Vista TIU Text Integration Utilities Clinical Coordinator & User Manual
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TEXT INTEGRATION UTILITIES (TIU)
CLINICAL COORDINATOR & USER
MANUAL
Version 1.0
July 1997
Updated January 2012
Department of Veterans Affairs
Product Development
ii
Revision History
Patch TIU*1*261
(Rescinding an Advance
Directive document ).
Patch 248 (Security For
The Tiu Option Missing
Text Cleanup)
Patch 250 (Line Count)
January 212
June 2011
J. Green,
C Arceneaux, T Downing
June 2010 C Arceneaux, T Downing
Patch 219 (DS Attending Requirements)
Patch 231 (Analyze potential Surgery TIU problems)
Patch 234 (Expected Cosigner Edit and Disallow
June 2008
January 2008
C Arceneaux, A Ebert
G. Werner, A. Scott
December 2007 C Arceneaux, S Madsen
Signed Document Edit)
Patch 215 (Disallow Edit) June 2007
Patch USR*1*31 (Informational on Business Rules) June 2007
C Arceneaux, S Madsen
C Arceneaux, S Madsen
Patch 220
Patch 200 (TUI HL7 Generic Interface)
Patch 214 (Mismatched ID Notes)
Patch 199
Patch 189 (Expected Cosigner)
Patch 191 (Disclosure of Adverse Event Note)
Patch 182 (Medicine Conversion)
Patch 173 (Unknown Addenda Cleanup)
December 2006 C Arceneaux, S Madsen
October 2006 C Arceneaux, D Rickard
September 2006 T Dawson, C Greening
May 2006
March 2006
May 2005
June 2005
April 2005
T Dawson, C Greening
T Dawson, C Greening
C Arceneaux, G Smith
C Arceneaux, G Smith
C Arceneaux, G Smith
Patch 157 (Additional Signer Changes)
Patches 174 & 177 (Blank Note)
Patch 171 (SCI Document Definitions)
192-352 applied (Patient Privacy Document
Scrubbing)
Patch 169 (C & P Document Definitions)
Patch 177 (Missing Text)
Patch 185 (Reassign Report)
Patch 112 (Surgery)
Patch 113 (Multidivision)
Patch 159 (WRIISC)
Patch 165 (Patient Record Flags)
Patch 137 (Anatomic Pathology)
Patch 158 (Alert Tools)
Patch 109 (Clinical Procedures)
Patches 61, 95, 100 & 105
Miscellaneous patches
Originally released
March 2005
Nov 2004
February 2005
June 2003
June 2002
April 2001
July 2000
July 1997
C Arceneaux, G Smith
C Arceneaux, G Smith
December 2004 C Arceneaux & S Wellman, P
Landy
December 2004 C Arceneaux, G Smith
October 2004
August 2004
February 2004
February 2004
October 2003
September 2003
June 2003
C Arceneaux, G Smith
Text Integration Utilities V. 1.0 Rev. May 2011 Clinical Coordinator & User Manual
Preface
Purpose of Text Integration Utilities
Text Integration Utilities (TIU) simplifies the access and use of clinical documents for both clinical and administrative VAMC personnel, by standardizing the way clinical documents are managed. In connection with Authorization/Subscription Utility (ASU), a hospital can set up policies and practices for determining who is responsible or has the privilege for performing various actions on required VHA documents.
The initial release of Version 1.0 includes Discharge Summary and Progress Notes. TIU replaces and upgrades the previous versions of these V
IST
A packages.
Scope of Manual
This manual provides descriptions of menus and options, as well as other information required to effectively use the Text Integration Utilities package.
Audience
Information in this manual is intended for Clinical Coordinators, Automated Data Processing
Application Coordinators (ADPACs), and end users: clinicians, MIS Managers, Medical
Record Technicians, and transcriptionists.
Related Manuals
Text Integration Utilities (TIU) Implementation Guide
Text Integration Utilities & Authorization/Subscription Utility
Installation Guide
Text Integration Utilities (TIU) Technical Manual
Authorization/Subscription Utility (ASU) User Manual
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Table of
Contents
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Section I: Introduction
Chapter 1: Introduction to TIU
Chapter 2: Orientation
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Chapter 1: Introduction to TIU
Purpose of Text Integration Utilities
The purpose of Text Integration Utilities (TIU) is to simplify the access and use of clinical documents for both clinical and administrative VAMC personnel, by standardizing the way clinical documents are managed. In connection with Authorization/
Subscription Utility (ASU), a hospital can set up policies and practices for determining who is responsible or has the privilege for performing various actions on required VHA documents.
The initial release of Version 1.0 includes Discharge Summary and Progress Notes.
Consult Reports was added with the release of Computerized Patient Record System
(CPRS). TIU replaces and upgrades the previous versions of these V
IST
A packages. It has also been designed to meet the needs of other clinical applications that address document handling.
TIU lets you continue to access Progress Notes and Discharge Summaries from OE/RR menus. The CPRS Graphical User Interface (GUI) allows point-and-click access to all
Progress Notes, Discharge Summaries, and Consults TIU documents.
Benefits
a. Standardized and common user interface
Clinicians can go through the same program to enter, review, and sign discharge summaries, progress notes, and other clinical documents that may be set up locally for processing through TIU.
b. Integration
Clinicians and management can search for and retrieve clinical documents more efficiently because documents reside in a single location within the database. This is also a benefit for other uses such as Incomplete Record Tracking, quality management, results reporting, order checking, research, etc.
c. Data Capture Flexibility
TIU accepts document input from a variety of data capture methodologies. Those initially supported are transcription and direct entry. TIU allows upload of ASCII formatted documents into V
IST
A.
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Benefits, cont’d
d. Links to Other Packages.
TIU interfaces, as appropriate, with such applications as Health Summary,
Problem List, Patient Care Encounter/Visit Tracking, and Incomplete Record
Tracking. Computerized Patient Record System (CPRS) further integrates
V
IST
A packages and allows point and click switching between packages.
A new Health Summary component is available (through Patch GMTS*2.7*12), Selected
Progress Notes, which allows selection of specific Progress Notes Titles for display on
Health Summaries. The PN, DS, and CWAD components now extract data from TIU, rather than Progress Notes (GMRP), or Discharge Summary (GMRD). Care has been taken to assure that the formatting and content of the components have remained the same, except that the signature block information will now reflect the author's (and cosigner's) name and title at the time of signature, rather than displaying their current values at the time of output.
e. Improved management of Documents.
TIU has a file structure called the Document Definition Hierarchy for defining elements and parameters of a document. It allows
Inheritance of document characteristics, such as signing, cosigning, visit linkage, etc.
Site definition of document characteristics
Shared components
Ownership (personal or class) of document definitions
Boilerplate text functionality
Interdisciplinary Note functionality.
Embedded “Object” functionality which can extract data from otherV
IST
A packages and insert it into boilerplate text
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Chapter 2: Orientation
Manual organization
This manual is divided into four major sections:
Section
I: Introduction
II: Using TIU
III: Managing TIU
Purpose
Presents overviews of TIU software and the User Manual.
Describes and demonstrates how to use the basic entry and reporting functions of TIU. This section is divided into subsections for the four major users of TIU: clinicians, MRTs,
MIS Managers, and transcriptionists.
Describes the options and tools available to coordinators and
IRMS for assigning menus, setting parameters, and other management functions. Also includes Troubleshooting and
Helpful Hints.
Definitions of terms and the index to the manual. Glossary and Index
How each chapter is formatted
Each chapter generally follows the format of:
Brief overview
Description of process (step-by-step description of how to use functions, if appropriate)
Examples
Online documentation: Intranet
Online Documentation for this product is available on the intranet at the following address: http://www.va.gov/vdl/
This address takes you to the Clinical Products page, which has a listing of all the clinical software manuals. Click on the Text Integration Utilities link and it will take you to the
TIU Homepage.
You can also get there by going straight to the following address: http://vista.med.va.gov/tiu/
Remember to bookmark this site for future reference.
Special Instructions for the new V
IST
A Computer User
If you are unfamiliar with this package or other Veterans Health Information Systems and
Technology Architecture (V
IST
A) software applications, we recommend that you study the DHCP User’s Guide to Computing. This orientation guide is a comprehensive handbook for first-time users of any V
IST
A application to help you become familiar with
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basic computer terms and the components of a computer. It is reproduced and distributed periodically by the Kernel Development Group. To request a copy, contact your local
Information Resources Management Service (IRMS) staff.
Graphic Conventions Used in This Manual
<Enter>
The Enter or Return key. It is pressed after every response you enter or when you wish to bypass a prompt, accept a default (//), or return to a previous action. In this manual, it is only included in examples when it might be unclear that such a keystroke must be entered.
Option examples
Menus and examples of computer dialogue that you see on the screen are shown in boxes:
Select Menu Option:
User responses
User responses are shown in boldface.
Select PATIENT NAME: TIUPATIENT,ONE
NOTE
The pointing finger with a NOTE is used to call your attention to something especially significant.
Example:
NOTE: You can respond to many prompts by typing the first few letters of a name, option, or action.
Select PATIENT NAME: TIUPATIENT,O TIUPATIENT,ONE
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TIU and VISTA Conventions
^ , ^^, ^^^
Enter the up-arrow (also known as a caret or circumflex) at a prompt to exit the current option, menu, sequence of prompts, or help. To get completely out of your current context and back to your original menu, you may need to enter two or three up-arrows. For example, when you’re reviewing a list of documents, one up-arrow takes you to the next document; you need to enter two up-arrows to get out of the option.
> >
TIU screens can contain more information to the right of the main screen display. To see this information, enter the > character. To return to the main screen, enter the < character.
NOTE: The arrow keys on the keypads of some keyboards can sometimes be used for navigation in List Manager applications, but this depends on the operating system. So if you get funny characters on your screen when you use those arrows, use the > and < symbols on the comma and period keys (the greater-than and less-than symbols).
Online Help ?, ??, ???
Online help is available by entering one, two, or three question marks at a prompt.
One question mark elicits a brief statement of what information is appropriate for responding to the prompt; two question marks shows a list (and sometimes descriptions) of more actions; and three question marks provide more detailed help, including a list of possible answers, if appropriate.
Defaults (//) Defaults are responses provided to speed up your entry process. They are either the most common responses, the safest responses, or the previous response.
Examples:
Most common: Enter the ending date: NOW//
Safest: Do you wish to delete the entire entry: NO//
Last entered Enter the Provider Name: TIUPROVIDER,THREE//
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List Manager Screen Display
Screen Title
Header area
# of pages indicated here
List area
Message window
Action Area
TIU uses the List Manager utility which enables TIU (and other applications) to display a list of items in a screen format.
Screen title
The screen title changes according to what type of information List Manager is displaying
(e.g., Progress Notes, Discharge Summary, etc.).
Header area
The header area is a “fixed” (non-scrollable) area that displays patient information.
List area
(scrolling region) This area scrolls if there are more items than will fit on one page. It displays a list of items, such as Unsigned Progress Notes, that you can take action on. If there’s more than one page of items, it’s listed in the upper right-hand corner of the screen (Page 1 of #).
Message window
This section displays a plus (+) sign, minus (-), or >> sign, or informational text (i.e.,
Enter ?? for more actions). If you enter a plus sign at the action prompt, List Manager
“jumps” forward a page. If a minus sign is displayed and you enter it at the action prompt, List Manager “jumps” back a screen. The plus, minus, and > signs are only valid actions if they are displayed in the message window.
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List Manager Screen Display cont’d
Action area
A list of actions display in this area of the screen. If you enter a double question mark (??) at the “Select Item(s)” prompt, you are shown a “hidden” list of additional actions that are available to use.
Entering Actions
The List Manager utility lets you: browse through the list select items that need action take action against those items select other actions without leaving the option
Actions are entered by typing the name or abbreviation at the “Select Action” prompt.
Shortcut: Actions may also be preselected by typing the action abbreviation, then the number of the document on the list (Example: ED=1 will let you edit entry 1, Consult
Report.
Besides the actions specific to the option you are working in, List Manager provides generic actions applicable to any List Manager screen. Enter a double question mark
(??) at the “Select Action” prompt for a list of all actions available. The abbreviation for each action is shown in brackets following the action name. These actions are described on the next page.
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List Manager Screen Display, cont’d
The following actions are available (enter ?? to see these):
+ Next screen GO Go to Page DD Detailed Display
- Previous Screen RD Re Display Screen EC Edit Cosigner
FS First Screen ADPL Auto Display(On/Off) CT Change Title
LS Last Screen Q Quit CWAD CWAD Display
UP Up a Line > Shift View to Right
DN Down a Line < Shift View to Left
Generic (hidden) actions
Action Description
Next Screen [+]
Previous Screen [-]
Up a Line [UP]
Down a Line [DN]
Shift View to Right [>]
Shift View to Left [<]
First Screen [FS]
Last Screen [LS]
Go to Page [GO]
Re Display Screen [RD]
Print Screen [PS]
Move to the next screen (may be shown as a default)
Move to the previous screen
Move up one line
Move down one line
Move the screen to the right if the screen width is more than 80 characters
Move the screen to the left if the screen width is more than 80 characters
Move to the first screen
Move to the last screen
Move to any selected page in the list
Redisplay the current screen
Prints the header and the portion of the list currently displayed
Print List [PL]
Search List [SL]
Prints the list of entries currently displayed
Finds selected text in list of entries
Auto Display (On/Off) [ADPL]
Toggles the menu of actions to be displayed/not displayed automatically
Change Title (CT)
Lets you change the Title of a note from, e.g., a CWAD
CWAD Display (CWAD)
note to a Nursing Note
Displays details of any CWAD notes available
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List Manager Screen Display, cont’d
Action
Edit Cosigner [EC]
Quit [QU]
Description
Allows authorized users to modify the Expected
Cosigner (Attending Physician for Discharge
Summaries) of documents without having access to the text of the document. It is intended for Clinical
Coordinators when they need to change the Expected
Cosigner of a document whose Expected Cosigner cannot be otherwise changed because it is already signed.
It permits the Expected Cosigner field to be edited for unsigned or uncosigned documents of type Progress
Notes, Consults, Clinical Procedures, or Discharge
Summaries.
Note:
Recent changes enforce limits on cosigning privileges. No provider may be a cosigner on Discharge
Summaries if the provider requires a cosignature. To correct expected cosigners who were erroneously assigned before this restriction went into effect, perform a search on uncosigned notes, then use the (hidden) Edit
Cosigner (EC) action to correct any problems.
Exits the screen (may be shown as a default)
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Section 2: Using TIU
Chapter 3: TIU for Clinicians
Chapter 4: TIU for MRTs
Chapter 5: TIU for MIS Managers
Chapter 6: TIU for Transcriptionists
Chapter 7: TIU for Remote Users
Chapter 8: Progress Notes Print Options
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Chapter 3: TIU for Clinicians
Progress Notes/Discharge Summary Menu
Using Progress Notes through OE/RR 2.5 or CPRS 1.0
Progress Notes Options
Progress Notes Actions and Statuses
Interdisciplinary Notes Actions
Discharge Summary Options
Discharge Summary Actions and Statuses
Integrated Document Management Options
Personal Preferences
Document Definitions
TIU and Health Summary
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Chapter 3: TIU for Clinicians
Progress Notes/Discharge Summary Menu
This is the main TIU menu for clinicians. It includes all of the options necessary for clinicians to manage their Progress Notes, Discharge Summaries, and other clinical documents which may be set up locally, either separately or in an integrated fashion. TIU also lets you continue to access Progress Notes and Discharge Summaries through
OE/RR menus. CPRS allows point and click access to all Progress Notes, Discharge
Summaries, and Consults TIU documents.
The Progress Notes/Discharge Summary (TIU) menu also includes a Personal Preferences menu that lets clinicians change their own parameters for viewing clinical documents.
Option Name Description
Progress Notes User Menu
This menu includes options for reviewing, entering, printing, and signing progress notes, either by individual patient or by multiple patients.
Discharge Summary User
Menu
Integrated Document
Management
Personal Preferences
This menu includes options for reviewing, entering, printing, and signing discharge summaries, either by individual patient or by multiple patients.
This menu lets clinicians perform actions on progress notes, discharge summaries, and other clinical documents from a single menu
For example, a clinician may want to bring up all his unsigned documents.
This menu allows users to
1) enter preferences about the behavior of the TIU Package.
These preferences include:
DEFAULT LOCATION,
REVIEW SCREEN SORT FIELD
SORT ORDER
DISPLAY MENUS
PATIENT SELECTION PREFERENCE
2) specify “pick lists” for document selection when composing or editing documents (e.g., when choosing documents from the class Progress Notes, “Let me see these three specific titles”).
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Using Progress Notes through OE/RR 2.5 or CPRS
Clinicians who enter and review Progress Notes through OE/RR 2.5 will also be able to do so with TIU. CPRS (Computerized Patient Record System) access to and operations on Progress notes is streamlined. Here we give an example of reviewing Notes through the List Manager version of CPRS. The GUI version has a different sequence of steps, but should seem even easier to most people.
Example: Reviewing and signing Notes through CPRS
1. Select the Clinician Menu from your CPRS menu.
OE CPRS Clinician Menu
RR Results Reporting Menu
AD Add New Orders
RO Act On Existing Orders
PP Personal Preferences ...
Select Clinician Menu Option: OE CPRS Clinician Menu
2. The Patient Selection screen is displayed. If you have a patient or team list defined, the patients are on this display.
Ward 2B Mar 17, 1997 17:07:09 Page: 1 of 1
Current patient: ** No patient selected **
Patient Name ID DOB Room-Bed
1 TIUPATIENT,ONE (3456) Jan 01, 1951
2 TIUPATIENT,THREE (1996) Mar 05, 1949
3 TIUPATIENT,FIVE (3779) Nov 19, 1991
4 TIUPATIENT,SEVEN (3234) Mar 03, 1966
5 TIUPATIENT,TEN (2432) Apr 04, 1932
6 TIUPATIENT,NINE (2591) Apr 25, 1931 9-B
If you have a
7 TIUPATIENT,ELEVEN (8910) Jan 01, 1934 A-4
8 TIUPATIENT,TWO (3243) Apr 04, 1954
9 TIUPATIENT,FOURTEEN (4723) Oct 23, 1927 A-2 patient list defined in your
Enter the number of the patient chart to be opened
personal
+ Next Screen CG Change List ... FD Find Patient
- Previous Screen SV Save as Default List Q Close preferences it is displayed here.
Select Patient: Close// 1 TIUPATIENT,ONE
Searching for the patient's chart ...
If not, just enter a patient name.
3. Select a patient by:
Entering a name from a list (if you have one defined and set as your default
Entering a patient’s name (or last initial + last 4 letters of SSN)
Entering FD (Find Patient), entering a ward or clinic name, then selecting a patient name from the list that appears.
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Example: Reviewing Notes, cont’d
4. The “Cover Sheet” for the patient’s record is displayed. Select Chart Contents.
Cover Sheet Mar 17, 1997 17:07:50 Page: 1 of 2
TIUPATIENT,ONE 666-12-3456 2B JAN 1,1951 (46) <CW>
Item Entered
Allergies/Adverse Reactions |
1 PENICILLIN 1 (rash, nausea,vomiting) | 01/03/97
|
Patient Postings |
2 CRISIS NOTE | 02/24/97 08:28
3 CRISIS NOTE | 12/03/96 10:44
4 CLINICAL WARNING | 02/21/97 09:16
5 CLINICAL WARNING | 01/15/97
|
Recent Vitals |
No data available |
|
Immunizations |
No immunizations found. |
|
+ Enter the numbers of the items you wish to act on. >>>
NW Document New Allergy CG (Change List ...) SP Select New Patient
+ Next Screen CC Chart Contents ... Q Close Patient Chart
Select: Next Screen// cc CHART CONTENTS
Shortcut: Enter CC;N to bypass the next screen.
5. A new set of actions is displayed. These are the Contents or categories of the Patient
Chart (also known as “Tabs.”) Select the Notes tab.
Cover Sheet Mar 17, 1997 17:07:50 Page: 1 of 2
TIUPATIENT,ONE 666-12-3456 2B JAN 1,1951 (46) <CW>
Alert Entered
Allergies/Adverse Reactions |
1 PENICILLIN 1 (rash, nausea,vomiting) | 01/03/97
|
Patient Postings |
2 CRISIS NOTE | 02/24/97 08:28
3 CRISIS NOTE | 12/03/96 10:44
4 CLINICAL WARNING | 02/21/97 09:16
5 CLINICAL WARNING | 01/15/97
|
Recent Vitals |
No data available |
+ Enter the numbers of the items you wish to act on. >>>
Cover Sheet Orders Imaging Reports
Problems Meds Consults
Notes Labs D/C Summaries
Select chart component: N Notes
Searching for the patient's chart ...
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Example: Reviewing Notes, cont’d
6. The patient’s completed progress notes are displayed. This is the default set up through Personal Preferences. You can “change view” to see a different status, such as unsigned notes.
Completed Progress Notes Mar 17, 1997 17:10:56 Page: 1 of 1
TIUPATIENT,ONE 666-12-3456 2B JAN 1,1951 (46) <CW>
Title Written Sig Status
1 CRISIS NOTE | 02/24/97 08:28 completed
2 CLINICAL WARNING | 02/21/97 09:16 completed
3 General Note | 01/24/97 14:18 completed
4 CLINICAL WARNING | 01/15/97 completed
5 SOAP - GENERAL NOTE | 12/04/96 14:39 completed
6 SOAP - GENERAL NOTE | 12/04/96 11:32 completed
7 CRISIS NOTE | 12/03/96 10:44 completed
8 SOAP - GENERAL NOTE | 12/03/96 10:31 completed
9 SOAP - GENERAL NOTE | 11/22/96 12:37 completed
Enter the numbers of the items you wish to act on. >>>
NW Write New Note CG Change List ... SP Select New Patient
+ Next Screen CC Chart Contents ... Q Close Patient Chart
Select: Chart Contents// CG CHANGE LIST
Date range Status
Select attribute(s) to change: S STATUS
Select Signature Status: completed//??
Enter the signature status you would like to screen on
Choose from:
amended
completed
deleted
purged
uncosigned
undictated
unreleased
unsigned
untranscribed
unverified
Select Signature Status: completed//UNSigned
Searching for the patient's chart ...
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Example: Reviewing Notes, cont’d
7. The patient’s unsigned notes are displayed.
Unsigned Progress Notes Mar 17, 1997 17:13:22 Page: 1 of 1
TIUPATIENT,ONE 666-12-3456 2B JAN 1,1951 (46) <CW>
Title Written Sig Status
1 Addendum to CLINICAL WARNING | 01/28/97 unsigned
Enter the numbers of the items you wish to act on. >>>
NW Write New Note CG Change List ... SP Select New Patient
+ Next Screen CC Chart Contents ... Q Close Patient Chart
Select: Chart Contents//
Example: Writing a note
Select: Chart Contents// NW Write New Note
Available note(s): 11/22/96 thru 02/24/97 (9)
Do you wish to review any of these notes? NO// YES
--- Select note(s) to review ---
Please specify a date range from which to select note(s):
List Notes Beginning: 11/22/96//
<Enter>
(NOV 22, 1996)
Thru: 02/24/97//
<Enter>
(FEB 24, 1997)
1 02/24/97 08:28 CRISIS NOTE Two TIUProvider
Adm: 09/21/95
2 02/21/97 09:16 CLINICAL WARNING Sixteen TIUProvider
Adm: 09/21/95
3 01/24/97 14:18 General Note Three TIUProvider
Adm: 09/21/95
SUBJECT: TEST
4 01/15/97 00:00 CLINICAL WARNING One TIUProvider, MD
Visit: 08/14/95
5 12/04/96 14:39 SOAP - GENERAL NOTE Three TIUProvider
Adm: 09/21/95
Choose Notes: (1-5):
<Enter>
Nothing selected.
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Example: Writing a note, cont’d
Personal PROGRESS NOTES Title List for NINE TIUPROVIDER
1 Crisis Note
2 Advance Directive
3 Adverse Reactions
4 Other Title
TITLE: (1-4): 3 Adverse React/Allergy
Creating new progress note...
Patient Location: 2B
Date/time of Admission: 09/21/95 10:00
Date/time of Note: NOW
Author of Note: TIUPROVIER,NINE
...OK? YES//
<Enter>
SUBJECT (OPTIONAL description):
Calling text editor, please wait...
1>TEST
2> <Enter>
EDIT Option:
Save changes? YES//
<Enter>
Saving Adverse React/Allergy with changes...
Enter your Current Signature Code: XXX SIGNATURE VERIFIED..
Print this note? No// YES
Do you want WORK copies or CHART copies? CHART//
<Enter>
DEVICE: HOME//
<Enter>
VAX
--------------------------------------------------------------------------
TIUPATIENT,ONE 666-12-3456 Progress Notes
--------------------------------------------------------------------------
NOTE DATED: 03/17/97 17:15 ADVERSE REACT/ALLERGY
ADMITTED: 09/21/95 10:00 2B
TEST
Signed by: /es/ NINE TIUPROVIDER
NINE TIUPROVIDER 03/17/97 17:15
Enter RETURN to continue or '^' to exit:
<Enter>
You may enter another Progress Note. Press RETURN to exit.
Select PATIENT NAME:
<Enter>
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Select Search through CPRS
You can narrow your view to signed notes by author, unsigned notes, etc. You can also specify the date order your notes will appear in: ascending (oldest first) or descending
(most recent first) order.
Caution: Avoid selecting too large a date range or too general a category, as big searches are very system-intensive. This means that not only might it slow down your work, but everyone else’s as well.
Progress Notes Apr 09, 1997 14:42:58 Page: 1 of 1
<CWA> P R O G R E S S N O T E S Last 15 note(s)
TIUPATIENT,ONE 666-12-3456 2B/ JAN 1,1951 (46)
Title Author Date/Time
1 Psychology Notes TIUPROVIDER,ONE 04/08/97 15:49 compl
2 CRISIS NOTE TIUPROVIDER,THR 04/08/97 00:00 compl
3 Adverse React/Allergy TIUPROVIDER,NIN 04/07/97 16:28 compl
6 Adverse React/Allergy TIUPROVIDER,NIN 04/03/97 19:31 compl
7 Adverse React/Allergy TIUPROVIDER,NIN 03/17/97 17:15 compl
8 CRISIS NOTE TIUPROVIDER,NIN 02/24/97 08:28 compl
+ Next Screen - Prev Screen ?? More Actions
NW New Note SP Select New Patient AD Make Addendum
B Browse SS Select Search $ Complete Note(s)
PC Print Copy RS Reset to All Signed Q Quit
Select Action: Quit// SS Select Search
Valid selections are:
1 - signed notes (all) 2 - unsigned notes 3 - uncosigned notes
4 - signed notes/author 5 - signed notes/dates
Select context: 1// 4 AUTHOR
Select AUTHOR: TIUPROVIDER,TWO// <Enter> jg
Please Specify Sort Order: descending// ?
Enter a code from the list.
Select one of the following:
A ascending (OLDEST FIRST)
D descending (NEWEST FIRST)
Please Specify Sort Order: descending// A ascending (OLDEST FIRST)
Searching for the progress notes.
Progress Notes Apr 09, 1997 14:42:50 Page: 1 of 1
<CWA> P R O G R E S S N O T E S 4 note(s)
TIUPATIENT,ONE 666-12-3456 2B/ JAN 1,1951 (46)
Title Author Date/Time
1 CRISIS NOTE TIUPROVIDER 02/24/97 08:28 compl
2 Adverse React/Allergy TIUPROVIDER 03/17/97 17:15 compl
3 Adverse React/Allergy TIUPROVIDER 04/03/97 19:31 compl
4 Adverse React/Allergy TIUPROVIDER 04/07/97 16:05 compl
+ Next Screen - Prev Screen ?? More Actions
NW New Note SP Select New Patient AD Make Addendum
B Browse SS Select Search $ Complete Note(s)
PC Print Copy RS Reset to All Signed Q Quit
Select Action: Quit//
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Progress Notes Options
Clinicians can review, enter, print, and sign progress notes, either by individual patient or by multiple patients, through TIU.
NOTE: When reviewing several notes sequentially, the up-arrow (^) entry takes you to the next note. To exit from the review, enter two up-arrows (^^).
Clinician's Progress Notes Menu
Option Description
Entry of Progress Note This is the main option for entering a new progress note. You can also edit patient progress notes.
Review Progress Notes by
Patient
Review Progress Notes
All MY UNSIGNED
Progress Notes
Show Progress Notes
Across Patients
Progress Notes Print
Options ...
List Notes By Title
Search by Patient AND
Title
Personal Preferences...
This option lets you review, edit, or sign a selected patient’s progress notes, by selected criteria.
This option lets clinicians get quickly to a patient’s list of notes, without preliminary prompts to select criteria for displaying notes.
This option retrieves all your unsigned progress notes for review, edit, or signature.
This option lets you search for and review progress notes by many different criteria: status, type, date range, and category.
Caution: Avoid selecting too large a date range or too general a category, as big searches are very system-intensive. This means that not only might it slow down your work, but everyone else’s as well.
The options on this menu support the printing of chart or work copies, by author, location, patient, or ward. These options are described in Chapter 8.
This option lets you look up progress notes by title within a specified date range.
This option lets you search for and review progress notes by patient, as well as many other criteria: status, type, date range, and category.
The two options on this menu let you customize the way TIU operates for you; that is, which prompts will appear, what lists you will see to select from, etc. You can also specify the way documents are displayed on your review screens, by patient, by author, by type, in chronological or reverse chronological order, etc.
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Entry of Progress Note
This is the main option for entering a new progress note. You can also edit patient progress notes.
Example 1: Inpatient progress note
Steps to use option:
1. Select Entry of Progress Note from your Progress Notes Menu. If you have a patient list set up (through Personal Preferences), it is displayed here.
Loading Ward Patient List...
2B ward list
1 TIUPATIENT,ONE (3456) ~ 8 TIUPATIENT,TWO (3243) A-4
2 TIUPATIENT,NINE (2591) ~ 9 TIUPATIENT,EIGHT (3242) ~
3 TIUPATIENT,FOUR (2384) ~ 10 TIUPATIENT,TEN (2432) A-2
4 TIUPATIENT,SEVEN (3234) ~ 11 TIUPATIENT,TWELV (3213) A-1
5 TIUPATIENT,THREE (1996) ~ 12 TIUPATIENT,FOURT (4723) ~
6 TIUPATIENT,FIVE (3779) ~ 13 TIUPATIENT,SIXTE (1321) A-3
7 TIUPATIENT,SIX (2476) 9-B 14 TIUPATIENT,ELEVE (1414) ~
2. Type in a patient name or a number from the list. Demographic data and CWAD
(Cautions, Warnings, Adverse Reactions, and Directives) notes are displayed. You are prompted to choose if you want to see any of the previous Progress Notes for this patient.
Select Patient(s): 7 TIUPATIENT,TWO 04-25-31 666043243P NO MILITARY
RETIREE
(6 notes) W: 01/27/97 15:17 (addendum 02/08/97 17:19)
A: Known allergies
(1 note ) D: 03/26/97 13:02
Available notes: 11/11/96 thru 04/15/97 (27)
Do you wish to see any of these notes? NO//
<Enter>
This indicates that there are 27 notes for this patient.
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Entry of Progress Note, cont’d
3. Select a Title. If you have a personal Progress Notes title list set up through Personal
Preferences, that list is displayed for you to choose from. Enter a Subject, if desired, and the text of the Progress Note.
Personal PROGRESS NOTES Title List for THREE TIUPROVIDER
1 Crisis Note
2 Advance Directive
3 Adverse Reactions
4 Other Title
TITLE: (1-4): 3//
<Enter>
Adverse React/Allergy
Creating new progress note...
Patient Location: 1A
Date/time of Admission: 05/30/97 10:43
Date/time of Note: NOW
Author of Note: TIUPROVIDER,NINE
...OK? YES//
<Enter>
SUBJECT (OPTIONAL description):
<Enter>
Calling text editor, please wait...
1>Mr. TIUPatient improving; renewed prescription.
2> <Enter>
EDIT Option:
Save changes? YES//
<Enter>
Saving Adverse React/Allergy with changes...
4. Enter your electronic signature code. If you wish to print the note (either a Work or
Chart copy), answer yes to the next prompt, and enter a printer device name.
Enter your Current Signature Code: XXX SIGNATURE VERIFIED..
Print this note? No// y YES
Do you want WORK copies or CHART copies? CHART// w WORK
DEVICE: HOME//
<Enter>
VAX
The note is printed. You are prompted to enter another note or to exit.
------------------------------------------------------------------------
TIUPATIENT,SEVEN 666-04-3234P Progress Notes
------------------------------------------------------------------------
NOTE DATED: 05/31/97 14:58 ADVERSE REACT/ALLERGY
ADMITTED: 05/30/97 10:43 1A
Mr. TIUPatient improving; renewed prescription.
Signed by: /es/ NINE TIUPROVIDER
NINE TIUPROVIDER 05/31/97 14:59
Enter RETURN to continue or '^' to exit:
You may enter another Progress Note. Press RETURN to exit.
Select PATIENT NAME:
<Enter>
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Example 2: Outpatient note
Outpatient notes require more information than inpatient notes, because every outpatient encounter must now be associated with a visit to get workload credit. Most Progress
Notes automatically get the visit data from Checkout or a scanned Encounter Form.
Steps to use option:
1. Select Entry of Progress Note from your Progress Notes Menu.
2. Type in a patient name.
Select Patient(s): TIUPATIENT,ONE TIUPATIENT,ONE 09-12-44 666233456 YES
SC VETERAN
(1 note ) C: 11/19/96 (addendum 01/28/97 09:55)
A: Known allergies
For Patient TIUPATIENT,ONE
3. Type in a Progress Note Title. You can use an existing Title or create a new one. If you have created a personal document list through the Personal Preferences’ Document
Management option, that list is displayed here.
Personal PROGRESS NOTES Title List for THREE TIUPROVIDER
1 Crisis Note
2 Advance Directive
3 Adverse Reactions
4 Other Title
TITLE: (1-4): 3 Adverse React/Allergy
4. Since this is a note for an outpatient, you may be prompted to select an existing
visit or create a new visit to associate the progress note with.
This patient is not currently admitted to the facility...
Is this note for INPATIENT or OUTPATIENT care? OUTPATIENT// <Enter>
The following VISITS are available:
1> FEB 24, 1997@09:00 DIABETES CLINIC
2> SEP 05, 1996@10:00 CARDIOLOGY
CHOOSE 1-2 or <N>EW VISIT
<RETURN> TO CONTINUE
OR '^' TO QUIT: N
Creating new progress note...
Patient Location: NUR 1A
Date/time of Visit: 02/24/97 14:29
Date/time of Note: NOW
Author of Note: TIUPROVIDER,THREE
...OK? YES//<Enter>
SERVICE: MEDICINE// <Enter> 111
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Entry of Progress Note, cont’d
5. Enter a subject for your note (optional).
SUBJECT (OPTIONAL description): ?
Enter a brief description (3-80 characters) of the contents
of the document.
SUBJECT (OPTIONAL description): Blue Note
6. Type in the text of the note. If it’s a SOAP Note or there’s a boilerplate for this, you can fill in the blanks or edit existing text. You can use the FileMan text editor or fullscreen editor. Sign the Note when you’re finished.
Calling text editor, please wait...
1>Follow-up visit to ensure compliance with regimen.
2><Enter>
EDIT Option: <Enter>
Save changes? YES//<Enter>
Saving General Note with changes...
Enter your Current Signature Code: [HIDDEN CODE] SIGNATURE VERIFIED..
7. Enter the Diagnosis associated with this Progress Note.
NOTE: To receive workload credit, VAMCs must now capture Provider,
Diagnosis, and Procedure for all outpatient visits.
