1 EHR For Coders and Data Entry

2 EHR will open to the Coversheet Click on aqua box to choose patient. You may choose by name or chart #. If chart # is less than four numbers enter leading zeros. The Appointment and Visits section of the coversheet will display similar to your displaying in PCC RPMS options. Just left click on a visit to see the display.

3 Display of Visit plus the Note when clicking on an Appointment/Visit

4 Prob/POV tab In order to see Visit Diagnosis you must select the Visit in the Yellow Visit Box. You will see Historical Diagnosis without having to select the visit in the Yellow Box

5 Services Tab If you show ALL you will see the CPT coding in Historical Services E&M is shown here This is the CPT coding for Selected Visit in Yellow Box

6 Notes Tab – Select the note you wish to view on the left and it will display on the right Shows this note I selected. This view is showing the last 100 notes. If you need to see more you can change your view under the View Dropdown menu.

7 Notification Scheduling - After reviewing the visit, if you have questions for provider 1.Go to Notifications Tab 2.Right Click in white area 3.Choose Schedule. And this window will open. 4. Click Add

8 Enter delivery date, Subject, Recipients, and Message Note this is associated with the patient, which normally you would leave checked. If your question is not patient related you may uncheck this. Remove your name by highlighting and click the left aqua arrow. Then just state OK to each window. Choose provider name and use aqua right arrow to move name to right.

9 Orders Tab – double left click on any order for Order Details I double clicked on the Lancets order and got order details.

10 Medications Tab - May click on any column to re-sort. May double click any med and get details like the Orders Tab

11 Triage Shows selected visit vitals and CC

12 Wellness Tab Health Factors, Reproductive Status, Educations, Exams, Immunizations and Skin Tests

13 Labs Tab Click these buttons to navigate to other lab results

14 Reports – Clinical Reports – Outpatient Encounters/Visits The Outpatient Diagnosis and Outpatient Encounter allow you to view visit information quickly. Can quickly change your date range.

15 Consults Tab – These consult progress notes are also viewable on the Notes Tab. Choose the consult. Click on the related documents to view the note.

16 D/C Summ Tab  This tab will allow viewing of discharge summaries from hospital stays.  This tab is like the Notes Tab.  Discharge Summaries are only viewable on this tab.  Versus, Consults are also viewable on the Notes Tab.

17 To review one provider in Coding Queue IHS Core  PCC Select Patient Care Component Option DEM Patient Care Data Entry Menu... ENT Enter/Modify/Append PCC Data... EHRC EHR/PCC Coding Audit Menu... Select EHR/PCC Coding Audit Menu Option:  EHRD EHR/PCC Coding Audit for Visits in Date Range  PEHR EHR/PCC Coding Audit for One Patient  TUR Count Unreviewed Visits by Date/Service Category  LIR List Unreviewed/Incomplete Visits

18 EHR/PCC Coding Audit for Visits in Date Range Please enter which FACILITY visits will be included in the list. Select one of the following: A ALL Locations/Facilities S Selected set or Taxonomy of Locations O ONE Location/Facility Enter a code indicating what LOCATIONS/FACILITIES are of interest: ALL Please enter which CLINIC (IHS clinic codes) visits will be included in the list. Select one of the following: A ALL Clinics S Selected set or Taxonomy of Clinics O ONE Clinic Enter a code indicating what CLINICS (IHS clinic code) are of interest: A// ONE Clinic Which CLINIC: PODIATRY 65

19 Visits by Date Range cont… Please enter which HOSPITAL LOCATIONS will be included in the list. Select one of the following: A ALL Hospital Locations S Selected set of Hospital Locations O ONE Hospital Location Enter a code indicating what HOSPITAL LOCATIONS are of interest: A for ALL Please enter the Providers whose visits you want to display This will screen on the primary provider on the visit. Select one of the following: A ALL Providers S Selected set or Taxonomy of Providers O ONE Provider Enter a code indicating which providers are of interest: A// LL Providers A chart deficiency reason may have been previously entered for a visit. If you wish to display only visits whose LAST chart deficiency reason matches one or more that you select, please enter them. Select one of the following: D Do NOT screen on Chart Deficiency Reason S Screen on Chart Deficiency Reason Select visits based on chart deficiency reason: D// o NOT screen This would display all locations using Clinic Code 65 Podiatry Plus all providers under that clinic code. You could also choose One Provider and enter the name.

