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OMR Transcription Options & Features Click Mouse to Advance OMR Transcription Overview The purpose of this presentation is to provide an overview of basic OMR transcription functions. Continue to View List of Contents Topics Included Keystrokes & conventions

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slide2

OMR Transcription Overview

The purpose of this presentation is to provide an overview of basic OMR transcription functions.

Continue to View List of Contents

slide3

Topics Included

  • Keystrokes & conventions
  • Accessing OMR & Transcription options
  • Entering a note in Transcription
    • Using free text
    • Using a template
    • Pasting from Word
  • Saving a transcribed note & forwarding
  • it for signature
  • Editing a transcribed note
  • Printing unsigned notes
  • Establishing margin & printing defaults

Click on a topic to go directly to the topic information or click on

Continue to review all topics sequentially.

Continue

slide4

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 <ESC>

To view help Enter a ? or

if in a word processor window press < F1 >

To select a menu optionEnter 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 <ENTER>.

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.

Continue

Return to Table of Contents

slide5

Accessing OMR & Transcription Options

Return to Table of Contents

Continue

slide6

Accessing OMR & Transcription Options

The Online Medical Record (OMR) is part of BIDMC’s

Clinical Computing System (CCC).

To obtain OMR access contact the IS Support Center

at (617) 754-8080.

Hospital computers provide direct access to OMR for

authorized users.

External transcription services can access OMR remotely.

Continue

slide7

Remote Access

  • Users can access OMR remotely using one of the following methods:
    • via the Meditech emulator program through a
    • dial-up connection using a modem
    • via Metaframe using an Internet connection
  • To install the Meditech emulator use the following link:
  • http://home.caregroup.org/portal.asp?category=emulator
  • To install Metaframe use the following link & follow the directions provided: http://home.caregroup.org/metaframe/
  • To obtain remote access help using any of these methods,
  • contact the IS Support Center at (617) 754-8080.

Continue

slide8

Beth Israel Deaconess

Medical Center

Clinical Computing – CCC System

Mary Smith Port: TS3.421

Online Medical Record

System

O

Appointments/Scheduling

Clinical Information

Online Medical Record

OPD Reg (Outpatient Admitting)

Select

NextPage

PrevPage

Done

Select

To access OMR, sign onto CCC.

Use the up & down arrow keys on your

keyboard to select Online Medical Record.

Continue

slide9

The Transcription Option menu includes options for:

    • Displaying & editing transcriptions
  • Entering transcriptions
  • Printing copies of unsigned notes
  • Establishing defaults

You have OMR messages.

Transcription Option

1 Clinical Information options

2 Display/Edit Transcription

3 Enter Transcription

4 Hard Copies - Unsigned

5 Insert test enter/edit

6 Letter/Notes Defaults

7 OMR Messages (Notes for printing)

8 Online Medical Record

9 Providers’ Schedules

10 Transcription Report

11 Utilities

Transcription Option: 3

Continue

Return to Table of Contents

slide10

Entering a Transcription

Continue

Return to Table of Contents

slide11

You have OMR messages.

Transcription Option

1 Clinical Information options

2 Display/Edit Transcription

3 Enter Transcription

4 Hard Copies - Unsigned

5 Insert test enter/edit

6 Letter/Notes Defaults

7 OMR Messages (Notes for printing)

8 Online Medical Record

9 Providers’ Schedules

10 Transcription Report

11 Utilities

Transcription Option: 3

Enter 3 at the Transcription Option prompt to enter a transcription.

Continue

slide12

OMR displays matches to the name you entered. Press <ENTER> to accept the name displayed.

OMR displays the provider’s default Service & Location. Press <ENTER> to accept this information or type in the Service & Location specified in the dictation.

At the Patient prompt, you can identify the patient in a variety of ways:

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

SMIT, MAR

PROVIDER:

1. SMITH, MARY 11- 111 PSYCHIATRY PAGE: 99999

OK? Y / /

Service and Location:

1. Psychiatry, Beth Israel Hospital Outpatient Department

Ok? Y / /

FROG,KERMIT

PATIENT:

0901910

123-12-1234

At the Provider prompt, enter the provider’s name using the format Last Name, First Name. Enter the first few letters of the name & OMR will display matches.

