type 1 Diabetes Type 2 Diabetes Gestational Diverticulitis GIBleed GERD Heart Disease Hyperlipidemia Hypertension Hypothyroidism Hyperthyroidism Tonsillectomy Carotid Endarterectomy Hip Replacement Knee Replacement Rheumatoid Arthritis RHSensitized Seizure Disorder Knee Arthroscopy Hepatitis Thyroid Disorder Rotator Cuff Repair Cervical Cancer Hepatitis B Tuberculosis Carpal Tunnel Colon Cancer xl Hepatitis Valvular Heart Disease x Intake Prenatal Visit Past Preg Genetic Flowsheet Lab Prenatal Ed Ultrasound PAP Entry HPI FH SH Risk Factors ROS Problems CPOE Instructions Plan Copyright Prev Form Ctrl PgUp Next Form 1 NOTE the Patient Entered Hx dated 02 21 2005 Prompt i
29. _vs Pej Problems CPOE Instructions Plan Copyright Prev Form Ctri PgUp Next Form Ctri PgDn 126 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved The following prompt appears Logician Message 2 The patient has a history of a myocardial infarction and is currently not on a beta blocker Click Yes to add a medication otherwise click No Clicking Yes opens the Beta blocker custom medication list If the provider orders a beta blocker it will automatically appear in the assessment field for the problem Subendocardial MI Clicking No will prompt the provider to document the contraindication see below Documenting the contraindication will prevent the prompt from reappearing on subsequent visits in addition to providing structured documentation of the specific contraindication Page 127 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved CDSS Contraindications Form The CDSS Contraindications form allows the provider to document contraindications to treatment diagnostics or to document a variety of staging values all from the same form This form can be customized by specialty CDSS Contraindications CCC Don C Bassett Clinical Decision Support System Documentation of Contraindications to T
30. description and ICD code is to be added to the patient s problem list or if a custom problem list containing several related diagnoses displays allowing the provider to select the diagnosis with the highest degree of specificity 3 The prefix Diagnosis of Minor Dx of Family History of etc for the problem being pushed to the patient s problem list is assigned in the customization 4 The number of days for a problem added as a Minor Dx to stay on the patient s active problem list can be specified in the customization 5 For Version 8 3 and forward there is no limit to the number of problems that can be listed on the Problem CCC form Previously the limitation was 125 list box items Please note that 125 list box items will display on the form without scrolling Adding more than 125 list box items will require the user to scroll down in the list box to see the additional items that do not fit in the normal display 6 For those providers using the VRI voice recognition any item on the Problem CCC form can now be voice activated A provider can add a diagnosis or access a custom problem list simply by saying Add diagnosis insert name of problem as listed on Problem CCC Form Examples Add diagnosis UTI adds the diagnosis UTI Add diagnosis diabetes displays the diabetes custom problem list The provider can use the Add diagnosis commands to add problems to the patient s problem list anywhere within an update that
31. diminished R femoral absent R femoral z diminished L popliteal absent L popliteal Extremities Normal Prior Clear no clubbing cyanosis edema or deformity noted trace left pedal edema with normal full range of motion of all joints 1 left pedal edema 7 2 left pedal edema 3 left pedal edema 4 left pedal edema trace right pedal edema 1 right pedal edema 2 right pedal edema 3 right pedal edema 4 right pedal edema Neurologic Normal Prior Clear Load Form Neurologic Exam no focal deficits CN I XII grossly intact with normal weakness noted ataxic reflexes coordination muscle stregnth and tone decreased reflexes CN deficit absentreflexes decreased sensation to PP decreased sensation to LT HPI PMH FH SH Risk Factors ROS _ Problems CPOE Instructions Plan Copyright Prev Form Ctrl PgUp Next Form Ctrl PgDn 1 The following be customized by specialty normal default values observation terms that are populated and the items in the two list boxes 2 The list box values may contain either normal or abnormal values 3 Charting by exception allows the provider to rapidly document a detailed PE as well as capture structured data which can be used for reporting or clinical decision support 4 The provider can use voice recognition CCC VRI Dragon 8 Medical to dictate into structured data fiel
32. normal default values observation terms that are populated and the items in the two list boxes 2 The list box values may contain either normal or abnormal values 3 Charting by exception allows the provider to rapidly document a detailed PE as well as capture structured data which can be used for reporting or clinical decision support 4 The provider can use voice recognition CCC VRI Dragon 8 Medical to dictate into structured data fields Page 38 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example GU Exam CCC Female GU 2 GU Exam CCC Custom Gynie GU 1 GU 2 Other Inguinal Prior Clear right inguinal tenderness no masses No masses tenderness or hernias noted tenderness left inguinal tenderness right inguinal hernia right inguinal mass left inguinal hernia left inguinal mass Bladder Normal Prior Clear Normal size without masses or tenderness distended tender mass Anus Perineum Normal Prior Clear Normal external exam 1 poor sphincter tone perineal lesion s absent anal wink mass external hemorrhoids abscess Rectal Normal Prior Clear Normal digital exam without masses normal digital exam external hemorrhoids hemoccult negative internal hemorrhoids mass abscess HPI Acv PMH FH SH Risk F
33. rc bw b b blank blank blank blank Y TUTTE S re Depending on which of the Core forms is being edited the column headers corresponding Instructions action buttons will be different For the PMH CCC form the columns will be 1 Label This is the value that appears in the list box on the PMH CCC form 2 Prob List Text This is the description that will be entered in the PMH field or pushed to the Problem List Obs Term This is the observation term you wish to populate leave blank if you do not wish to populate an obs term Obs Value This is the value that is to be pushed to the designated Obs Term leave blank if you do not wish to populate an obs term Dx Code This is the complete ICD or CPT code that is to be pushed to the problem list Be sure to include the ICD or CPT prefix If you do not wish to populate the problem list leave this field blank Dx Prefix This is the type of problem prefix to be added Dx of MDx of S P etc A complete list of the prefixes is available by clicking the Instructions action button If you leave this field blank the default is Dx of M F Place in this field to display the list box value for males only and F for females only The default blank field is for both male and female Page 104 Copyright 2005 Clinical Content Consultants LLC All rights re
34. Bleeding disorder Breast FH Cervical Ca FH of CHD FH CHD male 55 FH CHD female lt 65 FH of Colon Ca FH Thyroid Dz Colon Ca father FH Huntington s Dz 1 7 FH Learning Disabilities Neg FH Breast Neg FH Colon Neg FH CAD Migraine FH Osteoporosis FH Ovarian Ca FH Pancreatic Ca FH Prostate Ca FHRenal Dz FH Seizures Skin Ca FH Suicide FH Depression FH Diabetes FH CYA or Stroke FH Hypertension FH Hyperlipidemia FH Lung Ca Melanoma Insert FH Template Remove FH Template Replace w Prior FH Social History Insert Selected Values Last updated reviewed no changes required Check to insert into SH Edit Field Hx Domestic Abuse Religion Affecting Care Insert SH Template 5 Template Replace w Prior su Problems Flowsheet Medications Allergies HPI FHSH RiskFactors Ros PE Problems Instructions Plan Copyright gt Prev Form Ctri PgUp Next Form 1 The support staff or the provider checks the corresponding problems in the list boxes then clicks the yellow Insert Selected Values action button NOTE Values will not appear in text or push to Problem List until action button is clicked This allows for corrections to be made prior to committing 2 The list box values ar
35. CDSS and PSIA Embedded Within CPOE A amp P CCC Form Dx Specific Example of ACE I ARB Usage Reminder for Patients with CHF CDSS Contraindication Form Page 2 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Introduction Documenting the Patient Visit One of the most challenging aspects of implementing an Electronic Medical Record EMR for most providers is learning how to document the patient visit All of the advantages of an EMR quickly get lost in the mind of the provider if they cannot quickly and efficiently document their notes Many are used to dictating their visits while others have become comfortable using handwritten notes with or without the aid of form templates Making the successful transition requires a basic understanding of the power of the EMR coupled with the necessary tools CCCQE and training We recommend that any user of the EMR interested in understanding the basics and advanced principles or EMR refer to Electronic Medical Records Optimizing Use in the Medical Practice for detailed overviews of the following topics SOAP Note in the EMR Free Text vs Structured Text QuickText Text Components Form Components Dictation Placeholders Basic Voice Recognition Integrated Voice Recognition Page 3 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Co
36. Detailed GU Exam Female GU Exam CCC Female GU 1 GU Exam CCC Custom Gynie GU 1 GU 2 Other Genitourinary Exam Female Urethra Normal Prior Clear No lesions or discharge with palpitation urethral diverticulum Urethral Meatus Normal Prior Clear Normal size and location no lesions or discharge prolapsed urethral mucosa atrophic changes stricture urethral caruncle Vagina Normal Prior Clear Normal appearance no discharge or lesions No atrophic changes discharge evidence of cystocele enterocele or rectocele erythema ulceration condylomata mass malodourous frothy discharge Cervix Normal Prior Clear Normal without masses or lesions anterior polyp Py posterior discharge condyloma mass Chadwick s sign Uterus Normal Prior Clear Normal size and position without masses or tenderness Adnexa Normal Prior Clear Normal without masses or tenderness on palpation right ovarian enlargement left ovarian enlargement right adnexal tenderness left adnexal tenderness right adnexal mass left adnexal mass El HPI 5 Risk Factors ROS _vs _ Problems Instructions Plan Copyright Prev Form Ctri PgUp Next Form Close 1 The following may be customized by specialty
37. Exams Problems CCC Example of Problems CCC Customized for Family Practice Example of Problems CCC Customized for Endocrinology Example of Problems CCC Customized for OB GYN Example of Problems CCC Customized for Orthopedics General Problems Ortho CCC Site Specific Problem Lists CPOE A amp P CCC CPOE A amp P CCC Workflow Example of Beta Blocker Usage Post MI CDSS Reminders Adding Medications Using the CPOE A amp P CCC Form Ordering Tests or Diagnostics Using the CPOE A amp P CCC Form Example of Orthopedic Specific Upper Extremity Order Sets Documenting Review of Labs or Diagnostics Using the CPOE A amp P CCC Committing Assessments and Additional Documentation Example for Diabetes Example for Hyperlipidemia Example of CPOE Template and Workflow for Prenatal Care Patient Instructions CCC Adult Patient Instructions CCC Pediatric Patient Instructions CCC OB GYN Patient Instructions CCC Vital Signs CCC Serial Assessments CCC Section 2 Customizing CCCQE CCCQE Text File Editor TFE Users Guide Default Authorized TFE Users Setting Up Who Can Edit Files Suggestions Recommendations for Editing Using CCC TFE Section 3 Clinical Decision Support CDS and Patient Severity Index Assessment PSIA CCCQE Clinical Decision Support and Patient Severity Index Assessment Automatic Pop Ups Banner CDSS Embedded CDSS Prompts within Encounter Forms Example Framingham Cardiovascular Risk Calculator Example NCEP ATP Ill Lipid Form
38. Next Form Ctri PgDn Close 1 The following may be customized by specialty normal default values observation terms that are populated and the items in the two list boxes 2 The list box values may contain either normal or abnormal values 3 Charting by exception allows the provider to rapidly document a detailed PE as well as capture structured data which can be used for reporting or clinical decision support 4 The provider can use voice recognition CCC VRI Dragon 8 Medical to dictate into structured data fields Page 41 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Neurologic Exam CCC Cervical Neuro Cervical thoracic US Motor Reflexes Measure Special Cervical Exam Eeva Inspection deformity Cervical e NI Abnl Palpation spinal tenderness NI 7 Abni Location Forward Flexion degrees 60 Right Lateral Flexion degrees 45 Left Lateral Flexion degrees Hyperextension degrees 75 Right Lateral Rotation degrees 80 Left Lateral Rotation degrees Spurling Maneuver neg pos R pos pos centrally pos central non phys Right Left Prev Form Ctri PgUp Next Form Ctri PgDn 1 The following be customized by specialty normal default values observation terms that are populated and the items in the two lis
39. Next Form Ctrl PgDn Close 1 The Problem CCC list boxes can be customized by specialty The customization designates if a single diagnosis description and ICD code is to be added to the patient s problem list or if a custom problem list containing several related diagnoses displays allowing the provider to select the diagnosis with the highest degree of specificity The prefix Diagnosis of Minor Dx of Family History of etc for the problem being pushed to the patient s problem list is assigned in the customization The number of days for a problem added as a Minor Dx to stay on the patient s active problem list can be specified in the customization For Version 8 3 and forward there is no limit to the number of problems that can be listed on the Problem CCC form Previously the limitation was 125 list box items Please note that 125 list box items will display on the form without scrolling Adding more than 125 list box items will require the user to scroll down in the list box to see the additional items that do not fit in the normal display For those providers using the CCC VRI voice recognition any item on the Problem CCC form can now be voice activated A provider can add a diagnosis or access a custom problem list simply by saying Add diagnosis lt insert name of problem as listed on Problem CCC Form gt Examples Add diagnosis adds the diagnosis UTI Add diagnosis diabetes displays the di
40. Print Handout Assessment 4 Select problem enter assessment orders meds then click Commit Assessment HYPERLIPIDEMIA ICD 272 4 Commit Assessment Committed Clear All Recommended increasing dose of Lipitor but patient defers at this time Will reconsider if diet and referral does not improve LDL His updated medication list for this problem includes Lipitor 20 Mg Tab Atorvastatin calcium Take 1 tablet by mouth each evening Labs Reviewed Chol 250 05 06 2004 HDL 39 05 06 2004 LDL 144 06 15 2005 TG 222 05 06 2004 SGOT 14 06 07 2005 SGPT 13 06 07 2005 Lipid Goals Chol Goal 200 06 08 2005 HDL Goal 40 06 08 2005 LDL Goal 100 06 08 2005 TG Goal 150 06 08 2005 2 New Meds Meds auto insert R New Orders Insert Orders R Insert Template R Print Handout Add AII Meds to Note Remove New Meds from Note Rx Monitoring and General Alerts Rec Interventions Rec Tests Orders PMH FH SH Risk Factors ros _vs Problems CPOE AIP Instructions Plan Copyright Prev Form CtriPgUp Next Form Ctri PgDn Page 79 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Update Problems Potential problem list for Don Bassett Description Code OnsetDate Assessment
41. Quicktext can be used Page 54 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Problems CCC for Internal Medicine Family Practice continued Note the additional list box items in the last column that appear if provider scrolls Problems CCC Custom Adult Add Problems Form Note Unchecking a Problem from this form will NOT remove it from the Problem List ASCVD influenza J ABDOMINAL PAIN List Irritable Bowel Syndrome Abnormal Tests Labs Labrynthitis Acne Laryngitis acute Actinic Keratosis Menopause ASTHMA List MENSTRUAL DISORDER List Ataxia Muscle Spasm Atrial Fibrillation Nausea Back Pain Neuralgia Basal cell skin cancer Neuropathy peripheral BREAST Problems List Nevus benign Bronchitis Acute Obesity Bronchitis Chronic Onychomycosis CAD SPCABG BURSITIS List Osteoporosis COLON CA List CHF Otitis Externa CH F diastolic COPD OTTIS MEDIA List J Cholecystitis CV A Stroke PAIN List Knee Neck Shoulder Cholelihiasis CAROTID ARTERY List Peptic Ulcer Disease CRF Peripheral Vascular Disease Problems Medications Palpitations Allergies Orders Parkinson s T Paronychia Add Text to Note Carpal tunnel syndrome CELLULITIS ABSCESS List Cerebrovascular Disease Chest Pain
42. Symptom of HOARSE VOICE QUALITY Hoarse x 3 wks without other symptoms Summary Problems Medications Alerts Flowsheet Orders Documents Active Only C all Lookup problems with Medscape Problem Search CONGESTIVE HEART FAILURE ECHO done 11 26 1998 shows EF 40 with inferior posterior hypokinesis Update ICD 428 0 Details Onset Date 06 08 2005 End Date lt No End Date Entry Date 06 08 2005 8 35 AM Entered By Harry S Winston MD Responsible Harry S Winston MD EFFUSION PLEURAL bilateral ICD 511 9 EDEMA bilateral pedal ICD 782 3 Minor Diagnosis of INFLUENZA ICD 487 1 Minor Diagnosis of FUNGAL DERMATITIS ICD 111 9 Minor Diagnosis of FEVER ICD 780 6 Minor Diagnosis of COUGH ICD 786 2 View Problem Details 06 24 2005 Comment only Harry S Winston MD Will add niacin to the patient s regimen to try to get the LDL below a 100 His updated medication list for this problem includes Lipitor 20 Mg Tab Atorvastatin calcium 1 tablet by mouth each evening Labs Reviewed Chol 250 05 06 2004 HDL 39 05 06 2004 LDL 144 06 15 2005 TG 222 05 06 2004 5607 14 06 07 2005 SGPT 13 06 07 2005 06 15 2005 Comment only Harry S Winston MD Advised increasing Lipitor patient defers but agrees if repeat LDL not 100 06 08 2005 Comment only Harry S Winston MD Labs Reviewed Chol 190 09 10 2001 HDL
43. Toe Peripheral Neuropathy Pes Planus Plantar Faciitis Popliteal Cyst Post op Care Post op Infection Pre opEK G Pronation Radial Tunnel Syndrome Reflex Sympathetic Dystrophy Rheumatoid Arthritis Rupture Rotator Cuff Sciatica Scoliosis ldiopathic Arthritis Specify SPRAIN List Severs Disease Osteochondri Shoulder Dislocation Recurren Shoulder Instability Shoulder Pain Slipped Epiphysis Hip Spinal Stenosis Spondylolithesis Spondylolysis Spondylosis Stress Fracture Site Subluxation Patellar malalignm Subluxation radial head Note Unchecking a Problem from this form will NOT remove it from the Problem List Suture Removal SYNOVITIS List Site TFCCTear TearACL Tear Lateral Meniscus TearMCL Tear Medial Meniscus TENDONITIS List Tibial Torsion Total Hip Follow up Total Knee Follow up Traumatic Arthritis Trigger Finger Trochanteric Bursitus Ulnar Collateral Lig Tear Thumb Ulnar Neuritis Whiplash ORTHOPEDICS CUSTOM List Problems Medications Allergies Orders Add Text to Note Select Specialty Orthopedics E Cursor must be blinking in Yellow Field for CCC VRI New Problems Added most recent addition on top El HPI PMH FH SH Risk Factors ROS s P Problems CPOE Instructions Plan Copyright Prev Form Ctri PgUp
44. Up DIABETES MELLITUS TYPE II ICD 250 00 06 08 2005 COMMENT ONLY HYPERLIPIDEMIA ICD 272 4 06 08 2005 COMMENT ONLY Down CONGESTIVE HEART FAILURE ICD 428 0 09 16 2000 Sx of HOARSE VOICE QUALITY 09 16 2000 Left EFFUSION PLEURAL 1CD 511 9 09 07 2001 1 EDEMA ICD 782 3 09 07 2001 Right Minor dx of INFLUENZA ICD 487 1 06 08 2005 Minor dx of FUNGAL DERMATITIS ICD 111 9 06 08 2005 To Top Minor dx of FEVER ICD 780 6 06 08 2005 Minor dx of COUGH ICD 786 2 06 08 2005 x Assessment Comment New Improved Unchanged 7 Deteriorated Comment Only Referto Diabetes Education Program and schedule for a stress test prior to starting exercise program His updated medication list for this problem includes Glucophage 850 Mg Tab Metformin hcl Take 1 tablet by mouth each moming Amaryl 2 Mg Tab Glimepiride Take 1 tablet by mouth once a day Added new problem of SUBENDOCARDIAL M I ICD 410 70 Assessed DIABETES MELLITUS as comment only Refer to Diabetes Education Program and schedule for a stress test prior to starting exercise program His updated medication list for this problem includes Glucophage 850 Mg Tab Metformin hcl Take 1 tablet by mouth each morning Amaryl 2 Mg Tab Glimepiride Take 1 tablet by mouth once a day Aspirin 81 Mg Ec Tab Aspirin Take one 1 tablet by mouth daily New Change Change Back E A Note that all of
45. Winston 11 5 7 Wks Wt 132 100 68 Schedule OB Ultrasound and Genetics Clinic Referral For Help press F1 inn Sl 85 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Patient Instructions CCC The Patient Instructions CCC form is designed to allow for rapid point and click entry of the most common specialty specific medical surgical patient instructions provided during a visit The list box items can be customized by specialty In addition the customization can also determine if an observation term is automatically populated and with what value This decreases the time necessary to provide patient specific instructions as well as capture structured data which can be used for reporting or clinical decision support Example Adult Patient Instructions CCC Patient Instructions CCC Don C Bassett Patient Instructions Check boxes then Click to Enter or enter directly into edit field Cardiovascular Smoking Cessation Precontemplative Contemplative 6 Months Ready to Quit 30 Days Already Quit Quit Relapse Exercise Weight Loss Rec Pre Diabetes Aspirin Rx 81 MG Aspirin Rx 325 MG CHF Eduction Ref Salt Restriction 2GM Cardiac Rehab Ref NTG Instructions Cardiology Referral ETT Referral SBE Prophylaxis B Blocker Hold Prev Fo
46. changes edits Once this is determined open the CCCQE User Edit Setup txt file and search for the instructions function at the bottom of the file shown below The default conditional statement allows access for hwinston and kstarr Page 97 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Default Authorized TFE Users Authorized TFE Users This function must return the value of 1 for the user to be authorized For any and all users to use the CCC Text File Editor simply place the number 1 between the curly brackets Otherwise a conditional statement will be needed to limit the use of this encounter form ccc authorized users d Change the login names to those 2 authorized at your site Add case user loginname return 1 additional conditional statements if case user loginnames return 1 needed to allow more than two else return providers to have editing access endcond j Suggestions Recommendations for Editing Text Files Using The New CCC TFE 1 Make a back up copy of all you User Edit Files prior to any editing 2 Make all edits and test on a Test Server database OR in Network Training on a local workstation 3 Use either a blank open NotePad or WordPad page or the Dictation Box within CCC VRI Voice Recognition that comes with Dragon NaturallySpeaking 8 Medical when ente
47. extracted from data in patient s chart and Stage 1 SBP 140 159 DBP 90 99 cannot be changed unless the chart data is changed first Stage 2 SBP 160 179 DBP 100 109 Stage 3 SBP gt 180 gt 110 Identify Major Risk Factors Age 45 or greater yes C no Diabetes yes C no Last Glucose 86 09 20 2000 Hyperlipidemia yes C no Last Chol 190 09 10 2001 Last HDL 60 09 0 2001 LastLDL 100 09 10 2001 Hypertension yes C no FH of cardiovascular disease RISK GROUP C Ml in female 65 yes no Target organ damage and or Diabetes male age 55 yes no Smoking status current quit C never Identify Target Organ Damage Clinical CV Disease ASHD CAD or CABG yes C no 10 YEAR CHD RISK N A Prior Value 11 01 13 2005 LVH or CHF 6 yes C no Calculated from the following risk categories ee Stroke or TIA C yes C no Hot applicable Patient has known ASHD Peripheral vascular disease C yes C no Hephropathy Cr 2 0 yes C no Hypertensive Retinopathy yes C no Enter Today s Blood Pressure i mm Hg JHC VII Recommended BP Goal lt 130 80 Insert JNC VII Rec BP Goals gt a lt RiskFactors Ros PE Problems InstructionsPlan Copyright Prev Form Ctrl PgUp Next Form Automatically extracts risk factors from the database and calculates the pati
