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OMR Transcription Options & Features
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CAREGROUP
H EALTHCARE SYSTEM
OMR Transcription Overview
The purpose of this presentation is to provide an
overview of basic OMR transcription functions.
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Topics Included
• Keystrokes & conventions
• Accessing OMR & Transcription options
• Entering a note in Transcription
• Using free text
• Using a template
• Pasting from Word
• Saving a transcribed note & forwarding
it for signature
• Editing a transcribed note
• Printing unsigned notes
• Establishing margin & printing defaults
Click on a topic to go directly to the topic information or click on
Continue to review all topics sequentially.
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OMR Keystrokes & Conventions
To move back one level
Type an underscore (Shift hyphen)
To exit
Type a ^ (Shift 6) or
if in a word processor window press <ESC>
To view help
Enter a ? or
if in a word processor window press < F1 >
To select a menu option
Enter either the first letter of the item or
the number associated with the item
Default values
At certain prompts, the system provides default
values.
Default values always follow // .
To accept the default value, press <ENTER>.
To delete a previously
filed entry without
replacing the data
Enter an * (Shift 8).
Use these keystrokes & conventions when you work in OMR.
For this overview, only mouse clicking is required.
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Accessing OMR & Transcription Options
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Accessing OMR & Transcription Options
The Online Medical Record (OMR) is part of BIDMC’s
Clinical Computing System (CCC).
To obtain OMR access contact the IS Support Center
at (617) 754-8080.
Hospital computers provide direct access to OMR for
authorized users.
External transcription services can access OMR remotely.
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Remote Access
Users can access OMR remotely using one of the
following methods:
• via the Meditech emulator program through a
dial-up connection using a modem
• via Metaframe using an Internet connection
To install the Meditech emulator use the following link:
http://home.caregroup.org/portal.asp?category=emulator
To install Metaframe use the following link & follow the
directions provided: http://home.caregroup.org/metaframe/
To obtain remote access help using any of these methods,
contact the IS Support Center at (617) 754-8080.
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Beth Israel Deaconess
Medical Center
Clinical Computing – CCC System
Mary Smith
Port: TS3.421
System
O
Appointments/Scheduling
Clinical Information
Online
MedicalRecord
Record
Online Medical
OPD Reg (Outpatient Admitting)
Select
Select
NextPage
PrevPage
To access OMR, sign onto CCC.
Use the up & down arrow keys on your
keyboard to select Online Medical Record.
Done
Continue
You have OMR messages.
Transcription Option
1
2
3
4
5
6
7
8
9
10
11
Clinical Information options
Display/Edit Transcription
Enter Transcription
Hard Copies - Unsigned
Insert test enter/edit
Letter/Notes Defaults
OMR Messages (Notes for printing)
Online Medical Record
Providers’ Schedules
Transcription Report
Utilities
Transcription Option: 3
The Transcription Option menu includes options for:
• Displaying & editing transcriptions
• Entering transcriptions
• Printing copies of unsigned notes
• Establishing defaults
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Entering a Transcription
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You have OMR messages.
Transcription Option
1
2
3
4
5
6
7
8
9
10
11
Clinical Information options
Display/Edit Transcription
Enter Transcription
Hard Copies - Unsigned
Insert test enter/edit
Letter/Notes Defaults
OMR Messages (Notes for printing)
Online Medical Record
Providers’ Schedules
Transcription Report
Utilities
Transcription Option: 3
Enter 3 at the Transcription Option prompt to enter a transcription.
Continue
PROVIDER:
SMIT, MAR
1. SMITH, MARY
OK? Y / /
11- 111
PSYCHIATRY
PAGE: 99999
Service and Location:
1. Psychiatry, Beth Israel Hospital Outpatient Department
Ok? Y / /
PATIENT:
FROG,KERMIT
123-12-1234
0901910
At the Provider prompt, enter the provider’s name using the format Last Name,
First Name. Enter the first few letters of the name & OMR will display matches.
OMR displays matches to the name you entered. Press <ENTER> to accept the
name displayed.
OMR displays the provider’s default Service & Location. Press <ENTER> to accept this
information or type in the Service & Location specified in the dictation.
