Health ePractice

1
Health ePractice Electronic Medical
Record Clinical Companion
2

• The eClinicalWorks Clinical Companion
• This companion was created to assist you with the
  adoption of eClinicalWorks Medical Record
  Software. It will help familiarize you with
  eClinicalWorks terminology and functionality and
  offers an array of material pertaining to

• Basic eClinicalWorks Navigation Functionality
• How to Document Medications and Chief
  Complaint(s)
• How to Document Vital Signs and Patient History
• How to Document Results on an In-House Lab
• How to Abstract a Paper Chart
• Practice Scenarios

Your Companion will come in handy throughout your
eClinicalWorks adaption process, specifically

• When Watching Web-Based Training
  Modules
• To Prepare For Your Scheduled Training
  Sessions
• To Practice in the TRN Environment.
• To Help Assist You With Functionality
  During Your Go-Live

We look forward to working with you during your
transition process and making this as painless as
possible for all staff members! The Health
ePractice Team
3
How Do I Access?
St. John HealthPartners Website

1. In Windows Internet Explorer address bar type
   http//www.health-epractice.org/
2. St. John HealthPartners Website will display.

1. On the main tool bar hover over
   to display a drop-down menu.
2. From the drop-down menu click on Practice Tools
3. You have arrived at eClinicalWorks (PM/EMR)
   Practice Tools Home Page

3
4
How Do I Access?

• Web-Based Training (WBT) Modules

• On the eClinicalWorks (PM/EMR) Practice Tools
  home page scroll down to the Training Tools area.
• Select your appropriate role by clicking on the
  role button

1. A list of mandatory WBT Modules display for the
   selected role.
2. Click on the name of any module to open the
   content.

4
5
How Do I Access?
How do I log into eClinicalWorks Train
Environment?

1. Click on the button.
2. Click on the button.

1. The Run activity window displays. In the Open
   field type in the following MSTSC and click the
   OK button.

1. The Remote Desktop Connection activity window
   displays. In the Computer field type in the
   following Asp12.eclinicalweb.com9328 and click
   the Connect button.

5
6
How Do I Access?

1. The Log On to Windows activity window displays.
   

1. Input the User name and Password that was
   provided to you by your Implementation
   Coordinator.

1. eClinicalWorks Log-In screen displays.

1. Enter the Login ID and Password that was provided
   to you by the Implementation Coordinator.
2. Click on the button.

6
7
Basic eClinicalWorks Navigation
How do I log into eClinicalWorks Production
Environment?

1. Double-Click on the icon located on
   the desktop.
2. eClinicalWorks login screen appears.
3. Type in your login ID and password as
   appropriate.
4. Click on the button.

How do I log out of eClinicalWorks? There are
two ways to log out of eClinicalWorks

• Click on and select EXIT from the
  drop down menu.
• OR
• Click on the in the upper left hand corner
  of the screen.

7
8
Resetting Your Password

• From any area within the System
• 1. Select the File Menu
• 2. Select Change Password from the menu
• 3. The Change Password window opens

9
Local Settings Hiding Canceled appointments
Local Settings Hiding Canceled
Appointments/Show only billable visits
Rescheduled and Canceled Appointments will appear
on the Resource Schedule unless this local
setting is set.

1. From the File Menu, hover over settings and
   select Local Settings from the sub menu.

1. In the Local Settings window, select the Show
   Only Billable Visits

1. Click to save changes.

9
10
Basic eClinicalWorks Navigation

• Basic Navigation Tools

eClinicalWorks application window has five
standard navigation elements. These elements
appear in Resource Schedule, Office Visit, and
Progress Note workspace.
1
4
2
3
Element Details

• The Menu Bar
• Consists of the File, Patient, Schedule, EMR,
  Billing, Reports, CCD, Fax, Tools, Community,
  Lock Workstation, and Help drop down menus.
  Depending on your security, these menus can be
  used for basic functionality throughout the
  application.
• Patient Look-up Icon
• Launches the patient search activity window.
  When a patient is selected the Patient Hub
  displays. Clicking the down-arrow displays the
  last five (5) Progress Notes accessed.
• Toggle Buttons (Olive Buttons)
• Enables the user to show or hide application
  elements.
• Quick Launch Dashboard Taskbar (Jellybeans)
• Shortcut buttons to access items needing
  attention. The shortcut buttons also indicate the
  urgency and number of pending document reviews,
  and unread messages.
• Bands and Left Navigation Pane
• Provides access to functionality granted to the
  user by their security settings.

5
11
Basic eClinicalWorks Navigation
Patient Look-Up and Patient Hub Overview

1. You can look up a patient by clicking on the
   Patient Lookup Icon
2. The Patient Lookup activity window opens which
   gives you a list of all the patients in the
   system arranged alphabetically by their last
   name.
3. Patients can be searched by using a combination
   of different search options such as Name, SSN,
   DOB, Account No./Medical Record No., Phone No.,
   Subscriber No., Previous Name or Home, Work, and
   Cell phone. Patients can also be filtered by
   their default appointment facility.
4. When a patient is selected the Patient Hub will
   display.

3

1. The Patient Hub provides a convenient, single
   point of access to all information available in a
   patients record.

