Transcript Centers for Dialysis Care Electronic Medical Record

Centers for Dialysis Care
Electronic Medical Record
Clarity: Physician & APN Training Module
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Introduction
Comments and Notes
Table of Contents
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Table of Contents ⏎
Introduction
You may view the slides in order, or pick a topic by double clicking the box on the table of
contents. Return to the Table of Contents by double clicking the box next to page #.
The purpose of this presentation is to teach you
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Login in at the CDC facility
Login remotely over the Internet using the Citrix Server
Basic navigation from the Clarity Home Page
The Message and Task Application
Signing Orders
Documenting face to face rounding “Real-Time Charting (RTC)”
Documenting an Office Visit (MD office visit – electronic)
Documenting an Office Lab review (MD office lab review – electronic)
Writing Progress Notes
Problem Lists
Medication Lists
Writing Orders other than orders in the Physician Tab of Real-Time Charting
The Clarity Reports
Built in Clarity Help Functions
Frequently asked Questions from CDC MD users
Table of Contents ⏎
Notes
You must have a CDC User ID and Password to use the CDC electronic medical record.
If you are new to the CDC information systems, or if your current DiProton User ID and
Password do not work in Clarity, please call or email the Help Desk to set up a user account
at (216) 229-6170 x149.
Clarity does NOT support any browser BUT Internet Explorer.
The presentation assumes you know basic Windows and Internet Explorer navigation
techniques. If these terms are foreign to you, please call the Help Desk for assistance.
If you view this presentation on a computer connected to the Internet, clicking on the URL
links (ex: www.cdcare.org) on the slides will take you to the actual site on the Internet.
We will complete the roll out of Clarity to all of our facilities by the end of 2010. Some of the
screens demonstrated in this presentation may be slightly different from the production
application due to enhancements made as we go along. The essential functionality and
navigation process will not change.
Throughout this presentation the text “NPOrganizationE-Signature” denotes a path to take
from the Navigation Pane through the sub-menus. In this case to get to the E-Signature
screens from the Navigation Pane (NP).
Clarity uses ‘drop down’ boxes for selection choices.
Touching the down arrow reveals the choices. Scroll down and click your choice. Click ‘GO’
or ‘Search’ to finish.
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Note to MacIntosh (Apple) Users
1. While Clarity requires Internet Explorer, when you connect over the internet you
are connected to CDC’s citrix server. When you launch the
application you
will be using the Internet Explorer application within CDC.
2. The Problem for most Mac users is to launch the Citrix client successfully.
3. When you connect to www.cdcare.org you will see the following window. If you
try to start Clarity and you get a message about Citrix, download the “client” noted
in the message window. Also, be sure you have the most recent version of Safari or
Firefox.
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Table of Contents ⏎
Table of Contents
Introduction and Notes
Patient Progress Notes
Connecting to CDC EMR
Using Checklists
Navigating Clarity
Medications & Allergies
Signing Verbal Orders
Problem Lists
Writing Orders
Reports
Dialysis Rounds
Help Functions
cdc help desk
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Table of Contents ⏎
Connecting To the CDC EMR
Login at the Facility
Login over the Internet
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General Comments about Login
You may use Clarity from any computer in a CDC facility.
You may use Clarity over the internet using the CDC Citrix
Server.
In either case, the process will take you to the same Clarity
Login screen and Home Page.
Clarity functions the same way irrespective of how you launch
it.
You Login to the Home Page (Welcome Screen). If you
navigate to other Clarity sections you may be asked if you wish
to continue the Login Session (just say yes). If you are timedout of the Login, you will not lose the work in your active
window if you are doing a checklist or Real-Time Charting.
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Login from CDC Facility
Double click on
Clarity Login
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Login from CDC Facility
Note: Both User ID and Passwords
fields are case sensitive
Type in your User ID
(Press TAB to go to password box)
Type in your password
Click the “I Accept” button or hit
ENTER to complete login
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Login from the Internet
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Type http://www.cdcare.org/ in your
address bar in the browser
Mouse Over either to “CDC Users”
Double Click “CDC Citrix Login”
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Login from the Internet
1. Type your User name and Password as usual (case sensitive)
2. You can expedite this process by going directly to  https://citrix.cdcare.org/
3. You can also “drag” this URL from the address window to your desktop creating a
Desktop Short Cut
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Login from the Internet
Choose this Clarity icon
(NOT the desktop icon)
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Navigating through Clarity
Home Page
Window Control
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Clarity Home Page
YOUR NAME
Physician USER
You have 1 new message and 1 new task..
Your Name and system
notices
Navigation Pane
Click for sub-menus
Messages and Tasks Notification
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Welcome
Screen and
News area
Clarity Home Page, Messages and Tasks
USER,
YOURPhysician
NAME
Physician USER
Clicking on the Message or Task
Icon will open the indicated
window in the Welcome Screen.
Clicking on the date of the Task or
Message will reveal the contents.
Respond as you would to any
email. CDC has not developed a
procedure for these functions.
Messages sent via this utility stay
within Clarity. They do not go to
the CDCare.org e-mail system.
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Navigation: “Select a Patient”
