Hi-Tech Software Solutions Clinical Records System User Manual
Below you will find brief information for HTS. This manual introduces the Hi-Tech Menu System, covering topics like login procedures, password management, electronic signatures, and navigating applications. It also explains how to attach photos, manage face sheet information, and generate custom reports within the Clinical Records System.
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New User Orientation Hi-Tech Software Solutions
New User Orientation
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New User Orientation Hi-Tech Software Solutions
Hi-Tech Menu System
HTS Login Menu
The Login Menu is the first screen that displays when you click the HTS icon on your desktop.
This menu displays all HTS applications.
After you log in, you can access the applications used at your facility, based on menu security.
Update Memo Alert
After an update is installed, when you log in, the Master Menu will display the Review
Program Update Changes message (on right). Click the following:
View Memo Now to display/print the memo.
Remind Me Later to display the Alert again in 24 hours for this User ID.
Don’t Remind Me Again to stop the display of this Alert for this User ID.
The Alert will be displayed for up to 30 days until the user clicks View Memo Now or
Don’t Remind Me Again
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Log In to the HTS System
You must log in before you can use any programs.
Security can be added to a User ID to limit program choices.
NOTE: Your System Administrator (SA) must create a User ID for anyone who wants to log in to the System.
User ID: (1-10 alpha-numeric characters) Enter your User ID.
Press the [Enter] key or click in the Password field.
Password: Enter your Password (1-10 alpha-numeric characters) and press the [Enter] key.
If you enter the wrong User ID, the screen will display:
Invalid User ID/Password error message. Click OK and try again.
When you enter a valid User ID and Password:
Your Home Menu will display all applications authorized for your User ID.
Within those applications, if your User ID does not have access to a program, that menu option will be displayed in non-bold italics.
The Password field is a “blind” field. As you enter your codes, only bullets () will be displayed. Someone watching cannot see what you enter.
Keep your Password secret. If someone uses your User ID and Password, any changes they make or records viewed will be logged under your User ID.
IMPORTANT: Once you have logged into the HTS System, do not leave your computer unattended. Another person could access data, and this action would be logged under your User ID. If you leave your system, exit the program.
Create or Change a Password
From the Log In or Home screens, enter your User ID then click the Change
Password icon.
Edit User ID Records screen will be displayed with your User ID.
Old Password: If you are setting up the first password, leave this field blank. Press the [Enter] key.
Enter New Password (1-10 alpha-numeric characters).
Verify Password: Enter the same new password.
It must match the New Password entry or when you click Ok, the screen will display: New Passwords do not Match.
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Electronic Signatures
As you move towards more electronic documentation and signature in Hi-Tech, be sure that each staff person’s User ID record also includes credentials that should be included with the electronic signature.
Your System Administrator can access to these records through Utilities > System Structure > Maintenance
> User/Security.
In the Full Name field, add the credentials after the last name, as shown on the right.
In the IMAR System, enter the credentials in the Title field, as shown below:
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Inside an Application
Once you have selected an application, that application name displays at the top of your screen and the additional Home and Search icons will display on the left.
User Support Icons on Menu
Home: Click to return to your home menu.
Search Menus: Use to locate a menu option or specific report within the selected application. Example 1: You want to print the report shown below:
Continued on next page.
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Click the Search Menus icon to display the Search box:
You can search using the program name at top of the report i.e. HTW-NRPK.
Enter the information after
“HTW–“ i.e. NRPK. Click Find button.
Note: you can also search on common names for the program such as PICK.
This will display the menu name for program: Resident
– Clinical (see below)
Click the check box under View to display the Location Path of this program within the current application menu. Select those menu items to launch the program.
Make those selections on the menus:
Continued on next page
…
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Example 2: To edit a Physician
’s record, at Enter Search Description, enter PHYSICIAN,
(not Edit Physicians). Click Find button.
Check the view check box to display the Location Path. Make those menu selections:.
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More Support Icons
User Manual: From the Login Menu, view Part 1 of the Menu System: Instructions for General Users.
After you login and select an application, click this icon to view the instructions for that application.
HTS provides curr ent User’s Instructions with each application update.
Update Memos: Each time you install an update, the Memo for that Release is to this list. Select the Memo you want to read.
