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.
To set the status of vision rehabilitation
• Click the Yes, No or Unknown button.
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.
• ICD Code / Description: Type the ICD-9 or ICD-10 code in the text field.
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
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.
• To
expand the comment if it is not visible, click the Expand button.
• To
close the comment, click the Close button.
• To
save the comment, click the Save button.
NOTE: Any changes
made to the Review Comments area will not be saved unless the Save 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 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 button
to open the review comments box.
2.
Type the comment in the free text field and click the
Save 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 button. (The setting will not be saved unless
this button is clicked.)
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.
The Encounter
Actions menu allows the data abstractor to save the record, send it for review,
or cancel out of the current revisions.
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.