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2 | EPIP_CiF.zip\305\docs | tiuum.doc | Thu Jul 26 12:45:28 2018 UTC |
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1 | Te xt Integra tion Utili ties (TIU) Clinical Coordinato r & User M anualText Integratio n Utilitie s (TIU) | |
2 | Clinical C oordinator & User Ma nual | |
3 | ||
4 | Version 1. 0 | |
5 | Revised Ju ne 2018 | |
6 | Department of Vetera ns Affairs | |
7 | Office of Informatio n & Techno logy | |
8 | Product De velopment | |
9 | Revision H istory | |
10 | PatchPages DateAuthor / Project ManagerTI U*1*305 | |
11 | (Computer Downtime P rogress No tes / Post -Signature Alerts) U pdated Pag es 2-3, 17 8, 183, 19 2, 197, 20 1, and 203 . | |
12 | Added Chap ter 18: Se tting up C ontingency Downtime Bookmark P rogress No tes | |
13 | ||
14 | June 2018T . Turowski / | |
15 | R. Beltran -WestTIU*1 *308 | |
16 | Potential PIIPages 1 34, 140Mar ch 2017Dan iel Huffma n | |
17 | Rishan Cha ndaranaPat ch TIU*1*2 91 (CWAD/P ostings Au to-Demotio n Setup)Up dated Page s 2, 104, 116, 130, 134, 143, and 184Apr il 2016Bla ir Sanders | |
18 | Rishan Cha ndaranaPat ch TIU*1*2 96 (TIU Te xt Alerts) Updated Pa ges 4, 180 , 185, 200 , and 204. | |
19 | Added Chap ter 17: Se tting Up T IU Text Ev ents (Page 204).Marc h 2016D. B urger, | |
20 | L. Behunia kTIU*1*263 | |
21 | Changes fo r ICD-10Ad ded inform ation abou t ICD-10 R emediation , PaTIU*1* 305ge 2Mar ch 2014J. Green, Cra ig HintonP atch TIU*1 *279Added informatio n to New P atches sec tion, Page 4. Added PATIENT RE CORD FLAG CATEGORY I – MISSING PATIENT n ote to Pag e 195. Add ed TIU-Hea lth Summar y objects note to Pa ge 215.Nov ember 2013 R. Wilder, Debbie Ga llagherPat ch TIU*1*2 75 | |
22 | USH LEGAL SOLUTIONPa ges 5 and 197August 2013J. Gre en, Al Ebe rtPatch TI U*1*265 | |
23 | (PRF CAT I - HIGH RI SK FOR SUI CIDE)Pages 6 and 197 June-Decem ber 2012J. Green, Al EbertExpl anation of problem e xchanging TIU-HS Obj ects Page 221Decembe r 2012J. G reen, M. M cClenahanP atch TIU*1 *261 (Resc inding an Advance Di rective do cument). Pages 119 and REF r escindAdva ncedir \h | |
24 | \* MERGEF ORMAT 197J anuary 201 2J. Green, M. McClen ahan Patch 248 (Secu rity For T he TIU Opt ion Missin g Text Cle anup)Page 128 | |
25 | June 2011C Arceneaux , T Downin gPatch 250 (Line Cou nt)Pages 1 04, 143, a nd 146June 2010C Arc eneaux, T DowningPat ch 219 (DS Attending Requireme nts)June 2 008C Arcen eaux, A Eb ertPatch 2 31 (Analyz e potentia l Surgery TIU proble ms)January 2008G. We rner, A. S cottPatch 234 (Expec ted Cosign er Edit an d Disallow Signed Do cument Edi t)Dec 2007 C Arceneau x, S Madse nPatch 215 (Disallow Edit)June 2007C Arc eneaux, S MadsenPatc h USR*1*31 (Informat ional on B usiness Ru les)June 2 007C Arcen eaux, S Ma dsenPatch 220Dec 200 6C Arcenea ux, S Mads enPatch 20 0 (TUI HL7 Generic I nterface)O ctober 200 6C Arcenea ux, D Rick ardPatch 2 14 (Mismat ched ID No tes)Sept 2 006T Dawso n, C Green ingPatch 1 99May 2006 T Dawson, C Greening Patch 189 (Expected Cosigner)M arch 2006T Dawson, C GreeningP atch 191 ( Disclosure of Advers e Event No te)May 200 5C Arcenea ux, G Smit hPatch 182 (Medicine Conversio n)June 200 5C Arcenea ux, G Smit hPatch 173 (Unknown Addenda Cl eanup)Apri l 2005C Ar ceneaux, G SmithPatc h 157 (Add itional Si gner Chang es)March 2 005C Arcen eaux, G Sm ithPatches 174 & 177 (Blank No te)Nov 200 4C Arcenea ux, G Smit hPatch 171 (SCI Docu ment Defin itions)Feb ruary 2005 C Arceneau x, G Smith 192-352 ap plied (Pat ient Priva cy Documen t Scrubbin g)Dec 2004 C Arceneau x & S Well man, P Lan dyPatch 16 9 (C & P D ocument De finitions) Dec2 004C Arceneaux, G SmithPa tch 177 (M issing Tex t)October 2004Patch 185 (Reass ign Report )August 20 04Patch 11 2 (Surgery )February 2004Patch 113 (Multi division)F ebruary 20 04Patch 15 9 (WRIISC) October 20 03Patch 16 5 (Patient Record Fl ags)Sept 2 003Patch 1 37 (Anatom ic Patholo gy)June 20 03Patch 15 8 (Alert T ools)June 2003Patch 109 (Clini cal Proced ures)June 2002Patche s 61, 95, 100 & 105A pril 2001O riginally releasedJu ly 1997J G reen, J Ru ssell | |
26 | ||
27 | Table of C ontents | |
28 | iiRevision History | |
29 | ||
30 | ||
31 | 1Chapter 1 : Introduc tion to TI U | |
32 | ||
33 | ||
34 | 1Purpose o f Text Int egration U tilities | |
35 | ||
36 | ||
37 | 1Benefits | |
38 | ||
39 | ||
40 | 2Recent Pa tches | |
41 | ||
42 | ||
43 | 7Chapter 2 : Orientat ion | |
44 | ||
45 | ||
46 | 7Manual or ganization | |
47 | ||
48 | ||
49 | 7Online do cumentatio n: Intrane t | |
50 | ||
51 | ||
52 | 8Special I nstruction s for the new VISTA Computer U ser | |
53 | ||
54 | ||
55 | 8Graphic C onventions Used in T his Manual | |
56 | ||
57 | ||
58 | 9TIU and V istA Conve ntions | |
59 | ||
60 | ||
61 | 14Chapter 3: TIU for Clinician s | |
62 | ||
63 | ||
64 | 14Progress Notes/Dis charge Sum mary Menu | |
65 | ||
66 | ||
67 | 15Using Pr ogress Not es through CPRS | |
68 | ||
69 | ||
70 | 20Select S earch thro ugh CPRS | |
71 | ||
72 | ||
73 | 43Interdis ciplinary Notes | |
74 | ||
75 | ||
76 | 50Discharg e Summary | |
77 | ||
78 | ||
79 | 58Integrat ed Documen t Manageme nt | |
80 | ||
81 | ||
82 | 68Personal Preferenc es | |
83 | ||
84 | ||
85 | 73Document Definitio ns (Clinic ian) | |
86 | ||
87 | ||
88 | 77TIU and Health Sum mary | |
89 | ||
90 | ||
91 | 78Chapter 4: TIU for Medical R ecord Tech nicians | |
92 | ||
93 | ||
94 | 78MRT Menu | |
95 | ||
96 | ||
97 | 79Individu al Patient Document | |
98 | ||
99 | ||
100 | 80Multiple Patient D ocuments | |
101 | ||
102 | ||
103 | 83Review U pload Fili ng Events | |
104 | ||
105 | ||
106 | 85Print Do cument Men u | |
107 | ||
108 | ||
109 | 85Discharg e Summary Print | |
110 | ||
111 | ||
112 | 88Progress Note Prin t | |
113 | ||
114 | ||
115 | 91Clinical Document Print | |
116 | ||
117 | ||
118 | 95Search f or Selecte d Document s | |
119 | ||
120 | ||
121 | 96Unsigned /Uncosigne d Report | |
122 | ||
123 | ||
124 | 99Review U nsigned Ad ditional S ignatures | |
125 | ||
126 | ||
127 | 101Chapter 5: TIU fo r MIS/HIMS Managers | |
128 | ||
129 | ||
130 | 101MIS Man ager’s Men u | |
131 | ||
132 | ||
133 | 104Multipl e Patient Documents | |
134 | ||
135 | ||
136 | 105Print D ocument Me nu | |
137 | ||
138 | ||
139 | 117Rescind ing Advanc e Directiv es | |
140 | ||
141 | ||
142 | 119Statist ical Repor ts | |
143 | ||
144 | ||
145 | 144Chapter 6: TIU fo r Transcri ptionists | |
146 | ||
147 | ||
148 | 145Enter/E dit Discha rge Summar y | |
149 | ||
150 | ||
151 | 149Upload Menu | |
152 | ||
153 | ||
154 | 158Chapter 7: TIU fo r Remote U sers | |
155 | ||
156 | ||
157 | 159Individ ual Patien t Document | |
158 | ||
159 | ||
160 | 161Multipl e Patient Documents | |
161 | ||
162 | ||
163 | 164Chapter 8: Progre ss Notes P rint Optio ns | |
164 | ||
165 | ||
166 | 165Progres s Notes Pr int Menu | |
167 | ||
168 | ||
169 | 166MAS Opt ions to Pr int Progre ss Notes | |
170 | ||
171 | ||
172 | 178Chapter 9: Managi ng TIU: In troduction | |
173 | ||
174 | ||
175 | 179Legal R equirement s | |
176 | ||
177 | ||
178 | 180Links a nd Relatio nships wit h Other Pa ckages | |
179 | ||
180 | ||
181 | 181Chapter 10: Menus and Optio n Assignme nt | |
182 | ||
183 | ||
184 | 183TIU Con version Cl ean-up Men u [GMRP TI U] | |
185 | ||
186 | ||
187 | 184Suggest ed Clinica l Coordina tor Menu | |
188 | ||
189 | ||
190 | 185Menu As signment | |
191 | ||
192 | ||
193 | 186Chapter 11: Setti ng up TIU Parameters | |
194 | ||
195 | ||
196 | 186TIU Par ameters Me nu | |
197 | ||
198 | ||
199 | 187Chapter 12: Docum ent Defini tions | |
200 | ||
201 | ||
202 | 187Example of Docume nt Definit ion Hierar chy | |
203 | ||
204 | ||
205 | 189Chapter 13: Defin ing User C lasses | |
206 | ||
207 | ||
208 | 190Chapter 14: Natio nal Docume nt Titles | |
209 | ||
210 | ||
211 | 190Nationa l Classes | |
212 | ||
213 | ||
214 | 191Nationa l Document Classes | |
215 | ||
216 | ||
217 | 192Nationa l Titles | |
218 | ||
219 | ||
220 | 196Chapter 15: TIU A lert Tools | |
221 | ||
222 | ||
223 | 198Alert T ools FAQ | |
224 | ||
225 | ||
226 | 201Chapter 16: HL7 G eneric Int erface | |
227 | ||
228 | ||
229 | 201Message Manager | |
230 | ||
231 | ||
232 | 203Chapter 17: Setti ng Up TIU Text Event s | |
233 | ||
234 | ||
235 | 205Chapter 18: Setti ng up Cont ingency Do wntime Boo kmark Prog ress Notes | |
236 | ||
237 | ||
238 | 208Chapter 19: Helpf ul Hints/T roubleshoo ting | |
239 | ||
240 | ||
241 | 215Questio ns about Document D efinition | |
242 | ||
243 | ||
244 | 215(Classe s, Documen t Classes, Titles, B oilerplate text, Obj ects) | |
245 | ||
246 | ||
247 | 223Visit O rientation | |
248 | ||
249 | ||
250 | 224Glossar y | |
251 | ||
252 | ||
253 | 228Index | |
254 | ||
255 | ||
256 | ||
257 | ||
258 | Chapter 1: Introduct ion to TIU XE "Intro duction to TIU" | |
259 | Purpose of Text Inte gration Ut ilities XE "Purpose of Text In tegration Utilities" | |
260 | The purpos e of Text Integratio n Utilitie s (TIU) is to simpli fy the acc ess and us e of clini cal docume nts for bo th clinica l and admi nistrative VAMC pers onnel, by standardiz ing the wa y clinical documents are manag ed. In con nection wi th Authori zation/ Su bscription Utility ( ASU), a ho spital can set up po licies and practices for deter mining who is respon sible or h as the pri vilege for performin g various actions on required VHA docume nts. | |
261 | The initia l release of Version 1.0 inclu des Discha rge Summar y and Prog ress Notes . Consult Reports wa s added wi th the rel ease of Co mputerized Patient R ecord Syst em (CPRS). TIU repla ces and up grades the previous versions o f these VI STA packag es. It has also been designed to meet th e needs of other cli nical appl ications t hat addres s document handling. | |
262 | TIU allows you to co ntinue to access Pro gress Note s and Disc harge Summ aries from OE/RR men us. The CP RS Graphic al User In terface (G UI) allows point-and -click acc ess to all Progress Notes, Dis charge Sum maries, an d Consults TIU docum ents. | |
263 | Benefits X E "Benefit s" | |
264 | a. Standa rdized and common us er interfa ce XE "Sta ndardized user inter face" | |
265 | Clinicians can go th rough the same progr am to ente r, review, and sign discharge summaries, progress notes, and other cli nical docu ments that may be se t up local ly for pro cessing th rough TIU. | |
266 | b. Integr ation | |
267 | Clinicians and manag ement can search for and retri eve clinic al documen ts more ef ficiently because do cuments re side in a single loc ation with in the dat abase. Thi s is also a benefit for other uses such as Incompl ete Record Tracking, quality m anagement, results r eporting, order chec king, rese arch, etc. | |
268 | c. Data C apture Fle xibility | |
269 | TIU accept s document input fro m a variet y of data capture me thodologie s. Those i nitially s upported a re transcr iption and direct en try. TIU a llows uplo ad of ASCI I XE "ASCI I" format ted docume nts into V ISTA. | |
270 | Benefits, cont’d XE "Benefits" | |
271 | d. Links to Other P ackages XE "Linkages " . | |
272 | TIU interf aces, as a ppropriate , with suc h applicat ions as He alth Summa ry, Proble m List, Pa tient Care Encounter /Visit Tra cking, and Incomplet e Record T racking. C omputerize d Patient Record Sys tem (CPRS) further i ntegrates VISTA pack ages and a llows poin t and clic k switchin g between packages. | |
273 | A new Heal th Summary component is availa ble (throu gh Patch G MTS*2.7*12 ), Selecte d Progress Notes, wh ich allows selection of specif ic Progres s Notes Ti tles for d isplay on Health Sum maries. Th e PN, DS, and CWAD c omponents now extrac t data fro m TIU, rat her than P rogress No tes (GMRP) , or Disch arge Summa ry (GMRD). Care has been taken to assure that the formatting and conte nt of the components have rema ined the s ame, excep t that the signature block inf ormation w ill now re flect the author's ( and cosign er's) name and title at the ti me of sign ature, rat her than d isplaying their curr ent values at the ti me of outp ut. | |
274 | e. Improv ed managem ent of Doc uments. | |
275 | TIU has a file struc ture calle d the Docu ment Defin ition Hier archy XE " Document D efinition Hierarchy" for defi ning eleme nts and pa rameters o f a docume nt. It all ows: | |
276 | Inheritanc e of docum ent charac teristics, such as s igning, co signing, v isit linka ge, etc. | |
277 | Site defin ition of d ocument ch aracterist ics | |
278 | Shared com ponents | |
279 | Ownership (personal or class) of documen t definiti ons | |
280 | Boilerplat e text XE "Boilerpla te" funct ionality | |
281 | Interdisci plinary No te functio nality. | |
282 | Embedded “ Object” fu nctionalit y which ca n extract data from otherVISTA packages and insert it into b oilerplate text | |
283 | Recent Pat ches | |
284 | Patch TIU* 1*305 – Co ntingency Downtime B ookmark Pr ogress Not es / Post- Signature Alerts | |
285 | TIU*1.0*30 5 provides the follo wing enhan cements to VistA: | |
286 | Enables si tes to add a progres s note to the electr onic recor d of all i npatients and outpat ients who were seen during com puter syst em downtim e using th e new opti on Conting ency Downt ime Bookma rk Progres s Notes [T IU DOWNTIM E BOOKMARK PN] in th e TIU Main tenance Me nu [TIU IR M MAINTENA NCE MENU]. The note must use e ither the Veterans H ealth Admi nistration (VHA) ent erprise-st andard tit le COMPUTE R DOWNTIME or a loca lly-approv ed title t hat is map ped to the standard COMPUTER D OWNTIME ti tle. When creating t he note, u sers can e nter: the note title ; whether the comput er downtim e was sche duled or u nscheduled ; outage s tart/end t imes; the author of the note; a date/tim e stamp to sequence the note i n the note tree; cli nics to wh ich the ou tage appli es; users to receive an email notificati on listing the patie nts affect ed and whe ther the n ote was su ccessfully appended to each pa tient's re cord; an o ption to e dit the TI U note tex t; and an electronic signature to perfor m an admin istrative closure of the note to enter i t into the medical r ecord. The progress note state s that a c omputer ou tage occur red, and a lerts the user to se arch the p atient's p aper recor ds for non -electroni c document ation crea ted during the outag e. | |
287 | During the post-inst allation p hase, post -installat ion routin e TIU1P305 deletes a site’s ex isting tex t in the B OILERPLATE TEXT fiel d (#3) in the TIU DO CUMENT DEF INITION fi le (#8925. 1) and rep laces it w ith new st andard TIU note text . This new text can be modifie d by users when crea ting downt ime bookma rk progres s notes. T he install ation hist ory for th e patch wi ll capture the data from the B OILERPLATE TEXT fiel d so that local OIT personnel can retrie ve the pre vious boil erplate te xt, if nee ded. The i nstallatio n history can be rev iewed usin g the Inst all File P rint [XPD PRINT INST ALL FILE] option und er the KID S UTILITIE S sub-menu . | |
288 | Enables cl inicians a nd provide rs to crea te progres s notes th at automat ically gen erate a po st-signatu re alert t o designat ed recipie nts based on the pro gress note title. Th e new opti on Create Post-Signa ture Alert s [TIUFPC CREATE POS T-SIGNATUR E] in the Document D efinitions (Manager) [TIUF DOC UMENT DEFI NITION MGR ] menu all ows Clinic al Applica tion Coord inators (C ACs) or ot her superv isors to d efine who is alerted when a sp ecific pro gress note title is used. The note title to define is select ed at the "Select TI U DOCUMENT DEFINITIO N NAME:" p rompt. The option th en enables entry of the recipi ents to be notified (individua l, mail gr oup, or te am list), whether to alert the Primary C are Provid er, whethe r to print a chart c opy at the patient's location, and to op tionally s elect an o utput devi ce for pri nting at a nother loc ation. Thi s data is used to po pulate a M UMPS subro utine name in the PO ST-SIGNATU RE ACTION field (#4. 9) for a d ocument de finition i n the TIU DOCUMENT D EFINITION file (#892 5.1). The notificati on is made through V istA Kerne l Alerts a nd is sent to recipi ents immed iately upo n a clinic ian's entr y of an el ectronic s ignature f or the not e. | |
289 | Patch TIU* 1*291 – CW AD/Posting s Auto-Dem otion Setu p | |
290 | Patch TIU* 1*291 intr oduces the new Crisi s, Warning s, Allergi es and/or Adverse Re actions, a nd Advance Directive s (CWAD) n otes auto- demotion f unctionali ty. CWAD i s a sectio n of CPRS used for p osting pro gress note s, which a re more im portant th an standar d level no tes. These progress notes are made more easily ava ilable thr oughout CP RS. The po stings dia log box ca n become f ull of CWA D notes, r esulting i n importan t notes fr om being e asily dist inguishabl e from les s importan t notes. T he request ed enhance ment is to demote pr eviously d esignated notes from the CWAD postings t o a regula r note sta tus based on various criteria, such as t he passage of time o r a newer note of a particular title bei ng written which sup ersedes th e existing CWAD note . This is accomplish ed by conv erting an existing C lass III a pplication to Class I. | |
291 | Patch TIU* 1*296 – TI U Text Ale rts | |
292 | Patch TIU* 1*296 modi fies the T IU applica tion to se nd a TIU a lert to th e appropri ate servic e provider (s) immedi ately afte r a staff member scr eens a pat ient and s igns the a ssociated note. The service pr ovider(s) will be al erted prio r to the n ote being co-signed by the lic ensed clin ician resp onsible fo r reviewin g and appr oving the note. Prio r to this modificati on, TIU al erts were not sent t o all serv ice provid ers. This resulted i n missed o pportuniti es to prov ide needed services for patien ts while t he patient s are on s ite, and f orced staf f to take time to co ntact pati ents and r eschedule needed ser vices. | |
293 | This patch utilizes one new fi le (TIU TE XT EVENTS (#8925.71) ) used to define the words or phrase tha t will be searched f or in a TI U document (progress note, con sult, etc. ). If the words or p hrase are found in t he TIU doc ument, the n an alert is sent t o the team (s) specif ied in the TIU TEXT EVENTS fil e. | |
294 | A Text Eve nt Edit [T IU TEXT EV ENT EDIT] menu optio n was adde d to the T IU Mainten ance Menu [TIU IRM M AINTENANCE MENU]. Th is option is used to set up a text event in the TI U TEXT EVE NTS file. | |
295 | | |
296 | Note: Any TIU docume nt that is to be use d to trigg er these a lerts must have the MUMPS code 'D TASK^T IUTIUS(DA) ’ entered in the POS T-SIGNATUR E CODE fie ld (#4.9) in the TIU DOCUMENT DEFINITION file (#89 25.1). Thi s field ca n only be edited by IRM person nel. | |
297 | TIU*1*263 – Changes for ICD-10 | |
298 | This patch is part o f the Comp uterized P atient Rec ords Syste m CPRSv30 project. T his projec t will mod ify the Co mputerized Patient R ecord Syst em, Text I ntegration Utilities , Consults , Health S ummary, Pr oblem List , Clinical Reminders , and Orde r Entry/Re sults Repo rting to m eet the re quirements proposed by the Dep t. of Heal th and Hum an Service s | |
299 | to adopt ICD-10 cod e set stan dards for Clinic Ord ers. | |
300 | This patch makes all changes t o TIU that are requi red to mov e from the ICD-9 cod ing versio n to ICD-1 0. | |
301 | Changes Ma de to Acco mmodate IC D-10: | |
302 | Progress N otes, Vist A | |
303 | The TIU pa ckage will print and display I CD codes o btained fr om other V istA packa ges within a single Progress N otes that were captu red at the time the data was e ntered, in cluding: | |
304 | ICD-9-CM d iagnosis a nd procedu re codes | |
305 | ICD-10-CM diagnosis and ICD-10 -PCS proce dure codes | |
306 | The VistA TIU packag e will pri nt and dis play ICD c odes withi n a single progress note. | |
307 | Progress N otes, CPRS | |
308 | The CPRS T IU applica tion will print and display IC D-9 and IC D-10 diagn osis codes , procedur e codes, o btained fr om other p ackages wi thin Progr ess Notes at the tim e the data was enter ed. | |
309 | The CPRS T IU package will prin t and disp lay ICD co des within a single progress n ote. | |
310 | Discharge Summary | |
311 | The VistA TIU packag e will pri nt and dis play ICD-9 and ICD-1 0 diagnosi s and proc edure code s and desc riptions o btained fr om other V istA packa ges within Discharge Summaries that were captured at the tim e the data was enter ed. | |
312 | Patient Da ta Objects | |
313 | Patient Da ta Object VA-WRIISC Active Pro blems will be modifi ed to prin t and disp lay ICD-10 -CM diagno sis codes. | |
314 | NOTE: | |
315 | TIU Objec t VA-WRIIS C ACTIVE P ROBLEMS is the only nationally distribut ed TIU Obj ect which includes D iagnoses/P roblems. | |
316 | Health Sum mary | |
317 | The VistA TIU packag e will pri nt and dis play ICD-9 diagnosis codes obt ained from other Vis tA package s within H ealth Summ aries whic h display PN or DS. | |
318 | Problem Li st | |
319 | TIU VistA protocols permitting users to link probl ems direct ly to a TI U Progress Note have been disa bled. Not e: This me ans that a ll problem s linked d irectly to Progress Notes will predate t his patch and will t herefore b e ICD-9 pr oblems. | |
320 | Patch TIU* 1*279 – Cr eate Missi ng Patient PRF TIU i nstalls on e new Prog ress Note Title into the TIU D OCUMENT DE FINITION f ile (8925. 1) PATIENT RECORD FL AG CATEGOR Y I – MISS ING PATIEN T. The pat ch install ation link s the titl e to the e xisting do cument cla ss, PATIEN T RECORD F LAG CAT I. This titl e will be automatica lly linked to the MI SSING PATI ENT Patien t Record F lag during the insta ll of DG*5 .3*869. | |
321 | Patch TIU* 1*275 – US H LEGAL SO LUTION ins talls one new Progre ss Note Ti tle into t he TIU DOC UMENT DEFI NITION fil e (8925.1) : PATIENT RECORD FLA G CATEGORY I – URGEN T ADDRESS AS FEMALE. The patch installat ion links the title to the exi sting docu ment class , PATIENT RECORD FLA G CAT I. T his title will be au tomaticall y linked t o the URGE NT ADDRESS AS FEMALE Patient R ecord Flag during th e install of DG*5.3* 864. | |
322 | Patch TIU* 1*265 - PR F CAT I - HIGH RISK FOR SUICID E supports the Impro ve Veteran Mental He alth (IVMH ) initiati ve, High R isk Mental Health (H RMH) -Nati onal Remin der & Flag . | |
323 | This patc h installs one new T itle into the TIU DO CUMENT DEF INITION fi le (8925.1 ): PATIENT RECORD FL AG CATEGOR Y I - HIGH RISK FOR SUICIDE | |
324 | PATIENT RE CORD FLAG CATEGORY I - HIGH RI SK FOR SUI CIDE is us ed with th e new Pati ent Record Flag. | |
325 | Patch TIU* 1*261 perm its an aut horized us er to resc ind an Adv ance Direc tive docum ent by cha nging the title to R ESCINDED A DVANCE DIR ECTIVE. | |
326 | Patch TIU* 1*261 supp orts Imagi ng patch M AG*3.0*121 , which pr ovides the ability t o watermar k images " RESCINDED" . | |
327 | | |
328 | Note: EXAC T TITLE NA MES are RE QUIRED | |
329 | The title of the Adv ance Direc tive to be rescinded must be A DVANCE DIR ECTIVE | |
330 | The title it is cha nged to wh en it is b eing resci nded must be RESCIND ED ADVANCE DIRECTIVE | |
331 | Both LOCA L and Nati onal Stand ard titles must be a s above. Variations on either title wil l cause th e Change T itle actio n to fail to waterma rk images as rescind ed. | |
332 | These exa ct titles are requir ed by poli cy. See t he VHA HAN DBOOK 1004 .02 sectio n on Advan ce Directi ves: | |
333 | http://vaw w1. d o main /vhapublic ations/Vie wPublicati on.asp?pub _ID=2042 | |
334 | Patch TIU* 1*159 impl ements the War-Relat ed Illness and Injur y Study Ce nters (WRI ISC XE "WR IISC" pro nounced “r isk”) note title and template. The assoc iated note title is WRIISC XE "WRIISC" ASSESSMENT NOTE. Thi s note is described in the mem o Descript ion of WRI ISC Progra ms and Ass ociated Re ferral Pro cess accom panying th e patch. T o get it t o work pro perly a Cl inical Coo rdinator a uthorized to edit sh ared templ ates must perform th e followin g steps fr om the CPR S GUI: | |
335 | Go to the Notes tab. | |
336 | From the O ptions men u, select Edit Share d Template s. | |
337 | In the Sha red Templa tes pane h ighlight d ocument Ti tles. | |
338 | From the T ools menu select Imp ort Templa te. | |
339 | Select WRI ISCASSESSM ENT.TXML a nd press O pen. | |
340 | Highlight the WRIISC ASSESSMEN T template . | |
341 | In the Ass ociated Ti tle list b ox, select WRIISC AS SESSMENT N OTE. | |
342 | Press OK. | |
343 | Once these steps hav e been per formed, th e template and note title will work for all CPRS u sers. Furt her inform ation abou t setting up shared templates is availab le in the Computeriz ed Patient Record Sy stem (CPRS ) User Gui de in the section on Creating Personal D ocument Te mplates. | |
344 | Chapter 2: Orientati on XE "In troduction to the TI U User Man ual" | |
345 | Manual org anization XE "Manual organizat ion" | |
346 | This manua l is divid ed into fo ur major s ections: | |
347 | SectionPur poseI: Int roductionP resents ov erviews of TIU softw are and th e User Man ual.II: Us ing TIUDes cribes and demonstra tes how to use the b asic entry and repor ting funct ions of TI U. This se ction is d ivided int o sub-sect ions for t he four ma jor users of TIU: cl inicians, MRTs, MIS Managers, and transc riptionist s.III: Man aging TIUD escribes t he options and tools available to coordi nators and IRMS for assigning menus, set ting param eters, and other man agement fu nctions. A lso includ es Trouble shooting a nd Helpful Hints.Glo ssary and IndexDefin itions of terms and the index to the man ual.How ea ch chapter is format ted | |
348 | Each chapt er general ly follows the forma t of: | |
349 | Brief over view | |
350 | Descriptio n of proce ss (step-b y-step des cription o f how to u se functio ns, if app ropriate) | |
351 | Examples | |
352 | Online doc umentation : Intranet XE "Intra net" | |
353 | Online Doc umentation for this product is available on the in tranet at the follow ing addres s: | |
354 | http://www . d o main /vdl/ | |
355 | This addre ss takes y ou to the Clinical P roducts pa ge, which has a list ing of all the clini cal softwa re manuals . Click on the CPRS: Text Inte gration Ut ilities li nk and it will take you to the TIU Homep age. | |
356 | Note: Rem ember to b ookmark th is site fo r future r eference. | |
357 | Special In structions for the n ew VISTA C omputer Us er XE "Spe cial Instr uctions fo r the Firs t Time Com puter User " | |
358 | If you are unfamilia r with thi s package or other V eterans He alth Infor mation Sys tems and T echnology Architectu re (VISTA) software applicatio ns, we rec ommend tha t you stud y the DHCP User’s Gu ide to Com puting. Th is orienta tion guide is a comp rehensive handbook f or first-t ime users of any VIS TA applica tion to he lp you bec ome famili ar with ba sic comput er terms a nd the com ponents of a compute r. It is r eproduced and distri buted peri odically b y the Kern el Develop ment Group . To reque st a copy, contact y our local Informatio n Resource s Manageme nt Service (IRMS) st aff. | |
359 | Graphic Co nventions Used in Th is Manual XE "Graphi c Conventi ons" | |
360 | <Enter> XE "<Enter>" | |
361 | The Enter or Return key. It is pressed a fter every response you enter or when yo u wish to bypass a p rompt, acc ept a defa ult (//), or return to a previ ous action . In this manual, it is only i ncluded in examples when it mi ght be unc lear that such a key stroke mus t be enter ed. | |
362 | Option exa mples | |
363 | Menus and examples o f computer dialogue that you s ee on the screen are shown in boxes: | |
364 | Select Men u Option: | |
365 | User respo nses XE "U ser respon ses" | |
366 | User respo nses are s hown in bo ldface. | |
367 | Select PAT IENT NAME: TIUPATIEN T,ONE | |
368 | NOTE | |
369 | The pointi ng finger with a NOT E is used to call yo ur attenti on to some thing espe cially sig nificant. | |
370 | ||
371 | Example: | |
372 | ||
373 | NOTE: Y ou can res pond to ma ny prompts by typing the first few lette rs of a na me, option , or actio n. | |
374 | Select PAT IENT NAME: TIUPATIEN T,O TIUPATIENT ,ONE | |
375 | TIU and Vi stA Conven tions XE " TIU and VI STA Conven tions" | |
376 | ^ , ^^, ^^ ^ | |
377 | Enter the up-arrow ( also known as a care t or circu mflex) at a prompt to exit th e current option, me nu, sequen ce of prom pts, or he lp. To get completel y out of y our curren t context and back t o your ori ginal menu , you may need to en ter two or three up- arrows. Fo r example, when you’ re reviewi ng a list of documen ts, one up -arrow tak es you to the next d ocument; y ou need to enter two up-arrows to get ou t of the o ption. | |
378 | > > | |
379 | TIU screen s can cont ain more i nformation to the ri ght of the main scre en display . To see t his inform ation, ent er the > c haracter. To return to the mai n screen, enter the < characte r. | |
380 | NOTE: Th e arrow ke ys on the keypads of some keyb oards can sometimes be used fo r navigati on in List Manager a pplication s, but thi s depends on the ope rating sys tem. So if you get f unny chara cters on y our screen when you use those arrows, us e the > an d < symbol s on the c omma and p eriod keys (the grea ter-than a nd less-th an symbols ). | |
381 | Online Hel p XE "Onli ne Help" ?, ??, ??? | |
382 | ||
383 | Online hel p is avail able by en tering one , two, or three ques tion marks at a prom pt. One qu estion mar k elicits a brief st atement of what info rmation is appropria te for res ponding to the promp t; two que stion mark s shows a list (and sometimes descriptio ns) of mor e actions; and three question marks prov ide more d etailed he lp, includ ing a list of possib le answers , if appro priate. | |
384 | Defaults X E "Default s" (//) D efaults ar e response s provided to speed up your en try proces s. They ar e either t he most co mmon respo nses, the safest res ponses, or the previ ous respon se. Exampl es: | |
385 | ||
386 | Most commo n: | |
387 | Enter the ending dat e: NOW// | |
388 | ||
389 | Safest: | |
390 | Do you wis h to delet e the enti re entry: NO// | |
391 | ||
392 | Last enter ed | |
393 | Enter the Provider N ame: TIUPR OVIDER,THR EE// | |
394 | List Manag er Screen Display XE "Screen D isplay" | |
395 | ||
396 | ||
397 | ||
398 | TIU uses t he List Ma nager util ity XE "Li st Manager utility" which ena bles TIU ( and other applicatio ns) to dis play a lis t of items in a scre en format. | |
399 | Screen tit le | |
400 | ||
401 | The screen title cha nges accor ding to wh at type of informati on List Ma nager is d isplaying (e.g., Pro gress Note s, Dischar ge Summary , etc.). | |
402 | Header are a | |
403 | ||
404 | The header area is a “fixed” ( non-scroll able) area that disp lays patie nt informa tion. | |
405 | List area XE "List a rea" | |
406 | ||
407 | (scrolling region XE "Scrollin g region" ) This are a scrolls if there a re more it ems than w ill fit on one page. It displa ys a list of items, such as Un signed Pro gress Note s, that yo u can take action on . If there ’s more th an one pag e of items , it’s lis ted in the upper rig ht-hand co rner of th e screen ( Page 1 of #). | |
408 | Message wi ndow XE "M essage win dow" | |
409 | ||
410 | This secti on display s a plus ( +) sign XE "Plus (+) sign" , m inus (-), or >> sign XE "Minus (-) sign" , or info rmational text (i.e. , Enter ?? for more actions). If you ent er a plus sign at th e action p rompt, Lis t Manager “jumps” fo rward a pa ge. If a m inus sign is display ed and you enter it at the act ion prompt , List Man ager “jump s” back a screen. Th e plus, mi nus, and > signs are only vali d actions if they ar e displaye d in the m essage win dow. | |
411 | List Manag er Screen Display co nt’d | |
412 | Action are a | |
413 | ||
414 | A list of actions di splay in t his area o f the scre en. If you enter a d ouble ques tion mark (??) at th e “Select Item(s)” p rompt, you are shown a “hidden ” list of additional actions t hat are av ailable to use. | |
415 | Entering A ctions XE "Actions" | |
416 | The List M anager uti lity allow s you to: | |
417 | browse thr ough the l ist | |
418 | select ite ms that ne ed action | |
419 | take actio n against those item s | |
420 | select oth er actions without l eaving the option | |
421 | Actions ar e entered by typing the name o r abbrevia tion at th e “Select Action” pr ompt. | |
422 | Shortcut X E "Shortcu t" : Actio ns may als o be prese lected by typing the action ab breviation , then the number of the docum ent on the list (Exa mple: ED=1 will let you edit e ntry 1, Co nsult Repo rt. | |
423 | Besides th e actions specific t o the opti on you are working i n, List Ma nager prov ides gener ic actions applicabl e to any L ist Manage r screen. Enter a do uble quest ion mark ( ??) at the “Select A ction” pro mpt for a list of al l actions available. The abbre viation fo r each act ion is sho wn in brac kets follo wing the a ction name . These ac tions are described on the nex t page. | |
424 | List Manag er Screen Display, c ont’d XE " Screen Dis play" | |
425 | The follow ing action s are avai lable XE " hidden act ion menu" (enter ?? to see th ese): | |
426 | + Next screen GO Go to Pag e DD Det ailed Disp lay | |
427 | - Previ ous Screen RD Re Displa y Screen EC Edi t Cosigner | |
428 | FS First Screen ADPL Auto Disp lay(On/Off ) CT Cha nge Title | |
429 | LS Last Screen Q Quit CWAD CWA D Display | |
430 | UP Up a Line > Shift Vie w to Right | |
431 | DN Down a Line < Shift Vie w to Left | |
432 | Generic (h idden) act ions XE "H idden acti ons" | |
433 | ActionDesc riptionNex t Screen [ +]Move to the next s creen (may be shown as a defau lt) | |
434 | Previous S creen [-]M ove to the previous screen | |
435 | Up a Line [UP]Move u p one line | |
436 | Down a Lin e [DN]Move down one line | |
437 | Shift View to Right [>]Move th e screen t o the righ t if the s creen widt h is more than 80 ch aracters | |
438 | Shift View to Left [ <]Move the screen to the left if the scr een width is more th an 80 char acters | |
439 | First Scre en [FS]Mov e to the f irst scree n | |
440 | Last Scree n [LS]Move to the la st screen | |
441 | Go to Page [GO]Move to any sel ected page in the li st | |
442 | Re Display Screen [R D]Redispla y the curr ent screen | |
443 | Print Scre en [PS]Pri nts the he ader and t he portion of the li st current ly display ed | |
444 | Print List [PL]Print s the list of entrie s currentl y displaye d | |
445 | Search Lis t [SL]Find s selected text in l ist of ent ries | |
446 | Auto Displ ay (On/Off ) [ADPL]To ggles the menu of ac tions to b e displaye d/not disp layed auto matically | |
447 | Change Tit le (CT)All ows you to change th e Title of a note fr om, e.g., a CWAD not e to a Nur sing NoteC WAD Displa y (CWAD) | |
448 | Displays d etails of any CWAD n otes avail ableList M anager Scr een Displa y, cont’d | |
449 | ActionDesc riptionEdi t Cosigner [EC] XE " Edit Cosig ner [EC]" Allows aut horized us ers to mod ify the Ex pected Cos igner XE " modify the Expected Cosigner" (Attendin g Physicia n for Disc harge Summ aries) of documents without ha ving acces s to the t ext of the document. It is int ended for Clinical C oordinator s when the y need to change the Expected Cosigner o f a docume nt whose E xpected Co signer can not be oth erwise cha nged becau se it is a lready sig ned. It pe rmits the Expected C osigner fi eld to be edited XE "allow edi t" for un signed or uncosigned documents of type P rogress No tes, Consu lts, Clini cal Proced ures, or D ischarge S ummaries. | |
450 | Note: | |
451 | Recent cha nges enfor ce limits on cosigni ng privile ges. No pr ovider may be a cosi gner on Di scharge Su mmaries XE "Discharg e Summarie s" if the provider requires a cosignatu re. To cor rect expec ted cosign ers who we re erroneo usly assig ned before this rest riction we nt into ef fect, perf orm a sear ch on unco signed not es, then u se the (hi dden) Edit Cosigner (EC) actio n to corre ct any pro blems. | |
452 | Quit [QU] | |
453 | Exits the screen (ma y be shown as a defa ult)Chapte r 3: TIU f or Clinici ans | |
454 | Progress N otes/Disch arge Summa ry Menu XE "Progress Notes/Dis charge Sum mary [TIU] Menu" | |
455 | This is th e main TIU menu for clinicians XE "Clini cians" . I t includes all of th e options necessary for clinic ians to ma nage their Progress Notes, Dis charge Sum maries, an d other cl inical doc uments whi ch may be set up loc ally, eith er separat ely or in an integra ted fashio n. TIU als o allows y ou to cont inue to ac cess Progr ess Notes and Discha rge Summar ies throug h OE/RR me nus. CPRS allows poi nt and cli ck access to all Pro gress Note s, Dischar ge Summari es, and Co nsults TIU documents . | |
456 | The Progre ss Notes/D ischarge S ummary (TI U) menu al so include s a Person al Prefere nces menu that allow s clinicia ns to chan ge their o wn paramet ers for vi ewing clin ical docum ents. | |
457 | Option Nam eDescripti onProgress Notes Use r Menu XE "Progress Notes Use r Menu" Th is menu in cludes opt ions for r eviewing, entering, printing, and signin g progress notes, ei ther by in dividual p atient or by multipl e patients . | |
458 | Discharge Summary Us er Menu XE "Discharg e Summary User Menu" This men u includes options f or reviewi ng, enteri ng, printi ng, and si gning disc harge summ aries, eit her by ind ividual pa tient or b y multiple patients. | |
459 | Integrated Document Management XE "Inte grated Doc ument Mana gement" Th is menu al lows clini cians to p erform act ions on pr ogress not es, discha rge summar ies, and o ther clini cal docume nts from a single me nu | |
460 | For exampl e, a clini cian may w ant to bri ng up all his unsign ed documen ts. | |
461 | Personal P references XE "Pers onal Prefe rences" Us ing Progre ss Notes t hrough CPR S XE "Pro gress Note s/Discharg e Summary [TIU] Menu " | |
462 | Clinicians enter and review Pr ogress Not es through CPRS XE " CPRS" (Co mputerized Patient R ecord Syst em XE "Com puterized Patient Re cord Syste m" ) VistA and List Manager or through t he CPRS GU I. Here we give an e xample of reviewing Notes thro ugh the Li st Manager version o f CPRS. Th e GUI vers ion has a different sequence o f steps. | |
463 | Example: R eviewing a nd signing Notes thr ough CPRS | |
464 | XE "Revie wing Notes " | |
465 | 1. Select the Clini cian Menu from your CPRS menu. | |
466 | OE CPRS Clini cian Menu | |
467 | RR Results Re porting Me nu | |
468 | AD Add New Or ders | |
469 | RO Act On Exi sting Orde rs | |
470 | PP Personal P references ... | |
471 | Select Cli nician Men u Option: OE CPRS C linician M enu | |
472 | 2. The Pa tient Sele ction scre en is disp layed. If you have a patient o r team lis t defined, the patie nts are on this disp lay. | |
473 | Ward 2B Mar 17, 19 97 17:07:0 9 Pag e: 1 of 1 | |
474 | Current pa tient: ** No patient selected ** | |
475 | Patie nt Name ID DOB Room-Bed | |
476 | ||
477 | 1 TIUPA TIENT,ONE (345 6) Jan 01, 1951 | |
478 | 2 TIUPA TIENT,THRE E (199 6) Mar 05, 1949 | |
479 | 3 TIUPA TIENT,FIVE (377 9) Nov 19, 1991 | |
480 | 4 TIUPA TIENT,SEVE N (323 4) Mar 03, 1966 | |
481 | 5 TIUPA TIENT,TEN (243 2) Apr 04, 1932 | |
482 | 6 TIUPA TIENT,NINE (259 1) Apr 25, 1931 9-B | |
483 | 7 TIUPA TIENT,ELEV EN (891 0) Jan 01, 1934 A-4 | |
484 | 8 TIUPA TIENT,TWO (324 3) Apr 04, 1954 | |
485 | 9 TIUPA TIENT,FOUR TEEN (472 3) Oct 23, 1927 A-2 | |
486 | Enter the number of the patien t chart to be opened | |
487 | ||
488 | + Next S creen CG Change Lis t ... FD Find Patient | |
489 | - Previo us Screen SV Save as De fault List Q Clos e | |
490 | Select Pat ient: Clos e// 1 TIUPATI ENT,ONE | |
491 | Searching for the pa tient's ch art ... | |
492 | 3. Select a patient by: | |
493 | Entering a name from a list (i f you have one defin ed and set as your d efault | |
494 | Entering a patient’s name (or last initi al + last 4 letters of SSN) | |
495 | Entering F D (Find Pa tient XE " Find Patie nt" ), ent ering a wa rd or clin ic name, t hen select ing a pati ent name f rom the li st that ap pears. | |
496 | Example: R eviewing N otes, cont ’d | |
497 | 4. The “C over Sheet ” for the patient’s record is displayed. Select Ch art Conten ts. | |
498 | Cover Shee t Mar 17, 19 97 17:07:5 0 Pa ge: 1 of 2 | |
499 | TIUPATIENT ,ONE 666 -12-3456 2B JAN 1, 1951 (46) <CW> | |
500 | Item E ntered | |
501 | ||
502 | ||
503 | ||
504 | Aller gies/Adver se Reactio ns | | |
505 | 1 PENIC ILLIN 1 (r ash, nause a,vomiting ) | 01/03/97 | |
506 | | | |
507 | Patie nt Posting s | | |
508 | 2 CRISI S NOTE | 02/24/97 0 8:28 | |
509 | 3 CRISI S NOTE | 12/03/96 1 0:44 | |
510 | 4 CLINI CAL WARNIN G | 02/21/97 0 9:16 | |
511 | 5 CLINI CAL WARNIN G | 01/15/97 | |
512 | | | |
513 | Recen t Vitals | | |
514 | No da ta availab le | | |
515 | | | |
516 | Immun izations | | |
517 | No im munization s found. | | |
518 | | | |
519 | + En ter the nu mbers of t he items y ou wish to act on. >>> | |
520 | NW Docume nt New All ergy CG (Change Li st ...) SP Sele ct New Pat ient | |
521 | + Next S creen CC Chart Cont ents ... Q Clos e Patient Chart | |
522 | Select: Ne xt Screen/ / cc CHA RT CONTENT S | |
523 | ||
524 | 5. A new set of act ions is di splayed. T hese are t he Content s or categ ories of t he Patient Chart (al so known a s “Tabs.”) Select th e Notes ta b. | |
525 | Cover Shee t Mar 17, 19 97 17:07:5 0 P age: 1 of 2 | |
526 | TIUPATIENT ,ONE 666 -12-3456 2B JAN 1, 1951 (46) <CW> | |
527 | Alert Entered | |
528 | ||
529 | Aller gies/Adver se Reactio ns | | |
530 | 1 PENICI LLIN 1 (ra sh, nausea ,vomiting) | 01 /03/97 | |
531 | | | |
532 | Patie nt Posting s | | |
533 | 2 CRISI S NOTE | 02 /24/97 08: 28 | |
534 | 3 CRISI S NOTE | 12 /03/96 10: 44 | |
535 | 4 CLINI CAL WARNIN G | 02 /21/97 09: 16 | |
536 | 5 CLINI CAL WARNIN G | 01 /15/97 | |
537 | | | |
538 | Recen t Vitals | | |
539 | No da ta availab le | | |
540 | + En ter the nu mbers of t he items y ou wish to act on. >>> | |
541 | Cover Sh eet Orders Imaging Reports | |
542 | Problems Meds Consults | |
543 | Notes Labs D/C Summ aries | |
544 | Select cha rt compone nt: N No tes | |
545 | Searching for the pa tient's ch art ... | |
546 | Example: Reviewing Notes, con t’d | |
547 | 6. The pa tient’s co mpleted pr ogress not es are dis played. Th is is the default se t up throu gh Persona l Preferen ces. You c an “change view” to see a diff erent stat us, such a s unsigned notes. | |
548 | Completed Progress N otes Mar 17, 19 97 17:10:5 6 P age: 1 of 1 | |
549 | TIUPATIENT ,ONE 666 -12-3456 2B JAN 1,1 951 (46) <CW> | |
550 | Title Writt en Sig Statu s | |
551 | 1 CRISI S NOTE | 02/2 4/97 08:28 complete d | |
552 | 2 CLINI CAL WARNIN G | 02/2 1/97 09:16 complete d | |
553 | 3 Gener al Note | 01/2 4/97 14:18 complete d | |
554 | 4 CLINI CAL WARNIN G | 01/1 5/97 complete d | |
555 | 5 SOAP - GENERAL NOTE | 12/0 4/96 14:39 complete d | |
556 | 6 SOAP - GENERAL NOTE | 12/0 4/96 11:32 complete d | |
557 | 7 CRISI S NOTE | 12/0 3/96 10:44 complete d | |
558 | 8 SOAP - GENERAL NOTE | 12/0 3/96 10:31 complete d | |
559 | 9 SOAP - GENERAL NOTE | 11/2 2/96 12:37 complete d | |
560 | Ent er the num bers of th e items yo u wish to act on. >>> | |
561 | NW Write New Note CG Change Lis t ... SP Select New Patie nt | |
562 | + Next S creen CC Chart Cont ents ... Q Close Patient Ch art | |
563 | Select: Ch art Conten ts// CG CHANGE LIS T | |
564 | Date rang e Sta tus | |
565 | Select att ribute(s) to change: S STATU S | |
566 | Select Sig nature Sta tus: compl eted//?? | |
567 | Enter the signature status you would lik e to scree n on | |
568 | Choose fro m: | |
569 | amended | |
570 | complet ed | |
571 | deleted | |
572 | purged | |
573 | uncosig ned | |
574 | undicta ted | |
575 | unrelea sed | |
576 | unsigne d | |
577 | untrans cribed | |
578 | unverif ied | |
579 | Select Sig nature Sta tus: compl eted//UNSi gned | |
580 | Searching for the pa tient's ch art ... | |
581 | Example: R eviewing N otes, cont ’d | |
582 | 7. The pa tient’s un signed not es are dis played. | |
583 | Unsigned P rogress No tes Mar 17, 19 97 17:13:2 2 Pag e: 1 of 1 | |
584 | TIUPATIENT ,ONE 666 -12-3456 2B JAN 1, 1951 (46) <CW> | |
585 | Title W ritten Sig St atus | |
586 | 1 Adden dum to CLI NICAL WARN ING | 0 1/28/97 unsig ned | |
587 | En ter the nu mbers of t he items y ou wish to act on. >>> | |
588 | NW Write New Note CG Change Lis t ... SP Sele ct New Pat ient | |
589 | + Next S creen CC Chart Cont ents ... Q Clos e Patient Chart | |
590 | Select: Ch art Conten ts// | |
591 | Example: W riting a n ote | |
592 | Select: Ch art Conten ts// NW Write New Note | |
593 | Available note(s): 11/22/96 t hru 02/24/ 97 (9) | |
594 | Do you wis h to revie w any of t hese notes ? NO// YES | |
595 | --- Sel ect note(s ) to revie w --- | |
596 | Please spe cify a dat e range fr om which t o select n ote(s): | |
597 | List Notes Beginning : 11/22/96 //<Enter> (NOV 22, 1996) | |
598 | Thru : 02/24/97 //<Enter> (FEB 24, 1997) | |
599 | 1 02/24/ 97 08:28 CRISIS NOT E Tw o TIUProvi der | |
600 | Adm: 09/ 21/95 | |
601 | 2 02/21/ 97 09:16 CLINICAL W ARNING Si xteen TIUP rovider | |
602 | Adm: 09/ 21/95 | |
603 | 3 01/24/ 97 14:18 General No te Th ree TIUPro vider | |
604 | Adm: 09/ 21/95 | |
605 | SUBJEC T: TEST | |
606 | 4 01/15/ 97 00:00 CLINICAL W ARNING On e TIUProvi der, MD | |
607 | Visit: 08/ 14/95 | |
608 | 5 12/04/ 96 14:39 SOAP - GEN ERAL NOTE Th ree TIUPro vider | |
609 | Adm: 09/ 21/95 | |
610 | Choose Not es: (1-5) : <Enter> | |
611 | Nothing se lected. | |
612 | Example: W riting a n ote, cont’ d | |
613 | Personal P ROGRESS NO TES Title List for N INE TIUPRO VIDER | |
614 | 1 Cr isis Note | |
615 | 2 Ad vance Dire ctive | |
616 | 3 Ad verse Reac tions | |
617 | 4 Ot her Title | |
618 | TITLE: (1 -4): 3 Adverse Re act/Allerg y | |
619 | Creating n ew progres s note... | |
620 | Patient Lo cation: 2 B | |
621 | Date/ti me of Admi ssion: 09 /21/95 10: 00 | |
622 | D ate/time o f Note: N OW | |
623 | Author o f Note: T IUPROVIER, NINE | |
624 | ...OK? YES// <Ent er> | |
625 | SUBJECT (O PTIONAL de scription) : | |
626 | Calling te xt editor, please wa it... | |
627 | 1>TEST | |
628 | 2> <Ente r> | |
629 | EDIT Optio n: | |
630 | Save chang es? YES// <Enter> | |
631 | Saving Adv erse React /Allergy w ith change s... | |
632 | Enter your Current S ignature C ode: XXX SIGNATURE VERIFIED. . | |
633 | Print this note? No/ / YES | |
634 | Do you wan t WORK cop ies or CHA RT copies? CHART//<E nter> | |
635 | DEVICE: HO ME// <Ente r> VAX | |
636 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---- | |
637 | TIUPATIENT ,ONE 666 -12-3456 Progress Notes | |
638 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---- | |
639 | NOTE DATED : 03/17/97 17:15 ADVERSE RE ACT/ALLERG Y | |
640 | ADMITTED: 09/21/95 1 0:00 2B | |
641 | TEST | |
642 | Si gned by: / es/ NINE T IUPROVIDER | |
643 | NINE T IUPROVIDER 03/17/97 17:15 | |
644 | Enter RETU RN to cont inue or '^ ' to exit: <Enter> | |
645 | You may en ter anothe r Progress Note. Pre ss RETURN to exit. | |
646 | Select PAT IENT NAME: <Enter> | |
647 | Select Sea rch XE "Se arch" thr ough CPRS XE "CPRS" | |
648 | You can na rrow your view to si gned notes by author , unsigned notes, et c. You can also spec ify the da te order y our notes will appea r in: asce nding (old est first) or descen ding (most recent fi rst) order . | |
649 | Caution: A void selec ting too l arge a dat e range or too gener al a categ ory, as bi g searches are very system-int ensive. Th is means t hat not on ly might i t slow dow n your wor k, but eve ryone else ’s as well . | |
650 | Progress N otes Ap r 09, 1997 14:42:58 Pa ge: 1 of 1 | |
651 | <CWA> P R O G R E S S N O T E S Last 15 note(s) | |
652 | TIUPATIENT ,ONE 666 -12-3456 2B/ JA N 1,1951 ( 46) | |
653 | Tit le A uthor Date/ Time | |
654 | ||
655 | 1 Psy chology No tes TIUPR OVIDER,ONE 04/08/97 15:49 compl | |
656 | 2 CRI SIS NOTE TIUPR OVIDER,THR 04/08/97 00:00 compl | |
657 | 3 Adv erse React /Allergy TIUPR OVIDER,NIN 04/07/97 16:28 compl | |
658 | 6 Adv erse React /Allergy TIUPR OVIDER,NIN 04/03/97 19:31 compl | |
659 | 7 Adv erse React /Allergy TIUPR OVIDER,NIN 03/17/97 17:15 compl | |
660 | 8 CRI SIS NOTE TIUPR OVIDER,NIN 02/24/97 08:28 compl | |
661 | + Next Scr een - Pre v Screen ?? More Ac tions | |
662 | ||
663 | NW New N ote SP Select Ne w Patient AD Mak e Addendum | |
664 | B Brows e SS Select Se arch $ Com plete Note (s) | |
665 | PC Print Copy RS Reset to All Signed Q Qui t | |
666 | Select Act ion: Quit/ / SS Sel ect Search | |
667 | Valid sele ctions are : | |
668 | 1 - sign ed notes ( all) 2 - unsigned notes 3 - unco signed not es | |
669 | 4 - sign ed notes/a uthor 5 - signed no tes/dates | |
670 | Select con text: 1// 4 AUTHOR | |
671 | Select AUT HOR: TIUPR OVIDER,TWO // <Enter> j g | |
672 | Please Spe cify Sort Order: des cending// ? | |
673 | Enter a co de from th e list. | |
674 | Select one of the fo llowing: | |
675 | A ascending (OLDEST FI RST) | |
676 | D descending (NEWEST F IRST) | |
677 | Please Spe cify Sort Order: des cending// A ascend ing (OLDES T FIRST) | |
678 | Searching for the pr ogress not es. | |
679 | Progress N otes Apr 09, 1997 14:42:50 P age: 1 o f 1 | |
680 | <CWA> P R O G R E S S N O T E S 4 note (s) | |
681 | TIUPATIENT ,ONE 666-12-3 456 2B/ J AN 1,1951 (46) | |
682 | Tit le Author Dat e/Time | |
683 | ||
684 | ||
685 | 1 CRI SIS NOTE TIU PROVIDER 0 2/24/97 08 :28 co mpl | |
686 | 2 Adv erse React /Allergy TIU PROVIDER 0 3/17/97 17 :15 co mpl | |
687 | 3 Adv erse React /Allergy TIU PROVIDER 0 4/03/97 19 :31 co mpl | |
688 | 4 Adv erse React /Allergy TIU PROVIDER 0 4/07/97 16 :05 co mpl | |
689 | + Next Scre en - Prev Scree n ?? More A ctions | |
690 | ||
691 | ||
692 | NW New N ote SP Select Ne w Patient AD Mak e Addendum | |
693 | B Brows e SS Select Se arch $ Com plete Note (s) | |
694 | PC Print Copy RS Reset to All Signed Q Qui t | |
695 | Select Act ion: Quit/ / | |
696 | Progress N otes Optio ns XE "Pro gress Note s" | |
697 | Clinicians can revie w, enter, print, and sign prog ress notes , either b y individu al patient or by mul tiple pati ents, thro ugh TIU. | |
698 | NOTE: Wh en reviewi ng several notes seq uentially, the up-ar row (^) XE "Up-arrow (^)" ent ry takes y ou to the next note. To exit f rom the re view, ente r two up-a rrows (^^) . | |
699 | Clinician' s Progress Notes Men u XE "Prog ress Notes Menu" | |
700 | OptionDesc riptionEnt ry of Prog ress Note | |
701 | This is th e main opt ion for en tering a n ew progres s note. Yo u can also edit pati ent progre ss notes. | |
702 | Review Pro gress Note s by Patie ntThis opt ion allows you to re view, edit , or sign a selected patient’s progress notes, by selected c riteria. | |
703 | Review Pro gress Note sThis opti on allows clinicians to get qu ickly to a patient’s list of n otes, with out prelim inary prom pts to sel ect criter ia for dis playing no tes.All MY UNSIGNED Progress N otesThis o ption retr ieves all your unsig ned progre ss notes f or review, edit, or signature. | |
704 | Show Progr ess Notes Across Pat ientsThis option all ows you to search fo r and revi ew progres s notes by many diff erent crit eria: stat us, type, date range , and cate gory. Caut ion: Avoid selecting too large a date ra nge or too general a category, as big se arches are very syst em-intensi ve. This m eans that not only m ight it sl ow down yo ur work, b ut everyon e else’s a s well.Pro gress Note s Print Op tions ...T he options on this m enu suppor t the prin ting of ch art or wor k copies, by author, location, patient, or ward. T hese optio ns are des cribed in Chapter 8. List Notes By TitleT his option allows yo u to look up progres s notes by title wit hin a spec ified date range.Sea rch by Pat ient AND T itleThis o ption allo ws you to search for and revie w progress notes by patient, a s well as many other criteria: status, t ype, date range, and category. Personal P references ...The two options o n this men u let you customize the way TI U operates for you; that is, w hich promp ts will ap pear, what lists you will see to select from, etc. You can a lso specif y the way documents are displa yed on you r review s creens, by patient, by author, by type, in chronol ogical or reverse ch ronologica l order, e tc. | |
705 | Entry of P rogress No te XE "Ent ry of Prog ress Note" | |
706 | This is th e main opt ion for en tering a n ew progres s note. Yo u can also edit pati ent progre ss notes. | |
707 | Example 1: Inpatient progress note | |
708 | Steps to u se option: | |
709 | 1. Select Entry of P rogress No te from yo ur Progres s Notes Me nu. If you have a pa tient list set up (t hrough Per sonal Pref erences), it is disp layed here . | |
710 | Loading Wa rd Patient List... | |
711 | 2B ward list | |
712 | 1 TIUPA TIENT,ONE (3456) ~ 8 TIUPA TIENT,TWO (3243) A -4 | |
713 | 2 TIUPA TIENT,NINE (2591) ~ 9 TIUPA TIENT,EIGH T (3242) ~ | |
714 | 3 TIUPA TIENT,FOUR (2384) ~ 10 TIUPA TIENT,TEN (2432) A -2 | |
715 | 4 TIUPA TIENT,SEVE N (3234) ~ 11 TIUPA TIENT,TWEL V (3213) A -1 | |
716 | 5 TIUPA TIENT,THRE E (1996) ~ 12 TIUPA TIENT,FOUR T (4723) ~ | |
717 | 6 TIUPA TIENT,FIVE (3779) ~ 13 TIUPA TIENT,SIXT E (1321) A -3 | |
718 | 7 TIUPA TIENT,SIX (2476) 9 -B 14 TIUPA TIENT,ELEV E (1414) ~ | |
719 | 2. Type in a patient name or a number fr om the lis t. Demogra phic data and CWAD ( Cautions, Warnings, Adverse Re actions, a nd Directi ves) notes are displ ayed. You are prompt ed to choo se if you want to se e any of t he previou s Progress Notes for this pati ent. | |
720 | Select Pat ient(s): 7 TIUPAT IENT,TWO 0 4-25-31 666043243P NO MILITARY RETIREE | |
721 | (6 notes ) W: 01/2 7/97 15:17 (addendu m 02/08/97 17:19) | |
722 | A: Know n allergie s | |
723 | (1 note ) D: 03/2 6/97 13:02 | |
724 | Available notes: 11 /11/96 thr u 04/15/97 (27) | |
725 | Do you wis h to see a ny of thes e notes? N O// <Enter > | |
726 | ||
727 | Entry of P rogress No te, cont’d | |
728 | 3. Select a Title. If you hav e a person al Progres s Notes ti tle list s et up thro ugh Person al Prefere nces, that list is d isplayed f or you to choose fro m. Enter a Subject, if desired , and the text of th e Progress Note. | |
729 | Personal P ROGRESS NO TES Title List for T HREE TIUPR OVIDER | |
730 | 1 Crisi s Note | |
731 | 2 Ad vance Dire ctive | |
732 | 3 Ad verse Reac tions | |
733 | 4 Ot her Title | |
734 | TITLE: (1 -4): 3// < Enter> | |
735 | Advers e React/Al lergy | |
736 | Creating n ew progres s note... | |
737 | Patient Lo cation: 1 A | |
738 | Date/t ime of Adm ission: 0 5/30/97 10 :43 | |
739 | D ate/time o f Note: N OW | |
740 | Author o f Note: T IUPROVIDER ,NINE | |
741 | ...OK? YES// <Ent er> | |
742 | SUBJECT (O PTIONAL de scription) : <Enter> | |
743 | Calling te xt editor, please wa it... | |
744 | 1>Mr. TI UPatient i mproving; renewed pr escription . | |
745 | 2> <Ente r> | |
746 | EDIT Optio n: | |
747 | Save chang es? YES// <Enter> | |
748 | Saving Adv erse React /Allergy w ith change s... | |
749 | 4. Enter your elect ronic sign ature code . If you w ish to pri nt the not e (either a Work or Chart copy ), answer yes to the next prom pt, and en ter a prin ter device name. | |
750 | Enter your Current S ignature C ode: XXX SIGNATURE VERIFIED. . | |
751 | Print this note? No/ / y YES | |
752 | Do you wan t WORK cop ies or CHA RT copies? CHART// w WORK | |
753 | DEVICE: HO ME//<Enter > VAX | |
754 | The note i s printed. You are p rompted to enter ano ther note or to exit . | |
755 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- -- | |
756 | TIUPATIENT ,SEVEN 666 -04-3234P Pr ogress Not es | |
757 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- -- | |
758 | NOTE DATED : 05/31/97 14:58 ADVERSE RE ACT/ALLERG Y | |
759 | ADMITTED: 05/30/97 1 0:43 1A | |
760 | Mr. TIUPat ient impro ving; rene wed prescr iption. | |
761 | Si gned by: / es/ NINE T IUPROVIDER | |
762 | NINE T IUPROVIDER 05/31/97 14:59 | |
763 | Enter RETU RN to cont inue or '^ ' to exit: | |
764 | You may en ter anothe r Progress Note. Pre ss RETURN to exit. | |
765 | Select PAT IENT NAME: <Enter> | |
766 | Example 2: Outpatie nt note XE "Outpatie nt note" | |
767 | Outpatient notes req uire more informatio n than inp atient not es, becaus e every ou tpatient e ncounter m ust now be associate d with a v isit to ge t workload credit. M ost Progre ss Notes a utomatical ly get the visit dat a from Che ckout or a scanned E ncounter F orm. | |
768 | Steps to u se option: | |
769 | 1. Select Entry of P rogress No te from yo ur Progres s Notes Me nu. | |
770 | 2. Type in a patient name. | |
771 | Select Pat ient(s): T IUPATIENT, ONE TIUPAT IENT,ONE 09-12-44 666233456 YES SC VETERAN | |
772 | (1 note ) C: 11/1 9/96 (ad dendum 01/ 28/97 09:5 5) | |
773 | A: Know n allergie s | |
774 | For Patien t TIUPATIE NT,ONE | |
775 | 3. Type in a Progres s Note Tit le. You ca n use an e xisting Ti tle or cre ate a new one. If yo u have cre ated a per sonal docu ment list through th e Personal Preferenc es’ Docume nt Managem ent option , that lis t is displ ayed here. | |
776 | Personal P ROGRESS NO TES Title List for T HREE TIUPR OVIDER | |
777 | 1 Cr isis Note | |
778 | 2 Ad vance Dire ctive | |
779 | 3 Ad verse Reac tions | |
780 | 4 Ot her Title | |
781 | TITLE: (1 -4): 3 Adverse Re act/Allerg y | |
782 | 4. Since t his is a n ote for an outpatien t, you may be prompt ed to sele ct an exis ting visit or create a new vis it to asso ciate the progress n ote with. | |
783 | This patie nt is not currently admitted t o the faci lity... | |
784 | Is this no te for INP ATIENT or OUTPATIENT care? OUT PATIENT// <Enter> | |
785 | The follow ing VISITS are avail able: | |
786 | 1> FEB 24, 1997@ 09:00 DI ABETES CLI NIC | |
787 | 2> SEP 05, 1996@ 10:00 CA RDIOLOGY | |
788 | CHOOSE 1-2 or <N>EW VISIT | |
789 | <RETURN> T O CONTINUE | |
790 | OR '^' TO QUIT: N | |
791 | Creating n ew progres s note... | |
792 | Patient Lo cation: N UR 1A | |
793 | Da te/time of Visit: 0 2/24/97 14 :29 | |
794 | D ate/time o f Note: N OW | |
795 | Author o f Note: T IUPROVIDER ,THREE | |
796 | ...OK? YES//<Ente r> | |
797 | SERVICE: M EDICINE// <Enter> 111 | |
798 | Entry of P rogress No te, cont’d | |
799 | 5. Enter a subject f or your no te (option al). | |
800 | SUBJECT (O PTIONAL de scription) : ? | |
801 | Enter a brief des cription ( 3-80 chara cters) of the conten ts | |
802 | of the document. | |
803 | SUBJECT (O PTIONAL de scription) : Blue Not e | |
804 | 6. Type in the text of the not e. If it’s a SOAP No te or ther e’s a boil erplate fo r this, yo u can fill in the bl anks or ed it existin g text. Yo u can use the FileMa n text edi tor or ful l-screen e ditor. Sig n the Note when you’ re finishe d. | |
805 | Calling te xt editor, please wa it... | |
806 | 1>Follow -up visit to ensure compliance with regi men. | |
807 | 2><Enter > | |
808 | EDIT Optio n: <Enter> | |
809 | Save chang es? YES//< Enter> | |
810 | Saving Gen eral Note with chang es... | |
811 | Enter your Current S ignature C ode: [HIDD EN CODE] SIGNATURE VERIFIED. . | |
812 | 7. Enter t he Diagnos is XE "Dia gnosis" a ssociated with this Progress N ote. | |
813 | NOTE: To r eceive wor kload cred it, VAMCs must now c apture Pro vider, Dia gnosis, an d Procedur e for all outpatient visits. | |
814 | Please Ind icate the Diagnoses for which the Patien t was Seen : | |
815 | 1 Abd ominal Pai n | |
816 | 2 Abn ormal EKG | |
817 | 3 Abr asion | |
818 | 4 Abs cess | |
819 | 5 Adv erse Drug Reaction | |
820 | 6 AID S/ARC | |
821 | 7 Alc oholic, in toxication | |
822 | 8 Alc oholism, C hronic | |
823 | 9 All ergic Reac tion | |
824 | 10 Ane mia | |
825 | ANGINA: | |
826 | 11 Sta ble | |
827 | 12 Uns table | |
828 | 13 Ano rexia | |
829 | 14 App endicitis, Acute | |
830 | 15 Art hralgia | |
831 | ARTHRITIS | |
832 | 16 Ost eo | |
833 | 17 Rhe umatoid | |
834 | 18 Asc ites | |
835 | 19 ASH D | |
836 | 20 OTH ER Diagnos is | |
837 | Select Dia gnoses: ( 1-20): 9 | |