4
12
Basic eClinicalWorks Navigation
Quick Launch Task Buttons Overview

• E Menu The total number of e-prescriptions
  refill requests received and transmission errors
  displays on the button. Click to open the
  e-prescriptions window to review all
  e-prescriptions.
• S Menu Provides links to the Office Visits,
  Resource Schedule, and Progress Note windows. The
  number next to the S also indicates that number
  of patients marked as arrived. This number only
  displays for the providers and not for any other
  staff member other staff members will see this
  number change from 0.
• D Menu Provides the option of going directly to
  the Fax Inbox or Fax Outbox windows. The number
  next to D indicates the number of documents
  assigned to the logged in staff member. Click the
  button to open the Review Document window.
• R Menu Provides links to the Incoming Referrals
  or Outgoing Referrals windows. The total number
  of referrals assigned to the logged-on user
  displays in parentheses next to each link. The
  number next to the R indicates the number of
  combined incoming and outgoing referrals. Click
  the button that has the number to open the
  Outgoing Referrals window, or click the R
  itself, which will give you a drop down menu and
  from there you can select Incoming or Outgoing
  Referrals.
• T Menu Provides links to the Telephone/Web
  Encounters window, which includes new telephone
  and web encounters. The total number of
  encounters assigned to the user who is logged in
  will be displayed in parentheses next to each
  category. The number next to the T indicates
  the combined number of open telephone, web
  encounters and action items assigned to you.
  Click the button to open the Telephone/Web
  window.
• L Menu The L menu opens the labs and imaging
  window. The labs/imaging window opens directly to
  the To Be Reviewed Tab. The total number of labs
  and imaging assigned to the logged in user will
  display in parentheses next to each category. The
  number next to the L indicates the combined
  number of labs and imaging.
• M Menu Provides links to the Inbox, Outbox, or
  Deleted Messages windows, and includes a link to
  the Create New Message window. The number next to
  the M indicates the number of new messages in
  the inbox for the logged-in user. By clicking on
  the letter M you can choose to view the Inbox,
  Outbox, Deleted Messages and even Create New
  Messages.

13
Basic eClinicalWorks Navigation
Office Visit Schedule Overview
Office Visit view is the designated workspace for
Physicians and clinical staff. This workspace
displays all scheduled appointments and
distinguishes patients that have completed the
arrival process, and are ready to be seen by the
Physician.

• P/R Radio Buttons
• Enables to view Provider or Resource patients.
• Appointment Time and Date
• Defaults to the current date and enables the
  user to sort the schedule by using Morning,
  Afternoon, or All Day selection.
• Sort By
• Enables the user to sort patients by appt. time,
  patient name, or visit status.
• Visit Status
• Indicates if the patient has arrived for their
  appointment
• Room
• Indicates the exam room the patient is
  in.
• Status
• Current status of the patients visit
• Button Bar
• Displays the following options Progress Notes,
  Check In/Out, Billing Data, Refresh, View Orders,
  Lock Progress Notes (drop down displays several
  Template options), and eCliniForms.

14
Basic eClinicalWorks Navigation
Update a patients status code and enter a exam
room identifier in the Office Visit Screen

1. Select the patient from the schedule.

1. Click on the button.

1. The Encounter Activity window displays.
2. Click in the Check In box.
3. The Time In field will populate the time.
4. Click in the Room No field and enter patient room
   number.
5. Click on the button.

1. The patients arrival time, room number and
   status will appear on the Office Visit schedule.

8
15
Basic eClinicalWorks Navigation
Accessing the Patients Visit

1. To open a patients visit, double-click on the
   patients name from the office visits screen.
2. The patients visit opens in the Progress Notes
   view. All clinical documentation will be
   completed in this view.

1
2
16
Abstracting
How do I Abstract Clinical Data into
eClinicalWorks?

1. Click on the icon to search for the
   patient.
2. The patient Look-up activity window displays.
3. In the Search Patient field enter the patients
   name.

1. Select the desired patient from the list and
   click on the button.
2. The Patient HUB displays.

1. Click on the
   button.
2. The Telephone Encounter activity window displays.

17
Abstracting
8
9
13
14

1. In the Provider field click on the drop-down menu
   arrow and select the desired Provider.
2. In the Pharmacy field click on the ellipsis
   button.
3. Search for the patients preferred pharmacy on
   file by entering the Pharmacy name in the Lookup
   pharmacy field.

10

• Select the desired Pharmacy from the list.
• Click on the button.

11

1. In the reason field type in Abstract.
2. Click on the tab.
3. The Message field displays the outline of the
   Progress note.

12
18
Abstracting
Documenting Current Medications

• Click on Current Medication hyperlink to
  document the patients Current Medication.
• The Chief Complaint/Current Medication activity
  window displays.

2

1. In the Current Medication field click on the
   button.
2. The Select RX activity window displays.
3. In the Find field type in the PARTIAL name of the
   drug.
4. Select the desired drug from the list.
5. Select the desired strength.
6. The drug appears in the Selected RX field.
7. To add another medication repeat steps 3 8 or
   if you are done click on the button.

