Block 1 User`s Manual.book

Block 1 User`s Manual.book
CHCS II Block 1 User’s Manual
Build 838
for the
Composite Health Care System II
Prepared for:
The CHCS II Program Office
and the
MHS Clinical Information
Technology Program Office
27 July 2005
Prepared By:
Integic Corporation
Healthcare Practice Area
3675 Concorde Parkway, Suite 800B
Chantilly, Virginia 20151
Table 1: CHCS II Block 1 Changes
Functionality/
Change
Build
Module
Date
Replaced graphics in
CHCS II Training
System Module
838
CHCS II Training
System
5/18/05
Added Failover
Operations/Local
Cache Module
838
Local Cache
5/18/05
Army Profiles
833.8
837
Army Profile
8/18/04
Training System
Convergence
837
CHCS II Training
System
8/18/04
Hear 3.0
833.8
837
PKC Couplers
8/18/04
Allergy/Appt
Triggers
836
Appointments
Allergies
7/16/04
APV Turn-off
833.8
836
Appoimtments (6.4)
Disposition (13.2)
7/16/04
CAC
836
Getting Started (1.6)
7/16/04
HIPAA 837
836
Appointments (6.4)
A/P (8.2)
Disposition (13.2)
Screening (36.3)
Vitals (43.3)
Navigation
Patient Encounter
7/16/04
IBWA
836
Appointments (6.4)
Patient Encounter
Previous Encounters
Medications (19.3)
7/16/04
Immunizations Ph 1
836
Immunizations
7/16/04
Snareworks 5.16
836
Getting Started (1.2)
7/16/04
Block 1
Build 838
CHCS II User’s Manual
a
Table 1: CHCS II Block 1 Changes
Functionality/
Change
b
Build
Module
Date
Wellness
Enhancements
836
Wellness
A/P (8.7)
Reminder Mapping
7/16/04
Group A
835
Vitals (42.3)
4/29/04
Template Mgt Ph 1
835
Template Management
4/29/04
Medicomp Forms
Tool
834
S/O (38.3)
3/9/04
CHCS II User’s Manual
Block 1
Build 838
Table 1: CHCS II Block 1 Changes
Functionality/
Change
Block 1
Build 838
Build
Module
CHCS II User’s Manual
Date
c
d
CHCS II User’s Manual
Block 1
Build 838
Table of Contents
CHCS II User’s Manual
Table of Contents
1.0 GETTING STARTED ........................................................................................ 1–1
1.1 CHCS II Overview .................................................................................. 1–1
1.2 Security Overview .................................................................................. 1–1
1.3 Account Creation Process...................................................................... 1–2
1.4 Transferring an Account from One MTF to Another MTF ...................... 1–3
1.5 Account Management ............................................................................ 1–4
1.6 Logging Into CHCS II ............................................................................. 1–4
1.7 Changing the CHCS II Password........................................................... 1–7
1.8 Exiting CHCS II ...................................................................................... 1–9
1.9 Protecting Sensitive Material.................................................................. 1–9
1.10 Protecting Your Assigned Username and Password ........................... 1–9
1.11 Protecting Your Workstation ................................................................ 1–9
1.12 Break the Glass Privileges ................................................................. 1–10
2.0 CHCS II NAVIGATION .................................................................................... 2–1
2.1 Navigation Basics................................................................................... 2–1
2.2 Customizing the CHCS II User Interface................................................ 2–2
2.3 Opening a Module.................................................................................. 2–4
2.4 Closing a Module ................................................................................... 2–4
2.5 Startup Options ...................................................................................... 2–4
2.6 Patient ID Bar......................................................................................... 2–5
2.7 CHCS Access ........................................................................................ 2–6
3.0 FAILOVER OPERATIONS ................................................................................. 3–1
3.1 Failover Operations Overview................................................................ 3–1
3.2 Failover Mode ........................................................................................ 3–3
3.3 LCD Failure ............................................................................................ 3–5
3.4 CHCS Failure in Failover Mode ............................................................. 3–5
3.5 Failover Operations................................................................................ 3–6
3.6 Failover Mode Supported Modules ........................................................ 3–6
Block 1
Build 838
CHCS II User’s Manual
i
Table of Contents
3.7 User Configuration Data....................................................................... 3–11
4.0 WORK FLOWS ............................................................................................... 4–1
4.1 Basic Front Desk Clerk Workflow........................................................... 4–1
4.2 Basic Support Staff Workflow................................................................. 4–1
4.3 Basic Provider Workflow ........................................................................ 4–2
5.0 ALLERGY ....................................................................................................... 5–1
5.1 Allergy Overview .................................................................................... 5–1
5.2 Creating a Common List of Allergens .................................................... 5–3
5.3 Adding an Allergy ................................................................................... 5–4
5.4 Editing an Allergy ................................................................................... 5–5
5.5 Deleting an Allergy ................................................................................. 5–6
5.6 Verifying Allergies .................................................................................. 5–6
6.0 ALERT REVIEW MODULE ................................................................................ 6–1
6.1 Alert Review Overview ........................................................................... 6–1
6.2 Addressing an Alert................................................................................ 6–2
6.3 Addressing New and Priority Result Alerts ............................................ 6–2
6.4 Deleting an Alert..................................................................................... 6–3
6.5 Viewing Details of an Alert ..................................................................... 6–3
7.0 APPOINTMENTS ............................................................................................. 7–1
7.1 Appointments Overview ......................................................................... 7–1
7.2 Setting the Properties of the Appointments Module............................... 7–2
7.3 Filtering the List of Appointments........................................................... 7–3
7.4 Creating a New Appointment ................................................................. 7–5
7.5 Checking In a Patient ............................................................................. 7–9
7.6 Checking Out a Patient ........................................................................ 7–10
7.7 Adding an Additional Provider.............................................................. 7–10
7.8 Transferring an Appointment................................................................ 7–12
7.9 Canceling an Appointment ................................................................... 7–12
7.10 Printing the Insurance Form............................................................... 7–13
7.11 Viewing a Comment Associated with an Appointment....................... 7–13
ii
CHCS II User’s Manual
Block 1
Build 838
Table of Contents
8.0 ARMY PROFILE .............................................................................................. 8–1
8.1 Army Profile Overview............................................................................ 8–1
8.2 Creating a Profile Template ................................................................... 8–6
8.3 Using an Army Profile Template ............................................................ 8–7
8.4 Viewing and Printing the DA Form 3349 ................................................ 8–9
8.5 Deleting a Profile.................................................................................... 8–9
8.6 Removing a User Profile Template ...................................................... 8–10
9.0 ASSESSMENT AND PLAN (A/P) ....................................................................... 9–1
9.1 Assessment and Plan Overview ............................................................ 9–1
9.2 Associating Procedures, Orders, and Instructions ................................. 9–1
9.3 Documenting a Diagnosis ...................................................................... 9–2
9.4 Creating an Order Set from A/P ............................................................. 9–5
9.5 Documenting a Procedure ..................................................................... 9–7
9.6 Linking a Clinical Team Member to a Procedure ................................... 9–9
9.7 Addressing Reminders......................................................................... 9–11
9.8 Ordering a Consult ............................................................................... 9–15
9.9 Ordering a Laboratory Test .................................................................. 9–18
9.10 Ordering a Radiology Procedure........................................................ 9–28
9.11 Ordering a Medication........................................................................ 9–30
9.12 Requesting Location .......................................................................... 9–33
9.13 Adding Patient Instructions ................................................................ 9–36
9.14 Discontinuing an Order ...................................................................... 9–37
9.15 Placing an Order on Hold................................................................... 9–37
9.16 Showing the Details of an Order ........................................................ 9–37
9.17 Renewing/Modifying an Order............................................................ 9–38
10.0 CLINICAL NOTES........................................................................................ 10–1
10.1 Clinical Notes Overview ..................................................................... 10–1
10.2 Setting Time Preferences for the Clinical Notes Module.................... 10–5
10.3 Creating a New Note.......................................................................... 10–7
10.4 Editing a Note..................................................................................... 10–8
Block 1
Build 838
CHCS II User’s Manual
iii
Table of Contents
11.0 CONSULT LOG ........................................................................................... 11–1
11.1 Consult Log Overview ........................................................................ 11–1
11.2 Setting the Consult Log Filter............................................................. 11–2
11.3 Setting the Consults Change Selection Criteria ................................. 11–2
11.4 Printing a Consult............................................................................... 11–3
11.5 Removing a Consult........................................................................... 11–4
11.6 Viewing the History of a Consult ........................................................ 11–4
12.0 CO-SIGNS ................................................................................................. 12–1
12.1 Co-signs Overview ............................................................................. 12–1
12.2 Co-Signing an Encounter ................................................................... 12–1
12.3 Co-Signing an Encounter for Another Provider.................................. 12–2
12.4 Appending a Narrative ....................................................................... 12–3
12.5 Amending an Encounter..................................................................... 12–5
13.0 DEMOGRAPHICS ........................................................................................ 13–1
13.1 Demographics Overview .................................................................... 13–1
13.2 Editing Demographic Information....................................................... 13–2
13.3 Viewing Primary Care Provider Information ....................................... 13–3
13.4 Modifying Special Work Status .......................................................... 13–3
13.5 Viewing DEERS Eligibility .................................................................. 13–4
13.6 Updating Required Fields................................................................... 13–4
13.7 Printing the Insurance Form............................................................... 13–5
13.8 Entering New Third-Party Insurance Information ............................... 13–5
14.0 DISPOSITION ............................................................................................. 14–1
14.1 Disposition Overview.......................................................................... 14–1
14.2 Completing the Disposition ................................................................ 14–2
15.0 FLOWSHEETS ............................................................................................ 15–1
15.1 Flowsheets Overview ......................................................................... 15–1
15.2 Viewing Flowsheets ........................................................................... 15–1
15.3 Printing Flowsheets............................................................................ 15–2
iv
CHCS II User’s Manual
Block 1
Build 838
Table of Contents
16.0 HEALTH HISTORY ...................................................................................... 16–1
16.1 Health History Overview..................................................................... 16–1
16.2 Customizing the Health History Module ............................................. 16–2
16.3 Viewing Historical Modules ................................................................ 16–2
17.0 IMMUNIZATION ADMIN ................................................................................ 17–1
17.1 Immunizations Admin Overview......................................................... 17–1
17.2 Adding User-Defined Groups ............................................................. 17–2
17.3 Adding a Refrigerator ......................................................................... 17–3
17.4 Adding a Vaccine for Multiple Entry ................................................... 17–5
17.5 Assigning Vaccines to User Defined Groups ..................................... 17–6
17.6 Deleting Providers from Administering Immunizations....................... 17–6
17.7 Entering Multiple Vaccines for a Patient ............................................ 17–7
17.8 Logging Refrigerator Temperatures ................................................... 17–8
17.9 Modifying Refrigerator Temperature Logs ......................................... 17–9
17.10 Modifying a Refrigerator................................................................. 17–10
17.11 Printing Immunization Reports ....................................................... 17–11
17.12 Selecting a Default Vaccination Clinic............................................ 17–12
17.13 Viewing the Vaccine Lot Number List ............................................ 17–13
18.0 LABORATORY ............................................................................................ 18–1
18.1 Laboratory Overview .......................................................................... 18–1
18.2 Creating a Search Filter in the Lab Module........................................ 18–1
18.3 Setting Laboratory Module Preferences............................................. 18–3
18.4 Viewing Lab Results........................................................................... 18–4
18.5 Viewing Sensitive Lab Results ........................................................... 18–5
18.6 Copying Lab Results to a Note .......................................................... 18–5
18.7 Printing Lab Results ........................................................................... 18–6
19.0 LIST MANAGEMENT .................................................................................... 19–1
19.1 List Management Overview................................................................ 19–1
19.2 Adding an Item to a Favorites List...................................................... 19–2
19.3 Deleting an Item From a Favorites List .............................................. 19–3
19.4 Changing Location of Items on a List................................................. 19–3
Block 1
Build 838
CHCS II User’s Manual
v
Table of Contents
20.0 MEDICATIONS ............................................................................................ 20–1
20.1 Medications Overview ........................................................................ 20–1
20.2 Setting the Filter of the Medications Module ...................................... 20–2
20.3 Documenting an OTC/Outside Medication......................................... 20–2
20.4 Ordering a New Medication................................................................ 20–4
20.5 Reviewing a Medication ..................................................................... 20–5
20.6 Discontinuing a Medication ................................................................ 20–6
20.7 Renewing a Medication...................................................................... 20–6
21.0 NEW RESULTS .......................................................................................... 21–1
21.1 New Results Overview ....................................................................... 21–1
21.2 Viewing New Results ......................................................................... 21–2
21.3 Discarding New Results ..................................................................... 21–3
21.4 Saving New Results ........................................................................... 21–3
21.5 Forwarding New Results .................................................................... 21–4
21.6 Tossing New Results ......................................................................... 21–6
22.0 ORDER SETS............................................................................................. 22–1
22.1 Order Sets Overview.......................................................................... 22–1
22.2 Creating an Order Set from A/P ......................................................... 22–1
22.3 Using an Order Set in A/P.................................................................. 22–3
23.0 PATIENT ENCOUNTER ................................................................................ 23–1
23.1 Patient Encounter Overview............................................................... 23–1
23.2 Adding a Note .................................................................................... 23–3
23.3 Deleting a Note .................................................................................. 23–5
23.4 Editing a Note..................................................................................... 23–5
23.5 Adding an Additional Provider............................................................ 23–6
23.6 Loading an Encounter Template ........................................................ 23–8
23.7 Signing the Encounter Overview........................................................ 23–9
23.8 Saving an Encounter as a Template ................................................ 23–11
23.9 Unlocking an Encounter ................................................................... 23–12
24.0 PATIENT IMMUNIZATIONS ............................................................................ 24–1
24.1 Patient Immunizations Overview........................................................ 24–1
vi
CHCS II User’s Manual
Block 1
Build 838
Table of Contents
24.2 Adding a Vaccination ......................................................................... 24–2
24.3 Deleting Immunization History ........................................................... 24–4
24.4 Editing Immunization History.............................................................. 24–5
24.5 Editing Vaccination Groups................................................................ 24–6
24.6 Printing Immunization Records .......................................................... 24–7
24.7 Reviewing Immunization Records...................................................... 24–7
24.8 Selecting an Immunization ................................................................. 24–7
24.9 Selecting the Immunization Exempt Type.......................................... 24–8
25.0 PATIENT LIST ............................................................................................ 25–1
25.1 Patient List Overview ......................................................................... 25–1
25.2 Adding a Patient Name ...................................................................... 25–1
25.3 Deleting a Patient Name .................................................................... 25–2
25.4 Deleting the Entire List of Patients ..................................................... 25–2
26.0 PATIENT QUESTIONNAIRES......................................................................... 26–1
26.1 Patient Questionnaires Overview....................................................... 26–1
26.2 Viewing Questionnaires in an Encounter Document.......................... 26–1
26.3 Assigning a Questionnaire to a Patient .............................................. 26–1
26.4 Reviewing a Completed Questionnaire.............................................. 26–4
27.0 PATIENT SEARCH ...................................................................................... 27–1
27.1 Patient Search Overview.................................................................... 27–1
27.2 Conducting a Search.......................................................................... 27–1
27.3 Selecting a Patient Record Without a Search .................................... 27–3
28.0 PKC COUPLERS ........................................................................................ 28–1
28.1 PKC Couplers Overview .................................................................... 28–1
28.2 Running a New Coupler ..................................................................... 28–1
28.3 Viewing a Completed Coupler............................................................ 28–4
28.4 Updating a Completed Coupler.......................................................... 28–4
28.5 Using a Kiosk to Complete the HEAR Questionnaire ........................ 28–5
28.6 Finding Summary Report ................................................................... 28–6
28.7 Reviewing and Resolving the Finding Error Summary....................... 28–7
28.8 Printing or Previewing a Report ......................................................... 28–8
Block 1
Build 838
CHCS II User’s Manual
vii
Table of Contents
29.0 PREVIOUS ENCOUNTERS............................................................................ 29–1
29.1 Previous Encounters Overview .......................................................... 29–1
29.2 Appending a Narrative ....................................................................... 29–1
29.3 Amending a Previous Encounter........................................................ 29–4
29.4 Creating a New Encounter Template ................................................. 29–6
29.5 Copy Forward..................................................................................... 29–8
29.6 Printing Previous Encounter Documents ......................................... 29–10
30.0 PROBLEMS ................................................................................................ 30–1
30.1 Problems Overview ............................................................................ 30–1
30.2 Viewing the Problem List.................................................................... 30–1
30.3 Adding a Problem............................................................................... 30–2
30.4 Adding an Historical Procedure.......................................................... 30–3
30.5 Adding Family History Problems ........................................................ 30–5
30.6 Updating a Problem or Procedure...................................................... 30–6
30.7 Accessing Healthcare Maintenance................................................... 30–7
31.0 QUESTIONNAIRE SETUP ............................................................................. 31–1
31.1 Questionnaire Setup Overview .......................................................... 31–1
31.2 Copying a Questionnaire.................................................................... 31–3
31.3 Deleting a Questionnaire.................................................................... 31–4
31.4 Importing a Questionnaire or Question into a Questionnaire ............. 31–4
31.5 Maintaining Questionnaires................................................................ 31–5
32.0 RADIOLOGY ............................................................................................... 32–1
32.1 Radiology Overview ........................................................................... 32–1
32.2 Creating a Filter in the Radiology Module .......................................... 32–1
32.3 Setting Time Preferences in the Radiology Module ........................... 32–3
32.4 Viewing Radiology Results................................................................. 32–4
32.5 Printing Radiology Results ................................................................. 32–4
32.6 Copying Radiology Results to a Note ................................................ 32–4
33.0 READINESS ............................................................................................... 33–1
33.1 Readiness Overview .......................................................................... 33–1
33.2 Modifying Readiness Information....................................................... 33–1
viii
CHCS II User’s Manual
Block 1
Build 838
Table of Contents
34.0 REMINDER MAPPING .................................................................................. 34–1
34.1 Reminder Mapping Overview............................................................. 34–1
34.2 Setting a Default Action...................................................................... 34–3
34.3 Mapping Encounter Terms................................................................. 34–7
34.4 Managing Immunization Reminders................................................... 34–8
35.0 REPORTS .................................................................................................. 35–1
35.1 Reports Overview............................................................................... 35–1
35.2 Running Customized Reports ............................................................ 35–4
35.3 Running Preventive Reports .............................................................. 35–5
35.4 Running Standard Reports................................................................. 35–7
35.5 Running Population Health Reports................................................... 35–8
35.6 Exporting a Report ............................................................................. 35–9
36.0 RX ALTERNATIVES ..................................................................................... 36–1
36.1 Drug (RX) Alternatives Overview ....................................................... 36–1
36.2 Setting Drug Display Options ............................................................. 36–1
36.3 Adding a New Drug ............................................................................ 36–2
36.4 Adding Therapeutic Alternatives ........................................................ 36–3
36.5 Deleting a Drug .................................................................................. 36–4
37.0 SCREENING (REASON FOR VISIT) ............................................................... 37–1
37.1 Screening Overview ........................................................................... 37–1
37.2 Adding an Additional Provider............................................................ 37–1
37.3 Documenting the Reason for Visit...................................................... 37–3
37.4 Adding Female Only Data .................................................................. 37–4
37.5 Verifying Allergies .............................................................................. 37–5
37.6 Managing the Wellness Reminders ................................................... 37–6
38.0 SCREENING NOTIFICATION ......................................................................... 38–1
38.1 Screening Notification Overview ........................................................ 38–1
38.2 Selecting Screening Notification Reminder Search Options .............. 38–2
38.3 Notifying Patients about Screening Services ..................................... 38–4
Block 1
Build 838
CHCS II User’s Manual
ix
Table of Contents
39.0 SIGN ORDERS ........................................................................................... 39–1
39.1 Sign Orders Overview ........................................................................ 39–1
39.2 Cancelling a Non-Provider Order ....................................................... 39–1
39.3 Signing Non-Provider Orders ............................................................. 39–1
40.0 SUBJECTIVE/OBJECTIVE (S/O) ................................................................... 40–1
40.1 Subjective/Objective Overview........................................................... 40–1
40.2 S/O Templates Overview ................................................................... 40–3
40.3 S/O Template Personalization Overview ......................................... 40–12
40.4 MEDCIN Forms Overview................................................................ 40–27
41.0 TELEPHONE CONSULTS ............................................................................. 41–1
41.1 Telephone Consults Overview ........................................................... 41–1
41.2 Setting the Properties of the Telephone Consults Module................. 41–2
41.3 Canceling a Telephone Consult ......................................................... 41–4
41.4 Editing the Callback Phone Number .................................................. 41–4
41.5 Opening an Encounter ....................................................................... 41–5
41.6 Creating a New Telephone Consult ................................................... 41–5
41.7 Completing the Telcon Quick Entry Screen ....................................... 41–6
41.8 Transferring a Telephone Consult...................................................... 41–8
41.9 Viewing a Telcon Note ....................................................................... 41–8
42.0 TEMPLATE MANAGEMENT ........................................................................... 42–1
42.1 Template Management Overview ...................................................... 42–1
42.2 Organizing Templates ........................................................................ 42–2
42.3 Moving Templates to Folders............................................................. 42–4
42.4 Selecting an Encounter Template ...................................................... 42–5
42.5 Setting an Encounter Template as a Default ..................................... 42–7
42.6 Creating a New Template .................................................................. 42–8
42.7 Searching for a Template................................................................. 42–10
42.8 Editing a Template ........................................................................... 42–12
42.9 Merging Templates .......................................................................... 42–13
42.10 Copying a Template ....................................................................... 42–15
42.11 Removing/Adding to Favorites ....................................................... 42–15
x
CHCS II User’s Manual
Block 1
Build 838
Table of Contents
42.12 Importing/Exporting a Template ..................................................... 42–16
42.13 Deleting a Template ....................................................................... 42–17
42.14 Saving an Encounter as a Template .............................................. 42–18
43.0 CHCS II TRAINING SYSTEM ....................................................................... 43–1
43.1 CHCS II Training System Overview ................................................... 43–1
43.2 Logging into the Training System....................................................... 43–2
43.3 Using the Training System ................................................................. 43–5
43.4 Patient Information ............................................................................. 43–9
43.5 Removing the Training System ........................................................ 43–11
44.0 VITAL SIGNS.............................................................................................. 44–1
44.1 Vital Signs Overview .......................................................................... 44–1
44.2 Setting the Properties of the Vital Signs Module................................ 44–1
44.3 Entering New Vital Signs.................................................................... 44–2
44.4 Editing Vital Signs .............................................................................. 44–5
44.5 Deleting Vital Signs ............................................................................ 44–6
44.6 Graphing Vital Signs .......................................................................... 44–6
44.7 Reviewing Vital Signs......................................................................... 44–7
44.8 Vital Sign Ranges............................................................................... 44–9
45.0 WEB BROWSER ......................................................................................... 45–1
45.1 Web Browser Overview...................................................................... 45–1
45.2 Changing the Internet Home Page..................................................... 45–1
45.3 Accessing the Favorites List .............................................................. 45–3
45.4 Adding to the Favorites List................................................................ 45–3
45.5 Organizing the Favorites List ............................................................. 45–3
45.6 Importing HTML Bookmarks .............................................................. 45–5
45.7 Exporting HTML Bookmarks .............................................................. 45–5
45.8 Printing Web Pages ........................................................................... 45–6
46.0 WELLNESS ................................................................................................ 46–1
46.1 Wellness Overview............................................................................. 46–1
46.2 Setting the Filter for the Wellness Module ......................................... 46–1
46.3 Setting Preferences for the Wellness Module .................................... 46–3
Block 1
Build 838
CHCS II User’s Manual
xi
Table of Contents
46.4 Due Reminders Tab ........................................................................... 46–4
46.5 Documentation History Tab................................................................ 46–8
46.6 Wellness Schedule Tab ................................................................... 46–13
xii
CHCS II User’s Manual
Block 1
Build 838
1.0 GETTING STARTED
1.1
CHCS II Overview
As the target healthcare system of the Department of Defense (DoD), the Composite
Health Care System (CHCS) II provides a structured framework for accessing and
integrating medical information for patients. CHCS II is the Military Health System
(MHS) Computer-based Patient Record (CPR). It provides the DoD with an enterprise-wide system, governed by universal standards integrating data from multiple
sources and displaying the data at the point of care. Appropriate portions are easily
accessible to authorized users when and where needed. The CPR facilitates the worldwide delivery of healthcare, assists clinicians in making healthcare decisions, and supports leaders in making operational and resource allocation decisions.
CHCS II provides the essential capabilities, as identified by the functional community,
to support the creation of a CPR. CHCS II integrates the best of Government and commercial off-the shelf (COTS) products by interfacing the existing MHS Automated
Information Systems with new functionality.
1.2
Security Overview
CHCS II is installed in Military Treatment Facilities (MTFs) and clinics throughout
the world. As the security of patient data is of paramount importance in the military's
healthcare community, an elaborate and effective security methodology has been built
into CHCS II. The system administrator strictly controls access to all parts of
CHCS II.
An integral part of CHCS II security is the assignment of roles. Each user is assigned a
CHCS II role. This role is determined by the user's job skill set. These roles are cumulative, allowing greater access to patient information as roles are added. Similar in
concept to the CHCS user level, an individual's role determines what information can
be accessed or changed.
CHCS II is developed to provide an interface to data contained in the military health
care systems. The CHCS II product provides the DoD clinical team members with a
single-sign-on capability to retrieve patient data from multiple sources and locations
without the need to manually access each information repository. With the single-signon feature, CHCS II account users are able to retrieve site information stored in the
Clinical Data Repository (CDR) at Defense Information Systems Agency (DISA) and
to access their local CHCS application. The CHCS II account resides on the Enterprise Master Security Server (EMSS) at DISA with local control at each Host MTF.
The local access to the Enterprise system is granted, managed and inactivated at the
local sites using the local security object, similar to the CHCS account creation, granting access to the local CHCS. The management of the local access to CHCS II is
designed to meet MHS and DoD account management guidelines, while the Enterprise account remains intact for successful transfer to other CHCS II MTFs and access
to global user account information. Local sites do have the capability to delete the
Block 1
Build 838
CHCS II User’s Manual
1-1
Getting Started
Enterprise accounts in the event of a security violation. User accounts can and will be
suspended after 45 days and disabled/inactivated after 120 days of non-activity, or
when a user leaves the MTF.
The CHCS II Enterprise account enables users to transfer from one CHCS II MTF to
another CHCS II MTF, for reassignment or Temporary Duty (TDY), and continue to
access their CHCS II account settings, such as personal templates, and gain access to
the new CHCS II MTF clinical information. This process is referred to as Transferring
a CHCS II account.
1.3
Account Creation Process
CHCS II user account creation is an automated process. This process is initiated with
the creation of the CHCS user account. Upon creating and flagging the CHCS user
account with the settings “Active CHCS II user,” the user account information is sent
to the CDR and to SnareWorks to create the user account on the EMSS. Once the
EMSS receives the request for the account, the system sends an email to the Security
Administrator(s) at the local site, notifying the site that the account is ready for activation. The site system administrator then assigns the appropriate roles and privileges
and provides local access to the CDR and CHCS.
Upon CHCS II account accreditation, the Security Administrator, through a local process, notifies the user that his/her account has been accredited and he/she can proceed
to log into CHCS II. The user logs in to CHCS II using the CHCS Access/Verify code
and is prompted to change his/her password and enter a new User ID. This updates the
CHCS Verify code (password) and provides the user with a username for entering
CHCS II and CHCS (single sign-on), but does not change the CHCS Access code.
Note: According to the MHS Security Guidelines, the CHCS II password must meet
the following criteria.
1-2
•
Minimum of 8 and maximum of 20 characters
•
Minimum of 1 numeric character
•
Contain at least 1 of the following non-alphanumeric characters: !, @, #,
$, %, or &
•
Mixture of case
•
It should not be a previously used CHCS Verify code
•
@ sign cannot be used in the User ID or password
•
Passwords should not consist of words found in the dictionary
•
Should not be names, dates, etc., that are easy to guess
CHCS II User’s Manual
Block 1
Build 838
Getting Started
User submits
requests for
CHCS account.
HL 7 messaging handles the
request.
CDR
Before the CHCS II security officer assigns
privileges, the CHCS admin can notify the user
of access and verify codes. In this case, the
user can log in but does not have access to system functionality or patient information.
Transmission
ends.
If
No:
Submitted
information is If
Yes:
validated to
determine
whether user
is a CHCS II
user.
1) CHCS II user
account is created.
2) System sends
email to Clinic
Security Officer.
3) CHCS II Security Officer
assigns privileges
to user.
CHCS Admin
notifies user of
access/verify code.
User logs in and
changes username
and password.
Figure 1–1: Account Creation Process
1.4
Transferring an Account from One MTF to
Another MTF
Individuals who are on Permanent Change of Station (PCS) or are on Temporary Duty
(TDY) to another CHCS II MTF can access their CHCS II account with the same user
defaults and templates.
Follow the steps below to transfer an account to a new CHCS II MTF:
1. The user registers for a CHCS account at the new location to begin the account
creation process. When account information is sent to the CDR, it is associated
with the existing CHCS II information.
2. The system administrator at the new location must still credential the new account
at the new MTF.
3. Once the Security Administrator accredits the local account with the CHCS II
account information, the user is able to access the local CHCS nd the site specific
information on the CDR with his/her CHCS II User Name and Password. If the
CHCS II account has not been accredited at the new MTF, the user can only
access global information, such as Internet access.
Note: If a user prefers to have his/her new MTF Access and Verify code match his/
her existing CHCS II User Name and Password, the user needs to contact the
Security Administrator to have his/her account information updated.
Block 1
Build 838
CHCS II User’s Manual
1-3
Getting Started
1.5
Account Management
The ability to manage accounts is accessed through the local sites' Account Management web page. When users access the web page with their CHCS II logon information, they have the ability to reset passwords and change their personal contact
information.
1.6
Logging Into CHCS II
There are two methods used to login to CHCS II:
•
CHCS II icon on Windows desktop
•
Common Access Card (CAC)
Follow the steps below to login to CHCS II from the Windows desktop:
1. Double-click the CHCS II icon located on the Windows Desktop. The SnareWorks security warning window opens.
Figure 1–2: CHCS II Icon
2. Review the information in the window and click Acknowledge to accept the security message. The Login window opens.
Figure 1–3: CHCS II Login Window
3. In the User ID field, enter the assigned User ID.
4. In the Password field, enter the assigned password.
5. Click OK. Upon successful login, the Military Clinical Desktop displays, configured as it was upon the last exit.
Note: This method of login is always available if you do not have a CAC or if login
to CHCS II using your CAC fails.
Note: The CAC scanning option is currently only compatible with the 3-D Bar
Code.
1-4
CHCS II User’s Manual
Block 1
Build 838
Getting Started
Follow the steps below to login to CHCS II using a CAC:
1. Double-click the CHCS II icon located on the Windows Desktop. The SnareWorks security warning window opens.
Figure 1–4: CHCS II Icon
2. Review the information in the window and click Acknowledge to accept the security message. The Login window opens.
Figure 1–5: Login Window
3. At the Login screen, insert your CAC and click CAC Login.
4. At the CAC Login screen, enter your PIN.
Figure 1–6: CAC Login
Note: The first time you use your CAC to login to CHCS II, after you enter your
PIN, you are prompted to enter your normal User ID and password for validation purposes. Thereafter, you need only insert your CAC and PIN to login to
CHCS II.
Figure 1–7: CHCS II Security Window
5. Click OK. The Login screen displays.
Block 1
Build 838
CHCS II User’s Manual
1-5
Getting Started
Figure 1–8: Login Window
6. Enter your CHCS II User ID and Password and click OK. You are logged into
CHCS II. As stated in the Note above, the next time you login you do not have to
perform steps 5 and 6.
Note: If you make an error entering your PIN you receive the message shown below.
After three unsuccessful attempts at entering your PIN, the CAC is locked.
See your local CAC issuer for assistance.
Figure 1–9: Warning Window
Note: If you want to leave the workstation, you may lock your session by pressing
Ctrl + Z on your keyboard. Your session remains locked until you reinsert
your CAC and PIN. During the time your session is locked, other users can
use the workstation by inserting their CAC and PIN or by using normal login
procedures.
1-6
CHCS II User’s Manual
Block 1
Build 838
Getting Started
Figure 1–10: Log In Window
1.7
Changing the CHCS II Password
Upon 85 days after the creation of a new account or the last password change, the system prompts users to change their password within 5 days. This can be done directly
through CHCS II. Changing the CHCS II password automatically changes the CHCS
Verify code.
•
If user does not change the password within 5 days, the account password is
blocked. The Security Officer needs to unblock the account from the Web interface.
•
If user does not log into CHCS II for 90 days, the system automatically places the
account into dormant stage. The MTF must log a CHCS II Tier 1 ticket for assistance to remove an account from the dormant stage.
Note: According to the MHS Security Guidelines, the CHCS II password must meet
the following criteria.
Block 1
Build 838
•
Minimum of 8 and maximum of 20 characters
•
Minimum of 1 numeric character
•
Contain at least 1 of the following non-alphanumeric characters: !, @, #,
$, %, or &
CHCS II User’s Manual
1-7
Getting Started
1.7.1
•
Mixture of case
•
It should not be a previously used CHCS Verify code
•
@ sign cannot be used in User ID or password
•
Passwords should not consist of words found in the dictionary
•
Should not be names, dates, etc., that are easy to guess
Changing CHCS II Password
Follow the steps below to change the CHCS II password:
1. Access the File menu and select Change Password.
Figure 1–11: Change Password
2. Enter the existing password in the Enter Old Password field.
3. Enter the new password in the New Password field.
Figure 1–12: Change User Information Dialog Box
4. Click OK. A message displays stating that the password has been successfully
changed.
1.7.2
Changing CHCS II User ID
Follow the steps below to change the User ID (username):
1. Access the File menu and select Change Password.
2. Click Change User ID.
1-8
CHCS II User’s Manual
Block 1
Build 838
Getting Started
Figure 1–13: Change User ID Dialog Box
3. In the Change User ID dialog box, enter the new user ID in the Enter New User
ID field.
4. Click OK. A message displays stating that the user ID has been successfully
changed.
1.8
Exiting CHCS II
To exit CHCS II, do one of the following:
•
Access the File menu and click Exit.
OR
•
In the upper right-hand corner, click the ‘X’ as you would for any Windows application.
1.9
Protecting Sensitive Material
Do not provide data to persons contacting you by phone. Keep patient reports and confidential materials in a secure location. Report suspicious or malicious activity to your
supervisor.
1.10 Protecting Your Assigned Username and
Password
Change your password every 85 days. Create a password that avoids obvious words
and combinations, such as your spouse's name, birthday, or telephone number. Do not
use job titles. Never disclose your password to others. Memorize your password; do
not write it down.
1.11
Protecting Your Workstation
Never leave your workstation unattended. Do not use password-protected screensavers—you must log off or lock CHCS II. You can lock your session by pressing
Ctrl + Z on your keyboard. Your session remains locked until you enter your CHCS II
password in the CHCS II Lockout screen or reinsert your CAC and enter your PIN.
Position your workstation monitor so that it cannot be observed by passers-by. Never
use a disk of unknown origin. Do not load unauthorized software onto the workstation. Make no changes to any workstation settings unless directed to do so by your
supervisor.
Block 1
Build 838
CHCS II User’s Manual
1-9
Getting Started
1.12 Break the Glass Privileges
CHCS II provides authorized individuals with “Break the Glass” privileges to access
sensitive patient information.
There are three types of users involving the “Break the Glass” privilege:
•
Users who do not have the privilege at all.
•
Users who do have the privilege.
•
Users who already have the authority to see sensitive data and do not need the
privilege.
If you have “Break the Glass” privileges, you receive a warning when trying to access
sensitive data.
Click Yes to accept the warning message and view the sensitive results. CHCS II logs
and audits this access.
If you do not want to accept the warning message, click No. You cannot view the sensitive information.
1-10
CHCS II User’s Manual
Block 1
Build 838
2.0 CHCS II NAVIGATION
2.1
Navigation Basics
The appearance and navigation functions within CHCS II are very similar to the
appearance and navigation systems employed in other Windows operations. Many of
the common icons for Windows are also used by CHCS II. For example, the icons in
the upper-right corner of the screen are Minimize, Maximize, and Close. The Plus (+)
and Minus (-) signs are called expand and collapse icons and are used to show that
there are more folders above or below the folder that is currently being used. Also note
that when a topic is selected, the icon text on the folder list becomes highlighted.
Figure 2–1: Military Clinical Desktop
1. Menu Bar: The Menu bar is located at the top of the application’s user interface.
It allows you to perform various functions that are Windows based (e.g., print,
copy, paste), navigate to modules in CHCS II, and customize the appearance of
CHCS II based on your user account.
2. Tool Bar: The Tool bar is located under the Menu bar and allows you to access
CHCS II modules. You can customize the modules that display in the Tool bar to
show words, icons, both, or nothing at all by accessing the View pull-down menu.
3. Action Bar: The Action bar is an extension of the Tool bar. It contains functionality that pertains to individual modules. As modules are opened and closed, the
items on the Action bar change.
Block 1
Build 838
CHCS II User’s Manual
2-1
CHCS II Navigation
4. Patient ID Bar: The Patient ID bar is located under the Tool bar and Action bar.
It includes Patient Demographic information and icons denoting Special Work
Status, Command Interest, Command Security, allergy information and user
alerts.
5. Shortcuts: The Shortcuts allow you to access CHCS II modules. Clicking on a
particular icon or label opens the associated module. The Shortcuts can be customized to show words, icons, both, or neither by accessing the View pull-down
menu.
6. Folder List: The Folder List displays icons pertaining to the modules that are on
the desktop in an hierarchical manner. It allows all of the folders within the system
to be seen. The Folder List can be hidden using the View pull-down menu.
7. Reminders Pane: The Reminders Pane displays a listing of Wellness Reminders
that are due for the selected patient. If a patient encounter is opened, double-clicking on a reminder navigates you directly to the Reminders tab in the Assessment
and Plan (A/P) module so that you can address the reminder.
8. Workspace: The Workspace displays the open module and is where most actions
are performed.
9. Status Bar: The Status bar is located at the bottom of the application and shows
details about the screen currently displayed. The Status bar can be hidden using
the View pull-down menu.
2.2
Customizing the CHCS II User Interface
You can customize CHCS II to match how you navigate through and use the application. CHCS II allows you to display or hide the Tool bar, Action bar, Shortcuts, Folder
List, and/or Status bar.
2.2.1
Viewing/Hiding Folders
Follow the steps below to view/hide folders:
1. Click View on the Menu bar. The View pull-down menu displays.
2. Click Folders to view or hide the Folder List. A checkmark indicates that the
Folder List is viewable.
2.2.2
Viewing/Hiding Shortcuts
Follow the steps below to view/hide Shortcuts:
1. Click View on the Menu bar. The View pull-down menu displays.
2. Hover your mouse over Shortcuts to display the Shortcuts sub-menu and select
either Large Icons or Small Icons to view or hide the Shortcuts.
2-2
CHCS II User’s Manual
Block 1
Build 838
CHCS II Navigation
2.2.3
Viewing/Hiding the Action Bar
Follow the steps below to view/hide the Action bar:
1. Click View on the Menu bar. The View pull-down menu displays.
2. Hover your mouse over Action Bar to display the Action Bar sub-menu and
select one of the following:
•
Icons: Icons displays only icons on the Action bar.
•
Text: Text displays only text on the Action bar.
•
Both: Both displays icons and text on the Action bar.
•
None: None hides the Action bar.
2.2.4
Viewing/Hiding the Tool Bar
Follow the steps below to view/hide the Tool bar:
1. Click View on the Menu bar. The View pull-down menu displays.
2. Hover your mouse over Tool Bar to display the Tool Bar sub-menu and select one
of the following:
•
Icons: Icons displays only icons on the Tool bar.
•
Text: Text displays only text on the Tool bar.
•
Both: Both displays icons and text on the Tool bar.
•
None: None hides the Tool bar.
2.2.5
Viewing/Hiding the Status Bar
Follow the steps below to view/hide the Status bar:
1. Click View on the Menu bar. The View pull-down menu displays.
2. Click Status Bar to view or hide the Status bar. A checkmark indicates that the
Status bar is viewable.
2.2.6
Customizing the Tool Bar and Shortcut Options
The Tool bar is located below the Menu bar and allows you to access modules you
customized to display in the bar. Module icons and/or text display, depending on
whether or not they are patient-specific or encounter-specific. Modules that are added
to the Tool bar are also added to the Shortcuts.
Follow the steps below to customize the icons:
1. On the View menu, point to Tool Bar and click Customize to open the Customize
Toolbar window.
2. From the Available ToolBar Buttons picklist, select the module icon(s) you want
to display in the Tool bar.
Block 1
Build 838
CHCS II User’s Manual
2-3
CHCS II Navigation
3. Click Add to add the selected module icon(s) to the Selected ToolBar Buttons
picklist.
Note: You may drag and drop button icons within the Selected ToolBar Buttons
picklist to determine the order of presentation on the Tool bar. The icons and/
or text display according to whether they require a loaded patient record, open
encounter, or neither.
4. Click OK.
2.3
Opening a Module
There are generally four ways to access individual modules.
•
In the Folder List, click the icon associated with the module you want to open.
•
On the Shortcuts bar, click the icon associated with the module you want to open.
•
On the Tool bar, click the icon associated with the module you want to open.
Note: Icons on the Shortcuts and the Tool bar are only present if the desktop has
been customized to include them.
•
Access the Go pull-down menu from the Main menu bar and select the desired
module. All other modules can be found under the Tools pull-down menu.
2.4
Closing a Module
There are three ways to close a module. It is best to close each module before opening
a new one. The modules are opened one on top of the other and use unnecessary memory.
Perform one of the steps below to close a module:
•
Use the Actions pull-down menu and click Close.
•
On the Action bar, click Close.
•
In the upper, right-hand corner of the Workspace, click X.
2.5
Startup Options
CHCS II allows you to determine the module you want to display when you login to
the application. These modules are not patient-specific; therefore, you do not need a
patient record loaded or an encounter open.
Follow the steps below to select the module you want to display when you login:
1. On the Tools menu, click Startup Options to open the Startup Options window.
2-4
CHCS II User’s Manual
Block 1
Build 838
CHCS II Navigation
Figure 2–2: Startup Options
2. Select one of the options:
•
None: A blank workspace is displayed when you login.
•
Patient Search: The Patient Search module is displayed when you login.
•
Module: A module selected from the drop-down list is displayed when you
login.
3. Click OK to save the selection. The change takes effect with your next login.
2.6
Patient ID Bar
The Patient ID Bar is located under the Menu bar and includes patient demographic
information and icons denoting Special Work Status, Command Interest, Command
Security, allergy information and user alerts.
•
Patient-specific information is displayed when a patient record has been selected.
•
Work Status can be documented in the Screening, Demographics, or Disposition
modules. The Work Status icons are only documented in CHCS II and do not
interface with other systems.
•
The Allergy icons are based on the entries from the Allergy module and entries in
CHCS.
•
Command Interest and Command Security information is pulled from CHCS and
is displayed on the Demographics module.
•
An alert icon is displayed if you have items needing your attention.
Block 1
Build 838
CHCS II User’s Manual
2-5
CHCS II Navigation
2.6.1
Patient ID Bar Icons
Diving Status
Flying Status
Jumping Status
Mobility Status
Military Police Status
Personal Reliability Program
Status
Presidential Support
Program
Submarine Status
Patient Has Allergies
Allergies Have Not Been
Addressed
No Known Allergies
Command Interest Status
Security Command Interest
Status
New Results
Priority Results and CoSigns
Orders to Sign Icon Group
The Patient ID Bar icons display on the bar, if applicable to the patient or user.
2.7
CHCS Access
Some functions cannot be completed within CHCS II and need to be done in CHCS;
scheduling future appointments is a good example. CHCS II does contain the functionality to connect directly to CHCS through a telnet session. This window is independent of CHCS II.
Follow the steps below to access CHCS:
1. In the Tools menu, select CHCS-I Access or click CHCS-I from the Folder List.
2. A KEA! session opens, allowing tasks to be completed. CHCS II automatically
logs the user onto CHCS using the user's access and verify codes.
3. Close the KEA! session by clicking X in the top, right corner. When the confirmation window appears, click Yes to return to CHCS II.
2.7.1
In More Depth
CHCS II automatically logs you into CHCS using your access and verify codes. The
CHCS verify code and CHCS II password are synchronized during the CHCS II
Account Creation process. This synchronization process links your CHCS and
CHCS II accounts.
2-6
CHCS II User’s Manual
Block 1
Build 838
3.0 FAILOVER OPERATIONS
3.1
Failover Operations Overview
Prior to the release of 838, CHCS II architecture utilized a central database, the Clinical Data Repository (CDR). Because of this architectural design, CHCS II was dependent on its ability to access the CDR. CHCS II clinical team members could not
conduct basic patient services when the CDR was down or inaccessible due to a Wide
Area Network (WAN) issue.
With the release of 838, CHCS II will implement a Local Cache architecture. The purpose of the Local Cache architecture is to provide CHCS II clinical team members
with the ability to electronically document patient encounters in the event of a WAN
or application outage between the CHCS host site and the CDR. A local cache server
will be added at each host site that includes the Local Cache Database (LCD). During
the documentation of an encounter, all data will be saved to the LCD. Once an
encounter is signed, the encounter data are synced with the CDR.
Local Cache implementation consists of two main system modes: “normal mode” and
“failover mode.” If the CDR, LCD, and CHCS are available, the system is in normal
mode. If the CDR is unavailable, but the LCD and CHCS are available, the system is
in failover mode.
During failover mode, the CHCS II client presents data from the LCD and CHCS,
instead of the CDR. The change in the architecture allows clinical team members to
continue to document existing encounters, as well as to create new encounters in a
failover mode. Upon completion of the encounters in failover mode, the encounters
will be queued for later submission to the CDR. Once connectivity has been restored,
the completed encounters will be synced with the CDR automatically.
To ensure that the LCD contains pertinent clinical data in the case of failover, a nightly
push occurs from the CDR to the LCD. The data in this push include application data,
and patient data as well as user settings and immunization data.
•
•
Application Data:
•
Provider information: list of valid providers/properties
•
Clinic information: list of valid clinics/properties
•
Clinic/provider relationships
•
Cosigners, etc.
•
Ancillary lists
Patient-specific data are sent to the LCD for those patients with a scheduled
appointment the following day:
•
Appointment information
•
Last four previous encounters
•
Problem list (problems only, no associated encounters or treatments [orders])
Block 1
Build 838
CHCS II User’s Manual
3-1
Failover Operations
•
•
User settings are also sent to the LCD:
•
Favorite lists
•
Desktop sizing
•
Folder list vs. buttons
•
Autocite/print options
•
Templates (S/O and encounter)
Immunization data:
•
Lots/store information
Some modules are not supported in failover mode and will be unavailable. During
failover mode, all modules that support failover mode will write their data to the LCD
and/or CHCS.
Figure 3–1: Failover Mode Supported Modules
3-2
CHCS II User’s Manual
Block 1
Build 838
Failover Operations
The Training System will not simulate failover operations, as it is a self-contained system.
3.2
Failover Mode
When connectivity with the CDR is lost, a warning dialog box appears when the user
tries to perform an action that requires the CDR. The dialog box will inform the user
of the network loss and will provide the user with the option to either retry connecting
to the CDR by clicking Retry, or to exit the application by clicking Exit.
Note: The user is only permitted one attempt to restore the connection.
Figure 3–2: Network/Failover Notification Window
If the connection is re-established, the user can continue working in normal operations. If the connection cannot be re-established, the user is informed that CHCS II is
currently in failover mode. The user can elect to either continue by clicking OK, or
exit CHCS II by clicking Exit.
Block 1
Build 838
CHCS II User’s Manual
3-3
Failover Operations
Figure 3–3: Network/Failover Notification Window
When CHCS II switches over to failover mode, the application will provide two visually distinct identifiers. The Title Bar will display “Failover Mode—Enterprise Data
Not Available” and the Patient ID bar will be red. Additionally, modules that are not
supported will not be visible in the Folder List, the Shortcuts, or the Go pull-down
menu.
Note: If the user has modified their computer’s color scheme, the Patient ID bar
color may not appear in red. It is recommended that users keep the default
color scheme.
Figure 3–4: Military Clinical Desktop—Failover Mode
3-4
CHCS II User’s Manual
Block 1
Build 838
Failover Operations
If the user selects to exit the application, encounter information is saved to the LCD
and the signed encounter data are synced to the CDR when connectivity is restored.
3.3
LCD Failure
With the implementation of Local Cache, CHCS II is dependent on the LCD for both
normal and failover operations. When there is a loss of connectivity with the LCD,
CHCS II cannot operate. The system displays a dialog box informing the user that the
connection to the Data Source is lost and CHCS II cannot continue to operate. Any
data that had not been saved prior to this failure are lost. The user may click Retry
once to try to reconnect or Exit to exit CHCS II.
Note: Users should follow MTF policies to determine how to proceed in this situation.
3.4
CHCS Failure in Failover Mode
With the implementation of Local Cache in failover mode, CHCS II is dependent on
CHCS for certain functions. CHCS connectivity loss is detected when a module tries
to connect with CHCS and is unable to do so. When connectivity is lost, the system
will display the following message: “CHCS is currently unavailable.”
Any functions that require the availability of CHCS cannot be performed during this
state. Since failover mode reads/writes appointment records to CHCS during failover,
only the current encounter can be completed when CHCS connectivity is lost. Once
the current encounter is completed, no other encounters can be created.
If connection with CHCS fails, the following modules or actions will be incomplete or
unavailable:
•
Alerts
•
Allergies
•
Appointments
•
Consults
•
Demographics
•
Lab Order Entry
•
Medication Order Entry
•
New Appointment Sync
•
New Results
•
Patient Search
•
Previous Encounters
•
Rad Order Entry
Block 1
Build 838
CHCS II User’s Manual
3-5
Failover Operations
•
Telephone Consults
•
Walk-in/Unscheduled Visits
Note: Users should follow MTF policies to determine how to proceed in this situation.
3.5
Failover Operations
All modules that support failover mode will write their data to the LCD and/or CHCS
in failover mode. Data Sync will transfer any data changes (all ancillary patient data)
to the CDR when the connection is restored. Any module that is not supported in
failover mode will be unavailable.
If network connectivity is lost before the user logs in, the system will login the user in
failover mode. A warning dialog box will inform the user of the network loss and will
provide the user with the option to either Click OK to enter CHCS II in failover mode
or click Exit to exit the application.
3.6
Failover Mode Supported Modules
Modules that are supported by Failover operations are broken into two categories:
patient encounter data modules and ancillary patient data modules.
3.6.1
Patient Encounter Modules
Patient Encounter modules write their data to the LCD regardless of whether CHCS II
is in normal or failover operations. After an encounter is signed, the data will be
synced with the CDR. If the encounter is not signed, the data will continue to reside on
the LCD and will not write to the CDR. During failover operations, signed encounters
will be queued for later submission to the CDR when connectivity has been restored.
Patient Encounter modules:
•
Current Encounter Summary (SF600)
•
Screening
•
Vital Signs
•
S/O and A/P
•
Disposition
•
Co-Signs
Patient Encounter module functionality is not affected by failover operations, with the
noted exceptions.
3-6
CHCS II User’s Manual
Block 1
Build 838
Failover Operations
3.6.1.1
Current Encounter Summary (Electronic SF600)
“**Limited Patient Data at Time of Encounter**” displays in the top of the SF600,
and the warning “**Data in Autocites may be Incomplete**” displays on the first
line of the AutoCites section in the SF600.
