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Ehr Training

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Submitted By ScottAllison
Words 769
Pages 4
Patient Demographics
MU Core Set 7 Record Pt Demographics: Sex, race, ethnicity, date of birth & preferred language. More than 50%
MU Menu Set 4 Send reminders to patients via communication preference (recall) for follow up care. More than 20% of pts 65 & older or 5 & younger Launching Product
Login
Maneuver Keyboard
• Can use mouse
• Keyboard (alt & underlined letter)
• Tab or Enter-most efficient way to move from field to field (beginning of field)
• Shift, tab – takes you back to previous field
• Use end/home keys
• Arrow keys
• Ctrl+C=Copy
• Ctrl+V=Paste
• Ctrl+X=Copy/Cut
• Ctrl+N = Next Tab
• Ctrl+B = Prior Tab
Search for Patient – in Pt Demographic Screen
7 Different Ways Add a New Patient
Begin name w/ZZ for practice patients Special & Unique Features: Logoff takes you out and back in to the exact patient and exam tab on this station ACCESSING RECORD
• Choose the option Exam
• Choose the Medical Bag Icon OPTIONS
ADD
• Add New
• Choose the proper layout o Default o Show some of the other layouts – Transfer Paper SUMMARY TAB
• Do Not Fill out the Summary Tab – will auto fill from other tabs
• Overview of information entered for the date of service and historical data for sub folders CHIEF COMP - Chief Complaint/History of Present Illness
• Logic Fields – easy check boxes o New Patient o Consult – Medicare no longer reimburses for Consultations
**Yellow fields represent exam logic fields. They enable the system to interpret the documentation and then recommend the appropriate procedure code for billing.
• Dropdown – to open o Click on dropdown arrow o Hotkey F7 o Double click on choice or hit enter key o Choose the corresponding letter
• Control this feature via Login Rights o Type Ahead feature o Manual Entry
• To Add to Table, Type new entry, Rt click to add to table
• The new choice will be added to the bottom of the table
• This feature is Login specific o To exit without making a choice, right click in table or escape
• Referral History/Eligibility Screen is accessible from here – Record must be saved 1st
• Sub-Tables o To enter information into the sub-tables a Navigation Bar will be used o Hover over each button for a pop up hint o 1st Record o Previous record o Next record o Last record o + Insert/Add o - Delete o Edit o Save o x Cancel Edits
• Click on + (Insert/Add)
• Begin Typing Complaint – Type ahead feature
• Some Complaints trigger a smart event that sorts the list to only those choices that are pertinent to the complaint (Headaches)
• As the Complaint and elements of the complaint are entered, text fragments will auto populate in the details field – can free text any additions/revisions
• Can use Control C/Control V on any of the fields to Copy/Paste
• Do not enter N/A in HPI fields with no entry as these are yellow fields creating the exam logic
• Save
• Pain Scale
• Multiple complaints can be added for the same visit o indicate which is primary
• The highlighted line in the grid corresponds to the information in the fields below – each entry has it’s own set of corresponding fields ROS - Review of Systems
TAB – Left Click
• Encounter Favorite
• Assign Normal Values
• Forward from Last Visit
• Forward from Last Value
• Forward from Last Positive
• Create Encounter Favorite
• Clear Fields on Tab
• Close this Menu
FIELD – Right Click
• Forward From Last Visit
• View Historical Values
• Assign Normal
• Add to Drop Down
• View Lookup Table Name
• Time/Date Fields Additional Choices o Assign Current Time o Assign Current Date
**Very Important that all forward/default information is reviewed and modified if necessary. o Black – Entry was chosen from drop down o Red – Entry is the Default Value o Purple – Entry was Free Texted o Green – Entry Forwarded • SMBS/HgbA1c o Record Diabetic Details
• Surgeries o Systemic and Ocular Surgeries are together in the same database o Date picker field – drop down calendar (cannot type a partial entry such as month and year, but can leave field blank if pt doesn’t remember or type closest to pt’s recollection in memo field
• Memo Boxes - Hold unlimited amounts of data – once field is full, a scroll bar will appear to scroll and view all data PFSH
• Enter positive entries first
• Default Tab fill
MU Core Set 9 Record smoking status of patients 13 yrs and older > 50% (Button to add “History of Tobacco Use” to plan)
Up to the physician as to often this status is updated.
Cessation is pertaining to the Quality Measure only and just recommending quitting is not enough to check box.

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