Please Indicate the Diagnoses for which the Patient was Seen:
1 Abdominal Pain
2 Abnormal EKG
3 Abrasion
4 Abscess
A list of diagnoses
5 Adverse Drug Reaction
6 AIDS/ARC
7 Alcoholic, intoxication relating to the type of Progress Note is
8 Alcoholism, Chronic
9 Allergic Reaction presented for you to choose from.
10 Anemia
ANGINA:
11 Stable
12 Unstable
13 Anorexia
14 Appendicitis, Acute
15 Arthralgia
ARTHRITIS
16 Osteo
17 Rheumatoid
18 Ascites
19 ASHD
20 OTHER Diagnosis
Select Diagnoses: (1-20): 9
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Entry of Progress Note, cont’d
8. Enter the Procedure associated with this Progress Note.
Please Indicate the Procedure(s) Performed:
CARDIOVASCULAR
1 Cardioversion
2 EKG
3 Pericardiocentesis
4 Thoracotomy
MISCELLANEOUS
5 Abscess
6 Less than 2.5 cm
7 2.6 - 7.5 cm
8 Greater than 7.5 cm
9 Burns 1 * Local Treatment
10 Dressings Medium
11 Dressings Small
12 Transfusion
13 Venipuncture
UROLOGY
14 Foley Catheter
ENT
15 Removal Impacted Cerumen
16 Anterior, Simple
17 Anterior, complex
18 Posterior
EYE
19 Foreign Body Removal
20 OTHER Procedure
Select Procedure: (1-20): 19
A list of procedures relating to the type of Progress Note is presented for you to choose from.
You have indicated the following data apply to this visit:
DIAGNOSES:
995.3 Allergic Reaction <<< PRIMARY
PROCEDURES:
65205 Foreign Body Removal
...OK? YES//
<Enter>
Posting Workload Credit...
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8. If you wish, you can print the note now.
Print this note? No// y YES
Do you want WORK copies or CHART copies? CHART// work
DEVICE: HOME//
<Enter>
VAX
----------------------------------------------------------------------
TIUPATIENT,ONE 666-23-3456 Progress Notes
----------------------------------------------------------------------
NOTE DATED: 02/24/97 08:30 ADVERSE REACT/ALLERGY
VISIT: 02/24/97 08:30 GENERAL MEDICINE new tests
Signed by: /es/ THREE TIUPROVIDER
THREE TIUPROVIDER 02/24/97 08:30
Enter RETURN to continue or '^' to exit:
You may enter another CLINICAL DOCUMENT. Press RETURN to exit.
Select PATIENT NAME:
<Enter>
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Review Progress Notes by Patient
This option lets you review, edit, or sign a selected patient’s progress notes.
Steps to use option:
1. Select Review Progress Notes by Patient from the Progress Notes menu, then enter the name of the patient.
Select Progress Notes User Menu Option: 2 Review Progress Notes by Patient has
Select PATIENT NAME: TIUPATIENT,ONE TIUPATIENT,ONE 09-12-44 666233456
If the patient
SC VETERAN
Cautions,
Warnings,
Allergies, or
Directives
(CWAD), they are
2. Enter the date range of notes you wish to review.
displayed here.
Please specify a date range from which to select notes:
List notes Beginning: 12/01/96 (DEC 01, 1994)
Thru: 05/01/96//
<Enter>
(MAY 01, 1997)
3. From the selection displayed, choose the notes you wish to review.
1 04/18/97 11:38 Social Work Service Three TIUProvider, MD
Visit: 04/18/97
2 06/21/96 07:47 Lipid Clinic Three TIUProvider, MD
Visit: 06/18/96
3 06/07/96 00:00 Diabetes Education One TIUProvider, MD
Visit: 04/18/96
4 01/19/96 10:37 SOAP - General Note Three TIUProvider, MD
Visit: 1/10/96
Choose notes: (1-8): 2
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Review Progress Notes by Patient, cont’d
4. The note you selected is then displayed.
Opening Lipid Clinic record for review...
Browse Document Jun 26, 1996 10:55:18 Page: 1 of 4
Lipid Clinic
TIUPATIENT,O 666-23-3456 Visit Date: 06/18/96@10:00
DATE OF NOTE: JUN 21, 1996@07:47:47 ENTRY DATE: JUN 21, 1996@07:47:47
AUTHOR: TIUPROVIDER,ONE EXP COSIGNER:
URGENCY: STATUS: COMPLETED
SUBJECTIVE: 5 year old AMERICAN INDIAN OR ALASKA NATIVE MALE here for
initial evaluation of his DYSLIPIDEMIA.
COPIED FROM TIUCLIENT TO TIUPATIENT.
PMH:
Significant negative medical history pertinent to the
evaluation and treatment of DYSLIPIDEMIA:
FH:
+ + Next Screen - Prev Screen ?? More actions
Find Make Addendum Identify Signers
Print Sign/Cosign Delete
Edit Copy Link ...
Quit
Select Action: Next Screen// <Enter>
NOTE: The screen indicates that this is Page 1 of 4; press Enter after each screen to see all the pages of this note. When reviewing several notes, the up-arrow (^) entry takes you to the next note. To exit from the review, enter two up-arrows (^^).
Browse Document Jun 26, 1996 10:56:09 Page: 2 of 4
Lipid Clinic
TIUPATIENT,O 666-23-3456 Visit Date: 04/18/96@10:00
+
SH:
MEDICATION
HISTORY: CURRENT MEDICATIONS
DIET: Counseled on AHA Step I diet today by NINE TIUPROVIDER.
See her evaluation.
ACTIVITY:
OBJECTIVE: HT: 70 (08/23/95 11:45) WT: 207 (08/23/95 11:45)
+ + Next Screen - Prev Screen ?? More actions
Find Make Addendum Identify Signers
Print Sign/Cosign Delete
Edit Copy Link ...
Select Action: Next Screen// <Enter>
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Review Progress Notes by Patient, cont’d
Browse Document Jun 26, 1996 10:56:43 Page: 3 of 4 Lipid
Clinic
TIUPATIENT,O 666-23-3456 Visit Date: 04/18/96@10:00
TSH/T4: 1.7/1.1
FBG: 200 HEMOGLOBIN A1C: 15.2
SGOT: 44 URIC ACID: 4.7
ASSESSMENT: 1. MALE with / without documented CAD
2. CV Risk factors:
3. Lipid pattern:
PLAN: 1. Implement recommendations to lower fat intake.
2. Repeat FBG and HBG A1C on:
3. Return to review lab on:
+ + Next Screen - Prev Screen ?? More actions
Find Make Addendum Identify Signers
Print Sign/Cosign Delete
Edit Copy Link ...
Quit
Select Action: Next Screen// <Enter>
Browse Document Jun 26, 1996 10:57:04 Page: 4 of 4
Lipid Clinic
TIUPATIENT,O 666-23-3456 Visit Date: 04/18/96@10:00
+
/es/ Three TIUProvider, MD
Medical Intern
+ Next Screen - Prev Screen ?? More actions
Find Make Addendum Identify Signers
Print Sign/Cosign Delete
Edit Copy Link ...
Quit
Select Action: Quit//
5. You can then select an action to perform on the note.
Select Action: Quit// m Make Addendum
Adding ADDENDUM
DATE/TIME OF NOTE: 10/25/96@11:21// <Enter> (OCT 25, 1996@11:21:00)
AUTHOR OF NOTE: TIUPROVIDER,ELEVEN// <Enter> jg
Calling text editor, please wait...
1>Should say 55 year old...
2><Enter>
EDIT Option: <Enter>
Saving Addendum with changes...
Addendum Released.
Enter your Current Signature Code: xxxxxxx (code hidden) SIGNATURE VERIFIED..
Press RETURN to continue...<Enter>
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Review Progress Notes
This option lets clinicians get immediately to a patient’s list of notes, without preliminary prompts for selection criteria. It’s particularly useful for when physicians are seeing patients in clinics and want to pull up their records quickly, as they are able to do with
Progress Notes 2.5 (frequently accessed through OE/RR 2.5). Note that the actions below the black bar look more like OE/RR (and CPRS) actions than the ones you’ll see in other
TIU options.
1. Select Review Progress Notes from your Progress Notes or OE/RR menu, whichever one you commonly use. Then enter the name of the patient you are seeing.
Select Progress Notes User Menu Option: 2b Review Progress Notes
Select PATIENT NAME: TIUPATIENT,ONE TIUPATIENT,ONE 09-12-44 666233456
YES
SC VETERAN
(2 notes) C: 02/24/97 08:44
(1 note ) W: 02/21/97 09:19
A: Known allergies
(2 notes) D: 03/25/97 08:57
Searching for the progress notes.
2. A screen with a list of notes for your patient is displayed. Items with the plus symbol (+) have addenda. You can look at details of any of the notes shown (by selecting the Browse or Detailed Display action), create a new note, make an addendum, sign a note, or perform any of the other actions listed below (as well as hidden actions).
Progress Notes May 31, 1997 14:20:10 Page: 1 of 1
<CWAD> P R O G R E S S N O T E S Last 15 note(s)
TIUPATIENT,O 666-23-3456 SEP 12,1944 (52)
Title Author Date/Time
1 Adverse React/Allergy TIUPROVIDER,FIV 05/27/97 00:00 compl
2 Adverse React/Allergy TIUPROVIDER,ONE 05/20/97 17:18 compl
3 CRISIS NOTE TIUPROVIDER,THR 05/20/97 17:01 compl
4 Adverse React/Allergy TIUPROVIDER,SEV 05/20/97 11:23 compl
5 GENERAL NOTE TIUPROVIDER,SEV 05/20/97 11:21 compl
6 CARDIOLOGY NOTE TIUPROVIDER,SEV 05/20/97 10:56 compl
7 Adverse React/Allergy TIUPROVIDER,FIV 04/21/97 16:02 compl
8 Adverse React/Allergy TIUPROVIDER,FIV 04/15/97 06:23 compl
9 CARDIOLOGY NOTE TIUPROVIDER,FIV 04/11/97 12:09 compl
10 CRISIS NOTE TIUPROVIDER,FIV 04/11/97 09:09 compl
+ Next Screen - Prev Screen ?? More Actions
NW New Note SS Select Search IN Interdiscipl'ry Note
B Browse RS Reset to All Signed EE Expand/Collapse Entry
PC Print Copy AD Make Addendum Q Quit
SP Select New Patient $ Complete Note(s)
Select Action: Quit// B BROWSE
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Review Progress Notes, cont’d
3. If you select the action Browse, you can see more details of a note.
Select Action: Next Screen// b Browse
Select Progress Note(s): (1-15): 1
Reviewing Item #1
Opening Adverse React/Allergy record for review...
Browse Document May 31, 1997 14:29:07 Page: 1 of 1
Adverse React/Allergy
TIUPATIENT,O 666-23-3456 GENERAL MEDICINE Visit Date: 04/18/96@10:00
DATE OF NOTE: MAY 27, 1997 ENTRY DATE: MAY 27, 1997@12:15:13
AUTHOR: TIUPROVIDER,ONE EXP COSIGNER:
URGENCY: STATUS: COMPLETED
Another test...is the antibiotic working?
/es/ ONE TIUPROVIDER, MD
PGY2 Resident
Signed: 05/27/97 12:21
+ Next Screen - Prev Screen ?? More actions
Find Sign/Cosign Link ...
Print Copy Encounter Edit
Edit Identify Signers Interdiscipl'ry Note
Make Addendum Delete Quit
Select Action: Quit//
NOTE: When reviewing several notes sequentially, the up-arrow (^) entry takes you to the next note. To exit from the review, enter two up-arrows (^^).
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Review Progress Notes, cont’d
4. If you select the action Detailed Display, you can see even more details of a note.
Enter DT for Detailed Display. Detailed Display is a “hidden action,” an action that appears when you enter two question marks.
Select Action: Next Screen// det Detailed Display
Select Progress Note(s): (1-15): 1
Reviewing #1
Opening Adverse React/Allergy record for review........
Detailed Display May 31, 1997 13:36:09 Page: 1 of 2
Adverse React/Allergy
TIUPATIENT,O 666-23-3456 Visit Date: 04/18/96@10:00
Source Information
Reference Date: MAY 27, 1997@10:44:19 Author: TIUPROVIDER,ONE
Entry Date: MAY 27, 1997@10:44:19 Entered By: jg
Expected Signer: TIUPROVIDER,EIGHT Expected Cosigner: None
Urgency: None Document Status: COMPLETED
Line Count: 46 TIU Document #: 1132
Division: ISC-SLC-A4 VBC Line Count: 56.25
Subject: None
Associated Problem
s No linked problems.
E
Edit Information
Edit Date: JAN 17, 1997@10:45:08 Edited By: TIUPROVIDER,EIGHT
Reassignment History
Document Never Reassigned.
+ Next Screen - Prev Screen ?? More actions
Find Print Quit
Select Action: Next Screen// <Enter>
Detailed Display May 31, 1997 13:37:40 Page: 2 of 2
Adverse React/Allergy
TIUPATIENT,O 666-23-3456 Visit Date: 04/18/96@10:00
+
Signature Information
Signed Date: MAY 27, 1997@10:45:17 Signed By: TIUPROVIDER,ONE
Signature Mode: ELECTRONIC
Cosigned Date: None Cosigned By: None
Cosignature Mode: None
Document Body
Mr. TIUPATIENT'S allergies improved with medication.
06/08/97 ADDENDUM:
Improvement was temporary; patient relapsed after a few days.
SIXTEEN TIUPROVIDER
+ Next Screen - Prev Screen ?? More actions
Find Print Quit
Select Action: Quit//
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Review Progress Notes, cont’d
5. If you select the action Select Search, you can narrow your view to a specific context of notes: signed, unsigned, by author, or by a date or date range.
Progress Notes May 31, 1997 14:20:10 Page: 1 of 1
<CWAD> P R O G R E S S N O T E S Last 15 note(s)
TIUPATIENT,O 666-23-3456 SEP 12,1944 (52)
Title Author Date/Time
1 Adverse React/Allergy TIUPROVIDER,N 05/27/97 00:00 compl
2 Adverse React/Allergy TIUPROVIDER,N 05/20/97 17:18 compl
3 CRISIS NOTE TIUPROVIDER,N 05/20/97 17:01 compl
4 Adverse React/Allergy TIUPROVIDER,N 05/20/97 11:23 compl
5 GENERAL NOTE TIUPROVIDER,N 05/20/97 11:21 compl
6 CARDIOLOGY NOTE TIUPROVIDER,N 05/20/97 10:56 compl
7 Adverse React/Allergy TIUPROVIDER,T 04/21/97 16:02 compl
8 Adverse React/Allergy TIUPROVIDER,T 04/15/97 06:23 compl
9 CARDIOLOGY NOTE TIUPROVIDER,T 04/11/97 12:09 compl
10 CRISIS NOTE TIUPROVIDER,T 04/11/97 09:09 compl
+ Next Screen - Prev Screen ?? More actions
NW New Note SP Select New Patient AD Make Addendum
B Browse SS Select Search $ Complete Note(s)
PC Print Copy RS Reset to All Signed Q Quit
Select Action: Quit// ss
Select Search
Valid selections are:
1 - signed notes (all) 2 - unsigned notes 3 - uncosigned notes
4 - signed notes/author 5 - signed notes/dates
Select context: 1// 2 UNSIGNED NOTES
Progress Notes May 31, 1997 14:20:10 Page: 1 of 1
<CWAD> P R O G R E S S N O T E S 1 note(s)
TIUPATIENT,O 666-23-3456 1A/A-2 SEP 12,1944 (52)
Title Author Date/Time
1 Adverse React/Allergy TIUPROVIDER,N 05/31/97 15:51 unsig
+ Next Screen - Prev Screen ?? More Actions
NW New Note SP Select New Patient AD Make Addendum
B Browse SS Select Search $ Complete Note(s)
PC Print Copy RS Reset to All Signed Q Quit
Select Action: Quit//
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All MY UNSIGNED Progress Notes
When you select this option, the program retrieves all your unsigned progress notes for review, edit, or signature.
Steps to use option:
1. Select All My Unsigned Progress Notes from the Clinician’s Progress Notes Menu.
2. The list is then displayed, from which you can choose any of the listed actions.
My UNSIGNED Progress Notes Oct 25, 1996 11:33:52 Page: 1 of 1
by AUTHOR (TIUPROVIDER,ONE) or EXPECTED COSIGNER 2 documents
Patient Document Ref Date Status
1 TIUPATIENT(D3456) Psychology - Crisis 10/25/96 unsigned
2 TIUPATIENT(D3456) Addendum to Lipid Clinic 10/25/96 unsigned
+ Next Screen - Prev Screen ?? More Actions >>>
Find Sign/Cosign Change View
Add Document Detailed Display Copy
Edit Browse Delete Document
Make Addendum Print Quit
Link ... Identify Signers
Select Action: Quit// s Sign/Cosign
Select Progress Note(s): (1-2): 1
Opening Psychology - Crisis record for review...
SIGN/COSIGN Oct 25, 1996 11:34:21 Page:1 of 1
Psychology - Crisis
TIUPATIENT,ONE 666-23-3456 2B Visit Date: 10/25/96@11:32
DATE OF NOTE: OCT 25, 1996@11:32:55 ENTRY DATE: OCT 25, 1996@11:32:55
AUTHOR: TIUPROVIDER,ONE EXP COSIGNER:
URGENCY: STATUS: UNSIGNED
Six-month follow-up visit. Patient continues to improve; no change in treatment required.
+ Next Screen - Prev Screen ?? More Actions
Print No
Ready for Signature: NO// y Yes
Item #: 1 Added to signature list.
Enter your Current Signature Code: xxxxxxx (code hidden) SIGNATURE VERIFIED..
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Show Progress Notes Across Patients
This option lets you search for and review progress notes by many different criteria: status, type, date range, and cateogory. By different combinations of these criteria, you can see almost any view of your progress notes you could want.
NOTE: Use caution in how broad your search is (date range, # of patients, etc.), because searches for a lot of documents can be very system-intensive, slowing down response time for everyone.
Steps to use option:
1. Select Show Progress Notes Across Patients from the Clinician’s Progress Notes
Menu.
2. Select one of the following status(es) of progress notes:
undictated uncosigned
untranscribed
unreleased
completed
amended
unverified
unsigned
retracted
3. Select one of the following Progress Note Types.
Advance Directive Crisis Note Historical Titles
Adv React/Allergy Clinical Warning
4. Select one or more of the following search categories:
1 All Categories 6 Patient 11 Transcriptionist
2 Author 7 Problem 12 Treating Specialty
3 Division 8 Service 13 Visit
4 Expected Cosigner 9 Subject
5 Hospital Location 10 Title
5. Select the range of dates to include.
6. The notes meeting the criteria you selected are displayed.
UNSIGNED Progress Notes Jun 18, 1997 09:19:20 Page: 1 of 1
by AUTHOR from 06/15/96 to 06/18/97 2 documents
Patient Document Ref Date Status
1 TIUPATIENT,(R0482) Clinical Warning 06/14/97 unsigned
2 TIUPATIENT,(D4029) Crisis Note 06/14/97 unsigned
+ Next Screen - Prev Screen ?? More Actions >>>
Find Sign/Cosign Change View
Add Document Detailed Display Copy
Edit Browse Delete Document
Make Addendum Print Quit
Link ... Identify Signers
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Select Action: Quit//
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Progress Notes Print Options
See Chapter 8 for examples and further descriptions of these options.
Option Description
Author Print Progress Notes
This option produces chart or work copies of progress notes for an author for a selected date range.
Location Print Progress Notes
This option prints chart or work copies of progress notes for all patients who were at a specific location when the notes were written. The patients whose progress notes are printed on this report may not still be at that location.
If Chart is selected, each note will start on a new page.
Patient Print Progress Notes
Ward Print Progress Notes
This option prints or displays progress notes for a selected patient by selected date range.
This option lets you print progress notes for all patients who are now on a ward for a selected date range. This option is only for ward locations. NOTE: This option only prints to a printer, not to your computer screen.
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List Notes by Title
This option lets you look up progress notes by title within a specified date range. You can then take any of the usual actions on these notes.
Steps to use option:
1. Select List Notes by Title from the Clinician’s Progress Notes Menu. Select the titles (one or more) of progress notes to search for.
Select Progress Notes User Menu Option: 6 List Notes By Title
Please Select the PROGRESS NOTES TITLES to search for:
1) ??
Answer with TIU DOCUMENT DEFINITION NAME, or ABBREVIATION, or
PRINT NAME
Do you want the entire TIU DOCUMENT DEFINITION List? y (Yes)
Choose from:
ADMISSION ASSESSMENT TITLE
ADVANCE DIRECTIVE TITLE
ADVERSE REACTION/ALLERGY TITLE
CLINICAL WARNING TITLE
CRISIS NOTE TITLE
FINAL DISCHARGE NOTE TITLE
GENERAL NOTE TITLE
PATIENT EDUCATION TITLE
Please Select the Progress Notes TITLES to search for:
1) ADVERSE REACTION/ALLERGY TITLE
2) CLINICAL WARNING TITLE
3) <Enter>
2. Enter a beginning and ending date range to choose documents from. The selected documents are displayed.
Start Reference Date [Time]: T-2// t-10 (MAR 01, 1997)
Ending Reference Date [Time]: NOW//
<Enter>
(MAR 11, 1997@09:10)
Searching for the documents.........
Progress Notes by Title Mar 11, 1997 09:10:09 Page: 1 of 1
from 03/01/97 to 03/11/97 8 documents
Patient Document Ref Date Status
1 TIUPATIENT(H2591) Adverse React/Allergy 03/05/97 unsigned
2 TIUPATIENT(D3456) Adverse React/Allergy 03/05/97 completed
3 TIUPATIENT(R1239) CLINICAL WARNING 03/05/97 completed
4 TIUPATIENT(H2591) Adverse React/Allergy 03/11/97 completed
+ Next Screen - Prev Screen ?? More Actions >>>
Find Sign/Cosign Change View
Add Document Detailed Display Copy
Edit Browse Delete Document
Make Addendum Print Quit
Link ... Identify Signers
Select Action: Quit//
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List Notes by Title, cont’d
3. You may now choose an action such as Edit, Sign/Cosign, Make Addendum or
Detailed Display.
Progress Notes by Title Mar 11, 1997 09:10:09 Page: 1 of 1
from 03/01/97 to 03/11/97 8 documents
Patient Document Ref Date Status
1 TIUPATIENT(H2591) Adverse React/Allergy 03/05/97 unsigned
2 TIUPATIENT(D3456) Adverse React/Allergy 03/05/97 completed
3 TIUPATIENT(R1239) CLINICAL WARNING 03/05/97 completed
4 TIUPATIENT(H2591) Adverse React/Allergy 03/11/97 completed
5 TIUPATIENT(H2591) Adverse React/Allergy 03/10/97 completed
6 TIUPATIENT(S1462) CLINICAL WARNING 03/04/97 uncosigned
7 TIUPATIENT(P4365) Adverse React/Allergy 03/04/97 completed
8 TIUPATIENT(N1234) Adverse React/Allergy 03/06/97 completed
+ Next Screen - Prev Screen ?? More Actions >>>
Find Sign/Cosign Change View
Add Document Detailed Display Copy
Edit Browse Delete Document
Make Addendum Print Quit
Link ... Identify Signers
Select Action: Quit// DET=3
4. A detailed display of the note you chose appears on your screen.
Detailed Display Mar 11, 1997 09:21:40 Page: 1 of 2
CLINICAL WARNING
TIUPATIENT,NINE 666-12-1239 Visit Date: 02/04/97@13:00
Source Information
Reference Date: MAR 05, 1997@14:50:17 Author: TIUPROVIDER,ONE
Entry Date: MAR 05, 1997@14:50:18 Entered By: DP
Expected Signer: TIUPROVIDER,FIFTEEN Expected Cosigner: None
Urgency: None Document Status: COMPLETED
Line Count: 46 TIU Document #: 27752
Division: ISC-SLC-A4 VBC Line Count: 56.25
Subject: None
Associated Problems No linked problems.
Edit Information
Edit Date: MAR 05, 1997@14:50:41 Edited By: TIUPROVIDER,FIFTEEN
Signature Information
+ + Next Screen - Prev Screen ?? More actions
Find Print Quit
Select Action: Next Screen//
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Search by Patient AND Title
This option lets you search for and review progress notes by patient, as well as many other criteria: status, type, date range, and category. You can then take any of the usual actions on these notes.
Steps to use option:
1. Select the Search by Patient AND Title option from the Progress Notes User Menu.
2. Select a Patient.
Select Progress Notes User Menu Option: Search by Patient AND Title
Select PATIENT NAME: TIUPATIENT,ONE TIUPATIENT,ONE 09-12-44 666233456 YES
SC VETERAN
(1 note ) C: 07/22/91 11:27
(1 note ) W: 07/22/91 11:34
A: Known allergies
(1 note ) D: 04/01/92 10:58
If the patient has
Cautions,
Warnings,
3. Type in one or more Progress Note Titles to search for.
Allergies, or
Please Select the PROGRESS NOTE TITLES to search for:
1) Lipid CLINIC TITLE
2) Diabetes EDUCATION TITLE
3) <Enter>
Start Reference Date [Time]: T-2// <Enter> (SEP 10, 1996
Directives
(CWAD), they are displayed
Ending Reference Date [Time]: NOW//<Enter> (SEP 12, 1996@11:06)
Searching for the documents... here.
4. A list is displayed of all notes that meet the criteria you specified.
ALL Progress Notes Sep 12, 1996 11:06:24 Page: 1 of 1
by PATIENT from 07/14/96 to 09/12/96 2 documents
Patient Document Ref Date Status
1 TIUPATIENT,(D3456) Diabetes Education 09/12/96 completed
2 TIUPATIENT,(D3456) Addendum to Diabetes Edu 09/09/96 unsigned
+ Next Screen - Prev Screen ?? More Actions >>>
Find Sign/Cosign Change View
Add Document Detailed Display Copy
Edit Browse Delete Document
Make Addendum Print Quit
Link ... Identify Signers
Select Action: Quit// <Enter>
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Progress Notes Statuses and Actions
Statuses
Status Description
Amended *
Completed * deleted
Retracted *
The document has been completed and a privacy act issue has required its amendment. By design, only the following user classes are allowed to amend a note:
CHIEF, MIS
CHIEF, HIM
PRIVACY ACT OFFICER
The document has acquired all necessary signatures and is legally authenticated.
Status DELETED is no longer operable. Before status RETRACTED was introduced deleting a document removed the text of the document leaving a stub with status DELETED.
When a signed document is reassigned, amended, or deleted, a retracted copy of the original is kept for audit purposes.
Uncosigned * undictated unreleased unsigned untranscribed unverified
The document is complete with the exception of cosignature (e.g., by a supervisor).
The document is required and a record has been created in anticipation of dictation and transcription, but the system has not yet been informed of its dictation.
The document is in the process of being entered into the system, but has not yet been released by the originator (i.e., the person who entered the text directly online).
The document is online in a draft state, but the author hasn’t signed.
The document is required and the system has been informed of its dictation, but the transcription hasn’t been entered or received by upload.
The document has been released or uploaded, but must be verified before the document may be displayed.
* As of TIU*1*234, documents of these statuses (i.e., signed documents) cannot be edited regardless of business rules.
NOTE:
+ = a report has addenda.
* = priority (STAT) document.
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Progress Note Actions
Find Sign/Cosign Change View
Add Document Detailed Display Copy
Edit Browse Delete Document
Make Addendum Print Quit
Link ... Identify Signers
Action
Find
Add Document
New Note
Edit
Make Addendum
Link
Sign/Cosign
Detailed Display
Browse
Identify Signers
Change View
Copy
Delete Document
Change Title
Quit
Description
Allows you to search a list of documents for a text string (word or partial word) from the current position to the end of the list.
Lets you add a new Progress Note.
Same as Add Document, used in CPRS contexts.
Allows authorized users to edit selected documents online.
Allows authorized users to add addenda to selected documents online.
Physicians will be prompted for their signatures upon exit.
Allows you to link documents to either problems, visits, or other documents.
Such associations permit a variety of clinically useful “views” of the online record.
Allows clinicians to electronically sign selected discharge summaries or addenda. NOTE: Electronic signature carries the same legal ramifications that wet signature of a hard-copy discharge summary carries. You are advised to carefully review each discharge summary for content and accuracy before exercising this option.
Displays the report type, patient, urgency, line count, VBC line count, author, attending physician, transcriptionist, and verifying clerk, and also admission, discharge, dictation, transcription, signature, and amendment dates.
Lets you browse through Documents from the Review Screen, by scrolling sequentially through the selected documents and their addenda. You can search for a word or phrase, or print draft copies.
Allows you to print copies of VAF 10-1000 for selected summaries.
Allows authorized users to identify additional signers for a document.
Lets you change the displayed reports to signature status, review screen, or dictation date range.
Allows authorized users to copy one or more documents to other patients and encounters. This is particularly useful when documenting group sessions, etc.
Allows the author to delete an unsigned document. In rare cases, a signed document can be deleted but a copy is kept as a retracted document.
This action on the “hidden” list lets you change a Title for a Progress Note
(e.g., CWAD Notes) to another Title.
Lets you quit the current menu level.
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Interdisciplinary Notes
Interdisciplinary Notes are a new feature of Text Integration Utilities (TIU) for expressing notes from different care givers as a single episode of care. They always start with a single note by the initial contact person (e.g., triage nurse, attending) and continue with separate notes created and signed by other providers and attached to the original note.
To accomplish this, your facility must:
1.
Set up note titles for the initiating note and the attachment notes—also called parent note and child notes.
2.
Use version 15 of the CPRS Windows (GUI) interface or later.
The Text Integration Utilities (TIU) Implementation Guide contains a new appendix,
Appendix C, that describes in detail the technical aspects of setting up Interdisciplinary
Notes.
The rest of this section shows the actions Interdisciplinary Notes using Version 15 of the
CPRS Windows interface.
The Parent Note
You start any interdisciplinary note with a parent note. A parent is a note title that includes an ASU (Authorization/Subscription Utility) rule allowing attachments. Your facility should have set up these titles with unique names that allow you to easily identify them.
Only certain members of your team should start Interdisciplinary Notes. To establish a parent note for a patient and a specific episode of care, all they do is create a note with the proper title, and sign it.
The Child Note(s)
Continue an interdisciplinary note by attaching one or more child notes to the parent note. The intention is for each child note to be by a different provider involved in this episode of care. Again your facility has established a number of notes with unique titles to act as child notes.
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Interdisciplinary Notes, cont’d
Previously created note attachments are made to the parent node by dragging and dropping. (Dragging and dropping may be a new concept to you. To drag and drop:
1.
Point the cursor at the child note.
2.
Hold down the left mouse button.
3.
Move the cursor over the parent note. A ghost of the child note title will follow the cursor.
4.
Release the left mouse button.
The following dialog appears to confirm the attachment:
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Interdisciplinary Notes, cont’d
Menu Actions
There are two Interdisciplinary Note specific menu commands in the CPRS Windows interface. They are:
Add New Entry to ID Note
Detach from ID Note
These commands become active (usable) when the correct kind of note is selected as in these illustrations:
In the first case, the parent note has been selected. In this case, you can add a new note to the Interdisciplinary Note without having to later attach it (via drag and drop).
In the second case, one of the child notes has been selected. In this case, you can detach this note from the parent.
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Interdisciplinary Notes, cont’d
The Display
CPRS displays all notes in the Interdisciplinary Note reference date order unless one of the child notes is selected. In this case, CPRS displays the child note, then it displays all the notes in the Interdisciplinary Note reference date order; repeating the current note. In all other respects, the format of the display is the same as a regular note.
The display of unsigned notes depends upon the business rules in effect at your site.
These rules may allow you to view the unsigned child notes of other providers in the context of an Interdisciplinary Note. This is up to your local authorities.
Meaning of Icons
In the CPRS Windows interface, notes are listed in a tree-structured arrangement. This is intended to graphically show a number of things:
1.
Signed and Unsigned notes.
2.
Notes with an addendum attached.
3.
Interdisciplinary notes.
4.
Regular notes.
The meaning of the various icons is:
Icon Meaning
A list of notes, either signed or unsigned.
An Interdisciplinary Note. The open folder indicates that all the children are listed.
A child to an Interdisciplinary Note.
A regular note, or a child note that has not yet been attached to a parent.
The plus sign indicates an addendum is present.
An addendum
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Interdisciplinary Notes, cont’d
In the List Manager interface, similar devices are used to indicate the type of note:
Symbol Meaning
(Nothing) A regular note, or a child note that has not yet been attached to a parent.
<
>
+
+<
+>
An Interdisciplinary Note parent.
An Interdisciplinary Note child.
An addendum is present.
An Interdisciplinary Note with one or more addendum present. The addenda may be in the child note(s).
An Interdisciplinary Note child with one or more addendum present.
LM Considerations
CPRS
Interdisciplinary Notes are not supported in the List Manager (LM) interface of CPRS with the following exception: Interdisciplinary Notes are viewed and printed just as other notes supported by TIU.
TIU
To access the full range of Interdisciplinary Notes features, use the Progress Note User
Menu and choose exported option 2b, Review Progress Notes.
The IN (Interdiscipl'ry Note) action is the universal action for operations on
Interdisciplinary Notes. You should select a note before selecting this menu option. If the note selected is a parent note, it will prompt you to enter a child of this note. If the note selected is an unattached child note, it will prompt you to select the parent that goes with it.
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In this example, a new child note is added to an existing parent note:
Progress Notes Feb 14, 2001@15:09:32 Page: 1 of 6
<DA> P R O G R E S S N O T E S 74 note(s)
TIUPATIENT,FOUR 666-55-2384 MAR 3,1960 (40)
Title Author Date/Time _
1 - ID PARENT NINE TIUPROVIDER, 02/14/01 08:15 compl
2 |_ID CHILD OCCUPATIONAL THER TIUPROVIDER, 02/14/01 08:16 compl
3 ER NOTE TIUPROVIDER, 02/14/01 08:14 compl
4 - ID PARENT REHAB TREATMENT PL TIUPROVIDER, 02/08/01 08:26 compl
5 |_- ID CHILD REHAB INITIAL A TIUPROVIDER, 02/08/01 13:29 compl
6 | |_Addendum to ID CHILD R TIUPROVIDER, 02/14/01 08:11 compl
7 |_ID CHILD REHAB PSYCHOLOGY TIUPROVIDER, 02/09/01 09:13 compl
8 - ANGIOPLASTY NOTE TIUPROVIDER, 01/08/01 13:16 compl
9 |_Addendum to ANGIOPLASTY NO TIUPROVIDER, 02/14/01 08:13 compl
10 ID CHILD AMY TIUPROVIDER, 01/08/01 13:14 compl
11 ID ANY CHILD NOTE TIUPROVIDER, 01/02/01 07:52 compl
12 SEVEN'S CHILD SIX TIUPROVIDER, 12/28/00 13:49 compl
13 SEVEN'S CHILD FIVE TIUPROVIDER, 12/28/00 13:48 compl
14 +< SEVEN'S ID NOTE TIUPROVIDER, 12/28/00 13:31 compl
+ + Next Screen - Prev Screen ?? More Actions
NW New Note SS Select Search IN Interdiscipl'ry Note
B Browse RS Reset to All Signed EE Expand/Collapse Entry
PC Print Copy AD Make Addendum Q Quit
SP Select New Patient $ Complete Note(s)
Select Action: Next Screen// IN
To ADD a new entry to an interdisciplinary note, please select the
interdisciplinary note.
To ATTACH an existing stand-alone note to an interdisciplinary note,
please select the note you want to attach.
Select Progress Note: (1-14): 4
Are you adding a new interdisciplinary entry to this note? YES// <Enter>
Adding a new interdisciplinary entry to
ID PARENT REHAB TREATMENT PLAN
Please select a title for your entry:
TITLE: ??
