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Published byLars-Olof Axelsson Modified over 5 years ago
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CERNER MILLENNIUM Abstracting Chart Data Into Unity: Immunizations Excerpt
This presentation reviews strategies for moving immunization data from legacy records into the Unity chart. It is particularly pertinent to adult vaccinations recorded in legacy records but never also recorded in the state ImmPRINT immunization database. This is adapted from the larger lesson Abstracting Old Records Into Unity. This has been prepared using Millennium base code level & mPage 6.4; some aspects of mPage 6.5 appearance may also be seen at times. Subsequent updates may display cosmetic & functional changes. Use the keyboard or mouse to advance.
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Immunizations Via Direct Manual Entry
If you have access to paper records, ImmPRINT, or our legacy computer systems that show previous vaccinations, the simplest approach to add this to the Unity chart may be just to record it manually. Here’s how to do that. (You’ll see another approach via “Data Reconciliation” below.)
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Go to the Immunizations component of the a Workflow tab (mPage)
Go to the Immunizations component of the a Workflow tab (mPage). This could be one of the specialty-specific provider workflow mPages, or a nursing workflow mPage.
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Click the + Sign, & you’ll see a dropdown list. Click Document History.
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Scroll through the list & click on the vaccines you want to document
Scroll through the list & click on the vaccines you want to document. You can select more than one. In this example we’ll use Measles, Mumps, Rubella. When done click Select.
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Administration Date & Source of information are required fields
Administration Date & Source of information are required fields. Note that the dropdown list for Administration Date gives you options when you don’t know the exact date, such as just entering the year.
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If you know the exact brand/type of vaccine, you can pick that on the Product dropdown list. And there are links to add other information if known & important. When done, click Document.
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Make further entries as required
Make further entries as required. As you add information, the updates appear on the Immunizations component.
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Immunizations Via Data Reconciliation Tool
There is a tool designed to help migrate some data from our old systems to Unity. However, it is often more trouble to use than just manually entering data into Unity. More information is available in the Abstracting Old Records Into Unity lesson. That being said, the Data Reconciliation Tool can be useful to import immunization data into Unity. Here’s how it works.
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Near the bottom of the Table of Contents Menu you’ll see Data Reconciliation, which displays the External Document List. Here there may be one or more Summarization of Episode Notes. These are structured as CCDs, a standardized data exchange format. It’s fairly thorough, but often pretty cumbersome. In the future we may receive outside records this way, but initially these mostly contain data migrated from our legacy systems, Soarian & NextGen. You’ll see a Save to Chart button. You don’t really need to do that, since the document will always stay here.
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Click the Checkbox. (If there are multiple summarization notes you can review them all, but the latest one by the same Author will be the most useful & up-to-date choice.) Then click the Reconcile button.
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This gives you a way to review & import PAMI data: Problems, Allergies, Medications, & Immunizations. You can click the carat next to each section to expand. Problems, Allergies, Medications can be a pretty tedious to use, as discussed further in the Abstracting Old Records Into Unity lesson. But the Immunizations section gives you a way to import legacy vaccination data without having to open the old system.
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Data on the left is what is in the summary document you’ve selected
Data on the left is what is in the summary document you’ve selected. Data on the right is what is on the patient’s chart in Unity. If nothing has been entered in the chart yet, the right side will be empty.
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To import an immunization, click the carat next to it to review the specific listing.
If you want to move it to the Unity chart, click the blue arrow.
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In this example we’ll click the blue arrow for Tdap, & system will perform a search on the right. Review the results & select the one you want.
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Often the recorded date will appear
Often the recorded date will appear. Since you don’t know details about Manufacturer & Lot Number, just click Save.
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The Tdap is added to the list.
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Unfortunately, the search process doesn’t always work
Unfortunately, the search process doesn’t always work. Click the blue arrow for the first flu vaccine, & you’ll see the term is moved over, but there are no match results. This is because there is too much text entered to get a good match.
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Back out some of the text, or manually type a better search term, & you’ll start to see matches. Pick the desired result.
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But this doesn’t always transfer the date.
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So you may have to enter the date manually. When done, click Save.
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Continue the process until all immunizations have been moved to the chart. When complete, click Done.
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Conclusion It’s unfortunate that our prior immunization data did not migrate in a more automated fashion, but one of these two methods will give you an approach to getting the Unity chart up to date going forward.
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