If the patient has a scheduled appointment, AutoCites display Active Problems, CHCS
Allergies, CHCS Active Dispensed Medications, CHCS Labs, CHCS Rads, and
Active Family History.
If the patient is a walk-in/sick call patient for that day, no historical information will
be available except for what comes from CHCS. AutoCite will only display Allergies,
Medications, Laboratory, and Radiology results from the local CHCS host. Active
problems, active family history, questionnaires, and historical vitals are not displayed.
3.6.1.2
Screening
The Due Reminders tab is unavailable in failover mode. Special Work Status is disabled during failover operations, and cannot be edited in failover mode.
3.6.1.3
Vital Signs
The Review tab will only display any associated vital signs from the last four previous
encounters.
3.6.1.4
S/O and A/P
Templates from the user's favorites list are available for selection from the template
drop-down list. If the user had previously loaded a Clinic, MTF, or Enterprise template, its contents become the Current Encounter Template. During failover mode
operations, the embedded Current Encounter Template will continue to be available,
only for the specific encounter. No other Encounter templates are available during
failover mode operations.
Submitted orders are sent to CHCS and are also saved to the LCD as part of the
encounter data.
3.6.1.5
Disposition
Special Work Status is disabled during failover operations, and cannot be edited in
failover mode.
3.6.2
Ancillary Patient Data Modules
Ancillary patient data modules will have limited functionality in failover mode. In
normal operations, the ancillary patient data modules read/write their data to and from
the CDR directly. During failover operations, the ancillary patient data modules read/
write their information from/to the LCD and/or CHCS instead of the CDR.
Ancillary patient data modules:
•
Alert Review
Block 1
Build 838
CHCS II User’s Manual
3-7
Failover Operations
•
Allergy
•
Appointments
•
Demographics
•
Health History
•
Immunizations
•
Lab Results
•
List Management
•
Medications
•
Previous Encounters
•
Problems
•
Rad Results
•
Telephone Consults
3.6.2.1
Alert Review
Only CHCS non-Order Entry alerts will be available in failover mode. CHCS II-specific alerts are not supported and will not display.
3.6.2.2
Allergy
During failover mode, reactions to previously documented allergies are displayed in
the comments field.
Patient allergy information can be added, edited, deleted, or verified in failover mode.
The data are saved to CHCS. Although new allergies can be added in failover mode,
the new allergy reactions cannot be added directly. CHCS does not have a field for
reactions, so the reaction is not saved to CHCS. Instead, reactions should be documented in the Comments field. When connection to the CDR is restored, CHCS only
sends the new allergy and the comment field to the CDR. When normal operations are
restored, users can edit and modify those allergies that were added during failover
operations.
3.6.2.3
Appointments
The Appointments module reads and writes data from/to CHCS. Only scheduled
CHCS appointments will be available, along with all In Progress, Incomplete appointments, telcons and encounters needing cosignatures. Users should set the Appointments module properties to view both appointments and telcons.
Walk-in appointments and telcons can be created in failover mode; however, patient
searches will be limited to CHCS. After the appointment or telcon has been created,
the encounter data are saved to the LCD.
3-8
CHCS II User’s Manual
Block 1
Build 838
Failover Operations
3.6.2.4
Demographics
Patient demographic information can only be reviewed in failover mode. Special
Work Status is disabled during failover operations, and cannot be edited in failover
mode.
3.6.2.5
Health History
The Health History module will only display modules that are supported in failover
mode.
3.6.2.6
Immunizations
Immunizations can still be delivered to a patient and documented in the Immunizations module. The lot/store data are saved to the LCD. The Vaccine History tab will
display only the historical vaccines that were entered during failover mode.
3.6.2.7
Lab Results
Only the Lab results available from the CHCS host for the patient can be reviewed.
The filtering criteria available during this mode will be limited to the Sliding Time
Range and Specific Time Period (date range) options on the Time Search window.
3.6.2.8
List Management
The List Management module can be reviewed, edited, and added to in failover operations; however, any changes made will not be synced back to the CDR. When the
CDR connection is restored, the CDR-based settings will be utilized.
3.6.2.9
Medications
Medications can only be reviewed in failover mode. Over-the-Counter (OTC) medications cannot be documented in the Meds module during failover operation because
CHCS does not have any fields for OTC medications.
3.6.2.10 Previous Encounters
The last four previous encounters will be available for viewing during failover mode.
A previous encounter can be appended or amended providing it was completed in the
user’s current facility.
3.6.2.11 Problems
Health Care Maintenance and Dental Readiness are unavailable. The user can still
add, edit, or review problems. The changes will be saved to the LCD.
Block 1
Build 838
CHCS II User’s Manual
3-9
Failover Operations
3.6.2.12 Rad Results
Only the Radiology results available from the CHCS host for the patient can be
reviewed. The filtering criteria available during this mode will be limited to the Sliding Time Range and Specific Time Period (date range) options on the Time Search
window.
3.6.2.13 Telephone Consults
In failover mode, all telephone consults will be displayed in the Appointments module. The Appointments module will display all incomplete/in-progress telcons from
the current day and all previous incomplete telcons. The user is able to create new telcons during failover mode operations.
Note: When creating new telcons, your patient search will be limited to your CHCS
facility only.
Note: Although Microsoft corporation’s Internet Explorer (IE) displays as a module
in CHCS II, its web connection is completely unrelated to CHCS II. It is not
affected by either CHCS II normal or failover operations.
3.6.3
Unsupported Modules
During transition to failover mode, modules that are not supported during failover
operations close without saving. Any data that had been written to unsupported modules since the last save are lost and the module is removed from the Toolbar, Shortcuts
list, and Folders list. The user will be unable to access any unsupported modules in
failover mode. To minimize the potential impact, users are encouraged to save their
work and close modules that are not being used.
The following modules are not supported in failover mode:
3-10
•
Army Readiness
•
Consult Log
•
Clinical Notes
•
Flowsheets
•
Immunization Admin
•
New Results
•
OB Summary
•
Patient List
•
Patient Questionnaires
•
PKC Couplers
CHCS II User’s Manual
Block 1
Build 838
Failover Operations
•
Questionnaire Setup
•
Readiness
•
Reports
•
Rx Alternatives
•
Screening Notification
•
Sign Orders
•
Template Management
•
Vital Signs (Review)
•
Wellness
3.6.3.1
New Results
Although the New Results module is unavailable in failover mode, users can view
new results by clicking the CHCS I icon in the Folder List to launch a Telnet session
into CHCS.
3.6.3.2
Template Management
Although the Template Management module will not be available during failover
mode operations, encounter templates from the user's My Favorites list will be selectable from the drop-down lists in the S/O and A/P modules. Additionally, the contents
of encounter templates that have been loaded into a specific encounter become
embedded as a part of that encounter and renamed as the Current Encounter Template.
The contents of the Current Encounter Template will continue to be available for that
specific encounter when the system goes into failover mode operations.
3.7
User Configuration Data
User configuration data (i.e., Folder list, Shortcuts list, Desktop sizing, AutoCite/print
options) can be changed in failover mode; however, these changes only remain in
effect during the current failover mode event. Configuration data changes are not written back to the CDR when connectivity is restored. When the CDR connection is
restored, CHCS II will load the configuration data saved in the CDR.
Block 1
Build 838
CHCS II User’s Manual
3-11
Failover Operations
3-12
CHCS II User’s Manual
Block 1
Build 838
4.0 WORK FLOWS
4.1
Basic Front Desk Clerk Workflow
CHCS II Front Desk Clerk tasks typically include managing the appointments and
demographic information. Other tasks can be included depending on the clinic and
role of each individual clerk.
The basic front desk workflow may be:
1. Access the Appointments module.
2. Check-in a scheduled appointment.
3. Create a new walk-in appointment.
4. Review the demographic information and make any modifications.
Other modules the Front Desk Clerk can use include:
•
Telephone Consults
•
PKC Couplers
•
Web Browser
4.2
Basic Support Staff Workflow
CHCS II support staff tasks typically include entering the reason for visit in the
Screening module and documenting the vital signs. Other tasks can be included
depending on the clinic and role of each individual.
The basic support staff workflow may be:
1. Access the Appointments module.
2. Double-click the appointment from the list.
3. From the Patient Encounter module, click Screening and enter the reason for
visit.
4. On the Action bar, click Vital Signs. Enter the vital signs.
5. Close the Vital Signs module and the Patient Encounter module.
6. Return to the Appointments module to wait for the next patient.
Other modules the support staff can use include:
•
Wellness
•
Web Browser
•
Allergy
•
Clinical Notes
•
Health History
Block 1
Build 838
CHCS II User’s Manual
4-1
Work Flows
•
Reports
•
Immunizations
•
Medications
•
Readiness
4.3
Basic Provider Workflow
CHCS II Provider tasks typically include selecting an encounter template, documenting the subjective and objective (S/O) portion, completing the assessment and plan (A/
P), and ordering appropriate medications and laboratory and radiology tests. Other
tasks can be included depending on the clinic and role of each individual provider.
The basic provider workflow may be:
1. Access the Appointments module.
2. Double-click the desired appointment.
3. Click S/O.
4. Select an encounter template to load into the encounter.
5. Document the exam using the various tabs from the S/O module.
6. Click A/P. Document the diagnosis and procedures.
7. Order radiology and/or laboratory tests, medications, or consults. Associate any
procedures and/or orders with a diagnosis.
8. Click Disposition.
9. Complete the disposition.
10. Click Sign.
11. Enter the password and click Sign.
Other modules the Provider can use include:
4-2
•
Alert Review
•
Co-Signs Required
•
Medications
•
List Management
•
Laboratory
•
Patient List
•
Radiology
•
Flowsheets
•
Problems
•
Web Browser
•
Consult Log
CHCS II User’s Manual
Block 1
Build 838
Work Flows
•
Reports
•
Previous Encounters
•
Clinical Notes
•
New Results
•
Order Sets
•
Sign Orders
Block 1
Build 838
CHCS II User’s Manual
4-3
Work Flows
4-4
CHCS II User’s Manual
Block 1
Build 838
5.0 ALLERGY
5.1
Allergy Overview
The Allergy module maintains current allergy information for a patient. This information is pulled from CHCS and synchronized at different times during the encounter
documentation. The Allergy module allows information to be stored using data from
the Healthcare Data Dictionary (HDD). A common list of allergens can also be created to make entering data more convenient.
Figure 5–1: Military Clinical Desktop—Allergy Module
5.1.1
In More Depth
CHCS II uses three different Allergy icons to indicate the patient's allergy status.
These icons appear on the Patient ID bar. Clicking on the allergy icon opens the
Allergy module.
Block 1
Build 838
CHCS II User’s Manual
5-1
Allergy
No Known Allergies
Patient Has Allergies
No Allergies Specified
Allergy information is passed between CHCS and CHCS II every time there is a
change to allergy information. Any changes in CHCS are loaded into the CDR and
any changes in CHCS II are sent back to CHCS. Allergy synchronization occurs when
a new unscheduled visit is created in CHCS II and when the Allergy module is
opened. This ensures that the diagnoses and orders completed in each patient encounter are made with an awareness of the patient's current allergy profile. Clinical team
members need to be aware of the patient's allergy profile when prescribing medications and administering immunizations; thus, allergy information is also available in
the Medications and Immunizations modules.
If the patient has no known allergies, the Allergy module is blank except for the
checkbox.
Figure 5–2: Allergy Module
Allergy information should be verified during every encounter. The Verified This
Encounter checkbox is not active in the Allergy module when opening the module
through the Allergy icon. The checkbox is active when the Allergy module is opened
through the Screening module.
5-2
CHCS II User’s Manual
Block 1
Build 838
Allergy
5.2
Creating a Common List of Allergens
The Properties window associated with Allergies allows for the creation of a list of
allergens most often used. This list populates the drop-down list in the Allergen field
on the New Allergy window. This eliminates the need to conduct a lengthy search. A
default list is pre-populated when CHCS II is deployed; however, clinical team members can create their own list.
Follow the steps below to create a common list:
1. Click Options on the Allergy module. The Properties window opens.
Figure 5–3: Allergy Module Properties Window
2. Click Add. The Add to Common List Items window opens.
Figure 5–4: Add to Common List Items Window
3. Enter at least the first two letters of the allergen to be added.
4. Click Search. The search results are listed.
Block 1
Build 838
CHCS II User’s Manual
5-3
Allergy
5. Select the desired item(s).
6. Click Add to Common List. Continue to add allergies to the list until all allergens
you want have been selected.
7. Click Close. The Properties window displays the selected allergens.
8. Click Save.
Note: This list is combined with the pre-populated default list. Select the allergen
and click Delete from the properties window to delete an allergen from the
list.
5.3
Adding an Allergy
Clinical team members can add allergy information to a patient record through the
Allergy module. If a patient has no allergies, the No Known Allergies checkbox is
selected. If there is no allergy information for the patient, the No Known Allergies
checkbox is available for selection.
Follow the steps below to add a new allergy:
1. Click Add on the Action bar. The New Allergy pane opens.
Figure 5–5: New Allergy Pane
2. Click Allergen. The Health Care Data Dictionary window opens, allowing you to
search and add allergens.
3. Enter the allergen in the search field and click Search.
4. Select the desired allergen from the search results and click OK. You are returned
to the New Allergy window with the selected allergen in the field.
Note: The allergen can also be selected from the common list of allergies. Access
the list by opening the Allergen drop-down list.
5. Click Reaction. The Health Care Data Dictionary window opens, allowing you to
search and add reactions.
6. Enter the reaction in the search field and click Search.
5-4
CHCS II User’s Manual
Block 1
Build 838
Allergy
7. Select the desired reaction from the left column and click Add>> to move it to the
right column. Search for and move additional reactions, as needed.
8. Click OK. You are returned to the New Allergy window with the selected reaction
in the field.
Note: The reaction can also be selected from the common list of reactions. Access
the list by opening the Reaction drop-down list.
9. Enter the appropriate information in the following fields:
•
Info Source: The Info Source is set by default to Patient and can be changed
by selecting a different source from the drop-down list.
•
Onset: Enter a date in the date field (mm/dd/yyyy) to change the onset date
(defaults to current date), or click Onset to use the Calendar.
•
Entered By: Click Clinician to open the Clinician Search window to change
the associated clinician (defaults to clinician currently logged in), which
allows a clinician to be selected.
•
Comment: In the Comment area, type any needed notes.
10. Click Save. The new allergy is added to the patient's list of allergies.
Note: In some instances, the exact allergen is not included in the HDD. In this case,
search for and select the allergen Other {class}. On the New Allergy window,
use the comments field to state the exact allergen.
5.4
Editing an Allergy
Follow the steps below to edit an allergy:
1. Select the allergy to be modified.
2. Click Edit on the Action bar. The Edit Allergy pane opens.
Figure 5–6: Edit Allergy Pane
3. Update the appropriate information in the following fields:
•
Reaction
•
Info Source
Block 1
Build 838
CHCS II User’s Manual
5-5
Allergy
•
Onset
•
Entered by
•
Comments
Note: The Allergen is not editable.
4. Click Save.
5.5
Deleting an Allergy
Follow the steps below to delete an allergy:
1. Select the allergy on the Allergy module.
2. Click Delete on the Action bar.
3. At the Confirm Deletion prompt, click Yes.
5.6
Verifying Allergies
Allergy information should be verified during every encounter. The verification of the
allergy information, though, can only be done through the Screening module with an
open patient encounter. The documentation of this process is written onto the electronic SF600 and becomes part of the medical record.
Follow the steps below to verify a patient’s allergies:
1. In the Screening module, click Verify Allergy on the Action bar. You are transferred to the Allergy module.
2. Verify the patient’s allergies in the Allergy module and select the Verified This
Encounter checkbox.
3. Click Close on the Action bar to return to the Screening module.
5-6
CHCS II User’s Manual
Block 1
Build 838
Allergy
Figure 5–7: Verify Allergies Pane
Block 1
Build 838
CHCS II User’s Manual
5-7
Allergy
5-8
CHCS II User’s Manual
Block 1
Build 838
6.0 ALERT REVIEW MODULE
6.1
Alert Review Overview
The Alert Review module displays items that need immediate attention. It lists both
primary end user and surrogate end user alerts. A surrogate end user is authorized to
act on behalf of another end user. Unresolved alerts are in bold text and resolved alerts
are in regular text. The gray and yellow colored alert icon in the patient ID bar signifies that an encounter needs to be cosigned, critical results and priority results. The
blue and white colored alert icon signifies modified encounters, new results and orders
to be signed.
Figure 6–1: Military Clinical Desktop—Alert Review Module
6.1.1
In More Depth
An alert must be resolved within the module in which it resides.
New Result and Priority Result Alerts display as a result of actions performed in
CHCS (such as lab tests). Priority Result Alerts are New Result Alerts that contain
abnormal findings.
Types of Alerts:
•
Encounter Doc Needs Co-signature
•
You have priority results
•
You have New Results
Block 1
Build 838
CHCS II User’s Manual
6-1
Alert Review Module
•
Encounter Coding Information Has Modified
•
Orders to Sign
•
Mismatch ADM Coding
An alert icon is displayed on the Patient ID bar when a user has an alert. Two alert
icons exist, depending on the types of alerts. The gray and yellow colored alert icon
signifies that an encounter needs to be co-signed and priority results. The blue and
white colored alert icon signifies modified encounters, new results and orders to be
signed.
If an order needs to be signed, an additional icon displays on the Patient ID bar next to
the Alert icon.
Multiple ADM alert types are triggered when coding differences are detected between
CHCS and CHCS II based on factors such as ICD-9 code mismatches or secondary
Provider errors. When addressing an ADM alert, a dialog box directs the Provider to
go to the previous encounters for the patient and update the encounter in question.
6.2
Addressing an Alert
The primary end user or the surrogate end user can address an alert. If the primary end
user addresses an alert, it is automatically removed from the list of alerts upon resolution. An alert resolved by the surrogate end user remains on the primary end user’s list
of alerts until the primary end user deletes it. Alerts that have not been addressed are
indicated in bold text and alerts that have been addressed are indicated in plain text on
the alerts list. An alert must be resolved within the module in which it resides. If, for
example, you select a modified encounter alert to address, you are navigated directly
to the relevant encounter in the Previous Encounters module.
Follow the steps below to address an alert:
1. Select the bolded alert.
2. Click Address Alert on the Action bar. The module containing the alert opens.
3. Address the alert by completing the tasks associated with the alert.
4. Click Close. The alert can now be deleted from the list.
6.3
Addressing New and Priority Result Alerts
New Result and Priority Result Alerts display as a result of actions performed in
CHCS (such as lab tests). Priority Result Alerts are New Result Alerts that contain
abnormal findings.
Follow the steps below to address new and priority result alerts:
1. Select the alert.
2. Click Address Alert on the Action bar. The Lab or Rad module opens, depending
on the alert.
3. Select the New Result you want to review.
6-2
CHCS II User’s Manual
Block 1
Build 838
Alert Review Module
4. Either save or delete the result.
5. Click Close on the Action bar to return to the Alert Review module.
6.4
Deleting an Alert
Follow the steps below to delete an alert:
1. Select the alert.
2. Click Delete on the Action bar.
6.5
Viewing Details of an Alert
Follow the steps below to view details of an alert:
1. Select the desired alert.
2. Click Details on the Action bar. The Alert Details window opens.
Figure 6–2: Alert Details Window
3. Review the detailed information on the selected alert.
4. Click Close.
Block 1
Build 838
CHCS II User’s Manual
6-3
Alert Review Module
6-4
CHCS II User’s Manual
Block 1
Build 838
7.0 APPOINTMENTS
7.1
Appointments Overview
The Appointments module enables appointments that have been created in both
CHCS and CHCS II to be viewed according to clinics, providers, dates, or statuses.
Appointments can be selected to check in, transfer, cancel, and checkout. Only
unscheduled visits (walk-in, sick call) and telephone consults can be created in
CHCS II. Scheduled appointments are still created in CHCS and then uploaded to
CHCS II, real-time, along with appropriate patient information.
Figure 7–1: Military Clinical Desktop—Appointments Module
7.1.1
In More Depth
The Appointments module is comprised of several columns that can be re-arranged by
clicking and dragging the columns with your mouse. The columns include the following:
•
Appt. Date/Time: The date and time of the appointment.
•
Patient: The name of the patient.
•
Status: The status of the appointment (the location of the appointment in the clinical workflow—checked-in, waiting, in progress...).
•
Reason for Visit: The reason for the patient visit.
•
FMP/SSN: Family Member Prefix/Social Security Number.
Block 1
Build 838
CHCS II User’s Manual
7-1
Appointments
•
Checkin Time: The time the patient is checked in.
•
Type: The appointment type.
•
Classification: The status of the patient (outpatient or inpatient).
•
Home Phone: The patient’s home phone number.
•
Work Phone: The patient’s work phone number.
•
Comment: Comments about the appointment.
•
Encounter: A unique system generated ID that helps to track encounters.
•
Checkout Time: The time the patient checks out. This is entered if the Check-Out
option is used.
•
Appt IEN: A unique ID generated by CHCS for an appointment that is unique for
each MTF.
•
Appt ID: A unique ID generated by CHCS for an appointment that is unique for
each MTF.
The Appointments module is the default module that opens upon login. Most clinical
team members use this module as a ‘home base.’ The individual appointment statuses
can alert the team members as to where the patients are in the clinical workflow. For
example, if an appointment has a status of checked-in, the support staff knows that the
patient is ready to be screened. Statuses include the following:
•
Pending (blank field): CHCS scheduled appointment that has not been checkedin
•
Checked-in: The front desk has checked-in the patient and the patient is ready for
screening
•
Waiting: The screening is complete and the patient is waiting for the provider
•
In Progress: A clinical team member has opened the S/O, A/P, or disposition
module
•
Complete: The encounter has been signed.
•
Updating: The signed encounter is being updated
•
Updated: The signed encounter has been updated and re-signed
•
Needs Co-signature: The encounter has been signed but is awaiting co-signature
Once an appointment is created, checked in, or canceled, CHCS II sends the appointment status of Kept back to CHCS. Because of this, appointments should not be modified in the End of Day processing in CHCS.
7.2
Setting the Properties of the Appointments
Module
The Appointments Search Selections window is used to filter appointments by clinic,
provider, date and status. Once selections are made, they can be set as the default settings or for the current session only. The user can change the status that is being
7-2
CHCS II User’s Manual
Block 1
Build 838
Appointments
viewed without using the Appointment Search Selections dialog box. A filter dropdown list can be accessed from the Appointments module.
The Appointment Search Selections window is also used to set new column order
defaults. First, rearrange the column order by dragging the column by the column
header.
Follow the steps below to set the properties of the Appointments module:
1. On the Appointments window, click Change Selections. The Appointment
Search Selections window opens.
Tip:
Figure 7–2: Appointment Search Selections Window
2. In the Clinic area, select the clinic(s) you want to view. If you select the Selected
Clinics option, select the applicable clinic(s) from the list.
3. In the Provider area, select the provider(s) you want to view. If you select the
Selected Providers option, select the applicable provider(s) from the list.
4. In the Dates area, select the appointment search date. If you select the Date Range
option, select the applicable date range(s) from the drop-down list.
5. In the Status Selection area, select the appointment search status.
6. Click Set Selections as Default. The settings are now your default settings for the
Appointment module. All appointments meeting the above criteria are listed on
the Appointments module.
Note: To set the order of the columns, click Set Column Order as Default.
7.3
Filtering the List of Appointments
It is recommended to
set the date filter to
Today Only. This will
prevent the
appointment list from
showing
appointments
created prior to the
implementation of
CHCS II.
Tip:
The settings of the
default view will
primarily depend on
your role. Front Desk
Clerks and Support
Staff generally view
appointments for all
clinics and all
providers who are on
duty on the given
day. Providers
usually set the filter
to view assigned
appointments for all
clinics.
The list of appointments can be filtered by selecting a filter from the drop-down list in
the upper-right corner of the workspace.
Block 1
Build 838
CHCS II User’s Manual
7-3
Appointments
Figure 7–3: Appointments List Filter
This filter assumes the provider and clinic settings from the default filter and only
changes based on the selection made. Changing the filter here only changes the view
of the appointments for this session. When you open another module and then return
to the Appointments module, the view is based on the default settings, set through the
Change Selections button. Options include the following:
7-4
•
Default: The Appointments filter default is set by clicking Change Selections
and selecting the desired options. Click Set Selections as Default and then click
OK to save the selections as default.
•
Today: Appointments for today only.
•
Today + Incomplete: Appointments for the present day and all appointments that
have a status of incomplete that fall within the selection made in the Dates field
on the Appointment Search Selections window.
•
Any Status: All appointments regardless of their status that fall within the selection made in the Dates field on the Appointment Search Selections window.
•
Pending Only: Appointments that have a status of pending, which means they
have not been checked in yet and meet the date criteria in the Appointment Search
Selection window.
•
Checked In: Appointments that have been checked in and meet the date criteria
set in the Appointment Search Selections window.
•
Waiting: Appointments for which the patient has been checked in but is waiting
to be seen by the provider and meet the date criteria set in the Appointment Search
Selections window.
•
In Progress Only: Appointments that have been checked in, are in progress and
meet the date criteria set in the Appointment Search Selections window.
•
Needs Co-Signature: Appointments that must have a provider's co-signature in
order to be give a completed status and meet the date criteria set in the Appointment Search Selections window.
•
Updated: Whenever an appointment is amended or appended, its status is
changed to Updated. The updated appointments must meet the date criteria set in
the Appointment Search Selections window.
•
Completed Only: Appointments that have a completed status and meet the date
criteria set in the Appointment Search Selections window.
•
Incomplete: Appointments that are not complete and meet the date criteria set in
the Appointment Search Selections window.
CHCS II User’s Manual
Block 1
Build 838
Appointments
•
Checked In or Pending: Appointments that are currently checked in or show a
pending status in CHCS and that meet the date criteria set in the Appointment
Search Selections window.
7.4
Creating a New Appointment
Within CHCS II, only new Unscheduled Visit (USV) appointments can be created.
Scheduled appointments are still set up through CHCS and are then pulled into
CHCS II, along with accompanying patient information.
Telephone Consults can also be created in the Appointments module. Once scheduled,
though, they can only be seen in the Telephone Consults module.
Follow the steps below to create a new appointment:
1. Click New Appt on the Action bar.
2. The New Unscheduled Appointment/Telcon Visit window opens, immediately
overlaid by the Patient Search window. If the patient for whom the appointment is
being created is already loaded, click Cancel on the Patient Search window.
Figure 7–4: Patient Search Window
Block 1
Build 838
CHCS II User’s Manual
7-5
Appointments
3. If the patient’s record is not loaded, search for the patient for whom you are scheduling the new appointment. After the patient record is loaded, the New Unscheduled Appointment/Telcon Visit window is fully displayed.
Figure 7–5: New Unscheduled Appointment Window
4. In the New Unscheduled Appointment window, complete the following fields:
•
Date and Time: The default is the current date and time and cannot be
changed.
•
Assigned Clinic: Select the clinic from the drop-down list.
Note: Clinical Team Members are only able to create appointments for providers
assigned to the clinics to which they have access.
•
7-6
Provider: Use the drop-down list to select the desired provider. The provider
must be associated with the selected clinic.
CHCS II User’s Manual
Block 1
Build 838
Appointments
•
Appointment Type: Select an appointment type from the pick list. Available
options are based on the CHCS appointment types that are available for the
clinic and provider selected.
Note: Appointment types with a $ or * annotate those types of appointments that can
only be created by the clinic.
•
USV Type: Select Sick Call, as appropriate. The default is Walk-In.
•
Appointment Classification: This is based on the appointment classification
from CHCS and cannot be changed in CHCS II.
•
Observation: Select Observation, if appropriate. A checkmark here affects
the selection of E&M codes in the Disposition module.
•
Meets Outpt Visit Criteria (Workload)?: This field determines whether this
encounter is a count or no-count visit. Yes, is count; No is no-count. If No is
selected, the available E&M codes are no-count codes.
•
Related to Inpatient Stay?: If the selected patient has an appointment classification of inpatient, use this field to document the relationship between the
reason the patient is admitted and the reason for the outpatient appointment. If
this visit is related to the inpatient stay, the outpatient encounter is a no count.
If the visit is not related to the inpatient stay, the encounter is counted as a regular outpatient visit.
Note: If the visit is not related to the inpatient stay, a confirmation window appears.
Click No if the visit is not related.
•
Related to Injury/Accident?: If the appointment is related to an injury or an
accident, select this checkbox. The Date and Related Cause Code window
appears.
Tip:
For CHCS
scheduled
appointments, this
information can be
captured in the A/P
and Disposition
modules.
Figure 7–6: Date and Related Cause Code Window
Block 1
Build 838
CHCS II User’s Manual
7-7
Appointments
•
Complete all fields and click OK. Notice the checkbox indicating that the
date and Related Cause Code have been entered.
Note: An encounter marked as related to an injury or accident is required to contain
an E-code as one of the diagnoses. A notification appears when you attempt to
close the A/P module or sign the encounter if the encounter is marked as
related to an injury or accident and no E-code (diagnosis) was selected.
•
Reason for Appointment: Enter the reason the patient needs to be seen. This
is a free text field.
•
Comments: Enter any additional information, if needed.
Note: The Reason for Appointment and Comments are displayed on the electronic
SF600 once the encounter is opened.
Tip:
Double-click on an
appointment to begin
documentation and
open the encounter,
if role allows.
•
Call Back Number: This field is enabled when creating a telephone consult
and defaults to the patient’s home phone number. Change the number, as
appropriate.
•
Urgency: This field is enabled when a telephone consult is selected. Low is
the default setting. Select the radio button next to High or Medium, as appropriate.
5. Click OK. The appointment is displayed on the appointment list and the status is
checked-in.
Note: If you want to change the patient for whom you are creating the new appointment, click Change Patient. The Patient Search window opens, allowing you
to search for the desired patient.
7.4.1
Creating a Rounds Appointment
Rounds (RNDS) appointments can be created and completed in CHCS II. RNDS
appointments are scheduled on a daily basis by CHCS and are pulled into CHCS II
just like any other type of appointment. RNDS appointments can also be created in
CHCS II, by providers only, for patients with an appointment classification of inpatient. The workflow for RNDS appointments in CHCS II is the same for that of outpatient appointments. RNDS appointments are no-count for workload purposes and are
associated with the current “A” level Medical Expense Performance Reporting System (MEPRS) code.
Follow the steps below to create a RNDS appointment:
1. On the New Unscheduled Visit window, in the Clinic field, click the drop-down
arrow and select the Industry Based Workload Alignment (IBWA) clinic. Notice
that the RNDS appointment type becomes available and is selected.
7-8
CHCS II User’s Manual
Block 1
Build 838
Appointments
2. In the provider field, the default is the logged in provider. To select a different provider, click IBWA Provider Search to search for and locate another provider. The
provider must be associated with the selected clinic.
3. Click OK. The Inpatient Admissions window displays.
Figure 7–7: Inpatient Admissions Window
4. Select the admission for the patient.
Note: RNDS appointments require one of several admission types:
•
ABS-AD DIRECT TO NON US MILITARY HOSPITAL NEVER TRNF
TO MIL MTF
•
RON-REMAIN OVERNIGHT
•
CRO-CARDED FOR RECORD ONLY
•
Absence Status
5. Click OK. The appointment is displayed on the appointment list and the status is
checked-in.
7.5
Checking In a Patient
In the Appointments module, individual appointments that were scheduled in CHCS
can be checked-in for their appointments. Appointments that are checked in from
CHCS II do not need to be checked in on CHCS. Once an appointment is checked in,
CHCS II updates the appointment status in CHCS to Kept. Patients arriving for a
walk-in or sick call appointment are automatically checked-in upon creating the
appointment in CHCS II.
Follow the steps below to check in a patient:
1. Select the appointment from the appointment list.
Note: You can only check in appointments whose status is Pending.
Block 1
Build 838
CHCS II User’s Manual
7-9
Appointments
Tip:
To check-in multiple
appointments, select
an appointment from
the appointments list
and press Ctrl on
your keyboard while
selecting each
additional
appointments. Click
Check-In on the
Action bar.
2. On the Action bar, click Check-In.
Note: Appointments should not be modified in the End of Day processing in CHCS.
CHCS II writes back the appointment statuses of appointments managed in
CHCS II. Modifications in the EOD should not be necessary.
7.6
Checking Out a Patient
The Appointment Check Out window enables a patient to be checked out from the
selected appointment. This does not change the status of the appointment, nor is this
step required. On this window, forms can be selected to print for the patient.
The check out function allows the user to print out a patient copy of the SF 600, DD
2766 or a clinic-specific patient information form. Any orders entered for the patient
are automatically printed to this form along with any wellness items that are due.
Follow the steps below to check out a patient:
1. Select an appointment with a status of In Progress, Complete, or Updated from the
appointments list.
2. On the Action bar, click Check-Out. The Check Out window opens.
Figure 7–8: Check Out Window
Tip:
You can select more
than one form. Click
Print Preview to
view the forms
before printing.
3. Select the checkbox next to the associated print format.
4. Click OK. The forms are sent to your designated printer.
7.7
Adding an Additional Provider
An additional provider can be added to an encounter to receive credit for work performed on a patient.
Follow the steps below to add an additional provider:
1. On the Action bar, click Add Providers. The Provider and Roles window is displayed.
7-10
CHCS II User’s Manual
Block 1
Build 838
Appointments
Figure 7–9: Providers and Roles Window
2. Select the type of clinician you want to add.
3. In the Additional Provider #1 area, click the ellipsis button to search for a provider. The Clinician Search window opens.
Figure 7–10: Clinician Search Window
4. In the Last Name field, enter the last name of the desired clinician.
5. Select a facility from the drop-down list.
6. Select a clinic from the drop-down list.
7. Click the Find only clinicians who have login accounts on this system to view
only providers associated with CHCS II.
8. Click Find. The results are displayed in the bottom half of the Clinician Search
window.
9. Select the desired clinician.
10. Click Select. The name populates in the Additional Provider field on the Provider and Roles window.
Block 1
Build 838
CHCS II User’s Manual
7-11
Appointments
11. Click the Role drop-down list to select the additional provider’s role.
Note: Repeat steps 2-11 if you want to add a second additional clinician.
12. Click OK. The clinician(s) is(are) added to the appointment.
Tip:
To select multiple
appointments, use
the Ctrl key on your
keyboard. If
transferring multiple
appointments, the
patients must be
from the same clinic.
7.8
Transferring an Appointment
The Appointment Transfer window enables an individual appointment or a group of
appointments to be transferred to a different provider within the same clinic. Appointments can only be transferred to clinical team members who have the privilege to sign
an encounter.
Follow the steps below to transfer an appointment:
1. Select the appointment(s) to be transferred from the appointments list.
2. On the Action bar, click Transfer. The Appointment Transfer window opens.
Figure 7–11: Appointment Transfer Window
3. Select the new provider from the drop-down list. Only providers assigned to the
specific clinic are available.
4. Click OK. The appointment is assigned to the new provider.
7.9
Canceling an Appointment
The Cancel Appointment dialog box enables an appointment to be canceled. A reason
for cancellation — Patient Cancelled, Facility Canceled, No Show, Left Without
Being Seen — must be selected. Once an appointment is canceled, the appointment
status is updated on the appointment list. If an appointment is inadvertently canceled,
the user can undo the cancellation using the Undo button on the Action Bar. This
action cannot be performed on appointments that were cancelled in the past.
Follow the steps below to cancel an appointment:
Tip:
To select multiple
appointments, use
the Ctrl key on your
keyboard.
7-12
1. Select the appointment to be canceled from the appointment list.
2. On the Action bar, click Cancel. The Cancel Appointment window opens.
CHCS II User’s Manual
Block 1
Build 838
Appointments
Figure 7–12: Cancel Appointment Window
3. Select a Reason for Cancellation.
Note: Once a patient has been checked in, the only cancel options available are Left
Without Being Seen (LWOBS) or Facility Cancelled.
4. Click OK. This completes the encounter and the canceled appointment appears in
the Previous Encounter module indicating that the appointment was cancelled.
Note: If the appointment was canceled by mistake, select the appointment and click
Undo Cancel on the Action bar.
7.10 Printing the Insurance Form
A copy of the patient's insurance information can be printed for verification or to note
changes. The form can also be printed from the Appointments and Demographics
modules. This form defaults to the current date and includes demographic information
with space to update the address, phone numbers, current insurance information, and
questions for the patient to answer regarding any changes.
Follow the steps below to print the Insurance Form:
1. Click Ins. Form on the Action bar to print an insurance form for a patient. The
Print Preview window opens.
2. Click the printer icon on the Preview window to print the form. The form is sent to
your designated printer.
7.11
Viewing a Comment Associated with an
Appointment
If a comment was added on the New Appointment window, the full text of the comment can be viewed and edited. New comments can be added as well.
Follow the steps below to view a comment associated with an appointment:
1. Select the appointment that contains the comment.
2. On the Action bar, click View Comments. The Appointment Comments window
opens.
Block 1
Build 838
CHCS II User’s Manual
7-13
Appointments
Figure 7–13: Appointment Comments Window
3. To edit the comments, click Edit. The Appointment Comments window changes
from (Read Only) to (Edit Mode). Make the applicable changes.
4. Click Done.
7-14
CHCS II User’s Manual
Block 1
Build 838
8.0 ARMY PROFILE
8.1
Army Profile Overview
For users assigned appropriate roles, Army Profile enables you to create and track
Army profiles for a patient. The profile form (DA FORM 3349) is implemented by
surfacing the current Medbase profile functionality. As with the current Medbase
product, a new profile can be filled out (with subsequent edits allowed) by using a
blank profile or a profile template. Once a profile is complete, you can save it to the
Army Readiness module, save the profile as a template and print the DA FORM 3349
for required signatures on the hard copy and insertion in the patient’s medical record.
Note: Authorization to use this functionality is currently limited to Fort Bliss. Its use
by additional Army sites may be approved, in the future, by the Office of the
Surgeon General (OTSG).
Figure 8–1: Military Clinical Desktop—Army Readiness Module
8.1.1
In More Depth
In the current release, this functionality is completely separate and distinct from the
Temporary Profile capability that becomes available in the Disposition module when
the patient’s disposition is “Released w/work/duty/limitations.” Accordingly, if creat-
Block 1
Build 838
CHCS II User’s Manual
8-1
Army Profile
ing a Temporary Profile for a patient that is related to an encounter, the profile needs
to be documented in the Disposition module so that it becomes a part of the encounter.
Additionally, the Army Profile templates that are created and used in the Army Readiness module are unrelated to other CHCS II template capabilities.
8.1.2
Creating a New Profile
Follow the steps below to create a new profile:
1. Click New Profile on the Action bar. The Create a New Physical Profile window
opens.
Note: The window contains two generic System Templates.
Figure 8–2: Create a New Physical Profile Window
2. Select the As a Blank Physical Profile radio button and click OK. A blank Physical Profile form appears on top of the module.
8-2
CHCS II User’s Manual
Block 1
Build 838
Army Profile
Figure 8–3: Blank Physical Profile Form
Note: The field numbers on the form do not correspond exactly to the numbers on
the DA Form 3349. For example, Blocks 13, 17 and 22 are blank fields for
signatures on the DA Form 3349 and do not appear on the profile form.
3. Complete blocks 1–5 of the form as follows:
•
Block 1: Check either Injury, Illness/Disease, or both, if applicable, and
enter the description.
•
Block 2: Enter the appropriate Code(s).
Note: For a complete list of codes refer to Table 7-2 of Army Regulation (AR) 40501.
•
Block 3: Enter a single number from 1-4 in each of the boxes under the P
(Physical Capacity), U (Upper Extremities), L (Lower Extremities), H (Hearing), E (Eyes), and S (pSychiatric) columns. If the Profile is to be Permanent,
enter the numbers in the Permanent row.
Note: For a complete description of the numerical values used in the boxes, refer to
Table 7-1 of AR 40-501.
•
Block 1
Build 838
Block 4: For a Temporary Profile, select the Expiration Date from the popup calendar and select the YES radio button. When you do this, all remaining
options related to Permanent Profiles become disabled. For a Permanent Profile, complete “b” and “c” as appropriate.
CHCS II User’s Manual
8-3
Army Profile
•
Block 5: Select the appropriate YES or NO radio buttons for items a–f.
4. Complete blocks 6–11 as appropriate.
5. Complete blocks 12–26 of the form as follows:
•
Click Profiling Officer in Block 12. The Signature of Profiling Officer window displays. Enter the Profiling Officer's Name and Grade and click OK.
Figure 8–4: Signature of Profiling Officer Window
•
Complete the same actions for the Approving Officer (Block 16) and Unit
Commander (Block 19) blocks.
•
Select the appropriate radio buttons in Blocks 15 and 19.
6. Complete the Medical Facility field (Block 24). Enter the facility in the free text
field or search for a MEPRS identifier by clicking MEDICAL FACILITY. The
MEPRS Search window opens.
Figure 8–5: MEPRS Search Window
•
Search for and select the desired MEPRS code and click Select. Block 24
populates with your selection.
7. Complete the Unit field (Block 25). Click UNIT to search for the patient’s unit.
The Unit Search window opens.
8-4
CHCS II User’s Manual
Block 1
Build 838
Army Profile
Figure 8–6: Unit Search Window
•
Search for the desired Unit Code or Unit Name. Highlight the appropriate item and click Select. Block 25 populates with your selection.
8. Complete the free text fields in Block 26, if desired.
9. Click Save on the Action bar. The profile is saved to the Army Readiness module.
Click Cancel to clear the Profile Form from the workspace.
Block 1
Build 838
CHCS II User’s Manual
8-5
Army Profile
Figure 8–7: Army Readiness Module—Temporary Profile
Note: The letter “T” in the icon preceding the date in the Profile Tree identifies the
profile as a Temporary Profile. The letter “P” identifies it as a Permanent Profile.
8.2
Creating a Profile Template
Follow the steps below to save a completed or partially completed Profile Form as a
template:
1. Select the profile.
2. Click Save as Template on the Action bar. The New Physical Profile Template
window opens.
Figure 8–8: New Physical Profile Template Window
8-6
CHCS II User’s Manual
Block 1
Build 838
Army Profile
3. Select the type of template desired. Select the As a System Template radio button
to save the template as an Enterprise template. Enterprise templates cannot be
deleted.
4. The Template type defaults to As a User Template and the Name defaults to the
medical condition you entered on the Profile form in Block 1. You can also
change the Name of the template if you desire.
5. Click OK. The template is saved and is immediately available to you for use with
another patient.
8.3
Using an Army Profile Template
Follow the steps below to use an Army Profile template:
1. Click New Profile on the Action bar. The Create a New Physical Profile window
opens.
Figure 8–9: Create a New Physical Profile Window
2. Select either a System Template or a User Template and click OK. The template
Profile Form displays.
Note: The system contains several generic system templates. These include the following:
Block 1
Build 838
•
Ankle Sprain
•
Ankle Fracture
CHCS II User’s Manual
8-7
Army Profile
Figure 8–10: User Template Loaded
3. Make any changes necessary to the Profile Form and click Save. The Physical
Profile, with the changes you have made, is saved to the Army Readiness module.
Click Cancel to close the Profile Form. The new profile is displayed in the Army
Readiness module.
Figure 8–11: Army Readiness Module—Temporary Profile
8-8
CHCS II User’s Manual
Block 1
Build 838
Army Profile
8.4
Viewing and Printing the DA Form 3349
Follow the steps below to view and print the DA 3349:
1. Right-click the profile in the Profile Tree, and select Preview Profile Report
from the pop-up menu. The DA Form 3349 displays.
Figure 8–12: Right‐Click Menu—Preview Profile Form Selected
Figure 8–13: DA Form 3349
2. Click the printer icon on the Print Preview window. The DA Form 3349 prints
and the hardcopy can then be signed and inserted in the patient's medical record.
Note: If you do not want to view a print preview, click Print on the Action bar.
8.5
Deleting a Profile
Follow the steps below to delete a profile:
1. Right-click the profile in the Profile Tree and select Delete Profile from the popup menu. A warning window displays.
Block 1
Build 838
CHCS II User’s Manual
8-9
Army Profile
Figure 8–14: Delete Warning Window
2. On the warning window, click Yes. The profile is removed from the Army Readiness module.
8.6
Removing a User Profile Template
Follow the steps below to remove a user profile template:
1. Click New Profile on the Action bar. The Create a New Physical Profile window
opens.
Figure 8–15: User Template Selected for Removal
2. Select the User Template you want to remove and click Remove. The Delete Profile Template Warning window displays.
Figure 8–16: Delete Profile Template Warning Window
3. Click Yes. The User Template is removed.
Note: You cannot remove Enterprise (System) level templates.
8-10
CHCS II User’s Manual
Block 1
Build 838
9.0 ASSESSMENT AND PLAN (A/P)
9.1
Assessment and Plan Overview
The A/P module allows you to document your assessment of a patient's condition and
the plan for treatment by entering diagnoses, procedures, patient instructions, and
ordering consults, laboratory and radiology procedures, and medications.
Figure 9–1: Military Clinical Desktop—Assessment and Plan Module
9.1.1
In More Depth
When the A/P module is opened, the Diagnosis tab is displayed by default. The rest of
the tabs, along with the Diagnosis tab, are where you locate items to add to the Diagnosis box at the top of the module. This box displays the diagnoses for this patient and
is the interface by which you associate procedures and order consults, medications,
lab and radiology tests to one or more diagnoses. Provided buttons also enable the priority of a diagnosis to be changed and orders to be submitted from the queue. Each of
these tasks are covered in this section.
9.2
Associating Procedures, Orders, and
Instructions
You can enter procedures, orders, and consults (patient instructions) without associating a diagnosis. If you enter one without associating a diagnosis and attempt to close
the A/P module, the system displays an alert.
Block 1
Build 838
CHCS II User’s Manual
9-1
Assessment and Plan (A/P)
Figure 9–2: AnP Warning Window
All orders without a diagnosis receive a Count/No Count message if you attempt to
sign the encounter without associating a diagnosis to a procedure, order, or consult.
9.3
Documenting a Diagnosis
When displayed, a diagnosis entry includes the name of the diagnosis and its associated ICD code. This is one of the ways CHCS II merges documentation and coding.
By simply adding the diagnosis, the corresponding ICD code is documented as well.
E-Codes, for injuries or accidents, cannot be selected as a primary diagnosis. An information box displays if you attempt to select E-Code as a primary diagnosis.
The diagnoses are added in the order in which they are selected and priorities are also
associated in the same order. The first four diagnoses are sent to Standard Ambulatory
Data Record (SADR). This is similar to the “bubble sheet” process of selecting diagnoses in priority order of 1–4. The maximum number of diagnoses allowed in CHCS
II is 15.
Follow the steps below to document a diagnosis:
1. On the A/P module, click Diagnosis to view the Diagnosis tab.
9-2
CHCS II User’s Manual
Block 1
Build 838
Assessment and Plan (A/P)
Figure 9–3: A/P Diagnosis Tab
2. Locate the diagnosis using one of the following methods:
•
Template List: If an encounter template is loaded, the list defaults to the
diagnoses associated with the encounter template. Use the drop-down list to
select an encounter template and view default diagnoses for the selected
encounter template. Click the backward and forward buttons to view templates you have already loaded without using the drop-down list.
•
Problem List: Active Acute or Chronic diagnoses listed in the Problems
module display if you click Problem List.
•
Clinic List: This list allows you to view diagnoses established by a clinic or
user in the List Management module.
•
Search: In the Search field, enter the diagnosis and click Find Now. At least 2
characters must be entered. An alert message displays if the search criteria
returns more than 150 results.
3. In the list of diagnoses, select the diagnosis you want to add to the encounter. The
diagnosis must have an associated ICD code to be added.
4. Click Add to Encounter. The diagnosis is added to the list above in the Diagnosis
box.
Note: Click Add to Favorite List if you want to add the selected diagnosis to your
Favorites List. The diagnosis also displays in the List Management module.
•
Block 1
Build 838
Highlight the diagnosis to be changed and click on either the
or
button to move the item up or down to change the priority of the diagnosis.
CHCS II User’s Manual
9-3
Assessment and Plan (A/P)
Figure 9–4: Added Diagnosis
5. A comment may be entered for an added diagnosis.
a. Select a diagnosis that was added to the Diagnosis box. Be sure the diagnosis
has been expanded to display the comment underneath.
b. Click Comment. The Extended Comments window opens.
c. In the Comments box, enter a comment.
d. Click OK.
6. When a diagnosis is added, it is labeled Chronic or Acute. Select the added diagnosis, and click the default label (Chronic or Acute) to change the default. A dropdown list displays allowing you to select Chronic or Acute.
Note: When you perform a diagnosis search using an ICD code, the result is based
on a chart that lists those diagnoses that should be chronic and those that
should be acute. Diagnoses selected from the patient’s problem list default to
Chronic.
7. When the diagnosis is added, the type is either New or Follow-up. Select the
added diagnosis and click the default type (New or Follow-Up) to change the
diagnosis type. A drop-down list displays allowing you to select New or FollowUp. If a diagnosis is on the patient’s problem list, it is automatically set to FollowUp.
9.3.1
Documenting an E-code for Injury/Accident
If the appointment is related to an injury or an accident an E-code diagnosis must be
documented to explain the related cause. Enter the clinical diagnosis as the primary
diagnosis and the E-code as a secondary diagnosis. A notification appears when you
attempt to close the A/P module or sign the encounter if the encounter is marked as
related to an injury or accident and no E-code (diagnosis) was selected.
Follow the steps below to add an e-code:
1. Search for and locate the appropriate E-code. E-codes range from E800 - E999.
2. Select the diagnosis and click Add to Encounter. The Date and Related Cause
Code window appears.
9-4
CHCS II User’s Manual
Block 1
Build 838
Assessment and Plan (A/P)
Figure 9–5: Date and Related Cause Code Window
3. Complete all the fields and click OK. If this encounter has already been marked as
related to an injury or accident, you simply need to verify the information in the
Related Cause Code window.
9.4
Creating an Order Set from A/P
Building an order set is not an intuitive process and must be done inside an open
encounter. The best method is to use the A/P module to locate and save orders as part
of an order set. Although orders should not be submitted as part of this process, it is
best to be safe and create an appointment for a test patient in the test clinic.
Follow the steps below to create an order set from A/P:
1. In the A/P module, begin on one of the Order Entry tabs (Labs, Rads, or Meds).
2. Locate the first order you want to include in the order set.
3. When you have located the order, click Save to Queue. This saves the order without submitting it.
4. Continue with all three tabs, as appropriate, locating individual orders and clicking Save to Queue.
Tip:
Once an order has
been submitted, it
cannot be included in
an order set. Orders
must be located and
then Saved to
Queue.
Note: For Med and Rad orders, the SIG and clinical impression is used as the default
for those orders. These can be changed when using the order set in an actual
encounter.
5. Once you have finished locating the orders you want to include in your order set,
click the Order Set tab to display the orders that have been saved to queue.
Block 1
Build 838
CHCS II User’s Manual
9-5
Assessment and Plan (A/P)
Figure 9–6: Order Sets Tab
6. Click Save as Order Set.
7. In the Save Encounter Template window Template Name field, enter the template
name you want to use for the order set.
8. Click Save to save the order set. The order set encounter template can now be
merged with other encounter templates and/or accessed in the Template Management and A/P modules.
9.4.1
Adding Orders to an Existing Encounter Template
An order set can also be saved as part of an encounter template that has already been
built.