Choose from:
ER NURSE NOTE TITLE
ER PHYSICIAN NOTE TITLE
OCCUPATIONAL THERAPY CHILD NOTE TITLE
REHAB CHILD DISCHARGE PLANNING NOTE TITLE
REHAB CHILD INITIAL ASSESSMENT NOTE TITLE
REHAB CHILD NURSE NOTE TITLE
REHAB CHILD PHARMACY NOTE TITLE
REHAB CHILD PHYSICAL THERAPY NOTE TITLE
REHAB CHILD PSYCHOLOGY NOTE TITLE
^
TITLE: REHAB CHILD PHYSICAL THERAPY NOTE TITLE
Enter/Edit PROGRESS NOTE...
Patient Location: PULMONARY CLINIC
Date/time of Visit: 02/08/01 08:26
Date/time of Note: NOW
Author of Note: TIUPROVIDER,TWENTY ONE
...OK? YES// <Enter>
Calling text editor, please wait...
1>The Pt is doing very well ...
2>
EDIT Option: <Enter>
Saving ID CHILD REHAB PHYSICAL THERAPY NOTE with changes...
Enter your Current Signature Code: ********
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Progress Notes Feb 14, 2001@16:05:36 Page: 1 of 6
<DA> P R O G R E S S N O T E S 74 note(s)
TIUPATIENT,FOUR 666-55-2384 MAR 3,1960 (40)
Title Author Date/Time _
1 - ID PARENT NINE TIUPROVIDER, 02/14/01 08:15 compl
2 |_ID CHILD OCCUPATIONAL THER TIUPROVIDER, 02/14/01 08:16 compl
3 ER NOTE TIUPROVIDER, 02/14/01 08:14 compl
4 - ID PARENT REHAB TREATMENT PL TIUPROVIDER, 02/08/01 08:26 compl
5 |_+ ID CHILD REHAB INITIAL A TIUPROVIDER, 02/08/01 13:29 compl
6 |_ID CHILD REHAB PSYCHOLOGY TIUPROVIDER, 02/09/01 09:13 compl
7 |_ID CHILD REHAB PHYSICAL TH TIUPROVIDER, 02/14/01 16:02 compl
8 - ANGIOPLASTY NOTE TIUPROVIDER, 01/08/01 13:16 compl
9 |_Addendum to ANGIOPLASTY NO TIUPROVIDER, 02/14/01 08:13 compl
10 ID CHILD ONE TIUPROVIDER, 01/08/01 13:14 compl
11 ID ANY CHILD NOTE TIUPROVIDER, 01/02/01 07:52 compl
12 SEVEN'S CHILD SIX TIUPROVIDER, 12/28/00 13:49 compl
13 SEVEN'S CHILD FIVE TIUPROVIDER, 12/28/00 13:48 compl
14 +< SEVEN'S ID NOTE TIUPROVIDER, 12/28/00 13:31 compl
+ ** Entry attached **
NW New Note SS Select Search IN Interdiscipl'ry Note
B Browse RS Reset to All Signed EE Expand/Collapse Entry
PC Print Copy AD Make Addendum Q Quit
SP Select New Patient $ Complete Note(s)
Select Action: Next Screen//
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Discharge Summary
Clinicians can review, enter, print, and sign discharge summaries, either by individual patient or by multiple patients.
Clinician’s Discharge Summary Menu
Option
Individual Patient Discharge
Summary
All MY UNSIGNED Discharge
Summaries
Multiple Patient Discharge
Summaries
Description
This option lets you review, edit, or sign a patient’s discharge summaries.
This option shows you all unsigned discharge summaries for you to review, edit, or sign. You must have signing or cosigning privileges to sign or cosign, based on your document definition, user class status, and business rules governing these actions. See your
Clinical Coordinator if you have any problems or questions.
This option shows you discharge summaries for selected statuses, types, and categories, which you can then review, edit, and/or sign.
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Individual Patient Discharge Summary
This option lets you review, edit, or sign a patient’s discharge summaries.
Steps to use option:
1. Select Individual Patient Discharge Summary from your TIU menu, then select a patient.
Select Discharge Summary User Menu Option: Individual Patient Discharge Summary
Select PATIENT NAME: TIUPATIENT,ONE TIUPATIENT,ONE 09-12-44 666233456 YES SC
VETERAN
(2 notes) C: 05/28/96 12:37
(2 notes) W: 05/28/96 12:33
A: Known allergies
If the patient has any CWAD
(Crisis, Warning, Allergies,
Available summaries: 02/12/96 thru 02/12/96 (1) and Directives) notes, they are displayed here.
2. Enter a date range to select summaries from, then select a summary from the ones displayed. The selected summary is displayed. Then select an action.
Browse Document Jun 26, 1996 14:21:22 Page: 1 of 7
Discharge Summary
TIUPATIENT,O 666-23-3456 1A Adm: 07/22/91 Dis: 02/12/96
DICT DATE: JUN 09, 1996 ENTRY DATE: JUN 12, 1996@15:07:22
DICTATED BY: TIUPROVIDER,ONE ATTENDING: TIUPROVIDER,THREE
URGENCY: priority STATUS: UNSIGNED
DIAGNOSIS:
1. Status post head trauma with brain contusion.
2. Status post cerebrovascular accident.
3. Coronary artery disease.
4. Hypertension.
+ + Next Screen - Prev Screen ?? More actions
Find Make Addendum Identify Signers
Print Sign/Cosign Delete
Edit Copy Link ...
Quit
Select Action: Quit// p Print
DEVICE: HOME//<Enter> VAX
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Printed Discharge Summary Example
SALT LAKE CITY priority 06/26/96 14:24 Page: 1
-------------------------------------------------------------------------------
PATIENT NAME | AGE | SEX | RACE | SSN | CLAIM NUMBER
TIUPATIENT,ONE | 51 | M | MEXI | 666-23-3456 |
-------------------------------------------------------------------------------
ADM DATE | DISC DATE | TYPE OF RELEASE | INP | ABS | WARD NO
JUL 22, 1991 | FEB 12, 1996 | REGULAR |1666 | 0 | 1A
-------------------------------------------------------------------------------
DICTATION DATE: JUN 09, 1996 TRANSCRIPTION DATE: JUN 12, 1996
TRANSCRIPTIONIST: bs
DIAGNOSIS:
1. Status post head trauma with brain contusion.
2. Status post cerebrovascular accident.
3. End stage renal disease on hemodialysis.
4. Coronary artery disease.
5. Congestive heart failure.
6. Hypertension.
7. Non insulin dependent diabetes mellitus.
8. Peripheral vascular disease, status post thrombectomies.
9. Diabetic retinopathy.
OPERATIONS/PROCEDURES:
1. MRI.
2. CT SCAN OF HEAD.
HISTORY OF PRESENT ILLNESS:
Patient is a 49-year-old, white male with past medical history of end stage renal disease, peripheral vascular disease, status post BKA, coronary artery disease, hypertension, non insulin dependent diabetes mellitus, diabetic retinopathy, congestive heart failure, status post CVA, status post thrombectomy admitted from Anytown VA after a fall from his wheelchair in the hospital. He had questionable short-lasting loss of consciousness but patient is not very sure what has happened. He denies headache, vomiting, vertigo.
D R A F T
Press RETURN to continue or '^' to exit:
SALT LAKE CITY priority 06/26/96 14:24 Page: 2
-------------------------------------------------------------------------------
PATIENT NAME | AGE | SEX | RACE | SSN | CLAIM NUMBER
TIUPATIENT,ONE | 51 | M | MEXI | 666-23-3456 |
-------------------------------------------------------------------------------
On admission patient had CT scan which showed a small area of parenchymal hemorrhage in the right temporal lobe which is most likely consistent with hemorrhagic contusion without mid line shift or incoordination.
ACTIVE MEDICATIONS: Isordil 20 mgs p.o. t.i.d., Coumadin 2.5 mgs p.o. qd, ferrous sulfate 325 mgs p.o. b.i.d., Ativan 0.5 mgs p.o. b.i.d., Lactulose 15 ccs p.o. b.i.d., Calcium carbonate 650 mgs p.o. b.i.d. with food, Betoptic
0.5% ophthalmologic solution gtt OU b.i.d., Nephrocaps 1 tablet p.o. qd,
Pilocarpine 4% solution 1 gtt OU b.i.d., Compazine 10 mgs p.o. t.i.d. prn nausea, Tylenol 650 mgs p.o. q4 hours prn.
Patient is on hemodialysis, no known drug allergies.
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Printed Discharge Summary Example cont’d
PHYSICAL EXAMINATION: Patient had stable vital signs, his blood pressure was
160/85, pulse 84, respiratory rate 20, temperature 98 degrees. Patient was alert, oriented times three, cooperative. His speech was fluent, understanding of spoken language was good. Attention span was good. He had moderate memory impairment, no apraxia noted. Cranial nerves patient was blind, pupils are not reactive to light, face was asymmetric, tongue and palate are mid line. Motor examination showed muscle tone and bulk without significant changes. Muscle strength in upper extremities 5/5 bilaterally, sensory examination revealed intact light touch, pinprick and vibratory sensation. Reflexes 1+ in upper extremities, coordination finger to nose test within normal limits bilaterally. Alternating movements without significant changes bilaterally. Neck was supple.
LABORATORY: Showed sodium level 135, potassium 4.6, chloride 96, CO2 26,
BUN 39, creatinine 5.3, glucose level 138. White blood cell count was 7, hemoglobin 11, hematocrit 34, platelet count 77.
HOSPITAL COURSE: Patient was admitted after head trauma with multiple medical problems. His coumadin was held. Patient had cervical spine x-rays which showed definite narrowing of C5, C6 interspace, slight retrolisthesis at this level, prominent spurs at this level as well as above and below. CT scan on admission showed a moderate amount of scalp thinning with subcutaneous air overlying the left frontal lobe. The basal cisterns are patent and there is no mid line shift or uncal herniation. Patient has also a remote left posterior border zone infarct with hydrocephalus ex vaccuo of the left occipital horn, a rather large remote infarct in the inferior portion of the left cerebellar hemisphere. He had hemodialysis q.o.d. He restarted treatment with Coumadin. His last PT was 11.9, PTT 31. Patient refused before hemodialysis new blood tests. His condition remained stable.
DISCHARGE MEDICATIONS: Isordil 20 mgs p.o. t.i.d., Ferrous sulfate 325 mgs p.o. b.i.d., Ativan 0.5 mgs p.o. b.i.d., Lactulose 15 ccs p.o. b.i.d., Calcium carbonate 650 mgs p.o. b.i.d., Compazine 10 mgs p.o. t.i.d. prn nausea,
Betoptic 0.5% OU b.i.d., Nephrocaps 1 p.o. qd, Pilocarpine 4% solution 1 gtt
OU b.i.d., Coumadin 2.5 mgs p.o. qd, Tylenol 650 mgs p.o. q6 hours prn pain.
DISPOSITION/FOLLOW-UP:
Recommend follow PT/PTT. Patient is on coumadin and CBC with differential because patient has chronic anemia and thrombocytopenia.
Patient will be transferred to Anytown VA in stable condition on 5/19/96.
WORK COPY =========== UNOFFICIAL - NOT FOR MEDICAL RECORD ========== DO NOT FILE
SIGNATURE PHYSICIAN/DENTIST SIGNATURE APPROVING PHYSICIAN/DENTIST
THREE TIUPROVIDER, MD ONE TIUPROVIDER, MS
PGY2 Resident Medical Informaticist
=========================== CONFIDENTIAL INFORMATION ===========================
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All MY UNSIGNED Discharge Summaries
This option shows you all unsigned discharge summaries for you to review, edit, or sign.
You must have signing or cosigning privileges to sign or cosign, based on your document definition, user class status, and business rules governing these actions. See your Clinical
Coordinator if you have any problems or questions about electronic signature or cosigning.
Steps to use option:
1. Select All MY UNSIGNED Discharge Summaries from your TIU menu.
2. Your unsigned discharge summaries are displayed.
Discharge Summaries Jun 18, 1996 10:13:45 Page: 1 of 1
by AUTHOR (TIUPROVIDER,ONE) or EXPECTED COSIGNER 0 documents
Patient Document Ref Date Status
2 TIUPATIENT,S(T4831) Discharge Summary 03/15/96 uncosig
+ Next Screen - Prev Screen ?? More Actions >>>
Find Sign/Cosign Change View
Add Document Detailed Display Copy
Edit Browse Delete Document
Make Addendum Print Quit
Link ... Identify Signers
Select Action: Quit// COSIGN
3. Select an action such as Sign/Cosign if you are authorized to perform these.
NOTE: You can enter Cosign rather than Sign/Cosign if you want to cosign.
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Multiple Patient Discharge Summaries
This option shows you discharge summaries for selected statuses, types, and categories, which you can then review, edit, and/or sign.
Caution: Avoid making your requests too broad (in statuses, search categories, and date ranges) because these searches can use a lot of system resources, slowing the computer system down for everyone.
Steps to use option:
1. Select Multiple Patient Discharge Summaries from your TIU menu.
2. Select one or more of the following statuses:
untranscribed unreleased unverified
unsigned
amended
uncosigned completed
purged deleted
3. Select one of the following search categories:
1 All Categories 6 Patient 11 Transcriptionist
2 Author 7 Problem 12 Treating Specialty
3 Division 8 Service 13 Visit
4 Expected Cosigner 9 Subject
5 Hospital Location 10 Title
4. Enter a date range.
5. A list is displayed of the summaries that meet your specifications.
My UNSIGNED Disch Summaries Jun 05, 1997 14:02:15 Page: 1 of 1
by AUTHOR (TIUPROVIDER,ONE) from 05/06/97 to 06/05/97 1 documents
Patient Document Ref Date Status
1 + TIUPATIENT,T(T2591) Discharge Summary 06/02/97 UNSIGNED
+ Next Screen - Prev Screen ?? More actions
Find Sign/Cosign Change View
Add Document Detailed Display Copy
Edit Browse Delete Document
Make Addendum Print Quit
Link ... Identify Signers
Select Action: Quit// s
6. You can now take an appropriate action on one or all of the summaries.
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Discharge Summary Statuses and Actions
Statuses
Status
Amended *
Description
The document has been completed and a privacy act issue has required its amendment. By design, only the following user classes are allowed to amend a Discharge Summary:
Completed * deleted
Retracted * uncosigned * undictated unreleased unsigned untranscribed unverified
CHIEF, MIS
CHIEF, HIM
PRIVACY ACT OFFICER
The document has acquired all necessary signatures and is legally authenticated.
Status DELETED is no longer operable. Before status RETRACTED was introduced deleting a document removed the text of the document leaving a stub with status DELETED.
When a signed document is reassigned, amended, or deleted, a retracted copy of the original is kept for audit purposes.
The document is complete with the exception of cosignature (i.e., by the supervisor).
The document is required and a record has been created in anticipation of dictation and transcription but the system has not yet been informed of its dictation.
The document is in the process of being entered into the system but has not yet been released by the originator (i.e., the person who entered the text directly online).
The document is online in a draft state but the author hasn’t signed.
The document is required and the system has been informed of its dictation but the transcription hasn’t been entered or received by upload.
The document has been released or uploaded but must be verified before the document may be displayed.
* As of TIU*1*234, documents of these statuses (i.e., signed documents) cannot be edited regardless of business rules.
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Actions
Find Sign/Cosign Change View
Add Document Detailed Display Copy
Edit Browse Delete Document
Make Addendum Print Quit
Link ... Identify Signers
Actions
Add Document
Change View
Copy
Delete Document
Detailed Display
Edit
Find
Identify Signers
Link
Make Addendum
Quit
Sign/Cosign
Description
Enter a new Document.
Allows you to modify the list of reports by signature status, review screen, and dictation date range without exiting the review screen.
Allows authorized users to duplicate the current document. This is especially useful when composing a note for a group of patients (e.g., therapy group) and rapid duplication to all members of the group is appropriate.
Allows the author to delete an unsigned document. In rare cases, a signed document can be deleted but a copy is kept as a retracted document.
Displays the report type, patient, urgency, line count, VBC line count, author, attending physician, transcriptionist, and verifying clerk, in addition to the admission, discharge, dictation, transcription, signature and amendment dates, without showing the narrative report text.
Allows authorized users to edit the current document online. When electronic signature is enabled, physicians will be prompted for their signatures upon exit, thereby allowing doctors to review, edit, and sign as a one-step process.
Allows you to search for a text string (word or partial word) from the current position in the summary through its end. Upon reaching the end of the document, you will be asked whether to continue the search from the beginning of the document through the origin of the search.
Allows authorized users to identify additional users who are to be alerted for concurrence signature. These signers may enter an addendum if they do not concur with the content of the document, but they may not edit the document itself.
Allows you to link documents to either problems, visits, or other documents. Such associations permit a variety of clinically useful
“views” of the online record.
Allows authorized users to add an addendum to the current document online. When electronic signature is enabled, physicians are prompted for their signatures upon exit, thereby allowing doctors to review, edit and sign as a one-step process.
Allows you to print copies of selected documents on your corresponding VA Standard Forms to a specified device.
Allows you to quit the current menu level.
Allows clinicians to electronically sign the current summary. NOTE:
Electronic signature carries the same legal ramifications that wet signature of a hard-copy discharge summary carries. Carefully review each discharge summary for content and accuracy before exercising this option.
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Integrated Document Management
The options on this menu allow clinicians to review, edit, or sign progress notes, discharge summaries, and any other documents set up at your site. This menu is especially useful for clinicians who wish to see an integrated view of documents, to be able to edit or sign many types in one session without changing applications.
Option Name Description
Individual Patient Document
All MY UNSIGNED Documents
Multiple Patient Documents
Enter/edit Document
ALL Documents requiring my
Additional Signature
Allows you to interactively review, edit, or sign a designated clinical document for a designated patient.
Gets all unsigned documents for review, edit, and signature.
Provides an integrated Review Screen of all
TIU documents.
Allows you to enter and edit clinical documents directly online.
Prints a report showing all documents that require an additional signature.
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Individual Patient Document
Use this option to review an individual document for a patient. You can then edit, sign, delete, or perform other actions, as appropriate, on the document.
Steps to use option:
1. Select Individual Patient Document from your Integrated Document Management menu on your TIU menu.
2. Select a patient.
3. Enter a date range to display documents for. A list is displayed of that patient’s documents for the specified time period.
Please specify a date range from which to select documents:
List documents Beginning: 02/17/92// 1/96 (JAN 1996)
Thru: 06/07/96// <Enter> (JUN 07, 1996)
1 06/07/96 00:00 Diabetes Education ONE TIUPROVIDER, MD
Visit: 04/18/96
2 06/05/96 17:23 Lipid Clinic THREE TIUPROVIDER,
Visit: 04/18/96
3 06/05/96 11:10 Addendum to Lipid Clinic THREE TIUPROVIDER,
Visit: 04/24/96
4 05/28/96 12:37 Crisis Note SEVEN TIUPROVIDER
Visit: 02/20/96
5 05/28/96 12:37 Crisis Note SEVEN TIUPROVIDER
Visit: 02/20/96
4. Choose a document from the list.
Choose documents: (1-6): 1
Opening Diabetes Education record for review...
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Individual Patient Document cont’d
Browse Document Jun 26, 1996 17:08:45 Page: 1 of 1
Diabetes Education
TIUPATIENT 666-23-3456 Visit Date: 07/22/91@11:06
DATE OF NOTE: JAN 09, 1996@17:51:04 ENTRY DATE: JAN 09, 1996@17:51:04
AUTHOR: TIUPROVIDER,THREE EXP COSIGNER: TIUPROVIDER,SIX
URGENCY: STATUS: COMPLETED
Provided Mr. TIUPatient with Diabetes diet pamphlet and explained areas he especially needed to be concerned about.
/es/ TIUPROVIDER,THREE MD for TIUPROVER,SIX MS3
Medical Student III
+ Next Screen - Prev Screen ?? More actions
Find Make Addendum Identify Signers
Print Sign/Cosign Delete
Edit Copy Link…
Quit
Select Action: Quit//
5. Select one of the actions to perform on the document (e.g., edit, sign, make addendum).
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All MY UNSIGNED Documents
When you choose this option from the Integrated Document Management Menu, all your unsigned documents are displayed to review, edit, or sign.
Steps to use option:
1. Select All MY UNSIGNED Documents from your Integrated Document
Management menu on your TIU menu.
Select Integrated Document Management Option: All MY UNSIGNED Documents
Searching for the documents.
2. After all your unsigned documents are displayed, you can select an action such as add, edit, or sign/cosign, etc.
MY UNSIGNED Documents June 31, 1997 15:38:13 Page: 1 of 1
by AUTHOR (TIUPROVIDER,ONE) or EXPECTED COSIGNER 4 documents
Patient Document Ref Date Status Complete Auth
1 SC501050 ONE-PER-VISIT NOTE 12/18/02 com 12/24/02 TIUP
2 TB668832 Cardiology Note 09/23/02 uns CPRS
3 FW120870 CARDIOLOGY CS CONSULT 11/11/01 uns CPRS
4 - CPRSPATI Discharge Summary 10/12/01 com 01/16/01 ARTP
5 |_CPRSPA Addendum to Discharge Summ 02/09/01 comple 02/12/01 LUPR
+ Next Screen - Prev Screen ?? More actions
Add Document Detailed Display Delete Document
Edit Browse Interdiscipl'ry Note
Make Addendum Print Expand/Collapse Entry
Link ... Identify Signers Encounter Edit
Sign/Cosign Change View Quit
Select Action: Quit// s Sign/Cosign
Select Document(s): (1-5): 3-5
Opening Adverse React/Allergy record for review...
SIGN/COSIGN Jun 06, 1997 12:03:52 Page: 1 of 1
Adverse React/Allergy
TIUPATIENT,TWO 666-12-3243 2B Visit Date: 09/21/95@10:00
DATE OF NOTE: MAY 20, 1997@10:51:18 ENTRY DATE: MAY 20, 1997@10:51:18
AUTHOR: TIUPROVIDER,ONE EXP COSIGNER:
URGENCY: STATUS: UNSIGNED
MORE TESTS ORDERED
+ Next Screen - Prev Screen ?? More actions
Print No
Ready for Signature: NO// y Yes
Item #: 3 Added to signature list.
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All MY UNSIGNED Documents, cont’d
Opening General Note record for review...
SIGN/COSIGN Jun 06, 1997 12:04:59 Page: 1 of 1
General Note
TIUPATIENT,FIVE 666-04-3779P 2B Visit Date: 05/28/96@15:58
DATE OF NOTE: APR 07, 1997@15:50:26 ENTRY DATE: APR 07, 1997@15:37:25
AUTHOR: TIUPROVIDER,ONE EXP COSIGNER:
URGENCY: STATUS: UNSIGNED general malaise
+ Next Screen - Prev Screen ?? More actions
Print No
Ready for Signature: NO// y Yes
Item #: 4 Added to signature list.
Opening Adverse React/Allergy record for review...
SIGN/COSIGN Jun 06, 1997 12:04:10 Page: 1 of 1
Adverse React/Allergy
TIUPATIENT,ONE 666-23-3456 Visit Date: 07/22/91@11:06
DATE OF NOTE: MAR 24, 1997@11:03:39 ENTRY DATE: MAR 24, 1997@11:03:39
AUTHOR: TIUPROVIDER,FIVE EXP COSIGNER:
URGENCY: STATUS: UNSIGNED
Hay fever reactions severe – antihistamines not working. Prescribed new medication.
+ Next Screen - Prev Screen ?? More actions
Print No
Ready for Signature: NO// y Yes
Item #: 5 Added to signature list.
Enter your Current Signature Code: XXX SIGNATURE VERIFIED......
MY UNSIGNED Documents Jun 06, 1997 12:04:27 Page: 1 of 1
by AUTHOR (TIUPROVIDER,FIVE) or EXPECTED COSIGNER 5 documents
Patient Document Ref Date Status
1 + TIUPATIENT,FIVE (T3779) Discharge Summary 06/02/97 UNSIGNED
2 TIUPATIENT,ONE (T3456) Adverse React/Allergy 05/31/97 completed
3 TIUPATIENT,TWO (T3243) Adverse React/Allergy 05/20/97 completed
4 TIUPATIENT,FIVE (T3779) General Note 04/07/97 completed
5 TIUPATIENT,SIX (T3476) Adverse React/Allergy 03/24/97 completed
** Items 3, 4, 5 Signed. ** >>>
Find Sign/Cosign Change View
Add Document Detailed Display Copy
Edit Browse Delete Document
Make Addendum Print Quit
Link ... Identify Signers
Select Action: Quit//
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Multiple Patient Documents
Use this option to see an integrated Review Screen of all TIU documents.
Caution: Avoid making your requests too broad (in statuses, search categories, and date ranges) because these searches can use a lot of system resources, slowing the computer system down for everyone.
Steps to use option:
1. Select Multiple Patient Documents from your Integrated Document Management menu on your TIU menu.
Select Integrated Document Management Option: Multiple Patient Documents
2. Select one or more of the following statuses.
1 undictated 6 uncosigned
2 untranscribed 7 completed
3 unreleased 8 amended
4 unverified 9 purged
5 unsigned 10 deleted
Enter selection(s) by typing the name(s), number(s), or abbreviation(s).
Select Status: UNSIGNED//
<Enter>
3. Select a document type (from whatever you have set up at your site):
Select Clinical Documents Type(s): 1-3 Addendum
Discharge Summary
Progress Notes
4. Select one of the following search categories
1 All Categories 6 Patient 11 Transcriptionist
2 Author 7 Problem 12 Treating Specialty
3 Division 8 Service 13 Visit
4 Expected Cosigner 9 Subject
5 Hospital Location 10 Title
Enter selection(s) by typing the name(s), number(s), or abbreviation(s).
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Multiple Patient Documents, cont’d
5. Enter a date range.
Start Reference Date [Time]: T-7// T-60 (APR 01, 1997)
Ending Reference Date [Time]: NOW//
<Enter>
(MAY 31, 1997@15:42)
Searching for the documents.
6. All the documents for the criteria selected are displayed. Choose an action to perform, then the document to perform it on.
UNSIGNED Documents May 31, 1997 15:42:40 Page: 1 of 1
by AUTHOR (TIUPROVIDER,ONE) from 04/01/97 to 05/31/97 3 documents
Patient Document Ref Date Status
1 TIUPATIENT,FIVE (T3779) Discharge Summary 06/02/97 unsigned
2 TIUPATIENT,ONE (T3456) Adverse React/Allergy 05/31/97 unsigned
3 TIUPATIENT,TWO (T3243) Adverse React/Allergy 05/20/97 unsigned
+ Next Screen - Prev Screen ?? More actions
Find Sign/Cosign Change View
Add Document Detailed Display Copy
Edit Browse Delete Document
Make Addendum Print Quit
Link ... Identify Signers
Select Action: Quit//
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Enter/Edit Document
This option lets you enter and edit clinical documents directly online.
NOTE: All documents for outpatients must be associated with a Visit or Admission in order to receive workload credit.
NOTE: Signed notes may not be edited even if there is a business rule allowing them to be. Hard code within TIU prevents editing of signed documents. The following categories are considered signed: Un-cosigned, completed, amended, and retracted.
Steps to use option:
1. Select Enter/Edit Document from your Integrated Document Management menu on your TIU menu and enter a patient name.
Select Integrated Document Management Option: Enter/edit Document
Select PATIENT NAME: TIUPATIENT,ONE TIUPATIENT,ONE 09-12-44 666233456 YES
SC VETERAN
A: Known allergies
Select the Document type.
Select TITLE: ??
Choose from:
ADVANCE DIRECTIVE TITLE
ADVERSE REACTION/ALLERGY TITLE
CLINICAL WARNING TITLE
CRISIS NOTE TITLE
DISCHARGE SUMMARY TITLE
Select TITLE: ADVERSE REACTION/ALLERGY TITLE
3. If the patient is an outpatient, choose the Visit (admission) from the list displayed that you wish to associate with the Adverse Reaction/Allergy note.
This patient is not currently admitted to the facility...
Is this note for INPATIENT or OUTPATIENT care? OUTPATIENT// <Enter>
The following VISITS are available:
1> APR 18, 1996@10:00 GENERAL MEDICINE
2> FEB 21, 1996@08:40 PULMONARY CLINIC
3> FEB 20, 1996@10:00 ONCOLOGY
4> FEB 20, 1996@08:00 GENERAL MEDICINE
CHOOSE 1-4 or <N>EW VISIT
<RETURN> TO CONTINUE
OR '^' TO QUIT: 1
All outpatient TIU data has to be associated with a visit. If a visit related to TIU documents already exists, you only need to confirm it; otherwise you’ll have to enter a new visit.
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Enter/Edit Document cont’d
Creating new progress note...
Patient Location: GENERAL MEDICINE
Date/time of Visit: 04/18/96 10:00
Date/time of Note: NOW
Author of Note: TIUPROVIDER,NINE
...OK? YES// <Enter>
SUBJECT (OPTIONAL description): <Enter>
Calling text editor, please wait...
1>Mr. TIUPatient's allergies improved with medication.
2>
EDIT Option: <Enter>
Save changes? YES// <Enter>
Saving Adverse React/Allergy with changes...
Enter your Current Signature Code: xxx SIGNATURE VERIFIED..
Print this note? No// <Enter> NO
You may enter another CLINICAL DOCUMENT. Press RETURN to exit.
Select PATIENT NAME:
<Enter>
--- Clinician's Menu ---
1 Individual Patient Document
2 All MY UNSIGNED Documents
3 Multiple Patient Documents
4 Enter/edit Document
Select Integrated Document Management Option: <Enter>
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Documents Requiring Additional Signature
A report is available that will give you all documents requiring your additional signature.
This report is available from the Integrated Document Management Menu and the
Progress Notes User Menu.
To run this report:
1. From a menu, select ALL Documents requiring my Additional Signature.
2. The following report is displayed:
Select Integrated Document Management Option: ?
1 Individual Patient Document
2 All MY UNSIGNED Documents
3 All MY UNDICTATED Documents
4 Multiple Patient Documents
5 Enter/edit Document
6 ALL Documents requiring my Additional Signature
Enter ?? for more options, ??? for brief descriptions, ?OPTION for help text.
Select Integrated Document Management Option: 6 ALL Documents requiring my
Additional Signature
Searching for the documents.
My Identified Signer Docs Feb 21, 2005@19:00:32 Page: 1 of 1
ALL DOCUMENTS Requiring My Additional Signature
Patient Document Ref Date Status
1 CPRSPATIENT,S (C1050) ONE-PER-VISIT NOTE 12/18/02 completed
2 CPRSPATIENT,T (C6572) PATIENT EDUCATION 06/19/98 completed
3 CPRSPATIENT,T (C6572) MEDICINE CS CONSULT 06/09/98 completed
+ Next Screen - Prev Screen ?? More Actions >>>
Edit Browse Expand/Collapse Entry
Make Addendum Print Encounter Edit
Link ... Identify Signers Quit
Sign/Cosign Delete Document
Detailed Display Interdiscipl'ry Note
Select Action:Quit//
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Personal Preferences
The two options on this menu let you customize the way TIU operates for you; that is, which prompts will appear, what lists you will see to select from, etc. Thus, if you only work with Discharge Summaries or Progress Notes, or only a specific set within these categories, you can set your preferences so that only these documents appear on selection lists. You can also specify the way documents are displayed on your review screens: by patient, by author, by type, in chronological or reverse chronological order, etc.
If you require cosignatures on your documents (for example, because you’re a medical student, PA, or some other category that your site has designated as needing cosignature), you can designate your “Default Cosigner” and then this person will be the default when you’re prompted for the Expected Cosigner.
Option
Personal Preferences
Description
Document List Management
Specify defaults that you want in TIU (e.g., Default
Location, Sort Order, Display Menus, Patient Selection
Preference, etc.)
Specify your “pick lists” for document selection when composing or editing documents.
Personal Preferences
Steps to use option:
1. Select Personal Preferences from your TIU menu.
Select Progress Notes/Discharge Summary [TIU] Option: Personal Preferences
1 Personal Preferences
2 Document List Management
Select Personal Preferences Option: 1 Personal Preferences
2. Select Personal Preferences from your Personal Preferences menu.
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Personal Preferences, cont’d
3. Answer the following prompts, as appropriate.
Select Personal Preferences Option: Personal Preferences
Enter/edit Personal Preferences for TIUPROVIDER,ONE OT
Are you adding 'TIUPROVIDER,ONE' as
a new TIU PERSONAL PREFERENCES (the 5TH)? y (Yes)
DEFAULT LOCATION: Cardiology Clinic
REVIEW SCREEN SORT FIELD: ?
Specify the attribute by which the document list should be sorted.
Choose from:
P patient
D document type
R reference date
S status
C completion date
A author
E expected cosigner
REVIEW SCREEN SORT FIELD: p patient
REVIEW SCREEN SORT ORDER: ?
Please specify the order in which you want the list sorted
Choose from:
A ascending
D descending
REVIEW SCREEN SORT ORDER: a ascending
DISPLAY MENUS: ?
Indicate whether menus (for document selection, etc.) should
be displayed.
Choose from:
0 NO
1 YES
DISPLAY MENUS: 1 YES
PATIENT SELECTION PREFERENCE: ?
Please indicate your patient selection preference
Choose from:
S single
M multiple
PATIENT SELECTION PREFERENCE: m multiple
DEFAULT COSIGNER: ?
Indicate which person will usually cosign your Progress Notes.
Answer with NEW PERSON NAME, or INITIAL, or SSN, or NICK NAME, or DEA#,
or VA#
Do you want the entire 66-Entry NEW PERSON List? N
DEFAULT COSIGNER: TIUPATIENT,TWO TIUPATIENT, TWO, CA PHYSICIAN
ASK 'Save changes?' AFTER EDIT: y YES
ASK SUBJECT FOR PROGRESS NOTES: YES// ??
Enter YES if you want to be prompted for a SUBJECT when entering or
editing a Progress Note. Subject is a freetext, indexed field which
may help you to find notes about a given topic, etc.
Choose from:
1 YES
0 NO
ASK SUBJECT FOR PROGRESS NOTES: YES// <Enter>
NUMBER OF NOTES ON REV SCREEN: ??
This determines the number of notes that will be included in your
initial list when reviewing progress notes by patient.
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Personal Preferences, cont’d
NUMBER OF NOTES ON REV SCREEN: 5??
Type a Number between 15 and 100
NUMBER OF NOTES ON REV SCREEN: 15
SUPPRESS REVIEW NOTES PROMPT: ??
Allows user to specify whether to suppress the prompt to
Review Existing Notes on entry of a Progress Note. YES will
SUPPRESS the prompt, while NO, or no entry will allow the
site's default setting to take precedence.
Choose from:
1 YES
0 NO
SUPPRESS REVIEW NOTES PROMPT: 0
Select DAY OF WEEK: Monday
Are you adding 'Monday' as a new DAY OF WEEK (the 1ST for this TIU PERSONAL
PREFERENCES)? Y (Yes)
HOSPITAL LOCATION: GENERAL MEDICINE TIUPATIENT,TWO
Select DAY OF WEEK: <Enter>
1 Personal Preferences
2 Document List Management
Document List Management
This option lets you specify which types (Titles) of documents you wish to choose from when asked to select from a given Class (e.g., Discharge Summary or Progress Notes).
Then when you create a Progress Note, you will be prompted to select from the specified list of Titles, say, Lipid Clinic Note, History & Physical, Interservice Transfer Note, and
Discharge Planning, in that order. This option also lets you specify a default title for the selected Class.
Steps to use option:
1. Select Document List Management from your Personal Preferences Menu on your
TIU menu.
Select Personal Preferences Option: 2 Document List Management
--- Personal Document Lists ---
This option allows you to create and maintain lists of TITLES for any of the active CLASSES of documents supported by TIU at your site.
Explain Details? NO// y YES
When you use the option to enter a document belonging to a given class, you will be asked to select a TITLE belonging to that class.