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All patient specific actions (write or review a note, checklist, order,
or report) begin with the same patient selection screen shown on
the next slide.
You need only select clinic, patient, and status if you are looking for
one patient. If you are looking for groups of patients you can add
more filters from the drop down menus.
If you get a “no record found” message, you may have chosen the
wrong facility or status (choosing “All” under status will find patients
currently in the hospital or pending transfer in).
If you are switching from patient to patient in different facilities, the
program may revert to your default clinic.
A good way to find all your patients at a given facility is to specify
the clinic, choose “All” in the status box, choose your name from
the “Primary Nephrologist” drop down menu and click “Search.”
This action will list your patients. You can use the printing function
on your browser to print the displayed page from “print preview.”
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Navigation: “Select a Patient”
YOUR NAME
Click “search”
to find the
patient
Choosing yourself from the Primary
Nephrologist drop down list and
not specifying a patient, will
generate a list of all your patients in
the selected clinic
Choose “ALL” unless
you are sure your
patient is not in the
hospital or “pending”
If your search returns “No records
found,” check the Clinic choice,
Status and spelling of name
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Navigating through Clarity
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YOUR NAME
Physician USER
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From the Home Page
choose “Patient” on the
navigation pane.
Choosing “Patient” will
display a sub-menu of
choices within the Patient
specific applications.
In this case “immunizations”
were selected.
Choosing any of the values
in the Patient sub -menu will
take you to a patient
selection screen.
Notes On the Clarity Window Control
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The page that shows the navigation pane and the
Welcome message is the Home Page.
When you open a file from the navigation pane, some
will open in the area of the welcome message, some will
open as utility on their own page.
Those that open in their own page, will not have a
navigation pane.
In this case, the Home Page (Navigation Pane) may be in
a window behind the new window.
You can appreciate the sequence by toggling the
window size button on the Internet Explorer Title bar.
This perspective is demonstrated on the next few
slides.
You LOGOUT of the home page. You merely close the
other types of pages.
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Clarity Window Control
Toggling this icon will close the
page. If you close the home
page, it will log you off Clarity.
Closing pages without the
navigation pane will not log you
off clarity.
YOUR NAME
Clicking this icon minimizes the
window and puts it down on the
“start” bar on your desktop. Bring it
back by clicking on the title
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Clicking this icon will toggle
between a full screen and scalable
window. In the full screen mode,
the other windows will be behind
(not lost or closed). See next slide.
Clarity Window Control
Both of these windows are in the scalable mode. Toggling
these boxes will bring them to the full screen mode putting
the other window behind.
In the scalable mode, you can resize the
window by ‘click dragging’ this corner to
change the vertical/horizontal dimensions.
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Signing Verbal Orders
E-Signature
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Clarity E-Signature
(NPOrganizationE-Signature)
YOUR NAME
Physician
Physician USER User
You have 1 new message and 1 new task..
You sign your verbal orders via
this path to the screens shown
next.
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NPOrganizationE-Signature
Select Clinic and Status
Click Search
Orders are displayed one page at a
time
Click reject if you did not give the order
Clicking this box checks all the orders on the page, otherwise click one order at a time
Navigate from page to page
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Review all the orders. Check one at a time or all by checking the box on the first row.
Type your User Name and Password.
If you wish a copy of your signed orders, click Show Report.
Click “Sign Selected” (everything you checked will be signed, or the whole page if you checked the first box.
Go on to the next page and repeat the process.
If you ‘reject’ a medication order, it is placed on hold. Other rejected orders are cancelled. The facility runs a ‘rejected order’ report.
If you see numerous orders that you did not give or do not recognize, please notify the Facility Manager.
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Patient Progress Notes
Reviewing Patient Notes
Writing Patient Notes
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Clarity: Patient notes
There are 2 ways to write a note in Clarity:
1. A ‘free text’ note (NPPatientNotes)
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A typed text note with a “TYPE” drop down choice list, a summary line
and a text insertion window. Starts, as do all Patient choices at the
“Select Patient” screen.
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A ‘Check List’ (NPPatientPatient Checklists)
An “interactive” note that incorporates formatted text, current data
from the dialysis and laboratory results and free text insertion windows.
Once completed, it remains in its list form or can be printed as a report.
While their content is different, they all work the same way.
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We will discuss the Office Lab Review, Office Visit, and
Real Time Charting Physician Note in this presentation.
Table of Contents ⏎
Clarity: Free text patient notes.
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You can review, print and write
patient notes from
NPPatientNotes.
You can ‘import’ text notes from
the computer clipboard into these
notes.
You can review notes written from
checklists.
Orders written from
NPPatientPhysician Orders
are reviewable here.
This path will take you to “Select a
Patient” if you are not already