19
Abstracting

1. Update the dose/frequency at this time by
   clicking in the desired fields.
2. Indicate by clicking
   in the box.
3. Click on the button.

Documenting Allergies

1. Click on the Allergies/Intolerance hyperlink.
2. The Past Medical History/Allergies activity
   window displays.
3. To add a Drug (RX) Allergy click on the
   button.

1. To add a Environmental Allergy click on the
   button.
2. Select Structured for RX allergies and
   Non-Structured for environmental.
3. In the Agent/Substance field click on the
   drop-down arrow to select the desired allergy
   from the list.
4. Click in the Reaction field and then click on the
   drop down arrow to select the desired reaction of
   the allergy.
5. Document

3
4
8
7
6
5

1. Repeat steps 3 8 to document another allergy or
   click on the button.

20
Abstracting
Documenting Past Medical and Surgical History

1. Click on the desired history hyperlink Medical
   History Surgical History
2. The Activity Window displays.
3. Click on the button.
4. In the History field type in the past medical
   condition.
5. Repeat steps 3 4 to enter another condition.
6. Document by
   clicking in the box.
7. To document the Surgical history click on the
   icon.

1. The Surgical History activity window displays.

21
Abstracting

1. Click on the button.
2. In the Date field enter the Month/Date of the
   surgery if available.
3. In the Surgery field enter the Surgery name.
4. Repeat steps 9 11 to document more surgical
   history for the patient.
5. Document
6. Click on the button.

Documenting Family History

1. Click on the Family History hyperlink.
2. Family History activity window displays.
3. To indicate the status of a family member click
   in the status field One Click Alive, Two
   Clicks Deceased, and Three Clicks Unknown.
4. To document DOB, enter only the year the patient
   was born. Entering the year will default the age
   of the family member in the Age field.

• Click in the notes field to document any medical
  problems pertinent to the family member.
• The keywords activity window displays.
• In the find field type in the partial name of the
  medical problem.
• Select the desired name from the list.
• The medical problem moves to the Selected field.
• Select the appropriate relative to link the
  medical problem with.

22
Abstracting

1. To search for another medical problem, repeat
   steps 7 10.
2. Once you have completed the documentation click
   on the button.
3. Document .
4. Click on the button.

Adding to the Problem List

1. Click on the Assessment hyperlink.
2. The assessments activity window displays.

23
Abstracting

1. Enter the problem in the Find In field and
   click go.
2. Click on the desired problem from the list.
3. The problem appears in the Selected Assessments
   field.
4. Add the problem to the patients problem list to
   by clicking in the box in the PL field.
5. Repeat steps 3 6 to document another problem is
   applicable.
6. Click on the button.

Documenting Vital Signs

1. In the Telephone Encounter activity window,
   change the date field to match the date of the
   vital signs to be abstracted.

1. Click on the Vitals hyperlink.
2. Enter the Vitals Signs as appropriate in the
   designated field with the accurate date.

24
Abstracting

1. Once you have completed entering the vitals click
   on the button.
2. In order to abstract another set of vitals from a
   different date you will have to open a NEW
   telephone Encounter and repeat steps 1 3.

Documenting Immunizations/Injections

1. Click on the Immunizations hyperlink.
2. The immunizations/Injections activity window
   displays.

1. Click on the button.
2. The Immunization Details activity window
   displays.

1. In the find field search for the immunization.
2. Select the name from the list.
3. Click in the box next to Vaccination Given in
   the Past. This enables you to document the date
   the immunization was adminstered.

25
Abstracting

1. Enter all recommended fields as appropriate.
2. If you need to add more than one immunization
   click on the button
   and repeat steps 5 8.
3. Once completed click on the button.

Completing the Abstract Process

1. In the Telephone Encounter activity window click
   on the tab.
2. In the Actions Taken field click on the
   button.
3. Type in the field Chart Abstracted and click on
   the OK button.
4. Your name and the date will be time-stamped in
   the field.
5. To close the encounter click on the
   button.

26
Document Management
Correcting Scanned Documents
If a scanned document is scanned under the
incorrect patient, access the Patient Documents
module.

1. Select the document and click on the View button.

1. Click on the Save button.

1. Save the document to your desktop or a documents
   folder, click Save.

1. In Document Category click on Custom radio
   button.
2. Browse the folder you saved the document.
3. Documents in the folder will appear in the Scan
   bucket

4
5
27
Document Management
Correcting scanned documents

• If documented on the incorrect patient
• Search patient within the Document Management
  section using the Sel button, follow the below
  steps

1. Click on the document from the Scan Bucket.
2. Add to the appropriate folder.

• To delete the old document
• Click on the document from the folder structure.
• Click on the drop down arrow next to Add.
• Click Delete
• Note Only Super users and Office Managers have
  access to delete documents.