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Document List Management, cont’d
For any particular class, you may find that you only wish to choose from among a few highly specific titles (e.g., if you are a Pulmonologist entering a PROGRESS
NOTE, you may wish to choose from a short list of three or four titles related to Pulmonary Function, or Pulmonary Disease).
Rather than presenting you with a list of hundreds of unrelated titles, TIU will present you with the list you name here.
In the event that you need to select a TITLE which doesn't appear on your list, you will always be able to do so.
NOTE: If you expect to enter a single title, or would be unduly restricted by use of a short list, then we recommend that you bypass the creation of a list, and simply enter a DEFAULT TITLE for the class. This option will afford you the opportunity to do so.
2. Answer the following prompts, as appropriate.
Enter/edit Personal Document List for ONE TIUPROVIDER
Add a new Personal Document List? YES// <Enter>
CLASS: ?
Please select the parent group to which the document list
belongs. You may only pick CLASSES of documents at this
prompt.
Answer with TIU DOCUMENT DEFINITION NAME, or ABBREVIATION,
or PRINT NAME
Do you want the entire TIU DOCUMENT DEFINITION List? y (Yes)
Choose from:
DISCHARGE SUMMARY CLASS
PROGRESS NOTES CLASS
CLASS: Progress Notes
Edit (L)ist, (D)efault TITLE, or (B)oth? BOTH// <Enter> both
When selecting from this PARENT CLASS, which TITLES would you like to be presented with initially?
Select TITLE: PSYCHOLOGY - CRISIS
Select TITLE: PSYCHOLOGY - FAMILY THERAPY
Select TITLE: PSYCHOLOGY - NURSING NOTE
Select TITLE: NURSING NOTES - ENCOUNTER GROUP
Now, Specify the TITLE you'd like as your DEFAULT for PROGRESS NOTES
DEFAULT TITLE: ??
This determines what TITLE will be offered by default when
selecting from a given parent class (e.g., when entering a
PROGRESS NOTE, you may want the DEFAULT TITLE to be DIABETES
EDUCATION, etc.).
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Document List Management, cont’d
DEFAULT TITLE: PSYCHOLOGY
1 PSYCHOLOGY - BEHAV MED TITLE
2 PSYCHOLOGY - BIOFEEDBACK TITLE
3 PSYCHOLOGY - CRISIS TITLE
4 PSYCHOLOGY - FAMILY THERAPY TITLE
5 PSYCHOLOGY - IP SATC TITLE
TYPE '^' TO STOP, OR
CHOOSE 1-5: 3
Select PERSONAL DOCUMENT LIST Name: SUBSTANCE ABUSE
1 SUBSTANCE ABUSE TITLE
2 SUBSTANCE ABUSE COMMITTEE TITLE
3 SUBSTANCE ABUSE TLC TITLE
4 SUBSTANCE ABUSE TREATMENT CENTER CONSULT TITLE
CHOOSE 1-4: 1
Are you adding 'SUBSTANCE ABUSE' as
a new PERSONAL DOCUMENT LIST (the 1ST for this TIU PERSONAL DOCUMENT TYPE
LIST)? Y (Yes)
SEQUENCE: 1
DISPLAY NAME: SUBSTANCE ABUSE
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Document Definitions (Clinician)
TIU uses a structure called Document Definitions to organize Progress Notes, Discharge
Summaries, and other documents. It contains the Document Definition Hierarchy, which allows documents (Titles) to inherit characteristics of the higher levels, Class and
Document Class, such as signature requirements and print characteristics. This structure creates the capability for better integration, shared use of boilerplate text, components, and objects, and a more manageable organization of documents. End users (clinical, administrative, and MIS staff) need not be aware of the hierarchy. They work at the Title level, with the actual documents.
The Document Definitions menu for Clinicians may be assigned to those clinicians who are interested in creating and editing boilerplate text or in viewing or editing Document
Definition entries (Class, Document Class, or Title). You can also view available Objects that can be embedded in boilerplate text. See your Clinical Coordinator or the TIU
Implementation Guide if you need further information about these options or descriptions of Document Definition concepts.
Option
Edit Document
Definitions
Sort Document
Definitions
View Objects
Description
This option lets you view and edit entries. Entries are presented in hierarchy order. Items of an entry are in Sequence order, or if they have no Sequence, in alphabetic order by Menu Text, and are indented below the entry. Since Objects don’t belong to the hierarchy, they can’t be viewed/edited using the Edit Option.
The Sort option lets you view and edit entries, by sort criteria. It then displays selected entries in alphabetic order by Name, rather than in hierarchy order. Depending on sort criteria, entries can include Objects.
The option displays Objects within selected Start With and Go To values in alphabetic order by Name.
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Edit Document Definitions
This example shows you how to traverse the hierarchy to see details about a Title in
Document Definitions, in this case, an Advance Directive. The first screen shows just the top level of document types. A + indicates that there are items under that document type.
To see these, select Expand/Collapse, then enter the number of the document type to be expanded.
Select Document Definitions (Clinician) Option: 1 Edit Document Definitions
Edit Document Definitions Apr 17, 1997 16:42:53 Page: 1 of 1
BASICS
Name Type
1 CLINICAL DOCUMENTS CL
2 +DISCHARGE SUMMARY CL
3 +PROGRESS NOTES CL
4 +ADDENDUM DC
?Help >ScrollRight PS/PL PrintScrn/List +/- >>>
Expand/Collapse Detailed Display Quit
Jump to Document Def Try
Boilerplate Text Find
Select Action: Quit// e Expand/Collapse
Select Entry: (1-4): 3........
Edit Document Definitions Apr 17, 1997 16:43:56 Page: 1 of 1
BASICS
Name Type
1 CLINICAL DOCUMENTS CL
2 +DISCHARGE SUMMARY CL
3 PROGRESS NOTES CL
4 +ADVANCE DIRECTIVE DC
5 +ADVERSE REACTION/ALLERGY DC
6 +CRISIS NOTE DC
7 +CLINICAL WARNING DC
8 +HISTORICAL TITLES DC
9 +ADDENDUM DC
?Help >ScrollRight PS/PL PrintScrn/List +/- >>>
Expand/Collapse Detailed Display Quit
Jump to Document Def Try
Boilerplate Text Find
Select Action: Quit// Expand/Collapse=4
Shortcut:
Enter action, =, and the item number
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Edit Document Definitions, cont’d
Edit Document Definitions Apr 17, 1997 16:44:17 Page: 1 of 1
BASICS
Name Type
1 CLINICAL DOCUMENTS CL
2 +DISCHARGE SUMMARY CL
3 PROGRESS NOTES CL
4 ADVANCE DIRECTIVE DC
5 ADVANCE DIRECTIVE TL
6 +ADVERSE REACTION/ALLERGY DC
7 +CRISIS NOTE DC
8 +CLINICAL WARNING DC
9 +HISTORICAL TITLES DC
10 +ADDENDUM DC
?Help >ScrollRight PS/PL PrintScrn/List +/- >>>
Expand/Collapse Detailed Display Quit
Jump to Document Def Try
Boilerplate Text Find
Select Action: Quit// DET DETAILED DISPLAY
Select Entry: (1-11): 5
Non-Owner; View Only
Press RETURN to continue or '^' or '^^' to exit:
<Enter>
Detailed Display Apr 17, 1997 16:44:31 Page: 1 of 1
Title ADVANCE DIRECTIVE
Basics Note: Values preceded by * have been inherited
Name: ADVANCE DIRECTIVE
Abbreviation: ADIR
Print Name: ADVANCE DIRECTIVE
Type: TITLE
National
Standard: YES
Status: ACTIVE
Owner: CLINICAL COORDINATOR
In Use: YES
Items
Boilerplate Text
? Help +, - Next, Previous Screen PS/PL
Try Find Quit
Select Action: Quit//
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View Objects
This option displays Objects in alphabetical order by Name. You can print all available
Objects from your site, or specific ones.
--- Clinician Document Definition Menu ---
Edit Document Definitions
Sort Document Definitions
View Objects
Select Document Definitions (Clinician) Option: 3 View Objects
START WITH OBJECT: FIRST// <Enter>........................................
Objects Apr 17, 1997 11:57:57 Page: 1 of 3
Objects
Name Status
ACTIVE MEDICATIONS A
ALLERGIES/ADR A
BLOOD PRESSURE A
CURRENT ADMISSION A
NOW A
PATIENT AGE I
PATIENT DATE OF BIRTH A
PATIENT DATE OF DEATH A
PATIENT HEIGHT A
PATIENT NAME A
PATIENT RACE A
PATIENT SEX A
PATIENT SSN A
PATIENT WEIGHT A
PULSE A
RESPIRATION A
TEMPERATURE A
TODAY'S DATE A
VISIT DATE A
+ ?Help >ScrollRight PS/PL PrintScrn/List +/- >>>
Find Detailed Display Quit
Change View
Select Action: Next Screen//
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TIU and Health Summary
A new Health Summary component is available (through Patch GMTS*2.7*12), Selected
Progress Notes, which allows selection of specific Progress Notes Titles for display on
Health Summaries. Patch GMTS*2.7*45, Interdisciplinary Progress Notes, expands this functionality to include Interdisciplinary Notes.
All Progress Notes, Discharge Summary, and CWAD components now extract data from
TIU, rather than Progress Notes (GMRP), or Discharge Summary (GMRD).
Care has been taken to assure that the formatting and content of the components have remained the same, except that the signature block information will now reflect the author's (and cosigner's) name and title at the time of signature, rather than displaying their current values at the time of output.
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Chapter 4: TIU for MRTs
Individual Patient Document
Multiple Patient Documents
Review Upload Filing Events
Print Document Menu
Released/Unverified Report
Search for Selected Documents
Unsigned/Uncosigned Report
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Chapter 4: TIU for Medical Record Technicians
Medical Record Technicians in the MIS or HIMS of Medical Administration Service complete the tasks of assuring that all discharge summaries placed in a patient’s medical record have been verified for accuracy and completion. They are also responsible for assuring that a permanent chart copy has been placed in a patient’s medical record for each separate admission to the hospital.
MRT Menu
This is the main TIU menu for Medical Record Technicians (MRTs). It includes all of the options necessary for MRTs to review, edit, sign, and print documents, print reports on
TIU documents, search for documents, and review upload filing events.
Option Description
Individual Patient Document
Multiple Patient Documents
Review Upload Filing Events
This option allows MRTs to review, edit, or sign patient
Documents.
Text Integration Utilities review screen of all types of
TIU documents available for MRTs.
This option lets MRTs generate a list of all upload filing events (i.e., successes, filing errors, or missing field errors) by division, by status, by date range, and to print the corresponding error records or resolve the error (e.g., correct the Patient SSN or Admission date), and retry the filer.
Print Document Menu ...
Released/Unverified Report
Search for Selected Documents
Unsigned/Uncosigned Report
Reassignment Document Report
This menu lets MAS personnel print chart or work copies of discharge summaries, progress notes, or mixed
Documents.
This report gives information on documents for a specified time period that have been released from transcription but still aren’t verified.
This menu action can be eliminated if Transcription
Release or MAS Verification parameters are not enabled.
Allows MRT’s to generate lists of selected documents by extended search criteria (e.g., status, search category, and reference date range). These can then be reviewed individually or by groups, verified, sent back to transcription, reassigned, or printed.
Provides information on unsigned/uncosigned documents for one, multiple, or all divisions. The report can be either Summary or Full. The summary report lists the number of documents by the service or section of the author. The full report lists detailed document information (such as author, patient, patient SSN, etc.) by the service or section of the author.
Provides a list of reassigned notes based on date range.
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Option
Review unsigned additional signatures
Description
Gives a list of documents that require additional signatures. Provides either a detailed report listing each document that requires an additional signature, or a summary report.
Individual Patient Document
Use this option to review, verify, print or other actions an MRT can perform on clinical documents for a selected patient.
Steps to use option:
1. Select Individual Patient Document from the TIU MRT menu, and then enter a patient name to view documents for.
Select Text Integration Utilities (MRT) Option: 1 Individual Patient Document
Select PATIENT NAME: TIUPATIENT,ONE TIUPATIENT,ONE 666-23-3456 1A YES
SC VETERAN
(2 notes) W: 05/28/96 12:33
Available documents: 10/24/96 thru 10/28/96 (3)
If the patient has Cautions,
Warnings,
Enter a date range, then choose a document from the list.
Allergies, or
Please specify a date range from which to select documents:
List documents Beginning: 02/17/96// <Enter> (FEB 17, 1992)
Thru: 10/28/96//<Enter> (OCT 28, 1996)
1 10/28/96 17:11 BP TEST One TIUProvider, MD
Adm: 07/22/91 Dis: 02/12/96
2 10/25/96 11:32 Psychology - Crisis Four TIUProvider
Adm: 10/25/96
Choose documents: (1-6): 1
Directives
(CWAD), they are displayed here. In this case, the patient has a Warning
(W).
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Individual Patient Document, cont’d
3. The selected document is displayed. You may press Enter to see the remaining two pages, or choose an action to perform.
Browse Document Oct 30, 1996 10:33:54 Page: 1 of 3
BP TEST
TIUPATIENT, O 666-23-3456 1A Visit Date: 07/22/91@11:06
DATE OF NOTE: OCT 28, 1996@17:11:51 ENTRY DATE: OCT 28, 1996@17:11:51
AUTHOR: TIUPROVIDER, ONE EXP COSIGNER:
URGENCY: STATUS: COMPLETED
NAME: TIUPATIENT, ONE
SEX: MALE
DOB: SEP 12,1944
ALLERGIES: Amoxicillin, Aspirin, MILK
LABS:
WBC 8.7, RBC 5.1, HGB 16, HCT 47, MCV 91, MCH 29, MCHC 34, Plt 320
+ Next Screen - Prev Screen ?? More Actions >>>
Find Edit Copy
Verify/Unverify Send Back Print
On Chart Reassign Quit
Select Action: Next Screen//
Multiple Patient Documents
Use this option to display TIU documents of selected types, which can then be individually or multiply reviewed, verified, sent back to transcription, reassigned, or printed.
Caution: Avoid making your requests too broad (in statuses, search categories, and date ranges) because these searches can use a lot of system resources, slowing the computer system down for everyone.
Steps to use option:
1. Select Multiple Patient Documents from your TIU menu.
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Multiple Patient Documents, cont’d
2. Select one or more divisions.
Select division: ALL// ?
ENTER:
- Return for all divisions, or
- A division and return when all divisions have been selected--limit 20
Imprecise selections will yield an additional prompt.
(e.g. When a user enters 'A', all items beginning with 'A' are displayed.)
Answer with MEDICAL CENTER DIVISION NUM, or NAME, or FACILITY NUMBER, or
TREATING SPECIALTY
Choose from:
1 SALT LAKE OEX 660
2 ISC-SLC-A4 660HA
3 SALT LAKE CIOFO 660GC
Select division: ALL// <Enter>
3. Select one or more of the following statuses.
1 undictated 6 uncosigned
2 untranscribed 7 completed
3 unreleased 8 amended
4 unverified 9 purged
5 unsigned 10 deleted
Enter selection(s) by typing the name(s), number(s), or abbreviation(s).
Select Status: UNSIGNED// 4 UNVERIFIED
Multiple Patient Documents, cont’d
4. Select one of the following types (these may be different at your site):
Addendum
Discharge Summary
Progress Notes
Select Clinical Documents Type(s): All Addendum, Discharge Summary, Progress Notes
5. Enter a date range.
Start Entry Date [Time]: T-7// t-30 (May 02, 1997)
Ending Entry Date [Time]: NOW//
<Enter>
(JUN 02, 1997@14:31)
Searching for the documents............
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6. All the documents for the criteria selected are displayed. Choose an action to perform, then the document.
Verify action example
UNVERIFIED Documents Jun 02, 1997 14:31:12 Page: 1 of 1
from 05/02/97 to 06/02/97 9 documents
Patient Document Admitted Disch'd
1 TIUPATIENT,ONE(T1255) Adverse React/Allergy 05/03/97 05/31/97
2 TIUPATIENT,TWO(T3456) ADVANCE DIRECTIVE 05/18/96
3 TIUPATIENT,FIV(T3456) ADVANCE DIRECTIVE 08/14/95
4 *+ TIUPATIENT,(T1462) Discharge Summary 05/04/92 05/31/97
5 + TIUPATIENT,F(T3456) Discharge Summary 09/21/95
6 *+ TIUPATIENT,O(T3456) Discharge Summary 07/22/91 05/12/97
+ Next Screen - Prev Screen ?? More Actions >>>
Verify/Unverify Link with Request Print
On Chart Send Back Interdiscipl'ry Note
Edit Detailed Display Change View
Reassign Browse Quit
Select Action: Quit// V Verify/Unverify
Select Document(s): (1-3): 4
Opening Discharge Summary record for review...
7. The selected document is displayed for you to verify.
Verify Document Jun 02, 1997 14:38:22 Page: 1 of 20
Discharge Summary
TIUPATIENT,SEVEN 666-45-3234 1A Adm: 05/04/92 Dis: 05/31/97
DICT DATE: MAY 25, 1997 ENTRY DATE: MAY 26, 1997@08:54:19
DICTATED BY: TIUPROVIDER,THREE ATTENDING: TIUPROVIDER,ONE
URGENCY: priority STATUS: UNVERIFIED
*** Discharge Summary Has ADDENDA ***
DIAGNOSIS:
1. Status post head trauma with brain contusion.
2. Status post cerebrovascular accident.
3. End stage renal disease on hemodialysis.
4. Coronary artery disease.
+ + Next Screen - Prev Screen ?? More actions
Find Verify/Unverify
Print Quit
Select Action: Next Screen// v Verify/Unverify
Do you want to edit this Discharge Summary? NO// <Enter>
VERIFY this Discharge Summary? NO// y YES
Discharge Summary VERIFIED
Chart copy queued.
Refreshing the list.
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Review Upload Filing Events
Steps to use option:
1. Select Review Upload Filing Events from the TIU MRT menu.
Select Text Integration Utilities (MRT) Option: Review Upload Filing Events
Select division displayed.
Select division: ALL// SALT
1 SALT LAKE CIOFO 660GC
2 SALT LAKE OEX 660
CHOOSE 1-2: 2 SALT LAKE OEX 660
Select another division: <Enter>
Note: This prompt is only displayed if you are at a multi-division medical center. In other words, if the MULTIDIVISION MED
CENTER field of the MAS PARAMETERS file is set to YES.
3. Select the event type to be displayed.
Select Event Type: FILING ERRORS// ?
Enter a code from the list.
Select one of the following:
F Filing Errors
M Missing Field Errors
S Successes
A All Events
Select Event Type: FILING ERRORS// <Enter> Filing Errors
4. Select the Resolution Status (Unresolved Errors, Resolved Errors, or All Errors).
Select Resolution Status: UNRESOLVED// ?
Enter a code from the list.
Select one of the following:
U Unresolved Errors
R Resolved Errors
A All Errors
Select Resolution Status: UNRESOLVED// <Enter> Unresolved Errors
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Review Upload Filing Events, cont’d
5. Enter the range of dates.
Start Event Date [Time]: T-30// <Enter> (MAY 27, 1996)
Ending Event Date [Time]: NOW// <Enter>
Searching for the events.....
6. All the documents for the criteria selected are displayed. Choose an action to perform, then the document to perform it on.
Filing Events Jun 26, 1996 09:07:53 Page: 1 of 1
RESOLVED FILING EVENTS from 05/27/96 to 06/26/96
Document Type Event Type Event Date/time
1 DISCHARGE SUMMARY Filing Error 06/06/96 13:29
FILING ERROR: STAT DISCHARGE SUMMARY Record could not be found or created.
2 PROGRESS NOTES Filing Error 06/06/96 14:39
+ Next Screen - Prev Screen ?? More Actions >>>
Find Print event Quit
Display/Fix Change view
Select Action: Next Screen// Display/Fix=1-2
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Print Document Menu
This menu contains options that print chart or work copies of discharge summaries, progress notes, or mixed documents.
1 Discharge Summary Print
2 Progress Note Print
3 Clinical Document Print
Discharge Summary Print
Use this option to print chart or work copies of discharge summaries.
Steps to use this option:
1. Select Discharge Summary Print from the MIS Manager’s Print Document Menu.
2. Enter the name of the patient whose discharge summary you want to print.
1 Discharge Summary Print
2 Progress Note Print
3 Clinical Document Print
Select Print Document Menu Option: 1 Discharge Summary Print
Select PATIENT NAME: TIUPATIENT,ONE TIUPATIENT,ONE 09-12-44 666233456
YES
SC VETERAN
(2 notes) C: 05/28/96 12:37
(2 notes) W: 05/28/96 12:33
A: Known allergies
(2 notes) D: 05/28/96 12:36
Available summaries: 02/12/96 thru 02/12/96 (1)
3. Enter the range of dates from which to choose the discharge summary or summaries you want to print.
Please specify a date range from which to select summaries:
List summaries Beginning: 02/12/96// <Enter> (FEB 12, 1996)
Thru: 02/12/96// <Enter>
1 02/12/96 13:56 Discharge Summary ONE TIUPROVIDER, MD
Adm: 07/22/91 Dis: 02/12/96
Choose summaries: (1-1): 1
Do you want WORK copies or CHART copies? CHART// WORK
DEVICE: HOME// <Enter> VAX
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Discharge Summary Print Example
SALT LAKE CITY priority 06/27/96 08:45 Page: 1
-----------------------------------------------------------------------------
PATIENT NAME | AGE | SEX | RACE | SSN | CLAIM NUMBER
TIUPATIENT,ONE | 51 | M | MEXI | 666-23-3456 |
-----------------------------------------------------------------------------
ADM DATE | DISC DATE | TYPE OF RELEASE | INP | ABS | WARD NO
JUL 22, 1991 | FEB 12, 1996 | REGULAR |1666 | 0 | 1A
-----------------------------------------------------------------------------
DICTATION DATE: JUN 09, 1996 TRANSCRIPTION DATE: JUN 12, 1996
TRANSCRIPTIONIST: bs
DIAGNOSIS:
1. Status post head trauma with brain contusion.
2. Status post cerebrovascular accident.
3. End stage renal disease on hemodialysis.
4. Coronary artery disease.
5. Congestive heart failure.
6. Hypertension.
7. Non insulin dependent diabetes mellitus.
8. Peripheral vascular disease, status post thrombectomies.
9. Diabetic retinopathy.
10. Below knee amputation.
11. Chronic anemia.
OPERATIONS/PROCEDURES:
1. MRI.
2. CT SCAN OF HEAD.
HISTORY OF PRESENT ILLNESS:
Patient is a 49-year-old, white male with past medical history of end stage renal disease, peripheral vascular disease, status post BKA, coronary artery disease, hypertension, non insulin dependent diabetes mellitus, diabetic retinopathy, congestive heart failure, status post CVA, status post thrombectomy admitted from Anytown VA after a fall from his wheelchair in the hospital. He had questionable short lasting loss of consciousness but patient is not very sure what has happened. He denies headache, vomiting, vertigo.
On admission patient had CT scan which showed a small area of parenchymal hemorrhage in the right temporal lobe which is most likely consistent with hemorrhagic contusion without mid line shift or incoordination.
ACTIVE MEDICATIONS: Isordil 20 mgs p.o. t.i.d., Coumadin 2.5 mgs p.o. qd, ferrous sulfate 325 mgs p.o. b.i.d., Ativan 0.5 mgs p.o. b.i.d., Lactulose 15 ccs p.o. b.i.d., Calcium carbonate 650 mgs p.o. b.i.d. with food, Betoptic
0.5% ophthalmologic solution gtt OU b.i.d., Nephrocaps 1 tablet p.o. qd,
Pilocarpine 4% solution 1 gtt OU b.i.d., Compazine 10 mgs p.o. t.i.d. prn nausea, Tylenol 650 mgs p.o. q4 hours prn.
Patient is on hemodialysis, no known drug allergies.
PHYSICAL EXAMINATION: Patient had stable vital signs, his blood pressure was
160/85, pulse 84, respiratory rate 20, temperature 98 degrees. Patient was alert, oriented times three, cooperative. His speech was fluent, understanding of spoken language was good. Attention span was good. He had
D R A F T
Press RETURN to continue or '^' to exit: <Enter>
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Discharge Summary Print Example cont’d
SALT LAKE CITY priority 06/27/96 08:46 Page: 4
-----------------------------------------------------------------------------
PATIENT NAME | AGE | SEX | RACE | SSN | CLAIM NUMBER
TIUPATIENT,ONE | 51 | M | MEXI | 666-23-3456 |
----------------------------------------------------------------------------- moderate memory impairment, no apraxia noted. Cranial nerves patient was blind, pupils are not reactive to light, face was asymmetric, tongue and palate are mid line. Motor examination showed muscle tone and bulk without significant changes. Muscle strength in upper extremities 5/5 bilaterally, sensory examination revealed intact light touch, pinprick and vibratory sensation. Reflexes 1+ in upper extremities, coordination finger to nose test within normal limits bilaterally. Alternating movements without significant changes bilaterally. Neck was supple.
LABORATORY: Showed sodium level 135, potassium 4.6, chloride 96, CO2 26,
BUN 39, creatinine 5.3, glucose level 138. White blood cell count was 7, hemoglobin 11, hematocrit 34, platelet count 77.
HOSPITAL COURSE: Patient was admitted after head trauma with multiple medical problems. His coumadin was held. Patient had cervical spine x-rays which showed definite narrowing of C5, C6 interspace, slight retrolisthesis at this level, prominent spurs at this level as well as above and below. CT scan on admission showed a moderate amount of scalp thinning with subcutaneous air overlying the left frontal lobe. A small area of left parenchymal hemorrhage adjacent to the right petros bone in the temporal lobe which most likely represents a hemorrhagic contusion. Repeated CT scan on 5/13/94 didn’t show any progressive changes. Patient remained in stable condition. He had hemodialysis q.o.d. He restarted treatment with Coumadin. His last PT was 11.9, PTT 31.
Patient refused before hemodialysis new blood tests. His condition remained stable.
DISCHARGE MEDICATIONS: Isordil 20 mgs p.o. t.i.d., Ferrous sulfate 325 mgs p.o. b.i.d., Ativan 0.5 mgs p.o. b.i.d., Lactulose 15 ccs p.o. b.i.d., Calcium carbonate 650 mgs p.o. b.i.d., Compazine 10 mgs p.o. t.i.d. prn nausea, Betoptic
0.5% OU b.i.d., Nephrocaps 1 p.o. qd, Pilocarpine 4% solution 1 gtt OU b.i.d.,
Coumadin 2.5 mgs p.o. qd, Tylenol 650 mgs p.o. q6 hours prn pain.
DISPOSITION/FOLLOW-UP:
Recommend follow PT/PTT. Patient is on coumadin and CBC with differential because patient has chronic anemia and thrombocytopenia.
Patient will be transferred to Anytown VA in stable condition on 5/19/94.
WORK COPY ========= UNOFFICIAL - NOT FOR MEDICAL RECORD ======== DO NOT FILE
SIGNATURE PHYSICIAN/DENTIST SIGNATURE APPROVING PHYSICIAN/DENTIST
TIUPROVIDER, ONE, MD THREE TIUPROVIDER, MS
PGY2 Resident Medical Internist
========================= CONFIDENTIAL INFORMATION =========================
D R A F T
JUN 26, 1996@17:36:02 ADDENDUM:
Routine visit today--no change to condition.
SIGNATURE PHYSICIAN/DENTIST SIGNATURE APPROVING PHYSICIAN/DENTIST
Three TIUProvider, MD
Medical Internist
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Progress Note Print
Use this option to print chart or work copies of progress notes.
Steps to use option:
1. Select Progress Note Print from the Print Document Menu.
2. Enter a patient name.
Select Print Document Menu Option: 2 Progress Note Print
Select PATIENT NAME: TIUPATIENT,ONE TIUPATIENT,ONE 09-12-44 666233456
YES
SC VETERAN
(2 notes) C: 05/28/96 12:37
(2 notes) W: 05/28/96 12:33
A: Known allergies
(2 notes) D: 05/28/96 12:36
Available notes: 02/17/96 thru 06/21/96 (31)
3. Enter the range of dates for progress notes you want to print.
4. Choose a note from those listed.
Please specify a date range from which to select notes:
List notes Beginning: 02/17/96// <Enter> (FEB 17, 1996)
Thru: 06/21/96// <Enter> (JUN 21, 1996)
1 06/21/96 11:40 Lipid Clinic FIVE TIUPROVIDER
Visit: 02/21/96
2 06/21/96 11:38 Social Work Service FIVE TIUPROVIDER
Visit: 04/18/96
3 06/07/96 00:00 Diabetes Education ONE TIUPROVIDER MD
Visit: 04/18/96
4 05/15/96 13:10 Addendum to Diabetes Education SEVEN TIUPROVIDER
Visit: 02/21/96
5 04/24/96 15:41 Lipid Clinic THREE TIUPROVIDER
Visit: 04/24/96
6 02/23/96 14:08 Diabetes Education THREE TIUPROVIDER
Visit: 02/21/9
Choose notes: (1-6):3, 5
Do you want WORK copies or CHART copies? CHART// <Enter>
DEVICE: HOME// <Enter> VAX
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Progress Notes Print Example
-----------------------------------------------------------------------------
TIUPATIENT,ONE 666-23-3456 Progress Notes
-----------------------------------------------------------------------------
NOTE DATED: 06/07/96 17:51 DIABETES EDUCATION
ADMITTED: 07/22/95 11:06 1A
SUBJECT: Routine diabetes education
Patient understanding good.
Signed by: /es/ Three TIUProvider, MD
Medical Internist 06/23/96 08:34
Analog Pager: 555-1213
Digital Pager: 555-1215
Cosigned by: /es/ TIUProvider,Three
06/23/96 08:34
Analog Pager: 555-1213
Digital Pager:555-1215
NOTE DATED: 04/24/96 08:00 ARTERIAL EVALUATION - LOWER EXTREMITY
VISIT: 04/17/92 08:00 FOURTEEN’S CLINIC
SUBJECT: Rule out embolus, lower extremity
AGE: 50
UNIT: General Medicine
REFERRING MD: Eight CPRSProvider
DIAGNOSIS: Rule out embolus
HISTORY: severe pedal edema, foot ulcers
OTHER: cyanosis
SYMPTOMS:
RESTING SYMPTOMS:
EXERTIONAL SYMPTOMS:
LESIONS:
MEDICATIONS:
RECORDED RECORDED
AUDIBLE DOPPLER SIGNAL RIGHT LEFT DOPPLER WAVEFORM: RIGHT LEFT
COMMON FEMORAL _____ _____ COMMON FEMORAL _____ _____
SUPERFICIAL FEMORAL _____ _____ PRE-EXERCISE _____ _____
POPLITEAL _____ _____ POST-EXERCISE _____ _____
POSTERIOR TIBIAL _____ _____ OTHER _____ _____
DORSALIS PEDIS _____ _____
N=NORMAL ABN=ABNORMAL O=ABSENT B=BIPHASIC
TRANSCUTANEOUS PO2 VALUES:
RIGHT LEFT
SUBCLAVICULAR ___40___ ___40___
ABOVE KNEE ___39___ ___40___
HIGH BK ___39___ ___40___
CALF ___37___ ___39___
ANKLE ___36___ ___39___
DORSUM OF FOOT ___22___ ___38___
OTHER ___18___ ___38___
Enter RETURN to continue or '^' to exit: <Enter>
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Progress Notes Print Example cont’d
-----------------------------------------------------------------------------
TIUPATIENT,ONE 666-23-3456 Progress Notes
-----------------------------------------------------------------------------
04/24/92 08:00 ** CONTINUED FROM PREVIOUS SCREEN **
40 =ADEQUATE FOR HEALING
39-30 =EQUIVOCAL FOR HEALING
29-0 =INADEQUATE FOR HEALING
SEGMENTAL SYSTOLIC BLOOD PRESSURE:
RIGHT INDEX LEFT INDEX
ARM ______________ ______________
HIGH THIGH ______________ ______________
ABOVE KNEE ______________ ______________
BELOW KNEE ______________ ______________
ANKLE PT ______________ ______________
DP ______________ ______________
EXERCISE RESPONSE:
MPH: 5 mph
MAXIMUM WALKING TIME: _10_ MIN _30_ SEC
SYMPTOMS: Pedal edema, cyanosis
MAXIMUM HEART RATE ACHIEVED:
TIME RIGHT INDEX LEFT INDEX ARM
1 MINUTE ____________ ____________ ____________
3 MINUTES ____________ ____________ ____________
5 MINUTES ____________ ____________ ____________
10 MINUTES ____________ ____________ ____________
15 MINUTES ____________ ____________ ____________
20 MINUTES ____________ ____________ ____________
POST EXERCISE:
IMPRESSIONS:
Signed by: /es/ Three TIUProvider, MD
Medical Internist 04/24/96 14:19
Analog Pager: 555-1213
Digital Pager: 555-1215
Enter RETURN to continue or '^' to exit: ^
1 Discharge Summary Print
2 Progress Note Print
3 Clinical Document Print
Select Print Document Menu Option: <Enter>
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Clinical Document Print
Use this option to print chart or work copies of all clinical documents available through
TIU.
Steps to use option:
1. Select Clinical Document Print from the Print Document Menu, and then enter a patient name.
Select Print Document Menu Option: 3 Clinical Document Print
Select PATIENT NAME: TIUPATIONE,ONE TIUPATIENT,ONE 09-12-44 666233456
YES
SC VETERAN
(2 notes) C: 05/28/96 12:37
(2 notes) W: 05/28/96 12:33
A: Known allergies
(2 notes) D: 05/28/96 12:36
Available documents: 02/17/92 thru 06/21/96 (34)
2. Enter a date range that documents will be chosen from.
Please specify a date range from which to select documents:
List documents Beginning: 02/17/92// 6/1/96 (JUN 01, 1996)
Thru: 06/21/96// 6/8/96 (JUN 08, 1996)
1 06/07/96 00:00 Diabetes Education One TIUProvider, MD
Visit: 04/18/96
2 06/05/96 17:23 Lipid Clinic Three TIUProvider
Visit: 04/18/96
3 06/05/96 11:10 Addendum to Lipid Clinic Three TIUProvider
Visit: 04/24/96
3. Choose the document or documents you would like printed, and whether you want work or chart copies.
Choose documents: (1-3): 1-3
Do you want WORK copies or CHART copies? CHART// <Enter>
DEVICE: HOME// PRINTER
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Clinical Document Print Example
4. The document(s) will then be printed at the device you specify.
-----------------------------------------------------------------------------
TIUPATIENT,ONE 666-23-3456 Progress Notes
-----------------------------------------------------------------------------
NOTE DATED: 06/07/96 00:00 DIABETES EDUCATION
VISIT: 04/18/96 10:00 GENERAL MEDICINE
Routine diabetes education given as follow-up to lipid clinic visit.
Signed by: /es/ One TIUProvider, MD
PGY2 Resident 06/07/96 10:22
NOTE DATED: 06/05/96 17:23 LIPID CLINIC
VISIT: 04/18/96 10:00 GENERAL MEDICINE
SUBJECTIVE: 51 year old MEXICAN AMERICAN MALE here for
initial evaluation of his DYSLIPIDEMIA.
PMH:
Significant negative medical history pertinent to the
evaluation and treatment of DYSLIPIDEMIA:
FH:
SH:
MEDICATION
HISTORY: CURRENT MEDICATIONS
DIET: Counseled on AHA Step I diet today by Nine CPRSProvider.
See her evaluation.
ACTIVITY:
OBJECTIVE: HT: 72 (08/23/95 11:45) WT: 190 (08/23/95 11:45)
TSH/T4: /
FBG: 89 HEMOGLOBIN A1C:
SGOT: URIC ACID:
ASSESSMENT: 1. MALE with / without documented CAD
2. CV Risk factors:
3. Lipid pattern:
PLAN: 1. Implement recommendations to lower fat intake.