Follow the steps below to add orders to an existing template:
1. Locate your order(s) and save them to queue, following steps 1 - 4 above.
2. Once you have finished locating the order(s) you want to include in your order set,
click the Order Set tab to display the orders that have been saved to queue.
Figure 9–7: A/P Order Sets Tab
3. Click Save as Order Set.
4. In the Save Encounter Template window, select the encounter template to add to
and click Save.
9-6
CHCS II User’s Manual
Block 1
Build 838
Assessment and Plan (A/P)
Figure 9–8: Save Encounter Template Window
5. A pop-up window opens asking if you want to Replace or Add To the existing
template. Click Add To. The selected order(s) is(are) added to the existing template and can be viewed in the Template Management module or within A/P when
the template is loaded.
Figure 9–9: Template Name Option Box
9.5
Documenting a Procedure
The Procedure tab allows you to document and take credit for in-office procedures.
Workload credit can be given to the clinical team member performing the procedure as
well.
Just like the diagnoses, each procedure includes the associated CPT code. These codes
are part of how CHCS II enables you to code as you document. Each procedure added
here automatically adds the corresponding code to the E&M calculator in the Disposition module, ensuring accurate and complete coding for performed procedures.
Each procedure must be associated with a diagnosis and can be associated with multiple diagnoses. Associating each procedure with at least one diagnosis is a CMMS rule
and is required for billing purposes. At the Enterprise-level, this association is a quality of care issue that enables the MHS to ensure that proper procedures are being performed for appropriate diagnoses.
Follow the steps below to document a procedure:
1. On the A/P module, click Procedure to view the Procedure tab.
Block 1
Build 838
CHCS II User’s Manual
9-7
Assessment and Plan (A/P)
Figure 9–10: A/P Procedure Tab
2. The procedure list can be viewed using the following methods:
•
Template List: If an encounter template is loaded, the list defaults to the procedures associated with the encounter template. Use the drop-down list to
select an encounter template and view default procedures for the selected
encounter template. Click the backward and forward buttons to view templates you have already loaded without using the drop-down list.
•
Clinic List: Click Clinic List to view a list of pre-selected procedures created
at the clinic or user level.
•
Search: In the Search field, enter the procedure and click Find Now. At least
2 characters must be entered. If you want to search for standard procedures,
select Standard Procedures (CPTs). If you want to search for Health Care
Financing Administration Common Procedure Coding System (HCPCS) and
durable medical equipment, select HCPCS and Durable Med Equip
(DME).
3. In the list of procedures, select the procedure you want to add to the encounter.
4. In the Diagnosis box, select the diagnosis with which to associate the procedure.
5. Click Add to Encounter. The procedure is added to the Orders and Procedures
area.
Note: Click Add to Favorite List if you want to add the selected procedure to your
Favorites List. The procedure also displays in the List Management module.
Note: If you attempt to exit the A/P module and the procedure is not associated to a
diagnosis, a warning message displays. Click Yes to save and close the mod-
9-8
CHCS II User’s Manual
Block 1
Build 838
Assessment and Plan (A/P)
ule without associating the procedure to the diagnosis or No to go back and
associate the procedure with the diagnosis.
Figure 9–11: Added Procedures
9.6
Linking a Clinical Team Member to a
Procedure
Provider Procedure Linking enables users to link additional clinical team members to
a procedure. All information is sent to ADM easily recording correct workload credit.
1. On the A/P module, click the procedure added to the encounter. The Procedure
Details window displays:
Figure 9–12: Procedure Details Window
Note: You can also select a provider by clicking the Additional Provider drop-down
arrow to display a list of providers. This provider list is the log in user’s
assigned clinic list.
2. Click the ellipsis button next to the Additional Provider #1 field. The Clinician
Search window displays.
Block 1
Build 838
CHCS II User’s Manual
9-9
Assessment and Plan (A/P)
Figure 9–13: Clinician Search Window
3. In the Last Name field, enter the last name of the desired clinician.
4. Select a facility from the drop-down list.
5. Select a clinic from the drop-down list.
6. Click the Find only clinicians who have login accounts on this system to view
only providers associated with CHCS II.
7. Click Find. The results are displayed in the bottom half of the Clinician Search
window.
8. Select the desired clinician.
9. Click Select.
10. Click the drop-down arrow in the Roles field next to the Additional Provider #1
and select Additional Provider Role.
9-10
CHCS II User’s Manual
Block 1
Build 838
Assessment and Plan (A/P)
Figure 9–14: Selected Role
11. Click the checkbox next to the clinical team member who performed the procedure. Be sure to deselect the primary provider, as appropriate.
12. Click OK. The additional provider is now associated to the procedure.
9.7
Addressing Reminders
The Reminders tab enables you to view and address patient reminders. The reminders
listed on the Reminders tab in A/P are the same reminders that are in the Reminder
pane below the Folder List and those that are listed on the Due Reminders tab in the
Wellness module. The Reminders tab in A/P helps to streamline the process to address
these reminders. Reminders highlighted in yellow are due within 30 days and reminders highlighted in red are overdue.
Each reminder is associated with a default diagnosis and some with a default action. A
full list of the default diagnoses and actions can be found in the Reminder Mapping
module under the Tools folder on the Folder List. Once a reminder has been
addressed, the default diagnosis is automatically added to the encounter and the
default action is completed.
9.7.1
Viewing Reminders
When the Reminders tab is opened, the due reminders and immunizations that are
overdue or are due in one month, display, based on the default filter.
Follow the steps below to change the list of reminders:
1. On the A/P module, click Reminders. The Reminders tab displays.
2. Set the Reminders filter, if desired, by making a selection from the drop-down list.
Block 1
Build 838
CHCS II User’s Manual
9-11
Assessment and Plan (A/P)
Figure 9–15: Reminders Tab—Drop‐down List
3. Select the Show Most Recent Results checkbox to show the most recent results
for the listed reminders. These are results from past lab and radiology orders or
documented vital signs.
9.7.2
Addressing Reminders
Follow the steps below to address patient reminders:
1. On the A/P module, click Reminders. The Reminders tab displays.
Figure 9–16: Reminders Tab
2. Click the checkbox in the Select column for those reminders that are to be
addressed with no modifications.
Note: Click Select All to select all reminders. Click Unselect All to deselect all
reminders.
9-12
CHCS II User’s Manual
Block 1
Build 838
Assessment and Plan (A/P)
Figure 9–17: Reminders Tab
3. If you want to associate the reminder with a different diagnosis than the default,
select the diagnosis, and click the Associate With Selected Diagnosis radio button.
4. Click Submit. The reminder is documented in the Diagnosis box under the associated diagnosis and any actions are completed.
Figure 9–18: Reminders Tab
9.7.2.1
Modifying a Reminder
Follow the steps below to modify and address a reminder:
1. Click the checkboxes in the Select and Modify columns.
Block 1
Build 838
CHCS II User’s Manual
9-13
Assessment and Plan (A/P)
Figure 9–19: Reminders Tab—Select and Modify
2. If you want to associate the reminder with a different diagnosis than the default,
select the diagnosis, and click the Associate With Selected Diagnosis radio button.
3. Click Submit. The reminder is documented.
Note: To edit the comments, click Comment under the appropriate diagnosis.
9-14
CHCS II User’s Manual
Block 1
Build 838
Assessment and Plan (A/P)
Figure 9–20: Reminders Tab—Immunizations Documented
Note: The immunizations Reminders continue to persist until the appropriate action
of vaccination is taken in the Immunization module.
9.8
Ordering a Consult
The Order Consults tab allows you to enter a consult request for a specific encounter.
Follow the steps below to order a consult:
1. Click the Order Consults tab. The Order Consults tab displays.
Figure 9–21: A/P Order Consults Tab
Block 1
Build 838
CHCS II User’s Manual
9-15
Assessment and Plan (A/P)
2. When placing an order for a consult, complete the required fields:
Note: The system requires an entry or selection for each field except phone.
•
Consulting Network: Select the appropriate radio button. The Consulting
Network group of radio buttons includes Military/TRICARE (SF513) and
Civilian (DD2161). The default is Military/TRICARE Medical Care (SF513).
•
Refer To: Select the recipient of the consult from the drop-down list. The
associated specialty or clinic is automatically displayed in the corresponding
fields.
•
Specialty: This field defaults with the associated specialty from the item
selected in Refer To.
•
Clinic: This field defaults with the associated clinic from the item selected in
Refer To.
•
Reason for Request: The system enables the referring provider to enter a
free-text description. Click inside the text box and type the reason.
•
Provisional Diagnosis: A provisional diagnosis is the referring provider's
best estimate of the patient's actual diagnosis. Often the patient is being
referred because the diagnosis is uncertain, hence Provisional. If the Diagnosis code has been completed, it automatically populates the Provisional Diagnosis field. If the diagnosis has not been documented, enter the provisional
diagnosis in the Provisional Diagnosis field.
Note: CHCS II defaults the provisional diagnosis field to the diagnosis selected.
•
No (Number) of Visits: This number refers to the recommended number of
visits to complete the consult. Enter the desired number.
•
Referral Authorized until: The date until which this consult order is active.
It is pre-filled with a date 30 days from the current date. Enter the appropriate
date.
•
Consulting Provider: Select the consulting provider from the drop-down list.
•
Priority: Select the desired priority from the drop-down list.
•
Output Method: Select an output method from the drop-down list. The Output Method refers to how the results of the consult should be communicated.
The choices include Send Electronically Only, Send and Print, and Print Only.
The default is Send Electronically Only.
•
Consulting Provider's Duty Phone: If a clinic provider was selected, the
phone number displays here. The number is taken from information entered
during the initial registration.
3. After you enter the required information, click one of the following:
•
9-16
Submit: The system submits the newly created consult orders to CHCS for
routing and scheduling with the selected specialty. The status is then changed
CHCS II User’s Manual
Block 1
Build 838
Assessment and Plan (A/P)
to Submitted. The consult is also added to the Assessment and Planning module in the upper right corner with the list of procedures and is associated with
the highlighted diagnosis. Highlight the desired diagnosis and double-click
the consult to re-associate the consult with a different diagnosis.
•
Save As Draft: The consult request status is saved in draft form because the
request has not been submitted and can be edited.
•
Clear: Cancels the information entered for the consult.
Figure 9–22: Added Consults
9.8.1
Managing Active Consults
The Active Consults area at the bottom of the workspace lists consults by other providers for this patient as well as the ones ordered by you. The statuses for these consults include the following:
•
Pending Results
•
Updated
•
Draft
•
Pending Appointment
•
Pending Review
Active consults can be edited, copied as new, or deleted. You can also view the history
of the consult to track its progress through the workflow.
Follow the steps below to edit or copy the consult:
1. Select the consult from the Active Consults list.
2. Perform a right mouse click and select either Edit or Copy as New. The consult
fields are populated with the details from the active consult.
3. Make any necessary changes and click Submit.
Follow the steps below to delete an active consult:
1. Select the consult from the Active Consult list.
2. Perform a right mouse click and select Delete. The consult is deleted from the
Active Consults list.
Follow the steps below to view the history of a consult:
1. Select the consult from the Active Consult list.
2. Perform a right mouse click and select History. The Consult History window
opens.
Block 1
Build 838
CHCS II User’s Manual
9-17
Assessment and Plan (A/P)
3. Review the history and click OK to return to the A/P module.
9.9
Ordering a Laboratory Test
The Order Lab tab allows you to enter a laboratory test for a specific encounter in the
A/P module.
Follow the steps below to order laboratory tests:
1. Click the Order Lab tab. The Order Lab tab displays.
Figure 9–23: A/P Order Lab Tab
2. Complete the following sections:
•
Search: Enter the name of the desired lab test and click Search. The results
populate the Lab Test Name drop-down list.
•
Lab Section: Select the departments for the desired procedure. This narrows
the results of the search, but is not necessary. Select All Sections to see all
available departments.
•
Lab Test Name: The results of the search populate the drop-down list. Select
the desired laboratory test.
Note: If the pre-verify process identifies any conflicts regarding the order, the Lab
Override window opens. Type a reason for the override in the Warnings window and click Accept Override to override the warning message. Click Cancel Order and select an alternative order to ignore the warning override.
9-18
CHCS II User’s Manual
Block 1
Build 838
Assessment and Plan (A/P)
Figure 9–24: Lab Override Window
Note: The CHCS pre-verify process also identifies the laboratory test specimen,
type, and container requirements. If there is more than one option, the Lab
Collection Choices window opens and allows you to select preferences.
Figure 9–25: Lab Collection Choices Window
•
Block 1
Build 838
Showing Panel Contents: If a laboratory test is associated with two or more
subtests, the Show Items in Panel button is enabled. Click the button to display the Lab Panel Elements window for the selected laboratory test. Click
OK to return to the Lab Orders tab.
CHCS II User’s Manual
9-19
Assessment and Plan (A/P)
•
Processing Priority: Click the radio button in the Processing Priority area to
select a different processing priority. Options include Routine, ASAP, STAT,
Notify, and Preop.
•
Comments or Instructions: In the Comments field, enter comments.
Note: Lab free-text persists in the Comments field during an Order Entry session.
•
Show Collection Choices: If a laboratory test has two or more collection
options, the Lab Collection Choices window opens displaying the available
choices. Click Show Collection Choices to select specimen collection methods.
•
More Detail: Click More Detail to view options for Schedule, Collection Priority, Collection Method, and Requesting Location. Once you click More
Detail, the button changes to Less Detail.
•
Schedule: Click the One-Time or Continuous radio button. The default is
One-Time and Continuous is grayed out if the option is not appropriate for the
selected test. If Continuous is selected, the Timing, Start Date, Frequency,
and Duration fields become active. These fields have default values depending on the test selected.
•
Timing: Use the drop-down list to change the time.
•
Start Date: In the Start field, enter the desired date (or use the arrow keys in
the field to select a date). The start date may only be the current date or a date
in the future.
•
Frequency (for Continuous tests only): Use the drop-down list to change
the frequency.
•
Duration (Days) (for Continuous tests only): In the Duration (Days) field,
enter the preferred number of days.
•
Collection Priority: Use the drop-down list to select a priority. The default is
Routine.
•
Collection Method: Use the drop-down list to select a collection method. The
default is Send Patient to Lab.
•
Requesting Location: Use the drop-down list to select a requesting location.
The default is the location of the workstation.
3. Do one of the following:
•
If all necessary information has been added and you want to submit the order,
click Submit. The order is seen in the Outstanding Laboratory Orders area.
•
If you are not ready to submit the order, or if you have other orders you need
to add before submitting, Click Save to Queue. This saves the order so you
can submit it later.
Note: If the order is underlined, it is in a queue and has not been submitted. If the
order is underlined and bolded, it is in a queue but has not been associated
9-20
CHCS II User’s Manual
Block 1
Build 838
Assessment and Plan (A/P)
with a diagnosis or submitted. Click Submit All to submit orders in a queue.
Orders without a diagnosis cannot be submitted unless you add a diagnosis.
Note: Select the desired diagnosis and double-click the lab order to associate an
order with a diagnosis.
Figure 9–26: Added Laboratory Test
9.9.1
Anatomic Pathology Worksheets
Anatomic Pathology worksheets display for lab tests requiring additional pathology
information than what is needed for ordering other lab tests. The worksheet displays
when you search for a specified anatomic pathology lab test on the Order Labs tab in
the A/P module. There are five Anatomic Pathology worksheets:
•
Autopsy
•
Bone Marrow
•
Cytologic Gyn
•
Cytologic Non-Gyn
•
Tissue Exam
Note: The results for ordered Anatomic Pathology tests can be viewed in the Clinical Notes module. Open the Clinical Notes module for the selected patient to
view results. Click Filter to access the Filter tab on the Properties window
and select Specific Note Types. Click Add to access the Healthcare Data Dictionary Search for Clinical Note Types and search for Anatomical Pathology
Reports. Add this as your filter to view results for ordered anatomic pathology
tests.
9.9.1.1
Completing Autopsy Worksheets
The Autopsy Worksheet window appears when you order an anatomic pathology lab
test in the A/P module.
Block 1
Build 838
CHCS II User’s Manual
9-21
Assessment and Plan (A/P)
Figure 9–27: Autopsy Worksheet
Follow the steps below to complete an Autopsy worksheet:
1. Select a date and time for the requested autopsy. The current date and time are
defaulted to the user’s workstation date and time, and the checkbox is automatically selected.
2. Select the Requesting Location from the drop-down list. The location defaults to
your selected clinic.
3. Select the Autopsy Type being performed from the drop-down list.
4. If necessary, enter any comments in the Comments field.
5. If all necessary information has been added and you want to submit the order,
click Submit.
•
9.9.1.2
If you are not ready to submit the order, or if you have other orders you need
to add before submitting, click Save to Queue. This saves the order allowing
you to submit it at a later time.
Completing Bone Marrow Worksheets
The Bone Marrow Worksheet window appears when you order an anatomic pathology
lab test in the A/P module.
9-22
CHCS II User’s Manual
Block 1
Build 838
Assessment and Plan (A/P)
Figure 9–28: Bone Marrow Worksheet
Follow the steps below to complete a bone marrow worksheet:
1. Select a date and time for the bone marrow specimen collection. The current date
and time are defaulted to the user’s workstation date and time, and the checkbox is
automatically selected.
2. Select the Processing Priority for the specimen. Routine is selected as the default
priority.
3. Select the Requesting Location from the drop-down list. The location defaults to
your selected clinic.
4. Enter the container label and description for the specimen being collected. If the
specimen is frozen, select Yes.
5. Click Add.
Note: The specimen information displays in the Specimen List area. You can modify
or delete specific information, if necessary.
6. Enter a brief clinical history for the specimen.
7. Enter a brief PreOp diagnosis for the specimen.
Block 1
Build 838
CHCS II User’s Manual
9-23
Assessment and Plan (A/P)
8. If all necessary information has been added and you want to submit the order,
click Submit.
•
9.9.1.3
If you are not ready to submit the order, or if you have other orders you need
to add before submitting, click Save to Queue. This saves the order allowing
you to submit it at a later time.
Completing Cytologic Gyn Worksheets
The Cytologic Gyn Worksheet window appears when you order an anatomic pathology lab test in the A/P module.
Figure 9–29: Cytologic Gyn Worksheet
Follow the steps below to complete a Cytologic Gyn worksheet:
1. Select a date and time for the cytologic gyn specimen collection. The current date
and time are defaulted to the user’s workstation date and time, and the checkbox is
automatically selected.
2. Select a Specimen from the drop-down list.
3. Select the Processing Priority for the specimen. Routine is selected as the default
priority.
4. Select the Requesting Location from the drop-down list. The location defaults to
your selected clinic.
5. Indicate whether the patient is taking any of the following:
9-24
CHCS II User’s Manual
Block 1
Build 838
Assessment and Plan (A/P)
•
Birth Control Pills
•
IUD
•
Post-Menopausal
•
Hysterectomy
•
Hormone Therapy
6. If the patient is pregnant or recently gave birth, select the number of weeks from
the drop-down list.
7. Indicate the start dates for any of the following:
•
Last Menses
•
Radiation Therapy
•
Cytotoxic Therapy
8. Enter any related results or previous cytology diagnoses.
9. Enter any related cytology comments.
10. If all necessary information has been added and you want to submit the order,
click Submit.
•
9.9.1.4
If you are not ready to submit the order, or if you have other orders you need
to add before submitting, click Save to Queue. This saves the order allowing
you to submit it at a later time.
Completing Cytologic Non-gyn Worksheets
The Cytologic Non-gyn Worksheet window appears when you order an anatomic
pathology lab test in the A/P module.
Block 1
Build 838
CHCS II User’s Manual
9-25
Assessment and Plan (A/P)
Figure 9–30: Cytologic Non‐gyn Worksheet
Follow the steps below to complete a Cytologic Non-Gyn worksheet:
1. Select a date and time for the cytologic non-gyn specimen collection. The current
date and time are defaulted to the user’s workstation date and time, and the checkbox is automatically selected.
2. Select the Processing Priority for the specimen. Routine is selected as the default
priority.
3. Select the Requesting Location from the drop-down list. The location defaults to
your selected clinic.
4. Enter the container label and description for the specimen being collected. If the
specimen is frozen, select Yes.
5. Click Add.
Note: The specimen information displays in the Specimen List area. You can modify
or delete specimen information, as necessary.
6. Enter related Clinical History information for the specimen.
7. Enter related PreOp diagnoses for the specimen.
8. Enter related Operative Findings for the specimen.
9-26
CHCS II User’s Manual
Block 1
Build 838
Assessment and Plan (A/P)
9. Enter related PostOp diagnoses for the specimen.
10. If all necessary information has been added and you want to submit the order,
click Submit.
•
9.9.1.5
If you are not ready to submit the order, or if you have other orders you need
to add before submitting, click Save to Queue. This saves the order allowing
you to submit it at a later time.
Completing Tissue Exam Worksheets
The Tissue Exam Worksheet window appears when you order an anatomic pathology
lab test in the A/P module.
Figure 9–31: Tissue Exam Worksheet
Follow the steps below to complete a tissue exam worksheet:
1. Select a date and time for the tissue specimen collection. The current date and
time are defaulted to the user’s workstation date and time, and the checkbox is
automatically selected.
2. Select the Processing Priority for the specimen. Routine is selected as the default
priority.
3. Select the Requesting Location from the drop-down list. The location defaults to
your selected clinic.
Block 1
Build 838
CHCS II User’s Manual
9-27
Assessment and Plan (A/P)
4. Enter the container label and description for the specimen being collected. If the
specimen is frozen, select Yes.
5. Click Add.
Note: The specimen information displays in the Specimen List area. You can modify
or delete specimen information, as necessary.
6. Enter related Clinical History information for the specimen.
7. Enter related PreOp diagnoses for the specimen.
8. Enter related Operative Findings for the specimen.
9. Enter related PostOp diagnoses for the specimen.
10. If all necessary information has been added and you want to submit the order,
click Submit.
•
If you are not ready to submit the order, or if you have other orders you need
to add before submitting, click Save to Queue. This saves the order allowing
you to submit it at a later time.
9.10 Ordering a Radiology Procedure
The Order Rad tab allows you to order a radiology procedure for a specific encounter.
Follow the steps below to order a radiology procedure in the A/P module:
1. Click the Order Rad tab. The Order Rad tab displays.
Figure 9–32: A/P Order Rad Tab
2. Complete the following fields:
9-28
CHCS II User’s Manual
Block 1
Build 838
Assessment and Plan (A/P)
•
New Rad Order: In the Search field, enter the name of the desired radiology
test and click Search. The results populate the Procedure Name drop-down
list.
•
Rad Section: Select the departments for the desired procedure from the dropdown list. This narrows the results of the search but is not necessary. Select
All Sections to see all available departments.
Note: The pre-verify process identifies and displays warnings regarding the Radiology order. Type a reason for the override in the Warnings window and click
Accept Override to override the warning. Otherwise, click Cancel Order
and select an alternative order.
•
Procedure Name: Select the desired test from the drop-down list.
•
Clinical Impression: Enter the reason(s) for ordering the radiology procedure. This is a mandatory field.
Note: The previous clinical impression can carry over to the next radiology order by
selecting Yes in the dialog box.
•
Priority: Click the radio button in the Processing Priority area to select a different processing priority. Options include Routine, ASAP, STAT, Notify, and
Preop.
•
Immediate Reading: Click the Immediate Reading check box to denote that
the test should be read immediately.
•
Comments or Instructions: Enter any comments or instructions related to
the radiology procedure.
•
More Detail: Click More Detail to view options for Schedule, Patient Mobility, and Requesting Location. After you click More Detail, the button
changes to Less Detail.
•
Schedule: Select one-time or continuous.
Note: Timing, Frequency and Duration are only available if the continuous radio
button is checked in Schedule.
•
Timing: Select either AM or HS from the drop-down list.
•
Start Date: Click the drop-down arrow to open the calendar window. Select
the start date.
•
Frequency: Click the drop-down list and select the frequency.
•
Duration (Days): Enter the duration.
•
Patient Mobility: Select the option that best defines the patient's mobility
from the drop-down list.
Block 1
Build 838
CHCS II User’s Manual
9-29
Assessment and Plan (A/P)
•
Requesting Location: Select a requesting location from the drop-down list.
The default is the location of the workstation.
3. Do one of the following:
•
If all necessary information has been added and you want to submit the order,
click Submit. The order is seen in the Outstanding Radiology Orders area.
•
If you are not ready to submit the order, or if you have other orders you need
to add before submitting, click Save to Queue. This saves the order, allowing
you to submit it at a later time.
Note: If the order is underlined, it is in a queue and has not been submitted. If the
order is underlined and bolded, it is in a queue but has not been associated
with a diagnosis or submitted. Click Submit All to submit orders in a queue.
Orders without a diagnosis cannot be submitted unless you add a diagnosis.
Note: Select the desired diagnosis and double-click the procedure to associate the
procedure to a diagnosis.
Figure 9–33: Added Radiology Test
9.11
Ordering a Medication
As you submit an outpatient medication order, the order is verified in CHCS to ensure
that you have the proper privileges and that the selected medication is available. You
can submit new orders and modify, renew, discontinue or change the status of previously processed orders. CHCS validates each order as it is submitted and alerts you to
any requirements (such as co-signature required) or limiting circumstances (such as
availability or patient allergies).
Follow the steps below to order a medication:
1. Click the Order Med tab. The Order Med tab displays.
9-30
CHCS II User’s Manual
Block 1
Build 838
Assessment and Plan (A/P)
Figure 9–34: A/P Order Med Tab
2. Complete the following sections:
•
New Med Order: In the Search field, enter the medication name and click
Search. The results populate the Item Name drop-down list.
•
Item Name: Select the desired medication from the drop-down list populated
by the search function.
•
SIG: Enter a new SIG or use the one returned by the pre-verify process. If you
follow the SIG with a number preceded with the number sign (e.g. #30), and
press the <Enter> key, the Quantity field is populated with the number you
entered. Click Expand SIG to view an expanded version of the displayed SIG
code. The expanded SIG field provides a detailed explanation of the SIG
codes returned from CHCS.
•
Quantity: Enter the quantity to be dispensed. Use the unit of measure shown
in the Default Unit field on the right side of the tab or the quantity shown
with the name/description of the medication. Default = 30-days' supply, calculated from the SIG, Quantity, and Refill fields.
•
Refills: Enter the number of refills. (Look in the Maximum field for the maximum number of refills allowed.) An error message displays if the number of
refills is greater than the maximum (Maximum = maximum number of days'
supply allowed).
•
Start Date: Enter the date the medication is to start (or use the arrow cursor in
the field to select a date). The start date can only be the current date or a date
in the future.
•
Child Resistant Cap: If you do not want a child resistant cap, deselect Child
Resistant Cap.
•
Comment: Enter comments you want associated with the medication.
Block 1
Build 838
CHCS II User’s Manual
9-31
Assessment and Plan (A/P)
•
More Detail: Click More Detail to view options for the dispensing and
requesting locations. After clicking More Detail, the button changes to Less
Detail.
•
Requesting Location: Select a requesting location from the drop-down list.
The default is the location of the workstation.
•
Dispensing Location: This field defaults to the associated pharmacy. Use the
drop-down list to select another location.
3. Do one of the following:
•
If all necessary information has been added and you want to submit the order,
click Submit. You can see the order in the Current Outpatient Medications
area.
•
If you are not ready to submit the order, or if you have other orders you need
to add before submitting, click Save to Queue. This saves the order allowing
you to submit it at a later time.
CHCS pre-verifies the order against patient and medications records and displays any
resulting messages or warnings, as well as any SIG code(s) and standard order/refill
quantities associated with the medication. In addition, CHCS II now provides connectivity to the Pharmacy Data Transaction System (PDTS), a central data repository containing patient medication profiles for all beneficiaries. In order entry–meds, in the
Assessment and Plan module, PDTS provides the CHCS II user with:
•
Excessive and insufficient dose warnings
•
Interaction, overlap and duplicate warnings, and warning override capabilities
•
Warning overrides on renew and modify orders
If the pre-verify process identifies warnings regarding the order, the CHCS and PDTS
warnings display in the same window. Select a reason for override with the Warning
Override Reasons radio buttons to override the warning. Select a radio button under
the Order Cancellation Reasons to cancel an order.
9-32
CHCS II User’s Manual
Block 1
Build 838
Assessment and Plan (A/P)
Figure 9–35: CHCS and PDTS Warning Window
Note: If the order is underlined, it is in a queue and has not been submitted. If the
order is underlined and bolded, it is in a queue but has not been associated
with a diagnosis or submitted. Click Submit All to submit orders in a queue.
Orders without a diagnosis cannot be submitted unless you add a diagnosis.
Note: Select the desired diagnosis and double-click the order to associate the order
with a diagnosis.
Figure 9–36: Added Medications
9.12 Requesting Location
Follow the steps below to select a requesting location:
1. Click the More Detail button.
Block 1
Build 838
CHCS II User’s Manual
9-33
Assessment and Plan (A/P)
Figure 9–37: Order Med Tab
2. Click the Search icon. The Find Requesting Location window opens.
Figure 9–38: More Detail
Figure 9–39: Find Requesting Location Window
9-34
CHCS II User’s Manual
Block 1
Build 838
Assessment and Plan (A/P)
3. If necessary or desired you may refine a search by making a selection from the
Location Type drop-down list in conjunction with entering a search string.
Figure 9–40: Location Type Drop‐down List
4. Alternatively, enter a search string and click the Search button. The search results
display.
Figure 9–41: Search Results Displayed
5. Select the desired search results and click OK. The selected Requesting Location
display in the Requesting Location field.
Block 1
Build 838
CHCS II User’s Manual
9-35
Assessment and Plan (A/P)
Figure 9–42: Requesting Location Field Populated
9.13 Adding Patient Instructions
The Other Therapies tab allows you to add patient instructions for a specific encounter. The instructions should be associated with selected diagnoses or procedures. They
are not associated with patient handouts that may be provided to the patient.
Follow the steps below to enter other therapies:
1. On the A/P module, click Other Therapies to view the Other Therapies tab.
Figure 9–43: A/P Other Therapies Tab
2. Patient Instructions may be selected using the following methods:
9-36
•
Template List (see online help for descriptions)
•
Search (see online help for descriptions)
CHCS II User’s Manual
Block 1
Build 838
Assessment and Plan (A/P)
3. Select the instructions you want to add to the encounter.
Note: Instructions with a plus sign (+) next to them can be expanded to view associated instructions at a lower level. A minus sign (-) next to the instruction indicates the instruction is at the lowest level.
4. Click Add.
The instruction is added to the Orders and Procedures area and is associated with
the selected diagnosis.
•
Follow the steps below to associate the order with a different diagnosis:
a. In the diagnosis list, select the instruction under the associated diagnosis.
b. Click the Associates/Unassociates Orders & Procedures icon.
c. Select the instruction and the diagnosis, and click the Associates/Unnassociates Orders & Procedures icon to associate the instruction with the
alternative diagnosis.
5. On the Action bar, click Close. The completed A/P is AutoCited in the Patient
Encounter module.
Tip:
If the instruction was
not automatically
associated to the
diagnosis, highlight
the appropriate
diagnosis and select
the instruction.
Multiple instructions
can be added using
the same procedure.
9.14 Discontinuing an Order
Follow the steps below to discontinue an order:
1. From the Current Orders workspace at the bottom of any of the order entry tabs
(Order Lab, Order Rad, Order Med), click Show Orders.
2. Select the order.
3. Click Discontinue.
9.15 Placing an Order on Hold
Follow the steps below to place an order on hold:
1. From the Current Orders workspace at the bottom of any of the order entry tabs
(Order Lab, Order Rad, Order Med), click Show Orders.
2. Select the order.
3. Click Hold. The status of the order changes to Hold.
9.16 Showing the Details of an Order
Follow the steps below to show details of an order:
1. From the Current Orders workspace at the bottom of any of the order entry tabs
(Order Lab, Order Rad, Order Med), click Show Orders.
2. Select an order.
Block 1
Build 838
CHCS II User’s Manual
9-37
Assessment and Plan (A/P)
3. Click Show Detail to view the Detail window.
4. Click OK to return to the Order Entry tab.
9.17 Renewing/Modifying an Order
Follow the steps below to renew an order:
1. From the Current Orders workspace at the bottom of any of the order entry tabs
(Order Lab, Order Rad, Order Med), click Show Orders.
2. Select the order.
3. Click Renew. The Enter Reason For Action window opens.
4. Enter your reason for renewing the order.
5. Click OK to return to the Order Entry tab.
6. Click Submit.
Follow the steps below to modify an order:
1. From the Current Orders workspace at the bottom of any of the order entry tabs
(Order Lab, Order Rad, Order Med), click Show Orders.
2. Select the order.
3. Click Modify. The Enter Reason For Action window opens.
4. Enter your reason for modifying the order.
5. Click OK to return to the Order Entry tab.
6. Click Submit.
Note: Click Renew + Modify to renew and modify an order.
9-38
CHCS II User’s Manual
Block 1
Build 838
10.0 CLINICAL NOTES
10.1 Clinical Notes Overview
The Clinical Notes module displays patient-specific notes that are not associated with
an encounter, including those that have been imported from non-CHCS II system text
notes. Clinical Notes can be copied into the Add Note portion of the Encounter Summary (SF600).
Figure 10–1: Military Clinical Desktop—Clinical Notes Module
10.1.1
In More Depth
The Clinical Notes module allows a CHCS II user to enter, view, and edit notes for a
patient that are not associated with an encounter document.
The left side of the Clinical Notes screen displays a list of all the notes entered into the
patient’s medical record. The notes displayed are based on the Filter and Time search
criteria selected by the end user. For each clinical note, the following fields are displayed:
•
Date
•
Type
•
Status
•
Image
•
Clinician
Block 1
Build 838
CHCS II User’s Manual
10-1
Clinical Notes
•
Entered By
•
Edited By
•
Point of Care (POC) Facility
When you highlight a note from the left pane, a preview of the note appears in the
right side of the screen. The Expand checkbox in the upper right corner of the screen
allows you to review an expanded view of a selected clinical note. Deselecting the
checkbox returns the module to the default view.
In addition to creating and saving new notes to a patient’s record in the Clinical Notes
module, you can also view clinical notes that originate outside of the module. A consult ordered and completed in CHCS is viewable in the CHCS II Clinical Notes module as a Consult Report. Similarly, a consult ordered in CHCS II and completed in
CHCS is also viewable in the CHCS II Clinical Notes module.
A consult ordered in CHCS II is sent to CHCS for scheduling. The business process,
once the consult crosses over to CHCS, does not change. Depending on how the consult was ordered and completed, completed consults can be viewed as follows:
•
Consult ordered in CHCS and completed in CHCS: The consult is viewable in the
CHCS II Clinical Notes module and the CHCS Consults module.
•
Consult ordered in CHCS and completed in CHCS II: The consult is viewable as
an encounter in CHCS II and is written to the CHCS Consult module. The
appointment must first be linked to the CHCS II encounter.
•
Consult ordered in CHCS II and completed in CHCS: The consult is viewable in
the CHCS II Clinical Notes module and the CHCS Consults module.
•
Consult ordered in CHCS II and completed in CHCS II: The consult is viewable
as an encounter in CHCS II and is written to the CHCS Consults module. The
appointment must first be linked to the CHCS II encounter.
10.1.2
Setting the Filter Properties for the Clinical Notes Module
The Filter tab enables the filter name, note type, and associated clinician to be
selected.
Follow the steps below to set the filter properties for the Clinical Notes module:
1. Click Filter on the Clinical Notes module. The Properties window opens with the
Filter tab displayed.
10-2
CHCS II User’s Manual
Block 1
Build 838
Clinical Notes
Figure 10–2: Clinical Notes Properties Window (Filter Tab)
2. Select a filter name from the drop-down list.
3. Do one of the following:
•
If you want to view a list of all note types, select All Note Types.
•
If you want to view selected note types:
a. Select Specific Note Type(s).
b. Click Add. The Healthcare Data Dictionary Search for Clinical Note
Types window opens.
Block 1
Build 838
CHCS II User’s Manual
10-3
Clinical Notes
Figure 10–3: Healthcare Data Dictionary Search for Clinical Note Types Window
c. Select the report(s) you want to add.
d. Click Add.
e. When you have finished adding the selected report(s), click OK. The
selected reports display in the specific note type(s) area.
4. Do one of the following:
•
If you want to view clinic notes for all clinicians, select All Clinicians.
•
If you want to view clinic notes for selected clinicians:
a. Select Specific Clinician.
b. Click Clinician. The Clinician Search window opens.
10-4
CHCS II User’s Manual
Block 1
Build 838
Clinical Notes
Figure 10–4: Clinician Search Window
c. Search for the clinician.
5. Click Save.
Note: If it is a new filter selection, click Save As, enter the name of the new filter
and click Save.
10.2 Setting Time Preferences for the Clinical
Notes Module
The Preferences tab allows you to customize default times to be displayed on the Clinical Notes module.
Block 1
Build 838
CHCS II User’s Manual
10-5
Clinical Notes
Figure 10–5: Clinical Notes Properties Window (Preference Tab)
Tip:
You can also set
time preferences by
clicking Time on the
Clinical Notes
module.
Follow the steps below to set time preferences for the Clinical Notes module:
1. Click Default Time on the Preferences tab. The Time Search window opens.
Figure 10–6: Time Search Window
2. Select a time search option.
3. Click OK.
Note: The data on the Clinical Notes module is refreshed according to the selected
search option. All clinical notes meeting the criteria are listed on the Clinical
Notes module. These become your default settings.
10-6
CHCS II User’s Manual
Block 1
Build 838
Clinical Notes
10.3 Creating a New Note
Follow the steps below to create a new clinical note for a patient:
1. Click New on the Clinical Notes module. The New Clinical Note window opens.
Note: The Date field defaults to the current date. If you want to change the date,
enter a date or click Date. The Calendar window opens and a date can be
selected.
Note: The Clinician field defaults to the name of the clinician who is currently
logged on. If you want to change the clinician, click Clinician to search for
the clinician you want to add.
Figure 10–7: New Clinical Note Window
2. Select a Note type from the drop-down list.
3. Select a POC from the drop-down list.
4. In the text field, enter the note.
5. Do one of the following:
•
If you want to insert an image file (i.e., .tif, .bmp, .wmf) in the note:
a. Click Insert Image.
b. Select the file from the Select Destination File window.
Block 1
Build 838
CHCS II User’s Manual
10-7
Clinical Notes
Figure 10–8: Select Destination File Window
c. Click Open. The contents of the file are inserted in the note.
Note: Graphics that are imported must be 500K or less. If the file size is over this
amount, the system gives you a message prompt.
•
If you want to insert an existing file (e.g., .txt, .rtf, .html) in the note:
a. Click Load Existing File.
b. Select the file from the Select Destination File window.
c. Click Open. The contents of the file are inserted in the note.
6. Click Save. The note displays in the Clinical Notes module.
10.4 Editing a Note
Only the author of the note can modify clinical notes.
Follow the steps below to edit a note:
1. Select the note from the list of notes on the Clinical Notes module. The text of the
note displays in right-half of the workspace.
2. Click Edit on the Action bar. The Edit window opens.
3. Enter the applicable changes.
4. Click Save. The modifications display in the note.
Note: Text notes imported from non-CHCS II systems cannot be edited.
10-8
CHCS II User’s Manual
Block 1
Build 838
11.0 CONSULT LOG
11.1
Consult Log Overview
The Consult Log module displays all of your consults, both ordered and received. The
log displays and continually updates statuses and other information for each consult as
it progresses through its lifecycle. In this fashion, the system establishes a tracking log
of all actions. The Consult Log can be viewed by Consults Log For Me, Consults Log
From Me or Both.
Figure 11–1: Military Clinical Desktop—Consult Log Module
11.1.1
In More Depth
Consults can be sorted (by consult status, appointment date, FMP/SSN, clinical specialty, diagnosis, priority, patient, consulting provider, or PCM) by simply clicking on
the perspective column header.
Any actions that have occurred in reference to a consult listed in the Consult Log area
of the Consults module can be viewed. The SF 513 and DD 2161 can be printed from
the Consult Log module.
A consult ordered in CHCS II is sent to CHCS for scheduling. The business process,
once the consult crosses over to CHCS, does not change. Depending on how the consult was ordered and completed, completed consults can be viewed as follows:
•
Consult ordered in CHCS and completed in CHCS: The consult is viewable in the
CHCS II Clinical Notes module and the CHCS Consults module.
Block 1
Build 838
CHCS II User’s Manual
11-1
Consult Log
Tip:
Use the scrollbar at
the bottom of this
area to view the
additional Consult
Log fields.
•
Consult ordered in CHCS and completed in CHCS II: The consult is viewable as
an encounter in CHCS II and is written to the CHCS Consult module. The
appointment must first be linked to the CHCS II encounter.
•
Consult ordered in CHCS II and completed in CHCS: The consult is viewable in
the CHCS II Clinical Notes module and the CHCS Consults module.
•
Consult ordered in CHCS II and completed in CHCS II: The consult is viewable
as an encounter in CHCS II and is written to the CHCS Consults module. The
appointment must first be linked to the CHCS II encounter.
11.2
Setting the Consult Log Filter
The Consult Log can be viewed by Consults Log For Me, Consults Log From Me, or
both.
Select the filter from the drop-down list in the top, right corner of the Consult Log
window to set the Consult Log filter. The consults meeting the criteria appear in the
list of consults.
11.3
Setting the Consults Change Selection
Criteria
The Consult Log filter allows the user to show consults for the provider, from the provider, or both. The Consult Log Selections Dialog box enables you to apply more
advanced filters. Options are available to select a consult status, appointment date,
consult order date, patient SSN, PCM, or clinical specialty. Once selections are made,
you can make them the default settings or just for the current session.
Follow the steps below to set the consults change selection criteria:
1. Click Change Selections on the Consult Log module. The Consult Log Selections
window opens.
Figure 11–2: Consult Log Selections Window
11-2
CHCS II User’s Manual
Block 1
Build 838
Consult Log
2. Select an option in the Consults For area.
3. Select an option in the Consult Status Selection area.
4. Select an appointment date or range.
5. Select a consult order date or range.
6. Select the optional fields, as necessary, you want to display. The optional fields
display as additional columns in the Consult Log workspace.
7. Click OK to set the selected search criteria. The data on the Consult Log is
refreshed according to the search criteria.
11.4
Printing a Consult
You have the capability to print a selected consult on an SF513 form.
Follow the steps below to print a consult:
1. Select the consult you want to print from the Consult Log.
2. Click SF513 on the Action bar. A Print Preview window opens.
Figure 11–3: Consult Print Preview Window
3. Click the print icon. The form is sent to your designated printer.
Block 1
Build 838
CHCS II User’s Manual
11-3
Consult Log
11.5
Removing a Consult
A consult with a status of Draft or Pending Appointment can be removed from the
Consult Log. Consults should be removed from the log when appropriate. This
reduces the number of consults to be pulled from the database; therefore, reducing the
amount of time it takes to open a consult log module.
Follow the steps below to remove a consult:
1. Select the consult from the Consult Log.
2. Click Remove on the Action bar.
Figure 11–4: Consult Status—Cancelled
11.6
Viewing the History of a Consult
Any actions that have occurred in reference to a consult listed can be viewed.
Follow the steps below to view the history of a consult:
1. Select the appropriate consult from the Consult Log list.
2. Click History on the Action bar. The Consult History window opens.
Figure 11–5: Consult History Window
3. Review the information in the Consult History window.
4. Click OK.
11-4
CHCS II User’s Manual
Block 1
Build 838
12.0 CO-SIGNS
12.1 Co-signs Overview
The Co-Signs module displays a list of all of the encounters that an individual provider needs to co-sign. The provider can co-sign the appropriate encounters from this
module, as well as view encounter details, amend the encounter, and add a narrative.
Figure 12–1: Co‐signs Module
12.1.1
In More Depth
The top of the module displays a list of all the encounters requiring co-signatures for
the provider logged in. View details of a specific encounter by clicking once on the
desired encounter and viewing the details in the bottom half of the workspace.
Clinical team members can set a co-signer when signing an individual encounter or as
a default in the AutoCite Properties window.
12.2 Co-Signing an Encounter
All encounters needing co-signatures from the provider currently logged in are listed
at the top of the window with the status of Needs Co-Signature.
Block 1
Build 838
CHCS II User’s Manual
12-1
Co-Signs
Follow the steps below to co-sign an encounter:
1. Select the encounter you want to co-sign.
Tip:
2. Click Sign Encounter. The Co-Sign Encounter window opens.
Click the Sensitive
checkbox if you want
to mark the
appended note as
sensitive.
Figure 12–2: Co‐Sign Encounter Window
3. In the Enter Your Password field, enter your password.
4. Click Sign.
12.3 Co-Signing an Encounter for Another
Provider
Any provider with co-signing privileges can access and subsequently co-sign encounters assigned to another provider.
Follow the steps below to co-sign encounters for another provider:
1. Click Providers on the Co-Signs window. The Clinician Search window opens.
2. Search for the clinician. The Co-Signs window displays the list of encounters
requiring the selected provider's co-signature.
3. Select the encounter to be co-signed.
4. Click Sign Encounter. The Co-Sign Encounter window opens.
5. In the Enter Your Password field, enter your password.
6. Click Sign.
12-2
CHCS II User’s Manual
Block 1
Build 838
Co-Signs
12.4 Appending a Narrative
The Append Narrative function enables you to attach text or a graphic file to a completed encounter. Graphics that are imported cannot be greater than 500K. The narrative appears at the bottom of the encounter, stamped with the time, date, and author’s
name. Since the narrative is added after the encounter was signed, the note itself must
be signed by the author.
Follow the steps below to append a narrative:
1. Select an encounter.
2. Click Append Narrative on the Action bar. The Encounter Note window opens.
Figure 12–3: Encounter Note Window
Tip:
Copied text can be
pasted directly into
the text box.
3. Enter a note category, if appropriate.
4. Enter a note title, if appropriate.
5. Enter the note in the text box.
6. Do one of the following:
•
If you want to insert a file into the note:
a. Click Load File. The Select Destination File window opens.
Block 1
Build 838
CHCS II User’s Manual
12-3
Co-Signs
Figure 12–4: Select Destination File Window
b. Select the file to be added.
c. Click Open. The contents of the file are displayed in the text box.
Note: Graphics that are imported must be 500K or less.
•
If you want to print the note for your hardcopy records, click Print.
7. Click Save and Sign. The Sign Appended Note window opens, so you can review
the narrative before signing.
Figure 12–5: Sign Appended Note Window
8. Enter your password and click Sign. The narrative appears at the bottom of the
encounter summary with the Time, Date, and your name next to the narration.
12-4
CHCS II User’s Manual
Block 1
Build 838
Co-Signs
12.5 Amending an Encounter
Amending an encounter allows original information to be changed by the original provider or the provider's supervisor. Each section that is amended includes the cosigner's name and date stamp. A note is added to the document under Change History
at the bottom of the encounter summary stating that the encounter has been amended.
Follow the steps below to amend an encounter:
1. Select the encounter you want to amend.
2. Click Amend Encounter on the Action bar. The Patient Encounter window opens
for the selected encounter.
Note: The original AutoCited information is moved to the Change History section
of the electronic SF600. The AutoCites are refreshed with current information.
Figure 12–6: Patient Encounter Summary
3. Update applicable sections of the encounter.
Note: Any changes replace the original information on the electronic SF600. The
original information is moved to the Change History section.
Block 1
Build 838
CHCS II User’s Manual
12-5
Co-Signs
4. Once the changes have been made, you must sign the amended encounter. Click
Sign on the Action bar. The Co-Sign Encounter window opens.
Note: If information is changed in or added to the A/P module, you receive a warning message suggesting that you return to the Disposition module to verify the
E&M code.
Figure 12–7: Co‐Sign Encounter Window
5. In the Enter Your Password field, enter your password.
6. Click Sign to sign the encounter. The Change History section of the encounter is
documented with the amendments and you are returned to the Appointments module.
12-6
CHCS II User’s Manual
Block 1
Build 838
13.0 DEMOGRAPHICS
13.1 Demographics Overview
The Demographics module displays the patient's demographic information. Certain
demographic information can be updated. The patient's home address, city, state, zip
code, country, home and work phone, e-mail address, religion, comments, and the
location of the records can be modified in the Edit mode. Third-Party insurance information, Special Work Status, and Required Fields information can be viewed and
modified. Information on a patient's Primary Care Manager (PCM) and the Defense
Enrollment Eligibility Reporting System (DEERS) eligibility cannot be modified.
Figure 13–1: Military Clinical Desktop—Demographics Module
Note: Any edits to the demographic information in CHCS II are overwritten by
CHCS and DEERS updates.
13.1.1
In More Depth
The Demographics module contains pertinent information about the patient that is
pulled from CHCS. Although certain demographic elements can be edited in the
Demographics module, any edits to the demographic information are overwritten by
the information held in the Defense Eligibility Enrollment Reporting System
(DEERS).
Block 1
Build 838
CHCS II User’s Manual
13-1
Demographics
Most of the demographic information can be viewed and edited outside of an encounter. A current encounter must be open in order to modify the patient's Special Work
Status or enter new third-party insurance information.
13.2 Editing Demographic Information
Certain demographic information can be updated in the Patient Demographics module. These fields include a patient's religion, home address, home and work phone,
comments, and the location of the records. The rest of the information on the left is
read-only and can only be updated in CHCS.
Follow the steps below to edit demographic information:
1. In the Appointments List, select a patient name.
2. In the Folder list, click Demographics. The Demographics module opens.
3. On the Action bar, click Edit.
Figure 13–2: Demographics Module
4. Update the necessary fields in the Demographics module.
•
Home Address, Phone Numbers, and E-Mail: Enter necessary changes in
the applicable fields. Tab or use the mouse to move to the next field.
Note: The Country field is limited to 12 characters including spaces.
13-2
•
Religion: Use the drop-down list to select the desired religion.
•
Comments: In the Comments text box, enter information applicable to the
Demographics module.
•
Records Maintained At: Use the drop-down list to select the location of the
patient’s paper records. Use the scroll bar to view all options.
CHCS II User’s Manual
Block 1
Build 838
Demographics
5. On the Action bar, click Save. Once the information is saved, it is visible upon
returning to the Demographics module, unless it has been overwritten by CHCS
or DEERS.
13.3 Viewing Primary Care Provider Information
Tip:
Right-click in any of
the test fields to
access the editing
functions (cut, copy,
paste).
Follow the steps below to view primary care provider information:
1. Click Prim. Care Mgr. The Primary Care Manager Information window opens
containing read only information.
Figure 13–3: Primary Care Manager Information Window
2. Click Close to return to the Demographics module.
13.4 Modifying Special Work Status
An encounter must be open in order to modify Special Work Status. If an encounter is
not open, the Special Work Status button is disabled. When an encounter is open, the
button is enabled and Special Work Status information can also be modified. This
information can be modified in the Demographics module, the Screening module, and
the Disposition module.
Follow the steps below to modify special work status:
1. Click Spec Wrk Status. The Special Work Status window opens.
Block 1
Build 838
CHCS II User’s Manual
13-3
Demographics
Figure 13–4: Special Work Status
2. Select the checkbox next to each applicable work status.
3. Select Qualified or Disqualified for the associated work status.
4. Click OK. You are returned to the Demographics module and the icon associated
with the selected work status appears on the Patient ID Bar.
13.5 Viewing DEERS Eligibility
Follow the steps below to view DEERS Eligibility:
1. Click DEERS Eligibility. The DEERS Eligibility window opens. This is a readonly window.
Figure 13–5: DEERS Eligibility Window
13.6 Updating Required Fields
If the fields that are required for each patient have not been completed, SADR Data
Incomplete appears in red beside the button.