838 | NOTE: As o f patch TI U*1*263, Changes fo r ICD-10, TIU VistA Manager Ac tions whic h include TIU select ion of dia gnoses wil l permit s election f rom approp riate ICD diagnoses depending on the Dat e of Visit . The dial ogue confi rming the selections will incl ude the IC D coding s ystem as w ell as the ICD code. | |
839 | Entry of P rogress No te, cont’d | |
840 | 8. Enter t he Procedu re XE "Pro cedure" a ssociated with this Progress N ote. | |
841 | Please Ind icate the Procedure( s) Perform ed: | |
842 | CARDIOVASC ULAR | |
843 | 1 Car dioversion | |
844 | 2 EKG | |
845 | 3 Per icardiocen tesis | |
846 | 4 Tho racotomy | |
847 | MISCELLANE OUS | |
848 | 5 Abs cess | |
849 | 6 Les s than 2.5 cm | |
850 | 7 2.6 - 7.5 cm | |
851 | 8 Gre ater than 7.5 cm | |
852 | 9 Bur ns 1 * Loc al Treatme nt | |
853 | 10 Dre ssings Med ium | |
854 | 11 Dre ssings Sma ll | |
855 | 12 Tra nsfusion | |
856 | 13 Ven ipuncture | |
857 | UROLOGY | |
858 | 14 Fol ey Cathete r | |
859 | ENT | |
860 | 15 Rem oval Impac ted Cerume n | |
861 | 16 Ant erior, Sim ple | |
862 | 17 Ant erior, com plex | |
863 | 18 Pos terior | |
864 | EYE | |
865 | 19 For eign Body Removal | |
866 | 20 OTH ER Procedu re | |
867 | Select Pro cedure: ( 1-20): 19 | |
868 | You have i ndicated t he followi ng data ap ply to thi s visit: | |
869 | DIAGNOSES: | |
870 | (ICD-9- CM 995.3) Allergic Reaction <<< PRIMA RY | |
871 | PROCEDURES : | |
872 | 65205 Foreign Body Remov al | |
873 | ...OK? YES// <Ent er> | |
874 | Posting Wo rkload Cre dit... | |
875 | 8. If you wish, you can print the note n ow. | |
876 | Print this note? No/ / y YES | |
877 | Do you wan t WORK cop ies or CHA RT copies? CHART// w ork | |
878 | DEVICE: HO ME// <Ente r> VAX | |
879 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- | |
880 | TIUPATIENT ,ONE 666 -23-3456 Prog ress Notes | |
881 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- | |
882 | NOTE DATED : 02/24/97 08:30 ADVERSE RE ACT/ALLERG Y | |
883 | VISIT: 02/ 24/97 08:3 0 GENERAL MEDICINE | |
884 | new tests | |
885 | Si gned by: / es/ THREE TIUPROVIDE R | |
886 | THREE TIUPROVIDE R 02/24/97 08:30 | |
887 | Enter RETU RN to cont inue or '^ ' to exit: | |
888 | You may en ter anothe r CLINICAL DOCUMENT. Press RET URN to exi t. | |
889 | Select PAT IENT NAME: <Enter> | |
890 | Review Pro gress Note s by Patie nt XE "Rev iew Progre ss Notes b y Patient" | |
891 | This optio n allows y ou to revi ew, edit, or sign a selected p atient’s p rogress no tes. | |
892 | Steps to u se option: | |
893 | 1. Select Review Pro gress Note s by Patie nt from th e Progress Notes men u, then en ter the na me of the patient. | |
894 | Select Pro gress Note s User Men u Option: 2 Review Progress N otes by Pa tient | |
895 | Select PAT IENT NAME: TIUPATIEN T,ONE TIUP ATIENT,ONE 09-12 -44 66 6233456 YES | |
896 | SC VETERAN | |
897 | (2 notes ) C: 05/2 8/96 12:37 | |
898 | (2 notes ) W: 05/2 8/96 12:33 | |
899 | A: Know n allergie s | |
900 | (2 notes ) D: 05/2 8/96 12:36 | |
901 | Available notes: 02 /17/95 thr u 06/21/96 (31) | |
902 | 2. Enter t he date ra nge of not es you wis h to revie w. | |
903 | Please spe cify a dat e range fr om which t o select n otes: | |
904 | List notes Beginning : 12/01/96 (DEC 01, 1994) | |
905 | Thru : 05/01/96 // <Enter> (MAY 01, 1997) | |
906 | 3. From th e selectio n displaye d, choose the notes you wish t o review. | |
907 | 1 04/18/ 97 11:38 Social Wor k Service Three T IUProvider , MD | |
908 | Visit: 04/ 18/97 | |
909 | 2 06/21/ 96 07:47 Lipid Clin ic Three T IUProvider , MD | |
910 | Visit: 06/ 18/96 | |
911 | 3 06/07/ 96 00:00 Diabetes E ducation One TIU Provider, MD | |
912 | Visit: 04/ 18/96 | |
913 | 4 01/19/ 96 10:37 SOAP - Gen eral Note Three T IUProvider , MD | |
914 | Visit: 1/1 0/96 | |
915 | Choose not es: (1-8) : 2 | |
916 | Review Pro gress Note s by Patie nt, cont’d | |
917 | 4. The not e you sele cted is th en display ed. | |
918 | Opening Li pid Clinic record fo r review.. . | |
919 | Browse Doc ument Jun 26, 1996 1 0:55:18 Page: 1 of 4 | |
920 | Lipid C linic | |
921 | TIUPATIENT ,O 666-2 3-3456 Visit Date: 06/1 8/96@10:00 | |
922 | DATE OF NO TE: JUN 21 , 1996@07: 47:47 ENT RY DATE: J UN 21, 199 6@07:47:47 | |
923 | AUTH OR: TIUPRO VIDER,ONE EXP COSIGNER: | |
924 | URGEN CY: STA TUS: COMPL ETED | |
925 | SUBJECTIVE : 5 year old AMERIC AN INDIAN OR ALASKA NATIVE MAL E here for | |
926 | initial evaluatio n of his D YSLIPIDEMI A. | |
927 | COPIED FROM TIUCL IENT TO TI UPATIENT. | |
928 | PMH: | |
929 | Significan t negative medical h istory per tinent to the | |
930 | evalu ation and treatment of DYSLIPI DEMIA: | |
931 | FH: | |
932 | + + Next Scr een - Pre v Screen ?? More ac tions | |
933 | Find Ma ke Addendu m Identi fy Signers | |
934 | Print Si gn/Cosign Delete | |
935 | Edit Co py Link . .. | |
936 | Quit | |
937 | Select Act ion: Next Screen// < Enter> | |
938 | NOTE: The screen in dicates th at this is Page 1 of 4; press Enter afte r each scr een to see all the p ages of th is note. W hen review ing severa l notes, t he up-arro w (^) XE " Up-arrow ( ^)" entry takes you to the ne xt note. T o exit fro m the revi ew, enter two up-arr ows (^^). | |
939 | Browse Doc ument Jun 2 6, 1996 10 :56:09 Page : 2 of 4 | |
940 | Lipid C linic | |
941 | TIUPATIENT ,O 666 -23-3456 Visi t Date: 04 /18/96@10: 00 | |
942 | + | |
943 | SH: | |
944 | MEDICATION | |
945 | HISTORY: CURRE NT MEDICAT IONS | |
946 | DIET: Couns eled on AH A Step I d iet today by NINE TI UPROVIDER. | |
947 | See h er evaluat ion. | |
948 | ACTIVITY: | |
949 | OBJECTIVE: HT: 70 (08/23/ 95 11:45) WT: 207 (08/23/95 11:45) | |
950 | + + Next Scr een - Pre v Screen ?? More ac tions | |
951 | Find Ma ke Addendu m Identi fy Signers | |
952 | Print Si gn/Cosign Delete | |
953 | Edit Co py Link . .. | |
954 | Select Act ion: Next Screen// < Enter> | |
955 | Review Pro gress Note s by Patie nt, cont’d | |
956 | Browse Doc ument Jun 26, 1996 1 0:56:43 Page : 3 of 4 Lipid Cli nic | |
957 | TIUPATIENT ,O 666 -23-3456 Visi t Date: 04 /18/96@10: 00 | |
958 | TSH/T 4: 1.7/1.1 | |
959 | FB G: 200 HEM OGLOBIN A1 C: 15.2 | |
960 | SGO T: 44 URIC ACID: 4.7 | |
961 | ASSESSMENT : 1. MALE wi th / witho ut documen ted CAD | |
962 | 2. CV Risk factors: | |
963 | 3. Lipid p attern: | |
964 | PLAN: 1. Impleme nt recomme ndations t o lower fa t intake. | |
965 | 2. Repeat FBG and HB G A1C on: | |
966 | 3. Return to review lab on: | |
967 | + + Next Scr een - Pre v Screen ?? More ac tions | |
968 | Find Ma ke Addendu m Identi fy Signers | |
969 | Print Si gn/Cosign Delete | |
970 | Edit Co py Link . .. | |
971 | Quit | |
972 | Select Act ion: Next Screen// < Enter> | |
973 | Browse Doc ument Jun 2 6, 1996 10 :57:04 Page: 4 of 4 | |
974 | Lipid C linic | |
975 | TIUPATIENT ,O 666-2 3-3456 Visit D ate: 04/18 /96@10:00 | |
976 | + | |
977 | /es/ Three TIUProvid er, MD | |
978 | Medical In tern | |
979 | + Next Scr een - Pre v Screen ?? More ac tions | |
980 | Find Ma ke Addendu m Identi fy Signers | |
981 | Print Si gn/Cosign Delete | |
982 | Edit Co py Link . .. | |
983 | Quit | |
984 | Select Act ion: Quit/ / | |
985 | You can th en select an action to perform on the no te. | |
986 | Select Act ion: Quit/ / m Make Addendum | |
987 | Adding ADD ENDUM | |
988 | DATE/TIME OF NOTE: 1 0/25/96@11 :21// <Ent er> (OCT 25, 1996@1 1:21:00) | |
989 | AUTHOR OF NOTE: TIUP ROVIDER,EL EVEN// <En ter> jg | |
990 | Calling te xt editor, please wa it... | |
991 | 1>Should say 55 ye ar old... | |
992 | 2><Enter > | |
993 | EDIT Optio n: <Enter> | |
994 | Saving Add endum with changes.. . | |
995 | Addendum R eleased. | |
996 | Enter your Current S ignature C ode: xxxxx xx (code h idden) SIG NATURE VER IFIED.. | |
997 | Press RETU RN to cont inue...<En ter> | |
998 | Review Pro gress Note s XE "Revi ew Progres s Notes" | |
999 | This optio n allows c linicians to get imm ediately t o a patien t’s list o f notes, w ithout pre liminary p rompts for selection criteria. It’s part icularly u seful for when physi cians are seeing pat ients in c linics and want to p ull up the ir records quickly, as they ar e able to do with Pr ogress Not es 2.5 (fr equently a ccessed th rough OE/R R 2.5 XE " OE/RR 2.5" ). Note t hat the ac tions belo w the blac k bar look more like OE/RR (an d CPRS XE "CPRS" ) a ctions tha n the ones you’ll se e in other TIU optio ns. | |
1000 | Select Rev iew Progre ss Notes f rom your P rogress No tes or OE/ RR menu, w hichever o ne you com monly use. Then ente r the name of the pa tient you are seeing . | |
1001 | Select Pro gress Note s User Men u Option: 2b Review Progress Notes | |
1002 | Select PAT IENT NAME: TIUPATIEN T,ONE TIUP ATIENT,ONE 09- 12-44 666233456 YES | |
1003 | SC VETER AN | |
1004 | (2 notes ) C: 02/2 4/97 08:44 | |
1005 | (1 note ) W: 02/2 1/97 09:19 | |
1006 | A: Know n allergie s | |
1007 | (2 notes ) D: 03/2 5/97 08:57 | |
1008 | Searching for the pr ogress not es. | |
1009 | A screen w ith a list of notes for your p atient is displayed. Items wit h the plus symbol (+ ) have add enda. You can look a t details of any of the notes shown (by selecting the Browse or Detail ed Display action), create a n ew note, m ake an add endum, sig n a note, or perform any of th e other ac tions list ed below ( as well as hidden ac tions). | |
1010 | Progress N otes May 3 1, 1997 14 :20:10 Page: 1 of 1 | |
1011 | <CWAD> P R O G R E S S N O T E S La st 15 note (s) | |
1012 | TIUPATIENT ,O 666 -23-3456 SEP 12, 1944 (52) | |
1013 | Tit le Author Dat e/Time | |
1014 | ||
1015 | 1 Advers e React/Al lergy TIUPROVID ER,FIV 05/ 27/97 00:0 0 comp l | |
1016 | 2 Advers e React/Al lergy TIUPROVID ER,ONE 05/ 20/97 17:1 8 comp l | |
1017 | 3 CRISIS NOTE TIUPROVID ER,THR 05/ 20/97 17:0 1 comp l | |
1018 | 4 Advers e React/Al lergy TIUPROVID ER,SEV 05/ 20/97 11:2 3 comp l | |
1019 | 5 GENERA L NOTE TIUPROVID ER,SEV 05/ 20/97 11:2 1 comp l | |
1020 | 6 CARDIO LOGY NOTE TIUPROVID ER,SEV 05/ 20/97 10:5 6 comp l | |
1021 | 7 Advers e React/Al lergy TIUPROVID ER,FIV 04/ 21/97 16:0 2 comp l | |
1022 | 8 Advers e React/Al lergy TIUPROVID ER,FIV 04/ 15/97 06:2 3 comp l | |
1023 | 9 CARDIO LOGY NOTE TIUPROVID ER,FIV 04/ 11/97 12:0 9 comp l | |
1024 | 10 CRISIS NOTE TIUPROVID ER,FIV 04/ 11/97 09:0 9 comp l | |
1025 | + Next Scr een - Prev Scre en ?? More A ctions | |
1026 | ||
1027 | NW New N ote SS S elect Sear ch IN Inter discipl'ry Note | |
1028 | B Brows e RS R eset to Al l Signed EE Expan d/Collapse Entry | |
1029 | PC Print Copy AD M ake Addend um Q Quit | |
1030 | SP Selec t New Pati ent $ C omplete No te(s) | |
1031 | Select Act ion: Quit/ / B BROW SE | |
1032 | Review Pro gress Note s, cont’d | |
1033 | 3. If you select the action Br owse, you can see mo re details of a note . | |
1034 | Select Act ion: Next Screen// b Browse | |
1035 | Select Pro gress Note (s): (1-1 5): 1 | |
1036 | Reviewing Item #1 | |
1037 | Opening Ad verse Reac t/Allergy record for review... | |
1038 | Browse Doc ument May 31, 1997 1 4:29:07 Pag e: 1 of 1 | |
1039 | Ad verse Reac t/Allergy | |
1040 | TIUPATIENT ,O 666-2 3-3456 GE NERAL MEDI CINE Vis it Date: 0 4/18/96@10 :00 | |
1041 | DATE OF NO TE: MAY 27 , 1997 ENT RY DATE: M AY 27, 199 7@12:15:13 | |
1042 | AUTH OR: TIUPRO VIDER,ONE EXP COSIGNER: | |
1043 | URGEN CY: STATUS: C OMPLETED | |
1044 | Another te st...is th e antibiot ic working ? | |
1045 | /es/ ONE T IUPROVIDER , MD | |
1046 | PGY2 Resid ent | |
1047 | Signed: 05 /27/97 12: 21 | |
1048 | + Next Scr een - Pre v Screen ?? More ac tions | |
1049 | Find S ign/Cosign Link ... | |
1050 | Print C opy Encou nter Edit | |
1051 | Edit I dentify Si gners Inter discipl'ry Note | |
1052 | Make Addendum D elete Quit | |
1053 | Select Act ion: Quit/ / | |
1054 | | |
1055 | NOTE: | |
1056 | When revie wing sever al notes s equentiall y, the up- arrow (^) entry take s you to t he next no te. To exi t from the review, e nter two u p-arrows ( ^^). | |
1057 | Review Pro gress Note s, cont’d | |
1058 | 4. If you select the action De tailed Dis play XE "D etailed Di splay" , y ou can see even more details o f a note. | |
1059 | Enter DT f or Detaile d Display. Detailed Display is a “hidden action,” an action that appea rs when yo u enter tw o question marks. | |
1060 | Select Act ion: Next Screen// d et Detai led Displa y | |
1061 | Select Pro gress Note (s): (1-1 5): 1 | |
1062 | Reviewing #1 | |
1063 | Opening Ad verse Reac t/Allergy record for review... ..... | |
1064 | Detailed D isplay May 31, 1997 13:36:09 Page: 1 of 2 | |
1065 | Ad verse Reac t/Allergy | |
1066 | TIUPATIENT ,O 666-2 3-3456 Vis it Date: 0 4/18/96@10 :00 | |
1067 | Source I nformation | |
1068 | Referenc e Date: MA Y 27, 1997 @10:44:19 Author: T IUPROVIDER ,ONE | |
1069 | Entr y Date: MA Y 27, 1997 @10:44:19 Ent ered By: j g | |
1070 | Expected Signer: TI UPROVIDER, EIGHT Expected C osigner: N one | |
1071 | U rgency: No ne Document Status: C OMPLETED | |
1072 | Line Count: 46 TIU Doc ument #: 1 132 | |
1073 | Di vision: IS C-SLC-A4 VBC Lin e Count: 5 6.25 | |
1074 | S ubject: No ne | |
1075 | Associat ed Problem s No lin ked proble ms. | |
1076 | EEdit In formation | |
1077 | Edi t Date: JA N 17, 1997 @10:45:08 Ed ited By: T IUPROVIDER ,EIGHT | |
1078 | Reassign ment Histo ry Documen t Never Re assigned. | |
1079 | + Next Scr een - Pre v Screen ?? More ac tions | |
1080 | Find Print Qui t | |
1081 | Select Act ion: Next Screen// < Enter> | |
1082 | Detailed D isplay May 3 1, 1997 13 :37:40 Page: 2 of 2 | |
1083 | Ad verse Reac t/Allergy | |
1084 | TIUPATIENT ,O 666-2 3-3456 Vis it Date: 0 4/18/96@10 :00 | |
1085 | + | |
1086 | ||
1087 | Signature Informatio n | |
1088 | Signe d Date: MA Y 27, 1997 @10:45:17 Si gned By: T IUPROVIDER ,ONE | |
1089 | Signatu re Mode: E LECTRONIC | |
1090 | Cosigne d Date: No ne Cosi gned By: N one | |
1091 | Cosignatu re Mode: N one | |
1092 | Document B ody | |
1093 | Mr. TIUPAT IENT'S all ergies imp roved with medicatio n. | |
1094 | 06/08/97 A DDENDUM: | |
1095 | Improvemen t was temp orary; pat ient relap sed after a few days . | |
1096 | SIXTE EN TIUPROV IDER | |
1097 | + Next Screen - Prev Scre en ?? Mor e actions | |
1098 | Find Print Qui t | |
1099 | Select Act ion: Quit/ / | |
1100 | Review Pro gress Note s, cont’d | |
1101 | 5. If you select th e action S elect Sear ch XE "Sea rch" , you can narro w your vie w to a spe cific cont ext of not es: signed , unsigned , by autho r, or by a date or d ate range. | |
1102 | Progress N otes Ma y 31, 1997 14:20:10 Page: 1 of 1 | |
1103 | <CWAD> P R O G R E S S N O T E S La st 15 note (s) | |
1104 | TIUPATIENT ,O 666-2 3-3456 SEP 12,1944 (5 2) | |
1105 | Title Author Dat e/Time | |
1106 | ||
1107 | ||
1108 | ||
1109 | 1 Adver se React/A llergy TIUPROVID ER,N 05/ 27/97 00:0 0 comp l | |
1110 | 2 Adver se React/A llergy TIUPROVID ER,N 05/ 20/97 17:1 8 comp l | |
1111 | 3 CRISI S NOTE TIUPROVID ER,N 05/ 20/97 17:0 1 comp l | |
1112 | 4 Adver se React/A llergy TIUPROVID ER,N 05/ 20/97 11:2 3 comp l | |
1113 | 5 GENER AL NOTE TIUPROVID ER,N 05/ 20/97 11:2 1 comp l | |
1114 | 6 CARDI OLOGY NOTE TIUPROVID ER,N 05/ 20/97 10:5 6 comp l | |
1115 | 7 Adver se React/A llergy TIUPROVID ER,T 04/ 21/97 16:0 2 comp l | |
1116 | 8 Adver se React/A llergy TIUPROVID ER,T 04/ 15/97 06:2 3 comp l | |
1117 | 9 CARDI OLOGY NOTE TIUPROVID ER,T 04/ 11/97 12:0 9 comp l | |
1118 | 10 CRISI S NOTE TIUPROVID ER,T 04/ 11/97 09:0 9 comp l | |
1119 | + Next Scr een - Pre v Screen ?? More ac tions | |
1120 | NW New N ote SP Select Ne w Patient AD Mak e Addendum | |
1121 | B Brows e SS Select Se arch $ Com plete Note (s) | |
1122 | PC Print Copy RS Reset to All Signed Q Qui t | |
1123 | Select Act ion: Quit/ / ss | |
1124 | Select S earch | |
1125 | Valid sele ctions are : | |
1126 | 1 - sign ed notes ( all) 2 - unsigned notes 3 - unco signed not es | |
1127 | 4 - sign ed notes/a uthor 5 - signed no tes/dates | |
1128 | Select con text: 1// 2 UNSIGN ED NOTES | |
1129 | Progress N otes May 31, 1997 14:2 0:10 Pag e: 1 of 1 | |
1130 | <CWAD> P R O G R E S S N O T E S 1 no te(s) | |
1131 | TIUPATIENT ,O 666-2 3-3456 1A/A-2 S EP 12,1944 (52) | |
1132 | Tit le Aut hor Date/Ti me | |
1133 | ||
1134 | 1 Adv erse React /Allergy TIU PROVIDER,N 05 /31/97 15: 51 unsig | |
1135 | + Next Scr een - Pre v Screen ?? More Ac tions | |
1136 | ||
1137 | NW New N ote SP Select Ne w Patient AD Mak e Addendum | |
1138 | B Brows e SS Select Se arch $ Com plete Note (s) | |
1139 | PC Print Copy RS Reset to All Signed Q Qui t | |
1140 | Select Act ion: Quit/ / | |
1141 | All MY UNS IGNED Prog ress Notes XE "All M Y UNSIGNED Progress Notes" | |
1142 | When you s elect this option, t he program retrieves all your unsigned p rogress no tes for re view, edit , or signa ture. | |
1143 | Steps to u se option: | |
1144 | 1. Select All My Uns igned Prog ress Notes from the Clinician’ s Progress Notes Men u. | |
1145 | 2. The lis t is then displayed, from whic h you can choose any of the li sted actio ns. | |
1146 | My UNSIGNE D Progress Notes O ct 25, 199 6 11:33:52 Pag e: 1 of 1 | |
1147 | by AUTHOR (TIUPROVI DER,ONE) o r EXPECTED COSIGNER 2 document s | |
1148 | Patie nt Docume nt Ref Date Status | |
1149 | 1 TIUPA TIENT(D345 6) Psychol ogy - Cris is 10/25/96 unsigned | |
1150 | 2 TIUPA TIENT(D345 6) Addendu m to Lipid Clinic 10/25/96 unsigned | |
1151 | + Next Scre en - Prev Screen ? ? More Act ions >>> | |
1152 | Find S ign/Cosign Change Vi ew | |
1153 | Add D ocument D etailed Di splay Copy | |
1154 | Edit B rowse Delete Do cument | |
1155 | Make Addendum P rint Quit | |
1156 | Link ... I dentify Si gners | |
1157 | Select Act ion: Quit/ / s Sign /Cosign | |
1158 | Select Pro gress Note (s): (1-2 ): 1 | |
1159 | Opening Ps ychology - Crisis re cord for r eview... | |
1160 | SIGN/COSIG N Oct 25 , 1996 11: 34:21 Pa ge:1 of 1 | |
1161 | P sychology - Crisis | |
1162 | TIUPATIENT ,ONE 666-2 3-3456 2 B Visit Date : 10/25/96 @11:32 | |
1163 | DATE OF NO TE: OCT 25 , 1996@11: 32:55 ENTR Y DATE: OC T 25, 1996 @11:32:55 | |
1164 | AUTH OR: TIUPRO VIDER,ONE EXP COSIG NER: | |
1165 | URGEN CY: STATUS: U NSIGNED | |
1166 | Six-month follow-up visit. Pat ient conti nues to im prove; no change | |
1167 | in treatme nt require d. | |
1168 | + Next Scr een - Pre v Screen ?? More Ac tions | |
1169 | Print No | |
1170 | Ready for Signature: NO// y Yes | |
1171 | Item #: 1 Added to s ignature l ist. | |
1172 | Enter your Current S ignature C ode: xxxxx xx (code h idden) SIG NATURE VER IFIED.. | |
1173 | Show Progr ess Notes Across Pat ients XE " Show Progr ess Notes Across Pat ients" | |
1174 | This optio n allows y ou to sear ch for and review pr ogress not es by many different criteria: status, t ype, date range, and cateogory . By diffe rent combi nations of these cri teria, you can see a lmost any view of yo ur progres s notes yo u could wa nt. | |
1175 | | |
1176 | NOTE: | |
1177 | Use cautio n in how b road your search is (date rang e, # of pa tients, et c.), becau se searche s for a lo t of docum ents can b e very sys tem-intens ive, slowi ng down re sponse tim e for ever yone. | |
1178 | Steps to u se option: | |
1179 | 1. Select Show Progr ess Notes Across Pat ients from the Clini cian’s Pro gress Note s Menu. | |
1180 | 2. Select one of the following status(es ) of progr ess notes: | |
1181 | undicta ted | |
1182 | ||
1183 | uncos igned | |
1184 | untrans cribed | |
1185 | ||
1186 | compl eted | |
1187 | unrelea sed | |
1188 | ||
1189 | ||
1190 | amend ed | |
1191 | unverif ied | |
1192 | ||
1193 | ||
1194 | retra cted | |
1195 | unsigne d | |
1196 | ||
1197 | ||
1198 | 3. Select one of the following Progress Note Types . | |
1199 | ||
1200 | Advanc e Directiv e Crisis Not e H istorical Titles | |
1201 | ||
1202 | Adv Re act/Allerg y Clinical W arning | |
1203 | 4. Select one or mor e of the f ollowing s earch cate gories: | |
1204 | 1 All C ategories 6 Patient 11 Tra nscription ist | |
1205 | 2 Autho r 7 Problem 12 Tre ating Spec ialty | |
1206 | 3 Divis ion 8 Service 13 Vis it | |
1207 | 4 Expec ted Cosign er 9 Subject | |
1208 | 5 Hospi tal Locati on 10 Title | |
1209 | 5. Select the range of dates t o include. | |
1210 | 6. The not es meeting the crite ria you se lected are displayed . | |
1211 | UNSIGNED P rogress No tes Jun 18, 1997 0 9:19:20 Page: 1 of 1 | |
1212 | by AUTHOR from 06/15 /96 to 06/ 18/97 2 docu ments | |
1213 | Patie nt Docume nt Re f Date Status | |
1214 | 1 TIUPA TIENT,(R04 82) Clinic al Warning 06 /14/97 unsigned | |
1215 | 2 TIUPA TIENT,(D40 29) Crisis Note 06 /14/97 unsigned | |
1216 | + Ne xt Screen - Prev Sc reen ?? M ore Action s >>> | |
1217 | Find Sign /Cosign Change Vi ew | |
1218 | Add D ocument Deta iled Displ ay Copy | |
1219 | Edit Brow se Delete Do cument | |
1220 | Make Addendum Prin t Quit | |
1221 | Link ... Iden tify Signe rs | |
1222 | Select Act ion: Quit/ / | |
1223 | Progress N otes Print Options X E "Progres s Notes Pr int Option s" | |
1224 | See Chapte r 8 for ex amples and further d escription s of these options. | |
1225 | OptionDesc riptionAut hor Print Progress Notes XE " Author( Pr int Progre ss Notes" This optio n produces chart or work copie s of progr ess notes for an aut hor for a selected d ate range. | |
1226 | Location Print Prog ress Notes XE "Locat ion( Print Progress Notes" Thi s option p rints char t or work copies of progress n otes for a ll patient s who were at a spec ific locat ion when t he notes w ere writte n. The pat ients whos e progress notes are printed o n this rep ort may no t still be at that l ocation. I f Chart is selected, each note will star t on a new page. | |
1227 | Patient P rint Prog ress Notes XE "Patie nt( Print Progress Notes" Thi s option p rints or d isplays pr ogress not es for a s elected pa tient by s elected da te range. | |
1228 | Ward Prin t Progress Notes XE "Ward( Pri nt Progres s Notes" T his option allows yo u to print progress notes for all patien ts who are now on a ward for a selected date range . This opt ion is onl y for ward locations . NOTE: Th is option only print s to a pri nter, not to your co mputer scr een. | |
1229 | List Notes by Title XE "List N otes by Ti tle" | |
1230 | This optio n allows y ou to look up progre ss notes b y title wi thin a spe cified dat e range. Y ou can the n take any of the us ual action s on these notes. | |
1231 | Steps to u se option: | |
1232 | 1. Select List Notes by Title from the C linician’s Progress Notes Menu . Select the titles (one or m ore) of pr ogress not es to sear ch for. | |
1233 | Select Pro gress Note s User Men u Option: 6 List No tes By Tit le | |
1234 | Please Sel ect the PR OGRESS NOT ES TITLES to search for: | |
1235 | 1) ?? | |
1236 | Answer wit h TIU DOCU MENT DEFIN ITION NAME , or ABBRE VIATION, o r | |
1237 | PRINT NAME | |
1238 | Do you wa nt the ent ire TIU DO CUMENT DEF INITION Li st? y (Ye s) | |
1239 | Choose fro m: | |
1240 | ADMISSI ON ASSESSM ENT T ITLE | |
1241 | ADVANCE DIRECTIVE TITL E | |
1242 | ADVERSE REACTION/ ALLERGY TITLE | |
1243 | CLINICA L WARNING TITLE | |
1244 | CRISIS NOTE TITLE | |
1245 | FINAL D ISCHARGE N OTE T ITLE | |
1246 | GENERAL NOTE TITLE | |
1247 | PATIENT EDUCATION TITL E | |
1248 | Please Sel ect the Pr ogress Not es TITLES to search for: | |
1249 | 1) ADVE RSE REACTI ON/ALLERGY TITLE | |
1250 | 2) CLIN ICAL WARNI NG TITLE | |
1251 | 3) <Ente r> | |
1252 | 2. Enter a beginnin g and endi ng date ra nge to cho ose docume nts from. The select ed documen ts are dis played. | |
1253 | Start Refe rence Date [Time]: T -2// t-10 (MAR 01, 1997) | |
1254 | Ending Ref erence Dat e [Time]: NOW// <Ent er> (MAR 11, 1997@0 9:10) | |
1255 | Searching for the do cuments... ...... | |
1256 | Progress N otes by Ti tle Mar 1 1, 1997 09 :10:09 Page: 1 of 1 | |
1257 | from 03/0 1/97 to 03 /11/97 8 documents | |
1258 | Patie nt Documen t Re f Date St atus | |
1259 | ||
1260 | 1 TIUPA TIENT(H259 1) Adverse React/All ergy 03 /05/97 un signed | |
1261 | 2 TIUPA TIENT(D345 6) Adverse React/All ergy 03 /05/97 co mpleted | |
1262 | 3 TIUPA TIENT(R123 9) CLINICA L WARNING 03 /05/97 co mpleted | |
1263 | 4 TIUPA TIENT(H259 1) Adverse React/All ergy 03 /11/97 co mpleted | |
1264 | + Next Scr een - Pre v Screen ?? More Ac tions >>> | |
1265 | Find S ign/Cosign C hange View | |
1266 | Add Docu ment D etailed Di splay C opy | |
1267 | Edit B rowse D elete Docu ment | |
1268 | Make Add endum P rint Q uit | |
1269 | Link ... I dentify Si gners | |
1270 | Select Act ion: Quit/ / | |
1271 | List Notes by Title, cont’d | |
1272 | 3. You ma y now choo se an acti on such as Edit, Sig n/Cosign, Make Adden dum or Det ailed Disp lay. | |
1273 | Progress N otes by Ti tle Mar 1 1, 1997 09 :10:09 Page: 1 of 1 | |
1274 | from 03/0 1/97 to 03 /11/97 8 documents | |
1275 | Patie nt Documen t Re f Date St atus | |
1276 | ||
1277 | 1 TIUPA TIENT(H259 1) Adverse React/All ergy 03 /05/97 un signed | |
1278 | 2 TIUPA TIENT(D345 6) Adverse React/All ergy 03 /05/97 co mpleted | |
1279 | 3 TIUPA TIENT(R123 9) CLINICA L WARNING 03 /05/97 co mpleted | |
1280 | 4 TIUPA TIENT(H259 1) Adverse React/All ergy 03 /11/97 co mpleted | |
1281 | 5 TIUPA TIENT(H259 1) Adverse React/All ergy 03 /10/97 co mpleted | |
1282 | 6 TIUPA TIENT(S146 2) CLINICA L WARNING 03 /04/97 un cosigned | |
1283 | 7 TIUPA TIENT(P436 5) Adverse React/All ergy 03 /04/97 co mpleted | |
1284 | 8 TIUPA TIENT(N123 4) Adverse React/All ergy 03 /06/97 co mpleted | |
1285 | + Next Scr een - Pre v Screen ?? More Ac tions >>> | |
1286 | Find S ign/Cosign C hange View | |
1287 | Add Docu ment D etailed Di splay C opy | |
1288 | Edit B rowse D elete Docu ment | |
1289 | Make Add endum P rint Q uit | |
1290 | Link ... I dentify Si gners | |
1291 | Select Act ion: Quit/ / DET=3 | |
1292 | 4. A deta iled displ ay of the note you c hose appea rs on your screen. | |
1293 | Detailed D isplay Mar 1 1, 1997 09 :21:40 Page: 1 of 2 | |
1294 | CL INICAL WAR NING | |
1295 | TIUPATIENT ,NINE 66 6-12-1239 Vis it Date: 0 2/04/97@13 :00 | |
1296 | Source I nformation | |
1297 | Referenc e Date: MA R 05, 1997 @14:50:17 Author: T IUPROVIDER ,ONE | |
1298 | Entr y Date: MA R 05, 1997 @14:50:18 Ent ered By: D P | |
1299 | Expected Signer: TI UPROVIDER, FIFTEEN Expected Cosigner: None | |
1300 | U rgency: No ne Document Status: C OMPLETED | |
1301 | Line Count: 46 TIU Do cument #: 27752 | |
1302 | Di vision: IS C-SLC-A4 VBC Li ne Count: 56.25 | |
1303 | S ubject: No ne | |
1304 | Associat ed Problem s No lin ked proble ms. | |
1305 | Edit Inf ormation | |
1306 | Edi t Date: MA R 05, 1997 @14:50:41 Edited By: TIUPRO VIDER,FIFT EEN | |
1307 | Signatur e Informat ion | |
1308 | + + Next Scr een - Pre v Screen ?? More ac tions | |
1309 | Find Print Qui t | |
1310 | Select Act ion: Next Screen// | |
1311 | Search by Patient AN D Title XE "Search b y Patient AND Title" | |
1312 | This optio n allows y ou to sear ch for and review pr ogress not es by pati ent, as we ll as many other cri teria: sta tus, type, date rang e, and cat egory. You can then take any o f the usua l actions on these n otes. | |
1313 | Steps to u se option: | |
1314 | 1. Select the Search by Patien t AND Titl e option f rom the Pr ogress Not es User Me nu. | |
1315 | 2. Select a Patient. | |
1316 | Select Pro gress Note s User Men u Option: Search by Patient AN D Title | |
1317 | Select PAT IENT NAME: TIUPATIEN T,ONE TIUP ATIENT,ONE 09-12-44 66623345 6 YES SC VET ERAN | |
1318 | (1 note ) C: 07/2 2/91 11:27 | |
1319 | (1 note ) W: 07/2 2/91 11:34 | |
1320 | A: Know n allergie s | |
1321 | (1 note ) D: 04/0 1/92 10:58 | |
1322 | 3. Type in one or mo re Progres s Note Tit les to sea rch for. | |
1323 | Please Sel ect the PR OGRESS NOT E TITLES t o search f or: | |
1324 | 1) Lipi d CLINIC TI TLE | |
1325 | 2) Diab etes EDUCA TION TITLE | |
1326 | 3) <Ente r> | |
1327 | Start Ref erence Dat e [Time]: T-2// <Ent er> (SEP 1 0, 1996 | |
1328 | Ending Ref erence Dat e [Time]: NOW//<Ente r> (SEP 1 2, 1996@11 :06) | |
1329 | Searching for the do cuments... | |
1330 | 4. A list is display ed of all notes that meet the criteria y ou specifi ed. | |
1331 | ALL Progre ss Notes Sep 12, 1996 11:0 6:24 Page: 1 of 1 | |
1332 | by PATIENT f rom 07/14/ 96 to 09/1 2/96 2 documen ts | |
1333 | Patie nt Docu ment Ref Date Statu s | |
1334 | 1 TIUPA TIENT,(D34 56) Diab etes Educa tion 09/12/96 complet ed | |
1335 | 2 TIUPA TIENT,(D34 56) Adde ndum to Di abetes Edu 09/09/96 unsigne d | |
1336 | + N ext Screen - Prev S creen ?? More Actio ns >>> | |
1337 | Find S ign/Cosign C hange View | |
1338 | Add Docu ment D etailed Di splay C opy | |
1339 | Edit B rowse D elete Docu ment | |
1340 | Make Add endum P rint Q uit | |
1341 | Link ... I dentify Si gners | |
1342 | Select Act ion: Quit/ / <Enter> | |
1343 | Progress N otes Statu ses XE "Pr ogress Not es Statuse s" and Ac tions | |
1344 | Statuses | |
1345 | StatusDesc riptionAme nded * XE "Amended" The docume nt has bee n complete d and a pr ivacy act issue has required i ts amendme nt. By des ign, only the follow ing user c lasses are allowed t o amend a note: | |
1346 | CHIEF, MIS XE "CHIEF , MIS" | |
1347 | CHIEF, HIM XE "CHIEF , HIM" | |
1348 | PRIVACY AC T OFFICER XE "PRIVA CY ACT OFF ICER" Comp leted * XE "Complete d" The doc ument has acquired a ll necessa ry signatu res and is legally a uthenticat ed. | |
1349 | deleted XE "Deleted" Status DE LETED is n o longer o perable. B efore stat us RETRACT ED was int roduced de leting a d ocument re moved the text of th e document leaving a stub with status DE LETED. | |
1350 | Retracted *When a si gned docum ent is rea ssigned, a mended, or deleted, a retracte d copy of the origin al is kept for audit purposes. Uncosigned * XE "Unc osigned" T he documen t is compl ete with t he excepti on of cosi gnature (e .g., by a supervisor ). | |
1351 | undictated XE "Undic tated" The document is require d and a re cord has b een create d in antic ipation of dictation and trans cription, but the sy stem has n ot yet bee n informed of its di ctation. | |
1352 | unreleased XE "Unrel eased" The document is in the process of being ent ered into the system , but has not yet be en release d by the o riginator (i.e., the person wh o entered the text d irectly on line). | |
1353 | unsigned X E "unsigne d" The doc ument is o nline in a draft sta te, but th e author h asn’t sign ed. | |
1354 | untranscri bed XE "Un transcribe d" The doc ument is r equired an d the syst em has bee n informed of its di ctation, b ut the tra nscription hasn’t be en entered or receiv ed by uplo ad. | |
1355 | unverified XE "Unver ified" The document has been r eleased or uploaded, but must be verifie d before t he documen t may be d isplayed. | |
1356 | * As of TI U*1*234, d ocuments o f these st atuses (i. e., signed documents ) cannot b e edited r egardless of busines s rules. | |
1357 | NOTE: | |
1358 | ||
1359 | + = | |
1360 | a report h as addenda . | |
1361 | ||
1362 | * = | |
1363 | priority ( STAT) docu ment. | |
1364 | Progress N ote Action s XE "Acti ons" | |
1365 | Find Sign /Cosign Change V iew | |
1366 | Add Docume nt Deta iled Displ ay Copy | |
1367 | Edit Brow se Delete D ocument | |
1368 | Make Adden dum Prin t Quit | |
1369 | Link ... Iden tify Signe rs | |
1370 | ActionDesc riptionFin d XE "Find " Allows y ou to sear ch a list of documen ts for a t ext string (word or partial wo rd) from t he current position to the end of the li st. Add Do cument XE "Add Docum ent" Allow s you to a dd a new P rogress No te.New Not e XE "New Note" Same as Add Do cument, us ed in CPRS contexts. EditAllows authorize d users to edit sele cted docum ents onlin e. Make Ad dendum XE "Make Adde ndum" Allo ws authori zed users to add add enda to se lected doc uments onl ine. Physi cians will be prompt ed for the ir signatu res upon e xit.Link X E "Link" | |
1371 | Allows you to link d ocuments t o either p roblems, v isits, or other docu ments. Suc h associat ions permi t a variet y of clini cally usef ul “views” of the on line recor d.Sign/Cos ign XE "Si gn/Cosign" Allows c linicians to electro nically si gn selecte d discharg e summarie s or adden da. NOTE: Electronic signature carries t he same le gal ramifi cations th at wet sig nature of a hard-cop y discharg e summary carries. Y ou are adv ised to ca refully re view each discharge summary fo r content and accura cy before exercising this opti on.Detaile d Display XE "Detail ed Display " Displays the repor t type, pa tient, urg ency, line count, VB C line cou nt, author , attendin g physicia n, transcr iptionist, and verif ying clerk , and also admission , discharg e, dictati on, transc ription, s ignature, and amendm ent dates. BrowseAllo ws you to browse thr ough Docum ents from the Review Screen, b y scrollin g sequenti ally throu gh the sel ected docu ments and their adde nda. You c an search for a word or phrase , or print draft cop ies.Print Allows you to print copies of VAF 10-100 0 for sele cted summa ries.Ident ify Signer sAllows au thorized u sers to id entify add itional si gners for a document .Change Vi ew XE "Cha nge View" Allows you to change the displ ayed repor ts to sign ature stat us, review screen, o r dictatio n date ran ge.Copy XE "Copy" Al lows autho rized user s to copy one or mor e document s to other patients and encoun ters. This is partic ularly use ful when d ocumenting group ses sions, etc .Delete Do cument XE "Delete Do cument" Al lows the a uthor to d elete an u nsigned do cument. In rare case s, a signe d document can be de leted but a copy is kept as a retracted document.C hange Titl e XE "Chan ge Title" This actio n on the “ hidden” li st allows you to cha nge a Titl e for a Pr ogress Not e (e.g., C WAD Notes) to anothe r Title.Qu it XE "Qui t" Allows you to qu it the cur rent menu level.Inte rdisciplin ary Notes XE "Interd isciplinar y Notes" | |
1372 | Interdisci plinary No tes are a new featur e of Text Integratio n Utilitie s (TIU) fo r expressi ng notes f rom differ ent care g ivers as a single ep isode of c are. They always sta rt with a single not e by the i nitial con tact perso n (e.g., t riage nurs e, attendi ng) and co ntinue wit h separate notes cre ated and s igned by o ther provi ders and a ttached to the origi nal note. | |
1373 | To accompl ish this, your facil ity must: | |
1374 | ||
1375 | 1. Se t up note titles for the initi ating note and the a ttachment notes—also called pa rent note and child notes. | |
1376 | 2. Us e version 15 of the CPRS Windo ws (GUI) i nterface o r later. | |
1377 | The Text I ntegration Utilities (TIU) Imp lementatio n Guide co ntains a n ew appendi x, Appendi x C, that describes in detail the techni cal aspect s of setti ng up Inte rdisciplin ary Notes. | |
1378 | ||
1379 | The rest o f this sec tion shows the actio ns Interdi sciplinary Notes usi ng Version 15 of the CPRS Wind ows interf ace. | |
1380 | The Parent Note | |
1381 | You start any interd isciplinar y note wit h a parent note. A p arent is a note titl e that inc ludes an A SU (Author ization/Su bscription Utility) rule allow ing attach ments. You r facility should ha ve set up these titl es with un ique names that allo w you to e asily iden tify them. | |
1382 | Only certa in members of your t eam should start Int erdiscipli nary Notes . To estab lish a par ent note f or a patie nt and a s pecific ep isode of c are, all t hey do is create a n ote with t he proper title, and sign it. | |
1383 | The Child Note(s) | |
1384 | Continue a n interdis ciplinary note by at taching on e or more child note s to the p arent note . The inte ntion is f or each ch ild note t o be by a different provider i nvolved in this epis ode of car e. Again y our facili ty has est ablished a number of notes wit h unique t itles to a ct as chil d notes. | |
1385 | Interdisci plinary No tes, cont’ d | |
1386 | Previously created n ote attach ments are made to th e parent n ode by dra gging and dropping. (Dragging and droppi ng may be a new conc ept to you . To drag and drop: | |
1387 | 1. Po int the cu rsor at th e child no te. | |
1388 | 2. Ho ld down th e left mou se button. | |
1389 | 3. Mo ve the cur sor over t he parent note. A gh ost of the child not e title wi ll follow the cursor . | |
1390 | 4. Re lease the left mouse button. | |
1391 | ||
1392 | The follow ing dialog appears t o confirm the attach ment: | |
1393 | ||
1394 | Interdisci plinary No tes, cont’ d | |
1395 | Menu Actio ns XE "Men u Actions: Interdisc iplinary N otes" | |
1396 | There are two Interd isciplinar y Note spe cific menu commands in the CPR S Windows interface. They are: | |
1397 | A dd New Ent ry to ID N ote | |
1398 | D etach from ID Note | |
1399 | These comm ands becom e active ( usable) wh en the cor rect kind of note is selected as in thes e illustra tions: | |
1400 | ||
1401 | In the fir st case, t he parent note has b een select ed. In thi s case, yo u can add a new note to the In terdiscipl inary Note without h aving to l ater attac h it (via drag and d rop). | |
1402 | In the sec ond case, one of the child not es has bee n selected . In this case, you can detach this note from the parent. | |
1403 | Interdisci plinary No tes, cont’ d | |
1404 | The Displa y | |
1405 | CPRS displ ays all no tes in the Interdisc iplinary N ote refere nce date o rder unles s one of t he child n otes is se lected. In this case , CPRS dis plays the child note , then it displays a ll the not es in the Interdisci plinary No te referen ce date or der; repea ting the c urrent not e. In all other resp ects, the format of the displa y is the s ame as a r egular not e. | |
1406 | The displa y of unsig ned notes depends up on the bus iness rule s in effec t at your site. Thes e rules ma y allow yo u to view the unsign ed child n otes of ot her provid ers in the context o f an Inter disciplina ry Note. T his is up to your lo cal author ities. | |
1407 | Meaning of Icons XE "Meaning o f Icons" | |
1408 | In the CPR S Windows interface, notes are listed in a tree-st ructured a rrangement . This is intended t o graphica lly show a number of things: | |
1409 | 1. Si gned and U nsigned no tes. | |
1410 | 2. No tes with a n addendum attached. | |
1411 | 3. In terdiscipl inary note s. | |
1412 | 4. Re gular note s. | |
1413 | The meanin g of the v arious ico ns is: | |
1414 | IconMeanin gA list of notes, ei ther signe d or unsig ned.An Int erdiscipli nary Note. The open folder ind icates tha t all the children a re listed. A child to an Interd isciplinar y Note.A r egular not e, or a ch ild note t hat has no t yet been attached to a paren t.The plus sign indi cates an a ddendum is present.A n addendum Interdisci plinary No tes, cont’ d | |
1415 | In the Lis t Manager interface, similar d evices are used to i ndicate th e type of note: | |
1416 | SymbolMean ing(Nothin g)A regula r note, or a child n ote that h as not yet been atta ched to a parent.<An Interdisc iplinary N ote parent .> An Inte rdisciplin ary Note c hild. +An addendum is present .+<An Inte rdisciplin ary Note w ith one or more adde ndum prese nt. The ad denda may be in the child note (s).+> An Interdisci plinary No te child w ith one or more adde ndum prese nt. LM Co nsideratio ns XE "LM Considerat ions: Inte rdisciplin ary Notes" | |
1417 | CPRS | |
1418 | Interdisci plinary No tes are no t supporte d in the L ist Manage r (LM) int erface of CPRS with the follow ing except ion: Inter disciplina ry Notes a re viewed and printe d just as other note s supporte d by TIU. | |
1419 | TIU | |
1420 | To access the full r ange of In terdiscipl inary Note s features , use the Progress N ote User M enu and ch oose expor ted option 2b, Revie w Progress Notes. | |
1421 | The IN (In terdiscipl 'ry Note) action is the univer sal action for opera tions on I nterdiscip linary Not es. You sh ould selec t a note b efore sele cting this menu opti on. If the note sele cted is a parent not e, it will prompt yo u to enter a child o f this not e. If the note selec ted is an unattached child not e, it will prompt yo u to selec t the pare nt that go es with it . | |
1422 | In this ex ample, a n ew child n ote is add ed to an e xisting pa rent note: | |
1423 | Progress N otes Feb 14, 20 01@15:09:3 2 Pa ge: 1 o f 6 | |
1424 | <DA> P R O G R E S S N O T E S 74 note(s) | |
1425 | TIUPATIEN T,FOUR 666-55-23 84 MAR 3,1960 (40) | |
1426 | Ti tle Author Date/Tim e _ | |
1427 | 1 - ID PARENT NINE TIUPROVIDE R, 02/14/0 1 08:15 compl | |
1428 | 2 |_ID CHILD OCCUPATIO NAL THER TIUPROVIDE R, 02/14/0 1 08:16 compl | |
1429 | 3 ER NOTE TIUPROVIDE R, 02/14/0 1 08:14 compl | |
1430 | 4 - ID PARENT REHAB TREA TMENT PL TIUPROVIDE R, 02/08/0 1 08:26 compl | |
1431 | 5 |_- ID CHI LD REHAB I NITIAL A TIUPROVIDE R, 02/08/0 1 13:29 compl | |
1432 | 6 | |_Adde ndum to ID CHILD R TIUPROVIDE R, 02/14/0 1 08:11 compl | |
1433 | 7 |_ID CHILD REHAB PSY CHOLOGY TIUPROVIDE R, 02/09/0 1 09:13 compl | |
1434 | 8 - ANGIOPLAST Y NOTE TIUPROVIDE R, 01/08/0 1 13:16 compl | |
1435 | 9 |_Addendum to ANGIOP LASTY NO TIUPROVIDE R, 02/14/0 1 08:13 compl | |
1436 | 10 ID CHILD AMY TIUPROVIDE R, 01/08/0 1 13:14 compl | |
1437 | 11 ID ANY CHILD NOTE TIUPROVIDE R, 01/02/0 1 07:52 compl | |
1438 | 12 SE VEN'S CHIL D SIX TIUPROVIDE R, 12/28/0 0 13:49 compl | |
1439 | 13 SE VEN'S CHIL D FIVE TIUPROVIDE R, 12/28/0 0 13:48 compl | |
1440 | 14 +< SEVEN'S I D NOTE TIUPROVIDE R, 12/28/0 0 13:31 compl | |
1441 | + + Next Sc reen - Pr ev Screen ?? More A ctions | |
1442 | NW New Note SS Select Sea rch IN Inter discipl'ry Note | |
1443 | B Brow se RS Reset to A ll Signed EE Expan d/Collapse Entry | |
1444 | PC Prin t Copy AD Make Adden dum Q Quit | |
1445 | SP Sele ct New Pat ient $ Complete Note(s) | |
1446 | Select Ac tion: Next Screen// IN | |
1447 | To ADD a n ew entry t o an inter disciplina ry note, p lease sele ct the | |
1448 | interdisc iplinary n ote. | |
1449 | To ATTA CH an exis ting stand -alone not e to an in terdiscipl inary note , | |
1450 | please se lect the n ote you wa nt to atta ch. | |
1451 | Select Pr ogress Not e: (1-14) : 4 | |
1452 | Are you ad ding a new interdisc iplinary e ntry to th is note? Y ES// <Ente r> | |
1453 | Adding a n ew interdi sciplinary entry to | |
1454 | ID PARENT REHAB TRE ATMENT PLA N | |
1455 | | |
1456 | Please se lect a tit le for you r entry: | |
1457 | TITLE: ?? | |
1458 | Choose fr om: | |
1459 | ER NUR SE NOTE TITLE | |
1460 | ER PHY SICIAN NOT E T ITLE | |
1461 | OCCUPA TIONAL THE RAPY CHILD NOTE TITLE | |
1462 | REHAB CHILD DISC HARGE PLAN NING NOTE TIT LE | |
1463 | REHAB CHILD INIT IAL ASSESS MENT NOTE TIT LE | |
1464 | REHAB CHILD NURS E NOTE TITLE | |
1465 | REHAB CHILD PHAR MACY NOTE TIT LE | |
1466 | REHAB CHILD PHYS ICAL THERA PY NOTE TITLE | |
1467 | REHAB CHILD PSYC HOLOGY NOT E T ITLE | |
1468 | ^ | |
1469 | TITLE: RE HAB CHILD PHYSICAL T HERAPY NOT E TI TLE | |
1470 | | |
1471 | Enter/Edi t PROGRESS NOTE... | |
1472 | Patient L ocation: PULMONARY CLINIC | |
1473 | D ate/time o f Visit: 02/08/01 0 8:26 | |
1474 | Date/time of Note: NOW | |
1475 | Author of Note: TIUPROVIDE R,TWENTY O NE | |
1476 | ...OK? YES // <Enter> | |
1477 | Calling te xt editor, please wa it... | |
1478 | 1>The P t is doing very well ... | |
1479 | 2> | |
1480 | EDIT Opti on: <Enter > | |
1481 | Saving ID CHILD REH AB PHYSICA L THERAPY NOTE with changes... | |
1482 | Enter your Current S ignature C ode: ***** *** | |
1483 | Progress N otes Feb 14, 20 01@16:05:3 6 Pa ge: 1 o f 6 | |
1484 | <DA> P R O G R E S S N O T E S 74 note(s) | |
1485 | TIUPATIEN T,FOUR 666-55-23 84 MAR 3,196 0 (40) | |
1486 | Ti tle Author Date /Time _ | |
1487 | 1 - ID PARENT NINE TIUPROVIDE R, 02/14/0 1 08:15 compl | |
1488 | 2 |_ID CHILD OCCUPATIO NAL THER TIUPROVIDE R, 02/14/0 1 08:16 compl | |
1489 | 3 ER NOTE TIUPROVIDE R, 02/14/0 1 08:14 compl | |
1490 | 4 - ID PARENT REHAB TREA TMENT PL TIUPROVIDE R, 02/08/0 1 08:26 compl | |
1491 | 5 |_+ ID CHI LD REHAB I NITIAL A TIUPROVIDE R, 02/08/0 1 13:29 compl | |
1492 | 6 |_ID CHILD REHAB PSY CHOLOGY TIUPROVIDE R, 02/09/0 1 09:13 compl | |
1493 | 7 |_ID CHILD REHAB PHY SICAL TH TIUPROVIDE R, 02/14/0 1 16:02 compl | |
1494 | 8 - ANGIOPLAST Y NOTE TIUPROVIDE R, 01/08/0 1 13:16 compl | |
1495 | 9 |_Addendum to ANGIOP LASTY NO TIUPROVIDE R, 02/14/0 1 08:13 compl | |
1496 | 10 ID CHILD ONE TIUPROVIDE R, 01/08/0 1 13:14 compl | |
1497 | 11 ID ANY CHILD NOTE TIUPROVIDE R, 01/02/0 1 07:52 compl | |
1498 | 12 SE VEN'S CHIL D SIX TIUPROVIDE R, 12/28/0 0 13:49 compl | |
1499 | 13 SE VEN'S CHIL D FIVE TIUPROVIDE R, 12/28/0 0 13:48 compl | |
1500 | 14 +< SEVEN'S I D NOTE TIUPROVIDE R, 12/28/0 0 13:31 compl | |
1501 | + ** Entry attached * * | |
1502 | NW New Note SS Select Sea rch IN Inter discipl'ry Note | |
1503 | B Brow se RS Reset to A ll Signed EE Expan d/Collapse Entry | |
1504 | PC Prin t Copy AD Make Adden dum Q Quit | |
1505 | SP Sele ct New Pat ient $ Complete Note(s) | |
1506 | Select Ac tion: Next Screen// | |
1507 | Discharge Summary XE "Discharg e Summary" | |
1508 | Clinicians can revie w, enter, print, and sign disc harge summ aries, eit her by ind ividual pa tient or b y multiple patients. | |
1509 | Clinician’ s Discharg e Summary Menu XE "D ischarge S ummary Men u" | |
1510 | OptionDesc riptionInd ividual Pa tient Disc harge Summ aryThis op tion allow s you to r eview, edi t, or sign a patient ’s dischar ge summari es. | |
1511 | All MY UNS IGNED Disc harge Summ ariesThis option sho ws you all unsigned discharge summaries for you to review, e dit, or si gn. You mu st have si gning or c osigning p rivileges to sign or cosign, b ased on yo ur documen t definiti on, user c lass statu s, and bus iness rule s governin g these ac tions. See your Clin ical Coord inator if you have a ny problem s or quest ions. | |
1512 | Multiple P atient Dis charge Sum mariesThis option sh ows you di scharge su mmaries fo r selected statuses, types, an d categori es, which you can th en review, edit, and /or sign. | |
1513 | Individual Patient D ischarge S ummary XE "Individua l Patient Discharge Summary" | |
1514 | This optio n allows y ou to revi ew, edit, or sign a patient’s discharge summaries. | |
1515 | Steps to u se option: | |
1516 | 1. Select Individual Patient D ischarge S ummary fro m your TIU menu, the n select a patient. | |
1517 | Select Dis charge Sum mary User Menu Optio n: Indivi dual Patie nt Dischar ge Summary | |
1518 | Select PAT IENT NAME: TIUPATIEN T,ONE TIUP ATIENT,ONE 09-12-44 66623345 6 YES SC VETERAN | |
1519 | (2 notes ) C: 05/2 8/96 12:37 | |
1520 | (2 notes ) W: 05/2 8/96 12:33 | |
1521 | A: Know n allergie s | |
1522 | Available summaries: 02/12/96 thru 02/1 2/96 (1) | |
1523 | 2. Enter a date rang e to selec t summarie s from, th en select a summary from the o nes displa yed. The s elected su mmary is d isplayed. Then selec t an actio n. | |
1524 | Browse Doc ument Jun 26, 1996 14:21:22 Page: 1 of 7 | |
1525 | Discharge Summary | |
1526 | TIUPATIENT ,O 666-23 -3456 1A Adm: 07 /22/91 Di s: 02/12/9 6 | |
1527 | DICT DA TE: JUN 09 , 1996 ENT RY DATE: J UN 12, 199 6@15:07:22 | |
1528 | DICTATED BY: TIUPRO VIDER,ONE ATTENDING : TIUPROVI DER,THREE | |
1529 | URGEN CY: priori ty STATUS: U NSIGNED | |
1530 | DIAGNOSIS: | |
1531 | 1. Status post head trauma wi th brain c ontusion. | |
1532 | 2. Status post cere brovascula r accident . | |
1533 | 3. Corona ry artery disease. | |
1534 | 4. Hypert ension. | |
1535 | + + Next Scr een - Pre v Screen ?? More ac tions | |
1536 | Find Make Adden dum Iden tify Signe rs | |
1537 | Print Sign/Cosig n Dele te | |
1538 | Edit Copy Link ... | |
1539 | Quit | |
1540 | Select Act ion: Quit/ / p Prin t | |
1541 | DEVICE: HO ME//<Enter > VAX | |
1542 | Printed Di scharge Su mmary XE " Printed Di scharge Su mmary" Ex ample | |
1543 | SALT LAKE CITY pri ority 06/26/96 1 4:24 Page: 1 | |
1544 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- --------- | |
1545 | PATIENT NA ME | AGE | SEX | RAC E | SS N | CL AIM NUMBER | |
1546 | TIUPATIENT ,ONE | 51 | M | MEX I | 666-23 -3456 | | |
1547 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- --------- | |
1548 | ADM DATE | DISC DATE | TYPE OF RE LEASE | INP | ABS | WARD NO | |
1549 | JUL 22, 19 91 | FEB 1 2, 1996 | REGULAR |1 666 | 0 | 1A | |
1550 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- --------- | |
1551 | DICTATION DATE: JUN 09, 1996 TRANSCRIPT ION DATE: JUN 12, 19 96 | |
1552 | TRANSCRIPT IONIST: bs | |
1553 | DIAGNOSIS: | |
1554 | 1. Status post head trauma wi th brain c ontusion. | |
1555 | 2. Status post cere brovascula r accident . | |
1556 | 3. End st age renal disease on hemodialy sis. | |
1557 | 4. Corona ry artery disease. | |
1558 | 5. Conges tive heart failure. | |
1559 | 6. Hypert ension. | |
1560 | 7. Non in sulin depe ndent diab etes melli tus. | |
1561 | 8. Periph eral vascu lar diseas e, status post throm bectomies. | |
1562 | 9. Diabet ic retinop athy. | |
1563 | OPERATIONS /PROCEDURE S: | |
1564 | 1. MRI. | |
1565 | 2. CT SCAN OF HEAD. | |
1566 | HISTORY OF PRESENT I LLNESS: | |
1567 | Patient is a 49-year -old, whit e male wit h past med ical histo ry of end stage | |
1568 | renal dise ase, perip heral vasc ular disea se, status post BKA, coronary artery | |
1569 | disease, h ypertensio n, non ins ulin depen dent diabe tes mellit us, diabet ic | |
1570 | retinopath y, congest ive heart failure, s tatus post CVA, stat us post | |
1571 | thrombecto my admitte d from Any town VA af ter a fall from his wheelchair in the | |
1572 | hospital. He had qu estionable short-las ting loss of conscio usness but patient | |
1573 | is not ver y sure wha t has happ ened. He denies hea dache, vom iting, ver tigo. | |
1574 | D R A F T | |
1575 | Press RETU RN to cont inue or '^ ' to exit: | |
1576 | SALT LAKE CITY pri ority 06/26/96 1 4:24 Page: 2 | |
1577 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- --------- | |
1578 | PATIENT NA ME | AGE | SEX | RAC E | SS N | CL AIM NUMBER | |
1579 | TIUPATIENT ,ONE | 51 | M | MEX I | 666-23 -3456 | | |
1580 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- --------- | |
1581 | On admissi on patient had CT sc an which s howed a sm all area o f parenchy mal | |
1582 | hemorrhage in the ri ght tempor al lobe wh ich is mos t likely c onsistent with | |
1583 | hemorrhagi c contusio n without mid line s hift or in coordinati on. | |
1584 | ACTIVE MED ICATIONS: Isordil 2 0 mgs p.o. t.i.d., C oumadin 2. 5 mgs p.o. qd, | |
1585 | ferrous su lfate 325 mgs p.o. b .i.d., Ati van 0.5 mg s p.o. b.i .d., Lactu lose 15 | |
1586 | ccs p.o. b .i.d., Cal cium carbo nate 650 m gs p.o. b. i.d. with food, Beto ptic | |
1587 | 0.5% ophth almologic solution g tt OU b.i. d., Nephro caps 1 tab let p.o. q d, | |
1588 | Pilocarpin e 4% solut ion 1 gtt OU b.i.d., Compazine 10 mgs p. o. t.i.d. prn | |
1589 | nausea, Ty lenol 650 mgs p.o. q 4 hours pr n. | |
1590 | Patient is on hemodi alysis, no known dru g allergie s. | |
1591 | Printed Di scharge Su mmary Exam ple cont’d | |
1592 | PHYSICAL E XAMINATION : Patient had stabl e vital si gns, his b lood press ure was | |
1593 | 160/85, pu lse 84, re spiratory rate 20, t emperature 98 degree s. Patien t was | |
1594 | alert, ori ented time s three, c ooperative . His spe ech was fl uent, | |
1595 | understand ing of spo ken langua ge was goo d. Attent ion span w as good. He had | |
1596 | moderate m emory impa irment, no apraxia n oted. Cra nial nerve s patient was | |
1597 | blind, pup ils are no t reactive to light, face was asymmetric , tongue a nd | |
1598 | palate are mid line. Motor ex amination showed mus cle tone a nd bulk wi thout | |
1599 | significan t changes. Muscle s trength in upper ext remities 5 /5 bilater ally, | |
1600 | sensory ex amination revealed i ntact ligh t touch, p inprick an d vibrator y | |
1601 | sensation. Reflexes 1+ in upp er extremi ties, coor dination f inger to n ose test | |
1602 | within nor mal limits bilateral ly. Alter nating mov ements wit hout signi ficant | |
1603 | changes bi laterally. Neck was supple. | |
1604 | LABORATORY : Showed sodium lev el 135, po tassium 4. 6, chlorid e 96, CO2 26, | |
1605 | BUN 39, cr eatinine 5 .3, glucos e level 13 8. White blood cell count was 7, | |
1606 | hemoglobin 11, hemat ocrit 34, platelet c ount 77. | |
1607 | HOSPITAL C OURSE: Pa tient was admitted a fter head trauma wit h multiple medical | |
1608 | problems. His couma din was he ld. Patie nt had cer vical spin e x-rays w hich | |
1609 | showed def inite narr owing of C 5, C6 inte rspace, sl ight retro listhesis at this | |
1610 | level, pro minent spu rs at this level as well as ab ove and be low. CT s can on | |
1611 | admission showed a m oderate am ount of sc alp thinni ng with su bcutaneous air | |
1612 | overlying the left f rontal lob e. The bas al cistern s are pate nt and the re | |
1613 | is no mid line shift or uncal herniation . Patient has also a remote l eft | |
1614 | posterior border zon e infarct with hydro cephalus e x vaccuo o f the left | |
1615 | occipital horn, a ra ther large remote in farct in t he inferio r portion of the | |
1616 | left cereb ellar hemi sphere. H e had hemo dialysis q .o.d. He restarted treatment with Couma din. His last PT wa s 11.9, PT T 31. Pat ient refus ed before hemodialys is new blo od tests. His condi tion remai ned stable . | |
1617 | DISCHARGE MEDICATION S: Isordi l 20 mgs p .o. t.i.d. , Ferrous sulfate 32 5 mgs | |
1618 | p.o. b.i.d ., Ativan 0.5 mgs p. o. b.i.d., Lactulose 15 ccs p. o. b.i.d., Calcium | |
1619 | carbonate 650 mgs p. o. b.i.d., Compazine 10 mgs p. o. t.i.d. prn nausea , | |
1620 | Betoptic 0 .5% OU b.i .d., Nephr ocaps 1 p. o. qd, Pil ocarpine 4 % solution 1 gtt | |
1621 | OU b.i.d., Coumadin 2.5 mgs p. o. qd, Tyl enol 650 m gs p.o. q6 hours prn pain. | |
1622 | DISPOSITIO N/FOLLOW-U P: | |
1623 | Recommend follow PT/ PTT. Pati ent is on coumadin a nd CBC wit h differen tial | |
1624 | because pa tient has chronic an emia and t hrombocyto penia. | |
1625 | Patient wi ll be tran sferred to Anytown V A in stabl e conditio n on 5/19/ 96. | |
1626 | WORK COPY ========== = UNOFFICI AL - NOT F OR MEDICAL RECORD == ======== D O NOT FILE | |
1627 | SIGNATURE PHYSICIAN/ DENTIST SIGNATURE APPROVING PHYSICIAN/ DENTIST | |
1628 | THREE TIUP ROVIDER, M D ONE T IUPROVIDER , MS | |
1629 | PGY2 Resid ent Medical I nformatici st | |
1630 | ========== ========== ======= CO NFIDENTIAL INFORMATI ON ======= ========== ========== | |
1631 | All MY UNS IGNED Disc harge Summ aries XE " All MY UNS IGNED Disc harge Summ aries" | |
1632 | This optio n shows yo u all unsi gned disch arge summa ries for y ou to revi ew, edit, or sign. Y ou must ha ve signing XE "signi ng privile ge" or co signing pr ivilege XE "Cosignin g privileg e" s to si gn or cosi gn, based on your do cument def inition, u ser class status, an d business rules gov erning the se actions . See your Clinical Coordinato r if you h ave any pr oblems or questions about elec tronic sig nature or cosigning. | |
1633 | Steps to u se option: | |
1634 | 1. Select All MY UNS IGNED Disc harge Summ aries from your TIU menu. | |
1635 | 2. Your un signed dis charge sum maries are displayed . | |
1636 | Discharge Summaries Jun 1 8, 1996 10 :13:45 Page: 1 of 1 | |
1637 | by AUT HOR (TIUPR OVIDER,ONE ) or EXPEC TED COSIGN ER 0 docu ments | |
1638 | Patie nt Document Ref Date St atus | |
1639 | 2 TIUPATIE NT,S(T4831 ) Discharg e Summary 03/1 5/96 unc osig | |
1640 | + Ne xt Screen - Prev Sc reen ?? M ore Action s > >> | |
1641 | Find Sign/ Cosign C hange View | |
1642 | Add D ocument Detai led Displa y C opy | |
1643 | Edit Brows e D elete Docu ment | |
1644 | Make Addendum Print Q uit | |
1645 | Link ... Ident ify Signer s | |
1646 | Select Act ion: Quit/ / COSIGN | |
1647 | Select an action suc h as Sign/ Cosign if you are au thorized t o perform these. | |
1648 | | |
1649 | NOTE: | |
1650 | You can en ter Cosign rather th an Sign/Co sign if yo u want to cosign. | |
1651 | Multiple P atient Dis charge Sum maries XE "Multiple Patient Di scharge Su mmaries" | |
1652 | This optio n shows yo u discharg e summarie s for sele cted statu ses, types , and cate gories, wh ich you ca n then rev iew, edit, and/or si gn. | |
1653 | Caution: Avoid maki ng your re quests too broad (in statuses, search ca tegories, and date r anges) bec ause these searches can use a lot of sys tem resour ces, slowi ng the com puter syst em down fo r everyone . | |
1654 | Steps to u se option: | |
1655 | 1. Select Multiple P atient Dis charge Sum maries fro m your TIU menu. | |
1656 | 2. Select one or mor e of the f ollowing s tatuses: | |
1657 | untrans cribed | |
1658 | unrelea sed | |
1659 | unverif ied | |
1660 | unsigne d | |
1661 | ||
1662 | uncosig ned | |
1663 | complet ed | |
1664 | amended | |
1665 | ||
1666 | purged | |
1667 | deleted | |
1668 | 3. Select one of the following search ca tegories X E "Search categories " : | |
1669 | 1 All C ategories 6 Patient 11 Tra nscription ist | |
1670 | 2 Autho r 7 Problem 12 Tre ating Spec ialty | |
1671 | 3 Divis ion 8 Service 13 Vis it | |
1672 | 4 Expec ted Cosign er 9 Subject | |
1673 | 5 Hospi tal Locati on 10 Title | |
1674 | 4. Enter a date rang e. | |
1675 | 5. A list is display ed of the summaries that meet your speci fications. | |
1676 | My UNSIGNE D Disch Su mmaries Jun 05, 19 97 14:02:1 5 Page : 1 of 1 | |
1677 | by A UTHOR (TIU PROVIDER,O NE) from 0 5/06/97 to 06/05/97 1 document s | |
1678 | Patie nt Doc ument Ref Date Status | |
1679 | ||
1680 | 1 + TIU PATIENT,T( T2591) Dis charge Sum mary 06/02/97 UNSIGNE D | |
1681 | + Next Scre en - Prev Screen ? ? More act ions | |
1682 | Find Sign/Cosi gn Cha nge View | |
1683 | Add D ocument Detailed Display Cop y | |
1684 | Edit Browse Del ete Docume nt | |
1685 | Make Addendum Print Qui t | |
1686 | Link ... Identify Signers | |
1687 | Select Act ion: Quit/ / s | |
1688 | 6. You can now take an appropr iate actio n on one o r all of t he summari es. | |
1689 | Discharge Summary St atuses and Actions X E "Dischar ge Summary Statuses and Action s" | |
1690 | Statuses X E "Statuse s" | |
1691 | StatusDesc riptionAme nded * XE "Amended" The docume nt has bee n complete d and a pr ivacy act issue has required i ts amendme nt. By des ign, only the follow ing user c lasses are allowed t o amend a Discharge Summary: | |
1692 | CHIEF, MIS XE "CHIEF , MIS" | |
1693 | CHIEF, HIM XE "CHIEF , HIM" | |
1694 | PRIVACY AC T OFFICER XE "PRIVAC Y ACT OFFI CER" Compl eted * XE "Completed " The docu ment has a cquired al l necessar y signatur es and is legally au thenticate d.deleted XE "Delete d" Status DELETED is no longer operable. Before st atus RETRA CTED was i ntroduced deleting a document removed th e text of the docume nt leaving a stub wi th status DELETED.Re tracted *W hen a sign ed documen t is reass igned, ame nded, or d eleted, a retracted copy of th e original is kept f or audit p urposes.un cosigned * XE "Uncos igned" The document is complet e with the exception of cosign ature (i.e ., by the supervisor ).undictat ed XE "Und ictated" T he documen t is requi red and a record has been crea ted in ant icipation of dictati on and tra nscription but the s ystem has not yet be en informe d of its d ictation.u nreleased XE "Unrele ased" The document i s in the p rocess of being ente red into t he system but has no t yet been released by the ori ginator (i .e., the p erson who entered th e text dir ectly onli ne).unsign ed XE "Uns igned" The document is online in a draft state but the autho r hasn’t s igned.untr anscribed XE "Untran scribed" T he documen t is requi red and th e system h as been in formed of its dictat ion but th e transcri ption hasn ’t been en tered or r eceived by upload.un verified X E "Unverif ied" The d ocument ha s been rel eased or u ploaded bu t must be verified b efore the document m ay be disp layed.* As of TIU*1* 234, docum ents of th ese status es (i.e., signed doc uments) ca nnot be ed ited regar dless of b usiness ru les. | |
1695 | Actions XE "Actions" | |
1696 | Find Sign/Cosi gn Cha nge View | |
1697 | Add D ocument Detailed Display Cop y | |
1698 | Edit Browse Del ete Docume nt | |
1699 | Make Addendum Print Qui t | |
1700 | Link ... Identify Signers | |
