Clinical

user manual clinical suite 550 375 water street, vancouver, british columbia,canada, v6b 5c6 table of contents the work centre docid\ hv1pex5jlpbr913qbdzx7 work centre views the waiting room appointments window docid\ hv1pex5jlpbr913qbdzx7 load criteria calendar waiting room “being seen” area the patient holder toolbar icons for appointments display updating patient status “close attendance” printing the appointment list for the day printing the appointment list for selected appointments only unsigned transactions docid\ hv1pex5jlpbr913qbdzx7 reviewing unsigned transactions transactions toolbars signing off transactions making notes on transactions adding a new standard annotation entering clinical details docid\ hv1pex5jlpbr913qbdzx7 family and social history entering past history entering allergies entering measures recording current problems editing a problem and viewing history entering usual medications prescription alert factors new encounter docid\ hv1pex5jlpbr913qbdzx7 filtering recent contacts coding an encounter in rich text format using the soap format resolved/unresolved contacts editing encounters using inline editing typing templates and images docid\ hv1pex5jlpbr913qbdzx7 editing an existing typing template creating a new typing templated creating typing templates from within a new encounter using a typing template using images with typing templates prescriptions docid\ hv1pex5jlpbr913qbdzx7 prescribing a usual medication prescribing a new medication special authority forms non printing of restricted medications ordering investigations docid\ hv1pex5jlpbr913qbdzx7 adding investigations to the preferred list creating sets of investigations creating ad hoc investigations outward referrals docid\ hv1pex5jlpbr913qbdzx7 creating an outward referral from the work centre interventions docid\ hv1pex5jlpbr913qbdzx7 adding an intervention viewing a patient’s interventions completing an intervention from a new encounter completing an intervention from work centre chronic disease management (cdm) docid\ hv1pex5jlpbr913qbdzx7 creating a cdm form from the new encounter screen viewing cdm forms from the medical record viewing flow sheets from the medical record provincial ehr express view docid\ hv1pex5jlpbr913qbdzx7 the work centre typically, the work centre is set to open automatically when you log into profile you can also open it manually, using one of these methods click the icon on the toolbar go to organisation/work centre on the menu bar work centre views the work centre consists of several views displayed on the segment list the views you see may depend on your job role or level of access some of the more common views are today summarizes the information and activities that are typically top priority for providers appointments a view of filled and available time slots, waiting area, and exam rooms billing view billing for the currently logged in provider tasks a “to do” list referrals patients who have been referred to other providers unsigned transactions all lab results and inward transactions (such as scans) requiring acknowledgement the today view has multiple calendars the list of items on the right side of the window is called the category list the items in this list are based on filters that can be configured to show the information you want to see the waiting room the waiting room displays patients that have an appointment and have arrived and waiting to be seen patients who arrive as “walk in” appointments automatically appear in the waiting room the waiting time is displayed until the patient is noted as being “seen” by one of the following procedures select the patient from the waiting list and click the icon on the toolbar, or double click the patient’s name to open the medical record window, or right click the patient’s name and select is seen from the pop up menu appointments window load criteria the load criteria allow you to determine which appointment information you want to display you can specify the pos (place of service), prov (provider), and date calendar the calendar displays the current month, allowing you to navigate by clicking on any day in order to view the appointment load for that day you can view a different month by selecting the or arrows, or by clicking on the month name or the year and selecting a different month and/or year from the list hot tip the toolbar button will return the calendar to the today view waiting room the waiting room area provides a quick view of those patients who have arrived and are currently waiting to be seen, with a time clock kept of their waiting time the patient arrival will automatically show in the provider’s work centre “being seen” area the being seen area lists those patients who have been shown to an examining room it identifies which room they are in and which provider they are seeing patients who are presently with the provider are shown with the icon, while those still waiting are marked the patient holder the patient holder enables you to temporarily store a patient’s name and appointment details a useful feature of the patient holder is that the patient can then be dragged to an appointment slot, and all patient details automatically recorded toolbar icons for appointments display several toolbar icons control the display of appointment information also called attendance load display appointments for one day, one week, or one month display appointments for a group of providers at a time (for example, the doctors group, or the nurses group, or all providers) this is called the multi provider view show or hide the navigation bar area updating patient status “close attendance” upon completion of the patient visit, the attendance must be closed right click on the appointment (in the attendance location or the appointment slot), and select