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OMR Overview for Medical & Practice Assistants

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  1. OMR Overview for Medical & Practice Assistants Click Mouse to Advance

  2. OMR System Overview The purpose of this presentation is to provide an overview of basic OMR functionality for medical & practice assistants. Continue to View List of Contents

  3. Topics Included • What is OMR? • Keystrokes & conventions • Accessing OMR • Accessing a patient’s record • Patient information • Recording vital signs & immunizations • Entering notes • Editing notes • Establishing letter printing defaults • Additional information & assistance Click on a topic to go directly to the topic information or click on Continue to review all topics sequentially. Continue

  4. What is OMR? The Online Medical Record is a multi-featured ambulatory electronic patient record, available via the Clinical Computing system at the Medical Center and community health centers and practices. OMR features include, but are not limited to Notes, Problem Lists, and Medication and Allergy Lists, Screening and Flow Sheets. Return to Table of Contents Continue

  5. 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. Return to Table of Contents Continue

  6. Accessing OMR Hospital and community practice computers provide direct access to OMR for authorized users. Click on the CCC icon on your desktop OR click on CareWeb and then CCC Access via Metaframe. To obtain a key to access OMR, contact the I.S. Support Center at (617) 754-8080. Continue Return to Table of Contents

  7. 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. Return to Table of Contents Continue

  8. Accessing a Patient’s Record Return to Table of Contents Continue

  9. CONTINUE WITH LAST ENTRY: FROG,KERMIT ? N // 0901910 When you sign into OMR, the system displays the name of the patient whose record you last accessed. Enter “ Y “ to open this patient’s record OR Access another patient by entering one of the following: 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 To access another OMR option, press <ENTER> to accept the default of “ N “. There are several test patients in OMR to use for training. They include: Kermit Frog, MRN 0901910 Kermit Frog, MRN 1213367 Continue Return to Table of Contents

  10. Patient Information Display Return to Table of Contents Continue

  11. After selecting a patient, the OMR Display includes: Patient Demographics Primary Care & Specialty Provider Names To Edit Patient Phone Numbers or Provider Names select Order Entry. Select Display Summary to view more Patient Information. FROG, KERMIT 0901910 M41 Home: 781 555-1234 Work: 617 555-1234 Online Medical Record Option Doctor: SANDS, DANIEL Z. Nurse: LEDERMAN,JOAN Next: 05/07/01-RADIOLOGY 1 Clinical Information Options 2 Display Summary 3 Lookup 4 Medication Sheet Allergy 5 Notes Doctor: SEIKH,JAVED 6 Order Entry 7 Problem List Hematology/Oncology 8 Screening, Flow Sheets and Forms Doctor: SCHNIPPER,LOWELL E. 9 To Do List 10 Vital Signs Rapid Entry Infectious Disease 11 Utilities Doctor: BRODIE,SHARON Online Medical Record Option: (Edit or View More in Order Entry) Continue Return to Table of Contents

  12. 08/20/01 PODIATRY CLINIC 07/11/01 LEXINGTON OCCUPA 06/26/01 RADIOLOGY 06/22/01 PODIATRY CLINIC 06/19/01 RADIOLOGY 06/06/01 LEX PSYCH 05/23/01 HCA MEDICAL UNIT HYPERTENSION HYDROCHLOROTHIAZID LOW BACK PAIN IBUPROFEN TOBACCO ABUSE Medications Appointments scheduled in CCC To print a hard copy of the Display Summary: Enter “ T “ for To Print at the prompt. Enter “ M “ to view additional information about the patient’s medications Enter “ A “ to view more patient appointment information. 0901910 FROG,KERMIT M41 Drug Allergies: Last Entry 5/30/02 No Healthcare Proxy info on file ------------------------------------------- SUMMARY DISPLAY ----------------------------------------------- MEDICATION SHEET APPOINTMENTS HCA PROBLEM LIST View only Summary includes: Primary care problem list Problems/Meds/Screening/Flow/Appointments/Notes/To print/Quit : Q // Return to Table of Contents Continue