1701 | ActionsDes criptionAd d Document XE "Add D ocument" E nter a new Document. Change Vie w XE "Chan ge View" A llows you to modify the list o f reports by signatu re status, review sc reen, and dictation date range without e xiting the review sc reen.Copy XE "Copy" Allows aut horized us ers to dup licate the current d ocument. This is es pecially u seful when composing a note fo r a group of patient s (e.g., t herapy gro up) and ra pid duplic ation to a ll members of the gr oup is app ropriate.D elete Docu ment XE "D elete Docu ment" Al lows the a uthor to d elete an u nsigned do cument. In rare case s, a signe d document can be de leted but a copy is kept as a retracted document.D etailed Di splay XE " Detailed D isplay" Di splays the report ty pe, patien t, urgency , line cou nt, VBC li ne count, author, at tending ph ysician, t ranscripti onist, and verifying clerk, in addition to the adm ission, di scharge, d ictation, transcript ion, signa ture and a mendment d ates, with out showin g the narr ative repo rt text.Ed it XE "Edi t" Allows authorized users to edit the c urrent doc ument onli ne. When e lectronic signature is enabled , physicia ns will be prompted for their signatures upon exit , thereby allowing d octors to review, ed it, and si gn as a on e-step pro cess.Find XE "Find" Allows you to search for a tex t string ( word or pa rtial word ) from the current p osition in the summa ry through its end. Upon reac hing the e nd of the document, you will b e asked wh ether to c ontinue th e search f rom the be ginning of the docum ent throug h the orig in of the search.Ide ntify Sign ers XE "Id entify Sig ners" Al lows autho rized user s to ident ify additi onal users who are t o be alert ed for con currence s ignature. These sign ers may en ter an add endum if t hey do not concur wi th the con tent of th e document , but they may not e dit the do cument its elf.Link X E "Link" A llows you to link do cuments to either pr oblems, vi sits, or o ther docum ents. Such associati ons permit a variety of clinic ally usefu l “views” of the onl ine record .Make Adde ndum XE "M ake Addend um" Allows authorize d users to add an ad dendum to the curren t document online. W hen electr onic signa ture is en abled, phy sicians ar e prompted for their signature s upon exi t, thereby allowing doctors to review, e dit and si gn as a on e-step pro cess.Print XE "Print " Allows y ou to prin t copies o f selected documents on your c orrespondi ng VA Stan dard Forms to a spec ified devi ce. Quit X E "Quit" Allows you to quit t he current menu leve l.Sign/Cos ign XE "Si gn/Cosign" Allows cl inicians t o electron ically sig n the curr ent summar y. NOTE: Electronic signature carries t he same le gal ramifi cations th at wet sig nature of a hard-cop y discharg e summary carries. C arefully r eview each discharge summary f or content and accur acy before exercisin g this opt ion.Integr ated Docum ent Manage ment XE "I ntegrated Document M anagement" | |
1702 | The option s on this menu allow clinician s to revie w, edit, o r sign pro gress note s, dischar ge summari es, and an y other do cuments se t up at yo ur site. T his menu i s especial ly useful for clinic ians who w ish to see an integr ated view of documen ts, to be able to ed it or sign many type s in one s ession wit hout chang ing applic ations. | |
1703 | Option Nam eDescripti onIndividu al Patient Document XE "Indivi dual Patie nt Documen t" Allows you to int eractively review, e dit, or si gn a desig nated clin ical docum ent for a designated patient. | |
1704 | All MY UNS IGNED Docu ments XE " All MY UNS IGNED Docu ments" | |
1705 | Gets all u nsigned do cuments fo r review, edit, and signature. | |
1706 | Multiple P atient Doc uments XE "Multiple Patient Do cuments" P rovides an integrate d Review S creen of a ll TIU doc uments. | |
1707 | Enter/edit Document XE "Enter/ edit Docum ent" | |
1708 | Allows you to enter and edit c linical do cuments di rectly onl ine. | |
1709 | ALL Docume nts requir ing my Add itional Si gnature XE "ALL Docu ments requ iring my A dditional Signature" Prints a report sho wing all d ocuments t hat requir e an addit ional sign ature. | |
1710 | Individual Patient D ocument XE "Individu al Patient Document" | |
1711 | Use this o ption to r eview an i ndividual document f or a patie nt. You ca n then edi t, sign, d elete, or perform ot her action s, as appr opriate, o n the docu ment. | |
1712 | Steps to u se option: | |
1713 | 1. Select Individual Patient D ocument fr om your In tegrated D ocument Ma nagement m enu on you r TIU menu . | |
1714 | 2. Select a patient. | |
1715 | 3. Enter a date rang e to displ ay documen ts for. A list is di splayed of that pati ent’s docu ments for the specif ied time p eriod. | |
1716 | Please spe cify a dat e range fr om which t o select d ocuments: | |
1717 | List docum ents Begin ning: 02/1 7/92// 1/9 6 (JAN 19 96) | |
1718 | Thru: 06/0 7/96// <En ter> (JUN 07, 1996) | |
1719 | 1 06/07/9 6 00:00 D iabetes Ed ucation ONE T IUPROVIDER , MD | |
1720 | Visit: 04/ 18/96 | |
1721 | 2 06/05/9 6 17:23 L ipid Clini c THREE TIUPROVID ER, | |
1722 | Visit: 04/ 18/96 | |
1723 | 3 06/05/9 6 11:10 A ddendum to Lipid Cli nic THREE TIUPROVID ER, | |
1724 | Visit: 04/ 24/96 | |
1725 | 4 05/28/9 6 12:37 C risis Note SEVEN TIUPROVID ER | |
1726 | Visit: 02/ 20/96 | |
1727 | 5 05/28/9 6 12:37 C risis Note SEVEN TIUPROVID ER | |
1728 | Visit: 02/ 20/96 | |
1729 | 4. Choose a document from the list. | |
1730 | Choose doc uments: ( 1-6): 1 | |
1731 | Opening Di abetes Edu cation rec ord for re view... | |
1732 | Individua l Patient Document c ont’d | |
1733 | Browse Doc ument Jun 2 6, 1996 17 :08:45 Page: 1 of 1 | |
1734 | Diabetes Education | |
1735 | TIUPATIENT 666-23-34 56 Visit Date : 07/22/91 @11:06 | |
1736 | DATE OF NO TE: JAN 09 , 1996@17: 51:04 ENT RY DATE: J AN 09, 199 6@17:51:04 | |
1737 | AUTH OR: TIUPRO VIDER,THRE E EXP C OSIGNER: T IUPROVIDER ,SIX | |
1738 | URGEN CY: STATU S: COMPLET ED | |
1739 | Provided M r. TIUPati ent with D iabetes di et pamphle t and expl ained area s he espec ially need ed to be c oncerned a bout. | |
1740 | /es/ TIUPR OVIDER,THR EE MD | |
1741 | for TIUPRO VER,SIX MS 3 | |
1742 | Medical St udent III | |
1743 | + Next Scr een - Pre v Screen ?? More ac tions | |
1744 | Find Make A ddendum Identify S igners | |
1745 | Print Sign/C osign Delete | |
1746 | Edit Copy Link… | |
1747 | Quit | |
1748 | Select Act ion: Quit/ / | |
1749 | 5. Select one of the actions t o perform on the doc ument (e.g ., edit, s ign, make addendum). | |
1750 | All MY UNS IGNED XE " Unsigned" Documents XE "All M Y UNSIGNED Documents " | |
1751 | When you c hoose this option fr om the Int egrated Do cument Man agement Me nu, all yo ur unsigne d document s are disp layed to r eview, edi t, or sign . | |
1752 | Steps to u se option: | |
1753 | 1. Select All MY UNS IGNED Docu ments from your Inte grated Doc ument Mana gement men u on your TIU menu. | |
1754 | Select Int egrated Do cument Man agement Op tion: All MY UNSIGNE D Document s | |
1755 | Searching for the do cuments. | |
1756 | 2. After a ll your un signed doc uments are displayed , you can select an action suc h as add, edit, or s ign/cosign , etc. | |
1757 | MY UNSIGNE D Document s Jun e 31, 1997 15:38:13 Pag e: 1 of 1 | |
1758 | by AUT HOR (TIUPR OVIDER,ONE ) or EXPEC TED COSIGN ER 4 docum ents | |
1759 | Patie nt Docu ment Ref Dat e Status Complete Auth | |
1760 | 1 SC501 050 ONE- PER-VISIT NOTE 12/18/0 2 com 12/24/02 TIUP | |
1761 | 2 TB668 832 Card iology Not e 09/23/0 2 uns CPRS | |
1762 | 3 FW120 870 CARD IOLOGY CS CONSULT 11/11/0 1 uns CPRS | |
1763 | 4 - CPR SPATI Disc harge Summ ary 10/12/0 1 com 01/16/01 ARTP | |
1764 | 5 |_C PRSPA Adde ndum to Di scharge Su mm 02/09/0 1 comple 02/12/01 LUPR | |
1765 | + Next Screen - Prev Scre en ?? Mor e actions | |
1766 | Add D ocument D etailed Di splay Delete Document | |
1767 | Edit B rowse Interdi scipl'ry N ote | |
1768 | Make Addendum P rint Expand/ Collapse E ntry | |
1769 | Link ... I dentify Si gners Encount er Edit | |
1770 | Sign/ Cosign C hange View Quit | |
1771 | Select Act ion: Quit/ / s Sign/ Cosign | |
1772 | Select Doc ument(s): (1-5): 3- 5 | |
1773 | Opening Ad verse Reac t/Allergy record for review... | |
1774 | SIGN/COSIG N Jun 06, 1997 12:03:52 Page : 1 of 1 | |
1775 | Ad verse Reac t/Allergy | |
1776 | TIUPATIENT ,TWO 666-1 2-3243 2 B Vi sit Date: 09/21/95@1 0:00 | |
1777 | DATE OF NO TE: MAY 20 , 1997@10: 51:18 ENT RY DATE: M AY 20, 199 7@10:51:18 | |
1778 | AUTH OR: TIUPRO VIDER,ONE EXP C OSIGNER: | |
1779 | URGEN CY: STATUS: U NSIGNED | |
1780 | MORE TESTS ORDERED | |
1781 | + Nex t Screen - Prev Scr een ?? Mo re actions | |
1782 | Print No | |
1783 | Ready for Signature: NO// y Yes | |
1784 | Item #: 3 Added to s ignature l ist. | |
1785 | All MY UNS IGNED Docu ments, con t’d | |
1786 | Opening Ge neral Note record fo r review.. . | |
1787 | SIGN/COSIG N Jun 06, 1997 1 2:04:59 Page: 1 of 1 | |
1788 | General Note | |
1789 | TIUPATIENT ,FIVE 666- 04-3779P 2B Vi sit Date: 05/28/96@1 5:58 | |
1790 | DATE OF NO TE: APR 07 , 1997@15: 50:26 ENT RY DATE: A PR 07, 199 7@15:37:25 | |
1791 | AUTH OR: TIUPRO VIDER,ONE EXP C OSIGNER: | |
1792 | URGEN CY: STATUS: U NSIGNED | |
1793 | general ma laise | |
1794 | + Next Scree n - Prev Screen ?? More acti ons | |
1795 | Print No | |
1796 | Ready for Signature: NO// y Yes | |
1797 | Item #: 4 Added to s ignature l ist. | |
1798 | Opening Ad verse Reac t/Allergy record for review... | |
1799 | SIGN/COSIG N Ju n 06, 1997 12:04:10 Page : 1 of 1 | |
1800 | Ad verse Reac t/Allergy | |
1801 | TIUPATIENT ,ONE 666- 23-3456 Vi sit Date: 07/22/91@1 1:06 | |
1802 | DATE OF NO TE: MAR 24 , 1997@11: 03:39 ENT RY DATE: M AR 24, 199 7@11:03:39 | |
1803 | AUTH OR: TIUPRO VIDER,FIVE EXP COSIG NER: | |
1804 | URGEN CY: STATUS: U NSIGNED | |
1805 | Hay fever reactions severe – a ntihistami nes not wo rking. Pre scribed ne w medicati on. | |
1806 | + Next Screen - Prev Scre en ?? Mor e actions | |
1807 | Print No | |
1808 | Ready for Signature: NO// y Yes | |
1809 | Item #: 5 Added to s ignature l ist. | |
1810 | Enter your Current S ignature C ode: XXX SIGNATURE VERIFIED. ..... | |
1811 | MY UNSIGNE D Document s Jun 06, 1997 12:04:27 Page: 1 of 1 | |
1812 | b y AUTHOR ( TIUPROVIDE R,FIVE) or EXPECTED COSIGNER 5 docum ents | |
1813 | Patie nt Doc ument Ref D ate Sta tus | |
1814 | 1 + TIU PATIENT,FI VE (T3779) Discharge Summary 06/0 2/97 UNSI GNED | |
1815 | 2 TIUPA TIENT,ONE (T3456) Adverse R eact/Aller gy 05/3 1/97 comp leted | |
1816 | 3 TIUPA TIENT,TWO (T3243) Adverse R eact/Aller gy 05/2 0/97 comp leted | |
1817 | 4 TIUPA TIENT,FIVE (T3779) General N ote 04/0 7/97 comp leted | |
1818 | 5 TIUPA TIENT,SIX (T3476) Adverse R eact/Aller gy 03/2 4/97 comp leted | |
1819 | ** It ems 3, 4, 5 Signed. ** >>> | |
1820 | Find Sign/Cosi gn Cha nge View | |
1821 | Add D ocument Detailed Display Cop y | |
1822 | Edit Browse Del ete Docume nt | |
1823 | Make Addendum Print Qui t | |
1824 | Link ... Identify Signers | |
1825 | Select Act ion: Quit/ / | |
1826 | Multiple P atient Doc uments XE "Multiple Patient Do cuments" | |
1827 | Use this o ption to s ee an inte grated Rev iew Screen of all TI U document s. | |
1828 | Caution: Avoid maki ng your re quests too broad (in statuses, search ca tegories, and date r anges) bec ause these searches can use a lot of sys tem resour ces, slowi ng the com puter syst em down fo r everyone . | |
1829 | Steps to u se option: | |
1830 | 1. Select Multiple P atient Doc uments fro m your Int egrated Do cument Man agement me nu on your TIU menu. | |
1831 | Select Int egrated Do cument Man agement Op tion: Mult iple Patie nt Documen ts | |
1832 | 2. Select one or mor e of the f ollowing s tatuses. | |
1833 | 1 undic tated 6 uncos igned | |
1834 | 2 untra nscribed 7 complet ed | |
1835 | 3 unrel eased 8 amend ed | |
1836 | 4 unver ified 9 purge d | |
1837 | 5 unsig ned 1 0 delet ed | |
1838 | Enter sele ction(s) b y typing t he name(s) , number(s ), or abbr eviation(s ). | |
1839 | Select Sta tus: UNSIG NED// <Ent er> | |
1840 | 3. Select a document type (fro m whatever you have set up at your site) : | |
1841 | Select Cli nical Docu ments Type (s): 1-3 Addendum | |
1842 | Disch arge Summa ry | |
1843 | Progr ess Notes | |
1844 | 4. Select one of the following search ca tegories X E "Search categories " | |
1845 | 1 All C ategories 6 Patient 11 Tra nscription ist | |
1846 | 2 Autho r 7 Problem 12 Tre ating Spec ialty | |
1847 | 3 Divis ion 8 Service 13 Vis it | |
1848 | 4 Expec ted Cosign er 9 Subject | |
1849 | 5 Hospi tal Locati on 10 Title | |
1850 | Enter sele ction(s) b y typing t he name(s) , number(s ), or abbr eviation(s ). | |
1851 | Multiple P atient Doc uments, co nt’d XE "M ultiple Pa tient Docu ments" | |
1852 | 5. Enter a date rang e. | |
1853 | Start Refe rence Date [Time]: T -7// T-60 (APR 01, 1997) | |
1854 | Ending Ref erence Dat e [Time]: NOW// <Ent er> (MAY 31, 1997@1 5:42) | |
1855 | Searching for the do cuments. | |
1856 | 6. All the documents for the c riteria se lected are displayed . Choose a n action t o perform, then the document t o perform it on. | |
1857 | UNSIGNED D ocuments May 31, 1997 15:42:40 Page: 1 of 1 | |
1858 | by A UTHOR (TIU PROVIDER,O NE) from 0 4/01/97 to 05/31/97 3 document s | |
1859 | Patient Document Ref Date Stat us | |
1860 | 1 TIUPA TIENT,FIVE (T3779) Discharge Summary 06/0 2/97 unsi gned | |
1861 | 2 TIUPA TIENT,ONE (T3456) Adverse R eact/Aller gy 05/3 1/97 unsi gned | |
1862 | 3 TIUPA TIENT,TWO (T3243) Adverse R eact/Aller gy 05/2 0/97 unsi gned | |
1863 | + Next Scree n - Prev Screen ?? More acti ons | |
1864 | Find Sig n/Cosign Change View | |
1865 | Add Doc ument Det ailed Disp lay Copy | |
1866 | Edit Bro wse Delete Document | |
1867 | Make Ad dendum Pri nt Quit | |
1868 | Link .. . Ide ntify Sign ers | |
1869 | Select Act ion: Quit/ / | |
1870 | Enter/Edit Document XE "Enter/ Edit Docum ent" | |
1871 | This optio n allows y ou to ente r and edit clinical documents directly o nline. | |
1872 | | |
1873 | NOTE: | |
1874 | All docume nts for ou tpatients must be as sociated w ith a Visi t or Admis sion in or der to rec eive workl oad credit . | |
1875 | | |
1876 | NOTE: | |
1877 | Signed not es may not be edited XE "prohi bits editi ng" even if there i s a busine ss rule al lowing the m to be. H ard code w ithin TIU prevents e diting XE "prevents editing" of signed documents. The follo wing categ ories are considered signed: U n-cosigned , complete d, amended , and retr acted. | |
1878 | Steps to u se option: | |
1879 | 1. Select Enter/Edit Document from your Integrated Document Management menu on y our TIU me nu and ent er a patie nt name. | |
1880 | Select Int egrated Do cument Man agement Op tion: Ente r/edit Doc ument | |
1881 | Select PAT IENT NAME: TIUPATIEN T,ONE TIUP ATIENT,ONE 09-12-44 66623345 6 YES | |
1882 | SC VETERAN | |
1883 | A: Know n allergie s | |
1884 | Select the Document type. | |
1885 | Select TIT LE: ?? | |
1886 | Choose fro m: | |
1887 | ADVANCE DIRECTIVE TITL E | |
1888 | ADVERSE REACTION/ ALLERGY TITLE | |
1889 | CLINICA L WARNING TITLE | |
1890 | CRISIS NOTE TITLE | |
1891 | DISCHAR GE SUMMARY TITL E | |
1892 | Select TIT LE: ADVERS E REACTION /ALLERGY TITL E | |
1893 | 3. If the patient is an outpat ient, choo se the Vis it (admiss ion) from the list d isplayed t hat you wi sh to asso ciate with the Adver se Reactio n/Allergy note. | |
1894 | This patie nt is not currently admitted t o the faci lity... | |
1895 | Is this no te for INP ATIENT or OUTPATIENT care? OUT PATIENT// <Enter> | |
1896 | The follow ing VISITS are avail able: | |
1897 | 1> APR 18, 1996@ 10:00 GENERAL ME DICINE | |
1898 | 2> FEB 21, 1996@ 08:40 PULMONARY CLINIC | |
1899 | 3> FEB 20, 1996@ 10:00 ONCOLOGY | |
1900 | 4> FEB 20, 1996@ 08:00 GENERAL ME DICINE | |
1901 | CHOOSE 1-4 or <N>EW VISIT | |
1902 | <RETURN> T O CONTINUE | |
1903 | OR '^' TO QUIT: 1 | |
1904 | Enter/Edit Document cont’d | |
1905 | Creating n ew progres s note... | |
1906 | Patient Lo cation: G ENERAL MED ICINE | |
1907 | Da te/time of Visit: 0 4/18/96 10 :00 | |
1908 | D ate/time o f Note: N OW | |
1909 | Author o f Note: T IUPROVIDER ,NINE | |
1910 | ...OK? YES// <Ent er> | |
1911 | SUBJECT (O PTIONAL de scription) : <Enter> | |
1912 | Calling te xt editor, please wa it... | |
1913 | 1>Mr. TI UPatient's allergies improved with medic ation. | |
1914 | 2> | |
1915 | EDIT Optio n: <Enter > | |
1916 | Save chang es? YES// <Enter> | |
1917 | Saving Adv erse React /Allergy w ith change s... | |
1918 | Enter your Current S ignature C ode: xxx SIGNATURE VERIFIED. . | |
1919 | Print this note? No/ / <Enter> NO | |
1920 | You may en ter anothe r CLINICAL DOCUMENT. Press RET URN to exi t. | |
1921 | Select PAT IENT NAME: <Enter> | |
1922 | --- Clinic ian's Menu --- | |
1923 | 1 Individual Patient D ocument | |
1924 | 2 All MY UNS IGNED Docu ments | |
1925 | 3 Multiple P atient Doc uments | |
1926 | 4 Enter/edit Document | |
1927 | Select Int egrated Do cument Man agement Op tion: <Ent er> | |
1928 | Documents Requiring Additional Signature XE "Docum ents Requi ring Addit ional Sign ature" | |
1929 | A report i s availabl e that wil l give you all docum ents requi ring your additional signature . This rep ort is ava ilable fro m the Inte grated Doc ument Mana gement Men u and the Progress N otes User Menu. | |
1930 | To run thi s report: | |
1931 | From a men u, select ALL Docume nts requir ing my Add itional Si gnature XE "Addition al Signatu re" . | |
1932 | The follow ing report is displa yed: | |
1933 | Select Int egrated Do cument Man agement Op tion: ? | |
1934 | 1 Individual Patient D ocument | |
1935 | 2 All MY UNS IGNED Docu ments | |
1936 | 3 All MY UND ICTATED Do cuments | |
1937 | 4 Multiple P atient Doc uments | |
1938 | 5 Enter/edit Document | |
1939 | 6 ALL Docume nts requir ing my Add itional Si gnature | |
1940 | Enter ?? f or more op tions, ??? for brief descripti ons, ?OPTI ON for hel p text. | |
1941 | Select Int egrated Do cument Man agement Op tion: 6 A LL Documen ts requiri ng my Addi tional Sig nature | |
1942 | Searching for the do cuments. | |
1943 | My Identif ied Signer Docs Feb 21, 20 05@19:00:3 2 Page: 1 of 1 | |
1944 | ALL DOC UMENTS Req uiring My Additional Signature | |
1945 | Patie nt Doc ument Ref Date Sta tus | |
1946 | 1 CPRSP ATIENT,S ( C1050) ONE -PER-VISIT NOTE 12/ 18/02 com pleted | |
1947 | 2 CPRSP ATIENT,T ( C6572) PAT IENT EDUCA TION 06/ 19/98 com pleted | |
1948 | 3 CPRSP ATIENT,T ( C6572) MED ICINE CS C ONSULT 06/ 09/98 com pleted | |
1949 | + Next Scr een - Pre v Screen ?? More Ac tions >>> | |
1950 | Edit Browse Expan d/Collapse Entry | |
1951 | Make Addendum Print Encou nter Edit | |
1952 | Link ... Identify Signers Quit | |
1953 | Sign/ Cosign Delete Do cument | |
1954 | Detai led Displa y Interdisc ipl'ry Not e | |
1955 | Select Act ion:Quit// | |
1956 | Personal P references XE "Perso nal Prefer ences" | |
1957 | The two op tions on t his menu l et you cus tomize the way TIU o perates fo r you; tha t is, whic h prompts will appea r, what li sts you wi ll see to select fro m, etc. Th us, if you only work with Disc harge Summ aries or P rogress No tes, or on ly a speci fic set wi thin these categorie s, you can set your preference s so that only these documents appear on selection lists. Yo u can also specify t he way doc uments are displayed on your r eview scre ens: by pa tient, by author, by type, in chronologi cal or rev erse chron ological o rder, etc. | |
1958 | If you req uire cosig natures on your docu ments (for example, because yo u’re a med ical stude nt, PA, or some othe r category that your site has designated as needin g cosignat ure), you can design ate your “ Default Co signer” an d then thi s person w ill be the default w hen you’re prompted for the Ex pected Cos igner. | |
1959 | OptionDesc riptionPer sonal Pref erencesSpe cify defau lts that y ou want in TIU (e.g. , Default Location, Sort Order , Display Menus, Pat ient Selec tion Prefe rence, etc .) Documen t List Man agementSpe cify your “pick list s” for doc ument sele ction when composing or editin g document s.Personal Preferenc es | |
1960 | Steps to u se option: | |
1961 | 1. Select Personal P references from your TIU menu . | |
1962 | Select Pro gress Note s/Discharg e Summary [TIU] Opti on: Person al Prefere nces | |
1963 | 1 Personal P references | |
1964 | 2 Document L ist Manage ment | |
1965 | Select Per sonal Pref erences Op tion: 1 P ersonal Pr eferences | |
1966 | 2. Select Personal P references from your Personal Preference s menu. | |
1967 | Personal P references , cont’d | |
1968 | 3. Answer the follow ing prompt s, as appr opriate. | |
1969 | Select Per sonal Pref erences Op tion: Pers onal Prefe rences | |
1970 | Enter/e dit Person al Prefere nces for T IUPROVIDER ,ONE O T | |
1971 | Are you adding 'TI UPROVIDER, ONE' as | |
1972 | a new TIU PERSON AL PREFERE NCES (the 5TH)? y ( Yes) | |
1973 | DEFAULT LO CATION: Ca rdiology C linic | |
1974 | REVIEW SCR EEN SORT F IELD: ? | |
1975 | Specify t he attribu te by whic h the docu ment list should be sorted. | |
1976 | Choos e from: | |
1977 | P pati ent | |
1978 | D docu ment type | |
1979 | R refe rence date | |
1980 | S stat us | |
1981 | C comp letion dat e | |
1982 | A auth or | |
1983 | E expe cted cosig ner | |
1984 | REVIEW SCR EEN SORT F IELD: p p atient | |
1985 | REVIEW SCR EEN SORT O RDER: ? | |
1986 | Pleas e specify the order in which y ou want th e list sor ted | |
1987 | Choos e from: | |
1988 | A asce nding | |
1989 | D desc ending | |
1990 | REVIEW SCR EEN SORT O RDER: a a scending | |
1991 | DISPLAY ME NUS: ? | |
1992 | Indic ate whethe r menus (f or documen t selectio n, etc.) s hould | |
1993 | be d isplayed. | |
1994 | Choos e from: | |
1995 | 0 NO | |
1996 | 1 YES | |
1997 | DISPLAY ME NUS: 1 YE S | |
1998 | PATIENT SE LECTION PR EFERENCE: ? | |
1999 | Pleas e indicate your pati ent select ion prefer ence | |
2000 | Choos e from: | |
2001 | S sing le | |
2002 | M mult iple | |
2003 | PATIENT SE LECTION PR EFERENCE: m multipl e | |
2004 | DEFAULT CO SIGNER: ? | |
2005 | Indic ate which person wil l usually cosign you r Progress Notes. | |
2006 | Answer wi th NEW PER SON NAME, or INITIAL , or SSN, or NICK NA ME, or DEA #, | |
2007 | or VA# | |
2008 | Do you wa nt the ent ire 66-Ent ry NEW PER SON List? N | |
2009 | DEFAULT CO SIGNER: TI UPATIENT,T WO TIUP ATIENT, TW O, CA P HYSICIAN | |
2010 | ASK 'Save changes?' AFTER EDIT : y YES | |
2011 | ASK SUBJEC T FOR PROG RESS NOTES : YES// ?? | |
2012 | Enter YES if yo u want to be prompte d for a SU BJECT when entering or | |
2013 | editi ng a Progr ess Note. Subject i s a freete xt, indexe d field wh ich | |
2014 | may h elp you to find note s about a given topi c, etc. | |
2015 | Choos e from: | |
2016 | 1 YES | |
2017 | 0 NO | |
2018 | ASK SUBJEC T FOR PROG RESS NOTES : YES// <E nter> | |
2019 | NUMBER OF NOTES ON R EV SCREEN: ?? | |
2020 | This determines the numbe r of notes that will be includ ed in your | |
2021 | initi al list wh en reviewi ng progres s notes by patient. | |
2022 | Personal P references , cont’d | |
2023 | NUMBER OF NOTES ON R EV SCREEN: 5?? | |
2024 | Type a Number b etween 15 and 100 | |
2025 | NUMBER OF NOTES ON R EV SCREEN: 15 | |
2026 | SUPPRESS R EVIEW NOTE S PROMPT: ?? | |
2027 | Allow s user to specify wh ether to s uppress th e prompt t o | |
2028 | Revie w Existing Notes on entry of a Progress Note. YES will | |
2029 | SUPPR ESS the pr ompt, whil e NO, or n o entry wi ll allow t he | |
2030 | site' s default setting to take prec edence. | |
2031 | Choos e from: | |
2032 | 1 YES | |
2033 | 0 NO | |
2034 | SUPPRESS R EVIEW NOTE S PROMPT: 0 | |
2035 | Select DAY OF WEEK: Monday | |
2036 | Are you a dding 'Mon day' as a new DAY OF WEEK (the 1ST for t his TIU PE RSONAL PRE FERENCES)? Y (Yes) | |
2037 | HOSPITAL LOCATION: GENERAL M EDICINE TIUPA TIENT,TWO | |
2038 | Select DAY OF WEEK: <Enter> | |
2039 | 1 Personal P references | |
2040 | 2 Document L ist Manage ment | |
2041 | Document L ist Manage ment XE "D ocument Li st Managem ent" | |
2042 | This optio n allows y ou to spec ify which types (Tit les) of do cuments yo u wish to choose fro m when ask ed to sele ct from a given Clas s (e.g., D ischarge S ummary or Progress N otes). The n when you create a Progress N ote, you w ill be pro mpted to s elect from the speci fied list of Titles, say, Lipi d Clinic N ote, Histo ry & Physi cal, Inter service Tr ansfer Not e, and Dis charge Pla nning, in that order . This opt ion also a llows you to specify a default title for the selec ted Class. | |
2043 | Steps to u se option: | |
2044 | 1. Select Document L ist Manage ment from your Perso nal Prefer ences Menu on your T IU menu. | |
2045 | Select Per sonal Pref erences Op tion: 2 D ocument Li st Managem ent | |
2046 | -- - Personal Document Lists --- | |
2047 | This optio n allows y ou to crea te and mai ntain list s of TITLE S for any of the act ive CLASSE S of docum ents suppo rted by TI U at your site. | |
2048 | Explain De tails? NO/ / y YES | |
2049 | When you u se the opt ion to ent er a docum ent belong ing to a g iven class , you will be asked to select a TITLE be longing to that clas s. | |
2050 | Document L ist Manage ment, cont ’d | |
2051 | For any pa rticular c lass, you may find t hat you on ly wish to choose fr om among a few highl y specific titles (e .g., if yo u are a Pu lmonologis t entering a PROGRES S NOTE, yo u may wish to choose from a sh ort list o f three or four titl es related to Pulmon ary Functi on, or Pul monary Dis ease). | |
2052 | Rather tha n presenti ng you wit h a list o f hundreds of unrela ted titles , TIU will present y ou with th e list you name here . | |
2053 | In the eve nt that yo u need to select a T ITLE which doesn't a ppear on y our list, you will a lways be a ble to do so. | |
2054 | NOTE: If you expect to enter a single t itle, or w ould be un duly restr icted by u se of a sh ort list, then we re commend th at you byp ass the cr eation of a list, an d simply e nter a DEF AULT TITLE for the c lass. This option wi ll afford you the op portunity to do so. | |
2055 | 2. Answer the follow ing prompt s, as appr opriate. | |
2056 | Enter/edit Personal Document L ist for ON E TIUPROVI DER | |
2057 | Add a new Personal D ocument Li st? YES// <Enter> | |
2058 | CLASS: ? | |
2059 | Pleas e select t he parent group to w hich the d ocument li st | |
2060 | belon gs. You ma y only pic k CLASSES of documen ts at this | |
2061 | promp t. | |
2062 | Answe r with TIU DOCUMENT DEFINITION NAME, or ABBREVIATI ON, | |
2063 | or PR INT NAME | |
2064 | Do you wa nt the ent ire TIU DO CUMENT DEF INITION Li st? y (Ye s) | |
2065 | Choose fro m: | |
2066 | DISCHAR GE SUMMARY CLAS S | |
2067 | PROGRES S NOTES CLASS | |
2068 | CLASS: Pro gress Note s | |
2069 | Edit (L)is t, (D)efau lt TITLE, or (B)oth? BOTH// <E nter> bot h | |
2070 | When selec ting from this PAREN T CLASS, w hich TITLE S would yo u like to be present ed with in itially? | |
2071 | Select TIT LE: PSYCHO LOGY - CRI SIS | |
2072 | Select TIT LE: PSYCHO LOGY - FAM ILY THERAP Y | |
2073 | Select TIT LE: PSYCHO LOGY - NUR SING NOTE | |
2074 | Select TIT LE: NURSIN G NOTES - ENCOUNTER GROUP | |
2075 | Now, Speci fy the TIT LE you'd l ike as you r DEFAULT for PROGRE SS NOTES | |
2076 | DEFAULT TI TLE: ?? | |
2077 | This determines what TITL E will be offered by default w hen | |
2078 | selec ting from a given pa rent class (e.g., wh en enterin g a | |
2079 | PROGR ESS NOTE, you may wa nt the DEF AULT TITLE to be DIA BETES | |
2080 | EDUCA TION, etc. ). | |
2081 | Document L ist Manage ment, cont ’d | |
2082 | DEFAULT TI TLE: PSYCH OLOGY | |
2083 | 1 P SYCHOLOGY - BEHAV ME D TITLE | |
2084 | 2 P SYCHOLOGY - BIOFEEDB ACK TITLE | |
2085 | 3 P SYCHOLOGY - CRISIS TI TLE | |
2086 | 4 P SYCHOLOGY - FAMILY T HERAPY TITL E | |
2087 | 5 P SYCHOLOGY - IP SATC T ITLE | |
2088 | TYPE '^' T O STOP, OR | |
2089 | CHOOSE 1-5 : 3 | |
2090 | Select PER SONAL DOCU MENT LIST Name: SUBS TANCE ABUS E | |
2091 | 1 S UBSTANCE A BUSE TITLE | |
2092 | 2 S UBSTANCE A BUSE COMMI TTEE TITLE | |
2093 | 3 S UBSTANCE A BUSE TLC TI TLE | |
2094 | 4 S UBSTANCE A BUSE TREAT MENT CENTE R CONSULT T ITLE | |
2095 | CHOOSE 1-4 : 1 | |
2096 | Are you adding 'SU BSTANCE AB USE' as | |
2097 | a new PERSONAL D OCUMENT LI ST (the 1S T for this TIU PERSO NAL DOCUME NT TYPE LI ST)? Y (Yes) | |
2098 | SEQUENCE : 1 | |
2099 | DISPLAY NAME: SUBS TANCE ABUS E | |
2100 | Document D efinitions (Clinicia n) XE "Doc ument Defi nitions (C linician)" | |
2101 | TIU uses a structure called Do cument Def initions t o organize Progress Notes, Dis charge Sum maries, an d other do cuments. I t contains the Docum ent Defini tion Hiera rchy XE "D ocument De finition H ierarchy" , which al lows docum ents (Titl es) to inh erit chara cteristics of the hi gher level s, Class a nd Documen t Class, s uch as sig nature req uirements and print characteri stics. Thi s structur e creates the capabi lity for b etter inte gration, s hared use of boilerp late text, component s, and obj ects, and a more man ageable or ganization of docume nts. End u sers (clin ical, admi nistrative , and MIS staff) nee d not be a ware of th e hierarch y. They wo rk at the Title leve l, with th e actual d ocuments. | |
2102 | ||
2103 | The Docume nt Definit ions menu for Clinic ians may b e assigned to those clinicians who are i nterested in creatin g and edit ing boiler plate text or in vie wing or ed iting Docu ment Defin ition entr ies (Class , Document Class, or Title). Y ou can als o view ava ilable Obj ects that can be emb edded in b oilerplate text. See your Clin ical Coord inator or the TIU Im plementati on Guide i f you need further i nformation about the se options or descri ptions of Document D efinition concepts. | |
2104 | OptionDesc riptionEdi t Document Definitio ns XE "Edi t Document Definitio ns" T his option allows yo u to view and edit e ntries. En tries are presented in hierarc hy order. Items of a n entry ar e in Seque nce order, or if the y have no Sequence, in alphabe tic order by Menu Te xt, and ar e indented below the entry. Si nce Object s don’t be long to th e hierarch y, they ca n’t be vie wed/edited using the Edit Opti on.Sort Do cument Def initions X E "Sort Do cument Def initions" The Sort option all ows you to view and edit entri es, by sor t criteria . It then displays s elected en tries in a lphabetic order by N ame, rathe r than in hierarchy order. Dep ending on sort crite ria, entri es can inc lude Objec ts. View O bjects XE "View Obje cts" The XE "Objec ts" optio n displays Objects w ithin sele cted Start With and Go To valu es in alph abetic ord er by Name .Edit Docu ment Defin itions XE "Edit Docu ment Defin itions" | |
2105 | This examp le shows y ou how to traverse t he hierarc hy to see details ab out a Titl e in Docum ent Defini tions, in this case, an Advanc e Directiv e. The fir st screen shows just the top l evel of do cument typ es. A + in dicates th at there a re items u nder that document t ype. To se e these, s elect Expa nd/Collaps e, then en ter the nu mber of th e document type to b e expanded . | |
2106 | Select Doc ument Defi nitions (C linician) Option: 1 Edit Docu ment Defin itions | |
2107 | Edit Docum ent Defini tions Apr 17, 19 97 16:42:5 3 P age: 1 of 1 | |
2108 | BASI CS | |
2109 | Nam e Type | |
2110 | 1 CLI NICAL DOCU MENTS CL | |
2111 | 2 +D ISCHARGE S UMMARY CL | |
2112 | 3 +P ROGRESS NO TES CL | |
2113 | 4 +A DDENDUM DC | |
2114 | ?Help >Scroll Right PS /PL PrintS crn/List +/- >>> | |
2115 | Expan d/Collapse Detailed Display Qui t | |
2116 | Jump to Documen t Def Try | |
2117 | Boile rplate Tex t Find | |
2118 | Select Act ion: Quit/ / e Expa nd/Collaps e | |
2119 | Select Ent ry: (1-4) : 3....... . | |
2120 | Edit Docum ent Defini tions Apr 17, 19 97 16:43:5 6 Pag e: 1 of 1 | |
2121 | BASI CS | |
2122 | Nam e Type | |
2123 | 1 CLI NICAL DOCU MENTS CL | |
2124 | 2 +D ISCHARGE S UMMARY CL | |
2125 | 3 P ROGRESS NO TES CL | |
2126 | 4 +ADVANCE D IRECTIVE DC | |
2127 | 5 +ADVERSE R EACTION/AL LERGY DC | |
2128 | 6 +CRISIS NO TE DC | |
2129 | 7 +CLINICAL WARNING DC | |
2130 | 8 +HISTORICA L TITLES DC | |
2131 | 9 +A DDENDUM DC | |
2132 | ?He lp >Scro llRight PS/PL Prin tScrn/List +/- >>> | |
2133 | Expan d/Collapse Detailed Display Qui t | |
2134 | Jump to Documen t Def Try | |
2135 | Boile rplate Tex t Find | |
2136 | Select Act ion: Quit/ / Expand/C ollapse=4 | |
2137 | Edit Docum ent Defini tions, con t’d | |
2138 | Edit Docum ent Defini tions Ap r 17, 1997 16:44:17 P age: 1 of 1 | |
2139 | BASI CS | |
2140 | Nam e Type | |
2141 | 1 CLI NICAL DOCU MENTS CL | |
2142 | 2 +D ISCHARGE S UMMARY CL | |
2143 | 3 P ROGRESS NO TES CL | |
2144 | 4 ADVANCE D IRECTIVE DC | |
2145 | 5 ADVANCE DIRECTIVE TL | |
2146 | 6 +ADVERSE R EACTION/AL LERGY DC | |
2147 | 7 +CRISIS NO TE DC | |
2148 | 8 +CLINICAL WARNING DC | |
2149 | 9 +HISTORICA L TITLES DC | |
2150 | 10 +A DDENDUM DC | |
2151 | ?H elp >Scr ollRight PS/PL Pri ntScrn/Lis t +/- >>> | |
2152 | Expan d/Collapse Detailed Display Qui t | |
2153 | Jump to Documen t Def Try | |
2154 | Boile rplate Tex t Find | |
2155 | Select Act ion: Quit/ / DET DE TAILED DIS PLAY | |
2156 | Select Ent ry: (1-11 ): 5 | |
2157 | Non-Owner ; View Onl y | |
2158 | Press RETU RN to cont inue or '^ ' or '^^' to exit: < Enter> | |
2159 | Detailed D isplay Ap r 17, 1997 16:44:31 Pag e: 1 of 1 | |
2160 | Ti tle ADVANC E DIRECTIV E | |
2161 | Basics Note: Valu es precede d by * hav e been inh erited | |
2162 | Name: ADVANCE DI RECTIVE | |
2163 | Abbrev iation: ADIR | |
2164 | Prin t Name: ADVANCE DI RECTIVE | |
2165 | Type: TITLE | |
2166 | Na tional | |
2167 | St andard: YES | |
2168 | Status: ACTIVE | |
2169 | Owner: CLINICAL C OORDINATOR | |
2170 | In Use: YES | |
2171 | Items | |
2172 | Boilerpl ate Text | |
2173 | ? Help +, - Ne xt, Previo us Screen PS/PL | |
2174 | ||
2175 | ||
2176 | ||
2177 | Try Find Qui t | |
2178 | Select Act ion: Quit/ / | |
2179 | View Objec ts XE "Vie w Objects" | |
2180 | This optio n displays Objects X E "Objects " in alph abetical o rder by Na me. You ca n print al l availabl e Objects from your site, or s pecific on es. | |
2181 | --- Clinic ian Docume nt Definit ion Menu - -- | |
2182 | ||
2183 | Edit Docum ent Defini tions | |
2184 | ||
2185 | Sort Docum ent Defini tions | |
2186 | ||
2187 | View Objec ts | |
2188 | Select Doc ument Defi nitions (C linician) Option: 3 View Obje cts | |
2189 | START WITH OBJECT: F IRST// <En ter>...... .......... .......... .......... .... | |
2190 | Objects Apr 17, 1997 11:57:57 Pag e: 1 of 3 | |
2191 | Objects | |
2192 | Name St atus | |
2193 | ACTIVE MED ICATIONS A | |
2194 | ALLERGIES/ ADR A | |
2195 | BLOOD PRES SURE A | |
2196 | CURRENT AD MISSION A | |
2197 | NOW A | |
2198 | PATIENT AG E I | |
2199 | PATIENT DA TE OF BIRT H A | |
2200 | PATIENT DA TE OF DEAT H A | |
2201 | PATIENT HE IGHT A | |
2202 | PATIENT NA ME A | |
2203 | PATIENT RA CE A | |
2204 | PATIENT SE X A | |
2205 | PATIENT SS N A | |
2206 | PATIENT WE IGHT A | |
2207 | PULSE A | |
2208 | RESPIRATIO N A | |
2209 | TEMPERATUR E A | |
2210 | TODAY'S DA TE A | |
2211 | VISIT DATE A | |
2212 | + ?Help >S crollRight PS/PL P rintScrn/L ist +/- >>> | |
2213 | Find Deta iled Displ ay Quit | |
2214 | Change Vie w | |
2215 | Select Act ion: Next Screen// | |
2216 | TIU and He alth Summa ry XE "Hea lth Summar y" | |
2217 | A new Heal th Summary component XE "Healt h Summary component" is avail able (thro ugh Patch GMTS*2.7*1 2 XE "Patc h GMTS*2.7 *12" ), Se lected Pro gress Note s, which a llows sele ction of s pecific Pr ogress Not es Titles for displa y on Healt h Summarie s. Patch G MTS*2.7*45 , Interdis ciplinary Progress N otes, expa nds this f unctionali ty to incl ude Interd isciplinar y Notes. | |
2218 | All Progre ss Notes, Discharge Summary, a nd CWAD co mponents X E "CWAD co mponents" now extra ct data fr om TIU, ra ther than Progress N otes (GMRP ), or Disc harge Summ ary (GMRD) . | |
2219 | Care has b een taken to assure that the f ormatting and conten t of the c omponents have remai ned the sa me, except that the signature block info rmation wi ll now ref lect the a uthor's (a nd cosigne r's) name and title at the tim e of signa ture, rath er than di splaying t heir curre nt values at the tim e of outpu t. | |
2220 | Chapter 4: TIU for M edical Rec ord Techni cians | |
2221 | Medical Re cord Techn icians XE "Medical R ecord Tech nicians" in the MIS or HIMS o f Medical Administra tion Servi ce complet e the task s of assur ing that a ll dischar ge summari es placed in a patie nt’s medic al record have been verified f or accurac y and comp letion. Th ey are als o responsi ble for as suring tha t a perman ent chart copy has b een placed in a pati ent’s medi cal record for each separate a dmission t o the hosp ital. | |
2222 | MRT Menu X E "MRT Men u" | |
2223 | This is th e main TIU menu for Medical Re cord Techn icians (MR Ts) XE "MR Ts" . It i ncludes al l of the o ptions nec essary for MRTs to r eview, edi t, sign, a nd print d ocuments, print repo rts on TIU documents , search f or documen ts, and re view uploa d filing e vents. | |
2224 | OptionDesc riptionInd ividual Pa tient Docu ment XE "I ndividual Patient Do cument" Th is option allows MRT s to revie w, edit, o r sign pat ient Docum ents.Multi ple Patien t Document s XE "Mult iple Patie nt Documen ts" Text I ntegration Utilities review sc reen of al l types of TIU docum ents avail able for M RTs.Review Upload Fi ling Event s XE "Revi ew Upload Filing Eve nts" This option all ows MRTs t o generate a list of all uploa d filing e vents (i.e ., success es, filing errors, o r missing field erro rs) by div ision XE " division" , by statu s, by date range, an d to print the corre sponding e rror recor ds or reso lve the er ror (e.g., correct t he Patient SSN or Ad mission da te), and r etry the f iler.Print Document Menu ... X E "Print D ocument Me nu ..." Th is menu al lows MAS p ersonnel t o print ch art or wor k copies o f discharg e summarie s, progres s notes, o r mixed Do cuments.Re leased/Unv erified Re port XE "R eleased/Un verified R eport" Thi s report g ives infor mation on documents for a spec ified time period th at have be en release d from tra nscription but still aren’t ve rified. | |
2225 | This menu action can be elimin ated if Tr anscriptio n Release or MAS Ver ification parameters are not e nabled.Sea rch for Se lected Doc uments XE "Search fo r Selected Documents " Allows M RT’s to ge nerate lis ts of sele cted docum ents by ex tended sea rch criter ia (e.g., status, se arch categ ory, and r eference d ate range) . These ca n then be reviewed i ndividuall y or by gr oups, veri fied, sent back to t ranscripti on, reassi gned, or p rinted.Uns igned/Unco signed Rep ort XE "Se arch for S elected Do cuments" P rovides in formation on unsign ed/uncosig ned docume nts for on e, multipl e, or all divisions. The repor t can be e ither Summ ary or Ful l. The sum mary repor t lists th e number o f document s by the s ervice or section of the autho r. The ful l report l ists detai led docume nt informa tion (such as author , patient, patient S SN, etc.) by the ser vice or se ction of t he author. Reassign ment Docum ent Report XE " Reas signment D ocument Re port" Prov ides a lis t of reass igned note s based on date rang e.OptionDe scriptionR eview unsi gned addit ional sign atures XE "Review un signed add itional si gnatures" | |
2226 | Gives a li st of docu ments that require a dditional signatures . Provides either a detailed r eport list ing each d ocument th at require s an addit ional sign ature, or a summary report. In dividual P atient Doc ument XE " Individual Patient D ocument" | |
2227 | Use this o ption to r eview, ver ify, print or other actions an MRT can p erform on clinical d ocuments f or a selec ted patien t. | |
2228 | Steps to u se option: | |
2229 | 1. Select Individual Patient D ocument fr om the TIU MRT menu, and then enter a pa tient name to view d ocuments f or. | |
2230 | Select Tex t Integrat ion Utilit ies (MRT) Option: 1 Individua l Patient Document | |
2231 | Select PAT IENT NAME: TIUPATIEN T,ONE TIUP ATIENT,ONE 666-23 -3456 1A YES SC VETE RAN | |
2232 | (2 notes) W: 05/28 /96 12:33 | |
2233 | Available documents: 10/24/96 thru 10/2 8/96 (3) | |
2234 | Enter a da te range, then choos e a docume nt from th e list. | |
2235 | Please spe cify a dat e range fr om which t o select d ocuments: | |
2236 | List docum ents Begin ning: 02/1 7/96// <En ter> (FEB 17, 1992) | |
2237 | Thru: 10/2 8/96//<Ent er> (OC T 28, 1996 ) | |
2238 | 1 10/28/ 96 17:11 BP TEST One TI UProvider, MD | |
2239 | Adm: 07/ 22/91 Dis : 02/12/96 | |
2240 | 2 10/25/ 96 11:32 Psychology - Crisis Four T IUProvider | |
2241 | Adm: 10/ 25/96 | |
2242 | Choose doc uments: ( 1-6): 1 | |
2243 | Individual Patient D ocument, c ont’d XE " Multiple P atient Doc uments" | |
2244 | 3. The sel ected docu ment is di splayed. Y ou may pre ss Enter t o see the remaining two pages, or choose an action to perfor m. | |
2245 | Browse Doc ument Oct 3 0, 1996 10 :33:54 Page: 1 of 3 | |
2246 | BP TEST | |
2247 | TIUPATIENT , O 666-23-34 56 1A Visit Date : 07/22/91 @11:06 | |
2248 | DATE OF NO TE: OCT 28 , 1996@17: 11:51 ENT RY DATE: O CT 28, 199 6@17:11:51 | |
2249 | AUTH OR: TIUPRO VIDER, ONE EXP COSIGNER: | |
2250 | URGEN CY: STATUS: C OMPLETED | |
2251 | NAME: TIUPATIEN T, ONE | |
2252 | SEX: MALE | |
2253 | DOB: SEP 12,19 44 | |
2254 | ALLERGIES: Amoxicill in, Aspiri n, MILK | |
2255 | LABS: | |
2256 | WBC 8.7, R BC 5.1, HG B 16, HCT 47, MCV 91 , MCH 29, MCHC 34, P lt 320 | |
2257 | + Nex t Screen - Prev Scr een ?? Mo re Actions >>> | |
2258 | Find Edit Cop y | |
2259 | Verif y/Unverify Send Back Pri nt | |
2260 | On Ch art Reassign Qui t | |
2261 | Select Act ion: Next Screen// | |
2262 | Multiple P atient Doc uments XE "Multiple Patient Do cuments" | |
2263 | Use this o ption to d isplay TIU documents of select ed types, which can then be in dividually or multip ly reviewe d, verifie d, sent ba ck to tran scription, reassigne d, or prin ted. | |
2264 | | |
2265 | Caution: | |
2266 | Avoid maki ng your re quests too broad (in statuses, search ca tegories, and date r anges) bec ause these searches can use a lot of sys tem resour ces, slowi ng the com puter syst em down fo r everyone . | |
2267 | Steps to u se option: | |
2268 | Select Mul tiple Pati ent Docume nts from y our TIU me nu. | |
2269 | Multiple P atient Doc uments, co nt’d XE "M ultiple Pa tient Docu ments" | |
2270 | 2. Selec t one or m ore divisi ons. | |
2271 | Select div ision: ALL // ? | |
2272 | ENTER: | |
2273 | - Ret urn for al l division s, or | |
2274 | - A d ivision an d return w hen all di visions ha ve been se lected--li mit 20 | |
2275 | Impre cise selec tions will yield an additional prompt. | |
2276 | (e.g. When a us er enters 'A', all i tems begin ning with 'A' are di splayed.) | |
2277 | Answer with MEDI CAL CENTER DIVISION NUM, or NA ME, or FAC ILITY NUMB ER, or | |
2278 | TR EATING SPE CIALTY | |
2279 | Choose from: | |
2280 | 1 SALT LAKE OEX 660 | |
2281 | 2 ISC- SLC-A4 660HA | |
2282 | 3 SALT LAKE CIOF O 660G C | |
2283 | Select div ision: ALL // <Enter> | |
2284 | 3. Select one or mor e of the f ollowing s tatuses. | |
2285 | 1 undic tated 6 uncos igned | |
2286 | 2 untra nscribed 7 complet ed | |
2287 | 3 unrel eased 8 amend ed | |
2288 | 4 unver ified 9 purg ed | |
2289 | 5 unsig ned 10 delet ed | |
2290 | Enter sele ction(s) b y typing t he name(s) , number(s ), or abbr eviation(s ). | |
2291 | Select Sta tus: UNSIG NED// 4 UNVERIFIED | |
2292 | Multiple P atient Doc uments, co nt’d XE "M ultiple Pa tient Docu ments" | |
2293 | 4. Select one of the following types (th ese may be different at your s ite): | |
2294 | Addendum | |
2295 | Discharge Summary | |
2296 | Progress N otes | |
2297 | Select Cli nical Docu ments Type (s): All A ddendum, D ischarge S ummary, Pr ogress Not es | |
2298 | 5. Enter a date rang e. | |
2299 | Start Entr y Date [Ti me]: T-7// t-30 (Ma y 02, 1997 ) | |
2300 | Ending Ent ry Date [T ime]: NOW/ / <Enter> (JUN 02, 1997@14:3 1) | |
2301 | Searching for the do cuments... ......... | |
2302 | 6. All the documents for the c riteria se lected are displayed . Choose a n action t o perform, then the document. | |
2303 | Verify act ion XE "Ve rify actio n" exampl e | |
2304 | UNVERIFIED Documents Jun 02, 1997 14:31:12 Page: 1 of 1 | |
2305 | from 05/ 02/97 to 0 6/02/97 9 documents | |
2306 | Patient Docum ent Admitted Disch'd | |
2307 | 1 TIUPATI ENT,ONE(T1 255) Adve rse React/ Allergy 05/03/97 05/31/97 | |
2308 | 2 TIUPATI ENT,TWO(T3 456) ADVA NCE DIRECT IVE 05/18/96 | |
2309 | 3 TIUPATI ENT,FIV(T3 456) ADVA NCE DIRECT IVE 08/14/95 | |
2310 | 4 *+ TIUP ATIENT,(T1 462) Disc harge Summ ary 05/04/92 05/31/97 | |
2311 | 5 + TIUPA TIENT,F(T3 456) Disc harge Summ ary 09/21/95 | |
2312 | 6 *+ TIUPA TIENT,O(T3 456) Disc harge Summ ary 07/22/91 05/12/97 | |
2313 | + N ext Screen - Prev S creen ?? More Actio ns >>> | |
2314 | Verify /Unverify L ink with R equest Print | |
2315 | On Cha rt S end Back Interd iscipl'ry Note | |
2316 | Edit D etailed Di splay Change View | |
2317 | Reassi gn B rowse Quit | |
2318 | Select Act ion: Quit/ / V Ver ify/Unveri fy | |
2319 | Select Doc ument(s): (1-3): 4 | |
2320 | Opening Di scharge Su mmary reco rd for rev iew... | |
2321 | 7. The sel ected docu ment is di splayed fo r you to v erify. | |
2322 | Verify Doc ument Jun 0 2, 1997 14 :38:22 Page: 1 of 2 0 | |
2323 | Discharge Summary | |
2324 | TIUPATIENT ,SEVEN 666 -45-3234 1A Adm: 0 5/04/92 D is: 05/31/ 97 | |
2325 | DICT DA TE: MAY 25 , 1997 ENT RY DATE: M AY 26, 199 7@08:54:19 | |
2326 | DICTATED BY: TIUPRO VIDER,THRE E ATT ENDING: TI UPROVIDER, ONE | |
2327 | URGEN CY: priori ty STATUS: U NVERIFIED | |
2328 | *** Discha rge Summar y Has ADDE NDA *** | |
2329 | DIAGNOSIS: | |
2330 | 1. Status post head trauma wi th brain c ontusion. | |
2331 | 2. Status post cere brovascula r accident . | |
2332 | 3. End st age renal disease on hemodialy sis. | |
2333 | 4. Corona ry artery disease. | |
2334 | + + Nex t Screen - Prev Screen ?? Mo re actions | |
2335 | Find Verify/Un verify | |
2336 | Print Quit | |
2337 | Select Act ion: Next Screen// v Verify/U nverify | |
2338 | Do you wan t to edit this Disch arge Summa ry? NO// < Enter> | |
2339 | VERIFY thi s Discharg e Summary? NO// y Y ES | |
2340 | Discharge Summary VE RIFIED | |
2341 | Chart copy queued. | |
2342 | Refreshing the list. | |
2343 | Review Upl oad Filing Events XE "Upload F iling Even ts" | |
2344 | Steps to u se option: | |
2345 | 1. Select Review Upl oad Filing Events fr om the TIU MRT menu. | |
2346 | Select Tex t Integrat ion Utilit ies (MRT) Option: R eview Uplo ad Filing Events | |
2347 | Select div ision XE " division" displayed . | |
2348 | Select div ision: ALL // SALT | |
2349 | 1 S ALT LAKE C IOFO 660GC | |
2350 | 2 S ALT LAKE O EX 6 60 | |
2351 | CHOOSE 1-2 : 2 SALT LAKE OEX 660 | |
2352 | Select ano ther divis ion: <Ente r> | |
2353 | | |
2354 | Note: | |
2355 | This promp t is only displayed if you are at a mult i-division medical c enter. In other word s, if the MULTIDIVIS ION MED CE NTER field of the MA S PARAMETE RS file is set to YE S. | |
2356 | 3. Select the event type to be displayed . | |
2357 | Select Eve nt Type: F ILING ERRO RS// ? | |
2358 | Enter a co de from th e list. | |
2359 | Selec t one of t he followi ng: | |
2360 | F Filing Err ors | |
2361 | M Missing Fi eld Errors | |
2362 | S Successes | |
2363 | A All Events | |
2364 | Select Eve nt Type: F ILING ERRO RS// <Ente r> Filing Errors | |
2365 | 4. Select the Resolu tion Statu s XE "Reso lution Sta tus" (Unr esolved Er rors XE "U nresolved Errors" , Resolved E rrors, or All Errors ). | |
2366 | Select Res olution St atus: UNRE SOLVED// ? | |
2367 | Enter a co de from th e list. | |
2368 | Selec t one of t he followi ng: | |
2369 | U Unresolved Errors | |
2370 | R Resolved E rrors | |
2371 | A All Errors | |
2372 | Select Res olution St atus: UNRE SOLVED// < Enter> Un resolved E rrors | |
2373 | Review Upl oad Filing Events, c ont’d XE " Upload Fil ing Events " | |
2374 | 5. Enter t he range o f dates. | |
2375 | Start Eve nt Date [T ime]: T-30 // <Enter> (MAY 27, 1996) | |
2376 | Ending Eve nt Date [T ime]: NOW/ / <Enter> | |
2377 | Searching for the ev ents..... | |
2378 | 6. All the documents for the c riteria se lected are displayed . Choose a n action t o perform, then the document t o perform it on. | |
2379 | Filing Eve nts Jun 26, 1996 0 9:07:53 Page: 1 of 1 | |
2380 | RESOL VED FILING EVENTS fr om 05/27/9 6 to 06/26 /96 | |
2381 | Docum ent Type Event Type Event Date/time | |
2382 | 1 DISCHARG E SUMMARY Filin g Error 06/0 6/96 13:29 | |
2383 | FILING E RROR XE "F ILING ERRO R" : STAT DISCHARGE SUMMARY R ecord coul d not be f ound or cr eated. | |
2384 | 2 PROGRESS NOTES Filin g Error 06/0 6/96 14:39 | |
2385 | + Nex t Screen - Prev Scr een ?? Mo re Actions >>> | |
2386 | Find Print eve nt Qui t | |
2387 | Displ ay/Fix Change vi ew | |
2388 | Select Act ion: Next Screen// D isplay/Fix =1-2 | |
2389 | Print Docu ment Menu XE "Print Document M enu" | |
2390 | This menu contains o ptions tha t print ch art or wor k copies o f discharg e summarie s, progres s notes, o r mixed do cuments. | |
2391 | 1 Discharge Summary Pr int | |
2392 | 2 Progress N ote Print | |
2393 | 3 Clinical D ocument Pr int | |
2394 | Discharge Summary Pr int XE "Di scharge Su mmary Prin t" | |
2395 | Use this o ption to p rint chart or work c opies of d ischarge s ummaries. | |
2396 | Steps to u se this op tion: | |
2397 | 1. Select Discharge Summary Pr int from t he MIS Man ager’s Pri nt Documen t Menu. | |
2398 | 2. Enter t he name of the patie nt whose d ischarge s ummary you want to p rint. | |
2399 | 1 Discharge Summary Pr int | |
2400 | 2 Progress N ote Print | |
2401 | 3 Clinical D ocument Pr int | |
2402 | Select Pri nt Documen t Menu Opt ion: 1 Di scharge Su mmary Prin t | |
2403 | Select PAT IENT NAME: TIUPATIEN T,ONE TIUP ATIENT,ONE 09-12 -44 66 6233456 YES | |
2404 | SC VETERAN | |
2405 | (2 notes ) C: 05/2 8/96 12:37 | |
2406 | (2 notes ) W: 05/2 8/96 12:33 | |
2407 | A: Know n allergie s | |
2408 | (2 notes ) D: 05/2 8/96 12:36 | |
2409 | Available summaries: 02/12/96 thru 02/1 2/96 (1) | |
2410 | 3. Enter t he range o f dates fr om which t o choose t he dischar ge summary or summar ies you wa nt to prin t. | |
2411 | Please spe cify a dat e range fr om which t o select s ummaries: | |
2412 | List summa ries Begin ning: 02/1 2/96// < Enter> (FE B 12, 1996 ) | |
2413 | Thru: 02/1 2/96// <En ter> | |
2414 | 1 02/12/ 96 13:56 Discharge Summary ONE TIU PROVIDER, MD | |
2415 | Adm: 07/ 22/91 Dis : 02/12/96 | |
2416 | Choose sum maries: ( 1-1): 1 | |
2417 | Do you wan t WORK cop ies or CHA RT copies? CHART// W ORK | |
2418 | DEVICE: HO ME// <Ent er> VAX | |
2419 | Discharge Summary Pr int Exampl e | |
2420 | SALT LAKE CITY pri ority 06 /27/96 08: 45 P age: 1 | |
2421 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ------- | |
2422 | PATIENT NA ME | AGE | SE X | RACE | SSN | CLAIM NUMBER | |
2423 | TIUPATIENT ,ONE | 51 | M | MEXI | 666-23-34 56 | | |
2424 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ------- | |
2425 | ADM DATE | DISC DATE | TYPE OF RE LEASE | INP | ABS | WARD NO | |
2426 | JUL 22, 19 91 | FEB 1 2, 1996 | REGULAR |1 666 | 0 | 1A | |
2427 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ------- | |
2428 | DICTATION DATE: JUN 09, 1996 TRANSCRIPT ION DATE: JUN 12, 19 96 | |
2429 | TRANSCRIPT IONIST: bs | |
2430 | DIAGNOSIS: | |
2431 | 1. Status post head trauma wi th brain c ontusion. | |
2432 | 2. Status post cere brovascula r accident . | |
2433 | 3. End st age renal disease on hemodialy sis. | |
2434 | 4. Corona ry artery disease. | |
2435 | 5. Conges tive heart failure. | |
2436 | 6. Hypert ension. | |
2437 | 7. Non in sulin depe ndent diab etes melli tus. | |
2438 | 8. Periph eral vascu lar diseas e, status post throm bectomies. | |
2439 | 9. Diabet ic retinop athy. | |
2440 | 10. Below knee amput ation. | |
2441 | 11. Chroni c anemia. | |
2442 | OPERATIONS /PROCEDURE S: | |
2443 | 1. MRI. | |
2444 | 2. CT SCAN OF HEAD. | |
2445 | HISTORY OF PRESENT I LLNESS: | |
2446 | Patient is a 49-year -old, whit e male wit h past med ical histo ry of end stage | |
2447 | renal dise ase, perip heral vasc ular disea se, status post BKA, coronary artery | |
2448 | disease, h ypertensio n, non ins ulin depen dent diabe tes mellit us, diabet ic | |
2449 | retinopath y, congest ive heart failure, s tatus post CVA, stat us post | |
2450 | thrombecto my admitte d from Any town VA af ter a fall from his wheelchair in the | |
2451 | hospital. He had qu estionable short las ting loss of conscio usness but patient i s not very sure what has happe ned. He d enies head ache, vomi ting, vert igo. | |
2452 | On admissi on patient had CT sc an which s howed a sm all area o f parenchy mal | |
2453 | hemorrhage in the ri ght tempor al lobe wh ich is mos t likely c onsistent with | |
2454 | hemorrhagi c contusio n without mid line s hift or in coordinati on. | |
2455 | ACTIVE MED ICATIONS: Isordil 2 0 mgs p.o. t.i.d., C oumadin 2. 5 mgs p.o. qd, | |
2456 | ferrous su lfate 325 mgs p.o. b .i.d., Ati van 0.5 mg s p.o. b.i .d., Lactu lose 15 | |
2457 | ccs p.o. b .i.d., Cal cium carbo nate 650 m gs p.o. b. i.d. with food, Beto ptic | |
2458 | 0.5% ophth almologic solution g tt OU b.i. d., Nephro caps 1 tab let p.o. q d, | |
2459 | Pilocarpin e 4% solut ion 1 gtt OU b.i.d., Compazine 10 mgs p. o. t.i.d. prn | |
2460 | nausea, Ty lenol 650 mgs p.o. q 4 hours pr n. | |
2461 | Patient is on hemodi alysis, no known dru g allergie s. | |
2462 | PHYSICAL E XAMINATION : Patient had stabl e vital si gns, his b lood press ure was | |
2463 | 160/85, pu lse 84, re spiratory rate 20, t emperature 98 degree s. Patien t was | |
2464 | alert, ori ented time s three, c ooperative . His spe ech was fl uent, | |
2465 | understand ing of spo ken langua ge was goo d. Attent ion span w as good. He had | |
2466 | D R A F T | |
2467 | Press RETU RN to cont inue or '^ ' to exit: <Enter> | |
2468 | Discharge Summary Pr int Exampl e cont’d | |
2469 | SALT LAKE CITY pri ority 06 /27/96 08: 46 P age: 4 | |
2470 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ------- | |
2471 | PATIENT NA ME | AGE | SE X | RACE | SSN | CLAIM NUMBER | |
2472 | TIUPATIENT ,ONE | 51 | M | MEXI | 666-23-34 56 | | |
2473 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ------- | |
2474 | moderate m emory impa irment, no apraxia n oted. Cra nial nerve s patient was | |
2475 | blind, pup ils are no t reactive to light, face was asymmetric , tongue a nd | |
2476 | palate are mid line. Motor ex amination showed mus cle tone a nd bulk wi thout | |
2477 | significan t changes. Muscle s trength in upper ext remities 5 /5 bilater ally, | |
2478 | sensory ex amination revealed i ntact ligh t touch, p inprick an d vibrator y | |
2479 | sensation. Reflexes 1+ in upp er extremi ties, coor dination f inger to n ose test w ithin norm al limits bilaterall y. Altern ating move ments with out signif icant chan ges bilate rally. Ne ck was sup ple. | |
2480 | LABORATORY : Showed sodium lev el 135, po tassium 4. 6, chlorid e 96, CO2 26, | |
2481 | BUN 39, cr eatinine 5 .3, glucos e level 13 8. White blood cell count was 7, | |
2482 | hemoglobin 11, hemat ocrit 34, platelet c ount 77. | |
2483 | HOSPITAL C OURSE: Pa tient was admitted a fter head trauma wit h multiple medical p roblems. His coumad in was hel d. Patien t had cerv ical spine x-rays wh ich showed definite narrowing of C5, C6 interspace , slight r etrolisthe sis at thi s level, p rominent s purs at th is level a s well as above and below. CT scan on a dmission s howed a mo derate amo unt of sca lp thinnin g with sub cutaneous air overly ing the le ft frontal lobe. A small area of left p arenchymal hemorrhag e adjacent to the ri ght petros bone in t he tempora l lobe whi ch most li kely repre sents a he morrhagic contusion. Repeated CT scan on 5/13/94 d idn’t show any progr essive cha nges. Pat ient remai ned in sta ble condit ion. He h ad hemodia lysis q.o. d. He res tarted tre atment wit h Coumadin . His las t PT was 1 1.9, PTT 3 1. Patien t refused before hem odialysis new blood tests. Hi s conditio n remained stable. | |
2484 | DISCHARGE MEDICATION S: Isordi l 20 mgs p .o. t.i.d. , Ferrous sulfate 32 5 mgs | |
2485 | p.o. b.i.d ., Ativan 0.5 mgs p. o. b.i.d., Lactulose 15 ccs p. o. b.i.d., Calcium c arbonate 6 50 mgs p.o . b.i.d., Compazine 10 mgs p.o . t.i.d. p rn nausea, Betoptic 0.5% OU b. i.d., Neph rocaps 1 p .o. qd, Pi locarpine 4% solutio n 1 gtt OU b.i.d., C oumadin 2. 5 mgs p.o. qd, Tylen ol 650 mgs p.o. q6 h ours prn p ain. | |
2486 | DISPOSITIO N/FOLLOW-U P: | |
2487 | Recommend follow PT/ PTT. Pati ent is on coumadin a nd CBC wit h differen tial | |
2488 | because pa tient has chronic an emia and t hrombocyto penia. | |
2489 | Patient wi ll be tran sferred to Anytown V A in stabl e conditio n on 5/19/ 94. | |
2490 | WORK COPY ========= UNOFFICIAL - NOT FOR MEDICAL R ECORD ==== ==== DO NO T FILE | |
2491 | SIGNATURE PHYSICIAN/ DENTIST SIGNATURE APPROVING PHYSICIAN/ DENTIST | |
2492 | TIUPROVIDE R, ONE, MD THREE T IUPROVIDER , MS | |
2493 | PGY2 Resid ent Medical In ternist | |
2494 | ========== ========== ===== CONF IDENTIAL I NFORMATION ========= ========== ====== | |
2495 | D R A F T | |
2496 | JUN 26, 19 96@17:36:0 2 ADDENDU M: | |
2497 | Routine vi sit today- -no change to condit ion. | |
2498 | SIGNATURE PHYSICIAN/ DENTIST SIGNATURE APPROVING PHYSICIAN/ DENTIST | |
2499 | ||
2500 | ||
2501 | ||
2502 | ||
2503 | ||
2504 | ||
2505 | Three TIUP rovider, M D | |
2506 | ||
2507 | ||
2508 | Medical In ternist | |
2509 | Progress N ote Print XE "Progre ss Note Pr int" | |
2510 | Use this o ption to p rint chart or work c opies of p rogress no tes. | |
2511 | Steps to u se option: | |
2512 | Select Pro gress Note Print fro m the Prin t Document Menu. | |
2513 | Enter a pa tient name . | |
2514 | Select Pri nt Documen t Menu Opt ion: 2 Pr ogress Not e Print | |
2515 | Select PAT IENT NAME: TIUPATIE NT,ONE TIU PATIENT,ON E 09 -12-44 666233456 YES | |
2516 | SC VETERAN | |
2517 | (2 notes ) C: 05/2 8/96 12:37 | |
2518 | (2 notes ) W: 05/2 8/96 12:33 | |
2519 | A: Know n allergie s | |
2520 | (2 notes ) D: 05/2 8/96 12:36 | |
2521 | Available notes: 02 /17/96 thr u 06/21/96 (31) | |
2522 | Enter the range of d ates for p rogress no tes you wa nt to prin t. | |
2523 | Choose a n ote from t hose liste d. | |
2524 | Please spe cify a dat e range fr om which t o select n otes: | |
2525 | List notes Beginning : 02/17/96 // <Enter> (FEB 17, 1996) | |
2526 | Thru : 06/21/96 // <Enter> (JUN 21, 1996) | |
2527 | 1 06/21/ 96 11:40 Lipid Clin ic FI VE TIUPROV IDER | |
2528 | Visit: 02/ 21/96 | |
2529 | 2 06/21/ 96 11:38 Social Wor k Service FI VE TIUPROV IDER | |
2530 | Visit: 04/ 18/96 | |
2531 | 3 06/07/ 96 00:00 Diabetes E ducation ON E TIUPROVI DER MD | |
2532 | Visit: 04/ 18/96 | |
2533 | 4 05/15/ 96 13:10 Addendum t o Diabetes Education SE VEN TIUPRO VIDER | |
2534 | Visit: 02/ 21/96 | |
2535 | 5 04/24/ 96 15:41 Lipid Clin ic TH REE TIUPRO VIDER Visit : 04/24/96 | |
2536 | 6 02/23/ 96 14:08 Diabetes E ducation TH REE TIUPRO VIDER | |
2537 | Visit: 02/ 21/9 | |
2538 | Choose not es: (1-6) :3, 5 | |
2539 | Do you wan t WORK cop ies or CHA RT copies? CHART// < Enter> | |
2540 | DEVICE: HO ME// <Ente r> VAX | |
2541 | Progress N otes Print Example | |
2542 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ------- | |
2543 | TIUPATIENT ,ONE 666- 23-3456 Progress Notes | |
2544 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ------- | |
2545 | NOTE DATED : 06/07/96 17:51 DIABETES E DUCATION | |
2546 | ADMITTED: 07/22/95 1 1:06 1A | |
2547 | SUBJECT: R outine dia betes educ ation | |
2548 | Patient un derstandin g good. | |
2549 | Si gned by: / es/ Three TIUProvide r, MD | |
2550 | Medica l Internis t 06/23/96 08:34 | |
2551 | Analog Pager: 5 55-1213 | |
2552 | Digita l Pager: 5 55-1215 | |
2553 | Cosi gned by: / es/ TIUPro vider,Thre e | |
2554 | 06/23 /96 08:34 | |
2555 | Analog Pager: 55 5-1213 | |
2556 | Digita l Pager:55 5-1215 | |