27
28
Basic eClinicalWorks Navigation

• Progress Note Overview
• The progress note of the patient contains 3 major
  sections
• Patient Dashboard
• Patient Chart Panel
• Patient S.O.A.P. Note
• Patient Dashboard
• The patient dashboard displays
• The patients picture with demographic
  information.
• The patients insurance details, account balance,
  PCP first and last appointment.
• A sticky note panel and secure notes (Physician
  to Physician) panel that can be used for
  documenting any important non-chart information
  about the patient.
• Advance Directive shows the code entered by the
  front office in the demographics section.
• The menu bar gives a summary of all the data
  entered such as medical summary, list of labs,
  DI, procedures etc.,

4
3
2
1
Patient Chart Panel The patients chart panel is
the storage panel of all the previously entered
information such as Problem List, Current
Medication Summary, Allergies, Immunizations,
History, Comprehensive Summary of the Patients
Test Results, Telephone Encounters, Web
Encounters, and Clinical Decision Support System
that includes PCMH Alerts.
29
Subjective and Objective Documentation

• Documenting a Chief Complaint

1. In Progress Note click on Chief Complaint(s)

1

1. Chief Complaints activity window will display.

1. To add a chief complaint click on the browse
   button.

3

1. In the Find field type in the name of the
   complaint.

4
30
Subjective and Objective Documentation

1. Select the appropriate complaint from the list.
2. Click button.

5
6

1. The chief complaint is added. Click to
   close.

1. Chief Complaint entry will appear on the Progress
   Note.

31
Subjective and Objective Documentation
Current Medication Documentation

1. From the patients progress note, click on
   Current Medications.

1. The Current Medications Activity window will
   display.
   Note this window is also shared by chief
   complaints.
2. To document a current medication click on the
   button.

3

1. The RX Select activity window displays.
2. In the Find field, type the medication name.

• The medication name will appear in the left hand
  column and the strength(s) appear in the right
  column.
• Select the appropriate strength of the medication
  and it will populate under the Selected RX area.
• Repeat steps five through seven to add another
  medication..
• To complete this documentation click on the
  button .

5
6
7
32
Subjective and Objective Documentation

1. The Current Medication window displays with the
   added medication.
2. Document that Medications have been verified by
   clicking on the Medication Verified box.

11
Documenting Past Medical History

1. From the Progress Notes, click on Medical
   History
2. Click on the Browse or Add Button to add
   Medical History documentation to the patients
   chart.

2
3

1. Once documentation of Past Medical History has
   been completed, make sure to indicate the history
   has been verified by clicking on the History
   Verified box.

NOTE The Browse button shows a general list
of keywords that can be selected for the
patients Medical History. The Add button
allows you to free-text the history compared to
selecting from a list. Past Medical History gets
carried forward from visit to visit and history
information from the previous visit is
automatically displayed on the Progress Note.
33
Subjective and Objective Documentation
Documenting Allergies

1. Select Allergies/Intolerance from the Progress
   Note

1. The Allergies activity window displays (this
   window is also shared by Past Medical History).
2. To indicate the patient has No Known Drug
   Allergies (NKDA) click in the box next to NKDA.
3. To search for a drug allergy, click on the
   button.

4
3

1. In the Find field, search for the name of the
   drug allergy.
2. Select the appropriate allergy by clicking on the
   allergy name. The name will populate in the
   Selected RX field.
3. Click on the button.

34
Subjective and Objective Documentation

1. To search for a Environmental or Food Allergy
   click on the button.
2. In the Structured/Non Structured field click on
   the drop-down menu arrow.
3. Select Non Structured from the menu.
4. A warning will appear indicating if you free-text
   in the field it will be excluded from automated
   drug-allergy testing. Click
5. Click in the Agent/Substance field.
6. Click on the drop-down menu arrow and select the
   allergy from the list.

9

1. Click in the Reaction box.
2. Click on the drop down menu arrow and select the
   appropriate reaction.

1. Mark the allergies as verified by clicking in the
   Allergies Verified box.

16
14
15
35
Subjective and Objective Documentation
Documenting Surgical and Hospitalizations History

1. From the patients progress note, click on
   Surgical History. The following window opens

• Click on Browse or Add button to either add
  or update a new surgical history or
  hospitalization.
• When a patient has no surgical history or
  hospitalization, you can click on Denies Past
  Surgical History or Denies Past
  Hospitalization.
• Once documentation of Surgical History /
  Hospitalizations have been completed, make sure
  to indicate the components have been verified by
  clicking on both the Surgical History Verified
  and hospitalization Verified boxes.

Documenting Family History

1. From the patients progress note, click on
   Family History. The following window opens

36
Subjective and Objective Documentation

1. Under Status click in the field box to indicate
   a status of alive, deceased, or Unknown.
2. Click in the DOB field and enter a birth year.
   This will automatically calculate the age of the
   family member.
3. Click in the notes column to open the keyword
   window.

5
6

1. Select condition from the left pane to add it to
   the Selected Category in the center pane.
2. Select the relative on the right pane that are
   known to have the condition. NOTE you can
   select multiple relatives that have the condition
   by pressing the control key on the keyboard and
   holding it down while selecting the family member
   with the mouse.

Documenting Vital Signs

1. In the progress note click on Vitals

1. Vitals intake activity window will display
2. Click in first field box (in this instance HR)
   and type value
3. Use the tab key to move to following fields and
   continue typing values in appropriate fields.
   (Note BMI will auto-calculate for you)
4. When you have completed entering vitals, click on
   the red X to close the window.