48. field The provider can click the Insert Template button which will populate the following information into the assessment field for Prenatal Care EDC Weeks gestation and other values for today s visit such as weight BP FHR fundal height and position When the provider clicks the Commit Assessment action button the documentation in the assessment field will be pushed to the patient s problem list associated with the problem Prenatal Care CPOE A amp P CCC Sarah S Oberheim ARP 1 2 7 8 9 10 11 12 Select Specialty Obstetrics Gynecology Assessment 1 Select problem enter assessment orders and meds then click Commit Assessment Prob List PRENATAL CARE ICD V22 1 X _Commit Assessment Committed Clear All EDC 11 08 2005 Wks Gest 21 0 7 Wt 144 10268 18 FetalHR 180 Fetal Position breech Comments Folow up Referal to Genetics Clinic repeat U S prior to next visit in 2 weeks Her updated medication list for this problem includes Prenatal 1 1 Tabs Prenatal multivit min fe fa 1 po daily New Meds Change Meds Meds auto insert Ri New Orders Orders auto insert R Insert Template R Print Handout Assessment 2 Select problem enter assessment orders and meds then click Commit Assessment Commit Assessment 1 zi Add All Meds to Note Remove New Meds from Note Rx Monitoring and Gen
49. lesions Testes Scrotum Normal size testes bilateral without masses or tenderness Epididymides Normal without masses or tenderness Seminal Vesicles No masses or tenderness Inguinal No masses tenderness or hernias noted For Help press F1 5 T T Page 52 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Problems CCC The Problems CCC form is designed to allow for rapid point and click entry of the most common specialty specific medical surgical problems to the active problem list The list box values may be customized by specialty The customization can also designate if a single diagnosis code is pushed to the problem list of if a custom problem list is to be opened allowing the provider to select the diagnosis with the highest degree of specificity The prefix Diagnosis of Minor Diagnosis of etc and the number of days that a problem designated as a Minor Diagnosis stays on the patient s active problem list is also specified in the customization Finally for those sites using the CCC VRI module with Dragon NaturallySpeaking 8 Medical each diagnosis or problem list can also be triggered by using voice activated macros Example add diagnosis chest pain add diagnosis UTI Key Points 1 The Problem CCC list boxes can be customized by specialty 2 The customization designates if a single diagnosis descript
50. or review of diagnostic tests This documentation is automatically captured within the CPOE A amp P CCC form CPOE A amp P CCC Don C Bassett ASP1 2 A amp P3 4 asp s s asp7 s aspo to asp 11 12 Assessment 3 Select problem enter assessment orders and meds then click Commit Assessment ProbList DIABETES MELLITUS TYPE Il ICD 250 00 _Commit Assessment Clear All Hemoglobin 1 001453 Microalbumin urine 82043 Lipid Panel 303756 Future Orders EKG complete CPT 93000 08 25 2005 Labs Reviewed HgBA1c 8 4 12 07 2004 Creat 1 0 06 12 2002 Microalbumin 30 02 01 2004 Last Dialated Retinal Exam Normal 01 08 2005 Chol 250 05 06 2004 HDL 39 05 06 2004 LDL 144 06 15 2005 TG 222 05 06 2004 New Meds Change Meds Meds auto insert New Orders Orders auto insert R Insert Template R Print Handout Assessment 4 Select problem enter assessment orders meds then click Commit Assessment HYPERLIPIDEMIA ICD 272 4 Commit Assessment Clear All New Meds Insert Meds RI New Orders Insert Orders RI Insert Template Ri Print Handout Add All Meds to Note Remove New Meds from Note Rx Monitoring and General Alerts Rec interventions Rec Tests Orders HPI 5 Risk Factors ros _vs Pej Problems CPOE Instructions Plan Copyright Prev Form Ctri PgUp Next Form C
51. pulse absent left radial pulse Peripheral Circulation Normal Prior_ Clear no clubbing cyanosis or edema noted with normal no clubbing clubbing capillary refill no cyanosis cyanosis pedal edema pedal edema g normal capillary refill abnormal capillary refill HPI 5 Risk Factors ROS vs PE Problems CPOE A P Instructions Plan Copyright Prev Form Ctri PgUp Next Form Ctri PgDn Close 1 The following may be customized by specialty normal default values observation terms that are populated and the items in the two list boxes 2 The list box values may contain either normal or abnormal values 3 Charting by exception allows the provider to rapidly document a detailed PE as well as capture structured data which can be used for reporting or clinical decision support 4 The provider can use voice recognition CCC VRI Dragon 8 Medical to dictate into structured data fields 5 Additional fields may be added on the Special Tab such as ABI Ankle Brachial Index etc Page 34 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Abdomen GU PE CCC Don C Bassett Gen HEENT Neck Lung Heart Abd GU MSK ExtNeuro 5 Diabetes Exam Abdomen Normal Prior Clear bowel sounds positive abdomen
52. reviewed no changes required Replace w Prior PMH Problems Flowsheet Medications Allergies pe Surgical Medical Unremarkable Asthma Atrial Fibrillation Anemia Anxiety Autoimmune Disorder Cerebrovascular Disease CY A Stroke Coronary Heart Disease Crohn s Disease CRF Colon Cancer Cataract Extraction Tonsillectomy Carotid Endarterectomy Hip Replacement Knee Replacement Knee Arthroscopy Rotator Cuff Repair Insert Selected Values Onset Procedure Date optional Medical Medical Kidney Disease Kidney Stone Liver Disease MI Neurologic Disorder Osteoarthritis Osteoporosis Depression Diabetes Type 1 Diabetes Type 2 Diverticulitis Heart Disease Hyperlipidemia Hypertension Hypothyroidism Hyperthyroidism Rheumatoid Arthritis Seizure Disorder Thyroid Disorder Tuberculosis Valvular Heart Disease xl UT l Recurrent x HPI acy PMH FH SH Risk Factors ROS Problems CPOE Instructions Plan Copyright Prev Form Ctrl PgUp Next Form Ctrl PgDn Anesthesia Complications Blood Transfusions Carpal Tunnel LA F Bypass 1 The support staff or the provider check corresponding problems in the list boxes then clicks the yellow Insert Selected Values action
53. s BP gt mmHg JNC VII Recommended BP Goal lt 130 80 2 C Eye Exam done here TODAY Curren BP ENS Ee Eye Exam done elsewhere Eye Exam not due You may also manually enter change BP goals Go To Page Gen HEENT Neck Lung Heart Abd GU MSK Ext Neuro SIL Psych Exam Other Go Go Go J Go J Go To Go To HPI Acv PMH FH SH Risk Factors ros _vs Pej Problems CPOE Instructions Plan Copyright Prev Form Ctri PgUp Next Form Ctri PgDn NOTE The results push to multiple obs terms for outcomes tracking purposes i e Diab Eye Exam Monofilament Exam and Diab Foot Exam but each site can also designate one alternative observation term to populate for reporting consistency Page 50 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Text Translation for PE CCC Exam 5 1 00 0 P d inl x og a a 0 D d Go Actions Options Help YE3Desktop ESappts Drea fyRenots New view intenet Help ExT Don C Bassett CHECK PROTOCOLS Home 503 629 5541 Work 503 692 8954 59 Year Old Male DOB 11 25 1945 Patient ID 80 TESTO11 Insurance MCR Medicare Part B Find Pt Protocols Graph Handouts Probs Meds Refills Allergies Directives Flowsheet Orders End Up Summary Problems Medications
54. stage from the appropriate dropdown list then click the Commit to Flowsheet button Note more than one contraindication may be documented at a time using the same form update Page 68 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Contraindication to Test Procedure Documentation CDSS Contraindications CCC Don C Bassett Clinical Decision Support System Documentation of Contraindications to Treatment Deferment of Testing Procedures and Stage Documentation Contraindications to Treatment Treatment Contraindication Deferment of Testing Procedure Test or Procedure Reason for Deferment 4 4 Jm Colonoscopy PAP Smear Mammogram Classification Scheme Class or Stage Intake Prenatal visit Past Preg Hx Genetic Flowsheet Lab Prenatal Ed Ultrasound PAP Entry HPI PMH FH SH Risk Factors ROS vs Problems CPOE Instructions Plan Copyright Prev Form Ctri PgUp Close Page 69 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Staging Documentation CDSS Contraindications CCC Don C Bassett Clinical Decision Support System Documentation of Contraindications to Treatment Deferment of Testing Procedures and Stage Documentation Contraindicati
55. 20 Mg Tab Atorvastatin calcium Take 1 tablet by mouth each evening Labs Reviewed Chol 250 05 06 2004 HDL 39 05 06 2004 LDL 144 06 15 2005 TG 222 05 06 2004 SGOT 14 06 07 2005 SGPT 13 06 07 2005 Lipid Goals Chol Goal 200 06 08 2005 HDL Goal 40 06 08 2005 LDL Goal 100 06 08 2005 TG Goal 150 06 08 2005 Prior 10 Yr Risk Heart Disease 22 06 08 2005 New Meds Change Meds Meds auto insert New Orders Insert Orders R R Print Handout Add All Meds to Note Remove New Meds from Note Rx Monitoring and General Alerts Rec Interventions Rec Tests Orders insert Template HPI Acv PMH FH SH Risk Factors Ros _vs Pej Problems CPOE Instructions Plan Copyright Prev Form 0 Next Form Ctrl PgDn Clicking the Insert Template action button for the problem HYPERLIPIDEMIA automatically inserts Labs Reviewed and includes the last set of values for the tests which should be reviewed at each visit into the assessment field for that problem Note since patient is currently on a statin the last documented SGOT and SGPT also displayed Page 78 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Committing Assessments and Additional Documentation Providers can use Quicktext type or voice recognition to add in any additional assessme
56. 20 PM Lying 120 80 80 Harry 5 Winston MD 5 20 PM Sitting 110 70 100 Harry S Winston MD 5 20 PM Standing 100 60 120 Harry S Winston MD 5 40 PM Lying 120 80 80 Harry 5 Winston MD 5 40 PM Sitting 120 76 90 Harry S Winston MD 5 40 PM Standing 110 70 100 Harry S Winston MD z HPI acv PMH FH SH Risk Factors ros _ Problems CPOE AIP Instructions Plan Copyright Prev Form Ctri PgUp Close 1 Click the Time of Assessment action button to enter the time of assessment enter all values that are to be documented and click the Record action button 2 Repeat the process to record subsequent sets of measurements 3 A flowsheet view of the vital signs will be created in the Vital Signs this Visit data display and in the chart note 4 The Comments field may be used to document comments regarding patient status or treatment decisions Page 95 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Tabular Text Translation for Serial Assessments CCC Form Custom Adult CHECK PROTOCOLS Home None 55 Year Old Male DOB 04 75 0563001 Insurance RSS M TEL MEL NDS Protocols Graph Handouts Probs Meds Refills Allergies Directives Flowsheet Orders Summary Problems Medications Flowsheet Orders Documents Update Properties Office Visit at SOUT
57. 5 Risk Factors ROS _vs _ Problems AIP Instructions Plan Copyright Prev Form Ctri PgUp 1 Click the Time of Assessment action button to enter the time of assessment enter all values that are to be documented and click the Record action button 2 Repeat the process to record subsequent sets of measurements 3 A flowsheet view of the vital signs will be created in the Vital Signs this Visit data display and in the chart note 4 The Comments field may be used to document comments regarding patient status or treatment decisions see IV and fluid comments above Page 94 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Serial Assessments CCC Multiple Sites allows the documentation of additional blood pressure measurements by site Serial Assessments CCC Custom Adult Serial Assessments Time of Assessment 6 00 Any further values for the following will Vital Signs C Standard C Postural Multiple Sites NDA 1 Postural BP s Right Arm 120 I 80 mm Hg 2 Resp Rate 3 O2 Type LeftArm 118 1 ve mm Hg 4 PEF RightLeg 100 1 eo mm Hg LeftLeg 98 56 Hg Comments Go to Flowsheet for Corrections gt Flowsheet Vital Signs this Visit Position By 4 55 PM 120 80 80 10 Harry S Winston MD 5 15 PM 110 70 80 Harry S Winston MD 5
58. 5 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved To copy and paste the CCCQE MEL functions from the TFE form do the following Press CTRL A this selects all of the text within the update e Press CTRL C this copies all of the selected text to the clipboard of the workstation S Logician Harry S Winston MD Southside Clinic CCC Development JJ2 4 15 2005 9 37 AM Chart Go Actions Options Help VEsDesktop chart Appts ew intenet Hep EXT Custom Endocrine CHECK PROTOCOLS Home None Work None 55 Year Old Male DOB 04 06 1950 Patient ID 71 0563001 Insurance Group x A HK RM x B Find Pt Protocols Graph Handouts Probs Meds Refills Allergies Directives Flowsheet Orders End Up Summary Problems Medications Flowsheet Documents Update DociD 10 Properties CCC Text File Editing at SOUTH on 04 15 2005 8 41 AM by Harry S Winston MD Summary Change Properties CCC Text File Editor B z u E S S 9 El For Help press F1 i nm Click the Open Text File to Edit action button which will automatically open the CCCQE User Edit TFE text file CCCQE User Edit PMH Endo TFE Notepad File Edit Format View Help Page 107 Copyright 2005 Clinical Content Consultants LLC All rights reserv
59. 5 Clinical Content Consultants LLC All rights reserved Example ROS Renal Nephrology ROS CCC Don C Bassett Page 1 2 Templates View Ansert Patient Entered Hx View Insert Select Specialty Nephrology vj REVIEW OF SYSTEMS All Hegative 1 Heg 2 Heg 3 Heg Clear ALL View Positive ROS Clear View See HPI Show Only Positive Values in Note T Show Brief Version of Negative Values Note General ESRD CKD Transplant Resp GI GU Male e e e ESRD Complains of Denies See HPI anorexia IV anorexia Negative fatiqueweakness fatigueAweakness weight loss weight loss Ger insomnia insomnia chest pain IV chest pain dyspnea IV dyspnea v orthopnea PND edema v cough v nausea vomiting v restless legs IV itching rash Iv rash Comments a Oh by the way x Enter FH SH Risk Factors ROS Problems CPOE Instructions Plan Copyright Prev Form Ctrl PgUip Next Form Ctrl PgDn 1 order value of radio button headings customized by specialty Note the order of systems and values expanded for Nephrology in the example above Through customization this can also be problem specific i e ESRD displays ROS values for multiple systems all in one list box which allows the provider to rapidly document an intermediate disease specific RO
60. 7 Insert Selected Values Last updated reviewed no changes required Check to insert into FH Edit Field FH Alcoholism FH Arthritis FH Asthma FH Bleeding disorder FHBreast Ca Cervical Ca FH of CHD CHD male 55 65 FH of Colon Ca FH Colon Ca father FH Colon Ca mother Colon Polyps FH Depression FH Diabetes or Stroke FH Hypertension Hyperlipidemia FH Lung Ca Melanoma FH Migraine FH Osteoporosis FH Ovarian Ca FH Pancreatic Ca FH Prostate Ca FH Renal Dz FH Seizures FH Skin FH Suicide Thyroid Dz FH Huntington s Dz FH Learning Disabilities FHof ADD FHof ADHD NEG FHx Breast Cancer NEG FHx Cervical CA NEG FHx of Colon Canc NEG FHx Diabetes NEG FHx HTN NEG FHx DM HTN CAD Insert FH Template Remove FH Template Replace w Prior FH Social History Insert Selected Val Last updated reviewed no changes required Check to insert into SH Edit Field Hx Domestic Abuse Religion Affecting Care Foster Care Parents Divorced Lives wiGrandparents Adopted Passive Smoke Yes Passive Smoke No Immunizations LITD VES Immunizations UITD NO Current history of foster care Positive history of passive tobacco smoke exposure Immunizations not currently up to date Insert SH Template
61. A Medicare ANA _ HDL PT Prothrombin Time order a lab diagnostic test or referral gt click the New Orders action button Based the customization one of the following will occur Option 1 A custom order list will display examples CCC Adult CCC Pediatrics CCC Prenatal This can be customized to display any custom order list Option 2 Inserts an encounter form into the update and displays that encounter form for data entry In some cases using an encounter form is more effective when ordering multiple medications or monitoring regimens examples Chemotherapy Prescriptions go to Chemotherapy RX CCC form Option 3 The standard Update Orders dialog box with the last custom order list that was accessed will display Note this is the default if option 1 or option 2 is not selected or if the problem has not been customized in the CPOE NOTE Any labs or diagnostics associated with a diagnosis problem will automatically appear in the assessment field for that problem in the CPOE A amp P form see below Sx of HOARSE VOICE QUALT EFFUSION PLEURAL EDEMA Minor dx of INFLUENZA Minor dx of FUNGAL DERMAT Minor dx of FEVER Minor dx of COUGH Lipid Panel Unsigned DIABETES MELLITUS TYPE ions aa Page 72 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved CPOE A amp P CCC Do
62. AIN List Knee Neck Shoulder Wax in ears CAROTID ARTERY List GERD Peptic Ulcer Disease Weight Loss Carpal tunnel syndrome Peripheral Vascular Disease Problems Medications CELLULITIS ABSCESS List Palpitations Allergies Orders Cerebrovascular Disease Parkinson s Chest Pain Paronychia ___AddTexttoNote Cirrhosis Patellofemoral Syndrome Colitis Hormone Replacement Therap Pharyngitis Acute select Spocely Conjunctivitis HEADACHE List Plantar Fasciitis Internal Medicine Constipation Heart Murmur Pneumonia CONTRACEPTION List Hematuria Polymyalgia Rheumatica Cursor must be blinking in Coronary Atherosclerosis HEMORRHOIDS List Postmenopausal Status EEE METER EMS Costochondritis HERNIA List PROSTATE List Mm Cough Herpes Simplex Renal Stone Mon Aubin Crohn s Disease Herpes Zoster Rheumatoid Arthritis aost recent able Croup HYPERLIPIDEMIA List RHINTIS List HYPERTENSION List Sebaceous cyst Degenerative Disc Disease Hyperthyroidism Seborrheic Keratosis DEGENERATIVE JOINT DISEAS Hypothyroidism SEIZURE DISORDER List DERMATITIS List INCONTINENCE List SINUSITIS List xl Prev Form Ctri PgUp Next Form Ctri PgDn Close 1 The Problem CCC list boxes can be customized by specialty 2 The customization designates if a single diagnosis
63. CC C1Cardiology Cardiovascular Reports CCC AT END ccc Card exec Data Entry Enterprise CC C Data ccc Card exec Diagnostic Testing Review Form Enterprise CC C Diagnostic Testing Review CCC 2 ccc Card exec Echocardiogram Form Enterprise C CC Cardiology Echocardiogram CCC AT END ccc Card exec Pre op Evaluation Form Enterprise CCC Cardiology Cardiology Eval CCC 2 ccc Card exec Stress Test Form Enterprise CC CYCardiology Cardiology END ccc Card exec Renal Evaluation Form EnterpriseC CC Renal Renal Evaluation C C C 2 ccc Card exec New Patient Template ccc Card exec Acute Visit Template ccc Card exec Pacemaker Template ccc Card exec Pre op Template ccc Card exec Another template ccc Card exec Template 22 For Help press F1 Bist SI 112 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved To copy and paste the CCCQE MEL functions from the TFE form do the following Press CTRL A this selects all of the text within the update e Press CTRL C this copies all of the selected text to the clipboard of the workstation E Logician Harry S Winston MD Southside Clinic CCC Development JJ2 4 15 2005 2 58
64. Copyright 2005 Clinical Content Consultants LLC All rights reserved A variety of Custom Order Lists and Order Sets can be created to link with the CPOE A amp P CCC Form and templates see examples below of Pediatrics and Prenatal Example CCC Pediatric Custom Order List with Age Specific Custom Order Sets Update Orders Don C Bassett 59 Year Old Male DOB 11 25 1945 Orders Thisupdate Open All Coverage Futura Set Coverage Potential Diagnoses 06 28 2005 Hemoglobin A1c Unsigned DIABETES MELLITUS TYPE II CONGESTIVE HEART FAILURI 06 28 2005 Microalbumin uri i 1 M US umin urine Unsigned 10 BETES MELLITUS Sx of HOARSE VOICE QUALT 06 28 2005 Lipid Panel Unsigned DIABETES MELLITUS TYPE II JEFFUSION PLEURAL ex 08 25 2005 complete Unsigned DIABETES MELLITUS TYPE II EDEMA i Minor dx of INFLUENZA Minor dx of FUNGAL DERMAT Minor dx of FEVER Minor dx of COUGH ixl Remove Reorder Clear Diagnoses New Custom Lit Categories Search Order Details Use custom list Jocc Pediatric Organize Newborn Visit 4Month WCC DTAP 12 Month WCC Preventive Est 1yr infant Preventive Est 1yr infant Preventive Est 1 4 yrs PKU collection Comvax Pneumococcal Peds Chicken Pox 2 Admin immunization 2 Pneumococcal Peds Prev
65. Copyright 2005 Clinical Content Consultants LLC All rights reserved CCCQE Version 8 3 Users Manual Table of Contents Section 1 Introduction Documenting the Patient Visit Core Forms HPI CCC Example of HPI CCC for Orthopedics using List Box Templates Example of HPI CCC for Family Practice Internal Medicine Example of HPI CCC for OB GYN Example of HPI CCC for Pediatrics PMH CCC Example of PMH CCC for Family Practice Internal Medicine Example of PMH CCC for Orthopedics Example of PMH CCC for OB GYN with PatientLink Integration PMH PSH CCC FH SH CCC Example of FH SH for Family Practice Internal Medicine Example of FH SH for Cardiology Example of FH SH for Pediatrics Risk Factors CCC Expanded Risk Factors Options ROS CCC Example of ROS for Family Practice with PatientLink CCC Integration Example of Auto populated ROS for FP using PatientLink CCC Integration Example of ROS for Cardiology Example of Abbreviated ROS Text Translation Example of ROS for ENT Example of ROS for Renal Nephrology PE CCC General HEENT Neck Lung Heart Detailed Cardiovascular Exam Abdomen GU Detailed GU Exam Male Detailed GU Exam Female Musculoskeletal Extremities Neuro Detailed Neurologic Exam Skin Lymphatic Psych Diabetic Specific Exams Foot and Eye Page 1 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Text Translation for PE
66. ENT List Ear Wax Impacted Eating Disorder Nonorganic Learning Problem Lice Head Acne Eczema Lymphadenitis Acute Adenitis Encopresis Lymphadenopathy Allergic Rhinitis Enuresis Metatarsal Adductus Allergy Drug Epilepsy Migraine Common Allergy Food Epistaxis Monilial Rash Anemia Excessive Crying of Baby Nausea Anxiety Disorder Failure to Thrive Obesity ASTHMA List ADD ADHD List Bronchiolitis Bronchitis Acute BURN List CELLULTIS ABSCESS List CerebralPalsy Chest Pain Congenital Heart Disease Fatigue Feeding Problem Feeding Problem Newborn Fever Fifth s Disease FRACTURE List Fungal Infection Fussy Baby Gastroenteritis Oppositional Defiant Disorder Osgood Schlatter s Otalgia Otitis Externa Otitis Media Acute Otitis Media Serous Paronychia Toe Paronychia Finger Pharyngitis Acute Situational Disturbance Strep Throat Suture Removal Teething Syndrome Thrush Tonsillitis TRAUMA List URI Vaginitis Viral Syndrome Vomiting Well Child Exam Well Adolescent Exam Conjunctivitis GE Reflux Pneumonia Unsp Problems Medications Constipation Unsp Gynecomastia Precocious Puberty Allergies AUDI Cough HEADACHE List Poison Oak lvy Croup Hearing Loss Unsp Prematurity ___AddTextto Note Dac
67. Extremities Only AlWorma _ Prorvaues __ Clean Gait Normal Prior Clear Gait is normal unable to walk festinated Posture Normal Clear Posture is normal hyperlordotic scoliosis to left hypolordotic scoliosis to right kyphotic E Spasm Normal Prior Clear There is no paraspinal muscle spasm left cervical right cervical bilateral cervical left lumbar right lumbar bilateral lumbar xl Strength Normal Clear Strength in the upper and lower extremities is normal decreased LUE diminished LUE diminished RUE diminished LLE diminished RLE decreased RLE Strength cont Normal Right Right Left Shoulder Abd supraspin 5 5 Shoulder Abd supraspin 5 5_ Rt Hip Abductors 5 5 v Lt Hip Abductors ERI 7 Shoulder Abd infraspin 5 5 w Shoulder Abd infraspin 5 5 w Rt Hip Adductors 5 5 v Shoulder Abd deltoid 5 5 Shoulder Abd deltoid 575 Rt 5 5 Right Biceps 5 5 w Left Biceps 5 5 v Right Quads 55 5 Right Triceps 55 5 v Left Triceps 5 75 Rt Hamstring 5 5 v RightWristExtensors 9 5 Left Wrist Extensors 5 5 Rt Tibialis Anterior 5 5 Lt Tibialis Anterior Rt Handgrip 5 5 Lt Handgrip 5 5 Rt Ext HalicusLongus 5 5 Lt Ext Hallicus Longus 5 5 x Rt Interossei 5 5 v Lt Interos