2557 | NOTE DATED : 04/24/96 08:00 ARTERIAL E VALUATION - LOWER EX TREMITY | |
2558 | VISIT: 04/ 17/92 08:0 0 FOURTEEN ’S CLINIC | |
2559 | SUBJECT: R ule out em bolus, low er extremi ty | |
2560 | AGE: 50 | |
2561 | UNIT: General Medicine | |
2562 | REF ERRING MD: Eight CP RSProvider | |
2563 | DIAGNOSIS: Rule out embolus | |
2564 | HISTORY: severe p edal edema , foot ulc ers | |
2565 | OTHER: cyanosis | |
2566 | SYMPTOMS: | |
2567 | RESTING SYMPTOMS: | |
2568 | EXERTIONAL SYMPTOMS: | |
2569 | LESIONS: | |
2570 | ME DICATIONS: | |
2571 | RE CORDED RECORD ED | |
2572 | AUDIBLE DO PPLER SIGN AL RIGH T LEFT DOPPLER W AVEFORM: RIGHT L EFT | |
2573 | COMMON F EMORAL ____ _ _____ COMMON FEMORAL _____ _ ____ | |
2574 | SUPERFIC IAL FEMORA L ____ _ _____ PRE-EXE RCISE _____ _ ____ | |
2575 | POPLITEA L ____ _ _____ POST-EX ERCISE _____ _ ____ | |
2576 | POSTERIO R TIBIAL ____ _ _____ OTHER _____ _ ____ | |
2577 | DORSALIS PEDIS ____ _ _____ | |
2578 | N=NORMA L ABN=AB NORMAL O=ABSENT B=BIPHAS IC | |
2579 | TRANSCUTAN EOUS PO2 V ALUES: | |
2580 | R IGHT LEFT | |
2581 | SUBCLAV ICULAR _ __40___ ___40 ___ | |
2582 | ABOVE K NEE _ __39___ ___40 ___ | |
2583 | HIGH BK _ __39___ ___40 ___ | |
2584 | CALF _ __37___ ___39 ___ | |
2585 | ANKLE _ __36___ ___39 ___ | |
2586 | DORSUM OF FOOT _ __22___ ___38 ___ | |
2587 | OTHER _ __18___ ___38 ___ | |
2588 | Enter RETU RN to cont inue or '^ ' to exit: <Enter> | |
2589 | Progress N otes Print Example c ont’d | |
2590 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ------- | |
2591 | TIUPATIENT ,ONE 666-2 3-3456 Progress Notes | |
2592 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ------- | |
2593 | 04/24/92 0 8:00 ** CONTIN UED FROM P REVIOUS SC REEN ** | |
2594 | 40 =ADEQUATE FOR HEALI NG | |
2595 | 39-30 =EQUIVOCA L FOR HEAL ING | |
2596 | 29-0 =INADEQUA TE FOR HEA LING | |
2597 | SEGMENTAL SYSTOLIC B LOOD PRESS URE: | |
2598 | RI GHT INDE X LEFT I NDEX | |
2599 | ARM __ __________ __ _________ _____ | |
2600 | HIGH TH IGH __ __________ __ _________ _____ | |
2601 | ABOVE K NEE __ __________ __ _________ _____ | |
2602 | BELOW K NEE __ __________ __ _________ _____ | |
2603 | ANKLE PT __ __________ __ _________ _____ | |
2604 | DP __ __________ __ _________ _____ | |
2605 | EXERCISE RESPONSE: | |
2606 | MPH : 5 mp h | |
2607 | MAX IMUM WALKI NG TIME: _10_ MIN _ 30_ SEC | |
2608 | SYM PTOMS: Ped al edema, cyanosis | |
2609 | MAX IMUM HEART RATE ACHI EVED: | |
2610 | TIME RIGHT I NDEX LEFT IND EX ARM | |
2611 | 1 MINUTE _______ _____ ________ ____ _________ ___ | |
2612 | 3 MINUTES _______ _____ ________ ____ _________ ___ | |
2613 | 5 MINUTES _______ _____ ________ ____ _________ ___ | |
2614 | 1 0 MINUTES _______ _____ ________ ____ _________ ___ | |
2615 | 1 5 MINUTES _______ _____ ________ ____ _________ ___ | |
2616 | 2 0 MINUTES _______ _____ ________ ____ _________ ___ | |
2617 | POST EXERC ISE: | |
2618 | IMPRESSION S: | |
2619 | Si gned by: / es/ Three TIUProvide r, MD | |
2620 | Medica l Internis t 04/24/96 14:19 | |
2621 | Analog Pager: 5 55-1213 | |
2622 | Digita l Pager: 5 55-1215 | |
2623 | Enter RETU RN to cont inue or '^ ' to exit: ^ | |
2624 | 1 Discharge Summary Pr int | |
2625 | 2 Progress N ote Print | |
2626 | 3 Clinical D ocument Pr int | |
2627 | Select Pri nt Documen t Menu Opt ion: <Ente r> | |
2628 | Clinical D ocument Pr int XE "Cl inical Doc ument Prin t" | |
2629 | Use this o ption to print char t or work copies of all clinic al documen ts availab le through TIU. | |
2630 | Steps to u se option: | |
2631 | 1. Select Clinical D ocument Pr int from t he Print D ocument Me nu, and th en enter a patient n ame. | |
2632 | Select Pri nt Documen t Menu Opt ion: 3 Cl inical Doc ument Prin t | |
2633 | Select PAT IENT NAME: TIUPATION E,ONE TIUP ATIENT,ONE 09- 12-44 666233456 YES | |
2634 | SC VETERAN | |
2635 | (2 notes ) C: 05/2 8/96 12:37 | |
2636 | (2 notes ) W: 05/2 8/96 12:33 | |
2637 | A: Know n allergie s | |
2638 | (2 notes ) D: 05/2 8/96 12:36 | |
2639 | Available documents: 02/17/92 thru 06/2 1/96 (34) | |
2640 | 2. Enter a date rang e that doc uments wil l be chose n from. | |
2641 | Please spe cify a dat e range fr om which t o select d ocuments: | |
2642 | List docum ents Begin ning: 02/1 7/92// 6/1 /96 (JUN 01, 1996) | |
2643 | Thru: 06/2 1/96// 6/8 /96 (JUN 08, 1996) | |
2644 | 1 06/07/ 96 00:00 Diabetes E ducation One TIUP rovider, M D | |
2645 | Visit: 04/ 18/96 | |
2646 | 2 06/05/ 96 17:23 Lipid Clin ic Three TI UProvider | |
2647 | Visit: 04/ 18/96 | |
2648 | 3 06/05/ 96 11:10 Addendum t o Lipid Cl inic Three TI UProvider | |
2649 | Visit: 04/ 24/96 | |
2650 | Choose the document or documen ts you wou ld like pr inted, and whether y ou want wo rk or char t copies. | |
2651 | Choose doc uments: ( 1-3): 1-3 | |
2652 | Do you wan t WORK cop ies or CHA RT copies? CHART// < Enter> | |
2653 | DEVICE: HO ME// PRIN TER | |
2654 | Clinical D ocument Pr int Exampl e | |
2655 | 4. | |
2656 | The docume nt(s) will then be p rinted at the device you speci fy. | |
2657 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ------- | |
2658 | TIUPATIENT ,ONE 666- 23-3456 Progress Notes | |
2659 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ------- | |
2660 | NOTE DATED : 06/07/96 00:00 DIABETES E DUCATION | |
2661 | VISIT: 04/ 18/96 10:0 0 GENERAL MEDICINE | |
2662 | Routine di abetes edu cation giv en as foll ow-up to l ipid clini c visit. | |
2663 | Si gned by: / es/ One TI UProvider, MD | |
2664 | PGY2 R esident 06 /07/96 10: 22 | |
2665 | NOTE DATED : 06/05/96 17:23 LIPID CLIN IC | |
2666 | VISIT: 04/ 18/96 10:0 0 GENERAL MEDICINE | |
2667 | SUBJECTIVE : 51 ye ar old MEX ICAN AMERI CAN MALE h ere for | |
2668 | initi al evaluat ion of his DYSLIPIDE MIA. | |
2669 | PMH: | |
2670 | Signi ficant neg ative medi cal histor y pertinen t to the | |
2671 | evalu ation and treatment of DYSLIPI DEMIA: | |
2672 | FH: | |
2673 | SH: | |
2674 | MEDICATION | |
2675 | HISTORY: CURRE NT MEDICAT IONS | |
2676 | DIET: Couns eled on AH A Step I d iet today by Nine CP RSProvider . | |
2677 | See h er evaluat ion. | |
2678 | ACTIVITY: | |
2679 | OBJECTIVE: HT: 72 (08/23/ 95 11:45) WT: 190 (08/23/95 11:45) | |
2680 | TSH/T 4: / | |
2681 | FB G: 89 HEMO GLOBIN A1C : | |
2682 | SGO T: UR IC ACID: | |
2683 | ASSESSMENT : 1. MALE wi th / witho ut documen ted CAD | |
2684 | 2. CV Risk factors: | |
2685 | 3. Lipid p attern: | |
2686 | PLAN: 1. Impleme nt recomme ndations t o lower fa t intake. | |
2687 | 2. Repeat FBG and HB G A1C on: | |
2688 | 3. Return to review lab on: | |
2689 | Si gned by: / es/ Three TIUProvide r, MD | |
2690 | Intern ist 06/05 /96 17:23 | |
2691 | Analog Pager: 5 55-1213 | |
2692 | Digita l Pager: 5 55-1215 | |
2693 | Enter RETU RN to cont inue or '^ ' to exit: <Enter> | |
2694 | Clinical D ocument Pr int Exampl e cont’d | |
2695 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ------- | |
2696 | TIUPATIENT ,ONE 666- 23-3456 Progress Notes | |
2697 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ------- | |
2698 | NOTE DATED : 04/24/96 15:41 LIPID CLIN IC | |
2699 | VISIT: 04/ 24/96 15:4 0 DIABETIC EDUCATION -INDIV-MOD B | |
2700 | SUBJECTIVE : 51 ye ar old MEX ICAN AMERI CAN MALE h ere for | |
2701 | initi al evaluat ion of his DYSLIPIDE MIA. | |
2702 | PMH: | |
2703 | Signi ficant neg ative medi cal histor y pertinen t to the | |
2704 | evalu ation and treatment of DYSLIPI DEMIA: | |
2705 | FH: | |
2706 | SH: | |
2707 | MEDICATION | |
2708 | HISTORY: CURRE NT MEDICAT IONS | |
2709 | DIET: Couns eled on AH A Step I d iet today by NINE TI UPROVIDER. | |
2710 | See h er evaluat ion. | |
2711 | ACTIVITY: | |
2712 | OBJECTIVE: HT: 72 (08/23/ 95 11:45) WT: 190 (08/23/95 11:45) | |
2713 | TSH/T 4: / | |
2714 | FB G: 89 HEMO GLOBIN A1C : | |
2715 | SGO T: UR IC ACID: | |
2716 | ASSESSMENT : 1. MALE wi th / witho ut documen ted CAD | |
2717 | 2. CV Risk factors: | |
2718 | 3. Lipid p attern: | |
2719 | PLAN: 1. Impleme nt recomme ndations t o lower fa t intake. | |
2720 | 2. Repeat FBG and HB G A1C on: | |
2721 | 3. Return to review lab on: | |
2722 | Si gned by: / es/ Three TIUProvide r, MD | |
2723 | Intern ist 04/24/ 96 15:41 | |
2724 | Analog Pager: 5 55-1213 | |
2725 | Digita l Pager: 5 55-1215 | |
2726 | Enter RETU RN to cont inue or '^ ' to exit: <Enter> | |
2727 | 1 Discharge Summary Pr int | |
2728 | 2 Progress N ote Print | |
2729 | 3 Clinical D ocument Pr int | |
2730 | Released/U nverified Report XE "Released/ Unverified Report" | |
2731 | Use this o ption to p roduce a l ist of rel eased docu ments whic h haven’t been verif ied. | |
2732 | Steps to u se option: | |
2733 | 1. Select Released/U nverified Report fro m the MRT menu. | |
2734 | 2. Enter t he startin g and endi ng divisio n XE "divi sion" s fo r the repo rt. | |
2735 | 3. Enter t he startin g day for the report . | |
2736 | 4. Specify a printer . If neces sary, set the margin width to 132. | |
2737 | Select Tex t Integrat ion Utilit ies (MRT) Option: Re leased/Unv erified Re port | |
2738 | START WITH DIVISION: FIRST// 6 60 | |
2739 | GO TO DIVI SION: LAST // | |
2740 | START WITH RELEASE D ATE/TIME: FIRST// <E nter> | |
2741 | DEVICE: PRINTER | |
2742 | MAR GIN WIDTH IS NORMALL Y AT LEAST 132 | |
2743 | AR E YOU SURE ? No// YES | |
2744 | Released/U nverified Report - E LY | |
2745 | OCT 15,19 96 11:59 PAGE 1 | |
2746 | PATIENT SSN ADM DA TE DIS D ATE | |
2747 | L INE | |
2748 | DICTATED BY U RGENCY C OUNT | |
2749 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- | |
2750 | R ELEASE DAT E/TIME: JA N 10,1996 | |
2751 | TRANSCRI PTIONIST: DP | |
2752 | TIUPATIENT ,THREE 66604259 1P 02/27/ 92 03/05 /92 | |
2753 | TIUPROVI DER,FOUR r outine 1 D ischarg | |
2754 | - ------- | |
2755 | SUBTOTAL 1 | |
2756 | R ELEASE DAT E/TIME: SE P 10,1996 | |
2757 | TRANSCRI PTIONIST: BS | |
2758 | TIUPATIENT ,FOUR 66612345 6 09/21/ 95 | |
2759 | TIUPROVI DER,ONE r outine 7 2 A ddendum | |
2760 | TIUPATIENT ,FIVE 66645146 2 05/04/ 92 05/31 /96 | |
2761 | TIUPROVI DER,ONE p riority 7 8 A ddendum | |
2762 | - ------- | |
2763 | SUBTOTAL 1 50 | |
2764 | Discharge Summary Re leased/Unv erified Re port OCT 1 5,1996 11 :59 PAGE 2 | |
2765 | PATIENT SSN ADM DA TE DIS D ATE | |
2766 | L INE | |
2767 | DICTATED BY U RGENCY C OUNT | |
2768 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- | |
2769 | R ELEASE DAT E/TIME: OC T 4,1996 | |
2770 | TRANSCRI PTIONIST: jg | |
2771 | TIUPATIENT ,ONE 66623345 6 07/22/ 91 02/12 /96 | |
2772 | TIUPROVI DER,THRE r outine 1 D ischarg | |
2773 | - ------- | |
2774 | SUBTOTAL 1 | |
2775 | - ------- | |
2776 | TOTAL 1 52 | |
2777 | Press RETU RN to cont inue...<En ter> | |
2778 | Search for Selected Documents XE "Search for Selec ted Docume nts" | |
2779 | Use this o ption to p roduce a l ist of sel ected docu ments by e xtended se arch crite ria e.g., status, se arch categ ory, and r eference d ate range) . These ca n then be reviewed, verified, sent back to transcr iption, re assigned, or printed . | |
2780 | Steps to u se option: | |
2781 | 1. Select Search for Selected Documents from the T IU MRT men u. | |
2782 | 2. Select the status of docume nts you wa nt display ed. | |
2783 | Select Tex t Integrat ion Utilit ies (MRT) Option: 6 Search fo r Selected Documents | |
2784 | Select Sta tus: COMPL ETED// ? | |
2785 | 1 undic tated 5 unsigned 9 pur ged | |
2786 | 2 untra nscribed 6 uncosigne d 10 del eted | |
2787 | 3 unrel eased 7 completed 11 ret racted | |
2788 | 4 unver ified 8 amended | |
2789 | Enter sele ction(s) b y typing t he name(s) , number(s ), or abbr eviation(s ). | |
2790 | Select Sta tus: COMPL ETED// <En ter> com pleted | |
2791 | ||
2792 | 3. Select the docume nt type yo u want dis played. | |
2793 | Select CLI NICAL DOCU MENTS Type (s): Disch arge Summa ries// ? | |
2794 | 1 Discharg e Summarie s 2 Prog ress Notes 3 Ad dendum | |
2795 | Enter sele ction(s) b y typing t he name(s) , number(s ), or abbr eviation(s ). | |
2796 | Select CLI NICAL DOCU MENTS Type (s):Progre ss Notes Progress N otes | |
2797 | 4. Select the search category you want d isplayed. | |
2798 | Select SEA RCH CATEGO RIES: AUTH OR// ? | |
2799 | 1 All Cat egories 5 Pa tient 9 Titl e | |
2800 | 2 Author 6 Pr oblem 10 Tran scriptioni st | |
2801 | 3 Expecte d Cosigner 7 Se rvice 11 Trea ting Speci alty | |
2802 | 4 Hospita l Location 8 Su bject 12 Visi t | |
2803 | Enter sele ction(s) b y typing t he name(s) , number(s ), or abbr eviation(s ). | |
2804 | Select SEA RCH CATEGO RIES: AUTH OR// <Ente r> Autho r | |
2805 | Select AUT HOR: TIUP ROVIDER,ON E J G | |
2806 | Search for Selected Documents, cont’d | |
2807 | 5. Enter t he range o f dates yo u want dis played. | |
2808 | Start Ref erence Dat e [Time]: T-7//<Ente r> (MAY 26, 1997) | |
2809 | Ending Ref erence Dat e [Time]: NOW// <Ent er> (JUN 0 2, 1997@15 :46) | |
2810 | Searching for the do cuments... | |
2811 | 6. The doc uments fit ting the s earch crit eria you s elected ar e displaye d. Choose an action to perform on the re levant doc uments. | |
2812 | UNSIGNED D ocuments Jun 0 2, 1997 15 :46:28 Page : 1 of 1 | |
2813 | by A UTHOR (TIU PROVIDER,O NE) from 0 5/26/97 to 06/02/97 2 docu ments | |
2814 | Patient Documen t Ref Dat e Status | |
2815 | 1 TIUPATIE NT,ONE(T34 56) Advers e React/Al lergy 05/31/9 7 unsigne d | |
2816 | 2 TIUPATIE NT,FIV(T25 91) Advers e React/Al lergy 05/31/9 7 unsigne d | |
2817 | + Nex t Screen - Prev Screen ?? More A ctions >> > | |
2818 | Find Rea ssign Print | |
2819 | Verify/ Unverify Sen d Back Change View | |
2820 | On Char t Det ailed Disp lay Quit | |
2821 | Edit Bro wse | |
2822 | Select Act ion: Quit/ / | |
2823 | Unsigned/U ncosigned Report XE "Unsigned/ Uncosigned Report" | |
2824 | Lists deta iled docum ent inform ation such as author , patient, patient S SN, etc. f or notes w ith no sig nature and /or cosign ature. Opt ionally, a summary r eport can be generat ed showing the numbe r of unsig ned and un cosigned d ocuments i n each ser vice. | |
2825 | In the fol lowing exa mple, a su mmary repo rt is gene rated for a selected division XE "divisi on" : | |
2826 | Select OPT ION NAME: TIU UNS IGNED/UNCO SIGNED REP ORT Un signed/Unc osigned Re port r un routine | |
2827 | Select div ision: ALL // SALT | |
2828 | 1 S ALT LAKE C IOFO 660GC | |
2829 | 2 S ALT LAKE O EX 6 60 | |
2830 | CHOOSE 1-2 : 1 SALT LAKE CIOFO 660GC | |
2831 | Select ano ther divis ion: <Ente r> | |
2832 | Please spe cify an En try Date R ange: | |
2833 | Start Ent ry Date: t -365 (JAN 28, 2003) | |
2834 | Ending Ent ry Date: t (JAN 28, 2004) | |
2835 | Select ser vice: ALL/ / <Enter> | |
2836 | Selec t one of t he followi ng: | |
2837 | F FULL | |
2838 | S SUMMARY | |
2839 | Type of Re port: S S UMMARY | |
2840 | DEVICE: HO ME// <Ente r> ANYWHER E | |
2841 | U nsigned an d Uncosign ed Documen ts Jan 28, 2003 thru Jan 28, 2 | |
2842 | 004@23:59: 59Page 1 | |
2843 | PRINTED: for ELY | |
2844 | JAN 28, 20 04@16:33 | |
2845 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- -------- | |
2846 | Totals fo r Service: IRM--- UN SIGNED: 24 UNCOSIGN ED: 0 | |
2847 | Totals fo r Service: MEDICINE- -- UNSIGNE D: 112 UN COSIGNED: 0 | |
2848 | Totals fo r Service: OTHER--- UNSIGNED: 1 UNCOSIG NED: 0 | |
2849 | Totals fo r Service: PHARMACY- -- UNSIGNE D: 6 UNCO SIGNED: 0 | |
2850 | Totals fo r Service: SURGERY-- - UNSIGNED : 1 UNCOS IGNED: 0 | |
2851 | Totals fo r Service: UNKNOWN-- - UNSIGNED : 2 UNCOS IGNED: 0 | |
2852 | Totals for Division: ELY--- UN SIGNED: 14 6 UNCOSIG NED: 0 | |
2853 | Enter RETU RN to cont inue or '^ ' to exit: | |
2854 | | |
2855 | Note: | |
2856 | A full Uns igned/Unco signed Rep ort requir es a print er device capable of printing 132 column s. | |
2857 | Reassignme nt Documen t Report X E " Reassi gnment Doc ument Repo rt" | |
2858 | The reassi gn action reassigns a note to a differen t patient, admission , or visit . Besides this, the reassign a ction may be used to promote a n Addendum as an Ori ginal, swa p the Adde ndum and t he Origina l, or chan ge a disch arge summa ry to an A ddendum. | |
2859 | This repor t provides a list of reassigne d notes ba sed on dat e range. I n the foll owing exam ple TIU di splays a r eport of r eassigned documents over the p ast 6 mont hs: | |
2860 | Select Tex t Integrat ion Utilit ies (MRT) Option: ? | |
2861 | 1 Individual Patient D ocument | |
2862 | 2 Multiple P atient Doc uments | |
2863 | 3 Review Upl oad Filing Events | |
2864 | 4 Print Docu ment Menu ... | |
2865 | 5 Released/U nverified Report | |
2866 | 6 Search for Selected Documents | |
2867 | 7 Unsigned/U ncosigned Report | |
2868 | 8 Reassignme nt Documen t Report | |
2869 | Enter ?? f or more op tions, ??? for brief descripti ons, ?OPTI ON for hel p text. | |
2870 | Select Tex t Integrat ion Utilit ies (MRT) Option: 8 Reassignm ent Docume nt Report | |
2871 | ENTER STAR TING DATE: JAN 01, 2 003//t-180 (AUG 22, 1999) | |
2872 | ENTER ENDI NG DATE: A ug 04, 200 4// (AUG 04, 2004) | |
2873 | DEVICE: HO ME// ANY WHERE | |
2874 | Searching. .. | |
2875 | Date range searched: Aug 22, 1 999 - Aug 04, 2004 | |
2876 | Number of records se arched: 91 89 | |
2877 | Number of records fo und: 570 | |
2878 | Elapsed ti me: 0 minu te(s) 3 se cond(s) | |
2879 | Current us er: TIUPRO VIDER,SEVE N | |
2880 | Current da te: Aug 04 , 2004@10: 20:57 | |
2881 | TIU RE ASSIGNMENT DOCUMENT REPORT | |
2882 | DOCUMENT N AME INIT IAL PATIEN T FINAL PATIENT REASSI GNMENT DAT E/TIME | |
2883 | ========== === ==== ========== = ===== ======== ====== ========== ====== | |
2884 | Addendum TIUP ATIENT,EIG HT TIUPA TIENT,SIX Aug 23 , 1999@08: 46:41 | |
2885 | Addendum TIUP ATIENT,EIG HT TIUPA TIENT,SIX Aug 23 , 1999@08: 46:42 | |
2886 | Discharge Summa TIUP ATIENT,SEV EN TIUPA TIENT,SEVE N Aug 25 , 1999@11: 51:47 | |
2887 | PULMONARY CS CO TIUP ATIENT,EIG HT TIUPA TIENT,NINE Aug 25 , 1999@15: 41:40 | |
2888 | PULMONARY CS CO TIUP ATIENT,NIN E TIUPA TIENT,EIGH T Aug 25 , 1999@16: 03:24 | |
2889 | PULMONARY CS CO TIUP ATIENT,EIG HT TIUPA TIENT,NINE Aug 25 , 1999@16: 16:32 | |
2890 | PULMONARY CS CO TIUP ATIENT,EIG HT TIUPA TIENT,EIGH T Aug 25 , 1999@16: 36:05 | |
2891 | PULMONARY CS CO TIUP ATIENT,EIG HT TIUPA TIENT,EIGH T Aug 25 , 1999@16: 36:06 | |
2892 | PULMONARY CS CO TIUP ATIENT,EIG HT TIUPA TIENT,FIVE Aug 27 , 1999@10: 47:49 | |
2893 | PULMONARY CS CO TIUP ATIENT,EIG HT TIUPA TIENT,NINE Aug 27 , 1999@15: 56:28 | |
2894 | PULMONARY CS CO TIUP ATIENT,EIG HT TIUPA TIENT,SIX Aug 27 , 1999@16: 18:45 | |
2895 | PULMONARY CS CO TIUP ATIENT,EIG HT TIUPA TIENT,SIX Aug 27 , 1999@16: 41:45 | |
2896 | PULMONARY CS CO TIUP ATIENT,EIG HT TIUPA TIENT,SIX Aug 27 , 1999@16: 41:46 | |
2897 | PULMONARY CS CO TIUP ATIENT,EIG HT TIUPA TIENT,SIX Aug 31 , 1999@16: 14:29 | |
2898 | Addendum TIUP ATIENT,EIG HT TIUPA TIENT,SIX Aug 31 , 1999@17: 01:15 | |
2899 | Addendum TIUP ATIENT,EIG HT TIUPA TIENT,SIX Aug 31 , 1999@17: 01:16 | |
2900 | Enter RETU RN to cont inue or '^ ' to exit: | |
2901 | Review Un signed Add itional Si gnatures X E "Additio nal Signat ures" | |
2902 | This optio n prints e ither a de tailed or summary re port of do cuments re quiring ad ditional s ignatures. | |
2903 | In the det ailed repo rt the pat ient name is abbrevi ated to th e patient initials f ollowed by the last six digits of the so cial secur ity number to save s pace. | |
2904 | In the fol lowing exa mple, a de tailed rep ort is run covering a four mon th period: | |
2905 | Select Tex t Integrat ion Utilit ies (MRT) Option: ? | |
2906 | 1 Individual Patient D ocument | |
2907 | 2 Multiple P atient Doc uments | |
2908 | 3 Review Upl oad Filing Events | |
2909 | 4 Print Docu ment Menu ... | |
2910 | 5 Released/U nverified Report | |
2911 | 6 Search for Selected Documents | |
2912 | 7 Unsigned/U ncosigned Report | |
2913 | 8 Reassignme nt Documen t Report | |
2914 | 9 Review uns igned addi tional sig natures | |
2915 | Enter ?? f or more op tions, ??? for brief descripti ons, ?OPTI ON for hel p text. | |
2916 | You have P ENDING ALE RTS | |
2917 | Enter "VA to jump t o VIEW ALE RTS option | |
2918 | Select Tex t Integrat ion Utilit ies (MRT) Option: 9 Review un signed add itional si gnatures | |
2919 | Select div ision: ALL // | |
2920 | Please spe cify an En try Date R ange: | |
2921 | Start Ent ry Date: t -90 (NOV 09, 2004) | |
2922 | Ending Ent ry Date: t (FEB 07, 2005) | |
2923 | Select ser vice: ALL/ / | |
2924 | Selec t one of t he followi ng: | |
2925 | F FULL | |
2926 | S SUMMARY | |
2927 | Type of Re port: f F ULL | |
2928 | This repor t should b e sent to a 132 Colu mn Device | |
2929 | DEVICE: HO ME// ANY WHERE | |
2930 | Pending Ad ditional S ignature D ocuments f or ELY on Feb 07, 20 05@14:39:4 9 | |
2931 | Oct 10, 20 04 thru Fe b 07, 2005 @23:59:59 Page: 1 | |
2932 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- -------- | |
2933 | IDENT. SIG NER PAT IENT STA TUS ENTRY DATE DOCUME NT TITLE | |
2934 | DOCUMENT IEN | |
2935 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- | |
2936 | SERVICE: M EDICINE | |
2937 | CPRSPROVID ER, E EB1 11148 co m 10/15 /04@07:58: 50 ACUTE PAIN NOTE | |
2938 | 29303 | |
2939 | CPRSPROVID ER, F EH2 24567 co m 11/26 /04@14:39: 48 SURGE RY CS CONS ULT | |
2940 | 28002 | |
2941 | CPRSPROVID ER, F FC7 81990 co m 11/30 /04@07:39: 31 CARDI OLOGY NOTE | |
2942 | 29008 | |
2943 | CPRSPROVID ER, N FC7 81990 co m 10/20 /04@12:30: 10 MEDIC INE NOTE | |
2944 | 29079 | |
2945 | CPRSPROVID ER, O SH3 45377 co m 10/30 /04@12:40: 24 AB ID PARENT BA RRY TEST | |
2946 | 29019 | |
2947 | CPRSPROVID ER, O TH3 45377 co m 12/30 /04@12:40: 24 AB ID PARENT BA RRY TEST | |
2948 | 29019 | |
2949 | CPRSPROVID ER, S NC4 48661 co m 12/20 /04@13:08: 40 PODIA TRY CS CON SULTS | |
2950 | 27968 | |
2951 | CPRSPROVID ER, T OC3 24321 co m 01/29 /05@13:50: 35 CRISI S NOTE | |
2952 | 28840 | |
2953 | CPRSPROVID ER, T OC6 68847 co m 01/28 /05@11:16: 37 ACUTE PAIN NOTE | |
2954 | 29362 | |
2955 | Totals f or Service MEDICIN E: 9 | |
2956 | Totals for Division ELY: 9 | |
2957 | Enter RETU RN to cont inue or '^ ' to exit: | |
2958 | Chapter 5: TIU for M IS/HIMS Ma nagers | |
2959 | The Medica l Informat ion Sectio n (MIS), a lso called Health In formation Management Section X E "Health Informatio n Manageme nt Section " (HIMS X E "HIMS" ) , maintain s and mana ges record s of clini cal docume nts, inclu ding copie s of stati stical rep orts, and chart or w ork copies of discha rge summar ies and pr ogress not es. | |
2960 | MIS Manage r’s Menu X E "MIS Man ager’s Men u" | |
2961 | OptionDesc riptionInd ividual Pa tient Docu mentAllows you to re view or pr int patien t Clinical Documents . | |
2962 | Multiple P atient Doc umentsThis option al lows MIS M anagers to see any o f the avai lable TIU documents on the Tex t Integrat ion Utilit ies Review Screen. | |
2963 | Print Docu ment MenuT his menu g ives MAS p ersonnel a ccess to o ptions whi ch print C HART or WO RK copies of dischar ge summari es, progre ss notes, or mixed D ocuments o n demand. | |
2964 | Search for Selected DocumentsA llows MIS Managers t o generate a list of selected documents based on e xtended se arch crite ria; e.g., STATUS, S EARCH CATE GORY, and REFERENCE DATE RANGE ). | |
2965 | Statistica l ReportsT his menu a llows you to view or print sta tistical r eports for line coun ts and tim eliness by Author, T ranscripti onist, and Service. | |
2966 | Unsigned/U ncosigned Report XE "Search fo r Selected Documents " Provides informati on on uns igned and uncosigned documents for one, multiple, or all div isions. Th e report c an be eith er Summary or Full. The summar y report l ists the n umber of d ocuments b y the serv ice or sec tion of th e author. The full r eport list s detailed document informatio n (such as author, p atient, pa tient SSN, etc.) by the servic e or secti on of the author. | |
2967 | Missing Te xt ReportR eports whi ch TIU Doc uments tha t do not h ave any re port text, are missi ng the 0 n ode of the text node , or both cases. Doc uments may be of any type, inc luding add enda but n ot notes w ith compon ents or ad denda atta ched to th em. | |
2968 | Missing Te xt Cleanup This is a utility fo r assistin g with the cleanup o f document s without report tex t. In some cases you may choos e to corre ct documen ts manuall y, such as when the author is still avai lable or w hen the do cument was originall y an uploa d document .OptionDes criptionUN KNOWN Adde nda Cleanu p XE "Revi ew unsigne d addition al signatu res" | |
2969 | Gives a li st of surg ery addend a that are not conne cted to an Operation s Report a nd provide s options for review ing, assis tance in f inding the parent, a nd attachi ng to the parent.Mis sing Expec ted Cosign er ReportP rovides a list of do cuments th at have a status of “Uncosigne d” where t he “Expect ed Cosigne r” field i s null, 0 or -1. Mar k Document as ‘Signe d by Surro gate’Provi des a way to mark a document a s 'Signed by Surroga te'. This will set t he .09 fie ld of file 8925.7 to 1 - meani ng that th e signing for an Ad ditional S igner was done by a surrogate of that Ad ditional S igner.Mism atched ID NotesThis option run s a routin e that wil l report/f ix mismatc hed interd isciplinar y (ID) not es.TIU 215 ANALYSISS urgery cas es will be analyzed within a p articular date range and infor mation fro m Nurse In traoperati ve Report (NIR) and/ or Anesthe sia report s will be compared t o their co rrespondin g TIU note s. If the informati on does no t match, t he case nu mber will be recorde d as one t hat needs to be revi ewed.Trans cription B illing Ver ification ReportThis report ca n be run b y division and provi des inform ation on a ll transcr iptionists or one or more sele cted trans criptionis t. It repo rts based on an ente red date r ange. Sinc e the VBC Line Count XE "Line Count" | |
2970 | ||
2971 | XE "VBC L ine Count" is only calculated for trans cribed rep orts, it d oes not re port on an y document transcrib ed before the line c ount patch was insta lled.CWAD/ Postings A uto Demoti on SetupTh is option on the men u allows C linical Ap plication Coordinato rs and/or site desig nated pers onnel to c onfigure C WAD notes for auto d emotion us ing the CW AD/Posting s Auto-Dem otion Setu p.Individu al Patient Document XE "Indivi dual Patie nt Documen t" | |
2972 | Use this o ption to r eview or p rint TIU d ocuments f or a patie nt. | |
2973 | Steps to u se option: | |
2974 | 1. Select Individual Patient D ocument fr om the MIS Manager M enu, and t hen enter the patien t name. | |
2975 | Select Tex t Integrat ion Utilit ies (MIS M anager) Op tion: Ind ividual Pa tient Docu ment | |
2976 | Select PAT IENT NAME: TIUPATIEN T,SEVEN TI UPATIENT,S EVEN 04-2 5-31 66604 2591P NO MILITAR Y RETIREE | |
2977 | (2 notes ) W: 09/1 6/96 15:12 (addendu m 09/18/96 09:53) | |
2978 | A: Know n allergie s | |
2979 | Available documents: 08/11/95 thru 10/1 0/96 (131 ) | |
2980 | 2. Select a date ran ge for the documents you wish to review, and then choose one or more o f the docu ments disp layed. | |
2981 | Please spe cify a dat e range fr om which t o select d ocuments: | |
2982 | List docum ents Begin ning: 08/1 1/95// t-1 5 (SEP 30 , 1996) | |
2983 | Thru: 10/1 0/96// <En ter> (OCT 10, 1996) | |
2984 | 1 10/06/ 96 14:11 Addendum t o Diabetes Education Three TIUProvide r, | |
2985 | Adm: 09/ 28/96 | |
2986 | 2 10/05/ 96 13:56 Diabetes E ducation Six TI UProvder, | |
2987 | Adm: 09/ 28/96 | |
2988 | Choose doc uments: ( 1-3): 2 | |
2989 | 3. The doc ument(s) y ou chose i s displaye d. Choose an action to perform . | |
2990 | Browse Doc ument Oct 15, 1996 1 2:23:42 Page: 1 of 1 | |
2991 | Diabetes E ducation | |
2992 | TIUPATIENT ,SEVEN 666-04-2 591P 1A Visi t Date: 09 /28/96@15: 58 | |
2993 | DATE OF NO TE: SEP 05 , 1996@13: 51:03 ENT RY DATE: S EP 05, 199 6@13:51:03 | |
2994 | AUTH OR: TIUPRO VIDER,SIX EXP C OSIGNER: T IUPROVIDER ,THREE | |
2995 | URGEN CY: STATUS: C OMPLETED | |
2996 | TEST DRUG EFFICACY. | |
2997 | /es/ Six T IUProvider , MS3 /es/ Th ree TIUPro vider, MD | |
2998 | Medical St udent III | |
2999 | Signed: 10 /05/96 13: 51 C osigned: 1 0/05/96 14 :11 | |
3000 | + Nex t Screen - Prev Scr een ?? Mo re Actions >>> | |
3001 | Find On Chart Rea ssign | |
3002 | Print Amend Sen d Back | |
3003 | Edit Delete Qui t | |
3004 | Verif y/Unverify | |
3005 | Select Act ion: Quit/ / | |
3006 | Multiple P atient Doc uments XE "Multiple Patient Do cuments" | |
3007 | Use this o ption to d isplay TIU documents of specif ied types, which can then be r eviewed, v erified, s ent back t o transcri ption, rea ssigned, o r printed. | |
3008 | | |
3009 | Caution: | |
3010 | Avoid maki ng your re quests too broad (in statuses, search ca tegories, and date r anges) bec ause these searches can use a lot of sys tem resour ces, slowi ng the com puter syst em down fo r everyone . The exam ple below would prob ably be to o broad in a large h ospital. | |
3011 | Steps to u se option: | |
3012 | 1. Select Multiple P atient Doc uments fro m the MIS Manager me nu. Answer the promp ts that fo llow. | |
3013 | Select Tex t Integrat ion Utilit ies (MIS M ANAGER) Op tion: Mult iple Patie nt Documen ts | |
3014 | Select div ision: ALL // <Enter> | |
3015 | Select Sta tus: UNSIG NED// <Ent er> Uns igned | |
3016 | Select Cli nical Docu ments Type (s): ? | |
3017 | 1 Progress Notes 2 Discharg e Summary 3 Addendum | |
3018 | Enter sele ction(s) b y typing t he name(s) , number(s ), or abbr eviation(s ). | |
3019 | Select Cli nical Docu ments Type (s): 1-3 Addendum Discharge Summary | |
3020 | Progr ess Notes | |
3021 | Start Refe rence Date [Time]: T -7//t-15 ( MAR 19, 19 97) | |
3022 | Ending Ref erence Dat e [Time]: NOW// <Ent er> (APR 1 8, 1997@15 :21) | |
3023 | Searching for the do cuments... .......... ... | |
3024 | 2. When th e document s that fit the crite ria you en tered are displayed, choose an action an d a docume nt(s). | |
3025 | UNSIGNED D ocuments A pr 18,1996 15:21:44 P age:1 of 1 | |
3026 | by ALL CAT EGORIES from 03/19/96 to 04/18/9 6 15 documents | |
3027 | Patient Docu ment Admitte d Disch'd | |
3028 | 1 TIUPATIE NT,O (T 8101) Nurs ing Note 04/15/9 6 | |
3029 | 2 TIUPATIE NT,T (T 2760) Adde ndum 03/22/9 6 | |
3030 | 3 TIUPATIE NT,T (T 2760) Adde ndum 03/22/9 6 | |
3031 | 4 TIUPATIE NT,F (T 6641) Ambu l/Outp Car e 04/18/9 6 | |
3032 | 5 TIUPATIE NT,F (T 6641) Gene ral Note 04/18/9 6 | |
3033 | 6 TIUPATIE NT,F (T 6641) Diab etes Ed 03/20/9 6 | |
3034 | 7 TIUPATIE NT,S (T 0482) Diab etes Edu 03/25/9 6 | |
3035 | 8 TIUPATIE NT,S (T 0482) Adde ndum 03/25/9 6 | |
3036 | + Nex t Screen - Prev Scr een ?? Mo re Actions >>> | |
3037 | Verif y/Unverify Link with Request Print | |
3038 | On Ch art Send Back Inter discipl'ry Note | |
3039 | Edit Detailed D isplay Chang e View | |
3040 | Reass ign Browse QuitS elect | |
3041 | Action: Qu it// ON CH ART | |
3042 | Print Docu ment Menu XE "Print Document M enu" | |
3043 | This menu contains o ptions whi ch print c hart or wo rk copies of dischar ge summari es, progre ss notes, or mixed d ocuments. | |
3044 | 1 Discharge Summary Pr int | |
3045 | 2 Progress N ote Print | |
3046 | 3 Clinical D ocument Pr int | |
3047 | Discharge Summary Pr int XE "Di scharge Su mmary Prin t" | |
3048 | Use this o ption to p rint chart or work c opies of d ischarge s ummaries. | |
3049 | Steps to u se this op tion: | |
3050 | 1. Select Discharge Summary Pr int from t he MIS Man ager’s Pri nt Documen t Menu. | |
3051 | 2. Enter t he name of the patie nt whose d ischarge s ummary you want to p rint. | |
3052 | 1 Discharge Summary Pr int | |
3053 | 2 Progress N ote Print | |
3054 | 3 Clinical D ocument Pr int | |
3055 | Select Pri nt Documen t Menu Opt ion: 1 Di scharge Su mmary Prin t | |
3056 | Select PAT IENT NAME: TIUPATIEN T,ONE TIUP ATIENT,ONE 09-12 -44 66 6233456 YES | |
3057 | SC VETERAN | |
3058 | (2 notes ) C: 05/2 8/96 12:37 | |
3059 | (2 notes ) W: 05/2 8/96 12:33 | |
3060 | A: Know n allergie s | |
3061 | (2 notes ) D: 05/2 8/96 12:36 | |
3062 | Available summaries: 02/12/96 thru 02/1 2/96 (1) | |
3063 | 3. Enter t he range o f dates to choose th e discharg e summary or summari es you wan t to print . | |
3064 | Please spe cify a dat e range fr om which t o select s ummaries: | |
3065 | List summa ries Begin ning: 02/1 2/96// < Enter> (FE B 12, 1996 ) | |
3066 | Thru: 02/1 2/96// <En ter> | |
3067 | 1 02/12/ 96 13:56 Discharge Summary One TIU Provider, MD | |
3068 | Adm: 07/ 22/91 Dis : 02/12/96 | |
3069 | Choose sum maries: ( 1-1): 1 | |
3070 | Do you wan t WORK cop ies or CHA RT copies? CHART// W ORK | |
3071 | DEVICE: HO ME// <Ent er> VAX | |
3072 | Discharge Summary Pr int Exampl e | |
3073 | SALT LAKE CITY pri ority 06 /27/96 08: 45 P age: 1 | |
3074 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ------- | |
3075 | PATIENT NA ME | AGE | SE X | RACE | SSN | CLAIM NUMBER | |
3076 | TIUPATIENT ,ONE | 51 | M | MEXI | 666-23-34 56 | | |
3077 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ------- | |
3078 | ADM DATE | DISC DATE | TYPE OF RE LEASE | INP | ABS | WARD NO | |
3079 | JUL 22, 19 91 | FEB 1 2, 1996 | REGULAR |1 666 | 0 | 1A | |
3080 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ------- | |
3081 | DICTATION DATE: JUN 09, 1996 TRANSCRIPT ION DATE: JUN 12, 19 96 | |
3082 | TRANSCRIPT IONIST: bs | |
3083 | DIAGNOSIS: | |
3084 | 1. Status post head trauma wi th brain c ontusion. | |
3085 | 2. Status post cere brovascula r accident . | |
3086 | 3. End st age renal disease on hemodialy sis. | |
3087 | 4. Corona ry artery disease. | |
3088 | 5. Conges tive heart failure. | |
3089 | 6. Hypert ension. | |
3090 | 7. Non in sulin depe ndent diab etes melli tus. | |
3091 | 8. Periph eral vascu lar diseas e, status post throm bectomies. | |
3092 | 9. Diabet ic retinop athy. | |
3093 | 10. Below knee amput ation. | |
3094 | 11. Chroni c anemia. | |
3095 | OPERATIONS /PROCEDURE S: | |
3096 | 1. MRI. | |
3097 | 2. CT SCAN OF HEAD. | |
3098 | HISTORY OF PRESENT I LLNESS: | |
3099 | Patient is a 49-year -old, whit e male wit h past med ical histo ry of end stage | |
3100 | renal dise ase, perip heral vasc ular disea se, status post BKA, coronary artery | |
3101 | disease, h ypertensio n, non ins ulin depen dent diabe tes mellit us, diabet ic | |
3102 | retinopath y, congest ive heart failure, s tatus post CVA, stat us post | |
3103 | thrombecto my admitte d from Any town VA af ter a fall from his wheelchair in the | |
3104 | hospital. He had qu estionable short las ting loss of conscio usness but patient i s not very sure what has happe ned. He d enies head ache, vomi ting, vert igo. | |
3105 | On admissi on patient had CT sc an which s howed a sm all area o f parenchy mal | |
3106 | hemorrhage in the ri ght tempor al lobe wh ich is mos t likely c onsistent with | |
3107 | hemorrhagi c contusio n without mid line s hift or in coordinati on. | |
3108 | ACTIVE MED ICATIONS: Isordil 2 0 mgs p.o. t.i.d., C oumadin 2. 5 mgs p.o. qd, | |
3109 | ferrous su lfate 325 mgs p.o. b .i.d., Ati van 0.5 mg s p.o. b.i .d., Lactu lose 15 | |
3110 | ccs p.o. b .i.d., Cal cium carbo nate 650 m gs p.o. b. i.d. with food, Beto ptic | |
3111 | 0.5% ophth almologic solution g tt OU b.i. d., Nephro caps 1 tab let p.o. q d, | |
3112 | Pilocarpin e 4% solut ion 1 gtt OU b.i.d., Compazine 10 mgs p. o. t.i.d. prn | |
3113 | nausea, Ty lenol 650 mgs p.o. q 4 hours pr n. | |
3114 | Patient is on hemodi alysis, no known dru g allergie s. | |
3115 | PHYSICAL E XAMINATION : Patient had stabl e vital si gns, his b lood press ure was | |
3116 | 160/85, pu lse 84, re spiratory rate 20, t emperature 98 degree s. Patien t was | |
3117 | alert, ori ented time s three, c ooperative . His spe ech was fl uent, | |
3118 | understand ing of spo ken langua ge was goo d. Attent ion span w as good. He had | |
3119 | D R A F T | |
3120 | Press RETU RN to cont inue or '^ ' to exit: <Enter> | |
3121 | Discharge Summary Pr int Exampl e cont’d | |
3122 | SALT LAKE CITY pri ority 06 /27/96 08: 46 P age: 4 | |
3123 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ------- | |
3124 | PATIENT NA ME | AGE | SE X | RACE | SSN | CLAIM NUMBER | |
3125 | TIUPATIENT ,ONE | 51 | M | MEXI | 666-23-34 56 | | |
3126 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ------- | |
3127 | moderate m emory impa irment, no apraxia n oted. Cra nial nerve s patient was | |
3128 | blind, pup ils are no t reactive to light, face was asymmetric , tongue a nd | |
3129 | palate are mid line. Motor ex amination showed mus cle tone a nd bulk wi thout | |
3130 | significan t changes. Muscle s trength in upper ext remities 5 /5 bilater ally, | |
3131 | sensory ex amination revealed i ntact ligh t touch, p inprick an d vibrator y | |
3132 | sensation. Reflexes 1+ in upp er extremi ties, coor dination f inger to n ose test w ithin norm al limits bilaterall y. Altern ating move ments with out signif icant chan ges bilate rally. Ne ck was sup ple. | |
3133 | LABORATORY : Showed sodium lev el 135, po tassium 4. 6, chlorid e 96, CO2 26, | |
3134 | BUN 39, cr eatinine 5 .3, glucos e level 13 8. White blood cell count was 7, | |
3135 | hemoglobin 11, hemat ocrit 34, platelet c ount 77. | |
3136 | HOSPITAL C OURSE: Pa tient was admitted a fter head trauma wit h multiple medical p roblems. His coumad in was hel d. Patien t had cerv ical spine x-rays wh ich showed definite narrowing of C5, C6 interspace , slight r etrolisthe sis at thi s level, p rominent s purs at th is level a s well as above and below. CT scan on a dmission s howed a mo derate amo unt of sca lp thinnin g with sub cutaneous air overly ing the le ft frontal lobe. A small area of left p arenchymal hemorrhag e adjacent to the ri ght petros bone in t he tempora l lobe whi ch most li kely repre sents a he morrhagic contusion. Repeated CT scan on 5/13/94 d idn’t show any progr essive cha nges. Pat ient remai ned in sta ble condit ion. He h ad hemodia lysis q.o. d. He res tarted tre atment wit h Coumadin . His las t PT was 1 1.9, PTT 3 1. Patien t refused before hem odialysis new blood tests. Hi s conditio n remained stable. | |
3137 | DISCHARGE MEDICATION S: Isordi l 20 mgs p .o. t.i.d. , Ferrous sulfate 32 5 mgs | |
3138 | p.o. b.i.d ., Ativan 0.5 mgs p. o. b.i.d., Lactulose 15 ccs p. o. b.i.d., Calcium c arbonate 6 50 mgs p.o . b.i.d., Compazine 10 mgs p.o . t.i.d. p rn nausea, Betoptic 0.5% OU b. i.d., Neph rocaps 1 p .o. qd, Pi locarpine 4% solutio n 1 gtt OU b.i.d., C oumadin 2. 5 mgs p.o. qd, Tylen ol 650 mgs p.o. q6 h ours prn p ain. | |
3139 | DISPOSITIO N/FOLLOW-U P: | |
3140 | Recommend follow PT/ PTT. Pati ent is on coumadin a nd CBC wit h differen tial | |
3141 | because pa tient has chronic an emia and t hrombocyto penia. | |
3142 | Patient wi ll be tran sferred to Anytown V A in stabl e conditio n on 5/19/ 94. | |
3143 | WORK COPY ========= UNOFFICIAL - NOT FOR MEDICAL R ECORD ==== ==== DO NO T FILE | |
3144 | SIGNATURE PHYSICIAN/ DENTIST SIGNATURE APPROVING PHYSICIAN/ DENTIST | |
3145 | One TIUPro vider, MD Three TIUP rovider, M S | |
3146 | PGY2 Resid ent Medical In ternist | |
3147 | ========== ========== ===== CONF IDENTIAL I NFORMATION ========= ========== ====== | |
3148 | D R A F T | |
3149 | JUN 26, 19 96@17:36:0 2 ADDENDU M: | |
3150 | Routine vi sit today- -no change to condit ion. | |
3151 | SIGNATURE PHYSICIAN/ DENTIST SIGNATURE APPROVING PHYSICIAN/ DENTIST | |
3152 | ||
3153 | ||
3154 | Three TIUP rovider, M D | |
3155 | ||
3156 | ||
3157 | Medical In ternist | |
3158 | Progress N ote Print XE "Progre ss Note Pr int" | |
3159 | Use this o ption to p rint chart or work c opies of p rogress no tes. | |
3160 | Steps to u se option: | |
3161 | Select Pro gress Note Print fro m the Prin t Document Menu. | |
3162 | Enter a pa tient name . | |
3163 | Select Pri nt Documen t Menu Opt ion: 2 Pr ogress Not e Print | |
3164 | Select PAT IENT NAME: TIUPATIE NT,ONE TIU PATIENT,ON E 09 -12-44 666233456 YES | |
3165 | SC VETERAN | |
3166 | (2 notes ) C: 05/2 8/96 12:37 | |
3167 | (2 notes ) W: 05/2 8/96 12:33 | |
3168 | A: Know n allergie s | |
3169 | (2 notes ) D: 05/2 8/96 12:36 | |
3170 | Available notes: 02 /17/96 thr u 06/21/96 (31) | |
3171 | Enter the range of d ates for p rogress no tes you wa nt to prin t. | |
3172 | Choose a n ote from t hose liste d. | |
3173 | Please spe cify a dat e range fr om which t o select n otes: | |
3174 | List notes Beginning : 02/17/96 // <Enter> (FEB 17, 1996) | |
3175 | Thru : 06/21/96 // <Enter> (JUN 21, 1996) | |
3176 | 1 06/21/ 96 11:40 Lipid Clin ic Three TIUProvid er, | |
3177 | Visit: 02/ 21/96 | |
3178 | 2 06/21/ 96 11:38 Social Wor k Service Three TIUProvid er, | |
3179 | Visit: 04/ 18/96 | |
3180 | 3 06/07/ 96 00:00 Diabetes E ducation One T IUProvider , MD | |
3181 | Visit: 04/ 18/96 | |
3182 | 4 05/15/ 96 13:10 Addendum t o Diabetes Education Seven TIUProvid er | |
3183 | Visit: 02/ 21/96 | |
3184 | 5 04/24/ 96 15:41 Lipid Clin ic Three TIUProvid er, | |
3185 | Visit: 04/ 24/96 | |
3186 | 6 02/23/ 96 14:08 Diabetes E ducation Three TIUProvid er, | |
3187 | Visit: 02/ 21/96 | |
3188 | Choose not es: (1-6) :3, 5 | |
3189 | Do you wan t WORK cop ies or CHA RT copies? CHART// < Enter> | |
3190 | DEVICE: HO ME// <Ente r> VAX | |
3191 | Progress N otes Print Example | |
3192 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ------- | |
3193 | TIUPATIENT ,ONE 666- 23-3456 Progress Notes | |
3194 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ------- | |
3195 | NOTE DATED : 06/07/96 17:51 DIABETES E DUCATION | |
3196 | ADMITTED: 07/22/95 1 1:06 1A | |
3197 | SUBJECT: R outine dia betes educ ation | |
3198 | Patient un derstandin g good. | |
3199 | Si gned by: / es/ One TI UProvider, MD | |
3200 | Medica l Internis t 06/23/96 08:34 | |
3201 | Analog Pager: 5 55-1213 | |
3202 | Digita l Pager: 5 55-1215 | |
3203 | Cosi gned by: / es/ TIUPro vider,Six | |
3204 | 06/23 /96 08:34 | |
3205 | Analog Pager: 55 5-1213 | |
3206 | Digita l Pager:55 5-1215 | |
3207 | NOTE DATED : 04/24/96 08:00 ARTERIAL E VALUATION - LOWER EX TREMITY | |
3208 | VISIT: 04/ 17/92 08:0 0 FOURTEEN ’S CLINIC | |
3209 | SUBJECT: R ule out em bolus, low er extremi ty | |
3210 | AGE: 50 | |
3211 | UNIT: General Medicine | |
3212 | REF ERRING MD: Six TIUP rovider | |
3213 | DIAGNOSIS: Rule out embolus | |
3214 | HISTORY: severe p edal edema , foot ulc ers | |
3215 | OTHER: cyanosis | |
3216 | SYMPTOMS: | |
3217 | RESTING SYMPTOMS: | |
3218 | EXERTIONAL SYMPTOMS: | |
3219 | LESIONS: | |
3220 | ME DICATIONS: | |
3221 | RECORDED RECO RDED | |
3222 | AUDIBLE DO PPLER SIGN AL RIGH T LEFT DOPPLER W AVEFORM: RIGHT L EFT | |
3223 | COMMON F EMORAL ____ _ _____ COMMON FEMORAL _____ _ ____ | |
3224 | SUPERFIC IAL FEMORA L ____ _ _____ PRE-EXE RCISE _____ _ ____ | |
3225 | POPLITEA L ____ _ _____ POST-EX ERCISE _____ _ ____ | |
3226 | POSTERIO R TIBIAL ____ _ _____ OTHER _____ _ ____ | |
3227 | DORSALIS PEDIS ____ _ _____ | |
3228 | N=NORMA L ABN=AB NORMAL O=ABSENT B=BIPHAS IC | |
3229 | TRANSCUTAN EOUS PO2 V ALUES: | |
3230 | R IGHT LEFT | |
3231 | SUBCLAV ICULAR _ __40___ ___40 ___ | |
3232 | ABOVE K NEE _ __39___ ___40 ___ | |
3233 | HIGH BK _ __39___ ___40 ___ | |
3234 | CALF _ __37___ ___39 ___ | |
3235 | ANKLE _ __36___ ___39 ___ | |
3236 | DORSUM OF FOOT _ __22___ ___38 ___ | |
3237 | OTHER _ __18___ ___38 ___ | |
3238 | Enter RETU RN to cont inue or '^ ' to exit: <Enter> | |
3239 | Progress N otes Print Example c ont’d | |
3240 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ------- | |
3241 | TIUPATIENT ,ONE 666- 23-3456 Progress Notes | |
3242 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ------- | |
3243 | 04/24/92 0 8:00 ** CONTIN UED FROM P REVIOUS SC REEN ** | |
3244 | 40 =ADEQUATE FOR HEALI NG | |
3245 | 39-30 =EQUIVOCA L FOR HEAL ING | |
3246 | 29-0 =INADEQUA TE FOR HEA LING | |
3247 | SEGMENTAL SYSTOLIC B LOOD PRESS URE: | |
3248 | RI GHT INDE X LEFT I NDEX | |
3249 | ARM __ __________ __ _________ _____ | |
3250 | HIGH TH IGH __ __________ __ _________ _____ | |
3251 | ABOVE K NEE __ __________ __ _________ _____ | |
3252 | BELOW K NEE __ __________ __ _________ _____ | |
3253 | ANKLE PT __ __________ __ _________ _____ | |
3254 | DP __ __________ __ _________ _____ | |
3255 | EXERCISE RESPONSE: | |
3256 | MPH : 5 mp h | |
3257 | MAX IMUM WALKI NG TIME: _10_ MIN _ 30_ SEC | |
3258 | SYM PTOMS: Ped al edema, cyanosis | |
3259 | MAX IMUM HEART RATE ACHI EVED: | |
3260 | TIME RIGHT I NDEX LEFT IND EX ARM | |
3261 | 1 MINUTE _______ _____ ________ ____ _________ ___ | |
3262 | 3 MINUTES _______ _____ ________ ____ _________ ___ | |
3263 | 5 MINUTES _______ _____ ________ ____ _________ ___ | |
3264 | 1 0 MINUTES _______ _____ ________ ____ _________ ___ | |
3265 | 1 5 MINUTES _______ _____ ________ ____ _________ ___ | |
3266 | 2 0 MINUTES _______ _____ ________ ____ _________ ___ | |
3267 | POST EXERC ISE: | |
3268 | IMPRESSION S: | |
3269 | Si gned by: / es/ Three TIUProvide r, MD | |
3270 | Medica l Internis t 04/24/96 14:19 | |
3271 | Analog Pager: 5 55-1213 | |
3272 | Digita l Pager: 5 55-1215 | |
3273 | Enter RETU RN to cont inue or '^ ' to exit: ^ | |
3274 | 1 Discharge Summary Pr int | |
3275 | 2 Progress N ote Print | |
3276 | 3 Clinical D ocument Pr int | |
3277 | Select Pri nt Documen t Menu Opt ion: <Ente r> | |
3278 | Clinical D ocument Pr int XE "Cl inical Doc ument Prin t" | |
3279 | Use this o ption to p rint chart or work c opies of a ll clinica l document s availabl e through TIU. | |
3280 | Steps to u se option: | |
3281 | 1. Select Clinical D ocument Pr int from t he Print D ocument Me nu, and th en enter a patient n ame. | |
3282 | Select Pri nt Documen t Menu Opt ion: 3 Cl inical Doc ument Prin t | |
3283 | Select PAT IENT NAME: TIUPATIEN T,ONE TIUP ATIENT,ONE 09- 12-44 666233456 YES | |
3284 | SC VETERAN | |
3285 | (2 notes ) C: 05/2 8/96 12:37 | |
3286 | (2 notes ) W: 05/2 8/96 12:33 | |
3287 | A: Know n allergie s | |
3288 | (2 notes ) D: 05/2 8/96 12:36 | |
3289 | Available documents: 02/17/92 thru 06/2 1/96 (34) | |
3290 | 2. Enter a date rang e that doc uments wil l be chose n from. | |
3291 | Please spe cify a dat e range fr om which t o select d ocuments: | |
3292 | List docum ents Begin ning: 02/1 7/92// 6/1 /96 (JUN 01, 1996) | |
3293 | Thru: 06/2 1/96// 6/8 /96 (JUN 08, 1996) | |
3294 | 1 06/07/ 96 00:00 Diabetes E ducation One T IUProvider , | |
3295 | Visit: 04/ 18/96 | |
3296 | 2 06/05/ 96 17:23 Lipid Clin ic Three TIUProvid er, | |
3297 | Visit: 04/ 18/96 | |
3298 | 3 06/05/ 96 11:10 Addendum t o Lipid Cl inic Three TIUProvid er, | |
3299 | Visit: 04/ 24/96 | |
3300 | Choose the document or documen ts you wou ld like pr inted, and whether y ou want wo rk or char t copies. | |
3301 | Choose doc uments: ( 1-3): 1-3 | |
3302 | Do you wan t WORK cop ies or CHA RT copies? CHART// < Enter> | |
3303 | DEVICE: HO ME// PRIN TER | |
3304 | 4. | |
3305 | The docume nt(s) will then be p rinted at the device you speci fy. | |
3306 | Search for Selected Documents XE "Search for Selec ted Docume nts" | |
3307 | ||
3308 | Use this o ption to g enerate a list of se lected doc uments bas ed on exte nded searc h criteria (e.g., st atus, sear ch categor y, and ref erence dat e range). | |
3309 | Steps to u se option: | |
3310 | 1. Select Search for Selected Documents from the M IS Manager Menu. | |
3311 | 2. Select the status of the do cuments yo u want to view (comp leted, uns igned, ame nded, etc. ). | |
3312 | Select Tex t Integrat ion Utilit ies (MIS M anager) Op tion: Sea rch for Se lected Doc uments | |
3313 | Select Sta tus: COMPL ETED// UNV unverif ied | |
3314 | 3. Select the type o f document s you want to view ( progress n otes, disc harge summ ary, etc.) . | |
3315 | Select CLI NICAL DOCU MENTS Type (s): All Discharge Summary, P rogress No tes, Adden dum | |
3316 | 4. To make your sear ch more sp ecific, se lect one o r more cat egories fo r the docu ments you want to vi ew: | |
3317 | All Catego ries | |
3318 | Patient | |
3319 | Title | |
3320 | Author | |
3321 | Problem | |
3322 | Transcript ionist | |
3323 | Division Expected Cosigner | |
3324 | Service | |
3325 | Treating S pecialty Hosp ital Locat ion | |
3326 | Subject | |
3327 | Visit | |
3328 | Select SEA RCH CATEGO RIES: AUTH OR// SERVI CE | |
3329 | Select SER VICE: MEDI CINE | |
3330 | 5. To limi t the sear ch even fu rther, spe cify a tim e period f or the doc uments you want to v iew: | |
3331 | Start Ref erence Dat e [Time]: T-7//T-30 | |
3332 | Ending Ref erence Dat e [Time]: NOW// <Ent er> | |
3333 | Searching for the do cuments... . | |
3334 | Search for Selected Documents, cont’d | |
3335 | 6. After t he documen ts are dis played, yo u can choo se one of the action s listed b elow (amen d, browse, delete, e tc.) to pe rform on o ne or more of the do cuments. | |
3336 | UNVERIFIED Documents Ju n 09, 1997 10:11:11 Page : 1 of 1 | |
3337 | by ALL CATEGORIE S from 04/ 10/97 to 0 6/09/97 4 documents | |
3338 | Patien t Document Ref Date Status | |
3339 | 1 TIUPATIE NT (T3456) Addendum to Dischar ge Summary 06/05/97 unverified | |
3340 | 2 TIUPATIE NT (T3456) Addendum to Dischar ge Summary 06/05/97 unverified | |
3341 | 3 TIUPATIE NT (T3456) Addendum to Dischar ge Summary 06/04/97 unverified | |
3342 | 4+ TIUPATI EN (T3456) Discharge Summary 05/25/97 unverified | |
3343 | + Next Scre en - Prev Screen ? ? More Act ions >>> | |
3344 | Find Delete Do cument Bro wse | |
3345 | On Ch art Reassign Pri nt | |
3346 | Edit Send Back Cha nge View | |
3347 | Verif y/Unverify Detailed Display Qui t | |
3348 | Amend Document | |
3349 | Select Act ion: Quit/ / v=3 Ve rify/Unver ify | |
3350 | Opening Ad dendum rec ord for re view... | |
3351 | Verify Doc ument Jun 09, 1997 1 0:11:46 Page: 1 of 33 | |
3352 | Addendum | |
3353 | TIUPATIENT ,ONE 666 -12-3456 2B Visi t Date: 09 /21/95@10: 00 | |
3354 | DICT DA TE: JUN 04 , 1997 ENT RY DATE: J UN 05, 199 7@16:10:02 | |
3355 | DICTATED BY: TIUPRO VIDER,ONE ATTENDING : TIUPROVI DER,THREE | |
3356 | URGEN CY: routin e STATUS: U NVERIFIED | |
3357 | DIAGNOSIS: | |
3358 | 1. Status post head trauma wi th brain c ontusion. | |
3359 | 2. Status post cere brovascula r accident . | |
3360 | 3. End st age renal disease on hemodialy sis. | |
3361 | 4. Corona ry artery disease. | |
3362 | 5. Conges tive heart failure. | |
3363 | 6. Hypert ension. | |
3364 | 7. Non in sulin depe ndent diab etes melli tus. | |
3365 | + + Next Scr een - Pre v Screen ?? More ac tions | |
3366 | ||
3367 | Find Verify/Un verify | |
3368 | Print Quit | |
3369 | Select Act ion: Next Screen// v Verify/ Unverify | |
3370 | Do you wan t to edit this Disch arge Summa ry? NO// < Enter> | |
3371 | VERIFY thi s Discharg e Summary? NO// y Y ES | |
3372 | Discharge Summary VE RIFIED. | |
3373 | Refreshing the list. | |
3374 | Correcting Documents XE "Corre cting Docu ments" th at are Ent ered in Er ror XE "En tered in E rror: Corr ecting" | |
3375 | Reassignin g signed d ocuments i s restrict ed to the “Chief, MI S User Cla ss.” This includes n otes that are awaiti ng a co-si gnature. I f the docu ment is co mpletely u nsigned, u sers who a re Author/ Dictator o r users wi th proper authorizat ion may re assign XE "Reassign action" i t. | |
3376 | Besides re assigning a note to a differen t patient, admission , or visit , the reas sign actio n may be u sed to pro mote an Ad dendum as an Origina l, swap th e Addendum and the O riginal, c hange a di scharge su mmary to a n Addendum . | |
3377 | The basic reassign p rocess inc ludes the following steps: | |
3378 | Electronic signature challenge . If the d ocument is already s igned, TIU asks for the electr onic signa ture of th e Chief of MIS. | |
3379 | Retract. I f the docu ment is mo ved to a d ifferent p atient, TI U retracts the docum ent. | |
3380 | Re-edit or iginal vis it. If nec essary, th e PCE info rmation is updated f or the ori ginal visi t. | |
3381 | Edit desti nation vis it. If nec essary, PC E informat ion is col lected or revised fo r the new visit. | |
3382 | Sign. The original p rovider ne eds to sig n the docu ment. If t he documen t was move d to a dif ferent pat ient, TIU removes th e original signature . | |
3383 | In the fol lowing exa mple, an u nsigned no te is tran sferred fr om one pat ient to an other: | |
3384 | Select OPT ION NAME: TIU MAIN M ENU MGR Text Integ ration Uti lities (MI S Manager) | |
3385 | --- MIS Manage rs Menu -- - | |
3386 | 1 Individual Patient D ocument | |
3387 | 2 Multiple P atient Doc uments | |
3388 | 3 Print Docu ment Menu ... | |
3389 | 4 Search for Selected Documents | |
3390 | 5 Statistica l Reports ... | |
3391 | 6 Unsigned/U ncosigned Report | |
3392 | 7 Missing Te xt Report | |
3393 | 8 Missing Te xt Cleanup | |
3394 | 9 Signed/uns igned PN r eport and update | |
3395 | 10 UNKNOWN Ad denda Clea nup | |
3396 | 11 Missing Ex pected Cos igner Repo rt | |
3397 | 11 Missing Ex pected Cos igner Repo rt | |
3398 | 12 Mark Docum ent as 'Si gned by Su rrogate' | |
3399 | 13 Mismatched ID Notes | |
3400 | 14 TIU 215 AN ALYSIS ... | |
3401 | 15 Transcript ion Billin g Verifica tion Repor t | |
3402 | ...16 CWAD/Posti ngs Auto-D emotion Se tup | |
3403 | Select Tex t Integrat ion Utilit ies (MIS M anager) Op tion: 1 I ndividual Patient Do | |
3404 | cument | |
3405 | Select PAT IENT NAME: TIUPATIEN T,E | |
3406 | 1 TIU PATIENT,EL EVEN 4-2-44 66656876 5 YES NON-SE RVICE CONN EC | |
3407 | TED THI S IS A TES T | |
3408 | 2 TIU PATIENT,TW ENTY 4-1-48 66609093 4 NO NON-SER VICE CONNE CTED | |
3409 | CHOOSE 1-4 : 2 TIUPA TIENT,TWEN TY 4-1-48 666090934 NO NON-SERVI CE CO | |
3410 | Correcting Documents that are Entered in Error con t’d | |
3411 | NNECTED THIS IS A TEST | |
3412 | (1 note ) C: 03/1 6/99 10:20 | |
3413 | Available documents: 11/23/19 98 thru 01 /19/2001 (19) | |
3414 | Please spe cify a dat e range fr om which t o select d ocuments: | |
3415 | List docum ents Begin ning: 11/2 3/1998// < Enter> (N OV 23, 199 8) | |
3416 | Thru: 01/1 9/2001// < Enter> (J AN 19, 200 1) | |
3417 | 1 01/19/ 2001 10:27 Infectio n Control TIUPROVIDE R,O | |
3418 | Visit: 0 1/26/1999 | |
3419 | 2 12/30/ 2000 16:00 + Discha rge Summar y TIUPROVIDE R,T | |
3420 | Adm: 1 2/25/2000 Dis: 12/3 0/2000 | |
3421 | 3 11/01/ 2000 14:00 Discharg e Summary TIUPROVIDE R,T | |
3422 | Adm: 0 4/19/2000 Dis: 11/0 1/2000 | |
3423 | 4 04/24/ 2000 00:00 Discharg e Summary TIUPROVIDE R,T | |
3424 | Choose one or more d ocuments: (1-4):1 | |
3425 | Browse Doc ument Jan 19, 20 01 10:33:5 0 Pag e: 1 of 1◄ | |
3426 | Infection Control | |
3427 | TIUPATIENT ,NINE 666 -09-2591 AUDIOLOGY AND SPE Vi sit Date: 01/26/1999 17:50 | |
3428 | ◄ | |
3429 | DATE OF NO TE: JAN 19 ,2001@10:2 7:57 ENT RY DATE: J AN 19,2001 @10:27:58 | |
3430 | AUTH OR: TIUPRO VIDER,SEVE N EXP COSIG NER: | |
3431 | URGEN CY: STATUS: U NSIGNED | |
3432 | Pt is very sick... | |
3433 | + Next Scr een - Pre v Screen ?? More ac tions | |
3434 | Find On Chart Rea ssign | |
3435 | Print Amend Sen d Back | |
3436 | Edit Delete Qui t | |
3437 | Verif y/Unverify | |
3438 | Select Act ion: Quit/ / R Reas sign | |
3439 | Are you su re you wan t to REASS IGN this I nfection C ontrol? NO // Y YES | |
3440 | Please cho ose the co rrect PATI ENT and CA RE EPISODE : | |
3441 | Select PAT IENT NAME: TIUPATIEN T,N | |
3442 | 1 TIU PATIENT,NI NE *SENS ITIVE* *SENSITIVE * NO EMPLOYE E THIS | |
3443 | IS A TEST | |
3444 | 2 TIU PATIENT,NI NE 1-1-65 666344321 YES SC VETER AN THIS | |
3445 | IS A TEST | |
3446 | CHOOSE 1-2 : 2 TIUPA TIENT,NINE 1- 1-65 66 6344321 YES SC VETERAN | |
3447 | THIS IS A TEST | |
3448 | (1 note ) W: 09/1 5/98 08:29 | |
3449 | A: Know n allergie s | |
3450 | Enrollmen t Priority : GROUP 1 Categor y: IN PROC ESS End Date: | |
3451 | This patie nt is not currently admitted t o the faci lity... | |
3452 | Is this no te for INP ATIENT or OUTPATIENT care? OUT PATIENT// <Enter> | |
3453 | Correcting Documents that are Entered in Error con t’d | |
3454 | ||
3455 | The follow ing SCHEDU LED VISITS are avail able: | |
3456 | 1> AUG 20, 1999@ 08:00 NINE CLINI C | |
3457 | 2> JUL 30, 1999@ 09:00 NINE CLINI C | |
3458 | 3> JUL 29, 1999@ 09:15 NINE CLINI C | |
3459 | 4> JUN 03, 1999@ 13:00 NINE CLINI C | |
3460 | 5> JUL 22, 1997@ 09:00 INP ATIENT APP OINTMENT SIX CLINIC | |
3461 | CHOOSE 1-5 , or | |
3462 | <U>NSCHEDU LED VISITS , <F>UTURE VISITS, o r <N>EW VI SIT | |
3463 | <RETURN> T O CONTINUE | |
3464 | OR '^' TO QUIT: 2 J UL 30 1999 @09:00 | |
3465 | Enter/Edit PROGRESS NOTE... | |
3466 | Patient Lo cation: N INE CLINIC | |
3467 | Da te/time of Visit: 0 7/30/99 09 :00 | |
3468 | D ate/time o f Note: 0 1/19/01 10 :27 | |
3469 | Author o f Note: T IUPROVIDER ,SEVEN | |
3470 | ...OK? YES// | |
3471 | AUTHOR/DIC TATOR: TIU PROVIDER,S EVEN// | |
3472 | Infection Control Re assigned. | |
3473 | Press RETU RN to cont inue... | |
3474 | Select PAT IENT NAME: | |
3475 | Rescinding Advance D irectives | |
3476 | Patch TIU* 1*261 supp orts Imagi ng patch M AG*3.0*121 . The two patches ar e being r eleased in a combine d release, with TIU *1*261 req uiring MAG *3.0*121. Patch MAG *3.0*121 p rovides th e ability to waterma rk images "RESCINDE D". | |
3477 | Patch TIU *1*261 per mits an au thorized u ser to res cind an Ad vance Dire ctive docu ment by ch anging the title to RESCINDED ADVANCE DI RECTIVE. | |
3478 | MAG*3.0*12 1 takes it from ther e and wate rmarks any linked im ages | |
3479 | "RESCINDE D". | |
3480 | NOTE: Exa ct title n ames are r equired | |
3481 | Exact titl e names ar e required . The tit le of the Advance Di rective to be rescin ded must b e ADVANCE DIRECTIVE | |
3482 | The title it is chan ged to whe n it is be ing rescin ded must b e | |
3483 | R ESCINDED A DVANCE DIR ECTIVE | |
3484 | Both LOCAL and Natio nal Standa rd titles must be as above. Va riations o n either t itle will cause the Change Tit le action to fail to watermark images as rescinded . | |
3485 | These exa ct titles are requir ed by poli cy. See th e VHA HAND BOOK 1004. 02 section on Advanc e Directiv es: | |
3486 | http://vaw w1. d o main /vhapublic ations/Vie wPublicati on.asp?pub _ID=2042 | |
3487 | Example | |
3488 | Select OPT ION NAME: TIU MAIN M ENU MGR Text Int egration U tilities ( MIS Manage r) menu | |
3489 | Select Tex t Integrat ion Utilit ies (MIS M anager) Op tion: 1 I ndividual Patient Do cument | |
3490 | Select PAT IENT NAME: CPRSPATIE NT,TWO | |
3491 | (1 notes ) D: 12/ 20/2002 0 9:07 | |
3492 | Enrollmen t Priority : GROUP 3 Categor y: IN PROC ESS End Date: | |
3493 | Available documents: 12/17/19 98 thru 01 /10/2012 (231) | |
3494 | Please spe cify a dat e range fr om which t o select d ocuments: | |
3495 | List docum ents Begin ning: 12/1 7/1998// 0 1/10/11 ( JAN 10, 20 11) | |
3496 | Thru: 01/1 0/2012// (JAN 10, 2012) | |
3497 | 1 01/10/ 2012 11:44 ADVANCE DIRECTIVE CPRSPROVID ER,ONE | |
3498 | Adm: 1 2/20/2002 Dis: | |
3499 | One docume nt found w ithin date range... | |
3500 | Opening AD VANCE DIRE CTIVE reco rd for rev iew... | |
3501 | Browse Doc ument Jan 10, 20 12@11:52:5 7 Page: 1 of 1 | |
3502 | ADVANCE DI RECTIVE | |
3503 | CPRSPATIEN T,TWO 666 -54-8668 1A(1&2) A dm: 12/20/ 2002 Dis: | |
3504 | STANDARD T ITLE: ADVA NCE DIRECT IVE | |
3505 | DATE OF NO TE: JAN 10 , 2012@11: 44:13 ENT RY DATE: J AN 10, 201 2@11:44:13 | |
3506 | AUTH OR: CPRSPR OVIDER,ONE EXP COSIG NER: | |
3507 | URGEN CY: STATUS: U NSIGNED | |
3508 | ||
3509 | ||
3510 | ||
3511 | ||
3512 | DNR | |
3513 | ||
3514 | ||
3515 | ||
3516 | URGENCY: S TATUS: COM PLETED | |
3517 | VistA Imag ing - Scan ned Docume nt | |
3518 | *** SCANNE D DOCUMENT *** | |
3519 | SIGNATURE NOT REQUIR ED | |
3520 | Electronic ally Filed : 06/23/20 11 | |
3521 | by: CPRSPR OVIDER, ON E | |
3522 | + Next Scr een - Pre v Screen ?? More ac tions >>> | |
3523 | Find Sign/Cosi gn Lin k ... | |
3524 | Print Copy Enc ounter Edi t | |
3525 | Edit Identify Signers Int erdiscipl' ry Note | |
3526 | Make Addendum Delete Qui t | |
3527 | Select Act ion: Quit/ / ct CT | |
3528 | TITLE: ADV ANCE DIREC TIVE// RES CINDED ADV ANCE DIREC TIVE TITLE | |
3529 | Std Title: RES CINDED ADV ANCE DIREC TIVE | |
3530 | . ..OK? Yes/ / (Yes) | |
3531 | The title of this no te will be changed t o RESCINDE D ADVANCE DIRECTIVE and | |