E-mail Support: Send new support-related issues to: [email protected]
. Several support people receive at this address. If you email an individual and that person is out of the office, your email will not be read until he/she returns.
IMPORTANT: If you fax a support issue to HTS, follow up with a phone call to provide additional information and so your support issue can be logged in the order it is received.
GoToAssist: Establish Live Remote Assistance with the Hi-Tech Support Staff .
Wait for Hi-Tech Phone Support to tell you when to click above on GoToAssist.
This will connect you to Live Remote Assistance.
Enter your Name, Facility Name, and the Code that HTS will provide.
Phone Support will lead you through the process.
A GoToAssist session is available only through Phone Support during our Office
Hours: Monday -Friday: 8 am to 5 pm www.hitechsoftware.com
. Go to our website to review recent news and Webinar schedules, download updates, learn more about HTS history, staff, services and products.
Exit: Click to exit Hi-Tech.
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HTS System Structure
Information in the Hi-Tech Systems flows from one process to another eliminating duplicate data entry. For example:
1. You will first build the resid ent’s face sheet information in Edit Medical Record.
2. You will then enter Physician Orders, including the diet order and med orders.
3. When you enter an MDS or an MDS-RCA, these programs pull in existing face sheet information from Edit Medical Record.
4. For Residential care, the MDS-RCA will pull in medications from Physician Orders into;
Service Plan Part 1 will pull in the diet order from Physician Orders.
The System Flow Charts on the next page show how Library Codes and Face Sheet information is shared among other parts of the Hi-Tech Clinical Records System.
Libraries
HTS provides several libraries that you can edit to fit your facilit y’s needs. Select frequently used text from libraries rather than re-enter this information.
This will make your use of HTS much more efficient. Libraries include:
1. Physician Library (Name and address)
2. Med / Treatment Frequency
3. Routine / Diet / Standard Order
4. Allergy
5. Insurance
6. Hospital
7. Mortuary
8. City / Town
9. County
10. Problems / Goal / Approaches
(for care plans)
11. Resident Notes
12. Resident Inoculations
13. Activities
14. Events
15. Flow Sheet
16. CAA Resources
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System Flow Charts
Face Sheet Library Codes
ICD9
Diagnosis
Physicians
Insurance
Providers
Electronic
Medical Record
(Face sheet)
Edit Resident Medical Records
Electronic
Medical
Records
(Face
Sheets)
Vitals
Printed
Face
Sheets for the
Charts
Allergie s
Orders
Notes
Activities
ICD9
MDS
–
RCA
MDS 3.0
CAAs
Hospital s
Resident
Lists
Case Mix
Mortuarie s
Cod e lists
Flow
Sheets
Calendar
Events
Care Plans
Inoculations
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Attach a Photo to Resident’s EMR
Through Edit Medical Record, you can add a photo of the resident to the Demographics screen.
NOTE: Save photos as jpeg files (JPG) to the PICTURES folder on Hi-Tech DATA drive, or to another folder and path that you have defined through:
Libraries > Clinical Profile > Ok, Ok, Resident Photo Storage Path.
1. Click Attach Picture. The screen will default to your PICTURES folder or other path that you have defined. See NOTE above.
2. Choose a photo from the Image list. The photo will be displayed.
3. Click Ok
4. The photo will be added to the resident’s Demographics screen.
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Face Sheet Screens
Guidelines for entering face sheet information.
Enter dates, phone numbers, and social security numbers without spaces, slashes or dashes. The program will format the entry.
Do not use the letter O for the number zero, or the number zero for the letter O.
Libraries: You can click the binoculars to select a response from one of the system libraries.
HTS provides some of these libraries, such as the ICD9 Diagnosis library.
You must build other libraries of information that is specific to your facility, such as the
Physician library.
You can add some new library items from the Edit Medical Record program. For example, on the Physicians / Diagnosis screen, at Primary Physician enter a Physician code not yet on file. The program will ask, Do you wish to add this Doctor?. Click Yes. The program will allow you to create a new physician’s record.
Create codes and access existing code records through Libraries > Face Sheet and the edit program for that type of code. (Follow state and federal regulations when creating
codes.)
To print any library, choose the print icon at the bottom right corner of the screen.
Resident Inquiry
: Enter or lookup the Resident ID.
