Resource and patient management system



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30.0Reminders


Reminders setup is complex process. Refer to the Reminders manual for more information.

31.0Coding Tools


Your CAC can place a hyperlink in EHR to any Web resource. Below are some examples.

  1. The E&M Code Calculator from the Portland VHA.



Figure 31 76: VA E&M Code Helper

  1. Flash Code: http://66.17.18.109/flashcode/home.jsp (shown in the figure above.) This tool will help the provider pick a code. The color codes are: red is billable, green is non-billable; it prompts the user to click for another billable code.



Figure 31 77: Flash Code

  1. Palm Pilot Resource: Statcoder (http://www.statcoder.com)

32.0Drug Text Orders




Figure 32- : Sample Medication Order with Restrictions

Click the “Display Restrictions/Guidelines” link to get the following:





Figure 32- : Sample Restrictions/Guidelines Information

Step 1 – Create Drug Text

Select Health Systems Option: ^PDM

1 Pharmacy Data Management [PSS MGR] (PDM)

2 Print Documents Menu [BTIU MENU PRINT DOCS] (PDM)


Type '^' to stop, or choose a number from 1 to 2 :1 PDM Pharmacy Data Management

Dosages ...

Drug Enter/Edit

Drug Interaction Management ...

Electrolyte File (IV)

Lookup into Dispense Drug File

Medication Instruction File Add/Edit

Medication Route File Enter/Edit

Orderable Item Management ...

Orderable Item Report

Formulary Information Report

Drug Text Enter/Edit

Drug Text File Report

Pharmacy System Parameters Edit

Standard Schedule Edit

Synonym Enter/Edit

Controlled Substances/PKI Reports ...

Select Pharmacy Data Management Option: DRUG

1 Drug Enter/Edit

2 Drug Interaction Management

3 Drug Text Enter/Edit

4 Drug Text File Report

CHOOSE 1-4: 3 Drug Text Enter/Edit

This option enables you to edit entries in the DRUG TEXT file.

Select DRUG TEXT NAME: DANDOCILLIN DOSING

Are you adding 'DANDOCILLIN DOSING' as a new DRUG TEXT (the 45TH)? No// Y

(Yes)
There may be entries in your DRUG file and PHARMACY ORDERABLE ITEM file linked

to this Drug Text Name. Editing information related to this Drug Text entry

will affect the display of information related to these.
Do you want to review the list of drugs and orderable items linked to this Drug

Text entry? ? YES//

You may queue the report to print, if you wish.
DEVICE: HOME// VT Right Margin: 80//
Drug Text Report for drug text : DANDOCILLIN DOSING
Date printed: NOV 4,2004 Page: 1

===============================================================


PLEASE NOTE: The National Formulary Restriction Text is the original text

exported with the DRUG TEXT file (#51.7) and automatically linked to the DRUG

file (#50) entries based on the VA product match. No ORDERABLE ITEM file

(#50.7) entries were automatically linked with DRUG TEXT file (#51.7).


DRUG TEXT NAME: DANDOCILLIN DOSING
DRUG TEXT:
DRUG file entries:

-----------------

NONE
ORDERABLE ITEM file entries:

---------------------------


Enter RETURN to continue or '^' to exit:

Drug Text Report for drug text : DANDOCILLIN DOSING


Date printed: NOV 4,2004 Page: 2

==============================================================

NONE

----------------------------------------------------------------------


End of Report.

Press Return to continue:

Do you want to edit the Drug Text Name? NO//
IMPORTANT!! After editing the Drug Text Name OR Text, review the drugs and

orderable items linked to this entry for accuracy.


Do you want to edit the text for this entry? YES//

TEXT:


No existing text

Edit? NO// YES


A text editor will open up
==[ WRAP ]==[ INSERT ]==========< TEXT >=========[
H=Help ]====

AGE DANDOCILLIN DOSE

1-3 500MG

4-10 1000MG

>10 2000MG


<=======T=======T=======T=======T=======T=======T=======T======

Select SYNONYM: ??

You may enter a new SYNONYM, if you wish

This field will be used to allow quick lookup for the drug text defined.