3532 | linked ima ges will b e watermar ked 'RESCI NDED'. OK? NO// YES | |
3533 | Title chan ged; Image queued fo r watermar king. | |
3534 | Press RETU RN to cont inue... | |
3535 | Statistica l Reports XE "Statis tical Repo rts" | |
3536 | Use this m enu to pro duce stati stical rep orts for l ine counts and timel iness by A uthor, Tra nscription ist, or Se rvice. | |
3537 | | |
3538 | NOTE: | |
3539 | These repo rts are de signed for a margin width of 1 32. | |
3540 | OptionDesc riptionTRA NSCRIPTION IST Line C ount Stati sticsThis option all ows genera tion of st atistical reports of line coun ts and tim eliness da ta by tran scriptioni st (or the person wh o entered the docume nt). | |
3541 | SERVICE Li ne Count S tatisticsT his option allows ge neration o f statisti cal report s of line counts and timelines s data by SERVICE (e .g., Medic al Service , Surgical Service, Psychiatry Service, etc.). | |
3542 | AUTHOR Lin e Count St atisticsTh is option allows gen eration of statistic al reports of line c ounts and timeliness data by A UTHOR (or Dictating practition er). | |
3543 | TRANSCRIPT IONIST Lin e Count St atistics X E "TRANSCR IPTIONIST Line Count Statistic s" | |
3544 | DISCHARGE SUMMARY Li ne Count S tatistics by TRANSCR IPTIONIST - ISC-SLC- A4 | |
3545 | J UN 27,1996 09:51 PAGE 1 | |
3546 | Line | |
3547 | Transcribe r Count Re f Date Patient Dis ch-Dict Dict-Tra nscr Tran scr-Sign S ign-Cosign | |
3548 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- --------- | |
3549 | BS 0 JUN 19,1996 TIUPATIEN T,SEVEN 0 D ischarg | |
3550 | 73 JUN 11,1996 TIUPATIEN T,FIVE 1 D ischarg | |
3551 | 78 MAY 31,1996 TIUPATIEN T,SEVEN 7 1 D ischarg | |
3552 | 72 MAR 25,1996 TIUPATIEN T,EIGHT 1 0 0 D ischarg | |
3553 | 78 MAR 24,1996 TIUPATIEN T,NINE - 1 1 0 0 D ischarg | |
3554 | 73 MAR 23,1996 TIUPATIEN T,ELEVE 1 0 0 D ischarg | |
3555 | 73 FEB 12,1996 TIUPATIEN T,ONE 8 4 2 D ischarg | |
3556 | 80 FEB 8,1995 TIUPATIEN T,TWELV 0 44 0 Discha rg | |
3557 | 96 FEB 8,1995 TIUPATIEN T,ELEVE 0 44 0 D ischarg | |
3558 | ---- ---- -- - --- - -- --- | |
3559 | SUBTOTAL 623 9 0 7 88 0 | |
3560 | SUBCOUNT 9 3 9 5 5 | |
3561 | SUBMEAN 6 9.22 30 .00 0.78 1 7.60 | |
3562 | DP 1 JAN 10,1996 TIUPATIEN T,FIVE 10 04 0 0 0 D ischarg | |
3563 | ---- ---- -- - --- - -- --- | |
3564 | SUBTOTAL 1 10 04 0 0 0 | |
3565 | SUBCOUNT 1 1 1 1 1 | |
3566 | SUBMEAN 1.00 10 04.00 | |
3567 | SBW 0 MAY 25,1996 TIUPATIEN T,SEVEN 1 D ischarg | |
3568 | ---- ---- -- - --- - -- --- | |
3569 | SUBTOTAL 0 1 0 0 | |
3570 | SUBCOUNT 1 0 1 0 0 | |
3571 | SUBMEAN 1.00 | |
3572 | jg 0 FEB 12,1996 TIUPATIEN T,ONE 9 7 0 A ddendum | |
3573 | ---- ---- -- - --- - -- --- | |
3574 | SUBTOTAL 9 7 0 0 0 | |
3575 | SUBCOUNT 1 1 1 0 0 | |
3576 | SUBMEAN 97 .00 | |
3577 | ---- ---- -- - --- - -- --- | |
3578 | TOTAL 624 11 91 8 88 0 | |
3579 | COUNT 12 5 12 6 6 | |
3580 | MEAN 5 2.00 23 8.20 0.67 1 4.67 0.00 | |
3581 | Line Count Statistic s by AUTHO R XE "Line Count Sta tistics by AUTHOR" | |
3582 | DISCHARGE SUMMARY Li ne Count S tatistics by AUTHOR - ISC-SLC- A4 JUN 27, 1996 09:5 3 PAGE 1 | |
3583 | Line | |
3584 | Author C ount Ref Date Patient Disch- Dict Dic t-Transcr Transcr-S ign S ign-Cosign | |
3585 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- - | |
3586 | TIUPROVIDE R,T 0 FEB 12,1996 TIUPATIEN T,ONE 97 0 Addendu m | |
3587 | ---- ---- --- -- - --- --- | |
3588 | SUBTOTAL 97 0 0 0 | |
3589 | SUBCOUNT 1 1 1 0 0 | |
3590 | SUBMEAN 97.00 | |
3591 | TIUPROVIDE R,O 0 JUN 19,1996 TIUPATIEN T,SEV 0 Discharg | |
3592 | 73 JUN 11,1996 TIUPATIEN T,TWO 1 Discharg | |
3593 | 78 MAY 31,1996 TIUPATIEN T,SEV 7 1 Discharg | |
3594 | 72 MAR 25,1996 TIUPATIEN T,NIN 1 0 0 Discharg | |
3595 | 78 MAR 24,1996 TIUPATIEN T,SEV -1 1 0 0 Discharg | |
3596 | 73 MAR 23,1996 TIUPATIEN T,ELE 1 0 0 Discharg | |
3597 | 73 FEB 12,1996 TIUPATIEN T,ONE 84 2 Discharg | |
3598 | ---- ---- --- -- - --- --- | |
3599 | SUBTOTAL 447 90 7 0 0 | |
3600 | SUBCOUNT 7 3 7 3 3 | |
3601 | SUBMEAN 6 3.86 30.00 1. 00 | |
3602 | TIUPROVIDE R,S 80 FEB 8,1995 TIUPATIEN T,TWE 0 44 0 Discharg | |
3603 | 96 FEB 8,1995 TIUPATIEN T,THI 0 44 0 Discharg | |
3604 | ---- ---- --- -- - --- --- | |
3605 | SUBTOTAL 176 0 0 88 0 | |
3606 | SUBCOUNT 2 0 2 2 2 | |
3607 | SUBMEAN 8 8.00 44.00 | |
3608 | TIUPROVIDE R,F 1 JAN 10,1996 TIUPATIEN T,ONE1004 0 0 0 Discharg | |
3609 | ---- ---- --- -- - --- --- | |
3610 | SUBTOTAL 1 1004 0 0 0 | |
3611 | SUBCOUNT 1 1 1 1 1 | |
3612 | SUBMEAN 1.00 1004. 00 | |
3613 | TIUPROVIDE R,E 0 MAY 25,1996 TIUPATIEN T,EIG 1 Discharg | |
3614 | ---- ---- --- -- - --- --- | |
3615 | SUBTOTAL 0 1 0 0 | |
3616 | SUBCOUNT 1 0 1 0 0 | |
3617 | SUBMEAN 1. 00 | |
3618 | ---- ---- --- -- - --- --- | |
3619 | TOTAL 624 1191 8 88 0 | |
3620 | COUNT 12 5 1 2 6 6 | |
3621 | MEAN 5 2.00 238.2 0 0. 67 14.67 0.00 | |
3622 | Line Count Statistic s by SERVI CE XE "Lin e Count St atistics b y SERVICE" | |
3623 | DISCHARGE SUMMARY Li ne Count S tatistics by SERVICE - ISC-SLC -A4 J UN 27,1996 09:42 PAGE 1 | |
3624 | Line | |
3625 | Service C ount Ref Date Patient Disch-Di ct Dict-Tr anscr Tra nscr-Sign Sign -Cosign | |
3626 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- -------- | |
3627 | MEDICINE 0 JUN 19,1996 TIUPATIEN T,SEV 0 D ischarg | |
3628 | 73 JUN 11,1996 TIUPATIEN T,TWO 1 D ischarg | |
3629 | 78 MAY 31,1996 TIUPATIEN T,SEV 7 1 D ischarg | |
3630 | 80 FEB 8,1995 TIUPATIEN T,ELE 0 44 0 D ischarg | |
3631 | 96 FEB 8,1995 TIUPATIEN T,TWE 0 44 0 D ischarg | |
3632 | ---- ---- --- --- --- --- | |
3633 | SUBTOTAL 327 7 2 88 0 | |
3634 | SUBCOUNT 5 1 5 2 2 | |
3635 | SUBMEAN 6 5.40 7.00 0.40 44.0 0 | |
3636 | SURGERY 0 FEB 12,1996 TIUPATIEN T,ONE97 0 A ddendum | |
3637 | 1 JAN 10,1996 TIUPATIEN T,S1004 0 0 0 Di scharg | |
3638 | ---- ---- --- --- --- --- | |
3639 | SUBTOTAL 1 1101 0 0 0 | |
3640 | SUBCOUNT 2 2 2 1 1 | |
3641 | SUBMEAN 0.50 550.50 | |
3642 | ---- ---- --- --- --- --- | |
3643 | TOTAL 328 1108 2 88 0 | |
3644 | COUNT 7 3 7 3 3 | |
3645 | MEAN 4 6.86 369.33 0.29 29.33 0.00 | |
3646 | Unsigned/U ncosigned Report XE "Unsigned/ Uncosigned Report" | |
3647 | Lists deta iled docum ent inform ation such as author , patient, patient S SN, etc. f or notes w ith no sig nature and /or cosign ature. Opt ionally, a summary r eport can be generat ed showing the numbe r of unsig ned and un cosigned d ocuments i n each ser vice. | |
3648 | In the fol lowing exa mple, a su mmary repo rt is gene rated for all divisi ons XE "di vision" : | |
3649 | Select Tex t Integrat ion Utilit ies (MIS M anager) Op tion: 6 U nsigned/Un cosigned R eport | |
3650 | Select div ision: ALL // <Enter> | |
3651 | Please spe cify an En try Date R ange: | |
3652 | Start Ent ry Date: T -180 (AUG 08, 2003) | |
3653 | Ending Ent ry Date: T (FEB 04, 2004) | |
3654 | Select ser vice: ALL/ / <Enter> | |
3655 | Selec t one of t he followi ng: | |
3656 | F FULL | |
3657 | S SUMMARY | |
3658 | Type of Re port: S S UMMARY | |
3659 | DEVICE: HO ME// <Ente r> ANYWHER E | |
3660 | U nsigned an d Uncosign ed Documen ts Aug 08, 2003 thru Feb 04, 2 | |
3661 | 004@23:59: 59Page 1 | |
3662 | PRINTED: for SALT LAKE CITY HCS | |
3663 | FEB 04, 20 04@09:16 | |
3664 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- -------- | |
3665 | Totals fo r Service: IRM--- UN SIGNED: 1 UNCOSIGNE D: 0 | |
3666 | Totals for Division: SALT LAKE CITY HCS- -- UNSIGNE D: 1 UNCO SIGNED: 0 | |
3667 | Enter RETU RN to cont inue or '^ ' to exit: | |
3668 | Missing Te xt Report XE "Missin g Text Rep ort" | |
3669 | This repor t lists TI U Document s that do not have a ny report text, are missing th e 0 node o f the text node, or both cases . The rep ort result s have the following categorie s: | |
3670 | Missing Te xt Only. This means the note has a 0 TE XT node, b ut no text (and this can be fi ne dependi ng on the status of the docume nt, such a s undictat ed). | |
3671 | Missing 0 Node Only. This mean s the note has text but no 0 T EXT node. | |
3672 | Missing 0 node & Tex t. This me ans the no te doesn't have a 0 TEXT node or text. | |
3673 | This cause of this c ondition i s unknown and has on ly been re ported fro m a few si tes. Never theless, t his report should be run by al l sights. If any mis sing text documents are found, refer to the discus sion under Missing T ext Cleanu p below fo r guidance . | |
3674 | The report can be ru n as often as needed to track the occurr ences of d ocuments w ithout tex t and miss ing the 0 text node. It is ad vised to r un the rep ort on a r egular int erval (onc e per week or month) to track an increas e or decre ase of rep orted docu ments miss ing text o r the 0 te xt node. | |
3675 | A delimite d form of the report can be pr ovided for users who want to p ut the rep ort into a spreadshe et program . | |
3676 | In the fol lowing exa mple a rep ort is gen erated sta rting June 1, 2004: | |
3677 | Select Tex t Integrat ion Utilit ies (MIS M anager) Op tion: ? | |
3678 | 1 Individual Patient D ocument | |
3679 | 2 Multiple P atient Doc uments | |
3680 | 3 Print Docu ment Menu ... | |
3681 | 4 Search for Selected Documents | |
3682 | 5 Statistica l Reports ... | |
3683 | 6 Unsigned/U ncosigned Report | |
3684 | 7 Missing Te xt Report | |
3685 | 8 Missing Te xt Cleanup | |
3686 | 9 Signed/uns igned PN r eport and update | |
3687 | 10 UNKNOWN Ad denda Clea nup | |
3688 | 11 Missing Ex pected Cos igner Repo rt | |
3689 | Enter ?? f or more op tions, ??? for brief descripti ons, ?OPTI ON for hel p text. | |
3690 | Select Tex t Integrat ion Utilit ies (MIS M anager) Op tion: 7 M issing Tex t Report | |
3691 | START WITH REFERENCE DATE: Ja n 01, 2003 //jun 1, 2 004 (JUN 01, 2004) | |
3692 | GO TO REFERENCE DATE: Ma r 04, 2005 // <Enter> (MAR 04, 2005) | |
3693 | Would you like a del imited rep ort? NO// <Enter> | |
3694 | DEVICE: HO ME// <Ente r> ANYWHE RE | |
3695 | Searching. .. | |
3696 | Date range searched: Jun 01, 2004 - Mar 04, 2005 | |
3697 | # o f Records: | |
3698 | Se arched 1 074 | |
3699 | M issing Tex t Only 1 | |
3700 | Mis sing 0 Nod e Only 0 | |
3701 | Missi ng 0 node & Text 4 | |
3702 | - --- | |
3703 | Total 5 | |
3704 | Elap sed Time: 0 minute( s) 0 secon d(s) | |
3705 | Curr ent User: CPRSPROVI DER,SEVEN | |
3706 | Curr ent Date: Mar 04, 2 005@15:08: 43 | |
3707 | Doc # Entry Da te/Time Title | |
3708 | Missing Referenc e Date/Tim e Patien t | |
3709 | Status Signatur e Date/Tim e Author /Dictator | |
3710 | ------ -------- ---------- - ------ --------- | |
3711 | 28476 Jun 04, 2004@13:09 :06 MRS TE ST NOTE | |
3712 | 0/Text Jun 04, 2004@13:08 CPRSPA TIENT,TWO( 3213) | |
3713 | COMPLETED Jun 04, 2004@13:12 :08 CPRSPR OVIDER,FIV E | |
3714 | 28481 Jun 04, 2004@13:54 :45 H&P GE NERAL MEDI CINE | |
3715 | 0/Text Jun 04, 2004@13:54 CPRSPA TIENT,FIVE (8828) | |
3716 | COMPLETED Jun 04, 2004@13:57 :22 CPRSPR OVIDER,FIV E | |
3717 | 28520 Jun 04, 2004@13:54 :47 GENERA L MEDICINE | |
3718 | 0/Text Jun 04, 2004@13:54 CPRSPA TIENT,ONE( 8846) | |
3719 | COMPLETED Jun 04, 2004@13:57 :23 CPRSPR OVIDER,SEV EN | |
3720 | 28522 Jun 04, 2004@14:02 :49 H&P GE NERAL MEDI CINE | |
3721 | Text Jun 04, 2004@14:02 CPRSPA TIENTFEMAL E,EIGHT(86 62) | |
3722 | COMPLETED Jun 04, 2004@14:03 :43 CPRSPR OVIDER,FIV E | |
3723 | 29498 Jan 18, 2005@11:34 :16 PRIMAR Y CARE NOT E | |
3724 | 0/Text Jan 18, 2005@11:33 CPRSPA TIENT,THRE E(6626) | |
3725 | COMPLETED Jan 18, 2005@11:37 :34 CPRSPR OVIDER,TWO | |
3726 | Press RETU RN to cont inue...: | |
3727 | Missing T ext Cleanu p XE "Miss ing Text C leanup" | |
3728 | ( | |
3729 | Note: | |
3730 | The TIU MI SSING TEXT REPORT sh ould be ru n prior to running t he cleanup . Refer to the docum entation o n the prev ious page for TIU MI SSING TEXT REPORT fo r cause an d frequenc y to run t hat report . | |
3731 | This is a utility de signed to help clean up TIU do cuments wi th no text . Before u sing this utility, a number of other thi ngs should be tried. They are: | |
3732 | NO TEXT in DOCUMENT body with no attache d addendum or image, document may or may not have the "TEXT" 0 node as indicated by the re port. Dele te or retr act the do cument (ba sed upon s tatus); no disclaime r is neede d. | |
3733 | If the "TE XT" 0 node is missin g as indic ated by th e report a nd the doc ument has text: | |
3734 | For direct entry doc uments, co ntact auth or to make an addend um to the note and a dd the mis sing infor mation. S ites may d etermine t he allowab le timefra me to perm it the aut hor enteri ng the add endum with the missi ng informa tion. If the author is no lon ger at the site or t he timefra me has pas sed, the H IMS Manage r or desig nee should enter an addendum w ith the fo llowing di sclaimer: | |
3735 | "DISCLAIME R: This co mpleted do cument con tains miss ing text t hat was el ectronical ly deleted in error" | |
3736 | For upload ed documen ts, contac t the tran scription company to re-upload if possib le or cont act the au thor to ma ke an adde ndum to th e note and add the m issing inf ormation. | |
3737 | The cleanu p utility retracts d ocuments w ithin a da te range t hat meet c ertain cri teria. The criteria are: | |
3738 | Document m ay be of a ny type, i ncluding A DDENDUM wi th a STATU S of UNCOSIGNED /COMPLETED /AMENDED | |
3739 | Document m ust fall w ithin user entered d ate range | |
3740 | Document m ust NOT ha ve the "TE XT",0 node | |
3741 | Document m ust NOT ha ve any TEX T | |
3742 | Document m ust NOT ha ve any add enda ("DAD " cross-re ference) | |
3743 | Document m ust NOT ha ve any com ponents (" ADI" cross -reference ) | |
3744 | An informa tional ale rt is sent once the cleanup pr ocess is f inished. | |
3745 | In the fol lowing exa mple, the cleanup pr ocess is r un for doc uments in a one mont h period: | |
3746 | Select Tex t Integrat ion Utilit ies (MIS M anager) Op tion: ? | |
3747 | 1 Individual Patient D ocument | |
3748 | 2 Multiple P atient Doc uments | |
3749 | 3 Print Docu ment Menu ... | |
3750 | 4 Search for Selected Documents | |
3751 | 5 Statistica l Reports ... | |
3752 | 6 Unsigned/U ncosigned Report | |
3753 | 7 Missing Te xt Report | |
3754 | 8 Missing Te xt Cleanup | |
3755 | 9 Signed/uns igned PN r eport and update | |
3756 | 10 UNKNOWN Ad denda Clea nup | |
3757 | 11 Missing Ex pected Cos igner Repo rt | |
3758 | Enter ?? f or more op tions, ??? for brief descripti ons, ?OPTI ON for hel p text. | |
3759 | Select Tex t Integrat ion Utilit ies (MIS M anager) Op tion: 8 M issing Tex t Cleanup | |
3760 | START WITH REFERENCE DATE: Ja n 01, 2003 //jun1, 20 04 (JUN 0 1, 2004) | |
3761 | GO TO REFERENCE DATE: Ma r 04, 2005 //jul1, 20 04 (JUL 0 1, 2004) | |
3762 | Requested Start Time : NOW// ( MAR 04, 20 05@16:02:3 7) | |
3763 | Your task # is: 165 564 | |
3764 | Press RETU RN to cont inue...: | |
3765 | UNKNOWN Ad denda Clea nup XE "Pa rentless A ddenda" | |
3766 | Prior to t he release of TIU*1* 187 it was possible to leave s urgery add enda uncon nected to their asso ciated ope ration rep ort. The U NKNOWN add enda Clean up menu op tion is pr ovided in TIU*1*173 to assist in cleanin g up these unattache d addenda. | |
3767 | In the fol lowing exa mple an un known adde nda is att ached to a surgery c ase: | |
3768 | --- M IS Manager s Menu --- | |
3769 | 1 Individual Patient D ocument | |
3770 | 2 Multiple P atient Doc uments | |
3771 | 3 Print Docu ment Menu ... | |
3772 | 4 Search for Selected Documents | |
3773 | 5 Statistica l Reports ... | |
3774 | 6 Unsigned/U ncosigned Report | |
3775 | 7 Missing Te xt Report | |
3776 | 8 Missing Te xt Cleanup | |
3777 | 9 Signed/uns igned PN r eport and update | |
3778 | 10 UNKNOWN Ad denda Clea nup | |
3779 | 11 Missing Ex pected Cos igner Repo rt | |
3780 | 12 Mark Docum ent as 'Si gned by Su rrogate' | |
3781 | 13 Mismatched ID Notes | |
3782 | 14 TIU 215 AN ALYSIS ... | |
3783 | 15 Transcript ion Billin g Verifica tion Repor t | |
3784 | 16 CWAD/Posti ngs Auto-D emotion Se tup | |
3785 | ||
3786 | Select Tex t Integrat ion Utilit ies (MIS M anager) Op tion: 9 U NKNOWN Add enda Clean up | |
3787 | START WITH REFERENCE DATE: Ja n 01, 2003 // <Enter> (JAN 01, 2003) | |
3788 | GO TO REFERENCE DATE: Ap r 04, 2005 // <Enter> (APR 04, 2005) | |
3789 | Searching for the do cuments.. | |
3790 | TIU/Surger y Cleanup Apr 04, 20 05@08:48:5 3 Pa ge: 1 o f 1 | |
3791 | UNKNOW N ADDENDA from Jan 0 1, 2003 to Apr 04, 2 005 | |
3792 | Patie nt Doc IEN En try DT St atus Parent | |
3793 | 1 CPRSP ATIENT,T ( C5525) 2194 09 /29/04 UN SIGNED NO | |
3794 | 2 CPRSP ATIENT,T ( C5525) 2236 10 /14/04 UN SIGNED NO | |
3795 | 3 CPRSP ATIENT,T ( C5525) 2238 10 /14/04 UN SIGNED NO | |
3796 | ||
3797 | ||
3798 | Enter ?? f or more ac tions | |
3799 | Brows e Chang e View | |
3800 | Detai led Displa y Find Parent | |
3801 | Select Act ion: Quit/ / F Find Parent | |
3802 | Select Doc ument(s): (1-3) 3 | |
3803 | START WITH REFERENCE DATE: Ja n 01, 2003 // <Enter> (JAN 01, 2003) | |
3804 | GO TO REFERENCE DATE: Ap r 04, 2005 // <Enter> (APR 04, 2005) | |
3805 | Searching for the do cuments... | |
3806 | Operation Reports Apr 04, 20 05@08:49:0 4 Pa ge: 1 o f 1 | |
3807 | OPERATI ON REPORTS from Jan 01, 2003 t o Apr 04, 2005 | |
3808 | Patie nt Doc I EN Ent ry DT Sta tus Case # | |
3809 | 1 CPRSP ATIENT,T ( C5525) 2181 09/ 17/04 RET RACTED #90 | |
3810 | 2 CPRSP ATIENT,T ( C5525) 2182 09/ 20/04 RET RACTED #89 | |
3811 | 3 CPRSP ATIENT,T ( C5525) 2192 09/ 28/04 RET RACTED #90 | |
3812 | 4 CPRSP ATIENT,T ( C5525) 2195 09/ 29/04 COM PLETED #89 | |
3813 | 5 CPRSP ATIENT,T ( C5525) 2237 10/ 14/04 RET RACTED #90 | |
3814 | 6 CPRSP ATIENT,T ( C5525) 2284 01/ 20/05 UNV ERIFIED #90 | |
3815 | 7 CPRSP ATIENT,T ( C5525) 2292 01/ 28/05 UND ICTATED #109 | |
3816 | Enter ?? f or more ac tions | |
3817 | Brows e Chang e View | |
3818 | Detai led Displa y Attac h to Paren t | |
3819 | Select Ite m(s): Quit // 4 | |
3820 | Select Act ion: Attac h to Paren t// <Enter > | |
3821 | Attach the following UNKNOWN A ddenda: | |
3822 | TIU | |
3823 | Doc No. P atient Entr y DT/Time Statu s Par ent | |
3824 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ------ | |
3825 | 2238 C PRSPATIENT ,T (C5525 ) 10/14/04 @11:56:14 UNSIGNED None | |
3826 | to the fol lowing OPE RATION REP ORT? | |
3827 | TIU Surgical | |
3828 | Doc No. P atient Entr y DT/Time Statu s Cas e No. | |
3829 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ----- | |
3830 | 2195 C PRSPATIENT ,T (C5525 ) 09/29/04 @08:18:39 COMPLETED #89 | |
3831 | Do you wis h to begin attaching ? NO// Y YES | |
3832 | Attaching #2238 to # 2195 ... success! | |
3833 | Press <RET URN> to co ntinue | |
3834 | | |
3835 | Note: | |
3836 | Be sure to verify an y addenda before att aching to a parent d ocument. M any addend a are dupl icates of the origin al Operati on Report and may be deleted o nce they a re verifie d as UNSIG NED copies . | |
3837 | Only one d ocument ma y be selec ted as the potential parent to the previ ously sele cted adden da. | |
3838 | Users may NOT attach addenda t o a parent OPERATION REPORT wi th a diffe rent patie nt or an O PERATION R EPORT whos e ENTRY DA TE/TIME fa lls after the addend a. | |
3839 | Once a par ent docume nt has bee n selected , a confir mation scr een will d isplay the selected addenda an d parent i nformation and promp t the user to begin attaching the docume nts. | |
3840 | After the utility at tempts to associate the addend a with a p arent Oper ation Repo rt the use r will be returned t o the init ial List M anager dis play with successful associati ons being listed und er the "Pa rent" colu mn showing the TIU D ocument nu mber of th e parent t hat has be en assigne d. These d ocuments w ill no lon ger appear once the current se ssion is c losed or a new searc h is initi ated via t he CHANGE VIEW optio n. | |
3841 | Missing Ex pected Cos igner XE " Expected C osigner" Report XE "Missing E xpected Co signer Rep ort" | |
3842 | List detai led docume nt informa tion for n otes that have a sta tus of “un cosigned” where the expected c osigner fi eld is eit her null, 0 or -1. U sers will have a cho ice of 3 d ifferent r eport form ats: an 80 column st andard rep ort, a 132 column ex tended rep ort and a “^” delimi ted report for use i n exportin g the data to Excel. The 80 co lumn repor t will inc lude Patie nt Name (i nitials an d last 4 o f SSN), En try Date/T ime, Autho r, Title, and the No te IEN. Th e 132 colu mn report and the “^ ” delimite d report w ill includ e Patient Name (init ials and l ast 4 of S SN), Entry Date/Time , Author, Title, Aut hor’s Serv ice/Sectio n, Author’ s Job Titl e and the Note IEN. In either case if th e document is an Add endum then the paren t’s Docume nt Type, E ntry Date/ Time and E xpected Co signer wil l also be displayed. The cause of the pr oblem is b eing fixed in CPRS p atch OR*3. 0*215. Use rs should review the notes dis played on this repor t to deter mine who s hould be t he expecte d cosigner and then enter the expected c osigner. O nce a note is signed the softw are doesn' t permit e diting so they will need to us e FileMan. The autho r of the n ote may ne ed to be c ontacted t o determin e who shou ld be the expected c osigner. | |
3843 | In additio n this rep ort may be setup in Taskman to be run ni ghtly. The entry poi nt for thi s is NITE^ TIU189. Th is task wi ll look fo r notes mi ssing an e xpected co signer and send an e mail to th e mail gro up TIU MIS ALERTS. T his email will inclu de Patient Name (ini tials and last 4 of SSN), Entr y Date/Tim e, Author, Title, Au thor’s Ser vice/Secti on, Author ’s Job Tit le, Note I EN and if the note i s an adden dum the pa rent’s Doc ument Type , Entry Da te/Time an d Expected Cosigner. | |
3844 | Example 80 column re port: XE " division" | |
3845 | Select Tex t Integrat ion Utilit ies (MIS M anager) Op tion: 11 Missing Ex pected Cos igner Repo rt | |
3846 | START WITH REFERENCE DATE: Ja n 01, 2003 //1/1/2005 (JAN 01, 2005) | |
3847 | GO TO REFERENCE DATE: Ju n 28, 2005 // (JUN 2 8, 2005) | |
3848 | DEVICE: HO ME// TCP | |
3849 | NOTES WITH 'UNC OSIGNED' S TATUS THAT DON'T HAV E AN EXPEC TED COSIGN ER | |
3850 | Patient E ntry Date/ Time Title Author No te IEN | |
3851 | ------- - ---------- ---- ----- ------ -- ------ | |
3852 | XXX1234 J UN 28, 200 5@09:24:44 UROLOGY NO SHOW TIUAUTHO R,ONE 4 957352 | |
3853 | XXX1235 J UN 28, 200 5@09:36:20 Addendum TIUAUTHO R,TWO ~4 957353 | |
3854 | Parent D ocument Ty pe: UROLOG Y NO SHOW NOTE | |
3855 | Parent D ocument Da te: JUN 28 , 2005@09: 24:44 | |
3856 | Parent D ocument Co signer: | |
3857 | XXX1236 J UN 28, 200 5@10:16:21 PROGRESS NOTE TIUAUTHO R,THREE ~4 957355 | |
3858 | Enter RETU RN to cont inue or '^ ' to exit: | |
3859 | Example 13 2 column r eport: XE "division" | |
3860 | Select Tex t Integrat ion Utilit ies (MIS M anager) Op tion: 11 Missing Ex pected Cos igner Repo rt | |
3861 | START WITH REFERENCE DATE: Ja n 01, 2003 //1/1/2005 (JAN 01, 2005) | |
3862 | GO TO REFERENCE DATE: Ju n 28, 2005 // (JUN 2 8, 2005) | |
3863 | DEVICE: HO ME// TCP | |
3864 | NOTES WITH 'UNC OSIGNED' S TATUS THAT DON'T HAV E AN EXPEC TED COSIGN ER | |
3865 | Patient E ntry Date/ Time Title Au thor Service /Section Job Title N ote IEN | |
3866 | ------- - ---------- ---- ----- -- ---- ------- -------- --------- - ------- | |
3867 | XXX1234 J UN 28, 200 5@09:24:44 UROLOGY NO SHOW TI UAUTHOR,ON E CHIEF O F STAFF SUPERVISO R, PHYS ~ 4957352 | |
3868 | XXX1235 J UN 28, 200 5@09:36:20 Addendum TI UAUTHOR,TW O CHIEF O F STAFF SUPERVISO R, PHYS ~ 4957353 | |
3869 | Parent D ocument Ty pe: UROLOG Y NO SHOW NOTE | |
3870 | Parent D ocument Da te: JUN 28 , 2005@09: 24:44 | |
3871 | Parent D ocument Co signer: | |
3872 | Enter RETU RN to cont inue or '^ ' to exit: | |
3873 | Example “^ ” delimite d report ( lines are truncated for this e xample): X E "divisio n" | |
3874 | Select Tex t Integrat ion Utilit ies (MIS M anager) Op tion: 11 Missing Ex pected Cos igner Repo rt | |
3875 | START WITH REFERENCE DATE: Ja n 01, 2003 //1/1/2005 (JAN 01, 2005) | |
3876 | GO TO REFERENCE DATE: Ju n 28, 2005 // (JUN 2 8, 2005) | |
3877 | DEVICE: HO ME// TCP | |
3878 | Patient Na me^Entry D ate/Time^T itle^Autho r^Service/ Section^Jo b Title^No te … | |
3879 | XXX1234^JU N 28, 2005 @09:24^URO LOGY NO SH OW^TIUPROV IDER,ONE^P HYSICIAN^S UPERV… | |
3880 | YYY5678^JU L 01, 2005 @19:14^PRO GRESS NOTE ^TIUPROVID ER,TWO^NUR SE^SUPERIV OR^84… | |
3881 | Example em ail messag e: | |
3882 | Subj: MISS ING EXPECT ED COSIGNE R [#44068 5] 02/08/0 6@13:14 1 1 lines | |
3883 | From: XXXX In 'IN' basket. Page 1 | |
3884 | ---------- ---------- ---------- ---------- ---------- ---------- -------- | |
3885 | PATIENT: A BC1234 | |
3886 | ENTRY DATE /TIME: JAN 10, 2006@ 15:34:21 | |
3887 | NOTE TITLE : Addendum | |
3888 | AUTHOR: TI UAUTHOR,ON E | |
3889 | AUTHOR'S S ERVICE/SEC TION: CHIE F OF STAFF | |
3890 | AUTHOR'S T ITLE: SUPE RVISOR, PH YSICAL MED ICINE | |
3891 | NOTE IEN: `1234567 | |
3892 | PARENT DOC UMENT TYPE : ANESTHES IA POST OP NOTE | |
3893 | PARENT DOC UMENT ENTR Y DATE: JA N 09, 2006 @16:25:47 | |
3894 | PARENT DOC UMENT COSI GNER: | |
3895 | Enter mess age action (in IN ba sket): | |
3896 | Mark Docu ments ‘Sig ned by Sur rogate’ | |
3897 | This optio n allows d ocuments n eeding an Additional Signer, w here the a dditional signature was signed by a surr ogate of t he Additio nal Signer , to be ma rked as “S igned By S urrogate.” This shou ld not be needed for documents signed af ter patch TIU*1.0*19 9 is insta lled. | |
3898 | Example: X E "divisio n" | |
3899 | Select OPT ION NAME: TIU MAIN M ENU MGR Text I ntegration Utilities (MIS Mana ger) | |
3900 | --- MIS Manage rs Menu -- - | |
3901 | 1 Individual Patient D ocument | |
3902 | 2 Multiple P atient Doc uments | |
3903 | 3 Print Docu ment Menu ... | |
3904 | 4 Search for Selected Documents | |
3905 | 5 Statistica l Reports ... | |
3906 | 6 Unsigned/U ncosigned Report | |
3907 | 7 Missing Te xt Report | |
3908 | 8 Missing Te xt Cleanup | |
3909 | 9 Signed/uns igned PN r eport and update | |
3910 | 10 UNKNOWN Ad denda Clea nup | |
3911 | 11 Missing Ex pected Cos igner Repo rt | |
3912 | 12 Mark Docum ent as 'Si gned by Su rrogate' | |
3913 | 13 Mismatched ID Notes | |
3914 | 14 TIU 215 AN ALYSIS ... | |
3915 | 15 Transcript ion Billin g Verifica tion Repor t | |
3916 | 16 CWAD/Posti ngs Auto-D emotion Se tup | |
3917 | Select Tex t Integrat ion Utilit ies (MIS M anager) Op tion: 12 Mark Docum ent as 'Si gned by Su rrogate' | |
3918 | Select ADD ITIONAL SI GNER: TIUH EALTHTECHN ICIAN, ONE OTT 11 6 HEAL TH TECHNIC IAN | |
3919 | START WITH REFERENCE DATE: Ja n 01, 2003 //3/1/1998 (MAR 01, 1998) | |
3920 | GO TO REFERENCE DATE: Ju l 18, 2005 //4/1/1998 (APR 01, 1998) | |
3921 | SEQ PATIE NT DOCUMENT TYPE RE FERENCE DA TE | |
3922 | --- ----- -- --------- ---- -- ---------- -- | |
3923 | 1 CPRSP ATIENT,FOU R (C1234) DOMICILIA RY CARE SE CTION MA R 12, 1998 @09:52:21 | |
3924 | ENTER SEQU ENCE # TO MARK AS 'S IGNED BY S URROGATE', 'NEW' FOR A NEW SEA RCH, | |
3925 | OR '^' TO QUIT: | |
3926 | Mismatched ID Notes XE "Mismat ched ID No tes" | |
3927 | The option TIU MISMA TCHED ID N OTES is un der the TI U MAIN MEN U MGR, and it runs a routine t hat will r eport/fix mismatched interdisc iplinary ( ID) notes. There are cases whe re a child ID note p oints to a parent ID note and that paren t ID note is for a d ifferent p atient. Th ere are al so cases w here the G DAD cross reference links a ch ild ID not e to a par ent ID not e when in fact the c hild does not point to the par ent. In th ese cases, the situa tion will be reporte d/fixed. I f it is fo und that t here is a child ID n ote pointi ng to a pa rent that may not be an ID not e, this wi ll be repo rted but n ot fixed. | |
3928 | When this report is run in Rep ort Only m ode the re port looks like the first exam ple. When this repor t is run i n Report a nd Fix mod e the repo rt looks l ike the se cond examp le. | |
3929 | When this report is run in eit her Report Only mode or in Rep ort and Fi x mode an email will be sent t o the PSI- 06-030 mai l group on Forum. Th is email w ill contai n ONLY the site, the date, the report mo de and the result to tals. No p atient dat a of any k ind is sen t. The pur pose of th is is to t rack the e xtent of t his proble m. Note th at the ema ils do not report th e count of : CHILD ID NOTES POI NTING TO A PARENT TH AT MAY NOT BE AN ID NOTE. | |
3930 | Example of Report On ly mode:xe "division " | |
3931 | MI SMATCHED I NTERDISCIP LINARY NOT ES | |
3932 | CHILD DOCU MENT PAREN T DOCUMENT | |
3933 | ---------- ----- ----- --------- | |
3934 | Patient: TIUPATIENT ,ONE (P123 4) TIUPA TIENT,TWO (P5678) | |
3935 | Title: INTERDISCI PLINARY PA TIENT EDUC ATI PM&R KT | |
3936 | Entry DT: JAN 21, 19 98@15:28:2 7 FEB 0 1, 1996@14 :16:10 | |
3937 | Author: TIUAUTHOR, ONE TIUAU THOR,ONE | |
3938 | Note IEN: 345678 12345 6 | |
3939 | CHILD ID NOTES POIN TING TO A NON-EXISTE NT PARENT ID NOTE | |
3940 | Patient : TIUPATIE NT,THREE ( P9876) | |
3941 | Title : CARDIAC REHAB DAIL Y | |
3942 | Entry DT : APR 28, 2003@07:43 :49 | |
3943 | Author : TIUAUTHO R,TWO | |
3944 | Child IEN : 3300852 | |
3945 | Parent IEN : 3200408 | |
3946 | CHILD ID NOTES POIN TING TO A PARENT THA T MAY NOT BE AN ID N OTE | |
3947 | ** NOTE: THIS IS AN INFORMATI ONAL LIST FOR INVEST IGATION. | |
3948 | NOTHING WILL BE F IXED ** | |
3949 | Pa tient: TIU PATIENT,FO UR (J0222) | |
3950 | Parent Title: OPE RATION REP ORT-IEN: 1 734321 | |
3951 | Parent Ent ry DT: FEB 03, 2006@ 12:43:49 | |
3952 | Parent A uthor: TIU AUTHOR,THR EE | |
3953 | Child Title: NUR SE INTRAOP ERATIVE RE PORT-IEN: 1734320 | |
3954 | Pa tient: TIU PATIENT,FO UR (J0222) | |
3955 | Parent Title: TEL EPHONE CON TACT-IEN: 1734512 | |
3956 | Parent Ent ry DT: JUN 26, 2006@ 10:42:25 | |
3957 | Parent A uthor: TIU AUTHOR,FOU R | |
3958 | Child Title: ECU ADL SELF CARE PERFO RMANCE SUM MARY-IEN: 1734511 | |
3959 | TOTAL COUNTS FO R MISMATCH ED ID NOTE S | |
3960 | ----- ---------- ---------- ---------- - | |
3961 | 1173 CROSS REFE RENCES CHE CKED | |
3962 | 1 MIS S MATCHED NOTE(S) FO UND | |
3963 | 1 NON EXISTENT PARENT NOT E(S) | |
3964 | 2 PAR ENT MAY NO T BE AN ID NOTE | |
3965 | Example of Report an d Fix mode :xe "divis ion" | |
3966 | MI SMATCHED I NTERDISCIP LINARY NOT ES | |
3967 | CHILD DOCU MENT PAREN T DOCUMENT | |
3968 | ---------- ----- ----- --------- | |
3969 | Patient: TIUPATIENT ,ONE (P123 4) TIUPA TIENT,TWO (P5678) | |
3970 | Title: INTERDISCI PLINARY PA TIENT EDUC ATI PM&R KT | |
3971 | Entry DT: JAN 21, 19 98@15:28:2 7 FEB 0 1, 1996@14 :16:10 | |
3972 | Author: TIUAUTHOR, ONE TIUAU THOR,ONE | |
3973 | Note IEN: 345678 12345 6 | |
3974 | ..... Removed p ointer fro m child to parent. | |
3975 | Patient: TIUPATIENT ,THREE (P4 321) TIUPA TIENT,FOUR (P8746) | |
3976 | Title: PRIME CARE CLINIC PATIE NT/FAMILY EDUCATION DOC | |
3977 | Entry DT: FEB 04, 20 03@10:33:4 8 | |
3978 | Author: TIUAUTHOR, TWO | |
3979 | Note IEN: 3100784 30005 97 | |
3980 | ... C hild note did not po int to par ent. GDAD cross refe rence remo ved | |
3981 | CHILD ID NOTES POIN TING TO A NON-EXISTE NT PARENT ID NOTE | |
3982 | Patient : TIUPATIE NT,FIVE (P 2233) | |
3983 | Title : OTP DOSI NG NOTE | |
3984 | Entry DT : APR 28, 2003@07:54 :47 | |
3985 | Author : TIUAUTHO R,THREE | |
3986 | Child IEN : 3300864 | |
3987 | Parent IEN : 3200349 | |
3988 | ... Ch ild note d id not poi nt to pare nt. GDAD c ross refer ence remov ed. | |
3989 | Patient : TIUPATIE NT,SIX (P4 567) | |
3990 | Title : PM&R PT DISCHARGE | |
3991 | Entry DT : JAN 29, 2004@15:26 :57 | |
3992 | Author : TIUAUTHO R,FOUR | |
3993 | Child IEN : 4000224 | |
3994 | Parent IEN : 4000522 | |
3995 | ..... Removed p ointer fro m child to parent re moved. | |
3996 | CHILD ID NOTES POIN TING TO A PARENT THA T MAY NOT BE AN ID N OTE | |
3997 | ** NOTE: THIS IS AN INFORMATI ONAL LIST FOR INVEST IGATION. | |
3998 | NOTHING WILL BE F IXED ** | |
3999 | Pa tient: TIU PATIENT,SE VEN (J0202 ) | |
4000 | Parent Title: OPE RATION REP ORT-IEN: 1 834321 | |
4001 | Parent Ent ry DT: FEB 03, 2006@ 12:43:49 | |
4002 | Parent A uthor: TIU AUTHOR,FIV E | |
4003 | Child Title: NUR SE INTRAOP ERATIVE RE PORT-IEN: 1784320 | |
4004 | Pa tient: TIU PATIENT,EI GHT (P2539 ) | |
4005 | Parent Title: TEL EPHONE CON TACT-IEN: 1734552 | |
4006 | Parent Ent ry DT: JUN 26, 2006@ 10:42:25 | |
4007 | Parent A uthor: TIU AUTHOR,SIX | |
4008 | Child Title: ECU ADL SELF CARE PERFO RMANCE SUM MARY-IEN: 1734555 | |
4009 | TOTAL COUNTS FO R MISMATCH ED ID NOTE S | |
4010 | ----- ---------- ---------- ---------- - | |
4011 | 1173 CROSS REFE RENCES CHE CKED | |
4012 | 2 MIS S MATCHED NOTE(S) FO UND | |
4013 | 2 NON EXISTENT PARENT NOT E(S) | |
4014 | 2 PAR ENT MAY NO T BE AN ID NOTE | |
4015 | 1 POI NTER(S) FI XED FOR MI SMATCHED N OTES | |
4016 | 1 XRE F(S) FIXED FOR MISMA TCHED NOTE S | |
4017 | 1 POI NTER(S) FI XED FOR MI SSING NOTE S | |
4018 | 1 XRE F(S) FIXED FOR MISSI NG NOTES | |
4019 | Example of email sen t to G.PSI -06-030 in report on ly mode:xe "division " | |
4020 | Site Numbe r^Site Nam e | |
4021 | AUG 31, 20 06@15:24:0 9 | |
4022 | 1173 CROS S REFERENC ES CHECKED | |
4023 | 9 MISMATCH ED NOTE(S) FOUND | |
4024 | 7 NON EXIS TENT PAREN T NOTE(S) | |
4025 | MODE - REP ORT ONLY | |
4026 | Example of email sen t to G.PSI -06-030 in report an d fix mode :xe "divis ion" | |
4027 | Site Numbe r^Site Nam e | |
4028 | AUG 31, 20 06@15:24:0 9 | |
4029 | 1173 CROS S REFERENC ES CHECKED | |
4030 | 9 MISMATCH ED NOTE(S) FOUND | |
4031 | 7 NON EXIS TENT PAREN T NOTE(S) | |
4032 | MODE - REP ORT AND FI X | |
4033 | 5 POINTER( S) FIXED F OR MISMATC HED NOTES | |
4034 | 4 XREF(S) FIXED FOR MISMATCHED NOTES | |
4035 | 3 POINTER( S) FIXED F OR MISSING NOTES | |
4036 | 4 XREF(S) FIXED FOR MISSING NO TES | |
4037 | TIU 215 AN ALYSIS | |
4038 | A problem has been f ound with VistA patc h TIU*1.0* 215, relea sed June 2 8, 2007. One of the intents o f this pat ch was to only allow editing/a mending et c. from th e Surgery package to keep the Surgery fi le (#130) and TIU fi les in syn c. This w as for the Nurse Int raoperativ e Report ( NIR) and t he Anesthe sia Report only. Ho wever, if surgery pe rsonnel ma de changes to a surg ery case u sing one o f the case editors s uch as OSS Operation (Short Sc reen) [SRO MEN-OUT], they were asked if t hey wanted to create an addend um. After installat ion of TIU *1.0*215, the addend um was not created f or viewing via the S urgery Tab in CPRS, however, t he data wa s being up dated in t he Surgery applicati on files. | |
4039 | A new opti on, TIU 21 5 ANALYSIS , is set u p with ins tallation of patch T IU*1.0*231 and is be ing added as sequenc e 14 to th e TIU MAIN MENU MGR option. | |
4040 | TIU MAIN M ENU MGR Text I ntegration Utilities (MIS Mana ger) | |
4041 | T IU 215 ANA LYSIS ... | |
4042 | A ANALYZE P OTENTIAL S URGERY TIU PROBLEMS | |
4043 | V VIEW SING LE SURGERY CASE USIN G CASE # | |
4044 | T SEND ANAL YSIS OUTPU T TO TEXT FILE | |
4045 | Option A - Analyze Potential Surgery TI U Problems : | |
4046 | Allows fo r the anal ysis proce ss (which was run du ring the i nstallatio n of this patch) to be run aga in. Surger y cases wi ll be anal yzed withi n a partic ular date range and the inform ation from NIR and/o r Anesthes ia reports will be c ompared to their cor responding TIU notes . If the informatio n does not match, th e case num ber will b e recorded as one th at needs t o be revie wed. The i nformation generated by this o ption shou ld be pri nted, eith er by cutt ing and pa sting the results in to a text file, or y ou can sim ply print the MM tha t was gene rated duri ng install ation. It can be us ed to iden tify which TIU recor ds have ad denda and which do n ot. This is extreme ly importa nt as how a comparis on is hand led depend s directly on if the TIU recor d has adde nda. It c an also be used as a checklist , to make sure that every reco rd in ques tion is ex amined. | |
4047 | Option V - View the Contents o f a Surger y Case Usi ng Case #: | |
4048 | Views the content o f a Surger y Case fil e (#130). NIR data w ill be dis played fol lowed by t he Anesthe sia data. | |
4049 | Option T - Send Outp ut To Text File: | |
4050 | Sends outp ut to a Ho st text fi le on your productio n account' s server. This will be very us eful for s ites that have a lar ge number of cases t o review. Microsoft Word can then be us ed to comp are the te xt files, which is e xtremely h elpful bec ause discr epancies a re automat ically hig hlighted, thus exped iting the comparison process. | |
4051 | Option T O verview: | |
4052 | Option T w ill send d ata from b oth Surger y and TIU to respect ive output files. F irst, the user is pr ompted for a path to send outp ut files t o which sh ould look something like this: USER$:[< directory name>] . You may ne ed to coor dinate wit h your loc al IRM Vis tA system administra tor to det ermine exa ctly what the path s hould be. The user is then pr ompted for three fil enames; on e for Surg ery output , one for TIU output , and one for associ ated TIU a ddenda. I f the path and/or fi lenames ar e invalid you will | |
4053 | be prompte d to enter them agai n. | |
4054 | Option T w ill use th e same ana lysis tech nique as O ption A do es. Inste ad of just listing c ases that need revie w, it will write the contents of the ass ociated re ports to t ext files. For each case, wha t is on re cord in Su rgery will be writte n to one f ile, and w hat is on record in TIU will b e written to another file. Als o, if ther e are any associated TIU adden da with th e case, th ese addend ums will be written to a sepa rate file. Multiple cases wil l be writt en to a si ngle file, with the user pre-d efining th e maximum limit. Whe n this lim it is enco untered, a new set o f output f iles will be created . For ins tance, if there are a total of 50 cases found with possible discrepanc ies, and t he user se ts a maxim um of 25 c ases per f ile, then 2 Surgery output fil es will be created, two TIU ou tput files , and x nu mber of ad denda outp ut files. Note: The number of Surgery an d TIU file s will alw ays be the same; the number of addenda f iles may n ot. This is due to the fact n ot every S urgery cas e will hav e an | |
4055 | associated TIU adden da). Let' s say the names "Sur gery", "TI U", and "A DDENDA" ar e used for the outpu t filename s. You wo uld then h ave: Surg ery1.txt, Surgery2.t xt, TIU1.t xt, TIU2.t xt, and AD DENDA1.txt (and poss ibly ADDEN DA2.txt), each with 25 cases p er file. | |
4056 | ********** IMPORTANT* ********** ******IMPO RTANT***** ********** ** | |
4057 | NOTE!!!! T he host fi les create d in optio n T contai ns Patient Informati on and sho uld only b e sent to a server w ithin the system bou ndary of t he VA. Th e director y must be password p rotected. If you ar e going to download to a pc an d use the Microsoft Word Compa re feature for analy sis, it mu st be a VA approved encrypted PC. Both the host f iles and t he files d ownloaded to the pc must be de stroyed by an approv ed means w hen analys is/correct ion is com plete. Whe n the file s are dest royed the systems | |
4058 | manager, o fficial, o r the ISO should be notified t hey have b een destro yed. | |
4059 | ********** IMPORTANT* ********** ******IMPO RTANT***** ********** ** | |
4060 | CORRECTION PROCESS | |
4061 | The follow ing manual fix proce ss is prov ided by th e Surgery Enterprise Product S upport(EPS ) personne l: | |
4062 | The Surger y ADPAC sh ould revie w the repo rts. Healt h Informat ion Manage ment (HIM) personnel should al so be invo lved in th is process . If the programmer feels com fortable i n restorin g the data in the Su rgery pack age to wha t it was o riginally, then the programmer can, with the help of the Sur gery ADPAC do it, bu t we would encourage the site to enter a Surgery R emedy tick et, and we will step the site through th e process. | |
4063 | The progra mmer would edit the fields in the Surger y Case fil e (#130) t hat should be restor ed to thei r original data usin g FileMan enter/edit . | |
4064 | For the NI R, once th e cases th at need fi xing are r estored to their ori ginal data set(see e xamples on e and two) , one of t he circula ting nurse s listed i n the case , with the assistanc e of the S urgery ADP AC, should use the S urgery pac kage to pu t the chan ges back i nto the ca ses and si gn the add enda (see Options us ed to reen ter the da ta in Surg ery). | |
4065 | Similarly for the An esthesia R eport, onc e the case s that nee d fixing a re restore d to their original data set ( see exampl es one and two), the anestheti st with th e assistan ce of the Surgery AD PAC, shoul d use the Surgery pa ckage to p ut the cha nges back into the c ases and s ign the ad denda (see Options u sed to ree nter the d ata in Sur gery). | |
4066 | Example ON E using Fi leMan: | |
4067 | Step One: | |
4068 | Select OPT ION: 1 EN TER OR EDI T FILE ENT RIES | |
4069 | INPUT TO W HAT FILE: SURGERY// | |
4070 | EDIT WHICH FIELD: AL L// ANESTH ESIA TECHN IQUE (m ultiple) | |
4071 | EDIT WH ICH ANESTH ESIA TECHN IQUE SUB-F IELD: ALL/ / | |
4072 | THEN EDIT FIELD: | |
4073 | Select SUR GERY PATIE NT: `30536 TIUPATIE NT, FOUR | |
4074 | 08-18-07 | |
4075 | TOE X-XX-XX XXXXXXX XX YES SC VE TERAN GJ | |
4076 | Select ANE STHESIA TE CHNIQUE: G ENERAL// @ | |
4077 | SURE YO U WANT TO DELETE THE ENTIRE 'G ' ANESTHES IA TECHNIQ UE? Y (Ye s) | |
4078 | Select ANE STHESIA TE CHNIQUE: | |
4079 | Step Two: | |
4080 | THEN IN SU RGERY ADD THE GENERA L ANESTHES IA TECHNIQ UE BACK IN USING ONE OF THE SU RGERY OPTI ONS LISTED IN THE SE CTION "OPT IONS USED TO RE-ENTE R DATA IN SURGERY". | |
4081 | Example TW O using Fi leMan: | |
4082 | TIU HAS "C LEAN" FOR WOUND CLAS SIFICATION BUT SURGE RY HAS "CO NTAMINATED " | |
4083 | STEP ONE: | |
4084 | Select OPT ION: 1 EN TER OR EDI T FILE ENT RIES | |
4085 | INPUT TO W HAT FILE: SURGERY// | |
4086 | EDIT WHICH FIELD: AL L// WOUND CLASSIFICA TION | |
4087 | THEN EDIT FIELD: | |
4088 | Select SUR GERY PATIE NT: `30506 TIUPAT IENT,TWO 12-31-06 BAD F INGER | |
4089 | X-XX-XX XXXXXXX YES SC VETERAN GJ | |
4090 | WOUND CLAS SIFICATION : CONTAMIN ATED// CLE AN | |
4091 | 1 C LEAN | |
4092 | 2 C LEAN/CONTA MINATED | |
4093 | Choose 1-2 : 1 CLEAN | |
4094 | STEP TWO: | |
4095 | NOW REENTE R 'CONTAMI NATED' IN SURGERY US ING ONE OF THE OPTIO NS USED TO RE-ENTER DATA INTO SURGERY AN D IT WILL GENERATE A N ADDENDUM FORTIU | |
4096 | ***Options used to r eenter the data in S urgery.*** | |
4097 | NIR REPORT | |
4098 | OSS Operation (Short Scr een) | |
4099 | NR Nurse Intr aoperative Report | |
4100 | ANESTHESIA REPORT | |
4101 | AR Anesthesia Report | |
4102 | PAC Enter PAC( U) Informa tion | |
4103 | M Medication s (Enter/E dit) | |
4104 | For those sites that use the A nesthesia Report, th e followin g list of fields cre ate an add endum to t he NIR. | |
4105 | Sub-file | |
4106 | Field | |
4107 | Other Scru bbed Assis tant(s) | |
4108 | ||
4109 | Other Scru bbed Assis tant | |
4110 | Other Scru bbed Assis tant(s) | |
4111 | ||
4112 | Comments | |
4113 | O.R. Circu lating Nur se(s) | |
4114 | ||
4115 | O.R. Circu lating Nur se | |
4116 | O.R. Circu lating Nur se(s) | |
4117 | ||
4118 | Educationa l Status | |
4119 | O.R. Scrub Nurse(s) | |
4120 | ||
4121 | ||
4122 | O.R. Scrub Nurse | |
4123 | O.R. Scrub Nurse(s) | |
4124 | ||
4125 | ||
4126 | Educationa l Status | |
4127 | Other Pers ons in O.R . | |
4128 | ||
4129 | Other Pers on in O.R | |
4130 | Other Pers ons in O.R . | |
4131 | ||
4132 | Title/Orga nization | |
4133 | Position(s ) | |
4134 | ||
4135 | ||
4136 | ||
4137 | Position | |
4138 | Position(s ) | |
4139 | ||
4140 | ||
4141 | ||
4142 | Placed | |
4143 | Restraints and Posit ion Aids | |
4144 | ||
4145 | Restraint/ Position A id | |
4146 | Restraints and Posit ion Aids | |
4147 | ||
4148 | Applied By | |
4149 | Restraints and Posit ion Aids | |
4150 | ||
4151 | Comment | |
4152 | Principal CPT Modifi er | |
4153 | ||
4154 | CPT Modifi er | |
4155 | Other Proc edures Per formed | |
4156 | ||
4157 | Other Proc edure | |
4158 | Other Proc edures Per formed | |
4159 | ||
4160 | CPT Code | |
4161 | Other Proc edures Per formed | |
4162 | ||
4163 | CPT Modifi er | |
4164 | Tourniquet | |
4165 | ||
4166 | ||
4167 | ||
4168 | Time Appli ed | |
4169 | Tourniquet | |
4170 | ||
4171 | ||
4172 | ||
4173 | Time Relea sed | |
4174 | Tourniquet | |
4175 | ||
4176 | ||
4177 | ||
4178 | Site Appli ed | |
4179 | Tourniquet | |
4180 | ||
4181 | ||
4182 | ||
4183 | Pressure A pplied (in TORR)- | |
4184 | Tourniquet | |
4185 | ||
4186 | ||
4187 | ||
4188 | Applied By | |
4189 | Thermal Un it | |
4190 | ||
4191 | ||
4192 | ||
4193 | Thermal Un it | |
4194 | Thermal Un it | |
4195 | ||
4196 | ||
4197 | ||
4198 | Temperatur e | |
4199 | Thermal Un it | |
4200 | ||
4201 | ||
4202 | ||
4203 | Time On | |
4204 | Thermal Un it | |
4205 | ||
4206 | ||
4207 | ||
4208 | Time Off | |
4209 | Prosthesis Installed | |
4210 | ||
4211 | ||
4212 | Item | |
4213 | Prosthesis Installed | |
4214 | ||
4215 | ||
4216 | Sterility Checked | |
4217 | Prosthesis Installed | |
4218 | ||
4219 | ||
4220 | Sterility Expiration Date | |
4221 | Prosthesis Installed | |
4222 | ||
4223 | ||
4224 | RN Verifie r | |
4225 | Prosthesis Installed | |
4226 | ||
4227 | ||
4228 | Vendor | |
4229 | Prosthesis Installed | |
4230 | ||
4231 | ||
4232 | Model | |
4233 | Prosthesis Installed | |
4234 | ||
4235 | ||
4236 | Lot/Serial Number | |
4237 | Prosthesis Installed | |
4238 | ||
4239 | ||
4240 | Sterile Re sp | |
4241 | Prosthesis Installed | |
4242 | ||
4243 | ||
4244 | Size | |
4245 | Prosthesis Installed | |
4246 | ||
4247 | ||
4248 | Quantity | |
4249 | Medication s | |
4250 | ||
4251 | ||
4252 | ||
4253 | Medication | |
4254 | Medication s | |
4255 | ||
4256 | ||
4257 | ||
4258 | Time Admin istered | |
4259 | Medication s | |
4260 | ||
4261 | ||
4262 | ||
4263 | Route | |
4264 | Medication s | |
4265 | ||
4266 | ||
4267 | ||
4268 | Dose | |
4269 | Medication s | |
4270 | ||
4271 | ||
4272 | ||
4273 | Ordered By | |
4274 | Medication s | |
4275 | ||
4276 | ||
4277 | ||
4278 | Administer ed By | |
4279 | Medication s | |
4280 | ||
4281 | ||
4282 | ||
4283 | Comments | |
4284 | Irrigation Solution( s) | |
4285 | ||
4286 | ||
4287 | Irrigation Solution | |
4288 | Irrigation Solution( s) | |
4289 | ||
4290 | ||
4291 | Time Utili zed | |
4292 | Irrigation Solution( s) | |
4293 | ||
4294 | ||
4295 | Amount | |
4296 | Irrigation Solution( s) | |
4297 | ||
4298 | ||
4299 | Provider | |
4300 | Blood Repl acement Fl uids | |
4301 | ||
4302 | Replacemen t Fluid Ty pe | |
4303 | Blood Repl acement Fl uids | |
4304 | ||
4305 | Quantity ( ml)- | |
4306 | Blood Repl acement Fl uids | |
4307 | ||
4308 | Source Ide ntificatio n | |
4309 | Blood Repl acement Fl uids | |
4310 | ||
4311 | VA Identif ication | |
4312 | Blood Repl acement Fl uids | |
4313 | ||
4314 | Comments | |
4315 | Laser Unit (s) | |
4316 | ||
4317 | ||
4318 | ||
4319 | Laser Unit /ID | |
4320 | Laser Unit (s) | |
4321 | ||
4322 | ||
4323 | ||
4324 | Duration | |
4325 | Laser Unit (s) | |
4326 | ||
4327 | ||
4328 | ||
4329 | Wattage | |
4330 | Laser Unit (s) | |
4331 | ||
4332 | ||
4333 | ||
4334 | Operator | |
4335 | Laser Unit (s) | |
4336 | ||
4337 | ||
4338 | ||
4339 | Plume Evac uator | |
4340 | Laser Unit (s) | |
4341 | ||
4342 | ||
4343 | ||
4344 | Comments | |
4345 | Cell Saver (s) | |
4346 | ||
4347 | ||
4348 | ||
4349 | Cell Saver ID | |
4350 | Cell Saver (s) | |
4351 | ||
4352 | ||
4353 | ||
4354 | Operator | |
4355 | Cell Saver (s) | |
4356 | ||
4357 | ||
4358 | ||
4359 | Amount Sal vaged (ml) - | |
4360 | Cell Saver (s) | |
4361 | ||
4362 | ||
4363 | ||
4364 | Amount Rei nfused (ml )- | |
4365 | Cell Saver (s) | |
4366 | ||
4367 | ||
4368 | ||
4369 | Comments | |
4370 | Cell Saver (s) | |
4371 | ||
4372 | ||
4373 | ||
4374 | Disposable s Name | |
4375 | Cell Saver (s) | |
4376 | ||
4377 | ||
4378 | ||
4379 | Lot Number | |
4380 | Cell Saver (s) | |
4381 | ||
4382 | ||
4383 | ||
4384 | Quantity | |
4385 | Anesthesia Technique (s) | |
4386 | ||
4387 | Anesthesia Technique | |
4388 | Anesthesia Technique (s) | |
4389 | ||
4390 | Principal Technique | |
4391 | Anesthesia Technique (s) | |
4392 | ||
4393 | Anesthesia Agent | |
4394 | Anesthesia Technique (s) | |
4395 | ||
4396 | Dose (mg)- | |
4397 | Transcript ion Billin g Verifica tion Repor t XE "Tran scription Billing Ve rification Report" | |
4398 | ||
4399 | This repor t can be r un by divi sion and p rovides in formation on all tra nscription ists or on e or more selected t ranscripti onists. It reports b ased on an entered d ate range. Since the VBC Line Count XE " Line Count " | |
4400 | ||
4401 | XE "VBC L ine Count" is only calculated for trans cribed rep orts, it d oes not re port on an y document transcrib ed before the patch was instal led. | |
4402 | The accura cy of this report de pends on t he accurac y of the d ata. Speci fically, i t depends on whether transcrip tionists a re reliabl y recorded in the he ader of ea ch documen t. If you choose to use this r eport, you should fo llow the d irections in the Tex t Integrat ion Utilit ies (TIU) Line Count (TIU*1*25 0) Release Notes ava ilable fro m the VA D ocument Li brary (htt p://www4. d o main /vdl/) to insure tha t each upl oaded docu ment has t he needed data. | |
4403 | This examp le is a co mplete rep ort for al l faciliti es on the local Vist A system f or the mon th of Augu st: | |
4404 | --- MIS Manage rs Menu -- - | |
4405 | 1 Individual Patient D ocument | |
4406 | 2 Multiple P atient Doc uments | |
4407 | 3 Print Docu ment Menu ... | |
4408 | 4 Search for Selected Documents | |
4409 | 5 Statistica l Reports ... | |
4410 | 6 Unsigned/U ncosigned Report | |
4411 | 7 Missing Te xt Report | |
4412 | 8 Missing Te xt Cleanup | |
4413 | 9 Signed/uns igned PN r eport and update | |
4414 | 10 UNKNOWN Ad denda Clea nup | |
4415 | 11 Missing Ex pected Cos igner Repo rt | |
4416 | 12 Mark Docum ent as 'Si gned by Su rrogate' | |
4417 | 13 Mismatched ID Notes | |
4418 | 14 TIU 215 AN ALYSIS ... | |
4419 | 15 Transcript ion Billin g Verifica tion Repor t | |
4420 | 16 CWAD/Posti ngs Auto-D emotion Se tup | |
4421 | <CPM> Sele ct Text In tegration Utilities (MIS Manag er) Option : 15 Tran scription Billing Ve rification Report | |
4422 | --- Tr anscriptio n Billing Verificati on Report --- | |
4423 | Select div ision: ALL // <Enter> | |
4424 | Specific T ranscripti onist(s)? NO// YES | |
4425 | Select Tra nscription ist(s): | |
4426 | 1) ?? | |
4427 | Choose from: | |
4428 | INCORPO RATED,ASCO TT TRANSCR IPTION A TI TRANSCRI PTION SERV ICE | |
4429 | MEDTRAN ,INC M TI TRANSCRI PTION SERV ICE | |
4430 | ||
4431 | Please cho ose a KNOW N Transcri ptionist ( Duplicates not allow ed). | |
4432 | 1) ASCO TT INCORP ORATED,ASC OTT TRANSC RIPTION A TI TRANSCRI PTION SERV ICE | |
4433 | 2) MEDT RAN,INC MTI TRANSC RIPTION SE RVICE | |
4434 | 3) <Ent er> | |
4435 | Start Tran scription Date [Time ]: Jan 01, 2010// 1/ 1/09 (JAN 01, 2009) | |
4436 | Ending Tra nscription Date [Tim e]: Jan 31 , 2010@23: 59// <Ente r> (JAN 3 1, 2010@23 :59) | |
4437 | DEVICE: HO ME// <Ente r> TELNET PORT | |
4438 | Pag e 1 | |
4439 | ========== ========== ========== ========== ========== ========== ========== ========== | |
4440 | T R A N S C R I P T I O N B I L L I N G R E P O R T | |
4441 | CAMP M ASTER | |
4442 | for Docume nts Transc ribed: 01/ 01/2009 to 01/31/201 0 Print ed: 05/05/ 2010 11:18 | |
4443 | Tran Date Title P atient Aut VBC Lines | |
4444 | ========== ========== ========== ========== ========== ========== ========== ========== | |
4445 | ati 07/31 /09 Discha rge Summar y B CMA,ELEVEN -PATIENT ( 0011) JER 56.25 | |
4446 | 07/31 /09 Discha rge Summar y B CMA,ONE-PA TIENT ( 0001) JER 56.31 | |
4447 | ---------- | |
4448 | Total fo r Transcri ber ati = 112.56 | |
4449 | mti 07/23 /09 Discha rge Summar y E IGHTY,INPA TIENT ( 0880) JER 55.91 | |
4450 | 07/23 /09 Discha rge Summar y B CMA,FIFTEE N-PATIEN ( 0015) JER 57.31 | |
4451 | ---------- | |
4452 | Total fo r Transcri ber mti = 113.22 | |
4453 | tlc 08/13 /09 Discha rge Summar y B CMA,EIGHTY THREE-PA ( 0083) JER 55.91 | |
4454 | 08/27 /09 Discha rge Summar y N INETYEIGHT ,OUTPATI ( 0698) JER 55.91 | |
4455 | 08/27 /09 Discha rge Summar y C PRS,COMBAT VET T ( 0000) JER 55.91 | |
4456 | 08/27 /09 Discha rge Summar y F IVEHUNDRED ELEVEN,P ( 0511) JER 55.91 | |
4457 | Enter RETU RN to cont inue or '^ ' to exit: | |
4458 | Page 2 | |
4459 | ========== ========== ========== ========== ========== ========== ========== ========== | |
4460 | T R A N S C R I P T I O N B I L L I N G R E P O R T | |
4461 | CAMP M ASTER | |
4462 | for Docume nts Transc ribed: 01/ 01/2009 to 01/31/201 0 Print ed: 05/05/ 2010 11:18 | |
4463 | Tran Date Title P atient Aut VBC Lines | |
4464 | ========== ========== ========== ========== ========== ========== ========== ========== | |
4465 | 12/03 /09 OPERAT ION REPORT B CMA,EIGHT ( 0008) JER 1.40 | |
4466 | ---------- | |
4467 | Total fo r Transcri ber tlc = 225.04 | |
4468 | ---------- | |
4469 | T otal for D ivision = 450.82 | |
4470 | Press RETU RN to cont inue or '^ ' to exit: | |
4471 | Page 3 | |
4472 | ========== ========== ========== ========== ========== ========== ========== ========== | |
4473 | T R A N S C R I P T I O N B I L L I N G R E P O R T | |
4474 | CINCI NNATI | |
4475 | for Docume nts Transc ribed: 01/ 01/2009 to 01/31/201 0 Print ed: 05/05/ 2010 11:18 | |
4476 | Tran Date Title P atient Aut VBC Lines | |
4477 | ========== ========== ========== ========== ========== ========== ========== ========== | |
4478 | tlc 07/24 /09 Discha rge Summar y B CMA,EIGHTY SIX-PATI ( 0086) BA 56.54 | |
4479 | ---------- | |
4480 | Total fo r Transcri ber tlc = 56.54 | |
4481 | ---------- | |
4482 | T otal for D ivision = 56.54 | |
4483 | Press RETU RN to cont inue or '^ ' to exit: | |
4484 | Page 4 | |
4485 | ========== ========== ========== ========== ========== ========== ========== ========== | |
4486 | T R A N S C R I P T I O N B I L L I N G R E P O R T | |
4487 | SUMM ARY for ZZ ALBANY-PR RTP | |
4488 | for Docume nts Transc ribed: 01/ 01/2009 to 01/31/201 0 Print ed: 05/05/ 2010 11:18 | |
4489 | ========== ========== ========== ========== ========== ========== ========== ========== | |
4490 | Category Do cuments VBC Lines | |
4491 | ========== ========== ========== ========== ========== ========== ========== ========== | |
4492 | Division T otals | |
4493 | CAMP MAS TER 9 450.82 | |
4494 | CINCINNA TI 1 56.54 | |
4495 | Transcribe r Totals | |
4496 | ati 2 112.56 | |
4497 | mti 2 113.22 | |
4498 | tlc 6 281.58 | |
4499 | Station To tals | |
4500 | ZZ ALBAN Y-PRRTP 10 507.36 | |
4501 | Press RETU RN to cont inue or '^ ' to exit: <Enter> | |
4502 | Chapter 6: TIU for T ranscripti onists | |
4503 | Transcript ionists ty pically en ter Provid ers’ disch arge summa ries, prog ress notes , or other documents : | |
4504 | directly f rom dictat ion, or | |
4505 | from uploa ded transc ribed ASCI I document s in batch mode | |
4506 | from remot e microcom puters, us ing ASCII or KERMIT protocol u pload, or | |
4507 | from Host Files (i.e ., DOS or VMS ASCII files) on the host s ystem. | |
4508 | ||
4509 | Options on this menu can be as signed acc ordingly. | |
4510 | Transcript ionist Men u XE "Tran scriptioni st Menu" | |
4511 | Option Nam eDescripti onEnter/Ed it Dischar ge Summary XE "Enter /Edit Disc harge Summ ary" This option all ows you to enter or edit disch arge summa ries and p rogress no tes direct ly online. If the tr anscriptio nist holds the AUTOV ERIFY secu rity key, each disch arge summa ry will be verified automatica lly when t he transcr iptionist releases i t. | |
4512 | Enter/Edi t Document XE "Enter /Edit Docu ment" This option al lows you t o enter/ed it clinica l document s directly online. | |
4513 | Upload Men u ... XE " Upload Men u" This me nu include s options to upload batches of documents , and to g et help on the heade r formats for the va rious docu ments whic h have bee n defined for upload by your s ite. | |
4514 | List Docum ents for T ranscripti on | |
4515 | XE "List Documents for Transc ription" G ets all UN DICTATED a nd UNTRANS CRIBED Doc uments for review, e dit, and s ignature. | |
4516 | Review/Edi t Document | |
4517 | XE "Revie w/Edit Doc ument" All ows the us er to inte ractively review, ed it, and/or print doc uments. | |
4518 | Transcript ion Billin g Verifica tion Repor t | |
4519 | " | |
4520 | This optio n produces a report for the ve rification of transc ription bi lls, using the Visib le Black C haracter c ounting me thod descr ibed in VH A Directiv e 2008-042 . | |
4521 | Enter/Edit Discharge Summary X E "Enter/E dit Discha rge Summar y" | |
4522 | Use this o ption to e nter and e dit discha rge summar ies direct ly online. | |
4523 | Steps to u se option: | |
4524 | 1. Select Enter/Edit Discharge Summary f rom the Tr anscriptio nist Menu. | |
4525 | - -- Transcr iptionist Menu --- | |
4526 | 1 Enter/Edit Discharge Summary | |
4527 | 2 Enter/Edit Document | |
4528 | 3 Upload Men u ... | |
4529 | 4 List Docum ents for T ranscripti on | |
4530 | 5 Review/Edi t Document s | |
4531 | 6 Transcript ion Billin g Verifica tion Repor t | |
4532 | Select Tex t Integrat ion Utilit ies (Trans criptionis t) Option: 1 Enter/ Edit Disch arge Summa ry | |
4533 | 2. Enter a patient’s name and choose an Admission from the c hoices off ered. | |
4534 | Select Pat ient: TIUP ATIENT,ONE TIUPATIEN T,ONE 09-1 2-44 6662 33456 YES SC VETER AN | |
4535 | For Patien t TIUPATIE NT,ONE | |
4536 | The follow ing ADMISS ION is ava ilable: | |
4537 | 1> JUL 22, 1995@ 11:06 DIRECT TO: 1A | |
4538 | CHOOSE 1-1 : 1 JUL 2 2 1991@11: 06 | |
4539 | Patient: TIUPATIENT ,ONE SSN: 66 6-23-3456 Sex: M ALE | |
4540 | Race: MEXICAN AM ERICAN Age: 52 Claim #: U NKNOWN | |
4541 | Adm Date: 12/22/96 Ward: 1A | |
4542 | Dis Date: 02/12/97 | |
4543 | Adm Dx: Stage IV n on-Hodgkin ’s Lymphom a | |
4544 | ||
4545 | Correct VI SIT? YES// <Enter> | |
4546 | URGENCY: r outine// < Enter> ro utine | |
4547 | AUTHOR/DIC TATOR: TIU PROVIDER,O NE ot | |
4548 | DICTATION DATE: <Ent er> (FEB 12, 1997) | |
4549 | ATTENDING XE "ATTEND ING" PHYS ICIAN: TIU PROVIDER,O NE ot | |
4550 | Calling te xt editor, please wa it... | |
4551 | 1>DIAGNO SIS: | |
4552 | 2> | |
4553 | Enter/Edit Discharge Summary c ont’d | |
4554 | 3> | |
4555 | 4> | |
4556 | 5> | |
4557 | 6>OPERAT IONS/PROCE DURES: | |
4558 | EDIT Optio n: 1 | |
4559 | 1>DIAGNO SIS: | |
4560 | Replace : With : L ymphoma R eplace | |
4561 | DIAGNOS IS: Lympho ma | |
4562 | Edit line: 6 | |
4563 | 6>OPERAT IONS/PROCE DURES: | |
4564 | Replace : With : C hemotherap y Replace | |
4565 | OPERATI ONS/PROCED URES: Chem otherapy | |
4566 | Edit line: <Enter> | |
4567 | EDIT Optio n: <Enter> | |
4568 | Save chang es? YES// <Enter> | |
4569 | Saving Dis charge Sum mary with changes... | |
4570 | Is this Di scharge Su mmary read y to relea se from DR AFT? YES// n NO | |
4571 | NOT RELEA SED. | |
4572 | You may en ter anothe r Discharg e Summary. Press RET URN to exi t. | |
4573 | Select PAT IENT NAME: <Enter> | |
4574 | Enter/Edit Document XE "Enter/ Edit Docum ent" | |
4575 | This optio n allows t he transcr iptionist to enter a new docum ent (using a documen t title fr om the TIU document definition hierarchy ) or to re view, veri fy, send b ack to tra nscription , reassign , or print an existi ng documen t. The opt ion produc es a list of documen t definiti on types u sing searc h criteria such as s tatus, sea rch catego ry, and re ference da te range, from which you selec t a docume nt. | |
4576 | Steps to u se option: | |
4577 | 1. Select Enter/Edit Document from the T ranscripti onist Menu . | |
4578 | Select Tex t Integrat ion Utilit ies (Trans criptionis t) Option: 2 Enter/ Edit Docum ent | |
4579 | Select AUT HOR: TIUPR OVIDER,THR EE TIUPROV IDER,THREE TT | |
4580 | 2. Enter a patient’s name and choose the admission from the choices of fered. | |
4581 | Select Pat ient:TIUPA TIENT,SEVE N TIUPATIE NT,SEVEN 04-25-3 1 666042 591P NO MILITA RY RETIREE | |