There are several test patients in OMR to use for training.

They include: Kermit Frog, MRN 0901910

Kermit Frog, MRN 1213367

Continue

slide13

Choose Patient:

4

Frog,Kermit 25 M 000-00-0000 1 Jan 1976 OUTPT

1117257 11 Glendale St Everett 02149

Richard Mary Linda

Select

NextPage

PrevPage

Done

Select

4

1

2

3

4

Frog,Kermit 41 M 000-00-0000 21 Sep 1959 OUTPT

0901910 123 Main Street Anywhere 12345

Frogger Frogette Frogge

Frog,Kermit 79 M 000-00-0000 2 Feb 1922 OUTPT

0078199 (ACCESS RESTRICTED)

Ziggy Phyllis Nancy

Frog, Kermit 36 M 000-00-0000 28 Jul 1964 OUTPT

1058295 (ACCESS RESTRICTED)

Joseph Donna Fanny Frog

Frog,Kermit 25 M 000-00-0000 1 Jan 1976 OUTPT

1117257 11 Glendale St Everett 02149

Richard Mary Linda

After you enter the patient’s identifying information,

OMR displays a list of patients to choose from.

Use the up and down arrow keys on your keyboard to

highlight the correct patient and press <ENTER>.

Continue

slide14

There are 4 dictation types: initial note, letter, progress note, telephone

contact. Enter the type of dictation you want to create.

You can enter a dictation even if the patient did not have a visit recorded

in the system on the date of service entered.

DATE OF SERVICE:

T-1

Initial note

Letter

Progress note

Telephone contact

WHICH TYPE OF DICTATION?:

PROGRESS NOTE

No visit recorded for FROG,KERMIT

With SANDS,DANIEL Z. on 07/22/01

Enter dictation anyway? N / / Y

At the Date of Service prompt, enter the date using the format

MM/DD/YY or enter T-X. For example for yesterday, enter T-1.

Continue

slide15

--------------------------- ----------------------------- -------------------------- -------------------------

Medications before July 22, 2001

PROZAC 20MG—One by mouth at bedtime

No medications DC’d on July 22, 2001.

No medications prescribed on July 22, 2001.

--------------------------- ----------------------------- -------------------------- -------------------------

For help info press <F1>

To exit press <ESC>

To escape the notes screen: Press <ESC> at any time.

For HELP press <F1>

111-72-57 FROG,KERMIT M25

Provider: Smith, Mary

Date: July 22, 2001 Type of dictation: Progress note

OMR includes the patient’s medications as established by the clinician’s

default settings.

Continue to View Help

slide16

--------------------------- ----------------------------- -------------------------- -------------------------

Medications before July 22, 2001

PROZAC 20MG—One by mouth at bedtime

No medications DC’d on July 22, 2001.

No medications prescribed on July 22, 2001.

--------------------------- ----------------------------- -------------------------- -------------------------

For help info press <F1>

To exit press <ESC>

111-72-57 FROG,KERMIT M25

Provider: Smith, Mary

Date: July 22, 2001

: Progress Note

Top of Document F9

Additional Help F1

Select Text F2

Paste F3

Delete Word F4 & Shift F4

Text Inserts F6

Set Up Search F7

Search F8

Top of Document F9

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 <ESC>

Top of Document F9

OMR Help: Use the up & down arrow keys on your

keyboard to highlight a Help option.

To Exit Help: Press <ESC>.