close attendance from the pop‑up menu either the provider or the administration staff can complete this step the patient disappears from the exam room the appointment slot is marked to indicate that the attendance is closed printing the appointment list for the day open the appointments view for the day in question click the print list icon in the confirmation screen click all to print the appointments for all displayed providers; or click selected to print only the appointments for the highlighted provider printing the appointment list for selected appointments only to print appointments for a time range, follow the above steps, but in the confirmation screen, select the appointments after/appointments before radio button, and fill in the desired times unsigned transactions follow these instructions to view, annotate, and sign lab results reviewing unsigned transactions select the unsigned trans view of the work centre , or go to special/show unsigned transactions in the main menu click on an unsigned transaction from the list to review it transactions toolbars several toolbar icons control viewing and signing transactions mark a transaction as ready to be signed repeat this for other transactions you wish to sign in this session sign all ticked transactions at once forward the transaction to another user for action delete the transaction move the transaction to a different patient’s medical record assign a specific privacy role to the transaction refresh the list of transactions process transactions by stepping through them in order view a list of the last five transactions signed expand all the transactions in the list collapse all the transactions in the list sign an individual transaction sign a transaction and automatically add an annotation of “return ” sign a transaction and automatically add an annotation of “discuss ” add a manual annotation to the transaction signing off transactions once a transaction has been viewed, it can be signed with one of the following procedures select the transaction, then click the button, or click to place a tick next to transactions as you view them, and then click to sign them all at once hot tip you can sign a transaction either at the root (the patient’s name) or by the individual transaction; either way it will sign all the transactions in that tree (even if you sign a single transaction that is a part of several in that tree making notes on transactions to add a manual note to a transaction called annotation select the transaction, and then click the button the annotate window appears add an annotation by either typing the required text in the upper box or double clicking on one of the standard annotations in the lower box in the task field, select the required option from the drop‑down menu and enter the user or group name in the for field once the annotation is saved, the task will be sent to the appropriate person or group and includes two links one to the transaction and one to the patient’s alter patient screen to close this window, select one of the following options click annotate to add the annotation to the transaction, but leave it unsigned click annotate and sign to add the annotation and sign it at the same time click cancel to cancel the annotation and the task hot tip if one transaction tree (patient) has multiple transactions, you can only annotate the individual transaction if you select the root level showing all the transactions within that tree, the annotate function will not be available adding a new standard annotation to add an annotation to the list of standard annotations while the annotate window is open, click the button the create annotation window appears in the description field, type the desired text if appropriate, enter a plural form click \[ ok] to add the annotation to the standard list entering clinical details family and social history information entered into the family/social history tab is displayed in the patient’s medical record on the summary tab to add the patient’s family or social history, follow this procedure open the clinical details window for a patient select the family/social history tab click in the family history field and enter narrative details about the patient’s family history you can also enter family history information using data fields this will allow you to perform family history data base queries based on relationship, diagnosis, age and status of a family member to the patient click in each field to enter the information hot tip if the family member is a patient at your practice; click in the patient column and type in the family member’s name click in the social history field and enter details about the patient’s social history if required, use the toolbar to format the text default gives the selected text a low amount of emphasis gives the selected text a medium amount of emphasis gives the selected text a high amount of emphasis changes the alignment of the selected text (left, center, or right) makes the selected text a bulleted list decreases or increases the indent of the selected text entering past history to add coded past history items for the patient, follow this procedure open the clinical details window for a patient select the past history tab click the add problem window opens when you add a problem through the past history tab, the default status is “inactive” note if you click the down arrow you can select to add a problem of a particular type diagnosis , procedure , or social/risk enter a code in one of the following ways type the icd 10 number type part of the name a list of possible matches is shown double click the required code from the list enter any other required details click ok to save this problem entering allergies the allergies tab allows the addition of adverse reactions to a patient, which