Click the binoculars to display the Resident Inquiry screen:
Starting Last Name: Key in last name (not case-sensitive) and press [Enter] key
Click Page Up and Page Down buttons to move up and down the list of names.
Click column header to sort records by that topic. Click again to reverse-sort.
Uncheck at bottom of screen to include discharged residents.
To select a resident, click the checkbox to the left of the name.
The selected resident will be displayed.
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Admission Procedures >
Edit Medical Record
NR03
Edit Medical Record accesses “traditional” face sheet information and parts of a resident’s clinical record that can be maintained outside of the Edit Medical Record program.
After you select a resident, you can edit several parts of a resident’s clinical record from the button panel on the right side of the screen.
The top five buttons access parts of the “traditional” Face Sheet .
You might also have access to th e resident’s financial information when you click the Balances button at the bottom of the button panel.
Other buttons access information that you can also maintain outside of Edit Medical Record by selecting an edit option on a menu, for example, Documentation > Vitals.
If you select the button from the Edit Medical Record, when you complete processing in that record, the program will return you to the resident’s Demographics screen.
Your System Administrator can limit which users can access certain information. Call HTS for assistance.
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View Medical Record
Use this method to provide view-only access to Surveyors and users who can view, and not change, the Medical Record.
From the Clinical Menu, select View Medical Record.
This will display Edit Medical Record > Demographics.
Select the resident and then select the type of information in the button panel on the right side of the screen.
You will be able to view but not change the information on that screen.
Hi-Tech Software Solutions
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Reporting > Custom Reporting > Resident - Clinical
Custom Reporting
NRPK
You can design listings of information that you have entered into residents’ face sheets; for example:
Resident names and room numbers
Birth dates and age
Religions
Medicare and Medicaid numbers
Admit and discharge dates.
If you have already created and saved report designs, the program will first display a list of these reports (on right).
To print a report listed on this screen, click the checkbox in front of the report name to check mark it.
.
(You can select more than one.)
Click Print at bottom of the screen.
To design and print a new report, click New Report. See the next page.
To delete an existing report design, select report title and click Delete.
To change an existing report design, select that report and click Edit. The report will display the existing report design screens for you to change and record. See the next page.
Click End to end the program without printing.
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Design a New Report or Edit an Existing Report Design
You must complete two screens when designing a report. Screen 1 (below) allows you to select which residents will be included on the report, and in what order:
Select the Sort Order that you want. You will usually sort in alphabetic order by Last Name of in numeric order by resident ID. Choose the other options depending on the type of information you are printing. Please note that selecting Birth Date sorts by the year born, so oldest residents are listed first.
If this is a list that will include protected health information (PHI), and it will be disclosed to persons outside the facility for reasons other than treatment, payment, or other health care operations (TPO) click
Log Non-Care Purpose/Use and complete the
HIPAA Disclosure Information.
This record will be added to the HIPAA
Disclosure Log which can be printed by selecting from the Master Menu:
Utilities > HIPAA Processing > Print
Disclosure Log (on right).
Click User Manual icon on the Utilities
Menu for more information on HIPAA.
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Decide which residents to list. Active, All or Individual.
If Active Resident Only Yes, you can select to Include Zero Admit Dates (without Admit
Dates in the face sheet because not yet entered into the census:
If you respond No, you can list Active and/or Discharged residents, and enter a Census Date to list thos in the facility on that date.
: This will select only those residents with birthdays in a specific month. Enter the birthday month (i.e. 1 for January,
12 for December)
The next part of the screen allows you to be more specific about which residents should be included on the report.
If you do not want to exclude any residents, leave the existing selections.
If you do want to be more selective, click the opposite radio box
and enter a selection range at From and Thru.
Access to these items might depend on previous selections. For example, if you have selected
Active residents only, it makes no sense to ask for a discharge date range, because Active residents should have no discharge date in their face sheet.
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Page Break on…: This part of the screen depends on previous selections. For example, the text at the right will be displayed if you are sorting by Resident ID or Last
Name. If you select
Page Break it will print a separate page for each resident, which is not a good idea..
If you selected another sort order, for example
Unit /Room
Bed, the screen will display the options to the right. Clicking
Page Break and Break Total on Unit is a good idea because it will print each Unit on its own page, making the report easier to read.
