Diagnosis Tab

The Diagnosis tab allows the data abstractor or quality reviewer to add, edit, and delete information about the patient diagnosis, and to indicate whether the patient is in vision rehabilitation.

Diagnosis Tab Screenshot

 

To set the status of vision rehabilitation

      Click the Yes, No or Unknown button.

Vision Rehabilitation Screenshot

 

To add a diagnosis

1.      Click Add Diagnosis. .

2.      Use the following fields:

      Laterality: Select the laterality, i.e., Left Eye, Right Eye, Both or Not Specified.

Add Diagnosis Laterality

      ICD Code / Description: Type the ICD-9 or ICD-10 code in the text field.

Add Diagnosis Code and Description

3.      Click Add Diagnosis to add the diagnosis to the list, or Cancel to exit without retaining the settings.

4.      Click Save on the Encounter Actions menu to save, or Cancel to exit without saving.

To edit a diagnosis

1.      Click the corresponding Edit button

2.      Edit the fields as described above.

3.      Click Update to apply the revisions, or Cancel to exit without retaining the settings.

4.      Click Save on the Encounter Actions menu to save, or Cancel to exit without saving.

To remove a diagnosis

      Click the corresponding Delete link, and then click OK when prompted to confirm.

Review Comments

Review comments can be added to the Chief Complaint tab by the quality reviewer. The data abstractor can then view the comments and address them.

If a field is enabled for review comments, three comment buttons will be visible over that field.

Reviewer Comment Closed Screenshot

      To expand the comment if it is not visible, click the Expand Reviewer Comment - Expand Buttonbutton.

      To close the comment, click the Close Reviewer Comment - Close Button button.

      To save the comment, click the Save Reviewer Comment - Save Button button.

NOTE: Any changes made to the Review Comments area will not be saved unless the Save Reviewer Comment - Save Button button is clicked. That is, clicking the Save button on the Encounter Actions menu will not save these changes.

To update the record after review comments have been received (Data Abstractor role)

1.      Make the necessary revisions to the Chief Complaint tab based on the corresponding review comment.

2.      Once the comment has been addressed, click (select) the Resolved check box and click the Save Reviewer Comment - Save Button button to save the changes.

3.      When all comments have been addressed and the encounter is ready to be re-submitted, click the Send for Review link on the Encounter Actions menu.

4.      The quality reviewer will review the encounter, locating each comment and marking off the Approved check box for each revision that is approved.


 

To add review comments (Quality Reviewer role)

1.      Go to the area where the comment will be added and click the Expand Reviewer Comment - Expand Buttonbutton to open the review comments box.

Reviewer Comment - Expanded

2.      Type the comment in the free text field and click the Save Reviewer Comment - Save Button button. (The comment will not be saved unless this button is clicked.)

3.      When all comments have been added, click the Return to Abstractor link in the Encounter Actions menu to return the record for further processing. This will remove the encounter from the Reviewer Tasks grid until the data abstractor re-submits the record for review.

To approve changes after the data abstractor has made revision (Quality Reviewer role)

1.      Go to the field where the comment was added and resolved.

2.      If the review comment was addressed satisfactorily, click the Approved check box to select it, and then click the Save Reviewer Comment - Save Button button. (The setting will not be saved unless this button is clicked.)

Reviewer Comment - Expanded with Resolved and Approved Checkboxes

 

3.      Repeat this procedure for all resolved comments.

After all comments have been approved, the Review Comments grid in the General Tab will show the Is Approved check boxes as selected.

Updated Reviewer Comment List

 

Encounter Actions Menu

The Encounter Actions menu allows the data abstractor to save the record, send it for review, or cancel out of the current revisions.

Encounter Actions For Data Abstractors

Quality reviewers can use the Encounter Actions menu to save the record, return the record to the data abstractor after adding comments, send the completed, approved record to DVEIVR, or cancel out of the current operation.

Encounter Actions For Reviewer