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 2

TOPICPAGE Workflow4 Registration Check List5 Patient Information6 Contacts7 Imaging Results8 Patient Visit: Clinical Support Staff Check List9 Problems, Allergies, and Medication List10 Vital Signs11 Smoking Status and Family History13 Patient-Specific Education17 Lab Results19 Immunizations24 Patient Visit: Provider Check List26 Problem List27 Medication Reconciliation28 CPOE29 e-Prescriptions32 Electronic Note Signed33 Post Visit Check List34 Clinical Summaries35 Patient Portal: Pin Letter40 3

Registration Patient Visit: Clinical Support Staff Patient Visit: Provider Post Visit 4

Check List for Front Desk Staff  Patient Information  Sex  DOB (Date of Birth)  Race  Ethnicity  Language (Preferred)   Contacts  Patient Internet Access  Preferred Communication Method  Imaging Results 5

Race/Ethnicity are separate fields and each must be completed 6

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.’ 7

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 8

Clinical Support Staff Check List  Summary Page  Problems  Allergies  Medications List  Encounter Note  Vital Signs  Smoking Status  Family History (First Degree)  Patient-Specific Education  Lab Results  Immunization(s) 9

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 10

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 11

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 12

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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 16

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. 17

Documentation in the patient’s encounter note which states that patient education was provided is still required. 18

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. 19

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’ 20

Step 1 Step 2 Step 3 21

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 22

Screen 5 23

To Record History of a Vaccine: 1.Click Record Hist. 2.Click the Imm. Date radio button in Entry Mode 3.Select the date the Immunization was received 4.Stamp the Dose field of each immunization that was received on this date 24

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. 25

Check List for Providers  Problem List  Medication Reconciliation  CPOE (Computerized Provider Order Entry)  60% Medications  30% Labs  30% Radiology  Electronic Prescriptions  Patient-Specific Education (Refer back to Slide 17)  Electronic Note signed 26

27 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’

28 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’

29 Orders/Charges Meds Tab Summary Page

30 Orders/Charges Labs Tab Summary Page

31 Orders/Charges Summary Page Orders Tab

32 Remember the key is to select via: Electronic Transmission

33 Sign And Seal your Note Sign And Seal your Note

34  Generate Exchange Document  Clinical Summary  Referral Summary  Provide the Patient with PIN Letter

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  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. 35

36 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

37 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’

38 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’

39 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’

40 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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