Follow the steps below to update required fields:
1. Click Required Fields. The Required Fields window opens.
13-4
CHCS II User’s Manual
Block 1
Build 838
Demographics
Figure 13–6: Required Fields Window
2. The following fields must be updated if there are any changes or errors:
•
Family Member Prefix (FMP): Enter the FMP.
•
Military Grade/Rank: Enter the correct grade or rank.
•
Alternative Care Value (ACV): Use the drop-down list to select the additional insurance plan.
3. Click Save Changes to update the record and open the Demographics module.
Once the SADR information is complete, SADR Data Complete appears beside
the Required Fields button.
13.7 Printing the Insurance Form
A copy of the patient's insurance information can be printed for verification or to note
changes. The form can also be printed from the Appointments and Demographics
modules. This form defaults to the current date and includes demographic information
with space to update the address, phone numbers, current insurance information, and
questions for the patient to answer regarding any changes.
Follow the steps below to print the Insurance Form:
1. Click Ins. Form on the Action bar to print an insurance form for a patient. The
Print Preview window opens.
2. Click the printer icon on the Preview window to print the form. The form is sent to
your designated printer.
13.8 Entering New Third-Party Insurance
Information
An encounter must be open in order to enter third-party insurance information. If an
encounter is not open, No Encounter Open displays next to the disabled Enter
Changes to Patient Insurance Information button. When an encounter is open, the
button is enabled and insurance information can be documented.
Follow the steps below to enter new third-party insurance information:
1. Click Enter Changes to Patient Insurance Information. The Patient Insurance
Information window opens.
Block 1
Build 838
CHCS II User’s Manual
13-5
Demographics
Figure 13–7: Patient Insurance Information Window
2. Click either Yes or No in response to the first two questions.
3. Enter the applicable information into the following fields:
•
Insurance Company Name: Enter the name of the insurance company.
•
Insurance Company Telephone: Enter the company's phone number.
•
Insurance Company Address: Enter the company's address.
•
Insurance ID Number: Enter the policy number.
•
Group Name: Enter the name of the group with which the subscriber is associated.
•
Group Number: Enter the group number.
•
Subscriber's Name: Enter the name of the policy holder.
•
Patient's Relationship to Subscriber: Enter the relationship of the patient to
the person subscribed to the insurance policy.
•
Effective Date/Expiration Date: Select these buttons to access the Calendar
window in order to select the effective date and the expiration date for the
insurance policy.
Note: The system defaults to the current date.
13-6
CHCS II User’s Manual
Block 1
Build 838
Demographics
•
Person Capturing Information: Enter the name of the person filling out this
form.
•
Information Source: Enter the source of the insurance information.
•
Comments: Enter any comments for this entry.
4. Click Save.
Block 1
Build 838
CHCS II User’s Manual
13-7
Demographics
13-8
CHCS II User’s Manual
Block 1
Build 838
14.0 DISPOSITION
14.1 Disposition Overview
The Disposition module is used to document the disposition and E&M codes of an
encounter. In this module, you can record the discharge status of the patient from the
clinic, follow-up information, and the patient's understanding of the assessment and
plan. In addition, the E&M codes are calculated and selected.
Figure 14–1: Military Clinical Desktop—Disposition Module
14.1.1
In More Depth
The Disposition module is typically the last module in the patient encounter process. It
collects information from the entire process and begins the coding and billing processes. Options found on the Disposition module are dependent on the appointment
type, appointment classification and whether or not the appointment is a count or nocount visit.
The bottom part of the module houses the E&M Calculator. CHCS II calculates a suggested code for the encounter based on the structured terms and documentation
entered in the S/O and A/P modules and the appointment type, patient status, service
type and whether or not the encounter was a counseling visit. Calculation is completed
Block 1
Build 838
CHCS II User’s Manual
14-1
Disposition
using the 1997 Documentation Guidelines from the Centers for Medicare and Medicaid Services (CMS).
Note: The CMS organization was previously known as the Healthcare Financing
Administration (HCFA).
14.2 Completing the Disposition
14.2.1
Assigning a Disposition
Follow the steps below to assign a disposition:
1. Select the appropriate disposition from the Disposition drop-down list. You can
only select one option. Depending on whether the patient’s appointment classification is outpatient or inpatient, different options are available.
Figure 14–2: Disposition Drop‐down List Outpatient
Figure 14–3: Disposition Drop‐down List Inpatient
Based on your selection, additional fields become active and require input:
•
14-2
If Released with Work/Duty Limitations is selected, click Profile to document the limitation. The Temporary Profile window opens.
CHCS II User’s Manual
Block 1
Build 838
Disposition
Figure 14–4: Temp Profile Window
•
Start Date and End Date: Select the appropriate time frame by clicking
the drop-down arrow and selecting the dates from the calendar.
•
Diagnosis: Select the diagnosis causing the limitation from the dropdown list.
•
Limitation: In the Limitation free text field, describe the patient’s limitations.
•
Click OK. The profile is documented and is displayed on the electronic
SF600.
Note: You are still required to complete a paper profile form to be sent to the
patient’s supervisor.
•
If Sick at Home/Quarters is selected, specify the correct time period (24, 48,
or 72 hours).
•
If Immediate Referral is selected, enter the provider’s name to whom the
patient is being referred.
•
If Left Against Medical Advice is selected, click Comments to document
detailed information on the patient’s actions.
•
If Admitted is selected, click Comments to document detailed information
concerning the admission.
•
If Expired is selected, click Comments to document additional information.
14.2.2
Completing the Encounter Context Fields
The Encounter Context fields display in other areas of the application and simply need
to be reviewed here. The injury/accident designation typically occurs when creating
the appointment in CHCS II or in the A/P module when documenting an e-code diagnosis.
•
Block 1
Build 838
Related to Injury/Accident?: If the appointment is related to an injury or an
accident, select this checkbox. The Date and Related Cause Code window
appears.
CHCS II User’s Manual
14-3
Disposition
Figure 14–5: Date and Related Cause Code Window
•
Complete all fields and click OK. Notice the checkbox indicating that the
date and Related Cause Code have been entered.
Note: An encounter marked as related to an injury or accident is required to contain
an E-code as one of the diagnoses. A notification appears when you attempt to
close the A/P module or sign the encounter if the encounter is marked as
related to an injury or accident and no E-code (diagnosis) was selected.
Tip:
If the pregnancy and/
or injury/accident
information was
added in the
Screening module,
then you can review
the information here.
If the information
was not added in the
Screening module,
you can record the
information now.
Pregnancy information, for female patients, is gathered in the Screening module but
changes can be made in the Disposition module as well.
The fields associated with Female Only Data display for female patients 12 years of
age or older.
Follow the steps below to add female only data:
1. Click the Patient Pregnant checkbox to open the Pregnancy Related window.
2. In the Female Only Data area, select the checkboxes to all the fields that apply.
•
Pregnant
Note: If the patient is pregnant, the Last Menstrual Period and the Estimated DOB
are required fields.
14-4
•
Post Menopause
•
Post Hysterectomy
•
Last Menstrual Period: Select this checkbox to activate the date drop-down
field. Select the appropriate date.
CHCS II User’s Manual
Block 1
Build 838
Disposition
•
Estimated DOB: Select this checkbox to activate the date drop-down field.
Select the appropriate date.
Note: On the electronic SF600, the estimated DOB is written as the EDC (Estimated
Date of Confinement).
•
Birth Control Method: Click the checkbox next to the appropriate birth control method.
•
G, P, A, LC: Click the drop-down list and select the appropriate value.
3. Click OK.
14.2.3
Filling out the Billing and Admin Fields
These fields are completed based on information gathered in the Appointments and
A/P modules.
Follow the steps below to change the Billing and Admin information:
1. To change the Billing Chief Complaint, click the drop-down arrow to select
another diagnosis that was entered in the A/P module.
•
Use the ellipsis to search for a diagnosis that was not documented in the A/P
module. The Select Diagnosis window opens.
•
Check the Clinic and Favorites tab for the appropriate diagnosis. If the diagnosis is not on one of these tabs, click the Search tab.
•
Enter the diagnosis and click Search.
•
Select the diagnosis from the list and click OK. The selected diagnosis fills in
the appropriate field.
2. To change the Appointment Classification, click the drop-down arrow to select
from the options. The options available in the drop-down list will vary, based on
the patient’s appointment classification in CHCS. If the classification is Inpatient,
this field cannot be changed.
3. Click Admin Options to document additional information and work status. The
Administrative Options window opens.
Block 1
Build 838
CHCS II User’s Manual
14-5
Disposition
Figure 14–6: Administrative Options Window
Tip:
For a more detailed
description on Count
vs. Non-Count, click
the question mark
icon next to the dropdown list.
•
In the Admin Options area, select items that apply.
•
Click the checkbox next to the applicable work status(es) and select either
Qualified or Disqualified.
•
Click OK.
4. Meets Visit Criteria: This field determines whether this encounter is a count or
no-count visit. Yes, is count; No is no-count. If No is selected, the available E&M
codes are no-count codes.
14.2.4
Documenting Follow-up Information
This area allows you to document the instructions given to the patient about further
treatment or appointments. This information is written to the electronic SF600. Data
entered here concerning follow-up appointments does not trigger the scheduling of an
appointment. This must be done using the current process.
Follow the steps below to document follow-up information:
1. Click the checkbox to denote a follow-up appointment as needed (PRN) or with
the primary care manager (PCM).
2. Complete the time and location fields, as appropriate.
•
When: Select this option to enter a timeframe for the follow-up appointment.
•
14-6
Click the ellipsis button. The Follow-up in window opens.
CHCS II User’s Manual
Block 1
Build 838
Disposition
Figure 14–7: Follow‐up in Window
•
•
Click the appropriate numeric value and then the timeframe. Click
OK. Your selection populates the When field.
For Tx: The Follow-Up for Treatment window allows you to enter a
specified period of time and number of visits regarding treatments associated with the current encounter.
•
Click the ellipsis button. The Follow-up for Treatment window
opens.
Figure 14–8: Follow‐up for treatment Window
•
•
Select the applicable abbreviation (e.g., QIW = 4 times a week) and
the timeframe required for the treatment.
•
Select the time period and click OK. Your selection populates the For
Tx field.
In Clinic: Use the drop-down arrow and select the clinic in which the
patient needs to follow up.
3. Enter comments, as necessary.
14.2.5
Document a Patient’s Understanding of the A/P
This area allows you to document which items were discussed with the patient and
that the patient indicated understanding of each item.
Follow the steps below to document understanding:
1. Select items that were discussed with the patient.
Block 1
Build 838
CHCS II User’s Manual
14-7
Disposition
Tip:
The default setting
can be set via the
AutoCite Properties
window off the
Encounter Summary
module (electronic
SF600).
2. If all items were discussed and the patient understood each item, click the checkbox next to All Items Discussed. This marks each item as well as document the
patient’s understanding.
3. If the discussion occurred with someone other than the patient, use the drop-down
list to select the appropriate party.
4. Enter comments, as necessary.
14.2.6
Selecting an E&M Code
The E&M calculator provides a suggested E&M code. It takes into account each
structured term documented in the S/O note, the documented assessment and plan
items, and the settings of key filters to determine the suggested E&M code.
The 1997 HCFA Documentation Guidelines are the basis for E&M coding. There are
twelve parameters used to calculate the code. The CHCS II Disposition module pulls
data for each of these parameters from the structured data entered in the note. The
most important parameters are Overall History, Exam, and Medical Decision Making
(MDM).
Because the calculator uses structured terms to determine the code, if a provider uses a
lot of free text, the calculator is not as accurate. It is important, from a coding
perspective, then, to build and use templates that are made up of the structured terms.
In addition to the structured terms, the calculator relies on three filters to produce an
accurate code: Time Factor, Patient Status, and Service Type.
Follow the steps below to select the appropriate E&M code:
1. Change the following filters, as appropriate.
•
Time Factor: Select this option for visits in which more than 50% of the time
was spent counseling or coordinating care. In this case, the E&M code is
based on the amount of time spent with the patient. Adjust the Face-to-Face
Floor time, as appropriate. The time field defaults to the scheduled appointment duration.
•
Patient Status: The E&M code is partially based on the type of patient being
seen; a new patient or an existing patient. ‘New’ means that this is the first
time this patient has been seen in the clinic. ‘Existing’ means a chart exists for
that patient at that clinic. These two different options affect the coding for an
encounter because a new patient is calculated differently.
Note: Patient Status defaults to New Patient if the patient has not been seen in the
same Clinic/Specialty within the past three (3) years.
14-8
•
Setting: Use the drop-down list to select the appropriate setting for this
encounter.
•
Service Type: The most common selection is Outpatient Visit. Use the Preventive Evaluation or Management Type for routine physicals and well-
CHCS II User’s Manual
Block 1
Build 838
Disposition
baby checks. With these types of appointments, the E&M code is based on the
patient’s age.
Note: The options available in the Setting and Service type drop-down lists are
based on the appointment type and appointment classification.
•
Exam Type: The default exam type is General Multi-System. Use the dropdown list to select a more specific exam type.
2. Review and accept the suggested E&M code. If you wish to override the code, go
to step 3.
Note: The level of each of the twelve parameters is listed under the headings, highlighted in blue.
3. The suggested E&M code can be changed from the Calculated tab. Click the
desired numerical button underneath the parameters to indicate what the level
should be. As you change the levels, an additional E&M code is displayed beneath
the suggested code.
Note: The user overrides are highlighted in red.
Figure 14–9: Calculated Tab ‐ User Override Selected
4. As you change the levels, an additional E&M code is displayed beneath the suggested code. Click the With User overrides radio button to select the new E&M
code.
14.2.6.1 To manually select the E&M Code:
1. Click the Selection tab.
Block 1
Build 838
CHCS II User’s Manual
14-9
Disposition
Figure 14–10: Selection Tab
2. Select an E&M Category from the drop-down list.
3. Select an E&M code from the results list for the associated E&M category. The
E&M code and E&M help fields automatically populate with detailed code
information.
Note: The available options are determined by the patient’s status and the appointment type.
14.2.6.2 To add Additional E&M Codes or E&M Modifiers:
E&M code modifiers allow you to document altered services or procedures performed
during the patient encounter (i.e., an evaluation and management service with a procedure on the same day).
E&M code modifiers most frequently used include:
14-10
•
-21 Prolonged Evaluation and Management Services: Used only with the highest level of service within a given category or subcategory of E&M services. This
modifier is appended to the E&M service(s) when the service(s) provided is prolonged or otherwise greater than usually required for the highest level of E&M
service with a given category.
•
-24 Unrelated Evaluation and Management Service By the Same Physician
During a Postoperative Period: Used when a physician who has provided a surgical service related to one problem, now provides an E&M service unrelated to
the problem requiring the surgery, during the period of follow-up care for the surgery. The modifier -24 is also used to describe a visit to treat an underlying condition following surgery.
•
-25 Significant, Separate Identifiable Evaluation and Management Service
By the Same Physician on the Day of a Procedure: The physician may need to
indicate that on the day a procedure or other service identified by a CPT-4 code
was performed, the patient’s condition required a significant, separately identifiable E&M service above and beyond the usual preoperative and postoperative
care associated with the procedure that was performed.
•
-57 Decision For Surgery: Used to indicate that this encounter was the encounter
that resulted in the initial decision to perform surgery. While some carriers will
not pay E&M visits by the surgeon within a certain time period, this modifier
CHCS II User’s Manual
Block 1
Build 838
Disposition
should indicate that this visit should be considered as a separate charge from the
surgery due to the nature of the initial work-up. For Medicare, this modifier pertains to encounters the day before, or the day of, a major surgery (90 day postoperative period).
Follow the steps below to add a modifier or additional E&M code:
1. Click the Additional E&M Coding tab.
Note: The Calculated and Additional E&M Coding tabs are only enabled if the
Workload is set to Count.
2. Select additional coding modifiers from the drop-down lists. Up to three modifiers
can be associated with one E&M code. Select or uncheck the associated diagnoses, as appropriate.
Tip:
Tool Tips are
available when you
hover your mouse
over an individual
modifier.
3. Add additional E&M codes, as appropriate.
•
Click the ellipsis button next to E&M Code 2 to open the Selection window.
•
Select an E&M Category from the drop-down list.
•
Select an E&M code from the results list for the associated E&M category.
The E&M code and E&M help fields automatically populate with detailed
code information
4. Click Save on the Action bar.
Block 1
Build 838
CHCS II User’s Manual
14-11
Disposition
14-12
CHCS II User’s Manual
Block 1
Build 838
15.0 FLOWSHEETS
15.1 Flowsheets Overview
The purpose of the Flowsheets module is to display multiple data items such as lab
values, medication profile (drug, dosage, and frequency), and vital signs in a chronological descending format over a period of time without having to open an encounter.
You must select a patient to access this module.
Figure 15–1: Military Clinical Desktop—Flowsheets Module
15.2 Viewing Flowsheets
When you access the Flowsheet module, the Vital Signs Flowsheet is displayed by
default.
Follow the steps below to view a flowsheet:
1. Select Lab Results or Medications in the drop-down filter in the upper, right corner to view additional flowsheets. A flowsheet is created with all past data.
2. The Flowsheet can be configured to show desired information by clicking in the
checkbox next to the desired information shown at the right of the Flowsheet
module.
Note: Items in the Configuration Panel pertain only to the selected flowsheet.
Block 1
Build 838
CHCS II User’s Manual
15-1
Flowsheets
15.3 Printing Flowsheets
Follow the steps below to print flowsheets:
1. Select the flowsheet you want to print:
•
Vital Signs
•
Lab Results
•
Medications
2. Do one of the following:
•
If you want to print the entire flowsheet, click Print Entire Flowsheet. The
worksheet is sent to your local printer.
•
If you want to print a portion of the flowsheet:
a. Select the portion of the flowsheet you want to print.
b. Click Print Flowsheet Portion.
Note: The Print Flowsheet Portion button is inactive until the columns are
selected.
15-2
CHCS II User’s Manual
Block 1
Build 838
16.0 HEALTH HISTORY
16.1 Health History Overview
The Health History module displays historical patient data from various modules in
one window. The window can be customized to show different modules containing the
patient's information.
Figure 16–1: Military Clinical Desktop—Health History Module
16.1.1
In More Depth
When opening the Health History module for the first time, you must select the modules to display in the Health History module and design the window layout. The
Health History module is useful to the clinical team members because it provides a
quick “snapshot” of the patient's medical history. Reviewing a patient's medical history is an important step in the patient evaluation process because information about
allergies, lab results, problems, etc. can affect the current evaluation.
Block 1
Build 838
CHCS II User’s Manual
16-1
Health History
16.2 Customizing the Health History Module
Follow the steps below to customize the Health History module:
1. Click Options on the Health History module. The Design Summary window
opens.
Note: If opening Health History for the first time, you will receive a message stating
that no modules have been selected. Click OK and proceed with step 1.
Figure 16–2: Design Summary Window
2. Select Module Options for which you want patient information to display in the
Health History module. Each module selected is placed in the middle of the
design screen. Click and drag the module to position it within the design screen.
3. Click Align to allow the system to place the selected modules.
4. Click OK.
16.3 Viewing Historical Modules
Modules selected for display on the Health History module are easily accessible. Historical modules can be accessed and viewed by double-clicking the desired module in
the Health History module. The selected module opens. To return to the Health History module, close the current module.
16-2
CHCS II User’s Manual
Block 1
Build 838
17.0 IMMUNIZATION ADMIN
17.1 Immunizations Admin Overview
The Immunization Admin module is used to administer and manage vaccines, providers, reports, user groups, and refrigeration temperature logs. It is also used to document multiple vaccine entries for selected patients. The Immunizations Admin module
contains two tabs: Admin and Multiple Entry. The Immunizations Admin module can
be accessed without loading a patient’s medical record.
Figure 17–1: Military Clinical Desktop—Immunizations Admin Module
17.1.1
In More Depth
The Immunizations Admin tab is used to setup the Immunizations Clinic at an MTF.
Before immunizations can be administered to a patient, the vaccines must be placed in
stock in the Immunizations Clinic using CHCS II.
The recommended workflow for deploying CHCS II to a brand new Immunizations
Clinic is as follows:
•
Evaluate existing CHCS business processes
•
Establish business processes for CHCS II
•
Establish CHCS II user roles for clinic team members
•
Inventory vaccines
Block 1
Build 838
CHCS II User’s Manual
17-1
Immunization Admin
•
Immunization Admin updates Vaccine Management area in CHCS II (Vaccine in
Stock) with Vaccine Inventory for default clinic or multiple clinics
•
Immunization Admin sets up clinic defaults on applicable workstations
•
Develop a default encounter template for use by the Immunizations Clinic
•
Train Immunizations Clinic team members
A user with immunization administrator privileges is able to create or select a default
clinic. The Default Immunization Clinic in the Vaccine Management area is a preloaded clinic. When CHCS II is deployed to a brand new Immunizations Clinic, the
Vaccines in Stock lists all of the vaccines known by CHCS II. When a new clinic is
created, the immunization administrator has to select the vaccines in stock from the
list of Available Vaccines. Available Vaccines are standard throughout the DoD system. CHCS II allows you to enter specific vaccine elements such as vaccine name,
series, manufacturer, lot number, dosage, site, route, etc. for each vaccine schedule.
New vaccines are added to the list of available vaccines in CHCS II per approval by a
federal government panel. Following the approval process, the vaccine can be added
to the local MTF, but only by an end user with Enterprise-level access privileges. End
users at the local MTFs can not change vaccine schedules per new guidelines issued
by the Centers for Disease Control and Prevention.
If CHCS II is being deployed to an existing Immunizations Clinic, the Vaccines in
Stock may have already been populated by an immunization administrator. This information is stored in a database table.
The Immunization Admin can set up clinic defaults on applicable workstations. Setting the clinic defaults establishes the origin of vaccine information when vaccines are
administered to patients.
The Immunizations Admin Multiple Entry tab is used to document multiple vaccine
entries for patients selected from a Unit/UIC. You can access the Rapid Data Entry
option to quickly enter vaccine information using a bar code reader.
17.2 Adding User-Defined Groups
A user-defined group is a required set of immunizations for specified patient groups.
The groups can be created per clinic, patient, or deployment requirements. When a
Service member is assigned to a user-defined group, the required immunizations automatically adjust to include the immunizations that are a part of the group.
CHCS II allows you to create new user-defined groups. Service-specific groups
defined by the DoD are preloaded in the application.
Follow the steps below to add user-defined groups:
1. Click User Defined Groups on the Admin tab. The User Defined Groups area
displays.
17-2
CHCS II User’s Manual
Block 1
Build 838
Immunization Admin
Figure 17–2: Immunizations Admin—User Defined Groups
2. Click Add. The Add User Defined Group window opens.
Figure 17–3: Add User Defined Group Window
3. Enter the name of the user group you want to add.
4. Click OK.
17.3 Adding a Refrigerator
Follow the steps below to add a refrigerator:
1. Click Temperature Log on the Admin tab. The Refrigerator Temperature Log
area displays.
Block 1
Build 838
CHCS II User’s Manual
17-3
Immunization Admin
Figure 17–4: Immunizations Admin—Temperature Log
2. Select the clinic for which you are adding the refrigerator.
3. Click Add/Mod. The Add/Modify a Refrigerator window opens.
Figure 17–5: Add/Modify a Refrigerator Window
4. Complete the following fields:
•
Alias Name: Enter the name of the refrigerator (such as Maytag, GE, Westinghouse).
•
Serial Number: Enter the refrigerator's serial number for identification and
tracking purposes.
•
Low Temperature: Enter the refrigerator's low temperature. This is the minimum temperature at which the refrigerator should ever operate.
•
High Temperature: Enter the refrigerator's high temperature. This is the
maximum temperature at which the refrigerator should ever operate.
5. Click Add.
17-4
CHCS II User’s Manual
Block 1
Build 838
Immunization Admin
17.4 Adding a Vaccine for Multiple Entry
Follow the steps below to add a vaccine for Multiple Entry:
1. Click Add on the Multiple Entry tab. The Vaccines in Stock window opens.
Figure 17–6: Vaccines in Stock Window
2. Select a vaccine from the list of available vaccines.
3. Click OK. The vaccine is added to the list of vaccines on the Multiple Entry tab.
Note: Select a vaccine and click Delete to delete the vaccine from the multiple entry
list.
Note: In order to edit vaccine information from the multiple entry list, click in the
field you want to edit. Click the down arrow to open the applicable window
and modify the information.
Figure 17–7: Immunizations Admin—Multiple Entry Tab
Block 1
Build 838
CHCS II User’s Manual
17-5
Immunization Admin
4. Clicking the Rapid Data Entry button enables you to enter vaccines by bar code
reader.
17.5 Assigning Vaccines to User Defined
Groups
Follow the steps below to assign vaccines to User Defined Groups:
1. Click User Defined Groups on the Admin tab. The User Defined Groups area
displays.
Figure 17–8: Immunizations Admin—User Defined Groups
2. Select a User Defined Group.
3. Select a vaccine from the Generic Vaccine Names list.
4. Click the Right Arrow button to move the vaccine to the Assigned Generic Vaccine Names list.
17.6 Deleting Providers from Administering
Immunizations
A provider can be deleted from administering immunizations; however, the provider is
added back to the eligible provider list when he/she administers a vaccine.
Follow the steps below to delete a provider from administering immunizations:
1. Click Provider Management on the Admin tab. The Provider Management area
displays.
17-6
CHCS II User’s Manual
Block 1
Build 838
Immunization Admin
Figure 17–9: Immunizations Admin—Provider Management
2. Select a provider from the list in the Provider Management area.
3. Click Delete.
17.7 Entering Multiple Vaccines for a Patient
Follow the steps below to enter multiple vaccines for a patient:
1. Select an Immunization Provider from the drop-down list on the Multiple Entry
tab.
Block 1
Build 838
CHCS II User’s Manual
17-7
Immunization Admin
Figure 17–10: Immunizations Admin—Multiple Entry Tab
Note: The Immunization Date field defaults to the current date. Enter the applicable date in the field if the current date is not the correct date.
2. Select the patient for whom you want to enter multiple vaccines.
3. Click the Select field for the associated patient and click the down arrow to select
the patient.
Note: Click Select All if you want to enter the same multiple vaccines for every
patient in the list.
4. Click Log Selected.
17.8 Logging Refrigerator Temperatures
Follow the steps below to log refrigerator temperatures:
1. Click Temperature Log on the Admin tab. The Refrigerator Temperature Log
area displays.
17-8
CHCS II User’s Manual
Block 1
Build 838
Immunization Admin
Figure 17–11: Immunizations Admin—Temperature Log
2. Select a clinic from the drop-down list.
3. Select a refrigerator from the drop-down list.
4. Complete the following fields:
•
Temperature: Enter the temperature of the refrigerator you are logging in the
system. You can enter a temperature in degrees Fahrenheit or Celsius.
•
Date: Enter the date you are logging the temperature in dd mm yyyy format.
•
Time: Enter the time you are logging the temperature. You can enter the time
in AM, PM, or Military.
5. Click Add.
Note: Click the All Refrigerators radio button, then click Show All Entries to view
all logged refrigerator temperatures for the selected clinic.
17.9 Modifying Refrigerator Temperature Logs
Follow the steps below to modify refrigerator temperature logs:
1. Click Temperature Log on the Admin tab. The Refrigerator Temperature Log
area displays.
2. Select a clinic from the drop-down list.
3. Select a refrigerator from the drop-down list.
Block 1
Build 838
CHCS II User’s Manual
17-9
Immunization Admin
4. Select the Selected Only radio button.
Note: Click the All Refrigerators radio button, then click Show All Entries to view
all logged refrigerator temperatures for the selected clinic.
5. Click Show All Entries.
6. Update the following fields, as necessary:
•
Temperature
•
Date
•
Time
7. Click Modify.
17.10 Modifying a Refrigerator
Follow the steps below to modify a refrigerator:
1. Click Temperature Log on the Admin tab. The Refrigerator Temperature Log
area displays.
2. Select a clinic from the drop-down list.
3. Click Add/Mod. The Add/Modify a Refrigerator window opens.
Figure 17–12: Immunizations Admin—Add/Modify a Refrigerator
4. Double-click the refrigerator you want to modify.
5. Update the following fields, as necessary.
17-10
•
Alias Name: Enter the name of the refrigerator (such as Maytag, GE, Westinghouse).
•
Serial Number: Enter the refrigerator's serial number for identification and
tracking purposes.
•
Low Temperature: Enter the refrigerator's low temperature. This is the minimum temperature at which the refrigerator should ever operate.
CHCS II User’s Manual
Block 1
Build 838
Immunization Admin
•
High Temperature: Enter the refrigerator's high temperature. This is the
maximum temperature at which the refrigerator should ever operate.
6. Click Modify.
Note: If you want to delete the refrigerator, click Delete and click Yes at the confirmation prompt.
17.11 Printing Immunization Reports
Follow the steps below to print immunization reports:
1. Click Reports on the Admin tab. The Report Options area displays.
Figure 17–13: Immunizations Admin—Reports
2. Select a report from the drop-down list.
Note: Information for the selected report displays in the Report area. The information displayed depends on what report you select.
3. Click Print.
4. Select a print range on the Print window.
5. Click OK.
Block 1
Build 838
CHCS II User’s Manual
17-11
Immunization Admin
17.12 Selecting a Default Vaccination Clinic
Follow the steps below to select a default vaccination clinic:
1. Click Vaccine Management on the Admin tab. The Vaccine Management area
displays.
Figure 17–14: Immunizations Admin—Vaccine Management
2. Click the Ellipsis button
window opens.
next to the Default Clinic field. The Clinic List Edit
Figure 17–15: Clinic List Edit Window
3. Select the clinic from the list.
Note: If the clinic you want to select is not listed, click Add. In the text field, enter
the clinic name and press Enter on your computer keyboard.
4. Click Set Default. You are returned to the Vaccine Management area.
5. Do one of the following:
•
17-12
If you want to associate stocked vaccines to the default clinic:
CHCS II User’s Manual
Block 1
Build 838
Immunization Admin
•
Select a vaccine from the list of available vaccines.
•
Click the Right Arrow
in Stock list.
button. The vaccine is moved to the Vaccines
•
If you want to set the default typhoid product, select the typhoid product from
the drop-down list.
•
If you want to set the default body area where the vaccine is given, select the
site from the drop-down list.
•
If you want to view the manufacturer and lot number information for the vaccines in stock:
•
Click Mfg/Lot Nbr. The Vaccines in Stock Information window opens.
Figure 17–16: Vaccines In Stock Information Window
•
Click Close to return to the Admin tab.
17.13 Viewing the Vaccine Lot Number List
Follow the steps below to view the Vaccine Lot Number List:
1. Click Reports on the Admin tab. The Reports area displays.
Block 1
Build 838
CHCS II User’s Manual
17-13
Immunization Admin
Figure 17–17: Immunizations Admin—Reports
2. Click Lot Numbers. The Vaccine Lot Number List window opens.
Figure 17–18: Vaccine Lot Number List Window
3. Select a vaccine from the drop-down list. Manufacturer information displays for
each manufacturer associated with the selected vaccine.
4. Select a manufacturer.
5. Click Details. All patients associated with the vaccine distributed by the selected
manufacturer display.
Note: Click Details to edit the immunization history for the selected patient.
Note: You can also click the drop-down arrow to view detailed information for manufacturers and patients.
17-14
CHCS II User’s Manual
Block 1
Build 838
18.0 LABORATORY
18.1 Laboratory Overview
The Lab module is designed to display the results of laboratory tests. Results are
viewed, not ordered, from this module. Lab results are pulled from CHCS and an alert
is triggered when new results are received. The Lab module is defaulted to display ten
lab results. The default value can be changed, but this may impact your wait time and
system performance.
Figure 18–1: Military Clinical Desktop—Laboratory Module
18.1.1
In More Depth
During site activation or when an appointment is first made in CHCS II for a particular patient, 36 months worth of patient lab results are pulled from CHCS and are
stored in the CDR. These results are accessible through the Lab module.
Lab tests are ordered through CHCS II in the A/P module. The order is sent back to
CHCS for processing. When the test is complete and the results are entered into
CHCS, they are sent to the CDR and an alert is triggered in CHCS II for the ordering
provider. All lab results, then, are reviewed in the Lab module.
18.2 Creating a Search Filter in the Lab Module
The results listed in the Lab module can be filtered. You can create a filter to sort lab
results for which you are interested in.
Block 1
Build 838
CHCS II User’s Manual
18-1
Laboratory
Follow the steps below to create a filter for viewing lab results:
1. Click Options on the Lab module. The Lab Results Properties window opens.
2. Click the Filter tab.
Figure 18–2: Lab Results—Properties Window—Filter Tab
3. Select the applicable radio button for the lab results you want to view.
•
If All Labs is selected, all of the listed lab results are displayed.
•
If Specific Labs is selected, click Add to open the Add Lab Type window to
add specific lab results.
4. Click Save As. If this is a change to a pre-existing filter, click Save.
Figure 18–3: Save As Window
5. Enter the name for the filter.
6. Click Save.
Note: To delete a personal filter, select the filter from thelist and click Delete. At the
confirm deletion prompt, click Yes.
18-2
CHCS II User’s Manual
Block 1
Build 838
Laboratory
7. Click OK.
18.3 Setting Laboratory Module Preferences
The Preferences tab allows you to set default times and viewing options. Each time
you open the Lab module, the listed results match these defaults. The Lab module is
defaulted to display ten lab results. The default value can be changed, but this may
impact your wait time and system performance.
Figure 18–4: Lab Results—Properties Window—Preferences Tab
Follow the steps below to set Lab module preferences:
1. Click Options on the Lab module. The Lab Results Properties window opens.
2. Click the Preferences tab.
3. Click Default Time. The Lab Results warning window displays.
Figure 18–5: Warning Window
4. Click OK. The Time Search window opens.
Block 1
Build 838
CHCS II User’s Manual
18-3
Laboratory
Figure 18–6: Time Search Window
5. Select the radio button for the applicable Time Search Option and click OK.
Note: The items in the Summary Viewing Options area have no bearing on the
default display.
6. In the Result Viewing area, complete the following fields:
•
Symbol for comments: This field has no bearing on the Lab module.
•
Show abnormals using: This field has no bearing on the Lab module.
•
Number of results to display: Select the number of results to be displayed in
the Lab module.
•
Open result view: Select the desired view for the results. Options include
vertically and horizontally.
7. Click Show Reference Ranges and Units to display units upon opening the Lab
module.
8. Click OK.
18.4 Viewing Lab Results
Once the search criteria have been defined, the lab test results are displayed.
Figure 18–7: Lab Test Results
18-4
CHCS II User’s Manual
Block 1
Build 838
Laboratory
Select the desired test data to be viewed by selecting the test name. The data is displayed in the bottom of the Lab module. The Lab Result Profile area can be changed
according to individual preference.
•
Display All Test Results: Click Select All Results to view all test result data in
the test viewing area simultaneously.
•
Ref Range/Units: Select the check box to view the CHCS II normal range and
unit for each test.
•
Change Viewing Format: The layout of the results can either be seen vertically
or horizontally. Select the appropriate radio button.
•
Legend: Click Legend to view the codes used in the test results.
Tip:
To view any
comments
associated with the
result, double-click
on a cell with <o>,
<i>, <r>, or <a> to
view the order
comments,
interpretations,
results comments,
and amendments.
Note: Lab results cannot be printed directly from the Lab module. In order to print
lab results, you must first copy the lab result to a note and then print it as part
of a current encounter, or print the lab results from the Flowsheets module.
18.5 Viewing Sensitive Lab Results
Sensitive lab results are displayed with asterisks. Remaining columns are viewed as
normal. You must have “break the glass” privileges to view sensitive lab results.
Follow the steps below to view sensitive results:
1. Double-click the result. A security message is displayed stating that all further
actions are audited. If you do not have sufficient security privileges, a security
message is displayed and you cannot proceed.
Figure 18–8: Security Warning
2. Click Yes to continue. The sensitive lab results are displayed in the bottom portion
of the workspace.
18.6 Copying Lab Results to a Note
Details of a lab result can be copied to the clipboard or copied and placed directly into
the S/O portion of the current patient encounter summary.
Follow the steps below to copy lab results to a note:
1. Select the desired result so the details are in the bottom of the Lab module.
Block 1
Build 838
CHCS II User’s Manual
18-5
Laboratory
Tip:
To select the results,
click inside the top,
left box. Continue
holding down the
mouse button and
drag the mouse to
the lower-right
corner.
Figure 18–9: Lab Results Window (Copy Lab Results)
2. Select the result(s) you want to copy.
3. Perform a right-mouse click, then select either:
•
Copy: Copies the selection on the clipboard so it can be used in another location.
•
Copy to Note: Copies the details directly into the S/O portion of the current
patient encounter summary.
Note: You must open an encounter to use the Copy to Note function. The result is
pasted directly into the patient encounter. Once copied, the results cannot be
deleted from the note, so ensure that you only select the Copy to Note option
once, to avoid duplication.
Note: After you copy lab results into a note, you can print the lab results as part of
an encounter by printing the electronic SF600.
18.7 Printing Lab Results
Lab results cannot be printed directly from the Lab module. Lab results can only be
printed from the electronic SF600 as part of a current encounter after you copy the lab
results to a note or lab results can be printed from the Flowsheets module.
18-6
CHCS II User’s Manual
Block 1
Build 838
19.0 LIST MANAGEMENT
19.1 List Management Overview
The List Management module allows you to create and manage various lists within
CHCS II. These lists include Diagnoses, Procedures, and Complaints. The customized
lists are available within various modules to streamline the documentation process.
Figure 19–1: Military Clinical Desktop—List Management Module
19.1.1
In More Depth
Diagnoses and Procedures can be added to a user favorite list and all three items,
including Complaints can be added as clinic favorites. When creating each list, the
List Management module searches the MEDCIN nomenclature. The same nomenclature that is used in the Screening, S/O, A/P, Disposition, Problems, and Template
Management modules. Because it uses the same organization of clinical findings,
these lists are available in multiple modules.
Diagnoses:
•
A/P module, Diagnosis tab
•
Problems module, when adding a problem or Family History
Procedures:
•
A/P module, Procedures tab
•
Problems module, when adding a historical procedure
Block 1
Build 838
CHCS II User’s Manual
19-1
List Management
Complaints:
•
Screening module
The creation of personal and clinic favorites lists can reduced the amount of time
spent searching for common diagnoses, procedures, and complaints. You must have
the appropriate privileges to add to or remove from a clinic list.
The personal favorites lists can be created in the A/P and Problems modules as well.
Look for the Add to Favorite List button on the Diagnosis and Procedure tabs in the
A/P module. In the Problems module, look for the Add to User Favorites checkbox
when adding problems, historical procedures, or family history.
Once the personal favorites list is created, it is saved with your profile so your list is
available from any computer in your clinic.
19.2 Adding an Item to a Favorites List
Follow the steps below to add an item to a Favorites List:
1. Select the list to which you want to add an item (i.e., My Diagnoses). The Add
icon is not active until you select a list heading.
2. Click Add on the Action bar. The Select Diagnosis window opens.
Note: The title of the window changes, depending on the type of list you have
selected to add (such as diagnosis, procedure, clinic, user).
Figure 19–2: Select Diagnosis to Add to Clinic List Window
3. Enter search criteria.
19-2
CHCS II User’s Manual
Block 1
Build 838
List Management
4. Click Search. The bottom of the window populates with items matching the
search criteria.
5. Select the item to be added.
6. Click OK. The new item is added on the List Management module.
Note: Each item is added to your list with its associated ICD or CPT code.
19.3 Deleting an Item From a Favorites List
Follow the steps below to delete an item from a Favorites List:
1. Select the item you want to delete from the Favorites List.
2. Click Delete on the Action bar.
19.4 Changing Location of Items on a List
Follow the steps below to change the location of an item on a list:
1. Select the item to want to relocate.
2. Click Move Down or Move Up until the item is where you want it.
Block 1
Build 838
CHCS II User’s Manual
Tip:
Organize your list for
easy selection; most
common to least
common, or
alphabetical.
19-3
List Management
19-4
CHCS II User’s Manual
Block 1
Build 838
20.0 MEDICATIONS
20.1 Medications Overview
The Medications module lists the patient's past and present medications. The list
includes over-the-counter (OTC), outside, and CHCS II-ordered medications. Current
medications can be viewed, re-ordered, or modified and new medications can be
added and ordered. Only OTC/Outside medications can be documented without an
open encounter. A current encounter must be open in order to re-order, modify, or
order new medications.
Figure 20–1: Military Clinical Desktop—Medication Module
20.1.1
In More Depth
Typically, a medication is ordered through the A/P module and is sent to CHCS for
processing. Once the prescription has been filled in the pharmacy, the medication is
displayed in the Medication module in CHCS II.
Information available for each entry includes the SIG, quantity, refills, days supply,
dispensing location, clinic, status of the prescription, order information, and ordering
end user.
The default list of medications includes outpatient current medications for patients
with an appointment classification of Outpatient. When the Medications module is
opened for a patient whose classification is Inpatient, the default filter is Inpatient
Current.
Block 1
Build 838
CHCS II User’s Manual
20-1
Medications
In the list of medications, active medications appear in bold text and inactive medications appear in regular text. Those medications that were added as an OTC/Outside
medication will have a check in the OTC column.
20.2 Setting the Filter of the Medications Module
The default filter, either Outpatient Current or Inpatient Current, can be changed. The
Properties window in the Medications module contains the Default Filter drop-down
list. The Default Filter is used to set the default Search Filter in the Medications module.
Follow the steps below to change the filter:
1. Click Options on the Medications module. The Properties window opens.
Figure 20–2: Properties Window
2. Select the desired filter from the Default Filter drop-down list.
Figure 20–3: Default Filter Drop‐Down List
3. Click OK. The list of medications is refreshed based on the selected filter.
20.3 Documenting an OTC/Outside Medication
An OTC/Outside medication can be documented in the Medications module. Medications added as an OTC/Outside medication are not considered during the pre-verify
process that occurs when a medication is ordered. There are no drug-drug, drugallergy, or duplicate order warnings based on these documented medications.
20-2
CHCS II User’s Manual
Block 1
Build 838
Medications
Follow the steps below to document an OTC/Outside medication:
1. Click Add on the Action bar. The Select Type of New Medication window opens.
Note: In order to add new medications, an encounter must be open and the filter
must be set to Outpatient Current.
Figure 20–4: Select Type of New Medication Window
2. Click Record OTC/Outside Medication. The New OTC/Outside Medication
pane opens at the bottom of the workspace.
Figure 20–5: New OTC/Outside Medications Window
3. Click Medications to search for and locate the medication.
4. Enter the name of the medication and click Search.
5. Select the correct medication and click OK.
6. On the New OTC/Outside Medication window, complete the following fields:
•
Sig: free text field
•
Ordering Provider: free text field
•
Order Start Date: Click Order Start Date to enter the correct date using the
calendar or enter the date directly in the Start Date field.
•
Comment
7. Click OK. The OTC is added to the patient’s medication list.
Block 1
Build 838
CHCS II User’s Manual
20-3
Medications
20.4 Ordering a New Medication
Tip:
To add a new
medication, you
must set the filter to
Outpatient Current.
Medications can be ordered directly from the Medications module if an encounter is
open.
Follow the steps below to order a new medication:
1. Open the appropriate encounter.
2. In the Medications module, click Add on the Action bar. The Select Type of New
Medication window opens.
Figure 20–6: Select Type of New Medication Window
3. Click Order Medication. The New Order window displays at the bottom of the
workspace.
Figure 20–7: Order Entry Medications Window
4. Enter the name of the medication in the Search field and click Search.
5. Select the medication from the results displayed in the Item Name field.
6. Complete the following fields:
20-4
CHCS II User’s Manual
Block 1
Build 838
Medications
•
SIG
Note: If a CHCS sig exists for the selected medication, it auto-populates this field.
The SIG can be edited and changed.
•
Quantity
•
Refills
•
Start Date
•
Child Resistant Cap
•
Comment
•
Expanded SIG
•
Requesting Location
•
Dispensing Location
•
Ordering Provider
7. When all the necessary information has been added, click Submit. The ordered
medication displays on the medication list once it has been filled by the pharmacy.
Note: CHCS pre-verifies the order against patient and medication records and displays any resulting messages or warnings, as well as any SIG code(s) and
standard order/refill quantities associated with the medication. Warnings
include duplicate orders and drug–drug and drug–allergy interactions. To
override a warning in the Warnings window, enter a reason for the override
and click Accept Override. To ignore the warning override, click Cancel
Order.
20.5 Reviewing a Medication
Follow the steps below to review a medication:
1. Select the medication you want to review.
2. Click Details on the Action bar. The Details window opens and is read-only.
Block 1
Build 838
CHCS II User’s Manual
20-5
Medications
Figure 20–8: Details Window
3. Click Close Detail.
Tip:
You can still view
information for a
discontinued
medication by setting
up a filter that
displays
discontinued
medications.
20.6 Discontinuing a Medication
Both ordered and OTC/Outside medications can be discontinued from the Medications module. An encounter must be open, though, to discontinue an ordered medication.
Follow the steps below to discontinue a medication:
1. Select the medication to be discontinued.
2. Click Discontinue on the Action bar.
Note: There is no confirmation message when discontinuing an ordered medication.
3. At the Inactive Medications confirmation prompt, for an OTC/Outside medication, click OK.
Note: There is no confirmation message when discontinuing an ordered medication.
A message is displayed stating that the medication has been successfully discontinued.
20.7 Renewing a Medication
When the renew action is taken from the Medication module, the system automatically brings up the Order Entry Medication window. This function is only available
for prescriptions that were originally ordered through the pharmacy and if an encounter is open.
20-6
CHCS II User’s Manual
Block 1
Build 838
Medications
Follow the steps below to renew a medication:
1. Select the medication to be renewed.
2. Click Renew on the Action bar. The Order Entry Medication window opens.
Figure 20–9: Order Entry Medication Window
3. Change the SIG, Quantity or Refills, as appropriate.
4. Click Submit.
Block 1
Build 838
CHCS II User’s Manual
20-7
Medications
20-8
CHCS II User’s Manual
Block 1
Build 838
21.0 NEW RESULTS
21.1 New Results Overview
The New Results module displays a list of completed radiology procedures and laboratory tests. Once a procedure or test is filed and certified in CHCS, the order is displayed in the New Results module, allowing you to keep track of orders you have
placed. You can either view a high level summary or detailed result information for a
specific order. New Results can be viewed, discarded, tossed after viewing, forwarded
to another Provider, or saved within the New Results module.
Figure 21–1: Military Clinical Desktop—New Results Module
21.1.1
In More Depth
Typically, a lab test or radiology procedure is ordered in the A/P module of CHCS II
and is sent to CHCS for processing. Once the procedure or test is filed and certified,
the results are sent to the CDR, an Alert icon shows up in CHCS II, and the result
appears in the New Results module, as well as either the Lab or Radiology module.
Block 1
Build 838
CHCS II User’s Manual
21-1
New Results
An electronic signature is generated when certain actions are performed in the New
Results module. The following table illustrates the electronic signature process:
Table 1:
CHCS II New Results
Action
Electronic
Signature
Generated?
CHCS Reaction
View new lab or rad
result
New result displayed, but not
reviewed
No
View new lab or rad
result and toss result
after viewing
New result reviewed
Yes
Discard new lab or rad
result
Result removed from Review
New Results screen
No
View and save new lab
or rad result
New result reviewed
Yes
Forward new lab or rad
result to another
Provider that has not
been saved
New result forwarded to
another Provider’s New List of
Results or sent as mail
No
In the summary view, critical results appear in red and results that are normal or have
minor abnormalities appear in black.
There are two tabs that make up the New Results module: New Results and Saved
Results. The New Results lists all of the results that have been filed and certified in
CHCS. The Saved Results tab lists those results that have been saved from the New
Results tab.
21.2 Viewing New Results
The New Results module allows you to view detailed information for a selected result.
The New Results module interfaces with the Lab and Radiology modules when viewing detailed result information, depending on the selected result.
Follow the steps below to view results:
1. On the New Results tab, select the result you want to view.
2. Click View Result on the Action bar.
3. View the result in the Lab or Radiology module.
4. When you are finished viewing the detailed result information, close the Lab or
Radiology module to return to the New Results module.
21-2
CHCS II User’s Manual
Block 1
Build 838
New Results
21.3 Discarding New Results
The New Results module allows you to discard selected results. You can discard
results without viewing them (i.e., the result appears in your New Results list, but the
result was forwarded to you for a patient from another Provider).
Follow the steps below to discard results:
1. On the New Results tab, select the result you want to discard.
2. Click Discard on the Action bar.
3. At the discard confirmation prompt, click Yes.
Figure 21–2: Discard Prompt Window
21.4 Saving New Results
The New Results module allows you to save selected results. Saving a new result
removes it from the New Results tab and displays it on the Saved Results tab. You
must first view the result before you can save it.
Follow the steps below to save results:
1. On the New Results tab, select the result you want to save.
2. Click Save on the Action bar.
3. At the save confirmation prompt, click Yes.
Figure 21–3: Save New Results Prompt
4. View the result on the Saved Results tab.
Block 1
Build 838
CHCS II User’s Manual
21-3
New Results
Figure 21–4: Saved Results Tab
Note: Click New on the Action bar to move the results back to the New Results tab.
At the confirmation prompt, click Yes.
21.5 Forwarding New Results
The New Results module allows you to forward new results to other Providers. When
you forward a result to another Provider, a copy of the result is made and added to the
forwarding Provider’s New Results list. A Provider can only have a single copy of the
result. If you forward a saved result to a Provider, the result displays in the forwarding
Provider’s New Results list.
Follow the steps below to forward a new result to a Provider:
1. Click Provider Search to locate the Provider to whom you are forwarding the
new result.
21-4
CHCS II User’s Manual
Block 1
Build 838
New Results
Figure 21–5: Clinician Search Window
2. In the Last Name field, enter the last name of the desired clinician.
3. Select a facility from the drop-down list.
4. Select a clinic from the drop-down list.
5. Click the Find only clinicians who have login accounts on this system to view
only Providers associated with CHCS II.
6. Click Find. The results are displayed in the bottom half of the Clinician Search
window.
7. Select the desired clinician.
8. Click Select.
9. On the New Results tab, select the result you want to forward.
10. Click Forward on the Action bar.
11. At the forward confirmation prompt, click Yes.
Figure 21–6: Forward Confirmation Prompt Window
Block 1
Build 838
CHCS II User’s Manual
21-5
New Results
21.6 Tossing New Results
The New Results module allows you to remove new results from the New Result list.
You cannot toss a result that has not been viewed. If the result is on the Saved Results
list, it has already been viewed and therefore can be tossed.
Follow the steps below to toss results:
1. On the New Results tab or Saved Results tab, select the result you want to toss.
2. Click Toss on the Action bar.
3. At the toss confirmation prompt, click Yes.
Figure 21–7: Toss New Results Prompt Window
21-6
CHCS II User’s Manual
Block 1
Build 838
22.0 ORDER SETS
22.1 Order Sets Overview
Order sets are templates of laboratory, radiology, or medication orders that streamline
the ordering process. Order sets are created and saved as encounter templates and can
be managed in the Template Management module. Once an order set has been created,
it can be included in encounter templates.
22.1.1
In More Depth
Order sets can be created and organized in a variety of ways. Some users create order
sets based on a specific diagnosis; diabetes, for example. Others create an order set
template that includes the top twenty lab, radiology, and medication orders. This
encounter template is then merged with disease- or symptom-specific encounter templates.