At the Patient prompt, you can identify the patient in a variety of ways:
Last name, first name
7 digit CCC medical record number
Social security number
Room number for hospitalized patients
Last name for patients currently or recently hospitalized or in ED
There are several test patients in OMR to use for training.
They include: Kermit Frog, MRN 0901910
Kermit Frog, MRN 1213367
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Choose Patient: 4
1 Frog,Kermit
41 M 000-00-0000
21 Sep 1959
0901910
123 Main Street
Anywhere
12345
Frogger
Frogette Frogge
OUTPT
2 Frog,Kermit
0078199
Ziggy
Phyllis
79 M 000-00-0000
(ACCESS RESTRICTED)
Nancy
2 Feb 1922
OUTPT
36 M 000-00-0000
3 Frog, Kermit
1058295
(ACCESS RESTRICTED)
Joseph
Donna
Fanny
Frog
28 Jul 1964
OUTPT
25 MM
44 Frog,Kermit
Frog,Kermit
25
1117257
11 Glendale
St
1117257
Glendale St
Richard
Mary
Linda
Richard
Mary
Linda
Jan1976
1976
11 Jan
02149
02149
OUTPT
OUTPT
Select
Select
000-00-0000
000-00-0000
Everett
Everett
NextPage PrevPage Done
After you enter the patient’s identifying information,
OMR displays a list of patients to choose from.
Use the up and down arrow keys on your keyboard to
highlight the correct patient and press <ENTER>.
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DATE OF SERVICE:
T-1
Initial note
Letter
Progress note
Telephone contact
WHICH TYPE OF DICTATION?:
PROGRESS NOTE
No visit recorded for FROG,KERMIT
With SANDS,DANIEL Z. on 07/22/01
Enter dictation anyway? N / / Y
At the Date of Service prompt, enter the date using the format
MM/DD/YY or enter T-X. For example for yesterday, enter T-1.
There are 4 dictation types: initial note, letter, progress note, telephone
contact. Enter the type of dictation you want to create.
You can enter a dictation even if the patient did not have a visit recorded
in the system on the date of service entered.
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111-72-57
Provider: Smith, Mary
Date: July 22, 2001
FROG,KERMIT
M25
Type of dictation: Progress note
--------------------------- ----------------------------- -------------------------- ------------------------Medications before July 22, 2001
PROZAC 20MG—One by mouth at bedtime
No medications DC’d on July 22, 2001.
No medications prescribed on July 22, 2001.
--------------------------- ----------------------------- -------------------------- -------------------------
For help info press <F1>
To exit press <ESC>
OMR includes the patient’s medications as established by the clinician’s
default settings.
To escape the notes screen: Press <ESC> at any time.
For HELP press <F1>
Continue to View Help
111-72-57
FROG,KERMIT
Provider: Smith, Mary
Date: July 22, 2001
Top of Document
F9
M25
: Progress Note
Additional Help
F1
--------------------------- ----------------------------- -------------------------- ------------------------Select Text
F2
Medications before July 22, 2001
Paste
F3
Delete Word
F4 & Shift F4
PROZAC 20MG—One by mouth at bedtime
Text Inserts
F6
Set Up Search
F7
No medications DC’d on July 22, 2001.
Search
F8
Top
Document
F9
Top of
ofon
Document
F9
No medications prescribed
July 22, 2001.
End of Document F9
--------------------------- ----------------------------- -------------------------- ------------------------Page Up
Shift Up Arrow
Page Down
Shift Down Arrow
Word Back
Shift Left Arrow
Word Forward
Shift Right Arrow
Exit
<ESC>
For help info press <F1>
To exit press <ESC>
OMR Help: Use the up & down arrow keys on your
keyboard to highlight a Help option.
To Exit Help: Press <ESC>.
