Transcript Document

Presented By:
HCN Clinical Operations
The goal of this presentation is to demonstrate how to
correctly document within Intergy EHR v9 to:
 Improve Patient Care
 Standardize documentations for easier/faster review
of patient’s chart
 Achieving Meaningful Use requirements
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TOPIC
PAGE
Workflow
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Registration Check List
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Patient Information
6
Contacts
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Imaging Results
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Patient Visit: Clinical Support Staff Check List
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Problems, Allergies, and Medication List
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Vital Signs
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Smoking Status and Family History
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Patient-Specific Education
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Lab Results
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Immunizations
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Patient Visit: Provider Check List
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Problem List
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Medication Reconciliation
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CPOE
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e-Prescriptions
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Electronic Note Signed
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Post Visit Check List
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Clinical Summaries
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Patient Portal: Pin Letter
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Registration
Patient Visit:
Clinical
Support Staff
Patient Visit:
Provider
Post Visit
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Check List for Front Desk Staff
 Patient Information
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Sex
DOB (Date of Birth)
Race
Ethnicity
Language (Preferred)
eMail
 Contacts
 Patient Internet Access
 Preferred Communication
Method
 Imaging Results
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Race/Ethnicity are separate fields and each must be completed
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Once your organization has set up the Patient Portal, the
‘Preferred Comm. Method’ field will allow for documentation.
This field defaults to ‘Paper’ and must be manually changed to
‘Secure Message.’
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A standardized folder labeled
‘Routine Health Maintenance’ has
been created for your organization
to capture and report on the
following images:
•
• Colonoscopy
• Mammogram
Ophthalmology/Optometry
• Podiatry Report
• Sigmoidoscopy
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Clinical Support Staff Check List
 Summary Page
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Problems
Allergies
Medications List
 Encounter Note
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Vital Signs
Smoking Status
Family History (First Degree)
 Patient-Specific Education
 Lab Results
 Immunization(s)
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Maintaining a Patient’s
chart up-to-date includes
documenting:
• No Known Allergies
• No Active Problems
• No Active Medications
• Reported Medications
You can also mark the medication
list ‘Reconciled’ in this window
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 Blood Pressure is to be taken for
patients 3 and older
 Height and Weight should be
documented for all ages
 Height and Weight must be
documented within the same
encounter to obtain and calculate
the BMI
 CMS is looking for growth charts
of patients 0-20 years
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For audit purposes of patients 0-20 years, you can graph the vital signs within the ‘Vitals’ tab
in the patient’s chart. You only need to check the Blood Pressure, Height, Weight, and Body
Mass Index before selecting ‘Graph’ on the top right corner of the screen
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 Marking any ONE finding under the
Mother, Father, Sister, or Brother
columns will count your patient
compliant for Meaningful Use.
- OR –
 Select ANY diagnosis and change or
add any of the following ‘Prefix’ to
mark your patient compliant:
•
•
•
•
•
•
Maternal history of
Paternal history of
Sororal history of
Fraternal history of
Daughter’s history of
Son’s history of
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You can now ‘right click’ on either
a diagnosis, a medication, a lab
results’ component and generate
patient-specific education
referencing the item you have
selected.
Selecting this functionality defaults to the National Institutes of Health’s (NIH) Medline Plus website.
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Documentation in the patient’s encounter note which states that
patient education was provided is still required.
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If you are setup with a lab
interface and you receive
more than 40% of lab results
that your providers have
ordered using the CPOE, your
lab results are Automatically
updating the patient’s record
and satisfying this measures.
For those that Do Not have a lab
interface set up in your organization
or do not receive more than 40% of
lab results automatically to your
EHR, manual lab entry will be
required.
The following slide provides you
with step-by-step instructions
followed by screen shots of these
steps.
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1) From the Top left corner, click on Intergy EHR> Tools> Lab Information (this opens the Lab
Information screen within Intergy)
2) Select from list of options on the right side> Result Entry and then below that, select> New
3) Select the patient and the ‘New Lab Results’ window opens
4) The minimum fields requiring data are: Lab; Ordered By; Ordered; Received by Lab;
Reported by Lab. Once these fields have been completed, select Test
5) The final window opens at which point at minimum you will complete: Test Code; Flag
(abnormal, normal, high, low, etc.); Result Value (if a numeric value is applicable); Reported
(date you are entering the lab); and Stat (final report, preliminary report, etc.)
6) Upon completed the necessary fields, select ‘Add’ on the top right corner. You will then
proceed to repeat step 5 above for all the lab results you need to enter for said patient.