Continue

slide17

Options for Creating Notes

When you create any note type you can:

  • Paste in text from a word processing file
  • Type in freeform text
  • Use a personal text insert
  • Use a public text insert
  • Combine freeform text & text inserts in
  • a single note

Continue

slide18

Transcription with Text from a Word

Processing File

Return to Table of Contents

Continue

slide19

To Paste Text into OMR

  • Create the note in Word or other word processing
  • software program
  • Highlight or select the text and click on Copy
  • Initiate note or letter in OMR

MEDITECH Remote Workstation

  • Click on Edit
  • Click on Paste

Options Edit Help

Edit

Copy Alt+C

Paste Alt+V

Paste Alt+V

111-72-57 FROG,KERMIT M25

  • OMR pastes the Word text into the OMR note

Return to Table of Contents

Continue

slide20

Transcription with Freeform Text

Return to Table of Contents

Continue

slide21

--------------------------- ----------------------------- -------------------------- -------------------------

Medications before July 22, 2001

PROZAC 20MG—One by mouth at bedtime

No medications DC’d on July 22, 2001.

No medications prescribed on July 22, 2001.

--------------------------- ----------------------------- -------------------------- -------------------------

For help info press <F1>

To exit press <ESC>

111-72-57 FROG,KERMIT M25

Provider: Smith, Mary

Date: July 22, 2001 Type of dictation: Progress note

25 year old male with history of depression

Type in freeform text.

You can combine freeform text with insert text in a single note.

Press <F6> to access text inserts.

Continue

Return to Table of Contents

slide22

Transcription with a Template

Continue

Return to Table of Contents

slide23

{Psychiatr

{Psychia

*** (Index Term)****

Select

111-72-57

FROG.KERMIT

M25

Provider: Smith, Mary

Date: July 22, 2001

Type of dictation: Progress note

Select Topic

----------------------------------------------------------------------------------------------------------------

Medi

Pro

No m

No m

---------------------------------------------------------------------------------------------------------------

Name

GENERAL: Well appearing in no distress

***(Index Term)***

***(Index Term)***

***(Index Term)***

***(Index Term)***

***(Index Term)***

***(Index Term)***

***(Index Term)***

ExamNorm

{Antepartu

{Complianc

{Dermatolo

{Discharge

{Endocrine

{HCA}

{Psychia

NextPage

PrevPage

Done

Select

For help info press <F1>

To exit press <ESC>

When you press <F6>, OMR displays personal text inserts

first, followed by public text inserts organized by service.

You can use any service’s text inserts. Use the arrow keys

to select the Service from the list or enter the first

few letters of the Service name. Press <ENTER>.

Continue

slide24

HMFP treat

AMBULATORY SERVICES – HMFP PRACTICE GROU

HMFP treat

Select

111-72-57

FROG.KERMIT

M 25

Provider: Smith, Mary

Date: July 21, 2001

Type of dictation: Progress note

Select Topic

---------------------------------------------------------------------------------------------------------------------------

Medi

PR

No m

No m

---------------------------------------------------------------------------------------------------------------------------

Name

BETH ISRAEL DEACONESS MEDICAL CENTER

AMBULATORY SERVICES – HMFP PRACTICE GROU

AMBULATORY SERVICES – HMFP PRACTICE GROU

AMBULATORY SERVICES – HMFP GROUP PRACTIC

AMBULATORY SERVICES – HMFP PRACTICE GROU

AMBULATORY SERVICES – HMFP PRACTICE GROU

CONFIDENTIAL – NEUROPSYCHOLOGICAL DATA S

CONFIDENTIAL NEUROPSYCHOLOGICAL CONSULT

AMBULATORY SERVICES – RESIDENCY TRAINING

ED/Admit

HMFP eval

HMFP group

HMFP note

HMFP term

HMFP treat

NEURO data

NEURO eval

OPD eval

NextPage

PrevPage

Done

Select

For help info press <F1>

To exit press <ESC>

A list of departmental text inserts appears.

Use the arrow keys to select the template.

Continue to Use a Text Insert

slide25

0901910

FROG.KERMIT

M41

Provider: Smith, Mary

Date: July 21, 2001

Type of dictation: Progress note

Codes & Diagnosis Description

Axis I [ ]

Axis II [ ]

Axis III [ ]

Axis IV [ ]

Axis V: [ ]

TYPE OF TREATMENT: Include relevant modality, frequency and

duration of treatment; using the examples below.