22.2 Creating an Order Set from A/P
Building an order set is not an intuitive process and must be done inside an open
encounter. The best method is to use the A/P module to locate and save orders as part
of an order set. Although orders should not be submitted as part of this process, it is
best to be safe and create an appointment for a test patient in the test clinic.
Follow the steps below to create an order set from A/P:
1. In the A/P module, begin on one of the Order Entry tabs (Labs, Rads, or Meds).
2. Locate the first order you want to include in the order set.
3. When you have located the order, click Save to Queue. This saves the order without submitting it.
4. Continue with all three tabs, as appropriate, locating individual orders and clicking Save to Queue.
Tip:
Once an order has
been submitted, it
cannot be included in
an order set. Orders
must be located and
then Saved to
Queue.
Note: For Med and Rad orders, the SIG and clinical impression is used as the default
for those orders. These can be changed when using the order set in an actual
encounter.
5. Once you have finished locating the orders you want to include in your order set,
click the Order Set tab to display the orders that have been saved to queue.
Block 1
Build 838
CHCS II User’s Manual
22-1
Order Sets
Figure 22–1: Order Sets Tab
6. Click Save as Order Set.
7. In the Save Encounter Template window Template Name field, enter the template
name you want to use for the order set.
8. Click Save to save the order set. The order set encounter template can now be
merged with other encounter templates and/or accessed in the Template Management and A/P modules.
22.2.1
Adding Orders to an Existing Encounter Template
An order set can also be saved as part of an encounter template that has already been
built.
Follow the steps below to add orders to an existing template:
1. Locate your order(s) and save them to queue, following steps 1 - 4 above.
2. Once you have finished locating the order(s) you want to include in your order set,
click the Order Set tab to display the orders that have been saved to queue.
Figure 22–2: A/P Order Sets Tab
3. Click Save as Order Set.
4. In the Save Encounter Template window, select the encounter template to add to
and click Save.
22-2
CHCS II User’s Manual
Block 1
Build 838
Order Sets
Figure 22–3: Save Encounter Template Window
5. A pop-up window opens asking if you want to Replace or Add To the existing
template. Click Add To. The selected order(s) is(are) added to the existing template and can be viewed in the Template Management module or within A/P when
the template is loaded.
Figure 22–4: Template Name Option Box
22.3 Using an Order Set in A/P
Since an order set is considered an encounter template, you must select and load the
Encounter template into the A/P module in order to view and use the associated order
set.
Follow the steps below to load and use an order set:
1. Click the Order Sets tab.
2. If an encounter template with orders has not been loaded, use the template dropdown list to select the appropriate template. The orders associated with the
Encounter template are available.
Figure 22–5: A/P Order Sets Tab
Block 1
Build 838
CHCS II User’s Manual
22-3
Order Sets
3. Do one of the following:
•
If you want to select and submit all orders with no modifications, click Select
All.
•
If you want to select specific orders, click the checkbox in the Select column
next to each applicable order.
Note: You can also click the checkbox in the Modify column next to each applicable
order. Clicking a checkbox in the Modify column automatically puts a checkmark in the checkbox in the Select column.
4. Click Submit.
Note: Orders that were selected but not modified are sent out automatically. For
orders needing modification, the appropriate order entry module opens. Make
the desired modifications and click Submit on the order entry module.
22-4
CHCS II User’s Manual
Block 1
Build 838
23.0 PATIENT ENCOUNTER
23.1 Patient Encounter Overview
The CHCS II encounter document design is based on, and replaces, the SF600. Therefore, this module is commonly referred to as the electronic SF600. As the patient
progresses through the clinic workflow and as clinical team members document the
encounter, the Patient Encounter module collects and displays all of the documentation from each team member. It also contains buttons that correspond to each of the
different sections of the entire note. This makes for easy navigation to the various
modules that are used to document the encounter.
Figure 23–1: Military Clinical Desktop—Encounter Summary
23.1.1
In More Depth
The encounter document is the central interface for documenting the patient encounter, including documenting the S/O portion, performing the assessment and plan,
recording the patient disposition and signing the encounter.
At the top of the Patient Encounter module is the AutoCite area. This customizable
area contains patient information that is already known about the patient. Information
is pulled from various CHCS II modules, including Allergies, Problems, Medications,
Vital Signs and the result retrieval modules.
The encounter document workspace has a row of buttons along the left margin and the
text display area to the right. The buttons are used to access the different modules
within the encounter both to enter new information and review and/or edit current
Block 1
Build 838
CHCS II User’s Manual
23-1
Patient Encounter
information. Modules accessible from this area include Screening, Vitals, S/O, A/P,
and Disposition.
As data is entered into each of these modules, it displays in note form in the related
workspace once the entry module is closed. When you have completed the encounter,
this encounter document displays all the information documented for the patient visit.
This workspace design and application functionality support team-based care and the
clinic workflow. Multiple individuals can work within one encounter at the same time.
The system places time, date, and name stamps on each entry added to the encounter
note.
Once the support staff, nurse, and provider gather all the information, the encounter is
signed by the provider assigned to the encounter when the appointment was made.
23.1.2
Setting the Properties of the Patient Encounter Module
In the Patient Encounter module, the Signature Block and the items in AutoCite can be
customized. Once set, these configurations become the default for every encounter
you open.
Follow the steps below to set the properties of the Patient Encounter module:
1. Click Options in the top, right corner of the Patient Encounter module. The
Encounter Summary Properties window opens.
Figure 23–2: Encounter Summary Properties Window
2. In the Signature Block, enter the text you want for lines 2 and 3.
Note: Line 1 defaults to you and cannot be changed.
23-2
CHCS II User’s Manual
Block 1
Build 838
Patient Encounter
3. If you need a co-signer for every encounter you sign, click Search to assign a
default co-signer. The Clinician Search window opens allowing you to search for
a provider to select as a co-signer.
Note: With a default co-signer selected, each time you sign an encounter, an alert is
triggered for the co-signing provider.
4. In the AutoCite Preferences area, click the check box next to the items you want
to AutoCite. A check denotes the selected items.
•
Active Problems, Allergies, Active Medications, Active Family History,
Questionnaire, Expired Medications: Click the checkboxes to AutoCite the
patient's information. The AutoCited information is pulled from the Problems,
Medications, Allergy, and Patient Questionnaire modules.
•
Vitals, Labs, Rads: Select the checkboxes to AutoCite the patient's information. In the Last field, enter a numerical value and select the radio button to
select the time setting.
•
A/P Active Order Default: Select the checkbox(es) if you want to display
active medication, laboratory, or radiology orders when opening order entry
tabs.
•
Autosave S/O: Enter a numeric value to denote the frequency of the autosave.
The system saves the Form Tool or List Tool Notes according to this setting.
5. In the Disposition Follow Up Discussed with Default area, click the drop-down
list and select the person with whom the disposition follow up is discussed.
6. Select the Auto-Print checkbox to auto-print.
7. Select the Auto-save S/O checkbox to have the encounter automatically save S/O
at designated intervals. Click in the Min checkbox and enter the time.
Note: When vitals, labs, or rads are selected to AutoCite, additional fields become
active. In the Number field, enter the desired number and then select the
appropriate radio button. The system AutoCites vitals, labs, and rads according to these settings.
Tip:
For efficient system
performance, it is
recommended to
only select those
items that are
needed for every
encounter. CHCS II
pulls this information
from the CDR and
large amounts of
data could delay this
process.
8. Click OK. The settings are saved.
23.2 Adding a Note
You can add a note to the Encounter Document. This narrative appears in the note section of the Patient Encounter module with the Time, Date, and user name next to the
narration.
Follow the steps below to add a note:
1. On the Patient Encounter module, click Add Note on the Action bar. The Select
Note window opens.
Block 1
Build 838
CHCS II User’s Manual
23-3
Patient Encounter
Figure 23–3: Select Note Window
2. Click New Note to begin a new note. The Encounter Note window opens, allowing you to add notes to any phase of the encounter.
Figure 23–4: Encounter Note Window
3. Enter a Note Category, if necessary.
4. Enter a Note Title, if necessary.
5. Enter a note in the text box.
6. Do one of the following:
23-4
CHCS II User’s Manual
Block 1
Build 838
Patient Encounter
•
If you want to insert a file into the note:
a. Click Load File.
b. Select the desired file to be added.
c. On the Select Destination File window, click Open.
Note: Graphics that are imported must be 500K or less.
•
If you want to print the note for your hardcopy records, click Print.
7. Click Note Complete. The note appears in the encounter document.
Note: Click Save Draft to save the note as a draft. The note is displayed on the
Patient Encounter module in the Note section as a draft. The encounter cannot
be signed if a note exists in draft form.
23.3 Deleting a Note
Follow the steps below to delete a patient encounter note:
1. On the Patient Encounter module, click Add Note on the Action bar. The Select
Note window opens.
Figure 23–5: Select Note Window (With Data)
2. Select the note you want to delete.
3. Click Delete.
4. Click Yes. The Confirm Deletion of Note message appears.
23.4 Editing a Note
Follow the steps below to edit a note:
1. On the Patient Encounter module, click Add Note on the Action bar. The Select
Note window opens.
2. Select the note you want to edit.
3. Click Edit Note. The Encounter Note window opens.
Block 1
Build 838
CHCS II User’s Manual
23-5
Patient Encounter
Figure 23–6: Encounter Note Window (Edit Mode)
4. Make the applicable edits to the note.
5. Click Note Complete.
Note: If the note you are editing has been created by another person, a message
prompt appears asking if you want to create a note starting with the contents
of the note you selected—click Yes to use the contents of the selected note, or
No to create a note with no previous contents.
23.5 Adding an Additional Provider
An additional provider can be added to an encounter to receive credit for work performed on a patient.
Follow the steps below to add an additional provider:
1. On the Action bar, click Add Providers. The Provider and Roles window is displayed.
23-6
CHCS II User’s Manual
Block 1
Build 838
Patient Encounter
Figure 23–7: Providers and Roles Window
2. Select the type of clinician you want to add.
3. In the Additional Provider #1 area, click the ellipsis button to search for a provider. The Clinician Search window opens.
Figure 23–8: Clinician Search Window
4. In the Last Name field, enter the last name of the desired clinician.
5. Select a facility from the drop-down list.
6. Select a clinic from the drop-down list.
7. Click the Find only clinicians who have login accounts on this system to view
only providers associated with CHCS II.
8. Click Find. The results are displayed in the bottom half of the Clinician Search
window.
9. Select the desired clinician.
10. Click Select. The name populates in the Additional Provider field on the Provider and Roles window.
Block 1
Build 838
CHCS II User’s Manual
23-7
Patient Encounter
11. Click the Role drop-down list to select the additional provider’s role.
Note: Repeat steps 2-11 if you want to add a second additional clinician.
12. Click OK. The clinician(s) is(are) added to the appointment.
23.6 Loading an Encounter Template
An Encounter Template can be selected and loaded into an encounter. The Encounter
Template contains diagnoses, procedures, S/O templates, orders, and patient instructions. Encounter templates are typically loaded directly through the S/O or A/P modules to streamline the documentation process.
Follow the steps below to select an encounter template:
1. On the Patient Encounter module, click Templates on the Action bar. The Template Selections tab opens within the Template Management module.
Figure 23–9: Template Management Window—Template Selections Tab
2. Locate the template using on of the following methods:
•
Expand the My Favorites, Clinic, MTF, or Enterprise Folders.
•
Conduct a search for the template.
•
Enter the name of the template in the Name Search field and click Find
Now. The search results display in the Name Search Results Folder.
3. Select the template.
23-8
CHCS II User’s Manual
Block 1
Build 838
Patient Encounter
4. Click Add. The template is moved to the Selected Templates List.
Note: More than one template can be added to the encounter.
5. Click OK to load the template(s) in the encounter. The Patient Encounter module
opens with the embedded template(s).
Note: The template details are displayed within the S/O (Notes template) and A/P
(Diagnoses, Procedures, Orders, and Patient Instructions) modules.
23.7 Signing the Encounter Overview
When the provider is satisfied that the encounter is complete, the final step in the
encounter process is to sign the encounter. The primary provider performing the
encounter documentation must sign the encounter.
23.7.1
Requirements for Signing an Encounter
If an encounter is incomplete, the Encounter is not Complete window opens explaining which sections are incomplete. The primary provider has the option to return to the
current encounter to complete it.
Figure 23–10: Encounter is not Complete Window
To be complete, an encounter must contain the following:
•
At least one diagnosis
•
Disposition
•
E&M code
In addition, a note or consult cannot be in draft form. If the encounter is marked as
related to an Injury/Accident an E-code (diagnosis) must be included as a diagnosis.
Follow the steps below to sign the encounter:
1. Click Sign on the Action bar. The Sign Encounter window opens.
Block 1
Build 838
CHCS II User’s Manual
23-9
Patient Encounter
Figure 23–11: Sign Encounter Window
2. In the Enter Your Password field, enter your password.
3. Do one of the following:
•
If you do not want to auto-print the signed encounter, deselect the Auto-Print
checkbox. The system defaults to print the encounter summary.
•
If a co-signer is required:
a. Click the Co-Signer Required checkbox.
b. Click Search. The Clinician Search window opens.
c. Search for the clinician you want to designate as a co-signer.
•
If you want to mark the encounter as sensitive, click the Sensitive checkbox.
The system marks the encounter as sensitive.
Note: When opening the Previous Encounters module that contains a sensitive
encounter, asterisks display in place of the sensitive data. The provider must
have “break the glass” privileges to view the data.
4. Click Sign to sign the encounter.
Note: Only the provider who was assigned the appointment can sign the encounter.
Other Clinical Team Members can add to the encounter but cannot sign it.
23-10
CHCS II User’s Manual
Block 1
Build 838
Patient Encounter
23.8 Saving an Encounter as a Template
After an encounter has been documented, the structure and orders can be saved as an
encounter template. No patient-specific information is saved. This action can be performed from the Patient Encounter and Previous Encounter modules.
Follow the steps below to save an encounter as a template:
1. Document the encounter.
2. On the Action bar, click Save As Template. The Template Details tab on the Template Management module opens. Details from the selected encounter display in
their appropriate sections.
Figure 23–12: Template Management Window—Template Details Tab
3. Add or remove information from the following areas:
•
Associated Reasons for Visit, Associated Problems, Associated Appointment Types: These three areas are rarely used within CHCS II. These areas
determine those templates that the system suggests when you go to load a
template.
•
Items to AutoCite into Note:
•
Block 1
Build 838
•
Click Add.
•
Select an AutoCite selection from the list and click Add Items.
•
Click Done to return to the Template Details tab.
Diagnoses, Other Therapies, Procedures:
•
Click Add next to the appropriate section.
•
In the Search Term field, enter the first few letters of the procedure and
click Search.
CHCS II User’s Manual
23-11
Patient Encounter
•
•
Select the item from the search results and click Add Items.
•
Click Done to return to the Template Details tab.
Notes Templates:
•
Click Add.
•
Click Search to open the List Note Template Search window.
•
Enter search criteria in the window and click Search.
•
Select the note template and click Add Items.
•
Click Done to return to the Template Details tab.
4. Click Save As on the Action bar. The Save Encounter Template window opens.
Figure 23–13: Save Encounter Template Window
5. Select the template type from the Save-in drop-down list.
6. In the Template Name field, enter the template name.
7. Select the Specialty from the drop-down list.
8. Click the checkboxes to denote whether the template should be added to your
Favorites List or shared with other Clinical Team Members.
9. Click Save.
23.9 Unlocking an Encounter
More than one clinical team member can view and document a patient's record at the
same time. The S/O Note is the only module of the current encounter that can be documented concurrently. If this is the case, both S/O notes are saved to the patient
encounter. Only the primary provider can sign the encounter. The primary provider is
the provider who owns the appointment.
23-12
CHCS II User’s Manual
Block 1
Build 838
Patient Encounter
23.9.1
Two Providers Accessing the Same Module
Two providers cannot document the A/P or the Disposition at the same time. If this
occurs, a provider can take the section from the original provider. For example, if one
provider is documenting A/P and a second provider accesses the A/P module, a message window appears, stating that A/P is being used and asks whether to break the
lock. If the lock is broken, the second provider can document A/P. The original provider is informed upon saving A/P that this section was taken and no information from
that section can be saved.
Figure 23–14: Encounter Section Ownership Window
23.9.2
Second Provider Changing First Provider's Information
A second provider can go behind the original provider and change the A/P or Disposition section of the encounter. When this occurs, the documentation done by the original provider is saved in the Notes section of the encounter under the heading of
Change History.
Block 1
Build 838
CHCS II User’s Manual
23-13
Patient Encounter
23-14
CHCS II User’s Manual
Block 1
Build 838
24.0 PATIENT IMMUNIZATIONS
24.1 Patient Immunizations Overview
The Immunizations Module is used to manage and track patient immunization records
and vaccine history. The Immunizations module contains two tabs: Individual Immunizations and Vaccine History. The Immunization module is patient-specific; therefore, a patient's record must be loaded to the desktop to access this module.
Figure 24–1: Military Clinical Desktop—Patient Immunizations Module
24.1.1
In More Depth
Active duty service personnel have a required set of immunizations that must be
administered in order for the service member to be eligible for duty either in the
United States or overseas. These immunizations can be administered at any DoD
clinic and the immunization data must be updated.
The Individual Immunizations tab is used to select and administer vaccines to a
patient and allows you to view immunization information. A color status indicator is
used to quickly confirm immunizations that are current and those that are overdue per
the established vaccine schedules for the individual vaccinations. The patient’s allergy
information is displayed as read-only data. The Vaccine History tab is used to add a
vaccination to the patient's record, edit an immunization history, or delete an immunization history.
Block 1
Build 838
CHCS II User’s Manual
24-1
Patient Immunizations
The recommended workflow for documenting CHCS II encounters in the Immunizations Clinic is as follows. Some of the steps may not be applicable based on each
clinic’s established business processes:
•
Create a new walk-in appointment
•
Open the appointment
•
Document screening and verify allergies
•
Document vital signs
•
Administer immunization(s) to patient and document in CHCS II
•
Print DD 2766C for the patient chart
•
Document appropriate diagnostic and procedural codes in A/P module
•
Document disposition
•
Sign encounter
The DD Form 2766C in CHCS II is the Vaccine Administration Record. This form
contains the same information as the SF 601 currently used in Immunizations clinics.
For this reason, it is recommended that after the vaccinations have been documented
in CHCS II, the end user should print the DD 2766C and place it in the patient’s chart.
It is not necessary to print the SF 600 for the patient’s chart.
In the A/P module, a diagnosis and procedure code should be selected for each vaccine administered to the patient.
Note: A default encounter template should be created for use by the entire clinic
staff to streamline the documentation process. The encounter template should
contain all of the diagnostic and procedural codes used in the Immunizations
clinic. The encounter template can also contain a S/O visit template to document the reason for visit as immunization.
If multiple vaccines are given for a single diagnosis, the appropriate procedure code
for the first vaccine given should be associated to the diagnosis. The appropriate procedure code for each additional vaccine given should also be associated to the diagnosis. When administering multiple vaccinations, the users should use CPT multipliers
to accurately document vaccines and generate accurate workload credit for the clinic.
24.2 Adding a Vaccination
Vaccinations can be added to a patient’s record.
Follow the steps below to add a vaccination:
1. Click the Vaccine History tab on the Immunizations module. The Vaccine History
tab displays.
24-2
CHCS II User’s Manual
Block 1
Build 838
Patient Immunizations
Figure 24–2: Immunizations module—Vaccine History Tab
2. Click Add. The Vaccines window opens.
Figure 24–3: Vaccines Window
3. Select the vaccine you want to add.
Note: Click the List All Immunizations checkbox to view a list of all vaccines in
stock. All vaccines in stock appear on the list. Click Edit List to edit the list
of favorite vaccines. On the Edit Favorite Vaccine List window, select a vaccine from the All Vaccines list and click the right arrow to move the vaccine
to the Selected Vaccines list. Click Close.
4. Click Select. The Add Vaccine window opens.
Block 1
Build 838
CHCS II User’s Manual
24-3
Patient Immunizations
Figure 24–4: Add Vaccine Window
5. Complete the following fields:
•
Vacc Date: Enter a date, or click the ellipsis button and select a date from the
calendar, to assign a vaccination date.
•
Series Number: Enter the series number of the vaccine, if necessary.
•
Manufacturer: Select a manufacturer from the drop-down list, if necessary.
•
Lot Number: Enter the lot number of the vaccine, if necessary.
•
Dosage: Select a dosage for the vaccine from the drop-down list, if necessary.
•
Site: Select an area of the body where the vaccine is given from the dropdown list, if necessary.
•
Route: Select the vaccine route from the drop-down list, if necessary.
•
Next Vaccination Due: Click Recalc to automatically calculate the next vaccination due date. The date is automatically entered.
•
Exempt: Select an exemption from the drop-down list, if necessary.
•
Provider: Select a provider from the drop-down list, if necessary.
Note: The Immunization Provider selected from the drop-down list should be the
clinic team member who actually administered the vaccine(s) to the patient.
6. Click Update to save the data and return to the Vaccine History tab.
24.3 Deleting Immunization History
Follow the steps below to delete an immunization History:
1. Select the immunization you want to delete.
24-4
CHCS II User’s Manual
Block 1
Build 838
Patient Immunizations
2. Click Delete.
Note: You are not deleting the immunization from the patient's records, you are
deleting vaccination history associated with the selected immunization.
24.4 Editing Immunization History
If you note any discrepancies between the patient’s physical immunizations record
and the CHCS II record, you can edit the electronic record to match the physical
record. All new, modified, or deleted immunizations are automatically batch updated
to DEERS. All immunization history data in DEERS for the patient is replaced with
the contents of the database immunization record. This ensures consistent data for
patients across all Services.
Follow the steps below to edit an immunization history:
1. Select the immunization you want to edit.
2. Click Edit. The Immunization History Edit window opens.
Figure 24–5: Immunization History Edit Window
3. Complete the following fields:
•
Series
•
Manufacturer
•
Lot Number
•
Dosage
•
Site
•
Route
Block 1
Build 838
CHCS II User’s Manual
24-5
Patient Immunizations
•
Next Vacc Due
•
Exempt
•
Provider
4. Click Update to save the data and return to the Vaccine History tab.
24.5 Editing Vaccination Groups
All vaccination groups established for service type or occupational status are listed in
the Vaccination Groups field.
The patient receives vaccinations assigned to the selected group(s).
Follow the steps below to edit the Vaccination Groups:
1. Click Edit Groups in the Individual Immunization tab. The Immunization Groups
window opens.
Note: All vaccination groups established for service type or occupation status are
listed in the Immunization Groups list. The vaccination groups assigned to the
unit to which this patient belongs are shown in the Required Groups field.
These groups are assigned in the Unit window, and cannot be edited. Groups
defined by the support staff are listed in the User-Defined Groups field.
Figure 24–6: Immunization Groups Window
2. Select a group name from the Immunization Group or User-Defined Group list.
3. Click the right arrow to move the selected group to the Groups Selected list.
Note: Multiple groups can be selected to appear in the Vaccination Groups list.
4. Click Close. The selected groups appear on the Individual Immunization tab in
the Vaccination Groups list.
24-6
CHCS II User’s Manual
Block 1
Build 838
Patient Immunizations
24.6 Printing Immunization Records
There is an option to print the worksheet and the DD 2766C from the Individual
Immunization window. The report prints to your default printer.
Follow the steps below to print immunization records:
•
Print Worksheet: Use this function to print required immunizations for the
selected patient.
•
Print DD 2766C: Use this function to print a Vaccine Administration Record.
24.7 Reviewing Immunization Records
This area of the Individual Immunization tab displays all immunizations the patient is
required to have based on the vaccination groups to which the patient is assigned.
When immunizations are due, but have not been given, the column under Next Due
displays in red. Once the required immunizations have been given through the Give
VAX function, the column changes to green.
24.8 Selecting an Immunization
Follow the steps below to select an immunization:
1. Click Give Vacc on the Individual Immunizations tab. The Select Immunization
window opens.
Figure 24–7: Select Immunization Window
2. Select an Immunization.
Note: The Immunizations Recommended list is based on the vaccination groups to
which the patient is assigned.The Other Immunizations list is a list of all vaccines.
Block 1
Build 838
CHCS II User’s Manual
24-7
Patient Immunizations
3. Click the right arrow to move the items from the Immunizations Recommended
list or Other Immunizations list to the Immunizations Selected list.
Note: Click the double arrow to move the entire group of Immunizations Recommended to the Immunizations Selected list.
Note: Click the left arrow to remove the selected immunization from the Immunizations Selected list back to the Immunizations Recommended or Other
Immunizations list.
4. Click OK. The Vaccine Select window opens displaying the selected vaccines.
Figure 24–8: Vaccine Select Window
5. Select the vaccine(s).
6. Select the Immunization Provider from the drop-down list.
Note: The Immunization Provider selected from the drop-down list should be the
clinic team member who actually administered the vaccine(s) to the patient.
7. Click OK.
24.9 Selecting the Immunization Exempt Type
Follow the steps below to select the immunization exempt type:
24-8
•
Global: If a patient has never been given any of the immunizations that are listed
in the vaccination record section, he/she can be exempted using this function from
the Individual Immunization tab.
•
Focused: If an exemption has been given for that immunization, the exempt function must be performed from the Vaccine History tab.
CHCS II User’s Manual
Block 1
Build 838
Patient Immunizations
Follow the steps below to make a global exemption for all immunizations in the Individual Immunizations tab:
1. Select an Exempt Type from the drop-down list.
Note: If you select Medical (Temp), Admin (PCS), or Admin (Temp) as an
Exemption Type, an exempt date is required. The system formats that date.
2. Click, Click to Save Exemption.
Follow the steps below to make a focused exemption for a specific vaccination in the
Vaccine History tab:
1. Select the vaccination to be exempted.
2. Click Edit. The Immunization History Edit window opens.
Figure 24–9: Immunization History Edit Window
3. Select the exempt type from the Exempt drop-down list.
Note: Depending on the reason, an exempt date may be required. The system formats the date.
4. Click Update. The Exempt Reason appears on the Vaccine History tab.
Block 1
Build 838
CHCS II User’s Manual
24-9
Patient Immunizations
24-10
CHCS II User’s Manual
Block 1
Build 838
25.0 PATIENT LIST
25.1 Patient List Overview
The Patient List module displays your customized list of patients. You can set up the
patient list to contain patients specific to your caseload. Typically, this module is used
to manage patients frequently seen or patients with common problems. Patient records
can also be accessed from this module.
Figure 25–1: Military Clinical Desktop—Patient List Module
25.2 Adding a Patient Name
If the Patient List module is blank upon opening, no patients have been added.
Follow the steps below to add a patient name:
1. Click My Patient List on the Patient List window.
2. Click Add on the Action bar. The Patient Search window opens.
Block 1
Build 838
CHCS II User’s Manual
25-1
Patient List
Figure 25–2: Patient Search Window
3. Conduct a patient search. The selected patient is displayed in the list.
4. Repeat the process until all desired patient names have been added.
25.3 Deleting a Patient Name
Follow the steps below to delete a patient name:
1. Select the patient name to be deleted from the Patient List module.
2. Click Delete on the Action bar. The Delete patient from list warning window
opens.
3. Click OK. The patient name is deleted from the list.
25.4 Deleting the Entire List of Patients
Follow the steps below to delete the entire patient list:
1. Click Delete List on the Action bar. The Delete All Patients option window displays.
2. Click OK. All patient names are removed from your patient list.
25-2
CHCS II User’s Manual
Block 1
Build 838
26.0 PATIENT QUESTIONNAIRES
26.1 Patient Questionnaires Overview
The Patient Questionnaires module is used to administer questionnaires created in the
Questionnaire Setup module. Patients can complete questionnaires by using a kiosk or
through an interview process with a clinical team member. Patient questionnaires can
be viewed, modified, and/or associated to an encounter.
From CHCS II, the end user is able to quickly navigate to the Patient Questionnaires
module by loading a patient record and clicking Patient Questionnaires in the Folder
List.
A questionnaire can be administered in Single Question or Multiple Question View. In
Single Question View, questions are displayed one at a time as the patient completes
the questionnaire. In Multiple Question View, all questions are displayed in the module as the patient completes the questionnaire.
The current practice for administering patient questionnaires is to interview the patient
and document their responses on the electronic questionnaire in CHCS II. There is
CHCS II functionality that allows the patient to use an assigned PIN to access and
complete a questionnaire using a dedicated kiosk or other display device. Each MTF
will determine how its clinics will use the Patient Questionnaires module to administer patient questionnaires.
26.2 Viewing Questionnaires in an Encounter
Document
Follow the steps below to view a questionnaire in an Encounter document:
1. On the Patient Encounter module, click Options. The Encounter Summary Properties window opens.
2. In the AutoCite preferences area, select the Questionnaires checkbox.
3. Click OK.
26.3 Assigning a Questionnaire to a Patient
Follow the steps below to assign a questionnaire to a patient:
1. Within an open encounter, expand the Health History folder and select Patient
Questionnaires. The Patient Questionnaires module opens.
Block 1
Build 838
CHCS II User’s Manual
26-1
Patient Questionnaires
Figure 26–1: Questionnaire Module
2. Select the questionnaire that you want to assign to the encounter and click Setup
from the Action bar. The Assign PIN for Patient Questionnaire/Test window
opens.
Figure 26–2: Assign PIN for Patient Questionnaire/Test
3. The patients are then supplied with the login credentials that they use at the kiosk
to answer the questionnaire.
26-2
CHCS II User’s Manual
Block 1
Build 838
Patient Questionnaires
Figure 26–3: Kiosk and Login
4. The patients then proceed to the kiosk to answer the questionnaire. Patients select
Questionnaire from the folder list and the login window opens, prompting them
to enter their Patient ID and PIN.
5. Patients enter the requested information and click OK.
6. Patients then answer the questions that appear on screen.
Figure 26–4: Questions
7. When the questions have been answered, the patients click Save and then Done
from the Action bar.
Block 1
Build 838
CHCS II User’s Manual
26-3
Patient Questionnaires
26.4 Reviewing a Completed Questionnaire
You and your patients can review and modify a completed questionnaire, as necessary,
and assign it to an encounter.
Follow the steps below to review a completed questionnaire:
1. Under the Health History Questionnaire Folder, the provider sees a completed
Questionnaire screen. The Status shows Complete.
Figure 26–5: Completed Questionnaire
2. The questionnaire can be reviewed with the patient and you can make changes to
the patient's answers, as needed. A correction notation appears on any answers
that have been changed.
Figure 26–6: Correction Notation
3. You can link the questionnaire to an open encounter by clicking Encounter from
the Action bar. All open encounters for that particular patient appear.
4. Select the desired encounter and click OK. Click Cancel to return to the current
encounter.
5. Before you can view questionnaire data in the Encounter document, you must set
the encounter summary properties. Click Options in the upper, right corner of the
Patient Encounter module. The Encounter Summary Properties window opens.
6. In the Encounter Summary Properties window, select the Questionnaires checkbox.
26-4
CHCS II User’s Manual
Block 1
Build 838
Patient Questionnaires
7. Click OK.
8. Click AutoCite to refresh the current encounter. The Questionnaire information is
displayed in the S/O section.
Figure 26–7: Questionnaire in Encounter
Block 1
Build 838
CHCS II User’s Manual
26-5
Patient Questionnaires
26-6
CHCS II User’s Manual
Block 1
Build 838
27.0 PATIENT SEARCH
27.1 Patient Search Overview
The Patient Search module allows a specific patient record to be selected. Once a
patient name is selected, patient-specific functions are available. These modules are
visible in the Go pull-down menu, the Shortcuts, the Folder list, and the Tool bar.
This search locates patient records that have been pulled into the CDR from CHCS.
When scheduled appointments are made, patient information is loaded into the CDR
via the nightly processes.
27.2 Conducting a Search
In order to do any work with a specific patient's record, a patient search must be conducted.
Follow the steps below to conduct a search:
1. On the Folder List, click Search. The Patient Search window opens.
Figure 27–1: Patient Search Window
2. Enter search criteria into the appropriate field(s).
Block 1
Build 838
CHCS II User’s Manual
27-1
Patient Search
•
Quick Search: The Quick Search function allows a patient to be selected
using the following criteria:
•
L1234: Performs a search using the first letter of the last name and last 4
digits of the sponsor's SSN
•
L/1234: Performs a search using the first letter of the last name and last 4
digits of the patient's SSN
•
20/123456789: FMP/Sponsor SSN
•
Last Name: Performs a search using the patient's last name (use any combination of upper and lower-case).
•
First Name: Performs a search using the patient's first name (use any combination of upper and lower-case).
•
DOB: Performs a search using the patient's date of birth (use the format mm/
dd/yyyy). The search returns all patients who were born in a four-year range
from two years before the date to two years after the date.
•
UIC: Performs a search using the location of the patient’s/sponsor’s unit command.
•
SSN: Performs a search using the patient's Social Security Number.
•
FMP: Performs a search using the Family Member Prefix.
•
Sponsor SSN: Performs a search using the sponsor’s Social Security Number.
•
Sex: Performs a search using the patient's gender (choose a value from the
list).
Note: The value B (for Both) doesn't make the program search regardless of gender.
Rather, it indicates a search for the patients with a gender value of B, indicating that they are both male and female. U is for unknown (identifying
remains).
•
Tip:
When searching
CHCS II, if the
number of patients
meeting the criteria
exceeds 50, a
prompt is shown,
asking to continue
the search. Click Yes
to continue or No to
end the search and
display the first 50
matches.
27-2
Find only patients enrolled in this facility: Click the checkbox to narrow the
list of patients returned to only those patients enrolled in the current facility.
3. Click Find to view all patients who meet the selected criteria.
Note: When searching CHCS II, if the number of patients meeting the criteria
exceeds 50, a prompt is shown asking to continue the search. Click Yes to
continue or No to end the search and display the first 50 matches.
4. Select the patient from the list of results.
CHCS II User’s Manual
Block 1
Build 838
Patient Search
5. Click OK. The record opens in the Folder List with all available options.
Note: In the case of a patient who has not been seen in CHCS II, their records do not
yet exist in the CDR. To locate the records, you must enter the search criteria
and click Search CHCS.
Figure 27–2: Selected Patient’s Record in the Folder List
27.3 Selecting a Patient Record Without a
Search
CHCS II retains the last 20 patient records that were viewed. Patient records can be
selected from the list instead of performing a patient search.
Follow the steps below to select a patient without a search:
1. On the Go menu, scroll to Patient.
2. Select the desired patient from the list of recently viewed patient records.
Block 1
Build 838
CHCS II User’s Manual
27-3
Patient Search
Figure 27–3: Select Patient Using the Go Drop‐down Menu
27-4
CHCS II User’s Manual
Block 1
Build 838
28.0 PKC COUPLERS
28.1 PKC Couplers Overview
The questionnaires associated with the Problem Knowledge Couplers, Inc. (PKC)
Couplers module automate the collection of demographic and health data for patients.
The questionnaires provide the clinical team member a “snapshot” of the patient's
health, habits and other factors that can affect his/her overall health. The data is then
used to assess preventive service needs, identify services routinely used, and determine the appropriate level of medical expertise/care required for each patient. PKC
Couplers are patient-specific, so a patient’s record must be loaded to the Military Clinical Desktop before the PKC Couplers module is available.
Figure 28–1: PKC Couplers Module
28.1.1
In More Depth
The functions available upon accessing the PKC Couplers module depends on security access roles. A user, with the role of ward_clerk is permitted to generate and print
a patient password to be used by the patient to access the HEAR questionnaire at a
kiosk. The majority of other users are permitted to display, run, and update completed
questionnaires.
28.2 Running a New Coupler
Two types of questionnaires can be administered: Military and All Others.
Block 1
Build 838
CHCS II User’s Manual
28-1
PKC Couplers
Follow the steps below to run a new coupler:
1. On the Couplers module, click either the Military or All Others tab.
Figure 28–2: Military and All Others Tabs
2. Select the desired questionnaire.
3. Click Run Coupler to access the PKC Couplers application.
Figure 28–3: PKC Couplers Application
28-2
CHCS II User’s Manual
Block 1
Build 838
PKC Couplers
4. Read the medical disclosure statement and press Enter on your keyboard to indicate understanding of the statement.
Figure 28–4: PKC Couplers Application
5. Do one of the following:
•
If the questionnaire is from the Military tab, the questionnaire begins with an
opening sequence that presents options for running the questionnaire. To start
the questionnaire:
a. Click Click Here to Begin the HEAR 3.0 Questionnaire.
b. Answer the survey questions.
Note: If answers are missing or are invalid, an error message appears. To correct the
error, click Yes; click No to continue.
•
If the questionnaire is from the All Others tab, the system begins with an overview of the subject areas presented in the questionnaire. To start the questionnaire:
a. Click the applicable area.
b. Select a response to answer a question. Click twice to mark a question as
uncertain. Click a third time to clear the question.
c. On the toolbar, click the Next Arrow button to move to the next window
to respond to the next question.
Block 1
Build 838
CHCS II User’s Manual
28-3
PKC Couplers
6. At the end of the questionnaire, on the File/Couplers menu, click Exit & Return
to CHCS II.
7. Click Yes to save the findings and exit the questionnaire.
28.3 Viewing a Completed Coupler
The Coupler module displays completed questionnaires and a list of questionnaires
that can be administered. Each completed questionnaire can be viewed and updated.
Follow the steps below to view a completed coupler:
1. Select the desired questionnaire to be viewed on the Couplers module.
Figure 28–5: Couplers Module
2. Click View. The PKC application begins and the completed questionnaire is available to review.
28.4 Updating a Completed Coupler
Completed questionnaires can be updated if they have not been completed or if there
are errors that need to be resolved.
Follow the steps below to update a completed coupler:
1. Select the questionnaire to be updated.
2. Click Update. The PKC application opens to the completed questionnaire.
3. Update the questionnaire.
4. Save the questionnaire.
28-4
CHCS II User’s Manual
Block 1
Build 838
PKC Couplers
5. On the File/Couplers menu, click Exit & Return to CHCS II. The updated questionnaire is saved as a separate questionnaire. It does not replace the original questionnaire.
28.5 Using a Kiosk to Complete the HEAR
Questionnaire
The HEAR questionnaire can be completed through a stand-alone kiosk. A Clinical
Team Member generates a password for the patient to enter when using the kiosk. The
password is linked to that specific patient and is active for 24 hours. The ability to
access the Generate Password window is a separate role (ward_clerk) within CHCS II
and must be assigned before performing the following tasks.
Follow the steps below to start the HEAR Questionnaire:
1. Access the Coupler module. The Coupler Utility Application window opens.
Figure 28–6: Coupler Utility Application Window
2. Click Generate Password to create a password for the patient.
3. Click Print Password to print the password for the patient.
4. Direct the patient to the kiosk. The patient only has access to the Coupler module
to complete the questionnaire.
5. The patient clicks PKC/HEAR to view the HEAR Questionnaire Login window.
Figure 28–7: Kiosk Questionnaire Login Window
6. The patient types the given password and clicks OK to launch the questionnaire.
7. The system begins with an opening sequence that presents three options for running the questionnaire. Click Begin Questionnaire to start.
Block 1
Build 838
CHCS II User’s Manual
28-5
PKC Couplers
8. After answering a survey question, advance through screens in one of the following ways:
•
Select the box marked Press <F10> or Click Here to continue.
•
Press <F10>.
•
On the toolbar, click the Next Arrow button.
Note: Press <F9> or click Previous on the tool bar to see the previous screen.
•
If answers are missing or are invalid, an error message appears. Click Yes
to correct the error, No to continue.
9. At the end of questionnaire, click Exit & Return to CHCS II on File/Couplers on
the menu bar.
10. Click Yes to save the findings and exit the questionnaire.
11. The patient informs the Clinical Team Member that the questionnaire is complete.
The Clinical Team Member returns to the Coupler module and views the Coupler
Utility Application window.
12. Enter the name of the stand-alone workstation in the Workstation Name field.
13. Click Import to CDR to import the results. When a Clinical Team Member views
the Coupler module, the imported questionnaire is available for review.
28.6 Finding Summary Report
This option allows the proctor or provider to access and review the Finding Summary
report, which displays the patient's responses under specific headings, after the questionnaire is completed in the PKC application.
Follow the steps below to find the summary report:
1. On the Findings menu, click Finding Summary. The Finding Summary report
opens.
28-6
CHCS II User’s Manual
Block 1
Build 838
PKC Couplers
Figure 28–8: Couplers Finding Summary Report
2. View the answers that the patient entered. A checkmark indicates that the question
has been answered, a question mark indicates an uncertain answer.
3. Double-click an uncertain finding to return to the question in order to answer it
completely and correctly.
28.7 Reviewing and Resolving the Finding Error
Summary
This option allows the proctor or provider to access and review the Finding Error
Summary Report. An error message is displayed whenever the rules of a question
have been violated. The patient has the option of either correcting the error by answering the question, or moving forward without making the suggested corrections. All
error messages that are not corrected are displayed in the Finding Error Summary
Report. From this report, the error can be corrected.
Follow the steps below to review and resolve the finding error summary report:
1. When the questionnaire is completed, click Finding Error Summary on the
Findings menu. The Finding Error Summary Report opens.
Block 1
Build 838
CHCS II User’s Manual
28-7
PKC Couplers
Figure 28–9: Couplers Finding Error Summary Report
2. To resolve any error messages:
a. At the end of the error message, click the number in brackets (e.g., [13]).
b. Correct the error.
c. Repeat steps until all error messages are resolved.
3. At the end of questionnaire, click File/Couplers on the menu bar.
4. Click Exit.
5. Click Yes to save findings and exit the questionnaire.
28.8 Printing or Previewing a Report
Follow the steps below to print or preview a report:
1. Access the Reports pull-down menu and select Print Any Reports to view the
Print Any Reports window.
2. Select the report to be printed by clicking in the check box next to the desired
report.
3. Enter a Report Comment if necessary. If the comment needs to be saved, click
Save as Session Comment.
4. Select necessary Details for Primary Options to be printed if Details for Primary
Options is selected. Highlight the desired Primary Options for Plan Option if
Primary Option Index is selected.
28-8
CHCS II User’s Manual
Block 1
Build 838
PKC Couplers
5. Click OK to print.
6. Click Reset to clear any changes made to the form.
Block 1
Build 838
CHCS II User’s Manual
28-9
PKC Couplers
28-10
CHCS II User’s Manual
Block 1
Build 838
29.0 PREVIOUS ENCOUNTERS
29.1 Previous Encounters Overview
The Previous Encounters module displays a list of a patient's completed CHCS II
encounters. Select a previous encounter to view the signed electronic SF600 in the
bottom of the workspace. You must select a patient record to view previous encounters. You can append a narrative, amend an encounter, create a new Encounter Template from a completed encounter and “copy forward” the details of a previous
encounter to the current encounter, easing effort and saving time in documenting follow-up visits.
The Previous Encounters module defaults to display the last four previous encounters
for a patient. If you want to view all previous encounters for a patient, select the View
All radio button.
Figure 29–1: Military Clinical Desktop—Previous Encounters Module
29.2 Appending a Narrative
The Append Narrative function enables you to attach text or a graphic file to a completed encounter. Graphics that are imported cannot be greater than 500K. The narrative appears at the bottom of the encounter, stamped with the time, date, and author’s
name. Since the narrative is added after the encounter was signed, the note itself must
be signed by the author.
Block 1
Build 838
CHCS II User’s Manual
29-1
Previous Encounters
Follow the steps below to append a narrative:
1. Select an encounter.
2. Click Append Narrative on the Action bar. The Encounter Note window opens.
Figure 29–2: Encounter Note Window
Tip:
Copied text can be
pasted directly into
the text box.
3. Enter a note category, if appropriate.
4. Enter a note title, if appropriate.
5. Enter the note in the text box.
6. Do one of the following:
•
If you want to insert a file into the note:
a. Click Load File. The Select Destination File window opens.
29-2
CHCS II User’s Manual
Block 1
Build 838
Previous Encounters
Figure 29–3: Select Destination File Window
b. Select the file to be added.
c. Click Open. The contents of the file are displayed in the text box.
Note: Graphics that are imported must be 500K or less.
•
If you want to print the note for your hardcopy records, click Print.
7. Click Save and Sign. The Sign Appended Note window opens, so you can review
the narrative before signing.
Figure 29–4: Sign Appended Note Window
8. Enter your password and click Sign. The narrative appears at the bottom of the
encounter summary with the Time, Date, and your name next to the narration.
Block 1
Build 838
CHCS II User’s Manual
29-3
Previous Encounters
29.3 Amending a Previous Encounter
Amending an encounter allows original information to be changed by the original provider or the provider's supervisor. The amended encounter document must be signed.
When you sign an amended encounter, the amended information is sent to ADM to
update the original information.
Follow the steps below to amend an encounter:
1. Select the previous encounter you want to amend.
2. Click Amend Encounter on the Action bar. The Patient Encounter module opens
for the selected encounter.
Figure 29–5: Encounter Summary
3. Update applicable sections of the encounter.
4. Once the changes have been made, the amended encounter document must be
signed. Click Sign on the Action bar. The Sign Encounter window opens.
29-4
CHCS II User’s Manual
Block 1
Build 838
Previous Encounters
Figure 29–6: Sign Encounter Window
5. In the Enter Your Password field, enter your password.
•
If you do not want to Auto-Print the signed encounter, click the Auto-Print
checkbox to deselect this option.
•
If a co-signer is required, select the Cosigner Required checkbox.
•
If you want to mark the amended encounter as sensitive, select the Sensitive
checkbox. Sensitive data is displayed with asterisks. Providers other than the
primary and co-signing must have “break the glass” privileges to view the
sensitive data.
6. Click Sign to sign the encounter. The Change History section of the encounter is
documented with the amendments.
Block 1
Build 838
CHCS II User’s Manual
29-5
Previous Encounters
Figure 29–7: Change History Section of an Encounter
29.4 Creating a New Encounter Template
After you document an encounter, you can use the structure of the previous encounter
to create a new encounter template. No patient-specific information is saved in the
encounter template.
Follow the steps below to create a new encounter template:
1. Click New Template on the Action bar. The Template Management module opens
with details populated in the Template Details tab.
Figure 29–8: Template Management module—Template Details Tab
2. Add or remove information from the following areas:
•
29-6
Associated Reasons for Visit, Associated Problems, Associated Appointment Types: These three areas are rarely used within CHCS II. These areas
CHCS II User’s Manual
Block 1
Build 838
Previous Encounters
determine those templates that the system suggests when you go to load a
template.
•
•
•
Items to AutoCite into Note:
•
Click Add.
•
Select an AutoCite selection from the list and click Add Items.
•
Click Done to return to the Template Details tab.
Diagnoses, Other Therapies, Procedures:
•
Click Add next to the appropriate section.
•
In the Search Term field, enter the first few letters of the procedure and
click Search.
•
Select the item from the search results and click Add Items.
•
Click Done to return to the Template Details tab.
Notes Templates:
•
Click Add.
•
Click Search to open the List Note Template Search window.
•
Enter search criteria in the window and click Search.
•
Select the note template and click Add Items.
•
Click Done to return to the Template Details tab.
3. Click Save As on the Action bar. The Save Encounter Template window opens.
Figure 29–9: Save Encounter Template Window
4. Select the template type from the Save-in drop-down list.
5. In the Template Name field, enter the template name.
6. Select the Specialty from the drop-down list.
7. Click the checkboxes to denote whether the template should be added to your
Favorites List or shared with other Clinical Team Members.
Block 1
Build 838
CHCS II User’s Manual
29-7
Previous Encounters
8. Click Save.
29.5 Copy Forward
Users can “Copy Forward” a previous encounter document for use in the current
encounter. This enables you to quickly and efficiently copy work from previous
encounter(s) to the current encounter. This feature saves charting steps for a follow-up
visit or if the patient has many complicated problems. The diagnoses, orders, procedures, and other therapies of the previous encounter will copy forward as if it were an
Encounter Template.
Follow the steps below to Copy Forward a previous encounter:
1. With a current encounter open, click Previous Encounters in the Folder List. The
Previous Encounter module opens.
Figure 29–10: Previous Encounter Module
2. Select the previous encounter to copy forward.
3. Click Copy Forward on the Action bar. You are returned to the current encounter.
29-8
CHCS II User’s Manual
Block 1
Build 838
Previous Encounters
Figure 29–11: Current Encounter Summary
4. Click S/O. The S/O module opens.
Figure 29–12: Copy Forward Items Highlighted
Note: Items copied forward are marked in yellow. Click the copied forward items to
insert them into the current encounter note. Click AutoEnter on the S/O dashboard to insert all items copied forward.
5. After completing the S/O module, click A/P.
Note: To view the diagnoses, procedures, order sets or other therapies, open the template drop-down and select <Copy Forward Template>. The A/P information
associated with the previous encounter will display on the appropriate tabs.
Once the copy forward template is loaded, you can document the encounter as
if you were using any other encounter template.
Block 1
Build 838
CHCS II User’s Manual
29-9
Previous Encounters
29.6 Printing Previous Encounter Documents
Tip:
To print multiple
encounters, press
the Ctrl key on your
keyboard and select
each encounter.
Follow the steps below to print selected previous encounters:
1. Select the previous encounter you want to print.
2. Click File on the Menu bar, scroll over Print and select SF600. The Print window
opens.
3. Select the Print Range and click OK. The SF600 will print to the default printer
associated with your workstation.
Figure 29–13: Print Previous Encounter
29-10
CHCS II User’s Manual
Block 1
Build 838
30.0 PROBLEMS
30.1 Problems Overview
The Problems module displays a problem list, Healthcare maintenance, Dental Readiness Classification, Historical Procedures, and Family History information for the
selected patient in the top portion. Dental Readiness Classification information is populated by the Dental module and is read only. Problems (diagnoses) and Family History data added during an encounter automatically update the Problems module when
the encounter is signed.
Figure 30–1: Military Clinical Desktop—Problems Module
30.2 Viewing the Problem List
Use the two filter options to view selected problems on the list. The two filter criteria
are Chronicity and Status.
Follow the steps below to view the problem list:
1. Select a Chronicity filter from the drop-down list. The default is Chronic.
2. Select a Status filter from the drop-down list. The default is Active.
Tip:
Click the Expand All
checkbox to view the
associated
encounters and
orders for all
problems.
Note: Details about any associated encounters, procedures, medications, labs, and
radiology procedures associated with the selected problem can be displayed
by clicking the plus sign to the left of the item. Double-click the associated
encounter to view the encounter details in the Previous Encounter module.
Block 1
Build 838
CHCS II User’s Manual
30-1
Problems
Double-click the radiology or lab results to view the details in the respective
modules.
30.3 Adding a Problem
New problems are automatically added to the problem list every time an encounter is
signed. The diagnosis from each encounter becomes a problem. Use the following
procedure to add a problem that was not documented through an encounter.
Follow the steps below to add a problem:
1. Select the Problem List header.
2. Click Add on the Action bar. The Select Diagnosis window opens.
Figure 30–2: Problems—Select Diagnosis Window
3. Select the diagnosis you want to add. The selected problem appears in the New
Problem pane on the Problems module.
Note: The Select Diagnosis window contains three tabs:
30-2
•
Search: Click the Search tab and enter the first few letters of the diagnosis in the MEDCIN Search field and click Search. Select the diagnosis
and click OK.
•
Clinic List: Click the Clinic List tab and enter the first few letters of the
diagnosis in the Find field and click Find. Select the diagnosis from the
Clinic List results and click OK.