68. H FH SH Risk Factors ROS vs Problems CPOE AIP Instructions Plan Copyright Prev Form Ctri PgUp Close Select the contraindication or stage then click the Commit to Flowsheet action button Note more than one contraindication may be documented at one time using the same form update Page 129 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Contraindication to a Test or Procedure CDSS Contraindications CCC Don C Bassett Clinical Decision Support System Documentation of Contraindications to Treatment Deferment of Testing Procedures and Stage Documentation Contraindications to Treatment Treatment Contraindication Deferment of Testing Procedure Test or Procedure Reason for Deferment 4 4 Jm Colonoscopy PAP Smear Mammogram Classification Scheme Class or Stage intake Prenatal visit Past Preg Hx Genetic Flowsheet Lab J Prenatal Ed Ultrasound PAP Entry HPI PMH FH SH Risk Factors ROS vs Problems CPOE Instructions Plan Copyright Prev Form Ctri PgUp Close Page 130 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Staging Documentation CDSS Contraindications CCC Don C Bassett Clinical Decision Supp
69. H on 07 05 2005 2 35 PM by Harry 5 Winston MD Find Pt Serial Vital Signs Assessments Time Position BP Pulse Resp Temp By 4 55 PM 120 80 80 10 Harry S Winston MD 5 15 PM 110 70 80 Harry S Winston MD 5 20 PM Lying 120 80 80 Harry S Winston MD 5 20 PM Sitting 110 70 100 Harry S Winston MD 5 20 PM Standing 100 60 120 Harry S Winston MD 5 40 PM Lying 120 80 80 Harry S Winston MD 5 40 PM Sitting 120 76 90 Harry S Winston MD 5 40 PM Standing 110 70 100 Harry S Winston MD 6 00 PM R Arm 120 80 Harry S Winston MD 6 00 PM L Arm 118 76 Harry S Winston MD 6 00 PM R Leg 100 60 Harry S Winston MD 6 00 L Leg 98 56 Harry S Winston MD PEF PreRx PostRx Time 02 Sat 02 Type L min L min L min By 4 55 PM 98 Room air 500 Harry S Winston MD 5 15 PM 98 Room air 500 Harry S Winston MD Comments 5 40 PM 16G IV started left antecubital and 2 Liters LR given IV over 20 minutes By Harry S Winston MD For Help press F1 eri at ce T T Page 96 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Section 2 CCCQE Text File Editor TFE User Guide Overview The CCCQE Text File Editor TFE was designed to allow users to more easily and quickly customize edit or create specialty and site specific custom clinical content The Core CCCQE forms can be edited using the ne
70. L 06 12 2002 CAPTOPRIL 100 MG TAB Take 1 tablet by mouth twice a day 1 50 CAPTOPRIL 12 5 MG TAB Take 1 tablet by mouth twice a day 50 60 Insurance BHI Futura Current Medications zl ZAROXOLYN TAB SMG METOLAZON FUROSEMIDE TABS 20 MG FUROSEM p Define Medication NEXIUM 40 MG CAPDR ESOMEPRAZC EA Medication GLUCOPHAGE 850 MG TAB METFORI AMARYL 2 MG TAB GLIMEPIRIDE Instructions LIPITOR 20 MG TAB ATORVASTATIN ASPIRIN 81 MG EC TAB ASPIRIN gt Start Date 06 28 2005 m Stop Date a Duration Days Weeks C Months Current Allergies Preni ASA Quantity Refills Print Pt Handout Pharmacy Heal Pharmacy Authorized Starr MD Kelly G id 14625 SW Ithaca Beaverton OR 97007 USA Prescribing Method Telephone Ph 503 646 1194 Fax 503 646 1196 zi state regon A Addtocustomlist Drug Instructions Duration Qty Refils Save amp Continue ILo Cancel Page 125 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Clicking No returns Logician Message The provider can ignore the prompt and click No or else click Yes which will allow the contraindication to be documented using the CDSS Contraindication CCC form or any other form the site may have developed Example of Beta blocker Usage Post MI CDSS Note The CHF Medicatio
71. L Sprain right Contusion Hip NERVE DISORDERS LE List Bursitis Knee Lateral Meniscus Tear left DJD Hip PERIPHERAL VASCULAR DISE Bursitis Prepatellar Lateral Meniscus Tear right Hip Pain SKIN ORTHO List Bursitis Tibial collateral ligamne CL Sprain left Hip Replacement left SPRAIN TEAR KNEE List Contusion Knee MCL Sprain right Hip Replacement right Chondromalcia Patella Medial Meniscus Tear left Hip Sprain DJD Knee Medial Meniscus Tear right SCFE Hip Effusion Knee Osgood Schlatters Sprain Strain Hip Hemarthrosis Knee Patellar Dislocation left Subluxation Hip lliotibial band syndrome Patellar Dislocation right Synovitis Hip Joint Crepitus Knee Popliteal Cyst Tendinitis Hip Knee Pain left Knee Pain right Knee Replacement left Knee Replacement right PCL PCL Tear right Tendonitis Knee Tendonitis pes anserinus New Problems Added most recent addition on top E Problems Medications Allergies Orders Remove Text Cursor must be blinking Yellow Field for CCC Speak Back Exam pum Foot Ankle Exam Hand Wrist Exam Knee Exam Shoulder Elbow Exam P Risk Fact ors RO s vs Problems POE AIP Instructi ions Plan Copyright Prev Form CtrisPgUp Next Form Ctri PgDn 1 The Problem CCC list boxes can be customized by specialty
72. Last Value Next due Now Lipid Profile NOTE Many evidence based o eS guidelines come within the LDL between 70 and 100 application and are updated uo OMS quarterly but the latest release also Due every 365 days allows sites to create their own Last done 09 10 2001 protocols and recommendation alerts Last Value 100 Next due Now Providers can also set prompts based Dus avory 365 days on a range of lab results see Lipid Last done 09 20 2000 Profile Last Value 1 0 Next due Now Creat Microalb Urn Due every 365 days Last done N A Last Value Next due Now TSH Due every 365 days Last done Last Value Next due Now DRE Due every 365 days Last done Last Value Next due Now Pneumovax Due every 2190 days Last done Last Value Next due Now Flu Shot Due every 365 days Last done N Last Value 4 121 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Framingham Cardiovascular Risk Calculator NCEP Guidelines Encounter Form Cardiovascular Risk CCC Don C Bassett CV Risk Assessment Insert Text BP this visit Hot Recorded Yet Prior BP 140 96 04 02 2003 Stage of Hypertension at time of diagnosis if applicable High norrnal SBP 130 139 DBP 85 89 Some values in RED have been
73. MMENT ONLY HYPERLIPIDEMIA ICD 272 4 06 08 2005 COMMENT ONLY Down CONGESTIVE HEART FAILURE ICD 428 0 09 16 2000 Sx of HOARSE VOICE QUALITY 09 16 2000 Left EFFUSION PLEURAL ICD 511 9 09 07 2001 EDEMA ICD 782 3 09 07 2001 Right Minor dx of INFLUENZA ICD 487 1 06 08 2005 Minor dx of FUNGAL DERMATITIS ICD 111 9 06 08 2005 To Top Minor dx of FEVER ICD 780 6 06 08 2005 Minor dx of COUGH ICD 786 2 06 08 2005 Bottom Assessment Comment New Neues LI Deteriorated eee Added new problem of SUBENDOCARDIAL M ICD 410 70 Assessed DIABETES MELLITUS TYPE Il as comment only Refer to Diabetes Education Program and schedule for a stress test prior to starting exercise program His updated medication list for this problem includes Glucophage 850 Mg Tab Metformin hcl Take 1 tablet by mouth each morning Amaryl 2 Mg Tab Glimepiride Take 1 tablet by mouth once a Aspirin 81 Mg Ec Tab Aspirin Take one 1 tablet by mouth daily New Remove Change Back Eick OK to save Committed Assessments attach to Problem List for easy review Don C er CHECK PROTOCOLS 59 Year Old Male DO Patient ID 80 57011 Find Pt Protocols Graph Handouts Home 503 629 5541 Insurance BHI Futura G Work 503 692 8955 roup BHI8654 Web Lookup DIABETES MELLITUS TYPE 1 HYPERLIPIDEMIA
74. PgUp Next Form Ctri PgDn 1 The Problem CCC list boxes can be customized by specialty and or provider 2 The customization designates if a single diagnosis description and ICD code is to be added to the patient s problem list or if a custom problem list containing several related diagnoses displays allowing the provider to select the diagnosis with the highest degree of specificity 3 The prefix Diagnosis of Minor Dx of Family History of etc for the problem being pushed to the patient s problem list is assigned in the customization 4 The number of days for a problem added as a Minor Dx to stay on the patient s active problem list can be specified in the customization Page 61 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Problems Ortho CCC continued Problems Ortho CCC Custom Adult Select Region Hip Knee v Add Problems Form Note Unchecking a Problem from this form will NOT remove it from the Problem List ACLTearef _ Knee Replacement ieft Arihriis Hip AAi ACL Tear right Knee Replacement right Bursitis Hip left l ARTHRITI ARTHRALGIA LiSE Arthritis Knee Locked Knee Bursitis Hip right DISLOCATION List Arthroscopy Knee left Loose Body Knee CHD eft FRACTURES LE List Arthroscopy Knee right LCL Sprain left CH D right INFECTIONS List Baker s Cyst LC
75. Problems Instructions Plan Copyright Prev Form CtriPgUp Next Form Ctri PgDn The following prompt appears Logician Message The patient has a history of a myocardial infarction and is currently not on a beta blocker Click Yes to add a medication otherwise click No The provider can click Yes to display the Beta blocker custom medication list and select an appropriate medication to be added to the patient s medication list The provider can click No and a prompt will appear asking if the provider wishes to document the contraindication to the Beta blocker Page 66 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Documenting the contraindication will prevent the prompt from reappearing during subsequent visits as well as provide structured documentation for the specific contraindication The CDSS Contraindications Form allows the provider to document contra indications to treatment diagnostic tests or procedures or to document a variety of staging values The form can be customized by site and specialty CDSS Contraindications CCC Don C Bassett Clinical Decision Support System Documentation of Contraindications to Treatment Deferment of Testing Procedures and Stage Documentation Contraindications to Treatment Treatment Contraindication ACE Inhibitor 1 D
76. RD Kidney Stone and Osteoarthritis push to corresponding obs terms Flowsheet see examples below 9 Clicking the yellow button next to the problem or flowsheet action buttons explains to reminds the provider that removing a problem from the multi line edit field the Past Medical History or Past Surgical History does not automatically remove it from the problem list or flowsheet To do so you must go to the problem list or flowsheet highlight the problem then click Remove or Change Back Example Asthma GERD and Osteoarthritis pushed to Problem List update Problems x Potential problem list for David Neuro Onset Date Up ASTHMA ICD 493 90 GERD ICD 530 81 Down OSTEOARTHRITIS ICD 715 90 Left Fight Top Botta m Assessment Comment C New Improved Unchanged Deteriorated Comment Only Effects of this update Added new problem of ASTHMA ICD 493 90 Added new problem of G E R D ICD 530 81 Added new problem of OSTEOARTHRITIS ICD 715 90 New Change Remove Change Back Click OK to save all changes Click Cancel to discard all changes Cancel NOTE Highlight item then click Change Back to remove if entered in error Page 11 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Asthma GERD Kidney Stone and Osteoa
77. S 2 The list box values can be customized add subtract or modify values 3 Clicking a value in the denies column or complains of column automatically un checks the value in the opposite list box 4 Customization designates which body systems are populated by clicking the 1 NEG 2 NEG or 3 NEG action buttons 5 The super buttons All Negative or 1 NEG 2 NEG or 3 NEG action buttons may be hidden or not visible for sites that want to turn off those features through customization 6 Patient entered history from PatientLink or Kryptiq amp may be automatically inserted or the user may be prompted that patient entered history exists Page 29 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved PE CCC form is designed to allow for rapid point and click entry of a general physical exam as well as to load and go to a variety of expanded detailed examinations cardiac GU orthopedic ENT etc Each site can customize the normal default values the observation terms to which they are attached and the values in the two list boxes The list box values can be either normal or abnormal values Charting by exception allows the provider to rapidly document a detailed PE as well as capture structured data which can be used for reporting or clinical decision support Example General HEENT Gen HEEN
78. T Neck Lung Heat MSK ExtNeuro sPsych Examother i Physical Exam Select Specialty Family Practice E General Normal Prior Clear well developed well nourished in no acute distress normal appearance obese healthy appearing poor hygeine B unkept Head Normal Prior Clear normocephalic and atraumatic macrocephalic microcephalic Eyes Norma Clear Load Form EyeExam Diabetic Eye Exam PERRLAJEOM intact fundi benign conjunctiva and poor LR on left esotropia sciera clear poor LR on right exotropia cataract OS scleral icterus cataract OD conjunctival injection Ears Normal Prior Clear Load Form Exam TM s intact and clear with normal canals and hearing RTM dull RTMred RTM retracted R TM bulging deformity of L pinna deformity of R pinna deformity of both pinna 241 pinna tow set Hose Mormal Prior Clear deformity discharge inflammation or lesions L polyp nasal polyp epistaxis L nares epistaxis R nares clear nasal discharge purulent nasal discharge FBLnares 21 I FBRnares Mouth Normal Prior Clear ho deformity or lesions with good dentition a throat injected tonsilar enlargment white exudate zi post nasal drip poor dentition ulcerated lesions vessicul
79. T10 normal C decreased C absent C normal C decreased C absent Ti normal decreased absent C normal C decreased C absent T12 C normal C decreased absent C normal C decreased C absent Prev Form Ctri PgUp Next Form Ctri PgDn 1 The following be customized by specialty normal default values observation terms that are populated and the items in the two list boxes 2 The list box values may contain either normal or abnormal values 3 Charting by exception allows the provider to rapidly document a detailed PE as well as capture structured data which can be used for reporting or clinical decision support 4 The provider can use voice recognition CCC VRI Dragon 8 Medical to dictate into structured data fields Page 43 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Neurologic Exam CCC Lumbar Sacral Neurologic Exam CCC Don Bassett Neuro Cervical us Reflexes Measure Special LIS Exam Anoma 2 Inspection deformity L S NI Palpation spinaltenderness NI Forward Flexion degrees 60 Hyperextension degrees 25 Schober s cm gt 6 Right Lateral Bend degrees 25 Left Lateral Bend degrees 25 Squatting normal C abnormal Sciatic Notch Tenderness absent C present right C
80. Text File Editing at SOUTH on 04 15 2005 8 41 AM by Harry S Winston MD Summary Change Properties CCC Text File Editor Arial CCC Text File Editor The CCC Text File Editor form may be used to create or edit the customization for the following Core CCC forms e PMH CCC PMH PSH CCC FH SH CCC ROS CCC PE CCC Problems CCC CPOE A amp P CCC Patient Instructions CCC Page 99 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved 2 Select the Specialty CCC Text File Editor Custom Endocrine Page 1 Page2 Page Pages Pages Pages Page CCC Text File Editor For Use in Test Patient s Chart Only Select Specialty Endocrinology Select Encounter Form EJ 100 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved 3 Select the Encounter Form to create edit or customize CCC Text File Editor Custom Endocrine Page 1 Page2 Page Pages Pages Pages Page CCC Text File Editor For Use in Test Patient s Chart Only Select Specialty Endocrinology E Select Encounter Form CPOE A amp P CCC FH SH CCC HPLCCC Patient Instructions CCC Page 101 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Cl
81. Y HX FH Coronary Heart Disease in a male before age 55 OOFH Colon Canc Added new observation of COLONCAHXMOM yes 03 20 2005 16 _ Added nev of FH ALE MI 516 ded new observation of PAST MED HX AsthmaDDo ER deeem StoneOOHx of OsteoarthritisOO E e Change Remove Change Back p New to add or select an observation to change or remove Cancel NOTE Highlight item then click Change Back to remove if entered in error Page 18 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example FH SH CCC for Cardiology Debbie Diabetes Family History Select Specialty Cardiology Insert Selected Values E Last updated reviewed no changes required Check to insert into FH Edit Field FH of Aortic Aneurysm FH of Marfan s Syndrome FH of Sudden Death FH Alcoholism FH Arthritis FH Asthma FH Bleeding disorder FHBreast Ca FHCervical Ca FH of CHD 55 female lt 65 of Colon Colon Ca father Colon Ca mother Colon Polyps FH Depression FH Diabetes FH CYA or Stroke Hypertension Hyperlipidemia FHLung Melanoma FH Migraine FH Osteoporosis FH Ovarian Ca FH Pancreatic Ca FH Prostate Ca FHRenal Dz FH Seizures FH Skin FH Suicide
82. abetes custom problem list The provider can use the Add diagnosis commands to add problems to the patient s problem list anywhere within an update that Quicktext can be used Page 59 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Problems Ortho CCC The Problems Ortho CCC form is an alternative problem entry form for Orthopedic Specialists that allows problems to be grouped together by specific body regions Examples include Back Spine Elbow Knee Shoulder Hip etc Sites can also have more than one region per provider see examples below Problems Ortho CCC Custom Adult Select Region Add Problems Form Note Unchecking a Problem from this form will NOT remove it fy Back Spine E Hip Knee ACSeparation left FRACTURES List Brachial Neuropathy left Foot Ankle AC Separation right Frozen Shoulder left Brachial Neuropathy right Hand Wrist Finger Adhesive Capsulitisleft Frozen Shoulder right Brachial Plexus Injury left Shoulder Adhesive Capsulitis right Loose Body Shoulder Brachial Plexus Injury right Arthritis Shoulder Rotator Cuff Injury left Brachial Plexus Injury at Birth Bicipital Tendonitis left Rotator Cuff Injury right Brachial Plexus Lesion left Bicipital Tendonitis right Shoulder Pain left Brachial Plexus Lesion right Bursitis A C left Shoulder Pain r
83. actors ros s _ Problems CPOE Instructions Plan Copyright Prev Form CtrisPgUp Next Form CtrisPgDn 1 The following may be customized by specialty normal default values observation terms that are populated and the items in the two list boxes 2 The list box values may contain either normal or abnormal values 3 Charting by exception allows the provider to rapidly document a detailed PE as well as capture structured data which can be used for reporting or clinical decision support 4 The provider can use voice recognition CCC VRI Dragon 8 Medical to dictate into structured data fields Page 39 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example MSK Ext Neuro Musckuloskeletal Extremities Neurologic PE CCC Don C Bassett Gen HEENT Neck Lung tHeart Abd GU MsK Ext Neuro si Psych Exmoter Clear Load Forms Hand Wrist Elbow Shoulder Back Hip Foot Ankle joint tenderness Musculoskeletal no deformity or scoliosis noted with normal posture and gait pilonidal sinus tract joint redness spinal deformity joint warmth scoliosis to L decreased ROM scoliosis to R lordosis Pulses Normal Prior Clear Diabetic Foot Exam pulses normal in all 4 extremities diminished L femoral 4 absentL femoral
84. alty Family Practice PCP Smith v Referring Provider Jr Harrison Visit Type cc Acute Visit Child Check Sports Physical Follow up Visit E 4 Check Box to Insert Form s Clear All or Template Peds Acute Visit EF Bright Futures 1 2 Weeks Bright Futures 1 Month Bright Futures 2 Months Bright Futures 4 Months Bright Futures 6 Months Bright Futures 9 Months Bright Futures 1 Year Bright Futures 15 Months Bright Futures 18 Months Bright Futures 2 Years Bright Futures 3 Years Bright Futures 4 Years Bright Futures 5 Years Bright Futures 5 Years Bright Futures 7 8 Years Bright Futures 9 10 Years Bright Futures 11 14 Years Bright Futures 15 17 Years Bright Futures 18 20 Years History C brief 1 3 elements C extended 4 or more elements Problems Medications Allergies Universal Forms Oh by the way 7 Enter FH SH Risk Factors ROS Problems CPOE ap Instructions Plan Copyright Next Form Ctri PgDn Prey Form Ctr PaUpy 1 The Form s Template s list box can be customized to load encounter forms or insert custom text templates In this example the CCCQE Peds Acute Visit and Age specific Bright Futures Forms appear in the Form s Template s list box but any forms or Text Templates may be listed 2 To integrate with the E amp M Advis
85. am CCC Speech is fluent CV Exam CCC Cognition Problems CCC Cognition is intact CPOE CN 2 12 Patient Instructions c Pupils are equal round and reactive to light The fundi are normal and spontaneous venous pulsations are present Extraocular movements are intact Visual fileds are full to visual confrontation Trigeminal sensation is intact and the muscles of mastication are normal The face is symetric Weber is in the midline The tympanic membranes are clear Palate elevates in the midline Voice is normal Shoulder shrug is normal The tongue has normal motion without fasciculations Cerebellar Finger to nose and heel to shin are normal Rapid alternating movements are normal Finger dexterity is normal Tandem gait is normal Additional Neurologic Testing Romberg is normal There is no pronator drift or leg lag Hall Pike maneuvers are normal Cervical Exam Inspection deformity Normal Palpation spinal tenderness Normal gt I Sp x Page 51 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Text Translation for PE CCC Exam Detailed Cardiovascular and Detailed GU Exams Logician Harry S Winston MD Southside Clinic CCC Developme J2 6 15 2005 7 03 PM Chart Go Actions Qptions vEsdesktop C chart reports intenet
86. and or provider 2 The customization designates if a single diagnosis description and ICD code is to be added to the patient s problem list or if a custom problem list containing several related diagnoses displays allowing the provider to select the diagnosis with the highest degree of specificity 3 The prefix Diagnosis of Minor Dx of Family History of etc for the problem being pushed to the patient s problem list is assigned in the customization 4 The number of days for a problem added as a Minor Dx to stay on the patient s active problem list can be specified in the customization Page 62 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved CPOE A amp P CCC The CPOE CCC form is designed to allow providers to create a problem oriented assessment amp plan that automatically documents new medications medication changes lab and diagnostic tests reviewed new orders and any additional descriptions or patient instructions Using the CCC TFE text file editor sites can create custom CPOE Templates which can replace cumbersome encounter forms Disease or problem specific custom medication lists order sets and evaluation and management sets can be created CCC provides over 100 different CPOE templates for Family Practice Internal Medicine 50 different CPOE templates for Pediatrics and 20 for OB GYN Additional CPOE templates ar
87. ar lesions HPI FH SH Risk Factors ROS vs Problems CPOE ap Instructions Plan Copyright Prev Form Ctrl PgUp Next Form 1 The following be customized by specialty normal default values observation terms that are populated and the items in the two list boxes 2 The list box values may contain either normal or abnormal values 3 Charting by exception allows the provider to rapidly document a detailed PE as well as capture structured data which can be used for reporting or clinical decision support 4 A variety of expanded detailed examinations can be loaded and accessed by clicking the specific exam action button ENT Exam EYE Exam Diabetic Eye Exam highlighted in yellow if diagnosis on problem list CV Exam GU Exam Orthopedic Exams Diabetic Foot Exam highlighted in yellow if diagnosis on problem list and Neurologic Exam Page 30 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Neck Lung Heart PE CCC Don C Bassett Gen HEENT Neck Lung Heart MSK ExtNeuro siL Psych Examother a Neck Normal Prior Clear no masses thyromegally or abnormal cervical nuchal rigidity a midline cyst nodes decreased ROM J enlarged thyroid zi Lneckmass Chest Wall Normal Prior Clear no deformities or br
