Seamless flow

eClinicalWorksEMR
MedicalAssistant&Nurse
TrainingGuide
RachelJ.CohenPhDDOHMHTrainingManager
Rcohen5@health.nyc.gov

2127885718

Contents
Introduction..................................................................................................................................................3
LogIntoeClinicalWorks...............................................................................................................................4
TaskbarQuickLinks(Generallyreferredtoasjellybeans).......................................................................6
PatientLookupButton...................................................................................Error!Bookmarknotdefined.
PatientHub...................................................................................................................................................7
CreateaTelephoneEncounter.....................................................................................................................8
AccesstheOfficeVisitsScreen....................................................................................................................14
UpdatePatientRoomandVisitStatus........................................................................................................17
AccesstheProgressNote............................................................................................................................18
ProgressNotesTemplates..........................................................................................................................21
Vitals............................................................................................................................................................24
ChiefComplaints.........................................................................................................................................29
DocumentChiefComplaints....................................................................................................................29
CurrentMedication.....................................................................................................................................32
EnterCurrentMedication........................................................................................................................32
ReviewMedicationHistory......................................................................................................................34
AddaMedicationtothePatientsRecord...............................................................................................35
AddingorChangingthePharmacyonRecord............................................................................................39
ViewPhysicianOrders.................................................................................................................................40
Immunizations.............................................................................................................................................43
DocumentImmunizations.......................................................................................................................43
UpdateaGivenImmunization.................................................................................................................49
Billing...........................................................................................................................................................50
AddorRemovetheTCModifier..............................................................................................................51

Introduction

AspartofNewYorkCitysTakeCareNewYorkinitiative,thePCIPProjectisamultifacetedprogramtosupportthe
adoptionanduseofAmbulatoryHealthRecords(AHRs)amongprimarycareprovidersinNYC'sunderserved
communities.Itsmissionistoimprovepopulationhealththroughappropriatetechnologyandhealthinformation
exchange.

TheeClinicalWorkssystemwaschosenbyNewYorkCitysDepartmentofHealthandMentalHygieneastheirvendorof
choicetoaccomplishtheirgoals.

TheMedicalAssistantandNursingstaffatdoctorsoffices,clinics,outpatient,ambulatoryfacilitieswillbeperforming
theirroutinetasksintheAHR(ambulatoryhealthrecord)systemeClinicalWorks.Thefollowingpagesdocumentand
demonstratethesystemfunctionsnecessaryforcompletingcommonmedicalassistantandnursingtasks.

LogIntoeClinicalWorks

Afterloggingintothenetworkusingyourusernameandpassword,youwillnoticetheeCWicon
Clickthisicon.

onthedesktop.

Thelogonwindowappears.

Enteryourfirstinitialandlastname(example,jandrilli)intheLoginIDfieldandinitiallyyourpasswordwillbepassword1
(therewillbesubsequentinstructionsonhowtochangeyourpassword).

Displayofwhoisloggedin

Thisscreendefaultstotodaysdateandthefirstproviderlistedinyourdefaultclinic.

ClicktheSjellybeantoviewyourpatients.

TaskbarQuickLinks(Generallyreferredtoasjellybeans).

SMenu:LinkstotheOfficeVisitswindowwhichdisplaysthepatientsthathavearrivedfortheirvisit.

ThenumberintheSjellybeanindicatesthenumberofpatientsarrivedanddisplaysonlyintheproviders
view.Staffwillalwaysseea0.

DMenu:ProvidestheoptionofgoingdirectlytotheFaxInboxorFaxOutboxwindows.The
numbernexttoDindicatesthenumberofdocumentsassignedtotheloggedbyanotherstaff
member.ClickthebuttontoopentheReviewDocumentwindow.

RMenu:ProvideslinkstotheIncomingReferralsorOutgoingReferralswindows.Thetotal
numberofreferralsassignedtotheloggedonuserdisplaysinparenthesesnexttoeachlink.Thenumbernext
toRindicatesthecombinedtotalnumberofincomingandoutgoingreferrals.Clickthebuttonthathasthe
numbertoopentheOutgoingReferralswindoworclickontheRitselftoselectIncomingReferralsor
OutgoingReferralsfromadropdownlist.

TMenu:ProvideslinkstotheTelephone/WebEncounterswindow,whichincludesnewtelephoneandweb
encountersaswellasActionsandalinktoClaims.Thetotalnumberofencountersassignedtotheuserwhois
loggedinwillbedisplayedinparenthesesnexttoeachcategory.ThenumbernexttoTindicatesthe
combinednumberofopentelephoneandwebencountersassigned.Clickthebuttontoopenthe
Telephone/WebEncounterswindow.

