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Health ePractice Electronic Medical Record Physician Companion

Health ePractice Electronic Medical Record Physician Companion. 1. The eClinicalWorks Physician Companion

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Health ePractice Electronic Medical Record Physician Companion

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  1. Health ePracticeElectronic Medical RecordPhysician Companion Physician Companion eClinicalWorks 1

  2. The eClinicalWorks Physician 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: • A Complete Listing of Web-Based Training (WBT) Modules • Basic eClinicalWorks Navigation Functionality • Progress Note Documentation • Progress Note Shortcuts • Template Customization • Order Set Customization • How to Train Your Dragon Documents • 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 you and your staff! The Health ePractice Team Physician Companion eClinicalWorks

  3. 3 How Do I Access? St. John HealthPartners Website • In Windows Internet Explorer address bar type: http://www.health-epractice.org/ • St. John HealthPartners Website will display. • On the main tool bar hover over to display a drop-down menu. • From the drop-down menu click on Practice Tools • You have arrived at eClinicalWorks (PM/EMR) Practice Tools Home Page Physician Companion eClinicalWorks 3

  4. 2 3 4 How Do I Access? • 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 Web-Based Training (WBT) Modules • A list of mandatory WBT Modules display for the selected role. • Click on the name of any module to open the content. Physician Companion eClinicalWorks 4

  5. 2 1 3 4 How Do I Access? How do I log into eClinicalWorks Train Environment? • Click on the button. • Click on the button. • The Run activity window displays. In the Open: field type in the following: MSTSC and click the OK button. • The Remote Desktop Connection activity window displays. In the Computer: field type in the following: Asp12.eclinicalweb.com:9328 and click the Connect button. Physician Companion eClinicalWorks 5

  6. 6 8 How Do I Access? • The “Log On to Windows” activity window displays. • Input the User name: and Password: that was provided to you by your Implementation Coordinator. • eClinicalWorks Log-In screen displays. • Enter the Login ID and Password that was provided to you by the Implementation Coordinator. • Click on the button. Physician Companion eClinicalWorks 6

  7. 3 2 1 Basic eClinicalWorks Navigation How do I log into eClinicalWorks Production Environment? • Double-Click on the icon located on the desktop. • eClinicalWorks login screen appears. • Type in your login ID and password as appropriate. • 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. Physician Companion eClinicalWorks 7

  8. 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. Basic eClinicalWorks Navigation eClinicalWorks application window has five standard navigation elements. These elements appear in Resource Schedule, Office Visit, and Progress Note workspace. Basic Navigation Tools 1 4 2 3 5 Physician Companion eClinicalWorks 8

  9. 3 4 Basic eClinicalWorks Navigation Patient Look-Up and Patient Hub Overview • You can look up a patient by clicking on the Patient Lookup Icon • The Patient Lookup activity window opens which gives you a list of all the patients in the system arranged alphabetically by their last name. • 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. • When a patient is selected the Patient Hub will display. • The Patient Hub provides a convenient, single point of access to all information available in a patient’s record. Physician Companion eClinicalWorks 9

  10. 1 3 5 7 2 4 6 Basic eClinicalWorks Navigation Quick Launch Task Buttons Overview • E Menu: The total number of e-prescription refill requests received and transmission errors display on this 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 not 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. Also, by clicking on the letter “M” you can choose to view the Inbox, Outbox, Deleted Messages and even Create New Messages. Physician Companion eClinicalWorks 10

  11. 2 3 6 1 4 5 7 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 the user 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 patient’s 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. Physician Companion eClinicalWorks 11

  12. 1 2 4 6 5 7 8 Basic eClinicalWorks Navigation Update a patient’s status code and enter a exam room identifier in the Office Visit Screen • Select the patient from the schedule. • Click on the button. • The Encounter Activity window displays. • Click the Check In box. • The Time In field will populate the time automatically. • Click in the Room No field and enter patient room number. • Click on the button. • The patient’s arrival time, room number and status will appear on the Office Visit schedule. Physician Companion eClinicalWorks 12

  13. 1 2 Basic eClinicalWorks Navigation Accessing the Patient’s Visit Encounter • To open a patient’s visit, double-click on the patient’s name from the office visits screen. • The patient’s visit opens in the Progress Notes view. All clinical documentation will be completed in this view. Physician Companion eClinicalWorks 13