  13. 0901910 FROG,KERMIT M41 Drug Allergies: Last Entry 5/30/02 No Healthcare Proxy info on file • Appointment date & time • Service • Provider • Cancel/No Show Status or Billing Diagnosis -----------------------------------------------APPOINTMENT HISTORY---------------------------------------------------- 07/12/01 1:30 PM PODIATRY CLINIC PODIATRY,BASILE 07/11/01 3:00 PM LEXINGTON OCCUPA OT, LEX 06/26/01 3:00 PM RADIOLOGY LEX, RAD 1 06/22/01 8:30 AM PODIATRY CLINIC PODIATRY, LYONS CANCELLED 06/19/01 2:00 PM RADIOLOGY LEX, RAD 1 06/06/01 11:00 AM LEX PSYCH STEVENS, LEX NO SHOW 05/23/01 10:00 AM HCA MEDICAL UNIT DESAI, SAMEER HYPERTENSION Press < Enter > to continue. The Appointment History display shows the following for CCC appointments: Continue Return to Table of Contents

  14. To see a history of changes made to the medication order enter “ Y “ at the prompt. To return to the Display Summary without reviewing the history press <ENTER>. FROG,KERMIT 0901910 09/21/59 Drug Allergies: Last entry 05/30/02 ----------------------------------------------------------------------------------------------------------------------------------- 1. HYDROCHLOROTHIAZID 25MG PO Tablet [ #30 R3 ] 03/30/2001 One by mouth every day [SMITH] 2. IBUPROFEN 400 MG PO Tablet [#30 R0] 03/30/2001 One by mouth every 8 hours for low back pain [SMITH] History? N // The Medication List displays all active medications & the last date an allergy was entered. Continue

  15. Recording Vital Signs & Immunizations Continue Return to Table of Contents

  16. Use the Lookup option to view patient lab results. Select Vital Signs Rapid Entry to enter the patient’s vital signs 0901910 FROG,KERMIT M41 Home: 781 555-1234 Work: 617 555-1234 Online Medical Record Option Doctor: SANDS, DANIEL Z. Nurse: LEDERMAN,JOAN Next: 05/07/01-RADIOLOGY 1 Clinical Information Options 2 Display Summary 3 Lookup Allergy 4 Medication Sheet Doctor: SEIKH,JAVED 5 Notes 6 Order Entry Hematology/Oncology 7 Problem List Doctor: SCHNIPPER,LOWELL E. 8 Screening, Flow Sheets and Forms 9 To Do List 10 Vital Signs Rapid Entry Infectious Disease 11 Utilities Doctor: BRODIE,SHARON Online Medical Record Option: (Edit or View More in Order Entry) Continue Return to Table of Contents

  17. Vital Signs Rapid Entry 0901910 M41 FROG,KERMIT ------------------------------------------------------------------------------------------------------------------------------------------------ DATE: 8/14/2002 // BLOOD PRESSURE RESULT: 120/65 HEART RATE RESULT: 72 WEIGHT (IN LBS) RESULT: 115 TEMPERATURE RESULT: 97.5 OMR displays today’s date. Press <ENTER> to accept the date or type in another Date and press <ENTER> to continue. Then enter values at each vital sign prompt. Continue Return to Table of Contents

  18. 0901910 FROG,KERMIT M41 Home: 781 555-1234 Work: 617 555-1234 Online Medical Record Option Doctor: SANDS, DANIEL Z. Nurse: LEDERMAN,JOAN Next: 05/07/01-RADIOLOGY 1 Clinical Information Options 2 Display Summary 3 Lookup Allergy 4 Medication Sheet Doctor: SEIKH,JAVED 5 Notes 6 Order Entry Hematology/Oncology 7 Problem List Doctor: SCHNIPPER,LOWELL E. 8 Screening, Flow Sheets and Forms 9 To Do List 10 Vital Signs Rapid Entry Infectious Disease 11 Utilities Doctor: BRODIE,SHARON Online Medical Record Option: 8 (Edit or View More in Order Entry) Select Screening, Flow Sheets and Forms to enter immunization information. Continue Return to Table of Contents

  19. FROG,KERMIT 0901910 41 • Screening/Flow Sheets Option • Periodic Screening • Health Education • Health History • Vital Signs • Immunizations and PPD • Flow Sheets • Health care proxy • Eye refractions • Anticoagulation form • Diabetes Labs • Diabetes General • Screening/Flow Sheets Option: Select Immunizations and PPD to enter immunization information. Continue Return to Table of Contents