37
Subjective and Objective Documentation

1. The vitals information will appear in the
   progress note time stamped with the date, time,
   and name of the individual who documented the
   information.

38
Subjective and Objective Documentation

• How do I access the Initial Visit Smart Form to
  document certain components for PCMH
  certification?

1. In Progress Note click on the drop down menu
   arrow in the Smart Form (SF) field.

1

1. Select Initial Visit from the drop down menu.

2

1. The Initial Visit smart form displays.

• Fill in the appropriate information provided by
  the patient by using the drop down menus (if
  provided) or clicking in the box by the
  selection.
• NOTE You do not need to complete all
  of the fields on the form to move forward!!
• Click on the
• button to save the information that you
  documented and move to the next screen.

4
5
39
Subjective and Objective Documentation

1. The Tobacco Control form displays.

1. Depending on what you select under the Are you
   a field, options will appear for specific
   documentation pertaining to the choice selected.
   
2. After completion click on the

7
8
button.

1. The Alcohol Misuse/Abuse form displays.

1. Depending on what you select under Did you have
   a drink containing alcohol in the past year? More
   questions will appear for specific documentation.
2. At the completion of the form, you will receive a
   point value. This value will be used to select
   the interpretation of the form, Positive or
   Negative.
3. Once the form is completed click on the
   button.

10
11
12

1. The Depression Screening form displays.

1. Complete the form as appropriate.
2. Click on button to complete the
   Initial Visit Smart Form.

14
15
40
Subjective and Objective Documentation

1. A pop-up activity window will display stating
   that the Form Data Saved Successfully.
2. Click on the button.

1. You will return back to the Progress Note.

41
Subjective and Objective Documentation
ePrescribe

1. From the patients progress note, click on
   Treatment.

1. The Treatment Activity window will display.
   
   Note The individual tabs allow the physician to
   specifically address each symptom.

1. Click on the tab corresponding to the diagnosis
   for which medications need to be prescribed or
   refilled.
2. To refill patients current medication, click on
   the Cur Rx button, select the meds that need to
   be refilled and simply type in the number of
   refills in the refills column.
3. To document whether the patient was asked to
   increase/decrease/stop the current dose, click on
   the comment column and choose the respective
   comment.
4. To prescribe a new medication, click on the Add
   button and choose a new medication from the
   pre-populated medication list. Once the
   medication is chosen and when you click OK, the
   dosage details can be modified back on the
   Treatment screen.

42
Subjective and Objective Documentation
ePrescribe
7. The medication can then be printed or faxed or
electronically prescribed to the patients
pharmacy by clicking on either the Print button
(to print on prescription paper) or the green
arrow next to the Print button (to fax or
e-scribe).
43
Subjective and Objective Documentation
Updating Clinical Data Support Services
(Scenario 1)

1. From the Treatment Activity Window, Click on the
   CDSS button.

1. The CDSS Alerts Activity window will display.
   
   

Exiting the Progress Note
Click on the X in the top right corner of the
screen.

44
Subjective and Objective Documentation
Updating Clinical Data Support Services eCW notes
45
Subjective and Objective Documentation
Updating Clinical Data Support Services CDSS
(Scenario 2)

1. In Progress Note Click on the CDSS link in the
   Patient Dashboard Menu.

1. The CDSS Alerts Activity window will display.
   
   

1. All non-compliant CDSS alerts (i.e. alerts for
   which either the numerator or the denominator
   criteria is not satisfied) show up on the patient
   chart panel.
2. Note If any of the CDSS alerts on the chart
   panel are linked with an order set, it is
   indicated by a symbol before the alert name.
   Clicking on the symbol shows the order set
   associated with that alert. The order set can be
   applied to the patients progress note by either
   clicking on the OS button or by clicking on the
   arrow button, if it is a quick order set. For
   quick order sets, in addition to applying the
   order set, a status for the order can be chosen.

46
Subjective and Objective Documentation
Updating Clinical Data Support Services
(Scenario 2)

1. In Progress Note Click on the CDSS link in the
   Patient Dashboard Menu.

1. The CDSS Alerts Activity window will display.
   
   

47
Result Documentation
Viewing Patient Orders (In-House and Outpatient
Services)

• From the Office Visits screen select the Patient
  with outstanding orders by clicking on their
  name.
• Note Patients with outstanding orders names
  will be highlighted in green.

• Click on the View Orders button.
• Patient Orders Window opens.
• Note The In-House Orders will be highlighted in
  green.
• Click on the Quick Transmit button to open
  Transmit Orders window.
• Or Click on the individual order, then click on
  the view button (or double click on the order) to
  individually submit each order to its selected
  destination.

48
Result Documentation
Viewing Patient Orders (In-House and Outpatient
Services)
49
Checking Logs
Fax Outbox Log

1. To verify the status of a sent fax, click the
   Documents band on the left navigation panel.
2. Click Fax Outbox icon.
3. The Outbox lists the outgoing faxes. Fax Status
   column shows the status.
4. Click Refresh to update the statuses.
5. If desired, double click on a fax to view. This
   can only be done with faxes that have a Completed
   status.