Select SYNONYM:

INACTIVATION DATE:


Select DRUG TEXT NAME:

Step 2 – Link Drug Text to Drug

Select Pharmacy Data Management Option: DRUG

1 Drug Enter/Edit

2 Drug Interaction Management

3 Drug Text Enter/Edit

4 Drug Text File Report

CHOOSE 1-4: 1 Drug Enter/Edit
Select DRUG GENERIC NAME: DANDO

Lookup: GENERIC NAME



DANDOCILLIN-XR 06-14-04 55555-1234-99

...OK? Yes// (Yes)


GENERIC NAME: DANDOCILLIN-XR//

VA CLASSIFICATION:

DEA, SPECIAL HDLG: 5//
NATIONAL FORMULARY INDICATOR: Not Matched To NDF

LOCAL NON-FORMULARY:

VISN NON-FORMULARY:

Select DRUG TEXT ENTRY: DANDOCILLIN DOSING

Are you adding 'DANDOCILLIN DOSING' as

a new DRUG TEXT ENTRY (the 1ST for this DRUG)? No// Y (Yes)

Select DRUG TEXT ENTRY:

Select FORMULARY ALTERNATIVE:

Select SYNONYM: 055555123499//

SYNONYM: 055555123499//



Step 3 – Link Drug Text in orderable items dialog

Select Pharmacy Data Management Option: ORDERABLE

1 Orderable Item Management

2 Orderable Item Report

CHOOSE 1-2: 1 Orderable Item Management

Edit Orderable Items

Dispense Drug/Orderable Item Maintenance

Orderable Item/Dosages Report

Patient Instructions Report
Select Orderable Item Management Option: EDIT Orderable Items
This option enables you to edit Orderable Item names, Formulary status,

drug text, Inactive Dates, and Synonyms.

Select PHARMACY ORDERABLE ITEM NAME: DANDOCILLIN-XR DANDOCILLIN-XR TAB 08-06-

04

Orderable Item -> DANDOCILLIN-XR



Dosage Form -> TAB
List all Drugs/Additives/Solutions tied to this Orderable Item? YES//
Orderable Item -> DANDOCILLIN-XR

Dosage Form -> TAB


Dispense Drugs:

---------------

DANDOCILLIN-XR AUG 06, 2004

DANDOCILLIN (A) JUN 14, 2004
Are you sure you want to edit this Orderable Item? NO// YES
Now editing Orderable Item:

DANDOCILLIN-XR TAB

Orderable Item Name: DANDOCILLIN-XR//
This Orderable Item is Formulary.
Select OI-DRUG TEXT ENTRY: DANDOCILLIN DOSING

Are you adding 'DANDOCILLIN DOSING' as

a new OI-DRUG TEXT ENTRY (the 1ST for this PHARMACY ORDERABLE ITEM)? No// Y

33.0Creating Print Formats for CII Prescriptions


Federal law requires that the pharmacy have and maintain a signed copy of all CII prescriptions for at least two years (might vary by state). For this reason, the pharmacy still needs some type of a hand-signed prescription for all CII drugs.

Requirements for CII prescriptions are:



  1. be dated as of, and signed on, the day issued

  2. bear the full name and address of the patient

  3. bear the drug name, strength, dosage form, and quantity prescribed

  4. contain directions for the use

  5. list the name address and DEA registration number of the practitioner

  6. be signed by the practitioner in the same manner as a check or legal document

  7. written in ink, indelible pencil, or by typewriter

To facilitate the prescribing of CII medications through the EHR, the provider will order the medication. After the medication is ordered and signed, the provider must select File | Print. When prompted, select the appropriate print format (Chart Copy) and designate a printer. Before using this method, be sure that your Clinical Applications Coordinator has developed the chart copy print format to facilitate this process.

An example of this printout is shown below.

-------------------------------------------------------------------------------

    MEDICAL  RECORD        |            D O C T O R ' S    O R D E R  S

-------------------------------------------------------------------------------

NOTE:  Physician's signature must accompany each entry including standing  orders

Date and time for instituting and discontinuing the orders must be  recorded

-------------------------------------------------------------------------------

 DATE  & TIME |                  O  R D E R S                   |  SIGNATURES

-------------------------------------------------------------------------------

03/02/2005  10:00  MORPHINE TAB 15MG                        

                                     TAKE 1 TABLET BY MOUTH TWICE A  DAY

                  Quantity:  60                              ____________________

-------------------------------------------------------------------------------

Name:  SMITH,JOHN                        PHY:  WELBY, MARCUS

DOB: 04 JUN 1972                        ORD:  02 MAR 1998


CHEROKEE INDIAN HOSPITAL; HOSPITAL ROAD; CHEROKEE, NC  28719; PHONE 828.497.9163

The provider can sign the form and write down his DEA number (although all DEA numbers are stored in the RPMS) and send the Controlled Substance prescription to the pharmacy (or can have it print out in the pharmacy) where it can be filed and stored.