CHCS II User’s Manual
Block 1
Build 838
Problems
•
User List: Click the User List tab and enter the first few letters of the
diagnosis in the Find field and click Find. Select the diagnosis from the
User List results and click OK.
Note: If the Add to Favorites checkbox is selected, the selected diagnosis and ICD-9
code are added to your list of favorite diagnoses in the List Management module. All diagnoses in that list are available in the User List tab of the Problems
module. You cannot change the items in the Clinic List tab.
Figure 30–3: New Problem Pane
4. Complete the appropriate fields.
•
Onset Date: Click the drop-down arrow to select the correct date the problem
began.
•
Chronicity: Select Acute or Chronic from the drop-down list.
•
Status: Select Active, Deleted (Error), or Inactive from the drop-down list.
•
Comments: Add a note for a selected problem or procedure.
•
Source: The manner in which you received the problem information:
•
Patient
•
Encounter
•
HEAR
5. Click Save on the Action bar.
30.4 Adding an Historical Procedure
Historical procedures can be followed as problems. These procedures are not automatically populated from the A/P module when an encounter is signed, in the way diagnoses are. The procedures are added directly from the Problems module.
Follow the steps below to add an historical procedure:
1. Click the Historical Procedures header.
2. Click Add on the Action bar. The Select Procedure window opens.
Block 1
Build 838
CHCS II User’s Manual
30-3
Problems
Figure 30–4: Problems—Select Procedure Window
3. Select the procedure you want to add. The selected procedure displays in the New
Procedure pane on the Problems module.
Note: The Select Procedure window contains three tabs:
•
Search: Click the Search tab and enter the first few letters of the procedure in the MEDCIN Search field and click Search. Select the procedure
and click OK.
•
Clinic List: Click the Clinic List tab and enter the first few letters of the
procedure in the Find field and click Find. Select the procedure from the
Clinic List results and click OK.
•
User List: Click the User List tab and enter the first few letters of the procedure in the Find field and click Find. Select the procedure from the
User List results and click OK.
Note: If the Add to Favorites checkbox is checked, the selected Procedure and
CPT-4 codes are added to your list of favorite diagnoses in the List Management module. All diagnoses in that list are available in the User List tab of the
Problems module. The items in the clinic list cannot be changed by the user.
30-4
CHCS II User’s Manual
Block 1
Build 838
Problems
Figure 30–5: New Procedure Pane
4. Complete the appropriate fields:
•
Procedure Date: Click the drop-down arrow to select the date the procedure
was performed.
•
Status: Select Active, Deleted (Error), or Inactive from the drop-down list.
•
Comments: Add a note for a selected problem or procedure.
5. Click Save on the Action bar.
30.5 Adding Family History Problems
The Problems module allows you to document specific problems in a patient's family
history. Positive and negative family history documentation from the S/O module is
displayed in the Family History area in the Problems module.
Follow the steps below to add family history problems:
1. Select the Family History header.
2. Click Add on the Action bar. The Select Diagnosis window opens.
3. Select the diagnosis you want to add. The selected problem appears in the New
Family History pane on the Problems module.
Figure 30–6: New Family History Pane
4. Complete the appropriate fields:
•
Onset Date: Click the drop-down arrow to select the date of the onset of the
problem.
•
Status: Select Active, Deleted (Error), or Inactive from the drop-down list.
•
Sensitivity: Click the checkbox to mark the family history problem as sensitive.
•
Comments: Add a note for the family history problem.
•
Relationship: Select the family member from the drop-down list.
Block 1
Build 838
CHCS II User’s Manual
30-5
Problems
•
Source: The manner in which you received the family past medical history
problem.
5. Click Save on the Action bar.
30.6 Updating a Problem or Procedure
Problems and procedures can be updated from the Problem List, Historical Procedures, and Family History areas.
Follow the steps below to update a problem or procedure:
1. Select a problem or procedure. The Update Problem or Procedure pane displays
on the Problems module.
Figure 30–7: Update Problem Pane
Figure 30–8: Update Procedure Pane
2. Do one of the following:
•
•
•
30-6
If you are updating a problem, update the following fields, as necessary:
•
Onset Date
•
Status
•
Comments
•
Chronicity
•
Source
If you are updating a procedure, update the following fields, as necessary:
•
Procedure Date
•
Status
•
Comments
If you are updating a patient’s family history, update the following fields, as
necessary:
•
Onset Date
•
Status
CHCS II User’s Manual
Block 1
Build 838
Problems
•
Comments
•
Relationship
3. Click Save.
Note: Active problems added to the patient’s problem list auto-age to Acute-Inactive after 180 days.
30.7 Accessing Healthcare Maintenance
Health Care Maintenance items are the same wellness reminders found in the Wellness module, and the Reminders tab of the A/P module. Any expired medications for
the patient also display as Healthcare Maintenance items.
Healthcare Maintenance items can be viewed by clicking the plus sign next Healthcare Maintenance. The list of wellness reminders displays.
Figure 30–9: Healthcare Maintenance
Note: Select a maintenance item and click Guidelines on the Action bar to view a
description of the item.
Block 1
Build 838
Tip:
Select a Healthcare
Maintenance Item
and press F1 to view
the clinical guidelines
associated with the
item.
CHCS II User’s Manual
30-7
Problems
30-8
CHCS II User’s Manual
Block 1
Build 838
31.0 QUESTIONNAIRE SETUP
31.1 Questionnaire Setup Overview
The Questionnaire Setup module allows you to create and modify questionnaires.
Once created, you can modify, copy, delete, and mark obsolete these questionnaires.
An open encounter is not required for questionnaires to be created or modified. The
Questionnaire Setup module can be accessed from the Folder List by expanding
Tools.
Figure 31–1: Questionnaire Setup Module
31.1.1
In More Depth
The Status section of each questionnaire denotes the level of development or use of a
questionnaire. A new questionnaire always starts out as In Development.
•
Mark as Ready means the questionnaire is ready for use. A questionnaire must be
marked Ready for Use before it can be used in the Patient Questionnaires module.
Once marked, the status changes from In Development to Ready for Use.
•
Mark as Obsolete means a questionnaire has been removed from circulation. A
questionnaire that is marked obsolete can be made active again by selecting Ready
For Use. New Version means a questionnaire can be modified and saved as different version of a specific questionnaire.
A questionnaire can be copied and saved as another questionnaire so that questions
can be reused.
Block 1
Build 838
CHCS II User’s Manual
31-1
Questionnaire Setup
31.1.2
Creating a New Questionnaire
Follow the steps below to create a new questionnaire:
1. Click New on the Action bar. The New Questionnaire pane opens.
Figure 31–2: Questionnaire Setup — New Questionnaire
2. In the Name field, enter the name for the new questionnaire.
3. Select Questionnaire or Test from the Type drop-down list.
Note: The Status is In Development until you save the questionnaire.
4. Select the Level from the drop-down list.
5. Select the Owner from the drop-down list.
6. In the Instructions to Display field, enter any instructions related to the questionnaire for the patient.
7. Click Add to create a new question.
Note: The Question No. field is pre-populated in numerical order.
8. In the Question Text field, enter the question.
9. Select an answer type from the drop-down list. The Answer Type field allows different answer format styles to be assigned to the question.
31-2
CHCS II User’s Manual
Block 1
Build 838
Questionnaire Setup
•
Date: This field is used for questions requiring a specified date to be entered
as the answer.
•
Multiple Choice: This field is used for questions where a single choice is
available for selection.
•
Multi-Select: This is used for questions where more than one answer can be
selected.
•
Number: This is used for questions requiring a number to be entered. A minimum or maximum amount can be specified.
•
Yes/No: This is used for questions requiring a yes or no response.
Figure 31–3: Questionnaire Answer Format Styles
10. When you have finished adding questions, click Save on the Action bar to save
the questionnaire as completed.
11. Click Mark as Ready on the Action bar.
Note: The status changes from In Development to Ready for Use. The questionnaire must be marked Ready for Use before it can be used in the Patient
Questionnaires module.
31.2 Copying a Questionnaire
A questionnaire can be copied and saved as another questionnaire so that questions
can be reused.
Follow the steps below to copy a questionnaire:
1. Select the questionnaire you want to copy from the Questionnaire list.
2. Click Copy on the Action bar. The Copied Questionnaire displays.
Block 1
Build 838
CHCS II User’s Manual
31-3
Questionnaire Setup
3. In the Name field, enter the name of the questionnaire.
4. Select the question you want to modify, if necessary.
•
Make the modification.
5. Click Save on the Action bar.
6. Click Mark as Ready to mark the test as ready for use.
31.3 Deleting a Questionnaire
Only questionnaires that have never been used can be deleted. If a questionnaire is not
used, it can be deleted so it does not appear in the Questionnaire list available in either
the Questionnaire Setup or Patient Questionnaire Setup.
Follow the steps below to delete a questionnaire:
1. Select the questionnaire you want to delete from the Questionnaire list.
2. Click Delete on the Action bar.
3. Click Yes at the delete confirmation prompt.
31.4 Importing a Questionnaire or Question into
a Questionnaire
Entire questionnaires or selected questions can be imported into questionnaires.
Follow the steps below to import a questionnaire or question into a questionnaire:
1. Select the questionnaire into which you want to import.
2. Click Import.
3. Click OK at the import questionnaire prompt.
Figure 31–4: Import Questionnaire Prompt
4. Select the questionnaire you want to import from the Questionnaire list. The
Import Questionnaire window opens.
31-4
CHCS II User’s Manual
Block 1
Build 838
Questionnaire Setup
Figure 31–5: Import Question Window
5. Click the question(s) you want to import.
6. Click Import. The questions are imported after the last question in the questionnaire.
7. Click Save.
31.5 Maintaining Questionnaires
The Status section of each questionnaire denotes the level of development or use of a
questionnaire. A new questionnaire always starts out as In Development.
•
Mark as Ready: This marks the questionnaire as ready for use.
•
Mark as Obsolete: This allows a questionnaire to be removed from circulation.
•
New Version: This allows a questionnaire to be modified into another version of a
specific questionnaire.
Follow the steps below to mark a questionnaire as ready:
1. From the Questionnaires listed in the side bar, select the questionnaire to be
marked as Ready for Use.
2. From the Questionnaire Set Up module, click the Actions pull-down menu and
select Mark as Ready. Once marked ready, the questionnaire is available for use.
The Status bar reflects the questionnaire as Ready for Use.
Follow the steps below to mark a questionnaire as obsolete:
1. From the questionnaires listed in the side bar, select the questionnaire to be
marked obsolete.
Block 1
Build 838
CHCS II User’s Manual
31-5
Questionnaire Setup
2. From the Questionnaire Set Up module, click the Actions pull-down menu and
select Mark Obsolete. Once marked Obsolete, the questionnaire is not available
for use. The Status bar reflects the questionnaire as Obsolete.
Note: A questionnaire that is marked obsolete can be made active again by selecting
Ready For Use.
Follow the steps below to mark a questionnaire as a new version:
1. From the Questionnaires listed in the side bar, select the questionnaire to be
marked New Version.
2. From the Questionnaire Set Up module, click the Actions pull-down menu and
select New Version. Once marked New Version, the questionnaire is available for
use. The Status bar reflects the questionnaire as New Version.
Follow the steps below to delete a questionnaire:
Only questionnaires that have never been used can be deleted. If a questionnaire is not
used, it can be deleted so it does not appear in the Questionnaire list available in either
the Questionnaire Setup or Patient Questionnaire Setup. A questionnaire cannot be
deleted if it has been used.
31-6
CHCS II User’s Manual
Block 1
Build 838
32.0 RADIOLOGY
32.1 Radiology Overview
The Radiology (Rad) module enables you to view radiology test result data for desired
patients. Results are viewed, not ordered from this module. Radiology results are
pulled from CHCS. An alert is triggered when new results are received. Use the A/P
module to order radiology tests.
Figure 32–1: Military Clinical Desktop—Radiology Module
32.2 Creating a Filter in the Radiology Module
The Filter tab on the Properties window enables you to view radiology results by
selecting a previously saved filter from the drop-down list or creating a new filter.
Block 1
Build 838
CHCS II User’s Manual
32-1
Radiology
Figure 32–2: Radiology Properties Window—Filter Tab
Follow the steps below to create a new filter:
1. Click Filter on the Rad module. The Properties window opens.
2. Click the applicable radio button in the Note Type area.
•
All Note Types: If All Note Types is selected, all of the listed note types are
displayed.
•
Specific Note Type(s): If Specific Note Type(s) is selected, click Add to open
the Healthcare Data Dictionary Search window top search for and add specific clinical notes.
3. Click the applicable radio button in the Associated Clinician area.
Tip:
To delete a filter,
select the filter from
the drop-down list
and click Delete. At
the confirm deletion
prompt, click Yes.
•
All Clinicians: If All Clinicians is selected, all of the listed clinicians are displayed.
•
Specific Clinician: If Specific Clinician is selected, click Clinician to search
for and select the specific clinician(s).
4. Click Save As. The Save As window opens.
Note: If this is a change to a pre-existing filter, click Save.
5. Enter the name for the filter.
6. Click Save.
Note: To delete a filter, select the filter from the Filter Name drop-down list and
click Delete. At the confirm deletion prompt, click Yes.
32-2
CHCS II User’s Manual
Block 1
Build 838
Radiology
7. Click OK.
32.3 Setting Time Preferences in the Radiology
Module
The Preferences tab on the Properties window allows you to customize the default
times within the Radiology module.
Figure 32–3: Radiology Properties Window—Preferences Tab
Follow the steps below to set time preferences:
1. Click Options on the upper, right corner of the workspace. The Properties window opens.
2. Click the Preferences tab.
3. Click Default Time. The Time Search window opens.
Figure 32–4: Time Search Window
Block 1
Build 838
CHCS II User’s Manual
32-3
Radiology
4. Click the radio button for the applicable Time Search Option and click OK.
5. Click OK.
32.4 Viewing Radiology Results
Once the search criteria have been defined, the radiology results are displayed in the
workspace.
Select the desired test data to be viewed by selecting the test name (i.e., mammogram). The data is displayed in the bottom of the Radiology Results workspace.
Note: When mammogram results are ready, a letter is sent to the patient notifying
her that her results are ready. A copy of this letter can be found in the Clinical
Notes module.
32.5 Printing Radiology Results
Follow the steps below to print the radiology results:
1. Select the test(s) you want to print.
2. On the File menu, scroll over Print and click Rad Results.
32.6 Copying Radiology Results to a Note
Once the radiology result is displayed, the result can be copied for use in other modules or can be copied directly into the Note area of the patient encounter.
Follow the steps below to copy radiology results to a note:
1. Select the desired result so the details display in the bottom of the Radiology module.
32-4
CHCS II User’s Manual
Block 1
Build 838
Radiology
Figure 32–5: Radiology Results Module (Copy Radiology Results)
2. Select the portion of the result to be copied by left-clicking and dragging with
your mouse.
3. Perform a right-click on your mouse, then select either:
•
Copy: Copies the selection on the clipboard so it can be used in another location.
•
Copy to Note: Copies the details directly into the S/O area of the current
encounter.
Note: An encounter must be open to utilize the Copy to Note function. The result is
pasted directly into the patient encounter. Once copied, the result cannot be
deleted from the note, so ensure that you only select the Copy to Note option
once, to avoid duplicate entries in the note.
Block 1
Build 838
CHCS II User’s Manual
32-5
Radiology
32-6
CHCS II User’s Manual
Block 1
Build 838
33.0 READINESS
33.1 Readiness Overview
The Readiness module displays information to determine whether the patient is ready
for deployment. Most of the data displayed on the Readiness module is received from
other sources. Data edited in the Readiness module does not update data in its original
source.
Figure 33–1: Military Clinical Desktop—Readiness Module
33.2 Modifying Readiness Information
Most of the data displayed in the Readiness module are downloaded from other
sources. Editing data in the Readiness module does not update the data in its original
source.
Follow the steps below to modify readiness information:
1. Click Edit on the Action bar.
2. Complete the following areas, as necessary:
•
Lab Tests
•
Screening Exams
•
Profiles
•
Vision Readiness
Block 1
Build 838
CHCS II User’s Manual
Tip:
The fields in the
module are not
active until you click
Edit.
33-1
Readiness
3. Click Save.
Note: If the Readiness information was modified, you must click Save before closing the module; otherwise, the changes will be lost.
33-2
CHCS II User’s Manual
Block 1
Build 838
34.0 REMINDER MAPPING
34.1 Reminder Mapping Overview
The Reminder Mapping module enables authorized users to set and modify default
orders and other actions for Wellness Reminders. The default actions occur when the
individual reminder is addressed. Users who do not have the appropriate roles
assigned to them are able to view the Wellness Reminders and associated defaults, but
cannot perform any other actions.
Figure 34–1: Military Clinical Desktop—Reminder Mapping Module
34.1.1
In More Depth
Upon opening the Reminder Mapping module, a list of all Wellness Reminders is displayed, along with default diagnoses, orders, and documentation details. Each of these
defaults can be changed by Clinical Team Members with the appropriate privileges.
The default actions set up in the Reminder Mapping module allow for a more streamlined documentation of the Wellness reminders. Wellness Reminders can be met with
the documentation of vital signs, the ordering of a lab or radiology procedure, the documentation of a MEDCIN term, or the documentation that counseling was completed.
The default actions set within the Reminder Mapping module are seen within the A/P
module. The Reminders tab contains the active wellness reminders for a given patient
as well as the default settings for each reminder. The A/P module is where a clinical
Block 1
Build 838
CHCS II User’s Manual
34-1
Reminder Mapping
team member documents completed reminders; the Reminder Mapping module sets
up the default actions that are completed when a reminder is addressed in the A/P
module.
Note: A list of active Wellness reminders for the selected patient is displayed in the
Reminders Mapping window (bottom left of the desktop) and in the A/P module on the Reminders tab.
34.1.2
Setting a Default Diagnosis
When a reminder is addressed for an individual patient, through the A/P module, the
associated default diagnosis is added to the encounter automatically. The default diagnosis for Wellness Reminders is Patient Counseling V65.40, but this can be changed.
Follow the steps below to change the default diagnosis for a Reminder:
1. Select the Reminder and click Set Default Dx on the Action bar. The Default
Diagnosis Search window opens.
2. Enter a search string in the Search field and click Search. The search results display.
Figure 34–2: Default Diagnosis Search Window—Search Results
3. Select a Diagnosis and click OK. The selected diagnosis replaces the default diagnosis.
Figure 34–3: Default Diagnosis Changed
34-2
CHCS II User’s Manual
Block 1
Build 838
Reminder Mapping
34.1.3
Resetting a Diagnosis to the Default Diagnosis
Select the Reminder with the diagnosis you want to reset and click Reset Default Dx
on the Action bar to reset a diagnosis to the default diagnosis (Patient Counseling
V65.40). The diagnosis is reset to the default diagnosis.
34.2 Setting a Default Action
Along with a default diagnosis, each reminder can have a default action. The action
can be the placement of a lab, radiology or medication order, or the documentation of
patient instructions, vital signs, or simply that the reminder was completed or ordered.
When the reminder is addressed in the A/P module, the default action occurs automatically.
Follow the steps below to set a default action for a reminder:
1. Select the Wellness Reminder and click Set Default Action on the Action bar.
The Set Facility Default pop-up menu opens.
Figure 34–4: Set Facility Default Action Menu
You have multiple options from which to select.
34.2.1
Setting Document as the Default Action
If Document is the default action, CHCS II documents the reminder as complete or
ordered in the comments section of the default diagnosis in the A/P module. For
example, if the Nutrition Counseling reminder had a default diagnosis of Patient
Counseling and a default action of Document Complete, the result in A/P would look
like the figure below.
Figure 34–5: Example of A/P Documentation
Follow the steps below to set the default action to Document (Completed, Ordered):
1. Click the appropriate radio button.
2. Click OK. Document (Complete, Ordered) is the default action for the reminder.
Block 1
Build 838
CHCS II User’s Manual
34-3
Reminder Mapping
Figure 34–6: Reminder Set to Document Complete
34.2.2
Setting a Lab Order as the Default Action
Set the default action to automatically order a lab test when a reminder is addressed
through the Reminders tab in the A/P module. In this case, the default diagnosis is
documented and the default lab test is ordered and associated to the default diagnosis.
Follow the steps below to set the default action to Order a Lab Test:
1. Select the Wellness Reminder and click Set Default Action on the Action bar.
The Set Facility Default pop-up menu opens.
2. Select Order Lab Test and click OK. The Lab order window displays.
3. Enter a search string in the Search field and click Search. The search results
opens.
Figure 34–7: Order Lab Test Search Results
4. Select the lab order, fill in other fields as necessary, and click OK. The ordering of
the lab test is the default action.
Figure 34–8: Lab Order Default Added
Note: The lab test is not ordered until the provider addresses the Wellness Reminder
in the A/P module during a patient encounter.
34-4
CHCS II User’s Manual
Block 1
Build 838
Reminder Mapping
34.2.3
Setting a Radiology Order as the Default Action
Set the default action to automatically order a radiology test when a reminder is
addressed through the Reminders tab in the A/P module. In this case, the default diagnosis is documented and the default radiology test is ordered and associated to the
default diagnosis.
Follow the steps below to set the default action to Order a Radiology Test:
1. Select the Wellness Reminder, and click Set Default Action on the Action bar.
The Set Facility Default pop-up menu opens.
2. Select Order Radiology Test and click OK. The Order Rad window opens.
3. Enter a search string in the Search field and click Search. The search results display.
Figure 34–9: Rad Order Window—Search Results
4. Select the radiology test, fill in other fields as necessary, and click OK. The ordering of the radiology test is the default action.
Note: The radiology test is not ordered until the provider addresses the Wellness
Reminder in the A/P module during a patient encounter.
34.2.4
Setting a Medication Order as the Default Action
Set the default action to automatically order a medication when a reminder is
addressed through the Reminders tab in the A/P module. In this case, the default diagnosis is documented and the default medication is ordered and associated to the
default diagnosis.
Follow the steps below to set the default action to Order a Medication:
1. Select the Wellness Reminder and click Set Default Action on the Action bar.
The Set Facility Default pop-up menu opens.
2. Select Order Medication and click OK. The Order Medication window opens.
Block 1
Build 838
CHCS II User’s Manual
34-5
Reminder Mapping
3. Enter a search string in the Search field and click Search. The search results display.
Figure 34–10: Order Med Window—Search Results
4. Select the medication, fill in other fields as necessary, and click OK. Ordering
medication is the default action.
Figure 34–11: Medication Order Default Added
Note: The medication order is not ordered until the provider addresses the Wellness
Reminder in the A/P module during a patient encounter.
34.2.5
Clearing a Default Action
Follow the steps below to clear a default action for a Wellness Reminder:
1. Select the Wellness Reminder and click Set Default Action on the Action bar.
The Set Facility Default pop-up menu opens.
2. Select Clear Default Action and click OK. The Clear Reminder Option message
displays.
Figure 34–12: Clear Reminder Option Message
3. Click Yes. The default action is cleared.
34-6
CHCS II User’s Manual
Block 1
Build 838
Reminder Mapping
34.3 Mapping Encounter Terms
Follow the steps below to map encounter terms:
1. Click Enc Term Mapping on the Action bar. The Enc Term Search window
opens.
2. Select the radio button next to the type of term to be mapped:
•
Other Therapies (patient instructions)
•
Procedure
•
Diagnosis
•
S/O Item
3. Enter a search string and click Search. The search results display.
4. Select a term and click Add. Your selection is added in the lower pane of the window.
Figure 34–13: Selected Encounter Terms
34.3.1
Setting an Encounter Term as the Default
Follow the steps below to set one of the terms as the Default:
1. Select one of the terms.
2. Click Default. The terms Default column changes to Yes.
Block 1
Build 838
CHCS II User’s Manual
34-7
Reminder Mapping
Figure 34–14: Term Item Set as Default
3. Click Close. Your Enc Terms selections have been added to the Reminder.
Figure 34–15: Defaults Set
Note: The default term is displayed and the Term Mapping column shows the total
number of terms that you added (4).
34.4 Managing Immunization Reminders
34.4.1
Adding an Immunization
Immunizations must be added to the list before changing the default diagnosis or adding a default action.
Follow the steps below to locate and add an immunization to the list:
1. Click the Immunization radio button on the Reminder Mapping module. The
Immunizations window opens.
34-8
CHCS II User’s Manual
Block 1
Build 838
Reminder Mapping
Figure 34–16: Immunizations Window
2. Click Add Immunization on the Action bar. The Immunization Search window
opens.
3. Enter a search string in the Search field and click Search. The search results display.
Figure 34–17: Immunizations Search Results
4. Select the Immunization and click OK. The Immunization is added to the list.
Figure 34–18: Immunization Added
34.4.2
Setting the Default Diagnosis for an Immunization
Follow the steps below to change the default diagnosis for a Reminder:
1. Select the Reminder and click Set Default Dx on the Action bar. The Default
Diagnosis Search window opens.
2. Enter a search string in the Search field and click Search. The search results display.
Block 1
Build 838
CHCS II User’s Manual
34-9
Reminder Mapping
Figure 34–19: Default Diagnosis Search Window — Search Results — Immunization
3. Select a Diagnosis and click OK. The selected diagnosis replaces the default diagnosis.
Figure 34–20: Immunizations Window
34.4.3
Setting the Default Action for an Immunization
Follow the steps below to set the default action to Document (Completed, Ordered):
1. Select the immunization and click Set Default Action on the Action bar. The Set
Immunizations Default Action window opens.
Figure 34–21: Set Immunizations Default Action Window
34-10
CHCS II User’s Manual
Block 1
Build 838
Reminder Mapping
2. Click the appropriate radio button.
Note: Only Document Complete or Document Ordered are available as default
actions.
3. Click OK. Document (Complete, Ordered) is the default action for the immunization.
Figure 34–22: Immunization Default Action Set
Note: The Immunization is not documented until the Reminder is addressed in the
A/P module during a patient encounter. The documentation of an administered vaccine must be done in the Immunizations module.
Block 1
Build 838
CHCS II User’s Manual
34-11
Reminder Mapping
34-12
CHCS II User’s Manual
Block 1
Build 838
35.0 REPORTS
35.1 Reports Overview
The Reports module consists of four different types of predefined reports used to collect statistical data to determine the needs of MTFs, Clinics, or Providers. In order to
run Population Health Reports, special user privileges are required. If you do not have
these privileges and wish to run these reports, please contact your system administrator. Depending on the selected report, the user can select a scope of MTF, Clinic/Lab,
Provider, PCM, or Patient.
Figure 35–1: Military Clinical Desktop—Reports Module
35.1.1
In More Depth
The Reports module consists of four different types of predefined reports—Customized, Preventive, Standard, and Population Health—used to collect statistical data.
Customized Reports enable the user to run different types of reports for a desired
patient. Current pre-defined customized reports include:
•
Allergy Verified (Audit)
•
Appointments
•
Consults
•
Diagnoses
•
Disposition
Block 1
Build 838
CHCS II User’s Manual
35-1
Reports
•
E&M
•
Lab Tests Ordered
•
Medications Ordered
•
Primary Diagnoses
•
Procedures
•
Radiology Tests
Figure 35–2: Customized Reports
There are 21 different Preventive Reports that can be run for a desired patient. Available reports include:
35-2
•
2 Year Olds, DTP/OPV/MMR Immunizations
•
2 Year Olds, Hepatitis B Immunizations
•
2 Year Olds, Varicella Immunization
•
Cholesterol Screening Aggregate
•
CPS Services Due
•
CPS Summary
•
Discontinued Services Risk
•
High Cholesterol Follow-Up Counseling
•
High Cholesterol Follow-Up Repeat
•
High Cholesterol HDL/LDL Follow-Up
•
Immunizations Active Duty Hepatitis A-1 Dose
•
Immunizations Active Duty Hepatitis A-2 Dose
•
Mammography, Have Not
•
Mammography, Query for
•
MMR #2, HBV #3, Varicella and TD Immunizations for 13 year old
CHCS II User’s Manual
Block 1
Build 838
Reports
Figure 35–3: Preventive Report
There are 13 different predefined Standard Reports that can be run. Available reports
include:
•
Alphabetic Patient List for Encounters
•
Appointment by Status for Encounters
•
Diagnoses
•
Inpatient Workload
•
Insurance Change
•
Insurance Indicator
•
Insurance Indicator Not Marked
•
Outpatient Workload, for Clinic/Lab
•
Patient Categories by Disposition
•
Patient Categories by Provider
•
Patient Encounter
•
Procedures
•
Readiness
Figure 35–4: Standard Report
Block 1
Build 838
CHCS II User’s Manual
35-3
Reports
There are different predefined Population Health reports that can be run. Population
Health Reports include:
•
Figure 35–5: Population Health Report
35.2 Running Customized Reports
Customized Reports enable you to run different types of reports for a desired patient.
Current pre-defined customized reports include:
Tip:
If you select Clinic/
Lab or Provider from
the drop-down list,
click the Lookup
icon to search for the
desired clinic or
provider.
•
Allergy Verified (Audit)
•
Appointments
•
Consults
•
Diagnosis
•
Disposition
•
E&M
•
Laboratory Tests
•
Medication
•
Primary Diagnosis
•
Procedure
•
Radiology Tests
Follow the steps below to run customized reports:
1. Select the report from the Report on drop-down list on the Customized tab.
2. Select a scope from the With Scope of drop-down list. Depending on the selection, a default MTF, clinic/lab, or provider displays.
Note: Additional filters are available depending on the selected report. Use the dropdown lists to select the desired options.
35-4
CHCS II User’s Manual
Block 1
Build 838
Reports
3. Select a date range in the From and To fields.
Note: The date range defaults to the current date.
4. Click the checkbox if you want the report to display in a separate window.
5. Click the checkbox(es) if you want to group the results by clinic or provider.
6. Click Run Report. The customized report displays.
Figure 35–6: Customized Report
7. Click Print Reports to send the report to your local printer.
35.3 Running Preventive Reports
There are 22 different Preventive Reports that can be run for a desired patient.
Available reports include:
•
2 Year Olds, DTP/OPV/MMR Immunizations
•
2 Year Olds, Hepatitis B Immunizations
•
2 Year Olds, Varicella Immunization
•
Cholesterol Screening Aggregate
•
CPS Services Due
•
CPS Summary
•
Discontinued Services Risk
•
High Cholesterol Follow-Up Counseling
•
High Cholesterol Follow-Up Repeat
Block 1
Build 838
CHCS II User’s Manual
35-5
Reports
Tip:
If you select PCM,
the default PCM
displays. If you
select Patient, click
the Lookup icon to
search for the
desired patient. You
can also search for a
different PCM.
•
High Cholesterol HDL/LDL Follow-Up
•
Immunizations Active Duty Hepatitis A-1 Dose
•
Immunizations Active Duty Hepatitis A-2 Dose
•
Mammography, Have Not
•
Mammography, Query for
•
MMR #2, HBV #3, Varicella and TD Immunizations for 13 year old
•
PAP Smear, Have Not
•
Prevention Report Card
•
Query for Potential Heavy Alcohol Use
•
Safe Sex Counseling
•
Tobacco Use Screening
•
Tobacco, Advising Users to Quit
Follow the steps below to run preventive reports:
1. Select the report from the Report on drop-down list on the Preventive tab.
2. Select a scope from the With Scope of drop-down list.
Note: Additional filters are available depending on the selected report. Use the dropdown lists to select the desired options.
3. Select a date range in the From and To fields.
Note: The date range defaults to the current date.
4. Click the checkbox if you want the report to display in a separate window.
5. Click Run Report. The customized report displays.
35-6
CHCS II User’s Manual
Block 1
Build 838
Reports
Figure 35–7: Preventive Report
6. Click Print Reports to send the report to your local printer.
35.4 Running Standard Reports
There are 13 different predefined Standard Reports that can be run.
Available reports include:
•
Alphabetic Patient List for Encounters
•
Appointment by Status for Encounters
•
Diagnosis
•
Inpatient Workload
•
Insurance Change
•
Insurance Indicator
•
Insurance Indicator Not Marked
•
Outpatient Workload
•
Patient Categories by Disposition
•
Patient Categories by Provider
•
Patient Encounter
•
Procedures
•
Readiness
Tip:
Follow the steps below to run standard reports:
1. Select the report from the Report on drop-down list on the Standard tab.
Block 1
Build 838
CHCS II User’s Manual
Depending on the
selected report, you
can select a scope of
MTF, Clinic/Lab,
Provider, PCM, or
Patient. Click the
Lookup icon to
search for the
desired scope
option. Additional
scopes are available
depending on the
selected scopes.
35-7
Reports
2. Select a scope from the With Scope of drop-down list.
3. Select a date range in the From and To fields.
Note: The date range defaults to the current date.
4. Click the checkbox if you want the report to display in a separate window.
5. Click the checkbox(es) if you want to group the results by clinic or provider.
6. Click Run Report. The customized report displays.
Figure 35–8: Standard Report
7. Click Print to send the report to your local printer.
35.5 Running Population Health Reports
There are different pre-defined Population Health reports that can be run.
Note: In order to run Population Health Reports, special user privileges are required.
If you do not have these privileges and wish to run these reports, please contact your system administrator.
Follow the steps below to run a Population Health report:
1. Select the report from the Report on drop-down list on the Population Health tab.
35-8
CHCS II User’s Manual
Block 1
Build 838
Reports
2. Select a scope from the With Scope of drop-down list.
Note: Depending on the selected report, you can select a scope of MTF, Clinic/Lab,
Provider, PCM, or Patient. Click the Look up icon to search for the desired
scope option. Additional scopes are available depending on selected scopes.
3. Select a date range in the From and To fields.
Note: The date range defaults to the current date.
4. Click the checkbox if you want the report to display in a separate window.
5. Click Run Report to run the customized report.
6. Click Print to send the report to your local printer.
Figure 35–9: Population Health Tab
35.6 Exporting a Report
Follow the steps below to export a report:
1. Run the selected report.
2. Click the Export Report
icon. The Export window opens.
3. Select a Format from the drop-down list.
4. Select a Destination from the drop-down list.
Block 1
Build 838
CHCS II User’s Manual
35-9
Reports
5. Click OK.
35-10
CHCS II User’s Manual
Block 1
Build 838
36.0 RX ALTERNATIVES
36.1 Drug (RX) Alternatives Overview
The RX Alternatives module allows you to track the cost of primary and alternative
medications. When you add the cost associated with a medication in this module, the
information is used in populating population health medication cost reporting data.
Figure 36–1: Military Clinical Desktop—RX Alternatives Module
36.2 Setting Drug Display Options
The Drug Display Options window lets you establish the type of data that displays
when primary and alternative medications are added to the RX Alternatives module.
Follow the steps below to set the drug display options:
1. On the RX Alternatives module, click Options to open the Drug Display Options
window.
Block 1
Build 838
CHCS II User’s Manual
36-1
Rx Alternatives
Figure 36–2: Drug Display Options Window
2. Select data options to display for the new drug:
•
Price
•
Name
•
Drug Strength
•
UP Quantity
3. Select data options to display for therapeutic alternative drugs:
•
Name
•
Price
•
Drug Strength
•
UP Quantity
4. Click Save.
36.3 Adding a New Drug
The Select Drugs window allows you to add new drug cost information to the RX
Alternatives module. You can add drugs according to their name or description.
36-2
CHCS II User’s Manual
Block 1
Build 838
Rx Alternatives
Figure 36–3: Select Drugs Window
Follow the steps below to add a new drug:
1. On the RX Alternatives module, click Add New Drug to open the Select Drugs
window.
2. If you want to search for the drug by name, select Search against Generic Name.
3. If you want to search for the drug by description, select Search against Description.
4. In the Search Text field, enter the drug name or description.
5. Click Search.
6. Select the medication you want to add.
Note: Press the Ctrl key on the keyboard while you are selecting each medication to
select more than one medication.
7. Click Save. You are returned to the RX Alternatives module.
Tip:
If you do not see the
added medication(s),
on the RX
Alternatives module,
click Refresh.
36.4 Adding Therapeutic Alternatives
The Select Therapeutic Alternative window allows you to add therapeutic alternative
drug cost information to the RX Alternatives module for selected primary drugs. You
can add therapeutic alternatives according to their name or description.
Note: You must have a primary drug selected before you can add a therapeutic alternative.
Block 1
Build 838
CHCS II User’s Manual
36-3
Rx Alternatives
Figure 36–4: Select Therapeutic Alternative Window
Follow the steps below to add therapeutic alternatives:
1. On the RX Alternatives module, click Add Therapeutic Alt to open the Select
Therapeutic Alternative window.
Tip:
If you do not see the
added medication(s),
on the RX
Alternatives module,
click Refresh.
2. If you want to search for the drug by name, select Search against Generic Name.
3. If you want to search for the drug by description, select Search against Description.
4. In the Search Text field, enter the drug name or description.
5. Click Search.
6. Select the medication you want to add.
7. Click Save. You are returned to the RX Alternatives module.
36.5 Deleting a Drug
Follow the steps below to delete a drug from the RX Alternatives module:
1. In the RX Alternatives module select the primary or alternative drug you want to
delete.
2. On the action bar, click Delete Drug.
Tip:
If you want to delete
the therapeutic
alternative but keep
the primary drug, in
the Therapeutic
Alternative area,
select the alternative
and click Delete.
36-4
3. At the Delete Drug Ranking confirmation prompt, click Yes.
CHCS II User’s Manual
Block 1
Build 838
37.0 SCREENING (REASON FOR VISIT)
37.1 Screening Overview
The Screening module allows for the documentation of the screening information;
from the reason for visit, to injury and accident details, female specific information,
and Wellness Reminders.
The Screening module is made up of two tabs:
•
Reason for Visit: Allows you to document why the patient has an appointment
and other screening information.
•
Due Reminders: Displays due reminders from the Wellness module as health
maintenance items for the patient.
Figure 37–1: Military Clinical Desktop—Screening Module—Reason for Visit Tab
37.2 Adding an Additional Provider
An additional provider can be added to an encounter to receive credit for work performed on a patient.
Follow the steps below to add an additional provider:
1. On the Action bar, click Add Providers. The Provider and Roles window is displayed.
Block 1
Build 838
CHCS II User’s Manual
37-1
Screening (Reason for Visit)
Figure 37–2: Providers and Roles Window
2. Select the type of clinician you want to add.
3. In the Additional Provider #1 area, click the ellipsis button to search for a provider. The Clinician Search window opens.
Figure 37–3: Clinician Search Window
4. In the Last Name field, enter the last name of the desired clinician.
5. Select a facility from the drop-down list.
6. Select a clinic from the drop-down list.
7. Click the Find only clinicians who have login accounts on this system to view
only providers associated with CHCS II.
8. Click Find. The results are displayed in the bottom half of the Clinician Search
window.
9. Select the desired clinician.
10. Click Select. The name populates in the Additional Provider field on the Provider and Roles window.
37-2
CHCS II User’s Manual
Block 1
Build 838
Screening (Reason for Visit)
11. Click the Role drop-down list to select the additional provider’s role.
Note: Repeat steps 2-11 if you want to add a second additional clinician.
12. Click OK. The clinician(s) is(are) added to the appointment.
37.3 Documenting the Reason for Visit
Follow the steps below to document the reason for visit:
1. On the Reason For Visit tab, select a reason for the visit from one of the following
areas:
•
Patient Problem List: Displays entire history of the patient's past problems.
•
Clinic Favorites List: Displays a list of reasons specific to the clinic.
•
Search: Allows you to select a reason not listed in the Patient Problem List or
the Clinic Favorites List. Enter the desired reason (a minimum of two letters
must be typed) in the search field and click Find Now to conduct a search.
The search results appear in the third column.
2. Click Add. The selected reason displays in the Selected Reason(s) for Visit area.
Figure 37–4: Reason for Visit Tab
Note: Reasons from the patient's problem list are marked as Follow-Up and reasons
from the other lists are marked as New. Select the reason for visit and click in
the New vs. Follow-up column to change the status. A drop-down list displays, allowing a new selection.
Block 1
Build 838
CHCS II User’s Manual
37-3
Screening (Reason for Visit)
3. Click inside the Comments field next to the reason for visit to enter additional
comments for the selected reason for visit.
Note: You can also add general comments at the bottom of the module.
4. Complete the following:
•
Appointment Classification: This is determined by CHCS and cannot be
changed.
•
Special Work Status: Click Spec Wrk Status to view the Special Work Status window. Click the checkbox next to the applicable work status and click
Save.
•
Related to Injury/Accident?: If the appointment is related to an injury or an
accident, select this checkbox. The Date and Related Cause Code window
appears.
Figure 37–5: Date and Related Cause Code Window
•
Complete all fields and click OK. Notice the checkbox indicating that the
date and Related Cause Code have been entered.
Note: An encounter marked as related to an injury or accident is required to contain
an E-code as one of the diagnoses. A notification appears when you attempt to
close the A/P module or sign the encounter if the encounter is marked as
related to an injury or accident and no E-code (diagnosis) was selected.
5. Click OK.
37.4 Adding Female Only Data
The fields associated with Female Only Data display for female patients 12 years of
age or older.
37-4
CHCS II User’s Manual
Block 1
Build 838
Screening (Reason for Visit)
Follow the steps below to add female only data:
1. In the Female Only Data area, select the checkboxes to all the fields that apply.
•
Pregnant
Note: If the patient is pregnant, the Last Menstrual Period and the Estimated DOB
are required fields.
•
Post Menopause
•
Post Hysterectomy
•
Last Menstrual Period: Select this checkbox to activate the date drop-down
field. Select the appropriate date.
•
Estimated DOB: Select this checkbox to activate the date drop-down field.
Select the appropriate date.
Note: On the electronic SF600, the estimated DOB is written as the EDC (Estimated
Date of Confinement).
•
Birth Control Method: Click the checkbox next to the appropriate birth control method.
•
G, P, A, LC: Click the drop-down list and select the appropriate value.
37.5 Verifying Allergies
In every encounter, it is important to verify the patient’s current allergies. The Screening module is the only module in the workflow where you can document patient allergies in the encounter note.
Follow the steps below to verify a patient’s allergies during the screening process:
1. Click Verify Allergy on the Action bar. You are transferred to the Allergy module.
2. Verify the patient’s allergies in the Allergy module and click the Verified this
Encounter checkbox. This documents that the allergies have been verified on the
Patient Encounter.
3. Close the Allergy module to return to the Screening module.
Block 1
Build 838
CHCS II User’s Manual
37-5
Screening (Reason for Visit)
Figure 37–6: Verifying Allergies
37.6 Managing the Wellness Reminders
Wellness Reminders can be reviewed and addressed through the Screening module.
Tip:
These are the same
reminders found
under Healthcare
Maintenance in the
Remiders pan and
below the Folder List
on the Due
Reminders tab in the
Wellness module.
Follow the steps below to manage the wellness reminders:
1. Click the Due Reminders tab in the Screening module. A list of Healthcare Maintenance items display in the tab.
Figure 37–7: Due Reminders Tab (Screening Module)
2. Double-click a reminder. The Due Reminders tab in the Wellness module opens.
37-6
CHCS II User’s Manual
Block 1
Build 838
Screening (Reason for Visit)
Figure 37–8: Due Reminders Tab (Wellness Module)
3. Document the selected due reminder.
4. When you have completed documenting the due reminder in the Wellness module,
close the Wellness module to return to the Due Reminders tab in the Screening
module.
Block 1
Build 838
CHCS II User’s Manual
37-7
Screening (Reason for Visit)
37-8
CHCS II User’s Manual
Block 1
Build 838
38.0 SCREENING NOTIFICATION
38.1 Screening Notification Overview
The Screening Notification module allows you to notify patients via e-mail or letter
when a wellness reminder is scheduled. The Screening Notification module interfaces
with the Wellness module in tracking wellness reminders.
The Screening Notification module allows you to search for patients by Defense Medical Information System ID (DMIS ID) or Primary Care Manager (PCM).
Figure 38–1: Military Clinical Desktop—Screening Notification Module
38.1.1
In More Depth
Patients listed in the Screening Notification module have a date in the corresponding
wellness reminder column that determines when they need to be notified. The user can
notify patients by e-mail or letter. The Properties dialog box is used to determine how
the patient is notified. The properties selected become the user's default settings.
Screening service results depend on the selected wellness reminder and the number of
patients scheduled to be notified for the reminder. Viewing results for an entire DMIS
ID may produce extensive feedback and take an extended amount of time; therefore, it
may be more beneficial to view results for a specific PCM.
Block 1
Build 838
CHCS II User’s Manual
38-1
Screening Notification
38.2 Selecting Screening Notification Reminder
Search Options
Screening service results depend on the selected wellness reminder and the number of
patient(s) scheduled to be notified for the reminder. Viewing results for an entire
DMIS ID may produce extensive feedback and take an extended amount of time;
therefore, it may be more beneficial to view results for a specific PCM.
Follow the steps below to select Screening Notification reminder search options:
1. Click Change Selections, the Screening Notification Reminder Search Options
window opens.
Figure 38–2: Screening Notification Reminder Search Options Window
2. In the Available Reminder(s) list, select the reminder(s).
38-2
CHCS II User’s Manual
Block 1
Build 838
Screening Notification
3. Click the Associate Down Arrow button to move the reminder to the Selected
Reminder(s) list.
Note: Select the available reminders while pressing the Ctrl key on your keyboard
to select multiple reminders.
Note: Clicking the Associate All Down Arrow button moves all the Available
Reminders to the Selected Reminders list.
Note: Selected reminders can be removed from the Selected Reminders list by
selecting the reminders and clicking the Unassociate Up Arrow button.
4. Do one of the following:
•
If you want to search by DMIS ID, select the DMIS ID radio button and click
Search.
•
If you want to search for patients associated with a primary care manager,
select the PCM radio button and click Search to search for the provider.
Note: Performing a search for patients associated with a DMIS ID may take an
extended period of time.
5. If you want to filter reminders by reminder date, select the Narrow Result(s) By
Due Date checkbox and select the applicable date range.
6. If you want to include patients who have already been notified, select the Include
Patients Who Have Been Previously Notified checkbox.
7. Select a Method of notification from the drop-down list.
8. If you want to filter reminders by notification date, select the Narrow Result(s)
By Date Notified checkbox and select the applicable date range.
9. Click OK.
Block 1
Build 838
CHCS II User’s Manual
38-3
Screening Notification
Figure 38–3: Screening Notifications
38.3 Notifying Patients about Screening
Services
Patients listed in the Screening Notification module have a date in the corresponding
wellness reminder column that determines when they need to be notified, either by email, letter, or both.
Follow the steps below to notify patients about future screening services:
1. Select a patient(s) and double-click the Notify checkbox(es).
2. Click Notify on the Action bar to open the Notification Options window.
3. Select a notification option and click OK.
•
38-4
If you are notifying the patient by letter, the Print Preview window opens displaying a form letter for the patient you are notifying.
CHCS II User’s Manual
Block 1
Build 838
Screening Notification
Figure 38–4: Print Preview Window
•
Click the printer icon.
•
On the Print window, click OK. The letter(s) is sent to your designated
printer.
•
If you are printing labels, a Notification Reminders window opens. Click
Yes when you have manually loaded the printer with label-specific paper.
Click No if you are not printing envelope labels.
Tip:
The patient’s postal
and e-mail
addresses are
maintained in the
Demographics
module and can be
modified, if
necessary.
Figure 38–5: Notification Reminders Window
•
If you are notifying the patient by e-mail, the E-Mail Notifications window opens. Click Yes to send the patient a form e-mail notifying him/her
of the due screening service(s).
Note: The letter and e-mail notifications contain the same information, they are just
sent using different methods.
Block 1
Build 838
CHCS II User’s Manual
38-5
Screening Notification
38-6
CHCS II User’s Manual
Block 1
Build 838
39.0 SIGN ORDERS
39.1 Sign Orders Overview
The Sign Orders module allows you to validate orders submitted by non-providers.
When a non-provider submits a consult, lab order, radiology procedure, or medication
for a patient encounter in the A/P module, the assigned provider receives notification
that an order was entered on your behalf by the non-provider. The order’s status is
pending until you sign the order.
Figure 39–1: Sign Orders Alert
39.2 Cancelling a Non-Provider Order
The Sign Orders module lets you cancel orders entered by non-providers in the A/P
module.
Follow the steps below to cancel a non-provider order:
1. On the Sign Orders module, select the order(s) you want to cancel.
2. Click Cancel Selected Orders. A confirmation window appears.
3. Click Yes. The order(s) is removed from the Sign Orders module.
39.3 Signing Non-Provider Orders
The Sign Orders module allows you to validate orders entered by non-providers in the
A/P module. You do not need to have the patient’s encounter open to sign the order(s).
The Sign Orders icon displays in the patient ID line when you have orders that need to
be signed.
Follow the steps below to sign non-provider orders:
1. On the Sign Orders module, select the checkboxes for the order(s) you want to
sign.
2. Click Sign Selected Orders. The order(s) is removed from the Sign Orders module.
Note: If you want to sign all orders listed, click Sign All Orders. If you want to
view detailed information about the order, expand the order by clicking the
small plus (+) next to the order. If you want to expand all orders in the workspace, click Expand All.
Block 1
Build 838
CHCS II User’s Manual
39-1
Sign Orders
39-2
CHCS II User’s Manual
Block 1
Build 838
40.0 SUBJECTIVE/OBJECTIVE (S/O)
40.1 Subjective/Objective Overview
The S/O module is used to document the S/O portion of the note. Terms to describe
the exam findings are available to select into the note. Each term is coded and those
codes are one of the elements used to determine the E&M code in the Disposition
module. Templates and AIM Forms are used to rapidly document the patient visit.
Once the exam is documented and saved, the notes appear in the Encounter module.
The S/O module provides you with two different ways to document the encounter:
with an S/O template or with an AIM (Alternate Input Method) Form. Each of these
means enables you to document your findings with structured terms for a patient
encounter and enables you to produce accurate and complete coding. Templates can
be either user-created or provided with the system, while the forms are provided to
each clinic and MTF by the appropriate service. In this chapter we cover using both
templates and forms to document the S/O portion of an encounter.
Figure 40–1: Military Clinical Desktop—Subjective/Objective Module
Note: The use of this software is not intended to suggest or replace any professional
medical judgment, decisions, or actions with respect to a patient's medical
care. The user of this software must monitor and verify the input to the software and determine the accuracy, completeness, or appropriateness of any
diagnostic, clinical, or medical information, or other output provided by the
software.
Block 1
Build 838
CHCS II User’s Manual
40-1
Subjective/Objective (S/O)
40.1.1
In More Depth: Navigating and Using S/O
To navigate and use the S/O module, you need to be comfortable with several key concepts.
40.1.1.1 Navigating within the Module
To navigate within the module, simply use the S/O module tabs located along the left
margin of the workspace. These tabs correspond to the basic functional areas of S/O
and the sections in the encounter document and note.
40.1.1.2 Adding Terms
To add a term to the note, simply select the large plus or minus sign. When selected,
this sign becomes red (+) or blue (-). There are exceptions for more advanced users,
but generally, adding a term as positive means that it is an abnormal finding and adding a term as a negative denotes a normal finding.
40.1.1.3 Using the S/O Toolbar (Dashboard)
The S/O toolbar is a sophisticated and essential component of S/O documentation. It
enables you to add a range of detailed and explanatory information to any term you
add. As you’ll see in this lesson, selecting a term in the MEDCIN hierarchy populates
the term in the dashboard.
This means that the dashboard is focused on that term. The various elements of the
dashboard represent different functions for adding to or modifying the selected term.
We use this dashboard to add free-text to a note, document the duration of a condition,
and specify a term as a family history term. And perhaps most importantly, in this lesson you learn how to use AutoNeg to rapidly document normal findings.