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Options for Creating Notes
When you create any note type you can:
• Paste in text from a word processing file
• Type in freeform text
• Use a personal text insert
• Use a public text insert
• Combine freeform text & text inserts in
a single note
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Transcription with Text from a Word
Processing File
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To Paste Text into OMR
• Create the note in Word or other word processing
software program
• Highlight or select the text and click on Copy
• Initiate note or letter in OMR
• Click on Edit
• Click on Paste
MEDITECH Remote Workstation
Options
Edit Help
Copy Alt+C
Paste
Paste Alt+V
Alt+V
111-72-57
FROG,KERMIT
M25
• OMR pastes the Word text into the OMR note
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Transcription with Freeform Text
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111-72-57
FROG,KERMIT
Provider: Smith, Mary
Date: July 22, 2001
M25
Type of dictation: Progress note
--------------------------- ----------------------------- -------------------------- ------------------------Medications before July 22, 2001
PROZAC 20MG—One by mouth at bedtime
No medications DC’d on July 22, 2001.
No medications prescribed on July 22, 2001.
--------------------------- ----------------------------- -------------------------- ------------------------25 year old male with history of depression
For help info press <F1>
To exit press <ESC>
Type in freeform text.
You can combine freeform text with insert text in a single note.
Press <F6> to access text inserts.
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Transcription with a Template
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111-72-57
Provider: Smith, Mary
Date: July 22, 2001
FROG.KERMIT
M25
Type of dictation: Progress note
Select Topic
{Psychiatr
---------------------------------------------------------------------------------------------------------------Medi
Name
ExamNorm GENERAL: Well appearing in no distress
{Antepartu ***(Index Term)***
Pro
{Complianc ***(Index Term)***
{Dermatolo ***(Index Term)***
No m {Discharge ***(Index Term)***
{Endocrine ***(Index Term)***
***(Index Term)***
No m {HCA}
***(Index
Term)***
{Psychia
***
(Index Term)****
---------------------------------------------------------------------------------------------------------------
Select
Select
For help info press <F1>
NextPage PrevPage Done
To exit press <ESC>
When you press <F6>, OMR displays personal text inserts
first, followed by public text inserts organized by service.
You can use any service’s text inserts. Use the arrow keys
to select the Service from the list or enter the first
few letters of the Service name. Press <ENTER>.
Continue
111-72-57
FROG.KERMIT
Provider: Smith, Mary
Date: July 21, 2001
M 25
Type of dictation: Progress note
Select Topic
HMFP treat
--------------------------------------------------------------------------------------------------------------------------Medi
Name
BETH ISRAEL DEACONESS MEDICAL CENTER
ED/Admit
AMBULATORY SERVICES – HMFP PRACTICE GROU
PR
HMFP eval
HMFP group AMBULATORY SERVICES – HMFP PRACTICE GROU
HMFP note AMBULATORY SERVICES – HMFP GROUP PRACTIC
No m
HMFP term AMBULATORY SERVICES – HMFP PRACTICE GROU
HMFP treat
AMBULATORY SERVICES
SERVICES –– HMFP
HMFP PRACTICE
PRACTICEGROU
GROU
treat AMBULATORY
No m
NEURO data CONFIDENTIAL – NEUROPSYCHOLOGICAL DATA S
--------------------------------------------------------------------------------------------------------------------------NEURO eval CONFIDENTIAL NEUROPSYCHOLOGICAL CONSULT
AMBULATORY SERVICES – RESIDENCY TRAINING
OPD eval
Select
Select
NextPage
For help info press <F1>
PrevPage
Done
To exit press <ESC>
A list of departmental text inserts appears.
Use the arrow keys to select the template.
Continue to Use a Text Insert
0901910
FROG.KERMIT
Provider: Smith, Mary
Date: July 21, 2001
DSM-IV Diagnosis
Axis I
Axis II
Axis III
Axis IV
Axis V:
M41
Type of dictation: Progress note
Codes & Diagnosis Description
[ 296.33 ] Severe Depression
[ ]
[ ]
[ ]
[ ]
TYPE OF TREATMENT: Include relevant modality, frequency and
duration of treatment; using the examples below.
Modality: [ x ] Psychopharmacology
x
Frequency: [ ] Weekly [ ] Twice per month [ ] Monthly [ ] Quarterly [ ] Other, please specify:
Duration: [ x ] Within UR Protocol [ ] Out of Protocol
[ ] Long term maintenance [ ] Other, please specify:
For help info press <F1>
To exit press <ESC>
Type the appropriate information into the text insert.