working with a patient.
The next slide shows index screen
after you have selected a patient.
Clarity: Reviewing Patient Notes
You can change
patients by clicking
here.
By using “type” and/or “date” filters
you can look at specific notes. In
this case all the MD Office Lab
Reviews for this patient are listed.
Clicking “Notes Report” displays
the content of all the progress
notes in chronological order.
Clicking on the column
heading (in any table like this
in Clarity) will sort the rows
by that column.
Review an individual note
by clicking on the date.
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Clarity: Writing Patient Notes
By clicking on “Add New” you
can write a note on the
patient listed at the top of the
page.
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Clarity: Writing Progress Notes
The note can be attached to a
dialysis treatment by clicking
here.
Date and Time stamps are supplied.
Choose a type from the drop down
list. In this case “Hospital Progress
Note” is chosen.
‘Grayed’ out fields are not active in
the note writing screen.
Type a summary of the
note. Then type your
note in the note entry
box. When finished click
“Add.”
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Patient undergoing evaluation for GI bleeding …etc.
Any text that is on the computer ‘s clipboard can
be pasted [Ctrl-V] into this space such as discharge
summaries, op notes, x-ray reports etc.
Problem Lists
Multidisciplinary Problem and Diagnosis List
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Clarity: Problem List (NPPatientProblem List)
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Problems can be medical diagnoses,
or active care plan issues.
The completeness of this list will
support co-morbidity
documentation under the new
bundled payment system.
All disciplines can enter and modify
problems.
Problem List report: NPPatient
ReportsProblem List
The problems are printed on the
Problem List Report.
The following slide shows how to
add, modify (update), or delete a
problem.
Clarity: Problem List Maintenance
NPPatientProblem List
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Table of Contents ⏎
NPPatient ReportProblem List
“Add New” or Update (by clicking on) problem
Choose (or change) the category (organ system)
Indicate whether active or not
Free text comment or explanation
Put ICD9 code (search via “Select” ICD-9). Text
Automatically displayed.
Indicate if you wish the problem displayed
Place a start (or supply stop) date on reports
”Add,” “Submit,” or “Delete”
Problem List Report Looks like this
Medications & Allergies
Medication List
Medication Report
Patient Allergies
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Clarity: Medication List
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(NPPatientMedications)
Staff enters orders for medication
starts, stops, or changes at
NPPatient Medications
Either MD’s, or APN’s, or Staff can
enter Medication Allergies.
Allergies (NPPatientMedication
Allergies) are displayed both on the
List and the Report
MD’s and APN’s should place
medication orders in
NPPatientPhysician Orders (or
RTC orders)
Once the staff enters the order, it
will display on the Medication List
Report (NPReportsPatient Reports 
Medications)
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Clarity: Medication List and Report
NPReportsPatient
Report Medications
NPPatientMedications
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Displays Allergies
Choices for Status of Medication
Click on Med for order details and history
Not formatted for printing and filing in
office record.
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Printed version suitable to file in office chart
Run for a defined date range
Allergies and date of last med review displayed
Dose history of meds given during dialysis
listed (for date range)
Clarity: Medication Allergies
Add or update a medication allergy
Find medication in “Select Medication”
Specify the type of reaction
“Add” or “Submit” to display on
medication list and report
• Clicking “Update Allergy etc…” will
return an “Access Denied” error
message (don’t do it).
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Writing Notes Using Checklists
Checklists Office Lab Review:
Checklists: Office Visit
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Table of Contents ⏎
Clarity: Checklist
(NPPatientPatient Checklists)
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From the Navigation Pane
chose Patient
From the Patient Sub
Menu choose Patient
Checklists
On the next screen you
will chose what checklist
you wish to use
Clarity: Checklists, Office Lab Review
1. Choose “MD OFFICE LAB REVIEW (ELECTRONIC) & click “GO.”
2. The next slide shows the OFFICE LAB REVIEW check list.
3. Note that the Check List opens in its own window. There is no Navigation Pane on this
window. Clicking the “X” box
in the upper right hand corner will close this
window only. The Clarity navigation pane may be behind this window if you have not toggled
the scalable option.
4. You can print this checklist to document your review in your office record.
5. YOU CANNOT PUT ORDERS ON THIS CHECKLIST. That functionality is in development.
6. To write orders you must go “NPPatientPhysician Orders”
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Clarity: Checklists, Office Lab Review
After you have signed the note,
you can print it for your records.
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Select the appropriate Clinic and Patient from the drop down boxes.
Select your name from the Physician UPIN drop down box. Type month of the data reviewed.
You may review previous notes by using the History drop down menu.
Go through the list responding to the prompts.
Clicking on text like “View BP trends report” will display the most recent BP data in a PDF
page. Close the page after you review it.
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Enter free text as you wish in the adjacent “Notes” column.
Indicate whether the patient is stable or unstable (and the reason for the unstable status).
Sign the note with your User Name and Password.
If you wish to write orders, go to “NP  Patient  Physician Orders.”
Go on to the next patient by changing the Name and Clinic in the selection boxes.
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Clarity: Checklists, MD Office Visit