2. Repeat FBG and HBG A1C on:
3. Return to review lab on:
Signed by: /es/ Three TIUProvider, MD
Internist 06/05/96 17:23
Analog Pager: 555-1213
Digital Pager: 555-1215
Enter RETURN to continue or '^' to exit: <Enter>
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Clinical Document Print Example cont’d
-----------------------------------------------------------------------------
TIUPATIENT,ONE 666-23-3456 Progress Notes
-----------------------------------------------------------------------------
NOTE DATED: 04/24/96 15:41 LIPID CLINIC
VISIT: 04/24/96 15:40 DIABETIC EDUCATION-INDIV-MOD B
SUBJECTIVE: 51 year old MEXICAN AMERICAN MALE here for
initial evaluation of his DYSLIPIDEMIA.
PMH:
Significant negative medical history pertinent to the
evaluation and treatment of DYSLIPIDEMIA:
FH:
SH:
MEDICATION
HISTORY: CURRENT MEDICATIONS
DIET: Counseled on AHA Step I diet today by NINE TIUPROVIDER.
See her evaluation.
ACTIVITY:
OBJECTIVE: HT: 72 (08/23/95 11:45) WT: 190 (08/23/95 11:45)
TSH/T4: /
FBG: 89 HEMOGLOBIN A1C:
SGOT: URIC ACID:
ASSESSMENT: 1. MALE with / without documented CAD
2. CV Risk factors:
3. Lipid pattern:
PLAN: 1. Implement recommendations to lower fat intake.
2. Repeat FBG and HBG A1C on:
3. Return to review lab on:
Signed by: /es/ Three TIUProvider, MD
Internist 04/24/96 15:41
Analog Pager: 555-1213
Digital Pager: 555-1215
Enter RETURN to continue or '^' to exit: <Enter>
1 Discharge Summary Print
2 Progress Note Print
3 Clinical Document Print
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Released/Unverified Report
Use this option to produce a list of released documents which haven’t been verified.
Steps to use option:
1. Select Released/Unverified Report from the MRT menu.
2. Enter the starting and ending divisions for the report.
3. Enter the starting day for the report.
4. Specify a printer. If necessary, set the margin width to 132.
Select Text Integration Utilities (MRT) Option: Released/Unverified Report
START WITH DIVISION: FIRST// 660
GO TO DIVISION: LAST//
START WITH RELEASE DATE/TIME: FIRST// <Enter>
DEVICE: PRINTER
MARGIN WIDTH IS NORMALLY AT LEAST 132
ARE YOU SURE? No// YES
Released/Unverified Report - ELY
OCT 15,1996 11:59 PAGE 1
PATIENT SSN ADM DATE DIS DATE
LINE
DICTATED BY URGENCY COUNT
----------------------------------------------------------------------
RELEASE DATE/TIME: JAN 10,1996
TRANSCRIPTIONIST: DP
TIUPATIENT,THREE 666042591P 02/27/92 03/05/92
TIUPROVIDER,FOUR routine 1 Discharg
--------
SUBTOTAL 1
RELEASE DATE/TIME: SEP 10,1996
TRANSCRIPTIONIST: BS
TIUPATIENT,FOUR 666123456 09/21/95
TIUPROVIDER,ONE routine 72 Addendum
TIUPATIENT,FIVE 666451462 05/04/92 05/31/96
TIUPROVIDER,ONE priority 78 Addendum
--------
SUBTOTAL 150
Discharge Summary Released/Unverified Report OCT 15,1996 11:59 PAGE 2
PATIENT SSN ADM DATE DIS DATE
LINE
DICTATED BY URGENCY COUNT
----------------------------------------------------------------------
RELEASE DATE/TIME: OCT 4,1996
TRANSCRIPTIONIST: jg
TIUPATIENT,ONE 666233456 07/22/91 02/12/96
TIUPROVIDER,THRE routine 1 Discharg
--------
SUBTOTAL 1
--------
TOTAL 152
Press RETURN to continue...<Enter>
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Search for Selected Documents
Use this option to produce a list of selected documents by extended search criteria e.g., status, search category, and reference date range). These can then be reviewed, verified, sent back to transcription, reassigned, or printed.
Steps to use option:
1. Select Search for Selected Documents from the TIU MRT menu.
2. Select the status of documents you want displayed.
Select Text Integration Utilities (MRT) Option: 6 Search for Selected Documents
Select Status: COMPLETED// ?
1 undictated 5 unsigned 9 purged
2 untranscribed 6 uncosigned 10 deleted
3 unreleased 7 completed 11 retracted
4 unverified 8 amended
Enter selection(s) by typing the name(s), number(s), or abbreviation(s).
Select Status: COMPLETED// <Enter> completed
3. Select the document type you want displayed.
Select CLINICAL DOCUMENTS Type(s): Discharge Summaries// ?
1 Discharge Summaries 2 Progress Notes 3 Addendum
Enter selection(s) by typing the name(s), number(s), or abbreviation(s).
Select CLINICAL DOCUMENTS Type(s):Progress Notes Progress Notes
These may be different at your site.
4. Select the search category you want displayed.
Select SEARCH CATEGORIES: AUTHOR// ?
1 All Categories 5 Patient 9 Title
2 Author 6 Problem 10 Transcriptionist
3 Expected Cosigner 7 Service 11 Treating Specialty
4 Hospital Location 8 Subject 12 Visit
Enter selection(s) by typing the name(s), number(s), or abbreviation(s).
Select SEARCH CATEGORIES: AUTHOR// <Enter> Author
Select AUTHOR: TIUPROVIDER,ONE JG
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Search for Selected Documents, cont’d
5. Enter the range of dates you want displayed.
Start Reference Date [Time]: T-7//<Enter> (MAY 26, 1997)
Ending Reference Date [Time]: NOW// <Enter> (JUN 02, 1997@15:46)
Searching for the documents...
6. The documents fitting the search criteria you selected are displayed. Choose an action to perform on the relevant documents.
UNSIGNED Documents Jun 02, 1997 15:46:28 Page: 1 of 1
by AUTHOR (TIUPROVIDER,ONE) from 05/26/97 to 06/02/97 2 documents
Patient Document Ref Date Status
1 TIUPATIENT,ONE(T3456) Adverse React/Allergy 05/31/97 unsigned
2 TIUPATIENT,FIV(T2591) Adverse React/Allergy 05/31/97 unsigned
+ Next Screen - Prev Screen ?? More Actions >>>
Find Reassign Print
Verify/Unverify Send Back Change View
On Chart Detailed Display Quit
Edit Browse
Select Action: Quit//
Unsigned/Uncosigned Report
Lists detailed document information such as author, patient, patient SSN, etc. for notes with no signature and/or cosignature. Optionally, a summary report can be generated showing the number of unsigned and uncosigned documents in each service.
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In the following example, a summary report is generated for a selected division:
Select OPTION NAME: TIU UNSIGNED/UNCOSIGNED REPORT Unsigned/Uncosigned
Report run routine
Select division: ALL// SALT
1 SALT LAKE CIOFO 660GC
2 SALT LAKE OEX 660
CHOOSE 1-2: 1 SALT LAKE CIOFO 660GC
Select another division: <Enter>
Please specify an Entry Date Range:
Start Entry Date: t-365 (JAN 28, 2003)
Ending Entry Date: t (JAN 28, 2004)
Select service: ALL// <Enter>
Select one of the following:
F FULL
S SUMMARY
Type of Report: S SUMMARY
DEVICE: HOME// <Enter> ANYWHERE
Unsigned and Uncosigned Documents Jan 28, 2003 thru Jan 28, 2
004@23:59:59Page 1
PRINTED: for ELY
JAN 28, 2004@16:33
------------------------------------------------------------------------------
Totals for Service: IRM--- UNSIGNED: 24 UNCOSIGNED: 0
Totals for Service: MEDICINE--- UNSIGNED: 112 UNCOSIGNED: 0
Totals for Service: OTHER--- UNSIGNED: 1 UNCOSIGNED: 0
Totals for Service: PHARMACY--- UNSIGNED: 6 UNCOSIGNED: 0
Totals for Service: SURGERY--- UNSIGNED: 1 UNCOSIGNED: 0
Totals for Service: UNKNOWN--- UNSIGNED: 2 UNCOSIGNED: 0
Totals for Division: ELY--- UNSIGNED: 146 UNCOSIGNED: 0
Enter RETURN to continue or '^' to exit:
Note: A full Unsigned/Uncosigned Report requires a printer device capable of printing 132 columns.
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Reassignment Document Report
The reassign action reassigns a note to a different patient, admission, or visit. Besides this, the reassign action may be used to promote an Addendum as an Original, swap the
Addendum and the Original, or change a discharge summary to an Addendum.
This report provides a list of reassigned notes based on date range. In the following example TIU displays a report of reassigned documents over the past 6 months:
Select Text Integration Utilities (MRT) Option: ?
1 Individual Patient Document
2 Multiple Patient Documents
3 Review Upload Filing Events
4 Print Document Menu ...
5 Released/Unverified Report
6 Search for Selected Documents
7 Unsigned/Uncosigned Report
8 Reassignment Document Report
Enter ?? for more options, ??? for brief descriptions, ?OPTION for help text.
Select Text Integration Utilities (MRT) Option: 8 Reassignment Document Report
ENTER STARTING DATE: JAN 01, 2003//t-180 (AUG 22, 1999)
ENTER ENDING DATE: Aug 04, 2004// (AUG 04, 2004)
DEVICE: HOME// ANYWHERE
Searching...
Date range searched: Aug 22, 1999 - Aug 04, 2004
Number of records searched: 9189
Number of records found: 570
Elapsed time: 0 minute(s) 3 second(s)
Current user: TIUPROVIDER,SEVEN
Current date: Aug 04, 2004@10:20:57
TIU REASSIGNMENT DOCUMENT REPORT
DOCUMENT NAME INITIAL PATIENT FINAL PATIENT REASSIGNMENT DATE/TIME
============= =============== ============= ======================
Addendum TIUPATIENT,EIGHT TIUPATIENT,SIX Aug 23, 1999@08:46:41
Addendum TIUPATIENT,EIGHT TIUPATIENT,SIX Aug 23, 1999@08:46:42
Discharge Summa TIUPATIENT,SEVEN TIUPATIENT,SEVEN Aug 25, 1999@11:51:47
PULMONARY CS CO TIUPATIENT,EIGHT TIUPATIENT,NINE Aug 25, 1999@15:41:40
PULMONARY CS CO TIUPATIENT,NINE TIUPATIENT,EIGHT Aug 25, 1999@16:03:24
PULMONARY CS CO TIUPATIENT,EIGHT TIUPATIENT,NINE Aug 25, 1999@16:16:32
PULMONARY CS CO TIUPATIENT,EIGHT TIUPATIENT,EIGHT Aug 25, 1999@16:36:05
PULMONARY CS CO TIUPATIENT,EIGHT TIUPATIENT,EIGHT Aug 25, 1999@16:36:06
PULMONARY CS CO TIUPATIENT,EIGHT TIUPATIENT,FIVE Aug 27, 1999@10:47:49
PULMONARY CS CO TIUPATIENT,EIGHT TIUPATIENT,NINE Aug 27, 1999@15:56:28
PULMONARY CS CO TIUPATIENT,EIGHT TIUPATIENT,SIX Aug 27, 1999@16:18:45
PULMONARY CS CO TIUPATIENT,EIGHT TIUPATIENT,SIX Aug 27, 1999@16:41:45
PULMONARY CS CO TIUPATIENT,EIGHT TIUPATIENT,SIX Aug 27, 1999@16:41:46
PULMONARY CS CO TIUPATIENT,EIGHT TIUPATIENT,SIX Aug 31, 1999@16:14:29
Addendum TIUPATIENT,EIGHT TIUPATIENT,SIX Aug 31, 1999@17:01:15
Addendum TIUPATIENT,EIGHT TIUPATIENT,SIX Aug 31, 1999@17:01:16
Enter RETURN to continue or '^' to exit:
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Review Unsigned Additional Signatures
This option prints either a detailed or summary report of documents requiring additional signatures.
In the detailed report the patient name is abbreviated to the patient initials followed by the last six digits of the social security number to save space.
In the following example, a detailed report is run covering a four month period:
Select Text Integration Utilities (MRT) Option: ?
1 Individual Patient Document
2 Multiple Patient Documents
3 Review Upload Filing Events
4 Print Document Menu ...
5 Released/Unverified Report
6 Search for Selected Documents
7 Unsigned/Uncosigned Report
8 Reassignment Document Report
9 Review unsigned additional signatures
Enter ?? for more options, ??? for brief descriptions, ?OPTION for help text.
You have PENDING ALERTS
Enter "VA to jump to VIEW ALERTS option
Select Text Integration Utilities (MRT) Option: 9 Review unsigned additional signatures
Select division: ALL//
Please specify an Entry Date Range:
Start Entry Date: t-90 (NOV 09, 2004)
Ending Entry Date: t (FEB 07, 2005)
Select service: ALL//
Select one of the following:
F FULL
S SUMMARY
Type of Report: f FULL
This report should be sent to a 132 Column Device
DEVICE: HOME// ANYWHERE
Pending Additional Signature Documents for ELY on Feb 07, 2005@14:39:49
Oct 10, 2004 thru Feb 07, 2005@23:59:59 Page: 1
------------------------------------------------------------------------------
IDENT. SIGNER PATIENT STATUS ENTRY DATE DOCUMENT TITLE
DOCUMENT IEN
--------------------------------------------------------------------------------
SERVICE: MEDICINE
CPRSPROVIDER, E EB111148 com 10/15/04@07:58:50 ACUTE PAIN NOTE
29303
CPRSPROVIDER, F EH224567 com 11/26/04@14:39:48 SURGERY CS CONSULT
28002
CPRSPROVIDER, F FC781990 com 11/30/04@07:39:31 CARDIOLOGY NOTE
29008
CPRSPROVIDER, N FC781990 com 10/20/04@12:30:10 MEDICINE NOTE
29079
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CPRSPROVIDER, O SH345377 com 10/30/04@12:40:24 AB ID PARENT BARRY TEST
29019
CPRSPROVIDER, O TH345377 com 12/30/04@12:40:24 AB ID PARENT BARRY TEST
29019
CPRSPROVIDER, S NC448661 com 12/20/04@13:08:40 PODIATRY CS CONSULTS
27968
CPRSPROVIDER, T OC324321 com 01/29/05@13:50:35 CRISIS NOTE
28840
CPRSPROVIDER, T OC668847 com 01/28/05@11:16:37 ACUTE PAIN NOTE
29362
Totals for Service MEDICINE: 9
Totals for Division ELY: 9
Enter RETURN to continue or '^' to exit:
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Chapter 5: TIU for MIS/HIMS Managers
Individual Patient Document
Multiple Patient Documents
Print Documents Menu
Search for Selected Documents
Statistical Reports
Unsigned/Uncosigned Report
Missing Text Report
Missing Text Cleanup
UNKNOWN Addenda Cleanup
Missing Expected Cosigner Report
Mark Document as ‘Signed by Surrogate’
Mismatched ID Notes
TIU 215 ANALYSIS
Transcription Billing Verification Report
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Chapter 5: TIU for MIS/HIMS Managers
The Medical Information Section (MIS), also called Health Information Management
Section (HIMS), maintains and manages records of clinical documents, including copies of statistical reports, and chart or work copies of discharge summaries and progress notes.
MIS Manager’s Menu
Option
Individual Patient Document
Multiple Patient Documents
Description
Allows you to review or print patient Clinical Documents.
This option lets MIS Managers see any of the available TIU documents on the Text Integration Utilities Review Screen.
Print Document Menu
Search for Selected
Documents
This menu gives MAS personnel access to options which print CHART or WORK copies of discharge summaries, progress notes, or mixed Documents on demand.
Allows MIS Managers to generate a list of selected documents based on extended search criteria; e.g.,
STATUS, SEARCH CATEGORY, and REFERENCE
DATE RANGE).
Statistical Reports
This menu allows you to view or print statistical reports for line counts and timeliness by Author, Transcriptionist, and
Service.
Unsigned/Uncosigned Report
Provides information on unsigned and uncosigned documents for one, multiple, or all divisions. The report can be either Summary or Full. The summary report lists the number of documents by the service or section of the
Missing Text Report
author. The full report lists detailed document information
(such as author, patient, patient SSN, etc.) by the service or section of the author.
Reports which TIU Documents that do not have any report text, are missing the 0 node of the text node, or both cases.
Documents may be of any type, including addenda but not notes with components or addenda attached to them.
Missing Text Cleanup
This is a utility for assisting with the cleanup of documents without report text. In some cases you may choose to correct documents manually, such as when the author is still available or when the document was originally an upload document.
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Option
UNKNOWN Addenda Cleanup
Missing Expected Cosigner Report
Mark Document as ‘Signed by
Surrogate’
Mismatched ID Notes
TIU 215 ANALYSIS
Transcription Billing Verification
Report
Description
Gives a list of surgery addenda that are not connected to an Operations Report and provides options for reviewing, assistance in finding the parent, and attaching to the parent.
Provides a list of documents that have a status of
“Uncosigned” where the “Expected Cosigner” field is null, 0 or -1.
Provides a way to mark a document as 'Signed by
Surrogate'. This will set the .09 field of file 8925.7 to 1 - meaning that the signing for an Additional Signer was done by a surrogate of that Additional Signer.
This option runs a routine that will report/fix mismatched interdisciplinary (ID) notes.
Surgery cases will be analyzed within a particular date range and information from Nurse Intraoperative Report
(NIR) and/or Anesthesia reports will be compared to their corresponding TIU notes. If the information does not match, the case number will be recorded as one that needs to be reviewed.
This report can be run by division and provides information on all transcriptionists or one or more selected transcriptionist. It reports based on an entered date range. Since the VBC Line Count is only calculated for transcribed reports, it does not report on any document transcribed before the line count patch was installed.
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Individual Patient Document
Use this option to review or print TIU documents for a patient.
Steps to use option:
1. Select Individual Patient Document from the MIS Manager Menu, and then enter the patient name.
Select Text Integration Utilities (MIS Manager) Option: Individual Patient
Document
Select PATIENT NAME: TIUPATIENT,SEVEN TIUPATIENT,SEVEN 04-25-31 666042591P NO
MILITARY RETIREE
(2 notes) W: 09/16/96 15:12 (addendum 09/18/96 09:53)
A: Known allergies
Available documents: 08/11/95 thru 10/10/96 (131)
2. Select a date range for the documents you wish to review, and then choose one or more of the documents displayed.
Please specify a date range from which to select documents:
List documents Beginning: 08/11/95// t-15 (SEP 30, 1996)
Thru: 10/10/96// <Enter> (OCT 10, 1996)
1 10/06/96 14:11 Addendum to Diabetes Education Three TIUProvider,
Adm: 09/28/96
2 10/05/96 13:56 Diabetes Education Six TIUProvder,
Adm: 09/28/96
Choose documents: (1-3): 2
3. The document(s) you chose is displayed. Choose an action to perform.
Browse Document Oct 15, 1996 12:23:42 Page: 1 of 1
Diabetes Education
TIUPATIENT,SEVEN 666-04-2591P 1A Visit Date: 09/28/96@15:58
DATE OF NOTE: SEP 05, 1996@13:51:03 ENTRY DATE: SEP 05, 1996@13:51:03
AUTHOR: TIUPROVIDER,SIX EXP COSIGNER: TIUPROVIDER,THREE
URGENCY: STATUS: COMPLETED
TEST DRUG EFFICACY.
/es/ Six TIUProvider, MS3 /es/ Three TIUProvider, MD
Medical Student III
Signed: 10/05/96 13:51 Cosigned: 10/05/96 14:11
+ Next Screen - Prev Screen ?? More Actions >>>
Find On Chart Reassign
Print Amend Send Back
Edit Delete Quit
Verify/Unverify
Select Action: Quit//
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Multiple Patient Documents
Use this option to display TIU documents of specified types, which can then be reviewed, verified, sent back to transcription, reassigned, or printed.
Caution: Avoid making your requests too broad (in statuses, search categories, and date ranges) because these searches can use a lot of system resources, slowing the computer system down for everyone. The example below would probably be too broad in a large hospital.
Steps to use option:
1. Select Multiple Patient Documents from the MIS Manager menu. Answer the prompts that follow.
Select Text Integration Utilities (MIS MANAGER) Option: Multiple Patient
Documents
Select division: ALL// <Enter>
Select Status: UNSIGNED// <Enter> Unsigned
These may
Select Clinical Documents Type(s): ?
1 Progress Notes 2 Discharge Summary 3 Addendum differ at your site.
Enter selection(s) by typing the name(s), number(s), or abbreviation(s).
Select Clinical Documents Type(s): 1-3 Addendum Discharge Summary
Progress Notes
Start Reference Date [Time]: T-7//t-15 (MAR 19, 1997)
Ending Reference Date [Time]: NOW// <Enter> (APR 18, 1997@15:21)
Searching for the documents................
2. When the documents that fit the criteria you entered are displayed, choose an action and a document(s).
UNSIGNED Documents Apr 18,1996 15:21:44 Page:1 of 1 by ALL CATEGORIES from 03/19/96 to 04/18/96 15 documents
Patient Document Admitted Disch'd
1 TIUPATIENT,O (T8101) Nursing Note 04/15/96
2 TIUPATIENT,T (T2760) Addendum 03/22/96
3 TIUPATIENT,T (T2760) Addendum 03/22/96
4 TIUPATIENT,F (T6641) Ambul/Outp Care 04/18/96
5 TIUPATIENT,F (T6641) General Note 04/18/96
6 TIUPATIENT,F (T6641) Diabetes Ed 03/20/96
7 TIUPATIENT,S (T0482) Diabetes Edu 03/25/96
8 TIUPATIENT,S (T0482) Addendum 03/25/96
+ Next Screen - Prev Screen ?? More Actions >>>
Verify/Unverify Link with Request Print
On Chart Send Back Interdiscipl'ry Note
Edit Detailed Display Change View
Reassign Browse QuitSelect
Action: Quit// ON CHART
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Print Document Menu
This menu contains options which print chart or work copies of discharge summaries, progress notes, or mixed documents.
1 Discharge Summary Print
2 Progress Note Print
3 Clinical Document Print
Discharge Summary Print
Use this option to print chart or work copies of discharge summaries.
Steps to use this option:
1. Select Discharge Summary Print from the MIS Manager’s Print Document Menu.
2. Enter the name of the patient whose discharge summary you want to print.
1 Discharge Summary Print
2 Progress Note Print
3 Clinical Document Print
Select Print Document Menu Option: 1 Discharge Summary Print
Select PATIENT NAME: TIUPATIENT,ONE TIUPATIENT,ONE 09-12-44 666233456
YES
SC VETERAN
(2 notes) C: 05/28/96 12:37
(2 notes) W: 05/28/96 12:33
A: Known allergies
(2 notes) D: 05/28/96 12:36
Available summaries: 02/12/96 thru 02/12/96 (1)
3. Enter the range of dates to choose the discharge summary or summaries you want to print.
Please specify a date range from which to select summaries:
List summaries Beginning: 02/12/96// <Enter> (FEB 12, 1996)
Thru: 02/12/96// <Enter>
1 02/12/96 13:56 Discharge Summary One TIUProvider, MD
Adm: 07/22/91 Dis: 02/12/96
Choose summaries: (1-1): 1
Do you want WORK copies or CHART copies? CHART// WORK
DEVICE: HOME// <Enter> VAX
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Discharge Summary Print Example
SALT LAKE CITY priority 06/27/96 08:45 Page: 1
-----------------------------------------------------------------------------
PATIENT NAME | AGE | SEX | RACE | SSN | CLAIM NUMBER
TIUPATIENT,ONE | 51 | M | MEXI | 666-23-3456 |
-----------------------------------------------------------------------------
ADM DATE | DISC DATE | TYPE OF RELEASE | INP | ABS | WARD NO
JUL 22, 1991 | FEB 12, 1996 | REGULAR |1666 | 0 | 1A
-----------------------------------------------------------------------------
DICTATION DATE: JUN 09, 1996 TRANSCRIPTION DATE: JUN 12, 1996
TRANSCRIPTIONIST: bs
DIAGNOSIS:
1. Status post head trauma with brain contusion.
2. Status post cerebrovascular accident.
3. End stage renal disease on hemodialysis.
4. Coronary artery disease.
5. Congestive heart failure.
6. Hypertension.
7. Non insulin dependent diabetes mellitus.
8. Peripheral vascular disease, status post thrombectomies.
9. Diabetic retinopathy.
10. Below knee amputation.
11. Chronic anemia.
OPERATIONS/PROCEDURES:
1. MRI.
2. CT SCAN OF HEAD.
HISTORY OF PRESENT ILLNESS:
Patient is a 49-year-old, white male with past medical history of end stage renal disease, peripheral vascular disease, status post BKA, coronary artery disease, hypertension, non insulin dependent diabetes mellitus, diabetic retinopathy, congestive heart failure, status post CVA, status post thrombectomy admitted from Anytown VA after a fall from his wheelchair in the hospital. He had questionable short lasting loss of consciousness but patient is not very sure what has happened. He denies headache, vomiting, vertigo.
On admission patient had CT scan which showed a small area of parenchymal hemorrhage in the right temporal lobe which is most likely consistent with hemorrhagic contusion without mid line shift or incoordination.
ACTIVE MEDICATIONS: Isordil 20 mgs p.o. t.i.d., Coumadin 2.5 mgs p.o. qd, ferrous sulfate 325 mgs p.o. b.i.d., Ativan 0.5 mgs p.o. b.i.d., Lactulose 15 ccs p.o. b.i.d., Calcium carbonate 650 mgs p.o. b.i.d. with food, Betoptic
0.5% ophthalmologic solution gtt OU b.i.d., Nephrocaps 1 tablet p.o. qd,
Pilocarpine 4% solution 1 gtt OU b.i.d., Compazine 10 mgs p.o. t.i.d. prn nausea, Tylenol 650 mgs p.o. q4 hours prn.
Patient is on hemodialysis, no known drug allergies.
PHYSICAL EXAMINATION: Patient had stable vital signs, his blood pressure was
160/85, pulse 84, respiratory rate 20, temperature 98 degrees. Patient was alert, oriented times three, cooperative. His speech was fluent, understanding of spoken language was good. Attention span was good. He had
D R A F T
Press RETURN to continue or '^' to exit: <Enter>
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Discharge Summary Print Example cont’d
SALT LAKE CITY priority 06/27/96 08:46 Page: 4
-----------------------------------------------------------------------------
PATIENT NAME | AGE | SEX | RACE | SSN | CLAIM NUMBER
TIUPATIENT,ONE | 51 | M | MEXI | 666-23-3456 |
----------------------------------------------------------------------------- moderate memory impairment, no apraxia noted. Cranial nerves patient was blind, pupils are not reactive to light, face was asymmetric, tongue and palate are mid line. Motor examination showed muscle tone and bulk without significant changes. Muscle strength in upper extremities 5/5 bilaterally, sensory examination revealed intact light touch, pinprick and vibratory sensation. Reflexes 1+ in upper extremities, coordination finger to nose test within normal limits bilaterally. Alternating movements without significant changes bilaterally. Neck was supple.
LABORATORY: Showed sodium level 135, potassium 4.6, chloride 96, CO2 26,
BUN 39, creatinine 5.3, glucose level 138. White blood cell count was 7, hemoglobin 11, hematocrit 34, platelet count 77.
HOSPITAL COURSE: Patient was admitted after head trauma with multiple medical problems. His coumadin was held. Patient had cervical spine x-rays which showed definite narrowing of C5, C6 interspace, slight retrolisthesis at this level, prominent spurs at this level as well as above and below. CT scan on admission showed a moderate amount of scalp thinning with subcutaneous air overlying the left frontal lobe. A small area of left parenchymal hemorrhage adjacent to the right petros bone in the temporal lobe which most likely represents a hemorrhagic contusion. Repeated CT scan on 5/13/94 didn’t show any progressive changes. Patient remained in stable condition. He had hemodialysis q.o.d. He restarted treatment with Coumadin. His last PT was 11.9, PTT 31.
Patient refused before hemodialysis new blood tests. His condition remained stable.
DISCHARGE MEDICATIONS: Isordil 20 mgs p.o. t.i.d., Ferrous sulfate 325 mgs p.o. b.i.d., Ativan 0.5 mgs p.o. b.i.d., Lactulose 15 ccs p.o. b.i.d., Calcium carbonate 650 mgs p.o. b.i.d., Compazine 10 mgs p.o. t.i.d. prn nausea, Betoptic
0.5% OU b.i.d., Nephrocaps 1 p.o. qd, Pilocarpine 4% solution 1 gtt OU b.i.d.,
Coumadin 2.5 mgs p.o. qd, Tylenol 650 mgs p.o. q6 hours prn pain.
DISPOSITION/FOLLOW-UP:
Recommend follow PT/PTT. Patient is on coumadin and CBC with differential because patient has chronic anemia and thrombocytopenia.
Patient will be transferred to Anytown VA in stable condition on 5/19/94.
WORK COPY ========= UNOFFICIAL - NOT FOR MEDICAL RECORD ======== DO NOT FILE
SIGNATURE PHYSICIAN/DENTIST SIGNATURE APPROVING PHYSICIAN/DENTIST
One TIUProvider, MD Three TIUProvider, MS
PGY2 Resident Medical Internist
========================= CONFIDENTIAL INFORMATION =========================
D R A F T
JUN 26, 1996@17:36:02 ADDENDUM:
Routine visit today--no change to condition.
SIGNATURE PHYSICIAN/DENTIST SIGNATURE APPROVING PHYSICIAN/DENTIST
Three TIUProvider, MD
Medical Internist
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Progress Note Print
Use this option to print chart or work copies of progress notes.
Steps to use option:
1. Select Progress Note Print from the Print Document Menu.
2. Enter a patient name.
Select Print Document Menu Option: 2 Progress Note Print
Select PATIENT NAME: TIUPATIENT,ONE TIUPATIENT,ONE 09-12-44 666233456
YES
SC VETERAN
(2 notes) C: 05/28/96 12:37
(2 notes) W: 05/28/96 12:33
A: Known allergies
(2 notes) D: 05/28/96 12:36
Available notes: 02/17/96 thru 06/21/96 (31)
3. Enter the range of dates for progress notes you want to print.
4. Choose a note from those listed.
Please specify a date range from which to select notes:
List notes Beginning: 02/17/96// <Enter> (FEB 17, 1996)
Thru: 06/21/96// <Enter> (JUN 21, 1996)
1 06/21/96 11:40 Lipid Clinic Three TIUProvider,
Visit: 02/21/96
2 06/21/96 11:38 Social Work Service Three TIUProvider,
Visit: 04/18/96
3 06/07/96 00:00 Diabetes Education One TIUProvider, MD
Visit: 04/18/96
4 05/15/96 13:10 Addendum to Diabetes Education Seven TIUProvider
Visit: 02/21/96
5 04/24/96 15:41 Lipid Clinic Three TIUProvider,
Visit: 04/24/96
6 02/23/96 14:08 Diabetes Education Three TIUProvider,
Visit: 02/21/96
Choose notes: (1-6):3, 5
Do you want WORK copies or CHART copies? CHART// <Enter>
DEVICE: HOME// <Enter> VAX
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Progress Notes Print Example
-----------------------------------------------------------------------------
TIUPATIENT,ONE 666-23-3456 Progress Notes
-----------------------------------------------------------------------------
NOTE DATED: 06/07/96 17:51 DIABETES EDUCATION
ADMITTED: 07/22/95 11:06 1A
SUBJECT: Routine diabetes education
Patient understanding good.
Signed by: /es/ One TIUProvider, MD
Medical Internist 06/23/96 08:34
Analog Pager: 555-1213
Digital Pager: 555-1215
Cosigned by: /es/ TIUProvider,Six
06/23/96 08:34
Analog Pager: 555-1213
Digital Pager:555-1215
NOTE DATED: 04/24/96 08:00 ARTERIAL EVALUATION - LOWER EXTREMITY
VISIT: 04/17/92 08:00 FOURTEEN’S CLINIC
SUBJECT: Rule out embolus, lower extremity
AGE: 50
UNIT: General Medicine
REFERRING MD: Six TIUProvider
DIAGNOSIS: Rule out embolus
HISTORY: severe pedal edema, foot ulcers
OTHER: cyanosis
SYMPTOMS:
RESTING SYMPTOMS:
EXERTIONAL SYMPTOMS:
LESIONS:
MEDICATIONS:
RECORDED RECORDED
AUDIBLE DOPPLER SIGNAL RIGHT LEFT DOPPLER WAVEFORM: RIGHT LEFT
COMMON FEMORAL _____ _____ COMMON FEMORAL _____ _____
SUPERFICIAL FEMORAL _____ _____ PRE-EXERCISE _____ _____
POPLITEAL _____ _____ POST-EXERCISE _____ _____
POSTERIOR TIBIAL _____ _____ OTHER _____ _____
DORSALIS PEDIS _____ _____
N=NORMAL ABN=ABNORMAL O=ABSENT B=BIPHASIC
TRANSCUTANEOUS PO2 VALUES:
RIGHT LEFT
SUBCLAVICULAR ___40___ ___40___
ABOVE KNEE ___39___ ___40___
HIGH BK ___39___ ___40___
CALF ___37___ ___39___
ANKLE ___36___ ___39___
DORSUM OF FOOT ___22___ ___38___
OTHER ___18___ ___38___
Enter RETURN to continue or '^' to exit: <Enter>
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Progress Notes Print Example cont’d
-----------------------------------------------------------------------------
TIUPATIENT,ONE 666-23-3456 Progress Notes
-----------------------------------------------------------------------------
04/24/92 08:00 ** CONTINUED FROM PREVIOUS SCREEN **
40 =ADEQUATE FOR HEALING
39-30 =EQUIVOCAL FOR HEALING
29-0 =INADEQUATE FOR HEALING
SEGMENTAL SYSTOLIC BLOOD PRESSURE:
RIGHT INDEX LEFT INDEX
ARM ______________ ______________
HIGH THIGH ______________ ______________
ABOVE KNEE ______________ ______________
BELOW KNEE ______________ ______________
ANKLE PT ______________ ______________
DP ______________ ______________
EXERCISE RESPONSE:
MPH: 5 mph
MAXIMUM WALKING TIME: _10_ MIN _30_ SEC
SYMPTOMS: Pedal edema, cyanosis
MAXIMUM HEART RATE ACHIEVED:
TIME RIGHT INDEX LEFT INDEX ARM
1 MINUTE ____________ ____________ ____________
3 MINUTES ____________ ____________ ____________
5 MINUTES ____________ ____________ ____________
10 MINUTES ____________ ____________ ____________
15 MINUTES ____________ ____________ ____________
20 MINUTES ____________ ____________ ____________
POST EXERCISE:
IMPRESSIONS:
Signed by: /es/ Three TIUProvider, MD
Medical Internist 04/24/96 14:19
Analog Pager: 555-1213
Digital Pager: 555-1215
Enter RETURN to continue or '^' to exit: ^
1 Discharge Summary Print
2 Progress Note Print
3 Clinical Document Print
Select Print Document Menu Option: <Enter>
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Clinical Document Print
Use this option to print chart or work copies of all clinical documents available through
TIU.