After the note is complete, press <ESC>.
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Continue to Save Note
Save Transcription
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111-72-57
FROG.KERMIT
Provider: Smith, Mary
Date: July 21, 2001
M25
Type of dictation: Progress note
Note:
DSM-IV Diagnosis
Codes & Diagnosis Description
Axis I
[296.33] Severe Depression
Axis II
[
Select Choice
Axis III
[
S
Axis IV
[
Axis V:
[
Save and Exit
Discard and Exit
TYPE OF TREATMENT: In
y, frequency and
Duration of treatment; using the examples
below.
Modality: [x] Psychopharmacology
Frequency: [ ] Weekly [x] Twice per month [ ] Monthly [ ] Quarterly [ ] Other, please specify:
Duration: [x] Within UR Protocol [ ] Out of Protocol
[ ] Long term maintenance [ ] Other, please specify:
For help info press <F1>
To exit press <ESC>
When you complete data entry, press <ESC>, OMR prompts you to save
or discard your work.
You can save unfinished work & return to it later.
Continue
Review the note? N / /
Title (I.e. SUMMARY):
OK to file this note? Y / /
Notify provider to sign note? Y / /
When you choose to Save & File a note, OMR provides options to:
Review the text you entered
Enter a note title
File the note
Notify the provider that the note is ready to sign
If you press <ENTER> to accept the default of Yes, OMR sends
the note to the provider’s online list of notes requiring signature.
Enter “ N “ if you wish to return later to complete additional work on
the note before you forward it to the provider for signature.
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Display/Edit Transcription
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Editing Transcribed Notes
Unsigned notes
• Transcriptionists can edit any unsigned note
entered via transcription for services for which
they authorized
Signed notes
• Transcriptionists can not edit signed notes.
• Once a note has been signed, OMR permits
providers to make edits during the 3 hours following
signing. After that, providers can add addendums
at any time.
Continue to Display/Edit Transcription
Transcription Option
1
2
3
4
5
6
7
8
9
10
11
Clinical Information options
Display/Edit Transcription
Enter Transcription
Hard Copies - Unsigned
Insert test enter/edit
Letter/Notes Defaults
OMR Messages (Notes for printing)
Online Medical Record
Providers’ Schedules
Transcription Report
Utilities
Transcription Option: 2
You can display or edit any unsigned note entered via the
Transcription Option for services you are authorized to access.
Enter “ 2 “ at the Transcription Option prompt to
display or edit an unsigned note.
Continue
TRANSCRIPTION DATE OR PATIENT ID: T
PROVIDER: SMITH, MARY
1. SMITH, MARY
11-111
PSYCHIATRY
PAGE: 99999
You can display or edit notes using:
Transcription date
Patient ID
Enter the name of the provider whose notes
you want to display or edit.
Continue
U 1. FROG,KERMIT
2. FROG,KERMIT
U 3. FROG,KERMIT
PROVIDER: SMITH, MARY
1058295 PROGRESS NOTE
1117257 PROGRESS NOTE
1316942 PROGRESS NOTE
VISIT DATE: 07/24/01 MVW
VISIT DATE: 07/22/01 MVW
VISIT DATE: 07/23/01 MVW
Choose from above list to edit
or press <ENTER> to continue displaying
CHOOSE: 1
When you choose to display/edit transcriptions by transcription date
& enter the provider whose notes you wish to display/edit, OMR Lists
all notes entered via transcription for the transcription date specified.
OMR labels all unsigned Notes with a “ U “. Only the text of unsigned
notes can be displayed or edited.
OMR also includes the system initials of the transcriptionist who entered
the note.
At the prompt, enter the number associated with the note you wish to
display or edit.
Continue
PROVIDER:
SMITH, MARY / /
Service and Location:
1. Psychiatry, Beth Israel Outpatient Department
Ok? Y / /
PATIENT:
FROG,KERMIT / /
DATE OF SERVICE:
07/21/2001 / /
Initial note
Letter
Progress note
Telephone contact
WHICH TYPE OF DICTATION?: PROGRESS NOTE / /
The edit option allows you to make changes to unsigned notes entered using
the transcription option. By typing the new information in at the
appropriate prompt you can make edits to the following :
• Provider name
• Service & location
• Patient name
• Date of service
• Type of dictation
To retain the existing information, press <ENTER> at each prompt.