can be linked to the formulary or a disease code it can also be unlinked, for example “allergy to peanuts” to add allergies open the clinical details window for a patient select the allergies tab click the add problem window opens hot tip place a tick in the no adverse reactions recorded to formally record that a patient has no known allergies if you subsequently add any adverse reactions to this patient, the box will automatically be unchecked enter a code in one of the following ways to enter an uncoded allergen, type the name of the allergen enter any other required details, and click ok to save the allergy to enter a coded allergen and link it to the formulary, click to search the formulary the select disease code window opens enter the allergen and click search double click the required allergen from the search results click in the nature field to select the nature of the allergy optionally, a severity may be selected at the bottom of the window using the severity drop down list this is later displayed in the allergies tab click ok to save entering measures to add measures open the clinical details window for a patient select the measures tab by default, three key measures are available in the transaction panel height, weight, and blood pressure different items can be added in the source field, select embedded observations double click the desired observation from the available items panel in the transaction panel, if required, enter the date and time for the observation if nothing is entered, it will default to the current time and date click in the value field and enter the measurement double click in the column to indicate that the value is abnormal recording current problems to add coded problems for the patient open the clinical details window for a patient select the problems tab click the add problem window opens note if you click the down arrow you can select to add a problem of a particular type diagnosis , procedure , or social/risk enter a code in one of the following ways type the icd 10 number type part of the name a list of possible matches is shown double click the required code from the list enter any other required details click \[ ok] to save this problem editing a problem and viewing history to edit a problem, double click on the problem this opens the problem window make the changes and click \[ ok] to view the history of the edits, double click on the problem to open the problem window click the history tab to view the edits select the version in the list on the left to view the respective information on the right hot tip you can also view this information in the medical record/problems view by selecting the problem and clicking to show the detail panel click again to hide the panel entering usual medications the usual medications list enables you to see what medications a patient is regularly on and makes prescribing the medication faster on subsequent visits follow these procedures to add a medication to a patient’s usual medication list open the clinical details window for a patient select the usual medications tab click the formulary window appears enter at least the first two letters of the medication in the field below the toolbar click or press \[enter] the results of the search appear in the panel below click beside the required medication to view a list of existing instructions you can either click an existing instruction and click \[ ok] , or double click on \<new instruction> the instruction fields appear enter the required information, and ensure the remember box is checked if you would like to use this instruction for future prescriptions click \[ ok] when finished hot tip the \[ ok] button is only available when the prescription is complete to keep you from accidentally printing an incomplete prescription right click in the dose and freq fields to add a dose form or frequency from the options in the drop down lists prescription alert factors the bottom of the usual medications tab in clinical details lists various prescription alerts that may apply to the patient selected prescription alerts will trigger a warning during the prescription process when an applicable medication is prescribed alternatively, this view is also accessible in the medical record inside the medications view new encounter the new encounter window is used to record clinical notes about a contact and perform any necessary actions to open a patient’s medical record to the new encounter window click in the toolbar, or select clinical/new encounter from the menu bar, or double click on the patient’s name in the waiting room area of the work centre the upper part of the segment bar in the new encounter window allows you to go to other portions of the medical record you can go to another portion of the medical record at any time, and then return to the new encounter to finish your notes the lower part of the segment bar in the new encounter window is the actions panel this is used to perform new actions such as prescriptions, referrals, etc the right part of the new encounter window is the emr actions panel this panel lists all the actions performed during the encounter these actions will be transferred into an encounter text on exiting the new encounter window the most common new encounter toolbar icons are save or print the current encounter create or delete a problem within the new encounter edit encounter properties (time, date, provider, etc ) insert picture into current encounter access clinical details for current patient filtering recent contacts the new encounter window defaults to the review view, showing the patient’s problem list and recent contacts to filter recent contacts by a specific problem select a problem from the list, and then check dynamic the recent contacts panel will then show only the last five contacts