4582 | (1 note ) C : 11/30/95 17:36 | |
4583 | (2 notes) W : 09/16/96 15:12 (a ddendum 09 /18/96 09: 53) | |
4584 | A : Known al lergies | |
4585 | (1 note ) D : 11/30/95 17:38 | |
4586 | For Patien t TIUPATIE NT,SEVEN | |
4587 | Select DOC UMENT TYPE : discharg e summary T ITLE | |
4588 | The follow ing ADMISS ION(S) are available : | |
4589 | 1> MAY 28, 1996@ 15:58 A/C TO: 1A | |
4590 | 2> MAY 28, 1996@ 15:51 DIRECT TO: 1A | |
4591 | 3> MAY 22, 1996@ 17:41 DIRECT TO: 1A | |
4592 | 4> DEC 22, 1994@ 17:27 DIRECT TO: 1A | |
4593 | 5> DEC 22, 1994@ 17:22 DIRECT TO: 2B | |
4594 | CHOOSE 1-5 | |
4595 | <RETURN> T O CONTINUE | |
4596 | OR '^' TO QUIT: 1 M AY 28 1996 @15:58 | |
4597 | Patient: TIUPATIENT ,SIX SSN: 6 66-04-2591 P Sex: M ALE | |
4598 | Race: AMERICAN I NDIAN OR A LASKA NA Age: 65 Claim #: U NKNOWN | |
4599 | Adm Date: 05/28/96 W ard: 1A | |
4600 | Adm Dx: TEST | |
4601 | Correct VI SIT? YES// <Enter> | |
4602 | Enter/Edit Document, cont’d | |
4603 | 3. Enter t he urgency (if routi ne, press Enter), au thor/ dict ator, dict ation date , and atte nding phys ician. | |
4604 | URGENCY: r outine// < Enter> r outine | |
4605 | AUTHOR/DIC TATOR: TI UPROVIDER, THREE TIUP ROVIDER,TH REE TT | |
4606 | DICTATION DATE: 9/30 (SEP 30, 1996) | |
4607 | ATTENDING PHYSICIAN: TIUPROVID ER,ONE TIU PROVIDER,O NE T O PGY2 RE SIDENT | |
4608 | 4. Your pr eferred ed itor appea rs (with b oilerplate if any ha s been set up for th is title) and you ca n now ente r the text for this discharge summary. | |
4609 | Calling te xt editor, please wa it... | |
4610 | 1>DIAGNO SIS: | |
4611 | 2> | |
4612 | 3> | |
4613 | 4> | |
4614 | 5> | |
4615 | 6>OPERAT IONS/PROCE DURES: | |
4616 | EDIT Optio n: 2 | |
4617 | 2> | |
4618 | Replace <space> W ith diabet es retinop athy Repl ace | |
4619 | diabete s retinopa thy | |
4620 | Edit line: <Enter> | |
4621 | EDIT Optio n: <Enter> | |
4622 | Save chang es? YES// <Enter> | |
4623 | Saving Dis charge Sum mary with changes... | |
4624 | Is this Di scharge Su mmary read y to relea se from DR AFT? YES// <Enter> | |
4625 | Discharge Summary Re leased. | |
4626 | Chart copy queued. | |
4627 | You may en ter anothe r Discharg e Summary. Press RET URN to exi t. | |
4628 | Select PAT IENT NAME: <Enter> | |
4629 | Upload Men u XE "Uplo ad Menu" | |
4630 | The Upload Menu cont ains optio ns that al low the tr anscriptio nist to up load a bat ch of clin ical docum ents. | |
4631 | Option Nam eDescripti onUpload D ocuments X E "Upload Documents" This opti on allows transcript ionists to upload tr anscribed ASCII docu ments in b atch mode, either fr om remote microcompu ters, usin g ASCII or KERMIT pr otocol upl oad, or fr om Host Fi les (i.e., DOS or VM S ASCII fi les) on th e host sys tem. Your site may d efine the preferred file trans fer protoc ol and the destinati on within VistA to w hich each report typ e (e.g., d ischarge s ummary, pr ogress not es, Operat ive Report , etc.) sh ould be ro uted. | |
4632 | Help for U pload Util ity XE "He lp for Upl oad Utilit y" This op tion displ ays inform ation on t he formats of header s for dict ated docum ents that are transc ribed off- line and u ploaded in to VISTA. It also di splays “bl ank” chara cter, majo r delimite r, and end of messag e signal a s defined by your si te. | |
4633 | The upload utility p ermits mix ed report types with in a singl e batch. T his allows the trans criptionis t to enter each repo rt in arri val sequen ce into a single ASC II file on the remot e computer (e.g., us ing a prop rietary wo rd-process ing progra m), and to transmit the text t o the Vist A host sys tem as a o ne-step pr ocess. As this ASCII data arri ves at the VistA hos t, it is r ead into a “buffer” file, and stored for subsequen t “filing” by a spec ial backgr ound proce ss, called the “Rout er/filer X E "Router/ filer" .” | |
4634 | The Router /filer is queued upo n completi on of tran smission o f a given batch of r eports, an d will pro ceed to “r ead” each line of th e buffer f ile, looki ng for a h eader. Whe n a header is encoun tered, the filer wil l determin e whether the record correspon ds to a kn own report type, as defined by your site , and if s o, it will attempt t o direct t he record to the app ropriate f ile and fi elds in Vi stA. | |
4635 | On occasio n, the Rou ter/filer will not b e able to identify t he appropr iate recor d in the t arget file , and will , therefor e, be unab le to file the recor d. When th is happens , the proc ess will l eave the r ecord in t he buffer file and s end an ale rt to the user who i nvoked the upload ut ility, and to a grou p of users identifie d by the s ite as bei ng able to respond t o such fil ing errors . | |
4636 | Upload Men u cont’d | |
4637 | When any o f the aler t recipien ts chooses to act on one of th ese alerts (by enter ing “VA” a t any menu prompt, a nd choosin g the aler t on which they wish to act), they will be shown t he header of the fai led record , and allo wed to inq uire to th e patient record, be fore being presented with thei r preferre d VistA ed itor, and will then be allowed to edit t he buffer (e.g., cor rect a bad social se curity num ber, admis sion date, etc.) and retry the filer. Wi th each at tempt to c orrect the buffered data and r etry the f iler, all alerts ass ociated wi th that ba tch will b e deleted (and if th e conditio n remains uncorrecte d, re-sent ), until a ll records in the ba tch are su ccessfully filed. | |
4638 | Batch Uplo ad Reports XE "Batch Upload Re ports" ; | |
4639 | Kermit Pro tocol Uplo ad | |
4640 | If your si te is usin g the uplo ad option to transfe r batches of dischar ge summari es from a remote com puter usin g the Kerm it transfe r protocol , start th e upload p rocess by following the sequen ce below: | |
4641 | Choose UP from your Upload Men u. | |
4642 | You are cu rrently lo gged into DIVISION: SALT LAKE CITY HCS | |
4643 | If a hospi tal locati on cannot be determi ned for an uploaded | |
4644 | document, the docume nt's divis ion may be loaded wi th your lo g-in | |
4645 | division. | |
4646 | 1 Upload Doc uments | |
4647 | 2 Help for U pload Util ity | |
4648 | Select Upl oad Menu O ption: UP Batch upl oad report s | |
4649 | K E R M I T U P L O A D | |
4650 | Now start a KERMIT s end from y our system . | |
4651 | Starting K ERMIT rece ive. | |
4652 | #N3 | |
4653 | | |
4654 | Note: | |
4655 | When enter ing the Up load Menu XE "divisi on" you r eceive a w arning whi ch specifi es which d ivision yo u are logg ed into. I f division informati on is not explicitly available in the he ader, then it uses d ivision in formation from your most curre nt login. To change this divis ion withou t re-loggi ng in, you can use t he XUSER D IV CHG opt ion from t he TBOX me nu. | |
4656 | 2. When y ou see the #N3 promp t, initiat e the Kerm it file tr ansfer XE "File tran sfer" fro m your com puter. Try the defau lt setting s for the Kermit pro tocol as p rovided by your term inal emula tion softw are. If yo u have pro blems, con sult your terminal e mulator us er manual or contact your loca l IRM Serv ice. | |
4657 | 3. When t he transfe r is compl ete, you’l l see this message: | |
4658 | File trans fer was su ccessful. (1515 byt es) | |
4659 | Filer/Rout er Queued! | |
4660 | Press RETU RN to cont inue...<En ter> | |
4661 | 1 Upload Doc uments | |
4662 | 2 Help for U pload Util ity | |
4663 | Select Upl oad menu O ption: <E nter> | |
4664 | ASCII Prot ocol Uploa d XE "ASCI I Protocol Upload" | |
4665 | If your si te is usin g the uplo ad option to transfe r batches of dischar ge summari es from a remote com puter usin g the ASCI I transfer protocol, start the upload pr ocess by f ollowing t he example shown bel ow: | |
4666 | Choose UP from your Upload Men u. | |
4667 | 1 Upload Doc uments | |
4668 | 2 Help for U pload Util ity | |
4669 | Select Upl oad menu O ption: UP Batch upl oad report s | |
4670 | A S C I I U P L O A D | |
4671 | | |
4672 | Note: | |
4673 | If you are at a site that uses multiple division X E "divisio n" s, you will recei ve a warni ng at this time spec ifying whi ch divisio n you are logged int o. If divi sion infor mation is not explic itly avail able in th e header, then it us es divisio n informat ion from y our most c urrent log in. To cha nge this d ivision wi thout re-l ogging in, you can u se the XUS ER DIV CHG option fr om the TBO X menu. | |
4674 | When the “ Initiate u pload proc edure:” pr ompt appea rs, initia te the ASC II file tr ansfer XE "ASCII fil e transfer " from yo ur compute r. | |
4675 | | |
4676 | NOTE: | |
4677 | If you hav e problems , consult your local IRM Servi ce to see if the Ter minal and Protocol S et-up para meters hav e been set up as sho wn in the Implementa tion and M aintenance Section o f the TIU Technical Manual, or check the user manu al for you r terminal emulator. | |
4678 | Initiate u pload proc edure: | |
4679 | $HDR: DISCHARGE SUMMARY | |
4680 | >PATIENT N AME: TIUPATIEN T,ONE | |
4681 | >SOC SEC N UMBER: 666-12-12 12 | |
4682 | >ADMISSION DATE: 02/20/93 | |
4683 | >DISCHARGE DATE: 02/25/93 | |
4684 | >DICTATED BY: TIUPROVID ER,TWO | |
4685 | >DICTATION DATE: 02/26/93 | |
4686 | >ATTENDING PHYSICIAN : TIUPROVID ER,TEN | |
4687 | >TRANSCRIP TIONIST ID : T1212 | |
4688 | >URGENCY: PRIORITY | |
4689 | >DIAGNOSIS : | |
4690 | >1. Acute pericardi tis. | |
4691 | >2. Statu s post tra nsmetatars al amputat ion, left foot. | |
4692 | >3. Diabe tes mellit us requiri ng insulin . | |
4693 | >4. Diabe tic neurop athy. | |
4694 | > | |
4695 | >Operation s/Procedur es perform ed during current ad mission: | |
4696 | >1. Statu s post tra nsmetatars al amputat ion of lef t foot on 3/17/93. | |
4697 | >2. Echoc ardiogram done 3/17/ 93. | |
4698 | . | |
4699 | . | |
4700 | . | |
4701 | $END | |
4702 | Filer/Rout er Queued! | |
4703 | Press RETU RN to cont inue...<En ter> | |
4704 | Handling u pload erro rs XE "Upl oad errors :Correctin g" | |
4705 | ASCII PROT OCOL UPLOA D XE "ASCI I Protocol Upload" / WITH ALE RT: | |
4706 | 1 Upload Doc uments | |
4707 | 2 Help for U pload Util ity | |
4708 | UPLOAD PRO CESS (5559 72453) Fai led: LOOKU P FAILED | |
4709 | Enter "VA VIEW AL ERTS t o review a lerts | |
4710 | Select Upl oad menu O ption: VA View Aler ts | |
4711 | 1. UPLO AD PROCESS (55597245 3) Failed: LOOKUP FA ILED | |
4712 | Select fro m 1 to 1 | |
4713 | or Enter ? , A, I, P, M, R, or ^ to exit: 1 | |
4714 | The header of the fa iled recor d looks li ke this: | |
4715 | $HDR: DISC HARGE SUMM ARY | |
4716 | PATIENT NA ME: TIUPAT IENT,ONE | |
4717 | SOCIAL SEC URITY NUMB ER: 666-09 -1244P | |
4718 | DATE OF AD MISSION: 1 1/17/95 | |
4719 | DATE OF DI SCHARGE: | |
4720 | DICTATED B Y: TIUPROV IDER,TWENT Y | |
4721 | DICTATION DATE: 4/16 /96 | |
4722 | ATTENDING PHYSICIAN: TIUPROVID ER,ONE | |
4723 | TRANSCRIPT IONIST: C7 689 | |
4724 | URGENCY: P RIORITY | |
4725 | $TXT | |
4726 | Inquire to patient r ecord? YES // <Enter> | |
4727 | Select PAT IENT: TIUP ATIENT,ONE 09-12- 44 666 091244P TO VETER AN | |
4728 | The follow ing admiss ions are a vailable: | |
4729 | (dcs in dicates a Discharge Summary ex ists) | |
4730 | 0 9-12-44 81209124 4P SC VETERAN | |
4731 | 1 TIUPATIE NT,ONE Adm: 07/22 /95 Dis : 10/28/92 Open | |
4732 | 2 TIUPATIE NT,ONE Adm: 10/28 /95 Dis : 10/28/92 Open | |
4733 | 3 TIUPATIE NT,ONE Adm: 11/16 /92 Dis : Open | |
4734 | CHOOSE 1-3 : 3 | |
4735 | ASCII PROT OCOL UPLOA D / WITH A LERT (cont ’d) | |
4736 | Patient: T IUPATIENT, ONE SSN: 6 66-09-1244 P Sex: MALE | |
4737 | Ward: 1A Race: Age : 48 | |
4738 | Att Phys: TIUPROVIDE R,EIGHT Prim P hys: TIUPR OVIDER,EIG HT | |
4739 | Adm Date: 11/16/95 | |
4740 | Adm Dx: ILL | |
4741 | Select PAT IENT: <Ent er> | |
4742 | You may no w edit the buffered upload dat a.. . . | |
4743 | (Press PF 1 then H f or help) | |
4744 | ==[ WRAP ] ==[ INSERT ]======= ====< >== ========== ========== ====== | |
4745 | $HDR: DISC HARGE SUMM ARY | |
4746 | PATIENT NA ME: TIUPAT IENT,ONE | |
4747 | SOCIAL SEC URITY NUMB ER: 666-09 -1244P | |
4748 | DATE OF AD MISSION: 1 1/16/95 = Cursor to this po int and ch ange the 7 to a 6, t hen | |
4749 | DATE OF DI SCHARGE: Enter <PF1>E to exit and save | |
4750 | DICTATED B Y: TIUPROV IDER,THREE | |
4751 | DICTATION DATE: 4/16 /96 | |
4752 | ATTENDING PHYSICIAN: TIUPROVID ER,TWO | |
4753 | TRANSCRIPT IONIST: C7 689 | |
4754 | URGENCY: P RIORITY | |
4755 | $TXT | |
4756 | DIAGNOSES: | |
4757 | 1. Status post coron ary artery bypass gr aft. | |
4758 | 2. Unstabl e angina p rior to co ronary art ery bypass graft. | |
4759 | 3. End sta ge renal d isease. | |
4760 | 4. Diabete s mellitus . | |
4761 | 5. Hyperte nsion. | |
4762 | 6. History of peptic ulcer dis ease. | |
4763 | M=====T=== ===T====== T=======T= ======T=== ====T===== ==T======= T====T | |
4764 | Now would you like t o retry th e filer? Y ES// <Ente r> | |
4765 | Filer/Rout er Queued! | |
4766 | 1 Upload Doc uments | |
4767 | 2 Help for U pload Util ity | |
4768 | Select Upl oad menu O ption: <En ter> | |
4769 | In the exa mple above , notice t hat patien t One TIUP atient had no admiss ion on 11/ 17/96, so the filer could not create a r ecord in t he target file for t his discha rge summar y record. The user a cts on the alert to correct th e admissio n date as 11/16/96, and retrie s the file r, which i s now able to file t he record appropriat ely, and t he alerts are remove d for all recipients . | |
4770 | Avoiding U pload Erro rs XE "Upl oad errors :Avoiding" | |
4771 | TIU uses h eader info rmation to file uplo aded notes in the TI U Document File (#89 25 XE "892 5" ). Natu rally, if this infor mation is inaccurate , then eit her a fili ng error i s generate d or the n ote is fil ed incorre ctly. | |
4772 | | |
4773 | Note: | |
4774 | Certain er rors in th e upload h eader can cause the upload rou tine to fi le the not e incorrec tly. This is a patie nt safety issue, so the accura cy of capt ions shoul d be verif ied where possible. | |
4775 | Each type of documen t has a di fferent se t of uploa d captions and, in s ome cases, a differe nt upload routine. E ach routin e tries to avoid inc orrect fil ing of not es by cros s-checking the patie nt informa tion and d ates with other info rmation su ch as the consult nu mber or su rgery case number. S ome types of documen ts have un ique field s to assis t the uplo ad program in accomp lishing th ese cross checks and /or to fil e the docu ment. | |
4776 | A missing field erro r is gener ated eithe r when a r equired fi eld is mis sing, or a field doe s not matc h the exam ple data g iven in th e Upload H elp Displa y (see Dis play Uploa d Help bel ow). | |
4777 | The follow ing table gives info rmation on required fields and the cross -checks pe rformed on fields fo r several document c lasses: | |
4778 | Type of Do cumentCapt ionUsePROG RESS NOTES XE "Progr ess Notes: Upload" SS NRequired by filing routineVIS IT/EVENT D ATERequire d by filin g routine. The patie nt record indicated by the SSN is checke d for a ma tching vis it or even t.TITLEReq uired by f iling rout ineLOCATIO NRequired by filing routineAUT HORGenerat es missing field err orDATE/TIM E OF DICTG enerates m issing fie ld errorDI SCHARGE SU MMARY XE " Discharge Summary:Up load" PATI ENT SSNReq uired by f iling rout ineDATE OF ADMISSION Required b y filing r outine. Th e patient record ind icated by the SSN is checked f or a match ing admiss ion date.D ICTATED BY Generates missing fi eld errorD ICTATION D ATEGenerat es missing field err orATTENDIN G PHYSICIA NGenerates missing f ield error URGENCYGen erates mis sing field errorType of Docume ntCaptionU seCLINICAL PROCEDURE S XE "Clin ical Proce dures:Uplo ad" SSNReq uired by f iling rout ineTITLERe quired by filing rou tine. This is the na me of the procedure. The patie nt record indicated by the SSN is checke d for a ma tching pro cedure.VIS IT/EVENT D ATERequire d by filin g routine. The patie nt record indicated by the SSN is checke d for a ma tching vis it or even t.CONSULT REQUEST NU MBERRequir ed by fili ng routine . The pati ent record indicated by the SS N is check ed for a m atching co nsult, tha t the cons ult is a c linical pr ocedure, a nd that re sults are available for interp retation.T IU DOCUMEN T NUMBEROn ly require d by filin g routine when an in complete C P document has been attached b y the CPUs er program . In this case, the consult re quest is c hecked for a matchin g TIU Docu ment Numbe r.DATE/TIM E OF DICTA TIONRequir ed by fili ng routine LOCATIONRe quired by filing rou tineAUTHOR Generates missing fi eld errorC ONSULTS XE "Consults :Upload" S SNRequired by filing routineTI TLERequire d by filin g routineC ONSULT REQ UEST NUMBE RRequired by filing routine. T he patient record in dicated by the SSN i s checked for a matc hing consu lt.VISIT/E VENT DATER equired by filing ro utine. The patient r ecord indi cated by t he SSN is checked fo r a matchi ng visit.A UTHORGener ates missi ng field e rrorLOCATI ONRequired by filing routineDA TE/TIME OF DICTATION Generates missing fi eld errorT ype of Doc umentCapti onUsePROCE DURE REPOR TPATIENT S SNRequired by filing routineDO CUMENT NUM BERRequire d by filin g routine. If missin g, the upl oad routin e infers i t from the SSN and O peration D ate (an op tional fie ld).SURGIC AL CASEReq uired by f iling rout ine. If mi ssing, the upload ro utine infe rs it from the SSN a nd Operati on Date. T hen, if th ere is mor e than one matching surgical c ase, it ge nerates a missing fi eld error. DICTATION DATE Gene rates miss ing field errorATTEN DING SURGE ONGenerate s missing field erro rDICTATED BYGenerate s missing field erro rOPERATION REPORTPAT IENT SSNRe quired by filing rou tineDOCUME NT NUMBERR equired by filing ro utine. If missing, t he upload routine in fers it fr om the SSN and Opera tion Date (an option al field). SURGICAL C ASERequire d by filin g routine. If missin g, the upl oad routin e infers i t from the SSN and O peration D ate. Then, if there is more th an one mat ching surg ical case, it genera tes a miss ing field error.DICT ATION DATE Generate s missing field erro rDICTATING SURGEONGe nerates mi ssing fiel d errorATT ENDING SUR GEONGenera tes missin g field er rorSTAT or ROUTINEGe nerates mi ssing fiel d errorDis play Uploa d Help | |
4779 | XE "Displ ay Upload Help" Tran scriptioni sts may se lect this option in the Upload Menu to d isplay the formats e xpected by the uploa d process for the re port types defined a t your sit e. | |
4780 | The captio ned header s XE "Capt ioned head ers" may be capture d as ASCII data and used to bu ild macros using a c ommercial word-proce ssors XE " Word-proce ssors" (e .g., WordP erfect or Microsoft Word), the reby avoid ing having to retype the capti oned heade rs, while minimizing the risk of spellin g errors o r inconsis tencies wi th the for mats expec ted by the host syst em. | |
4781 | UP Batch uplo ad reports | |
4782 | HLP Display up load help | |
4783 | Select Upl oad menu O ption: HLP Display upload hel p | |
4784 | Select REP ORT TYPE: DISCHARGE SUMMARY// <Enter> D ischarge S ummary | |
4785 | $HDR: DISCHARGE SUMMARY | |
4786 | SOC SEC NU MBER: 666-12-121 2 | |
4787 | ADMISSION DATE: 02/21/96 | |
4788 | DISCHARGE DATE: 02/25/96 | |
4789 | DICTATED B Y: TIUPROVIDE R,TWO | |
4790 | DICTATION DATE: 02/26/96 | |
4791 | ATTENDING: TIUPROVIDE R,SEVEN | |
4792 | TRANSCRIPT IONIST ID: T1212 | |
4793 | URGENCY: PRIORITY | |
4794 | $TXT | |
4795 | DISCHARG E SUMMARY Text | |
4796 | $END | |
4797 | *** File s hould be A SCII with width no g reater tha n 80 colum ns. | |
4798 | *** Use "_ __" for "B LANKS" (wo rd or phra se in dict ation that isn’t und erstood). | |
4799 | Press RETU RN to cont inue...<En ter> | |
4800 | Chapter 7: TIU for R emote User s | |
4801 | The option s on this menu allow remote us ers (e.g., VBA RO XE "VBA RO" personnel ) to acces s document s which ha ve been co mpleted (i .e., legal ly authent icated by signature or cosigna ture, if n ecessary), to facili tate proce ssing of c laims. | |
4802 | Remote Use r Menu XE "Remote Us er Menu" | |
4803 | OptionDesc riptionInd ividual Pa tient Docu mentThis o ption allo ws remote users (e.g ., VBA RO personnel) to access individua l document s which ha ve been co mpleted. | |
4804 | Multiple P atient Doc umentsThis option al lows remot e users (e .g., VBA R O personne l) to revi ew and pri nt multipl e document s which ha ve been co mpleted | |
4805 | Individual Patient D ocument XE "Individu al Patient Document" | |
4806 | Steps to u se option: | |
4807 | 1. Select Individual Patient D ocument fr om your TI U menu. | |
4808 | Select Int egrated Do cument Man agement Op tion: Indi vidual Pat ient Docum ent | |
4809 | Select a p atient. | |
4810 | Select PAT IENT NAME: TIUPATIEN T,ONE 09-12-4 4 6662 33456 YES SC V ETERAN | |
4811 | (2 notes ) C: 05/2 8/96 12:37 (addendu m 08/12/96 16:04) | |
4812 | (2 notes ) W: 05/2 8/96 12:33 | |
4813 | A: Know n allergie s | |
4814 | (3 notes ) D: 07/0 8/96 14:14 | |
4815 | Available documents: 02/17/92 thru 10/2 8/96 (54) | |
4816 | 3. Enter a date rang e to displ ay documen ts for. | |
4817 | Please spe cify a dat e range fr om which t o select d ocuments: | |
4818 | List docum ents Begin ning: 02/1 7/96// <En ter> (FEB 17, 1992) | |
4819 | Thru: 10/2 8/96// <En ter> (OCT 28, 1996) | |
4820 | Adm: 12/ 22/94 | |
4821 | 1 01/09/9 6 17:51 D iabetes Ed ucation FOUR TIUPROVID ER, MS3 | |
4822 | Adm: 07/ 22/91 | |
4823 | SUBJEC T: Diet et c. | |
4824 | 2 09/29/9 5 16:54 L ipid Clini c FIVE TIUPROVID ER | |
4825 | Adm: 08/ 14/95 | |
4826 | SUBJEC T: Dyslipi dosis | |
4827 | 3 04/24/9 6 08:28 L ipid Clini c ONE TIUPROVIDE R, MD | |
4828 | Visit: 04/ 24/92 | |
4829 | SUBJEC T: Lipid t est | |
4830 | 4 02/17/9 6 08:00 A rterial Ev aluation - THRE E TIUPROVI DER, | |
4831 | Visit: 02/ 17/92 | |
4832 | SUBJEC T: Rule ou t embolus, lower ext remity ' ^' TO STOP : 2 | |
4833 | Individual Patient D ocument, c ont’d | |
4834 | 4. Choose a document from the list. | |
4835 | Choose doc uments: ( 1-4): 1 | |
4836 | Opening Di abetes Edu cation rec ord for re view... | |
4837 | Browse Doc ument Jun 2 6, 1996 17 :08:45 Page: 1 of 1 | |
4838 | Diabete s Educatio n | |
4839 | TIUPATIENT ,ONE 666-2 3-3456 Vi sit Date: 01/09/96@1 7:06 | |
4840 | DATE OF NO TE:JAN 09, 1996@17:51 :04 ENTRY DATE:JAN 09, 1996@1 7:51:04 | |
4841 | AUTH OR: TIUPRO VIDER,ONE EXP C OSIGNER: T IUPROVIDER ,THREE | |
4842 | URGEN CY: STATUS: C OMPLETED | |
4843 | Provided M r. TIUPati ent with D iabetes di et pamphle t and expl ained area s he espec ially need ed to be c oncerned a bout. | |
4844 | /es/ Three TIUProvid er, MD | |
4845 | for Five T IUProvider , MS3 | |
4846 | Medical St udent III | |
4847 | + Next Scr een - Pre v Screen ?? More ac tions | |
4848 | Find Print Qui t | |
4849 | Select Act ion: Quit/ / Print | |
4850 | 5. The doc ument is p rinted at the device you speci fied. | |
4851 | ---------- ---------- ---------- ---------- ---------- ---------- ----- | |
4852 | TIUPATIENT ,ONE 666- 23-3456 Progress N otes | |
4853 | ---------- ---------- ---------- ---------- ---------- ---------- ----- | |
4854 | NOTE DATED : 01/09/96 17:51 DIABETES E DUCATION | |
4855 | ADMITTED: 07/22/91 1 1:06 1A | |
4856 | SUBJECT: L ipid TEST | |
4857 | Provided M r. TIUPati ent with D iabetes di et pamphle t and expl ained area s he espec ially need ed to be c oncerned a bout. | |
4858 | Si gned by: / es/ TIUPRO VIDER,FIVE , MD | |
4859 | Medical S tudent III 01/23/96 08:34 | |
4860 | Analog Pager: 1 -900-555-8 398 | |
4861 | Digita l Pager: 1 -900-555-7 883 | |
4862 | Cosi gned by: / es/ TIUPRO VIDER,THRE E | |
4863 | 01/23 /96 08:34 | |
4864 | Analog Pager: 1- 900-555-83 98 | |
4865 | Digita l Pager:1- 900-555-78 83 | |
4866 | Multiple P atient Doc uments XE "Multiple Patient Do cuments" | |
4867 | Use this o ption to s ee a list of clinica l document s for more than one patient in TIU. You can specif y types, c ategories, and time range. | |
4868 | | |
4869 | Caution: A void makin g your req uests too broad (in statuses, search cat egories, a nd date ra nges) beca use these searches c an use a l ot of syst em resourc es, slowin g the comp uter syste m down for everyone. The examp le below w ould proba bly be too broad in a large ho spital. | |
4870 | Steps to u se option: | |
4871 | 1. Select Multiple P atient Doc uments fro m your TIU menu. | |
4872 | --- Remote Use r Menu --- | |
4873 | 1 Individual Patient D ocument | |
4874 | 2 Multiple P atient Doc uments | |
4875 | Select Tex t Integrat ion Utilit ies (Remot e User) Op tion: 2 M ultiple Pa tient Docu ments | |
4876 | 2. Enter a status. | |
4877 | Select Sta tus: COMPL ETED// all undicta ted untra nscribed unreleased | |
4878 | unverif ied unsig ned uncos igned | |
4879 | complet ed amended purged deleted | |
4880 | 3. Select a document type (suc h as Disch arge Summa ry, Progre ss Notes, Addendum). | |
4881 | Select Cli nical Docu ments Type (s): All D ischarge S ummary, Pr ogress Not es, Addend um | |
4882 | 4. Select one of the following search ca tegories | |
4883 | 1 All C ategories 6 Patient 11 Trans criptionis t | |
4884 | 2 Autho r 7 Problem 12 Treat ing Specia lty | |
4885 | 3 Divis ion 8 Service 13 Visit | |
4886 | 4 Expec ted Cosign er 9 Subject | |
4887 | 5 Hospi tal Locati on 10 Title | |
4888 | Enter sele ction(s) b y typing t he name(s) , number(s ), or abbr eviation(s ). | |
4889 | Select SEA RCH CATEGO RIES: AUTH OR// all All Categ ories | |
4890 | Multiple P atient Doc uments, co nt’d XE "M ultiple Pa tient Docu ments" | |
4891 | 5. Enter a date rang e. | |
4892 | Start R eference D ate [Time] : T-7// <E nter> (J UN 02, 199 7) | |
4893 | Ending Reference Date [Time ]: NOW// < Enter> ( JUN 09, 19 97@11:19) | |
4894 | Searching for the do cuments.. | |
4895 | 6. All the documents for the c riteria se lected are displayed . Choose a n action t o perform, then the document t o perform it on. | |
4896 | ALL Docume nts Jun 09, 1997 11:2 0:01 Page: 1 of 1 | |
4897 | by ALL CAT EGORIES fr om 06/02/9 7 to 06/09 /97 14 documents | |
4898 | Patient Documen t Ref Date Status | |
4899 | 1 TIUPATI E (T1965) ADVANCE DI RECTIVE 06/06/97 completed | |
4900 | 2 TIUPATI E (T1255) Addendum t o CLINICAL WARNING 06/05/97 completed | |
4901 | 3 TIUPATI E (T1239) Adverse Re act/Allerg y 06/05/97 completed | |
4902 | 4 TIUPATI E (T1239) CRISIS NOT E 06/05/97 completed | |
4903 | 5 TIUPATI E (T1255) FANCY RAT NOTES 06/04/97 completed | |
4904 | 6 TIUPATI E (T1255) Addendum t o Adverse React/Alle r 06/04/97 completed | |
4905 | 7 TIUPATI E (T1255) Addendum t o Adverse React/Alle r 06/04/97 completed | |
4906 | 8 TIUPATI E (T3456) FANCY RAT NOTES 06/04/97 completed | |
4907 | 9 TIUPATI E (T1255) Addendum t o Adverse React/Alle r 06/03/97 completed | |
4908 | 10 TIUPATI E (T2591) FANCY RAT NOTES 06/03/97 completed | |
4909 | 11 TIUPATI E (T1462) Addendum t o FANCY RA T NOTES 06/03/97 completed | |
4910 | 12 + TIUPA TI(T1462) FANCY RAT NOTES 06/03/97 completed | |
4911 | 13 + TIUPA TI(T2591) Discharge Summary 06/02/97 completed | |
4912 | 14 TIUPATI E (T2591) Addendum t o Discharg e Summary 06/02/97 unsigned | |
4913 | + Next Scree n - Prev Screen ?? More Acti ons >>> | |
4914 | Find Browse Cha nge View | |
4915 | Detai led Displa y Print Qui t | |
4916 | Select Act ion: Quit/ / P=13 | |
4917 | DEVICE: HO ME// PRI NTER | |
4918 | Multiple P atient Doc uments, co nt’d XE "M ultiple Pa tient Docu ments" | |
4919 | SALT LAKE CITY 06/09/97 1 1:29 Page: 1 | |
4920 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- | |
4921 | PATIENT NA ME | AGE | SEX | RAC E | SS N | CL AIM NUMBER | |
4922 | TIUPATIENT ,SEVEN | 66 | M | AME R | 666-04 -2591P| | |
4923 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- | |
4924 | ADM DATE | DISC DATE | TYPE OF RE LEASE | INP | ABS | WARD NO | |
4925 | MAY 30, 19 97 | | | | | | |
4926 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- | |
4927 | DICTATION DATE: JUN 02, 1997 TRAN SCRIPTION DATE: JUN 02, 1997 | |
4928 | TRANSCRIPT IONIST: jg | |
4929 | DIAGNOSIS: | |
4930 | toe injury | |
4931 | OPERATIONS /PROCEDURE S: | |
4932 | evaluated for prosth esis | |
4933 | C O P Y | |
4934 | SIGNATURE APPROVING PHYSICIAN/ DENTIST | |
4935 | /es/ NINE TIUPROVIDE R | |
4936 | NINE TIUPR OVIDER | |
4937 | NINE TIUPR OVIDER | |
4938 | JUN 02, 19 97@16:55:5 6 ADDENDU M: | |
4939 | In remissi on. | |
4940 | SIGNATURE APPROVING PHYSICIAN /DENTIST | |
4941 | Three TIUP rovider, M S | |
4942 | Chapter 8: Progress Notes Prin t Options | |
4943 | XE "Print Options" | |
4944 | Clinicians can print progress notes but most print ing is gea red toward s MAS and managing t his functi on on a me dical cent er level. | |
4945 | TIU offers two metho ds of prin ting docum ents: | |
4946 | 1. Print a ctions XE "Print act ions" on option scr eens: Clin icians may print all types of documents using a va riety of m ethods fro m the List Manager i nterface f or TIU, in cluding Pr ogress Not es, Discha rge Summar ies, Consu lts, etc. Work and c hart copie s are poss ible. Char t copies a re the rec ommended t ype of pri nted copy, but many sites stil l want to print work copies. F or example , you may want to pr int work c opies of u nsigned no tes. | |
4947 | Other than the above List Mana ger printi ng, all ot her print options ar e on print menus. On ly signed notes are available from these options. | |
4948 | Progress N otes Print Menus | |
4949 | Progress N otes Print Menu | |
4950 | For many t ypes of us ers: clini cal, admin istrative, managemen t. | |
4951 | MAS Option s to Print Progress Notes | |
4952 | For printi ng at the Wards and Clinics, b oth by ind ividual pa tient and batch prin ting. | |
4953 | Progress N otes Print Menu | |
4954 | XE "Progr ess Notes Print Menu " | |
4955 | All of the options o n this men u support the printi ng of char t or work copies. | |
4956 | NOTE: The location print opti on prints for any lo cation tha t has sign ed notes e ntered for it, but i t doesn’t track anyt hing. | |
4957 | OptionDesc riptionAut hor Print Progress Notes XE " Author( Pr int Progre ss Notes" This optio n produces chart or work copie s of progr ess notes for an aut hor, for a selected date range . | |
4958 | Location Print Prog ress Notes XE "Locat ion( Print Progress Notes" Thi s option p rints char t or work copies of progress n otes for a ll patient s who were at a spec ific locat ion when t he notes w ere writte n. The pat ients whos e progress notes are printed o n this rep ort may no t still be at that l ocation. I f Chart Co py is sele cted, each note will start on a new page . | |
4959 | Patient P rint Prog ress Notes XE "Patie nt( Print Progress Notes" Thi s option p rints or d isplays pr ogress not es for a s elected pa tient by a selected date range . | |
4960 | Ward Prin t Progress Notes XE "Ward( Pri nt Progres s Notes" T his option allows yo u to print progress notes for all patien ts who are now on a ward for a selected date range . This opt ion is onl y for ward locations . NOTE: Co pies can o nly be pri nted to a printer, n ot to a co mputer scr een. | |
4961 | MAS Option s to Print Progress Notes XE " MAS Option s to Print Progress Notes" | |
4962 | The MAS op tions are intended f or printin g at the W ards and C linics, bo th by indi vidual pat ient and b atch print ing. | |
4963 | OptionDesc riptionAdm ission- Pr ints all P Ns for Cur rent Admis sion XE "A dmission- Prints all PNs for C urrent Adm ission" Th is option prints all progress notes for a selected patient f or the cur rent admis sion if pa tient is a n inpatien t or LAST admission if the pat ient has b een discha rged. | |
4964 | Batch Prin t Outpt PN s by Divis ion XE "Di vision" Th is option batch prin ts outpati ent progre ss notes i n terminal digit ord er by divi sion. Loc ations tha t the site would lik e excluded from this job may e dit field #3 in file #8925.93. If the l ocation is not enter ed in file #8925.93, it WILL b e included . | |
4965 | Outpatient Location- Print Pro gress Note s XE "Outp atient Loc ation- Pri nt Progres s Notes" T his option is design ed to be u sed primar ily by MAS . It prod uces CHART ABLE notes and track s the last note prin ted for th e selected outpatien t location . Output is sorted in alphabe tical orde r by patie nt. | |
4966 | Ward- Prin t Progress Note XE " Ward—Print Progress Notes" sTh is option allows the printing of Progres s Notes fo r ALL pati ents on th e ward at the time t he job is queued to print. All of the no tes for a selected d ate range (regardles s of the l ocation of the note) will prin t. This op tion is on ly for WAR D location s. NOTE: C opies can only be pr inted to a printer, not to a c omputer sc reen. | |
4967 | Author Pr int Progre ss Notes E xample | |
4968 | ---Print Progress N otes--- | |
4969 | PNPA Author- Pr int Progre ss Notes | |
4970 | PNPL Location- Print Prog ress Notes | |
4971 | PNPT Patient- P rint Progr ess Notes | |
4972 | PNPW Ward- Prin t Progress Notes | |
4973 | Select Pro gress Note s Print Op tions Opti on: author - Print Pr ogress Not es | |
4974 | P rint Progr ess Notes for a Sele cted AUTHO R | |
4975 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- --- | |
4976 | AUTHOR: TIUPROVID ER,THREE TT MD | |
4977 | Available notes: Aug 24, 1995 thru Oct 0 3, 1996 | |
4978 | Print Note s Beginnin g: t-100 (MAY 01, 1 996) | |
4979 | Thr u: t-60 ( JUL 10, 19 96) | |
4980 | Searching for the no tes....... . | |
4981 | >> 8 notes found for TIUProvid er,Three | |
4982 | Do you wan t WORK cop ies or CHA RT copies? CHART// < Enter> | |
4983 | DEVICE: HO ME// PRINT ER | |
4984 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- --- | |
4985 | ANDERSON,H C 666-12 -3456 P rogress No tes | |
4986 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- --- | |
4987 | NOTE DATED : 05/08/96 11:01 DIABETES E DUCATION | |
4988 | ADMITTED: 04/21/96 1 0:00 2B | |
4989 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- --- | |
4990 | SUBJECTIVE : 45 ye ar old AME RICAN INDI AN here fo r | |
4991 | initi al evaluat ion of his DYSLIPIDE MIA. | |
4992 | COPIE D FROM TIU CLIENT TO TIUPATIENT ... | |
4993 | PMH: | |
4994 | Signi ficant neg ative medi cal histor y pertinen t to the | |
4995 | evalu ation and treatment of DYSLIPI DEMIA: | |
4996 | FH: | |
4997 | SH: | |
4998 | MEDICATION | |
4999 | HISTORY: CURRE NT MEDICAT IONS | |
5000 | DIET: Couns eled on AH A Step I d iet today by NINE TI UPROVIDER. | |
5001 | See h er evaluat ion. | |
5002 | ACTIVITY: | |
5003 | OBJECTIVE: HT: 70 (08/23/ 95 11:45) WT: 207 (08/23/95 11:45) | |
5004 | TSH/T 4: 1.7/1.1 | |
5005 | FB G: 200 HEM OGLOBIN A1 C: 15.2 | |
5006 | SGO T: 44 URIC ACID: 4.7 | |
5007 | Enter RETU RN to cont inue or '^ ' to exit: <Enter> | |
5008 | Author Pr int Progre ss Notes E xample con t’d | |
5009 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---- | |
5010 | TIUPATIENT ,ONE 666- 12-3456 Progress N otes | |
5011 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---- | |
5012 | 06/05/96 1 5:18 ** CONTIN UED FROM P REVIOUS SC REEN ** | |
5013 | ASSESSMENT : 1. MALE wi th / witho ut documen ted CAD | |
5014 | 2. CV Risk factors: | |
5015 | 3. Lipid p attern: | |
5016 | PLAN: 1. Impleme nt recomme ndations t o lower fa t intake. | |
5017 | 2. Repeat FBG and HB G A1C on: | |
5018 | 3. Return to review lab on: | |
5019 | Si gned by: / es/ Three TIUProvid er, MS | |
5020 | Physic ian Assist ant 06/21/ 96 07:47 | |
5021 | Analog Pager: 5 55-1213 | |
5022 | Digita l Pager: 5 55-1215 | |
5023 | Enter RETU RN to cont inue or '^ ' to exit: <Enter> | |
5024 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---- | |
5025 | TIUPATIENT ,ONE 666- 12-3456 Progress N otes | |
5026 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---- | |
5027 | NOTE DATED : 06/21/96 11:38 SOCIAL WOR K SERVICE | |
5028 | ADMITTED: 06/01/96 1 0:00 2B | |
5029 | Follow-up to 6/1/96 visit. | |
5030 | Si gned by: / es/ Three TIUProvide r, MS | |
5031 | Physic ian Assist ant 06/21/ 96 07:47 | |
5032 | Analog Pager: 5 55-1213 | |
5033 | Digita l Pager: 5 55-1215 | |
5034 | Enter RETU RN to cont inue or '^ ' to exit: <Enter> | |
5035 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---- | |
5036 | TIUPATIENT ,SEVEN 666 -04-2591P Progress N otes | |
5037 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---- | |
5038 | NOTE DATED : 07/03/96 14:18 LIPID CLIN IC | |
5039 | ADMITTED: 05/28/96 1 5:58 1A | |
5040 | SUBJECTIVE : 65 ye ar old AME RICAN INDI AN OR ALAS KA NATIVE MALE here for | |
5041 | initi al evaluat ion of his DYSLIPIDE MIA. | |
5042 | MORE STUFF... | |
5043 | PMH: | |
5044 | Signi ficant neg ative medi cal histor y pertinen t to the | |
5045 | evalu ation and treatment of DYSLIPI DEMIA: | |
5046 | FH: | |
5047 | SH: | |
5048 | MEDICATION | |
5049 | HISTORY: CURRE NT MEDICAT IONS | |
5050 | DIET: Couns eled on AH A Step I d iet today by NINE TI UPROVIDER. | |
5051 | ACTIVITY: | |
5052 | Author Pr int Progre ss Notes E xample con t’d | |
5053 | OBJECTIVE: HT: 70 (08/23/ 95 11:45) WT: 178 (07/01/96 17:15) | |
5054 | TSH/T 4: 1.7/1.1 | |
5055 | FB G: 223 HEM OGLOBIN A1 C: 15.2 | |
5056 | SGO T: 44 URIC ACID: 4.7 | |
5057 | ASSESSMENT : 1. MALE wi th / witho ut documen ted CAD | |
5058 | 2. CV Risk factors: | |
5059 | 3. Lipid p attern: | |
5060 | PLAN: 1. Impleme nt recomme ndations t o lower fa t intake. | |
5061 | 2. Repeat FBG and HB G A1C on: | |
5062 | 3. Return to review lab on: | |
5063 | Si gned by: / es/ Three TIUProvid er, MS | |
5064 | Physic ian Assist ant 07/03/ 96 14:19 | |
5065 | Analog Pager: 1 -900-555-8 398 | |
5066 | Digita l Pager: 1 -900-555-7 883 | |
5067 | Enter RETU RN to cont inue or '^ ' to exit: ^ | |
5068 | AUTHOR: <E nter> | |
5069 | Location Print Prog ress Notes Example | |
5070 | Select Pro gress Note s Print Op tions Opti on: Locati on- Print Progress N otes | |
5071 | Pr int Progre ss Notes f or a Selec ted LOCATI ON | |
5072 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- --- | |
5073 | Select HOS PITAL LOCA TION NAME: GENERAL M EDICINE TIUPRO VIDER,TWEN TY | |
5074 | Available notes: Sep 06, 1995 thru Oct 0 2, 1996 | |
5075 | Print Note s Beginnin g: t-30 ( SEP 08, 19 96) | |
5076 | Thr u: t (OCT 08, 1996) | |
5077 | Searching for the no tes.. | |
5078 | >> 2 notes found for GENERAL M EDICINE | |
5079 | Do you wan t WORK cop ies or CHA RT copies? CHART// < Enter> | |
5080 | DEVICE: HO ME// <Ente r> VAX | |
5081 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---- | |
5082 | TIUPATIENT ,ONE 666-2 3-3456 Pr ogress Not es | |
5083 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---- | |
5084 | NOTE DATED : 10/01/96 11:59 BP TEST | |
5085 | VISIT: 04/ 18/96 10:0 0 GENERAL MEDICINE | |
5086 | NAME: TIUPATIEN T,ONE | |
5087 | SEX: MALE | |
5088 | DOB: SEP 12,19 44 | |
5089 | ALLERGIES: Amoxicill in, Aspiri n, MILK | |
5090 | LABS: No data a vailable | |
5091 | LIPIDS: No data a vailable | |
5092 | HT: 72 (08/23 /95 11:45) | |
5093 | WT: 190 (08/2 3/95 11:45 ) | |
5094 | Si gned by: / es/ Three TIUProvide r, MS | |
5095 | 10/01/ 96 15:38 | |
5096 | Analog Pager: 1 -900-555-8 398 | |
5097 | Digita l Pager: 1 -900-555-7 883 | |
5098 | Enter RETU RN to cont inue or '^ ' to exit: <Enter> | |
5099 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---- | |
5100 | TIUPATIENT ,SEVEN 666 -04-2591P Progress N otes | |
5101 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---- | |
5102 | NOTE DATED : 09/17/96 13:37 LIPID CLIN IC | |
5103 | VISIT: 08/ 18/96 08:0 0 GENERAL MEDICINE | |
5104 | SUBJECTIVE : 55 ye ar old AME RICAN INDI AN OR ALAS KA NATIVE MALE here for | |
5105 | initi al evaluat ion of his DYSLIPIDE MIA. | |
5106 | PMH: | |
5107 | Signi ficant neg ative medi cal histor y pertinen t to the | |
5108 | evalu ation and treatment of DYSLIPI DEMIA: | |
5109 | FH: | |
5110 | SH: | |
5111 | MEDICATION | |
5112 | HISTORY: CURRE NT MEDICAT IONS | |
5113 | DIET: Couns eled on AH A Step I d iet today by NINE TI UPROVIDER. | |
5114 | Enter RETU RN to cont inue or '^ ' to exit: <Enter> | |
5115 | Location Print Prog ress Notes Example c ont’d | |
5116 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---- | |
5117 | TIUPATIENT ,SEVEN 66 6-04-2591P Progress N otes | |
5118 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---- | |
5119 | 09/17/96 1 3:37 ** CONTIN UED FROM P REVIOUS SC REEN ** | |
5120 | ACTIVITY: | |
5121 | OBJECTIVE: HT: 70 (08/23/ 96 11:45) WT: 207 (08/23/96 11:45) | |
5122 | TSH/T 4: 1.7/1.1 | |
5123 | FB G: 200 HEM OGLOBIN A1 C: 15.2 | |
5124 | SGO T: 44 URIC ACID: 4.7 | |
5125 | ASSESSMENT : 1. MALE wi th / witho ut documen ted CAD | |
5126 | 2. CV Risk factors: | |
5127 | 3. Lipid p attern: | |
5128 | PLAN: 1. Impleme nt recomme ndations t o lower fa t intake. | |
5129 | 2. Repeat FBG and HB G A1C on: | |
5130 | 3. Return to review lab on: | |
5131 | Si gned by: / es/ Three TIUProvide r, MD | |
5132 | 10/02/ 96 10:34 | |
5133 | Analog Pager: 1 -900-555-8 398 | |
5134 | Digita l Pager: 1 -900-555-7 883 | |
5135 | Enter RETU RN to cont inue or '^ ' to exit: ^ | |
5136 | Select HOS PITAL LOCA TION NAME: ^Patient Print Pro gress Note s Example | |
5137 | Location Print Prog ress Notes Example c ont’d | |
5138 | Select Pro gress Note s Print Op tions Opti on: p Pati ent-Print Progress N otes | |
5139 | Pr int Progre ss Notes f or a Selec ted PATIEN T | |
5140 | ---------- ---------- ---------- ---------- ---------- ---------- ------ | |
5141 | Select PAT IENT NAME: TIUPATIENT ,THIRTEEN 04-01-44 6667766 41 | |
5142 | YES SC VETERAN | |
5143 | (1 note ) W: 09/0 2/95 09:00 | |
5144 | Available notes: Sep 06, 1995 thru Mar 2 1, 1996 | |
5145 | Print Note s Beginnin g: t-360 (APR 08, 1 995) | |
5146 | Thr u: t (APR 02, 1996) | |
5147 | Searching for the no tes..... | |
5148 | >> 5 notes found for TIUPATIEN T,THIRTEEN | |
5149 | Do you wan t WORK cop ies or CHA RT copies? CHART// < Enter> | |
5150 | Do you wan t to start each note on a new page? NO// <Enter> | |
5151 | DEVICE: HO ME// <Ente r> LAT TE RMINALS | |
5152 | ---------- ---------- ---------- ---------- ---------- ---------- ------ | |
5153 | TIUPATIENT ,EIGHT 66 6-77-6641 Progres s Notes | |
5154 | ---------- ---------- ---------- ---------- ---------- ---------- ------ | |
5155 | NOTE DATED : 09/01/95 12:00 General No te | |
5156 | VISIT: CARDIOL OGY | |
5157 | This is a very sad s ituation. It is als o a genera l progress | |
5158 | note. We hope the p atient doe s better i n the futu re. | |
5159 | She is qui te nice, c lean and n ice. | |
5160 | Si gned by: / es/ NINE T IUPROVIDER | |
5161 | VERIFI ER 09/06/9 5 21:51 | |
5162 | NOTE DATED : 09/02/95 09:00 Clinical W arning | |
5163 | VISIT: CARDIOL OGY | |
5164 | Beware: th is patient bites. | |
5165 | Si gned by: / es/ NINE T IUPROVIDER | |
5166 | VERIFI ER 09/06/9 5 21:53 | |
5167 | NOTE DATED : 11/08/95 15:20 History & Physical E x | |
5168 | VISIT: 09/ 05/95 11:0 0 DIABETES CLINIC | |
5169 | SUBJECT: T ESTING THE GLUCOSE L EVEL | |
5170 | 1. Chief C omplaint: Numbness i n legs | |
5171 | Reason for Admiss ion (if di fferent fr om #1) | |
5172 | 2. History of Presen t Illness: Type 2 on set 1993 | |
5173 | Medicat ion Allerg ies: Penic illin caus es rash | |
5174 | Current Medicatio ns: Oral i nsulin | |
5175 | Enter RETU RN to cont inue or '^ ' to exit: <Enter> | |
5176 | Patient P rint Progr ess Notes Example co nt’d | |
5177 | ---------- ---------- ---------- ---------- ---------- ---------- -------- | |
5178 | TIUPATIENT ,EIGHT 66 6-77-6641 Progres s Notes | |
5179 | ---------- ---------- ---------- ---------- ---------- ---------- -------- | |
5180 | 11/08/95 1 5:20 ** CONTIN UED FROM P REVIOUS SC REEN ** | |
5181 | PAST HISTO RY | |
5182 | 1. Hosp italizatio ns: 6/10/9 3 | |
5183 | Surg eries: Injuries: | |
5184 | Illn ess: Disa bilities: | |
5185 | Tran sfusion(s) : ( )Yes ( X)No | |
5186 | If Yes, give date( s): | |
5187 | 2. Unus ual Childh ood Illnes ses: | |
5188 | Immu nizations: | |
5189 | (X)D T last boo ster: 1/90 ( )Pne umonia ( )Flu | |
5190 | ( )H ep B ( )Oth er: | |
5191 | 3. Habi ts: (x)S moking (x)Alc ohol ( )Drugs | |
5192 | Caff eine Use: (x)Coffee ( )Tea ( )Cola | |
5193 | ( )S uicide Att empts ( )OTH ER: | |
5194 | 4. SOCIAL/ MILITARY H ISTORY (Oc cupations) : | |
5195 | ( )W WI ( )WW II ( )K OREAN ( x)VIETNAM ( )GULF WAR | |
5196 | Trav el: Liv es with: | |
5197 | Sour ce of Inco me: ( )Job ( )Retire d (x)Pens ion ( )Ot her | |
5198 | 5. REVIEW OF SYSTEMS : | |
5199 | 6. PHYSICA L: | |
5200 | 1. Ht. HEIGHT Wt. WEIGH T T emp. Res p. | |
5201 | BP: Lying: Sitt ing: St anding: | |
5202 | 2. Gene ral: (x)W ell ( )Ob ese ( )Th in ( )Maln ourished ( )Neat | |
5203 | ( )C hronically Ill ( )Toxic ( )Acute Dis tress | |
5204 | Head: | |
5205 | Eyes: | |
5206 | ENT: | |
5207 | Enter RETU RN to cont inue or '^ ' to exit: <Enter> | |
5208 | Patient P rint Progr ess Notes Example co nt’d | |
5209 | ---------- ---------- ---------- ---------- ---------- ---------- ------- | |
5210 | TIUPATIENT ,EIGHT 66 6-77-6641 Progres s Notes | |
5211 | ---------- ---------- ---------- ---------- ---------- ---------- ------- | |
5212 | 11/08/95 1 5:20 ** CONTIN UED FROM P REVIOUS SC REEN ** | |
5213 | 6. Neck : | |
5214 | 7. Ches t and Brea sts: | |
5215 | 8. Lung s: | |
5216 | 9. Lymp hatics (Ce rvical, Ep itrocholea r, Axillar y, Inguina l, Poplite al): | |
5217 | 10. Hear t: | |
5218 | 11. Abdo men: | |
5219 | 12. Pelv ic/Genital ia (Penis, Scrotum, Testicles) : | |
5220 | 13. Rect al: | |
5221 | 14. Neur ological: | |
5222 | Cran ial Nerves : | |
5223 | Peri pheral Neu rological exam: | |
5224 | _ | |
5225 | Refl exes: 0 - No reflex ( ) | |
5226 | 1 - Hyporeflex ia __l__ | |
5227 | 2 - Average \/ l \/ | |
5228 | 3 - Brisk ___l___ | |
5229 | 4 - Hypereflex ia / \ | |
5230 | l l | |
5231 | _l l _ | |
5232 | 15. Musc uloskeleta l: | |
5233 | Uppe r Extremit ies: | |
5234 | Lowe r Extremit ies: | |
5235 | Spin e: | |
5236 | 16. Psyc hiatric: | |
5237 | a. A re any cog nitive imp airments n oted? ( )Yes ( )No | |
5238 | b. A re any com munication impairmen ts noted? ( )Yes ( )No | |
5239 | 17. Skin : | |
5240 | 7. WOMEN'S GYNECOLOG ICAL HISTO RY AND PHY SICAL EXAM | |
5241 | HISTORY : | |
5242 | Menarch e: ( ) Yes ( )No ne Interv al/Duratio n: | |
5243 | Charact eristics: | |
5244 | Enter RETU RN to cont inue or '^ ' to exit: <Enter> | |
5245 | Patient P rint Progr ess Notes Example co nt’d | |
5246 | ---------- ---------- ---------- ---------- ---------- ---------- ------ | |
5247 | TIUPATIENT ,EIGHT 66 6-77-6641 Progres s Notes | |
5248 | ---------- ---------- ---------- ---------- ---------- ---------- ------ | |
5249 | 11/08/95 1 5:20 ** CONTIN UED FROM P REVIOUS SC REEN ** | |
5250 | Last Pa p: Re sults: Previo us Gyn Sur gery: | |
5251 | Birth C ontrol Met hod: Number of Pregna ncies: | |
5252 | Miscarr iages: | |
5253 | Stillbi rths: Li ve Births: Menopa use Onset: What ef fect: | |
5254 | Hormone s: Prior STD Histor y: | |
5255 | Last Ma mmogram: Result s: | |
5256 | Number of sexual partners i n the past six month s? | |
5257 | Y N SYM PTOMS DESCRIPTI ON | |
5258 | ( ) ( ) Stress Inc ontinence | |
5259 | ( ) ( ) Vaginal Di scharge/It ching | |
5260 | ( ) ( ) Rash/Sores | |
5261 | ( ) ( ) Lower Abdo minal Pain | |
5262 | ( ) ( ) Dyspareuni a | |
5263 | ( ) ( ) Breast Lum ps/Pain | |
5264 | ( ) ( ) Breast Ras h/Nipple D ischarge | |
5265 | ( ) ( ) Abnormal B leeding | |
5266 | ( ) ( ) Other: | |
5267 | PHYSICA L EXAMINAT ION: | |
5268 | NOTE: Ohio State Law requires that every female in patient re ceive a br east and p elvic exam unless on e was perf ormed with in the pre ceding 12 months or the patien t refuses the examin ation in w riting. (P atient mus t sign bel ow). | |
5269 | BREASTS : l l DESCRIPTIO N/QUADRANT | |
5270 | ______l l ______ | |
5271 | / / \ \ | |
5272 | l l l l l l | |
5273 | l l --o-- - -o-- l l | |
5274 | l l l l l l | |
5275 | GENITAL IA (Vulva, Urethra, Vagina, Ce rvix, Fund us, Adnexa ) | |
5276 | PATIENT R EFUSAL OF EXAMINATIO N | |
5277 | [ ] I do n ot wish to receive a breast or pelvic ex am at this time. | |
5278 | [ ] I woul d like to be schedul ed for an outpatient breast an d pelvic e xam at the Women's H ealth Clin ic. | |
5279 | Patient 's Signatu re:_______ __________ __________ __________ _ | |
5280 | 8. INITIAL IMPRESSIO N/ASSESSME NT: | |
5281 | 9. WORKING DIAGNOSIS : | |
5282 | 10. PLAN: | |
5283 | Enter RETU RN to cont inue or '^ ' to exit: <Enter> | |
5284 | Patient P rint Progr ess Notes Example, c ont’d | |
5285 | ---------- ---------- ---------- ---------- ---------- ---------- ------ | |
5286 | TIUPATIENT ,TWENTY 6 66-77-6641 Progres s Notes | |
5287 | ---------- ---------- ---------- ---------- ---------- ---------- ------ | |
5288 | 11/08/95 1 5:20 ** CONTIN UED FROM P REVIOUS SC REEN ** | |
5289 | NOTE DATED : 03/20/96 08:30 Diabetes E ducation - Glucose M onitoring | |
5290 | VISIT: 03/ 19/96 08:0 0 DIABETES EDUCATION | |
5291 | SUBJECT: T ESTING MUL TIPLE COPY | |
5292 | Date of Cl ass: | |
5293 | Class: Advantage Blood Gluc ose Monito r | |
5294 | Process: Lecture, D emonstrati on, and Re turn Demon stration | |
5295 | Issued: A dvantage m onitor, Le vel I and II glucose control s olutions, and 3 boxe s (50 each ) Advantag e test str ips. | |
5296 | Subjective : Patient states: | |
5297 | __________ _Tests his BG_______ _times/day | |
5298 | __________ _Has not r eceived pr evious dir ections. | |
5299 | Objective: | |
5300 | Patient at tended cla ss. With Significan t Other? No Yes | |
5301 | Any observ ed barrier s to learn ing? No Yes | |
5302 | Concepts: | |
5303 | 1. Locati on of batt eries. | |
5304 | 2. Using memory. | |
5305 | 3. Coding machine. | |
5306 | 4. Using glucose co ntrol. The se expire 3 mo after opening. | |
5307 | 5. Perfor ming a blo od glucose test. | |
5308 | A. Clea n fingerti p (only) w ith warm s oap and wa ter. | |
5309 | B. Use s ide of any or all fi ngertips u nless ther e is sore or | |
5310 | other dama ge present . | |
5311 | 6. Proper care and storage of machine a nd strips. | |
5312 | 7. Dispos al of lanc ets in pun cture-proo f containe r. Label. | |
5313 | A: Knowle dge defici t r/t Adva ntage SBGM | |
5314 | P: If no previous d irections received, recommend 1-2 X day test and p rn any sig ns low blo od sugar. | |
5315 | RX: | |
5316 | 1. Advant age glucos e monitor kit (To ph armacy) | |
5317 | 2. Advant age glucos e control solutions. Disp 1 bo x Q 3 mo. Refill X3 . (To phar macy). | |
5318 | 3.___No__A dvantage T est Strips .Disp:__0_ __Boxes Q 3 mo. Refi ll X3. | |
5319 | ___No___ _Monojecto r. Only o ne. No Re fill. | |
5320 | ___No___ ___Lancets . #100 Q 3 mo. Ref ill X3. | |
5321 | Evidence o f Learning : Patient coded, u sed glucos e controls , | |
5322 | and checke d his own blood suga r during c lass. Whe n mistakes were made , they wer e acknowle dged by pa tient and corrective action st ated. | |
5323 | Si gned by: / es/ TIUPRO VIDER,THRE E | |
5324 | PGY3 MEDIC AL RESIDEN T 03/20/96 08:31 | |
5325 | Ward Prin t Progress Notes Exa mple | |
5326 | This optio n is usual ly used by the night ward cler k. The out put is in RM/BED ord er to faci litate fil ing. It pr ints all n otes after the last time they were print ed, and fo r ALL curr ent inpati ents on th e ward, re gardless o f whether the locati on of the note is th at ward, a nice feat ure for tr ansferred patients o r patients with outp atient cli nic appoin tment note s. This pr int option requires that you s pecify a p rinter; yo u can’t pr int to the screen. | |
5327 | Print by W ard XE "Pr int by War d" is des igned to s upport bat ch printin g XE "Batc h printing " . It has the uniqu e ability to determi ne when th e last not e was prin ted so tha t sites ca n now capt ure the in famous “or phan” note which was a problem under Pro gress Note s 2.5. A n ew page is started f or each pa tient. | |
5328 | Pri nt Progres s Notes fo r ALL pati ents on WA RD | |
5329 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- | |
5330 | Select WAR D Location : 6 1A | |
5331 | Print Note s Starting With (DAT E/TIME): t -20 (MAY 23, 1997). ........ | |
5332 | .......... . | |
5333 | >> 32 note s found fo r WARD 1A | |
5334 | DEVICE: PR INTER | |
5335 | ========== ========== ========== ========== ========== ========== ========== | |
5336 | MEDICAL RE CORD Pr ogress Not es | |
5337 | ========== ========== ========== ========== ========== ========== ========== | |
5338 | NOTE DATED : 05/27/97 12:13 C LINICAL WA RNING | |
5339 | ADMITTED: 04/20/97 15:58 1A | |
5340 | Mr. TIUPat ient is be coming vio lent and s elf-destru ctive agai n. Will tr y a new | |
5341 | Prescripti on. | |
5342 | ||
5343 | ||
5344 | ||
5345 | ||
5346 | ||
5347 | Signed by: / es/ Ten TIUProvide r, MD | |
5348 | ||
5349 | ||
5350 | ||
5351 | ||
5352 | ||
5353 | 05/27/97 12:14 | |
5354 | 05/28/98 09:45 Addendum | |
5355 | Mr. TIUPat ient is mo re calm, a nd respond ing to cou nseling an d medicati on | |
5356 | ||
5357 | ||
5358 | ||
5359 | ||
5360 | ||
5361 | Signed by: / es/ Ten TIUProvide r, MD | |
5362 | ||
5363 | ||
5364 | ||
5365 | ||
5366 | ||
5367 | 05/28/97 10:14 | |
5368 | NOTE DATED : 04/20/97 12:13 C LINICAL WA RNING | |
5369 | ADMITTED: 04/20/97 15:58 1A | |
5370 | Mr. TIUPat ient is vi olent and self-destr uctive aga in. Prescr ibed tranq uilizer. | |
5371 | ||
5372 | ||
5373 | ||
5374 | ||
5375 | ||
5376 | Signed by: / es/ Ten TIUProvide r, MD | |
5377 | ||
5378 | ||
5379 | ||
5380 | ||
5381 | ||
5382 | 04/20/97 01:20 | |
5383 | TIUPATIENT ,SEVEN RE GION 5 Printed: 06/09/97 11:50 | |
5384 | Chapter 9: Managing TIU: Intro duction XE "Introduc tion, Mana ging TIU " | |
5385 | TIU is man aged throu gh use of the follow ing tools: | |
5386 | Menu assig nments | |
5387 | Parameter set-ups | |
5388 | Document D efinitions | |
5389 | User Class set-up | |
5390 | See the TI U Implemen tation Gui de for mor e detailed instructi ons on per forming th ese variou s set-ups. | |
5391 | TIU Mainte nance Menu XE "Maint enance Men u" | |
5392 | Option Nam eMenu Text Descriptio nTIU PARAM ETERS MENU XE "TIU S ET-UP MENU " TIU Para meters Men uThis opti on allows the Clinic al Coordin ator or IR MS Applica tion Speci alist to s et up eith er the Bas ic or Uplo ad Paramet ers for TI U | |
5393 | TIUF DOCUM ENT DEFINI TION MGR D ocument De finitions (Manager | |
5394 | )Document Definition s menu, wh ich includ es: | |
5395 | Edit Docum ent Defini tions | |
5396 | Sort Docum ent Defini tions | |
5397 | Create Doc ument Defi nitions | |
5398 | Create Obj ects | |
5399 | Create Pos t-Signatur e Alerts | |
5400 | USR CLASS MANAGEMENT MENUUser Class Mana gementMenu of option s for mana ging User Class Defi nition and Membershi p | |
5401 | TIU IRM TE MPLATE MGM TTIU Templ ate Mgmt F unctionsMe nu options for manag ing pre-de fined temp lates crea ted by you r medical center. | |
5402 | TIUHL7 XE "TIUHL7" Message Ma nagerTIUHL 7 MSG MGRU tility for viewing m essage goi ng in and out of the TIU Gener ic HL7 Int erface. | |
5403 | TIU TEXT E VENT EDITT ext Event EditMenu o ption to s et up a te xt event i n the TIU TEXT EVENT S file (#8 925.71) so that an a lert will be sent to the team( s) specifi ed in the TIU TEXT E VENTS file immediate ly after a TIU docum ent (progr ess note, consult, e tc.) is cr eated and signed.TIU DOWNTIME BOOKMARK P NContingen cy Downtim e Bookmark Progress NotesMenu option to set up not es to aler t clinicia ns of comp uter downt ime during defined t ime period s so that clinicians can check patients’ paper rec ords, if n ecessary.L egal Requi rements XE "Legal Re quirements " | |
5404 | Patient Co nfidential ity | |
5405 | TIU works with patie nt records and docum ents. All users are reminded t o be aware of the co nfidential ity of the se records . | |
5406 | Electronic Signature | |
5407 | TIU uses a combinati on of menu access, U ser Classe s, and Ele ctronic Si gnature co des to mai ntain secu rity and r esponsibil ity. Indiv iduals in the system who have authority to approve actions, at whateve r level, h ave an ele ctronic si gnature co de. Like t he access and verify codes use d when gai ning acces s to the s ystem, the electroni c signatur e code is not visibl e on the s creen. The se codes a re also en crypted so that they are unrea dable to o ther users , even whe n viewed i n the user file by t hose with the highes t levels o f access. Electronic signature codes are required by TIU for every act ion that c urrently r equires a signature on paper. | |
5408 | How to Cha nge Your E lectronic Signature Code XE "E lectronic Signature Code" | |
5409 | Select Use r’s Toolbo x from the Mailman M enu. | |
5410 | Select Edi t Electron ic Signatu re Code fr om the Use r’s Toolbo x menu. | |
5411 | Select Opt ion: User' s Toolbox | |
5412 | Displa y User Cha racteristi cs | |
5413 | Edit E lectronic Signature code | |
5414 | Edit U ser Charac teristics Menu Templ ates ... | |
5415 | Spoole r Menu ... | |
5416 | TaskMa n User | |
5417 | User H elp | |
5418 | Select Use r's Toolbo x Option: Edit Elect ronic Sign ature code | |
5419 | This optio n is desig ned to per mit you to enter or change you r Initials , Signatur e Block In formation and Office Phone num ber. In ad dition, yo u are perm itted to e nter a new Electroni c Signatur e Code or to change an existin g code. | |
5420 | Enter your initials. | |
5421 | At the “Si gnature Bl ock Printe d Name:” p rompt, ent er your na me as you want it pr inted on f orms that require yo ur signatu re. | |
5422 | At the “Si gnature Bl ock Title: prompt,” enter your job title as you wa nt it prin ted on for ms that re quire your signature . | |
5423 | Enter your office ph one number . | |
5424 | Enter your signature code. | |
5425 | Electronic Signature , cont’d | |
5426 | INITIAL: J G | |
5427 | SIGNATURE BLOCK PRIN TED NAME: FIVE TIUPR OVIDER | |
5428 | SIGNATURE BLOCK TITL E: Clinica l Coordina tor | |
5429 | OFFICE PHO NE: (101)5 55-5736 | |
5430 | Enter your Signature Code:xxxx xxx | |
5431 | Cosignatur e | |
5432 | Cosignatur e requirem ents are d etermined at local l evels. Sit es or depa rtments ca n set Cosi gnature re quirements for certa in kinds o f document s through the Docume nt Paramet er Edit op tion on th e TIU Para meters Men u. Individ ual clinic ians can d esignate a default c osigner on their Per sonal Pref erences op tion. | |
5433 | Links and Relationsh ips with O ther Packa ges XE "Li nks and Re lationship s with Oth er Package s" | |
5434 | TIU is clo sely linke d to other applicati ons and ut ilities — Authorizat ion/Subscr iption Uti lity (ASU) List Mana ger utilit y, the Com puterized Patient Re cord Syste m (CPRS XE "CPRS" ), Visit Tra cking XE " Visit Trac king" , et c. This li nkage shou ld remain transparen t to users , but the IRM Servic e and Clin ical Coord inators wi ll need to coordinat e the comp onents. | |
5435 | Instructio ns will be provided (with a TI U patch) f or setting up the in terface wi th CPRS. | |
5436 | See the Us er and Tec hnical Man uals of th e above-li sted packa ges for fu rther inst ructions a bout inter faces. | |
5437 | Chapter 10 : Menus an d Option A ssignment XE "Menus and Option Assignmen t" | |
5438 | TIU menus and option s are not exported o n a single menu, but as indivi dual menus intended for catego ries of us ers. These are descr ibed in ea rlier sect ions of th is manual and also h ere. Sites may rearr ange these as needed . Recommen ded assign ments are also liste d on the f ollowing p ages. We’v e also inc luded an e xample of a potentia l Clinical Coordinat or Menu. | |
5439 | Progress N otes(s)/Di scharge Su mmary [TIU ] ... | |
5440 | 1 Progres s Notes Us er Menu .. . | |
5441 | 1 Entry of P rogress No te | |
5442 | 2 Review Pro gress Note s by Patie nt | |
5443 | 2b Review Pro gress Note s | |
5444 | 3 All MY UNS IGNED Prog ress Notes | |
5445 | 4 Show Progr ess Notes Across Pat ients | |
5446 | 5 Progress N otes Print Options… | |
5447 | 6 List Notes By Title | |
5448 | 7 Search by Patient AN D Title | |
5449 | 8 Personal P references … | |