LMenu:OpensthewindowdirectlytotheToBeReviewedtab.Thetotalnumberoflabsandimaging
assignedtotheloggedonuserdisplaysinparenthesesnexttoeachcategory.ThenumbernexttotheL
indicatesthecombinednumberoflabsandimaging.ThetabbedsectionsincludeOutstanding,Tobe
reviewed,Reviewed,Future,Bypatient,andAll.

MMenu:ProvideslinkstomessagesintheInbox,Outbox,orDeletedMessageswindows,andincludesa
linktotheCreateNewMessagewindow.ThenumbernexttoMindicatesthenumberofnewmessagesin
theInboxfortheloggedinuser.ClickontheletterMtoviewtheInbox,Outbox,DeletedMessagesor
CreateNewMessages.

PatientLookupButton

ThePatientLookupbuttonisyourstartingpointforalmostalleClinicalWorksactivities.Youcansearchfora
patientbyusingthePatientLookupbutton.

ToSearchforaPatient

Not
necessarily

1:ClickthePatientLookupbutton.

ThePatientLookupwindowopens.

trueasthey
willbeusing

officevisits
screenfor

everything
except

telephone
encounters

2:TypethelastnameofthepatientintheSearchPatientfield.
3:Clickonthenameofthepatient.
4:ClickthePatientInfobuttontoopenthePatientInformationwindowORclickOKtoopenthePatientHub.

PatientHub

ThePatientHubisaptlynamedbecauseallofthemajorcomponentsofthepatient'selectronicmedical
recordsareaccessibledirectlyfromtheHub.Likethehubofawheel,thePatientHubisthecentralpointof
accessforimportantfeaturessuchasAlerts,Demographics,andProgressNotes.

TheHubcontainsnavigationbuttons,staticpatientinformation,andatoolbarthatlinkstocommonareasof
theapplication.ManyofthemainwindowsintheapplicationcontainalinkorbuttonbacktotheHub,
makingiteasyfortheusertoquicklynavigatebackandforthtotheHubaspartoftheworkflow.Youmay
easilycreatenewtelephoneencountersandaccesstheprogressnotesfromthePatientHub.

TelephoneEncounters

TheTquicklinkintheStatusTaskbarandtheTelephoneEncounterswindowenablesofficestafftokeep
trackofinformationcommunicatedtothepracticeaboutapatientthatrequiresactiontobetaken.Whena
patientorfamilymembercallsintoaskaquestionorprovideacomment,recordallrelevantinformationina
telephoneencounter.

TheTaskbarquicklinkalsokeepstrackofthenumberoftelephoneencountersassignedtostaffforreview(by
user).HighprioritymessagesarenotedwitharedquicklinkandaredexclamationmarkontheTelephone
Encounterswindow.

ToCreateaTelephoneEncounter

1:FromtheTquicklinkintheStatusTaskbar,openthedropdownlistandselectNewTelephone
Encounter.

TheTelephoneEncounterwindowopens.TheAnsweredby,Date,Time,andStatus(Open)fieldsare
automaticallypopulated.

2:ClicktheSelectbuttonabovethePatientfield.

ThePatientLookupwindowopens.

3:Searchforthepatientinthedatabase.Doubleclickonthepatientsname.ThePatientLookupwindow
closesandthepatient'snameisaddedtothePatientfield.

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4:SelectthepatientsproviderfromtheProviderdropdownlist.

HighPriority:Ifthisisanurgentmessagethatneedstobeaddressedassoonaspossible,checkthe
HighPrioritycheckbox.TheTquicklinkturnsredandtheencounterismarkedwithared
exclamationmarkontheTelephoneEncounterswindow.

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5
6

10
11

12

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5:ReviewthePharmacyinformation,iffilledin,orclicktheChangebuttonandselectapharmacyfromthe
Pharmacieslistifthecallisforaprescriptionorrefill.
6:TypethenameofthecallerintotheCallerfield.
7:ReviewtheFacilityandchange,ifnecessary.
8:TypethereasonforthecallintotheReasonfield,orselectitfromthedropdownlist.
9:ClicktheMore()buttontoselecttheprovider,resourceorstaffpersonwhowillhandlethecallfromthe
AssignedTodropdownlist.
10:TypethemessageintotheMessagefield.
11:ClicktheComplaintsbuttontoaddprimarysymptomsorChiefComplaintsforthepatient,ifappropriate.
12:IfthepatientwishestoknowanyinformationontheirLabs/DItests,clickontheLabs/DItab.TheLab
sectionoftheencounteropens.ChoosebetweentheoptionsLabsorDIfromthedropdownlist.Thedates
theywereordered,thereasonforthetestsandtheresultscanbeviewedinthissection.

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13:Ifthepatientneedsarefilloranewmedication,clickontheRxtab.TheRxsectionofthewindowopens.

14:ClickontheCurRxbuttontoviewthecurrentmedicationsofthepatient.Selectamedicationifneeded

andclickOK.