Steps to use option:
1. Select Clinical Document Print from the Print Document Menu, and then enter a patient name.
Select Print Document Menu Option: 3 Clinical Document Print
Select PATIENT NAME: TIUPATIENT,ONE TIUPATIENT,ONE 09-12-44 666233456
YES
SC VETERAN
(2 notes) C: 05/28/96 12:37
(2 notes) W: 05/28/96 12:33
A: Known allergies
(2 notes) D: 05/28/96 12:36
Available documents: 02/17/92 thru 06/21/96 (34)
2. Enter a date range that documents will be chosen from.
Please specify a date range from which to select documents:
List documents Beginning: 02/17/92// 6/1/96 (JUN 01, 1996)
Thru: 06/21/96// 6/8/96 (JUN 08, 1996)
1 06/07/96 00:00 Diabetes Education One TIUProvider,
Visit: 04/18/96
2 06/05/96 17:23 Lipid Clinic Three TIUProvider,
Visit: 04/18/96
3 06/05/96 11:10 Addendum to Lipid Clinic Three TIUProvider,
Visit: 04/24/96
Choose the document or documents you would like printed, and whether you want work or chart copies.
Choose documents: (1-3): 1-3
Do you want WORK copies or CHART copies? CHART// <Enter>
DEVICE: HOME// PRINTER
4. The document(s) will then be printed at the device you specify.
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Search for Selected Documents
Use this option to generate a list of selected documents based on extended search criteria
(e.g., status, search category, and reference date range).
Steps to use option:
1. Select Search for Selected Documents from the MIS Manager Menu.
2. Select the status of the documents you want to view (completed, unsigned, amended, etc.).
Select Text Integration Utilities (MIS Manager) Option: Search for Selected
Documents
Select Status: COMPLETED// UNV unverified
3. Select the type of documents you want to view (progress notes, discharge summary, etc.).
Select CLINICAL DOCUMENTS Type(s): All Discharge Summary, Progress Notes,
Addendum
4. To make your search more specific, select one or more categories for the documents you want to view:
All Categories
Author
Patient Title
Problem Transcriptionist
Division Expected Cosigner Service
Treating Specialty Hospital Location Subject
Visit
Select SEARCH CATEGORIES: AUTHOR//
SERVICE
Select SERVICE: MEDICINE
5. To limit the search even further, specify a time period for the documents you want to view:
Start Reference Date [Time]: T-7//T-30
Ending Reference Date [Time]: NOW// <Enter>
Searching for the documents....
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Search for Selected Documents, cont’d
6. After the documents are displayed, you can choose one of the actions listed below
(amend, browse, delete, etc.) to perform on one or more of the documents.
UNVERIFIED Documents Jun 09, 1997 10:11:11 Page: 1 of 1
by ALL CATEGORIES from 04/10/97 to 06/09/97 4 documents
Patient Document Ref Date Status
1 TIUPATIENT (T3456) Addendum to Discharge Summary 06/05/97 unverified
2 TIUPATIENT (T3456) Addendum to Discharge Summary 06/05/97 unverified
3 TIUPATIENT (T3456) Addendum to Discharge Summary 06/04/97 unverified
4+ TIUPATIEN (T3456) Discharge Summary 05/25/97 unverified
+ Next Screen - Prev Screen ?? More Actions >>>
Find Delete Document Browse
On Chart Reassign Print
Edit Send Back Change View
Verify/Unverify Detailed Display Quit
Amend Document
Select Action: Quit// v=3 Verify/Unverify
Opening Addendum record for review...
Verify Document Jun 09, 1997 10:11:46 Page: 1 of 33
Addendum
TIUPATIENT,ONE 666-12-3456 2B Visit Date: 09/21/95@10:00
DICT DATE: JUN 04, 1997 ENTRY DATE: JUN 05, 1997@16:10:02
DICTATED BY: TIUPROVIDER,ONE ATTENDING: TIUPROVIDER,THREE
URGENCY: routine STATUS: UNVERIFIED
DIAGNOSIS:
1. Status post head trauma with brain contusion.
2. Status post cerebrovascular accident.
3. End stage renal disease on hemodialysis.
4. Coronary artery disease.
5. Congestive heart failure.
6. Hypertension.
7. Non insulin dependent diabetes mellitus.
+ + Next Screen - Prev Screen ?? More actions
Find Verify/Unverify
Print Quit
Select Action: Next Screen// v Verify/Unverify
Do you want to edit this Discharge Summary? NO//
<Enter>
VERIFY this Discharge Summary? NO// y YES
Discharge Summary VERIFIED.
Refreshing the list.
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Correcting Documents that are Entered in Error
Reassigning signed documents is restricted to the “Chief, MIS User Class.” This includes notes that are awaiting a co-signature. If the document is completely unsigned, users who are Author/Dictator or users with proper authorization may reassign it.
Besides reassigning a note to a different patient, admission, or visit, the reassign action may be used to promote an Addendum as an Original, swap the Addendum and the
Original, change a discharge summary to an Addendum.
The basic reassign process includes the following steps:
1. Electronic signature challenge. If the document is already signed, TIU asks for the electronic signature of the Chief of MIS.
2. Retract. If the document is moved to a different patient, TIU retracts the document.
3. Re-edit original visit. If necessary, the PCE information is updated for the original visit.
4. Edit destination visit. If necessary, PCE information is collected or revised for the new visit.
5. Sign. The original provider needs to sign the document. If the document was moved to a different patient, TIU removes the original signature.
In the following example, an unsigned note is transferred from one patient to another:
Select OPTION NAME: TIU MAIN MENU MGR Text Integration Utilities (MIS Manager)
--- MIS Managers Menu ---
1 Individual Patient Document
2 Multiple Patient Documents
3 Print Document Menu ...
4 Search for Selected Documents
5 Statistical Reports ...
6 Unsigned/Uncosigned Report
7 Missing Text Report
8 Missing Text Cleanup
9 Signed/unsigned PN report and update
10 UNKNOWN Addenda Cleanup
11 Missing Expected Cosigner Report
11 Missing Expected Cosigner Report
12 Mark Document as 'Signed by Surrogate'
13 Mismatched ID Notes
14 TIU 215 ANALYSIS ...
15 Transcription Billing Verification Report
Select Text Integration Utilities (MIS Manager) Option: 1 Individual Patient Do cument
Select PATIENT NAME: TIUPATIENT,E
1 TIUPATIENT,ELEVEN 4-2-44 666568765 YES NON-SERVICE
CONNEC
TED THIS IS A TEST
2 TIUPATIENT,TWENTY 4-1-48 666090934 NO NON-SERVICE
CONNECTED
CHOOSE 1-4: 2 TIUPATIENT,TWENTY 4-1-48 666090934 NO NON-
SERVICE CO
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Correcting Documents that are Entered in Error cont’d
NNECTED THIS IS A TEST
(1 note ) C: 03/16/99 10:20
Available documents: 11/23/1998 thru 01/19/2001 (19)
Please specify a date range from which to select documents:
List documents Beginning: 11/23/1998// <Enter> (NOV 23, 1998)
Thru: 01/19/2001// <Enter> (JAN 19, 2001)
1 01/19/2001 10:27 Infection Control TIUPROVIDER,O
Visit: 01/26/1999
2 12/30/2000 16:00 + Discharge Summary TIUPROVIDER,T
Adm: 12/25/2000 Dis: 12/30/2000
3 11/01/2000 14:00 Discharge Summary TIUPROVIDER,T
Adm: 04/19/2000 Dis: 11/01/2000
4 04/24/2000 00:00 Discharge Summary TIUPROVIDER,T
Choose one or more documents: (1-4):1
Browse Document Jan 19, 2001 10:33:50 Page: 1 of 1◄
Infection Control
TIUPATIENT,NINE 666-09-2591 AUDIOLOGY AND SPE Visit Date: 01/26/1999 17:50
◄
DATE OF NOTE: JAN 19,2001@10:27:57 ENTRY DATE: JAN 19,2001@10:27:58
AUTHOR: TIUPROVIDER,SEVEN EXP COSIGNER:
URGENCY: STATUS: UNSIGNED
Pt is very sick...
+ Next Screen - Prev Screen ?? More actions
Find On Chart Reassign
Print Amend Send Back
Edit Delete Quit
Verify/Unverify
Select Action: Quit// R Reassign
Are you sure you want to REASSIGN this Infection Control? NO// Y YES
Please choose the correct PATIENT and CARE EPISODE:
Select PATIENT NAME: TIUPATIENT,N
1 TIUPATIENT,NINE *SENSITIVE* *SENSITIVE* NO EMPLOYEE THIS
IS A TEST
2 TIUPATIENT,NINE 1-1-65 666344321 YES SC VETERAN THIS
IS A TEST
CHOOSE 1-2: 2 TIUPATIENT,NINE 1-1-65 666344321 YES SC VETERAN
THIS IS A TEST
(1 note ) W: 09/15/98 08:29
A: Known allergies
Enrollment Priority: GROUP 1 Category: IN PROCESS End Date:
This patient is not currently admitted to the facility...
Is this note for INPATIENT or OUTPATIENT care? OUTPATIENT// <Enter>
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Correcting Documents that are Entered in Error cont’d
The following SCHEDULED VISITS are available:
1> AUG 20, 1999@08:00 NINE CLINIC
2> JUL 30, 1999@09:00 NINE CLINIC
3> JUL 29, 1999@09:15 NINE CLINIC
4> JUN 03, 1999@13:00 NINE CLINIC
5> JUL 22, 1997@09:00 INPATIENT APPOINTMENT SIX CLINIC
CHOOSE 1-5, or
<U>NSCHEDULED VISITS, <F>UTURE VISITS, or <N>EW VISIT
<RETURN> TO CONTINUE
OR '^' TO QUIT: 2 JUL 30 1999@09:00
Enter/Edit PROGRESS NOTE...
Patient Location: NINE CLINIC
Date/time of Visit: 07/30/99 09:00
Date/time of Note: 01/19/01 10:27
Author of Note: TIUPROVIDER,SEVEN
...OK? YES//
AUTHOR/DICTATOR: TIUPROVIDER,SEVEN//
Infection Control Reassigned.
Press RETURN to continue...
Select PATIENT NAME:
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Rescinding Advance Directives
Patch TIU*1*261 supports Imaging patch MAG*3.0*121. The two patches are being released in a combined release, with TIU*1*261 requiring MAG*3.0*121. Patch
MAG*3.0*121 provides the ability to watermark images "RESCINDED".
Patch TIU*1*261 permits an authorized user to rescind an Advance Directive document by changing the title to RESCINDED ADVANCE DIRECTIVE.
MAG*3.0*121 takes it from there and watermarks any linked images
"RESCINDED".
NOTE: Exact title names are required
Exact title names are required. The title of the Advance Directive to be rescinded must be ADVANCE DIRECTIVE
The title it is changed to when it is being rescinded must be
RESCINDED ADVANCE DIRECTIVE
Both LOCAL and National Standard titles must be as above. Variations on either title will cause the Change Title action to fail to watermark images as rescinded.
These exact titles are required by policy. See the VHA HANDBOOK 1004.02 section on
Advance Directives: http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=2042
Example
Select OPTION NAME: TIU MAIN MENU MGR Text Integration Utilities (MIS
Manager) menu
Select Text Integration Utilities (MIS Manager) Option: 1 Individual Patient
Document
Select PATIENT NAME: CPRSPATIENT,TWO
(1 notes) D: 12/20/2002 09:07
Enrollment Priority: GROUP 3 Category: IN PROCESS End Date:
Available documents: 12/17/1998 thru 01/10/2012 (231)
Please specify a date range from which to select documents:
List documents Beginning: 12/17/1998// 01/10/11 (JAN 10, 2011)
Thru: 01/10/2012// (JAN 10, 2012)
1 01/10/2012 11:44 ADVANCE DIRECTIVE CPRSPROVIDER,ONE
Adm: 12/20/2002 Dis:
One document found within date range...
Opening ADVANCE DIRECTIVE record for review...
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Browse Document Jan 10, 2012@11:52:57 Page: 1 of 1
ADVANCE DIRECTIVE
CPRSPATIENT,TWO 666-54-8668 1A(1&2) Adm: 12/20/2002 Dis:
STANDARD TITLE: ADVANCE DIRECTIVE
DATE OF NOTE: JAN 10, 2012@11:44:13 ENTRY DATE: JAN 10, 2012@11:44:13
AUTHOR: CPRSPROVIDER,ONE EXP COSIGNER:
URGENCY: STATUS: UNSIGNED
DNR URGENCY: STATUS: COMPLETED
VistA Imaging - Scanned Document
*** SCANNED DOCUMENT ***
SIGNATURE NOT REQUIRED
Electronically Filed: 06/23/2011 by: CPRSPROVIDER, ONE
+ Next Screen - Prev Screen ?? More actions >>>
Find Sign/Cosign Link ...
Print Copy Encounter Edit
Edit Identify Signers Interdiscipl'ry Note
Make Addendum Delete Quit
Select Action: Quit// ct CT
TITLE: ADVANCE DIRECTIVE// RESCINDED ADVANCE DIRECTIVE TITLE
Std Title: RESCINDED ADVANCE DIRECTIVE
...OK? Yes// (Yes)
The title of this note will be changed to RESCINDED ADVANCE DIRECTIVE and linked images will be watermarked 'RESCINDED'. OK? NO// YES
Title changed; Image queued for watermarking.
Press RETURN to continue...
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Statistical Reports
Use this menu to produce statistical reports for line counts and timeliness by Author,
Transcriptionist, or Service.
NOTE: These reports are designed for a margin width of 132.
Option
TRANSCRIPTIONIST Line Count
Statistics
Description
This option allows generation of statistical reports of line counts and timeliness data by transcriptionist (or the person who entered the document).
SERVICE Line Count Statistics
AUTHOR Line Count Statistics
This option allows generation of statistical reports of line counts and timeliness data by SERVICE
(e.g., Medical Service, Surgical Service, Psychiatry
Service, etc.).
This option allows generation of statistical reports of line counts and timeliness data by AUTHOR (or
Dictating practitioner).
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TRANSCRIPTIONIST Line Count Statistics
DISCHARGE SUMMARY Line Count Statistics by TRANSCRIPTIONIST - ISC-SLC-A4
JUN 27,1996 09:51 PAGE 1
Line
Transcriber Count Ref Date Patient Disch-Dict Dict-Transcr Transcr-Sign Sign-
Cosign
-------------------------------------------------------------------------------------------------------------
BS 0 JUN 19,1996 TIUPATIENT,SEVEN 0
Discharg
73 JUN 11,1996 TIUPATIENT,FIVE 1
Discharg
78 MAY 31,1996 TIUPATIENT,SEVEN 7 1
Discharg
72 MAR 25,1996 TIUPATIENT,EIGHT 1 0 0
Discharg
78 MAR 24,1996 TIUPATIENT,NINE -1 1 0 0
Discharg
73 MAR 23,1996 TIUPATIENT,ELEVE 1 0 0
Discharg
73 FEB 12,1996 TIUPATIENT,ONE 84 2
Discharg
80 FEB 8,1995 TIUPATIENT,TWELV 0 44
0 Discharg
96 FEB 8,1995 TIUPATIENT,ELEVE 0 44 0
Discharg
-------- --- --- --- ---
SUBTOTAL 623 90 7 88 0
SUBCOUNT 9 3 9 5 5
SUBMEAN 69.22 30.00 0.78 17.60
DP 1 JAN 10,1996 TIUPATIENT,FIVE 1004 0 0 0
Discharg
-------- --- --- --- ---
SUBTOTAL 1 1004 0 0 0
SUBCOUNT 1 1 1 1 1
SUBMEAN 1.00 1004.00
SBW 0 MAY 25,1996 TIUPATIENT,SEVEN 1
Discharg
-------- --- --- --- ---
SUBTOTAL 0 1 0 0
SUBCOUNT 1 0 1 0 0
SUBMEAN 1.00 jg 0 FEB 12,1996 TIUPATIENT,ONE 97 0
Addendum
-------- --- --- --- ---
SUBTOTAL 97 0 0 0
SUBCOUNT 1 1 1 0 0
SUBMEAN 97.00
-------- --- --- --- ---
TOTAL 624 1191 8 88 0
COUNT 12 5 12 6 6
MEAN 52.00 238.20 0.67 14.67 0.00
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Line Count Statistics by AUTHOR
DISCHARGE SUMMARY Line Count Statistics by AUTHOR - ISC-SLC-A4 JUN 27,1996 09:53 PAGE 1
Line
Author Count Ref Date Patient Disch-Dict Dict-Transcr Transcr-Sign Sign-Cosign
---------------------------------------------------------------------------------------------------------------
TIUPROVIDER,T 0 FEB 12,1996 TIUPATIENT,ONE 97 0 Addendum
-------- --- --- --- ---
SUBTOTAL 97 0 0 0
SUBCOUNT 1 1 1 0 0
SUBMEAN 97.00
TIUPROVIDER,O 0 JUN 19,1996 TIUPATIENT,SEV 0 Discharg
73 JUN 11,1996 TIUPATIENT,TWO 1 Discharg
78 MAY 31,1996 TIUPATIENT,SEV 7 1 Discharg
72 MAR 25,1996 TIUPATIENT,NIN 1 0 0 Discharg
78 MAR 24,1996 TIUPATIENT,SEV -1 1 0 0 Discharg
73 MAR 23,1996 TIUPATIENT,ELE 1 0 0 Discharg
73 FEB 12,1996 TIUPATIENT,ONE 84 2 Discharg
-------- --- --- --- ---
SUBTOTAL 447 90 7 0 0
SUBCOUNT 7 3 7 3 3
SUBMEAN 63.86 30.00 1.00
TIUPROVIDER,S 80 FEB 8,1995 TIUPATIENT,TWE 0 44 0 Discharg
96 FEB 8,1995 TIUPATIENT,THI 0 44 0 Discharg
-------- --- --- --- ---
SUBTOTAL 176 0 0 88 0
SUBCOUNT 2 0 2 2 2
SUBMEAN 88.00 44.00
TIUPROVIDER,F 1 JAN 10,1996 TIUPATIENT,ONE1004 0 0 0 Discharg
-------- --- --- --- ---
SUBTOTAL 1 1004 0 0 0
SUBCOUNT 1 1 1 1 1
SUBMEAN 1.00 1004.00
TIUPROVIDER,E 0 MAY 25,1996 TIUPATIENT,EIG 1 Discharg
-------- --- --- --- ---
SUBTOTAL 0 1 0 0
SUBCOUNT 1 0 1 0 0
SUBMEAN 1.00
-------- --- --- --- ---
TOTAL 624 1191 8 88 0
COUNT 12 5 12 6 6
MEAN 52.00 238.20 0.67 14.67 0.00
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Line Count Statistics by SERVICE
DISCHARGE SUMMARY Line Count Statistics by SERVICE - ISC-SLC-A4 JUN 27,1996 09:42 PAGE 1
Line
Service Count Ref Date Patient Disch-Dict Dict-Transcr Transcr-Sign Sign-Cosign
------------------------------------------------------------------------------------------------------------
MEDICINE 0 JUN 19,1996 TIUPATIENT,SEV 0 Discharg
73 JUN 11,1996 TIUPATIENT,TWO 1 Discharg
78 MAY 31,1996 TIUPATIENT,SEV 7 1 Discharg
80 FEB 8,1995 TIUPATIENT,ELE 0 44 0 Discharg
96 FEB 8,1995 TIUPATIENT,TWE 0 44 0 Discharg
-------- --- --- --- ---
SUBTOTAL 327 7 2 88 0
SUBCOUNT 5 1 5 2 2
SUBMEAN 65.40 7.00 0.40 44.00
SURGERY 0 FEB 12,1996 TIUPATIENT,ONE97 0 Addendum
1 JAN 10,1996 TIUPATIENT,S1004 0 0 0 Discharg
-------- --- --- --- ---
SUBTOTAL 1 1101 0 0 0
SUBCOUNT 2 2 2 1 1
SUBMEAN 0.50 550.50
-------- --- --- --- ---
TOTAL 328 1108 2 88 0
COUNT 7 3 7 3 3
MEAN 46.86 369.33 0.29 29.33 0.00
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Unsigned/Uncosigned Report
Lists detailed document information such as author, patient, patient SSN, etc. for notes with no signature and/or cosignature. Optionally, a summary report can be generated showing the number of unsigned and uncosigned documents in each service.
In the following example, a summary report is generated for all divisions:
Select Text Integration Utilities (MIS Manager) Option: 6 Unsigned/Uncosigned
Report
Select division: ALL// <Enter>
Please specify an Entry Date Range:
Start Entry Date: T-180 (AUG 08, 2003)
Ending Entry Date: T (FEB 04, 2004)
Select service: ALL// <Enter>
Select one of the following:
F FULL
S SUMMARY
Type of Report: S SUMMARY
DEVICE: HOME// <Enter> ANYWHERE
Unsigned and Uncosigned Documents Aug 08, 2003 thru Feb 04, 2
004@23:59:59Page 1
PRINTED: for SALT LAKE CITY HCS
FEB 04, 2004@09:16
------------------------------------------------------------------------------
Totals for Service: IRM--- UNSIGNED: 1 UNCOSIGNED: 0
Totals for Division: SALT LAKE CITY HCS--- UNSIGNED: 1 UNCOSIGNED: 0
Enter RETURN to continue or '^' to exit:
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Missing Text Report
This report lists TIU Documents that do not have any report text, are missing the 0 node of the text node, or both cases. The report results have the following categories:
Missing Text Only. This means the note has a 0 TEXT node, but no text (and this can be fine depending on the status of the document, such as undictated).
Missing 0 Node Only. This means the note has text but no 0 TEXT node.
Missing 0 node & Text. This means the note doesn't have a 0 TEXT node or text.
This cause of this condition is unknown and has only been reported from a few sites.
Nevertheless, this report should be run by all sights. If any missing text documents are found, refer to the discussion under Missing Text Cleanup below for guidance.
The report can be run as often as needed to track the occurrences of documents without text and missing the 0 text node. It is advised to run the report on a regular interval (once per week or month) to track an increase or decrease of reported documents missing text or the 0 text node.
A delimited form of the report can be provided for users who want to put the report into a spreadsheet program.
In the following example a report is generated starting June 1, 2004:
Select Text Integration Utilities (MIS Manager) Option: ?
1 Individual Patient Document
2 Multiple Patient Documents
3 Print Document Menu ...
4 Search for Selected Documents
5 Statistical Reports ...
6 Unsigned/Uncosigned Report
7 Missing Text Report
8 Missing Text Cleanup
9 Signed/unsigned PN report and update
10 UNKNOWN Addenda Cleanup
11 Missing Expected Cosigner Report
Enter ?? for more options, ??? for brief descriptions, ?OPTION for help text.
Select Text Integration Utilities (MIS Manager) Option: 7 Missing Text Report
START WITH REFERENCE DATE: Jan 01, 2003//jun 1, 2004 (JUN 01, 2004)
GO TO REFERENCE DATE: Mar 04, 2005// <Enter> (MAR 04, 2005)
Would you like a delimited report? NO// <Enter>
DEVICE: HOME// <Enter> ANYWHERE
Searching...
Date range searched: Jun 01, 2004 - Mar 04, 2005
# of Records:
Searched 1074
Missing Text Only 1
Missing 0 Node Only 0
Missing 0 node & Text 4
----
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Total 5
Elapsed Time: 0 minute(s) 0 second(s)
Current User: CPRSPROVIDER,SEVEN
Current Date: Mar 04, 2005@15:08:43
Doc # Entry Date/Time Title
Missing Reference Date/Time Patient
Status Signature Date/Time Author/Dictator
------ ------------------- ---------------
28476 Jun 04, 2004@13:09:06 MRS TEST NOTE
0/Text Jun 04, 2004@13:08 CPRSPATIENT,TWO(3213)
COMPLETED Jun 04, 2004@13:12:08 CPRSPROVIDER,FIVE
28481 Jun 04, 2004@13:54:45 H&P GENERAL MEDICINE
0/Text Jun 04, 2004@13:54 CPRSPATIENT,FIVE(8828)
COMPLETED Jun 04, 2004@13:57:22 CPRSPROVIDER,FIVE
28520 Jun 04, 2004@13:54:47 GENERAL MEDICINE
0/Text Jun 04, 2004@13:54 CPRSPATIENT,ONE(8846)
COMPLETED Jun 04, 2004@13:57:23 CPRSPROVIDER,SEVEN
28522 Jun 04, 2004@14:02:49 H&P GENERAL MEDICINE
Text Jun 04, 2004@14:02 CPRSPATIENTFEMALE,EIGHT(8662)
COMPLETED Jun 04, 2004@14:03:43 CPRSPROVIDER,FIVE
29498 Jan 18, 2005@11:34:16 PRIMARY CARE NOTE
0/Text Jan 18, 2005@11:33 CPRSPATIENT,THREE(6626)
COMPLETED Jan 18, 2005@11:37:34 CPRSPROVIDER,TWO
Press RETURN to continue...:
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Missing Text Cleanup
Note: The TIU MISSING TEXT REPORT should be run prior to running the cleanup. Refer to the documentation on the previous page for
TIU MISSING TEXT REPORT for cause and frequency to run that report.
This is a utility designed to help clean up TIU documents with no text. Before using this utility, a number of other things should be tried. They are:
NO TEXT in DOCUMENT body with no attached addendum or image, document may or may not have the "TEXT" 0 node as indicated by the report. Delete or retract the document (based upon status); no disclaimer is needed.
If the "TEXT" 0 node is missing as indicated by the report and the document has text: o For direct entry documents, contact author to make an addendum to the note and add the missing information. Sites may determine the allowable timeframe to permit the author entering the addendum with the missing information. If the author is no longer at the site or the timeframe has passed, the HIMS Manager or designee should enter an addendum with the following disclaimer:
"DISCLAIMER: This completed document contains missing text that was electronically deleted in error" o For uploaded documents, contact the transcription company to re-upload if possible or contact the author to make an addendum to the note and add the missing information.
The cleanup utility retracts documents within a date range that meet certain criteria. The criteria are:
Document may be of any type, including ADDENDUM with a STATUS of
UNCOSIGNED/COMPLETED/AMENDED
Document must fall within user entered date range
Document must NOT have the "TEXT",0 node
Document must NOT have any TEXT
Document must NOT have any addenda ("DAD" cross-reference)
Document must NOT have any components ("ADI" cross-reference)
An informational alert is sent once the cleanup process is finished.
In the following example, the cleanup process is run for documents in a one month period:
Select Text Integration Utilities (MIS Manager) Option: ?
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1 Individual Patient Document
2 Multiple Patient Documents
3 Print Document Menu ...
4 Search for Selected Documents
5 Statistical Reports ...
6 Unsigned/Uncosigned Report
7 Missing Text Report
8 Missing Text Cleanup
9 Signed/unsigned PN report and update
10 UNKNOWN Addenda Cleanup
11 Missing Expected Cosigner Report
Enter ?? for more options, ??? for brief descriptions, ?OPTION for help text.
Select Text Integration Utilities (MIS Manager) Option: 8 Missing Text Cleanup
START WITH REFERENCE DATE: Jan 01, 2003//jun1, 2004 (JUN 01, 2004)
GO TO REFERENCE DATE: Mar 04, 2005//jul1, 2004 (JUL 01, 2004)
Requested Start Time: NOW// (MAR 04, 2005@16:02:37)
Your task # is: 165564
Press RETURN to continue...:
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UNKNOWN Addenda Cleanup
Prior to the release of TIU*1*187 it was possible to leave surgery addenda unconnected to their associated operation report. The UNKNOWN addenda Cleanup menu option is provided in TIU*1*173 to assist in cleaning up these unattached addenda.
In the following example an unknown addenda is attached to a surgery case:
--- MIS Managers Menu ---
1 Individual Patient Document
2 Multiple Patient Documents
3 Print Document Menu ...
4 Search for Selected Documents
5 Statistical Reports ...
6 Unsigned/Uncosigned Report
7 Missing Text Report
8 Missing Text Cleanup
9 Signed/unsigned PN report and update
10 UNKNOWN Addenda Cleanup
11 Missing Expected Cosigner Report
12 Mark Document as 'Signed by Surrogate'
13 Mismatched ID Notes
14 TIU 215 ANALYSIS ...
15 Transcription Billing Verification Report
Select Text Integration Utilities (MIS Manager) Option: 9 UNKNOWN Addenda
Cleanup
START WITH REFERENCE DATE: Jan 01, 2003// <Enter> (JAN 01, 2003)
GO TO REFERENCE DATE: Apr 04, 2005// <Enter> (APR 04, 2005)
Searching for the documents..
TIU/Surgery Cleanup Apr 04, 2005@08:48:53 Page: 1 of 1
UNKNOWN ADDENDA from Jan 01, 2003 to Apr 04, 2005
Patient Doc IEN Entry DT Status Parent
1 CPRSPATIENT,T (C5525) 2194 09/29/04 UNSIGNED NO
2 CPRSPATIENT,T (C5525) 2236 10/14/04 UNSIGNED NO
3 CPRSPATIENT,T (C5525) 2238 10/14/04 UNSIGNED NO
You may select more than one document by using #-# or #,# notation.
The parent document may be
Browse Change View
Detailed Display Find Parent
Select Action: Quit// F Find Parent
Select Document(s): (1-3) 3
START WITH REFERENCE DATE: Jan 01, 2003// <Enter> (JAN 01, 2003)
GO TO REFERENCE DATE: Apr 04, 2005// <Enter> (APR 04, 2005)
Searching for the documents...
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Operation Reports Apr 04, 2005@08:49:04 Page: 1 of 1
OPERATION REPORTS from Jan 01, 2003 to Apr 04, 2005
Patient Doc IEN Entry DT Status Case #
1 CPRSPATIENT,T (C5525) 2181 09/17/04 RETRACTED #90
2 CPRSPATIENT,T (C5525) 2182 09/20/04 RETRACTED #89
3 CPRSPATIENT,T (C5525) 2192 09/28/04 RETRACTED #90
4 CPRSPATIENT,T (C5525) 2195 09/29/04 COMPLETED #89
5 CPRSPATIENT,T (C5525) 2237 10/14/04 RETRACTED #90
6 CPRSPATIENT,T (C5525) 2284 01/20/05 UNVERIFIED #90
7 CPRSPATIENT,T (C5525) 2292 01/28/05 UNDICTATED #109
Enter ?? for more actions
Browse Change View
Detailed Display Attach to Parent
Select Item(s): Quit// 4
Select Action: Attach to Parent// <Enter>
Attach the following UNKNOWN Addenda:
TIU
Doc No. Patient Entry DT/Time Status Parent
----------------------------------------------------------------------------
2238 CPRSPATIENT,T (C5525) 10/14/04@11:56:14 UNSIGNED None to the following OPERATION REPORT?
TIU Surgical
Doc No. Patient Entry DT/Time Status Case No.
---------------------------------------------------------------------------
2195 CPRSPATIENT,T (C5525) 09/29/04@08:18:39 COMPLETED #89
Do you wish to begin attaching? NO// Y YES
Attaching #2238 to #2195 ... success!
Press <RETURN> to continue
Note: Be sure to verify any addenda before attaching to a parent document. Many addenda are duplicates of the original
Operation Report and may be deleted once they are verified as
UNSIGNED copies.
Only one document may be selected as the potential parent to the previously selected addenda.
Users may NOT attach addenda to a parent OPERATION REPORT with a different patient or an OPERATION REPORT whose ENTRY DATE/TIME falls after the addenda.
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Once a parent document has been selected, a confirmation screen will display the selected addenda and parent information and prompt the user to begin attaching the documents.
After the utility attempts to associate the addenda with a parent Operation Report the user will be returned to the initial List Manager display with successful associations being listed under the "Parent" column showing the TIU Document number of the parent that has been assigned. These documents will no longer appear once the current session is closed or a new search is initiated via the CHANGE VIEW option.
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Missing Expected Cosigner Report
List detailed document information for notes that have a status of “uncosigned” where the expected cosigner field is either null, 0 or -1. Users will have a choice of 3 different report formats: an 80 column standard report, a 132 column extended report and a “^” delimited report for use in exporting the data to Excel. The 80 column report will include
Patient Name (initials and last 4 of SSN), Entry Date/Time, Author, Title, and the Note
IEN. The 132 column report and the “^” delimited report will include Patient Name
(initials and last 4 of SSN), Entry Date/Time, Author, Title, Author’s Service/Section,
Author’s Job Title and the Note IEN. In either case if the document is an Addendum then the parent’s Document Type, Entry Date/Time and Expected Cosigner will also be displayed.
The cause of the problem is being fixed in CPRS patch OR*3.0*215. Users should review the notes displayed on this report to determine who should be the expected cosigner and then enter the expected cosigner. Once a note is signed the software doesn't permit editing so they will need to use FileMan. The author of the note may need to be contacted to determine who should be the expected cosigner.
In addition this report may be setup in Taskman to be run nightly. The entry point for this is NITE^TIU189. This task will look for notes missing an expected cosigner and send an email to the mail group TIU MIS ALERTS. This email will include Patient Name (initials and last 4 of SSN), Entry Date/Time, Author, Title, Author’s Service/Section, Author’s
Job Title, Note IEN and if the note is an addendum the parent’s Document Type, Entry
Date/Time and Expected Cosigner.
Example 80 column report:
Select Text Integration Utilities (MIS Manager) Option: 11 Missing Expected
Cosigner Report
START WITH REFERENCE DATE: Jan 01, 2003//1/1/2005 (JAN 01, 2005)
GO TO REFERENCE DATE: Jun 28, 2005// (JUN 28, 2005)
DEVICE: HOME// TCP
NOTES WITH 'UNCOSIGNED' STATUS THAT DON'T HAVE AN EXPECTED COSIGNER
Patient Entry Date/Time Title Author Note IEN
------- --------------- ----- ------ --------
XXX1234 JUN 28, 2005@09:24:44 UROLOGY NO SHOW TIUAUTHOR,ONE 4957352
XXX1235 JUN 28, 2005@09:36:20 Addendum TIUAUTHOR,TWO ~4957353
Parent Document Type: UROLOGY NO SHOW NOTE
Parent Document Date: JUN 28, 2005@09:24:44
Parent Document Cosigner:
XXX1236 JUN 28, 2005@10:16:21 PROGRESS NOTE TIUAUTHOR,THREE ~4957355
Enter RETURN to continue or '^' to exit:
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Example 132 column report:
Select Text Integration Utilities (MIS Manager) Option: 11 Missing Expected Cosigner Report
START WITH REFERENCE DATE: Jan 01, 2003//1/1/2005 (JAN 01, 2005)
GO TO REFERENCE DATE: Jun 28, 2005// (JUN 28, 2005)
DEVICE: HOME// TCP
NOTES WITH 'UNCOSIGNED' STATUS THAT DON'T HAVE AN EXPECTED COSIGNER
Patient Entry Date/Time Title Author Service/Section Job Title Note IEN
------- --------------- ----- ------ --------------- --------- --------
XXX1234 JUN 28, 2005@09:24:44 UROLOGY NO SHOW TIUAUTHOR,ONE CHIEF OF STAFF SUPERVISOR, PHYS ~4957352
XXX1235 JUN 28, 2005@09:36:20 Addendum TIUAUTHOR,TWO CHIEF OF STAFF SUPERVISOR, PHYS ~4957353
Parent Document Type: UROLOGY NO SHOW NOTE
Parent Document Date: JUN 28, 2005@09:24:44
Parent Document Cosigner:
Enter RETURN to continue or '^' to exit:
Example “^” delimited report (lines are truncated for this example):
Select Text Integration Utilities (MIS Manager) Option: 11 Missing Expected
Cosigner Report
START WITH REFERENCE DATE: Jan 01, 2003//1/1/2005 (JAN 01, 2005)
GO TO REFERENCE DATE: Jun 28, 2005// (JUN 28, 2005)
DEVICE: HOME// TCP
Patient Name^Entry Date/Time^Title^Author^Service/Section^Job Title^Note …
XXX1234^JUN 28, 2005@09:24^UROLOGY NO SHOW^TIUPROVIDER,ONE^PHYSICIAN^SUPERV…
YYY5678^JUL 01, 2005@19:14^PROGRESS NOTE^TIUPROVIDER,TWO^NURSE^SUPERIVOR^84…
Example email message:
Subj: MISSING EXPECTED COSIGNER [#440685] 02/08/06@13:14 11 lines
From: XXXX In 'IN' basket. Page 1
--------------------------------------------------------------------
PATIENT: ABC1234
ENTRY DATE/TIME: JAN 10, 2006@15:34:21
NOTE TITLE: Addendum
AUTHOR: TIUAUTHOR,ONE
AUTHOR'S SERVICE/SECTION: CHIEF OF STAFF
AUTHOR'S TITLE: SUPERVISOR, PHYSICAL MEDICINE
NOTE IEN: `1234567
PARENT DOCUMENT TYPE: ANESTHESIA POST OP NOTE
PARENT DOCUMENT ENTRY DATE: JAN 09, 2006@16:25:47
PARENT DOCUMENT COSIGNER:
Enter message action (in IN basket):
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Mark Documents ‘Signed by Surrogate’
This option allows documents needing an Additional Signer, where the additional signature was signed by a surrogate of the Additional Signer, to be marked as “Signed By
Surrogate.” This should not be needed for documents signed after patch TIU*1.0*199 is installed.