To enable this functionality, you’ll need to reword your chart copy print formats and adjust your chart copy parameters.

Set up the print parameters by creating a new parameter. The new parameter created in this example is called “Chart Copy Footer1.”

Select Print/Report Parameters Option:
AL Allocate OE/RR Security  Keys...

FP Print Formats  ...

PM Performance Monitor  Report


Select CPRS Configuration (Clin Coord) Option: FP Print Formats
Select OE/RR PRINT FORMATS NAME: CHART COPY  FOOTER1  

NAME: CHART COPY FOOTER1//

Select FIELDS: HORIZONTAL  LINE//

FIELDS: HORIZONTAL LINE//

ROW: 1//  

 COLUMN: 1//

CAPTION (Optional):  

SUPPRESS CAPTION:

Select FIELDS:

ROWS: 5//

ORDER TEXT LENGTH: 132//

SINGLE: NO//


OK to compile print format? Yes// (Yes)
... 'CHART COPY FOOTER1' format has been compiled.
|||||------------------------     Column Numbers     ------------------------|||||

0---+----1----+----2----+----3----+----4----+----5----+----6----+----7----+----8

1 0 0 0 0 0 0 0 0

-------------------------------------------------------------------------------

Name: SMITH,JOHN                        PHY:  WELBY, MARCUS

DOB:                                    ORD:  02 MAR 1998


CHEROKEE INDIAN HOSPITAL; HOSPITAL ROAD; CHEROKEE, NC  28719; PHONE 828.497.9163
Select OE/RR PRINT FORMATS NAME:  

Finally, go back to your print/reports parameters and add in your new field(s)

Select Patient List Mgmt Menu Option:

AL Allocate OE/RR Security Keys



PR Print/Report Parameters ...

PM Performance Monitor Report


Select CPRS Configuration (Clin Coord) Option: PR Print/Report Parameters

CC Chart Copy Parameters

WC Work Copy Parameters

SC Service Copy Parameters

RE Requisition/Label Parameters

UM Summary Report Parameters

HO Print Parameters for Hospital

LO Print Parameters for Wards/Clinics
Select Print/Report Parameters Option: CC Chart Copy Parameters
Chart Copy Definition for System:  CHEROKEE-HO.NSH.IHS.GOV

----------------------------------------------------------------------------

Chart Copy Format CHART COPY BODY

Chart Copy Header CHART COPY HEADER

Chart Copy Footer CHART COPY FOOTER1

Expand Continuous Orders NO

Print  Chart Copy When signing orders

Prompt for Chart Copy PROMPT AND NOT ASK  DEVICE

----------------------------------------------------------------------------

CHART COPY FORMAT: CHART COPY BODY// CHART COPY BODY

CHART COPY HEADER: CHART COPY HEADER// CHART COPY HEADER

CHART COPY FOOTER: CHART COPY FOOTER1// CHART COPY  FOOTER1

EXPAND CONTINUOUS ORDERS: NO//

PRINT CHART COPY WHEN: signing orders//

PROMPT FOR CHART COPY: PROMPT AND NOT ASK DEVICE//

The following are the chart copy parameters we chose for printing out orders:

Select Patient List Mgmt Menu Option:

AL Allocate OE/RR Security Keys ...



PR Print/Report Parameters ...