  20. 0901910 M41 FROG,KERMIT From the options listed select: “ F “ to display all information for each immunization. “ R “ to enter several immunizations. “ E “ to edit an existing immunization entry. ------------------------------------------------------------------------------------------------------------------------------------------------ • INFLUENZA 12/18/2001 • PNEUMOCOCCAL • TETANUS (Q 10 YRS) 02/02/1990 TD • HFLU (ONCE) • HEPATITIS A • HEPATITIS B • MENINGOCOCCAL • MMR • MEASLES • MUMPS • PPD (5 TU) + CTRL • POLIO (INACTIVE) • RUBELLA • VARICELLA • YELLOW FEVER • TYPHOID • LYME VACCINE • Add / Edit / Delete / Rapid entry / Full display / Quit: Q // A OMR displays the patient’s most recent immunization information “ D “ to delete an immunization entry. Enter “ A “ to add a new immunization. Return to Table of Contents Continue

  21. OK TO FILE ON SCREENING SHEET? Y // At the final prompt press < ENTER > to file the immunization information. ADD 0901910 M41 FROG,KERMIT ------------------------------------------------------------------------------------------------------------------------------------------------ PNEUMOCOCCAL VAX DATE: 08/14/2002 // RT DELTOID COMMENT: FOOTNOTE ( CO./LOT # …) : #431-929 / Exp 12/03 OMR displays today’s date. Press <ENTER> to accept the date or type in another date. Press <ENTER> to continue and enter values at each prompt. Return to Table of Contents Continue

  22. 0901910 M41 FROG,KERMIT ------------------------------------------------------------------------------------------------------------------------------------------------ • INFLUENZA 12/18/2001 • PNEUMOCOCCAL • TETANUS (Q 10 YRS) 02/02/1990 TD • HFLU (ONCE) • HEPATITIS A • HEPATITIS B • MENINGOCOCCAL • MMR • MEASLES • MUMPS • PPD (5 TU) + CTRL • POLIO (INACTIVE) • RUBELLA • VARICELLA • YELLOW FEVER • TYPHOID • LYME VACCINE • Add / Edit / Delete / Rapid entry / Full display / Quit: Q // 08/14/2002 RT DELTOID # LOT #431-929 After filing, OMR updates the display with the new immunization information. Press < ENTER > to accept the default of “ Q “ and return to the main OMR menu Continue Return to Table of Contents

  23. OMR Notes Continue to Create New Note Return to Table of Contents

  24. Select Notes to view, edit or create a new note. 0901910 FROG,KERMIT M41 Home: 781 555-1234 Work: 617 555-1234 Online Medical Record Option Doctor: SANDS, DANIEL Z. Nurse: LEDERMAN,JOAN Next: 05/07/01-RADIOLOGY 1 Clinical Information Options 2 Display Summary 3 Lookup Allergy 4 Medication Sheet Doctor: SEIKH,JAVED 5 Notes 6 Order Entry Hematology/Oncology 7 Problem List Doctor: SCHNIPPER,LOWELL E. 8 Screening, Flow Sheets and Forms 9 To Do List 10 Vital Signs Rapid Entry Infectious Disease 11 Utilities Doctor: BRODIE,SHARON Online Medical Record Option: (Edit or View More in Order Entry) Continue to Notes Return to Table of Contents

  25. 0901910 M41 NOTES FROG,KERMIT 1. 07/12/01 2. 07/11/01 3. 07/11/01 INITIAL BASILE (POD) 4. 06/06/01 LETTER KECK Mr. Desai (RHAB) 5. 05/23/01 INITIAL KECK (RHAB) INITIAL BIRNBAUM (PSYC) INITIAL DESAI (MED) 1 To view any note, enter the number associated with the note on the list. ------------------------------------------------------------------------------------------------------------------------------------------------ New/Edit/View/Review/Cosign/Print/Forward/Delete/Monitor/Quit: Notes Summary Display includes: Note date, type, author, status/title & service. Return to Table of Contents Continue to View Note

  26. FROG,KERMIT 0901910 M41 NOTES Enter “ Q “ to return to the Notes List. ------------------------------------------------------------------------------------------------------------------------------------------------ Date: 07/12/01 Signed on: 07/12/01 ------------------------------------------------------------------------------------------------------------------------------------------------ Medications before July 12, 2001: HYDORCHLOROTHIAZIDE 25MG—One by mouth every day IBUPROFEN 400MG—One by mouth every 8 hours as needed for low back pain No medications DC’d on July 12, 2001. No medications prescribed on July 12, 2001 ------------------------------------------------------------------------------------------------------------------------------------------------ Patient seen for fungal toe nail infection. Treatment options discussed. Patient will consider options and call with a decision regarding which he prefers. Continue / Back up / Quit : Q Return to Notes List Return to Table of Contents