88. avior 2 The provider does not have to complete every field but any fields completed will be structured allowing for clinical decision support and reporting in the future 3 Risk Factor values can be automatically populated from the FH SH CCC form and the new PSIA CDSS application within the CPOE A amp P form Page 22 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved ROS CCC The ROS CCC form is designed to allow for rapid point and click entry of specialty specific medical surgical review of systems The headings and list box items can be customized as well as the order in which they appear and the observation terms with which they are associated This decreases the time necessary document the visit as well as to capture structured data which can be used for reporting or clinical decision support ROS CCC Don Bassett 1 2 Templates View nsert Patient Entered Hx View lnsert Refresh Family Practice REVIEW OF SYSTEMS El Negative 1 Heg 2 Heg 3 Heg Clear View Positive ROS Clear See HPI Show Brief Version of Negative Values in Note _ General Eyes ENT Resp Gl GU e C C e Oh by the way x Enter FH SH Risk Factors ROS Problems Instructions Plan Copyright Prev Form Ctri PgUp Next Form Ctrl PgDn
89. be used Page 53 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Problem CCC Form Customized for Family Practice Internal Medicine Problems CCC Custom Adult Add Problems Form Note Unchecking a Problem from this form will NOT remove it from the Problem List ASCVD DIABETES List Influenza Sleep Apnea ABDOMINAL PAIN List Diarrhea irritable Bowel Syndrome SQUAMOUS SKIN Abnormal Tests Labs Diverticulitis Labrynthitis Stye Hordeolum Acne Diverticulosis Laryngitis acute SYNCOPE List Actinic Keratosis Dizziness Menopause ASTHMA List Dyspnea shortness of breath MENSTRUAL DISORDER List Temporal Arteritis Ataxia Dysphagia Muscle Spasm TENDONITIS List Atrial Fibrillation Dysuria Nausea Tonsillitis Back Pain Eczema Neuralgia MURI Basal cell skin cancer ELECTROLYTE Imbalanace Lisi Neuropathy peripheral UTI BREAST Problems List Epicondylitis medial Nevus benign Urticaria Bronchitis Acute Epicondyiitis lateral Obesity VASCULAR List Bronchitis Chronic Epistaxis Onychomycosis Vaginitis BURSITIS List Erectile Dysfunction Osteoporosis Vertigo CHF Fever Otitis Externa Vomiting COPD Fibromyalgia OTITIS MEDIA List Wart viral CV A Stroke Fungal Dermatitis P
90. blem CCC form Previously the limitation was 125 list box items Please note that 125 list box items will display on the form without scrolling Adding more than 125 list box items will require the user to scroll down in the list box to see the additional items that do not fit in the normal display 6 For those providers using the CCC VRI voice recognition any item on the Problem CCC form can now be voice activated A provider can add a diagnosis or access a custom problem list simply by saying Add diagnosis lt insert name of problem as listed on Problem CCC Form gt Examples Add diagnosis adds the diagnosis UTI Add diagnosis diabetes displays the diabetes custom problem list The provider can use the Add diagnosis commands to add problems to the patient s problem list anywhere within an update that Quicktext can be used Page 58 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Problem CCC Form Customized for Orthopedics Problems CCC Custom Adult Add Problems Form AC Degeneration Chronic ACL Sprain Chronic AC Separation Gameskeeper Thumb Ganglion Hand Wrist Gout Achiles Tendon Rupture HNP Cervical Adhesive Capsulitis HNP Lumbar AMPUTATION List Specify Hallux Rigidus Arm Leg Finger Toe Pain Hallux Valgus Aseptic Necrosis Hammertoe Back Pain
91. button NOTE Values will not appear in text or push to problem list until the action button is clicked This allows for corrections to be made prior to committing The list box headings and list box values are customizable The items that push to the problem list or flowsheet as structured obs terms are also customizable 4 The Onset Procedure Date optional may be entered in the Date field 5 Corresponding problems in list boxes push to the multi line edit field Past Medical History as well as to the problem list and flowsheet 6 The provider can also enter clinical information using QuickText typing inserting text templates or using voice recognition for any items not listed or if additional information is desired NOTE any information entered using these methods will only populate the PAST MED HX or PAST SURG the information will not populate specific obs terms and will not add problems to the patient s problem list 10 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved 7 The first 15 items in each of the list boxes can be visualized additional items beyond 15 per list box require scrolling the bar on the right side of the list box is a visual cue that additional items are in the list box 8 In the example above Asthma GERD and Osteoarthritis pushed to problem list but all four problems Asthma GE
92. cation list for this problem includes Glucophage 850 Mg Tab Metformin hcl Take 1 tablet by mouth each moming Amaryl 2 Mg Tab Glimepiride Take 1 tablet by mouth once a day Effects of this update Added new problem of SUBENDOCARDIAL M I ICD 410 70 Assessed DIABETES MELLITUS as comment only Refer to Diabetes Education Program and schedule for a stress test prior to starting exercise program His updated medication list for this problem includes Glucophage 850 Mg Tab Metformin hcl Take 1 tablet by mouth each morning Amaryl 2 Mg Tab Glimepiride Take 1 tablet by mouth once a day Aspirin 81 Mg Ec Tab Aspirin Take one 1 tablet by mouth daily New Change Remove Change Back Eick save al changes Cancelto decad chang cw Committed assessments attach to Problem List for easy review n MD Southside Clinic CCC Development JJ2 6 28 2005 3 41 PM Chart Go Actions Options Heb C chart Reports Anew intemet Hep Don C Bassett CHECK PROTOCOLS Home 503 629 5541 Work 503 692 8955 59 Year Old Male DO Patient ID 80 TEST011 Insurance BHI Futura Group BHI8654 Web Lookup Summary Problems medications Alerts Flowsheet Orders Documents update Details Onset Date 06 08 2005 ICD 250 00 End Date lt No End Date gt
93. contraindication in the CCCQE CHF Form Would you like to complete now IF so then load the CHF Form Other examples include post MI patients not on aspirin or beta blocker patients at risk for ASCVD and LDL gt 100 and not on statin patients on methotrexate who are due for screening monitoring labs Page 118 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example of prompt for tests services due based on diagnosis and treatment Logician Message xi 2 The Following tests are now due 1 Lipid Panel 2 Hepatic Profile 3 Electrolytes 4 HbAic 5 Creatinine 6 Microalbumin urine Would you like to see the Indications For these recommended tests Click Yes to see the Indications Otherwise click Clicking Yes displays the indications Logician Message 2 Test Indications 1 Lipid Panel Hx of Coronary Dz Previous LDL gt 100 and was last checked gt 3 months ago 09 10 2001 currently on Statin Rx 2 Hepatic Profile Currently taking Statin Last SGPT ALT done gt 6 months ago 09 20 2000 3 Electrolytes Currently taking Diuretic Last Potassium gt 6 months ago 09 20 2000 4 HbA1C Dx of Diabetes and no HbA1C reported 5 Creatinine Dx of Diabetes and last value gt 1 year ago 09 20 2000 6 Microalbumin urine Dx of Diabetes and no value reported Would yo
94. creased left face decreased RUE decreased LUE decreased RLE decreased LLE decreased RE decreased LE pw eee ee miea 1 The following may be customized by specialty normal default values observation terms that are populated and the items in the two list boxes 2 The list box values may contain either normal or abnormal values 3 Charting by exception allows the provider to rapidly document a detailed PE as well as capture structured data which can be used for reporting or clinical decision support 4 The provider can use voice recognition CCC VRI Dragon 8 Medical to dictate into structured data fields Page 46 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Neurologic Exam CCC Reflexes Neurologic Exam CCC Don C Bassett Neuro Cervical Thoracic US Motor Sensory Reflexes Measure Special Reflex Exam _AlNormal Lower Extremities Ony Car 2 DTR s Normal Increased Decreased Clear Normal Lower Ext Only Norm Lower Incr Lower Decr Lower Double Simultaneous Stimulation Left Right Bilateral Prior Clear Sterognosis Normal C AbnormalR C AbnormalL Deep tendon reflexes in the upper and lower extremities are normal bilaterally Il xe Right Biceps T LeftBiceps x Right
95. ds 5 Click the Diabetic Foot Exam action button to go to the Diabetic Foot Exam section the button is highlighted in yellow if a diagnosis of Diabetes is on the patient s Problem List 6 Click the Neurologic Exam action button to load and go to detailed neurologic exam form Page 40 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Detailed Neurologic Exam Neurologic Exam CCC Speech Cognition Cranial Nerves Cerebellar Other Neurologic Exam CCC Don C Bassett Neuro us Motor Sensory Reflexes Special Detailed Neurological Exam Speech Normal Speech is fluent f expressive aphasia slurred recptive aphasia thickened zi apraxia Cognition Normal Clear Cognition is intact a confused decreased mentation disoriented 21 withdrawn CN 2 12 Normal Clear Pupils equal round and reactive to light The fundi normal and spontaneous venous pulsations are present Extraocular movements are intact Visual fileds are full to visual confrontation Trigeminal sensation is intact and the muscles of mastication normal The face is symetric Weber is in the midline The tympanic membranes are clear Palate elevates in the midline Voice is normal Shoulde
96. e CCC Cardic JEnterprise CCC Cardic JEnterprise CCC Renal S Depending on which of the Core forms is being edited the column headers and corresponding Instructions action buttons will be different For the HPI CCC form the columns will be 1 EF Template Name This is the value that appears in the list box on the HPI CCC form describing the encounter form name or the text template name that will be loaded or inserted 2 EF Path Template This is where the path name for the encounter form you wish to load or the text template you wish to insert NOTE Users of CCCQE VRI with Dragon NaturallySpeaking 8 Medical can use the Edit All voice macro to open a larger text box to edit templates Users of CCCSpeak can use the Edit Now voice macro to open up a larger text box to edit templates 3 EF Button Opens a list of common forms and paths that can be copied and pasted into the form 4 M F Place in this field if you only want the list box values to appear for males only and F for females only The default blank field is for both male and female Page 111 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Click the yellow Put Updated Values into Text action button to write the CCCQE MEL Code The action button will turn blue grey J2 4 15 2005 2 51 PM Chart
97. e continuously being developed for various medical surgical subspecialties With the release of Version 8 3 a fully customizable clinical decision support system CDSS and patient severity index assessment PSIA application has been built into the CPOE A amp P CCC form Using a combination of provider specialty specific CPOE Templates CDSS and PSIA protocols providers can manage any problem assuring evidence based quality therapeutic review diagnostic test ordering and diagnosis specific management no matter what specialty or condition With a properly customized and managed CPOE A amp P module the need for diagnosis or disease specific encounter forms is eliminated This decreases the amount of time necessary to develop design train and maintain encounter forms Key Points 1 CPOE Templates can be set up by provider and or by specialty based on specific diagnosis codes 2 Once the provider selects a problem from the dropdown list which contains a listing of the patient s active problems with newly added problems listed at the top the customization associated with that problem allows the provider to quickly and easily e navigate to problem oriented disease specific Custom Medication Lists e navigate to problem oriented disease specific Custom Order Lists e insert custom templates to document the review of protocol specific labs diagnostics or other structured data as well as insert patient instructions o
98. e customizable 3 The items that push to the problem list or flowsheet as structured obs terms are also customizable Page 16 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Corresponding problems in list boxes push to multi line edit field Family History or Social History as well as to the problem list and flowsheet The provider can also enter clinical information using QuickText typing inserting text templates or using voice recognition for any items not listed or if additional information is desired NOTE any information entered using these methods will only populate the Family History Family HX or Social History Social Hx obs terms the information will not populate specific obs terms and will not add problems to the patient s problem list In the example above FH Coronary Heart Disease in a male before age 55 and FH Colon Cancer in mother pushed to the problem list and to the corresponding obs terms flowsheet see examples below Clicking the yellow button next to the Problem or Flowsheet action buttons explains to reminds the provider that removing a problem from the multi line edit field the Family History or Social History does not automatically remove it from the problem list or flowsheet To do so you must go to the Problem List or Flowsheet highlight the problem then click Remove or Change Back Update Probl
99. e number of days for a problem added as a Minor Dx to stay on the patient s active problem list can be specified in the customization Page 60 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Problems Ortho CCC continued Problems Ortho CCC Custom Adult Add Problems Form Abnormal involuntary Movemer AMPUTATION List Avascular Necrosis AVN Boutonniere Deformity Bursitis Olecranon Carpal instability DISVVISVDRU Carpal Tunnel Syndrome CTS Cubital Tunnel Syndrome Clinodactyly Compartment Syndrome Hand DeQuervain s Tenosynovitis DIABETES COMPLICATIONS Li DuPuytren s contracture Epicondylitis medial Epicondylitis lateral Gamekeepers Thumb Cyst Joint Ganglion Cyst Tendon sheath Granuloma pyogenic GCT Tendon Sheath Arthropathy Heterotopic Ossificiation Implant failure mechanical com Inflammatory infectious complic Internal Derangement Wrist joint arthroplasty shoulder joint arthroplasty elbow joint arthroplasty wrist SP joint arthroplasty other Kienbocks Disease Kienbock s Disease Pediatric Lipoma upper extremity Little League Elbow Loose Body Elbow Mallet Finger Mallet Finger Bony Myositis Ossificans Traumatic Nailbed Laceration Paintgun Injury Pol
100. east masses noted a pectus excavatum a L breast mass pectus carinatum Rbreast mass 21 supernumary nipple Breasts Prior Clear masses or gynecomastia noted no masses a gynecomastia 7 gl adenopathy palpable mass 21 no swelling palable node s 1 Lungs Normal Prior Clear decreased BS onL decreased BS on R decreased BS bilateral clear bilaterally to A amp P a rhonchiL rhonchiR rhonchi bilateral tachypneic retractions on L retractions on R retractions bilateral wheezesonL wheezesonR Heart Norma Prior Clear Load Form CV Exam regular rate and rhythm 51 52 without murmurs Grade 6 SEM loudest primary aortic a rubs gallops or clicks Grade 6 SEM loudest LLSB Grade 6 SEM loudest at apex axillt Grade 6 DM loudest at primary aortic Grade 6 DM loudest at LLSB Grade 6 DM loudest at apex pericardial friction rub HPI ACV PMH 5 Risk Factors ROS s _ Problems CPOE Instructions Plan Copyright Prev Form CtrisPgUp Next Form 1 The following may be customized by specialty normal default values observation terms that are populated and the items in the two list boxes 2 The list box values may contain either normal or abnormal values 3 Click the CV Exam action button to load and go to detailed cardiovascular
101. eatinine 1 0 mg dL 06 12 2002 CAPTOPRIL 100 MG TAB Take 1 tablet by mouth twice a day 1 50 CAPTOPRIL 12 5 MG TAB Take 1 tablet by mouth twice a day 50 60 Insurance BHI Futura Current Medications n ZAROXOLYN TAB 5MG METOLAZON sm FUROSEMIDE TABS 20 MG FUROSEM Define Medication NEXIUM 40 MG CAPDR ESOMEPRAZC Medication GLUCOPHAGE 850 MG TAB METFORI AMARYL 2 MG TAB GLIMEPIRIDE Instructions LIPITOR 20 MG TAB ATORVASTATIN ASPIRIN 81 MG TAB ASPIRIN gt Start Date 06 28 2005 B Stop Date B Duration 6 Days Weeks 7 Months ASA Prescription Quantty Refills Print Pt Handout Pharmacy deal Pharmacy Authorized Starr MD Kelly G id 14625 SW Ithaca Select Beaverton OR 97007 USA Prescribing Method Telephone M Ph 503 646 1194 oregon k Fax 503 646 1196 zi State 9769 4 n Add to custom list Drug Instructions Duration Qty Refils Save amp Continue ILo Cancel Current Allergies The provider can click No and no further pop up messages will display or the provider can click Yes which will allow them to document the contraindication using the CDSS Contraindication CCC form or any other form the site may have developed Page 65 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example of Beta blocker Usage Post MI CDSS The provid
102. ed Copyright 2005 Clinical Content Consultants LLC All rights reserved To paste the CCCQE MEL functions into the CCCQE User Edit TFE text file do the following Press CTRL V this inserts the selected text into the TFE text file Press CTRL S this saves the TFE text file Close the TFE text file Open the Text File Editor form component Click the Remove from Text action button to remove the CCCQE MEL functions from the chart note Click the Insert Formatted Text action button to insert a summary description of customizations into the chart note Copy and paste the formatted text into a Word document for your records Page 108 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Customize the HPI CCC T gt m Start an update test patient s chart and insert the CCC Text File Editor encounter form Select the specialty of the form you wish to customize Select the encounter form to be customized The first time you select a form to edit your old CCCQE User Edit text file customization will be extracted and inserted into the TFE A yellow alert with instructions will appear In order to extract the gender specific functionality from the old text file format you must close the form go to the Registration module and change the test patient s sex form male to female or female t
103. ed Copyright 2005 Clinical Content Consultants LLC All rights reserved CCC Text File Editor Custom Cardiology Page 1 Page2 3 Page 4 Page 5 Page 6 Page 7 CCC Text File Editor For Use Test Patient s Chart Only Select Specialty Cardiology Select Encounter Form HP CCC insert Values for Editing PutUpdated Valesinto Text _ Remove tromText insert Formatted Text Open Text File to Edt 2 Search Medications Search Problems _Load EF for Reference EF Template Name EF Path T oo Instructions Instructions Li ist Instructions S Instructions _ Instructions e Instructions S Instr Acute VistForm Anticoagualtion Forr v Chest Pain Hx Form CHF Fom 7 Diabetes Form Hypertension Form JLipid NCEP Il Form Prior Treatment Forn v Cardiovascular Risk v Cardiovascular Rep v Data Entry Diagnostic Testing R v Echocardiogram For v Pre op Evaluation Fc Stress v Renal Evaluation For v New Patient Templat v Acute Visit Template v Pacemaker Template Pre op Template EnerpiseCCC Adut JEnterprise CCC CPOE JEnterprise CCC Cardic JEnterprise CCC CHF JEnterprise CCC Diabe EnterpriseiCCC Hype JEnterprise CCC Lipid JEnterprise CCC Prior JEnterprise CCC Cardi JEnterprise CCC Cardic JEnterprise CCC Data JEnterprise CCC Diagn JEnterprise CCC Cardic JEnterpris
104. eferment of Testing Procedure Test or Procedure Reason for Deferment Stage Documentation Classification Scheme Class or Stage um Intake Prenatal visit Past Preg Hx Genetic Flowsheet Lab Prenatal Ed Ultrasound PAP Entry HPI Acv PMH FH SH Risk Factors ROS vs _ Problems CPOE Instructions Plan Copyright Prev Form Close Select the Treatment Test Procedure or Staging to be documented from the appropriate dropdown list Page 67 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved CDSS Contraindications CCC Don C Bassett Clinical Decision Support System Documentation of Contraindications to Treatment Deferment of Testing Procedures and Stage Documentation Contraindications to Treatment Treatment Contraindication ACE inhibitor Eough Deferment of Testing Procedure hypotension Test or Procedure 55 renal insufficiency lo renal artery stenosis Stage Documentation Classification Scheme Class or Stage Intake Prenatal visit Past Preg Hx Genetic Flowsheet Lab Prenatal Ed Ultrasound PAP Entry HPI Acv PMH FH SH Risk Factors ROS vs Problems CPOE AIP Instructions Plan Copyright Prev Form Ctri PgUp Select the contraindication or
105. ems xj Potential problem list for David Neuro ASTHMA ICD 493 90 GERD ICD 530 81 OSTEOARTHRITIS ICD 715 90 FAMILY HISTORY CORONARY HEART DISEASE MALE 55 FAMILY HISTORY COLON CANCER MOTHER ey Assessment Comment New Improved Unchanged Deteriorated Comment Only Effects of this update Added new problem of ASTHMA ICD 493 90 Added new problem of G E R D ICD 530 81 Added new problem of OSTEOARTHRITIS ICD 715 90 Added new problem of FAMILY HISTORY CORONARY HEART DISEASE MALE 55 17 3 problem of FAMILY HISTORY COLON CANCER MOTHER 16 0 Added new New demove Change Back Click OK to save all changes Click Cancel to discard all changes Cancel NOTE Highlight item then click Change Back to remove if entered in error Page 17 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Update Flowsheet Potential Observation list for David Neuro View lt All gt 03 20 2005 yes COLONCAHXMC FH Coron lt 55 AsthmaDD 5 yes yes E Effects of this update Added new observation of SOCIAL HX Religious Belief amp ffecting Care 03 20 2005 16 45 Added new observation of FAMIL
106. ent s 10 year risk of heart disease Page 122 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Framingham Cardiovascular Risk Calculator Guidelines Encounter Form Cardiovascular Risk CCC Judy S Pullman CV Risk Assessment Insert Text BP this visit 150 100 Prior BP 128 72 08 12 2002 Stage of Hypertension at time of diagnosis if applicable High norrnal SBP 130 139 DBP 85 89 Some values in RED have been extracted from data in patient s chart and Stage 1 SBP 140 159 DBP 90 99 cannot be changed unless the chart data is changed first Stage 2 SBP 160 179 DBP 100 109 Stage 3 SBP gt 180 DBP gt 110 Identify Major Risk Factors Age 55 or greater yes C no Diabetes C yes C LastGlucose 112 08 15 2002 Hyperlipidernia 6 yes C no LastChol 146 08 15 2002 LastHDL 90 11 09 2000 Last LDL 64 11 09 2000 Hypertension C yes C no FH of cardiovascular disease RISK GROUP B Prior Value B 01 14 2005 MI in female 65 yes At least 1 risk factor EXCLUDIHG diabetes with HO target organ damage male 55 yes no Smoking status current quit C never Identify Target Organ Damage Clinical CV Disease ASHD CAD or CABG yes C no 10 YEAR CHD RISK 9 Prior Value 1 01 14 2005 LVH or CHF C yes C no Calculated from the foll
107. entive Est 1yr infant Pv 9 Month WCC Admin Immunization 2 Comvax Pneumococcal Peds Preventive Est 1yr infant 15 Month WCC DTAP Admin Immunization 2 CBC Complete Preventive Est 1 4 yrs 6Month WCC Lead Screen State HIB PRP T 4 dose Pneumococcal Peds Preventive Est 1yr infant Venipuncture MMR Admin Immunization 2 Admin Immunization 2 smoses ox Page 75 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Orthopedic Specific Upper Extremity Custom Order List Update Orders Don C Bassett 59 Year Old Male DOB 11 25 1945 Orders Thisupdate Open All Primary Coverage BHI Futura DIABETES MELLITUS TYPE Il DIABETES MELLITUS TYPE Potential Diagnoses DIABETES MELLITUS TYPE Il HYPERLIPIDEMIA CONGESTIVE HEART FAILURI Hemoglobin 1 Unsigned Microalbumin urine Sx of HOARSE VOICE QUALT Lipid Panel Unsigned DIABETES MELLITUS I zm EFFUSION PLEURAL EKG complete Unsigned DIABETES MELLITUS TYPE EDEMA new teary Ofc Vst Est Level Ofc Vst Est Level II Ofc Vst Est Level ill Ofc Vst Est Level V Ofc Vst Est Level V Ofc Vst New Level Ofc New Level Il
108. er selects Subendocardial MI from dropdown list Note The CHF medications that the patient is being treated with automatically appear in the section for CHF as do all problem medication class designated problems CPOE A amp P CCC Don C Bassett A amp P 1 2 apse asp7 s amp 9 10 asp 11 12 __Load Documentation Form Select Specialy Faiy Assessment 1 Select problem enter assessment orders and meds then click Commit Assessment Prob List CONGESTIVE HEART FAILURE ICD 428 0 _Commit Assessment Clear All His updated medication list for this problem includes Zaroxolyn Tab 5mg Metolazone 1 po qd Furosemide Tabs 20 Mg Furosemide 1 po bid Aspirin 81 Mg Ec Tab Aspirin Take one 1 tablet by mouth daily New Meds Change Meds Insert Meds New IN Insert Orders Ri Insert Template R Print Handout 3 Assessment 2 Select problem enter assessment orders meds then click Commit Assessment commitment Clear Alt SUBENDOCARDIAL M I ICD 410 70 DIABETES MELLITUS ICD 250 00 HYPERLIPIDEMIA ICD 272 4 CONGESTIVE HEART FAILURE ICD 428 0 Sx of HOARSE VOICE QUALITY EFFUSION PLEURAL ICD 511 9 Add AII Meds to Note Remove New Meds from Note Rx Monitoring and General Alerts Rec Interventions Rec Tests Orders 5 Risk Factors ros _vs