PM Performance Monitor  Report


Select CPRS Configuration (Clin Coord) Option: PR   Print/Report Parameters

CC Chart Copy Parameters

WC Work Copy Parameters

SC Service Copy Parameters

RE Requisition/Label Parameters

UM Summary Report Parameters

HO Print Parameters for Hospital

LO Print Parameters for Wards/Clinics
Select  Print/Report Parameters Option: CC  Chart Copy  Parameters
Chart Copy Definition for System:  CHEROKEE-HO.NSH.IHS.GOV

------------------------------------------------------------------------------

Chart Copy Format CHART COPY BODY

Chart Copy Header CHART COPY HEADER

Chart Copy Footer CHART COPY FOOTER1

Expand Continuous Orders NO

Print  Chart Copy When signing orders

Prompt for Chart Copy PROMPT AND NOT ASK DEVICE

------------------------------------------------------------------------------

CHART  COPY FORMAT: CHART COPY BODY// CHART COPY BODY

CHART  COPY HEADER: CHART COPY HEADER// CHART COPY HEADER

CHART  COPY FOOTER: CHART COPY FOOTER1// CHART COPY  FOOTER1

EXPAND CONTINUOUS ORDERS: NO//

PRINT CHART COPY WHEN: signing orders//



PROMPT FOR CHART COPY: PROMPT AND NOT ASK DEVICE//

34.0Glossary


Term

Definition

Associations

Some procedures found in the pick list may be linked to associations. Associations enable the addition of one or more data fields, which may include: additional CPT codes, CPT code modifiers, patient education, exams, health factors, ICD diagnosis, ICD procedure, immunization, skin test, or transaction code.

Boilerplate Text

A pre-defined Progress Notes or Discharge Summary template containing standard text, with blanks to fill in for specific data about a patient.

Business Rule

Business rules control what actions can be taken on a particular note.

CAC

Clinical Application Coordinator.

Chart Copy

Each hospital can only have one format for Chart Copies. Chart copies can also be automatically printed on the ward.

Clinician

A doctor or provider in a healthcare facility who is authorized to provide patient care.

Consults

Consults are referrals of patients by the physician to another hospital service/specialty, to obtain a medical opinion based on patient evaluation and completion of any procedures or treatments the consulting specialist deems necessary to render a medical opinion.

Cover Sheet

A screen of the patient chart that displays an overview of the patient’s record, with tabs at the bottom representing components of a patient’s chart.

GUI

Graphical User Interface. A type of display format the enables users to choose commands, initiate programs, and other options by selecting pictorial representations (icons) via a mouse or a keyboard.

Health Summary

A product that can be viewed through the application. It includes snapshots of part of all of a patient’s tests and results.

Icon

A picture or symbol that graphically represents an object or concept.

Imaging

A component of the patient chart that includes Radiology, X-rays, Nuclear Medicine, etc.

Modal

A state or “mode” in which the user can only act or respond to a single dialog or window. You must select a response before you can exit or do anything else in the program.

Namespace

A convention for naming package elements.

Notifications

Alerts regarding specific patients that appear on the patient chart.

Object

Object is data to be inserted into a note that is retrieved from the RPMS file.

Orderable

Orderable items correspond to those services or products that might be requested and provided by the patient care services; they can be things such as a lab test, an imaging procedure, or a medication.

OE/RR

Order Entry/Result Reporting.

PCMM

Patient Care Management Module.

Print Format: Service Copy

Copies of orders and actions for a particular service that can be printed upon request for the use of that service. The service copy can also be set up for automatic printing at a defined location. Contains header, body, and footer.

Print Format: Chart Copy

The official document that reflects the information in the EHR. A copy of all current orders that appear on a patient’s chart, using a pre-defined format. Each facility can only have one format for Chart Copies. Chart copies can also be automatically printed on the ward.

Print Format: Label

A copy of the order that is printed on a label to be stuck on the container of the order (e.g., lab sample).

Progress Notes

Progress Notes are used by healthcare givers to enter and sign online patient progress notes and are used by transcriptionists to enter notes to be signed by caregivers at a later date. Caregivers can review progress notes online or print them in chart format for filing in a patient’s record.

SP513

The Consult form.

Team List

A list containing patients related to several providers. These providers are the list’s users.

TIU

Text Integration Utility. This package consists of Progress Notes, Discharge Summary, and a set of utilities for managing clinical documents.

35.0Contact Information


If you have any questions or comments regarding this distribution, please contact the OIT User Support (IHS).

Phone: (505) 248-4371 (local) or (888) 830-7280 (toll free)

Fax: (505) 248-4363

Web: http://www.ihs.gov/GeneralWeb/HelpCenter/Helpdesk/index.cfm

Email: support@ihs.gov

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