  14. 4 3 2 1 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 patient’s picture with demographic information. • The patient’s 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., 5 Patient Chart Panel The patient’s 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 Patient’s Test Results, Telephone Encounters, Web Encounters, and Clinical Decision Support System that includes PCMH Alerts. Physician Companion eClinicalWorks 14

  15. 3 Abstracting How do I Abstract Clinical Data into eClinicalWorks? • Click on the icon to search for the patient. • The patient Look-up activity window displays. • In the Search Patient field enter the patient’s name. • Select the desired patient from the list and click on the button. • The Patient HUB displays. • Click on the button. • The Telephone Encounter activity window displays. Physician Companion eClinicalWorks

  16. Abstracting 8 9 13 14 • In the Provider field click on the drop-down menu arrow and select the desired Provider. • In the Pharmacy field click on the ellipsis button. • Search for the patient’s 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 • In the reason field type in Abstract. • Click on the tab. • The Message field displays the outline of the Progress note. 12 Physician Companion eClinicalWorks

  17. Abstracting 5 7 6 8 Documenting Current Medications • Click on Current Medication: hyperlink to document the patient’s Current Medication. • The Chief Complaint/Current Medication activity window displays. 2 • In the Current Medication field click on the button. • The Select RX activity window displays. • In the Find field type in the PARTIAL name of the drug. • Select the desired drug from the list. • Select the desired strength. • The drug appears in the Selected RX field. • To add another medication repeat steps 3 – 8 or if you are done click on the button. Physician Companion eClinicalWorks

  18. Abstracting 11 10 • Update the dose/frequency at this time by clicking in the desired fields. • Indicate by clicking in the box. • Click on the button. Documenting Allergies • Click on the Allergies/Intolerance: hyperlink. • The Past Medical History/Allergies activity window displays. • To add a Drug (RX) Allergy click on the button. • To add a Environmental Allergy click on the button. • Select Structured for RX allergies and Non-Structured for environmental. • In the Agent/Substance field click on the drop-down arrow to select the desired allergy from the list. • Click in the Reaction field and then click on the drop down arrow to select the desired reaction of the allergy. • Document 3 4 8 5 6 7 • Repeat steps 3 – 8 to document another allergy or click on the button. Physician Companion eClinicalWorks

  19. Abstracting 9 13 10 11 3 6 4 7 Documenting Past Medical and Surgical History • Click on the desired history hyperlink: Medical History:Surgical History: • The Activity Window displays. • Click on the button. • In the History field type in the past medical condition. • Repeat steps 3 – 4 to enter another condition. • Document by clicking in the box. • To document the Surgical history click on the icon. • The Surgical History activity window displays. Physician Companion eClinicalWorks

  20. Abstracting 3 4 • Click on the button. • In the Date field enter the Month/Date of the surgery if available. • In the Surgery field enter the Surgery name. • Repeat steps 9 – 11 to document more surgical history for the patient. • Document • Click on the button. Documenting Family History • Click on the Family History: hyperlink. • Family History activity window displays. • To indicate the status of a family member click in the status field: One Click = Alive, Two Clicks = Deceased, and Three Clicks = Unknown. • 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. Physician Companion eClinicalWorks

  21. Abstracting 4 7 9 10 6 5 3 8 • To search for another medical problem, repeat steps 7 – 10. • Once you have completed the documentation click on the button. • Document . • Click on the button. Adding to the Problem List • Click on the Assessment: hyperlink. • The assessments activity window displays. Physician Companion eClinicalWorks

  22. Abstracting 3 1 • Enter the problem in the “Find In” field and click go. • Click on the desired problem from the list. • The problem appears in the Selected Assessments field. • Add the problem to the patient’s problem list to by clicking in the box in the PL field. • Repeat steps 3 – 6 to document another problem is applicable. • Click on the button. Documenting Vital Signs • In the Telephone Encounter activity window, change the date field to match the date of the vital signs to be abstracted. • Click on the Vitals: hyperlink. • Enter the Vitals Signs as appropriate in the designated field with the accurate date. Physician Companion eClinicalWorks

  23. Abstracting 5 6 7 • Once you have completed entering the vitals click on the button. • 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 • Click on the Immunizations: hyperlink. • The immunizations/Injections activity window displays. • Click on the button. • The Immunization Details activity window displays. • In the find field search for the immunization. • Select the name from the list. • Click in the box next to “Vaccination Given in the Past.” This enables you to document the date the immunization was adminstered. Physician Companion eClinicalWorks