109. eral Alerts Orders Intake Prenatal visit Past Preg Hx Genetic Flowsheet Lab Prenatal Ed Ultrasound PAP Entry HPI Acv PMH FH SH Risk Factors ROS _vs _ Problems CPOE Instructions Plan Copyright Prev Form Ctri PgUp Next Form Ctri PgDn Close Page 84 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Problem List showing Committed Assessments for Prenatal Care CHECK PROTOCOLS Home 503 626 1988 Work 503 639 5877 237 TEST011 CHC Gold Plan up CHC3587 a Find Pt E Graph Handouts Update Phone Nt Refills Web Lookup Details Onset Date 04 24 2005 Descripti DIABETES MELLITUS INSULIN DEPENDENT IDDM since 4 years old well controlled last 15 years PRENATAL CARE ICD V22 1 End Date No End Date Entry Date 04 24 2005 9 56 AM Entered By Harry S Winston MD Responsible Harry S Winston MD View Problem Details Assessment 06 28 2005 Comment only Harry S Winston MD EDC 11 08 2005 Wks Gest 21 0 7 Wt 144 BP 10268 18 FetalHR 180 Fetal Position breech Comments Folow up Referalto Genetics Clinic repeat U S prior to next visit 2 weeks Her updated medication list for this problem includes Prenatal 1 1 Tabs Prenatal multivit min fe fa 1 po daily 04 24 2005 Comment only Harry S
110. exam form Page 31 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Detailed Cardiovascular Exam CV Exam CCC Neck Neck Heart vascular Special Other Neck Carotids Normal Prior Clear Carotids full and equal bilaterally without bruits left carotid bruit right carotid bruit bilateral carotid bruits radiation of murmur into carotids diminished left carotid pulse diminished right carotid pulse absent left carotid pulse absent right carotid pulse zl Neck Veins Normal Prior Clear Normal no JVD flat neck veins HPI PMH FH SH Risk Factors ros 5 Problems CPOE Instructions Plan Copyright Prev Form Ctri PgUp Next Form Close 1 The following may be customized by specialty normal default values observation terms that are populated and the items in the two list boxes 2 The list box values may contain either normal or abnormal values 3 Charting by exception allows the provider to rapidly document a detailed PE as well as capture structured data which can be used for reporting or clinical decision support 4 The provider can use voice recognition CCC VRI Dragon 8 Medical to dictate into structured data fields Page 32 Copyright 2005 Clinical Content Consultants LLC All rights reserved C
111. gery Thyroid Surgery S P ccc Endo PMH exec Prostate Surgery Prostate Surgery Hx ofM ccc Endo PMH exec T U R P T U R P Hx of M ccc Endo PMH exec Other Surgery Other Surgery ccc Endo PMH exec CB ccc Endo PMH exec Alcoholism Alcoholism PMHAL COHOLSM yes l CD 305 00 Dx ccc Endo PMH exec Anemia Anemia PMH ANEMIA yes Dx of ccc Endo PMH exec Anesthetic Complications Complications with Anesthesia PMH ANSTHCMP yes Hx of ccc Endo PMH exec Anxiety Anxiety PMH ANXIETY yes ICD 300 00 Hx ccc Endo PMH exec Asthma Asthma PMH ASTHMA yes ICD 493 90 Dx of ccc Endo PMH exec Birth Defects Birth Defects PMH BIRTH DF yes Dx ccc Endo PMH exec Blood Transfusions Blood Transfusions PMH XFUSION yes Hx of ccc Endo PMH exec Colon Rectal Cancer Colon Cancer PHHCOLONCANC yes ICD V10 05 Hx oft ccc_Endo_PMH_exec Arthritis Crippling Arthritis PMH ARTHRITS yes Dx of ccc Endo PMH exec Depression Depression DEPRESSION yes ICD 311 Dx of ccc Endo PMH exec Diabetes Diabetes Dx of ccc Endo PMH exec Growth Development Disorder Growth D evelopment Disorder PMH GRWTHDSE yes Hx of El For Help press F1 Breas Note if you inserted the form component as a reference during the editing process you will need to remove the form component from the chart update before doing the steps listed below Page 106 Copyright 200
112. gue MALIGNANT List Medulloadrenal hyperfunction MENOPAUSE List MENSTRUAL List M Hist MONONEURTIS List Obesity Orthostatic hypotension Osteomalacia unspecified OSTEOPOROSIS List OTHER List OVARIAN DYSFX List Palpitations Pancreatic steatorrhea Panhypopituitarism Peripheral vascular disease ur Pituitary dwarfism POISONING Endocrine List Polycystic ovaries POLYGLANDULAR List Postablative ovarian failure Urinary tract infection Venous insufficiency unspecif VISION PROBLEMS List Visual field defects VITAMIN D DEFICIENT List Volume depletion Xanthelasma Problems Medications Allergies Orders Add Text to Note Select Specialty Endocrinology EA Cursor must be blinking in Chronic Renal Failure Hypertrophy of breast Postablative testicular hypofun ew eR In E CORE CHF Heart Failure Hypertrophy of prostate Precocious sexual developmer d Corticoadrenal Insuffiency 2 tivppcalcoma Premenstrual tension syndrom N Problems Added COPD Hypoglycemic coma PROSTATE List CIUS TUTO Cushings Syndrome Hypoglycemic unspecified TESTICULAR List CV A Stroke Hypoparathyroidism Tetany Cyst of Thyroid HYPOTHYROID List THYROIITIS List DECUBITUS ULCER List latrogenic pituitary disorders Thyroid amp thyroid derivatives Delay in sexual development ai Impaired fasting g
113. harting by exception allows the provider to rapidly document a detailed PE as well as capture structured data which can be used for reporting or clinical decision support 4 The provider can use voice recognition CCC VRI Dragon 8 Medical to dictate into structured data fields Page 33 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example CV Exam CCC Vascular CV Exam CCC Don C Bassett Neck Heart Vascular Special Other Vascular Abdominal Aorta Prior Clear no palpable masses pulsations or audible bruits audible abdominal bruit Femoral Pulses Normal Prior Clear normal femoral pulses bilaterally diminished right femoral pulse diminshed left femoral pulse absent right femoral pulse absent left femoral pulse Pedal Pulses Normal Prior Clear normal pedal pulses bilaterally diminished right dorsalis pedis pulse diminished right posterior tibial pulse absent right dorsalis pedis pulse absent right posterior tibial pulse diminished left dorsalis pedis pulse diminished left posterior tibial pulse absent left dorsalis pedis pulse absent left posterior tibial pulse Radial Pulses Normal Prior Clear normal radial pulses bilaterally diminished right radial pulse diminished left radial pulse absent right radial
114. he most common patient health risk factors The results are entered as structured data which can be used for reporting or clinical decision support Risk Factors CCC Don C Bassett Risk Factors 2 Select Specialty ENT ha Tobacco Use Alcoholuse yes no current C never Passive smoke exp yes C no Drug use C no Exercise yes no HIV high risk behavior C yes no Caffeine use drinks day 2 7 Seatbelt use 50 MESH Sun Exposure frequently E Ml in female age 65 C no Date of Last Colonoscopy Ml in male age lt 55 C no Oh by the way j Enter PMH FH SH Risk Factors ROS Problems CPOE AP Instructions Plan Prev Form Ctrl PgUp Next Form Ctrl PgDn 1 Risk factor items be expanded for more detailed data entry Examples Tobacco Use Alchol Use Drug Use HIV high risk behavior 2 The provider does not have to complete every field but any fields completed will be structured allowing for clinical decision support and reporting in the future 3 Risk Factor values can be automatically populated from the FH SH CCC form and the new PSIA CDSS application within the CPOE A amp P form Page 21 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example E
115. iabetes Education c New Patient Template C brief 1 3 elements extended 4 or more elements Problems Medications Allergies Universal Forms Oh by the way v Enter Coag AsthmaHx AsthmaPlan Back Dyspepsia _ Lipids Prevent Risk HPI Acv PMH FH SH Risk Factors ROS PE Problems CPOE Instructions Plan Copyright Next Form Ctrl PgDn Prey Form 1 Form s Template s list box customized to load encounter forms or insert custom text templates In this example the CCCQE Disease Management Forms appear in the list boxes but any forms or Text Templates may be listed 2 To integrate with the E amp M Advisor the provider must check either the brief 1 3 elements or extended 4 or more elements radio button 3 Text can be entered into the multi line edit field using QuickText typing inserting text templates or using voice recognition 4 Navigation Buttons at bottom of form allow quick navigation between the Core Forms NOTE All CCC forms are best viewed using display settings of 1024 X 768 5 For certain specialties specialty specific navigation buttons appear at the bottom of the form 6 If a patient has a problem on their active Problem List that may be documented using one of the CCCQE Disease Management forms the action button for the cor
116. ies Directives Flowsheet Orders End Upd Summary Problems Medications Alerts Orders Update Doc ID 431 Properties Office Visit at SOUTH on 05 10 2005 2 35 PM by Harry S Winston MD Summary Change Properties HPI CCC PMH CCC FH SH CCC Review of Systems Risk Factors CCC ROS CCC Adult Vital Signs CCC Complains of chest pain at rest and palpitations PE CCC Problems CCC Resp Test Management CCc Complains of cough and wheezing CPOE Patient Instructions C Neuro Complains of dizziness The review of systems is negative for General Endo GU MS Eyes Derm Psych Heme Allergy and ENT Adult Vital Signs C CC PE CCC For Help press F1 Em ZZ 27 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example ROS ENT ROS CCC Don C Bassett Page 1 2 Templates Yiewinsert Patient Entered Hx View Insert Select Specialty JENT REVIEW OF SYSTEMS All Negative 1 Heg 2 Heg 3 Heg Clear ALL View Positive ROS Clear View See HPI Show Brief Version of Negative Values Note Ears Hose Throat Allergy Resp Cardiac GI GU oie E Ears Complains of Denies See HPI ear pain ear pain Hegative drainage drainage change in hearing change in heari
117. ight Phlebitis Upper Extremity left Bursitis A C right SPRAIN STRAIN List Phiebitis Upper Extremity right Bursitis Shoulder left Bursitis Shoulder right Bursitis Subacromial left Bursitis Subacromial right Calcific Tendonitis left Calcific Tendonitis right Contracture Shoulder Contusion Shoulder Derangement Shoulder DISLOCATION List DJD Shoulder Sprenge s Deformity Tendonitis Shoulder left Tendonitis Shoulder right New Problems Added most recent addition on top Problems Medications Allergies Orders Remove Text Cursor must be blinking in Yellow Field for CCC Speak EN Back Exam Finger Exam Foot Ankle Exam Hand Wrist Exam Hip Exam Knee Exam Shoulder Elbow Exam HPI Acv PMH FH SH Risk Factors ROS vs Problems Instructions Plan Copyright Prev Form Ctri PgUp Next Form CtrisPgDn 1 Problem CCC list boxes be customized by specialty and or provider 2 The customization designates if a single diagnosis description and ICD code is to be added to the patient s problem list or if a custom problem list containing several related diagnoses displays allowing the provider to select the diagnosis with the highest degree of specificity 3 The prefix Diagnosis of Minor Dx of Family History of etc for the problem being pushed to the patient s problem list is assigned in the customization 4 Th
118. inical Content Consultants LLC All rights reserved The first time you select a form to edit it will pull in the old CCCQE User Edit text files A yellow alert with instructions will appear Page 1 page2 Page3 Pages Pages Pages Page7 CCC Text File Editor For Use in Test Patient s Chart Only Select Specialty Endocrinology Select Encounter Form PMH CCC TT In order to extract the gender specific functionality from the old text file format you must close the form go to the Registration module then change the test patient s sex form male to female or female to male When the update is re opened the yellow prompt will be gone and the TFE tools will appear Page 102 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved CCC Text File Editor Custom Endocrine Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 CCC Text File Editor For Use Test Patient s Chart Only Select Specialty Endocrinology Select Encounter Form PMH CCC insert Values for Editing Putupdated Values into Text Remove fromText insert Formatted Text Open Text File to Edit Search Medications Search Problems El Load EF for Reference Label Prob List Text Obs Term Obs Value Dx Code Dx Prefix MIF Instructions Instructions Instructions Instructions Instr
119. ion and ICD code is to be added to the patient s problem list or if a custom problem list containing several related diagnoses displays allowing the provider to select the diagnosis with the highest degree of specificity 3 The prefix Diagnosis of Minor Dx of Family History of etc for the problem being pushed to the patient s problem list is assigned in the customization 4 The number of days for a problem added as a Minor Dx to stay on the patient s active problem list can be specified in the customization 5 For Version 8 3 and forward there is no limit to the number of problems that can be listed on the Problem CCC form Previously the limitation was 125 list box items Please note that 125 list box items will display on the form without scrolling Adding more than 125 list box items will require the user to scroll down in the list box to see the additional items that do not fit in the normal display 6 For those providers using the CCC VRI voice recognition any item on the Problem CCC form can now be voice activated A provider can add a diagnosis or access a custom problem list simply by saying Add diagnosis insert name of problem as listed on Problem CCC Form Examples Add diagnosis UTI adds the diagnosis UTI Add diagnosis diabetes displays the diabetes custom problem list The provider can use the Add diagnosis commands to add problems to the patient s problem list anywhere within an update that Quicktext can
120. ions Check boxes then Click to Enter or Clear All enter directly into edit field Anticipatory guidance handouts for age 9 months given Take 650 1000mg every 4 6 hours as needed for relief of pain or comfort of fever but DO NOT take more than 4 grams in a 24 hour Clear liquid gt progress Force fluids Fast Overnight period can cause liver damage in higher doses WCC Preventive Care Newborn visit 2month visit 4 month visit Acute Care Abdominal Pain 24Hr recheck Abdominal Pain chronic Abrasion Laceration Allergies Bronchiolitis Thickened Feedings Avoid Bottle to Bed Respiratory Asthma Ed Referred Asthma Ed Refused Asthma Ed Attending Asthma Ed Completed Follow up 2 months Follow up 3 months Follow up 4 months Follow up 6 months Follow up 1 year Follow up prn Shots 2 weeks Shots in 2 weeks WIC Referral Orthopedic Miscellaneous Ankle Sprain Out of School Return to School Out of Sports Phys Ed Return to Sports Phys Ed Burn Circumcision Care Colic Cord Care Constipation Croup Diarrhea Gastroenteritis Eating Healthy 12 month visit 15 month visit 18 month visit Ibuprofen Throat Culture Done AB pending Throat Culture OTCMeds Sinusitis subacute 14D Sinusitis Acute Chronic Bronchitis Otitis Media Otitis E
121. itis Emphysema GI Bleed Heart Attack Hepatitis Hepatitis B Hepatitis C High Blood Pressure Hv Hypothyroidism Irregular Heart Beat Kidney Failure Liver Problems Lupus Migraines Neurological Disorder Numbness Tingling Urinary Tract Infection Poor Circulation Pulmonary Embolism Reflux Rheumatoid Arthritis Seizures Sleep Apnea Stroke Ulcers Unremarkable HP FH SH RiskFactors Ros PE Problems InstructionsPlan Copyright Prev Form Ctrl PgLp Next Form Ctrl PgDn 1 NOTE This site chose not to have any headings and to limit the number of items in the list boxes 2 The list box values may be manually checked by support staff using information entered in Patient History questionnaires or automatically entered through a patient entered data interface PatientLink Kryptiq See samples of Patient History Questionnaires and PatientLink interface in the Appendix Page 13 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example PMH CCC for OB GYN Customization amp Patient Entered Data Prompt Past Medical History Select Specialty Obstetrics Gynecology Ej Last update 08 01 2003 reviewed no changes required Diabetes Type Il Replace w Prior PMH Hypertension Hyperlipidemia Problems
122. k Date Weeks FundHt FHR LbrSxs Position CxEff CxSta ves SmokHx RTC Res Prec 06 28 2005 2107 ie 180 fyes wvilbreech wil wil wl l rf wi Cn S BS S S SS EE LSS Sa Se aS SEs aee m 7 e e i per f SSS e pem per poe pnr SS per p pr ped p pt Jer ped pd prd e n d ed e pend pend pr pr perd pet pd per pad ped cd pen rd pd me cd pd dl eri pee ami emi ej pens red emi emm eed pw perii ea nf pend E EE m d E ea rd p Ed ped En zai mns T ri ma nn peni re tm Ee rai rv fien aan rl oe e i n ee Ti ra n a ag e a ra s Intake Prenatal Visit Past Preg Hx Genetic Flowsheet Lab Prenatal Ed Ultrasound PAP Entry FH SH Risk Factors ROS vs Problems Instructions Plan Copyright Prev Form Ctri PgUp Next Form Ctri PgDn The provider can review the data and enter comments within the OB Flowsheet form or skip directly to the CPOE A amp P form and select Prenatal Care Page 83 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved In the CPOE A amp P form the patient s current medications automatically populate the assessment
123. k Factors ROS Problems Instructions Plan Copyright Prev Form Ctrl PgUp Next Form Ctrl PgDn Click the All Negative action button first then click View Insert Patient Entered History The following pop up box displays Logician Message us the or OK buttons do not appear at the bottom of this box then press the ENTER Key to close this Patient Entered History for ROS General malaise fatique 05 10 2005 chest pains palpitations 05 10 2005 Resp cough wheezing 05 10 2005 GI constipation change of bowel habits 05 10 2005 Click Yes to add these values to today s ROS otherwise click No NOTE Any Positive values in the ROS added this update will be over written with these values Yes d 1 Click Yes to insert the patient entered history 2 Positive complaints will automatically be checked see below Page 24 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Patient Entered ROS for Family Practice CV ROS CCC Don C Bassett 1 2 Templates View nsert Patient Entered Hx Select Specialty Family Practice REVIEW OF SYSTEMS Hegative 1 2 3 Neg Clear ALL View Positive Ros Clear View See HPI Show Brief Version of Negative Values in Note
124. king the BMI Calc and BSA Calc action buttons A nursing pain assessment may be documented by clicking the yes radio button for Patient in Pain The location intensity and type of pain can be documented For female patients a LMP edit field will display to document the Last Menstrual Period LMP date The second page of the form component allows a vision screening to be documented NOTE With Version 8 3 the FD and FS files for the Vital Signs CCC form are available so each site can make further changes customization to meet their needs Page 90 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Serial Assessments CCC Standard allows the documentation of multiple standard vital sign measurements Serial Assessments CCC Custom Adult Serial Assessments Time of Assessment 455 Vital Signs Standard C Postural C Multiple Sites BP 120 1 aso mm Hg Record Pulse 80 1 min Resp 10 min deg F lt Standard C Metric 02 Sat ss on Room air 500 L min Pre Rx PEF L min Post Rx PEF L min Comments Go to Flowsheet for Corrections Flowsheet zu Vital Signs this Visit HPI 5 Risk Factors ros _vs _ Problems Instructions Plan Copyright Prev Form Ctri PgUp 1 Click the Time of Assess
125. logic Exam CCC Measure Neurologic Exam CCC Don C Bassett Neuro Cervical Thoracic US Motor Reflexes Measure Special Measurements Normal Prior Clear Right Left 4 Measurement of the extremities demonstrates that Right Wrist v cm Left Wrist 1 cm they are symmetric and without atrophy Right Forearm Date FEAN Right Arm v cm Left v cm Right Thigh v cm Left Thigh v cm Right Calf v cm Left Calf cm liac Crest to Lat Malleolus v cm liac Crest to Lat Malleolus Y cm Pulses Normal Clear Right Left Absent on the left Normal pulses in the upper and lower extremities Absent on the right Right side 4 Left side 4 Other Findings Prior Prev Form Ctri PgUp Next Form Ctri PgDn 1 The following may be customized by specialty normal default values observation terms that are populated and the items in the two list boxes 2 The list box values may contain either normal or abnormal values 3 Charting by exception allows the provider to rapidly document a detailed PE as well as capture structured data which can be used for reporting or clinical decision support 4 The provider can use voice recognition CCC VRI Dragon 8 Medical to dictate into structured data fields Page 48 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Co
126. lucose THYROTOXICOSIS List xl HP _acv FH sH RiskFactors Ros vs Problems InstructionsiPlan Copyright Prev Form Ctri PgUp Next Form Ctri PgDn Close 1 The Problem CCC list boxes can be customized by specialty 2 The customization designates if a single diagnosis description and ICD code is to be added to the patient s problem list or if a custom problem list containing several related diagnoses displays allowing the provider to select the diagnosis with the highest degree of specificity 3 The prefix Diagnosis of Minor Dx of Family History of etc for the problem being pushed to the patient s problem list is assigned in the customization 4 The number of days for a problem added as a Minor Dx to stay on the patient s active problem list can be specified in the customization 5 For Version 8 3 and forward there is no limit to the number of problems that can be listed on the Problem CCC form Previously the limitation was 125 list box items Please note that 125 list box items will display on the form without scrolling Adding more than 125 list box items will require the user to scroll down in the list box to see the additional items that do not fit in the normal display 6 For those providers using the VRI voice recognition any item on the Problem CCC form can now be voice activated A provider can add a diagnosis or access a custom problem list simply by saying Add diag
127. ment action button to enter the time of assessment enter all values that are to be documented and click the Record action button 2 Repeat the process to record the next set of measurements 3 A flowsheet view of the vital signs will be created in the Vital Signs this Visit data display and in the chart note 4 The Comments field may be used to document comments regarding patient status or treatment decisions Page 91 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Serial Assessments CCC Standard continued Serial Assessments CCC Custom Adult Serial Assessments Time of Assessment 5 15 Any further values for the following will Vital Signs Standard C Postural C Multiple Sites 1 02 Pulse 80 min Resp 1 min Temp deg F lt Standard 7 Metric o2Sat 86 on Roomar i PEF soo Limin Pre Rx PEF Post Rx PEF Comments Go to Flowsheet for Corrections gt Flowsheet L min L min Vital Signs this Visit Time Position BP Pulse Resp Temp By 4 55 PM 120 80 80 10 Harry S Winston MD HPI PMH FH SH Risk Factors ros _vs _ Problems CPOE AIP Instructions Plan Copyright Prev Form Ctri PgUp 1 Click the Time of Assessment action button to enter the time of assessment enter all value
128. mitie decreased entire left upper extrem decreased entire left lower extrem decreased left C2 decreased left C3 decreased left C4 decreased left C5 decreased left C6 decreased left C7 decreased left L1 decreased left L2 decreased left L3 decreased left L4 decreased left L5 54 Normal pin prick in upper 4 decreased entire right upper extrei decreased entire right lower extrei decreased right C2 decreased right C3 decreased right C4 decreased right C5 decreased right C6 decreased right C7 decreased right L1 decreased right L2 decreased right L3 decreased right L4 decreased right L5 Normal pin prick in upper extremitie J Normal pin prick in lower extremitie 4 decreased entire right upper extrei decreased entire left upper extrem decreased entire right lower extrei decreased entire left lower extrem decreased right C2 decreased left C2 decreased right C3 decreased left C3 decreased right C4 decreased left C4 decreased right CS decreased left CS decreased right C6 decreased left C6 decreased right C7 decreased left C7 decreased right L1 decreased left L1 decreased right L2 decreased left L2 decreased right L3 decreased left L3 decreased right L4 decreased left L4 decreased right Ls decreased left L5 decreased right face de