1
2
3
4
49
50
Checking Logs
ePrescription Logs (list of only ePrescribed
medications)

• Click the Documents band on the left navigation
  panel.
• Click the ePrescriptions icon.
• Change the filters if you are looking for
  specific criteria.
• This logs lists only the Rxs that have been sent
  via ePrescribe.
• View the Status column to verify if the
  ePrescription status.
• Click Refresh to update the status column.
• A RED Success status means a denial was sent to
  the Pharmacy successfully.
• These denials include
• Physicians denying an electronic Rx request.
• Controlled substances that cannot legally
  transmit via ePrescribe. Provider needs to open
  a telephone encounter and send the controlled
  substance via fax (or it can be printed and
  picked up by patient). It is set up
  like this to prepare for when we can transmit
  controlled Rxs electronically.

3
1
7
2
5
6
50
51
Checking Logs
Prescription Logs (list of only faxed and
printed prescriptions)

• Click the Documents band on the left navigation
  panel.
• Click the Prescriptions icon.
• Change the filters if you are looking for
  specific criteria.
• This logs lists only the Rxs that have been
  faxed or printed.
• Click Refresh to update the status column.
• Double click on any line item to view the
  prescription that was sent/printed.
• Status Columns
• Faxed-Only successful faxes will appear. Check
  the Sent Date column.
• Printed-Printed fax status will appear as Logged.

3
1
2
7a
6
5
7b
51
52
Checking Logs
Prescription Log Report (contains All
prescriptions and is printable)

1. The Prescriptions log report contains a printable
   list of ALL prescriptions sent.
2. At the top of the screen, click
   ReportsgtEMRgtPrescriptions Log Report.
3. In the Prescriptions Log Report Screen, adjust
   the provider and dates and click Get Report
   button.
4. Print Preview and Print buttons are available at
   the bottom of the window.

2
3
52
4
53
Telephone Encounters
Attaching a Document to a Telephone Encounter

• From the Patient Documents window, you can
  attach a document to a telephone encounter
  without first inserting it into a patients
  chart.
• To attach a document to a telephone encounter
• From the Documents band, click the Patient
  Documents icon.

1
2
1

• Once in the encounter click on the Sel button
  and select a patient from the Patient Lookup
  window
• Under View click on File View
• In File View, click a document from the list and
  select it to display a drip-down list. .
• From the list, select Create Telephone
  Encounter
• The Patient Lookup window opens

53
54
Telephone Encounters
Attaching a Document to a Telephone Encounter

• Select the patient and click the OK button.
• The Telephone Encounter window opens.
• The message, Document attached from fax inbox
  displays in the telephone encounter indicating
  the document is attached.

6
54
55
Section III How To Guides Advanced Features
Document Management Scanning Results without
an Order
For paper or electronically faxed results can be
attached to an order to satisfy the Results
Received. At the Document Description window
complete the below tasks.

1. Scan document as directed in the Document
   Management Scanning Section, at step 7 click
   the Add Description box and click OK.
2. Click on the Assigned To ellipse

• Click on the New button of the Orders window.

1. Click on Sel. To search the order Select the
   order. Assign the Facility, Assigned To, Results
   Received and Result info. Click OK

1. Check the newly added order and click OK.

55
Complete the Document details as applicable
56
Section III How To Guides Advanced Features
Document Management Scanning Results to an
Order
For paper or electronically faxed results can be
attached to an order to satisfy the Results
Received. At the Document Description window
complete the below tasks.

1. Scan document as directed in the Document
   Management Scanning Section, at step 7 click
   the Add Description box and click OK.
2. Click on the Assigned To ellipse

1. Check the box for the order and click OK.

1. Document that the result has been received by
   checking the box.

Note If this is a lab, you can input the
discrete results in the attribute fields in the
Results section.
Orders will appear with a paperclip to identify
that there is a scanned report attached to the
order.
56
57
Training Scenarios

• In this section you will be given scenarios that
  will help you to learn the system as it pertains
  to a daily workflow within your office.
• Each scenario can be run through by using the
  patients you were assigned to at training, if
  there is an item required in order to conduct the
  scenario it will be listed in blue text for you.
• Good Luck and enjoy your learning experience!

58
Checking - In

• Checking a Patient In at the Mid-Office Level
• Training Scenario
• Your Patient has been checked in at the front
  office for their appointment. You must now
  document that they have been taken from the
  waiting room to an exam room.
• 1. From the Practice band, click the Office
  Visits icon.
• The Office Visits window opens.
• 2. Left click once on an appointment to
  highlight it.
• 3. Click the Check In/Out button.
• The encounter window opens for the Patient,
  DOB, Sex,
• Appointment Time, and Reason fields
  automatically populated.
• 4. Check the Check In check box.
• The Time In field is automatically populated
  with the current time.
• 5. Type the exam room the patient is being taken
  to in the Room No. field.
• 6. Click the More () button next to the Status
  field.
• The Status Codes window opens
• 7. Left-click once on the desired status.
• 8. Click OK to close the Status Codes window.
• 9. Click OK to close the Encounter window.