5450 | 9 ALL Docume nts requir ing my Add itional Si gnature XE "Addition al Signatu re" | |
5451 | 2 Dischar ge Summary User Menu ... | |
5452 | 1 Individual Patient D ischarge S ummary | |
5453 | 2 All MY UNS IGNED Disc harge Summ aries | |
5454 | 3 Multiple P atient Dis charge Sum maries | |
5455 | 3 Integra ted Docume nt Managem ent | |
5456 | 1 Individual Patient D ocument | |
5457 | 2 All MY UNS IGNED Docu ments | |
5458 | 3 All MY UND ICTATED Do cuments | |
5459 | 4 Multiple P atient Doc uments | |
5460 | 5 Enter/edit Document | |
5461 | 6 ALL Docume nts requir ing my Add itional Si gnature | |
5462 | 4 Persona l Preferen ces ... | |
5463 | 1 Personal P references | |
5464 | 2 Document L ist Manage ment | |
5465 | Text Integ ration Uti lities (MR T) ... | |
5466 | 1 Individu al Patient Document | |
5467 | 2 Multiple Patient D ocuments | |
5468 | 3 Review U pload Fili ng Events | |
5469 | 4 Print Do cument Men u ... | |
5470 | 1 D ischarge S ummary Pri nt | |
5471 | 2 P rogress No te Print | |
5472 | 3 C linical Do cument Pri nt | |
5473 | 5 Released /Unverifie d Report | |
5474 | 6 Search f or Selecte d Document s | |
5475 | 7 Unsigned /Uncosigne d Report | |
5476 | 8 Reassign ment Docum ent Report | |
5477 | 9 Review u nsigned ad ditional s ignatures XE "Reassi gnment Doc ument Repo rt" | |
5478 | TIU Menus and Option s cont’d | |
5479 | Text Integ ration Uti lities (MI S Manager) ... | |
5480 | 1 Individu al Patient Document | |
5481 | 2 Multiple Patient D ocuments | |
5482 | 3 Print Do cument Men u ... | |
5483 | 1 D ischarge S ummary Pri nt | |
5484 | 2 P rogress No te Print | |
5485 | 3 C linical Do cument Pri nt | |
5486 | 4 Search f or Selecte d Document s | |
5487 | 5 Statisti cal Report s... | |
5488 | 6 Unsigned /Uncosigne d Report | |
5489 | 7 Missing Text Repor t | |
5490 | 8 Missing Text Clean up | |
5491 | 9 Signed/u nsigned PN report an d update | |
5492 | 10 UNKNOWN Addenda Cl eanup | |
5493 | 11 Missing Expected C osigner Re port | |
5494 | 12 Mark Doc ument as ' Signed by Surrogate' | |
5495 | 13 Mismatch ed ID Note s | |
5496 | 14 TIU 215 ANALYSIS . .. | |
5497 | 15 Transcri ption Bill ing Verifi cation Rep ort | |
5498 | 16 CWAD/Pos tings Auto -Demotion Setup | |
5499 | Text Integ ration Uti lities (Tr anscriptio nist) ... | |
5500 | 1 Enter/Ed it Dischar ge Summary | |
5501 | 2 Enter/Ed it Documen t | |
5502 | 3 Upload M enu... | |
5503 | 1 U pload Docu ments | |
5504 | 2 H elp for Up load Utili ty | |
5505 | 4 List Doc uments for Transcrip tion | |
5506 | 5 Review/E dit Docume nts | |
5507 | 6 Transcri ption Bill ing Verifi cation Rep ort | |
5508 | CWAD/Posti ngs Auto-D emotion Se tup ... | |
5509 | 1 Select a CWAD/Post ings TITLE for auto- demotion | |
5510 | 2 Select a Non-Posti ng TITLE a s the demo tion targe t | |
5511 | 3 Enter RE TURN to co ntinue or ‘^’ to exi t | |
5512 | 4 Done. Po st-Signatu re code ha s been set (or reset ) as follo ws: | |
5513 | 5 TITLE: a nd POST-SI GNATURE AC TION: | |
5514 | ||
5515 | Text Integ ration Uti lities (Re mote User) ... | |
5516 | 1 Ind ividual Pa tient Docu ment | |
5517 | 2 Mul tiple Pati ent Docume nts | |
5518 | ||
5519 | Progress N otes Print Options . .. | |
5520 | PNPA Au thor- Prin t Progress Notes | |
5521 | PNPL Lo cation- Pr int Progre ss Notes | |
5522 | PNPT Pa tient- Pri nt Progres s Notes | |
5523 | PNPW Wa rd- Print Progress N otes | |
5524 | ||
5525 | Document D efinitions (Clinicia n) ... | |
5526 | 1 Edi t Document Definitio ns | |
5527 | 2 Sor t Document Definitio ns | |
5528 | 3 Vie w Objects | |
5529 | MAS Op tions to P rint Progr ess Notes. .. | |
5530 | ||
5531 | ||
5532 | Admission- Prints al l PNs for Current Ad mission | |
5533 | ||
5534 | ||
5535 | Batch Prin t Outpt PN s by Divis ion | |
5536 | ||
5537 | ||
5538 | Outpatient Location- Print Pro gress Note s | |
5539 | ||
5540 | ||
5541 | Ward- Prin t Progress Notes | |
5542 | TIU Menus and Option s cont’d | |
5543 | XE "TI U Maintena nce Menu" | |
5544 | ||
5545 | XE "TIU M aintenance Menu" TIU Maintenan ce Menu... | |
5546 | 1 T IU Paramet ers Menu.. . | |
5547 | 1 Basic TIU Parameters | |
5548 | 2 Modify Upl oad Parame ters | |
5549 | 3 Document P arameter E dit | |
5550 | 4 Progress N otes Batch Print Loc ations | |
5551 | 5 Division - Progress Notes Prin t Params | |
5552 | 2 D ocument De finitions (Manager) ... | |
5553 | 1 Edit Docum ent Defini tions | |
5554 | 2 Sort Docum ent Defini tions/Obje cts | |
5555 | 3 Create Doc ument Defi nitions | |
5556 | 4 Create Obj ects | |
5557 | 5 Create TIU /Health Su mmary Obje cts | |
5558 | 6 Create Pos t-Signatur e Alerts | |
5559 | 3 U ser Class Management ... | |
5560 | 1 User Class Definitio n | |
5561 | 2 List Membe rship by U ser | |
5562 | 3 List Membe rship by C lass | |
5563 | 4 Manage Bus iness Rule s | |
5564 | 4 T IU Templat e Mgmt Fun ctions ... | |
5565 | 1 Delete TIU templates for selec ted user. | |
5566 | 2 Edit auto template c leanup par ameter. | |
5567 | 3 Delete tem plates for ALL termi nated user s. | |
5568 | 5 TIU Alert Tools | |
5569 | 6 | |
5570 | Unsigne d/Uncosign ed Report | |
5571 | 7 TIUHL7 Mes sage Manag er | |
5572 | 8 Title Mapp ing Utilit ies | |
5573 | 10 Unauthoriz ed Abbrevi ations (En ter/Edit) | |
5574 | 11 List Unaut horized Ab breviation s | |
5575 | 12 Text Event Edit | |
5576 | ||
5577 | 13 Contingenc y Downtime Bookmark Progress N otes | |
5578 | TIU Conver sion Clean -up Menu X E "TIU Con version Cl ean-up Men u" [GMRP TIU] | |
5579 | This menu comes with Patch GMR P*2.5*44 XE "Conver sion Clean -up Menu" XE "GMRP TIU" whic h is distr ibuted pri or to TIU to help cl ean up the Generic P rogress No tes File ( #121) and the Generi c Progress Notes Tit le File XE "Generic Progress N otes Title File" (1 21.2). It also conta ins option s to assis t in popul ating the TIU Docume nt Definit ion File X E "Documen t Definiti on File" (8925.1 XE "8925.1" ), which i s roughly equivalent to file # 121.2 XE " 121.2" . | |
5580 | This menu is NOT exp orted on a ny existin g menu. It should be assigned to the per son respon sible for getting th e Progress Notes pac kage ready for conve rsion to T IU. We sug gest that this be li mited to o ne person per site o r several people wor king close ly togethe r on these clean-up exercises. | |
5581 | 1 Calcul ate Number of PNs pe r TITLE | |
5582 | 2 Number of Notes per TITLE - Report | |
5583 | 3 DELETE a Progres s Notes TI TLE | |
5584 | 4 MOVE N otes to An other TITL E | |
5585 | 5 Edit T ITLE - Ent er/Edit Do c Class | |
5586 | 6 TITLEs Sorted by Document Class - Re port | |
5587 | 7 CONVER T TITLEs ( #121.2) to TIU (#892 5.1) | |
5588 | PRT Titl e of Progr ess Note | |
5589 | UN List Unsigned Progress N otes by AU THOR | |
5590 | DEL Dele te a Signe d Progress Note | |
5591 | Suggested Clinical C oordinator Menu | |
5592 | TIU doesn’ t export a Clinical Coordinato r Menu XE "Clinical Coordinato r Menu" . However, s ites may w ish to cre ate one wh ich includ es most of the other menus and options, except pos sibly IRM options re quiring pr ogrammer a ccess. | |
5593 | Text In tegration Utilities (Transcrip tionist) . .. | |
5594 | Text In tegration Utilities (MRT) ... | |
5595 | Progres s Notes(s) /Discharge Summary [ TIU] ... | |
5596 | Text In tegration Utilities (MIS Manag er) ... | |
5597 | Text In tegration Utilities (Remote Us er) ... | |
5598 | Progres s Notes Pr int Option s ... | |
5599 | MAS Opt ions to Pr int Progre ss Notes… | |
5600 | Documen t Definiti ons ... | |
5601 | TIU Par ameters Me nu... | |
5602 | User Cl ass Manage ment ... | |
5603 | ||
5604 | Upload Men u | |
5605 | Menu Assig nment | |
5606 | We recomme nd assigni ng menus a s follows: | |
5607 | Option Nam eMenu Text Descriptio nAssign to :TIU MAIN MENU | |
5608 | TRANSCRIP- TIONText I ntegration Utilities (Transcri ptionist)M ain Text I ntegration Utilities menu for transcript ionists.Tr anscrip-ti onistsTIU MAIN MENU MRTText In tegration Utilities (MRT)Main Text Integ ration Uti lities men u for Medi cal Record s Technici ans.Medica l Records Technician sTIU MAIN MENU MGRTe xt Integra tion Utili ties (MIS Manager)Ma in Text In tegration Utilities menu for M IS Manager s.MIS Mana gers.TIU M AIN MENU C LINICIANPr ogress Not es(s)/ Dis charge Sum mary [TIU] Main Text Integrati on Utiliti es menu fo r Clinicia ns. Clinic iansTIU MA IN MENU RE MOTE USERT ext Integr ation Util ities (Rem ote User)T his option allows re mote users (e.g., VB A RO perso nnel) to a ccess only those doc uments tha t have bee n complete d, to faci litate pro cessing of claims on a need-to -know basi s.VBA RO p ersonnel, etc.TIU PR INT PN USE R MENUProg ress Notes Print Opt ionsMenu f or printin g Progress Notes.ADP ACs, | |
5609 | managersTI U MAS PRIN T PN MENUM AS Options to Print Progress N otesMenu o f options for printi ng Progres s Notes fo r specific locations , individu ally or by batchMAS ADPACs & s upervisors TIUF DOCUM ENT DEFINI TIONDocume nt Definit ionsDocume nt Definit ion | |
5610 | (Cli nician) | |
5611 | Document D efinition | |
5612 | (Man ager)Clini cians | |
5613 | Clinical C oordinator , IRM staf f TIU IRM MAINTENANC E MENUIRM Maintenanc e MenuThis option al lows IRM s taff to se t/modify t he various parameter s controll ing the be havior of TIU, as we ll as the definition of TIU do cuments. I RM, maybe Clinical C oordinator s (or some of the op tions on t he menu)GM RP TIUTIU Conversion Clean-up MenuA menu of option s for gett ing the Pr ogress Not es package ready for conversio n to TIU A DPACs, IRM , or Clini cal Coordi nators. Li mit to few .Chapter 1 1: Setting up TIU Pa rameters X E "Paramet ers" | |
5614 | TIU Parame ters Menu | |
5615 | ||
5616 | XE " Para meters Men u " | |
5617 | This menu contains o ptions for Clinical Coordinato rs or IRM Applicatio n Speciali sts to set up the ba sic parame ters (incl uding Uplo ad paramet ers) for T IU. | |
5618 | Menu TextO ption Name Descriptio nBasic TIU Parameter sTIU BASIC PARAMETER EDITThis option all ows you to enter the basic or general pa rameters w hich gover n the beha vior of th e Text Int egration U tilitiesMo dify Uploa d Paramete rsTIU DOCU MENT PARAM ETER EDITT his option allows th e definiti on and mod ification of paramet ers for th e batch up load of do cuments in to VistA.D ocument Pa rameter Ed itTIU UPLO AD PARAMET ER EDITThi s option a llows you to enter t he paramet ers that a pply to sp ecific doc uments (i. e., Titles ), or grou ps of docu ments (i.e ., Classes , or Docum ent Classe s).Divisio n - Progre ss Notes P rint Param sTIU PRINT PN DIV PA RAMThese p arameters are used b y the [TIU PRINT PN BATCH INTE RACTIVE] a nd [TIU PR INT PN BAT CH SCHEDUL ED] option s. If the site desir es a heade r other th an what is returned by $$SITE^ VASITE th e .02 fiel d of the 1 st entry i n this fil e will be used. For example, Waco-Templ e-Marlin c an have th e institut ion of the ir progres s notes as “CENTRAL TEXAS HCF. ”Progress Notes Batc h Print Lo cationsTIU PRINT PN LOC PARAMS Option for entering hospital l ocations u sed for [T IU PRINT P N OUTPT LO C] and [TI U PRINT PN WARD] opt ions. If l ocations a re not ent ered in th is file th ey will no t be selec table from these opt ions. NOT E: | |
5619 | The TIU Im plementati on Guide a nd TIU Tec hnical Man ual contai n instruct ions and e xamples fo r using th ese option s. | |
5620 | Chapter 12 : Document Definitio ns XE "Doc ument Defi nitions" | |
5621 | TIU uses a document storage da tabase cal led the Do cument Def inition hi erarchy XE "Document Definitio n Hierarch y" . This hierarchy provides t he buildin g blocks f or Text In tegration Utilities (TIU). It allows doc uments (Ti tles XE "T itles" ) t o inherit characteri stics of t he higher levels, Cl ass XE "Cl ass" and Document C lass XE "D ocument Cl ass" , suc h as signa ture requi rements an d print ch aracterist ics. This structure, while com plex to se t up, crea tes the ca pability f or better integratio n, shared use of boi lerplate t ext, compo nents, and objects, and a more manageabl e organiza tion of do cuments. E nd users ( clinical, administra tive, and MIS staff) need not be aware o f the hier archy. The y work at the Title level with the actua l document s. | |
5622 | Plan the D ocument De finition H ierarchy y our site o r service will use b efore inst allation o f TIU and conversion of progre ss notes. This step is critica l to the o rganizatio n of exist ing and fu ture docum ents in ea ch site’s implementa tion of TI U. A works heet is pr ovided in Appendix A of the TI U Implemen tation Gui de to help build the three bas ic levels. | |
5623 | Example of Document Definition Hierarchy | |
5624 | ||
5625 | Document D efinition Options XE "Document Definitio n Options" | |
5626 | Option | |
5627 | Text Optio n NameDesc ription | |
5628 | Edit Docum ent Defini tions XE " Edit Docum ent Defini tions" TIU F XE "TIUF " H EDIT D DEFS This option all ows you to view and edit entri es. Entrie s are pres ented in h ierarchy o rder. Item s of an en try are in sequence order, or if they ha ve no sequ ence, in a lphabetic order by m enu text, and are in dented bel ow the ent ry. Since Objects do n’t belong to the hi erarchy, t hey can’t be viewed/ edited usi ng the Edi t Options. | |
5629 | Create Doc ument Defi nitions XE "Create D ocument De finitions" TIUFC CRE ATE DDEFS This optio n allows y ou to crea te new ent ries of an y type (Cl ass, Docum ent Class, Title, Co mponent) e xcept Obje ct, placin g them whe re they be long in th e hierarch y. Althoug h entries can be cre ated using the Edit and Sort o ptions, th e Create o ption stre amlines th e process. This opti on present s entries in hierarc hy order, traversing ONE line of descent , starting with Clin ical Docum ents at th e top. | |
5630 | The Create option pe rmits you to view, e dit, and c reate entr ies, but o nly from w ithin the current li ne of desc ent. The C reate Opti on doesn’t let you c opy an ent ry. | |
5631 | Sort Docum ent Defini tions XE " Sort Docum ent Defini tions" TIU FA SORT DD EFS This o ption allo ws you to view parts of the hi erarchy by selected sort crite ria. It di splays the selected entries in alphabeti c order by Name, rat her than i n hierarch y order. D epending o n sort cri teria, ent ries can i nclude Obj ects. The Sort optio n allows y ou to view and edit entries. | |
5632 | Create Obj ectsTIUFJ CREATE OBJ ECTS MGRTh is option allows you to create new objec ts or edit existing objects. F irst you s elect Star t With and Go To val ues, and t he existin g Objects within tho se values are displa yed in alp habetical order. | |
5633 | View Objec tsTIUFJ VI EW OBJECTS MGRThis o ption allo ws you to look at or edit exis ting objec ts. First you select Start Wit h and Go T o values, and the ex isting Obj ects withi n those va lues are d isplayed i n alphabet ical order . | |
5634 | XE "Docum ent Defini tion Optio ns" | |
5635 | NOTE: | |
5636 | For furthe r informat ion about using the Document D efinition system, se e the TIU/ ASU Implem entation G uide or th e TIU Tech nical Manu al. | |
5637 | Chapter 13 : Defining User Clas ses XE "De fining Use r Classes" | |
5638 | The Author ization/Su bscription Utility ( ASU XE "AS U" ), whic h is distr ibuted wit h TIU, pro vides a me chanism fo r sites to associate users wit h User Cla sses, allo wing them to specify the level of author ization ne eded to si gn or orde r specific document types and orderables . It also allows pri vileges to be inheri ted, throu gh its use of a hier archical s tructure. A set of B usiness Ru les (which can be mo dified or added to b y sites) f urther str engthens t he Utility ’s ability to defin e roles an d responsi bilities f or clinica l document s. | |
5639 | See the AS U Clinical Coordinat or Manual or the TIU /ASU Imple mentation Guide for more infor mation abo ut ASU, it s relation ship to TI U, and its implement ation. | |
5640 | User Class Managemen t Menu XE "User Clas s Manageme nt Menu" | |
5641 | Option Opt ion NameDe scriptionU ser Class Definition | |
5642 | USR CLASS DEFINITION This optio n allows r eview, add ition, edi ting, and removal of User Clas ses. | |
5643 | List Membe rship by U ser | |
5644 | USR LIST M EMBERSHIP BY USER Th is option allows rev iew, addit ion, editi ng, and re moval of i ndividual members to and from User Class es. | |
5645 | List Membe rship by C lassUSR LI ST MEMBERS HIP BY CLA SSThis opt ion allows review, a ddition, e diting, an d removal of individ ual member s to and f rom User C lasses. | |
5646 | Edit Busin ess RulesU SR EDIT BU SINESS RUL ESThis opt ion allows the user to enter B usiness Ru les author izing spec ific users or groups of users to perform specified actions o n document s in parti cular stat uses (e.g. , an UNSIG NED PROGRE SS NOTE ma y be EDITE D by a PRO VIDER who is also th e EXPECTED SIGNER of the note, etc.). | |
5647 | Manage Bus iness Rule sUSR BUSIN ESS RULE M ANAGEMENTT his option allows yo u to list the Busine ss rules d efined by ASU, and t o add, edi t, or dele te them, a s appropri ate. | |
5648 | Chapter 14 : National Document Titles XE "national: document t itles" | |
5649 | Certain en tries in t he Documen t Definiti on file ha ve been ex ported eit her with T IU and/or with vario us TIU pat ches. The operation of certain functions in VistA and CPRS d epends on these entr ies being there. The se entries include c ertain cla sses, docu ment class es, and ti tles. Most exported Document D efinitions are marke d “Nationa l.” Local editing of National Document D efinitions is severe ly restric ted. | |
5650 | | |
5651 | Note: | |
5652 | You must l imit your editing of national Documents Definition s to actio ns permitt ed by the exported D ocument De finition o ptions. Ot her editin g will cau se certain functions of VistA and CPRS t o not work properly. | |
5653 | National C lasses | |
5654 | Classes ar e the most fundament al unit of organizat ion in the Document Definition file. | |
5655 | CLINICAL D OCUMENTS i s the root class for all other classes a nd documen t classes. | |
5656 | PROGRESS N OTES conta ins note t itles that appear on the Notes tab of CP RS. | |
5657 | DISCHARGE SUMMARY co ntains not e titles t hat appear on the D/ C Summ (Di scharge Su mmary) tab of CPRS. | |
5658 | LR LABORAT ORY REPORT S was rele ased with patch TIU* 1*137 in s upport of Anatomic P athology. You should not add a ny local d ocument cl asses to t his class. | |
5659 | CLINICAL P ROCEDURES was releas ed with pa tch TIU*1* 109. | |
5660 | SURGICAL R EPORTS was released with patch TIU*1*112 and is no t used unt il the sur gery patch SR*3*100 is install ed. | |
5661 | National D ocument Cl asses | |
5662 | Four of th e national document classes ar e in suppo rt of CWAD (CRISIS N OTE, CLINI CAL WARNIN G, ADVERSE REACTION/ ALLERGY, A DVANCE DIR ECTIVE). I f these ar e changed, then CWAD will not function p roperly. T he same is true for other docu ment class es such as ADDENDUM, DISCHARGE SUMMARIES , and ASI- ADDICTION SEVERITY I NDEX. The last of th ese contai ns notes p ushed from the Psych iatry Pack age. | |
5663 | For the LR ANATOMIC PATHOLOGY XE "ANATO MIC PATHOL OGY (AP)" document c lass, nine (9) busin ess rules were expor ted by pat ch USR*1*2 3, the com panion pat ch to TIU* 1*137. The se rules h elp to ens ure that t he Anatomi c Patholog y features of the La b Package function p roperly. A ll access to the tit les in thi s document class (cr eating, ed iting, sig ning, cosi gning, and printing) except vi ewing take s place th rough the Lab Packag e. Local s ites must not circum vent the r ules by ad ding, modi fying, or overriding the busin ess rules. (A list o f the expo rted busin ess rules is in the TIU/ASU Im plementati on Guide, Exported B usiness Ru les sectio n.) | |
5664 | | |
5665 | Note: | |
5666 | The TIU cl ass, docum ent class, user clas s, note ti tles, and business r ules insta lled by pa tch TIU*1* 137 and US R*1*23 mus t not be m odified in any way o r the Anat omic Patho logy enhan cements to the Lab P ackage wil l not work properly. An except ion exists in the ca se of USR* 1*31, whic h directed medical c enters to change the se rules t o refer to CHIEF, MI S or CHIEF , HIM rath er than th e LR ANATO MIC PATHOL OGY EMPTY CLASS. The VA Office of Inspec tor Genera l (OIG) de termined t hat these rules are not in har mony with VHA Handbo ok 1907.1. See the s ection USR *1*31 Impa ct on Busi ness Rules in the TI U Implemen tation Gui de for det ails. | |
5667 | For docume nt class P ATIENT REC ORD FLAG C AT I, a b usiness ru le was exp orted by p atch USR*1 *24, the c ompanion p atch to TI U*1*165, t hat limits the writi ng of note s in this document c lass to a select gro up. This s elect grou p is made up of memb ers of the user clas s DGPF PAT IENT RECOR D FLAGS MG R. Circumv enting thi s rule vio lates the intent of keeping th e flag doc umentation process i n the hand s of quali fied domai n experts. | |
5668 | Patch TIU* 1*171 inst alled docu ment title s and obje cts to sup port Spina l Cord Inj ury. It al so creates the Docum ent Class SCI OUTCOM ES. The ob jects are listed on the TIU We b Page at http://vis ta.med. d o main /tiu/html/ objects.ht ml. | |
5669 | HISTORICAL PROCEDURE S XE "HIST ORICAL PRO CEDURES" contains m edicine pr ocedures t hat were c onverted t o TIU note s by TIU*1 *182 in su pport of t he Medicin e Package Conversion XE "Medic ine Conver sion" pat ch MD*1*5. This docu ment class must be l eft with s tatus INAC TIVE. | |
5670 | The comple te list of national document c lasses is: | |
5671 | ADDENDUM | |
5672 | ADDICTION SEVERITY I NDEX | |
5673 | ADVANCE DI RECTIVE | |
5674 | ADVERSE RE ACTION/ALL ERGY | |
5675 | C & P EXAM INATION RE PORTS | |
5676 | CLINICAL W ARNING | |
5677 | CRISIS NOT E | |
5678 | DISCHARGE SUMMARIES | |
5679 | HISTORICAL PROCEDURE S XE "HIST ORICAL PRO CEDURES" | |
5680 | LR ANATOMI C PATHOLOG Y | |
5681 | PATIENT RE CORD FLAG CAT I | |
5682 | PATIENT RE CORD FLAG CAT II | |
5683 | OPERATION REPORTS | |
5684 | NURSE INTE ROPERATIVE REPORTS | |
5685 | ANESTHESIA REPORTS | |
5686 | PROCEDURE REPORT (NO N-O.R.) | |
5687 | SCI OUTCOM ES | |
5688 | | |
5689 | Note: | |
5690 | Although C ONSULTS wa s not expo rted as “N ational,” the same c autions ap ply. If yo u make exp licit chan ges to CON SULTS, the n the Cons ults tab o f CPRS may not work properly. | |
5691 | TIU*1*169 supports p atch DVBA* 2.7*53 C & P WORKSHE ET MODULE PHASE. The se patches together allow user s to creat e C & P Ex amination documents and store them in TI U. The adv antage to this is th at provide rs are all owed to vi ew the C & P exams i n CPRS alo ng with th e rest of a patient’ s medical record. C & P docume nts are en tered thro ugh the C & P Worksh eet Module using a t itle in th e C & P EX AMINATION REPORTS Do cument Cla ss. Upon s igning, th e C & P Ex ams are re tained in AMIE and s tored in T IU. | |
5692 | Further in formation on this ca n be found in the AM IE Regiona l Office U ser Manual . | |
5693 | National T itles | |
5694 | ADDENDUM | |
5695 | ADVANCE DI RECTIVE | |
5696 | ADVERSE RE ACTION/ALL ERGY | |
5697 | ANESTHESIA REPORT | |
5698 | ASI-ADDICT ION SEVERI TY INDEX | |
5699 | CLINICAL W ARNING | |
5700 | DISCLOSURE OF ADVERS E EVENT NO TE | |
5701 | COMPUTER D OWNTIME | |
5702 | ||
5703 | CRISIS NOT E | |
5704 | DISCHARGE SUMMARY | |
5705 | HISTORICAL CARDIAC C ATHETERIZA TION PROCE DURE XE "H ISTORICAL PROCEDURES " | |
5706 | HISTORICAL ECHOCARDI OGRAM PROC EDURE | |
5707 | HISTORICAL ELECTROCA RDIOGRAM P ROCEDURE | |
5708 | HISTORICAL ELECTROPH YSIOLOGY P ROCEDURE | |
5709 | HISTORICAL ENDOSCOPI C PROCEDUR E | |
5710 | HISTORICAL EXERCISE TOLERANCE TEST PROCE DURE | |
5711 | HISTORICAL HEMATOLOG Y PROCEDUR E | |
5712 | HISTORICAL HOLTER PR OCEDURE | |
5713 | HISTORICAL PACEMAKER IMPLANTAT ION PROCED URE | |
5714 | HISTORICAL PRE/POST SURGERY RI SK NOTE | |
5715 | HISTORICAL PULMONARY FUNCTION TEST PROCE DURE | |
5716 | HISTORICAL RHEUMATOL OGY PROCED URE | |
5717 | LR AUTOPSY REPORT | |
5718 | LR CYTOPAT HOLOGY REP ORT | |
5719 | LR ELECTRO N MICROSCO PY REPORT | |
5720 | LR SURGICA L PATHOLOG Y REPORT | |
5721 | NURSE INTE RPRETATIVE REPORT | |
5722 | OPERATION REPORTS | |
5723 | PATIENT RE CORD FLAG CATEGORY I | |
5724 | PATIENT RE CORD FLAG CATEGORY I - HIGH RI SK FOR SUI CIDE | |
5725 | PATIENT RE CORD FLAG CATEGORY I – URGENT ADDRESS AS FEMALE | |
5726 | PATIENT RE CORD FLAG CATEGORY I – MISSING PATIENT | |
5727 | RISK OF CJ D | |
5728 | SCI CRAIG HANDICAP A SSESSMENT& REPORTING TECHNIQUE- SHORT FORM | |
5729 | SCI DIENER SATISFACT ION WITH L IFE SCALE | |
5730 | SCI GENERA L NOTE | |
5731 | SCI FUNCTI ONAL INDEP ENDENCE ME ASURE | |
5732 | WRIISC XE "WRIISC" ASSESSMENT NOTE | |
5733 | PROCEDURE REPORT | |
5734 | | |
5735 | Note: | |
5736 | The HISTOR ICAL title s in docum ent class HISTORICAL PROCEDURE S XE "HIST ORICAL PRO CEDURES" were creat ed by patc h TIU*1*18 2 with sta tus INACTI VE. The st atus of th ese titles MUST REMA IN inactiv e in order to preven t users fr om enterin g notes on these tit les. All notes on t hese title s are auto -generated by the Me dicine Con version XE "Medicine Conversio n" patch MD*1*5. | |
5737 | | |
5738 | Note: | |
5739 | The TIU do cument cla sses, user class, ca tegory I n ote title, and categ ory I busi ness rule installed by patches TIU*1*165 and USR*1 *24 must n ot be modi fied in an y way or P atient Rec ord Flags may not wo rk properl y. | |
5740 | Note: | |
5741 | PATIENT RE CORD FLAG CATEGORY I - HIGH RI SK FOR SUI CIDE was c reated for the High Risk Menta l Health P atient – R eminder an d Flag. Th is new tit le is used with the new High R isk for Su icide PRF | |
5742 | Note: | |
5743 | PATIENT RE CORD FLAG CATEGORY I – URGENT ADDRESS AS FEMALE wa s created for the Hi gh Risk Me ntal Healt h Patient – Reminder and Flag Increment 6. This ne w title is used with the new U RGENT ADDR ESS AS FEM ALE Suicid e PRF, man dated by t he Underse cretary of Health’s legal solu tion. | |
5744 | Note: | |
5745 | PATIENT RE CORD FLAG CATEGORY I – MISSING PATIENT w as created for missi ng and wan dering pat ients. Th is new tit le is used with the Missing Pa tient, PRF . | |
5746 | Patch TIU* 1*159 impl ements the War-Relat ed Illness and Injur y Study Ce nters (WRI ISC XE "WR IISC" pro nounced “r isk”) note title and template. The assoc iated note title is WRIISC XE "WRIISC" ASSESSMENT NOTE. Thi s note is described in the mem o Descript ion of WRI ISC Progra ms and Ass ociated Re ferral Pro cess accom panying th e patch. T o get it t o work pro perly a Cl inical Coo rdinator a uthorized to edit sh ared templ ates must perform th e followin g steps fr om the CPR S GUI: | |
5747 | Go to the Notes tab. | |
5748 | From the O ptions men u, select Edit Share d Template s. | |
5749 | In the Sha red Templa tes pane h ighlight d ocument Ti tles. | |
5750 | From the T ools menu select Imp ort Templa te. | |
5751 | Select WRI ISCASSESSM ENT.TXML a nd press O pen. | |
5752 | Highlight the WRIISC ASSESSMEN T template . | |
5753 | In the Ass ociated Ti tle list b ox, select WRIISC AS SESSMENT N OTE. | |
5754 | Press OK. | |
5755 | Once these steps hav e been per formed, th e template and note title will work for all CPRS u sers. Furt her inform ation abou t setting up shared templates is availab le in the Computeriz ed Patient Record Sy stem (CPRS ) User Gui de in the section on Creating Personal D ocument Te mplates. | |
5756 | Patch TIU *1*261 per mits an au thorized u ser to res cind an Ad vance Dire ctive docu ment by ch anging the title to RESCINDED ADVANCE DI RECTIVE. | |
5757 | Patch TIU* 1*261 supp orts Imagi ng patch M AG*3.0*121 , which pr ovides the ability t o watermar k images " RESCINDED" . | |
5758 | | |
5759 | Note: EXAC T TITLE NA MES are RE QUIRED | |
5760 | The title of the Adv ance Direc tive to be rescinded must be A DVANCE DIR ECTIVE | |
5761 | The title it is cha nged to wh en it is b eing resci nded must be RESCIND ED ADVANCE DIRECTIVE | |
5762 | Both LOCA L and Nati onal Stand ard titles must be a s above. Variations on either title wil l cause th e Change T itle actio n to fail to waterma rk images as rescind ed. | |
5763 | These exa ct titles are requir ed by poli cy. See t he VHA HAN DBOOK 1004 .02 sectio n on Advan ce Directi ves: | |
5764 | http://vaw w1. d o main /vhapublic ations/Vie wPublicati on.asp?pub _ID=2042 | |
5765 | Chapter 15 : TIU Aler t Tools XE "Alert To ols" | |
5766 | Starting w ith patch TIU*1*158 XE "TIU*1* 158" , the re is a ne w option i n the TIU Management Menu that allows re fresh and manipulati on of TIU alerts, es pecially w ith respec t to signa tures XE " signatures " . These tools are designed t o assist C ACs, and o ther users with TIU management responsib ilities, t o help con trol the b acklog of unsigned n otes. It a ccomplishe s this by providing flexible c ontrol ove r alert ge neration. | |
5767 | The follow ing action s are avai lable: | |
5768 | BROWSE DOC UMENT—If a uthorized, presents a read onl y view of a selected document. | |
5769 | CHANGE VIE W—Allows e ntry new s earch crit eria. | |
5770 | COMBINATIO N ALERTS—A llows the sending of new alert s for sing le or mult iple docum ents to th e expected signers ( AUTHOR/ DI CTATOR, EX PECTED COS IGNER/ATTE NDING PHYS ICIAN, and ADDITIONA L SIGNER(S )) and one or more t hird parti es. RESEND rules out lined belo w apply fo r a docume nt's expec ted signer s. | |
5771 | DELETE ALE RTS—Allows deletion of all the alerts fo r a single or multip le documen ts. | |
5772 | DETAILED D ISPLAY—If authorized , allows t he viewing of docume nt details . | |
5773 | EDIT DOCUM ENT—If aut horized, a llows the editing a selected T IU documen t. | |
5774 | IDENTIFY S IGNERS—If authorized , allows t he editing of the ex pected sig ners of a TIU docume nt and rem oval of ad ditional s igners. | |
5775 | RESEND ALE RTS—Allows the regen eration of alerts fo r a single document or multipl e document s; all ale rts associ ated with each docum ent are de leted befo re being r esent. Pre viously se nt 3rd Par ty Alerts would be d eleted and need to b e resent. Alerts are sent appr opriate to the docum ent's stat us and onl y to expec ted signer s as follo ws: | |
5776 | The Au thor/Dicta tor & Expe cted Co-si gner/Atten ding—only receive al erts if th ey have no t signed. | |
5777 | Additi onal Signe r(s)—will only recei ve alerts if the doc ument has been signe d. | |
5778 | THIRD PART Y ALERTS—A llows the sending of new alert s for a si ngle docum ent or mul tiple docu ments to o ne or more third par ties regar dless of t he documen t's status . | |
5779 | Business r ules are c hecked and adhered t o, so whil e anyone w ho has acc ess to thi s option c an use it, you may b e blocked from certa in functio ns such as viewing u nsigned no tes. | |
5780 | In the fol lowing exa mple, TUI Alert Tool s are acce ssed throu gh the TIU Maintenan ce Menu [T IU IRM MAI NTENANCE M ENU], a ye ar of note s are chec ked for Dr . Snow, th en alerts are resent XE "resen d alerts" for an un signed not e: | |
5781 | Select TIU Maintenan ce Menu Op tion: ? | |
5782 | 1 TIU Parame ters Menu ... | |
5783 | 2 Document D efinitions (Manager) ... | |
5784 | 3 User Class Managemen t ... | |
5785 | 4 TIU Templa te Mgmt Fu nctions .. . | |
5786 | 5 TIU Alert Tools | |
5787 | 6 Active Tit le Cleanup Report [T IU ACTIVE TITLE CLEA NUP] | |
5788 | 7 TIUHL7 Mes sage Manag er | |
5789 | 8 Title Mapp ing Utilit ies ... | |
5790 | 10 Unauthoriz ed Abbrevi ations (En ter/Edit) | |
5791 | 11 List Unaut horized Ab breviation s | |
5792 | 12 Text Event Edit | |
5793 | ||
5794 | 13 Contingenc y Downtime Bookmark Progress N otes | |
5795 | Enter ?? f or more op tions, ??? for brief descripti ons, ?OPTI ON for hel p text. | |
5796 | Select TIU Maintenan ce Menu Op tion: 5 T IU Alert T ools | |
5797 | Select DOC UMENT STAT US: UNSIGN ED// ? | |
5798 | 1 undi ctated 5 unsigned 9 pu rged | |
5799 | 2 untr anscribed 6 uncosign ed 10 de leted | |
5800 | 3 unre leased 7 complete d 11 re tracted | |
5801 | 4 unve rified 8 amended | |
5802 | Enter sel ection(s) by typing the name(s ), number( s), or abb reviation( s). | |
5803 | Select ST ATUS: UNSI GNED// ALL undicta ted untra nscribed unreleased | |
5804 | unverif ied unsig ned uncos igned com pleted | |
5805 | amended purged deleted r etracted | |
5806 | Select SE ARCH CATEG ORY: AUTHO R// ? | |
5807 | 1 Auth or 3 Expected Cosigner 5 Ad ditional S igner | |
5808 | 2 Dict ator 4 Attendin g Physicia n | |
5809 | Enter sel ection(s) by typing the name(s ), number( s), or abb reviation( s). | |
5810 | Select SE ARCH CATEG ORY: AUTHO R// ALL Author Di ctator Ex pected Cos igner | |
5811 | Attending Physician | |
5812 | Additional Signer | |
5813 | Select NE W PERSON: TIUPROVIDE R,SEVEN CRS PHY SICIAN | |
5814 | Start Ref erence Dat e [Time]: T-7//t-365 (JUN 04, 2002) | |
5815 | Ending Ref erence Dat e [Time]: Jun 04, 20 03// <Ente r> (JUN 04 , 2003) | |
5816 | Searching for the do cuments... . TIU Aler t Tools Jun 04, 2003@14:01 :48 Page: 1 of 1. | |
5817 | Clinical D ocuments 5 D ocuments | |
5818 | by (ADD 'L SIGNER, AUTHOR,DIC TATOR,EXPE CTED COSIG NER,ATTEND ING PHYSIC IAN) | |
5819 | for (TIUPROVID ER,SEVEN) from 06/04 /02 to 06/ 04/03 | |
5820 | Patie nt Doc ument R ef Date S tatus . | |
5821 | 1 TIUPA TIENT,FO ( T8832) OT ASSESSMENT NOTE 0 9/09/02 c ompleted | |
5822 | 2 TIUPA TIENT,FO ( T8832) Car diology No te 0 9/23/02 u nsigned | |
5823 | 3 TIUPA TIENT,FI ( T0150) ONE -PER-VISIT NOTE 1 2/18/02 c ompleted | |
5824 | 4 TIUPA TIENT,SI ( T3323) Dis charge Sum mary 0 2/27/03 u nreleased | |
5825 | 5 TIUPA TIENT,SE ( T6351) H&P GENERAL M EDICINE 0 2/27/03 c ompleted | |
5826 | Enter ?? f or more ac tions >>> | |
5827 | Brows e Edit | |
5828 | Chang e View Ident ify Signer s | |
5829 | Combo Alert(s) Resen d Alert(s) | |
5830 | Delet e Alert(s) Third Party Ale rt(s) | |
5831 | Detai led Displa y | |
5832 | Select Act ion:Quit// R Resen d Alert(s) | |
5833 | Select Doc ument(s): (1-5) 2 | |
5834 | Resend Ale rts for th e followin g document s: | |
5835 | 2 TIUPA TIENT,FOUR (T8832) C ardiology Note 09/23/02 unsigned | |
5836 | Send these aler ts as OVER DUE? NO// Y YES | |
5837 | Is th is correct ? YES// <E nter> | |
5838 | Sendi ng Alerts. ... | |
5839 | Finis hed. | |
5840 | Enter RETURN to continue or '^' to exit: | |
5841 | Alert Tool s FAQ XE " Alert Tool s FAQ" | |
5842 | Q. My sea rch result s by an AD DITIONAL S IGNER and UNSIGNED d ocuments aren' t showing any matche s but I kn ow they ex ist. What' s wrong? | |
5843 | A. Additi onal signe rs are usu ally added AFTER a d ocument ha s been sig ned or co- signed. A dd UNCOSIG NED and CO MPLETED do cuments to your sear ch criteri a. | |
5844 | Q. I wan t to regen erate aler ts for an UNCOSIGNED document, but I don 't want th e AUTHOR t o get aler ted. Shou ld I just send a 3rd Party Ale rt to the EXPECTED C OSIGNER? | |
5845 | A. You c ould, but if you sel ect RESEND ALERTS, XE "resend alerts" the regene rated aler ts are con text sensi tive and s ent only t o individu als that h ave NOT si gned the d ocument; i n this cas e, only th e EXPECTED COSIGNER and any AD DITIONAL S IGNERS tha t have not signed wi ll be aler ted. | |
5846 | Q. I sele cted RESEN D ALERTS a nd my 3rd Party Aler ts disappe ared! What hap pened? | |
5847 | A. A docu ment's ale rts are de leted befo re being r egenerated so that t hey remain accurate regarding the docume nt's statu s; 3rd Par ty Alerts are delete d as well and must b e resent s ince they are not of ficially p art of the document' s record a nd cannot be automat ically reg enerated. | |
5848 | Q. I chan ged the AD DITIONAL S IGNER for a document using IDE NTIFY SIGN ERS, but i t didn't u pdate in t he display . Why not ? | |
5849 | A. Becaus e there ca n be more than one A DDITIONAL SIGNER, un less the A DDITIONAL SIGNER mat ches the s earch crit eria, it w on't be di splayed. | |
5850 | Q. I adde d an ADDIT IONAL SIGN ER for a d ocument us ing IDENTI FY SIGNERS , but it d idn't upda te in the display. Why not? | |
5851 | A. Becaus e there ca n be more than one A DDITIONAL SIGNER, un less the A DDITIONAL SIGNER mat ches the s earch crit eria, it w on't be di splayed. | |
5852 | Q. The AU THOR of se veral docu ments (req uiring co- signature) is gone a nd I want to regener ate the al erts for t he EXPECTE D COSIGNER so they c an SIGN an d COSIGN t hese UNSIG NED docume nts. Shoul d I use RE SEND? | |
5853 | A. It dep ends. Def ault alert behavior would be t o send the alert AFT ER the aut hor has si gned and i n this cas e, the EXP ECTED COSI GNER would have neve r received the alert s initiall y or even after usin g RESEND. | |
5854 | Howe ver, with TIU*1*151, a new doc ument para meter was added that could be set so tha t the EXPE CTED COSIG NER could receive th e alert IM MEDIATELY; even if t he AUTHOR has not si gned. | |
5855 | This parameter is shown below: | |
5856 | --- --- | |
5857 | SEN D COSIGNAT URE ALERT: After Aut hor has SI GNED// ? | |
5858 | Specify w hen the al ert for co signature should be sent | |
5859 | Choose fr om: | |
5860 | 0 After Au thor has S IGNED | |
5861 | 1 Immediat ely | |
5862 | --- --- | |
5863 | If y ou have NO T specific ally set t his parame ter or hav e it set t o "After A uthor has SIGNED", y ou'll need to use a 3rd Party Alert to t he EXPECTE D COSIGNER or change the param eter's set ting to "I mmediately " before u sing RESEN D. | |
5864 | If y ou HAVE se t this par ameter to "Immediate ly", you c an use RES END. | |
5865 | Q. I used RESEND AL ERT and th e EXPECTED COSIGNER didn't get alerted! Why? | |
5866 | A. Two po ssible rea sons. The first, ple ase see th e question just befo re this on e. | |
5867 | The second, th e EXPECTED COSIGNER may be ina ctivated o r DIUSER'd . Currentl y, kernel does not a lert these individua ls who are inactive or termina ted. | |
5868 | TIU* 1.0*158 wi ll inform the user t hat an ind ividual en tered as a 3rd Party Alert rec ipient is inactive/D IUSER'd. However, i t does not verify ev ery indivi dual attac hed to a d ocument si nce this w ould be to o system i ntensive a nd time co nsuming on a batch s end of ale rts. | |
5869 | Q. I used RESEND AL ERT and no alerts we re resent to anyone, even thou gh it appe ared that alerts wer e being re -generated . Why? | |
5870 | A. While TIU may cr eate and a ttempt to regenerate the alert s (this wi ll always happen if TIU Alerts attempts to fulfill a user's request), it has no way of act ually conf irming whe ther or no t kernel w ill send a n alert to an indivi dual assoc iated with a documen t (See #7) . | |
5871 | The important rule to re member is that kerne l will not actually send alert s to inact ivated or terminated users. | |
5872 | Addi tionally, TIU sends alerts bas ed on the current st atus of th e document and wheth er or not the recipi ent still needs to s ign the do cument. I f an indiv idual has already si gned, they should no t receive an alert. However, if a user associated with a do cument has already s igned and they are s ent a 3RD PARTY ALER T, they wi ll receive another a lert. | |
5873 | Q. I sent the AUTHO R (who has already s igned) a 3 RD PARTY A LERT and n ow they ca n't proces s it! Wha t should I do? | |
5874 | Just RESEND AL ERTs for t hat docume nt. All a lerts will be delete d and rege nerated; 3 RD PARTY A LERTS that had been manually g enerated w ill have t o be re-en tered (See #3). | |
5875 | Chapter 16 : HL7 Gene ric Interf ace XE " H L7 Generic Interface " XE "HL 7 Troubles hooting" | |
5876 | The purpos e of the H L7 Generic Interface is to cre ate a Heal th Level S even (HL7) line to T ext Integr ation Util ities (TIU ) that wil l support the upload of a wide -range of textual do cuments fr om Commerc ial-Off-th e-Shelf (C OTS XE "CO TS" ) appl ications i n use now and in the future at Veteran A dministrat ion (VA) M edical Cen ters. Proj ects that may work w ith the in terface ar e the Remo te Order E ntry Syste m (ROES) s oftware us ed by the Denver Dis tribution Center (DD C), the Pr ecision Da ta Solutio ns Transcr iption Ser vice softw are, and t he VA Home Telehealt h software . | |
5877 | The projec t creates a single C OTS/applic ation inte rface spec ification to allow t extual doc uments to be uploade d and disp layed in C PRS XE "CP RS" . This allows cl inicians t o view inf ormation f rom the CO TS package without l eaving the patient’s electroni c medical record. | |
5878 | Generic HL 7 will not work with external software u nless it i s specific ally set u p to do so . The deta ils of how to do thi s are cont ained in t he Text In tegration Utilities (TIU) Gene ric HL7 Ha ndbook. Th is handboo k describe s the HL7 fields req uired for each docum ent types and gives additional informati on on syst em feature s and vend or guideli nes. To re trieve thi s document go to the VistA Doc ument Libr ary at (ht tp://www. d o main /vdl/), th en click o n CPRS: Te xt Integra tion Utili ty (TIU). | |
5879 | Message Ma nager | |
5880 | The only p lace where the Gener ic HL7 Int erface is visible is in the TI U Maintena nce Menu. The TIUHL7 Message M anager has been adde d to this menu to as sist medic al center in setting up the in terface. | |
5881 | If an erro r message XE "error code" is returned, it will be contained in clear text expla ining the error. | |
5882 | The follow ing is an example of using the HL7 messa ge Manager to check an error m essage XE "error mes sage" : | |
5883 | Select TIU Maintenan ce Menu Op tion: ? | |
5884 | 1 TIU Parame ters Menu ... | |
5885 | 2 Document D efinitions (Manager) ... | |
5886 | 3 User Class Managemen t ... | |
5887 | 4 TIU Templa te Mgmt Fu nctions .. . | |
5888 | 5 TIU Alert Tools | |
5889 | 6 Active Tit le Cleanup Report | |
5890 | 7 TIUHL7 Mes sage Manag er | |
5891 | 8 Title Mapp ing Utilit ies ... | |
5892 | 10 Unauthoriz ed Abbrevi ations (En ter/Edit) | |
5893 | 11 List Unaut horized Ab breviation s | |
5894 | 12 Text Event Edit | |
5895 | ||
5896 | 13 Contingenc y Downtime Bookmark Progress N otes | |
5897 | Select TI U Maintena nce Menu O ption: 7 TIUHL7 Mes sage Manag er | |
5898 | Searching for messag es..... | |
5899 | Refre sh Message List | |
5900 | TIUHL7 Mes sage Manag er Aug 04, 20 06@15:47:1 9 Page: 1 of 1 | |
5901 | TIU HL7 Receiv ed Message s | |
5902 | Receivin g Send ing Message | |
5903 | Messag e ID Date/Time Processed Applicat ion Appl ication Status | |
5904 | 1 999530 44 Jul 31, 20 06@11:24:5 3 TIUHL7 HTAP PL Rejected | |
5905 | 2 999530 46 Jul 31, 20 06@11:27:1 4 TIUHL7 HTAP PL Rejected | |
5906 | 3 999530 48 Jul 31, 20 06@11:28:4 4 TIUHL7 HTAP PL Accepted | |
5907 | 4 200T40 029200608 Aug 02, 20 06@11:35:1 1 TIUHL7 HTAP PL Accepted | |
5908 | 5 200T40 003200608 Aug 02, 20 06@14:28:1 4 TIUHL7 HTAP PL Accepted | |
5909 | 6 999530 50 Aug 02, 20 06@15:45:4 1 TIUHL7 HTAP PL Accepted | |
5910 | Enter ?? f or more ac tions | |
5911 | View Message Delet e Message( s) | |
5912 | Refre sh Message List | |
5913 | Select Act ion: Quit // 2 | |
5914 | TIUHL7 Me ssage View er Aug 04, 20 06@15:47:2 2 Page: 1 of 1 | |
5915 | MSA^AR^999 53046^TIUH L7^HTAPPL | |
5916 | ERR^PV1^44 ^^0000.00~ Could not find a vis it for Jul 31, 2006@ 16:21. | |
5917 | MSH^~|\&^H TAPPL^00T5 ~VAWW.VITE RION.CC.ME D. D O MAIN ~DNS^TIUHL 7^689~ANON YMOUS.MED. V | |
5918 | A.GOV~DNS^ 2006073109 2708-0700^ ^MDM~T02~M DM_T02^999 53046^T^2. 4^^^AL^AL^ USA | |
5919 | EVN^T02 | |
5920 | PID^^^~~~U SVHA~NI|~~ ~USSSA~SS| 290~~~USVH A~PI||^^TI UPATIENT~F IVE | |
5921 | PV1^^^GI W ALK-IN^^^^ ^^^^^^^^NE W^^^^^^^^^ ^^^^^^^^^^ ^^^^^^2004 0626011903 | |
5922 | TXA^^^TEXT ^200607311 621^^^^^33 271~TIUPRO VIDER~THRE E~~~~~USVH A^~^^~USVH A^^^^PROGR E | |
5923 | SS NOTE^^^ ^^^~~~~~~~ ~~~~~~~~~~ ~~~~~~~~~~ ~ | |
5924 | OBX^1^TX^S UBJECT~Thi s is the s ubject ^^N EW TEST TO DAY NEW Location NEW TEST n | |
5925 | ew REF dat e for GI W ALK-IN . | |
5926 | Enter ?? f or more ac tions | |
5927 | Delet e Message Repro cess Messa ge | |
5928 | Select Ite m(s): Quit // | |
5929 | The messag es display ed by the Message Ma nager are from the X TEMP Globa l XE "XTEM P Global" , which is set to de lete messa ges after seven (7) days. In o ther words , VistA di scards HL7 messages that are m ore than s even (7) d ays old. | |
5930 | Chapter 17 : Setting Up TIU Tex t Events | |
5931 | Patch TIU* 1*296 modi fies the T IU applica tion to se nd a TIU a lert to th e appropri ate servic e provider (s) immedi ately afte r a staff member scr eens a pat ient and s igns the a ssociated note. The service pr ovider(s) will be al erted prio r to the n ote being co-signed by the lic ensed clin ician resp onsible fo r reviewin g and appr oving the note. Prio r to this modificati on, TIU al erts were not sent t o all serv ice provid ers. This resulted i n missed o pportuniti es to prov ide needed services for patien ts while t he patient s are on s ite, and f orced staf f to take time to co ntact pati ents and r eschedule needed ser vices. | |
5932 | A new Text Event Edi t [TIU TEX T EVENT ED IT] option is availa ble in the TIU Maint enance men u. | |
5933 | Select OPT ION NAME: TIU MAINTE NANCE MENU TIU IRM MAINTENANC E MENU TIU Maint enance Men u | |
5934 | 1 TIU Parame ters Menu ... | |
5935 | 2 Document D efinitions (Manager) ... | |
5936 | 3 User Class Managemen t ... | |
5937 | 4 TIU Templa te Mgmt Fu nctions .. . | |
5938 | 5 TIU Alert Tools | |
5939 | 6 Active Tit le Cleanup Report | |
5940 | 7 TIUHL7 Mes sage Manag er | |
5941 | 8 Title Mapp ing Utilit ies ... | |
5942 | 10 Unauthoriz ed Abbrevi ations (En ter/Edit) | |
5943 | 11 List Unaut horized Ab breviation s | |
5944 | 12 Text Event Edit | |
5945 | ||
5946 | 13 Contingenc y Downtime Bookmark Progress N otes | |
5947 | Select the Text Even t Edit men u option t o set up a “text eve nt” in the TIU TEXT EVENTS fil e (#8925.7 1). Comple te all fie lds, inclu ding the t rigger tex t to be se arched for in a TIU document ( progress n ote, consu lt note, e tc.). If t he trigger text is f ound in th e TIU docu ment, then an alert is sent to the team( s) specifi ed in the file. | |
5948 | The follow ing exampl e shows “a b color bl indness” a s the trig ger text [ TEXT TO SE ARCH]. The alert mes sage [ALER T MESSAGE] patient has ab col or blindne ss will be sent to t he specifi ed service provider [CPRS TEAM ]. An aler t [SIGNER ALERT MESS AGE] is al so sent to the indiv idual who signed the note. | |
5949 | Select TIU Maintenan ce Menu <T EST ACCOUN T> Option: txt Text Event Edi t | |
5950 | Select TIU TEXT EVEN TS NAME: t est 5 | |
5951 | Are you adding 'te st 5' as a new TIU T EXT EVENTS (the 8TH) ? No// yes (Yes) | |
5952 | NAME: test 5// | |
5953 | STATUS: ? | |
5954 | Enter a 0 for i nactive or a 1 for a ctive | |
5955 | Choos e from: | |
5956 | 0 INAC TIVE | |
5957 | 1 ACTI VE | |
5958 | STATUS: 1 ACTIVE | |
5959 | TEXT TO SE ARCH: ? | |
5960 | Answe r must be 3-200 char acters in length. | |
5961 | TEXT TO SE ARCH: ab c olor blind ness | |
5962 | CASE SENSI TIVE: ? | |
5963 | Enter a 0 for N O or a 1 f or YES. | |
5964 | Choos e from: | |
5965 | 0 NO | |
5966 | 1 YES | |
5967 | CASE SENSI TIVE: no NO | |
5968 | INCLUDE SP ACES: yes YES | |
5969 | ALERT MESS AGE: patie nt has ab color blin dness | |
5970 | SIGNER ALE RT MESSAGE : ? | |
5971 | Answe r must be 1-6 charac ters in le ngth. | |
5972 | SIGNER ALE RT MESSAGE : ab | |
5973 | Select CPR S TEAM: te am test | |
5974 | Select CPR S TEAM: TE ST TEAM ?? | |
5975 | Select CPR S TEAM: TE AM TEST | |
5976 | . ..OK? Yes/ / YES (Ye s) | |
5977 | CPRS TEA M: TEAM TE ST// | |
5978 | Select CPR S TEAM: | |
5979 | Select TIU TEXT EVEN TS NAME: | |
5980 | | |
5981 | Note: Any TIU docume nt that is to be use d to trigg er these a lerts must have the MUMPS code 'D TASK^T IUTIUS(DA) ’ entered in the POS T-SIGNATUR E CODE fie ld (#4.9) in the TIU DOCUMENT DEFINITION file (#89 25.1). Thi s field ca n only be edited by IRM person nel. | |
5982 | Select OPT ION: ENTER OR EDIT F ILE ENTRIE S | |
5983 | INPUT TO W HAT FILE: TIU DOCUME NT DEFINIT ION// | |
5984 | EDIT WHICH FIELD: AL L// 4.9 P OST-SIGNAT URE CODE | |
5985 | THEN EDIT FIELD: | |
5986 | Select TIU DOCUMENT DEFINITION NAME: NURSING PR OGRESS NOT E TITL E | |
5987 | Std Title: NUR SING NOTE | |
5988 | POST-SIGNA TURE CODE: D TASK^TI UTIUS(DA)/ / | |
5989 | Chapter 18 : Setting up Conting ency Downt ime Bookma rk Progres s Notes | |
5990 | The Contin gency Down time Bookm ark Progre ss Notes o ption in t he TIU Mai ntenance M enu allows sites to add a prog ress note to the ele ctronic re cord of al l inpatien ts and out patients w ho were se en during computer s ystem down time. The progress n ote states that a co mputer out age occurr ed, and al erts medic al staff t o search t he patient 's paper r ecords for non-elect ronic docu mentation created du ring the o utage. | |
5991 | To set up a continge ncy downti me bookmar k progress note: | |
5992 | ||
5993 | Select the Contingen cy Downtim e Bookmark Progress Notes [TIU DOWNTIME BOOKMARK P N] option from the TIU Mainte nance Menu [TIU IRM MAINTENANC E MENU]. T he “Bookma rk Progres s Note aft er a Downt ime” scree n displays . | |
5994 | Bookmark P rogress No te after a Downtime | |
5995 | This is the uti lity to ad d a bookma rk to the progress n ote of | |
5996 | each inpatient' s electron ic record after a Vi stA downti me. | |
5997 | You w ill be ask ed a few q uestions, and then t he utility | |
5998 | will place the note on th e patient' s record. | |
5999 | Select the PROGRESS NOTE TITLE to be use d for fili ng conting ency downt ime | |
6000 | bookmark p rogress no tes. The selected t itle must be mapped to the | |
6001 | VHA ENTERP RISE STAND ARD TITLE of "COMPUT ER DOWNTIM E". | |
6002 | Select TIU DOCUMENT DEFINITION NAME:// ?? | |
6003 | ||
6004 | Enter a TI U DOCUMENT DEFINITIO N NAME. Us e either t he VHA ent erprise-st andard tit le COMPUTE R DOWNTIME or a loca lly-approv ed title t hat is map ped to the standard COMPUTER D OWNTIME ti tle. | |
6005 | ||
6006 | Enter "S" or "U" to define whe ther the d owntime wa s Schedule d or Unsch eduled. | |
6007 | Was the do wntime (S) cheduled o r (U)nsche duled? UNS CHEDULED | |
6008 | What was t he startin g time of the outage ? T-2@2200 (NOV 07, 2017@22:0 0) | |
6009 | What was t he ending time of th e outage? T-2@23:47 (NOV 07, 2017@23:47 ) | |
6010 | Who will b e the AUTH OR of the note? TIUU SER,ONE// OT D EVELOP | |
6011 | ER | |
6012 | What shall the Date/ Time of th e Note be? NOW// T-2 @23:54 (N OV 07, 201 7@23:54) | |
6013 | Selec t one of t he followi ng: | |
6014 | A All Clinic s | |
6015 | S Selected C linics | |
6016 | N No Outpati ent Clinic s | |
6017 | File Notes for Outpa tient Clin ics [A/S/N ]: All Cli nics | |
6018 | In addi tion to yo urself, wh o shall re ceive emai l notifica tion | |
6019 | of this event? | |
6020 | Select NEW PERSON NA ME: EPIP,U SER UE 118 ADMIN ASSISTANT | |
6021 | Select ano ther NEW P ERSON NAME : | |
6022 | ||
6023 | Enter the starting t ime of the outage. F or example , enter "T @[24-hour time]" to set the da te as toda y. Type "? ?" and the n press En ter to see all valid time form ats. | |
6024 | ||
6025 | Enter the ending tim e of the o utage. | |
6026 | ||
6027 | Enter the Author of the note ( using "las tname,firs tname" for mat). The default en try is the logged-in user. | |
6028 | ||
6029 | Enter the Date/Time of the not e; the def ault is NO W. This en try determ ines where the note appears in a sorted list of al l progress notes. | |
6030 | ||
6031 | Specify wh ether All (A), Selec ted (S), o r No (N) o utpatient clinics we re affecte d by the o utage. Cho osing "Sel ected" ope ns the HOS PITAL LOCA TION file. Enter the desired c linics to include. P ress Enter at the pr ompt to co ntinue to the next s tep. | |
6032 | ||
6033 | At the "Se lect NEW P ERSON NAME :" prompt, enter the name (in "lastname, firstname" format) o f any othe r user(s) that you w ish to rec eive a not ification of the dow ntime even t. To ente r multiple names, pr ess Enter after each entry. Th e notifica tion will list the p atients wh o have had this down time bookm ark progre ss note ap pended to their reco rd. | |
6034 | At multi-d ivisional sites, the "Select d ivision: A LL//" prom pt appears . Enter th e division (s) affect ed by the outage. Yo u can use MEDICAL CE NTER DIVIS ION NUM, N AME, FACIL ITY NUMBER , or TREAT ING SPECIA LTY to des ignate the division. Type "?" to display a numbere d list of available divisions. | |
6035 | The system creates a progress note conta ining stan dard text and genera tes a prev iew of the note. Ent er “Yes” a t the "Do you wish t o edit the text?" pr ompt if yo u wish to edit the p rogress no te text. A text edit or will op en, from w hich you c an edit th e note tex t. Press C TRL+E to e xit the te xt editor. The "Do y ou wish to edit the text?" pro mpt displa ys again; enter "No" to contin ue. | |
6036 | Date/Time of Note: Nov 07, 20 17@23:54 | |
6037 | Creating T IU note te xt, you wi ll have an opportuni ty to edit the text | |
6038 | The progre ss note wi ll be gene rated with the follo wing text: | |
6039 | -------- P otential I nterruptio n in Elect ronic Medi cal Record Keeping --------- | |
6040 | An unsched uled inter ruption in access to the elect ronic medi cal record s | |
6041 | occurred f or 1 hour and 47 min utes betwe en: | |
6042 | Tuesd ay, Nov 07 , 2017 22: 00 and Tue sday, Nov 07, 2017 2 3:47 | |
6043 | Before, du ring and a fter this period of downtime, medical re cord | |
6044 | documentat ion may ha ve been co llected on paper. D ocuments s uch as | |
6045 | progress n otes, orde rs, result s, medicat ion admini stration r ecords | |
6046 | (MAR) and procedure reports ma y have bee n collecte d, but may not be | |
6047 | reflected in the ele ctronic re cord or th ey may be scanned in to the | |
6048 | record at a later da te. | |
6049 | Do you wis h to edit the text? No// | |
6050 | The downti me note wi ll be sign ed as an A dministrat ive Closur e, so the Administra tive Closu re signatu re block i s displaye d. At the "Enter you r Current Signature Code" prom pt, enter your code to sign an d close th e note. If you do no t enter th e signatur e within 6 0 seconds, you must restart en try of the note. | |
6051 | The note(s ) will hav e the foll owing admi nistrative closure ( not a sign ature): | |
6052 | Admin istrative Closure: 4 /11/16 | |
6053 | by: T IUUSER, ON E, Develop er | |
6054 | D eveloper | |
6055 | You wil l now be a sked for a n electron ic signatu re to begi n this pro cess. | |
6056 | This is a securit y measure to start t he backgro und task, but it is not used | |
6057 | to sign the notes themselve s. If you are not t he AUTHOR, your name will | |
6058 | show fo r the admi nistrative closure, but not as the autho r of the n ote. | |
6059 | You have 6 0 seconds/ try and a maximum of 3 attempt s to enter a proper code. | |
6060 | Enter your Current S ignature C ode: SI GNATURE VE RIFIED | |
6061 | At the "Qu eue the re port to Ta skman?" pr ompt, ente r “No” to view the r eport on y our screen now or en ter “Yes” to send th e report t o Taskman to view la ter. The r eport list s the pati ents impac ted by the downtime, grouped b y inpatien ts, discha rged patie nts, and o utpatient clinics, a nd indicat es whether the downt ime progre ss note wa s successf ully appen ded to eac h patient' s record. Regardless of your r esponse, a n email me ssage cont aining the patient l ist and pr ogress not e status i s sent to the recipi ents desig nated in s tep 9. | |
6062 | Note: You might want to queue the report since the generatio n of a lar ge report can tie up your comp uter for a long peri od of time . | |
6063 | To view th e Continge ncy Downti me Bookmar k Progress Notes, lo ok at the Progress N otes in a patient's record in VistA or t he CPRS GU I. | |
6064 | Chapter 19 : Helpful Hints/Trou bleshootin g XE "Trou bleshootin g" | |
6065 | FAQs XE "F AQs" (Fre quently As ked Questi ons XE "Fr equently A sked Quest ions" ) | |
6066 | NOTE: Mo st of thes e question s were rec eived from TIU/ASU t est sites. Thanks to everyone who contri buted! | |
6067 | Q: We just entered a ll of our Providers into the P erson Clas s file XE "Person Cl ass file" (when the Ambulator y Care Rep orting Pro ject came out). Do w e have to do this al l over aga in for the User Clas s file XE "User Clas s file" i n ASU? Why can’t TIU and ASU j ust use th e Person C lass? | |
6068 | A: The Pro vider Clas s XE "Prov ider Class " in ASU fulfills a different function, and there fore its d atabase de sign is a different kind of hi erarchy. | |
6069 | ||
6070 | A patch to ASU in th e near fut ure will h elp assure that your efforts i n populati ng the Per son Class Membership at your s ite are no t lost, or repeated. We are de veloping a mapping b etween a s ubset of t he exporte d User Cla sses and t he Person Class File (i.e., fo r each Per son Class, there wil l be a cor responding User Clas s), which will help you “autop opulate” U ser Class Membership , assure t hat future changes t o an indiv idual’s Pe rson Class Membershi p are refl ected auto matically in his Use r Class Me mbership, and allow resolution of privil eges for i nter-facil ity access to data. We recomme nd that yo u initiall y implemen t TIU and ASU by pop ulating on ly the mos t essentia l User Cla sses (i.e. , Provider ; MRT; Chi ef, MIS; a nd Transcr iptionist) , and use the forthc oming patc h to assis t you in a utopopulat ing more s pecific Us er Classes when you have becom e acquaint ed with th e two prod ucts. | |
6071 | Q: We’ve h eard that implementa tion of TI U is very complex an d time-con suming. Ho w long doe s is take? | |
6072 | A: TIU im plementati on is comp lex, but t he amount of time it takes to implement has to do with the c omplexity of the sit e, how man y users, t he databas e and hier archy size , the leve l of users , and how dependent the site i s on the p ackage (ob viously a site that is totally electroni c has very different issues th an a site where part icipation is optiona l. It took a test si te with a million+ n otes about 2.5 weeks to run th eir Progre ss Notes c onversion. | |
6073 | FAQs cont’ d | |
6074 | Q: Will th e Discharg e Summary and Progre ss Notes p ackages be gone once files are converted to TIU? | |
6075 | A: Discha rge Summar y V. 1.0 X E "Dischar ge Summary V. 1.0" and Progre ss Notes V . 2.5 XE " Progress N otes V. 2. 5" should be made " Out of Ord er" once t he convers ions have been run, staff trai ned, and t he cut-ove r started. The data in files 1 21 and 128 will rema in until y our site d ecides to purge thes e files. W e suggest that they remain int act until you're sur e the conv ersions ha ve run cor rectly and the imple mentation is going s moothly. | |
6076 | Q: Can TI U be used without co nverting t he Dischar ge Summari es until m uch later? | |
6077 | A: TIU ca n be used without co nverting D ischarge S ummary, bu t we stron gly recomm end that P rogress No tes and Di scharge Su mmary both be conver ted to TIU at the sa me time, t o avoid co mplication s. | |
6078 | NOTE: You cannot run dual implementa tions of D ischarge S ummary; th at is, Dis charge Sum mary 1.0 a nd Dischar ge Summary through T IU. | |
6079 | Q: Is it p ossible to load ASU in product ion and st art popula ting the g roups befo re we load TIU? | |
6080 | A: Yes yo u can. The Business Rules XE " Business R ules" wil l not be f unctional because th ey are tie d to the D ocument De finition F ile, but y ou will be able to p opulate th e Class me mberships. | |
6081 | Q: Do we have to de lete or si gn unsigne d notes be fore we ca n convert them? | |
6082 | A: No, yo u don’t ha ve to dele te or sign the unsig ned notes. The conv ersion wil l move the m as is. However, y ou probabl y don’t wa nt to be m oving old, irrelevan t notes fr om one pac kage to th e other. B y the way, notes for test pati ents are N OT moved; they are i gnored. | |
6083 | FAQs cont’ d | |