40.1.1.4 Using the Narrative Pane
To the right of the S/O module is the narrative pane, which displays the narrative for
this encounter based on the terms selected and the modifiers added to these terms. The
narrative as it appears in this pane, is identical to the narrative that appears in the
encounter note.
In terms of an S/O workflow, these four key concepts work together to create an effective tool that is easy to use:
1. Use the tabs to get where you need to be.
2. Use the MEDCIN terms to document the patient visit.
3. Use the toolbar to add detailed and specific information to a selected term.
4. Use the narrative pane to see how your documentation is read in the encounter
note.
40-2
CHCS II User’s Manual
Block 1
Build 838
Subjective/Objective (S/O)
40.2 S/O Templates Overview
Use of a template to document a patient visit is a key feature of CHCS II. Template
use greatly streamlines the documentation process and ensures that coding is accurate
and complete when the encounter is done.
A template pre-positions clinical terms for rapid entry and reflects how providers typically document encounters. If a template is created correctly, a provider should be
able to, with minimal clicks, document a normal exam. Personal templates should be
built and utilized to use the S/O module efficiently. Templates should match the common visit types you see and include terms from each of the following:
•
Physical Exam (PE): A good PE section includes items that are typically
reviewed for each physical exam.
•
Review of Systems (ROS): Each provider has a list of questions that is asked of
every patient in regards to the ROS. Therefore, the section should reflect those
questions. A comprehensive ROS section can be included in a template with a
large repository of findings to deal with “oh, by the way” situations.
•
Past Medical History (PMH): The PMH section deals with common questions
concerning previous hospitalizations and family and social history. Again, findings should be selected that reflect what is normally asked of the patient.
•
Procedure (PROC): Procedure notes are blocks of free-text that cover routine
procedure, education, and informed consent notes. These can be added using the
free-text icon from the PE tab or by typing the free-text to an actual term (e.g.,
attaching a procedure note to the term skin biopsy).
•
History of Present Illness: This section includes the chief complaint and common symptoms based on the theme of the template.
40.2.1
Putting It into Practice
When a patient has a common reason for an appointment, for example, asthma followup, the provider simply loads the Asthma Template that contains the appropriate terms
(PE, ROS, PMH, PROC). If, in the process of the exam, the patient complains of a
sore throat, the provider can load just the Sore Throat template to document the “oh,
by the way” symptom.
40.2.2
Selecting an S/O Template
The most efficient way to document the S/O note is to use an S/O template that you
have customized. Once a template is loaded, there are various approaches to document
findings from certain tabs. Generally, positive or abnormal findings are documented
first in order to capitalize on the AutoNeg function. This can be done on the HPI,
ROS, and PE tabs.
Follow the steps below to select an S/O template:
1. Click Template Mgt. from the Action bar to view the S/O Template Management
module.
Block 1
Build 838
CHCS II User’s Manual
40-3
Subjective/Objective (S/O)
Figure 40–2: S/O Template Management Module
2. Search for the desired template by typing in the name or type of the template
(URI, visit).
3. Click Find Now to view the templates that meet the search criteria.
4. Select the template and click Load on the Action bar.
Note: S/O templates are displayed with the
icon. The
icon delineates an S/O
Form.
Figure 40–3: Loaded Template
40-4
CHCS II User’s Manual
Block 1
Build 838
Subjective/Objective (S/O)
5. After a template is loaded, terms from the template are displayed on the appropriate tabs. If there is a small plus sign next to a parent term, click it to expand the list
and view the associated children terms. A small minus sign indicates the term has
been expanded completely.
Figure 40–4: Parent/Child Relationship
40.2.3
Documenting from the HPI Tab
Figure 40–5: HPI Tab
Block 1
Build 838
CHCS II User’s Manual
40-5
Subjective/Objective (S/O)
Follow the steps below to document from the HPI tab:
1. Document all the positive or abnormal findings first by clicking the large plus sign
next to the term. The selected terms are added to the Narrative pane under the History of Present Illness (HPI) heading.
2. Once all the positive or abnormal terms have been selected, click AutoNeg to
document the rest of the terms as normal findings.
Note: One can document rapidly and accurately using the AutoNeg function. This is
active only for the Symptoms, Review of Systems, and Physical Exam tabs.
Clicking AutoNeg enters all the top-level, parent findings in the list as negative or normal. This is extremely helpful for physical exams and review of
systems.
3. Click the opposite sign to change a finding. Click the sign that was selected to
delete it.
4. If desired terms are not present on the template or the HPI needs to be characterized, a subjective free-text note can be added. Click the Notepad icon in the upper
right corner of the findings list.
5. Enter the note.
Figure 40–6: S/O Notepad
6. Click OK to add the note to the encounter.
40.2.4
Documenting from the PMH Tab
In order to document from the History (PMH) tab, simply add positive or negative
responses to the terms by clicking the large plus or minus sign.
Note: The AutoNeg function cannot be used on the PMH tab.
40-6
CHCS II User’s Manual
Block 1
Build 838
Subjective/Objective (S/O)
Figure 40–7: PMH Tab
40.2.5
Documenting from the ROS Tab
Figure 40–8: ROS Tab
To document from the ROS tab, document the positive or abnormal findings first by
clicking the large plus sign next to the term. Click AutoNeg to document the rest of
the findings as normal. Be careful when using AutoNeg as all items must be discussed.
Block 1
Build 838
CHCS II User’s Manual
40-7
Subjective/Objective (S/O)
40.2.6
Documenting from the PE Tab
Figure 40–9: PE Tab
Follow the steps below to document from the PE tab:
1. Document all the positive or abnormal findings first by clicking the large plus sign
next to the term.
2. Once all the positive or abnormal terms have been selected, click AutoNeg to
document the rest of the terms as normal.
Note: The use of the AutoNeg function assumes the template has been customized
to fit your workflow. If you own the template, the narration for normal findings is already known and can be added with confidence.
3. Once all findings are documented, click Close to save the note and return to the
Encounter.
40.2.7
Adding Details to a Finding
Once a term has been selected from the findings list, it is displayed in the Entry
details for Current Selections field and in the Narrative pane. Use the S/O Tool bar
or the Dashboard to further explain the finding.
Figure 40–10: Toolbar and Dashboard
40-8
CHCS II User’s Manual
Block 1
Build 838
Subjective/Objective (S/O)
Follow the steps below to add details to a finding:
If the button is not
appropriate for the
selected finding, it is
grayed out.
1. Select the term in the Findings list.
2. Select the desired detail or modifier:
•
ROS (Review of Systems): Flips the highlighted finding between the Review
of Systems and History of Present Illness headings.
•
History: Sets the prefix to History of, then adds the current finding to the
documentation.
•
Family History: Sets the prefix to Family History of then adds the current
finding to the documentation.
•
Entry Details for Current Selection Free-Text Field: Enter in any additional information in the free-text field next to the Entry Details For Current
Selection field and press Enter. The ellipse button displays the entire freetext field.
•
Duration and Onset: Click the grid to enter the associated date.
•
Modifier and Unit: Access the pull-down menus to add the adjective to the
finding.
•
Value: Enter in the appropriate value.
40.2.8
Tip:
Using the Search Capabilities
Use one of the following tools to search for specific terms or to dynamically build a
Visit template. Each tool is found on the Action bar.
40.2.8.1 Find Term
This feature searches for a term in the MEDCIN terminology. This conceptual search
returns terms relevant to the search text regardless of spelling. Abbreviations such as
HTN (hypertension) or CHF (congestive heart failure) are recognized.
1. Click Find Term from the Action bar to view the Search String window.
Figure 40–11: Find Term Search String
2. Enter the desired term and click Search.
40.2.8.2 Dx Prompt
This feature creates a list of findings based on one or more selected diagnoses. This is
helpful when adding the history of present illness to a visit template or when building
a visit template on the fly.
1. Click Dx Prompt from the Action bar to view the Search String window.
Block 1
Build 838
CHCS II User’s Manual
40-9
Subjective/Objective (S/O)
Figure 40–12: Dx Prompt Search String
2. In the Search String window, enter the diagnosis and click Search.
3. In the Select Diseases for Consideration window, select the appropriate disease
and click OK. A template relevant to the term selected is displayed. Use the List
Size button to control the number of terms on each tab.
Figure 40–13: Select Diseases for Consideration
40.2.8.3 Prompt
This feature builds a finding list based on a single highlighted term.
1. Highlight a term from the Findings list.
2. Click Prompt on the S/O Tool bar.
Tip:
This tool is helpful for
multi-symptom
patients. You may
want to see a list of
relevant terms for
consideration to help
document the note.
40.2.8.4 I-Prompt (Intelligence Prompt)
This feature builds a list of terms based on the documentation in the Narrative pane.
Once terms have been documented, click I Prompt on the S/O Tool bar to view a list
of additional terms that might also be considered.
40.2.8.5 List Size
This feature creates a broader or narrower list of findings. Three levels exist: short
(List Size 1), medium (List Size 2), and long (List Size 3). Use List Size after conducting a Find Term, Prompt, Dx Prompt or I Prompt.
40-10
CHCS II User’s Manual
Block 1
Build 838
Subjective/Objective (S/O)
40.2.8.6 Browse from Here
This feature displays the highlighted finding as it appears within the MEDCIN terminology. Related Findings can be seen and selected.
1. From the Findings list, select the term to be located.
2. Click Browse from Here on the Action bar.
40.2.9
Tip:
The Browse from
Here function is
helpful when locating
PE terms.
Importing/Exporting an S/O Template
An S/O template can be imported or exported from other facilities using CHCS II.
Follow the steps below to export an S/O template:
1. From the S/O Template Management module, select the template to export.
2. Click Export from the Action bar to view the Export S/O List Template window.
Figure 40–14: Export S/O List Template Window
3. Select the desired location for the template, type in the name of the template, and
click Save.
Follow the steps below to export multiple templates:
1. Select the templates to export by holding down the Ctrl key.
2. Click Export from the Action bar to view the Select Export Path window.
Figure 40–15: Select Export Path Window
3. Select the location for the exported templates and click OK.
Block 1
Build 838
CHCS II User’s Manual
40-11
Subjective/Objective (S/O)
Follow the steps below to import a template:
1. From the S/O Template Management module, click Import from the Action bar to
view the Import MEDCIN Template window.
Figure 40–16: Import MEDCIN Template Window
2. In the left pane, navigate to the location of the template(s). Once the location is
determined, the available templates are displayed.
3. Select the template(s) to be imported and use the arrow keys to move the templates to the Selected Templates column.
4. Click Import to save the template(s) as is. Click Edit to open the template in
Template Edit mode to add or remove terms prior to saving.
Note: If a template currently exists with the same name as a template being
imported, a message is displayed asking whether or not to override the existing template.
40.3 S/O Template Personalization Overview
CHCS II contains a list of common templates as a starting point. Though these are
helpful, there will be times when clinicians need to customize their own templates to
optimize the use of the application in clinical practice. Templates are the key to rapid
documentation and accurate coding.
The first step to creating a useful set of templates is to review the templates that currently exist. Each service has created their own set of templates that have been
reviewed. Identify the templates that fit with your documentation style and physical
exams for the most common visit types you see. Once identified, use these templates
as you see patients to become familiar with the terms on the template as well as the
terms that are not on the template.
As you begin to familiarize yourself with the templates, you may notice that some
templates do not exactly meet your documentation style. This is where the personaliztion comes in. Each template can be edited to match your personal style.
This section will cover the key skills needed when editing a template.
40-12
CHCS II User’s Manual
Block 1
Build 838
Subjective/Objective (S/O)
40.3.1
Editing a Template
A template can be edited using Template Edit mode. It allows for quick addition or
removal of terms as well as easy merging of component templates.
Follow the steps below to edit a template:
1. From the S/O Template Management module, import the VISIT--URI Brief template provided by your instructor.
2. Highlight the template and click Edit from the Action bar to view the template in
Edit Mode.
Figure 40–17: Template Edit Mode
40.3.1.1 Removing Terms from the Template
In this scenario remove the following terms:
•
nasal passage blockage (stuffiness)
•
skin symptoms
•
yellow sclera (icterus)
To remove terms from the template:
1. Locate and select nasal passage blockage from the template outline. The finding is
displayed in the findings list on the left.
2. Select the plus sign in the MEDCIN tress to remove the finding.
3. Complete the steps above to remove the two other findings.
New findings can be added by using one of the search capabilities to locate and select
the finding. Once selected, the new term is added to the outline on the right. We will
look at these search capabilities as they are used to add terms to the different sections
of the template.
Block 1
Build 838
CHCS II User’s Manual
40-13
Subjective/Objective (S/O)
40.3.2
Personalizing the Physical Exam Section
When personalizing any PE section of a template, keep in mind the AutoNeg function.
If a template is built correctly, documentation of a normal PE can be done by clicking
AutoNeg.
Because so much of your physical exams are normal, the AutoNeg capability is especially well suited to this section--as is the approach we teach here—the approach of
documenting by exception.
As we discussed earlier, AutoNeg enables you to automatically—and with a single
click—document all normal findings from a template.
In this lesson, we cover several key concepts. These concepts are key to understanding
how to add terms to the PE section and are discussed in more detail later in this lesson.
•
Bilateral structures. Bilateral structures are the two sides or halves of the same
organ—in this lesson, the right and left ears. Adding bilateral structures enables
you to document that you checked both parts of the structure. In this case, our
template lets us document that we checked both tympanic membranes for
erythema.
•
Common positives. Common positives are terms contained within a parent term
that you commonly find as abnormal findings with your patients. Adding common
positives enables you to document frequently abnormal findings while still using a
parent term to document the normal finding.
•
Free-text added to a Term: Free-text can be added to an individual finding for
clarification. For example, if the finding 'Lymph Node: Normal' needs to be clarified to state there are no nodules present, highlight the finding Lymph Nodes:
Normal and enter the desired text in the free-text field in the dashboard. Press
Enter to add the note to the Narrative pane.
40.3.2.1 Setting the Scene
In this demonstration, we build a PE template for a routine URI exam.
In our routine physical exam, we normally:
•
Examine the left and right tympanic membranes for erythema
•
Check for nasal discharge and frequently find either mucoid or purulent discharge
•
Examine the neck, and, if normal, we qualify normal by writing: neck: normal
with no thyromegaly.
40.3.2.2 Adding Bilateral Structures
Now let's continue personalizing our template by adding our routine exam of the left
and right tympanic membranes for erythema.
To add these terms, we use the skill of adding bilateral structures. We use this skill
when we want to document two sides or halves of the same organ—in this case, the
right and left ears.
40-14
CHCS II User’s Manual
Block 1
Build 838
Subjective/Objective (S/O)
To add this bilateral structure, we use a basic search capability of MEDCIN—the
Browse from Here feature. This feature enables you to search through the MEDCIN
hierarchy to find the terms you want.
When displayed with this feature, the MEDCIN hierarchy is organized by organ system—so we'll be exploring the Ears term to find the terms we want.
To add bilateral structures:
1. With the template in Template Edit mode, select the Nasal Discharge term from
the outline and click Browse from Here in the Action bar. The MEDCIN hierarchy appears in the left pane of the workspace.
2. Now, we close the Nose term and expand the Ears term, then navigate to the
Tympanic Membrane term and open it.
3. The Tympanic Membrane term contains an Erythematous term, so we open it.
4. We're now ready to add our bilateral structures—as this term contains both right
and left ears as terms. So we select both terms to add to the template.
Note: Adding bilateral structures enables you to document that you checked both
parts of the structure. In this case, our template lets us document that we
checked both tympanic membranes for erythema.
Figure 40–18: Bilateral Structures
40.3.2.3 Adding Common Positives
The second part of our physical exam for a URI patient is our examination for nasal
discharge.
We want our template to reflect that we examine the patient for nasal discharge, and,
more specifically, we frequently find either purulent or mucoid nasal discharge.
Block 1
Build 838
CHCS II User’s Manual
40-15
Subjective/Objective (S/O)
We want our template to enable us to document that we examined the patient for nasal
discharge and to identify, if applicable, the type of discharge we find.
To do this, we use the skill of adding common positives to add the general nasal discharge term as well as the more specific mucoid and purulent discharge terms.
To add common positives:
1. Start by opening the Nose term. We can see that Nasal Discharge is available as
one of its children terms and is already part of the template.
2. Since we also want more specific terms in our template, we open the Nasal Discharge term and see both Mucoid and Purulent as children.
3. Those are the two terms we want, so select both terms.
Figure 40–19: Adding Common Positives
40.3.2.4 Why Add Common Positives?
Adding common positives enables you to document frequently abnormal findings
while still using a parent term to document the normal finding.
Now, when I'm using this template for a patient with a normal finding, Nasal Discharge is added as a normal finding when we click AutoNeg.
But, for a patient where we find one of these types of discharge, we can manually add
the common positive to document the specific type of discharge.
This is the value of embedding common positives in your template—cover a normal
finding with the parent term yet have the flexibility, with an abnormal finding, to be
specific about the findings.
40.3.2.5 Adding Free-Text to a Term
The final skill we use in the PE section is adding free-text to a term.
40-16
CHCS II User’s Manual
Block 1
Build 838
Subjective/Objective (S/O)
This skill is used when you cannot find an exact match for how you write a note—and
you want to essentially customize an existing term to reflect your documentation style.
In this demonstration, add free-text to a term so the template reflects the current note,
written for a normal neck exam—neck: normal, supple with no thyromegaly.
To add free-text to a term:
1. Let’s start by opening the Neck term. With the term open, we don't see an available term that matches our written note.
2. Now, to add a customized term, start by adding Neck as a negative finding. The
term populates the details section at the top of the workspace.
3. In the associated details field, enter the free-text note: (supple with no thyromegaly). We enter this free-text in parentheses so we can differentiate it from the
structured term in the note.
4. Press Enter on the keyboard.
5. We can see the free-text note in the narrative pane.
6. Now, in our physical exam, if a patient has a normal neck finding, clicking
AutoNeg populates the narrative pane with our normal note.
Figure 40–20: Adding Free Text
40.3.3
Personalizing the ROS and HPI Sections
The ROS and HPI sections of the template are both made up of symptoms so they use
the same portion of the MEDCIN tree, the Symptoms. One symptom cannot be in both
sections so providers routinely decide which terms should be in the ROS section and
which terms should be in the HPI. Because the two areas use the same term set, this
lesson will focus on the skills needed to add terms to both sections.
In this lesson, we cover several key template-editing skills, including:
•
Use Find Term to locate terms in MEDCIN
Block 1
Build 838
CHCS II User’s Manual
40-17
Subjective/Objective (S/O)
•
Use the ROS/HPI Button when ROS term is HPI
•
Use the Prompt to locate terms
•
Use List Size to expand the search
•
Use the Dx Prompt to locate terms
These concepts are key to understanding how to edit templates and are discussed in
more detail later in this lesson.
•
FindTerm: This feature, available in the S/O action bar, enables you to search for
terms directly in the MEDCIN hierarchy. In this lesson we show you how to find
dizziness in the MEDCIN hierarchy.
•
Prompt: This feature uses the term you select in the MEDCIN hierarchy—dizziness in this case—as the search value and returns terms related conceptually to
that term. To use this feature, which is available in the S/O dashboard, select the
term you want, then click Prompt. The conceptual matches populate the workspace.
•
List Size: By design, CHCS II displays a limited set of search results--the most
likely relevant results based on the diagnosis you searched for. The ListSize button, available in the dashboard, enables you to view these longer lists of terms.
•
Dx Prompt: This feature allows you to search for a list of terms that are conceptually related to a specific diagnosis. Be careful with this search - it only works with
a diagnosis as the search value.
40.3.3.1 Setting the Scene: Symptom
We are building this template to cover our standard terms for a patient complaining of
dizziness, UIR symptoms, and pharyngitis, so we will add terms relative to each
theme.
In our ROS, we ask the patient about several symptoms, including:
•
Dizziness
•
Palpitations
•
Fainting
•
Disorientation
In the HPI, we want the following symptoms:
•
Headaches
•
Swollen glands in the neck
•
Difficulty swallowing
To edit the template:
1. In the Action bar, click Find Term. Find Term enables us to search for dizziness
as a term as we begin building our template.
2. In the search window, enter dizziness and click Search. We are returned to the HPI
tab of the S/O module.
40-18
CHCS II User’s Manual
Block 1
Build 838
Subjective/Objective (S/O)
3. Click ROS because that is where we want to term to be located.
4. Start by adding Dizziness to the template. The Find Term feature did not return
the rest of the terms we want for this template.
Figure 40–21: ROS Tab
5. We’re now going to use another search feature—the Prompt feature. This feature
uses the term you select in the MEDCIN hierarchy—dizziness in this case—as the
search value and returns terms related conceptually to that term.
6. To use this feature, with dizziness selected, click Prompt in the Dashboard.
7. The Prompt feature returns the terms related to our search value, but we have to
click ROS to return to the tab we want.
8. You can see two of the terms we want—Palpitations and Fainting—so add both
terms.
9. The search results, though, don't include the last term we want to add. To find this
term, click List Size in the Action bar, to expand the search.
10. Complete the ROS section by adding Disorientation.
11. The first term to be added to the HPI section is Headaches. This term is already in
the template but nder the ROS section. To move it to the HPI section, select the
term from the template outline.
12. Click ROS/HPI from the Dashboard. The term headache moves to the HPI section.
13. There are two more terms to locate for the HPI ssection. Because we are looking
to include terms related to pharyngitis, we can use the Dx Prompt. Click Dx
Prompt in the Action bar.
14. In the search field, enter pharyngitis and click OK.
15. In the Select Diesease for Consideration window, select pharyngits and click OK.
The MEDCIN tree is populated with terms related to the specified diagnosis.
Block 1
Build 838
CHCS II User’s Manual
40-19
Subjective/Objective (S/O)
16. Now we can add the last tow terms, swollen glands in the neck and difficulty swallowing.
40.3.3.2 Personalizing the PHM Section
In this lesson, you learn the concepts and skills associated with building a PMH template. The PMH section deal with common questions concerning previous hospitalizations, family, and social history.
Again, findings should be selected that reflect what the provider normally asks the
patient.
In this lesson, we cover several key concepts. These concepts are key to understanding
how to build PMH templates and are discussed in more detail later in this lesson.
Anchor terms. Anchor terms are high-level terms that correspond with the different
types of PMH information you can collect. They are a crucial part of any PMH template—they enable you to document PMH findings not already covered by your template, as you can add free-text to each of these terms to document the unforeseen
finding.
FindTerm. One of S/O’s basic search features, this enables you to search the database
of MEDCIN terms. In this lesson, we show you how this search returns the terms you
want by including them in more general terms or nodes.
40.3.3.3 Setting the Scene
To build this template, we start by adding the template’s anchor-terms. These anchor
terms--Past Medical History, Family Medical History (reported), and Social History-are simply terms that indicate the type of finding and enable you to add more detail by
adding free-text to the anchor.
For example, you can use the Family Medical History term to document a patient’s
family history for which you don’t have the appropriate term included in your template.
Including anchor terms enables you to document a patient answer or finding that is not
explicitly covered by a term included in the template.
With our anchor terms added to the template, we now move on to use the FindTerm
feature to find and add different types of PMH terms.
To build our template, we add terms for:
•
a social history of cigarette smoking
•
a personal history of hypertension
•
a family history of colon cancer
•
a procedure history of tonsillectomy to our template.
These terms reflect common types of PMH questions.
To build our PMH template, we employ several key skills:
•
40-20
using the two hidden MEDCIN nodes to locate diagnosis and procedure terms
CHCS II User’s Manual
Block 1
Build 838
Subjective/Objective (S/O)
•
using the dashboard to add prefixes to a term
•
using FindTerm feature to locate PMH terms
40.3.3.4 Adding Anchor Terms
When you personalize PMH sections, start by adding your anchor terms. By adding
these anchor terms, you allow for the flexibility to document any PMH finding not
included in your template—simply add the anchor term, then add free-text to the
anchor to document the condition.
To add our anchor terms:
1. The first step is to navigate to the History section of the MEDCIN tree. The easiest way to do this is by clicking the Browse tab and expanding History.
2. Expand Past Medical History and add Medical and Surgical / Procedural, Family
Medical History (reported), and Social History to the template.
Figure 40–22: PMH Tab
3. With our anchor terms added, we're now ready to add the rest of our terms to this
template.
40.3.3.5 Using Find Term
Though we've covered the Find Term search in previous lessons, there are several distinctive features when used to add to this section.
In this lesson, we use FindTerm for:
•
a social history search
•
a diagnosis search
•
a family history search
Block 1
Build 838
CHCS II User’s Manual
40-21
Subjective/Objective (S/O)
•
a procedure search
40.3.3.6 Social History Search
For our social history search, we want to add cigarette smoking to our template. To
locate this term we use the Find Term feature.
To find a social history term:
1. Click Find Term and search for cigarette smoking. The search results populate
the left pane.
2. Click the PMH tab and add Smoking Cigarettes.
Figure 40–23: PMH Tab
40.3.3.7 Diagnosis Search
For our diagnosis search, let's add hypertension to our template. Again, we use the
Find Term feature to locate this term.
To find a diagnosis term:
1. Click Find Term, and then search for hypertension. The search results populate
the left pane, but we don't see hypertension in the results.
2. We don't see hypertension because, with the Find Term feature, diagnoses terms
are located in the History of Diagnoses, Syndromes, and Conditions term—so
we open the term.
3. We now see Hypertension, so add it to the template.
40-22
CHCS II User’s Manual
Block 1
Build 838
Subjective/Objective (S/O)
Figure 40–24: PMH Tab
40.3.3.8 Family History Search
For our family history search, let's add colon cancer to our template. Again, we use
the FindTerm feature to locate this term.
To find a family history term:
1. With the PMH tab displayed, click Find Term, then search for colon cancer. The
search results populate the left pane, but we don't see colon cancer in the results.
2. Again, like the diagnosis search, terms for a family history search are contained
within the parent term History of Diagnoses, Syndromes, and Conditions—so
we open the term.
3. Colon cancer doesn't appear verbatim, but History of Large Intestine Neoplasm
Malignant does appear. This is because MEDCIN sometimes uses language and
terms from the World Health Organization for some of its conditions. Now, simply
add the term as a positive finding.
4. Because we want this term as a family history term, we need to define it as a family history term—so we click FamHist.
Block 1
Build 838
CHCS II User’s Manual
40-23
Subjective/Objective (S/O)
Figure 40–25: PMH Tab
40.3.3.9 Procedure Search
For our procedure search, let's add tonsillectomy to our template. Again, we use the
Find Term feature to locate this term.
1. With the PMH tab displayed, click Find Term, then search for tonsillectomy. The
search results populate the left pane, but we don't see tonsillectomy in the results-but we do see a History of Therapy term.
2. So open the term and see the search term.
3. Add History of Tonsillectomy.
Figure 40–26: PMH Tab
40-24
CHCS II User’s Manual
Block 1
Build 838
Subjective/Objective (S/O)
40.3.4
Saving the Template
1. When all findings are included in the template, click Save As from the Action bar
to view the Save List Note Template window.
Figure 40–27: Save List Note Template Window
2. On the Save List Note Template window, enter the name of the template using the
convention ‘VISIT--theme--[name].’ This organizes the templates together so they
can be easily found.
3. The template is automatically added to your Favorites List (unless the checkbox is
deselected). Select the Shared checkbox to make your template available to other
clinical team members.
4. Click Save to save the template. Cancel closes the module without saving the
template.
5. In order to test the template, load it into the encounter, click each tab, and practice
using a patient schenario. On the PE tab, simply click AutoNeg. The resulting
note should display an accurate narrative for a normal exam. Those findings that
are not selected should be the findings that are used to document any abnormalities. When using this template to see patients, document the abnormals first and
the click AutoNeg to denote all other findings as normal.
Block 1
Build 838
CHCS II User’s Manual
40-25
Subjective/Objective (S/O)
Figure 40–28: Personalized Template
40.3.5
Creating a Free Text Template
A free text template can be used for routine procedure, education, and informed consent notes.
Follow the steps below to build a free text template:
1. Click the PE tab and click Notepad to open the free text window.
Figure 40–29: Free‐Text Window
2. Enter the first words of the note the category of the template (e.g., “Procedure
Note:” or “Education Note:”).
3. Enter the rest of the free text.
4. Click Save and Close. The note is added to the Narrative pane.
40-26
CHCS II User’s Manual
Block 1
Build 838
Subjective/Objective (S/O)
5. Click Save As from the Action bar and name the template “PROC--[name]” or
“EDU--[name]” as appropriate.
Note: A free text note can also be attached to a structured test term. Highlight the
desired term (e.g., Skin biopsy) and add the procedure in the free-text field in
the Dashboard. Press Enter, then save the template.
6. Test the use of this template by loading it into an encounter. Remember to look on
the PE tab for the procedure note.
Figure 40–30: Procedure Note
40.4 MEDCIN Forms Overview
The MEDCIN Forms provide you with easy-to-use tools and a library of service-provided forms that enable you to document the S/O section of the patient encounter.
MEDCIN has over 250,000 clinical terms, subsets of which are grouped together in a
form. Each form is built around a theme, a diagnosis or a symptom.
These forms were created and approved by Tri-service clinical consultants. These consultants are collaborating to create a standard library of forms to be used DoD-wide.
MEDCIN Forms are an easy, streamlined way to complete the S/O documentation for
an encounter. You can think of MEDCIN Forms as an electronic version of paperbased overprints, helping to ease the transition from paper-based medical records to
electronic medical records.
Although in many ways forms and templates are simply two alternative ways of documenting S/O, there is a major difference that can help you determine which means to
use. The forms provided by the system cannot be edited or modified, which means
you are unable to customize a form to reflect your documentation style. If your style
Block 1
Build 838
CHCS II User’s Manual
40-27
Subjective/Objective (S/O)
matches the form provided, forms can be a very easy, streamlined way to complete the
S/O documentation for an encounter.
Figure 40–31: Military Clinical Desktop—MEDCIN Forms Tool
40.4.1
Loading a Form
To use a form to document the S/O portion of an encounter, you can either load the
form from the Quick-Load list or you can click Template Mgt. on the Action bar and
load the form there.
Follow the steps below to load with the Quick-Load menu:
1. In the encounter document, click S/O. The S/O module opens.
2. Display the Quick-Load menu by clicking the small down-arrow. The menu
appears.
3. Scroll through the menu to the form you want, then select it. The form populates
the workspace.
Note: All forms in the Quick-Load menu begin with AIM; Alternative Input
Method.
40-28
CHCS II User’s Manual
Block 1
Build 838
Subjective/Objective (S/O)
Figure 40–32: Military Clinical Desktop—Quick‐Load List
Follow the steps below to load a form from S/O Template Management:
1. Click Template Mgt from the Action bar to open the S/O Template Management
module.
Note: Forms are represented by the
icon.
Figure 40–33: S/O Template Management Module
Block 1
Build 838
CHCS II User’s Manual
40-29
Subjective/Objective (S/O)
2. Enter the name of the form in the Search field.
3. Click Find Now to view the forms that meet the search criteria.
4. Select the form and click Load on the Action bar.
5. After a form is loaded, it populates the S/O module.
40.4.2
Navigating a Form
Navigation in MEDCIN Forms is similar to the other modules in CHCS II. Use the
Action bar to perform basic actions in the MEDCIN Forms workspace. In addition to
the Action bar, you can also use the Forms Toolbar and Tabs to navigate within the
workspace.
40.4.2.1 Forms Toolbar
Figure 40–34: Forms Toolbar
The Forms Toolbar is located at the top of the workspace and provides you with formspecific functionality. This toolbar only appears when you have loaded a form and the
form populates the workspace. The toolbar contains six options.
These options are as follows:
40-30
•
AutoNeg: AutoNeg enables you to document all currently undocumented HPI or
ROS findings as False or to document that the patient denied the symptoms. On
the PE tab, it documents the statements as True or clinically normal. It is also a
dual-purpose option that enables you to automatically select all positive or all negative values for a displayed form page. In order use this option, simply click the
arrow to the right of the option, then select either AutoPos or AutoNeg. Selecting
one of the options populates the form with the type of value you chose.
•
Undo: This option enables you to undo your last actions. If you just selected a single item, clicking this option undoes that single action. If you have just clicked
AutoNeg or AutoPos, this option undoes that action completely, returning the
form to the previous state.
•
Details: Clicking this button displays the Details pane in the bottom of the workspace. In this pane you can add more detailed information for the finding selected
in the forms. In order to select a finding, single-click the finding you want, then
click Details.
CHCS II User’s Manual
Block 1
Build 838
Subjective/Objective (S/O)
Figure 40–35: Details
•
Browse: This option enables you to display the Browse pane in the workspace.
This pane populates one-third of the form. The Browse pane displays the child
term of a selected parent term. On the form, parent terms cause the cursor to
change to a question mark. Perform a right mouse click to view the child terms in
the Browse pane. Click Browse to remove the Browse pane after you have
selected the appropriate terms.
Figure 40–36: Browse
Block 1
Build 838
CHCS II User’s Manual
40-31
Subjective/Objective (S/O)
•
Shift Browse: Use this option to shift where the Browse pane appears. If it currently populates the right-third of the form, clicking this button moves the pane to
the left-third. You can use this option if you want to keep the Browse pane always
available as you move through the columns in a form.
•
Note View: This option enables you to navigate from the Forms tool to the traditional S/O layout, where you can see how your documentation is progressing
based on what you have selected in the form. Click Form View on the Toolbar to
return to the form view.
Figure 40–37: Note View
40.4.2.2 MEDCIN Forms Tabs
All of the forms included with the system use tabs to enable navigation from section to
section: History, Physical Exam, Help, and Outline view.
Click the tabs to navigate to different sections within the form.
40-32
CHCS II User’s Manual
Block 1
Build 838
Subjective/Objective (S/O)
Figure 40–38: Physical Exam Tab
40.4.2.3 MEDCIN Forms Workspace
The workspace uses three columns, with findings and terms and related options
included in each column. This is the basic view of a form, and the form is fully displayed.
The second view of a form is the Details view. You access this view by selecting a
term of finding in the form, then clicking Details in the toolbar. In the Details view,
you can add more detailed information to the term you selected, including a prefix,
modifier, onset date, or status.
40.4.3
Documenting S/O with a Form
Because of the number and diversity of the forms provided with the system, there are
different ways you can use each form to document the S/O for an encounter. In this
section we cover some of the basics of using a form.
40.4.3.1 Adding Terms
You should always view each finding as a statement that is either True or False. On the
History tab, the statements always describe an abnormal condition; the patient has
severe menstrual bleeding. On the History tab, True responses always imply a clinical
abnormality.
Tip:
On the History tab,
True = abnormal. On
the PE tab, True =
normal.
On the PE tab, the statement always describes a clinically normal condition (i.e., the
heart is of regular rate and rhythm, the abdomen is soft without masses). True
responses always imply a clinically normal condition on the PE tab.
Block 1
Build 838
CHCS II User’s Manual
40-33
Subjective/Objective (S/O)
Figure 40–39: MEDCIN Form
40.4.3.2 Changing the Stats of a Term
If you accidentally clicked the wrong box (clicked the true box instead of false), you
can simply click the opposite box to change the response.
40.4.3.3 Removing a Term
If you want to deselect a term and remove it from the note entirely, simply deselect the
box that is currently marked. A warning window appears, asking if you want to
remove the term. Click OK to remove the term, or Cancel to keep it.
Figure 40–40: MedActiveForms Window
40.4.3.4 Using the Free Text Icon
Click the free text icon next to a term to add more details to that term. A free text window opens, allowing you to add text. After you enter your free text, click Close The
Note Dialog to close the window and add your free text. Notice that the icon changes
once free text is added to a term.
Note: There is a 2,000 character restriction for each free text area.
40-34
CHCS II User’s Manual
Block 1
Build 838
Subjective/Objective (S/O)
Figure 40–41: Free Text Field
40.4.3.5 Using the Free Text Fields
There are multiple free text fields located throughout the forms. Use these fields to
add additional information that pertains to the specific section of the note. Click in the
free text field and enter your note. Double-clicking in the free text field opens the free
text field in a separate window where text can be added, using either the virtual keyboard or your regular keyboard. Virtual keyboard letters are added by clicking them
with your mouse.
Note: There is a 2,000 character restriction for each free text area.
Figure 40–42: Free Text Field Window
40.4.3.6 Using Numeric/Date Entry
Some of the answers to the questions on the forms will be numbers or dates. In these
cases, either click in the field and enter the value or double-click in the field to open
the Numeric/Date Entry window. The Numeric/Date Entry window displays either the
Interval view tab or Calendar view tab, depending on the field. Click the value(s), then
click OK.
Block 1
Build 838
CHCS II User’s Manual
40-35
Subjective/Objective (S/O)
Figure 40–43: Interval View Tab
Figure 40–44: Calendar View Tab
40.4.3.7 Using AutoNeg
The “Neg” in AutoNeg is “clinically negative,” which means clinically normal. Use
AutoNeg to document all undocumented findings as clinically normal. Use this feature by manually selecting your true findings, then click AutoNeg to document the
remaining terms. This is called documentation by exception.
AutoNeg also is a dual-purpose option that enables you to automatically select all positive or all negative values for a displayed form page. In order use this option, simply
click the arrow to the right of the option, then select either AutoPos or AutoNeg.
Selecting one of the options populates the form with the type of value you chose.
40-36
CHCS II User’s Manual
Block 1
Build 838
Subjective/Objective (S/O)
Figure 40–45: MEDCIN Form
40.4.3.8 Flipping Terms between the HPI and ROS Headings
In the HPI section, you have the option to flip an HPI finding to ROS. Click the HPI
button provided next to each term. The term is flipped into the ROS. The ROS section
includes similar buttons, but these enable you to flip a term found in the ROS to the
HPI. Click the ROS button to flip the ROS terms into the HPI.
Figure 40–46: ROS/HIP Flip
40.4.3.9 Adding Details to an Individual Term
The Details section is hidden on the Forms workspace until you want to view it. To
access the Details section, click Details on the Toolbar. The Details pane appears at
the bottom of the workspace. When the Details section is visible, any time you click
on an item in the Form, details about that item appear in the details section. In the
details view, you can add more detailed information to the term you selected, including a prefix, a modifier, an onset date or a status. You can also see how the finding is
worded in the encounter note.
Block 1
Build 838
CHCS II User’s Manual
40-37
Subjective/Objective (S/O)
Figure 40–47: Details
40.4.3.10Browsing the MEDCIN Hierarchy
MEDCIN is organized as an hierarchical tree of clinical findings. A high level finding,
such as the abdominal exam (Parent), has subordinate or children findings, such as
inspection, auscultation, percussion and so forth. Children findings may have their
own children as well. MEDCIN has many levels in this parent/child hierarchy. When
you add terms to the S/O, you must pay careful attention because MEDCIN allows a
negative response on a parent term, while allowing a positive response on a child
term. This would be clinically incorrect.
A form includes many of these parent terms. These terms have children in the MEDCIN hierarchy, but the child terms are not present on the form. Roll your cursor over
an item on the form to determine whether that item has associated children. If the item
has children, the cursor will change to a cursor-question mark.
Figure 40–48: Cursor‐Question Mark
Right-click the term to display the children. A Browse pane displays, either on the
right-third or left-third of the form, showing the additional terms. Select either the
large plus (+) or large minus (-) sign next to the terms you want. You can close the
Browse pane by clicking Close Trees on the Browse pane or by clicking Browse on
the Toolbar. You can shift the Browse pane to the left-third or right-third of the form
by clicking Shift Trees on the Browse pane, or by clicking Shift Browse on the Toolbar.
40-38
CHCS II User’s Manual
Block 1
Build 838
Subjective/Objective (S/O)
Figure 40–49: Browse Pane
Block 1
Build 838
CHCS II User’s Manual
40-39
Subjective/Objective (S/O)
40-40
CHCS II User’s Manual
Block 1
Build 838
41.0 TELEPHONE CONSULTS
41.1 Telephone Consults Overview
The Telephone Consults module enables telephone calls to be recorded and tracked.
The Telephone Consult (telcons) module displays telephone consults for specified
clinics, providers, dates, and statuses. From the Telephone Consults module, telcons
can be created, viewed, transferred to another provider, and canceled. Phone numbers
can be edited, notes viewed, and an encounter can be opened for that appointment.
Figure 41–1: Military Clinical Desktop—Telephone Consults Module
41.1.1
In More Depth
The Telephone Consults module enables telephone calls to be recorded and tracked.
The Telephone Consult (telcons) module displays telephone consults for specified
clinics, providers, dates, and statuses. From the Telephone Consults module, telcons
can be created, viewed, transferred to another provider, and cancelled. Phone numbers
can be edited, notes viewed, and an SF600 can be created for that appointment
Similar to the Appointments function telcons can be filtered for the following:
•
Set as Default: Customized default settings from the Telephone Consult Search
Selections dialog box.
•
All Outstanding: Telephone consults with the status 'outstanding.'
•
Today Only: Today's telephone consults.
Block 1
Build 838
CHCS II User’s Manual
41-1
Telephone Consults
•
Today Plus Incomplete: Today's telephone consults that have a status of incomplete.
•
Any Status: Telephone consults that meet any status and meet the date criteria set
in the Telephone Consult Log Selections window.
•
Pending: Telephone Consults that have a status of pending and meet the date criteria set in the Telephone Consult Log Selections dialog box. No note has been
initiated.
•
InProgress: Telephone Consults that have a status of In Progress and meet the
date criteria set in the Telephone Consult Log Selections window. The note has
been initiated.
•
Complete: Telephone consults that have a status of complete and meet the date
criteria set in the Telephone Consult Log Selections dialog box. The encounter
document has been signed.
•
Updated: Telephone consults that have a status of updated and meet the date criteria set in the Telephone Consult Log Selections window. The encounter document has been completed and then amended. Use this function to filter the
telephone consult list for the current session. Use the Change Selections function
to select a filter to use as the default. To filter the list of telephone consults, select
a filter from the drop-down list in the top, right corner on the Telephone Consults
module.
•
Transfer: The Telcon Transfer option enables an individual telcon or a group of
telcons to be transferred to a different provider within the same clinic.
•
Notes: Allows notes associated with the telephone consult to be viewed.
•
Edit Phone #: Allows the call back number to be changed. The system defaults to
the home number.
•
Close: Closes the Telephone Consult module.
Note: If the column headings have been re-ordered on the Telephone Consults module, click Set Column Order as Defaults to keep this heading order each
time the Telephone Consults module is opened. Click Restore Column
Order Defaults to return the column heading order to the system default.
41.2 Setting the Properties of the Telephone
Consults Module
Follow the steps below to set the properties of the Telephone Consults module:
1. On the Telephone Consults module, click Change Selections. The Telephone
Consult Search Selections window opens.
41-2
CHCS II User’s Manual
Block 1
Build 838
Telephone Consults
Figure 41–2: Telephone Consult Search Selections Window
2. Select the applicable option in the Clinics area.
•
This Clinic: Telephone consults for this clinic only.
•
All My Clinics: Telephone consults for all of the provider’s clinics.
•
Selected Clinic(s): Only telephone consults for the selected clinics.
3. Select the applicable option in the Providers area.
•
Me: Telephone consults for the current provider only.
•
All for this Clinic(s): All telephone consults for the current clinic(s).
•
Selected Providers: Only telephone consults for the selected providers.
4. Select the applicable option in the Dates area.
•
All Outstanding: Telephone consults with the status of outstanding.
•
Today Only: Only today's telephone consults.
•
Today Plus Incomplete: Today's telephone consults that have a status of
incomplete.
•
One Date: Only telephone consults for a selected date.
•
Date Range: All telephone consults that fall within a specified date range.
5. Select the applicable option in the Status Selection area.
•
Any Status: Telephone consults that meet any status and meet the date criteria set in the Telephone Consult Log Selections window.
•
Pending: Telephone Consults that have a status of pending and meet the date
criteria set in the Telephone Consult Log Selections window. No note has
been initiated.
•
InProgress: Telephone Consults that have a status of In Progress and meet
the date criteria set in the Telephone Consult Log Selections window. The
note has been initiated.
Block 1
Build 838
CHCS II User’s Manual
41-3
Telephone Consults
•
Complete: Telephone consults that have a status of complete and meet the
date criteria set in the Telephone Consult Log Selections window. The
encounter document has been signed.
•
Updated: Telephone consults that have a status of updated and meet the date
criteria set in the Telephone Consult Log Selections window. The encounter
document has been completed and then amended.
6. Click Set Selections as Default or click OK to set the selected search criteria as
the default criteria. The telephone consults that meet the required criteria displays.
Note: If the column headings have been re-ordered on the Telephone Consults module, click Set Column Order as Defaults to keep this heading order each
time the Telephone Consults module is opened. Click Restore Column
Order Defaults to return the column heading order to the system default.
41.3 Canceling a Telephone Consult
Follow the steps below to cancel a telephone consult:
1. Select the telephone consult to be canceled.
2. On the Action bar, click Cancel. The Cancel Telcon window opens.
Figure 41–3: Cancel Telcon Window
3. Select a reason for the cancellation from the drop-down list.
4. Click OK.
41.4 Editing the Callback Phone Number
Follow the steps below to edit the callback phone number:
1. Select the telephone consult to be modified.
Tip:
This does not
change the patient's
home phone number
in the Demographics
module.
2. On the Action bar, click Edit Phone #. The Change Callback Number window
opens.
Figure 41–4: Change Callback Number Window
41-4
CHCS II User’s Manual
Block 1
Build 838
Telephone Consults
3. In the Callback Phone Number field, enter the new phone number.
4. Click OK.
41.5 Opening an Encounter
Follow the steps below to open an encounter:
1. Select the telephone consult on the Telephone Consult module.
2. On the Action bar, click Open. The Telcon Quick Entry window opens.
3. Click Cancel. The Telcon Quick Entry window closes and the patient encounter is
displayed.
41.6 Creating a New Telephone Consult
Follow the steps below to create a new telephone consult:
1. On the Action bar, click New Telcon. The New Unscheduled Appointment/Telcon
Visit window opens, immediately overlaid by the Patient Search window.
2. Search for the patient you want to schedule a telephone consult for, or if the
patient is already loaded, click Cancel. The New Unscheduled Appointment/Telcon Visit window displays.
Figure 41–5: New Unscheduled Appointment/Telcon Visit Window
Block 1
Build 838
CHCS II User’s Manual
41-5
Telephone Consults
3. Complete the following fields:
•
Assigned Clinic: Select the assigned clinic from the drop-down list.
•
Provider: Use the drop-down list to select the desired provider.
•
Appointment Type: The only Appointment Type choice is TELEPHONE
CONSULT (T-CON*) 20.
Note: Appointment types with a $ or * annotate those types of appointments that can
only be created by the clinic.
•
Appointment Classification: This defaults based on the patient’s appointment classification.
•
Meets Outpt Visit Criteria (Workload?): Defaults to Yes, but if the patient
does not meet outpatient visit criteria, select No.
•
Related to Injury/Accident: Select the checkbox to indicate that the telcon is
related to an injury/accident.
•
Call Back Number: Enter the phone number where the patient can be
reached. The default number is the patient's home phone.
•
Reason for Telephone Consult: Enter a short description of the problem for
the patient called.
•
Urgency: Select either High, Medium, or Low.
•
Notes: Enter any comments pertaining to the telephone consult.
4. Click OK to save the appointment.
Note: Click Change Patient to search for a new patient. The Patient Search window
opens. If you click Change Patient before clicking OK, the telephone consult
for the patient cannot be created.
Note: If you have privileges to view encounter information, the Telcon Quick Entry
window opens, allowing for continued documentation.
41.7 Completing the Telcon Quick Entry Screen
Follow the steps below to complete the Telcon Quick Entry screen:
1. Double-click the desired telephone consult from the list. The Telcon Quick Entry
window opens.
41-6
CHCS II User’s Manual
Block 1
Build 838
Telephone Consults
Figure 41–6: Telcon Quick Entry Window
2. Complete the applicable fields:
•
Provider Note: Enter free-text to document the S/O portion of the encounter.
•
Diagnoses: The diagnoses can be selected from the Template List, Problem
List (Acute or Chronic), or Clinic and User Favorite Lists. You can also
search for the diagnosis by entering the diagnosis in the Search field and
clicking Find Now. Select the diagnosis and click Add to add the diagnosis to
the Selected Diagnosis list.
•
E&M: Select an E&M code from the drop-down list.
3. Select the desired Save option:
•
Save and Sign: Saves the information and opens the Sign Encounter window.
•
Save and Open A/P: Saves the information, writes it into the Patient Encounter module, and opens the Assessment and Plan module.
•
Save and Return to Encounter: Saves the information and returns you to the
encounter document.
Block 1
Build 838
CHCS II User’s Manual
41-7
Telephone Consults
4. Click OK.
Note: Once information has been entered and saved via the Quick Entry Screen, the
Quick Entry Screen is not available to document additional data.
41.8 Transferring a Telephone Consult
The Telcon Transfer window enables an individual telcon or a group of telcons to be
transferred to a different provider within the same clinic.
Follow the steps below to transfer a telephone consult:
Tip:
If transferring
multiple telcons, the
patients must be
from the same clinic.
1. Select the telephone consults to be transferred.
2. On the Action bar, click Transfer. The Telcon Transfer window opens.
Figure 41–7: Telcon Transfer Window
3. Select a new provider from the New Provider drop-down list. Only providers
assigned to the specific clinic are available.
4. Click OK to execute the transfer. The telephone consult is added to the new provider's telephone consults list.
41.9 Viewing a Telcon Note
If a comment was added on the New Telcon window, the full text of the comment cannot be seen on the Telephone Consults module.
Follow the steps below to view a telcon note:
1. Select the telephone consult on the Telephone Consult module.
2. On the Action bar, click Notes. The Appointment Note window opens containing
the comment.
41-8
CHCS II User’s Manual
Block 1
Build 838
Telephone Consults
Figure 41–8: Appointment Note Window
3. Click Done to close the window and return to the Telephone Consults module.
Note: Click Edit Note to edit information in the note. When all edits have been
made, click Save.
Block 1
Build 838
CHCS II User’s Manual
41-9
Telephone Consults
41-10
CHCS II User’s Manual
Block 1
Build 838
42.0 TEMPLATE MANAGEMENT
42.1 Template Management Overview
Templates are used to streamline the encounter documentation process. Each encounter template contains placeholders for diagnoses, procedures, orders, S/O Notes templates, AutoCited items, and the associated reason for visit. Once an encounter
template has been selected and loaded into the encounter, the pre-positioned lists are
available within S/O and A/P. The Template Management module is generally
accessed while in an encounter after the screening process and before any charting is
completed. The Encounter templates can be viewed and edited without an open
encounter.
Figure 42–1: Military Clinical Desktop—Template Management Module
42.1.1
In More Depth
The Encounter template contains details of the encounter in terms of AutoCite items,
diagnoses, procedures, S/O templates, orders, and patient instructions. The system
provides suggested templates based on the reason for visit and the patient problems
associated with the current, open encounter. Typically, the provider selects an encounter template from the Patient Encounter module before documenting the exam.
The top portion of the workspace shows the criteria for the suggested templates. The
Reason for Visit and Problems are included in the criteria by default. The suggested
templates are listed in the Autosearch Results folder. Templates denoted as favorites
or in the clinic list are displayed in the applicable folder.
Block 1
Build 838
CHCS II User’s Manual
42-1
Template Management
Templates can be added to the Favorites List to be seen as suggested templates for
every encounter. A template search can also be conducted with only the Favorites List.
Templates can be added to or removed from the Favorites List from either the Template Selections or Search/Browse tab.
