Medical Records Reports

1. Medical Records Reports AAO Coding Que Training January 18, 2007 & January 19, 2007

2. Policy & Procedures • HIMS policy and procedures for • Contingency Plan • How will you get the information into PCC data entry if your computers are offline? • Unsigned Orders • How long do you give your providers/users to complete a hand written PCC? • Unsigned Notes • How long do you give your providers/users to complete and sign all patient orders? • Electronic Chart Corrections • How long are you going to give a provider/user to correct/add/delete a CPT or POV code?

3. Daily Reports • Unsigned Notes • Unsigned Orders • Alert Management

4. UNSIGNED NOTES

5. Unsigned Notes • Should align with the HIMS policy for unsigned documents • Perform Daily • Allows user to search: • All document status’s or by individual status • All documents or individual documents • All providers or by individual providers

6. Unsigned Notes TIU Menu for Medical Records Options: • IPD – Individual patient documents • Option allows user to view one patient’s document • MPD – Multiple patient documents • Option allows user to view multiple patients document • SIG – Awaiting Signature Listing • Use this option to pull a list of charts in the Incomplete Chart System that are waiting for signatures on TIU documents • SSD- Search for Selected Documents • Allows Medical Records staff to generate a list of selected documents based on extended search criteria (i.e. status, search category, & reference date range)

7. UNSIGNED ORDERS

8. Unsigned Orders • Should align HIMS policy on unsigned orders • Report should be processed daily • Allows user to search by: • Signed/Released Orders • Unsigned Orders • Unsigned/Unreleased Orders

9. Unsigned Orders • Unsigned Orders Search • Allows the user to search for either released but signed orders or just unsigned orders and sort them by • Service/Section • Provider • Patient • Location • A start date entry will allow the site to ignore orders that fall within their allowed grace period. • If a site allows the provider 48 hours to sign unsigned orders, you would enter T-2 days or longer for a start date in order to account for the allotted grace period. • A stop date entry will allow the site to ingore orders older than the date entered • If you wanted to ignore unsigned orders that were placed prior to when you started using CPRS (i.e. EHR)

10. ALERT MANAGEMENT

11. Alert Management • Used primarily by the Medical Records supervisor and/or the CAC • This option provides a menu of options for managing alerts (AKA Notifications) • These options include the ability to delete options based on a time or a particular user, to generate a new alert, etc

12. Alert Management • SURO Alerts – Set/Remove Surrogates for User • Delete Old (>14d) Alerts • Make an Alert on the Fly • Set Backup Reviewer for Alerts • Surrogate for which users

13. Alert Management • SURO Alerts – Set/Remove Surrogate for User • Provided so that IRM or ADPAC personnel can set or remove a surrogate for receiving alerts for a user. • Option ask for a user to be selected, then is ready to specify a new surrogate for the selected user, or to remove the current surrogate for that user • NOT needed by the individual users who may select to name or remove a surrogate as one of the options while processing alerts

14. Alert Management • Delete Old (>14 d) Alerts • This option is used to remove Alerts which remain in the User file after a period of at least 2 weeks • It is assumed that if a user has not either seen or performed an action associated with an alert for this period, that it can not be urgent item for the user

15. Alert Management • Make an alert on the fly • This option will allow the user to create an ALERT and send it to users or mail groups on the fly • Purge Alerts for a user • Permits user holding the correct key to delete alerts for another user • This is intended for when a user has been inactive for a period of time (e.g. vacation, etc) and has accumulated a number of alerts which should not need processing

16. Alert Management • Set Backup Reviewer for Alerts • Provides a mechanism for a user to set entries into the parameter file which will assign an individual as backup reviewer for alerts if there is a date specified for days for backup reviewer in the alert • If this the case, an alert which remains unread for the indicated number of days will be forwarded to the backup reviewer found for the lowest level of the user in the parameter file starting with the user and progressing through OERR team, Team, service, division, up to system

17. Alert Management • Surrogate for which Users? • Option provides a view of which users have specified a selected user as surrogates for themselves.