59
Chief Complaints

• Documenting a Chief Complaint for a Patient
• Training Scenario
• Your Patient has been checked in and taken to an
  exam room, You must now record their chief
  complaint, which includes headaches and fatigue.
• 1. From the patients progress note, click Chief
  Complaints.
• The Chief Complaints window opens.
• NOTE if a reason was documented in the Reason
  field on the Appointment
• window by the front staff it will appear here.
• 2. Click the Add button.
• A new row appears with a blank Complaint
  field.
• 3. Click in the Complaint field for row 1 and
  type headaches
• 4. Click the Add button.
• A second row appears with a blank Complaint
  field.
• 5. Click in the Complaint field for row 2 and
  type fatigue
• 6. When asked which complaint is more severe,
  the patient states that the fatigue is
• the primary complaint, so left- click once on
  the fatigue field and click the
• button on the right.
• The fatigue complaint is now moved up one row
  to row 1.

60
Current Medications

• Adding a Current Medication from the Database
• Training Scenario
• Your Patient has been prescribed two medications
  from another physician since their last visit.
  These two medications are Aspirin, at an 81mg
  dose and Ibuprofen, which they do not know the
  dose for. You must now document these
  medications.
• 1. Click on Current Medications from the
  patients progress note.
• The Current Medications window opens.
• 2. Click the Add button in the Current
  Medications section.
• The Select Rx window opens.
• 3. Ensure Medispan is selected from the Type
  drop-down list and type aspirin into
• the find field.
• A list of medications starting with aspirin
  displays in the left
• pane.
• 4. Click the aspirin medication.
• A list of the various strengths and
  formulations for this medication
• displays in the top right pane.
• 5. From the list, choose the option with 81 mg
  in the Strength column and tablet
• in the Formulation column.
• The medication is now transferred to the
  Selected Rx pane.

61
Medical History

• Adding Medical History
• Training Scenario
• Your Patient has a medical history of
  Hypertension and Measles. They also have had
  bouts of Chicken Pox and influenza since the last
  time they were at the office, which must now be
  documented in their medical history.
• For this scenario you will need
• the keyword influenza added to the Medical
  History keyword database
• 1. From the patients Progress Note, click
  Medical History.
• The Past Medical History window opens with
  past visit medical history already populated.
• 2. Click the Add button.
• A third row appears with a blank History
  field.
• 3. Click once in the History field of row 3.
• 4. Type Chicken Pox into the History field for
  row 3.
• 5. Click the Browse button.
• The Medical History List window opens.
• 6. Type influenza into the find field.
• All Medical history keywords beginning with
  influenza display in the left pane.
• 7. Click the influenza keyword in the left
  pane.
• The influenza keyword is added to the right
  pane.

62
Allergies

• Documenting a Non-Drug Allergy
• Training Scenario
• Your patient has discovered since their last
  visit the they are allergic to hazelnuts, which
  gives them a rash. You must now document this new
  allergy.
• 1. From the patients Progress Note, click
  Allergies.
• The Past Medical History window opens with all
  allergies that have
• been recorded on previous visits displayed in
  the Allergies section.
• 2. Click the Add button in the Allergies
  section.
• A new blank row appears in the Allergies
  section.
• 3. Select Non-Structured from the
  Structured/Non-Structured column
• 4. Type Hazelnuts into the Agent/Substance
  field.
• 5. Click in the blank Reaction field for the new
  row.
• 6. Either type rash here or select it from the
  drop-down list.
• The patients non-drug allergies are now
  documented.
• 7. Select Active in the Status column.
• 8. Check the Allergies Verified check box
• Documenting a Drug Allergy

63
Allergies

• Documenting a Patient with No Known Allergies
• Training Scenario
• Your patient has come in for their routine
  physical examination. They have no allergies
  that they know of. You must document their lack
  of known allergies in the system.
• For this scenario you will need
• A scheduled appointment
• 1. From the patients Progress Note, click
  Allergies.
• The Allergies window opens.
• 2. Check the N.K.D.A. (No Known Drug Allergies)
  check box.
• The Allergies Verified check box is
  automatically checked.

64
Surgical History and Hospitalizations

• Documenting Surgical History
• Training Scenario
• Your Patient has undergone a Hysterectomy
  operation since the last time she was seen at the
  practice. You must now document this information
  in her Surgical History.
• For this scenario you will need
• A scheduled appointment
• 1. From the patients Progress Note, click
  Surgical History.
• The Surgical history window opens with all
  surgical history entries
• automatically populated.
• 2. Click the Add button.
• A new row appears with blank Date and Surgery
  fields.
• 3. Type the date that this surgery occurred into
  the Date field in mm/yyyy format.
• 4. Type hysterectomy into the Surgery field.
• The patients surgical history is now
  documented.
• Documenting a Patient with No Surgical History
• Training Scenario

65
Surgical History and Hospitalizations

• Documenting Hospitalizations
• Training Scenario
• Your Patient has been hospitalized for a bout of
  Chicken Pox since their last visit to the office.
  You must document this information in their
  Hospitalizations history.
• 1. From the patients Progress note, click
  Hospitalizations.
• The surgical history window opens with all
  hospitalizations entered
• in the past automatically populated.
• 2. Click the Add button
• A new row appears with blank Date and Reason
  Fields.
• 3. Type the date that this hospitalization
  occurred into the Date field in mm/yyyy
• format.
• 4. Type Chicken Pox into the Reason field.
• 5. Check the Hospitalization Verified check box
• Your patients hospitalizations have been
  documented and verified.
• Documenting a Patient with No Hospitalizations