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YoumayalsousethedropdownarrownexttotheCurRxbuttontoviewandselectfromtheCurrentRx,Rx
HistoryorExternalRxHistoryofthepatient.

15:OncethemedicationisaddedtotheRefilledMedicineslist,clickonthefieldstospecifytheComments,
Name,Strength,Formulation,Take,Route,Frequency,Duration,Dispense,Refill,and
Auth.

Todeleteamedication,selectamedicationfromtheRefilledMedicationslistandclickDelete.

16:ReturntotheMessagetabandclicktheAddActionTakenbutton.TheNoteswindowopens.Typea
descriptionofyouractiontakenandclickOK.
Yourname,thecurrentdate,andtheexacttimeareautomaticallypopulatedintotheActionTakenfieldalong
withyournotes.
17:ClickOKontheTelephoneEncounterwindow.

Openvs.Addressed:BesurethatyouleavetheencountermarkedasOpenintheStatussection.Ifit
ismarkedAddressed,thistelephoneencounterwillbelockedfromfutureeditingandtheprovider
willneverbenotifiedofthisassignedtelephoneencounter.

Thetelephonemessageaboutthepatientisnowdocumentedandassigned.

AccesstheOfficeVisitsScreen

Toaccessthelistofarrivedpatients,clicktheSjellybeanonthetaskbarquicklink(

14

).

TheOfficeVisitswindowopens.

Patientsdisplayedinthiswindowarethosewhohavebeenregisteredand/orthosecheckedinbythefront
desk.

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Note:Ifyouareinaclinicwhereyouservicemultipleclinicspatients,usetheFacilityGroupselection
dropdownforthemostefficientviewofyourpatients.Ifnot,useFacilityastheselectioncriteriawhichwill
providealistofallpatientsinthatclinic.

Clickthedrop
downand
chooseFacility
Group

or,clickthe
dropdownand
chooseFacility

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UpdatePatientRoomandVisitStatus

Toroomapatient:

1:ClickintheRoomfieldforthepatient.TheRoomNo.windowopens.
2:Typeorclickthenumbersonthekeypadtoenterthetriageroomnumber.
3:ClicktheOKbuttton.YouarereturnedtotheOfficeVisitswindow.

Toupdateapatientsstatus:

1:ClickintheStatusfieldforthepatient.TheStatusCodeswindowopens.

Tip:Scroll
downtoseeall
availablestatus
codes.

2:ClickTRI.YouarereturnedtotheOfficeVisitswindow.

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AccesstheProgressNote

Therearemultiplewaystoaccessapatient'sProgressNotesfromwithintheeCWapplication.Patientcare
workflowvariesgreatlyamongstaffmemberswithdifferentjobtaskssotheProgressNoteisreadily
accessiblefromanumberofworkareas.
Thefollowinglistdescribesthevariousmethodsofaccessingapatient'sProgressNote:

1.FromtheOfficeVisitswindow:Doubleclickthepatient'snameintheOfficeVisitswindowtolaunch
theProgressNotesforthepatient.Alternatively,checkthecheckboxnexttothepatientsnameand
clickViewProgressNotes.

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2.Fromtheleftnavigationbar:ClickthePracticeband,andthenclicktheProgressNotesicon.

3.FromthePatientHub:ClicktheProgressNotesbutton.

4.FromtheCentralResourceSchedulewindowortheProviderSchedulewindow:
Rightclickthemousebuttononanappointmentslot.ClickViewProgressNotesinthedropdownlist.

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CentralResourceScheduleWindow:

ProviderSchedulewindow:

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ProgressNotesTemplates

AProgressNotestemplateprovidesdetailsaboutobservationsandtreatmentstrategies.Usingatemplate
canmaximizeapatientvisitbyfocusingonlyonthepertinentinformation.Theusageoftemplatesassistsin
documentingtheProgressNotefasterforcommonanddiscreteproblems.

ToCopyandMergeaGenericTemplate

Agenerictemplateismostusefulbecauseitcanbeusedforanypatient.Thereisnopatientspecific
informationinit.Physicians,nurses,andotherauthorizedstaffwithaccesstoProgressNotescancopyor
mergetheselectedtemplateintothepatient'sProgressNotes.

1.OntheProgressNoteswindow,clickthegreenarrownexttotheTemplatesbuttoninthebottomtoolbar
(or,fromtheFilemenu,selectTemplates)andselectCopyandMergefromTemplatesfromthedropdown
list.

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TheProgressNotesTemplatewindowopens.

2.Thepatient'snameandtheencounterdateappearintheTemplateForsectionatthetopofthewindow.
3.UnderChooseTemplate,clickGeneric.
4.ClickontheCategorydropdownlistandselecttheAllcategory.Alistoftemplatesdisplaysonthe
bottom.