129. move the text Page 105 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Click the yellow Put Updated Values into Text action button to write the CCCQE MEL Code The action button will turn blue grey 9 Logician Harry S Winston MD Southside Clinic CCC Development JJ2 4 15 2005 9 36 AM Chart Go Actions Options Help 45 Print Endocrine CHECK PROTOCOLS None Work None 55 Year Old Male DOB 04 06 1950 Patient ID 71 0563001 Insurance Group 9 x EB A Find Pt Protocols Graph Handouts Probs Meds Refills Allergies Directives Flowsheet Orders End Up Internet EXIT Summary Problems Medications Alerts Fiowsheet Orders Documents Update Doc iD 10 Properties CCC Text File Editing at SOUTH on 04 15 2005 8 41 AM by Harry S Winston MD Summary Change Properties aa he see ccc Endo PMH exec Unremarkable Unremarkable ccc Endo PMH exec Appendix Surgery Appendectomy appendectomy yes CPT 44950 S P ccc Endo PMH Surgery Breast Surgery S P ccc Endo PMH exec Heart Surgery Heart Surgery S P ccc Endo PMH Surgery Hernia Surgery S P ccc Endo PMH exec Thyroid Sur
130. mp 99 2 deg Temp 37 33 deg C Site oral Resp E BP supine I Site 02 Sat 98 Pst Ste Puse a8 sic Pulse Ortho 80 prmn cufsze vi Rhythm reguar 7 Load Serial Assessments Form Ht conversion table BMI Calc in Ibs BSA Calc m2 Pain Assessment Patient in pain C yes C no Chief Complaint v Clinical Lists View Prob List View Med List View Allergies View Directives View Protocols Due Update Prob List Update Med List Update Allergies Update Directives HPI ACV PMH FH SH Risk Factors Ros _vs Problems CPOE AIP Instructions Plan 1 The patient s vital signs can be entered in either Standard or Metric units To convert to the other standard click the Convert to Metric Convert to Standard action button 2 Previously recorded values will display along with the date recorded for quick review 3 This form allows the documentation of lying sitting and standing BP in multiple sites NOTE to document more than one set of vital signs click the Load Serial Assessments Form action button and enter multiple sites serial values using this new form Page 89 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved The BMI and BSA values may be calculated by clic
131. ms CPOE Instructions Plan Copyright Next Form Ctrl PgDn Prey Form 1 The support staff checks the items the Form s Template s list box based responses entered by the patient in the questionnaire then clicks the Insert Template action button which has turned yellow and completes the data entry 2 This information may also be entered using patient entered data interface PatientLink Kryptiq 3 Samples of Specialty Specific Patient Questionnaires can be found in the Appendix Page 5 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example HPI CCC for Family Practice or Internal Medicine HPI Adaltional Hx History of Present Illness Select Specialty Family Practice 7 Marcus Welby v Referring Provider John Smith Visit Type inital Consult Check Box to Insert Form s History Clear Acute Visit Form Anticoaguattion Form Asthma History Form Asthma Plan Form Back Pain Form CHFForm Depression Form Diabetes Form Dyspepsia Form Headache Form Hypertension Form Lipid NCEP Ill Form Minor Procedures Form Preventive Care Form Annual Physical Cardiovascular Risk Form Cardiovascular Reports DataEntry D
132. n C Bassett ASP1 2 A amp P3 4 aspse asp7 s aspo to asp 11 12 Assessment 3 Select problem enter assessment orders and meds then click Commit Assessment Prob List DIABETES MELLITUS TYPE II ICD 250 00 v _Commit Assessment Clear All His updated medication list for this problem includes Glucophage 850 Mg Tab Metformin hcl Take 1 tablet by mouth each morning Amaryl 2 Mg Tab Glimepiride Take 1 tablet by mouth once a day Aspirin 81 Mg Ec Tab Aspirin Take one 1 tablet by mouth daily Orders Hemoglobin A1c 001453 Microalbumin urine CPT 82043 Lipid Panel 303756 El New Meds _Change Meds Meds auto insert R Orders auto insert R InsertTemplate R Print Handout Assessment 4 Select problem enter assessment orders and meds then click Commit Assessment Commit Assessment Clear All Add All Meds to Note Remove New Meds from Note Rx Monitoring and General Alerts Rec Interventions Orders 5 Risk Factors Ros _vs Problems Instructions Plan Copyright Prev Form Ctri PgUp Next Form Ctri PgDn NOTE Any labs or diagnostics associated with diagnosis problem will automatically appear in the assessment field for that problem in the CPOE A amp P form see above Page 73 Copyright 2005 Clinical Content Con
133. n red and the list box items that are automatically checked using the PatientLink or Kryptiq questionnaire interface 2 After verifying the information with the patient the provider clicks the yellow Insert Selected Values action button to commit the information NOTE Values will not appear in text or push to problem list until the action button is clicked This allows for corrections to be made prior to committing Page 14 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved PMH PSH CCC Some sites prefer to enter all past medical problems into the obs term PAST MED HX while entering all past surgical problems into the obs term PAST SURG HX For those sites there is the PMH PSH CCC form which functions the same as the PMH CCC form except that there is a second tab labeled PSH to enter the PSH Example PMH PSH CCC PMH PSH CCC Don Bassett 9 PMH PSH Past Surgical History z Last update ir E Replace w Prior PSH Problems Flowsheet Medications Allergies n Insert Selected Values Onset Procedure Date optional Surgical Health Status TURP Excellent Abd Surg type CABG PTCA Tonsillectomy Carotid Endarterectomy Hip Replacement Knee Replacement Knee Arthroscopy Rotator Cuff Repair Carpal Tunnel LA F Bypass RA F Bypass B A F By
134. ne 55 Year Old Female DOB 04 14 1 Pati 01 Insuranci eae Find Pt Protocols Graph Handouts Probs Meds Refills Allergies Directives Flowsheet Orders End Up Summary Problems Medications Alerts Flowsheet Orders Documents Doc iD 6 Properties CCC Text File Editing at SOUTH on 04 15 2005 2 19 PM by Harry S Winston MD CCC Text File Editor Arial HPI CCC Encounter Form Content for Card List Box Values Acute Visit Form EF Path Name Enterprise CCC Adult ACV CCC 2 Gender specific M or F no Anticoagualtion Form EF Path Name Enterprise CCC CPOE Anticoagulation C CC 2 Gender specific M or F no Chest Pain Hx Form EF Path Name Enterprise CCC Cardiology Cardiology Chest Pain Hx CCC 2 Gender specific M or F no CHF Form EF Path Name Enterprise CCC CHF Q amp E CCC 2 Gender specific M or F no Diabetes Form EF Path Name Enterprise CCC Diabetes Q amp E CCC 2 Gender specific M or F no Hypertension Form EF Path Name Enterprise CCC Hypertension Q amp E CCC 2 Gender specific M or F no For Help press F1 Sl 115 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Section 3 CCCQE Clinical Decision Support and Patient Severity Index Asses
135. ng ____ Ger hearing loss hearing loss ringinghead noise dizziness imbalance ear infection ringinghead noise dizziness imbalance ear infection Comments Oh by the way zl v Enter PMH FH SH Risk Factors ROS Problems CPOE ap Instructions Plan Copyright Prev Form Next Form Ctrl PgDn 1 The order and value of radio button headings be customized by specialty 2 The list box values can be customized add subtract or modify values Note in the example above the order of the body systems and the body system values are expanded for ENT 3 Clicking a value in the denies column or complains of column automatically un checks the value in the opposite list box 4 Customization designates which body systems are populated by clicking the 1 NEG 2 NEG or 3 NEG action buttons 5 The super buttons All Negative or 1 NEG 2 NEG or 3 NEG action buttons may be hidden or not visible for sites that want to turn off those features through customization 6 problem oriented ROS ESRD Prenatal etc may be created through customization 7 Patient entered history from PatientLink amp or Kryptiq may be automatically inserted or the user may be prompted that patient entered history exists Page 28 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 200
136. ngs of 1024 X 768 Example HPI CCC for Orthopedics Using List Box Templates HPI Additional Hx History of Present Illness Select Specialty Orthopedics Marcus Welby Referring Provider Jr John Smith j Visit Type Jinital Consult pind CC knee pain Check Box to Insert Form s History RHanded LHanded C Ambidex Insert Template Clear All or Template saw Don Bassett in the office today for an initial visit He is a right handed 59 year old man with the complaint of left knee pain The patient states that this is a legal or third person liability case Date of Injury 03 05 2005 The injury occured at Walmart Worker s Comp Initial The injury is described as tripped over a box lying in the aisle Pain lateral left Worker s Quality sharp Post op Visit Intensity 1 10 6 Legal 3rd Party Yes Onset 3 weeks ago after injury Legal 3rd Party No Radiation none Legal 3rd Party Potential Better with rest ice Motrin Worse with walking or work Pain Assessment Form MD Review of HPI brief 1 3 elements extended 4 or more elements Problems Medications Allergies Universal Forms Oh by the way v Enter Back Exam Finger Foot Ankle Exam Hand rist Exam Hip Exam Knee Exam Shoulder Elbow Exam HPI PMH FH SH Risk Factors ROS Proble
137. normal default values observation terms that are populated and the items in the two list boxes 2 The list box values may contain either normal or abnormal values 3 Charting by exception allows the provider to rapidly document a detailed PE as well as capture structured data which can be used for reporting or clinical decision support 4 The provider can use voice recognition CCC VRI Dragon 8 Medical to dictate into structured data fields Page 49 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Diabetic Specific Exams Foot and Eye Exam Neck Lung Heart Abd GU MSK Ext Neuro S L Psych Exam Other Diabetes Exam Diabetic Exam Foot inspection and exam is suggested EVERY VISIT Foot Exam Sensory Pinprick Light touch Left Clear All R L Right All Normal Medial foot L 4 C normal diminished absent C normal diminished absent Dorsal foot L 5 C normal diminished absent diminished 7 absent Lateral foot 5 1 normal diminished absent C normal diminished absent Sensory other 8 Sensory Monofilament Left Right Foot C normal C diminished absent C normal diminished C absent Inspection Left Right Foot C normal C abnormal C normal C abnormal Most Recent Eye Exam Next eye exam due now Blood Pressure Previous eye exam not recorded Enter Today
138. normal or abnormal values 3 Charting by exception allows the provider to rapidly document a detailed PE as well as capture structured data which can be used for reporting or clinical decision support 4 The provider can use voice recognition CCC VRI Dragon 8 Medical to dictate into structured data fields 5 Click the GU Exam action button to load and go to detailed genitourinary exam form male or female Page 35 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Detailed GU Exam Male GU Exam CCC Male GU 1 GU Exam CCC Don C Bassett GU 1 GU 2 Other Genitourinary Exam Male Urethra Normal Prior Clear No lesions or discharge noted normal urethra no lesions noted Urethral Meatus Normal Prior Clear Normal size and location no lesions or discharge normal size normal location no lesions or discharge Normal Prior Clear Normal without lesions El Testes Scrotum Normal Prior Clear Normal size testes bilateral without masses or tenderness absent left testes tenderness left testicle left testicular mass absent right testes tenderness right testicle right testicular mass zl hydrocele Epididymides Normal Prior Clear Normal without masses or tenderness tenderness on the right
139. nosis insert name of problem as listed on Problem CCC Form gt Examples Add diagnosis UTI adds the diagnosis UTI Add diagnosis diabetes displays the diabetes custom problem list The provider can use the Add diagnosis commands to add problems to the patient s problem list anywhere within an update that Quicktext can be used Page 57 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Problem CCC Form Customized for OB GYN Problems CCC Custom Adult Add Problems Form Abdominal Pain Abnormal Mammogram Abnormal Pap Smear Amenorrhea Def Unsp Anemia Simple Chronic Anovulation Bartholin s Duct Cyst Bartholin s Gland Abscess BCPs New Rx BCPs Subsequent Rx Breast Mass Carcinoma Situ Vulva Carcinoma of Breast Carcinoma of Cervix Carcinoma of Endometrium Carcinoma of Ovary Carcinoma of Vagina Carcinoma of Vulva Cervical Dysplasia Cervical Polyp Cervicitis Cholesterolemia Condyloma Accuminata Contraceptive Mgmt General Cystitis Acute Cystocele Rectocele Note Unchecking a Problem from this form will NOT remove it from the Problem List Enterocele FH Breast Fatigue Fibrocystic Breast Changes Galactorrhea Non OB Headache Hematuria Herpes Genital Unsp Hirsuitism
140. ns for the patient automatically appear in the assessment field for CHF as do all problem medication class designated problems When the provider selects Subendocardial MI from the dropdown list on the CPOE A amp P form CPOE A amp P CCC Don C Bassett A amp P 1 2 AspP 34 aspse asp7 s amp 9 10 asp 11 12 Load Documentation Form Select Specialy Assessment 1 Select problem enter assessment orders and meds then click Commit Assessment Prob List CONGESTIVE HEART FAILURE ICD 428 0 Commit Assessment Clear All His updated medication list for this problem includes Zaroxolyn Tab 5mg Metolazone 1 po qd Furosemide Tabs 20 Mg Furosemide 1 po bid Aspirin 81 Mg Ec Tab Aspirin Take one 1 tablet by mouth daily New Meds Change Meds Insert Meds New Orders Insert Orders R Insert Template R Print Handout Assessment 2 Select problem enter assessment orders and meds then click Commit Assessment SSS omit sessment Clear Alt SUBENDOCARDIAL M ICD 410 70 DIABETES MELLITUS Il ICD 250 00 HYPERLIPIDEMIA ICD 272 4 CONGESTIVE HEART FAILURE ICD 428 0 Sx of HOARSE VOICE QUALITY EFFUSION PLEURAL ICD 511 9 Add All Meds to Note Remove New Meds from Note Rx Monitoring and General Alerts Rec Interventions Rec Tests Orders 5 Risk Factors Ros
141. nsultants LLC All rights reserved Core Forms In physical training for many sports strength training focusing on the core has become recognized as a key to the success of many an athlete In much the same way we believe that providing a good core set of clinical documentation forms and the skills to master their purpose navigation and use and will lead to a successful EMR implementation HPI CCC HPI Additional Hx History of Present Illness Select Specialty Neurosurgery v PCP Dr Marcus Welby Referring Provider Dr John Smith Es Visit Type inital Consult x cc Check Box to Insert Form s left should i History RHanded LHanded C Ambidex ren or Template Initial Consult Consult IME Initial IME Followy up Worker s Comp Initial Worker s Comp FiU Post op Visit Neck Pain Left Shoulder Pain Right Shoulder Pain Bilateral Shoulder Pain Left Arm Right Arm Bilateral Arm Thoracic Back Pain Low Back Left buttock Right buttock Bilateral buttock iz Leftleg pain C brief 1 3 elements extended 4 or more elements Problems Medications Allergies Universal Forms 7 Oh by the way 7 Enter FH SH Risk Factors ROS Problems CPOE Instructions Plan Copyright Next Form Ctrl PgDn Prey Form Ctr PaU
142. nsultants LLC All rights reserved Example Skin Lymphatic Psych PE CCC Don C Bassett Gen HEENT Neck Lung Heart Aba Gu msK Ext Neuro S L Psych ExamOter a Skin i Prior Clear intact without lesions or rashes eczematous rash papular rash macular rash maculopapular rash pustular rash vessicular rash nevus wart s Cervical Nodes Normal Prior Clear no significant adenopathy tender L anterior 4 tender L posterior tender anterior tender posterior non tender L anterior non tender L posterior Axillary Nodes Normal_ Prior Clear no significant adenopathy a f tender L axillary non tender L axillary zj tender R axillary non tender R axillary Inguinal nodes Normal Prior Clear no significant adenopathy a tender L inguinal non tender L inguinal tender R inguinal non tender R inguinal Psych Normal Prior Clear alert and cooperative normal mood and affect depressed affect hyperactive normal attention span and concentration anxious agitated easily distracted auditory halucinations poor concentration visual hallucinations poor memory HPI PMH FH SH Risk Factors ROS _vs _ Problems CPOE Instructions Plan Copyright Prev Form Ctrl PgUp Next Form Ctrl PgDn 1 The following be customized by specialty
143. nt and plan information for each diagnosis Once the assessment is complete if the provider clicks the yellow Commit Assessment action button the documentation in the assessment field white space will be pushed to the Problem List and will be associated with that diagnosis for that date This allows for more detailed problem oriented notes and treatment plans see examples below Once the Commit Assessment button is clicked for a given problem assessment the word Committed will appear in red to the right of the Commit Assessment action button CPOE A amp P CCC Don C Bassett ASP1 2 A amp P3 4 asp7 s aspo to agp 11 12 Assessment 3 Select problem enter assessment orders meds then click Commit Assessment Prob List DIABETES MELLITUS TYPE 1 ICD 250 00 _Commit Assessment Committed Clear All Refer to Diabetes Education Program and schedule for a stress test prior to starting exercise program His updated medication list for this problem includes Glucophage 850 Mg Tab Metformin hcl Take 1 tablet by mouth each morning Amaryl 2 Mg Tab Glimepiride Take 1 tablet by mouth once a day Aspirin 81 Mg Ec Tab Aspirin Take one 1 tablet by mouth daily Orders Hemoglobin A1c 001453 Microalbumin urine CPT 82043 Lipid Panel 303756 2 New Meds Change Meds Meds auto insert New Orders Orders auto insert Ri Insert Template R
144. nter directly into edit field Patient Instructions CCC Sarah S Oberheim Select Specialty Obstetrics Gynecology Clear liquid gt progress Dietician Referral GERD Prevention Physical Activity No Restrictior Level 1 Restriction Level 2 Restriction Level 3 Restriction Out of work Limited work zu Second Trimester Premature Labor Sx s Envir Work Hazards Travel during Pregnancy Seat Belt Use Hospital Choice Undecided St Luke s Hospital Mercy Hospital First Trimester Prenatal Education Prenatal ED Pack Given Young Parenting Rec Young Parenting Enrld Nutrition NL wt gain Diet Advice Reflux Instructions Folate Prenatal Vits Completed Child Birth Class Declined Child Birth Class Preregister Information Preregistration Done Preregistration Declined Hospital Tour Recommended Hospital Tour Completed Hospital Tour Declined Birth Ctr Tour Recommended Birth Ctr Tour Completed Birth Ctr Tour Declined Alcohol Drugs Toxo precautions MSAFP Reviewed MSAFP Declined Counseling Declined Labor signs reviewed on Third Trimester Breast Feed Info Given Lactation Consult Le Leche League Bottle Feeding Circumcision Reviewed Circumcision Yes Circumcision No Family Role Adjustment Support system eval Newborn Car Seat NSVD planned
145. number of days for a problem added as a Minor Dx to stay on the patient s active problem list can be specified in the customization 5 For Version 8 3 and forward there is no limit to the number of problems that can be listed on the Problem CCC form Previously the limitation was 125 list box items Please note that 125 list box items will display on the form without scrolling Adding more than 125 list box items will require the user to scroll down in the list box to see the additional items that do not fit in the normal display 6 For those providers using the VRI voice recognition any item on the Problem CCC form can now be voice activated A provider can add a diagnosis or access a custom problem list simply by saying Add diagnosis insert name of problem as listed on Problem CCC Form Examples Add diagnosis UTI adds the diagnosis UTI Add diagnosis diabetes displays the diabetes custom problem list The provider can use the Add diagnosis commands to add problems to the patient s problem list anywhere within an update that Quicktext can be used Page 56 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Problem CCC Form Customized for Endocrinology Problems CCC Custom Adult Add Problems Form ASCVD ABDOMINAL PAIN List Abnormal Tests Labs Abnormal glucose tolerance Abnormal Thyroid scan up
146. o male When the update is re opened the yellow prompt will be gone and the TFE tools will appear CCC Text File Editor Custom Cardiology Page 1 Page2 Page 3 Page 4 Page 5 Page6 Page 7 CCC Text File Editor For Use in Test Patient s Chart Only Select Specialty Cardoloy v 4 uml oi im wi wi iE 88 YO a ll Select Encounter Form HP CCC 109 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved CCC Text File Editor Custom Cardiology Page 1 page2 3 Page 4 Page 5 Page 6 Page 7 CCC Text File Editor For Use Test Patient s Chart Only Select Specialty Cardiology wi Select Encounter Form JHP ccc wi _Insert Values for Editing El Put Updated Values into Text El Remove from Text 2 Insert Formatted Text Open Text File to Edt Search Medications Search Problems _Load EF for Reference EF Template Name EF Path Template EF Instructions Instructions List Instructions Instructions Instructions Instructions Instr ng JW B E o 4 T Close CCC TFE action buttons Tools for 1 General Instructions click this button to open a pop up window with general in
147. ons to Treatment Treatment Contraindication wife sCommitto Flowsheet Deferment of Testing Procedure Test or Procedure Reason for Deferment Stage Documentation Classification Scheme Class or Stage Emoking Cessation Breslow s for melanoma Canadian Cardiovascular Society Duke s for Colon CA Killip Class for MI NYHA CHF Classification Smoking Cessation intake Prenatal visit Past Preg Hx Genetic Flowsheet Lab J Prenatal Ed Ultrasound PAP Entry HPI PMH FH SH Risk Factors ROS vs Problems CPOE Instructions Plan Copyright Prev Form Ctri PgUp Close Page 70 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Adding Medications Using the CPOE A amp P Form To add a new medication click the New Meds action button Based on the customization one of the following will occur Option 1 A custom medication list will display examples CCC Lipids CCC Antibiotics UT Option 2 Inserts an encounter form into the update and displays that encounter form for data entry In some cases using an encounter form is more effective when ordering multiple medications or monitoring regimens examples Asthma gt go to the Asthma Management CCC form Atrial Fibrillation or DVT gt go to the CPOE Anticoagulation CCC form Option 3 The s
148. opyright 2005 Clinical Content Consultants LLC All rights reserved Example CV Exam CCC Heart CV Exam CCC Don C Bassett Neck Heart Vascular Special Other Heart Inspection Prior Clear no deformities no deformities or lifts noted pectus excavatum heaving lifts pectus carinatum lift noted Palpation Normal Prior Clear normal with no thrills palpable a f normal PHI thrill palpable no thrills PMI displaced Auscultation Normal Prior Clear regular rate and rhythm 51 52 without murmurs rubs gallops or clicks summation gallop mid systolic click pericardial friction rub Grade 6 SEM loudest primary aort Grade 6 SEM loudest LLSB Grade 6 SEM loudest at apex gt a normal split 52 Grade 6 DM loudest at primary ao fixed split 52 Grade 6 DM loudest at LLSB 53 gallop x Grade 6 DM loudest at apex x regular rhythm normal rate murmurs no rubs no gallops accentuated P2 HPI Acv PMH FH SH Risk Factors ROS _vs _ Problems CPOE Instructions Plan Copyright Prev Form CtrisPgUp Next Form CtrisPgDn 1 The following be customized by specialty normal default values observation terms that are populated and the items in the two list boxes 2 The list box values may contain either normal or abnormal values 3 C