20 Visits by Date Range cont… I will display visits that meet the following criteria: VISIT DATES: Nov 15, 2006 to Nov 15, 2006 SERVICE CATEGORY: A, O, S, C, T VISIT TYPE: NOT Contract Visits with at least one POV and Primary Provider. LOCATION OF ENCOUNTER: All CLINICS: All HOSPITAL LOCATIONS: All PRIMARY PROVIDER ON VISIT: All CHART DEFICIENCY REASONS: All (includes visits with no chart deficiency reason e ntered Do you wish to continue? Y// ES

21 Visits by Date Range cont… Choose how you want it displayed. Example: N for Patient Name Please note: On the list of visits that will be displayed there is a column labeled 'INS', in this column M stands for Medicare, C stands for Medicaid and P stands for Private Insurance. This does not mean the visit is billable, it just is an indication of whether or not the patient has a policy on file that is currently active. Select one of the following: N Patient Name H HRN D Date of Visit T Terminal Digit of HRN S Service Category L Location of Encounter C Clinic O Hospital Location P Primary Provider A Chart Audit Status R Chart Deficiency Reason (Last one entered) I Has Medicare/Medicaid or PI

22 Visits by Date Range cont… PCC/EHR VISIT AUDIT Nov 16, :03:20 Page: 1 of 2 Visit Dates: May 01, 2006 to Nov 16, 2006 * an asterisk beside the visit number indicates the visit has an error # VISIT DATE PATIENT NAME HRN FAC HOSP LOC CL INS PRIM PROV STATU 1)* DEMO,ADULT PA WRH CVD ENCO A 06 DICKSON,E.99 2) DEMO,ADULT PA WRH URGENT C A 80 WATTS,SIL 3)* DEMO,ADULT PA WRH PHARMACY A 39 MARBELLO, NO 4)* DEMO,ADULT PA WRH INPATIEN A 76 M CHAMBERLA NO 5)* DEMO,ADULT PA WRH HURFORD A 14 M MOORE,CAT NO 6)* DEMO,ADULT PA WRH PREOP PH A 28 M WYLIE,ROB NO 7)* DEMO,ADULT PA WRH SOCIAL S A 48 M MOORE,CAT NO 8)* DEMO,ADULT PA WRH OB ANTEP A 83 M CONDOJANI NO 9)* DEMO,ADULT PA WRH COLPO A C3 M MAHONEY,D NO 10)* DEMO,ADULT PA WRH PHYSICAL A 28 M CLARK,ELI NO 11)* DEMO,ADULT PA WRH PHYSICAL A 28 M CLARK,ELI NO 12) DEMO,ADULT PA WRH ANTICOAG A 39 M ROBERTS,R Q - Quit/?? for more actions/+ next/- previous >>> D Display Visit S Status Update X Visit Delete N Note Display R Resort List + Next Screen M Modify Visit C Chart Audit History - Previous Screen A Append to Visit H Health Summary Q Quit G Visit Merge O One Patient's Visits

23 Visits by Date Range cont…Commands Q - Quit/?? for more actions/+ next/- previous >>> D Display Visit S Status Update X Visit Delete N Note Display R Resort List + Next Screen M Modify Visit C Chart Audit History - Previous Screen A Append to Visit H Health Summary Q Quit G Visit Merge O One Patient's Visits Note: You can display the Visit and display the progress note from this menu as well. You can do ?? to see additional commands.

24 PEHR EHR/PCC Coding Audit for One Patient Select PATIENT NAME: ZANY,ADOLESCENT FEMALE F CL Select one of the following: D Date of Visit S Service Category L Location of Encounter C Clinic O Hospital Location P Primary Provider A Chart Audit Status R Chart Deficiency Reason (Last one entered) How would you like the list of visits sorted: D//