66
Family History

• Documenting a Patients Family History
• Training Scenario
• Since the last time Your Patient was seen at this
  practice, their father has passed away, their
  brother has been diagnosed with heart disease,
  and their mother has been diagnosed with
  diabetes. You must now document these changes,
  as well as the date of birth and age of the
  patients mother and father.
• 1. From the patients Progress Note, click Family
  History.
• The Family History window opens with all the
  information that was
• recorded in past visits automatically
  populated.
• 2. Click twice in the Status field for the
  Father row to change the status to deceased.
• 3. Type the date Crystals father was born in
  the DOB field for the Father row. (07/1925)
• 4. Type the age Crystals father was when he
  passed away into the Age(yrs) field for
• the Father row.
• 5. Click in the Notes field for the Sibling row.
• 6. Type Brother into the middle pane.
• 7. Type heart disease into the Find field.
• A list of keywords that begin with heart
  disease displays in the
• left pane.
• 8. Click the Heart Disease option in the left
  pane.
• The Heart Disease option is added after
  Brother in the middle

67
Family History

• Documenting a Patient with a Non-Contributory
  Family History
• Training Scenario
• Your Patient was adopted as a child and has
  little to no information about his biological
  family history. You must document this in the
  system.
• 1. From the patients Progress Note, click Family
  History.
• The Family History window opens.
• 2. Check the Non-Contributory box
• 3. Check the Family History Verified box.

68
Social History

• Documenting a Patients Social History
• Training Scenario
• Since their last visit to your office, Your
  Patient has retired from their job, traveled to
  England, and bought a dog. You must document all
  these changes to their Social History.
• 1. From the patients Progress Note, click
  Social History.
• The Social History window opens with all the
  information that was populated in past visits
  automatically.
• 2. Click in the Details field of the Occupation
  row.
• 3. Add retired in the right pane.
• 4. Click OK to close the Social History Notes
  window.
• 5. Click twice in the Travel Outside US row,
  options column.
• A yes appears in the Options field
• 6. Click in the Details field of the Travel
  Outside US row.
• The Social History Notes window opens.
• 7. Type England in the right pane.
• 8. Click OK to close the Social History Notes
  window.
• 9. Click once in the Options field of the Pets
  row.
• Cats Dogs is added to the details column of
  the Pets row
• 10. Click in the Details field of the Pets row.

69
Recording Vitals

• Documenting Patient Vitals
• Training Scenario
• Your Patient is being seen today and you must now
  record their vital signs.
• 1. From the patients Progress Note, click
  Vitals.
• The Vitals window opens with todays visit
  highlighted in yellow.
• 2. After taking the patients temperature. She is
  slightly above normal, so type 98.8 into the
  Temp field.
• 3. Measure the height of your patient. Her
  height has not changed since the last
• visit so type 60 into the Ht(in) field.
• 4. Weigh your patient on the scale. She has lost
  2 pounds since her last visit so type
• 158 into the Wt(lbs) field.
• 5. Take your patients blood pressure. It is
  measuring at 140/85 so type this into the
• BP field.
• 6. Take your patients heart rate. It is reading
  at 75, so type this into the HR field.
• 7. Check the Vitals Taken check box.
• The patients vitals are now recorded.

70
Patient Orders

• Viewing Patient Orders
• Training Scenario
• Your Patient is being seen for a routine physical
  and the doctor has ordered a Chest X-ray as well
  as a Urinalysis.
• For this scenario you will need
• A scheduled appointment with an ordered chest
  x-ray and urinalysis.
• 1. From the Office Visits screen your patients
  name will be highlighted in green
• when there are pending orders.
• 2. Check the box in for the row of the patient
  you would like to view orders on.
• 3. Click the View Orders button.
• The patient orders window opens.
• 4. All requested orders for this patient will be
  listed in this window.
• 5. Click on an order to highlight it.
• 6. Select the View button to view the details
  for the highlighted order.
• Documenting Completed Orders on a Patient
• Training Scenario

71
Checking - Out

• Checking a Patient Out at the Mid Office Level
• Training Scenario
• Your patients medical information has been
  documented, and a treatment plan has been
  specified. You must now check them out at the
  mid office level and send them to check out at
  the front office.
• For this scenario you will need
• A scheduled appointment with the patient checked
  in at the mid office level
• 1. From the Practice Band, click the Office
  visits icon.
• The Office Visits window opens.
• 2. Left-click once on the row containing your
  patients appointment to highlight it.
• 3. Click the Check In/Out button.
• The Encounter window opens.
• 4. Check the Check Out check box.
• The time out field is automatically populated
  with the current time.
• 5. Click the More () button next to the Status
  field.
• The Status Codes window opens
• 6. Left-Click once on the desired status.
• 7. Click OK to close the Status Codes window.
• 8. Click OK to close the Encounter window.