149. or the provider must check either the brief 1 3 elements or extended 4 or more elements radio button 3 Text can be entered into the multi line edit field using QuickText typing inserting text templates or using voice recognition 4 NOTE For Family Practice if the patient is less than 18 years old or the cut off age set by that site the customization from the CCCQE User Edit HPI Peds will appear Page 8 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved PMH CCC or PMH PSH CCC The PMH CCC and PMH PSH CCC forms are designed to allow for rapid point and click entry of the most common specialty specific medical surgical conditions The list box items can be customized by specialty In addition the customization can also determine which conditions will automatically populate the active Problem List or not as well as whether an observation term is automatically populated and with what value This decreases the time necessary to capture structured data which can be used for reporting or clinical decision support Example PMH CCC for Family Practice Internal Medicine Past Medical History Select Specialty Family Practice Last update reviewed no changes required Replace w Prior PMH Problems Flowsheet Medications Allergies Insert Selected Values Onset Procedure Date optional
150. ort System Documentation of Contraindications to Treatment Deferment of Testing Procedures and Stage Documentation Contraindications to Treatment Treatment Contraindication wife sCommitto Flowsheet Deferment of Testing Procedure Test or Procedure Reason for Deferment Stage Documentation Classification Scheme Class or Stage Emoking Cessation Breslow s for melanoma Canadian Cardiovascular Society Duke s for Colon CA Killip Class for MI NYHA CHF Classification Smoking Cessation intake Prenatal visit Past Preg Hx Genetic Flowsheet Lab J Prenatal Ed Ultrasound PAP Entry HPI PMH FH SH Risk Factors ROS vs Problems CPOE Instructions Plan Copyright Prev Form Ctri PgUp Close Page 131 Copyright 2005 Clinical Content Consultants LLC All rights reserved
151. owing risk categories en Stroke or TIA C yes C no Age 8 points HDL 2 points LDL 2 points Peripheral vascular disease C yes C no BP 3 points Smoking 2 points Diabetes 0 points Hephropathy gt 2 0 yes C no HTN Dx 0 points Hypertensive Retinopathy yes C no Today s Blood Pressure fi 50 i fi 00 mm Hg JHC VII Recommended BP Goal lt 140 90 2 Current BP Goals gt 140 0 lt RiskFactors Ros PE Problems InstructionsPlan Copyright Prev Form Ctrl PgUp Next Form Page 123 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example NCEP ATP Ill Guidelines Encounter Form Lipid Q amp E Risk Hx Pt Educ Information Metabolic Synaromere Flowsheet Lipid Management Most Recent Labs Lipid Flowsheet View Current Lipid Meds Therapeutic Recommendations NCEP Adult Treatment Panel Ill Risk Factors Goals Automatically Calculated based on Risk Factors Age 45 or greater 6 yes no Check here to manually change Lipid Goals Early menopause w o HRT C WA C WA Goals based on CAD PVD CVA TIA or Aortic aneurysm AHD diabetes smoker or LDL gt 130 HDL lt 40 and trig gt 200 Diabetes 6 yes no HDL lt 40 mg dl Chol LDL HDL Trig HDL gt 60mgjidi neg risk yes no Goal
152. p 1 The support staff enters the PCP Referring Provider Visit Type and Chief Complaint information this information can also automatically populate if entered in registration or through patient entered data interface PatientLink Kryptiq 2 Handedness field appears for Neurology Neurosurgery and Orthopedics and will automatically pull into templates and be added into database for future visits or reporting 3 The Responsible Provider s specialty of the update automatically populates field and pulls in specialty specific forms templates in the Form s Template s list box 4 The Form s Template s list box can be customized to load encounter forms or insert custom text templates Page 4 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved 5 To integrate with the E amp M Advisor the provider must check either the brief 1 3 elements or extended 4 or more elements radio button 6 Text can be entered into the multi line edit field using QuickText typing inserting text templates or using voice recognition 7 Alternatively the form can be closed and a Dictation Placeholder be inserted into the update and later imported using a transcription service 8 Navigation Buttons at the bottom of the form allow quick navigation between the Core Forms NOTE All CCC forms are best viewed using display setti
153. pass Very good Prev Form Ctrl PgUp Next Form Ctrit PgDn Good Fair Poor 1 The data in the multi line edit field pushes to the ObsTerm PAST SURG HX 2 The headings and list box items can be customized the same way as the PMH form by editing the CCCQE User Edit PSH txt file Immunizations UTD Yes Immunizations UTD No Surgical Complications No Surgical Complications Yes Anesthesia Prob No Anesthesia Prob Yes Page 15 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved FH SH CCC The FH SH CCC form is designed to allow for rapid point and click entry of the most common specialty specific family history and social history conditions The list box items can be customized by specialty In addition the customization can also determine which conditions will automatically populate the active Problem List or not as well as whether an observation term is automatically populated and with what value This decreases the time necessary to capture structured data which can be used for reporting or clinical decision support Example FH SH for Family Practice Internal Medicine Family History Select Specialty Family Practice _Insert Selected Values Last updated reviewed no changes required Check to insert into FH Edit Field FH Alcoholism FH Arthritis FH Asthma FH
154. pulate the chart note and the Patient Instruction Handout Click the Print Patient Instructions action button to select and print the handout 1 pushed to that obs term 2 terms 3 4 The Patient Instructions Handout may be further customized Note that in the example above the headings and instructions are broken into First Second and Third Trimester as well as High Risk Post Partum care Page 88 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Vital Signs CCC The Vital Signs CCC form is designed to allow for rapid point and click entry of the most common vital signs Since each site has unique documentation needs the Vital Signs CCC form is the only CCC form that can be fully customized by a site With the CCCQE Version 8 3 release CCC is providing the fd and fs files to allow sites to edit or further customize the form CCC has also created a Serial VS Form which allows the documentation of multiple serial sets of vital signs including postural BPs and multiple BP sites Example New Vital Signs CCC Form Vital Signs CCC Custom Adult Vital signs Vision Vital Signs VS View Standard Metric Convert to Metric VS Entered By gt Lisa Lou July 5 2005 2 37 Standard Previous Values Metric Previous Values Height 68 inches Height 172 72 Weight 188 pounds Weight 85 45 Te
155. r diagnosis specific details e trigger a set of automatic clinical decision support reminders that are dynamic allow provider to act on recommendations order tests order medications and document clinical information all with a single click 3 Starting with Version 8 3 the CCC Text File Editor TFE can be used to customize the CPOE A amp P forms see section on TFE Page 63 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved CPOE A amp P CCC Workflow Step 1 Select a problem from the dropdown list The dropdown list contains a listing of the patient s active problems with newly added problems listed at the top beginning with Version 8 3 CPOE A amp P CCC Don C Bassett A amp P 1 2 Asp 3 4 sese asp7 s amp 9 10 asp 11 12 Select Specialty Obstetrics Gynecology Assessment 1 Select problem enter assessment orders and meds then click Commit Assessment Prob List Commit Assessment Clear All DIABETES MELLITUS ICD 250 00 T HYPERLIPIDEMIA ICD 272 4 CONGESTIVE HEART FAILURE ICD 428 0 Sx of HOARSE VOICE QUALITY EFFUSION PLEURAL ICD 511 9 EDEMA ICD 782 3 Assessment 2 Select problem enter assessment orders and meds then click Commit Assessment v Commit Assessment Clear All Add All Meds to Note Remove New Meds from No
156. r shrug is normal The tongue has normal motion without fasciculations decreased sensation L V2 decreased sensation R V2 decreased sensation L V3 decreased sensation R V3 decreased mm mastication L facial droop R facial droop Weber lateral to L Weber lateral to R palate deviates to L palate deviates to R hoarseness tongue deviates to L tongue deviates to R pupils unequal L gt R pupils unequal R L fundal pallor fundal atrophy hypertensive changes pulsations absent palsy L Ill nn palsy Rl nn palsy nn palsy RIV nn palsy L Vinn palsy R Vinn decreased visual fields decreased sensation L V1 n Cerebellar Normal Clear abnormal finger to nose L abnormal finger to nose R abnormal heel to shin L abnormal heel to shin R diminished finger dexterity R abnormal tandem gait Finger to nose and heel to shin are normal Rapid alternating movements normal Finger dexterity is normal Tandem gait is normal I slowed rapid mvt L Other Normal Prior Clear Romberg is normal There is no pronator drift or leg C Romberg NI C Romberg L C Romberg R E ES NORIS POOR No Pronator drift Pronator drift L Pronator drift R C NoLeg lag C Leglag L Leglag R Prev Form Ctrl PgUp
157. reatment Deferment of Testing Procedures and Stage Documentation Contraindications to Treatment Treatment Contraindication ACE Inhibitor Deferment of Testing Procedure Test or Procedure Reason for Deferment 8 m Stage Documentation Classification Scheme Class or Stage m si E Intake Prenatal visit Past Preg Hx Genetic Flowsheet Lab Prenatal Ed Ultrasound PAP Entry HPI PMH FH SH Risk Factors ROS vs Problems CPOE Instructions Plan Copyright Prev Form Ctrl PgUp Close Select the Treatment Test Procedure or Staging to be documented Page 128 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Contraindication to Treatment CDSS Contraindications CCC Don C Bassett Clinical Decision Support System Documentation of Contraindications to Treatment Deferment of Testing Procedures and Stage Documentation Contraindications to Treatment Treatment Contraindication ACE Inhibitor Eough Deferment of Testing Procedure hypotension Test or Procedure hyperkalemia gt 5 5 renal insufficiency renal artery stenosis Stage Documentation Classification Scheme Class or Stage Intake Prenatal visit Past Preg Hx Genetic Flowsheet Lab Prenatal Ed Ultrasound PAP Entry HPI PM
158. responding form will be highlighted in yellow as a visual cue NOTE These action buttons only LOAD the corresponding forms They are not a Load and Go To function based on workflow considerations Page 6 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example HPI CCC for OB Gyn x HPI Additional e History of Present Illness Select Specialty Obstetrics Gynecology Patient Entered Hx PCP Marcus Welby v Referring Provider John Smith vj View Insert Visit Type inital Consult knee pain 7 Check Box to Insert Form s History Clear All or Template Acute Visit Form Prenatal Visit Form Initial Prenatal Visit Form Past Pregnancy Hx Form Genetic Hx Form Prenatal Flowsheet Form Prenatal Lab Form Prenatal Education Form OB Ultrasound Form Cardiovascular Risk Form Diabetes Form Hypertension Form Lipid NCEP IIl Form Preventive Care Form Procedure Data Entry Form Colposcopy Form LEEP Form Post Partum Form Post Op Form Template 20 brief 1 3 elements extended 4 or more elements Problems Medications Allergies Universal Forms Oh by the way J Enter Intake Prenatal Visit Past Preg Hx Genetic Flowsheet b Prenatal Ed Ultrasound T PAP Entry A cv
159. ring large amounts of text descriptions or templates into small edit fields 4 Be sure to have wordwrap turned off within NotePad or WordPad If wordwrap is on when you cut and paste text into the CCC TFE any text after the first carriage return WILL NOT paste into the edit field 5 Read the instructions below as well as those within the editor itself before attempting to edit any files 6 Be patient with time and experience making edits and customizations will become routine Page 98 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved 1 Getting Started Start an update in a test patient s chart and insert the CCC Text File Editor encounter form located in the Enterprise CCC TFE folder in Centricity amp Logician Harry S Winston MD Southside Clinic CCC Development JJ2 4 15 2005 8 51 AM Chart Go Actions Options Help SG sDesktop Chart Eamets Reo fE renorts amp bPrnt internet EXT Custom Endocrine CHECK PROTOCOLS Home None Work None 55 Year Old Male DOB 04 06 1950 Patient ID 71 0563001 Insurance Group 96 9 A X MR x E X Find Pt Protocols Graph Handouts Probs Meds Refills Allergies Directives Flowsheet Orders End Up Summary Problems Medications Alerts Flowsheet Orders Documents Update Doc 10 Properties CCC
160. rkflows made available with 116 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Automatic Pop up Windows CDSS prompting may significantly impact the healthcare delivered to the patient These pop ups can be turned on off based on specialty job description or provider preference Example Prompt for disease management and preventive care services due Logician Message xi 9 Don C Bassett 59 Year Old Male The Following Tests are now due 1 Lipid Panel 2 Hepatic Profile 3 Electrolytes The Following Procedures are now due 1 Due For Colorectal Cancer Screening Would you like to see the Indications For these recommended Tests Procedures Click Yes to see the Indications Otherwise click Yes d Clicking Yes displays the indications for the recommendations Logician Message 9 Don C Bassett 4 59 Year Old Male Test Indications 1 Lipid Panel Hx of Coronary Dz Previous LDL gt 100 and was last checked gt 3 months ago 09 10 2001 currently on Statin Rx 2 Hepatic Profile Currently taking Statin Last SGOT AST done gt 6 months ago 09 20 2000 3 Electrolytes Currently taking Diuretic Last Potassium gt 6 months ago 09 20 2000 Procedure with Indications 1 Colorectal Cancer Screening Age over 50 and no documented colonoscopy Fle
161. rm Ctri PgUp 1 The Patient Instructions CCC list boxes be customized by specialty and or provider Customization options include list box headings list box items the obs term that is to be populated by clicking the list box item and the value that gets pushed to that obs term 2 The provider clicks all of the applicable instructions and clicks the Click to Enter action Endocrine GI Blood Glucose Monitoring HgBA1c Monitoring Diabetic Eye Exam Microalbumin Foot Care Low BS Prevention Blood Pressure ACE Inhibitor ARB Rec Diabetes Education Ref TLC Lipid Diet Hypothyroidism Hyperthyroid Hyperthyroid Gastroenteritis Diverticulitis Subacute Diverticular Diet Select Specialty Family Practice E Diet Instructions Clear liquid gt progress Force fluids Fast Overnight Low Residue Diet Low Sodium Diet Sodium Restriction 2GM Sodium Restriction 4GM Protein Restriction 40GM Protein Restriction 60GM Potassium Restriction Stone Prevention Fluids GERD Prevention Respiratory Asthma Ed Referred Asthma Ed Refused Asthma Ed Attending Asthma Ed Completed MDI instruction Instruction AMP Reviewed UR Tylenol Ibuprofen Throat Culture Done AB pending Throat Culture OTC Meds Sinusitis subacute lt 14D Sinusitis Acute Chronic Bronchitis Otitis Media Otitis Externa
162. rm you are editing for reference purposes 10 Buttons next to each action button click these buttons to explain what the larger buttons do Page 103 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example PMH CCC Form Opened with CCC TFE CCC Text File Editor Custom Endocrine Page 1 Page2 pages 4 Pages Pages Page7 CCC Text File Editor For Use in Test Patient s Chart Only Select Specialty Endocrinology v SelectEncounterForm PMH CCC insert Values for Editing PutUpdated Values intoText fromText insert Formatted Text Open Text File to Edit El Search Medications Search Problems El Load EF for Reference Label Prob List Text Obs Term Obs Value Dx Code Dx Prefix MIF Instructions Instructions Instructions Instructions Instructions Instructions Instr Unremarkable Unremarkable Appendix Surgery Breast Surgery v1 Heart Surgery 7 Hernia Surgery 7 Thyroid Surgery 7 Prostate Surgery x bak l vi Other Surgery vi bak vi Appendectomy Breast Surgery Heart Surgery Hernia Surgery Thyroid Surgery Prostate Surgery Other Surgery Other appendectomy ves 44950 TTT blank blank blank blank b b panh
163. rthritis push to corresponding ObsTerms Flowsheet Potential Observation list for David Neuro View lt Preterred internal gt TEMPERATURE TEMP SITE PULSE RATE PULSE RHYTHM RESP RATE Effects of this update Added new observation of PMH KIDNY ST yes 03 20 2005 16 45 Added new observation of PMH GERD yes 03 20 2005 16 45 Added new ob ation of PMH ASTHMA yes 037 005 16 45 4 New Change Remove Back New to add or select observation to change or remove Cancel NOTE Highlight item then click Change Back to remove if entered in error Page 12 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example PMH CCC for Orthopedics List Box Customization Past Medical History Select Specialty Orthopedics EA Last update reviewed no changes required Asthma GERD Kidney Stone Hx of Osteoarthritis Replace w Prior PMH Problems Flowsheet El Medications Allergies Insert Selected Values Onset Procedure Date optional Anemia Angina Anxiety Asthma Bleeding Disorder Blood Clot Cancer Chronic Back Pain Congestive Heart Failure Depression Diabetes Diabetic Foot Ulcers Dialysis Diverticul
164. ryostenosis Cong Heart Murmur Purulent Rhinitis Dehydration Hematochezia Rash Select Spocaly DERMATITIS List HERNIA List Reactive Airway Disease Pediatrics 2 Dermatitis Atopic Ringworm Dermatitis Contact Hip Dysplasia Roseola Cursor must be blinking in Dermatitis Seborrheic Hydrocele RSV EE METER EMG Dermatitis Viral Warts Impetigo Scabies Developmental Delay Infectious Mononeucleosis Scarlet Fever New Problems Added DIABETES List influenza Scoliosis recent able top Diaper Rash Jaundice Neonatal Seizure Febrile Diarrhea JOINT PAIN List SEIZURE DISORDER List Dysfunctional Uterine Bleeding Labial Adhesions Short Stature Dysmenorrhea Lactose intolerance Sinusitis Acute Dysuria Laryngitis Acute w o Obst Sinusitis Chronic xl Prev Form Ctri PgUp Next Form Ctri PgDn Close 1 The Problem CCC list boxes can be customized by specialty 2 The customization designates if a single diagnosis description and ICD code is to be added to the patient s problem list or if a custom problem list containing several related diagnoses displays allowing the provider to select the diagnosis with the highest degree of specificity 3 The prefix Diagnosis of Minor Dx of Family History of etc for the problem being pushed to the patient s problem list is assigned in the customization 4 The
165. s 200 70 40 150 FH of cardiovascular disease Last value 190 100 60 210 MI in female age lt 65 C yes no Last date 09 10 2001 09 10 2001 09 10 2001 09 10 2001 MI in male age lt 55 yes no Next due Now Now How Now Smoking status current quit never All lipid goals have NOT been met Hypertension 6 yes no Consider interventions to lower LDL HDL goal has been met ASHD CAD or CABG yes no Consider interventions to lower triglycerides Stroke or TIA C yes no Peripheral vascular disease yes no LDL cholesterol goal met C Yes C Ho Abdominal Aortic Aneurysm yes no Enter Today s BP mm Hg HPI 5 Risk Factors ROS Problems CPOE Instructions Plan Copyright Prev Form Ctr PgLp Next Form Clicking the Therapeutic Recommendations action button returns patient specific recommendations x 1 Patient s LDL cholesterol is greater than 70 and is at very high risk due to ASHD PVD or Cerebrovascular Dz AND at least one other major risk Factor Diabetes Smoking Consider increasing the dose of the current lipid lowering agent or adding another agent to get LDL below 70 2 Consider Therapeutic Lifestyle Change TLC diet or Dietary Referral since triglycerides are above goal 3 Patient s last liver Function tests have been over 6 months ago and is on the Following medications HMG CoA Reductase Inhibitor Sta
166. s that are to be documented and click the Record action button 2 Repeat the process to record subsequent sets of measurements 3 A flowsheet view of the vital signs will be created in the Vital Signs this Visit data display and in the chart note 4 The Comments field may be used to document comments regarding patient status or treatment decisions Page 92 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Serial Assessments CCC Postural allows the documentation of postural blood pressure pulse measurements Serial Assessments CCC Custom Adult Serial Assessments Time of Assessment 5 20 Any further values for the following will Vital Signs C Standard Postural C Multiple Sites TW UNIT T 1 Resp Rate Lying 120 I 80 Hg Pulse 80 min 2 02 Type 3 PEF Sitting 110 1 70 mm Hg Pulse 100 min Standing 100 60 Hg 120 min Comments Go to Flowsheet for Corrections gt Flowsheet Vital Signs this Visit Time Position BP Pulse Resp Temp By 4 55 PM 120 80 80 10 Harry S Winston MD 5 15 PM 110 70 80 Harry 5 Winston MD HPI PMH FH SH Risk Factors ros _vs _ Problems CPOE AIP Instructions Plan Copyright Prev Form Ctri PgUp 1 Click the Time of Assessment action button to enter the time of a
167. sei 5 S Rt Plantar 5 5 v Lt Plantar Flexor 57 5 v Rt Dorsiflex 5 5 v Lt Dorsiflex 5 5 Prev Form Ctri PgUp Next Form Ctri PgDn 1 The following may be customized by specialty normal default values observation terms that are populated and the items in the two list boxes 2 The list box values may contain either normal or abnormal values 3 Charting by exception allows the provider to rapidly document a detailed PE as well as capture structured data which can be used for reporting or clinical decision support 4 The provider can use voice recognition CCC VRI Dragon 8 Medical to dictate into structured data fields Page 45 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Neurologic Exam CCC Sensory Neurologic Exam CCC Don C Bassett Neuro Cervical Thoracic US Motor Sensory Reflexes Measure Special Sensory Exam _Allormal Lower Extremities Sensation to Pin Normal Prior Clear Right Normal sensation to pin prick the upper and lower gt extremities Vibratory Sensation Normal Prior Clear Right Left Normal vibratory sensation in the upper and lower extremities Light Touch Normal Prior Clear Right Left No evidence for sensory loss __ _ 5 Left Normal pin prick in lower extre
168. served 3 Copyright 2005 Clinical Content Consultants LLC All rights reserved CCC Text File Editor Custom Endocrine Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page7 Select Specialty Endocrinology Y insert Values for Editing 2 Open Text File toEdt 2 CCC Text File Editor For Use in Test Patient s Chart Only Select Encounter FormJPMH ccc vj Remove fromText insert Formatted Text Search Problems Load EF for Reference Dx Code Dx Prefix Put Updated Values into Text Search Medications Prob List Text Obs Term Obs Value MIF Instructions Instructions Instructions Instructions Instructions mu Instructions pon E Unremarkabe Unemakabe 7 a i oras I Breast Surgery BreastSurgery 1 OS HeatSugey fHeartSurgery fF Hernia Surgery HerniaSurgery 1 0 7 Thyroid Surgery Thyroid Sugey Prostate Surgery ProstateSurgery 1 blank BM LL 1 p amp mJWJU Lg TURP rune BM Bu A gb w e fixo Other Surgery oerswey B B B H blank B B B B 1L H blank blank blank blank blank blank blank blank blank Click the yellow Put Updated Values into Text action button to write the CCCQE MEL code The action button will turn blue grey Click the Remove from Text action button to re
169. sment The CCCQE Clinical Decision Support CDS and Patient Severity Index Assessment PSIA applications were designed to improve the clinical workflow and provide clinical decision support during the assessment and plan of the patient visit As more and more insurers and regulators require documentation of quality of care and patient disease severity additional charting and documentation responsibilities are being demanded of the provider The CCCQE CDS and PSIA application allows the provider to receive a variety of cascading clinical decision support prompts that remind the provider to document specific clinical quality indicators In order to make this process non intrusive and time efficient the prompts automatically provide the clinical data entry and documentation without having to search for encounter forms or go to flowsheets to enter the information Some examples of the CCCQE CDS PSIA application include rapid prompting and documentation of Smoking Status Smoking Cessation Discussed Smoking Stage Diabetes Complications Correct Treatment Deficiencies or Document Contraindications examples CHF ACE inhibitors Post MI beta blockers The CCCQE CDS PSIA application resides in the CCCQE CPOE A amp P encounter form part of the CCCQE core forms and is triggered when a problem is selected from the dropdown list The following screenshots will serve as an example of the various types of decision support prompts and wo