Modality: [ ] Psychopharmacology

Frequency: [ ] Weekly [ ] Twice per month [ ] Monthly [ ] Quarterly [ ] Other, please specify:

Duration: [ ] Within UR Protocol [ ] Out of Protocol

[ ] Long term maintenance [ ] Other, please specify:

DSM-IV Diagnosis

296.33

Severe Depression

x

x

x

For help info press <F1>

To exit press <ESC>

Type the appropriate information into the text insert.

After the note is complete, press <ESC>.

Return to Table of Contents

Continue to Save Note

slide26

Save Transcription

Continue

Return to Table of Contents

slide27

S

Select Choice

Save and Exit

Save and Exit

Discard and Exit

111-72-57

FROG.KERMIT

M25

Provider: Smith, Mary

Date: July 21, 2001

Type of dictation: Progress note

Codes & Diagnosis Description

Axis I [296.33] Severe Depression

Axis II [

Axis III [

Axis IV [

Axis V: [

TYPE OF TREATMENT: In y, frequency and

Duration of treatment; using the examples below.

Modality: [x] Psychopharmacology

Frequency: [ ] Weekly [x] Twice per month [ ] Monthly [ ] Quarterly [ ] Other, please specify:

Duration: [x] Within UR Protocol [ ] Out of Protocol

[ ] Long term maintenance [ ] Other, please specify:

Note:

DSM-IV Diagnosis

Save and Exit

For help info press <F1>

To exit press <ESC>

When you complete data entry, press <ESC>, OMR prompts you to save

or discard your work.

You can save unfinished work & return to it later.

Continue

slide28

Enter a note title

File the note

Notify the provider that the note is ready to sign

If you press <ENTER> to accept the default of Yes, OMR sends

the note to the provider’s online list of notes requiring signature.

Enter “ N “ if you wish to return later to complete additional work on

the note before you forward it to the provider for signature.

Review the note? N / /

Title (I.e. SUMMARY):

OK to file this note? Y / /

Notify provider to sign note? Y / /

When you choose to Save & File a note, OMR provides options to:

Review the text you entered

Return to Table of Contents

Continue

slide29

Display/Edit Transcription

Return to Table of Contents

Continue

slide30

Editing Transcribed Notes

  • Unsigned notes
  • Transcriptionists can edit any unsigned note
  • entered via transcription for services for which
  • they authorized
  • Signed notes
  • Transcriptionists can not edit signed notes.
  • Once a note has been signed, OMR permits
  • providers to make edits during the 3 hours following
  • signing. After that, providers can add addendums
  • at any time.

Continue to Display/Edit Transcription

slide31

Enter “ 2 “ at the Transcription Option prompt to

display or edit an unsigned note.

Transcription Option

1 Clinical Information options

2 Display/Edit Transcription

3 Enter Transcription

4 Hard Copies - Unsigned

5 Insert test enter/edit

6 Letter/Notes Defaults

7 OMR Messages (Notes for printing)

8 Online Medical Record

9 Providers’ Schedules

10 Transcription Report

11 Utilities

Transcription Option: 2

You can display or edit any unsigned note entered via the

Transcription Option for services you are authorized to access.

Continue

slide32

Enter the name of the provider whose notes

you want to display or edit.

TRANSCRIPTION DATE OR PATIENT ID: T

PROVIDER:

1. SMITH, MARY 11-111 PSYCHIATRY PAGE: 99999

SMITH, MARY

You can display or edit notes using:

Transcription date

Patient ID

Continue

slide33

OMR labels all unsigned Notes with a “ U “. Only the text of unsigned

notes can be displayed or edited.

OMR also includes the system initials of the transcriptionist who entered

the note.

At the prompt, enter the number associated with the note you wish to

display or edit.

