Introductory EMR Training. Division of Staff and Patient Education, April 2010. What are the benefits of an Electronic Medical Record (EMR) ?. As you begin this module, please ask yourself these questions…. How is an EMR laid out?. What five identifiers should be
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Division of Staff and Patient Education, April 2010
As you begin this module,
please ask yourself these
Learn the five identifiers to check for when working in a patient record.
Learn the benefits of an EMR.
EMRs put patient information at your finger tips and allow you to give
better service. Critical patient data can be accessed by providers through a
secure and auditable platform anytime, anywhere.
EMRs can improve patient safety and quality of care. E-Prescribing
through the EMR automatically checks prescriptions against a patient’s
medications and allergies.
EMRs meet Federal Meaningful Use requirements, awarding monies to physician practice areas. Finances improve through improved accuracy of coding and reimbursement.
With an EMR there is easy fingertip access to data , allowing staff to
address and interactwith patients knowledgeably. Interactions and
interoperability with labs, pharmacies and specialties are improved with the
secure exchange of information.
EMRs can improve data management and analysis setting the stage for
growth. Reporting for outcomes analysis, recalls, patient populations,
business analysis and more are generated from the EMR. Compliance with
clinical reporting guidelines is facilitated with disease management templates
designed to capture patient information at the point of care.
in the Farmington IMA clinic.
accessed through menus and toolbars.
to meet clinical reporting guidelines for pay-for-performance programs.
consistent, real-time clinical and administrative workflow among nursing,
office staff and providers.
Now that you understand some of the benefits of EMRs, this next section will take you through a series of NextGen simulations to help you become familiar with some of NextGen’s basics.
NextGen Desktop Icon
Your NextGen login and password will be given you at your first scheduled training session.
-To access NextGen you will enter your User Name and Password in the lines provided and then choose “University Medical Group” from the two dropdown menus.
-Click the “Sign on” radio button to get to the NextGen opening screen.
The Menu Bar provides access to screens and functions through drop down lists. At your first live training session you will be shown how to select default settings for things like “provider choice” and “user preferences”.
To log out of NextGen click on File.
The drop drop down menu opens. Click Exit.
Main Menu Bar
The Provider Approval Queue is where the provider will sign off on all Labs, Radiology and Pathology reports. It is password protected and only Providers have access to it. Click on the
the PAQ button to gain access.
Click the Inbox Icon to open the Workflow.
- The left side of the Workflow Inbox displays patient appointments that are in
IDX scheduling systems. The various appointment status will display from IDX to
NextGen as: A=Arrival, P=Pending, C=Cancelled, R=Rescheduled, and B=Bump.
The right side displays the listing of a staff’s workflow, or “tasks”.
Click the Patient icon from the Main Toolbar for the
Patient Lookup screen to appear.
1. Enter patient identification information into Patient Lookup.
2. Click ‘find’.
3. Choose the correct patient in the Matching Records window.
4. Click ‘open.’
The Patient Chart Summary opens.
Once you open a chart the Patient’s name will appear in the upper left hand corner
of the window, in the dark blue banner .
The Patient’s name remains visible here and the chart active until the chart is closed.
- Click Close Patient
Now let’s return to learn more about the Adult Chart Summary.
The Chart Summary contains an overview of the patient chart: demographics, medications, visit history, problem lists, alerts, allergies, medical orders, blood pressure readings, and more.It offers a quick overview of the patient for the beginning of an office visit or when speaking to a patient on the phone. With permission, patients will have their pictures taken by the front desk staff and added to the Chart Summary template.
Alerts indicate vital patient care information such as Deaf or Language Interpreter Required and are indicated in red. Alerts come across from the IDX Registration system. Click the alert (in red) to get to an ‘Alert’ screen that gives more information.
Click the History Icon from the Top Toolbar to open the History Toolbar.
-The History Toolbar lists all patient encounters by date, time, and type of
encounter. It also gives button or tab access to blank templates and sections of the
chart. The History Toolbar is made up of: Patient/chart encounters ,
categories, or sections of the chart, and History Tool BarIcons that connect with
specialty templatessuch as the lab module.
the History Toolbar
History Toolbar Icon
AKA “Tic Tac Toe Square”
Categories are sections of the chart such as Progress Notes, Radiology, Pathology, Telephone Encounters, and Stress Testing. Click the Categories Tab to see the History Toolbar in this format.
Internal and external paper documents are scanned into NextGen based on their documentation type. They will file under the appropriate category and appear as encounters with a date and time.
Also known as the
“Tic Tac Toe Square”
The History Toolbar Icons give click access to:
-Templates - Ability to modify images to illustrate status
-All available documents -View and/or add procedures
- View and/or add diagnosis - View, add or modify Allergies
- View and/or add prescriptions - Access to the lab Module
Click the Lab Icon from the tick tac toe area to bring up the Lab Module. Lab results from UCHC and Quest labs will be available in NextGen.
E-prescribing is a two way, computer to computer communication of prescription information between the provider’s office and pharmacy , or the pharmacy to the provider’s office. NextGen links to current pharmacy databases and insurance formularies. Looking up a pharmacy address, fax and phone number is easily done through a series of drop down menus.
- Click the Prescription Icon
in the History Toolbar to
Tostart a Patient visit, open the Adult Chart Summary.
Click the center blue HOME button to link to the Master IM .
- The Master IM template opens.
*Encounters are automatically created
for patients arrived in IDX.
With easy movement through the chart
it is important to know where you are at all times.
Check That the Right EMR & Encounter Are Open
Anytime you create or move to a new section of a chart perform
the 5 Point Check: Correct….
1 - Patient Name 4 - MRN
2- Location 5 - Encounter Date & Time
3 - Provider
The Master IM serves as the Home Page for Internal Medicine. Visit information is entered into the Master Template, or Specialty Template Set through drop down lists and/or free form text. In all templates the History Toolbar is visible if it is kept toggled on.
Become familiar with the nine sections of the main template.
6. Reviewed and Updated Chronic Problems
7. Reviewed Alerts
8. Reviewed and documented Advance Directives
Set and managed Disease Management and
Health Maintenance Protocols located under Health Monitor section
5 point Check to verify correct patient: Patient, MRN,
Provider location and encounter date.
2. Visit type
3. Reasons for visit from pick list
Reviewed and updated allergies
Reviewed and updated Medications
The Navigation Toolbar, located to the left in the Master IM, lists and gives
access to demographics and commonly
used specialty templates including
notes and forms.
1. The Preview button at the bottom
allows the User to generate a note.
2. Incomplete notes allows the User
to track notes requiring completion.
3. Patient Tracking allows clinic staff to
track patients during an office visit.
4. Nurse Doc allows the nurse to quickly
access Nursing Documentation.
A note is generated from the information entered into the various templates used during an encounter. To preview the note, click the preview button at the bottom of the Navigation Tool Bar.
TheDocument Library in the Navigational Toolbar gives options to create documents. A download of information occurs when a note or form template is chosen. Print it out to give to a patient or send it electronically to one of the network Providers. Click on the Document Library to gain access.
Once an order or procedure has been completed the charge can be added to the patient’s bill through the Submit to Superbill button. This is found on order and result templates throughout NextGen. The patient’s Superbill should be accessed to review and check for accuracy of charges at the end of all visits.