Click Ok to display Screen 2. On Screen 2, select the columns of information that will be listed on the report.
Hi-Tech Software Solutions
Sorted by lists sort order selected on Screen 1.
Space Left indicates how much space is left on the page (from left to right margin) for information to be printed each time you select an item.
Click an item to check mark it: 01 Resident ID. Selected items will be listed under
Selection
Order
in the sequence selected. Column headings will be printed in this same order. To change the order you can uncheck an item, and then check it again to add it to the end of the order.
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Run To print or display the selected records. Does not save the design.
End To end the program without printing.
Reset To remove selections from Screen 2 so you can choose again.
List Choices To print a listing of the items on the screen.
Save To save this report design.
When saving a report design, the program first lists the existing report designs (on right). Enter a Code not yet in use and the description of the report, for example:
Click Save. The program will ask if you want to print the report now.
The next time you run this program, the saved report will be available for selection:
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Reporting Options: Print, Display, Create File
Most Reporting programs will display in the following format and provide options to print a paper copy.
Print the Report
Make your selections on the program screen. Click Ok or Print .
The report will be displayed. For example:
Click the Print Report or Print Page buttons (on left) to print to paper all or portions of the displayed report. The report will remain on the screen.
To view other parts of the report:
Click Beginning of Report or End of Report to move directly to the top or bottom of the report.
Click PageUp PageDn to move up or down one page at a time.
Use Jump to Page of 002 to move to a specific page of the report.
Use the vertical scroll bars on the right side of the screen to scroll up and down through the report. Click the up or down arrow to move one line at a time, or click and hold on the movable button to scroll quickly.
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Condense Print
Condense Print: A wide report with several columns will be condensed to fit on one screen, and it might be difficult to read.
Uncheck Condense Print to expand the text.
Y ou won’t see the entire report, so click
at the bottom of the report to display the right side of the report. A vertical dashed line indicates the viewing edge of the report.
To move this edge to see more text, adjust using the up and down arrows. On the sample below, we increased the Panel Freeze Point to display the age:
We then reduced the Freeze Point to display the Physician name for the phone number that is displayed.
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Create a File
To create a file that can be imported into Excel or other spread sheet application, check mark
Create File.
File Path/Name: after CREATED \ enter a file name of your choice (up to 8 characters).
Type in the full path to save the file in a different drive and directory.
Click Ok. The file will be given the extension .HTF (for Hi-Tech File) and be saved in the specified directory.
In the spreadsheet program, import the file.
See your spreadsheet software user’s manual .
If you can access Utilities, to display or print the file, select Utilities > Created Files > Display or Print.
At the Enter FILE NAME prompt, click Browse to display a list of files that you have spooled.
Select the file and click Ok.
The report will be displayed or printed.
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Libraries > Face Sheet
Statistics
RB18
The Resident Billing System uses these codes to maintain statistics on the census changes processed through the Census programs. Clinical can use these same codes to identify residents through Edit Medical Record. If your Clinical and Billing Systems are integrated, please consult with your billing office before accessing these programs.
Each type of census record has its own input screen where you can describe the code.
10 - DAY STATISTICS should only be accessed by your billing office.
11 - LEVEL CODES
Purpose of stat: Defines the Level of Care codes used in
Census so you can track number of residents in each level of care.
The following are already defined. Do not delete or
change these codes:
1 = SNF (skilled)
2 = ICF
3 = RCF (Residential Care), BC or BCF
4 = MR
5 = Other
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Sample Face Sheet
Page 1 of 2
Hi-Tech Software Solutions
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Page 2 of 2
Hi-Tech Software Solutions
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Key features
HTS Login & Security
Electronic Signatures
Resident Face Sheet
Custom Reporting
System Flow Charts
User Support Icons
Frequently asked questions
Enter your User ID and Password on the Login Menu. Your System Administrator must create a User ID for you. The Password field is a blind field for security.
From the Log In or Home screens, enter your User ID and click the Change Password icon. If setting up the first password, leave the Old Password field blank.
Use the Search Menus icon to locate a menu option or specific report within the selected application. Enter the program name or a common name for the program.
Through Edit Medical Record, you can add a photo of the resident to the Demographics screen. Save photos as jpeg files (JPG) to the PICTURES folder on Hi-Tech DATA drive.