Optum PM and Physician EMR allows you to assign shortcut keys to quick text entries (see Medical Record Module > Templates > Using Quick Text (Clinical Macros) > Creating Quick Text) and use the shortcut keys to include the text in rich text boxes to document a patient note.
Using Quick Text (Clinical Macros)
To Insert Quick Text Using Shortcut Keys:
1. Access the Medical Record module using one of the following methods:
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Pull the patient into context, and click the Medical Record module.•
(Recommended) If the patient has an appointment, click the patient name in the Appointments application of the Clinical Today module.2. In the Clinical toolbar, click Progress Notes . The Progress Notes Template window displays.
Note: The New Progress Note window launches only if an encounter is in context. The encounter launches into context when accessing the patient medical record via the Appointments application of the Clinical Today module. If documenting a progress note that is not based on an
appointment, the encounter dialog box displays enabling you to create a new encounter.
3. Click in the section of the template to insert the quick text entry.
4. Press the shortcut key assigned, and then press CTRL+SPACE BAR to populate the text.
Example: If P was entered in the box when creating a quick text, you can populate the text by pressing the [P] key, and then pressing [CTRL+SPACE BAR] to pull the quick text entry into the template.
Note: The shortcut key assigned is case sensitive so it is important that you use the exact case assigned to the entry.
Dictating a Note
4 Dictating a Note
The dictation feature is an alternate method within a template for documenting a patient encounter. You can dictate a medical note into a phone or a recording device. When the note is dictated, the audio file is generated and saved directly into the patient's progress note with the file name. The file name is
automatically created by the system, and includes the date and time the recording was completed. You must transcribe the WAV file into a medical note using an in-house, or third party transcription or application service. If using a third party transcription service, you can play and transcribe the audio file directly into Optum PM and Physician EMR. When the audio file is transcribed, the transcribed text is saved into the progress note by replacing the file name. The responsible provider must review, edit and sign the progress note. This vital information becomes a component of the patient's chart and the final legal medical documentation.
To dictate a note:
1. Access the Medical Record module using one of the following methods:
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Pull the patient into context, and click the Medical Record module.•
(Recommended) If the patient has an appointment, click the patient name in the Appointments application of the Clinical Today module.2. In the Clinical toolbar, click Progress Notes . The Progress Notes Template window displays.
Note: The Progress Notes Template window launches only if an encounter is in context. The encounter launches into context when accessing the patient medical record via the Appointments application of the Clinical Today module. If documenting a progress note that is not based on an appointment, the Encounter dialog box displays enabling you to create a new encounter.
3. Click in the section of the template to enter the dictation.
4. Click Dictation . The Add Attachment dialog box displays.
Note: You can record and play audio files only if your computer is equipped with a microphone and a sound card. Contact your practice System Administrator to configure audio settings for your computer.
5. Click Record to begin recording.
6. Click Stop to end the recording. Optum PM and Physician EMR saves the WAV file in the rich text box.
Dictating a Note
Note: You can dictate an entire note or a portion of the note as necessary.
7. Click Save to save the dictated note to the patient's medical record. The WAV file name populates in the narrative on the left-hand pane.
Note: A progress note that includes a file that needs transcription cannot be signed until it is transcribed. The progress note is saved in the Encounters and Progress Notes sections in the patient's medical record. It is also saved in the responsible provider's Open Encounters list and the Untranscribed Notes list of the Clinical Today module. When the file is transcribed, the transcribe text is saved in the progress note and the provider can review, edit and sign the note via the Open Encounters application.
About Point and Click Templates
5 About Point and Click Templates
Optum PM and Physician EMR provides the capability to document notes using the point and click mechanism. Point and click mechanism enables you to document a patient note by selecting items from pre-structured templates. You can point and click to select appropriate choices from lists, check boxes and extended pop ups to record a patient encounter. This reduces the chances of medical errors since the data is documented in customized forms.
Each control used in the point and click mechanism is described below.
CONTROLS
Control Function
Text Box A data entry field used to enter text, date, time and numeric information.
or or Check Box Used for "Yes/No" and "Abnormal/Normal"
entries. It is also used as a single check box to select items.
Clear All Used as a "Select All" option. Clicking the + symbol, selects all Yes entries. Clicking the - symbol, select all No entries.
Note: You can click the Clear All link to clear all selections made on items in a section without having to deselect each item individually. Clicking the Clear All link also deletes entries selected or entered in drop-down lists and text boxes in the section.
Push Button
A push button that triggers a pre-defined action such as displaying a dialog box to enter additional information.
Active Text A link that triggers a Medcin (Medcin: A system of standardized medical terminology intended for use in Electronic Medical Record (EMR) systems. The system includes over 250,000 clinical data elements encompassing symptoms, history, physical examination, tests, diagnoses and therapy. The system was developed by Medicomp Systems, Inc.) compliant dialog box to enter additional information.