18. REPORTS MENU FOR ALERTS

19. Report Menu For Alerts • These reports should align with the medical records policy for chart corrections (i.e. missing POV, CPT, etc) • This menu provides several options for generating reports on alerts for users or patients • This report should be processed on a routine basis • Can be used by both Data Entry and Medical Record Technicians to track notifications to users

20. Report Menu For Alerts • 5 Different reports available • Critical Alerts Count Report • List Alerts for a user from a specified date • Patient Alert List for specified date • User Alerts Count Report • View data for Alert Tracking file entry

21. CRITICAL ALERTS COUNT REPORT

22. Critical Alerts Count Report • Used to generate a report of users who have more than a specified number of alerts containing the word “critical” or the words “abnormal imaging” between the specified start and end dates • The report is presented in descending order for the number of critical/abnormal imaging alerts present • Each user who has the specified number of critical/abnormal imaging alerts or more, the report includes: • Users name • Section/service for the user • Number of alerts in the ALERTS file • Last sign-on date • Number of Critical alerts or Abnormal Imaging alerts • Date of the oldest alert

23. Critical Alerts Count Report COUNT of ALERTS - users with more than 1 on Jan 15, 2007@21:03:31 for date range 01/10/2007 to 01/15/2007 CRIT column indicates number of CRITICAL alerts and ABNORMAL IMAGING alerts Total Oldest Name Service/section Alerts Last Sign-on CRIT Alert ---------------------------------- ------------------- ------ ------------------- -------- -------------- MOORE,LORI B CLINICAL PHARMACY 2 DEC 01, 2006 1 07/06/2006 MOORE,LORI B PHARM PHARMACY 5 JAN 15, 2007 1 12/18/2006

24. LIST ALERTS FOR A USER FROM A SPECIFIED DATE

25. List Alerts for a User from a Specified Date • Used to obtain an interactive list of alerts from the ALERT TRACKING file for a specified user starting from a specified date • Listings include: • Internal entry number for the alert in the ALERT TRACKING file • Date and time the alert was generated • Message text of the alert • Information about any option or routine to be executed for processing the alert

26. List Alerts for a User from a Specified Date Alerts for User MOORE,LORI B PHARM (DFN=1983)for dates Oct 07, 2006 through Jan 15, 2007 DEMO,DEMO (999990): UNSIGNED CHART REVIEW OVERDUE for SIGNATURE. 11/11/2006@23:00:20 [ROU] ien=50274 DEMO,DEMO (999990): UNSIGNED CHART REVIEW OVERDUE for SIGNATURE. 11/12/2006@23:00:21 [ROU] ien=50312 DEMO,DEMO (999990): UNSIGNED CHART REVIEW OVERDUE for SIGNATURE. 11/13/2006@23:00:22 [ROU] ien=50546 DEMO,DEMO (D9999): New consult HEPATITIS C (Routine) 11/14/2006@21:32:51 [ROU] ien=50726 DEMO,DEMO (999990): UNSIGNED HEPATITIS C CONSULT available for SIGNATURE. Computer Generated 11/14/2006@21:34:41 [ROU] ien=50727 DEMO,DEMO (D9999): Completed Consult HEPATITIS C 11/14/2006@21:34:43 [ROU] ien=50728 Visit is missing a purpose of visit. 11/14/2006@21:39:14 ien=50729 DEMO,DEMO (999990): UNSIGNED CHART REVIEW OVERDUE for SIGNATURE. 11/14/2006@23:00:21 [ROU] ien=50748 DEMO,GLEN (D9999): Order requires electronic signature. 11/15/2006@09:12:35 [ROU] ien=50762 DEMO,DEMO (999990): UNSIGNED CHART REVIEW OVERDUE for SIGNATURE. User generated 11/15/2006@23:00:26 [ROU] ien=50894 DEMO,DEMO (999990): UNSIGNED CHART REVIEW OVERDUE for SIGNATURE. 11/16/2006@23:00:20 [ROU] ien=51093 test test test test test 01/17/2007@17:52:17 ien=59613 User generated Alert Tracking Number

27. PATIENT ALERT LIST FOR SPECIFIED DATE

28. Patient Alert List for Specified Date • Used to obtain a list of alerts for a specified patient from the ALERT TRACKING file for a selected date • A prompt is provided to obtain: • A quick scan listing of dates with at least some alerts for the patient • DVB alerts: • Other patient related alerts that need to be identified by looking at each alert’s message text and are included in the full list, but not the quick scan