A template can be imported to or exported from another location. All of the details of
the template are included when it is imported or exported. Since the template contains
all details, the order sets included are specific to the originating clinic. If the template
is imported/exported to another clinic or host location, the orders are deleted upon
import. You can import/export a template from the Template Selections or Search/
Browse tab.
After an encounter has been documented, the structure can be saved as an encounter
template. No patient-specific information is saved. This action can be performed from
the Current Encounter and Previous Encounter modules.
42.2 Organizing Templates
The Template Selections tab allows you to organize templates in the Template Management module. The Template Selections tab lets you add, edit and delete folders to
manage encounter templates.
Note: You must have a current encounter open to access the Template Selections
tab.
Figure 42–2: Template Folders
Follow the steps below to organize encounter templates:
1. In the Template Management module, Template Selections tab, click Folders to
open the Template Folder Management window.
42-2
CHCS II User’s Manual
Block 1
Build 838
Template Management
Figure 42–3: Clinic Templates Sub Folders
2. Click New to create a new folder for encounter templates.
Note: If there is a folder you want to modify, click Edit. If there is a folder you want
to delete, click Delete.
Figure 42–4: Template Folder Management Window
Block 1
Build 838
CHCS II User’s Manual
42-3
Template Management
3. In the New Folder window, enter the name of the folder you are using to organize
your templates.
4. Click OK to add the folder to the Template Management module. You are
returned to the Template Folder Management window.
Note: In the Template Folder Management window, select the top-level folder and
click New to add a sub-folder. Enter the name of the sub-level folder and click
OK.
5. Repeat steps 3 and 4 for each template management folder you want to add. When
you are finished adding the folders, click Close to return to the Template Management module Template Selections tab.
Figure 42–5: Template Folder Management Window—Complete
42.3 Moving Templates to Folders
The Template Management module lets you easily move templates from one folder to
another. This enables templates to be categorized into proper folders allowing you to
access and use templates more efficiently.
Note: Moving templates from one folder to another does not create a copy of the
template. Therefore, it is not recommended that you move templates out of
shared folders into personal folders without commanding officer consent.
42-4
CHCS II User’s Manual
Block 1
Build 838
Template Management
Follow the steps below to move templates to a specific folder:
1. In the Template Management module, select the template you want to move.
2. Perform a right mouse click and select Move to Folder.
3. In the Template Folder Management module, select the folder where you want to
move the template.
4. Click Move. The template is moved from the original (folder) location to the new
location.
42.4 Selecting an Encounter Template
An Encounter Template can be selected and loaded into an encounter. The Encounter
template contains details of the encounter in terms of AutoCite items, diagnoses, procedures, S/O templates, orders, and patient instructions. The system provides suggested templates based on the reason for visit and the patient problems associated with
the current, open encounter. Typically, the provider selects an encounter template from
the Patient Encounter module before documenting the exam.
Follow the steps below to select an encounter template from the Patient Encounter
module:
1. Click Templates on the Action bar. The Template Management module opens
with the Template Selections tab defaulted.
Note: The top portion of the workspace shows the criteria for the suggested templates. The Reason for Visit and Problems are included in the criteria by
default. Click the checkboxes to remove them. If changes are made to the criteria, the system displays an updated list.
Tip:
If the desired
template is not listed
in any of the folders
a search can be
conducted. In the top
portion of the
workspace type in
the name of the
template in the
Name Search field.
Click Find Now to
view the results in
the Name Search
Results folder.
Note: The Template Selection tab auto-refreshes when a template is imported, displaying the imported template in the template list.
Note: The suggested templates are listed in the Autosearch Results folder. Templates denoted as favorites or in the clinic list are displayed in the applicable
folder.
Block 1
Build 838
CHCS II User’s Manual
42-5
Template Management
Figure 42–6: Template Management Module—Template Selections Tab
2. Select the Folders button to add, edit or delete a folder. The Template Folder
Management window opens.
•
In the Template Folder Management window, click New. The New Folder
window opens.
•
In the New Folder window, enter the name of the new folder and click OK.
The new folder is added to the Template Folder Management window.
•
Highlight the folder and click New to add a sub-folder. The New Folder window opens.
•
Enter the name of the sub-folder and click OK. The sub-folder is added in the
Template Folder Management window.
•
Add additional sub-folders in the same manner. When finished, click Close.
The new folders and sub-folders are added to the Template Selections tab of
the Templates Management module.
3. Select the template to be used in the encounter from one of the folders or through
a template search.
4. Click Add to move the template into the Selected Templates area. More than one
template can be added to an encounter.
5. Click OK to load the template(s) into the encounter. The Patient Encounter module opens with the embedded template(s).
Note: The template details are displayed within the Patient Encounter (AutoCite),
S/O (notes template), and A/P (diagnoses, procedures, orders, and patient
instructions) modules.
42-6
CHCS II User’s Manual
Block 1
Build 838
Template Management
Follow the steps below to set an Encounter Template as a default that automatically
loads for each subsequent new encounter:
1. Highlight the desired template in the Encounter Template list.
2. Right-click on the highlighted template and select Default Encounter Template
from the right-click pop-up menu.
42.5 Setting an Encounter Template as a Default
Any encounter template may be designated to load for every encounter. This eliminates the need to open the Template Management module to load a template. Typically, the most common diagnoses, procedures, and orders are included in this default
encounter template. Once an encounter template is designated as the default template,
it can be reset so that no encounter template is automatically loaded.
Follow the steps below to set an Encounter Template as a default:
1. On the Search/Browse tab or the Template Selections tab, highlight the desired
template in the Encounter Template list.
2. Right click on the highlighted template and select Default Encounter Template
from the right-click pop-up menu.
Figure 42–7: Setting the Default Encounter Template
3. The highlighted template is now followed with the indication of Default Encounter Template.
Block 1
Build 838
CHCS II User’s Manual
42-7
Template Management
Figure 42–8: Default Encounter Template Set
Follow the steps below to reset the default encounter template:
1. On the Search/Browse tab or the Template Selections tab, highlight the current
default encounter template.
2. Right click on the highlighted template and select Reset Default Encounter Template.
3. The default template designation is removed from the template.
42.6 Creating a New Template
Follow the steps below to create a new template, begin on the Template Selections or
Search/Browse tabs.
1. Click New on the Action bar. The Template Details tab displays.
42-8
CHCS II User’s Manual
Block 1
Build 838
Template Management
Figure 42–9: Template Management Module—Template Details Tab
2. Complete the following fields on the Template Details tab:
•
Owner Type: Select the desired owner type from the drop-down list. Options
include Personal, Clinic, MTF, or Enterprise. The user's role determines
whether the template can be saved as clinic, MTF, or enterprise.
•
Specialty: Select the specialty to which the template belongs from the dropdown list. This is a required field.
•
E&M Code Category: Select the desired codes for the template from the
drop-down list.
Note: The template name is added upon saving and the User field is read-only. Templates can only be shared between providers in the same clinic.
3. Click Add to add details to the template in the following areas, where applicable:
•
Associated Reasons for Visit: In the Search Term field, enter the first few
letters of the complaint and click Search. Select the complaint from the
search results and click Add Items. Click Done to return to the Template
Details tab.
•
Associated Problems: In the Search Term field, enter the first few letters of
the problem and click Search. Select the problem from the search results and
click Add Items. Click Done to return to the Template Details tab.
•
Diagnoses: In the Search Term field, enter the first few letters of the diagnosis and click Search. Select the diagnosis from the search results and click
Add Items. Click Done to return to the Template Details tab.
•
Notes Templates: Click Search to open the List Note Template Search window. Enter search criteria in the window and click Search. Select the note
Block 1
Build 838
CHCS II User’s Manual
Tip:
The Associated
Reasons for Visit,
the Associated
Problems,
Associated
Appointment Types
and Items to Autocite
into Note areas lend
limited support in the
creation and use of
an encounter
template.
42-9
Template Management
template and click Add Items. Click Done to return to the Template Details
tab.
•
Other Therapies: In the Search Term field, enter the first few letters of the
therapy and click Search. Select the therapy from the search results and click
Add Items. Click Done to return to the Template Details tab.
•
Associated Appointment Types: In the Search Term field, enter the first
few letters of the appointment type and click Search. Select the appointment
type from the search results and click Add Items. Click Done to return to the
Template Details tab.
•
Items to AutoCite into Note: Select an AutoCite selection from the list and
click Add Items. Click Done to return to the Template Details tab.
•
Procedures: In the Search Term field, enter the first few letters of the procedure and click Search. Select the procedure from the search results and click
Add Items. Click Done to return to the Template Details tab.
4. Click Save As. The Save Encounter Template window opens.
Figure 42–10: Save Encounter Template Window
5. Select a template type from the Save in drop-down list.
6. In the Template Name field, enter the template name.
7. Select a Specialty from the drop-down list.
Note: Click Add to Favorites if you want the template to be added to the Favorites
List to be shared with other Clinical Team members.
8. Click Save.
42.7 Searching for a Template
In order to do any work with a template, you must select a template with the Template
Selections or Search/Browse tabs.
42-10
CHCS II User’s Manual
Block 1
Build 838
Template Management
Follow the steps below to search for a template:
1. Click Search. The Encounter Template Search window opens.
Figure 42–11: Encounter Template Search Window
2. Complete the following search criteria fields, as necessary:
•
Template Name: Enter the name or the first word of the template. Select the
applicable radio button to denote if the template name begins with or contains
entered text. The search is case-insensitive by default. Deselect the checkbox
to make the search case-sensitive.
•
Select from My Favorites Only: Select the checkbox to search Favorite templates only.
•
Owner Type: Use the drop-down list to select the desired type. Options
include:
•
Personal
•
Clinic, MTF
•
Enterprise
•
Owners: Click Add to open the Template Owner Lookup window and select
another provider. This enables you to search another provider's templates.
•
Specialty: Select the specialty to which the template belongs from the dropdown list.
•
Associated Reason for Visit: Click Add to add a reason for visit by which to
search.
•
Associated Appointment Type: Click Add to add an appointment type by
which to search.
•
Associated Problem: Click Add to add problems by which to search.
Block 1
Build 838
CHCS II User’s Manual
42-11
Template Management
•
Replace Search Results or Add to Search Results: Click a radio button to
either show results from the current search (Replace) or add the current results
to the list of templates (Add).
3. Click Search to view the templates that match the criteria. The templates are displayed on the Search/Browse tab.
Note: Once a template has been found and selected, the following actions can be
taken:
•
View and edit the template
•
Merge templates (more than one template must be selected)
•
Copy a template
•
Remove or add to the Favorites List
•
Export a template
•
Delete a template
•
Select an Encounter template
42.8 Editing a Template
Follow the steps below to edit a template:
1. Search for the template you want to edit using the Template Selections or Search/
Browse tab.
2. Select the desired template.
3. Click View/Edit on the Action bar. The Template Details tab displays.
42-12
CHCS II User’s Manual
Block 1
Build 838
Template Management
Figure 42–12: Template Management Module—Template Details Tab
4. Add or remove information in the following fields, as necessary:
•
Associated Reasons for Visit
•
Associated Problems
•
Diagnoses
•
Notes Templates
•
Other Therapies
•
Associated Appointment Types
•
Items to AutoCite into Note
•
Procedures
5. Click Save on the Action bar.
Tip:
Click Save As to
save the template
under a new name.
42.9 Merging Templates
Templates can be combined to create a completely new template.
Follow the steps below to merge templates:
1. Search for the templates you want to merge. The templates appear in the Search/
Browse tab.
Block 1
Build 838
CHCS II User’s Manual
42-13
Template Management
Figure 42–13: Template Management Module—Search/Browse Tab
2. Select the templates by pressing the Ctrl key on your keyboard and clicking on
each template you want to merge.
3. Click Merge on the Actions menu. The Template Details tab displays the details
from the selected templates.
4. Edit the template if necessary.
5. Click Save As on the Action bar. The Save Encounter Template window opens.
Figure 42–14: Save Encounter Template Window
6. Select a template type from the Save in drop-down list.
7. In the Template Name field, enter the template name.
8. Select a Specialty from the drop-down list.
9. Select the checkbox to denote whether the template should be added to the Favorites List or shared with other Clinical Team members.
42-14
CHCS II User’s Manual
Block 1
Build 838
Template Management
10. Click Save to save the template.
42.10 Copying a Template
A current template can be copied, edited, and renamed to create a new template.
Tip:
Follow the steps below to copy a template:
1. Search for the template you want to copy.
2. Select the template in the Search/Browse tab.
The title of the
template changes to
Copy of …(selected
template).
3. Right click and point to New Template and then click Copy from Selection. The
Template Details tab displays with the selected template details.
4. Edit the template if necessary.
5. Click Save As on the Action bar. The Save Encounter Template window opens.
6. Select a template type from the Save in drop-down list.
7. In the Template Name field, enter the template name.
8. Select a Specialty from the drop-down list.
9. Click the checkbox to denote whether the template should be added to the Favorites List or shared with other Clinical Team members.
10. Click Save to save the template.
42.11 Removing/Adding to Favorites
Templates can be added to the Favorites List to be seen as suggested templates for
every encounter. A template search can also be conducted with only the Favorites List.
Templates can be added to or removed from the Favorites List from either the Template Selections or Search/Browse tab.
Follow the steps below to add a template to the Favorites List:
1. Search for the template you want to add.
2. Select the template in the Search/Browse tab.
3. Click Add Favorite on the Action bar. The Favorite column on the Search/
Browse tab changes from No to Yes and the template is added to My Favorites
folder on the Template Selections tab.
Follow the steps below to remove a template from the Favorite List:
1. Search for the template you want to remove.
2. Select the template in the Search/Browse tab.
3. Click Remove Favorite on the Action menu.
4. At the confirmation prompt, click Yes.
Block 1
Build 838
CHCS II User’s Manual
42-15
Template Management
42.12 Importing/Exporting a Template
A template can be imported from or exported to an electronic storage device for use at
another location. All of the details of the template are included when it is imported or
exported. Since the template contains all details, the order sets included are specific to
the originating clinic. If the template is imported/exported to another clinic or host
location, the orders are deleted upon import. You can import/export a template from
the Template Selections or Search/Browse tab.
Follow the steps below to import a template:
1. Click Import on the Action bar. The Import Encounter Template window opens.
Figure 42–15: Import Encounter Template Window
2. Select a template from the Available Templates list.
Note: If the template is not in the defaulted folder, browse to the folder where the
templates are located.
3. Click the arrow buttons to move the selections to the Selected Templates list.
4. Do one of the following:
•
If you want to edit the selected template before you save it:
a. Click Edit. The Template Details tab displays with the details of the
imported template.
b. Add or remove information in the following fields:
42-16
•
Associated Reasons for Visit
•
Associated Problems
•
Diagnoses
•
Notes Templates
•
Other Therapies
•
Associated Appointment Types
•
Items to AutoCite into Note
•
Procedures
CHCS II User’s Manual
Block 1
Build 838
Template Management
•
If you want to import the template as is, click Import. The Template Details
tab displays with the details for the imported template.
5. Click Save As on the Action bar. The Save Encounter Template window opens.
6. Select a template type from the Save in drop-down list.
7. In the Template Name field, enter the template name.
8. Select a Specialty from the drop-down list.
Note: Click Add to Favorites if you want the template to be added to the Favorites
list to be shared with other Clinical Team members.
9. Click Save.
Follow the steps below to export a template:
1. Search for the template you want to export.
2. Select the template from the Search/Browse tab.
3. Click Export. The Export Encounter Template window opens.
Figure 42–16: Export Encounter Template Window
4. Browse to the folder location where you want to export the template.
5. Click Save.
42.13 Deleting a Template
A template can be deleted from the Search/Browse tab.
Follow the steps below to delete a template:
1. Search for the template you want to delete.
2. Select the template from the Search/Browse tab.
3. Click Delete on the Action menu.
4. At the delete confirmation prompt, click Yes.
Block 1
Build 838
CHCS II User’s Manual
42-17
Template Management
42.14 Saving an Encounter as a Template
After an encounter has been documented, the structure can be saved as an encounter
template. No patient-specific information is saved. This action can be performed from
the Patient Encounter and Previous Encounter modules.
Follow the steps below to save an encounter as a template:
1. Document the encounter.
2. On the Actions menu, click Save As Template. The Template Details tab on the
Template Management module opens.
Figure 42–17: Template Management module—Template Details Tab
3. Select an owner type from the drop-down list, if necessary.
4. Select a specialty from the drop-down list, if necessary.
5. Select an E&M code category from the drop-down list, if necessary.
6. Add or remove information from the following areas:
•
Associated Reasons for Visit
•
Associated Problems
•
Diagnoses
•
Notes Templates
•
Other Therapies
•
Associated Appointment Types
•
Items to AutoCite into Note
•
Procedures
7. Click Save As on the Action bar. The Save Encounter Template window opens.
42-18
CHCS II User’s Manual
Block 1
Build 838
Template Management
Figure 42–18: Save Encounter Template Window
8. Select the template type from the Save-in drop-down list.
9. In the Template Name field, enter the template name.
10. Select the specialty from the drop-down list.
11. Select the checkboxes to denote whether the template should be added to the
Favorites List or shared with other Clinical Team members.
12. Click Save.
Block 1
Build 838
CHCS II User’s Manual
42-19
Template Management
42-20
CHCS II User’s Manual
Block 1
Build 838
43.0 CHCS II TRAINING SYSTEM
43.1 CHCS II Training System Overview
The CHCS II Training System (CTS) is a stand-alone training application. The goal of
this tool is to enable you to participate in the CHCS II courses that teach you the skills
you need to perform your assigned duties as well as practice on your own. The Training System contains staged data to help you through your course and assist you in
understanding CHCS II functionality.
The CHCS II Training System contains the same core functionality available in
CHCS II; however, interface capabilities between CHCIS II and components (e.g.,
CHCS) are simulated to produce a realistic data exchange process. The Training System is not role based—users, regardless of their clinic roles and responsibilities, have
access to the same functionality.
You can differentiate between CHCS II and the Training System by the Patient ID bar
and the “Training Use Only” watermark. The Training System uses a green Patient ID
bar and CHCS II uses a gray Patient ID bar.
Note: If the user has modified their computer’s color scheme, the Patient ID bar
color may not appear in green or gray. It is recommended that users keep the
default color scheme.
Block 1
Build 838
CHCS II User’s Manual
43-1
CHCS II Training System
Figure 43–1: CTS Appointments Module
Note: Performing an auto-update from build 833.8 to 837.2 will not load the training
system. Once the auto-update is complete, additional files must be installed.
These files are located in the Support folder. Double-click CTS_AddOn.exe
to install the training system for build 837.2. In the future, the auto-update
will provide the latest version of the live system, as well as the training system. Refer to section 5.2 of the System Installation Guild Clinical Workstation, Version 2.59.1, dated 24 September 2004, for complete instructions on
loading the training system on your CWS. If you elect NOT to install the
training system with build 837.2, future CHCS II releases will not provide the
procedures described above, and a complete un-install re-install will need to
be performed to load both the training system and the live system on the
CWS. Subsequently, you may use auto-update, and both the live system and
the training system will be updated.
43.2 Logging into the Training System
The Training System is built with an automatic login.
Follow the steps below to login to the Training System:
1. Double-click the CTS icon on your desktop.
43-2
CHCS II User’s Manual
Block 1
Build 838
CHCS II Training System
Figure 43–2: Training System Icon
2. First, you are asked to choose a training clinic (Medical, Dental, SRTS II). This
specifies which role you will assume. Select the appropriate clinic from the list
and click OK.
•
Medical: Assumes the role of a Provider.
•
Dental: Assumes the role of a Dental Provider.
•
SRTS II:
Figure 43–3: Role Identification Selection Window
3. Read the purpose statement on the first splash screen and click the small x in the
top, right corner or press Esc on your keyboard.
Figure 43–4: Purpose Statement
Block 1
Build 838
CHCS II User’s Manual
43-3
CHCS II Training System
4. The second splash screen highlights the functionality of the Training System.
Again, click the small x in the top, right corner or press Esc on your keyboard.
Figure 43–5: Training System Functionality Statement
5. The Training System moves through the automatic logon.
Figure 43–6: Automatic Logon
6. Once complete, the application opens to the Appointments module.
43-4
CHCS II User’s Manual
Block 1
Build 838
CHCS II Training System
Figure 43–7: Appointments Module
The Training System allows you to assume only one role at a time. Therefore, if you
need to use the Training System for a different role, you need to log out of the application, then logon again, choosing the appropriate role as in step #2 above. You should
also reset the Training System database before proceeding.
43.3 Using the Training System
Once logged in, the Training System works similarly to the CHCS II application. The
sections below highlight some of the features of the Training System.
43.3.1
Training System Database
The Training System comes with two databases. One database houses all the prepositioned information relative to the appointments, patients, templates, and encounters.
The first time you log into the Training System, this information is available and ready
for use.
The second database is used as you navigate through the application and make
changes or additions to the original baseline database. Information you add or modify
(appointments, templates, or patient information), is stored within this database.
43.3.2
Database Reset
The Training System comes with the ability to reset the database to the original baseline. You can delete the appointments, encounters, and templates you created and
return to the original baseline data prepositioned with the system.
Follow the steps below to reset the database:
1. Select the Tools menu.
2. Select Training System Database Reset.
3. You have three options from which to choose. Click Templates, Encounter Data,
or Entire Database.
Block 1
Build 838
CHCS II User’s Manual
43-5
CHCS II Training System
Figure 43–8: Reset Options
4. Upon completion, click Done. The Training System closes and returns to the
desktop.
Figure 43–9: Reset Complete
5. Log back in to the Training System to begin using the application.
43.3.3
Locking the Training System
If you want to leave the workstation you may lock your session by pressing Ctrl + Z
on your keyboard. Your session remains locked until you click OK.
43-6
CHCS II User’s Manual
Block 1
Build 838
CHCS II Training System
Figure 43–10: CTS Lock Out Screen
Note: The CTS lock out screen is visually different from the CHCS II lock out
screen. Notice also that unlike the CHCS II lock out screen, a password does
not need to be entered to unlock the session.
43.3.4
Appointments
The Appointments module is the default module to be viewed upon login. Prepositioned appointments, located in the baseline database, are immediately available for
medical, dental and SRTS II training. The default date of the appointments is the date
of installation or reset. So, if the Training System is installed on March 1, the prepositioned appointments is not visible on March 2nd unless the filter is changed.
43.3.5
MEDCIN (S/O) Starter Templates
The Training System is loaded with starter MEDCIN (S/O) templates. Use these as a
beginning point when building your own, customized templates.
Follow the steps below to access the MEDCIN starter templates:
1. Open a patient encounter.
Block 1
Build 838
CHCS II User’s Manual
43-7
CHCS II Training System
2. Click S/O from the Patient Encounter module.
3. Click Template Mgt. in the Action bar.
4. Expand the My Favorites folder to view the available templates.
Figure 43–11: MEDCIN Templates
The starter templates are organized by component and type (ex: Well Child templates).
Load and use any of the starter templates as a beginning point when customizing your
own templates.
43.3.6
Encounter Starter Templates
The encounter starter templates are located in the Template Management module.
From the Search/Browse tab, perform a search for templates that include the words
starter kit.
Follow the steps below to access the Encounter Starter Kit Templates:
1. Click on the + next to the Tools folder in the Folder List.
2. Click Template Management from the Folder List.
3. On the Search/Browse tab, click Search from the Action bar.
4. In the Template Name field, enter starter kit.
43-8
CHCS II User’s Manual
Block 1
Build 838
CHCS II Training System
Figure 43–12: Encounter Template Search
5. Click Search to view all of the Encounter Starter Kit Templates. Load and use any
of the starter templates as a beginning point when customizing your own templates.
Figure 43–13: Encounter Starter Kit Templates
43.4 Patient Information
The Training System contains patients of various ages and ailments. The system is
populated with a male and a female patient that match the critical stages of development.
Certain patients have associated clinical data (lab and rad results, problems, medications).
43.4.1
Patient Search–Training System Functionality
The Patient Search module contains two features that are not part of CHCS II. One is
the All Patients feature and the other is Patient Details.
Block 1
Build 838
CHCS II User’s Manual
43-9
CHCS II Training System
•
All Patients: Allows you to view all the patients in the Training System database
•
Patient Details: Allows you to view all the patient-specific information (age,
associated clinical data)
Follow the steps below to locate patients in the Training System database:
1. Click Search from the Folder List to view the Patient Search window.
2. Click All Patients to view all the patients in the database.
Figure 43–14: All Patients
3. Click Patient Details. A table displays with all the patient information in the
search results area.
4. Review the details.
43-10
CHCS II User’s Manual
Block 1
Build 838
CHCS II Training System
Figure 43–15: Patient Details
Note: To perform a search after viewing patient details, click Cancel.
43.5 Removing the Training System
Since the Training System is now part of CHCS II, you cannot remove the Training
System without removing CHCS II. When removing CHCS II and the Training System from your workstation, use the standard Windows Add/Remove function.
Follow the steps below to remove CHCS II and the Training System:
1. On your workstation desktop, select Start, point to Settings, and then click Control Panel.
2. Double-click Add/Remove Programs.
3. Click the CHCS II listing and then click Remove.
4. Click Yes at the prompt.
5. The InstallShield Wizard removes CHCS II and the Training System from your
computer. Click Finish when the task is complete.
Block 1
Build 838
CHCS II User’s Manual
43-11
CHCS II Training System
43-12
CHCS II User’s Manual
Block 1
Build 838
44.0 VITAL SIGNS
44.1 Vital Signs Overview
The Vitals Sign module enables you to view, edit, delete, and add vital signs information for a patient. The Vital Signs module can be accessed in two different areas on the
Folder List, under Health History and under Current Encounter. If Vital Signs
(Review) is accessed under Health History, only past vitals can be reviewed. If Vital
Signs (Entry) is accessed through the current encounter, vital signs can be reviewed,
entered, edited, or deleted.
Figure 44–1: Vital Signs Module (Entry Tab)
44.2 Setting the Properties of the Vital Signs
Module
When accessing Vital Signs (Review) under Health History in the Folder List or a current encounter, you can customize the default settings for both the Entry and Review
tabs.
Follow the steps below to set the properties of the Vital Signs module:
1. In the Vital Signs workspace, click Options in the upper, right corner. The Properties window opens.
Block 1
Build 838
CHCS II User’s Manual
44-1
Vital Signs
Figure 44–2: Vital Signs—Properties Window
2. Set the following preferences:
•
Default Time: Click Default Time to view the Time Search window. Select
the desired option for the date range of the records to be viewed on the
Review tab. Searches include: All Time Periods, Last ‘N,’ Sliding Time
Range and Specific Time Period.
•
Height and Weight: Using the drop-down lists, select the Height and Weight
units displayed in the Entry tab.
•
Default Number of Panels to Review: Use the drop-down list to select the
desired number of panels to be reviewed in the Review tab.
•
Tab to Start With: Use the drop-down list to select the tab that appears when
you open the Vital Signs module.
•
Chart Vital Signs: Entry Tab
•
Review Vital Signs: Review Tab
3. Click OK to save the selected settings as the default settings.
Note: The new settings will take effect after you close the Vital Signs module.
44.3 Entering New Vital Signs
The Entry tab allows vital signs to be entered under three different categories:
•
Adult
•
Obstetric (Female Only Patients)
•
Pediatric
The default view is Adult, which displays Standard Vital Signs, Height/Weight, and
Tobacco Use. Selecting either Obstetric or Pediatric brings up additional panels specific to their respective category. Vital signs must be entered in the Current Encounter
Vital Signs (Entry) module in an open encounter.
44-2
CHCS II User’s Manual
Block 1
Build 838
Vital Signs
Follow the steps below to enter new vital signs:
1. Open a patient encounter.
2. In the Encounter Summary module (electronic SF600), click Vitals. The Vital
Signs module opens and the Entry tab is displayed by default.
Tip:
You can also access
the Vitals module by
opening the Current
Encounter folder and
clicking Vital Signs
(Entry) on the Folder
List.
Figure 44–3: Vital Signs Entry Module—Entry Tab
3. Select the category for which you are entering vitals from the drop-down list to
the right of the Action bar.
Note: The default is Adult. The Obstetric option, for female patients, includes the
adult panels plus the Urine Dip Stick panel. The Pediatric option includes the
adult panels plus the Head Circumference panel and a Pediatric Pain Scale.
Figure 44–4: Vital Signs Categories
4. Select the checkbox for any of the following to display additional vital sign input
fields, if necessary:
•
Visual Acuity
•
Oxygen Saturation
•
Peak Flow
Block 1
Build 838
CHCS II User’s Manual
44-3
Vital Signs
Figure 44–5: Vitals Module—Entry Tab
5. Enter the correct data in the following fields and tab to the next field.
•
Standard Vital Signs: Enter blood pressure, heart rate, respiratory rate and
temperature (in Celsius or Fahrenheit). The Blood Pressure and Heart Rate
fields allow you to add modifiers. Click Display Orthostatic if you want to
enter orthostatic vital signs for the patient.
•
Habits: Select the radio button to denote the usage of tobacco and/or alcohol.
Clicking the Yes radio button activates the Ellipsis button. Click the Ellipsis
button to document the frequency/duration.
Figure 44–6: Tobacco Frequency/Duration Window
44-4
CHCS II User’s Manual
Block 1
Build 838
Vital Signs
Figure 44–7: Alcohol Frequency/Duration Window
•
Height/Weight: Enter patient height information in inches, feet, or centimeters and weight in pounds, ounces, grams, or kilograms. The height and
weight can be entered using decimals (i.e., 75.6). You can add modifiers to
both the height and weight categories. The system automatically calculates
the Body Mass Index (BMI) and the Body Surface Area (BSA).
•
Comments: Enter any comments.
Note: If the data is abnormal, a Vital Sign Range Warning appears. Click Yes to continue with the entered data. Click No to go back and re-enter the data.
Note: Click the Ellipsis button to add modifier information to the associated vital
sign.
6. Click OK to save the vitals or click Save Vitals on the Action bar.
44.4 Editing Vital Signs
You can only edit vital signs for the current encounter.
Follow the steps below to edit vital signs:
1. On the Review tab, select the vital signs you want to edit.
2. Click Edit Vitals on the Action bar. The Entry tab automatically opens.
Note: The Edit Vitals option is not available if you access the Vital Signs (Review)
module under the Health History folder on the Folder List.
3. Enter any additional comments or add any values in the following areas:
•
Block 1
Build 838
Standard Vital Signs
CHCS II User’s Manual
44-5
Vital Signs
•
Habits
•
Height/Weight
•
Comments
•
Visual Acuity
•
Oxygen Saturation
•
Peak Flow
•
Pain Scale
4. Click OK to save the information. The edits are documented in the Change History portion of the Encounter Document.
44.5 Deleting Vital Signs
You can only delete vital signs for the current encounter.
Follow the steps below to delete vital signs:
1. On the Review tab, select the vital signs you want to delete.
Tip:
The Delete Vitals
option is not
available if you
access the Vital
Signs (Review)
module under the
Health History folder
on the Folder List.
Figure 44–8: Vital Signs Entry Module (Review Tab)
2. Click Delete Vitals on the Action bar. A confirmation message appears.
3. Click Yes. The deletion is documented in the Change History portion of the
encounter summary module.
44.6 Graphing Vital Signs
You can only graph vital signs for a current encounter.
44-6
CHCS II User’s Manual
Block 1
Build 838
Vital Signs
Follow the steps below to graph vital signs:
Tip:
1. On the Review tab, select the set of vitals you want to graph.
2. Click Graph Vitals on the Action bar. The Graph Vitals window opens.
More than one set of
vital signs must be
selected to generate
the graph.
Figure 44–9: Graph Vitals Window
3. Select the checkbox(es) to change the graph options, if necessary. The default displays both data lines and data point values.
4. Select the radio buttons to change the chart type, if necessary. The default displays
the chart in a 2-D line.
5. Click Print to print the current graph.
6. Click OK to close the Graph Vitals window and return to the Vital Signs module.
44.7 Reviewing Vital Signs
Follow the steps below to review past vital signs:
1. On the Review tab, view past vital sign information.
2. Do one of the following:
•
If you want to customize the number of vital sign entries listed in the tab:
a. Click Search Type. The Time Search window opens.
Block 1
Build 838
CHCS II User’s Manual
44-7
Vital Signs
Figure 44–10: Time Search Window
b. Select the desired time option.
c. Click OK. The entries meeting the search criteria appear in the tab.
•
If you want to view details on a specific set of vital signs:
a. Select the set of vital signs for which you want to view detailed information.
b. The details populate the text field in the bottom of the tab.
•
If you want to change the unit of temperature values for a set of vitals:
a. Select the set of vital signs.
b. Click the Temp toggle button on the Action bar.
44-8
CHCS II User’s Manual
Block 1
Build 838
Vital Signs
44.8 Vital Sign Ranges
The following are valid ranges for entering vital signs information.
Vital Signs
Ranges
Blood Pressure:
Systolic
80–200 mm Hg
Diastolic
Must be less than systolic and 40–120 mm Hg
Heart Rate
40–150 Beats per minute
Respiratory Rate
5–40 breaths per minute
Temperature
95–105° F
Height
12–84 inches
Weight
1–350 pounds
Visual Acuity
10–999
Oxygen Saturation
70–100 percent
Peak Flow
40–650 liters per min
Head Circumference
(Pediatric)
10–22 inches
Pain Sensitivity
Adult: 0–10 (with 0 being pain free and 10
being totally disabling)
Child: 0–5 (with 0 being no hurt and 5 being
hurts worst)
Note: If you enter a vital range that is out of the ordinary, a warning window
appears. Click Yes to accept the vital sign entry, or click No to re-enter the
vital sign.
Figure 44–11: Warning Window
Block 1
Build 838
CHCS II User’s Manual
44-9
Vital Signs
44-10
CHCS II User’s Manual
Block 1
Build 838
45.0 WEB BROWSER
45.1 Web Browser Overview
CHCS II is installed with the Internet Explorer Web Browser. This functionality
enables you to access the Internet for the purpose of researching information from a
variety of favorite medical sites without exiting CHCS II. Because the Web Browser is
contained within CHCS II, the application does not time out while searching the Internet. Navigation in the Web Browser is done through the Action bar.
Figure 45–1: Military Clinical Desktop—Web Browser
45.2 Changing the Internet Home Page
Once the Web Browser has been accessed, the internet home page is displayed in the
Workspace. The internet home page can be changed according to individual preference.
Follow the steps below to change the Internet home page:
1. On the Windows Task bar, click Start.
2. Point to Settings and click Control Panel. The Control Panel window opens.
Block 1
Build 838
CHCS II User’s Manual
45-1
Web Browser
Figure 45–2: Control Panel
3. Double-click Internet Options. The Internet Properties window opens with the
General tab defaulted.
Figure 45–3: Internet Properties Window
4. In the Home Page area enter the desired URL in the Address field.
5. Click OK. This is the webpage that displays when you access the Web Browser.
Click Home on the Action bar to return to the home page at any time.
45-2
CHCS II User’s Manual
Block 1
Build 838
Web Browser
45.3 Accessing the Favorites List
The Favorites list is a shortcut to Internet sites that are frequently accessed.
Follow the steps below to access the favorites list:
1. Click Favorites on the Action bar. The Goto Favorite window opens.
Figure 45–4: Goto Favorite Window
2. Select the desired URL and click OK. The site displays in the Workspace.
45.4 Adding to the Favorites List
Follow the steps below to add to the favorites list:
1. Navigate to the website you would like to add to your favorites list.
2. Click Add on the Action bar. The Add Favorites window opens.
Figure 45–5: Add Favorite Window
Note: Notice that a default website name is displayed in the Name field. You can use
this website name, or enter a new name in the Name field. It does not have to
be the exact name for the website, but should be something that reminds you
of the site.
3. Click OK. The website is added to your favorites list.
45.5 Organizing the Favorites List
Once Internet sites are added to your favorites list, you can organize, rename or delete
them.
1. Click Organize on the Action bar. The Organize Favorites window opens.
Block 1
Build 838
CHCS II User’s Manual
45-3
Web Browser
Figure 45–6: Organize Favorites Window
2. Click Close after you are finished organizing your favorites list.
45.5.1
Creating a New Folder
Follow the steps below to create a new folder:
1. Click Create Folder on the Organize Favorites window. A new folder is created
at the end of your favorites list.
2. Enter the name of your new folder and press Enter on your keyboard.
45.5.2
Moving a Favorite into a Folder
Follow the steps below to move a favorite into a folder:
1. Select a favorite from the Organize Favorites window and click Move to Folder.
The Browse for Folder window opens.
Figure 45–7: Browse for Folder Window
2. Select a folder and click OK. The favorite is now moved into the selected folder.
45-4
CHCS II User’s Manual
Block 1
Build 838
Web Browser
45.5.3
Renaming Favorites
Follow the steps below to rename a favorite:
1. Select a favorite from the Organize Favorites window and click Rename.
2. Enter the new name of the favorite and press Enter on your keyboard. Your favorite is now renamed.
45.5.4
Deleting Favorites
Follow the steps below to delete a favorite:
1. Select a favorite from the Organize Favorites window and click Delete. The Confirm File Delete window appears.
2. Click Yes. The favorite is now deleted from your favorites list.
45.6 Importing HTML Bookmarks
Follow the steps below to import HTML bookmarks:
1. Click Import on the Action bar. The Import Bookmarks HTML into Favorites
window opens.
2. Navigate to where the HTML bookmark is stored.
3. Select the HTML bookmark and click Open. The Browse for folder window
opens.
4. Double-click the favorites folder where you want to convert the bookmarks into
favorites and click OK. The Import Favorites warning window displays.
5. Click Yes. The Import Favorites warning window displays notifying you that
favorites were imported successfully.
6. Click OK. The bookmarks are now accessible through your favorites list.
45.7 Exporting HTML Bookmarks
Follow the steps below to export HTML bookmarks:
1. Click Export on the Action bar. The Browse for folder window opens.
2. Select the folder that contains the favorites you want to export into an HTML
bookmark and click OK.
3. Navigate to where you want the HTML bookmark to be created.
4. Enter the name of your HTML bookmark in the File Name field and click Save.
The WebBrowser warning window appears, notifying you that your HTML bookmark was created successfully.
5. Click OK.
Block 1
Build 838
CHCS II User’s Manual
45-5
Web Browser
45.8 Printing Web Pages
Follow the steps below to print a web page:
1. Click Print WebPage on the Action bar. The Print window opens.
2. Select your print options and click Print.
45-6
CHCS II User’s Manual
Block 1
Build 838
46.0 WELLNESS
46.1 Wellness Overview
The Wellness module generates preventive health reminders for a patient. These
reminders are tied to the United States Preventive Services Task Force guidelines for
the general population. Additionally, text-based reminders can be created to notify a
provider of special information on a particular patient. Active wellness reminders are
placed on the Patient's Problem List area in the Health Maintenance section. Reminders tied to a measurable clinic event, such as a lab test, are automatically addressed as
the event is completed. Service that is performed at an outside facility can be manually
addressed.
Figure 46–1: Military Clinical Desktop—Wellness Module
46.2 Setting the Filter for the Wellness Module
Click Options on the Wellness module or Filter on the Documentation History tab to
open the Properties window in which display information can be customized.
Block 1
Build 838
CHCS II User’s Manual
46-1
Wellness
Figure 46–2: Wellness Properties Window—Filter Tab
The Filter tab provides the ability to select a previously saved filter from the dropdown list, or to create a new filter.
Follow the steps below to set the filter for the Wellness module:
1. On the Filter tab, select a Filter Name from the drop-down list.
2. Do one of the following:
•
If you want all of the listed statuses to display, select All Statuses.
•
If you want to display specific statuses:
•
Select Specific Statuses.
•
Select a status from the list.
•
Click Add to move the status to the Selected Statuses column.
3. Do one of the following:
•
•
46-2
If this is a new filter selection:
•
Click Save As.
•
Enter a new name for the filter.
•
Click Save.
If this is a change to a pre-existing filter, click Save.
CHCS II User’s Manual
Block 1
Build 838
Wellness
46.3 Setting Preferences for the Wellness
Module
The Preferences tab allows the time period selection to be used when displaying documented wellness items on the Documentation History tab. Once a time period is
selected, it becomes the default setting.
Figure 46–3: Wellness Properties Window—Preferences Tab
Follow the steps below to set preferences for the Wellness module:
1. On the Properties window, select the Preferences tab.
2. In the Reminder Time option, click Default Time to select a time option for
reminders.
Figure 46–4: Time Search Window
3. In the Time Search window, select time search options for reminders.
4. Click OK.
Block 1
Build 838
CHCS II User’s Manual
46-3
Wellness
5. In the Documentation Time option, click Default Time to select a time option for
documentation.
6. In the Time Search window, select time search options for documentation.
7. Click OK.
8. Click OK to set the time criteria. The data on the Documentation History window
is refreshed according to the search criteria.
46.4 Due Reminders Tab
The Due Reminders tab allows you to display active reminders and documentation
history (for documented reminders, either manually or automatically) for the current
patient. The Due Reminders tab indicates services due in the future or due as of the
current date. The tab allows you to alter the schedule of a reminder, as well as display
reminders for either all patients or only the currently selected patient. The system displays the Due Reminders list grouped by wellness reminder type and then alphabetically.
Due Reminders are listed with the type of procedure, the status, the earliest date the
procedure should be implemented and any comments.
Figure 46–5: Wellness Module—Due Reminders Tab
Note: All reminders appear in the Reminder Mapping window and in the A/P
Reminders tab.
Note: Reminders are generated through the Wellness module for each individual
patient.
46-4
CHCS II User’s Manual
Block 1
Build 838
Wellness
46.4.1
Documenting a Due Reminder in the Due Reminders Tab
Follow the steps below to document a due reminder in the Due Reminders tab:
1. Click Document on the Action bar. The Document window opens.
Figure 46–6: Document Window
2. Complete the following fields to document the reminder:
•
Status: Refers to the status of the reminder:
•
Completed: The action has been taken.
•
Ordered: The action has been ordered.
•
Refused: The action has been refused by the patient.
•
Clinician: Enter the name of the person administering the action. The default
is whoever is currently logged in. Click Clinician to search for a different clinician.
•
Type: Select the action to be taken from the drop-down list. The default is the
task for which the reminder is being documented.
•
Coded: Select a more detailed status of service from the drop-down list. For
example, Preventive Service Completed Report Reviewed.
•
Free-text: Enter any additional comments in the field.
•
Date: Select the date the action occurred.
•
Information Source: Select the relationship to the patient reporting the
action from the drop-down list.
•
Admin. Location: Enter the location where the action occurred.
3. Click Save.
Block 1
Build 838
CHCS II User’s Manual
46-5
Wellness
46.4.2
Editing a Due Reminder in the Due Reminders Tab
Follow the steps below to edit a due reminder in the Due Reminders tab:
1. Select an item from the list on the Due Reminders tab.
2. Click Edit on the Action bar. The Edit window opens. Coded and free-text Comments are the only two fields that can be changed.
Figure 46–7: Edit Due Reminders Window
3. Select a code from the drop-down list.
4. Enter any free-text to further explain the code or in place of the code.
5. Click OK.
46.4.3
Inactivating a Due Reminder in the Due Reminders Tab
Inactivating a reminder prevents it from being generated.
Follow the steps below to inactivate a reminder in the Due Reminders tab:
1. Select a reminder from the Due Reminder list.
2. Click Inactivate on the Action bar.
3. At the Confirm Inactivation prompt, click Yes. The Inactivation window opens.
Tip:
To activate an item
that has been
inactivated, select
the Wellness
Schedule tab to
activate the selected
reminder.
46-6
Figure 46–8: Inactivate Due Reminders Window
4. Select a code from the coded drop-down list.
CHCS II User’s Manual
Block 1
Build 838
Wellness
5. Enter any free-text to further explain the code or to take the place of a code.
6. Click OK.
46.4.4
Viewing Due Reminder Details in the Due Reminders Tab
Follow the steps below to view due reminder details in the Due Reminder tab:
1. Select the reminder on the Due Reminders tab.
2. Click Details on the Action bar. The Detail Information window opens.
Figure 46–9: Due Reminders Detail Window
3. After viewing the due reminder information, click OK to close the window.
46.4.5
Adding a Wellness Schedule in the Due Reminders Tab
Follow the steps below to add a wellness schedule in the Due Reminders tab:
1. Click Add on the Action bar. The Add Wellness Schedule window opens.
Figure 46–10: Add Wellness Schedule Window
2. Select a Wellness Item from the drop-down list.
3. Select a Patient Specific Schedule from the drop-down lists to document the frequency of the wellness item.
4. Click Save to save the new schedule.
Block 1
Build 838
CHCS II User’s Manual
46-7
Wellness
46.5 Documentation History Tab
The Documentation History tab allows you to define all Wellness-related events,
including Immunizations or satisfaction of Wellness Reminders. The Documentation
History tab allows you to document the appropriate service for the selected reminder.
The tab also allows you to select either a coded or free-text comment to associate with
a Wellness Reminder.
Figure 46–11: Wellness Module—Documentation History Tab
46.5.1
Adding a Reminder History in the Documentation History
Tab
Follow the steps below to add a reminder history in the Documentation History tab:
1. Click Add History on the Action bar. The Select History Type window opens.
Figure 46–12: Select History Type Window
2. Select the desired procedure.
46-8
CHCS II User’s Manual
Block 1
Build 838
Wellness
3. Click OK. The new History window opens with the clinician's name and type prefilled.
Note: The Date, Information Source, and Status are required fields.
Figure 46–13: History Window
4. Complete the required fields.
•
Status: The status can be changed to Completed, Ordered, or Refused.
•
Date: Select the date the action occurred.
•
Information Source: Enter the relationship to the patient reporting the
action.
5. Update information in the remaining fields, if necessary.
•
Clinician: Enter the name of the person administering the action. The default
is whoever is currently logged in.
•
Type: Select the action to be taken from the drop-down list. The default is the
task for which the reminder is being documented.
•
Coded: Select a more detailed status of service by accessing the drop-down
list.
•
Free-text: Enter any additional comments.
•
Admin. Location: Enter the location where the action occurred.
6. Click Save to add this reminder history information to the documentation history
list.
Block 1
Build 838
CHCS II User’s Manual
46-9
Wellness
46.5.2
Deleting Documentation History in the Documentation
History Tab
Follow the steps below to delete documentation history in the Documentation History
tab:
1. Select the item to be deleted.
2. Click Delete on the Action bar.
3. On the Confirm Deletion prompt, click Yes to delete.
46.5.3
Editing a Reminder History in the Documentation History
Tab
Follow the steps below to edit a reminder history in the Documentation History tab:
1. Select the reminder to be modified.
2. Click Edit on the Action bar. The Documentation History Edit window opens.
Figure 46–14: Documentation History Edit Window
3. Modify the desired data.
4. Click Save.
46.5.4
Reminder History Tab
The Reminder History tab displays a history of reminders.
46-10
CHCS II User’s Manual
Block 1
Build 838
Wellness
Figure 46–15: Wellness Module—Reminder History Tab
46.5.5
Setting the Time Filter in the Reminder History Tab
Follow the steps below to set the time filter in the Reminder History tab:
1. Click Time. The Time Search window opens.
Figure 46–16: Time Search Window
2. Select Time Search Options for reminders.
3. Click OK. The data on the Reminder History List screen is refreshed according to
the search criteria.
46.5.6
Editing a Reminder History in the Reminder History Tab
Follow the steps below to edit a reminder history in the Reminder History tab:
1. Select the Reminder History to be modified.
2. Click Edit on the Action bar. The Edit Reminder window opens.
Block 1
Build 838
CHCS II User’s Manual
46-11
Wellness
Figure 46–17: Due Reminder Edit Window
3. Select a code from the coded drop-down list.
4. Enter any necessary free-text to provide further explanation or to take the place of
a code.
5. Click OK.
46.5.7
Activating/Inactivating a Reminder in the Reminder
History Tab
The Activate/Inactivate button toggles between activate and inactivate depending on
the state of the selected reminder. If the reminder is already active, the Inactivate button is seen. If the reminder is inactive, the Activate button is seen.
Follow the steps below to activate/inactivate a reminder in the Reminder History tab:
1. Select the inactive reminder.
2. Click Activate on the Action bar.
3. On the Confirm Reminder Activation window, click Yes.
Follow the steps below to inactivate a reminder:
1. Select the active reminder.
2. Click Inactivate on the Action bar. The Inactivation window opens.
Figure 46–18: Inactivate Reminder Window
3. Enter a reason for the inactivation as a coded or free-text comment.
46-12
CHCS II User’s Manual
Block 1
Build 838
Wellness
4. Click OK.
5. On the Confirm Inactivation window, click Yes to inactivate the reminder.
46.5.8
Viewing Reminder History Details in the Reminder History
Tab
Follow the steps below to view reminder history details in the Reminder History tab:
1. Select the reminder.
2. Click Details on the Action bar. The Detail Information window opens.
Figure 46–19: Due Reminder Detail Window
3. View the detailed reminder information in the window.
4. Click OK.
46.6 Wellness Schedule Tab
The Wellness Schedule tab displays the type of action, the administration schedule,
the status of the reminder and a comment.
Block 1
Build 838
CHCS II User’s Manual
46-13
Wellness
Figure 46–20: Wellness Module—Wellness Schedule Tab
46.6.1
Adding a Wellness Schedule Reminder in the Wellness
Schedule Tab
Follow the steps below to add a wellness schedule reminder in the Wellness Schedule
tab:
1. Click Add on the Action bar. The Add Wellness Schedule window opens.
Figure 46–21: Add Wellness Schedule Window
2. Select a wellness item from the drop-down list.
3. Specify a patient schedule using the drop-down list to document the frequency of
the wellness item.
4. Click Save.
46.6.2
Editing a Wellness Schedule Reminder in the Wellness
Schedule Tab
Follow the steps below to edit a wellness schedule reminder in the Wellness Schedule
tab:
1. Select the reminder to be modified.
46-14
CHCS II User’s Manual
Block 1
Build 838
Wellness
2. Click Edit on the Action bar. The Reminder Schedule window opens.
Figure 46–22: Reminder Schedule Window
3. Do one of the following:
•
If you want the wellness schedule reminder to occur once a year, select the
Recommended Schedule radio button.
Note: Recommended schedule varies based on the type of test—does not automatically set reminders to one year in all cases.
•
If you want to establish a patient-specific schedule:
•
Select Patient Specific.
•
Select a time from the drop-down list.
4. Click OK to set the reminder schedule.
46.6.3
Activating/Inactivating a Wellness Reminder in the
Wellness Schedule Tab
The Activate/Inactivate button toggles between activate and inactivate depending on
the state of the selected reminder. If the reminder is already active, the Inactivate button is seen. If the reminder is inactive, the Activate button is seen.
Follow the steps below to activate a wellness reminder in the Wellness Schedule tab:
1. Select the inactive reminder.
2. Click Activate on the Action bar. The Confirm Reminder Activation window
opens.
Figure 46–23: Confirm Reminder Activation Window
3. Click Yes to activate the reminder.
Follow the steps below to inactivate a reminder in the Wellness Schedule tab:
1. Select a reminder.
Block 1
Build 838
CHCS II User’s Manual
46-15
Wellness
2. Click Inactivate on the Action bar.
3. On the Confirm Inactivation window, click Yes. The Inactivation window opens.
Figure 46–24: Inactivation Window
4. Select a code from the drop-down list or type free-text in place of the code.
5. Click OK.
46-16
CHCS II User’s Manual
Block 1
Build 838
Was this manual useful for you? yes no
Thank you for your participation!

* Your assessment is very important for improving the work of artificial intelligence, which forms the content of this project

Download PDF

advertisement