  27. FROG,KERMIT 0901910 M41 NOTES 1. 07/12/01 2. 07/11/01 3. 07/11/01 INITIAL BASILE (POD) 4. 06/06/01 LETTER KECK Mr. Desai (RHAB) 5. 05/23/01 INITIAL KECK (RHAB) INITIAL BIRNBAUM (PSYC) INITIAL DESAI (MED) Enter “ N “ to create a new note. ------------------------------------------------------------------------------------------------------------------------------------------------ New/Edit/View/Review/Cosign/Print/Forward/Delete/Monitor/Quit: N Continue Return to Table of Contents

  28. Service/Location – Press <ENTER> to accept your default service/location. Type of Note – Type the first letter of the option which best suits your note: Copy, Initial, Letter, Progress, or Telephone Contact. Date of Contact - System defaults in today’s date. Enter mm/dd/yy or T +/- n for another date. For three days ago, enter “ T – 3 “. Service and Location: 1. General Medicine/Primary Care at APG Sharon Ok? Y / / Copy a note Initial note Letter Progress note Telephone contact Which type of note?: TELEPHONE CONTACT DATE OF CONTACT: 08/14/2002 / / When you create a new note the system prompts for: Continue Return to Table of Contents

  29. 0901910 FROG,KERMIT M41 To escape the notes screen: Press <ESC> at any time. For HELP press <F1> Date: August 14, 2002 Note type: Telephone Contact Author: Mary Smith Note: For help info press <F1> To exit press <ESC> Return to Table of Contents Continue

  30. OMR Help: Use the up & down arrow keys on your keyboard to select a Help option. To Exit Help: Press <ESC>. 0901910 FROG,KERMIT M41 Date: August 14, 2002 Note type: Telephone Contact Author: Mary Smith Note: Additional Help F1 Select Text F2 Paste F3 Delete Word F4 & Shift F4 Text Inserts F6 Set Up Search F7 Top of Document F8 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> For help info press <F1> To exit press <ESC> Continue Return to Table of Contents

  31. Options for Creating Notes When you create any note type you can: • Type in freeform text • Use text insert • Combine freeform text • & text inserts in a single note • Copy & edit text from an existing • note To learn more about text inserts and copying existing notes, click on HELP on the CareGroup website, then click on CCC/OMR help and select OMR Notes Documentation. Return to Table of Contents Continue

  32. 090-19-10 FROG.KERMIT M41 Date: August 14, 2002 Note type: Telephone Contact Author: Mary Smith Note: Patient called for last date of MRI for comparison. Gave date of 1/2 For help info press <F1> To exit press <ESC> Type in freeform text. Return to Table of Contents Continue

  33. S Select Choice Save and Exit Save and Exit Discard and Exit 0901910 FROG.KERMIT M41 Date: August 14, 2002 Note type: Telephone Contact Author: Mary Smith Note: Patient called for last date of MRI for comparison. Gave date of 1/2 Save and Exit For help info press <F1> To exit press <ESC> Enter “ S “ to save and exit. Return to Table of Contents Continue

  34. Monitor: Use this option if you wish the system to notify you when any clinician views your note for this patient. This feature is note specific and must be turned on for each note you wish to monitor. • PROGRESS NOTE for FROG,KERMIT • 1. Exit • 2. Forward • 3. Monitor • 4. Print • 5. Sign • Choice: 5 / / Forward: Use this option to forward a copy of this note to the patient’s PCP, referring MD, or other provider. Continue Return to Table of Contents

  35. Enter the number associated with the affiliation for the note Press <ENTER> to save the affiliation as a default for all your notes/letters. Enter your CCC key to complete the signing process. 0901910 M41 NOTES FROG,KERMIT ------------------------------------------------------------------------------------------------------------------- PROGRESS NOTE for FROG,KERMIT 1. Exit 2. Forward 3. Monitor 4. Print 5. Sign Choice: 5 / / 5 Select “ 5 “ to sign your note. Select an affiliation to indicate in which record this note/letter belongs. 1. BIDMC 2. HMFP Practice 3. APG Practice 4. Other Private Practice Affiliation: 3 Save APG Practice as your default affiliation ? Y // KEY: Continue Return to Table of Contents