7) After entering the last lab for this patient and ‘Adding’ it to the patient’s record, select
‘Finish’
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Step 1
Step 2
Step 3
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Screen 4
 Lab: Select the Manual lab created by your Organization
 Ordered By: Select the provider that will be tasked the lab result for review
 Ordered, Received by Lab, and Reported by Lab: Dates on the lab Report containing results
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Screen 5
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To Record History of a Vaccine:
1.
2.
3.
4.
Click Record Hist.
Click the Imm. Date radio button in Entry Mode
Select the date the Immunization was received
Stamp the Dose field of each immunization that was received on this date
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To Record History of Immune or
Contraindicated:
1) Click Record Hist.
2) Click the Other radio button in
Entry Mode
3) Select the Immune or
Contraindicated
4) Stamp the Dose field of the
associated immunization
Although you can mark Prev. Hist and
Refused, note that the patient’s record will
not be marked compliant as this is not an
exclusion for the measure.
Flu vaccines CAN be marked refused for
Meaningful Use credit.
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Check List for Providers
 Problem List
 Medication Reconciliation
 CPOE (Computerized Provider Order Entry)
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60% Medications
30% Labs
30% Radiology
 Electronic Prescriptions
 Patient-Specific Education (Refer back to Slide 17)
 Electronic Note signed
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Maintaining an up-to-date problem list remains
one of the most important aspects of a
functional EHR. It is tied to almost all aspects of
the patient’s chart as well as many reports.
You can now copy an assessment directly from
the encounter note into the Problem list!
Simply right click on the diagnosis and choose
‘Copy to Problem’
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NEW! Once you have reviewed the
patient’s medication list, simply click on
‘Mark as Reconciled’
TIP!
Any action (renewing, prescribing,
adding reported meds) will
automatically ‘Mark as Reconciled’
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Summary Page
Meds Tab
Orders/Charges
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Orders/Charges
Labs Tab
Summary
Page
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Orders/Charges
Summary Page
Orders
Tab
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Remember the key is to
select via:
Electronic Transmission
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Sign
Sign
And
And
Seal
Seal
your
your
Note
Note
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 Generate Exchange Document
 Clinical Summary
 Referral Summary
 Provide the Patient with PIN Letter
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A summary of the patient’s visit must be provider to the patient within one (1) business day. In order to
generate a complete clinical summary, the following must be available/updated during the patient visit:
 Patient Name
 Provider’s name and office contact
information
 Date and location of the visit
 Reason for the office visit
 Current problem list
 Current medication list
 Procedures performed during the visit
 Immunizations or medications
administered during the visit
 Vital signs taken during the visit (or other
recent vital signs)
 Laboratory test results
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List of diagnostic tests pending
Clinical instructions
Future appointments
Referrals to other providers
Future appointments
Referrals to other providers
Future schedule tests
Demographic information (sex, race, ethnicity,
date of birth, preferred language)
 Smoking status
 Care plan field(s), including goals and
instructions
 Recommended patient decision aids
Any information previously entered in the patient’s chart that is discussed in the current visit,
must be cited into the note to appear in the clinical summary (e.g., Lab results received or
entered on a previous date reviewed with the patient during this encounter.
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1)
Once the patient encounter note is
completed, click ‘Sign’
2)
Verify ‘Exchange Document’ is checked
and ‘Print Clinical Summary’ is selected
from the drop down option
3)
Click ‘Sign’
4)
Select the printer and print
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1)
Once the patient encounter note is completed, and you are ready to generate and send the visit summary via
the patient portal, click ‘Sign’
2)
Verify ‘Exchange Document’ is checked and ‘Open Generate Dialog’ is selected from the drop down option
3)
Select the following:
i. To: Patient
ii. What: Clinical Summary
iii. Include: De-Select any data that may be harmful for the patient
4)
Click ‘Send’
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Once an encounter note has been created, the ‘Print Summary’ option will appear on the top right
corner in the patient’s summary page. When the provider has completed the necessary information
and you are ready to generate the summary:
1) Click ‘Print Summary’
2) Select the printer and ‘Print’
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Once an encounter note has been created, the ‘Print Summary’ option will appear on the top right
corner in the patient’s summary page. When the provider has completed the necessary information
and you are ready to generate and ‘send’ the visit summary via the patient portal:
1) Click ‘More’
2) The ‘Generate Exchange Document’ window will open at which point you may make any edits
required.
3) When ready to generate the summary, click ‘Send’
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Within Intergy, under Menu:
1) Open Communications and select
‘Letters and Labels’
2) Click ‘Patient Portal Letter’
3) Search for the patient
4) Select ‘Run’ and print the letter
Within Intergy, under Patient Information:
1) Choose ‘Reports’ from the Menu screen
2) Select ‘Letters/Labels’
3) Click ‘Patient Portal Letter’
4) Select ‘Run’ and print the letter
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