  24. Abstracting 1 2 4 5 Enter all recommended fields as appropriate. If you need to add more than one immunization click on the button and repeat steps 5 – 8. Once completed click on the button. Completing the Abstract Process • In the Telephone Encounter activity window click on the tab. • In the Actions Taken field click on the button. • Type in the field “Chart Abstracted” and click on the OK button. • Your name and the date will be time-stamped in the field. • To close the encounter click on the button. Physician Companion eClinicalWorks

  25. 1 2 Document Management Correcting Scanned Documents If a scanned document is scanned under the incorrect patient, access the Patient Documents module. • Select the document and click on the View button. • Click on the “Save” button. • Save the document to your desktop or a documents folder, click Save. • In “Document Category” click on Custom radio button. • Browse the folder you saved the document. • Documents in the folder will appear in the “Scan bucket” 4 5 Physician Companion eClinicalWorks

  26. 2 3 3 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: • Click on the document from the Scan Bucket. • 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. Physician Companion eClinicalWorks 26

  27. Progress Note Documentation • In Progress Note click on Chief Complaint(s): Subjective and Objective Documentation: Documenting a Chief Complaint 1 • Chief Complaints activity window will display. • To add a chief complaint click on the browse button. 3 • In the “Find:” field type in the name of the complaint. 4 Physician Companion eClinicalWorks 27

  28. Progress Note Documentation • Select the appropriate complaint from the list. • Click button. 5 6 • The chief complaint is added. Click to close. • Chief Complaint entry will appear on the Progress Note. Physician Companion eClinicalWorks 28

  29. 3 5 6 7 9 Progress Note Documentation Subjective and Objective Documentation: Current Medication Documentation • From the patient’s progress note, click on “Current Medications”. • The Current Medications Activity window will display. Note: this window is also shared by chief complaints. • To document a current medication click on the button. • The RX Select activity window displays. • In the Find field, type the medication name. • The medication name will appear in the left hand column and the strength appears 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 . Physician Companion eClinicalWorks 29

  30. 11 2 3 Progress Note Documentation • The Current Medication window displays with the added medication. • Document the Medications have been verified by clicking on the Medication Verified box. Subjective and Objective Documentation: Documenting Past Medical History • From the Progress Note, click on “Medical History” • Click on the “Browse” or “Add” Button to add Medical History documentation to the patient’s chart. • 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 patient’s Medical History. The ‘Add” button allows you to free-text the history as opposed 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.

  31. 5 6 7 4 3 Progress Note Documentation Subjective and Objective Documentation: Documenting Allergies • Select Allergies/Intolerance from the Progress Note • The Allergies activity window displays (this window is also shared by Past Medical History). • To indicate the patient has No Known Drug Allergies (NKDA) click in the box next to NKDA. • To search for a drug allergy, click on the button. • In the Find field, search for the name of the drug allergy. • Select the appropriate allergy by clicking on the allergy name. The name will populate in the Selected RX field. • Click on the button. Physician Companion eClinicalWorks 31

  32. 9 13 16 14 15 Progress Note Documentation • To search for a Environmental or Food Allergy click on the button. • In the Structured/Non Structured field click on the drop-down menu arrow. • Select Non Structured from the menu. • A warning will appear indicating if you free-text in the field it will be excluded from automated drug-allergy testing. Click • Click in the Agent/Substance field. • Click on the drop-down menu arrow and select the allergy from the list. • Click in the Reaction box. • Click on the drop down menu arrow and select the appropriate reaction. • Mark the allergies as verified by clicking in the Allergies Verified box. Physician Companion eClinicalWorks 32

  33. 2 3 4 Progress Note Documentation Subjective and Objective Documentation: Documenting Surgical and Hospitalizations History • From the patient’s 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. Physician Companion eClinicalWorks 33

  34. 2 3 4 6 5 Progress Note Documentation Subjective and Objective Documentation: Documenting Family History • From the patient’s progress note, click on “Family History”. The following window opens: • Under “Status” click in the field box to indicate a status of “alive,” “deceased,” or “Unknown.” • Click in the DOB field and enter a birth year. This will automatically calculate the age of the family member. • Click in the notes column to open the keyword window. • Select condition from the left pane to add it to the Selected Category in the center pane. • Select the Relative(s) 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. Physician Companion eClinicalWorks 34

