TIU Management - Notes

OBJECTIVES Use naming conventions and standardization Create and Inactivate a Note Title Change or Rename a Note Title Reassign a Note to the Correct Visit Retract a Note Monitor Late Entries Review the Use of Addendums Print Notes and other Patient Health Information Compare and Contrast Proper Use of the “CWADF”

OBJECTIVES cont. Correct Errors Assign User Class Configure Cosigners Create and Manage Business Rules Compare and Contrast the Utilization of Cosigner versus Additional Signer Create an Electronic Copy of Health Information Electronically File Transcribed medical reports

TIU Note Titles TIU Progress Note Titles are created before users can write progress notes TIU operates from a structured Document Definition Hierarchy The Hierarchy allows documents (note titles) to “inherit” characteristics (behavior) from higher levels

Creating Note Titles Use Naming Conventions/Standardization Keep Titles Short Use Underscore/No Spaces Keep the Number of Note Titles to a Minimum (no more than 30) Use Caution When Changing Note Titles

Document Definition Hierarchy

Hierarchy Relationship Business Rules for the note title documents follow this relationship - Best Advice: Do not edit Business Rules!

Note Titles with Special Properties Some Note Titles are built with predefined properties. Use of these Note Titles triggers the CWADF button, including: –Crisis Notes – C –Clinical Warnings – W –Allergies-A Not a note title –Advance Directives – D –Patient Flag-F Not a note title

Business Rules EHR comes with all the business rules you need to get started. Business rules control who can view, print, sign a note. Sites follow their policies in determining how business rules are setup

Example of Business Rules

5 Parts Document the rule is written for Status of the document The Action that is occurring The user class and/or The user role Example: An UNSIGNED (CLASS) CLINICAL DOCUMENT may BE SIGNED by an EXPECTED SIGNER

Understanding Rules Rules are exclusive When a user class is assigned a rule, they are the ONLY ones who can do the action in the rule Multiple rules may be needed for same action Always make the same rule for the CHIEF, MIS when a rule for other users includes VIEW, PRINT, DELETE

TIU User Class – New Provider New Providers are added according to local policy (Site Manager, HIM, CAC, Credentialing staff) Keys needed by Providers are added according to local policy Everyone using EHR needs a TIU User Class, including HIM staff

Adding a TIU User Class TIU Maintenance Menu (TMM) User Class Management (UCM) List Membership by User (UCM2) Enter User Name ADD User Class Set start date back a couple of days Do not enter a termination date

Electronic Signature Anyone writing a note or placing orders needs an electronic signature Each User sets up their own using User Toolbox Must be 8-20 characters in caps If user forgets their code, contact ?? Per local policy C-sig menu option

Correcting Documents Entered in Error A note has been entered in error. The author writes an addendum to the note requesting the note be removed from the patient’s record You receive the call to delete the note and the attached addendum This can be done in either TIU or EHR

Deleting a Document in EHR Open the note in EHR Right click or select “Action” menu Select “Delete progress note” You will see the following:

Deleting a Document in EHR, cont. In this example, I chose Administrative Action because I am deleting the note due to the author entering it in error Select “Yes” on the confirm deletion screen The status of the note will become Retracted Notes are never deleted – only Retracted from view by others

Deleting a Document in TIU TIUM Menu Search for Selected Document (SSD) Select Status – ALL is a choice Select Clinical Document Type Select Search Category – Author or Patient Select Date Range Select Action

Deleting a Document in TIU, cont.

Correct/Amend a Signed Document Amend a record per facility policy Can be done if facility agrees with patient request to correct/amend their health information under HIPAA Privacy Act Can be done to remove erroneous information in a note

Correct/Amend continued While viewing a note in TIU, select the action “Amend” You will be prompted to enter your signature code The TIU Editor will allow you to make edits The original note will be retracted and the new note will have a status of Amended

Reassigning Documents The reassign action reassigns a note to an different admission or visit The reassign action may also be used to promote an Addendum as an Original, swap the Addendum and the Original. CAUTION: If reassigning notes to different patients - Incorrect data objects may transfer with note. Use this option carefully.

CHANGE NOTE TITLE Notes titles may be changed TIUM, SSD At Select Action, type CT (Change Title) CT IS A HIDDEN CHOICE Choose the document to be changed

Late Entry Late Entries should be made according to facility policy. The late entry must be noted with the actual date the event occurred vs. the date of documentation. Notation as to the reason for the delay is also suggested. Providers should: –Select Visit –Select New Note –Change Date to Date of Visit –Record Note and Sign

Addendums To enter, Right Click on Note Used to add information or clarify what has been recorded Recommended for ongoing data entry within the same visit Choose correct note to addend to – Nursing should addend to Nursing Notes Date of Addendum is date written

Electronically Filed Medical Reports “cut and paste” Copy the desired report Choose the visit that the note is for Select New Note Choose appropriate Note Title Change date to date visit occurred Paste the document in the note Sign note – Use pen or right click Add Additional Signer if this is your policy

Identify an Additional Signer Adding an Additional Signer sends a notification to a provider that a note has been added and needs his attention Does not prevent the note from being seen by others until the additional signature is added Requiring a Cosigner keeps the note in “unsigned” status until signature is added – not viewable

Questions and Answers