relating to the selected problem coding an encounter in rich text format when a new encounter is created, the first contact is automatically labelled problem 1 to code the contact, follow one of these procedures drag and drop an item from the problem list in the actions panel onto the problem 1 label, or click the problem 1 label the contact properties window opens code the contact with either a diagnosis code or a text description for diagnosis , type the icd‑10 number for diagnosis , type part of the name a list of possible matches is shown double click the required code from the list check add to problem list to add the diagnosis code to the patient's problem list click \[ ok] the problem window will appear, enter any additional information, click \[ ok] using the soap format entering clinical notes using the soap concept ensures the information is recorded based on a consistent structure, while still allowing relative freedom and flexibility to set the encounter style to the soap format go to organization/preferences/clinical in the main menu select the encounter tab in the edit encounters style dropdown, select soap click \[ ok] to save the change and close the preferences window the soap notes format will take effect after closing and re opening the medical record window to code an encounter in soap format click in the dx field and enter the diagnostic code check the problem list box to add this diagnosis to the problem list the problem window will appear; enter any additional information and click \[ ok] resolved/unresolved contacts unresolved contact means that the notes for the specific encounter have not been finished all “unresolved” contacts will be listed under contacts view of the work centre window for the logged in provider click to mark the unfinished contact unresolved go to work centre/contacts a list of unresolved contacts will appear double click on the contact you wish to open and edit the encounter window will appear for that contact when you are finished with your encounter click to label the contact/problem “resolved” this will remove the encounter from your contacts list editing encounters encounters can be edited in the medical record the edited encounter will be a version of the original encounter, which will be dated and accessible click on the encounters view in the medical record window to edit an encounter, in the encounters view of the medical record window, double click on the encounter that you wish to edit this opens the encounter make the changes, and close the window or click in the encounter window toolbar using inline editing observations commonly entered in clinical notes such as height, weight, and blood pressure are recognised as clinical observations and stored in the contact as blue underlined text observations can be edited by clicking on them and typing over them while in a contact if you type… it will display in the contact as… bp 120/80 bp 120/80 mmhg height 170 or ht 170 height 170cm height 1 5m or ht 1 5m height 150cm weight 75 3 or wt 75 3 weight 75 3kg temp 37 6 temp 37 6 c pr 140 pulse rate 140 typing templates and images typing templates give you the ability to quickly enter complex or repetitive text into profile editing an existing typing template on the main menu, go to maintain/templates/typing double click an existing template to view or alter it make changes using the editor, and click \[ ok] to save the template creating a new typing templatead on the main menu, go to maintain/templates/typing click the new page to start a new typing template enter a code enter a description to identify the template select whether it should be available to everyone in the practice or a subset of users enter the body of the template, including any formatting you want to include include placeholders where you would want to enter data in a form when entering data in your clinical notes with the typing template, use the \[f4] key to cycle through the available placeholders for easy data entry creating typing templates from within a new encounter in the new encounter area type the text you wish to use to create your typing template highlight your text select the button which will now be enabled this will open the typing template properties window assign a code and a description to your template check available to to edit availability options format your template text as desired using a typing template you can use a typing template in the encounter text or in most free text areas of profile the correct format to bring up a typing template is to type the code of template and \ (backslash) eg why\ = why do i continually have to type this out?? note using the \ symbol tells profile you want to use a typing template not just typing a word using images with typing templates profile has image typing templates available for use these are mainly used in encounters but can be used in any free text area of profile you can view a list of these templates through maintain/templates/typing type the code of the image you want to use, e g , imageeyes\ double click on the image to activate microsoft paint to draw or insert text onto the image close the window by selecting the red x in the top right corner this now becomes a part of the contact prescriptions open a new encounter for a patient and click scripts from the actions panel , or go to clinical/scripts in the main menu prescribing a usual medication drag and drop the medication from usual meds to the current order , or double click the medication to add it to the order prescribing a new medication click the formulary window appears enter at least the first two letters of the medication in the field below the toolbar click or press \[enter] the results of the search appear in the panel below click beside the required medication to view a list of