  36. Editing Notes • Unsigned notes • Editable at any time • Signed notes • Editable for 3 hours after signing • Users can add an addendum at any time Return to Table of Contents Continue

  37. FROG,KERMIT 0901910 M41 NOTES 1. 8/14/02 2. 07/11/01 3. 07/11/01 PHON SMITH (MED) 4. 06/06/01 LETTER KECK Mr. Desai (RHAB) 5. 05/23/01 INITIAL KECK (RHAB) INITIAL BIRNBAUM (PSYC) INITIAL DESAI (MED) Enter “ E “ to edit the unsigned note. Then specify the number associated with the note you wish to edit. ------------------------------------------------------------------------------------------------------------------------------------------------ UNSIGNED New/Edit/View/Review/Cosign/Print/Forward/Delete/Monitor/Quit: E Continue Return to Table of Contents

  38. Enter “ 2 “ to edit the note text. FROG, KERMIT 0901910 M41 TELEPHONE CONTACT ---------------------------------------------------------------------------------------------------------------------------------- Date of Contact Display Title 08/14/02 PHONE SMITH UNSIGNED (MED) Edit: 1. Display title 2. Note 3. Date of contact Select: 2 Continue Return to Table of Contents

  39. 090-19-10 FROG.KERMIT M41 Date: May 4, 2001 Note type: Telephone Contact Author: Mary Smith Note: Patient called for last date of MRI for comparison. Gave date of 1/2 /2001 For help info press <F1> To exit press <ESC> Edit existing text or enter new text. Press <ESC> to exit and file edits. Return to Table of Contents Continue

  40. S Select Choice Save and Exit Save and Exit Discard and Exit 090-19-10 FROG.KERMIT M41 Date: May 4, 2001 Note type: Telephone Contact Author: Mary Smith Note: Patient called for last date of MRI for comparison. Gave date of 1/2 /2001 Save and Exit For help info press <F1> To exit press <ESC> Enter “ S “ to save and exit. Continue Return to Table of Contents

  41. Enter the number associated with the affiliation for the note Save APG Practice as your default affiliation ? Y // Press <ENTER> to save the affiliation as a default for all your notes/letters. KEY: Enter your CCC key to complete the signing process. TELEPHONE CONTACT for FROG,KERMIT 1. Exit 2. Forward 3. Monitor 4. Print 5. Sign Choice: 5 / / 5 Select “ 5 “ to sign your note. Select an affiliation to indicate in which record this note/letter belongs. 1. BIDMC 2. HMFP Practice 3. APG Practice 4. Other Private Practice Affiliation: 3 Continue Return to Table of Contents

  42. Letter Printing Default Settings Continue Return to Table of Contents

  43. To access Defaults, enter “ 3 “ for Management Options and Reports. You have NOTES. Online Medical Record Option 1 Alerts, Notes, and Attestations 2 Clinical Information Options 3 Management Options and Reports 4 Patient Selection –OMR 5 Utilities Online Medical Record Option 3 Default settings allow users to establish margins used for letter printing and the number of copies printed. Continue Return to Table of Contents

  44. Enter “ 5 “ for Defaults. Management/Report Option 1 Notes reprint 2 Prescriptions reprint 3 To Do List Personal Entries Display 4 Anticoagulation lists 5 Defaults 6 Insert text 7 Access notification list 8 To change access reason 9 OMR Support Options 10 Copy Reminders (Alerts/Notes/Attestations) Management/Report Option: 5 Continue Return to Table of Contents

  45. To establish margin and printing defaults, enter “ 3 “ for Notes/Letters. Default option 1 Access notification 2 Medication printing 3 Notes/Letters 4 Show open appointments Default option: 3 Return to Table of Contents Continue

  46. Enter “ 3 “ for Printing to establish margins and other printing defaults. Notes default setting 1 Forward automatically 2 Medications into progress/initial notes 3 Printing 4 Service/Location 5 Sign-off Notes default setting: 2 Continue Return to Table of Contents

  47. 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 Return to Table of Contents

  48. 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. Continue Return to Table of Contents

  49. For Additional Information Continue Return to Table of Contents

  50. Click on HELP on the CareGroup portal for detailed CCC/OMR help. Continue Return to Table of Contents