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From “NPPatientPatient
Checklists”
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Choose “MD Office Visit (electronic)”
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Choose the patient from the “Select
Patient” screen.
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Complete the check list as noted in
the next screen.
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1. You may document your H & P on
this check list.
2. You can review dialysis, BP,
medications, and cumulative
laboratory results.
3. You can print this report to place in
your office record.
4. As of yet, you CANNOT write
orders in this checklist.
5. You can write orders by “NP 
Patient Physician Orders.
Clarity: Checklists, MD Office Visit
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Choose the Clinic and Patient.
Choose your name from the MD list.
Record the CC, PI etc. in either of the text entry
boxes (Value or Notes).
View the Linked Reports. Comment in the
adjacent Notes column.
Record your Exam by clicking the organ system
and adding the observations in the adjacent
Notes column.
Complete your assessment and plans.
Sign with your User Name and Password.
Print the report for your office records.
To write orders you must go
“NPPatientPhysician Orders
Writing Orders
Orders not Associated with Dialysis Real-Time Charting
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Clarity Writing Orders
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(NPPatient Physician Orders)
From the navigation pane
chose “Patient”
From the Patient SubMenu chose “Physician
Orders”
Select Patient from the
“Select Patient” screen
The next screen is the
physician order panel.
Clarity Writing Orders
1. You can review existing orders by clicking on the order’s date.
2. You can change patients by clicking the “Change” box to bring
up the “Select Patient” screen.
3. You can add a new order for the patient listed by clicking
“Add New”
4. Clicking “Add New” brings up the screen shown in the panel
to the right.
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(NPPatient Physician Orders)
The date and time stamp are supplied
Write a summary of the order in the “Summary” box.
Write the order(s) in the text entry window.
You may write as many orders as you wish.
Please put each order on its own line.
Please use the standard hospital order writing conventions.
No abbreviations. “Increase Dry Weight to 68 KG” NOT “
dw to 68.”
8. Click “Add”. If the “Add” button is not displayed, you cannot
enter the order. You are likely in an some other user’s login.
9. These orders are checked twice a day. You should call the
facility if the order you wrote is urgent or if it pertains to
today’s dialysis.
Dialysis Rounds
The Treatment Menu
Rounding Physician Dashboard
Real-Time Charting
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Clarity: The Treatment Menu
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Treatment History lists an individual
patient’s treatments. You can click on
the date to see the treatment.
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Rounding Physician Dashboard (see
next slide) lists your patients for that
day. This is useful place to plan your
rounds.
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RTC Status states the current status
of dialyzing patients.
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Real-Time Charting (RTC) is where
you do and document your face to
face rounding.
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These as table format reports.
Clicking underlined text opens the
treatment or patient dialysis RTC
record.
Clarity: Rounding Physician Dashboard
One, Patient
Two, Patient
Three, Patient
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Pick your name and today’s date. “Search” will list all patients assigned to you.
Clicking on the patient’s name will open their RTC record.
The table lists the scheduled time and treatment station.
Any requests from the RN staff are listed in the last two columns.
You can get a list of your rounding patients by printing this table using the
printer function of your browser through print preview.
6. There should be a list of your patients in your CDC mailbox.
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Clarity: Dialysis Rounds “Real-Time Charting”
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Dialysis, face to face rounding is done through a utility named “RealTime Charting.”
You can review all the current dialysis data, nursing and tech
documentation, and machine data through this application.
Through the Physician “tab,” you can review previous dialysis
records, laboratory, BP and medication reports.
You can write orders through this application.
You can receive messages from the nursing staff about issues
requiring your attention during rounds.
You can document your participation in the Unstable Care Plan IDT
meeting.
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Notes on Rounding at CDC
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We expect that notes are entered during or shortly after
the visit.
The computer stands can be lowered, allowing you to sit
and talk to the patient while reviewing their data.
If the system is down, there are down time forms for you
to use.
Hand Hygiene
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You must wear disposable gloves when you use the chair-side
computer terminals.
You should do hand hygiene before and after using terminals at
the center desk, though you do not need to wear gloves at the
terminals away from the chair-side.
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Clarity: Real Time Charting (RTC)
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From the “NPTreatmentsRealTime Charting”
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If you use the terminals at the station,
the utility will already be open. You
need to choose the patient from the
“Start” bar in the Windows desktop.
Patient, Name
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Patient, Name
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You can review the dialysis
prescription (though there is a more
efficient way – see patient reports)
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The next slides go through the
process of documenting face to face
rounding.
Clarity: Real-Time Charting