Example:
Select OPTION NAME: TIU MAIN MENU MGR Text Integration Utilities (MIS
Manager)
--- MIS Managers Menu ---
1 Individual Patient Document
2 Multiple Patient Documents
3 Print Document Menu ...
4 Search for Selected Documents
5 Statistical Reports ...
6 Unsigned/Uncosigned Report
7 Missing Text Report
8 Missing Text Cleanup
9 Signed/unsigned PN report and update
10 UNKNOWN Addenda Cleanup
11 Missing Expected Cosigner Report
12 Mark Document as 'Signed by Surrogate'
13 Mismatched ID Notes
14 TIU 215 ANALYSIS ...
15 Transcription Billing Verification Report
Select Text Integration Utilities (MIS Manager) Option: 12 Mark Document as
'Signed by Surrogate'
Select ADDITIONAL SIGNER: PAGETT,OTTIS OAP 116 HEALTH TECHNICIAN
START WITH REFERENCE DATE: Jan 01, 2003//3/1/1998 (MAR 01, 1998)
GO TO REFERENCE DATE: Jul 18, 2005//4/1/1998 (APR 01, 1998)
SEQ PATIENT DOCUMENT TYPE REFERENCE DATE
--- ------- ------------- --------------
1 BIGBEE,DARREN L (B0181) DOMICILIARY CARE SECTION MAR 12, 1998@09:52:21
ENTER SEQUENCE # TO MARK AS 'SIGNED BY SURROGATE', 'NEW' FOR A NEW SEARCH,
OR '^' TO QUIT:
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Mismatched ID Notes
The option TIU MISMATCHED ID NOTES is under the TIU MAIN MENU MGR, and it runs a routine that will report/fix mismatched interdisciplinary (ID) notes. There are cases where a child ID note points to a parent ID note and that parent ID note is for a different patient. There are also cases where the GDAD cross reference links a child ID note to a parent ID note when in fact the child does not point to the parent. In these cases the situation will be reported/fixed. If it is found that there is a child ID note pointing to a parent that may not be an ID note, this will be reported but not fixed.
When this report is run in Report Only mode the report looks like the first example.
When this report is run in Report and Fix mode the report looks like the second example.
When this report is run in either Report Only mode or in Report and Fix mode an email will be sent to the PSI-06-030 mail group on Forum. This email will contain ONLY the site, the date, the report mode and the result totals. No patient data of any kind is sent.
The purpose of this is to track the extent of this problem. Note that the emails do not report the count of: CHILD ID NOTES POINTING TO A PARENT THAT MAY NOT
BE AN ID NOTE.
Example of Report Only mode:
MISMATCHED INTERDISCIPLINARY NOTES
CHILD DOCUMENT PARENT DOCUMENT
--------------- --------------
Patient: TIUPATIENT,ONE (P1234) TIUPATIENT,TWO (P5678)
Title: INTERDISCIPLINARY PATIENT EDUCATI PM&R KT
Entry DT: JAN 21, 1998@15:28:27 FEB 01, 1996@14:16:10
Author: TIUAUTHOR,ONE TIUAUTHOR,ONE
Note IEN: 345678 123456
CHILD ID NOTES POINTING TO A NON-EXISTENT PARENT ID NOTE
Patient: TIUPATIENT,THREE (P9876)
Title: CARDIAC REHAB DAILY
Entry DT: APR 28, 2003@07:43:49
Author: TIUAUTHOR,TWO
Child IEN: 3300852
Parent IEN: 3200408
CHILD ID NOTES POINTING TO A PARENT THAT MAY NOT BE AN ID NOTE
** NOTE: THIS IS AN INFORMATIONAL LIST FOR INVESTIGATION.
NOTHING WILL BE FIXED **
Patient: TIUPATIENT,FOUR (J0222)
Parent Title: OPERATION REPORT-IEN: 1734321
Parent Entry DT: FEB 03, 2006@12:43:49
Parent Author: TIUAUTHOR,THREE
Child Title: NURSE INTRAOPERATIVE REPORT-IEN: 1734320
Patient: TIUPATIENT,FOUR (J0222)
Parent Title: TELEPHONE CONTACT-IEN: 1734512
Parent Entry DT: JUN 26, 2006@10:42:25
Parent Author: TIUAUTHOR,FOUR
Child Title: ECU ADL SELF CARE PERFORMANCE SUMMARY-IEN: 1734511
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TOTAL COUNTS FOR MISMATCHED ID NOTES
------------------------------------
1173 CROSS REFERENCES CHECKED
1 MISS MATCHED NOTE(S) FOUND
1 NON EXISTENT PARENT NOTE(S)
2 PARENT MAY NOT BE AN ID NOTE
Example of Report and Fix mode:
MISMATCHED INTERDISCIPLINARY NOTES
CHILD DOCUMENT PARENT DOCUMENT
--------------- --------------
Patient: TIUPATIENT,ONE (P1234) TIUPATIENT,TWO (P5678)
Title: INTERDISCIPLINARY PATIENT EDUCATI PM&R KT
Entry DT: JAN 21, 1998@15:28:27 FEB 01, 1996@14:16:10
Author: TIUAUTHOR,ONE TIUAUTHOR,ONE
Note IEN: 345678 123456
..... Removed pointer from child to parent.
Patient: TIUPATIENT,THREE (P4321) TIUPATIENT,FOUR (P8746)
Title: PRIME CARE CLINIC PATIENT/FAMILY EDUCATION DOC
Entry DT: FEB 04, 2003@10:33:48
Author: TIUAUTHOR,TWO
Note IEN: 3100784 3000597
... Child note did not point to parent. GDAD cross reference removed
CHILD ID NOTES POINTING TO A NON-EXISTENT PARENT ID NOTE
Patient: TIUPATIENT,FIVE (P2233)
Title: OTP DOSING NOTE
Entry DT: APR 28, 2003@07:54:47
Author: TIUAUTHOR,THREE
Child IEN: 3300864
Parent IEN: 3200349
... Child note did not point to parent. GDAD cross reference removed.
Patient: TIUPATIENT,SIX (P4567)
Title: PM&R PT DISCHARGE
Entry DT: JAN 29, 2004@15:26:57
Author: TIUAUTHOR,FOUR
Child IEN: 4000224
Parent IEN: 4000522
..... Removed pointer from child to parent removed.
CHILD ID NOTES POINTING TO A PARENT THAT MAY NOT BE AN ID NOTE
** NOTE: THIS IS AN INFORMATIONAL LIST FOR INVESTIGATION.
NOTHING WILL BE FIXED **
Patient: TIUPATIENT,SEVEN (J0202)
Parent Title: OPERATION REPORT-IEN: 1834321
Parent Entry DT: FEB 03, 2006@12:43:49
Parent Author: TIUAUTHOR,FIVE
Child Title: NURSE INTRAOPERATIVE REPORT-IEN: 1784320
Patient: TIUPATIENT,EIGHT (P2539)
Parent Title: TELEPHONE CONTACT-IEN: 1734552
Parent Entry DT: JUN 26, 2006@10:42:25
Parent Author: TIUAUTHOR,SIX
Child Title: ECU ADL SELF CARE PERFORMANCE SUMMARY-IEN: 1734555
TOTAL COUNTS FOR MISMATCHED ID NOTES
------------------------------------
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1173 CROSS REFERENCES CHECKED
2 MISS MATCHED NOTE(S) FOUND
2 NON EXISTENT PARENT NOTE(S)
2 PARENT MAY NOT BE AN ID NOTE
1 POINTER(S) FIXED FOR MISMATCHED NOTES
1 XREF(S) FIXED FOR MISMATCHED NOTES
1 POINTER(S) FIXED FOR MISSING NOTES
1 XREF(S) FIXED FOR MISSING NOTES
Example of email sent to G.PSI-06-030 in report only mode:
Site Number^Site Name
AUG 31, 2006@15:24:09
1173 CROSS REFERENCES CHECKED
9 MISMATCHED NOTE(S) FOUND
7 NON EXISTENT PARENT NOTE(S)
MODE - REPORT ONLY
Example of email sent to G.PSI-06-030 in report and fix mode:
Site Number^Site Name
AUG 31, 2006@15:24:09
1173 CROSS REFERENCES CHECKED
9 MISMATCHED NOTE(S) FOUND
7 NON EXISTENT PARENT NOTE(S)
MODE - REPORT AND FIX
5 POINTER(S) FIXED FOR MISMATCHED NOTES
4 XREF(S) FIXED FOR MISMATCHED NOTES
3 POINTER(S) FIXED FOR MISSING NOTES
4 XREF(S) FIXED FOR MISSING NOTES
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TIU 215 ANALYSIS
A problem has been found with VistA patch TIU*1.0*215, released June 28, 2007. One of the intents of this patch was to only allow editing/amending etc. from the Surgery package to keep the Surgery file (#130) and TIU files in sync. This was for the Nurse
Intraoperative Report (NIR) and the Anesthesia Report only. However, if surgery personnel made changes to a surgery case using one of the case editors such as OSS
Operation (Short Screen) [SROMEN-OUT], they were asked if they wanted to create an addendum. After installation of TIU*1.0*215, the addendum was not created for viewing via the Surgery Tab in CPRS, however, the data was being updated in the Surgery application files.
A new option, TIU 215 ANALYSIS, is set up with installation of patch TIU*1.0*231 and is being added as sequence 14 to the TIU MAIN MENU MGR option.
TIU MAIN MENU MGR Text Integration Utilities (MIS Manager)
TIU 215 ANALYSIS ...
A ANALYZE POTENTIAL SURGERY TIU PROBLEMS
V VIEW SINGLE SURGERY CASE USING CASE #
T SEND ANALYSIS OUTPUT TO TEXT FILE
Option A - Analyze Potential Surgery TIU Problems:
Allows for the analysis process (which was run during the installation of this patch) to be run again. Surgery cases will be analyzed within a particular date range and the information from NIR and/or Anesthesia reports will be compared to their corresponding
TIU notes. If the information does not match, the case number will be recorded as one that needs to be reviewed. The information generated by this option should be printed, either by cutting and pasting the results into a text file, or you can simply print the MM that was generated during installation. It can be used to identify which TIU records have addenda and which do not. This is extremely important as how a comparison is handled depends directly on if the TIU record has addenda. It can also be used as a checklist, to make sure that every record in question is examined.
Option V - View the Contents of a Surgery Case Using Case #:
Views the content of a Surgery Case file (#130). NIR data will be displayed followed by the Anesthesia data.
Option T - Send Output To Text File:
Sends output to a Host text file on your production account's server. This will be very useful for sites that have a large number of cases to review. Microsoft Word can then be used to compare the text files, which is extremely helpful because discrepancies are automatically highlighted, thus expediting the comparison process.
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Option T Overview:
Option T will send data from both Surgery and TIU to respective output files. First, the user is prompted for a path to send output files to which should look something like this:
USER$:[<directory name>] . You may need to coordinate with your local IRM VistA system administrator to determine exactly what the path should be. The user is then prompted for three filenames; one for Surgery output, one for TIU output, and one for associated TIU addenda. If the path and/or filenames are invalid you will be prompted to enter them again.
Option T will use the same analysis technique as Option A does. Instead of just listing cases that need review, it will write the contents of the associated reports to text files. For each case, what is on record in Surgery will be written to one file, and what is on record in TIU will be written to another file. Also, if there are any associated TIU addenda with the case, these addendums will be written to a separate file. Multiple cases will be written to a single file, with the user pre-defining the maximum limit. When this limit is encountered, a new set of output files will be created. For instance, if there are a total of
50 cases found with possible discrepancies, and the user sets a maximum of 25 cases per file, then 2 Surgery output files will be created, two TIU output files, and x number of addenda output files. Note: The number of Surgery and TIU files will always be the same; the number of addenda files may not. This is due to the fact not every Surgery case will have an associated TIU addenda). Let's say the names "Surgery", "TIU", and "ADDENDA" are used for the output filenames. You would then have: Surgery1.txt, Surgery2.txt,
TIU1.txt, TIU2.txt, and ADDENDA1.txt (and possibly ADDENDA2.txt), each with 25 cases per file.
**********IMPORTANT*****************IMPORTANT*****************
NOTE!!!! The host files created in option T contains Patient Information and should only be sent to a server within the system boundary of the VA. The directory must be password protected. If you are going to download to a pc and use the Microsoft Word
Compare feature for analysis, it must be a VA approved encrypted PC. Both the host files and the files downloaded to the pc must be destroyed by an approved means when analysis/correction is complete. When the files are destroyed the systems manager, official, or the ISO should be notified they have been destroyed.
**********IMPORTANT*****************IMPORTANT*****************
CORRECTION PROCESS
The following manual fix process is provided by the Surgery Enterprise Product
Support(EPS) personnel:
The Surgery ADPAC should review the reports. Health Information Management (HIM) personnel should also be involved in this process. If the programmer feels comfortable in restoring the data in the Surgery package to what it was originally, then the programmer can, with the help of the Surgery ADPAC do it, but we would encourage the site to enter a Surgery Remedy ticket, and we will step the site through the process.
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The programmer would edit the fields in the Surgery Case file (#130) that should be restored to their original data using FileMan enter/edit.
For the NIR, once the cases that need fixing are restored to their original data set(see examples one and two), one of the circulating nurses listed in the case, with the assistance of the Surgery ADPAC, should use the Surgery package to put the changes back into the cases and sign the addenda (see Options used to reenter the data in Surgery).
Similarly for the Anesthesia Report, once the cases that need fixing are restored to their original data set (see examples one and two), the anesthetist with the assistance of the
Surgery ADPAC, should use the Surgery package to put the changes back into the cases and sign the addenda (see Options used to reenter the data in Surgery).
Example ONE using FileMan:
Step One:
Select OPTION: 1 ENTER OR EDIT FILE ENTRIES
INPUT TO WHAT FILE: SURGERY//
EDIT WHICH FIELD: ALL// ANESTHESIA TECHNIQUE (multiple)
EDIT WHICH ANESTHESIA TECHNIQUE SUB-FIELD: ALL//
THEN EDIT FIELD:
Select SURGERY PATIENT: `30536 GLTLPLN,TJXSS HAIXY 08-18-07
TOE X-XX-XX XXXXXXXXX YES SC VETERAN GJ
Select ANESTHESIA TECHNIQUE: GENERAL// @
SURE YOU WANT TO DELETE THE ENTIRE 'G' ANESTHESIA TECHNIQUE? Y (Yes)
Select ANESTHESIA TECHNIQUE:
Step Two:
THEN IN SURGERY ADD THE GENERAL ANESTHESIA TECHNIQUE BACK IN
USING ONE OF THE SURGERY OPTIONS LISTED IN THE SECTION "OPTIONS
USED TO RE-ENTER DATA IN SURGERY".
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Example TWO using FileMan:
TIU HAS "CLEAN" FOR WOUND CLASSIFICATION BUT SURGERY HAS
"CONTAMINATED"
STEP ONE:
Select OPTION: 1 ENTER OR EDIT FILE ENTRIES
INPUT TO WHAT FILE: SURGERY//
EDIT WHICH FIELD: ALL// WOUND CLASSIFICATION
THEN EDIT FIELD:
Select SURGERY PATIENT: `30506 NANNIE,ETHAN HAIXY 12-31-06 BAD FINGER
X-XX-XX XXXXXXX YES SC VETERAN GJ
WOUND CLASSIFICATION: CONTAMINATED// CLEAN
1 CLEAN
2 CLEAN/CONTAMINATED
Choose 1-2: 1 CLEAN
STEP TWO:
NOW REENTER 'CONTAMINATED' IN SURGERY USING ONE OF THE OPTIONS
USED TO RE-ENTER DATA INTO SURGERY AND IT WILL GENERATE AN
ADDENDUM FORTIU
***Options used to reenter the data in Surgery.***
NIR REPORT
OSS Operation (Short Screen)
NR Nurse Intraoperative Report
ANESTHESIA REPORT
AR Anesthesia Report
PAC Enter PAC(U) Information
M Medications (Enter/Edit)
For those sites that use the Anesthesia Report, the following list of fields create an addendum to the NIR.
Sub-file
Other Scrubbed Assistant(s)
Other Scrubbed Assistant(s)
O.R. Circulating Nurse(s)
O.R. Circulating Nurse(s)
O.R. Scrub Nurse(s)
O.R. Scrub Nurse(s)
Field
Other Scrubbed Assistant
Comments
O.R. Circulating Nurse
Educational Status
O.R. Scrub Nurse
Educational Status
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Other Persons in O.R.
Other Persons in O.R.
Position(s)
Position(s)
Restraints and Position Aids
Restraints and Position Aids
Restraints and Position Aids
Principal CPT Modifier
Other Procedures Performed
Other Procedures Performed
Other Procedures Performed
Tourniquet
Tourniquet
Tourniquet
Tourniquet
Tourniquet
Thermal Unit
Thermal Unit
Thermal Unit
Thermal Unit
Prosthesis Installed
Prosthesis Installed
Prosthesis Installed
Prosthesis Installed
Prosthesis Installed
Prosthesis Installed
Prosthesis Installed
Prosthesis Installed
Prosthesis Installed
Prosthesis Installed
Medications
Medications
Medications
Medications
Medications
Medications
Medications
Irrigation Solution(s)
Irrigation Solution(s)
Irrigation Solution(s)
Irrigation Solution(s)
Blood Replacement Fluids
Blood Replacement Fluids
Blood Replacement Fluids
Blood Replacement Fluids
Blood Replacement Fluids
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Other Person in O.R
Title/Organization
Position
Placed
Restraint/Position Aid
Applied By
Comment
CPT Modifier
Other Procedure
CPT Code
CPT Modifier
Time Applied
Time Released
Site Applied
Pressure Applied (in TORR)-
Applied By
Thermal Unit
Temperature
Time On
Time Off
Item
Sterility Checked
Sterility Expiration Date
RN Verifier
Vendor
Model
Lot/Serial Number
Sterile Resp
Size
Quantity
Medication
Time Administered
Route
Dose
Ordered By
Administered By
Comments
Irrigation Solution
Time Utilized
Amount
Provider
Replacement Fluid Type
Quantity (ml)-
Source Identification
VA Identification
Comments
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Laser Unit(s)
Laser Unit(s)
Laser Unit(s)
Laser Unit(s)
Laser Unit(s)
Laser Unit(s)
Cell Saver(s)
Cell Saver(s)
Cell Saver(s)
Cell Saver(s)
Cell Saver(s)
Cell Saver(s)
Cell Saver(s)
Cell Saver(s)
Anesthesia Technique(s)
Anesthesia Technique(s)
Anesthesia Technique(s)
Anesthesia Technique(s)
Laser Unit/ID
Duration
Wattage
Operator
Plume Evacuator
Comments
Cell Saver ID
Operator
Amount Salvaged (ml)-
Amount Reinfused (ml)-
Comments
Disposables Name
Lot Number
Quantity
Anesthesia Technique
Principal Technique
Anesthesia Agent
Dose (mg)-
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Transcription Billing Verification Report
This report can be run by division and provides information on all transcriptionists or one or more selected transcriptionists. It reports based on an entered date range. Since the VBC Line
Count is only calculated for transcribed reports, it does not report on any document transcribed before the patch was installed.
The accuracy of this report depends on the accuracy of the data. Specifically, it depends on whether transcriptionists are reliably recorded in the header of each document. If you choose to use this report, you should follow the directions in the Text Integration Utilities (TIU) Line
Count (TIU*1*250) Release Notes available from the VA Document Library
( http://www4.va.gov/vdl/ ) to insure that each uploaded document has the needed data.
This example is a complete report for all facilities on the local VistA system for the month of
August:
--- MIS Managers Menu ---
1 Individual Patient Document
2 Multiple Patient Documents
3 Print Document Menu ...
4 Search for Selected Documents
5 Statistical Reports ...
6 Unsigned/Uncosigned Report
7 Missing Text Report
8 Missing Text Cleanup
9 Signed/unsigned PN report and update
10 UNKNOWN Addenda Cleanup
11 Missing Expected Cosigner Report
12 Mark Document as 'Signed by Surrogate'
13 Mismatched ID Notes
14 TIU 215 ANALYSIS ...
15 Transcription Billing Verification Report
<CPM> Select Text Integration Utilities (MIS Manager) Option: 15 Transcription
Billing Verification Report
--- Transcription Billing Verification Report ---
In this example, these company
Select division: ALL// <Enter> names have been entered into
Specific Transcriptionist(s)? NO// YES the New Person file and marked
Select Transcriptionist(s): as belonging to the
1) ?? transcriptionist user class.
Choose from:
INCORPORATED,ASCOTT TRANSCRIPTION ATI TRANSCRIPTION SERVICE
MEDTRAN,INC MTI TRANSCRIPTION SERVICE
Please choose a KNOWN Transcriptionist (Duplicates not allowed).
1) ASCOTT INCORPORATED,ASCOTT TRANSCRIPTION ATI
TRANSCRIPTION SERVICE
2) MEDTRAN,INC MTI TRANSCRIPTION SERVICE
3) <Enter>
Start Transcription Date [Time]: Jan 01, 2010// 1/1/09 (JAN 01, 2009)
Ending Transcription Date [Time]: Jan 31, 2010@23:59// <Enter> (JAN 31,
2010@23:59)
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DEVICE: HOME// <Enter> TELNET PORT
Page 1
These are the initials
================================================================================ of the transcriptionist
CAMP MASTER as taken from the for Documents Transcribed: 01/01/2009 to 01/31/2010 Printed: 05/05/2010 11:18
New Person file.
Tran Date Title Patient Aut VBC Lines
================================================================================ ati 07/31/09 Discharge Summary BCMA,ELEVEN-PATIENT (0011) JER 56.25
07/31/09 Discharge Summary BCMA,ONE-PATIENT (0001) JER 56.31
----------
Total for Transcriber ati = 112.56 mti 07/23/09 Discharge Summary EIGHTY,INPATIENT (0880) JER 55.91
07/23/09 Discharge Summary BCMA,FIFTEEN-PATIEN (0015) JER 57.31
----------
Total for Transcriber mti = 113.22 tlc 08/13/09 Discharge Summary BCMA,EIGHTYTHREE-PA (0083) JER 55.91
08/27/09 Discharge Summary NINETYEIGHT,OUTPATI (0698) JER 55.91
08/27/09 Discharge Summary CPRS,COMBATVET T (0000) JER 55.91
08/27/09 Discharge Summary FIVEHUNDREDELEVEN,P (0511) JER 55.91
Enter RETURN to continue or '^' to exit:
Page 2
================================================================================
T R A N S C R I P T I O N B I L L I N G R E P O R T
CAMP MASTER for Documents Transcribed: 01/01/2009 to 01/31/2010 Printed: 05/05/2010 11:18
Tran Date Title Patient Aut VBC Lines
================================================================================
12/03/09 OPERATION REPORT BCMA,EIGHT (0008) JER 1.40
----------
Total for Transcriber tlc = 225.04
----------
Total for Division = 450.82
Press RETURN to continue or '^' to exit:
Page 3
================================================================================
T R A N S C R I P T I O N B I L L I N G R E P O R T
CINCINNATI for Documents Transcribed: 01/01/2009 to 01/31/2010 Printed: 05/05/2010 11:18
Tran Date Title Patient Aut VBC Lines
================================================================================ tlc 07/24/09 Discharge Summary BCMA,EIGHTYSIX-PATI (0086) BA 56.54
----------
Total for Transcriber tlc = 56.54
----------
Total for Division = 56.54
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Press RETURN to continue or '^' to exit:
Page 4
================================================================================
T R A N S C R I P T I O N B I L L I N G R E P O R T
SUMMARY for ZZ ALBANY-PRRTP for Documents Transcribed: 01/01/2009 to 01/31/2010 Printed: 05/05/2010 11:18
================================================================================
Category Documents VBC Lines
================================================================================
Division Totals
CAMP MASTER 9 450.82
CINCINNATI 1 56.54
Transcriber Totals
ati 2 112.56
mti 2 113.22
tlc 6 281.58
Station Totals
ZZ ALBANY-PRRTP 10 507.36
Press RETURN to continue or '^' to exit: <Enter>
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Chapter 6: TIU for Transcriptionists
Enter/Edit Discharge Summary
Enter Document
Upload Menu
List Documents for Transcription
Review/Edit Document
Transcription Billing Verification Report
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Chapter 6: TIU for Transcriptionists
Transcriptionists typically enter Providers’ discharge summaries, progress notes, or other documents:
1. directly from dictation, or
2. from uploaded transcribed ASCII documents in batch mode a. from remote microcomputers, using ASCII or KERMIT protocol upload, or b. from Host Files (i.e., DOS or VMS ASCII files) on the host system.
Options on this menu can be assigned accordingly.
Transcriptionist Menu
Option Name Description
Enter/Edit Discharge Summary
This option lets you enter or edit discharge summaries and progress notes directly online. If the transcriptionist holds the AUTOVERIFY security key, each discharge summary will be verified automatically when the transcriptionist releases it.
Enter/Edit Document
This option lets you enter/edit clinical documents directly online.
Upload Menu ...
This menu includes options to upload batches of documents, and to get help on the header formats for the various documents which have been defined for upload by your site.
List Documents for
Transcription
Review/Edit Document
Transcription Billing
Verification Report
Gets all UNDICTATED and UNTRANSCRIBED
Documents for review, edit, and signature.
Allows the user to interactively review, edit, and/or print documents.
This option produces a report for the verification of transcription bills, using the Visible Black Character counting method described in VHA Directive 2008-042.
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Enter/Edit Discharge Summary
Use this option to enter and edit discharge summaries directly online.
Steps to use option:
1. Select Enter/Edit Discharge Summary from the Transcriptionist Menu.
--- Transcriptionist Menu ---
1 Enter/Edit Discharge Summary
2 Enter/Edit Document
3 Upload Menu ...
4 List Documents for Transcription
5 Review/Edit Documents
6 Transcription Billing Verification Report
Select Text Integration Utilities (Transcriptionist) Option: 1 Enter/Edit
Discharge Summary
2. Enter a patient’s name and choose an Admission from the choices offered.
Select Patient: TIUPATIENT,ONE TIUPATIENT,ONE 09-12-44 666233456 YES SC
VETERAN
For Patient TIUPATIENT,ONE
The following ADMISSION is available:
1> JUL 22, 1995@11:06 DIRECT TO: 1A
CHOOSE 1-1: 1 JUL 22 1991@11:06
Patient: TIUPATIENT,ONE SSN: 666-23-3456 Sex: MALE
Race: MEXICAN AMERICAN Age: 52 Claim #: UNKNOWN
Adm Date: 12/22/96 Ward: 1A
Dis Date: 02/12/97
Adm Dx: Stage IV non-Hodgkin’s Lymphoma
Correct VISIT? YES// <Enter>
The attending must not be a provider that
URGENCY: routine// <Enter> routine
AUTHOR/DICTATOR: TIUPROVIDER,ONE ot requires a cosignature,
DICTATION DATE: <Enter> (FEB 12, 1997)
ATTENDING PHYSICIAN: TIUPROVIDER,ONE ot
Calling text editor, please wait...
1>DIAGNOSIS:
2> and must be in User
Class PROVIDER (or a subclass).
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Enter/Edit Discharge Summary cont’d
3>
4>
5>
6>OPERATIONS/PROCEDURES:
EDIT Option: 1
1>DIAGNOSIS:
Replace : With : Lymphoma Replace
DIAGNOSIS: Lymphoma
Edit line: 6
6>OPERATIONS/PROCEDURES:
Replace : With : Chemotherapy Replace
OPERATIONS/PROCEDURES: Chemotherapy
Edit line: <Enter>
The text editor brought up a boilerplate template used for Discharge
Summaries; entries are added after the colons.
EDIT Option: <Enter>
Save changes? YES// <Enter>
Saving Discharge Summary with changes...
Is this Discharge Summary ready to release from DRAFT? YES// n NO
NOT RELEASED.
You may enter another Discharge Summary. Press RETURN to exit.
Select PATIENT NAME: <Enter>
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Enter/Edit Document
This option allows the transcriptionist to enter a new document (using a document title from the TIU document definition hierarchy) or to review, verify, send back to transcription, reassign, or print an existing document. The option produces a list of document definition types using search criteria such as status, search category, and reference date range, from which you select a document.
Steps to use option:
1. Select Enter/Edit Document from the Transcriptionist Menu.
Select Text Integration Utilities (Transcriptionist) Option: 2
Enter/Edit Document
Select AUTHOR: TIUPROVIDER,THREE TIUPROVIDER,THREE TT
2. Enter a patient’s name and choose the admission from the choices offered.
Select Patient:TIUPATIENT,SEVEN TIUPATIENT,SEVEN 04-25-31
666042591P NO MILITARY RETIREE
(1 note ) C: 11/30/95 17:36
(2 notes) W: 09/16/96 15:12 (addendum 09/18/96 09:53)
A: Known allergies
(1 note ) D: 11/30/95 17:38
For Patient TIUPATIENT,SEVEN
Select DOCUMENT TYPE: discharge summary TITLE
The following ADMISSION(S) are available:
1> MAY 28, 1996@15:58 A/C TO: 1A
2> MAY 28, 1996@15:51 DIRECT TO: 1A
3> MAY 22, 1996@17:41 DIRECT TO: 1A
4> DEC 22, 1994@17:27 DIRECT TO: 1A
5> DEC 22, 1994@17:22 DIRECT TO: 2B
CHOOSE 1-5
<RETURN> TO CONTINUE
OR '^' TO QUIT: 1 MAY 28 1996@15:58
Patient: TIUPATIENT,SIX SSN: 666-04-2591P Sex: MALE
Race: AMERICAN INDIAN OR ALASKA NA Age: 65 Claim #: UNKNOWN
Adm Date: 05/28/96 Ward: 1A
Adm Dx: TEST
Correct VISIT? YES// <Enter>
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Enter/Edit Document, cont’d
3. Enter the urgency (if routine, press Enter), author/ dictator, dictation date, and attending physician.
URGENCY: routine// <Enter> routine
AUTHOR/DICTATOR: TIUPROVIDER,THREE TIUPROVIDER,THREE TT
DICTATION DATE: 9/30 (SEP 30, 1996)
ATTENDING PHYSICIAN: TIUPROVIDER,ONE TIUPROVIDER,ONE TO
PGY2 RESIDENT
4. Your preferred editor appears (with boilerplate if any has been set up for this title) and you can now enter the text for this discharge summary.
Calling text editor, please wait...
1>DIAGNOSIS:
2>
3>
4>
5>
6>OPERATIONS/PROCEDURES:
EDIT Option: 2
2>
Replace <space> With diabetes retinopathy Replace
diabetes retinopathy
Edit line: <Enter>
EDIT Option: <Enter>
Save changes? YES// <Enter>
Saving Discharge Summary with changes...
Is this Discharge Summary ready to release from DRAFT? YES// <Enter>
Discharge Summary Released.
Chart copy queued.
You may enter another Discharge Summary. Press RETURN to exit.
Select PATIENT NAME:
<Enter>
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Upload Menu
The Upload Menu contains options that allow the transcriptionist to upload a batch of clinical documents.
Option Name
Upload Documents
Help for Upload Utility
Description
This option lets transcriptionists upload transcribed ASCII documents in batch mode, either from remote microcomputers, using ASCII or KERMIT protocol upload, or from Host Files (i.e., DOS or VMS ASCII files) on the host system. Your site may define the preferred file transfer protocol and the destination within V
IST
A to which each report type (e.g., discharge summary, progress notes, Operative Report, etc.) should be routed.
This option displays information on the formats of headers for dictated documents that are transcribed off-line and uploaded into V
IST
A. It also displays “blank” character, major delimiter, and end of message signal as defined by your site.
The upload utility permits mixed report types within a single batch. This allows the transcriptionist to enter each report in arrival sequence into a single ASCII file on the remote computer (e.g., using a proprietary word-processing program), and to transmit the text to the V
IST
A host system as a one-step process. As this ASCII data arrives at the
V
IST
A
host, it is read into a “buffer” file, and stored for subsequent “filing” by a special background process, called the “Router/filer.”
The Router/filer is queued upon completion of transmission of a given batch of reports, and will proceed to “read” each line of the buffer file, looking for a header. When a header is encountered, the filer will determine whether the record corresponds to a known report type, as defined by your site, and if so, it will attempt to direct the record to the appropriate file and fields in V
IST
A.
On occasion, the Router/filer will not be able to identify the appropriate record in the target file, and will, therefore, be unable to file the record. When this happens, the process will leave the record in the buffer file and send an alert to the user who invoked the upload utility, and to a group of users identified by the site as being able to respond to such filing errors.
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Upload Menu cont’d
When any of the alert recipients chooses to act on one of these alerts (by entering “VA” at any menu prompt, and choosing the alert on which they wish to act), they will be shown the header of the failed record, and allowed to inquire to the patient record, before being presented with their preferred V
IST
A editor, and will then be allowed to edit the buffer (e.g., correct a bad social security number, admission date, etc.) and retry the filer.
With each attempt to correct the buffered data and retry the filer, all alerts associated with that batch will be deleted (and if the condition remains uncorrected, re-sent), until all records in the batch are successfully filed.
Batch Upload Reports
Kermit Protocol Upload
If your site is using the upload option to transfer batches of discharge summaries from a remote computer using the Kermit transfer protocol, start the upload process by following the sequence below:
1. Choose UP from your Upload Menu.
You are currently logged into DIVISION: SALT LAKE CITY HCS
If a hospital location cannot be determined for an uploaded document, the document's division may be loaded with your log-in division.
1 Upload Documents
2 Help for Upload Utility
Select Upload Menu Option: UP Batch upload reports
K E R M I T U P L O A D
Now start a KERMIT send from your system.
Starting KERMIT receive.
#N3
Note: When entering the Upload Menu you receive a warning which specifies which division you are logged into. If division information is not explicitly available in the header, then it uses division information from your most current login. To change this division without re-logging in, you can use the
XUSER DIV CHG option from the TBOX menu.
2. When you see the #N3 prompt, initiate the Kermit file transfer from your
computer. Try the default settings for the Kermit protocol as provided by your terminal emulation software. If you have problems, consult your terminal emulator user manual or contact your local IRM Service.
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3. When the transfer is complete, you’ll see this message:
File transfer was successful. (1515 bytes)
Filer/Router Queued!
Press RETURN to continue...<Enter>
1 Upload Documents
2 Help for Upload Utility
Select Upload menu Option: <Enter>
ASCII Protocol Upload
If your site is using the upload option to transfer batches of discharge summaries from a remote computer using the ASCII transfer protocol, start the upload process by following the example shown below:
1. Choose UP from your Upload Menu.
1 Upload Documents
2 Help for Upload Utility
Select Upload menu Option: UP Batch upload reports
A S C I I U P L O A D
Note: If you are at a site that uses multiple divisions, you will receive a warning at this time specifying which division you are logged into. If division information is not explicitly available in the header, then it uses division information from your most current login. To change this division without re-logging in, you can use the XUSER DIV CHG option from the TBOX menu.