  35. 5 3 Progress Note Documentation Subjective and Objective Documentation: Documenting Vital Signs • In the progress note click on “Vitals”. • Vitals intake activity window will display. • Click in first field box (in this instance: *HR) and type value. • Use the tab key to move to following fields and continue typing values in appropriate fields. (Note: BMI will auto-calculate for you) • When you have completed entering vitals, click on the red “X” to close the window. • The vitals documentation will appear in the progress note time stamped with the date, time, and name of the individual who documented the information. Physician Companion eClinicalWorks 35

  36. 4 5 Progress Note Documentation • In progress note, click on the drop down menu arrow in the Smart Form (SF) field. Subjective and Objective Documentation: Accessing the Initial Visit Smart Form • Select Initial Visit from the drop down menu. 1 2 • 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 to move forward. • Click on the button to move to save the information that you documented and move to the next screen. Physician Companion eClinicalWorks 36

  37. 7 8 10 11 12 14 15 Progress Note Documentation • Depending on what you select under the “Are you a:” field, options will appear for specific documentation pertaining to the choice selected. • After completion click on the button. • The Tobacco Control form displays. • The Alcohol Misuse/Abuse form displays. • Depending on what you select under: “Did you have a drink containing alcohol in the past year?” More questions will appear for specific documentation. • 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. • Once the form is completed click on the button. • The Depression Screening form displays. • Complete the form as appropriate. • Click on the button to complete the Initial Visit Smart Form. Physician Companion eClinicalWorks 37

  38. Progress Note Documentation • A pop-up activity window will display stating that the Form Data Saved Successfully. • Click on the button. • You will return back to the Progress Note. Physician Companion eClinicalWorks 38

  39. 2 3 4 5 Progress Note Documentation Subjective and Objective Documentation: Documenting History of Present Illness (HPI) • From the progress note, click on the HPI link, and the following window displays: • Click on a HPI category on the left side panel and the symptoms belonging to that category appear on the right side panel of the screen. • Click on the box in the “c/o” or “denies” field to document the symptom. • If the “show pop up for c/o” box is checked then when you select in the c/o field an option list will pop up which will give you one-click access to common phrases that apply to the symptom. • Click on the Notes field to add a description or type in your own notes related to that symptom. • Close out of the HPI activity window by clicking on the button. • All HPI documentation appears in the progress note. Physician Companion eClinicalWorks 39

  40. 2 7 3 4 5 6 Progress Note Documentation Subjective and Objective Documentation: Documenting Review of Symptoms (ROS) • From the patient’s progress note, click on ROS. The following window opens: • If the patient complains of a symptom, click once in the “Presence” column to display “No,” click again to display “Yes” or leave blank (no response or not asked). • Click on “Default for All” to select the predefined defaults for all body systems/categories defined for ROS. • “Clear All” changes the observations back to blank. • Click on “Default per Category” to select the predefined default answers for all body systems/categories defined for ROS. • “Clear Category” changes all the observations in the selected category to blank. • To add additional notes to each symptom, simply click on the “Notes” cell corresponding to that symptom and type-in or select the notes keywords as required. Physician Companion eClinicalWorks 40

  41. 6 3 4 5 2 Progress Note Documentation Documenting the Assessment • From the progress note, click on “Assessment”. The following window opens: • Assessments can be searched by entering the diagnosis code or the name in the “Find In” field. Search by selecting one of the three options from the drop-down list: “starts with,” “contains,” or “all words.” • Once you locate the assessment, highlight it to select it. Once selected, it goes into the selected assessment list for that patient. • The “Notes” section next to the selected diagnosis can be used to write any notes for that specific diagnosis, whereas, the notes section located at the bottom of the activity window is common to all diagnoses. • To add the diagnosis to the Problem List check the PL box adjacent to the diagnosis. • “Previous Assessment” gives the list of all the diagnoses given to this patient in the past. It also contains the list of the diagnoses added to the problem list. Physician Companion eClinicalWorks 41

  42. Progress Note Documentation 2 5 Progress Note Documentation Documenting the Treatment Plan • From the progress note, click on “Treatment”; the following window displays: • Patient assessments made in the assessment section appear as individual tabs on the Treatment window. The individual tabs allow the physician to specifically address each diagnosis appropriately. ePrescribing/Refilling Medications • Click on the ‘tab’ corresponding to the diagnosis for which medications need to be prescribed or refilled. • To refill patient’s current medications, click on “Cur Rx” button, select the meds that need to be refilled and type in the number of refills in the “refills” column. To document whether the patient was asked to increase/decrease/stop the current dose, click on the “comment” column and choose the comment. To prescribe a new medication, click on “Add” button and choose a new medication from the ‘drug dictionary’. Once the medication is chosen and when you click on ‘Ok’, the dosage details can be modified back on ‘Treatment’ screen. • Medications can be printed, faxed or electronically prescribed to the patient’s pharmacy by clicking on either the “Print” button (to print on prescription paper) or click on the drop down menu arrow next to the “Print” button (to fax or e-prescribe). Physician Companion eClinicalWorks 42