If you enter your note after the
treatment is signed off by the RN,
it will not appear in this list.
1. There are 6 tabs. You will document only in “Phy Rounding.”
2. Make the appropriate clinic and patient selection choices.
3. You may review previous notes by the History drop down choice. (Be sure to
return to today’s date before writing a note).
4. The record and types of notes (RP monthly assessment or Rounding Visit) are
listed.
5. The record of hospitalizations is listed.
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Clarity: Real-Time Charting
1. A series of links to current data reports can be opened and reviewed.
2. You may make your comments in the Notes column adjacent to the value column.
3. Do not put orders in the Notes column.
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Clarity: Real-Time Charting
Select the Level of Visit (mandatory field).
If you are doing an “RP Monthly Assessment,” check the box. Add comments as appropriate to
the adjacent Notes column.
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Clarity: Real-Time Charting
Document your H & P as indicated.
Respond to the “Physician Request” if one is present. If no response needed, *NONE* will appear in this space.
Review the listed Dialysis and Laboratory data.
Indicate if your rounds are part of an IDT unstable care conference.
You may write orders on this check list. Tell the charge nurse about any STAT orders.
Sign with User Name and Password. Change to the next patient from the selection box at the top of the form.
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Clarity: Real-Time Charting
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If you make a comment in the Notes column and there are a
series of ‘radio’ buttons in the values column, be sure to check
one of them.
If you miss a required field, you will not be able to sign off the
note until that field is completed.You will get an error message
in red identifying the missing information. Correct the
omission and re-sign the note.
You cannot change to the next patient until you have signed off
the current patient.
As you round, you will inevitably think of things that we can
add, change or make better. Please e-mail your suggestions to
the help desk. We do want this application to serve your
needs. We will work with the physician users to enhance this
program.
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Running Reports
Patient Specific Reports
Batch Reports using “Advanced Mode”
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Clarity: Patient Specific Reports (NPReports  Patients)
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From
NPReportsPatient
Reports
To a “Select Patient”
screen if you are not
already working with a
specific patient.
To a report selection drop
down menu if you are
already working with a
patient.
Run for current patient
or Select a new patient
Select a date range
Select Output Type
then Run Report
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Choose a report type
Clarity: Regularly Useful Reports
NPReportsPatient Reports  <select>
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Dialysis Orders >> “Dialysis Prescription”
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Medication List >> “Medications”
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Vascular Access >> “Access History” (includes transonic results)
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Completed Flow Sheets >> “RTC Hemodialysis Treatment Information”
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General review of orders, labs, treatments >> “Patient Summary”
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Lab Results >> “Monthly Labs: expanded”
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HGB trends with meds history >> “Anemia Trends”
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Demographics >> “Registration Information”
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Dry weight and Blood Pressure History >> “Blood Pressure Trends”
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Attendance and treatment time adherence >> ”Hemodialysis Treatment Times”
You can get a description of the report by clicking on the “More Info” link:
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Clarity: Combining Patient Reports with the
“advanced mode” to create and save a batch
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A useful way to review your patients each month, is to
run key reports that help you to interpret dialysis and
laboratory data.
By combining BP, Treatment Time, HGB & trends, in to a
single report run for all your patients at a given facility,
you can save the time of opening each of these.
Run them to a .pdf file that you keep open on your
desktop and you can review each patient quickly as you
complete the check list.
The next few slides demonstrate this method.
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Clarity: Batch Reporting
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Report  Patient Report
Choose a patient
Choose the first report
Click “Advanced Mode”
“Add” additional reports
Select a date range
Click “Next”
Clarity: Batch Reporting
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Select yourself from the
“care provider” box.
“Run” the report.
The report will open in a
PDF file.
You can “find” the patients
in the file by putting their
name in search box at the
top of the file.
pdf reader tool
bar
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Help With Clarity
Built in Help Functions
CDC Frequently Asked Questions
The CDC IT Help Desk
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Clarity: Help Functions
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There are a number of
useful built in help
functions.
Additionally, as shown on
the following slide, there a
screen and report specific
help functions.
Clarity: Help Functions
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Page Specific help is seen in
the upper right hand corner
of many screens. Clicking it
will open a help window.
Reports list the content and
source of data in the “More
Info” link.
Checking these does not
alter your report or login
status.
All of these functions are
‘read only.’ Feel free to
explore, you cannot hurt the
data base (or break the
internet).
Frequently Asked CDC MD Questions