Find Details Displays a dialog box to enter additional information on a specific data element. The Finding Details dialog box is standard across all templates. If additional data is available or can be recorded for the selected data element
About Point and Click Templates
CONTROLS
Control Function
in the progress note template, the Finding Details dialog box displays.
Pop Up Displays a dialog box to enter additional information on a specific data element.
A list box used to select information from pre-set values. Some drop-down lists provide the option of making multiple selections and clicking Save & Close at the end of the list.
Inserting Documents and Images
6 Inserting Documents and Images
Optum PM and Physician EMR provides the ability to embed patient related documents such as lab and radiology results, flow sheets and more when documenting an encounter. Any changes made to the document, reflect in the document attached to the progress note. In addition, templates provide the ability to insert images from a library of images. This helps to quickly identify and describe the exact location of the condition by annotating images and saving in the note.
To insert a document or image in a Progress Note:
1. Access the Medical Record module using one of the following methods:
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Pull the patient into context, and click the Medical Record module.•
(Recommended) If the patient has an appointment, click the patient name in the Appointments application of the Clinical Today module.2. In the Clinical toolbar, click Progress Notes . Optum PM and Physician EMR displays the Progress Notes Template window.
Note: The Progress Notes Template window launches only if an encounter is in context. The encounter launches into context when accessing the patient medical record via the Appointments application of the Clinical Today module. If documenting a progress note that is not based on an appointment, the Encounter dialog box displays enabling you to create a new "visit" type
encounter.
3. Click the section of the template to insert the document or image.
4. Click Insert Image . The Insert Image dialog box displays images uploaded to the patient’s record followed by images from the global image library.
5. Click the required image. Optum PM and Physician EMR embeds the image in the progress note.
6. (Optional) Click the Annotate link beneath the image. Optum PM and Physician EMR displays the Document Management View dialog box.
7. Mark up the image using the annotation tools listed in the table below.
8. Click Annotate and select a markup tool to annotate the image. The table below describes each tool: Example: You can scan or attach a standard growth chart into a patient’s medical record and mark measurements such as weight and height to analyze the child’s growth progress.
Note: You can add multiple annotations on an image.
ANNOTATION OPTIONS
Icon Tool Description
Rectangle Click and drag to draw a rectangular shaped markup with no fill.
Inserting Documents and Images
ANNOTATION OPTIONS
Icon Tool Description
Ellipse Click and drag to draw an oval shaped markup with no fill.
Line Click and drag to draw a straight line.
Freehand Click and drag to draw a freehand line.
Text Click and drag to draw a text box with a white background. Double-click the box to add or edit text.
Sticky Note Click and drag to draw a yellow note on the document. Double-click the note to edit the text.
Highlight Click and drag to highlight an area in yellow.
Redaction Click and drag to draw a filled shape.
Note: You can hide markups to the document by selecting the Hide Annotations check box.
9. (Optional) You can customize the appearance of the annotations, if necessary.
To customize annotation properties:
a. Right click the annotation, and click Change Annotation Properties. Optum PM and Physician EMR displays the annotation properties dialog box.
Note: The fields that display in the Annotation Properties dialog box are based on the type of annotation you want to customize. For example, the text size and text color fields are only available when customizing the appearance of Text type annotations.
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To change the color of an annotation (outline color, fill color, text color), click the color picker icon and click on a new color. Alternatively, you can type the name of the color in the text box.•
To change the width of a line or the resize text, use the slider to increase or decrease the size or width. Alternatively you can manually enter a number (1-100) in the box to change the width of the line or size of the text.b. Click Save in the Annotation Properties window. Optum PM and Physician EMR saves the markups on the page and location you drew or added text.
10. Click Save when finished. Optum PM and Physician EMR saves the markups on the page and location you drew or added text.
11. Click Save to display the annotated image in the narrative.
Optional Progress Note Template Features
7 Optional Progress Note Template Features
The templates accessed via the Progress Note Template application consists of several optional features you can use when documenting a patient encounter.
Support: To add the following features to your template, log a ToDo to the Support entity.
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The ability to pull forward height information recorded in a previous visit to the current note, and automatically calculate Body Mass Index (BMI).•
The ability to display the Home Monitoring form for company specific templates. Additionally, you can display home monitoring data recorded via the Vital Signs application in the narrative. If multiple sequences of vital data are recorded, the progress note displays all sequences with a sequence number, and the date and time of the recording.•
The ability to include office tests and procedures in a template to capture the CPT codes for visit capture. This allows you to capture visit information via the Visit application when the progress note is saved. When the progress notes is saved, the CPT codes of the tests performed in the office are automatically selected in the Visit application to capture visit information.•
The ability to automatically update the Visit application with the procedure and diagnosis codes selected when documenting a patient encounter.•
The ability to cite a patient's lab results in the progress note. You can view the patient's recent lab results while in a progress note and indicate the lab results that were reviewed with the patient. All results marked as reviewed are saved under the Results Reviewed with Patient section in the narrative.•
The ability to display the patient's Primary Care Physician (PCP) and referring provider information recorded in the Demographics application in the narrative.•
The ability to display active diagnoses information recorded in the default tab of the Problem List application in the narrative. Example: Typically, the Problem List tab includes problems withoutOptional Progress Note Template Features
the V or E ICD-9 codes. Therefore, if the Problem List application defaults to the Problem List tab, the narrative displays problems without the V or E ICD-9 codes.