6084 | Q: Can we require a Cosignatu re for a p articular note? | |
6085 | A. Yes, y ou can set Cosignatu re require ments for document c lasses or titles. Us e the opti on Documen t Paramete r Edit, as described in the TI U Implemen tation Gui de. Indivi dual clini cians can designate an expecte d Cosigner through t heir Perso nal Prefer ences opti on (descri bed on pag e 64 of th is manual) . | |
6086 | Q Why do we have to enter Vis its and en counter da ta for Pro gress Note s? What ar e “Histori cal Visits XE "Histo rical Visi ts" ”? | |
6087 | A: Visit d ata is now required for every outpatient encounter . The vast majority of Progres s Notes ar e already linked to an admissi on and don ’t require additiona l visit in formation to be adde d. | |
6088 | ||
6089 | A historic al visit o r encounte r is a vis it that oc curred at some time in the pas t or at so me other l ocation (p ossibly no n-VA). Alt hough thes e are not used for w orkload cr edit, they can be us ed for set ting up th e PCE remi nder maint enance sys tem, or fo r other no n-workload -related r easons. | |
6090 | NOTE: If m onth or da y aren’t k nown, hist orical enc ounters wi ll appear on encount er screens or report s with zer oes for th e missing dates; for example, 01/00/95 o r 00/00/94 . | |
6091 | Q: Are th ere any te rminal set tings XE " Terminal s ettings" that we ne ed to be a ware of fo r TIU? On the VT400 setting i n Smart Te rm, the bo ttom half of the Cre ate Docume nt Definit ions scree n was not scrolling properly. It was wri ting over previous l ines and g ot very co nfusing! | |
6092 | A: Variou s terminal emulators can affec t applicat ions using the List Manager in terface. The VT220 and 320 w ork very w ell with L ist Manage r. | |
6093 | FAQs cont’ d | |
6094 | Q: I have gotten my 600 clinic and ward locations set up, bu t when I t ry to prin t by ward I am only allowed to print to a printer. This is n ot true un der the Pr int by Hos pital Loca tion, wher e I can pr int to the screen. W hat is the differenc e? | |
6095 | A: Print by Ward XE "Print by Ward" is designed to support batch pri nting XE " Batch prin ting" . It has the u nique abil ity to det ermine whe n the last note was printed so that site s can now capture th e infamous “orphan” note which was a pro blem under Progress Notes 2.5. You might consider adding a m essage on entry into the optio n to infor m users th at they ca n only pri nt to a pr inter (not on screen ). | |
6096 | Q: Can we share bus iness rule s XE "Busi ness Rules " with ot her sites. | |
6097 | A: It isn ’t yet kno wn how app ropriate o r desirabl e it is to share bus iness rule s amongst sites. The package i s exported with all the busine ss rules n eeded to r un the sta ndard pack age. The d ifferences are usual ly on a me dical cent er basis. | |
6098 | For exampl e, one sit e wants al l users to be able t o see all UNSIGNED n otes. ON the flip s ide, anoth er site do esn’t want any users to be abl e to print or view U NCOSIGNED notes unti l the cosi gner has s igned. Tw o very dif ferent vie ws. Just b ecause you are in th e same VIS N doesn’t mean you w ould view these issu es in the same light . Another example is the hospi tal that w ants to re strict the entering/ viewing/ p rinting of every Pro gress Note by TITLE. You can d o this, bu t it is no t somethin g we would recommend . | |
6099 | We strongl y recommen d that you work with the expor ted busine ss rules f or a while before ma king any c hanges. | |
6100 | Q: When I read my Di scharge Su mmaries af ter they c ome back f rom the tr anscriptio nist, ther e are dash es (or oth er funny c haracters) sprinkled throughou t; what do these mea n and what am I supp osed to do ? | |
6101 | ||
6102 | A: These characters (your sit e determin es whether they will be dashes , hyphens or some ot her charac ter) indic ate words or phrases that the transcript ionist was unable to understan d. You nee d to repla ce these w ith the in tended wor d or phras e before y ou’ll be a ble to sig n the docu ment. | |
6103 | FAQs cont’ d | |
6104 | Q: What i s the best editing/w ord-proces sing progr am XE "Wor d-processi ng program " and how can I lea rn how to use it? | |
6105 | ||
6106 | A: This i s partly a matter of personal preference and partl y a matter of what’s available at your s ite. Comme rcial word -processor s are avai lable at s ome sites. The FileM an line ed itor XE "L ine editor s" and Sc reen Edito r XE "Scre en Editor" are avai lable at a ll sites. Of these t wo, most D ischarge S ummary use rs prefer the Screen Editor XE "Screen E ditor" . Y our IRM of fice or AD PACs can h elp you ge t set up w ith the ap propriate editor and provide t raining. T he Clinici an Quick R eference C ard summar izes the F ileMan Scr een Editor functions . | |
6107 | Q: Why sho uld a site require “ release fr om transcr iption XE "Release f rom transc ription" ” ? | |
6108 | A: Releas e from tra nscription is requir ed to prev ent a disc harge summ ary from b ecoming vi sible to o ther users before th e person e ntering th e summary has comple ted the en try. For e xample, if a transcr iptionist needed to leave the terminal, the summar y would no t be avail able for a nyone else to look a t until th e summary is “releas ed from tr anscriptio n.” | |
6109 | Q: Why can ’t we use extended A SCII chara cters XE " ASCII char acters" ( e.g., °, ≥ , ∆, etc.) in our do cuments to be upload ed? | |
6110 | A: These a lternate c haracter s ets are no t standard ized acros s operatin g systems and your M UMPS syste m may not be set up to store t hem. | |
6111 | FAQs cont’ d | |
6112 | Questions about Repo rts and Up load | |
6113 | XE "Repor ts and Upl oad" | |
6114 | Q: At pres ent we put all disch arges in t he Dischar ge Summary package. We do allo w Spinal C ord Injury to put “i nterim” su mmaries in on their patients e very 6 mon ths or ann ually. The se reports stack up under the admission date and a re all und er that on e date upo n discharg e. | |
6115 | ||
6116 | When patie nts are tr ansferred to the Int ensive Car e Units, t hey may ha ve a very long/compl icated sum mary to de scribe the care whil e in the u nit. This should be an interwa rd transfe r note XE "Interward transfer note" , bu t some of our physic ians feel that due t o the comp lexity of care deliv ered in th e unit, th is should be include d in their Discharge Summary, BUT should have its own date ( episode of care). I realize th at the int erward tra nsfer note is a prog ress note and very f ew of our physicians are using progress notes. Our physician s seem to want to ha ve that in terward tr ansfer inf ormation i n these co mplex case s attached to the Di scharge Su mmary. | |
6117 | ||
6118 | My questio n is will TIU offer us anythin g differen t that wil l satisfy our physic ians? I s till do no t have a m ental pict ure of wha t it will look like when I go to look up a DCS or PN from th e TIU pack age. Will the docume nts be int ermingled and arrang ed by date ? I am a firm beli ever in ca lling thin gs what th ey are and putting t hem where they belon g when it comes to o rganizing our electr onic recor d. I hate to see the DSC and i nterward t ransfers g o together now in th e DCS pack age as it does creat e a proble m when the patient i s actually discharge d and Inco mplete Rec ord Tracki ng (IRT) t hinks he w as dischar ged when t he interim was writt en. Does a nyone have any thoug hts and ca n someone show me ho w it looks when I ge t TIU and look up do cuments on a patient ? | |
6119 | A: From: TIU Develo per | |
6120 | ||
6121 | Interim Su mmaries XE "Interim Summaries" may be e asily defi ned in TIU , and link ed with th e correspo nding IRT deficiency XE "IRT d eficiency" . Paramet ers determ ining thei r processi ng require ments, as well as th e format o f a header XE "Heade r" for up loading th em in mixe d batches with Disch arge Summa ries, Oper ative Repo rts, C&P e xams XE "C &P exams" , and Prog ress Notes can all b e defined without mo difying an y code. A patch will be necess ary to lin k them to a specific transfer movement, and to int roduce a c hart copy of the app ropriate S tandard Fo rm. This i nvolves a modest pro gramming e ffort, but will have to be pri oritized a long with a number o f other re quests. | |
6122 | FAQs cont’ d | |
6123 | ||
6124 | We need th e help of the user c ommunity t o try to s ort out th e relative prioritie s of each of these t asks, alon g with you r patience , as we wo rk to deli ver as man y of them as possibl e, as time ly as poss ible... | |
6125 | A: From a user/coor dinator: | |
6126 | ||
6127 | A possible solution to the pro blem of ro tating res idents XE "Rotating residents" is to se t up your summary pa ckage with the autho r not need ing to sig n the summ ary. This allows the attending physician to sign t he report. While the residents may rotat e in and o ut, the at tending us ually rema ins the sa me through the cours e of the p atients st ay. | |
6128 | Q. What a re sites d oing with C&Ps, & op notes? | |
6129 | ||
6130 | It is my u nderstandi ng that C& Ps are a t ype of dis charge sum mary. | |
6131 | ||
6132 | I’ve tried creating “C&P EXAM XE "C&P EX AM" ” as a title und erneath th e “DISCHAR GE SUMMARY ” document class. I get TYPE e rrors when uploading test docu ments. The document parameters are defin ed for the upload fi elds. | |
6133 | A: From a user/coord inator: OP reports X E "OP repo rts" and C&P exams reside in their appr opriate pa ckages. Yo u can use the TIU up load utili ty to put them there . | |
6134 | ||
6135 | As for OP notes, we have sever al titles (i.e. Surg eon’s Post -OP note). | |
6136 | ||
6137 | Do you hav e TIU in t he APPLICA TION GROUP field of the Surger y and C&P file? | |
6138 | Our FILE F ile has th is for our Surgery f ile: | |
6139 | NUMBER: 13 0 NAME: SURG ERY | |
6140 | APPLICATIO N GROUP: G MRD | |
6141 | APPLICATIO N GROUP: T IU | |
6142 | Q: Can we do batch u pload of P rogress No tes XE "Ba tch upload of Progre ss Notes" by vendor through T IU? | |
6143 | A: Yes, y ou may now batch upl oad XE "Ba tch upload " Progres s Notes th rough TIU. See instr uctions ea rlier in t his manual (under Se tting Para meters) or in the TI U Technica l Manual. | |
6144 | FAQs cont’ d | |
6145 | Q: Current ly our Rad iology rep orts XE "R adiology r eports" a re uploade d by the v endor. Can this func tionality be built i nto TIU? | |
6146 | A: You may upload Ra diology Re ports, but it will b e necessar y to write a LOOKUP METHOD XE "LOOKUP ME THOD" to store seve ral identi fying fiel ds in the Radiology Patient Fi le. The re mainder ar e stored i n the Radi ology Repo rts File, along with the Impre ssion and Report Tex t. (The TI U and Radi ology deve lopment te ams will w ork togeth er on a lo okup metho d, as deve lopment pr iorities a llow.) | |
6147 | Q: We have hundreds of entries in files 128.1 and 128.5 to b e cleaned up, becaus e many dup licate dis charge sum maries wer e mistaken ly uploade d by the t ranscripti onists of our vendor . How can we clean u p these fi les? | |
6148 | A: You can use the I ndividual Patient Do cument opt ion on the GMRD MAIN MENU MGR menu, alon g with VA FileMan, t o clean up the Disch arge Summa ry file XE "Clean up the Disch arge Summa ry file" s . | |
6149 | Questions about Doc ument Defi nition | |
6150 | (Classes, Document C lasses, Ti tles, Boil erplate te xt, Object s) | |
6151 | Q: After t he initial document definition hierarchy XE "Docum ent Defini tion Hiera rchy" is built and used, can we modify the hierar chy XE "Mo dify the h ierarchy" structure if we fee l it is in correctly built? How flexible is this fi le? | |
6152 | A: Once en tries in t he hierarc hy are in use, you c an’t move them aroun d. It woul d be wise to think y our hierar chy throug h before i nstallatio n. Don’t r ush the pr ocess. If necessary, create ne w classes, document classes, a nd titles (the Copy function s treamlines creating new titles ), and dea ctivate th e old ones . The user s won’t be aware of the change if the Pr int Name i s the same , but the .01 Name i s new. | |
6153 | FAQs cont’ d | |
6154 | Q: Who cre ates title s XE "Titl es" and b oilerplate s XE "Boil erplates" at a site ? | |
6155 | A: Many t est sites restrict t he creatio n of title s and boil erplates a s much as possible. At one sit e, users s ubmit a re quest for a title or boilerpla te. IRMS o r the clin ical coord inator cre ate the bo ilerplate and/or tit le and for ward it to the Chair man of the Medical R ecords Com mittee for approval. Once appr oved it is made avai lable for use. Title s are name -spaced by service a nd the use of titles is restri cted by us er class. With the a bility to search by title, kee ping the n umber of t itles smal l and thei r use spec ific can b e very use ful. For e xample, wh en patient medicatio n educatio n is docum ented on a n electron ic progres s note it can be rev iewed easi ly. | |
6156 | Some of th e other si tes allow the ADPACs to create boilerpla tes withou t going th rough such a formal review pro cess. Anot her site r estricts t his functi on to the Clinical C oordinator . It was d esigned so that site s can do w hatever th ey are mos t comforta ble with. | |
6157 | Q: The roo t Class su pplied wit h the pack age is CLI NICAL DOCU MENTS XE " CLINICAL D OCUMENTS" . Can a pe er class l evel be ma de using o ur configu ration opt ions? Ex: ADMINISTR ATIVE DOCU MENTS | |
6158 | A: You ca nnot enter a class o n the same level as Clinical D ocuments. | |
6159 | In TI U Version 1.0, entri es can onl y be creat ed under C linical Do cuments. | |
6160 | Q: I’ve c hanged the technical and print names for a Documen t Class, b ut it does n’t seem t o have cha nged when I select d ocuments a cross pati ents. What am I doin g wrong? | |
6161 | A: When y ou select documents across pat ients, you are prese nted with a three-co lumn menu. The entri es in this menu are from the M enu Text s ubfield of the Item Multiple. To make a consistent change, y ou must up date Menu Text as we ll as Prin t Name whe n you chan ge a Docum ent Defini tion name. | |
6162 | FAQs cont’ d | |
6163 | Q: How can I print w hen I’m in Document Definition s options? | |
6164 | A: All Do cument Def initions p rinting XE "Document Definitio ns printin g" is don e using th e hidden a ctions Pri nt Screen and Print List. Firs t, locate the data t o be print ed so that it shows on the scr een and th en select either the action PS or PL. To locate th e appropri ate data u se the Edi t, Sort, o r Create o ption to l ist approp riate entr ies. | |
6165 | To print a list, sel ect the PS or PL act ion at thi s point. T o print in formation on a singl e given en try, first locate th e entry in one of th e above li sts, then select eit her the De tailed Dis play actio n or the E dit Items action. Ed it View sh ows all av ailable in formation for a give n entry. E dit Items shows the items of a given ent ry. Then s elect PS o r PL. Ente r PS for P rint Scree n to print the curre nt display screen. I t only pri nts what i s currentl y visible on the scr een, ignor ing inform ation that can be mo ved to hor izontally or vertica lly (pages ), so you should mov e left/rig ht and up/ down to th e desired informatio n before p rinting. | |
6166 | Enter PL f or Print L ist to pri nt more th an one vis ible scree n of infor mation. Pr int List p rints the entire ver tical list of entrie s and info rmation, i ncluding e ntries and informati on not cur rently vis ible but w hich are d isplayed w hen you mo ve up or d own. If th e action i s selected from the leftmost p osition of the scree n, you’re asked whet her to pri nt ALL col umns or on ly those c olumns vis ible on th e current leftmost p osition of the scree n. If you select the action af ter scroll ing to the right, on ly the cur rently vis ible left/ right colu mns are pr inted. | |
6167 | Q: Is it p ossible fo r sites to share obj ects XE "S hare objec ts" they create loc ally? | |
6168 | A: As sit es develop their own Objects, they can b e shared w ith other sites thro ugh a mail box entitl ed TIU OBJ ECTS in SH OP,ALL (re ached via FORUM). | |
6169 | NOTE: Obj ect routin es used fr om SHOP,AL L XE "SHOP ,ALL" are not suppo rted by th e CIO Fiel d Offices (formerly known as I SCs or IRM FOs). Use at your ow n risk! | |
6170 | NOTE: TIU -Health Su mmary obje cts that a re exchang ed between sites wil l always i mport in w ith “NO OW NER” (fiel d #.05-PER SONAL OWNE R in file #8925.1 TI U DOCUMENT DEFINITIO N). The s ystem soft ware canno t be made to automat ically use the impor ting user’ s name dur ing the in stallation process. The TIU-HS objects w ill work f ine in rem inder dial ogs, but y ou may fin d a proble m with not being abl e to VIEW the object in the CP RS GUI Tem plate Edit or due to “no owner” being des ignated af ter instal ling. When you try t o select a n object i n the CPRS Template editor, yo u may get an error m essage. Se e the TIU Technical Manual for instructi ons on how to assign yourself as an owne r. | |
6171 | Helpful Hi nts/Troubl eshooting, cont’d | |
6172 | Q: | |
6173 | Is there a ny way to change the Title of a Progress Note? For example, if I want to change one of my CWAD notes to a Nurs ing Psycho logy note, is that p ossible? | |
6174 | A: | |
6175 | Yes. Use t he “hidden ” action C hange Titl e XE "Chan ge Title" . | |
6176 | Q: Is the re a way t o access p rogress no tes that h ave been l inked to a problem? I can’t s eem to fin d how this is done. | |
6177 | A: Assumi ng that no tes are be ing linked to proble ms, you ca n use the Show Progr ess Notes Across Pat ients opti on to sear ch for not es by Prob lem XE "Se arch for n otes by Pr oblem" . W hen prompt ed to Sele ct SEARCH CATEGORIES XE "Searc h categori es" :, ent er Problem XE "Probl em" . | |
6178 | Select Pro gress Note s User Men u Option: Show Prog ress Notes Across | |
6179 | Patients | |
6180 | Select Sta tus: COMPL ETED// ALL undicta ted untra nscribed unreleased unverifi ed unsign ed uncosi gned compl eted, ame nded purg ed delete d | |
6181 | Select Pro gress Note s Type(s): ALL Advan ce Directi ve, Adv Re act/Allerg y Crisis Note Clin ical Warni ng Histor ical Title s | |
6182 | Select SEA RCH CATEGO RIES: AUTH OR// PROB Problem | |
6183 | Select PRO BLEM: ANGI NA PECTORI S, UNS | |
6184 | 2 matches found | |
6185 | 1 | |
6186 | Angina pec toris, uns table | |
6187 | 2 | |
6188 | Other and unspecifie d angina p ectoris | |
6189 | Type “^” to STOP or Select 1- 2: 1 | |
6190 | Start Refe rence Date [Time]: T -2// T-999 9 (JAN 20 , 1970) | |
6191 | Ending Ref erence Dat e [Time]: NOW// <Ent er> (JUN 06,1997@0 9:00)) | |
6192 | Searching for the do cuments. | |
6193 | Of course, this quer y has seve ral limita tions: | |
6194 | Only one p roblem may be select ed at a ti me (i.e., you can’t select ANG INA PECTOR IS OR AIHD as a sear ch criteri on) | |
6195 | Problems c an’t be “g rouped” or expressed ambiguous ly (e.g., a search f or ANGINA PECTORIS, rather tha n ANGINA P ECTORIS, U NSTABLE, w ould not h ave found this recor d), and | |
6196 | The only w ay for thi s benefit to be exer cised at a ll is for the clinic ians at yo ur facilit y to be ac tively usi ng Problem List. | |
6197 | Still, if you’re int erested in a focused search fo r all note s about a specific p roblem, an d if your facility h as committ ed to the use of the Problem L ist packag e, this ca n be a pow erful asse t for retr ospective research, utilizatio n review, and epidem iological studies. W ith the Pr eventive M easures fo r certain chronic di seases bei ng made pa rt of the Director’s performan ce apprais al, being able to ea sily pull notes that document what was d one for th ose proble ms is of H IGH import ance. | |
6198 | Facts & He lpful info rmation | |
6199 | Action abb reviations XE "Actio n abbrevia tions" on List Mana ger screen s | |
6200 | The TIU an d ASU pack ages don’t use mnemo nics XE "M nemonics" (abbrevia tions or n umbers) fo r actions (protocols ) on List Manager sc reens, par tly becaus e it’s dif ficult to make them consistent with othe r packages and what users expe ct. Sites, however, can feel f ree to add whatever their user s would li ke to have (e.g., $ for Sign). | |
6201 | Shortcuts XE "Shortc uts" | |
6202 | At any “Se lect Actio n” prompt, you can t ype the ac tion abbre viation, t hen the = sign and t he entry n umber (e.g ., E=4). | |
6203 | Jump to Do cument Def in the Ed it Documen t Definiti on option takes you directly t o a docume nt definit ion (Class , Document Class, or Title) if you know the name. | |
6204 | When revie wing sever al notes, the up-arr ow (^) XE "Up-arrow (^)" entr y takes yo u to the n ext note. To exit XE "Exit" f rom the re view, ente r two up-a rrows (^^) . | |
6205 | Visit Info rmation | |
6206 | XE "Visit Informati on" | |
6207 | When you e nter a Pro gress Note for an ou tpatient, this Progr ess Note n ow needs t o be assoc iated with a “visit. ” For the majority o f Progress Notes, th is visit a ssociation is done i n the back ground, ba sed on Sch eduling or Encounter Form data . If a vi sit has al ready been recorded for the da te your Pr ogress Not e refers t o, but the Progress Notes wasn ’t linked (e.g., for standalon e visits s uch as tel ephone or walk-in vi sits), you can selec t a visit from the c hoices pre sented to you during the PN di alogue. If no visit has been r ecorded, y ou must cr eate a new visit. Se e the exam ple below. | |
6208 | NOTE: As o f patch TI U*1*269 – Updates fo r ICD-10, selection from appro priate ICD diagnoses or proced ures (ICD- 9 or ICD-1 0) can be made, depe nding on t he Date of Visit. T he dialogu e confirmi ng the sel ections wi ll include the ICD c oding syst em as well as the IC D code. | |
6209 | Example: E ntry of Pr ogress Not e that nee ds Visit I nformation | |
6210 | Select PAT IENT NAME: TIUPATIEN T,FIVE TI UPATIENT,F IVE 4-9-46 6 66668829 | |
6211 | YES SC VETERAN | |
6212 | (7 notes ) D: 07/1 1/00 08:41 | |
6213 | A: Know n allergie s | |
6214 | Enter RETU RN to cont inue or '^ ' to exit: <Enter> | |
6215 | Enrollmen t Priority : GROUP 3 Categor y: IN PROC ESS End Date: | |
6216 | Available notes: 11 /25/1998 t hru 07/13/ 2000 (71) | |
6217 | Do you wis h to see a ny of thes e notes? N O// <Enter > | |
6218 | TITLE: ADV ERSE 11/1 2 ADVERSE REACTION/A LLERGY TITLE | |
6219 | Example: E ntry of Pr ogress Not e, cont’d | |
6220 | This patie nt is not currently admitted t o the faci lity... | |
6221 | Is this no te for INP ATIENT or OUTPATIENT care? OUT PATIENT// <Enter> | |
6222 | The follow ing SCHEDU LED VISITS are avail able: | |
6223 | 1> JUN 29, 1999@ 08:00 ONCOLOGY | |
6224 | 2> JUN 24, 1999@ 11:00 NO ACTION TAK EN ONCOLOGY | |
6225 | 3> JUN 24, 1999@ 10:00 NO ACTION TAK EN ONCOLOGY | |
6226 | 4> JUN 24, 1999@ 09:00 NO ACTION TAK EN CARDIOLOGY | |
6227 | 5> JUN 24, 1999@ 08:00 GENERAL ME DICINE | |
6228 | CHOOSE 1-5 , or | |
6229 | <U>NSCHEDU LED VISITS , <F>UTURE VISITS, o r <N>EW VI SIT | |
6230 | <RETURN> T O CONTINUE | |
6231 | OR '^' TO QUIT: N | |
6232 | PATIENT LO CATION: GE NERAL MEDI CINE// <En ter> | |
6233 | Enter Visi t Date/Tim e: NOW// <Enter> ( JUL 13, 20 00@09:21:2 4) | |
6234 | TYPE OF VI SIT: AMBUL ATORY// <E nter> (WAL K-IN) AM BULATORY ( WALK-IN) | |
6235 | Enter/Edit PROGRESS NOTE... | |
6236 | Patient Lo cation: G ENERAL MED ICINE | |
6237 | Da te/time of Visit: 0 7/13/00 09 :21 | |
6238 | D ate/time o f Note: N OW | |
6239 | Author o f Note: T IUPROVIDER ,SEVEN | |
6240 | ...OK? YES//<Ente r> | |
6241 | Calling te xt editor, please wa it... | |
6242 | 1>Treatm ent for al lergic rea ction to i njury. | |
6243 | 2><Enter > | |
6244 | EDIT Optio n: <Enter> | |
6245 | Saving Adv erse React /Allergy w ith change s... | |
6246 | Is this Ad verse Reac t/Allergy ready to r elease fro m DRAFT? Y ES// <Ente r> | |
6247 | Adverse Re act/Allerg y Released . | |
6248 | Enter your Current S ignature C ode: <Ente r Signatur e> SIGNATU RE VERIFIE D.. | |
6249 | Select PRI MARY PROVI DER: TIUPR OVIDER,SEV EN // <Ent er> TIUPR OVIDER,SEV EN C RS P HYSICIAN | |
6250 | Please Ind icate the Diagnoses for which TIUPATIENT ,FOUR was Seen: | |
6251 | 18 As cites 34 Shoulde r | |
6252 | 1 Abdomin al Pain 19 AS HD MISC (2) | |
6253 | 2 Abnorma l EKG 20 As thma 35 DIETARY SURVEIL/C OUN | |
6254 | 3 Abrasio n 21 At rial Fibri llation 36 Catarac t(s) | |
6255 | 4 Abscess 22 At ypical Che st Pain 37 Cardiac Arrest | |
6256 | 5 Adverse Drug Reac tio 23 Av ulsion, Fi ngernail 38 Cardia Arrthythmi a | |
6257 | 6 AIDS/AR C BITE: 39 Cerebra l Concussi on | |
6258 | 7 Alcohol ic, intoxi cat 24 An imal 40 Cerumen | |
6259 | 8 Alcohol ism, Chron ic 25 In sect Bite 41 Chest P ain | |
6260 | 9 Allergi c Reaction MISC 42 Chest W all Pain | |
6261 | 10 Anemia 26 Bl eeding, GI 43 CHF | |
6262 | ANGINA: 27 Bl urred Visi on 44 Cholecy stitis | |
6263 | 11 Stable 28 BP H 45 Cirrhos is | |
6264 | 12 Unstabl e 29 Br onchitis, acute 46 Conjunc tivitis | |
6265 | 13 Anorexi a BURN: 47 Constip ation | |
6266 | 14 Appendi citis, Acu te 30 Fi rst Degree 48 Contusi on | |
6267 | 15 Arthral gia 31 Se cond Degre e 49 COPD | |
6268 | ARTHRITIS 32 Th ird Degree 50 Costoch odritis | |
6269 | 16 Osteo BURSI TIS: 51 CVA | |
6270 | 17 Rheumat oid 33 El bow 52 Cyst, P ilonidal | |
6271 | Example: E ntry of Pr ogress Not e, cont’d | |
6272 | Select Dia gnoses (<R ETURN> to see next p age of cho ices): (1 -52): 9 | |
6273 | Please Ind icate the Procedure( s) Perform ed on TIUP ATIENT,EIG HT | |
6274 | NEW PATIEN T 16 Ca rdioversio n 29 Small J oint (Phal anx | |
6275 | 1 Brief V isit 17 EK G DISLOCATIO N REG. MAN | |
6276 | 2 Limited Exam 18 Pe ricardioce ntesis 30 Elbow | |
6277 | 3 Interme diate Exam 19 Th oracotomy 31 Nasal | |
6278 | 4 Extende d Exam ENT 32 Phalanx | |
6279 | 5 Compreh ensive Exa m 20 Re moval Impa cted Cer 33 Radial Head | |
6280 | ESTABLISHE D PATIENT NASAL CAUTERING AND 34 Shoulde r | |
6281 | 6 Brief E xam 21 An terior, Si mple 35 Temporo mandibular | |
6282 | 7 Limited Exam 22 An terior, co mplex 36 Finger Splint | |
6283 | 8 Interme diate Exam 23 Po sterior 37 Forearm Splint | |
6284 | 9 Extende d Exam EYE 38 Injecti on Tendon She | |
6285 | 10 Compreh ensive Exa m 24 Fo reign Body Removal LIGAMENT/T RIGGER | |
6286 | CONSULTATI ONS -26 PROFESSION AL C PULMONARY | |
6287 | 11 Brief V isit -32 MANDATED S ERVI 39 Admin O xygen | |
6288 | 12 Limited Visit 25 Ai r ambulanc e servic 40 Inhalat ion Therap y | |
6289 | 13 Interme diate Visi t 26 PE T follow S PECT 41 Peak Fl ow Spirome try | |
6290 | 14 Extende d Visit ORTHO PEDIC UROLOGY | |
6291 | 15 Compreh ensive Vis it ARTHR OCENTESIS 42 Foley C atherter | |
6292 | 27 In termediate MISCELLANE OUS | |
6293 | CARDIOVASC ULAR 28 Ma jor Joint (shoulde I&D | |
6294 | Select Pro cedures (< RETURN> to see next page of ch oices): ( 1-42): 24 | |
6295 | 43 Abcess | |
6296 | SIMPLE REP AIR, WOUND | |
6297 | 44 Less th an 2.5 cm | |
6298 | 45 2.6 - 7 .5 cm | |
6299 | 46 Greater than 7.5 cm | |
6300 | SOFT TISSU E: | |
6301 | 47 Burns 1 * Local T rea | |
6302 | 48 Dressin gs Medium | |
6303 | 49 Dressin gs Small | |
6304 | 50 Transfu sion | |
6305 | 51 Venipun cture | |
6306 | 52 OTHER P rocedure | |
6307 | Select Pro cedures: (1-52): 48 | |
6308 | FOREIGN BO DY REMOVAL W/ MOD W/ MOD X 2: | |
6309 | How many t imes was t he procedu re perform ed? 1// <E nter> | |
6310 | Current CP T Modifier s: | |
6311 | -26 P ROFESSIONA L COMPONEN T | |
6312 | -32 M ANDATED SE RVICES | |
6313 | Select ano ther CPT M ODIFIER: ? ? | |
6314 | Choose from: | |
6315 | 22 UNUSUAL PROCEDURA L SERVICES | |
6316 | 23 UNUSUAL ANESTHESI A | |
6317 | 26 PROFESS IONAL COMP ONENT | |
6318 | 32 MANDATE D SERVICES | |
6319 | 47 ANESTHE SIA BY SUR GEON | |
6320 | 50 BILATER AL PROCEDU RE | |
6321 | 51 MULTIPL E PROCEDUR ES | |
6322 | 52 REDUCED SERVICES | |
6323 | 53 DISCONT INUED PROC EDURE | |
6324 | 54 SURGICA L CARE ONL Y | |
6325 | 55 POSTOPE RATIVE MAN AGEMENT ON LY | |
6326 | 56 PREOPER ATIVE MANA GEMENT ONL Y | |
6327 | 57 DECISIO N FOR SURG ERY | |
6328 | Example: E ntry of Pr ogress Not e, cont’d | |
6329 | 58 STAGED OR RELATED PROC BY S AME PHYS D URING POST OP PERIOD | |
6330 | 59 DISTINC T PROCEDUR AL SERVICE | |
6331 | 62 TWO SUR GEONS | |
6332 | 66 SURGICA L TEAM | |
6333 | 73 DISC O/ P HOSP/AMB SURG CENT ER (ASC) P ROC PRIOR ADMIN-ANES TH | |
6334 | 74 DISC O/ P HOSP/AMB SURG CENT ER (ASC) P ROC AFTER ADMIN-ANES TH | |
6335 | 76 REPEAT PROCEDURE BY SAME PH YSICIAN | |
6336 | 77 REPEAT PROCEDURE BY ANOTHER PHYSICIAN | |
6337 | 78 RETURN TO OP ROOM FOR RELAT ED PROC DU RING POSTO P PERIOD | |
6338 | 79 UNRELAT ED PROC OR SERVICE B Y SAME PHY S DURING P OSTOP PERI OD | |
6339 | 80 ASSISTA NT SURGEON | |
6340 | 81 MINIMUM ASSISTANT SURGEON | |
6341 | 82 ASSISTA NT SURGEON (WHEN QUA L RES SURG EON NOT AV AIL) | |
6342 | 90 REFEREN CE (OUTSID E) LABORAT ORY | |
6343 | 99 MULTIPL E MODIFIER S | |
6344 | AA ANESTHE SIA PERF B Y ANESGST | |
6345 | AS PA,NP,C N ASSIST-S URG | |
6346 | QX CRNA SV C W/ MD ME D DIRECTIO N | |
6347 | QZ CRNA SV C W/O MED DIR BY MD | |
6348 | SG ASC FAC ILITY SERV ICE | |
6349 | TC TECHNIC AL COMPONE NT | |
6350 | Select ano ther CPT M ODIFIER: 4 7 AN ESTHESIA B Y SURGEON | |
6351 | Select ano ther CPT M ODIFIER: < Enter> | |
6352 | DRESSINGS MEDIUM: | |
6353 | How many t imes was t he procedu re perform ed? 1// <E nter> | |
6354 | Select CPT MODIFIER: <Enter> | |
6355 | Was this e ncounter r elated to any of the following : | |
6356 | Service Co nnected Co ndition? Y YES | |
6357 | You have i ndicated t he followi ng data ap ply to thi s visit: | |
6358 | DIAGNOSES: | |
6359 | (ICD-9- CM 995.3) Allergic Reaction <<< PRIMA RY | |
6360 | PROCEDURES : | |
6361 | 65205 Foreign Body Remov al W/ Mod w/ mod x 2 | |
6362 | CP T Modifier (s): | |
6363 | -26 P ROFESSIONA L COMPONEN T | |
6364 | -32 M ANDATED SE RVICES | |
6365 | -47 A NESTHESIA BY SURGEON | |
6366 | 16015 Dressing s Medium | |
6367 | SERVICE CO NNECTION: | |
6368 | Service Connected ? YES | |
6369 | ...OK? YES// <Ent er> | |
6370 | Posting Wo rkload Cre dit...Done . | |
6371 | Print this note? No/ / <Enter> NO | |
6372 | You may en ter anothe r Progress Note. Pre ss RETURN to exit. | |
6373 | Select PAT IENT NAME: | |
6374 | Visit Ori entation X E "Visit O rientation " | |
6375 | Why associ ate Progre ss Notes w ith Visits ? | |
6376 | Database d esign: An event (cli nical or o therwise) may be ful ly describ ed by five key attri butes or p arameters: Who, what , when, wh ere, and w hy. Three of these ( i.e., who, when, and where), a re all enc oded in th e Visit Fi le entry i tself. The remaining two param eters (wha t, and why ), are gen erally inc luded in t he content of the do cument. | |
6377 | The VHA Op erations M anual, M-1 , Chapter 5 requires that ever y ambulato ry visit h ave at lea st one Pro gress Note . Deficien cies with respect to this requ irement ca n only be identified if Progre ss Notes a re associa ted with t heir corre sponding V isits. | |
6378 | Inter-faci lity data transfer X E "Inter-f acility da ta transfe r" requir es identif ication of the Facil ity from w hich the d ata origin ated. Beca use the Fa cility is an attribu te of the Visit file entry, it is not ne cessary to maintain a referenc e to the f acility wi th every c linical do cument. | |
6379 | Workload C apture XE "Workload Capture" , particula rly for te lephone an d standalo ne encount ers, where the only record of the encoun ter is fre quently a Progress N ote, can b e easily a ccommodate d, provide d that not es are ass ociated wi th visits. | |
6380 | “Roll-up” of documen tation by Care Episo de XE "Car e Episode" . To allo w access t o all info rmation pe rtaining t o a given episode of care (e.g ., for clo se-out of a hospital ization), a visit or ientation is essenti al. | |
6381 | Integratio n with PCE XE "PCE" , Ambulato ry Care Da ta Capture XE "Ambul atory Care Data Capt ure" , and CIRN XE " CIRN" . T he visit o rientation provides a useful a ssociative entity fo r interfac es with ot her clinic al data re positorie XE "Data r epositorie " s XE "Cl inical dat a reposito ries" tha t allow qu ery and re port gener ation base d on the e xistence o f a variet y of coded data elem ents. For example, a search of PCE to id entify all patients with AIHD who were d ischarged without a prescripti on for asp irin proph ylaxis mig ht identif y a cohort of patien ts for fur ther evalu ation. The ability t o call for all the c ardiology notes ente red during the corre sponding c are episod es could r evolutioni ze retrosp ective cha rt review) . | |
6382 | Glossary | |
6383 | XE "Gloss ary" | |
6384 | ASU XE "AS U" | |
6385 | Authorizat ion/Subscr iption Uti lity, an a pplication that allo ws sites t o associat e users wi th user cl asses, all owing them to specif y the leve l of autho rization n eeded to s ign or ord er specifi c document types and orderable s. ASU is distribute d with TIU in this v ersion; ev entually i t will pro bably beco me indepen dent, to b e used by many VistA packages. | |
6386 | Action XE "Action" | |
6387 | A function al process that a cl inician or clerk use s in the T IU compute r program. For examp le, “Edit” and “Sear ch” are ac tions. Pro tocol is a nother nam e for Acti on. | |
6388 | Boilerplat e Text XE "Boilerpla te Text" | |
6389 | A pre-defi ned TIU te mplate XE "Template" that can be filled in for Ti tles, spee ding up th e entry pr ocess. TIU exports s everal Tit les with b oilerplate text whic h can be m odified to meet spec ific needs ; sites ca n also cre ate their own. | |
6390 | Business R ule XE "Bu siness Rul e" | |
6391 | Part of AS U, Busines s Rules au thorize sp ecific use rs or grou ps of user s to perfo rm specifi ed actions on docume nts in par ticular st atuses (e. g, an unsi gned progr ess note m ay be edit ed by a pr ovider who is also t he expecte d signer o f the note ). | |
6392 | Class XE " Class" | |
6393 | Part of Do cument Def initions, Classes gr oup docume nts. For e xample, “P rogress No tes” is a class with many kind s of progr ess notes under it. | |
6394 | ||
6395 | Classes ma y be subdi vided into other Cla sses or Do cument Cla sses. Besi des groupi ng documen ts, Classe s also sto re behavio r which is then inhe rited by l ower level entries. | |
6396 | Clinician XE "Clinic ian" | |
6397 | A doctor o r other pr ovider in the medica l center w ho is auth orized to provide pa tient care . | |
6398 | Component XE "Compon ent" | |
6399 | Components are “sect ions” or “ pieces” of documents , such as Subjective , Objectiv e, Assessm ent, and P lan in a S OAP XE "SO AP" Progr ess Note. Components may have (sub)Compo n-ents as items. The y may have Boilerpla te Text. C omponents may be des ignated as “Shared.” | |
6400 | Glossary, cont’d | |
6401 | CPRS XE "C PRS" | |
6402 | Computeriz ed Patient Record Sy stem. A co mprehensiv e VistA pr ogram, whi ch allows clinicians and other s to enter and view orders, Pr ogress Not es and Dis charge Sum maries (th rough a li nk with TI U), Proble m List, vi ew results , reports (including health su mmaries), etc. | |
6403 | CWAD XE "C WAD" | |
6404 | Cautions, Warnings, Adverse Re actions, D irectives; a type of Progress Note. | |
6405 | Discharge Summary XE "Discharg e Summary" | |
6406 | Discharge summaries are summar ies of a p atient’s m edical car e during a single ho spitalizat ion, inclu ding the p ertinent d iagnostic and therap eutic test s and proc edures as well as th e conclusi ons genera ted by tho se tests. They are r equired fo r all disc harges and transfers from a VA medical c enter, dom iciliary, or nursing home care . The auto mated Disc harge Summ ary module of TIU pr ovides an efficient and immedi ate mechan ism for cl inicians t o capture transcribe d patient discharge summaries online, wh ere they’r e availabl e for revi ew, signin g, adding addendum, etc. | |
6407 | Document C lass XE "D ocument Cl ass" | |
6408 | Document C lasses are categorie s that gro up documen ts (Titles ) with sim ilar chara cteristics together. For examp le, Nursin g Progress Notes mig ht be a Do cument Cla ss, with N ursing Dia lysis Prog ress Notes , Nursing psychology Progress Notes, etc . as Title s under it . Or maybe the Docum ent Class would be P sychology Notes, wit h Psycholo gy Nursing Notes, Ps ychology S ocial Work er Notes, Psychology Patient E ducation N otes, etc. under tha t Document Class.. | |
6409 | Document D efinition XE "Docume nt Definit ion" | |
6410 | Document D efinition is a subse t of TIU t hat provid es the bui lding bloc ks for TIU , by organ izing the elements o f document s into a h ierarchy s tructure. This struc ture allow s document s (Titles) to inheri t characte ristics (s uch as sig nature req uirements and print characteri stics) of the higher levels, C lass and D ocument Cl ass. It al so allows the creati on and use of boiler plate text and embed ded object s. | |
6411 | Glossary, cont’d | |
6412 | HIMS | |
6413 | Hospital I nformation Managemen t System, common abb reviation/ synonym us ed at VA s ite facili ties; also known as MIS (see b elow). | |
6414 | IRT XE "IR T" | |
6415 | Incomplete Record Tr acking, a package TI U can inte rface with to transm it incompl ete progre ss notes a nd dischar ge summari es. | |
6416 | Interdisci plinary No te | |
6417 | A new feat ure of Tex t Integrat ion Utilit ies (TIU) for expres sing notes from diff erent care givers as a single episode of care. The y always s tart with a single n ote by the initial c ontact per son (e.g., triage nu rse, case manager, a ttending) and contin ue with se parate not es created and signe d by other providers , then att ached to t he origina l note. | |
6418 | MIS XE "MI S" | |
6419 | Common abb reviation/ synonym us ed at VA s ite facili ties for t he Medical Informati on Section of Medica l Administ ration Ser vice. May be called HIMS XE "H IMS" (Hea lth Inform ation Mana gement Sec tion). | |
6420 | MIS Manage r XE "MIS Manager" | |
6421 | Manager of the Medic al Informa tion Secti on of Medi cal Admini stration S ervice at the site f acility wh o has ulti mate respo nsibility to see tha t MRTs co mplete the ir duties. | |
6422 | MRT XE "MR T" | |
6423 | Medical Re cord Techn ician in t he Medical Informati on Section of Medica l Administ ration Ser vice at th e site fac ility who completes the tasks of assurin g that all discharge summaries placed in a patient ’s medical record ha ve been ve rified for accuracy and comple tion and t hat a perm anent char t copy has been plac ed in a pa tient’s me dical reco rd for eac h separate admission to the ho spital. | |
6424 | Glossary, cont’d | |
6425 | Object XE "Object" | |
6426 | Objects ar e a device to extrac t data fro m other Vi stA packag es to inse rt into bo ilerplate text of pr ogress not es or disc harge summ aries. Thi s is done by having a placehol der name e mbedded in the prede fined boil erplate te xt of Titl es, such a s: “PATIEN T AGE.” Th e creator of the Obj ect types the placeh older name into the boilerplat e text of a Title, e nclosed by '|'s. If a Title h as the fol lowing boi lerplate t ext: | |
6427 | ||
6428 | “Patient i s a health y |PATIENT AGE| year old male ...” | |
6429 | ||
6430 | Then a use r who ente rs such a note for a 56 year o ld patient would be presented with the t ext: | |
6431 | ||
6432 | “Patient i s a health y 56 year old male . ..” where the age fo r this spe cific pati ent is pul led from t he patient database. | |
6433 | Progress N otes XE "P rogress No tes" | |
6434 | The Progre ss Notes m odule of T IU is used by health care give rs to ente r and sign online pa tient prog ress notes and by tr anscriptio nists to e nter notes to be sig ned by car egivers at a later d ate. Careg ivers may review pro gress note s online o r print pr ogress not es in char t format f or filing in the pat ient’s rec ord. | |
6435 | TIU | |
6436 | Text Integ ration Uti lities | |
6437 | Title XE " Title" | |
6438 | Titles are definitio ns for doc uments. Th ey store t he behavio r of the d ocuments w hich use t hem. | |
6439 | User Class XE "User Class" | |
6440 | User Class es are the basic com ponents of the User Class hier archy of A SU (Author ization/ S ubscriptio n Utility) which all ows sites to designa te who is authorized to do wha t to docum ents or ot her clinic al entitie s. | |
6441 | Index | |
6442 | <Enter> | |
6443 | 8 | |
6444 | 121.2 | |
6445 | 183 | |
6446 | 8925 | |
6447 | 154 | |
6448 | 8925.1 | |
6449 | 183 | |
6450 | Action | |
6451 | 224 | |
6452 | Action abb reviations | |
6453 | 219 | |
6454 | Actions | |
6455 | 11, 42, 57 | |
6456 | Add Docume nt | |
6457 | 42, 57 | |
6458 | Additional Signature | |
6459 | 67, 181 | |
6460 | Additional Signature s | |
6461 | 99 | |
6462 | Admission- Prints al l PNs for Current Ad mission | |
6463 | 166 | |
6464 | Alert Tool s | |
6465 | 196 | |
6466 | Alert Tool s FAQ | |
6467 | 198 | |
6468 | ALL Docume nts requir ing my Add itional Si gnature | |
6469 | 58 | |
6470 | All MY UNS IGNED Disc harge Summ aries | |
6471 | 54 | |
6472 | All MY UNS IGNED Docu ments | |
6473 | 58, 61 | |
6474 | All MY UNS IGNED Prog ress Notes | |
6475 | 35 | |
6476 | allow edit | |
6477 | 13 | |
6478 | Ambulatory Care Data Capture | |
6479 | 223 | |
6480 | Amended | |
6481 | 41, 56 | |
6482 | ANATOMIC P ATHOLOGY ( AP) | |
6483 | 191 | |
6484 | ASCII | |
6485 | 1 | |
6486 | ASCII char acters | |
6487 | 212 | |
6488 | ASCII file transfer | |
6489 | 151 | |
6490 | ASCII Prot ocol Uploa d | |
6491 | 151, 152 | |
6492 | ASU | |
6493 | 189, 224 | |
6494 | ATTENDING | |
6495 | 145 | |
6496 | Author( Pr int Progre ss Notes | |
6497 | 37, 165 | |
6498 | Batch prin ting | |
6499 | 177, 211 | |
6500 | Batch uplo ad | |
6501 | 214 | |
6502 | Batch uplo ad of Prog ress Notes | |
6503 | 214 | |
6504 | Batch Uplo ad Reports | |
6505 | 150 | |
6506 | Benefits | |
6507 | 1, 2 | |
6508 | Boilerplat e | |
6509 | 2 | |
6510 | Boilerplat e Text | |
6511 | 224 | |
6512 | Boilerplat es | |
6513 | 216 | |
6514 | Business R ule | |
6515 | 224 | |
6516 | Business R ules | |
6517 | 209, 211 | |
6518 | C&P EXAM | |
6519 | 214 | |
6520 | C&P exams | |
6521 | 213 | |
6522 | Captioned headers | |
6523 | 157 | |
6524 | Care Episo de | |
6525 | 223 | |
6526 | Change Tit le | |
6527 | 42, 218 | |
6528 | Change Vie w | |
6529 | 42, 57 | |
6530 | CHIEF, HIM | |
6531 | 41, 56 | |
6532 | CHIEF, MIS | |
6533 | 41, 56 | |
6534 | CIRN | |
6535 | 223 | |
6536 | Class | |
6537 | 187, 224 | |
6538 | Clean up t he Dischar ge Summary file | |
6539 | 215 | |
6540 | Clinical C oordinator Menu | |
6541 | 184 | |
6542 | Clinical d ata reposi tories | |
6543 | 223 | |
6544 | Clinical D ocument Pr int | |
6545 | 91, 111 | |
6546 | CLINICAL D OCUMENTS | |
6547 | 216 | |
6548 | Clinical P rocedures | |
6549 | Upload | |
6550 | 155 | |
6551 | Clinician | |
6552 | 224 | |
6553 | Clinicians | |
6554 | 14 | |
6555 | Completed | |
6556 | 41, 56 | |
6557 | Component | |
6558 | 224 | |
6559 | Computeriz ed Patient Record Sy stem | |
6560 | 15 | |
6561 | Consults | |
6562 | Upload | |
6563 | 155 | |
6564 | Conversion Clean-up Menu | |
6565 | 183 | |
6566 | Copy | |
6567 | 42, 57 | |
6568 | Correcting Documents | |
6569 | 114 | |
6570 | Cosigning privilege | |
6571 | 54 | |
6572 | COTS | |
6573 | 201 | |
6574 | CPRS | |
6575 | 15, 20, 31 , 180, 201 , 225 | |
6576 | Create Doc ument Defi nitions | |
6577 | 188 | |
6578 | CWAD | |
6579 | 225 | |
6580 | CWAD compo nents | |
6581 | 77 | |
6582 | Data repos itorie | |
6583 | 223 | |
6584 | Defaults | |
6585 | 9 | |
6586 | Defining U ser Classe s | |
6587 | 189 | |
6588 | Delete Doc ument | |
6589 | 42, 57 | |
6590 | Deleted | |
6591 | 41, 56 | |
6592 | Detailed D isplay | |
6593 | 33, 42, 57 | |
6594 | Diagnosis | |
6595 | 25 | |
6596 | Discharge Summaries | |
6597 | 13 | |
6598 | Discharge Summary | |
6599 | 50, 225 | |
6600 | Upload | |
6601 | 154 | |
6602 | Discharge Summary Me nu | |
6603 | 50 | |
6604 | Discharge Summary Pr int | |
6605 | 85, 105 | |
6606 | Discharge Summary St atuses and Actions | |
6607 | 56 | |
6608 | Discharge Summary Us er Menu | |
6609 | 14 | |
6610 | Discharge Summary V. 1.0 | |
6611 | 209 | |
6612 | Display Up load Help | |
6613 | 157 | |
6614 | division | |
6615 | 78, 83, 94 , 97, 123, 130, 131, 132, 133, 134, 135, 150, 151 | |
6616 | Division | |
6617 | 166 | |
6618 | Document C lass | |
6619 | 187, 225 | |
6620 | Document D efinition | |
6621 | 225 | |
6622 | Document D efinition File | |
6623 | 183 | |
6624 | Document D efinition Hierarchy | |
6625 | 2, 73, 187 , 215 | |
6626 | Document D efinition Options | |
6627 | 188 | |
6628 | Document D efinitions | |
6629 | 187 | |
6630 | Document D efinitions (Clinicia n) | |
6631 | 73 | |
6632 | Document D efinitions printing | |
6633 | 217 | |
6634 | Document L ist Manage ment | |
6635 | 70 | |
6636 | Documents Requiring Additional Signature | |
6637 | 67 | |
6638 | Edit | |
6639 | 57 | |
6640 | Edit Cosig ner [EC] | |
6641 | 13 | |
6642 | Edit Docum ent Defini tions | |
6643 | 73, 74, 18 8 | |
6644 | Electronic Signature Code | |
6645 | 179 | |
6646 | Enter/Edit Discharge Summary | |
6647 | 144, 145 | |
6648 | Enter/edit Document | |
6649 | 58 | |
6650 | Enter/Edit Document | |
6651 | 65, 144, 1 47 | |
6652 | Entered in Error | |
6653 | Correcting | |
6654 | 114 | |
6655 | Entry of P rogress No te | |
6656 | 22 | |
6657 | error code | |
6658 | 201 | |
6659 | error mess age | |
6660 | 201 | |
6661 | Exit | |
6662 | 219 | |
6663 | Expected C osigner | |
6664 | 130 | |
6665 | FAQs | |
6666 | 208 | |
6667 | File trans fer | |
6668 | 150 | |
6669 | FILING ERR OR | |
6670 | 84 | |
6671 | Find | |
6672 | 42, 57 | |
6673 | Find Patie nt | |
6674 | 15 | |
6675 | Frequently Asked Que stions | |
6676 | 208 | |
6677 | Generic Pr ogress Not es Title F ile | |
6678 | 183 | |
6679 | Glossary | |
6680 | 224 | |
6681 | GMRP TIU | |
6682 | 183 | |
6683 | Graphic Co nventions | |
6684 | 8 | |
6685 | Header | |
6686 | 213 | |
6687 | Health Inf ormation M anagement Section | |
6688 | 101 | |
6689 | Health Sum mary | |
6690 | 77 | |
6691 | Health Sum mary compo nent | |
6692 | 77 | |
6693 | Help for U pload Util ity | |
6694 | 149 | |
6695 | hidden act ion menu | |
6696 | 12 | |
6697 | Hidden act ions | |
6698 | 12 | |
6699 | HIMS | |
6700 | 101, 226 | |
6701 | HISTORICAL PROCEDURE S | |
6702 | 191, 192, 193 | |
6703 | Historical Visits | |
6704 | 210 | |
6705 | HL7 Generi c Interfac e | |
6706 | 201 | |
6707 | HL7 Troubl eshooting | |
6708 | 201 | |
6709 | Identify S igners | |
6710 | 57 | |
6711 | Individual Patient D ischarge S ummary | |
6712 | 51 | |
6713 | Individual Patient D ocument | |
6714 | 58, 59, 78 , 79, 103, 159 | |
6715 | Integrated Document Management | |
6716 | 14, 58 | |
6717 | Interdisci plinary No tes | |
6718 | 43 | |
6719 | Inter-faci lity data transfer | |
6720 | 223 | |
6721 | Interim Su mmaries | |
6722 | 213 | |
6723 | Interward transfer n ote | |
6724 | 213 | |
6725 | Intranet | |
6726 | 7 | |
6727 | Introducti on to the TIU User M anual | |
6728 | 7 | |
6729 | Introducti on to TIU | |
6730 | 1 | |
6731 | Introducti on, Managi ng TIU | |
6732 | 178 | |
6733 | IRT | |
6734 | 226 | |
6735 | IRT defici ency | |
6736 | 213 | |
6737 | Legal Requ irements | |
6738 | 179 | |
6739 | Line Count | |
6740 | 102, 141 | |
6741 | Line Count Statistic s by AUTHO R | |
6742 | 121 | |
6743 | Line Count Statistic s by SERVI CE | |
6744 | 122 | |
6745 | Line edito rs | |
6746 | 212 | |
6747 | Link | |
6748 | 42, 57 | |
6749 | Linkages | |
6750 | 2 | |
6751 | Links and Relationsh ips with O ther Packa ges | |
6752 | 180 | |
6753 | List area | |
6754 | 10 | |
6755 | List Docum ents for T ranscripti on | |
6756 | 144 | |
6757 | List Manag er utility | |
6758 | 10 | |
6759 | List Notes by Title | |
6760 | 38 | |
6761 | LM Conside rations | |
6762 | Interdisci plinary No tes | |
6763 | 47 | |
6764 | Location( Print Prog ress Notes | |
6765 | 37, 165 | |
6766 | LOOKUP MET HOD | |
6767 | 215 | |
6768 | Maintenanc e Menu | |
6769 | 178 | |
6770 | Make Adden dum | |
6771 | 42, 57 | |
6772 | Manual org anization | |
6773 | 7 | |
6774 | MAS Option s to Print Progress Notes | |
6775 | 166 | |
6776 | Meaning of Icons | |
6777 | 46 | |
6778 | Medical Re cord Techn icians | |
6779 | 78 | |
6780 | Medicine C onversion | |
6781 | 191, 193 | |
6782 | Menu Actio ns | |
6783 | Interdisci plinary No tes | |
6784 | 45 | |
6785 | Menus and Option Ass ignment | |
6786 | 181 | |
6787 | Message wi ndow | |
6788 | 10 | |
6789 | Minus (-) sign | |
6790 | 10 | |
6791 | MIS | |
6792 | 226 | |
6793 | MIS Manage r | |
6794 | 226 | |
6795 | MIS Manage r’s Menu | |
6796 | 101 | |
6797 | Mismatched ID Notes | |
6798 | 133 | |
6799 | Missing Ex pected Cos igner Repo rt | |
6800 | 130 | |
6801 | Missing Te xt Cleanup | |
6802 | 126 | |
6803 | Missing Te xt Report | |
6804 | 124 | |
6805 | Mnemonics | |
6806 | 219 | |
6807 | modify the Expected Cosigner | |
6808 | 13 | |
6809 | Modify the hierarchy | |
6810 | 215 | |
6811 | MRT | |
6812 | 226 | |
6813 | MRT Menu | |
6814 | 78 | |
6815 | MRTs | |
6816 | 78 | |
6817 | Multiple P atient Dis charge Sum maries | |
6818 | 55 | |
6819 | Multiple P atient Doc uments | |
6820 | 58, 63, 64 , 78, 80, 81, 104, 1 61, 162, 1 63 | |
6821 | national | |
6822 | document t itles | |
6823 | 190 | |
6824 | New Note | |
6825 | 42 | |
6826 | Object | |
6827 | 227 | |
6828 | Objects | |
6829 | 73, 76 | |
6830 | OE/RR 2.5 | |
6831 | 31 | |
6832 | Online Hel p | |
6833 | 9 | |
6834 | OP reports | |
6835 | 214 | |
6836 | Outpatient Location- Print Pro gress Note s | |
6837 | 166 | |
6838 | Outpatient note | |
6839 | 24 | |
6840 | Parameters | |
6841 | 186 | |
6842 | Parameters Menu | |
6843 | 186 | |
6844 | Parentless Addenda | |
6845 | 128 | |
6846 | Patch GMTS *2.7*12 | |
6847 | 77 | |
6848 | Patient( P rint Prog ress Notes | |
6849 | 37, 165 | |
6850 | PCE | |
6851 | 223 | |
6852 | Person Cla ss file | |
6853 | 208 | |
6854 | Personal P references | |
6855 | 14, 68 | |
6856 | Plus (+) s ign | |
6857 | 10 | |
6858 | prevents e diting | |
6859 | 65 | |
6860 | ||
6861 | 57 | |
6862 | Print acti ons | |
6863 | 164 | |
6864 | Print by W ard | |
6865 | 177, 211 | |
6866 | Print Docu ment Menu | |
6867 | 85, 105 | |
6868 | Print Docu ment Menu ... | |
6869 | 78 | |
6870 | Print Opti ons | |
6871 | 164 | |
6872 | Printed Di scharge Su mmary | |
6873 | 52 | |
6874 | PRIVACY AC T OFFICER | |
6875 | 41, 56 | |
6876 | Problem | |
6877 | 218 | |
6878 | Procedure | |
6879 | 26 | |
6880 | Progress N ote Print | |
6881 | 88, 108 | |
6882 | Progress N otes | |
6883 | 21, 227 | |
6884 | Upload | |
6885 | 154 | |
6886 | Progress N otes Menu | |
6887 | 21 | |
6888 | Progress N otes Print Menu | |
6889 | 165 | |
6890 | Progress N otes Print Options | |
6891 | 37 | |
6892 | Progress N otes Statu ses | |
6893 | 41 | |
6894 | Progress N otes User Menu | |
6895 | 14 | |
6896 | Progress N otes V. 2. 5 | |
6897 | 209 | |
6898 | Progress N otes/Disch arge Summa ry [TIU] M enu | |
6899 | 14, 15 | |
6900 | prohibits editing | |
6901 | 65 | |
6902 | Provider C lass | |
6903 | 208 | |
6904 | Purpose of Text Inte gration Ut ilities | |
6905 | 1 | |
6906 | Quit | |
6907 | 42, 57 | |
6908 | Radiology reports | |
6909 | 215 | |
6910 | Reassign a ction | |
6911 | 114 | |
6912 | Reassignme nt Documen t Report | |
6913 | 78, 98 | |
6914 | Reassignme nt Documen t Report | |
6915 | 181 | |
6916 | Release fr om transcr iption | |
6917 | 212 | |
6918 | Released/U nverified Report | |
6919 | 78, 94 | |
6920 | Remote Use r Menu | |
6921 | 158 | |
6922 | Reports an d Upload | |
6923 | 213 | |
6924 | resend ale rts | |
6925 | 197, 198 | |
6926 | Resolution Status | |
6927 | 83 | |
6928 | Review Pro gress Note s | |
6929 | 31 | |
6930 | Review Pro gress Note s by Patie nt | |
6931 | 28 | |
6932 | Review uns igned addi tional sig natures | |
6933 | 79, 102 | |
6934 | Review Upl oad Filing Events | |
6935 | 78 | |
6936 | Review/Edi t Document | |
6937 | 144 | |
6938 | Reviewing Notes | |
6939 | 15 | |
6940 | Rotating r esidents | |
6941 | 214 | |
6942 | Router/fil er | |
6943 | 149 | |
6944 | Screen Dis play | |
6945 | 10, 12 | |
6946 | Screen Edi tor | |
6947 | 212 | |
6948 | Scrolling region | |
6949 | 10 | |
6950 | Search | |
6951 | 20, 34 | |
6952 | Search by Patient AN D Title | |
6953 | 40 | |
6954 | Search cat egories | |
6955 | 55, 63, 21 8 | |
6956 | Search for notes by Problem | |
6957 | 218 | |
6958 | Search for Selected Documents | |
6959 | 78, 95, 10 1, 112 | |
6960 | Share obje cts | |
6961 | 217 | |
6962 | SHOP,ALL | |
6963 | 217 | |
6964 | Shortcut | |
6965 | 11 | |
6966 | Shortcuts | |
6967 | 219 | |
6968 | Show Progr ess Notes Across Pat ients | |
6969 | 36 | |
6970 | Sign/Cosig n | |
6971 | 42, 57 | |
6972 | signatures | |
6973 | 196 | |
6974 | signing pr ivilege | |
6975 | 54 | |
6976 | SOAP | |
6977 | 224 | |
6978 | Sort Docum ent Defini tions | |
6979 | 73, 188 | |
6980 | Special In structions for the F irst Time Computer U ser | |
6981 | 8 | |
6982 | Standardiz ed user in terface | |
6983 | 1 | |
6984 | Statistica l Reports | |
6985 | 119 | |
6986 | Statuses | |
6987 | 56 | |
6988 | Template | |
6989 | 224 | |
6990 | Terminal s ettings | |
6991 | 210 | |
6992 | Title | |
6993 | 227 | |
6994 | Titles | |
6995 | 187, 216 | |
6996 | TIU and VI STA Conven tions | |
6997 | 9 | |
6998 | TIU Conver sion Clean -up Menu | |
6999 | 183 | |
7000 | TIU Mainte nance Menu | |
7001 | 183 | |
7002 | TIU SET-UP MENU | |
7003 | 178 | |
7004 | TIU*1*158 | |
7005 | 196 | |
7006 | TIUF | |
7007 | 188 | |
7008 | TIUHL7 | |
7009 | 178 | |
7010 | Transcript ion Billin g Verifica tion Repor t | |
7011 | 144 | |
7012 | Transcript ion Billin g Verifica tion Repor t | |
7013 | 141 | |
7014 | TRANSCRIPT IONIST Lin e Count St atistics | |
7015 | 120 | |
7016 | Transcript ionist Men u | |
7017 | 144 | |
7018 | Troublesho oting | |
7019 | 208 | |
7020 | Uncosigned | |
7021 | 41, 56 | |
7022 | Undictated | |
7023 | 41, 56 | |
7024 | Unreleased | |
7025 | 41, 56 | |
7026 | Unresolved Errors | |
7027 | 83 | |
7028 | unsigned | |
7029 | 41 | |
7030 | Unsigned | |
7031 | 56, 61 | |
7032 | Unsigned/U ncosigned Report | |
7033 | 96, 123 | |
7034 | Untranscri bed | |
7035 | 41, 56 | |
7036 | Unverified | |
7037 | 41, 56 | |
7038 | Up-arrow ( ^) | |
7039 | 21, 29, 21 9 | |
7040 | Upload Doc uments | |
7041 | 149 | |
7042 | Upload err ors | |
7043 | Avoiding | |
7044 | 154 | |
7045 | Correcting | |
7046 | 152 | |
7047 | Upload Fil ing Events | |
7048 | 83, 84 | |
7049 | Upload Men u | |
7050 | 144, 149 | |
7051 | User Class | |
7052 | 227 | |
7053 | User Class file | |
7054 | 208 | |
7055 | User Class Managemen t Menu | |
7056 | 189 | |
7057 | User respo nses | |
7058 | 8 | |
7059 | VBA RO | |
7060 | 158 | |
7061 | VBC Line C ount | |
7062 | 102, 141 | |
7063 | Verify act ion | |
7064 | 82 | |
7065 | View Objec ts | |
7066 | 73, 76 | |
7067 | Visit Info rmation | |
7068 | 219 | |
7069 | Visit Orie ntation | |
7070 | 223 | |
7071 | Visit Trac king | |
7072 | 180 | |
7073 | Ward( Prin t Progress Notes | |
7074 | 37, 165 | |
7075 | Ward—Print Progress Notes | |
7076 | 166 | |
7077 | Word-proce ssing prog ram | |
7078 | 212 | |
7079 | Word-proce ssors | |
7080 | 157 | |
7081 | Workload C apture | |
7082 | 223 | |
7083 | WRIISC | |
7084 | 6, 193, 19 4 | |
7085 | XTEMP Glob al | |
7086 | 202 | |
7087 | ||
7088 | ||
7089 | Screen Tit le | |
7090 | ||
7091 | # of pages indicated here | |
7092 | ||
7093 | Header are a | |
7094 | ||
7095 | List area | |
7096 | ||
7097 | Action Are a | |
7098 | ||
7099 | Message wi ndow | |
7100 | ||
7101 | If you hav e a patien t list def ined in yo ur persona l preferen ces it is displayed here. If n ot, just e nter a pat ient name. | |
7102 | ||
7103 | Shortcut: Enter CC;N to bypass the next screen. | |
7104 | ||
7105 | This indic ates that there are 27 notes f or this pa tient. | |
7106 | ||
7107 | A list of diagnoses relating t o the type of Progre ss Note is presented for you t o choose f rom. | |
7108 | ||
7109 | A list of procedures relating to the typ e of Progr ess Note i s presente d for you to choose from. | |
7110 | ||
7111 | If the pat ient has C autions, W arnings, A llergies, or Directi ves (CWAD) , they are displayed here. | |
7112 | ||
7113 | ||
7114 | ||
7115 | If the pat ient has C autions, W arnings, A llergies, or Directi ves (CWAD) , they are displayed here. | |
7116 | ||
7117 | ||
7118 | If the pat ient has a ny CWAD (C risis, War ning, Alle rgies, and Directive s) notes, they are d isplayed h ere. | |
7119 | ||
7120 | ||
7121 | All outpat ient TIU d ata has to be associ ated with a visit. I f a visit related to TIU docum ents alrea dy exists, you only need to co nfirm it; otherwise you’ll hav e to enter a new vis it. | |
7122 | ||
7123 | Shortcut: | |
7124 | Enter acti on, =, and the item number | |
7125 | ||
7126 | If the pat ient has C autions, W arnings, A llergies, or Direct ives (CWAD ), they ar e displaye d here. In this case , the pati ent has a Warning (W ). | |
7127 | ||
7128 | These may be differe nt at your site. | |
7129 | ||
7130 | ||
7131 | These may differ at your site. | |
7132 | ||
7133 | ||
7134 | ||
7135 | You may se lect more than one d ocument by using #-# or #,# no tation. | |
7136 | ||
7137 | The parent document may be out side the o riginal da te range. | |
7138 | ||
7139 | In this ex ample, the se company names hav e been ent ered into the New Pe rson file and marked as belong ing to the transcrip tionist us er class. | |
7140 | ||
7141 | These are the initia ls of the transcript ionist as taken from the New P erson file . | |
7142 | ||
7143 | The attend ing must n ot be a pr ovider tha t requires a cosigna ture, and must be in User Clas s PROVIDER (or a sub class). | |
7144 | ||
7145 | The text e ditor brou ght up a b oilerplate template used for D ischarge S ummaries; entries ar e added af ter the co lons. | |
7146 | ||
7147 | CLASS | |
7148 | ||
7149 | TITLES | |
7150 | ||
7151 | DOCUMENT C LASSES | |
7152 | ||
7153 | CLASSES | |
7154 | ||
7155 | Eye Clinic Nursing | |
7156 | Notes | |
7157 | ||
7158 | Cardiology Nursing | |
7159 | Notes | |
7160 | ||
7161 | ICU | |
7162 | Nursing | |
7163 | Notes | |
7164 | ||
7165 | Other | |
7166 | Notes | |
7167 | ||
7168 | Psychologi st Notes | |
7169 | ||
7170 | Dietitian Notes | |
7171 | ||
7172 | Nursing No tes | |
7173 | ||
7174 | Clinician Notes | |
7175 | ||
7176 | Other | |
7177 | ||
7178 | Discharge Summary | |
7179 | ||
7180 | Progress N otes | |
7181 | ||
7182 | ||
7183 | Clinical D ocuments | |
7184 | ||
7185 | Note Error message. | |
7186 | ||
7187 | A list of diagnoses relating t o the clin ic, as def ined using the AICS package, i s presente d for you to choose from. | |
7188 | ||
7189 | A list of CPT Modifi ers can be printed o ut by ente ring two q uestion ma rks (??) a t the prom pt. | |
7190 | ||
7191 | ||
7192 | �Blue high lighting i ndicates c orrections /updates t o document that are not direct ly related to our pa tch. | |
7193 | �Blue high lighting i ndicates c orrections /updates t o document that are not direct ly related to our pa tch. | |
7194 | �Update to document; our patch makes use of this n ational ti tle but di d not crea te it. | |
7195 | �Blue high lighting i ndicates c orrections /updates t o document that are not direct ly related to our pa tch. | |
7196 | �Blue high lighting i ndicates c orrections /updates t o document that are not direct ly related to our pa tch. | |
7197 | �Blue high lighting i ndicates c orrections /updates t o document that are not direct ly related to our pa tch. | |
7198 | ||
7199 | ii | |
7200 | Text Integ ration Uti lities V. 1.0 | |
7201 | June 2018 | |
7202 | Clinical C oordinator & User Ma nual | |
7203 | June 2018 | |
7204 | Text Integ ration Uti lities V. 1.0 | |
7205 | v ii | |
7206 | ||
7207 | Clinical C oordinator & User Ma nual |
Araxis Merge (but not the data content of this report) is Copyright © 1993-2016 Araxis Ltd (www.araxis.com). All rights reserved.