Health Information Management (HIM) EHR Monitoring

1. Health Information Management (HIM) EHR Monitoring EHR for HIM

2. Presenter Peggy Shults RHIA, CCS Claremore Hospital

3. Learning Objectives: • Manage Unsigned and Uncosigned Notes • Print multiple progress notes by date range • Identify Missing Text & Clean up • Identify Reassignment of Documents • List Active Document Titles

4. Manage unsigned/uncosigned Notes TIUM TIU Menu for Medical Records ... SSD Search for Selected Documents SIG Awaiting Signature Listing

5. Select TIU Menu for Medical Record Option: SSD 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

6. Select TIU Menu for Medical Record Option: SSD (cont) Select CLINICAL DOCUMENTS Type(s): Progress Notes// ? 1 Progress Notes 3 Discharge Summaries 5 Laboratory Reports 2 Addendum 4 Clinical Procedures 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:

7. Select TIU Menu for Medical Record Option: SSD Select Type – Includes all document classes Select PROGRESS NOTE Type(s): Advance Directive// ? 1 Advance Directive 7 Medicine Service Note Dictate Notes 2 Adv React/Allergy Id Parent Notes Consults 3 Crisis Note Id Child Notes Operative Reports 4 Clinical Warning Pharmacy Notes Deleted Progress Note 5 Sample Titles Nursing Notes Enter selection(s) by typing the name(s), number(s), or abbreviation(s). May select ALL to see all progress notes

8. TIU Medical Records Menu Options (TIUM)

9. Individual Patient DocumentIPD

10. Select TIU Menu for Medical Record Option: SSD Select Category Select SEARCH CATEGORIES: AUTHOR// ? 1 All Categories 7 Service 2 Author 8 Subject 3 Expected Cosigner 9 Title 4 Hospital Location 10 Transcriptionist 5 Patient 11 Treating Specialty 6 Problem 12 Visit Enter selection(s) by typing the name(s), number(s), or abbreviation(s).

11. Report of All Progress Notes

12. Hidden Actions (??) The following actions are also available: + Next screen > Shift View to Right - Previous Screen GO Go to Page FS First Screen RD Re Display Screen LS Last Screen PL Print List UP Up a Line QQ Quick Quit DN Down a Line ADPL Auto Display(On/Off) < Shift View to Left CP Copy CT Change Title CWAD CWAD Display EE Expand/Collapse Entry F Find EX Expand/Collapse Entry

13. PDM Print Documents Menu Print Documents Menu (DEMO WALK-IN CENTER) PDM1 Discharge Summary Print PDM2 Progress Note Print PDM3 Clinical Document Print Select Print Documents Menu Option:

14. PDM2 Progress Note Print Print Documents Menu (DEMO WALK-IN CENTER) Select Print Documents Menu Option: Progress Note Print Select PATIENT NAME: DEMO,PATIENT M 10-01-1947 XXX-XX-1234 4 No notes on file for DEMO,PATIENT Press RETURN to continue...

15. Notes Title Report

16. To get a list of unsigned notes Select TIU Menu for Medical Records Option: SSD Search for Selected Documents Select Status: ALL// UNS,UNCO unsigned uncosigned Select CLINICAL DOCUMENTS Type(s): Progress Notes// ALL Progress Notes Addendum Discharge Summaries Clinical Procedures Laboratory Reports Select SEARCH CATEGORIES: AUTHOR// ALL All Categories Start Reference Date [Time]: T-7// T-365 (NOV 14, 2005) Ending Reference Date [Time]: NOW// (NOV 14, 2006@08:37) This will list all unsigned and uncosigned notes, addendums, and discharge summaries for all authors.

17. Report by Author Select TIU Menu for Medical Records Option: SSD Search for Selected Documents Select Status: ALL// 5,6 unsigned uncosigned Select CLINICAL DOCUMENTS Type(s): Progress Notes// ALL Progress Notes Addendum Discharge Summaries Clinical Procedures Laboratory Reports Select AUTHOR: USER,ONE ON LPN Start Reference Date [Time]: T-7// T-365 (NOV 14, 2005) Ending Reference Date [Time]: NOW//

18. Example of a report by author. Print to provide a copy to provider

19. View a User’s Alerts (VUA)(Located under TIU Menu for Medical Records) '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: mouse MOUSE,MINNIE MAA ADP SITE MANAGER 4alerts found for MOUSE,MINNIE: 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 Rather than printing the unsigned list, Check to verify they have a pending notification. If so, advise user to process notifications.

20. 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. 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

21. Identify Missing Text and Clean UP TIUM TIU Menu for Medical Records ... HIMS Special HIMS TIU Reports…. 1 Missing Text Report 2 Missing Text Cleanup 3 Reassignment Document Report

22. Identify Reassigment of Documents TIUM TIU Menu for Medical Records ... HIMS Special HIMS TIU Reports…. 1 Missing Text Report 2 Missing Text Cleanup 3 Reassignment Document Report

23. TIU Reassignment Report

24. List Active Document Titles TIUM TIU Menu for Medical Records ... LAD List of Active Document Titles

25. LAD Actions • ?? To see actions available:

26. Search LAD List

27. Print LAD List

28. Policy & Procedure Review

29. Questions and Discussion