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5.IntheFindfield,typeNursingtofilterthetemplateslist.IntheFacilityfield,selectafacilityforwhich
thetemplatewassavedfromthefacilitydropdownlist.Atemplateis(oralistoftemplatesare)displayed.
6.Clickonthedesiredtemplate.
7.UnderAllOptions,clickthecheckboxforthetemplateinformationtobeincluded.Ifallinformationis
desiredtobeincluded,clickAllOptions.
8.SelectCopyTemplateorMergeTemplate.CopyTemplateremovestheinformationfromthepatient's
ProgressNotes,andsubstitutesthetemplatevalues.MergeTemplateleavestheexistinginformationinthe
patient'sProgressNotes,andappendstheadditionalinformationfromthetemplate.
CopyingtemplateinformationwilloverwritetheexistinginformationintheProgress
Note:Ifunsureaboutoverwritinginformation,chooseMergetoaddthenewtemplate
informationtotheexistingProgressNote.

ThePatientsProgressNoteispopulatedwiththeinformationcopiedormergedfromtheTemplate.
9.ClickClosetoexitthescreen.

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Vitals

TheVitalswindowiswhereapatientsvitalsignsatthetimeoftheencounterarerecorded.Vitalsignswill
generallybetakenbyamedicalassistant.

DocumentVitals

1.OntheOfficeVisitsscreen,clickonthepatientsnametoopentheProgressNoteswindow.
2.ClicktheVitalslinkintheprogressnote.TheVitalswindowopens.Thecurrentvisitishighlightedin
yellow.

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3.Checkthepopupcheckboxtoenableapopupwindowtoenterinformationforeachvitalitem.

4.Chooseavitalitemwhichneedstoberecordedbyclickingonthevitalspecificfieldintherow
highlightedinyellow.Awindowcontainingthevitalspecificinformationappears.Thefollowingvitals
windowappearswhentheHeightfieldisclicked.

5.Iftheheightistoberecordedinfeetandinches(e.g.5feet4inches),enterthevaluesintheFtandIn
fieldsrespectively.IftheHeightistoberecordedinmeterandcentimeter,enterthevaluesinmandcm
fieldsrespectively.
TheHeightisautomaticallyconvertedintoinchesiftheunitofmeasurementissetasinchesforheightin
theVitalsAdminSettings.
Iftheheighthasbeenenteredinapreviousencounter,clickCopyHeighttoimporttheheightfromthe
previousvisit.
6.ThefollowingwindowappearswhentheWeightfieldisclicked.Iftheweightistoberecordedin
KilogramsandGrams,enterthevaluesinKgandgmfieldsrespectively.Ifthevaluesaretoberecordedin
poundsandounces,enterthevaluesinthelbandozfieldsrespectively.Theweightisautomatically
convertedtopoundsiftheunitofmeasurementissetaspoundsforweightintheVitalsAdminSettings.
Thenumberbuttonscanalsobeusedtoenterthevaluesintherespectivefields.

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7.Clickthe>buttontodisplaythevitalsontheright.ClickDeletetodeletethevitals.

8.ClickApplytoimportthepatientsvitalsintheVitalswindowandexitthevitalspecificwindow.Or,click
Nextinthevitalspecificwindowtogoontothenextvitaltype.Theinformationprovidedis
automaticallyimportedintothepatientsVitalswindow.
WhenHeightandWeightareentered,theBMIisautomaticallycalculated.

9.UsethepagearrowtopageforwardorbackwardandviewtheotherVitalItemsonthelist.Clickthe
HearingfieldtoentertheHearingTestdata.TheHearingwindowopens.

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a.AdefaultdecibellevelappearsintheDecibelscolumnbutitcanbechangedtorecordthe
actualdecibellevelduringthetest.RefertotheSettingssectionformoreinformationon
settingadefaultdecibellevel.
b.ClickinacellforasideandafrequencyandthenclickPforpassorFforfail.ClickPforallorF
foralltorecordpassorfailforalltests.ClickClearalltoclearallcellsandreenterdata.
c.ClickontheappropriateRadiobuttonunderComments.EnternotesintheOtherfieldifOther
isselected.
d.ClickApplytodocumentthedataintotheVitalswindowandtoexitthewindow.Or,clickNext
tomovetotheentrywindowfornextdataitem.
10.IntheVitalswindow,clicktheVisionfieldtoentertheVisionTestdata.TheVisionwindowopens.

a.Selectresultsforleft,rightorbotheyesfromtheirrespectivedropdownlistormanuallyenter
theresultsintothefields.
b.RecordtheFusiontestresultsintotheFusionfieldandthecolorperceptiontestresultsintothe
Colorfield.
c.ClickonanappropriateradiobuttonunderCommentstorecordwhetherachildwastooyoung
totestorthepatientworeglassesforthetest.
d.SelectOthertorecordadditionalcommentsintotheOtherfield.
e.ClickApplytodocumentthedataintotheVitalswindowandtoexitthewindow.Or,clickNext
tomovetotheentrywindowfornextdataitem.

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11.IntheVitalswindow,clickonthePainScalecelltorecordapatientsassessmentofpain.

Enteranumberbetween0and10thatrepresentsthelevelofpainthatthepatientisexperiencing.
ClickApplytodocumentthedataintotheVitalswindowandtoexitthewindow.Or,clickNextto
movetotheentrywindowfornextdataitem.
12.ChecktheVitalsTakencheckboxtodocumentthatvitalsweretakenduringthevisit.
Thisfieldisforindicationpurposesonly,anditdoesnotdisplayonthechart.Itinsertsastethoscope
indicatoronNotesStatusfieldintheOfficeVisitswindowtoinformtheproviderthatthevitalshavebeen
recordedandthepatientisreadytobeseen.

13.ForthisWalkthrough,exittheVitalswindowtoviewthevitalsinthePatientsProgressNote.

Exercise
YourpatientTestEMR##vitalsignshavebeingtakenbythenurse.Thefollowingvitalswererecorded:
Temperature98.4F,Weight155lbs,Height54,BP130/84,HR60perminute.DocumentTestEMR##vitals
inthepatientsprogressnotes.

Exercise

Oncethevitalshavebeendocumentedintotheprogressnotes,notifytheproviderthroughthesystemthat
thevitalsignsforTestEMR##havebeentaken.

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ChiefComplaints

TheChiefComplaintswindowiswheretheprimarysymptomsorcomplaintsforthecurrentencounterare
recorded.

DocumentChiefComplaints
1.FromthepatientsProgressNotes,clickChiefComplaint(s).

TheChiefComplaintswindowopens.AnytextenteredintotheReasonfieldontheappointmentwindow
bythefrontofficestaffappearshereasthefirstChiefComplaint.

2.ClickBrowsetoselectacomplaintfromapredefinedlistofmedicalconditions.TheChiefComplaints
Keywordswindowopens.Toselectacomplaint,clickthecomplaintintheleftpane.Theselected
complaintdisplaysintherightpane.Tolookupachiefcomplaint,enterthefirstfewlettersofthe
complaintintheFindfield.Alistofcomplaintsdisplay.

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Theleftpanedisplaysalistofgeneralcomplaintstochoosefrom.Therightpanedisplaysthelistof
complaintschosenfromtheleftpane.Clickthe<buttontoremoveacomplaintfromtheselectedlist.Click
the<<buttontoremoveallthecomplaintsfromtheselectedlist.ClickNexttoscrollthroughthelistof
complaints.
3.Toselectacomplaintfrompatientsmedicalhistory,clicktheFollowUptabtoseetheMedicalHistory.

InformationthatisdocumentedintheMedicalHistorysectionforthecurrentvisitisvisibleintheFollowUp
section.Thisinformationcanalsobeaddedtothisvisit'sChiefComplaints.
4.ClickonthemedicalhistoryinformationfromtheFollowUpwindow.Theselectedmedicalhistory
informationappearsontherightpane.
5.ClickOKtoclosetheChiefComplaintskeywordswindow.ThecomplaintsselectedfromtheChief
Complaintskeywordswindowaredocumentedinthissection.Thephrase"Followup"isappendedtothe
symptomsgatheredfromtheMedicalHistory.

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6.Toenterachiefcomplaintmanually,clickAddintheChiefComplaintssectionoftheChiefComplaints
window.AblankrowappearsintheChiefComplaintswindow.
7.Clickontheblankrowandenteranotherreasonforthevisit.

8.Toremoveachiefcomplaint,clickontherowandclickRemove.Todeletetextinsidearow,placethe
cursorinsidetherowandmanuallydeletethem.
9.Toarrangetheorderofthechiefcomplaints,usetheupanddownarrows.
10.ForthisWalkthrough,exitthewindowtoviewthechiefcomplaintsinthepatientsProgressNotes.

Exercise
YourpatientTestEMR##complainsoffatigueanddepression.Documentthesecomplaintsintothepatients
progressnotes.

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CurrentMedications

TheCurrentMedicationswindowiswherecurrentlyprescribedmedicationsandapatient'sprescription
historyarerecorded.Thisfeatureletstheprovidertrackthecurrentmedicationsapatientistakingandreview
theirprescriptionhistory.CurrentMedicationscanbecarriedforwardvisittovisitbyusingthefollowingsteps.
Failuretodocumentthepatient'scurrentmedicationsonanyProgressNotewillcausethemedicationson
thatProgressNotetomovetotheRxhistoryinsteadofCurrentRx.

AlthoughalloftheinformationisretainedintheRxHistorysection,theprovider'sworkflowisfasterand
simplerifthepatient'sCurrentMedicationsectionisupdatedoneachvisit.

ToEnterCurrentMedications

1.FromtheProgressNotes,clickCurrentMedication.

TheChiefComplaintswindowopens.

Todisplaythedrugnameonly,withoutanydosageinformation,checkRxNameOnlycheckboxinthe
CurrentMedicationSectionoftheTreatmentScreen.Todisplaymedicationsalongwithdosage
information,leavethisboxunchecked.Dosageinformationcanbealteredoncethemedicationhasbeen
selected.

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2.IntheCurrentMedicationssection,clicktheCurRxbuttontoselectamedicationthatthepatientis
currentlytakingfromthepatientsmedicationhistoryasofthelastvisit.

TheSelectMedicationwindowopens.

Thiswindowdisplaysallmedicationsthepatientwasonorhadstartedtakingduringtheirlastvisit.This
wouldincludethemedicationsthatweredocumentedintheCurrentMedicationSectionaswellasthe
medicationsthatwereprescribedtothemintheTreatmentsectionoftheprogressnotesduringtheirlast
visit.

3.Clickonalinecontainingthemedicationtoselectit.Theselectedmedicationisnowhighlightedin
yellow.

4.Toselectallmedication,clickSelectAll.Toremoveallselections,clickDeselectAll.

5.ClickOK.ThemedicationisnowlistedontheCurrentMedicationSectionoftheprogressnotes.

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TheCurrentMedicationlistingletsthephysicianalterStrength,Take,FrequencyandStartDateas
appropriateforthepatient.Clickinthecelltoactivatethefreetextfunctionalityandtoalterdosage
information.

ToReviewMedicationHistory

Thissectiondisplaysahistoryofmedicationsthatthepatienthasbeentakingorhadtakeninthepast.
1.FromtheCurrentMedicationsectionoftheChiefComplaintswindow,clickthegreenarrowbesideCur
Rx,andthenselectRxHistory.

TheSelectMedicationwindowopens.

2.Choosefromoneofthefollowingoptionstosortthemedicationhistoryofthepatient.

Thepatientencountersarelistedbydate,startingwiththemostrecent.Anydateinboldhasmedication
information.
3.CurRxliststhemedicationsthatweredocumentedintheCurrentMedicationsectionoftheProgress
Notefortheencounterdatethatslisted.ClickontheCurRxradiobutton.Alistofencountersdisplay
bydatesontheleftpane.Clickonadatetoviewthemedicationsontherightpane.Toaddthat
medicationtotodaysCurrentMedication,clickonthemedication.Theselectedmedicationis
highlightedinyellow.ClickOK.

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4.RxbyDatelistsanymedicationprescribedtothepatientwithineachencounter.ClickontheRxBy
Dateradiobutton.Alistofencountersdisplaybydatesontheleftpane.Clickonadatetoviewthe
medicationsontherightpane.ToaddthatmedicationtotodaysCurrentMedication,clickonthe
medication.Theselectedmedicationishighlightedinyellow.ClickOK.

5.RxbyNameliststhenameofanyprescriptioneverprescribedtothepatient,sortedbyname.Clickon
theRxByNameradiobutton.Alistofmedicationsdisplayontheleftpane.Clickonamedicationto
viewdosageinformationontherightpane.ToaddthatmedicationtotodaysCurrentMedication,click
onthemedication.Theselectedmedicationishighlightedinyellow.ClickOK.

6.ThemedicationsselectedintheRxHistorysectionareaddedtotheCurrentMedicationSection.

ToAddaMedicationtothePatientsRecord

Ifapatientiscurrentlyonamedicationthatisnotlistedintheirpastrecords,thenthemedicationneedstobe
manuallyaddedfromthedrugdatabasetothepatientsCurrentMedicationSection.

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1.FromtheCurrentMedicationsectionoftheChiefComplaintswindow,clicktheAddbutton.

TheSelectRxwindowopens.

2.FromtheTypedropdownlistselectthedrugdatabase.TheoptionsintheTypedropdownlistare:All
Rx,CustomRx,MedispanRx,andEquip/SuppliesRx.MedispanRxisadatabaseforawidelyusedlistof
medications.Thiswillbeusedinthemajorityofcasestochooseamedication.CustomRxisa
customizablelistofmedicationsmanagedandusedbytheProvidertomakemodificationstoandadd
tomedications.Equip/Suppliesisanonpharmaceuticallistofitemsrecommendedfortreatment.

3.Alistofmedicationsdisplay.UsetheRxdropdownoptions:StartsWith,ContainsandAllWordsto
facilitatethesearch.EnterthenameofthemedicationintheFindfieldtonarrowdownthesearch.
Selectfromthelistofmedications.

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4.Theavailableformulationsanddosagesaredisplayedhere.Clickthedosethatneedstobeprescribed.
5.ThemedicationanddosageareaddedtotheSelectedRxlist.

6.Selectthemedication.ToremovetheselectedmedicationfromtheSelectedRxpanel,clickRemove.
7.ClickOKtosavetheselectionandreturntotheCurrentMedicationsectionoftheChiefComplaints
window.ThenewmedicationisnowincludedontheCurrentMedicationlist.
8.ClickontheDatefieldtospecifyadatewhenthepatientstartedtakingthemedication.

37

Pleaseaddtheyearandmonthsearch
asmostofourpatientshavebeenon
theirmedsforyears

9.Themedicationisnowdocumentedalongwithdosageandthestartdateinformation.

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AddingorChangingthePharmacyonRecord

Youcanaddorchangeapharmacyonthepatientrecord.

1.AccessthePatientInformationwindowinanyoneofthefollowingways:
ClicktheInfobuttonnexttopatientsnamefromtheProgressNotesscreenorthePatientHub.The
PatientInfowindowopens.

Or,clickthePatientInfobuttononthePatientLookupwindow.ThePatientInfowindowopens.
Page1

Page2

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2.FromthePatientInformationwindow,clicktheAdditionalInfobutton.ThesecondpageofthePatient
Informationwindowopens.

3.ClicktheSel(Select)button.ThePharmaciesLookupwindowopens.

4.BegintypingthenameofthepharmacyintheLookupPharmacyfield.
5.Selectthepatient'spharmacyfromthelist.
6.ClickOK.TheaddressoftheselectedpharmacyappearsinthePharmacywindowonthePatient
Informationscreen.
7.ClickOKonthePatientInformationwindow.

ViewPhysicianOrders
Asapatientprogressesthroughtheirvisit,thephysicianwillmostprobablyenterlaband/ordiagnostic
imagingorders.Someofthelabordersandallimmunizationordersareperformedintheofficeandassuch
arereferredtoasinhouseorders.TherearemultipleindicatorsthatanurseorMAisneededtoperformin
houseorders:

StatusindicatesNurseneeded
Physicianverballyindicatesanorderispresent,or
Theorderisnoticedinthetreatmentsectionoftheprogressnote.

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ViewOrdersforaPatient

1.FromtheOfficeVisitsscreen,clicktheappointmentforthepatient.
2.ClicktheViewOrdersbutton.

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ThePatientOrderswindowopens.

3.Reviewthetabbedsectionforcurrentorders:CurrentLabs,,CurrentDiagnosticImaging,,and.Depending
ontheclinic,testswillbeorderedbyproviders.
ProcedurescanbeviewedbyhighlightingthedesiredprocedureandclickingtheViewbuttonforthe
associatedprocedure.

4.IfInterfacedselectthelabtosentandhitthequicktransmitbuttontosendthelabtotheselected
company.

5.Ifreferralreviewreferralhitviewandprintorderforpatientsamefordiagnosticimage
6.ClickClose.YouarereturnedtotheOfficeVisitswindow.

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Immunizations

TheImmunizationssectioniswherethenursedocumentsanyimmunizationthatwasorderedforapatient.
Thenursecaneasilyrefertothepatient'srecordofpastimmunizations.

DocumentImmunizations

1.

FromthepatientsProgressNote,clickImmunizations.

TheImmunizations/Injectionswindowopens.

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2.ClicktheAddbuttontoaddanimmunization.TheImmunizationDetailwindowopens.

3.UsetheFindfieldtolocateanimmunizationfromthelistintheleftpane.

4.Oncelocated,clickthedesiredimmunization.TheselectedimmunizationdisplaysintheImmunizationfield

intheImmunizationDetailsection.

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5.Ifapplicable,selectanencounterdatebyusingtheVisitDatedropdownlistofpatientencounters.

Immunizationscanbeassociatedwithaspecificvisitdate.TheVisitDatefielddisplayswhen
thecheckboxforVaccinationGiveninthePastissettoN.IftheVaccinationGiveninthe
PastischeckedasN,theGivenDatedefaultstotheVisitDateandcannotbeedited.Ifthe
VaccinationGiveninthePastischeckedasY,theGivenDatefieldisactivated.

6.Ifactivated,usetheGivenDatedropdowncalendarfeaturetoselectthedateonwhichtheimmunization
wasgiven.Bydefaultthegivendatedefaultstotodaysdateandthesystemautomaticallysavestheexact
timeintheGivenDatefield.

8.Eachimmunizationhasbeensetupwiththecorrectdosagesothisfieldisprepopulated.

9.ClickOK.

10.Iftheimmunizationispartofaseries,usetheDoseNumberdropdownlisttoselectthedosenumber.

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11.clicktheMore(...)buttonnexttotheGivenByfield.

TheStaffLookupwindowopens.Selectyournamefromthestafflist.ClickOK.

12.ClickontheLocationdropdownlisttoselecttheareaofthebodythroughwhichtheimmunizationwas
administered.

13.IntheLotNumberfield,clicktheMore()buttontoopentheLotNumberswindow.

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14.ClickontheSelfieldnexttoFacility.SelecttheFacilityfromtheFacilityListswindow.Immunizationlot
numberwillbeenteredbyfacility.Immunizationsassociatedwiththeselectedfacilitydisplays.Checkthe
DisplayLotsforselectedvaccineonlycheckboxtoviewlotnumbersfortheselectedvaccine.

15.TypetheVaccineLotNumberintheFindfield.Theimmunizationwithselectedlotnumberdisplays.

16.Clicktherowcontainingthelotnumbertohighlightit,andthenclickOKtoaddittotheLotNumberfield.
Ifthelotnumberyouareusingisnotlisted,additbyupdatingthefield.

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17.TheLotNumber,DateonVIS,ExpDate,andManufacturergetspopulatedintheImmunizationDetail
window.
18.Thisdefaultstocurrentdate.
19.UsetheRouteofAdministrationdropdownlisttoselectthemethodofdelivery.

20.EnteranycommentsintotheCommentsfield.

21.IfthevaccineisassociatedwiththeCDC'sVFCprogram(VaccinesforChildren),usetheVFCdropdownlist
toselectthestatus.
22.UsetheVaccinationGiveninthePastcheckboxtoindicateifthevaccinationwasgiveninthepastand
onlyenterthedateiswasgivenasinputforthisindicator.

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23..AllimmunizationsshouldbesetupwiththeappropriateCPTcodeusedforbillingalongwiththe
immunizationadministrationcode.

24.Toquicklyaddmorethanonevaccine,clickSaveandNewtosavethecurrentinformationandkeepthe
ImmunizationDetailswindowopentoaddanothervaccine.Itwillbenecessarytomanuallyaddthemultiple
givenCPTcodeinthebillingwindow.

WhenSaveandNewisused,informationisclearedfromtheImmunization,Dose,DoseNumber,
GivenBy,Manufacturer,DateonVIS,VISGiven,ExpirationDate,andCommentsfields.

25.ClickOKtoaddtheselectedimmunizationinformationtothepatientscurrentvisit.Theimmunizationis
documentedinthepatientsProgressNote.

ToUpdateaGivenImmunization

TheselectedimmunizationsarevisiblefromtheImmunizationssectionofthechartlinksinthePatient
DashboardorfromtheImmunizationssectionoftheProgressNoteandPatientHub.
1.ClickonanyoftheaboveoptionstoopentheImmunizationswindow.

2.Theimmunizationsthatweregiveninthepasttothepatientcanbeviewedinthiswindow.
3.SelectanimmunizationandclickUpdate.TheUpdateImmunizationDetailswindowopens.

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4.AllthefieldsareeditableexcepttheImmunizationname.EditanydetailsonthiswindowandclickOK.

Exercise

YourpatientTestEMR##wasgivenavaccinationforTetanusToxoide.Documenttheimmunizationinthe
patientsProgressNote,usingtheLotnumberTest123.Therouteofadministrationisintramuscularandthe
locationisleftlowerforearm.ThevaccinationwasgivenbyEileenPowell.

Billing

ThebillingwindowcontainsinformationabouttheICDCodesassociatedwiththecurrentdiagnosis,CPTcodes
associatedwithanyproceduresorderedforthecurrentvisitandEvaluationandManagementCodes(E&M
Codes).ThewindowalsohasanoptiontochoosemodifiersandappropriateE&Mcodes.TheEMCodertool
canbeaccessedfromtheBillingwindow.TheBillingwindowalsoincludesaNotessectionforbillingrelated
notes,aswellasafollowuptooltokeeptrackofbillinginformationforthepatient.

AllimmunizationshavetheTC(technicalcomponent)modifieralreadyassignedas90%ofthetimenurses
providethisservice.Pediatricianswillneedtodeletethatmodifierastheygiveimmunizationstotheir
patients.Thisistrueofanyinhouseproceduresaswell.Wherethenursegenerallyprovidestheservice,the
TCmodifierisalreadyassignedtotheCPTcodesointheeventaphysicianprovidestheservice,theTC
modifiermustberemovedforthephysiciantogetcreditfortheservice.

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AddorRemovetheTCModifier

1:ClickNextAppointment,VisitCodeorProcedureCodeintheProgressNotetoaccesstheBillingwindow.

TheBillingwindowopens.

2:Clickintheappropriatemodifierfield.TheNoteswindowopens.

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3:ToaddtheTCmodifier,clickinthemodifierfieldandtypeTCorclicktheSelbuttonandchooseTC
fromthelistofoptions.ToremovetheTCmodifier,clickinthemodifierfieldanddeletetheTCentry.
4:ClickOKtosaveandreturntotheBillingwindow.

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