  43. 2 Progress Note Documentation Orders • In the Lab/Diagnostic Imaging/Procedures section, click on “Browse” to open either option as needed • Select the Lab, DI or Procedure radio button • Using the Dx list on the left side of the window, select the assessment to add an order by checking the box. • To select a labs/DI for future, click on the “Future Orders” ‘Look up’ box. Select the appropriate date. To select labs/DI for current day, click on “Today’s Orders.” • Enter the name of the lab in the “Lookup” field. • Standing Orders for labs can be ordered by clicking on the “Add Standing Orders” button. 1 5 4 3 6 Physician Companion eClinicalWorks 43

  44. Progress Note Documentation 3 1 Medication Summary • Select the “Medication Summary” tab • Click on “C” to continue, “R” to Refill with the numbers indicated the refill amount, or “S” to Stop the medication • To ‘Add New Rx’ click on the “New RX” tab. • Type the medication in the “Find” field. 2 4 Physician Companion eClinicalWorks 44

  45. Progress Note Documentation Outgoing Referral • The outgoing referral button on the treatment screen opens the window where you can enter information for creating a referral. • Enter the information into the fields and then print the referral or assign it to someone who takes care of it at the practice • The referral can be sent through the P2P network, as well. Physician Companion eClinicalWorks 45

  46. Progress Note Documentation Immunizations/Injections • From the progress notes, click on “Immunizations”. The Injections/Immunization window opens for the patient. Click on “Add” button to add an immunization. • Use the “Find” field to locate the immunization from the list in the left pane. Once located, select the desired immunization by simply clicking on it. • After selecting the immunization, document the other required fields on the “Immunizations” screen (such as “given by,” dosage details, location, etc). 1 2 3 Physician Companion eClinicalWorks 46

  47. Progress Note Documentation Reviewing Past Order Results • The previously ordered labs are available on the Labs/DI section on the right side chart panel of the patient. • If the results are already marked off as “reviewed” by the provider, the lab appears in a normal size. If it has not yet been reviewed, the lab name appears in bold text. • There is a blue arrow next to the lab name. Clicking on this blue arrow will move the lab result to the current progress notes under the “past results” section. Documenting Procedures • From the progress notes, click on the “Procedure” heading, choose the respective procedure which was performed on the patient and that needs to be documented. • Type in the respective notes as required. • The “Default per category” can be set to populate default notes for each “category” (or sub-heading) within the selected procedure. Physician Companion eClinicalWorks 47

  48. Progress Note Documentation Preventive Medicine • The preventive medicine is used to document the necessary counseling given to the patient. • The categories are available on the left side and the items under the categories are in the right side. • There is also a miscellaneous notes section in the bottom of the section. 2 3 Physician Companion eClinicalWorks 48

  49. Progress Note Documentation Entering the billing codes and follow-up details From the progress notes, click on “Visit code” to open the “Billing” window. • The “Assessment” section will have all the diagnoses added by the provider. The provider can also add diagnosis from here. • “Procedure Codes” section will have all the procedure codes and also the E&M (or Visit) Code. • There are two ways to enter the E&M Code: • Provider can enter the E&M (Office Visit) code by clicking on the ‘Add E&M’ button. • eClinicalWorks has the E&M calculator which can be found under the “EM Coder” button. • “Chart based EM coder” – will calculate an appropriate visit code based on the amount of information that has been documented on the progress note. • “Time based EM coder” – will calculate the visit code based on the face-time the provider chooses (depending on how much face time was actually spent). 1 2 3a 3b 4 5 6 Physician Companion eClinicalWorks 49

  50. Progress Note Documentation • If the provider wants to put in some notes for the biller, those can be typed in the “billing notes” section. • A follow-up appointment with respective details can be entered in the “Follow-up” section. The details entered here will be displayed in the “Appointment” screen and can be seen by the receptionist during the check-out process. • “Done” indicates to the billing department that the note is “ready to be billed”, whereas “Close” means that the provider will still work on the note and might enter additional billing information. Physician Companion eClinicalWorks 50

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