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OMR Transcription Options & Features

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  1. OMR Transcription Options & Features Click Mouse to Advance

  2. OMR Transcription Overview The purpose of this presentation is to provide an overview of basic OMR transcription functions. Continue to View List of Contents

  3. 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

  4. 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

  5. Accessing OMR & Transcription Options Return to Table of Contents Continue

  6. 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

  7. 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

  8. 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

  9. 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

  10. Entering a Transcription Continue Return to Table of Contents

  11. 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

  12. 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

  13. 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

  14. 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

  15. --------------------------- ----------------------------- -------------------------- ------------------------- 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

  16. --------------------------- ----------------------------- -------------------------- ------------------------- 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

  17. 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

  18. Transcription with Text from a Word Processing File Return to Table of Contents Continue

  19. 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

  20. Transcription with Freeform Text Return to Table of Contents Continue

  21. --------------------------- ----------------------------- -------------------------- ------------------------- 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

  22. Transcription with a Template Continue Return to Table of Contents

  23. {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

  24. 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

  25. 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

  26. Save Transcription Continue Return to Table of Contents

  27. 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

  28. 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

  29. Display/Edit Transcription Return to Table of Contents Continue

  30. 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

  31. 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

  32. 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

  33. 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

  34. 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

  35. 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

  36. Printing Unsigned Notes Return to Table of Contents Continue

  37. 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

  38. Establishing Margin & Printing Defaults Return to Table of Contents Continue

  39. 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

  40. 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

  41. 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

  42. 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

  43. For Additional Information Continue to Additional Information about OMR

  44. Click on HELP on the CareGroup portal for detailed CCC/OMR help. Continue

  45. Click on CCC/OMR Help for OMR Documentation topics. Continue

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

  47. 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

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