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The ability to group plan items and diagnoses in the narrative. For example, if two diagnoses and two plan items are selected, the information lists the two diagnoses first followed by the two plan items indicating that the selected plan items pertain to the two diagnoses. You can click the Diagnosis/Assessment header in the narrative to do the following:•
Change the order in which the diagnoses display in the narrative.•
Link multiple plan items with multiple diagnoses.•
The ability to display ICD-9 codes associated with diagnoses in the narrative.•
The ability to display medication instructions, quantity, and other medicine information on a single line below the medication name in the progress note narrative.•
The ability to display detailed information pertaining to the immunization administered in the Immunization Given Today section of the narrative. The information includes lot number, administered date, expiration date, series, Date VIS given to patient, and dosage.•
The ability to display the growth, height, and head circumference percentiles calculated for children via the Flowsheet application in the narrative.•
The ability to carry forward height information recorded from a previous visit to the current visit, and automatically calculate Body Mass Index (BMI) information. If you want height information automatically moved from visit to visit, log a ToDo to the Support entity.•
The ability to display the names of clinical letters attached to a ToDo or printed for the patient during the encounter in the Clinical Letters section of the narrative.•
The ability to display all operators who created an order, prescription or immunization in the footnote of a narrative.•
The ability to display before each section in the narrative(Narrative: A view of your clinical documentation on the left side of the progress note template) the name, date and time of the operator who documented the information in the section or display all of the contributors in the footnote of the narrative.•
The ability to display the operator's time zone in the narrative. The time zone is set for each individual operator via the Operators and Roles application in the Administration module.Important: The time zone defaults to Eastern Standard Time (EST) if no time zone is set for the operator. It is important to set the correct time zone if you are not in the EST time zone.
Default Progress Note Template Features
8 Default Progress Note Template Features
The templates accessed via the Progress Note Template application consists of several default features you can use when documenting a patient encounter.
Note: The features available are based on the version of the template and the specialty.
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The progress note template displays a standard toolbar to access applications such as Rx, Orders, Order Sets, Immunizations, Referrals, Patient Education, and more. Additionally, the narrative displays information recorded in the Rx, Orders, Immunizations, Referrals and Patient Education applications for the current encounter.Note: The patient education information that display on the narrative also includes the websites accessed via the Link tab of the Patient Education application.
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The progress note template displays a check mark in the Problem List Reviewed, Allergy List Reviewed, Medication List Reviewed check boxes when you click Mark Reviewed in the Chart Summary.•
The progress note template displays a check mark in the Problem List Reviewed check box when you click Confirm No Known Problems or Mark Reviewed in the Problem List application.Additionally, the Problem List section of the narrative displays No Known Problems or Problem List Reviewed with the current date.
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The progress note template displays a check mark in the Allergy List Reviewed check box when you click Confirm No Known Allergies or Mark Reviewed in the Allergies application.Additionally, the Allergies section of the narrative displays No Known Allergies or Allergies Reviewed with the current date.
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The progress note template displays a check mark in the Medication List Reviewed check box when you click Confirm No Known Medications or Mark Reviewed in the Medicationsapplication. Additionally, the Medications section of the narrative displays No Known Medications or Medications Reviewed with the current date.
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The narrative displays No Refills when the number of refills in the Rx Writer application is set to 0.•
The narrative displays the patient's current medications with the renewal date for medications prescribed and the original date for medications manually entered.Support: To remove the date from the narrative, log a ToDo to the Support entity.
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The Medications Administered Today section of the narrative displays medications recorded via the Administered Medication dialog box.•
The progress note template helps you easily identify popup buttons with information recorded by displaying in orange. This helps when copying information from a previous note to the current note as reminder that data is recorded in the pop up windows associated with the pop up button.Example: You can record information on each joint of a homunculus in a popup window by clicking the popup button in a Rheumatology template. This displays the popup button in orange to indicate
Default Progress Note Template Features
that data is recorded.
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The progress note template displays a Finding Details icon next to Medcin nodes. You can click the Finding Details icon to access the Finding Details dialog box to record additionalinformation about the Medcin nodes.
Default Progress Note Template Features
The Finding Details dialog box allows you to do the following: