OMR Overview for

1
OMR Overview for Medical Practice Assistants
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2
OMR System Overview
The purpose of this presentation is to provide an
overview of basic OMR functionality for medical
practice assistants.
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3
Topics Included

• What is OMR?
• Keystrokes conventions
• Accessing OMR
• Accessing a patients record
• Patient information
• Recording vital signs immunizations
• Entering notes
• Editing notes
• Establishing letter printing defaults
• Additional information assistance

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information or click on Continue to review all
topics sequentially.
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4
What is OMR?
The Online Medical Record is a multi-featured
ambulatory electronic patient record, available
via the Clinical Computing system at the Medical
Center and community health centers and
practices. OMR features include, but are not
limited to Notes, Problem Lists, and Medication
and Allergy Lists, Screening and Flow Sheets.
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5
OMR Keystrokes Conventions
To move back one level Type an underscore
(Shift hyphen)   To exit Type a (Shift 6)
or if in a word processor window press ltESCgt
To view help Enter a ? or if in a word
processor window press ltF1gt   To select a menu
option Enter either the first letter of the item
or the number associated with the item
Default values At certain prompts, the system
provides default values. Default values
always follow // . To accept the default
value, press ltENTERgt. To delete a
previously Enter an (Shift 8). filed entry
without replacing the data  
Use these keystrokes conventions when you work
in OMR. For this overview, only mouse clicking is
required.
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6
Accessing OMR
Hospital and community practice computers provide
direct access to OMR for authorized users. Click
on the CCC icon on your desktop OR click on
CareWeb and then CCC Access via Metaframe. To
obtain a key to access OMR, contact the I.S.
Support Center at [phone].
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7
System
O
Appointments/Scheduling Clinical
Information Online Medical Record OPD Reg
(Outpatient Admitting)
NextPage
PrevPage
Done
Select
Select
To access OMR, sign onto CCC. Use the up down
arrow keys on your keyboard to select Online
Medical Record.
Continue
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8
Accessing a Patients Record
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9
CONTINUE WITH LAST ENTRY FROG,KERMIT ?
N //
0901910
When you sign into OMR, the system displays the
name of the patient whose record you last
accessed. Enter Y to open this patients
record OR Access another patient by entering one
of the following Last name, first
name 7 digit CCC medical record number
Social security number
Room number for hospitalized patients
Last name for patients currently or recently
hospitalized or in ED To access another OMR
option, press ltENTERgt to accept the default of
N .
There are several test patients in OMR to use for
training. They include Kermit Frog, MRN
0901910 Kermit Frog,
MRN 1213367
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10
Patient Information Display
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11
FROG, KERMIT 0901910 M41
Home 781 555-1234
Work 617 555-1234
Online Medical Record Option
Doctor SANDS, DANIEL Z.
Nurse LEDERMAN,JOAN
Next 05/07/01-RADIOLOGY
1 Clinical Information Options
2 Display Summary
3 Lookup
4 Medication Sheet
Allergy
5 Notes
Doctor SEIKH,JAVED
6 Order Entry
7 Problem List
Hematology/Oncology
8 Screening, Flow Sheets and Forms
Doctor SCHNIPPER,LOWELL E.
9 To Do List
10 Vital Signs Rapid Entry
Infectious Disease
11 Utilities
Doctor BRODIE,SHARON
Online Medical Record Option
(Edit or View More in Order Entry)
Continue
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12
0901910 FROG,KERMIT M41
Drug Allergies Last Entry 5/30/02 No
Healthcare Proxy info on file
-------------------------------------------
SUMMARY DISPLAY ---------------------------------
--------------
MEDICATION SHEET
APPOINTMENTS
HCA PROBLEM LIST
 
 
View only Summary includes
Primary care problem list
Problems/Meds/Screening/Flow/Appointments/Notes/To
print/Quit Q //
Continue
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13
0901910 FROG,KERMIT M41
Drug Allergies Last Entry 5/30/02 No
Healthcare Proxy info on file
-----------------------------------------------APP
OINTMENT HISTORY----------------------------------
------------------
07/12/01 130 PM PODIATRY CLINIC
PODIATRY,BASILE 07/11/01 300 PM LEXINGTON
OCCUPA OT, LEX 06/26/01 300 PM
RADIOLOGY LEX, RAD 1 06/22/01 830
AM PODIATRY CLINIC
PODIATRY, LYONS CANCELLED 06/19/01
200 PM RADIOLOGY LEX, RAD
1 06/06/01 1100 AM LEX PSYCH
STEVENS, LEX NO SHOW 05/23/01
1000 AM HCA MEDICAL UNIT DESAI,
SAMEER HYPERTENSION
Press lt Enter gt to continue.
The Appointment History display shows the
following for CCC appointments
Continue
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14
FROG,KERMIT
0901910 09/21/59
Drug Allergies Last entry 05/30/02
--------------------------------------------------
--------------------------------------------------
-------------------------------
1. HYDROCHLOROTHIAZID 25MG PO Tablet
30 R3
03/30/2001 One by mouth every day

SMITH 2.
IBUPROFEN 400 MG PO Tablet 30
R0 03/30/2001 One by mouth every
8 hours for low back pain
SMITH
History? N //
The Medication List displays all active
medications the last date an allergy was
entered.
Continue
15
Recording Vital Signs Immunizations
Continue
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16
0901910
FROG,KERMIT
M41
Home 781 555-1234
Work 617 555-1234
Online Medical Record Option
Doctor SANDS, DANIEL Z.
Nurse LEDERMAN,JOAN
Next 05/07/01-RADIOLOGY
1 Clinical Information Options
2 Display Summary
3 Lookup
Allergy
4 Medication Sheet
Doctor SEIKH,JAVED
5 Notes
6 Order Entry
Hematology/Oncology
7 Problem List
Doctor SCHNIPPER,LOWELL E.
8 Screening, Flow Sheets and Forms
9 To Do List
10 Vital Signs Rapid Entry
Infectious Disease
11 Utilities
Doctor BRODIE,SHARON
Online Medical Record Option
(Edit or View More in Order Entry)
Continue
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17
           
Vital Signs Rapid Entry
FROG,KERMIT
0901910
M41
--------------------------------------------------
--------------------------------------------------
--------------------------------------------
DATE 8/14/2002
//
BLOOD PRESSURE RESULT
120/65
HEART RATE RESULT
72
WEIGHT (IN LBS) RESULT
115
TEMPERATURE RESULT
97.5
OMR displays todays date. Press ltENTERgt to
accept the date or type in another Date and press
ltENTERgt to continue. Then enter values at each
vital sign prompt.
Continue
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18
0901910
FROG,KERMIT
M41
Home 781 555-1234
Work 617 555-1234
Online Medical Record Option
Doctor SANDS, DANIEL Z.
Nurse LEDERMAN,JOAN
Next 05/07/01-RADIOLOGY
1 Clinical Information Options
2 Display Summary
3 Lookup
Allergy
4 Medication Sheet
Doctor SEIKH,JAVED
5 Notes
6 Order Entry
Hematology/Oncology
7 Problem List
Doctor SCHNIPPER,LOWELL E.
8 Screening, Flow Sheets and Forms
9 To Do List
10 Vital Signs Rapid Entry
Infectious Disease
11 Utilities
Doctor BRODIE,SHARON
Online Medical Record Option 8
(Edit or View More in Order Entry)
Select Screening, Flow Sheets and Forms to enter
immunization information.
Continue
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19

• FROG,KERMIT 0901910 41
• Screening/Flow Sheets Option
• Periodic Screening
• Health Education
• Health History
• Vital Signs
• Immunizations and PPD
• Flow Sheets
• Health care proxy
• Eye refractions
• Anticoagulation form
• Diabetes Labs
• Diabetes General
• Screening/Flow Sheets Option

Select Immunizations and PPD to enter
immunization information.
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20
           
FROG,KERMIT
0901910
M41
--------------------------------------------------
--------------------------------------------------
--------------------------------------------

• INFLUENZA 12/18/2001
• PNEUMOCOCCAL
• TETANUS (Q 10 YRS) 02/02/1990
  TD
• HFLU (ONCE)
• HEPATITIS A
• HEPATITIS B
• MENINGOCOCCAL
• MMR
• MEASLES
• MUMPS
• PPD (5 TU) CTRL
• POLIO (INACTIVE)
• RUBELLA
• VARICELLA
• YELLOW FEVER
• TYPHOID
• LYME VACCINE
• Add / Edit / Delete / Rapid entry / Full display
  / Quit Q //

 
 








 

A
OMR displays the patients most recent
immunization information
D to delete an immunization entry.
Enter A to add a new immunization.
Continue
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21
           
ADD
FROG,KERMIT
0901910
M41
--------------------------------------------------
--------------------------------------------------
--------------------------------------------
PNEUMOCOCCAL VAX
DATE
08/14/2002 //
RT DELTOID
COMMENT
FOOTNOTE ( CO./LOT )
431-929 / Exp 12/03
OMR displays todays date. Press ltENTERgt to
accept the date or type in another date. Press
ltENTERgt to continue and enter values at each
prompt.
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22
           
FROG,KERMIT
0901910
M41
--------------------------------------------------
--------------------------------------------------
--------------------------------------------

• INFLUENZA 12/18/2001
• PNEUMOCOCCAL
• TETANUS (Q 10 YRS) 02/02/1990
  TD
• HFLU (ONCE)
• HEPATITIS A
• HEPATITIS B
• MENINGOCOCCAL
• MMR
• MEASLES
• MUMPS
• PPD (5 TU) CTRL
• POLIO (INACTIVE)
• RUBELLA
• VARICELLA
• YELLOW FEVER
• TYPHOID
• LYME VACCINE
• Add / Edit / Delete / Rapid entry / Full display
  / Quit Q //

08/14/2002 RT DELTOID
LOT 431-929
After filing, OMR updates the display with the
new immunization information.
Press lt ENTER gt to accept the default of Q
and return to the main OMR menu
Continue
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23
OMR Notes
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Continue to Create New Note
24
0901910
FROG,KERMIT
M41
Home 781 555-1234
Work 617 555-1234
Online Medical Record Option
Doctor SANDS, DANIEL Z.
Nurse LEDERMAN,JOAN
Next 05/07/01-RADIOLOGY
1 Clinical Information Options
2 Display Summary
3 Lookup
Allergy
4 Medication Sheet
Doctor SEIKH,JAVED
5 Notes
6 Order Entry
Hematology/Oncology
7 Problem List
Doctor SCHNIPPER,LOWELL E.
8 Screening, Flow Sheets and Forms
9 To Do List
10 Vital Signs Rapid Entry
Infectious Disease
11 Utilities
Doctor BRODIE,SHARON
Online Medical Record Option
(Edit or View More in Order Entry)
Continue to Notes
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25
           
0901910
M41 NOTES
FROG,KERMIT
--------------------------------------------------
--------------------------------------------------
--------------------------------------------
New/Edit/View/Review/Cosign/Print/Forward/Delete/M
onitor/Quit
Notes Summary Display includes Note date, type,
author, status/title service.
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Continue to View Note
26
FROG,KERMIT
0901910
M41 NOTES
--------------------------------------------------
--------------------------------------------------
--------------------------------------------
Date 07/12/01 Signed on 07/12/01
--------------------------------------------------
--------------------------------------------------
--------------------------------------------
Medications before July 12, 2001 HYDORCHLOROTHIA
ZIDE 25MGOne by mouth every day IBUPROFEN
400MGOne by mouth every 8 hours as needed for
low back pain No medications DCd on July 12,
2001. No medications prescribed on July 12,
2001
--------------------------------------------------
--------------------------------------------------
--------------------------------------------
Patient seen for fungal toe nail infection.
Treatment options discussed. Patient will
consider options and call with a decision
regarding which he prefers.
Continue / Back up / Quit Q
Return to Notes List
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27
           
FROG,KERMIT
0901910
M41 NOTES
--------------------------------------------------
--------------------------------------------------
--------------------------------------------
New/Edit/View/Review/Cosign/Print/Forward/Delete/M
onitor/Quit N
Continue
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28
Service and Location
1. General Medicine/Primary Care at APG Sharon
Ok? Y / /
Copy a note Initial note Letter Progress
note Telephone contact
Which type of note? TELEPHONE CONTACT
DATE OF CONTACT
08/14/2002 / /
When you create a new note the system prompts for
Continue
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29
FROG,KERMIT
0901910
M41
Date August 14, 2002 Note type Telephone
Contact
Author Mary Smith
Note

For help info press ltF1gt
To exit press ltESCgt
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30
FROG,KERMIT
0901910
M41
Date August 14, 2002 Note type Telephone
Contact
Author Mary Smith
Note

Additional Help F1 Select Text
F2 Paste
F3 Delete Word
F4 Shift F4 Text Inserts
F6 Set Up Search F7 Top of
Document F8 End of Document
F9 Page Up Shift
Up Arrow Page Down Shift
Down Arrow Word Back Shift
Left Arrow Word Forward Shift
Right Arrow Exit
ltEscgt
For help info press ltF1gt
To exit press ltESCgt
Continue
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31
Options for Creating Notes
When you create any note type you can

• Type in freeform text

• Use text insert

• Combine freeform text
• text inserts in a single note
• Copy edit text from an existing
• note

To learn more about text inserts and
copying existing notes, click on HELP on the
CareGroup website, then click on CCC/OMR help and
select OMR Notes Documentation.
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32
090-19-10
FROG.KERMIT
M41
Date August 14, 2002 Note type Telephone
Contact
Author Mary Smith
Note

Patient called for last date of MRI for
comparison. Gave date of 1/2
For help info press ltF1gt
To exit press ltESCgt
Type in freeform text.
Continue
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33
0901910
FROG.KERMIT
M41
Date August 14, 2002 Note type Telephone
Contact
Author Mary Smith
Note
Patient called for last date of MRI for
comparison. Gave date of 1/2
Save and Exit
For help info press ltF1gt
To exit press ltESCgt
Enter S to save and exit.
Continue
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34

• PROGRESS NOTE for FROG,KERMIT
• 1. Exit
• 2. Forward
• 3. Monitor
• 4. Print
• 5. Sign
• Choice 5 / /

Forward Use this option to forward a copy of
this note to the patients PCP, referring MD, or
other provider.
Continue
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35
0901910
M41 NOTES
FROG,KERMIT
--------------------------------------------------
--------------------------------------------------
---------------
PROGRESS NOTE for FROG,KERMIT 1. Exit 2.
Forward 3. Monitor 4. Print 5. Sign Choice
5 / / 5
Select 5 to sign your note.
Select an affiliation to indicate in which record
this note/letter belongs. 1. BIDMC 2. HMFP
Practice 3. APG Practice 4. Other Private
Practice Affiliation
3
Save APG Practice as your default affiliation ?
Y //
KEY
Continue
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36
Editing Notes

• Unsigned notes
• Editable at any time
• Signed notes
• Editable for 3 hours after signing
• Users can add an addendum at any time