existing instructions you can either click an existing instruction and click \[ ok] , or double click on \<new instruction> the instruction fields appear enter the required information, and ensure the remember box is checked if you would like to use this instruction for future prescriptions click \[ ok] when finished click in the order toolbar to print the prescription special authority forms to locate special authority forms in the form view, click the browse button in the nb special authorization folder, select the form to fill out and press ok non printing of restricted medications restricted medications can be entered as a prescription so there is a record in profile, but printing a prescription form for these medications is forbidden ordering investigations on the actions panel in a new encounter, click for pathology or for radiology select the supplier from the drop down menu, if necessary add the required investigations to the current order using any of these methods from the preferred tab, drag and drop the investigation from the list into the current order area, or from the find tab, enter the name or part of the name of the required investigation in the look for field, and then click find once found, drag and drop to the current order area, or from the set tab, click on the set and drag and drop it to the current order area from the standing tab, drag and drop the investigation from the list into the current order area in the information column, enter any specific details about the ordered test in the details tab, clinical details field, enter any relevant information from the insert clinical toolbar, you can also click to insert the disease code description of all contacts within the current encounter or click to insert the disease code description of the current contact this information will be inserted into the clinical details field in the details tab, click to check any of the following boxes as necessary include rx – if checked, the patient's current usual medications will be printed at the end of the order urgent – if checked, 'yes' will be printed next to the 'urgent' label in the order anon – if checked, only the first letter of the patient's surname and name will appear on the printout fasting reqd – if check, 'yes' will be printed next to the 'fasting' label in the order in the prov, cc, pay tab, in the cc field(s) enter the provider(s) to whom you want a copy of the result to go these fields pull from the list of college of physicians and surgeons in the information tab, enter any additional information on or to the supplier in the standing tab, click to check the standing order checkbox enter notes in the additional instructions for standing order field enter a start and end date in the from and to fields enter any repeats if necessary by selecting the time period from the second repeat field dropdown menu and then entering the number in the first repeat field if the standing order has already been created and needs to be closed, click to check the close standing order checkbox click to print the investigation form adding investigations to the preferred list right click on the investigation in the current order or in the results in the find tab select set preferred creating sets of investigations to create a set from the investigations in your current order right click in the current order and select new set the investigation set – new set window appears enter a name for the set click save & close the new set will appear in the bottom of the list on the set tab creating ad hoc investigations click the ad hoc investigation window appears enter the investigation information check add to reference list to include this on the investigations list to be used again in the future click \[ ok] to add the investigation to the current order outward referrals outward referrals are used to refer a patient to an external or internal provider click the referrals view from the actions panel to initiate a new referral double click on a name from the most common referrals list the outward referral window appears, with the selected provider’s information already entered click and make sure outward option is selected the outward referral window appears the general tab allows you to input specific information regarding the referral in the from tab, the logged in user’s name will automatically populate in the provider field enter the name of the provider who has initiated the referral, if necessary in the to tab perform the following actions in the providers panel, enter the internal provider to whom the referral is going in the provider field enter the external provider to whom the referral is going in the ext prov field in the reason for referral panel, enter the diagnosis and the narrative which will appear on your letter in the management panel, a priority and time frame for when the patient should be seen can be entered in the tracking panel, enter any patient contact instructions, or information that will assist the administration staff in making the appointment the reason letter tab populates the referral letter and allows you to add information from the medical record the information and recipients icon allows you to view who the referral is going and alter some properties of the referral, click to add an additional recipient to the referral, click to insert the additional recipient’s name and address into the referral letter use the toolbar to add any other necessary details insert data insert encounters insert measures insert results select the required data from the right hand panel, and then click insert the data will be inserted where the cursor has been placed in the letter you may also enter text by typing directly into the body of the letter in the status field, select the applicable option from the pull down menu