I am in the hospital, at home, or in my office, how do I connect to the CDC EMR?

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I am in the hospital, how do I get dialysis orders and treatment summaries?

NPReportPatient Reports<select> “Dialysis Prescription”

NPReportsPatient Reports<select> “RTC Hemodialysis Treatment Information” <select>
“date range”
I am in the hospital and I want to make a progress note about the condition of the
patient and update orders for return to CDC.

NPPatientNotes <select> “Hospital Progress Note”

NPPatientPhysician Orders <select> “Add New”  write summary and order 
<select> “Add”
I would like to print a medication list for my office chart.


From any Internet Explorer web browser type http://www.cdcare.org follow the instructions in
this slide set here. Internet Login
NPReportsPatient Reports <select> “Medications”
I want to include a copy of the patient labs for my office chart.
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NPReportsPatient Reports<select> “Monthly labs: expanded” (continued)
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Frequently Asked CDC MD Questions con’t

I want to add a new event/diagnosis to co-morbidities where do I add this?

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I want to write an order for a new medication, where to I write it?

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NPPatientPhysician Ordersfree text orders
How do I sign off verbal orders?

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NPPatientProblem List <select> “Add New”
NPOrganizationE Signature
I want to order labs on a patient.
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NPPatientPhysician Ordersfree text orders
Table of Contents ⏎
Contacting CDC Help Desk
8 am to 5 pm, Monday thru Friday
(216) 229-6170 x149
[email protected]
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Clarity Quiz

Please take quiz and fax to Education Department
(216) 229-2692
Table of Contents ⏎