TIU for Medical Records

1. TIU for Medical Records TIU stands for Text Integration Utility

2. TIUM TIU Menu for Medical Records ... • Select TIU Menu for Medical Records Option: ? • IPD Individual Patient Document • LAD List of Active Document Titles • MPD Multiple Patient Documents • PDM Print Documents Menu ... • SIG Awaiting Signature Listing • SSD Search for Selected Documents • STR Statistical Reports ... • UPL TIU Upload Menu ... • VUA View a User's Alerts

3. Individual Patient Document Select TIU Menu for Medical Records Option: individual Patient Document Select PATIENT NAME: 999999 ZZDEMO,PATIENT <CWAD> F 10-17-1963 000002222 RLHO 999999 Available documents: 12/06/2004 thru 04/19/2005 (19) Please specify a date range from which to select documents: List documents Beginning: 12/06/2004// T-30 (MAR 27, 2005) Thru: 04/19/2005// (APR 19, 2005) 1 04/19/2005 13:16 MEDICATION REFILL ZIETLOW,K Visit: 04/19/2005 2 04/18/2005 14:01 GENERAL ENCOUNTER ANDERSON,M Visit: 04/15/2005 3 04/14/2005 11:25 GENERAL ENCOUNTER HAMSTRA,S Visit: 04/14/2005 4 04/14/2005 11:25 GENERAL ENCOUNTER BORROMEO,M Visit: 04/14/2005 Choose one or more documents: (1-4): 4

4. Individual Patient Document

5. Choose the Edit List Manager command You may not edit a completed document. Press RETURN to continue... Do you wish to ADD a new ADDENDUM? NO// Y • This then opens up into screen editor and you can create your note, exit, and then sign it. • The clinician will receive a view alert that you entered an addendum to his note.

6. List Manager Commands

7. Select TIU Menu for Medical Records Option: Search for Selected Documents Select Status: ALL// ? 1 undictated 5 unsigned 9 purged 2 untranscribed 6 uncosigned 10 deleted 3 unreleased 7 completed 11 retracted 4 unverified 8 amended Enter selection(s) by typing the name(s), number(s), or abbreviation(s). Select Status: ALL// COMP completed Select CLINICAL DOCUMENTS Type(s): Progress Notes// Progress Notes Select SEARCH CATEGORIES: AUTHOR// ? 1 All Categories 5 Patient 9 Title 2 Author 6 Problem 10 Transcriptionist 3 Expected Cosigner 7 Service 11 Treating Specialty 4 Hospital Location 8 Subject 12 Visit Select SEARCH CATEGORIES: AUTHOR//TI Title Please Select the PROGRESS NOTE TITLES to search for: 1) LETTER TITLE TITLE 2) Start Reference Date [Time]: T-7// T-30 (MAR 27, 2005) Ending Reference Date [Time]: NOW//

8. Additional TIU options List of Active Document Titles' Synonym: LAD Displays a list of active titles sorted by document class. Multiple Patient Documents' Synonym: MPD IHS version of report to view documents from multiple patients. Awaiting Signature Listing' Synonym: SIG Use this option to pull a list of charts in the Incomplete Chart system that are waiting for signatures on TIU documents. You can update the Incomplete Chart file here and print out a chart copy of the document. Statistical Reports' Synonym: STR IHS version of Statistical Reports Menu. Contains IHS option and header code. AUT AUTHOR Line Count Statistics DTS Dictation Timeliness Statistics SER SERVICE Line Count Statistics TRA TRANSCRIPTIONIST Line Count Statistics This one did not work when I tried it.

9. View a User’s Alerts 'View a User's Alerts' Synonym: VUA Displays a user's alert list. Used to compare alert list with MYU list which medical records personnel can see via SSD option. Select TIU Menu for Medical Records Option: vua View a User's Alerts Select NEW PERSON: maggie ANDERSON,MARGARET A MAA ADP SITE MANAGER 4 alerts found for ANDERSON,MARGARET A: 1 DEMO,PATI (999999): UNSIGNED GENERAL ENCOUNTER OVERDUE for SIGNATURE. 2 DEMO,PATI (999999): UNSIGNED EMPLOYMENT PHYSICAL OVERDUE for SIGNATURE. 3 DEMO,PATI (D9999): Labs resulted - [GLUCOSE] 4 DEMO,PATI (D9999): Critical lab: GLUCOSE 950 03/09 16:21

10. Print Documents Menu PDM This menu allows medical records personnel access to options which print CHART or WORK copies of Discharge Summaries, Progress Notes, or mixed Documents on demand. • PDM1 Discharge Summary Print • PDM2 Progress Note Print • PDM3 Clinical Document Print

11. Screen Editor Commands Exiting/Saving Exit and save text <F1>E Quit with optional save <F1>Q Deleting Character before cursor <Backspace> Entire line <F1>D Formatting Join current line to next line <F1>J Reformat paragraph <F1>R To see all of the commands <F1>H=Help

12. Editing with replace… Example: SIGNATURE BLOCK TITLE: V23 SENIOR SYSTEM ANALYST Replace The "Replace" and "With" prompts are case sensitive. If you want to replace the entire entry, you can enter ellipsis points—three periods (...) at the "Replace" prompt and then type in the new entry at the "With" prompt. Also, these prompts are only presented to you when an entry is greater than or equal to 20 characters in length. If the entry is less than 20 characters, you will merely be shown the current default entry, if any, and you must type in your entire new entry after the prompt. These are VA FileMan conventions. … If you wish to replace the whole line END If you wish to add to the end of the line @ If you wish to delete the entire entry

13. General RPMS Conventions ? Provides information about what the system expects to receive at a given prompt. ?? Provides more detail concerning what the system expects to receive at a given prompt ??? Provides maximum information concerning what the system expects to receive at a given prompt

14. Conventions, continued… • ^ Will allow you to exit an option or prompt • @ This is the delete command • // A prompt followed by this indicates a default answer. • You may either press enter to accept or change the answer. • DEVICE • Enter a printer • Enter HOME or just press enter to display to your screen • Enter p-message to convert to a mail message

15. Create an addendum in EHR 2. Highlight the note • 3. Rt. Click in body • This pop-up menu • Choose Make Addendum 1. Click on Notes

16. Enter your note • Enter the note • Click on the signature icon (hand/pen) • Sign the note