Continue
105-82-95
FROG,KERMIT
Provider: Smith, Mary
Date: July 24, 2001
M36
Type of dictation: Telephone contact
Patient called to discuss test results.
Asked patient to schedule follow-up appointment.
For help info press <F1>
To exit press <ESC>
Edit existing text or enter new text.
Press <ESC> to exit and file edits.
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Continue
Printing Unsigned Notes
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Transcription Option
1 Clinical Information options
2 Display/Edit Transcription
3 Enter Transcription
4 Hard Copies - Unsigned
5 Insert test enter/edit
6 Letter/Notes Defaults
7 OMR Messages (Notes for printing)
8 Online Medical Record
9 Providers’ Schedules
10 Transcription Report
11 Utilities
Transcription Option: 4 Hard Copies – Unsigned
PROVIDER: SMITH, MARY
1. SMITH, MARY
11-111 PSYCHIATRY PAGE 99999
OK? Y / /
Select one of the following, or press <Enter> for all:
Initial note
Letter
Progress note
Telephone contact
WHICH TYPE OF DICTATION?:
To print out copies of unsigned notes for review or manual editing, enter “ 4 “ at the
Transcription Option prompt.
Enter the name of the provider whose unsigned notes you wish to print.
Enter the type of unsigned note you wish to print. To print all types, press <ENTER>.
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Establishing Margin & Printing Defaults
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Transcription Option
1
2
3
4
5
6
7
8
9
10
11
Clinical Information options
Display/Edit Transcription
Enter Transcription
Hard Copies - Unsigned
Insert test enter/edit
Letter/Notes Defaults
OMR Messages (Notes for printing)
Online Medical Record
Providers’ Schedules
Transcription Report
Utilities
Transcription Option: 6
To establish margin & printing defaults, enter “ 6 “ for Letter/Notes Defaults
at the Transcription Option prompt.
Continue
Default option
1 Letter printing
2 Notes printing
Default option: 1
To establish margin defaults, enter “ 1 “ for Letter Printing at the
Default Option prompt.
Continue
LETTER PRINTING
L
LS
M
B
W
PS
ESFL
EDIT:
LETTERHEAD:
Beth Israel Hospital (2 inch top margin) / /
SECOND PAGE LETTERHEAD:
MARGINS:
Two (2) inch left margin / /
BOTTOM MARGIN:
Increased margin (1.25 inch) / /
WINDOWS PAGE BREAK OFF?:
PRINT SINGLE COPY OF LETTER (ON STATIONARY)?: Y / /
PRINT “ELECTRONIC SIGNATURE ON FILE” ON LETTERS
PESFL
B
M
S
L
If you print letters for providers, you can use the Letter Printing
Default options to establish margins for provider letters.
Enter “ L “ at the prompt to establish the top margin.
Enter “ M “ at the prompt to establish the left margin.
Enter “ B “ at the prompt to establish the bottom margin.
Enter “ PS “ at the prompt to control how many copies OMR prints of
each letter.
Enter “ ESFL “ at the prompt if you wish “ Electronic Signature
on File “ to print on each letter.
Continue
Default option
1 Letter printing
2 Notes printing
Default option: 2 Notes printing
NOTE PRINTING
PU PRINT UNSIGNED NOTES DOUBLE SPACED?:
ESFN PRINT “ELECTRONIC SIGNATURE ON FILE” ON NOTES?:
EDIT:
PU
ESFN
Enter “ PU “ at the prompt to print all unsigned notes double spaced.
Enter “ ESFN “ at the prompt if you wish to have “ Electronic Signature
on File “ printed on all notes.
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For Additional Information
Continue to Additional Information about OMR
Click on HELP on the CareGroup portal for detailed CCC/OMR help.
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OMR documentation topics include: General Information, Medications, Notes,
Problem Lists, Management Options, and Transcription Information.
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Questions or Problems
For computer & printer problems
• Call the IS Support Center
x48080
For questions about how to use OMR
• Email [email protected]
• Receive a response within 1 business day
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