170. soft and RUQ tenderness hepatomegally non tender without masses organomegally or splenomegally LUQ tenderness haiste aois mass RUQ RLQ tenderness mass LUQ LLQ tenderness mass RLQ epigastric tenderness mass 10 L flank tenderness epigastric mass R flank tenderness L flank mass with guarding R flank mass without guarding L inguinal hernia with rebound Ringuinal hernia without rebound ascites noted positive Murphy s sign zi Rectal Normal Clear normal external exam A hemoccult positive rectal mass external hemorrhoid poor sphincter tone zl internal hemorrhoid Genitalia Norma _ _GU Exam normal male testes descended bilaterally without E masses no hernias noted Rhydrocele Ltestes high canal Ltesticular mass Rtestes high in canal Rtesticular mass Ltestes absent Rtestes absent ambiguous genitalia zi micropenis Prostate Prior Clear normal size prostate without masses or assymetry normal size prostate prostate mass no masses prostate tenderness zl enlarged prostate assymetry noted L 1 1 1 1 1 1 1 1 1 1 21 Prev Form Ctrl PgUp Next Form Ctri PgDn 1 The following may be customized by specialty normal default values observation terms that are populated and the items in the two list boxes 2 The list box values may contain either
171. ssessment enter all values that are to be documented and click the Record action button 2 Repeat the process to record subsequent sets of measurements 3 A flowsheet view of the vital signs will be created in the Vital Signs this Visit data display and in the chart note 4 The Comments field may be used to document comments regarding patient status or treatment decisions Page 93 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Serial Assessments CCC Postural continued Serial Assessments CCC Custom Adult Serial Assessments Time of Assessment 5 40 Any further values for the following will Vital Signs C Standard Postural C Multiple Sites nat be added to the owahe 1 Postural BP s Lying 120 1 80 Hg Pulse 80 I min 2 Resp Rate xi 3 02 Sitting 120 mm Hg Pulse 90 min 4 PEF Standing 110 70 mm Hg Pulse 100 I min Comments Go to Flowsheet for Corrections gt Flowsheet 16G started left antecubital and 2 Liters LR given IV over 20 minutes Vital Signs this Visit Time Position BP Pulse Resp Temp By 4 55 PM 120 80 80 10 Harry S Winston MD 5 15 PM 110 70 80 Harry 5 Winston MD 5 20 PM Lying 120 80 80 Harry S Winston MD 5 20 Sitting 110 70 100 Harry S Winston MD 5 20 PM Standing 100 60 120 Harry S Winston MD HPI
172. structions on how to use the CCC TFE 2 Insert Values for Editing click this button to automatically extract the values from your current CCCQE User Edit Files NOTE Be sure to click the yellow Insert Values for Editing action button on every tab before starting to edit or customize 3 Open Text File to Edit click this button to automatically open the correct CCCQE User Edit TFE text file to create edit Once the form is complete you ll copy and paste the new code into this file then click save 4 Put Updated Values into Text click this button to rewrite the new CCCQE User Edit MEL code which can be copied and pasted in the CCCQE User Edit TFE text file 5 Remove from Text click this button to remove the new CCCQE User Edit MEL code 6 Search Medications click this button to open the Medication Module of Centricity and search the medications database 7 Search Problems click this button to open the Problems Module of Centricity and search the problems database ICD and CPT codes 8 Insert Formatted Text click this button to create a plain text translation of all of the customization that has been created see example 9 Load EF for Reference click this button to load the corresponding encounter form you are editing for reference purposes 10 Buttons next to each action button click these buttons to explain what the larger buttons do Page 110 Copyright 2005 Clinical Content Consultants LLC All rights reserv
173. sultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Future orders display as Future Orders with the associated future date see below CPOE A amp P CCC Don C Bassett ASP 1 2 A amp P3 4 ae asp7 s asp e to 11 12 Assessment 3 Select problem enter assessment orders and meds then click Commit Assessment Prob List DIABETES MELLITUS TYPE 1 ICD 250 00 _Commit Assessment Amaryl 2 Mg Tab Glimepiride Take 1 tablet by mouth once day Aspirin 81 Mg Ec Tab Aspirin Take one 1 tablet by mouth daily Orders Hemoglobin A1c 001453 Microalbumin urine CPT 82043 Lipid Panel 303756 Future Orders EKG complete CPT 93000 08 25 2005 New Meds Change Meds Meds auto insert RI New Orders Orders auto insert Insert Template R Print Handout Assessment 4 Select problem enter assessment orders meds then click Commit Assessment gt Commit Assessment Clear All x Add All Meds to Note Remove New Meds from Note Rx Monitoring and General Alerts Rec Interventions Rec Tests Orders HPI Acv FH SH Riskractors Ros vs Problems Instructions Plan Copyright Prev Form CtrisPgUp Next Form Ctri PgDn Page 74 Copyright 2005 Clinical Content Consultants LLC All rights reserved
174. t boxes 2 The list box values may contain either normal or abnormal values 3 Charting by exception allows the provider to rapidly document a detailed PE as well as capture structured data which can be used for reporting or clinical decision support 4 The provider can use voice recognition CCC VRI Dragon 8 Medical to dictate into structured data fields Page 42 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Neurologic Exam CCC Thoracic Neurologic Exam CCC Don C Bassett Neuro Cervical Thoracic US Motor Reflexes Measure Special Thoracic Exam __Priorvatwes _ Inspection deformity Thoracic C NI Abni Palpation spinaltenderness NI Abnl Sensory Exam Pinprick RIGHT AllNorm LEFT AllNorm _ Ciar T1 C normal decreased C absent C normal C decreased C absent T2 C normal C decreased C absent C normal C decreased absent T3 C normal C decreased absent C normal C decreased C absent T4 C normal decreased C absent C normal C decreased C absent TS normal C decreased C absent C normal C decreased C absent T6 normal decreased absent C normal C decreased C absent T C normal C decreased C absent C normal C decreased C absent T8 C normal C decreased C absent C normal C decreased absent T9 C normal C decreased C absent C normal C decreased C absent
175. takt Abnormality of secretion of ga Acquired acanthosis nigricans Acromegaly amp gigantism Acute Pancreatitis Adrenogential disorders ANEMIA List ANGINA List Anomalies of other endocrine Anorexia nervosa Antithyroid agents Arthropathy associated with n Atrial Fibrillation Atrial Flutter Azoospermia BREAST PROBLEMS List CAROTID ARTERY List Carpel tunnel syndrome Celiac disease CELLULITIS ABSCESS List CHROMOSOMAL ANOMALIES Chronic fatigue syndrome Chronic Pancreatitis Note Unchecking a Problem from this form will NOT remove it from the Problem List Diabetes Insipidus DIABETES List Disorder Autonomic Nervous S Diplopia DISEASES of HAIR List DISORDERS List Dysmetabolic syndrome X Ectopic hormone secretion not ELECTROLYTE FLUID List Endocrine exophthalmos Euthyroid sick syndrome FRACTURE List Galactorrhea not associated w Gastroparesis GOITER List Gonadal dysgenesis Heart failure Hemmorrhage amp infarction of tr HEPATITIS List Hirsutism Homonymous bilateral field def HYPERALDOSTERONISM List Hypercalcemia HYPERPARATHYROID List HYPERTENSION List HYPERLIPIDEMIA List HYPERTHYROID List Impaired glucose tolerance tes Impotence of organic origin INFERTILITY List Intracerebral hemorrhage Klinefelters syndrome Malaise and fati
176. tandard Update Medications dialogue box will display Note this is the default if option 1 or option 2 is not selected or if the problem has not been customized in the CPOE CPOE A amp P CCC Don C Bassett A amp P1 2 A amp P3 4 aspss A amp P 7 8 asp 9 10 aap 11 12 Assessment 3 Select problem enter assessment orders and meds then click Commit Assessment Prob List DIABETES MELLITUS TYPE II ICD 250 00 _Commit Assessment Clear All His updated medication list for this problem includes Glucophage 850 Mg Tab Metformin hcl Take 1 tablet by mouth each morning Amaryl 2 Mg Tab Glimepiride Take 1 tablet by mouth once a day Aspirin 81 Mg Ec Tab Aspirin Take 1 tablet by mouth daily New Meds Change Meds Meds auto insert New Orders Orders auto insert R Insert Template R Print Handout Assessment 4 Select problem enter assessment orders and meds then click Commit Assessment gt Commit Assessment Clear All Add All Meds to Note Remove New Meds from Note Rx Monitoring and General Alerts Rec Interventions Rec Orders PMH FH SH Risk Factors ros _vs Problems CPOE AIP Instructions Plan Copyright Prev Form CtriPgUp Next Form Ctri PgDn To change or remove a medication gt click Change Meds action button Page 71 Copyright 2005 Clinical Content Consultants LLC All rights reserved
177. te Rx Monitoring and General Alerts Orders Intake Prenatal visit Past Preg Hx Genetic Flowsheet Lab Prenatal Ed Ultrasound PAP Entry HPI PMH FH SH Risk Factors ros _vs _ Problems CPOE Instructions Plan Copyright Prev Form Ctri PgUp Next Form Ctri PgDn Page 64 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Step 2 If programmed for the selected diagnosis a series of dynamic clinical decision support prompts will automatically appear allowing the provider to take action or document why the recommended action was not necessary Logician Message 2 The patient has CHF and is currently not on an ACE I or ARB Click Yes to add a medication otherwise click No The provider can click Yes to display the ACE Inhibitors custom medication list and select an appropriate medication to be added to the patient s medication list Name Don C Bassett Find Medication Birth 11 25 1945 Custom List CCC ACE I Reference List Age 59 Year Old Male Height 71 in 180 cm ALTACE 10 MG CAP Take 1 capsule by mouth once a day 1 20 Weight 210 Ib 95 3 kg ALTACE 1 25 MG CAP Take 1 capsule by mouth once a day 50 83 ALTACE 2 5 MG CAP Take 1 capsule by mouth once a day 0 97 BSA 2 15 sqm ALTACE 5 MG CAP Take 1 capsule by mouth once a day 51 04 Cr
178. the documentation entered in the assessment field multi line edit field has been committed or attached to the designated problem on the patient s problem list Problem specific assessments may be easily reviewed in the future simply by going to the problem list Assessments can be reviewed by date This is much easier than reviewing previous visits to determine the assessment plan for a given problem over time Page 80 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Problem List Assessment for Diabetes Update Problems Potential problem list for Don Bassett Description Up DIABETES MELLITUS TYPE Il ICD 250 00 06 08 2005 COMMENT ONLY HYPERLIPIDEMIA ICD 272 4 06 08 2005 COMMENT ONLY Down CONGESTIVE HEART FAILURE ICD 428 0 09 16 2000 Sx of HOARSE VOICE QUALITY 09 16 2000 Left EFFUSION PLEURAL 0 511 9 09 07 2001 EDEMA ICD 782 3 09 07 2001 Right Minor dx of INFLUENZA ICD 487 1 06 08 2005 Minor dx of FUNGAL DERMATITIS 1 0 111 9 06 08 2005 Minor dx of FEVER ICD 780 6 06 08 2005 Minor dx of COUGH ICD 786 2 06 08 2005 Bottom Assessment Comment C New Improved Unchanged Deteriorated Comment Only Referto Diabetes Education Program and schedule for a stress test priorto starting exercise program His updated medi
179. tin Order LFT s NOW and every 6 months or as otherwise indicated 4 LDL goal not met and patient is on a Thiazide diuretic Stopping the thiazide diuretic MAY improve lipid control Page 124 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved CDSS PSIA Embedded within the CPOE A amp P CCC Form With the release of CCCQE Version 8 3 CCC has provided sites with the ability to embed workflow friendly clinical decision support within the CPOE A amp P CCC form When programmed a series of dynamic clinical decision support prompts will automatically appear allowing the provider to take action or to document why action was not necessary Example of ACE I ARB Usage in Patients with CHF Logician Message 2 The patient has CHF and is currently not on an or ARB Click Yes to add a medication otherwise click No Clicking Yes brings provider to custom medication list for ACE Inhibitors Name Don C Bassett Find Medication Birth 11 25 1945 Custom List v Reference List Age 59 Year Old Male Height 71 in 180 cm ALTACE 10 MG CAP Take 1 capsule by mouth once a day 1 20 ALTACE 1 25 MG Take 1 capsule by mouth once a day 50 83 E ALTACE 2 5 MG CAP Take 1 capsule by mouth once a day 0 97 BSA 2 15 sqm ALTACE 5 MG CAP Take 1 capsule by mouth once a day 51 04 Creatinine 1 0 mg d
180. tri PgDn Clicking the Insert Template action button for the problem DIABETES MELLITUS automatically inserts Labs Reviewed and includes the last set of values for the tests which should be reviewed at each visit into the assessment field for that problem Page 77 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved CPOE A amp P CCC Don C Bassett ASP1 2 A amp P3 4 aspse asp7 s aspo to asp 11 12 Assessment 3 Select problem enter assessment orders and meds then click Commit Assessment Prob List DIABETES MELLITUS TYPE II ICD 250 00 EA Commit Assessment Clear All Hemoglobin A1c 001453 E Microalbumin urine CPT 82043 Lipid Panel 303756 Future Orders EKG complete CPT 93000 08 25 2005 Labs Reviewed HgBA1c 8 4 12 07 2004 Creat 1 0 06 12 2002 Microalbumin 30 02 01 2004 Last Dialated Retinal Exam Normal 01 08 2005 Chol 250 05 06 2004 HDL 39 05 06 2004 LDL 144 06 15 2005 TG 222 05 06 2004 New Meds Change Meds Meds auto insert RI New Orders Orders auto insert mt gj Insert Tem plate Al _ Print Handout Assessment 4 Select problem enter assessment orders and meds then click Commit Assessment HYPERLIPIDEMIA ICD 272 4 v _Commit Assessment Clear All His updated medication list for this problem includes Lipitor
181. u like to order these tests now Click Yes to order Otherwise click No You may remove any ordered test simply by unchecking the appropriate boxes Page 119 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Embedded CDSS Prompts Within Encounter Forms Example The new Test Management Form allows providers to review labs on one screen and based on diagnosis be alerted to labs services due With a single click the provider can order appropriate tests services Test Management CCC Don C Bassett _ _ Select Speciatty Family Practice Emi Order Date 03 09 2005 Diagnosis SIABETES MELLITUS TYPE I ICD 250 01 4 Go to Orders Clear All Fields After Committing Orders Tests Reviewed Add New Orders to Text Check to Order Last Val Date Check to Order Last Val Date Check to Order Last Val Date Nar Ma 09 20 2000 T Protein ERN CBC widiff view 17 X 09 20 2000 Albumin ia8 09 21 2000 jo 09 20 2000 Globulin x 388 09 21 2000 NoD 33 09 20 2000 Uric Acid 53 09 20 2000 AnemiaPanel View anona _ soPratT 09 20 2000 Lipids view BUN is 09 20 2000 scor sr i7 09 20 2000 CoagStudies view creat t0 o920 2000 Thyroid Fx View BGRandom 88 09 20 2000 D5 09 20 2000
182. uctions Instructions Instr 4 4 T Close CCC TFE action buttons Tools for PMH CCC 1 General Instructions click this button to open a pop up window with general instructions on how to use the CCC TFE 2 Insert Values for Editing click this button to automatically extract the values from your current CCCQE User Edit Files NOTE Be sure to click the yellow Insert Values for Editing action button on every tab before starting to edit or customize 3 Open Text File to Edit click this button to automatically open the correct CCCQE User Edit TFE text file to create edit Once the form customization is complete copy and paste the new code into this file then click Yes to save 4 Put Updated Values into Text click this button to rewrite the new User Edit MEL code which be copied and pasted the CCCQE User Edit TFE text file 5 Remove from Text click this button to remove the new CCCQE User Edit MEL code 6 Search Medications click this button to open the Medication Module of Centricity and search the medication database 7 Search Problems click this button to open the Problems Module of Centricity and search the problems database ICD and CPT codes 8 Insert Formatted Text click this button to create a plain text translation of all the customization that has been created see example 9 Load EF for Reference click this button to load the corresponding encounter fo
183. unia Norplant Insertion Urinary Retention Dysuria Norplant Removal Surv Urinary Tract Infection inus ToC sib cee ka Endometrial Hyperplasia Obesity Vaginal Discharge Endometrial Polyp Oligomenorrhea Hypomenorrhe Vaginal Dysplasia Endometriosis Ovary Ovarian Cyst Vaginal Lesion Endometriosis Unsp PID Acute Vaginitis Nonsp Endometritis Acute P1D Chronic Vaginitis Atrophic xl Intake Prenatal Visit Past Preg Hx netic Flowsheet b Prenatal Ed Ultrasound PAP Entry HPI P FH SH Risk Fact s vs Probl F POE AIP Instructions Plan Copyright Prev Form Ctri PgUp Next Form Ctrl PgDn 1 The Problem CCC list boxes can be customized by specialty 2 The customization designates if a single diagnosis description and ICD code is to be added to the patient s problem list or if a custom problem list containing several related diagnoses displays allowing the provider to select the diagnosis with the highest degree of specificity 3 The prefix Diagnosis of Minor Dx of Family History of etc for the problem being pushed to the patient s problem list is assigned in the customization 4 The number of days for a problem added as a Minor Dx to stay on the patient s active problem list can be specified in the customization 5 For Version 8 3 and forward there is no limit to the number of problems that can be listed on the Pro
184. w CCC Text File Editor encounter form This new editor automatically rewrites the MEL code for the CCCQE User Edit text files and can be used to edit the following forms HPI CCC PMH CCC PMH PSH CCC FH SH CCC ROS CCC PE CCC e PE Age Specific for FP and Pediatrics e PE Detailed Specialty Specific Forms such as o ENT Cardiovascular Thyroid and GU Problems CCC e CPOE A amp P CCC e Patient Instructions CCC There is a separate TFE form to create custom templates for the new Test Management CCC encounter form The CCCQE Text File Editor TFE will allow sites that have previously customized their CCCQE User Edit files to pull those changes forward and rewrite the MEL code into the new TFE format In writing the new TFE format CCC has significantly decreased the size of the files and memory requirements of the new CCCQE MEL functions which will be reflected in improved performance and speed Detailed instructions for using the new CCC TFE are built directly into the TFE Encounter Form Clicking the yellow General Instructions action button will open the directions needed to get started For more detailed instructions for any action button contained within the editor simply click on the various action buttons next to each item for expanded instructions Since sites will want to limit restrict access to editing of the text files you will need to determine the users within the group who will have the privilege to make
185. xible sigmoidoscopy or barium enema Would you like to order these tests now Click Yes to order Otherwise click No You may remove any ordered test simply by unchecking the appropriate boxes Page 117 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example Prompt alerting provider and or staff that an outdated ICD code appears on this patient s problem list When Medicare CMS changes ICD codes each quarter failure to update the patient s problem list with the updated code can lead to non payment Logician Message xi v NOTICE The following problem s with its diagnosis code s does not match the accepted approved diagnosis code s Either the code has changed or has become obsolete 1 HYPERPARATHYROIDISM ICD 252 0 2 ULCER DECUBITUS NOS ICD 707 0 Click Yes to edit the Problem List otherwise click No Yes i Clicking Yes opens the patient s Problem list to automatically make the correction at the time of service Example Prompt alerting provider if patient with a particular condition is not on a certain class of medication shown to improve outcomes j xi Patient has a diagnosis of CHF but no ACE Inhibitor or ARB is Found in the Medication List and no contraindication has been documented Assuming the patient has no allergy to ACE I then consider adding an Inhibitor or else document
186. xpanded Risk Factor CCC Form Showing Additional Data Entry Fields Risk Factors CCC Don Bassett Risk Factors Insert all prior values into note including any changes made today Select Speciaty ENT vj Tobacco Use Alcohol use yes C no current C quit C never EN 7 Year started A Drinks per day E Cigarettes yes Amt 12 pckiday Has patient Cigars C yes no Amt ghweek Felt need to cut down C Y CN Smokeless C yes no Amt per day Been annoyed by complnts Y Counseled to quiticut down yes C no Felt guilty re drinking C Y Passive smoke exp no Needed eye Y Drug use no Comments Substance Counseled to quiticut down yes comet 22 Exercise yes no HIY high risk behavior yes C no Times per week 1 E Comments pensa EDGE m Type of exercise Caffeine use drinksiday 2 Seatbelt use 9 50 EN Sun Exposure Jfrequently MI in female age 65 Date of Last Colonoscopy 8 FH Ml in male age lt 55 yes Oh by the way Enter HPI PMH FH SH Risk Factors ROS Problems CPOE Instructions Plan Prev Form Ctrl PgUp Next Form Ctrl PgDn 1 Risk factor items be expanded for more detailed data entry Examples Tobacco Use Alchol Use Drug Use HIV high risk beh
187. xterna Conjunctivitis Pulmonary Rehab Referral l 555 51 m ia zd m 7 9 year visit 10 11 year visit 12 14 year visit 15 16 year visit 17 18 year visit 18 year last visit Gastroenteritis URI Vomiting Oral Rehydration Toddler Behavior Potty Training 1 The Patient Instructions CCC list boxes can be customized by specialty and or provider Customization options include list box headings list box items the obs term that is to be populated by clicking the list box item and the value that gets pushed to that obs term 2 The provider clicks all of the applicable instructions and clicks the Click to Enter action button to populate the patient instructions field and any specified obs terms 3 The values populate the patient instructions field the INSTRUCTIONS obs term which populate the chart note and the Patient Instruction Handout Click the Print Patient Instructions action button to select and print the handout 4 The Patient Instructions Handout may be further customized Note that in the example above the headings and instructions are broken into Well Child Check and other sections appropriate for Pediatrics Page 87 Copyright 2005 Clinical Content Consultants LLC All rights reserved Copyright 2005 Clinical Content Consultants LLC All rights reserved Example OB GYN Patient Instructions CCC Patient Instructions Check boxes then Click to Enter or e
188. ydactyly Fingers Select Region Hand Wrist Finger vi Note Unchecking a Problem from this form will NOT remove it from the Problem List Pronator Syndrome Radial Tunnel Syndrome Scar Adherent Scar Keloid Scapholunate injury no instabil Scapholunate Dissociation Scapholunate Sprain Strain Scleroderma Stiffness elbow forearm Stiffness wristhand Subungual Hematoma Syndactyly fingers bony fusio Tenosynovitis hand amp wrist Tenosynovitis infectious Tendinitis wrist Sprain Strain Trigger Finger Ulnocarpal Impingement Ulnocarpal Impingement Os ORTHOPEDIC CUSTOM LIST ARTHRITIS List CONTRACTURE STIFFNESS CONTUSION List CRUSH INJURY List DISLOCATION List FRACTURES List FOREIGN BODY List INFECTION List NEOPLASMS List NERVE List PAIN List SPRAIN STRAIN TENDON R TENDON INJURIES List VASCULAR List LATE EFFECT List OPEN WOUND List Je New Problems Added most recent addition on top E Problems Medications Allergies Orders Remove Text Cursor must blinking in Yellow Field for CCC Speak 6 Foot Ankle Exam Hand Wrist Exam Hip Exam Knee Exam Shoulder Elbow Exam PMH FH SH Risk Factors ros vs Problems CPOE AIP Instructions Plan Copyright Prev Form Ctri

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