29. Patient Alert List for Specified Date • Listing includes the: • Internal entry number for the alert in the ALERT TRACKING file • Date and time the alert was generated • Message text of the alert • Information about any option or routine to be executed for processing the alert

30. Patient Alert List for Specified Date Do you want to scan for a list of dates that have at least some alerts for this patient? YES Select one of the following: 1 1 Week ago 2 1 month ago 3 3 months ago 4 6 months ago 5 1 year ago 6 As far back as possible The oldest entry in your Alert Tracking file is from 04/09/2004 Select a period for starting: 6 As far back as possible Dates and number of alerts found in () [may not be all of them] 10/04/2005 (3) 10/05/2005 (3) 10/06/2005 (6) 10/19/2005 (1) 11/06/2005 (1) 11/07/2005 (1) 12/13/2005 (1) 12/21/2005 (1) 01/18/2006 (1) START DATE: TODAY// (JAN 29, 2007) *** WARNING ***: Do not specify too many days - each entry in the Alert Tracking file must be checked for the date range specified. END DATE: (1/29/2007 - 1/29/2007): Jan 29, 2007// Do you want to list only alerts containing specific words or phrase(s)? YES ALL words or phrases connected by -AND- must appear in the message for an alert to be selected Enter a word or phrase: LAB -AND- Enter another word or phrase: Select one of the following: 1 Both Action and Info Only 2 Action Alerts 3 Info Only Alerts Select Alert Type(s) desired: 1// Both Action and Info Only DEVICE: HOME// VIRTUAL Found 0 Selected Alerts for Patient DEMO,DEMO D (D) for dates Jan 29, 2007 through Selected alerts containing: LAB --- OR --- Selected alerts containing: CRITICAL --- OR --- Selected alerts containing: POV

31. USER ALERTS COUNT REPORT

32. User Alerts Count Report • Used to generate a report on users who have more than a specified number of alerts in the ALERTS file • The report covers a specified range of dates • Can be sorted by: • User name • Number of alerts • Service/section • In addition, the report in each of these formats may be generated by Divisions if desired

33. User Alerts Count Report • Report includes: • Specified number of alerts or more • User name • Section/service for the user • Number of alerts in the ALERTS file • Last sign-on date • Number of Critical alerts or Abnormal Imaging • Date of oldest alert

34. User Alerts Count Report COUNT of ALERTS - users with more than 100 on Jan 15, 2007@21:05:14 for date range 01/10/2007 to 01/15/2007 CRIT column indicates number of CRITICAL alerts and ABNORMAL IMAGING alerts: Total Oldest Name Service/section Alerts Last Sign-on CRIT Alert ----------------- --------------------------- ------ ------------------- ------ ----------------- DR. DEMO MEDICAL SERVICE 115 JAN 11, 2007 1 01/06/2007

35. VIEW DATA FOR ALERT TRACKING FILE ENTRY

36. View Data For Alert Tracking File Entry • Used to view data for one or more entries in the Alert Tracking file in captioned format • Internal entry numbers for the entries to be displayed must be entered individually

37. View Data For Alert Tracking File Entry Select Report Menu for Alerts Option: VIEW DATA FOR ALERT TRACKING FILEg file entry Internal Entry number in Alert Tracking File: (1693-59216): 51093 Another Internal Entry number in Alert Tracking File: (1693-59216): DEVICE: HOME// VIRTUAL NUMBER: 51093 NAME: TIU8188;41;3061116.23002 DATE CREATED: NOV 16, 2006@23:00:20 PKG ID: TIU8188 GENERATED BY: LEATHAM,ROSS GENERATED WHILE QUEUED: YES DISPLAY TEXT: DEMO,DEMO (999990): UNSIGNED CHART REVIEW OVERDUE for SIGNATURE. ROUTINE TAG: ACT ROUTINE FOR PROCESSING: TIUALRT DATA FOR PROCESSING: 8188^ RECIPIENT: MOORE,LORI B PHARM ALERT FIRST DISPLAYED: NOV 17, 2006@07:11:18 DELETED ON: NOV 17, 2006@23:00:18

38. Questions?