PROVIDER: SMITH, MARY

U 1. FROG,KERMIT

2. FROG,KERMIT

U 3. FROG,KERMIT

1058295

1117257

1316942

VISIT DATE: 07/24/01 MVW

VISIT DATE: 07/22/01 MVW

VISIT DATE: 07/23/01 MVW

PROGRESS NOTE

PROGRESS NOTE

PROGRESS NOTE

Choose from above list to edit

or press <ENTER> to continue displaying

CHOOSE: 1

When you choose to display/edit transcriptions by transcription date

& enter the provider whose notes you wish to display/edit, OMR Lists

all notes entered via transcription for the transcription date specified.

Continue

slide34

Provider name

  • Service & location
  • Patient name
  • Date of service
  • Type of dictation

PROVIDER: SMITH, MARY / /

Service and Location:

1. Psychiatry, Beth Israel Outpatient Department

Ok? Y / /

PATIENT: FROG,KERMIT / /

DATE OF SERVICE: 07/21/2001 / /

Initial note

Letter

Progress note

Telephone contact

WHICH TYPE OF DICTATION?: PROGRESS NOTE / /

The edit option allows you to make changes to unsigned notes entered using

the transcription option. By typing the new information in at the

appropriate prompt you can make edits to the following :

To retain the existing information, press <ENTER> at each prompt.

Continue

slide35

Edit existing text or enter new text.

105-82-95 FROG,KERMIT M36

Provider: Smith, Mary

Date: July 24, 2001 Type of dictation: Telephone contact

Patient called to discuss test results.

Asked patient to schedule follow-up appointment.

For help info press <F1>

To exit press <ESC>

Press <ESC> to exit and file edits.

Continue

Return to Table of Contents

slide36

Printing Unsigned Notes

Return to Table of Contents

Continue

slide37

Transcription Option

Enter the name of the provider whose unsigned notes you wish to print.

Enter the type of unsigned note you wish to print. To print all types, press <ENTER>.

1 Clinical Information options

2 Display/Edit Transcription

3 Enter Transcription

4 Hard Copies - Unsigned

5 Insert test enter/edit

6 Letter/Notes Defaults

7 OMR Messages (Notes for printing)

8 Online Medical Record

9 Providers’ Schedules

10 Transcription Report

11 Utilities

Transcription Option: 4 Hard Copies – Unsigned

PROVIDER:

SMITH, MARY

1. SMITH, MARY 11-111 PSYCHIATRY PAGE 99999

OK? Y / /

Select one of the following, or press <Enter> for all:

Initial note

Letter

Progress note

Telephone contact

WHICH TYPE OF DICTATION?:

To print out copies of unsigned notes for review or manual editing, enter “ 4 “ at the Transcription Option prompt.

Continue

Return to Table of Contents

slide38

Establishing Margin & Printing Defaults

Return to Table of Contents

Continue

slide39

Transcription Option

1 Clinical Information options

2 Display/Edit Transcription

3 Enter Transcription

4 Hard Copies - Unsigned

5 Insert test enter/edit

6 Letter/Notes Defaults

7 OMR Messages (Notes for printing)

8 Online Medical Record

9 Providers’ Schedules

10 Transcription Report

11 Utilities

Transcription Option: 6

To establish margin & printing defaults, enter “ 6 “ for Letter/Notes Defaults

at the Transcription Option prompt.

Continue

slide40

Default option

1 Letter printing

2 Notes printing

Default option: 1

To establish margin defaults, enter “ 1 “ for Letter Printing at the

Default Option prompt.

Continue

slide41

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:

Enter “ L “ at the prompt to establish the top margin.

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

slide42

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.

Return to Table of Contents

Continue

slide43

For Additional Information

Continue to Additional Information about OMR

slide46

OMR documentation topics include: General Information, Medications, Notes, Problem Lists, Management Options, and Transcription Information.

Continue

slide47

Questions or Problems

  • For computer & printer problems
    • Call the IS Support Center
    • x48080
  • For questions about how to use OMR
    • EmailOMRSupport@caregroup.harvard.edu
    • Receive a response within 1 business day

Continue

slide48

…And OMR Overview Training is Complete

Click Here to Return to CCC/OMR Help

OR

Click Here to Return to the CareGroup Portal