Continue
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37
           
FROG,KERMIT
0901910
M41 NOTES
--------------------------------------------------
--------------------------------------------------
--------------------------------------------
UNSIGNED
New/Edit/View/Review/Cosign/Print/Forward/Delete/M
onitor/Quit E
Continue
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38
FROG, KERMIT
0901910 M41 TELEPHONE CONTACT
--------------------------------------------------
--------------------------------------------------
------------------------------
Date of Contact Display Title
08/14/02 PHONE SMITH
UNSIGNED
(MED)
Edit
1. Display title 2. Note 3. Date of contact
Select 2
Continue
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39
090-19-10
FROG.KERMIT
M41
Date May 4, 2001 Note type Telephone Contact
Author Mary Smith
Note
Patient called for last date of MRI for
comparison. Gave date of 1/2
/2001
For help info press ltF1gt
To exit press ltESCgt
Edit existing text or enter new text.
Press ltESCgt to exit and file edits.
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40
090-19-10
FROG.KERMIT
M41
Date May 4, 2001 Note type Telephone Contact
Author Mary Smith
Note
Patient called for last date of MRI for
comparison. Gave date of 1/2
/2001
Save and Exit
For help info press ltF1gt
To exit press ltESCgt
Enter S to save and exit.
Continue
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41
TELEPHONE CONTACT for FROG,KERMIT 1. Exit 2.
Forward 3. Monitor 4. Print 5. Sign Choice
5 / / 5
Select 5 to sign your note.
Select an affiliation to indicate in which record
this note/letter belongs. 1. BIDMC 2. HMFP
Practice 3. APG Practice 4. Other Private
Practice Affiliation
3
Continue
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42
Letter Printing Default Settings
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43
You have NOTES.
Online Medical Record Option
1 Alerts, Notes, and Attestations 2
Clinical Information Options 3 Management
Options and Reports 4 Patient Selection OMR
5 Utilities
Online Medical Record Option
3
Default settings allow users to establish margins
used for letter printing and the number of copies
printed.
Continue
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44
Management/Report Option
1 Notes reprint 2 Prescriptions reprint
3 To Do List Personal Entries Display 4
Anticoagulation lists 5 Defaults 6 Insert
text 7 Access notification list 8 To
change access reason 9 OMR Support Options 10
Copy Reminders (Alerts/Notes/Attestations) Mana
gement/Report Option 5
Continue
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45
Default option
1 Access notification 2 Medication
printing 3 Notes/Letters 4 Show open
appointments Default option 3
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46
Notes default setting
1 Forward automatically 2 Medications
into progress/initial notes 3 Printing 4
Service/Location 5 Sign-off Notes default
setting
2
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47
LETTER PRINTING L LETTERHEAD
Beth Israel Hospital (2 inch top margin) /
/ LS SECOND PAGE LETTERHEAD M
MARGINS Two (2) inch
left margin / / B BOTTOM MARGIN
Increased margin (1.25 inch) / / W
WINDOWS PAGE BREAK OFF? PS PRINT SINGLE
COPY OF LETTER (ON STATIONARY)? Y / / ESFL
PRINT ELECTRONIC SIGNATURE ON FILE ON
LETTERS EDIT
M
B
PS
ESFL
L
If you print letters for providers, you can use
the Letter Printing Default options to establish
margins for provider letters.
Enter M at the prompt to establish the left
margin.
Enter B at the prompt to establish the bottom
margin.
Enter PS at the prompt to control how many
copies OMR prints of each letter.
Enter ESFL at the prompt if you wish
Electronic Signature on File to print on each
letter.
Continue
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48
Default option 1 Letter printing 2
Notes printing Default option 2 Notes
printing NOTE PRINTING PU PRINT UNSIGNED
NOTES DOUBLE SPACED? ESFN PRINT ELECTRONIC
SIGNATURE ON FILE ON NOTES? EDIT
PU
ESFN
Enter PU at the prompt to print all unsigned
notes double spaced.
Enter ESFN at the prompt if you wish to have
Electronic Signature on File printed on all
notes.
Continue
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49
For Additional Information
Continue
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50
Click on HELP on the CareGroup portal for
detailed CCC/OMR help.
Continue
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51
Click on CCC/OMR Help for OMR Documentation
topics.
Continue
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52
OMR documentation topics include General
Information, Medications, Notes, Problem Lists,
Management Options, and Transcription Information.
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53
Questions or Problems

• For computer printer problems
• Call the IS Support Center
• [phone]

• For questions about how to use OMR
• Email OMRSupport_at_caregroup.harvard.edu
• Receive a response within 1 business day

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54
And OMR Overview Training is Complete Click
Here to Return to CCC/OMR Help OR
Click Here to Return to the CareGroup Portal
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