draft, approved, or final click the referral will now be viewable in the referrals view of the work centre window for the administration staff to action creating an outward referral from the work centre go to work centre/referrals view the outward referral list will appear the providers panel allows you to see to whom you have sent the referral the tracking panel shows you the progress of communication to the patient regarding appointment information the appointment panel allows you to change the status of the referral and will show you appointment information for the referral patient when the referral process is complete; change the status to closed this will remove the referral from the pending referral list if you require more information on the original referral select the button click icon to create a new outward referral the select patient window will appear enter the patient’s name for whom you are creating a referral complete necessary referral information interventions you can use interventions to manage and track intended follow up visits for patients these may be single visits or part of a series such as annual physicals or cervical smears adding an intervention while in a new encounter, click care plans and tasks from the actions panel click in the intervention field, if today is the first occurrence of the visit leave today’s date, otherwise change to the appropriate date enter the reason set a pattern in the repeat fields if required click \[ ok] to save viewing a patient’s interventions to view the interventions for a patient go to clinical/care plans in the main menu, or from the patient’s medical record, click care plans in the segment bar, or click the interventions icon on the segment list of the work centre window select the appropriate view filter change the date range to search by clicking in the respective field to display a calendar, or select the date and click to refresh the list completing an intervention from a new encounter to complete an intervention when in a new encounter for a patient in a new encounter, click care plans and tasks from the actions panel select the intervention you want to complete click completing an intervention from work centre display the list of interventions; see point 3) under viewing a patient’s interventions section select the intervention and click to open the intervention completion window date and time defaults to today’s date; adjust if necessary ensure that the status field is set to “complete” check done elsewhere box if applicable check series complete if the intervention is not needed anymore review and adjust the information in the rest of the fields type explanation in the comments free text field click \[ok] to save the information and close the window chronic disease management (cdm) profile offers a comprehensive system of managing patients with chronic diseases follow the instructions to create, view and manage cdm forms and viewing flow sheets creating a cdm form from the new encounter screen select the form icon on the actions panel double click a form from the most used form templates area or click the icon to search for a new form double click on the form you want to create the general tab allows you to enter new measurements and shows you the last measures entered and whether they are outdated the outdated record is symbolized with an icon beside the date of the value complete any required fields click the button to move to the next tab the diabetes tab allows you to enter disease specific information note labs can be ordered directly from this area by checking the check boxes in the examinations panel when the form has been closed, you will be directed to the pathology area of the new encounter to print out your order form click the button to move to the next tab the counseling tab allows you to enter additional information click the button to move to the next tab the diabetes notes tab allows you to view the last 12 months of encounters related to diabetes when you are finished, select complete from the form status drop down menu the form status can be left as incomplete if the form is to be completed at a later time click to save the form click yes if you want to add the diagnosis of diabetes to the encounter and add the form to the current encounter note viewing cdm forms from the medical record select the forms view from the medical record to see a list of forms on the left hand side double click the form you want to view to open it note in the status column of the forms type list, “ parked ” indicates the form is incomplete viewing flow sheets from the medical record select flow sheets from the segment bar of the medical record select the name of the flowsheet you want to view from the flow sheets list any flowsheets relevant to this patient are shown to see others, click from the flow sheets view toolbar this opens the list of flow sheets for the patient select the desired flow sheets by clicking in the checkboxes the items area will display the guidelines, the last value entered and the most recent date these values were entered a cumulative view of values is displayed in date columns use the following icons on the toolbar to perform the following actions to show measures in a graph format to show measures in a tabular format to create a manual transaction to add prior medications to the flowsheet provincial ehr express view to access the provincial ehr express view click the button on the main toolbar if prompted, search for the patient to view in the provincial ehr express view if a patient is already in context, the window will automatically launch for the selected patient the provincial ehr express view will launch in a new window note the contents of the provincial ehr express view window are managed by the new brunswick department of health