2. When the “Initiate upload procedure:” prompt appears, initiate the ASCII file
transfer from your computer.
NOTE: If you have problems, consult your local IRM Service to see if the Terminal and Protocol Set-up parameters have been set up as shown in the Implementation and Maintenance Section of the TIU Technical Manual, or check the user manual for your terminal emulator.
Initiate upload procedure:
$HDR: DISCHARGE SUMMARY
>PATIENT NAME: TIUPATIENT,ONE
>SOC SEC NUMBER: 666-12-1212
>ADMISSION DATE: 02/20/93
>DISCHARGE DATE: 02/25/93
>DICTATED BY: TIUPROVIDER,TWO
>DICTATION DATE: 02/26/93
>ATTENDING PHYSICIAN: TIUPROVIDER,TEN
>TRANSCRIPTIONIST ID: T1212
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>URGENCY: PRIORITY
>DIAGNOSIS:
>1. Acute pericarditis.
>2. Status post transmetatarsal amputation, left foot.
>3. Diabetes mellitus requiring insulin.
>4. Diabetic neuropathy.
>
>Operations/Procedures performed during current admission:
>1. Status post transmetatarsal amputation of left foot on 3/17/93.
>2. Echocardiogram done 3/17/93.
.
.
.
$END
Filer/Router Queued!
Press RETURN to continue...<Enter>
Handling upload errors
ASCII PROTOCOL UPLOAD / WITH ALERT:
1 Upload Documents
2 Help for Upload Utility
UPLOAD PROCESS (555972453) Failed: LOOKUP FAILED
Enter "VA VIEW ALERTS to review alerts
Select Upload menu Option: VA View Alerts
1. UPLOAD PROCESS (555972453) Failed: LOOKUP FAILED
Select from 1 to 1
or Enter ?, A, I, P, M, R, or ^ to exit: 1
The header of the failed record looks like this:
$HDR: DISCHARGE SUMMARY
PATIENT NAME: TIUPATIENT,ONE
SOCIAL SECURITY NUMBER: 666-09-1244P
DATE OF ADMISSION: 11/17/95
DATE OF DISCHARGE:
DICTATED BY: TIUPROVIDER,TWENTY
DICTATION DATE: 4/16/96
ATTENDING PHYSICIAN: TIUPROVIDER,ONE
TRANSCRIPTIONIST: C7689
URGENCY: PRIORITY
$TXT
Inquire to patient record? YES// <Enter>
Select PATIENT: TIUPATIENT,ONE 09-12-44 666091244P TO VETERAN
The following admissions are available:
(dcs indicates a Discharge Summary exists)
09-12-44 812091244P SC VETERAN
1 TIUPATIENT,ONE Adm: 07/22/95 Dis: 10/28/92 Open
2 TIUPATIENT,ONE Adm: 10/28/95 Dis: 10/28/92 Open
3 TIUPATIENT,ONE Adm: 11/16/92 Dis: Open
CHOOSE 1-3: 3
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ASCII PROTOCOL UPLOAD / WITH ALERT (cont’d)
Patient: TIUPATIENT,ONE SSN: 666-09-1244P Sex: MALE
Ward: 1A Race: Age: 48
Att Phys: TIUPROVIDER,EIGHT Prim Phys: TIUPROVIDER,EIGHT
Adm Date: 11/16/95
Adm Dx: ILL
Select PATIENT: <Enter>
You may now edit the buffered upload data.. . .
(Press PF1 then H for help)
==[ WRAP ]==[ INSERT ]===========< >============================
$HDR: DISCHARGE SUMMARY
PATIENT NAME: TIUPATIENT,ONE
SOCIAL SECURITY NUMBER: 666-09-1244P
DATE OF ADMISSION: 11/16/95 = Cursor to this point and change the 7 to a 6,
then
DATE OF DISCHARGE: Enter <PF1>E to exit and save
DICTATED BY: TIUPROVIDER,THREE
DICTATION DATE: 4/16/96
ATTENDING PHYSICIAN: TIUPROVIDER,TWO
TRANSCRIPTIONIST: C7689
URGENCY: PRIORITY
$TXT
DIAGNOSES:
1. Status post coronary artery bypass graft.
2. Unstable angina prior to coronary artery bypass graft.
3. End stage renal disease.
4. Diabetes mellitus.
5. Hypertension.
6. History of peptic ulcer disease.
M=====T======T======T=======T=======T=======T=======T=======T====T
Now would you like to retry the filer? YES// <Enter>
Filer/Router Queued!
1 Upload Documents
2 Help for Upload Utility
Select Upload menu Option: <Enter>
In the example above, notice that patient One TIUPatient had no admission on
11/17/96, so the filer could not create a record in the target file for this discharge summary record. The user acts on the alert to correct the admission date as 11/16/96, and retries the filer, which is now able to file the record appropriately, and the alerts are removed for all recipients.
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Avoiding Upload Errors
TIU uses header information to file uploaded notes in the TIU Document File (#8925).
Naturally, if this information is inaccurate, then either a filing error is generated or the note is filed incorrectly.
Note: Certain errors in the upload header can cause the upload routine to file the note incorrectly. This is a patient safety issue, so the accuracy of captions should be verified where possible.
Each type of document has a different set of upload captions and, in some cases, a different upload routine. Each routine tries to avoid incorrect filing of notes by crosschecking the patient information and dates with other information such as the consult number or surgery case number. Some types of documents have unique fields to assist the upload program in accomplishing these cross checks and/or to file the document.
A missing field error is generated either when a required field is missing, or a field does not match the example data given in the Upload Help Display (see Display Upload Help below).
The following table gives information on required fields and the cross-checks performed on fields for several document classes:
Type of Document
PROGRESS NOTES
Caption
SSN
VISIT/EVENT DATE
Use
Required by filing routine
TITLE
LOCATION
AUTHOR
DATE/TIME OF DICT
DISCHARGE SUMMARY PATIENT SSN
DATE OF ADMISSION
DICTATED BY
DICTATION DATE
ATTENDING PHYSICIAN
URGENCY
Required by filing routine.
The patient record indicated by the SSN is checked for a matching visit or event.
Required by filing routine
Required by filing routine
Generates missing field error
Generates missing field error
Required by filing routine
Required by filing routine.
The patient record indicated by the SSN is checked for a matching admission date.
Generates missing field error
Generates missing field error
Generates missing field error
Generates missing field error
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Type of Document
CLINICAL PROCEDURES SSN
TITLE
CONSULTS
Caption
VISIT/EVENT DATE
Use
Required by filing routine
Required by filing routine.
This is the name of the procedure. The patient record indicated by the SSN is checked for a matching procedure.
Required by filing routine.
The patient record indicated by the SSN is checked for a matching visit or event.
CONSULT REQUEST NUMBER Required by filing routine.
The patient record indicated by the SSN is checked for a matching consult, that the consult is a clinical procedure, and that results are available for interpretation.
TIU DOCUMENT NUMBER Only required by filing routine when an incomplete
CP document has been attached by the CPUser program. In this case, the consult request is checked for a matching TIU Document
Number.
DATE/TIME OF DICTATION
LOCATION
AUTHOR
Required by filing routine
Required by filing routine
Generates missing field error
SSN
TITLE
Required by filing routine
Required by filing routine
CONSULT REQUEST NUMBER Required by filing routine.
The patient record indicated by the SSN is checked for a matching consult.
VISIT/EVENT DATE Required by filing routine.
The patient record indicated by the SSN is checked for a matching visit.
AUTHOR
LOCATION
DATE/TIME OF DICTATION
Generates missing field error
Required by filing routine
Generates missing field error
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Type of Document
PROCEDURE REPORT
Caption
PATIENT SSN
DOCUMENT NUMBER
SURGICAL CASE
OPERATION REPORT
DICTATION DATE
ATTENDING SURGEON
DICTATED BY
PATIENT SSN
DOCUMENT NUMBER
SURGICAL CASE
DICTATION DATE
DICTATING SURGEON
ATTENDING SURGEON
STAT or ROUTINE
Use
Required by filing routine
Required by filing routine. If missing, the upload routine infers it from the SSN and
Operation Date (an optional field).
Required by filing routine. If missing, the upload routine infers it from the SSN and
Operation Date. Then, if there is more than one matching surgical case, it generates a missing field error.
Generates missing field error
Generates missing field error
Generates missing field error
Required by filing routine
Required by filing routine. If missing, the upload routine infers it from the SSN and
Operation Date (an optional field).
Required by filing routine. If missing, the upload routine infers it from the SSN and
Operation Date. Then, if there is more than one matching surgical case, it generates a missing field error.
Generates missing field error
Generates missing field error
Generates missing field error
Generates missing field error
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Display Upload Help
Transcriptionists may select this option in the Upload Menu to display the formats expected by the upload process for the report types defined at your site.
The captioned headers may be captured as ASCII data and used to build macros using a commercial word-processors (e.g., WordPerfect or Microsoft Word), thereby avoiding having to retype the captioned headers, while minimizing the risk of spelling errors or inconsistencies with the formats expected by the host system.
UP Batch upload reports
HLP Display upload help
Select Upload menu Option: HLP Display upload help
Select REPORT TYPE: DISCHARGE SUMMARY// <Enter> Discharge Summary
$HDR: DISCHARGE SUMMARY
SOC SEC NUMBER: 666-12-1212
ADMISSION DATE: 02/21/96
DISCHARGE DATE: 02/25/96
DICTATED BY: TIUPROVIDER,TWO
DICTATION DATE: 02/26/96
ATTENDING: TIUPROVIDER,SEVEN
TRANSCRIPTIONIST ID: T1212
URGENCY: PRIORITY
$TXT
DISCHARGE SUMMARY Text
$END
*** File should be ASCII with width no greater than 80 columns.
*** Use "___" for "BLANKS" (word or phrase in dictation that isn’t understood).
Press RETURN to continue...<Enter>
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Chapter 7: TIU for Remote Users
Individual Patient Document
Multiple Patient Documents
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Chapter 7: TIU for Remote Users
The options on this menu allow remote users (e.g., VBA RO personnel) to access documents which have been completed (i.e., legally authenticated by signature or cosignature, if necessary), to facilitate processing of claims.
Remote User Menu
Option
Individual Patient
Document
Multiple Patient Documents
Description
This option allows remote users (e.g., VBA RO personnel) to access individual documents which have been completed.
This option allows remote users (e.g., VBA RO personnel) to review and print multiple documents which have been completed
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Individual Patient Document
Steps to use option:
1. Select Individual Patient Document from your TIU menu.
Select Integrated Document Management Option: Individual Patient Document
2. Select a patient.
Select PATIENT NAME: TIUPATIENT,ONE 09-12-44 666233456 YES SC
VETERAN
(2 notes) C: 05/28/96 12:37 (addendum 08/12/96 16:04)
(2 notes) W: 05/28/96 12:33
A: Known allergies
(3 notes) D: 07/08/96 14:14
Available documents: 02/17/92 thru 10/28/96 (54)
3. Enter a date range to display documents for.
Please specify a date range from which to select documents:
List documents Beginning: 02/17/96// <Enter> (FEB 17, 1992)
Thru: 10/28/96// <Enter> (OCT 28, 1996)
Adm: 12/22/94
1 01/09/96 17:51 Diabetes Education FOUR TIUPROVIDER, MS3
Adm: 07/22/91
SUBJECT: Diet etc.
2 09/29/95 16:54 Lipid Clinic FIVE TIUPROVIDER
Adm: 08/14/95
SUBJECT: Dyslipidosis
3 04/24/96 08:28 Lipid Clinic ONE TIUPROVIDER, MD
Visit: 04/24/92
SUBJECT: Lipid test
4 02/17/96 08:00 Arterial Evaluation - THREE TIUPROVIDER,
Visit: 02/17/92
SUBJECT: Rule out embolus, lower extremity '^' TO STOP: 2
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Individual Patient Document, cont’d
4. Choose a document from the list.
Choose documents: (1-4): 1
Opening Diabetes Education record for review...
Browse Document Jun 26, 1996 17:08:45 Page: 1 of 1
Diabetes Education
TIUPATIENT,ONE 666-23-3456 Visit Date: 01/09/96@17:06
DATE OF NOTE:JAN 09,1996@17:51:04 ENTRY DATE:JAN 09, 1996@17:51:04
AUTHOR: TIUPROVIDER,ONE EXP COSIGNER: TIUPROVIDER,THREE
URGENCY: STATUS: COMPLETED
Provided Mr. TIUPatient with Diabetes diet pamphlet and explained areas he especially needed to be concerned about.
/es/ Three TIUProvider, MD for Five TIUProvider, MS3
Medical Student III
+ Next Screen - Prev Screen ?? More actions
Find Print Quit
Select Action: Quit// Print
5. The document is printed at the device you specified.
-----------------------------------------------------------------
TIUPATIENT,ONE 666-23-3456 Progress Notes
-----------------------------------------------------------------
NOTE DATED: 01/09/96 17:51 DIABETES EDUCATION
ADMITTED: 07/22/91 11:06 1A
SUBJECT: Lipid TEST
Provided Mr. TIUPatient with Diabetes diet pamphlet and explained areas he especially needed to be concerned about.
Signed by: /es/ TIUPROVIDER,FIVE, MD
Medical Student III 01/23/96 08:34
Analog Pager: 1-900-555-8398
Digital Pager: 1-900-555-7883
Cosigned by: /es/ TIUPROVIDER,THREE
01/23/96 08:34
Analog Pager: 1-900-555-8398
Digital Pager:1-900-555-7883
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Multiple Patient Documents
Use this option to see a list of clinical documents for more than one patient in TIU. You can specify types, categories, and time range.
Caution: Avoid making your requests too broad (in statuses, search categories, and date ranges) because these searches can use a lot of system resources, slowing the computer system down for everyone. The example below would probably be too broad in a large hospital.
Steps to use option:
1. Select Multiple Patient Documents from your TIU menu.
--- Remote User Menu ---
1 Individual Patient Document
2 Multiple Patient Documents
Select Text Integration Utilities (Remote User) Option: 2 Multiple Patient Documents
2. Enter a status.
Select Status: COMPLETED// all undictated untranscribed unreleased
unverified unsigned uncosigned
completed amended purged deleted
3. Select a document type (such as Discharge Summary, Progress Notes,
Addendum).
Select Clinical Documents Type(s): All Discharge Summary, Progress Notes,
Addendum
4. Select one of the following search categories
1 All Categories 6 Patient 11 Transcriptionist
2 Author 7 Problem 12 Treating Specialty
3 Division 8 Service 13 Visit
4 Expected Cosigner 9 Subject
5 Hospital Location 10 Title
Enter selection(s) by typing the name(s), number(s), or abbreviation(s).
Select SEARCH CATEGORIES: AUTHOR// all All Categories
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Multiple Patient Documents, cont’d
5. Enter a date range.
Start Reference Date [Time]: T-7//
<Enter>
(JUN 02, 1997)
Ending Reference Date [Time]: NOW//
<Enter>
(JUN 09, 1997@11:19)
Searching for the documents..
6. All the documents for the criteria selected are displayed. Choose an action to perform, then the document to perform it on.
ALL Documents Jun 09, 1997 11:20:01 Page: 1 of 1
by ALL CATEGORIES from 06/02/97 to 06/09/97 14 documents
Patient Document Ref Date Status
1 TIUPATIE (T1965) ADVANCE DIRECTIVE 06/06/97 completed
2 TIUPATIE (T1255) Addendum to CLINICAL WARNING 06/05/97 completed
3 TIUPATIE (T1239) Adverse React/Allergy 06/05/97 completed
4 TIUPATIE (T1239) CRISIS NOTE 06/05/97 completed
5 TIUPATIE (T1255) FANCY RAT NOTES 06/04/97 completed
6 TIUPATIE (T1255) Addendum to Adverse React/Aller 06/04/97 completed
7 TIUPATIE (T1255) Addendum to Adverse React/Aller 06/04/97 completed
8 TIUPATIE (T3456) FANCY RAT NOTES 06/04/97 completed
9 TIUPATIE (T1255) Addendum to Adverse React/Aller 06/03/97 completed
10 TIUPATIE (T2591) FANCY RAT NOTES 06/03/97 completed
11 TIUPATIE (T1462) Addendum to FANCY RAT NOTES 06/03/97 completed
12 + TIUPATI(T1462) FANCY RAT NOTES 06/03/97 completed
13 + TIUPATI(T2591) Discharge Summary 06/02/97 completed
14 TIUPATIE (T2591) Addendum to Discharge Summary 06/02/97 unsigned
+ Next Screen - Prev Screen ?? More Actions >>>
Find Browse Change View
Detailed Display Print Quit
Select Action: Quit// P=13
DEVICE: HOME// PRINTER
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Multiple Patient Documents, cont’d
SALT LAKE CITY 06/09/97 11:29 Page: 1
----------------------------------------------------------------------
PATIENT NAME | AGE | SEX | RACE | SSN | CLAIM NUMBER
TIUPATIENT,SEVEN | 66 | M | AMER | 666-04-2591P|
----------------------------------------------------------------------
ADM DATE | DISC DATE | TYPE OF RELEASE | INP | ABS | WARD NO
MAY 30, 1997 | | | | |
----------------------------------------------------------------------
DICTATION DATE: JUN 02, 1997 TRANSCRIPTION DATE: JUN 02, 1997
TRANSCRIPTIONIST: jg
DIAGNOSIS: toe injury
OPERATIONS/PROCEDURES: evaluated for prosthesis
C O P Y
SIGNATURE APPROVING PHYSICIAN/DENTIST
/es/ NINE TIUPROVIDER
NINE TIUPROVIDER
NINE TIUPROVIDER
JUN 02, 1997@16:55:56 ADDENDUM:
In remission.
SIGNATURE APPROVING PHYSICIAN/DENTIST
Three TIUProvider, MS
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Chapter 8: Progress Notes Print Options
Admission– Prints all PNs for Current Admission
Author Print Progress Notes
Batch Print Outpt PNs by Division
Location Print Progress Notes
Outpatient Location – Print Progress Notes
Patient Print Progress Notes
Ward Print Progress Notes
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Chapter 8: Progress Notes Print Options
Clinicians can print progress notes but most printing is geared towards MAS and managing this function on a medical center level.
TIU offers two methods of printing documents:
1. Print actions on option screens: Clinicians may print all types of documents using a variety of methods from the List Manager interface for TIU, including Progress Notes,
Discharge Summaries, Consults, etc. Work and chart copies are possible. Chart copies are the recommended type of printed copy, but many sites still want to print work copies. For example, you may want to print work copies of unsigned notes.
Other than the above List Manager printing, all other print options are on print menus.
Only signed notes are available from these options.
2. Progress Notes Print Menus
Progress Notes Print Menu
For many types of users: clinical, administrative, management.
MAS Options to Print Progress Notes
For printing at the Wards and Clinics, both by individual patient and batch printing.
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Progress Notes Print Menu
All of the options on this menu support the printing of chart or work copies.
NOTE: The location print option prints for any location that has signed notes entered for it, but it doesn’t track anything.
Option
Author Print Progress Notes
Location Print Progress Notes
Patient Print Progress Notes
Ward Print Progress Notes
Description
This option produces chart or work copies of progress notes for an author, for a selected date range.
This option prints chart or work copies of progress notes for all patients who were at a specific location when the notes were written. The patients whose progress notes are printed on this report may not still be at that location.
If Chart Copy is selected, each note will start on a new page.
This option prints or displays progress notes for a selected patient by a selected date range.
This option lets you print progress notes for all patients who are now on a ward for a selected date range. This option is only for ward locations. NOTE: Copies can only be printed to a printer, not to a computer screen.
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MAS Options to Print Progress Notes
The MAS options are intended for printing at the Wards and
Clinics, both by individual patient and batch printing.
Option
Admission- Prints all PNs for
Current Admission
Batch Print Outpt PNs by
Division
Outpatient Location- Print
Progress Notes
Ward- Print Progress Notes
Description
This option prints all progress notes for a selected patient for the current admission if patient is an inpatient or
LAST admission if the patient has been discharged.
This option batch prints outpatient progress notes in terminal digit order by division. Locations that the site would like excluded from this job may edit field #3 in file #8925.93. If the location is not entered in file
#8925.93, it WILL be included.
This option is designed to be used primarily by MAS. It produces CHARTABLE notes and tracks the last note printed for the selected outpatient location. Output is sorted in alphabetical order by patient.
This option allows the printing of Progress Notes for
ALL patients on the ward at the time the job is queued to print. All of the notes for a selected date range
(regardless of the location of the note) will print. This option is only for WARD locations. NOTE: Copies can only be printed to a printer, not to a computer screen.
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Author Print Progress Notes Example
---Print Progress Notes---
PNPA Author- Print Progress Notes
PNPL Location- Print Progress Notes
PNPT Patient- Print Progress Notes
PNPW Ward- Print Progress Notes
Select Progress Notes Print Options Option: author- Print Progress Notes
Print Progress Notes for a Selected AUTHOR
-------------------------------------------------------------------------
AUTHOR: TIUPROVIDER,THREE TT MD
Available notes: Aug 24, 1995 thru Oct 03, 1996
Print Notes Beginning: t-100 (MAY 01, 1996)
Thru: t-60 (JUL 10, 1996)
Searching for the notes........
>> 8 notes found for TIUProvider,Three
Do you want WORK copies or CHART copies? CHART// <Enter>
DEVICE: HOME// PRINTER
-------------------------------------------------------------------------
ANDERSON,H C 666-12-3456 Progress Notes
-------------------------------------------------------------------------
NOTE DATED: 05/08/96 11:01 DIABETES EDUCATION
ADMITTED: 04/21/96 10:00 2B
-------------------------------------------------------------------------
SUBJECTIVE: 45 year old AMERICAN INDIAN here for
initial evaluation of his DYSLIPIDEMIA.
COPIED FROM TIUCLIENT TO TIUPATIENT...
PMH:
Significant negative medical history pertinent to the
evaluation and treatment of DYSLIPIDEMIA:
FH:
SH:
MEDICATION
HISTORY: CURRENT MEDICATIONS
DIET: Counseled on AHA Step I diet today by NINE TIUPROVIDER.
See her evaluation.
ACTIVITY:
OBJECTIVE: HT: 70 (08/23/95 11:45) WT: 207 (08/23/95 11:45)
TSH/T4: 1.7/1.1
FBG: 200 HEMOGLOBIN A1C: 15.2
SGOT: 44 URIC ACID: 4.7
Enter RETURN to continue or '^' to exit: <Enter>
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Author Print Progress Notes Example cont’d
--------------------------------------------------------------------------
TIUPATIENT,ONE 666-12-3456 Progress Notes
--------------------------------------------------------------------------
06/05/96 15:18 ** CONTINUED FROM PREVIOUS SCREEN **
ASSESSMENT: 1. MALE with / without documented CAD
2. CV Risk factors:
3. Lipid pattern:
PLAN: 1. Implement recommendations to lower fat intake.
2. Repeat FBG and HBG A1C on:
3. Return to review lab on:
Signed by: /es/ Three TIUProvider, MS
Physician Assistant 06/21/96 07:47
Analog Pager: 555-1213
Digital Pager: 555-1215
Enter RETURN to continue or '^' to exit:<Enter>
--------------------------------------------------------------------------
TIUPATIENT,ONE 666-12-3456 Progress Notes
--------------------------------------------------------------------------
NOTE DATED: 06/21/96 11:38 SOCIAL WORK SERVICE
ADMITTED: 06/01/96 10:00 2B
Follow-up to 6/1/96 visit.
Signed by: /es/ Three TIUProvider, MS
Physician Assistant 06/21/96 07:47
Analog Pager: 555-1213
Digital Pager: 555-1215
Enter RETURN to continue or '^' to exit:<Enter>
--------------------------------------------------------------------------
TIUPATIENT,SEVEN 666-04-2591P Progress Notes
--------------------------------------------------------------------------
NOTE DATED: 07/03/96 14:18 LIPID CLINIC
ADMITTED: 05/28/96 15:58 1A
SUBJECTIVE: 65 year old AMERICAN INDIAN OR ALASKA NATIVE MALE here for
initial evaluation of his DYSLIPIDEMIA.
MORE STUFF...
PMH:
Significant negative medical history pertinent to the
evaluation and treatment of DYSLIPIDEMIA:
FH:
SH:
MEDICATION
HISTORY: CURRENT MEDICATIONS
DIET: Counseled on AHA Step I diet today by NINE TIUPROVIDER.
ACTIVITY:
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Author Print Progress Notes Example cont’d
OBJECTIVE: HT: 70 (08/23/95 11:45) WT: 178 (07/01/96 17:15)
TSH/T4: 1.7/1.1
FBG: 223 HEMOGLOBIN A1C: 15.2
SGOT: 44 URIC ACID: 4.7
ASSESSMENT: 1. MALE with / without documented CAD
2. CV Risk factors:
3. Lipid pattern:
PLAN: 1. Implement recommendations to lower fat intake.
2. Repeat FBG and HBG A1C on:
3. Return to review lab on:
Signed by: /es/ Three TIUProvider, MS
Physician Assistant 07/03/96 14:19
Analog Pager: 1-900-555-8398
Digital Pager: 1-900-555-7883
Enter RETURN to continue or '^' to exit: ^
AUTHOR: <Enter>
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Location Print Progress Notes Example
Select Progress Notes Print Options Option: Location- Print Progress Notes
Print Progress Notes for a Selected LOCATION
-------------------------------------------------------------------------
Select HOSPITAL LOCATION NAME: GENERAL MEDICINE TIUPROVIDER,TWENTY
Available notes: Sep 06, 1995 thru Oct 02, 1996
Print Notes Beginning: t-30 (SEP 08, 1996)
Thru: t (OCT 08, 1996)
Searching for the notes..
>> 2 notes found for GENERAL MEDICINE
Do you want WORK copies or CHART copies? CHART//
<Enter>
DEVICE: HOME// <Enter> VAX
--------------------------------------------------------------------------
TIUPATIENT,ONE 666-23-3456 Progress Notes
--------------------------------------------------------------------------
NOTE DATED: 10/01/96 11:59 BP TEST
VISIT: 04/18/96 10:00 GENERAL MEDICINE
NAME: TIUPATIENT,ONE
SEX: MALE
DOB: SEP 12,1944
ALLERGIES: Amoxicillin, Aspirin, MILK
LABS: No data available
LIPIDS: No data available
HT: 72 (08/23/95 11:45)
WT: 190 (08/23/95 11:45)
Signed by: /es/ Three TIUProvider, MS
10/01/96 15:38
Analog Pager: 1-900-555-8398
Digital Pager: 1-900-555-7883
Enter RETURN to continue or '^' to exit:
<Enter>
--------------------------------------------------------------------------
TIUPATIENT,SEVEN 666-04-2591P Progress Notes
--------------------------------------------------------------------------
NOTE DATED: 09/17/96 13:37 LIPID CLINIC
VISIT: 08/18/96 08:00 GENERAL MEDICINE
SUBJECTIVE: 55 year old AMERICAN INDIAN OR ALASKA NATIVE MALE here for
initial evaluation of his DYSLIPIDEMIA.
PMH:
Significant negative medical history pertinent to the
evaluation and treatment of DYSLIPIDEMIA:
FH:
SH:
MEDICATION
HISTORY: CURRENT MEDICATIONS
DIET: Counseled on AHA Step I diet today by NINE TIUPROVIDER.
Enter RETURN to continue or '^' to exit:
<Enter>
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Location Print Progress Notes Example cont’d
--------------------------------------------------------------------------
TIUPATIENT,SEVEN 666-04-2591P Progress Notes
--------------------------------------------------------------------------
09/17/96 13:37 ** CONTINUED FROM PREVIOUS SCREEN **
ACTIVITY:
OBJECTIVE: HT: 70 (08/23/96 11:45) WT: 207 (08/23/96 11:45)
TSH/T4: 1.7/1.1
FBG: 200 HEMOGLOBIN A1C: 15.2
SGOT: 44 URIC ACID: 4.7
ASSESSMENT: 1. MALE with / without documented CAD
2. CV Risk factors:
3. Lipid pattern:
PLAN: 1. Implement recommendations to lower fat intake.
2. Repeat FBG and HBG A1C on:
3. Return to review lab on:
Signed by: /es/ Three TIUProvider, MD
10/02/96 10:34
Analog Pager: 1-900-555-8398
Digital Pager: 1-900-555-7883
Enter RETURN to continue or '^' to exit: ^
Select HOSPITAL LOCATION NAME: ^Patient Print Progress Notes Example
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Select Progress Notes Print Options Option: p Patient-Print Progress Notes
Print Progress Notes for a Selected PATIENT
------------------------------------------------------------------
Select PATIENT NAME:TIUPATIENT,THIRTEEN 04-01-44 666776641
YES SC VETERAN
(1 note ) W: 09/02/95 09:00
Available notes: Sep 06, 1995 thru Mar 21, 1996
Print Notes Beginning: t-360 (APR 08, 1995)
Thru: t (APR 02, 1996)
Searching for the notes.....
>> 5 notes found for TIUPATIENT,THIRTEEN
Do you want WORK copies or CHART copies? CHART// <Enter>
Do you want to start each note on a new page? NO//<Enter>
DEVICE: HOME// <Enter> LAT TERMINALS
------------------------------------------------------------------
TIUPATIENT,EIGHT 666-77-6641 Progress Notes
------------------------------------------------------------------
NOTE DATED: 09/01/95 12:00 General Note
VISIT: CARDIOLOGY
This is a very sad situation. It is also a general progress note. We hope the patient does better in the future.
She is quite nice, clean and nice.
Signed by: /es/ NINE TIUPROVIDER
VERIFIER 09/06/95 21:51
NOTE DATED: 09/02/95 09:00 Clinical Warning
VISIT: CARDIOLOGY
Beware: this patient bites.
Signed by: /es/ NINE TIUPROVIDER
VERIFIER 09/06/95 21:53
NOTE DATED: 11/08/95 15:20 History & Physical Ex
VISIT: 09/05/95 11:00 DIABETES CLINIC
SUBJECT: TESTING THE GLUCOSE LEVEL
1. Chief Complaint: Numbness in legs
Reason for Admission (if different from #1)
2. History of Present Illness: Type 2 onset 1993
Medication Allergies: Penicillin causes rash
Current Medications: Oral insulin
Enter RETURN to continue or '^' to exit: <Enter>
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Patient Print Progress Notes Example cont’d
--------------------------------------------------------------------
TIUPATIENT,EIGHT 666-77-6641 Progress Notes
--------------------------------------------------------------------
11/08/95 15:20 ** CONTINUED FROM PREVIOUS SCREEN **
PAST HISTORY
1. Hospitalizations: 6/10/93
Surgeries: Injuries:
Illness: Disabilities:
Transfusion(s): ( )Yes (X)No
If Yes, give date(s):
2. Unusual Childhood Illnesses:
Immunizations:
(X)DT last booster: 1/90 ( )Pneumonia ( )Flu
( )Hep B ( )Other:
3. Habits: (x)Smoking (x)Alcohol ( )Drugs
Caffeine Use: (x)Coffee ( )Tea ( )Cola
( )Suicide Attempts ( )OTHER:
4. SOCIAL/MILITARY HISTORY (Occupations):
( )WWI ( )WWII ( )KOREAN (x)VIETNAM ( )GULF WAR
Travel: Lives with:
Source of Income: ( )Job ( )Retired (x)Pension ( )Other
5. REVIEW OF SYSTEMS:
6. PHYSICAL:
1. Ht. HEIGHT Wt. WEIGHT Temp. Resp.
BP: Lying: Sitting: Standing:
2. General: (x)Well ( )Obese ( )Thin ( )Malnourished ( )Neat
( )Chronically Ill ( )Toxic ( )Acute Distress
Head:
Eyes:
ENT:
Enter RETURN to continue or '^' to exit: <Enter>
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Patient Print Progress Notes Example cont’d
-------------------------------------------------------------------
TIUPATIENT,EIGHT 666-77-6641 Progress Notes
-------------------------------------------------------------------
11/08/95 15:20 ** CONTINUED FROM PREVIOUS SCREEN **
6. Neck:
7. Chest and Breasts:
8. Lungs:
9. Lymphatics (Cervical, Epitrocholear, Axillary, Inguinal, Popliteal):
10. Heart:
11. Abdomen:
12. Pelvic/Genitalia (Penis, Scrotum, Testicles):
13. Rectal:
14. Neurological:
Cranial Nerves:
Peripheral Neurological exam:
_
Reflexes: 0 - No reflex ( )
1 - Hyporeflexia __l__
2 - Average \/ l \/
3 - Brisk ___l___
4 - Hypereflexia / \
l l
_l l_
15. Musculoskeletal:
Upper Extremities:
Lower Extremities:
Spine:
16. Psychiatric:
a. Are any cognitive impairments noted? ( )Yes ( )No
b. Are any communication impairments noted? ( )Yes ( )No
17. Skin:
7. WOMEN'S GYNECOLOGICAL HISTORY AND PHYSICAL EXAM
HISTORY:
Menarche: ( )Yes ( )None Interval/Duration:
Characteristics:
Enter RETURN to continue or '^' to exit: <Enter>
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Patient Print Progress Notes Example cont’d
------------------------------------------------------------------
TIUPATIENT,EIGHT 666-77-6641 Progress Notes
------------------------------------------------------------------
11/08/95 15:20 ** CONTINUED FROM PREVIOUS SCREEN **
Last Pap: Results: Previous Gyn Surgery:
Birth Control Method: Number of Pregnancies:
Miscarriages:
Stillbirths: Live Births: Menopause Onset: What effect:
Hormones: Prior STD History:
Last Mammogram: Results:
Number of sexual partners in the past six months?
Y N SYMPTOMS DESCRIPTION
( ) ( ) Stress Incontinence
( ) ( ) Vaginal Discharge/Itching
( ) ( ) Rash/Sores
( ) ( ) Lower Abdominal Pain
( ) ( ) Dyspareunia
( ) ( ) Breast Lumps/Pain
( ) ( ) Breast Rash/Nipple Discharge
( ) ( ) Abnormal Bleeding
( ) ( ) Other:
PHYSICAL EXAMINATION:
NOTE: Ohio State Law requires that every female inpatient receive a breast and pelvic exam unless one was performed within the preceding 12 months or the patient refuses the examination in writing. (Patient must sign below).
BREASTS: l l DESCRIPTION/QUADRANT
______l l______
/ / \ \
l l l l l l
l l --o-- --o-- l l
l l l l l l
GENITALIA (Vulva, Urethra, Vagina, Cervix, Fundus, Adnexa)
PATIENT REFUSAL OF EXAMINATION
[ ] I do not wish to receive a breast or pelvic exam at this time.
[ ] I would like to be scheduled for an outpatient breast and pelvic exam at the
Women's Health Clinic.
Patient's Signature:______________________________________
8. INITIAL IMPRESSION/ASSESSMENT:
9. WORKING DIAGNOSIS:
10. PLAN:
Enter RETURN to continue or '^' to exit: <Enter>
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------------------------------------------------------------------
TIUPATIENT,TWENTY 666-77-6641 Progress Notes
------------------------------------------------------------------
11/08/95 15:20 ** CONTINUED FROM PREVIOUS SCREEN **
NOTE DATED: 03/20/96 08:30 Diabetes Education - Glucose Monitoring
VISIT: 03/19/96 08:00 DIABETES EDUCATION
SUBJECT: TESTING MULTIPLE COPY
Date of Class:
Class: Advantage Blood Glucose Monitor
Process: Lecture, Demonstration, and Return Demonstration
Issued: Advantage monitor, Level I and II glucose control solutions, and 3 boxes (50 each) Advantage test strips.
Subjective: Patient states:
___________Tests his BG________times/day
___________Has not received previous directions.
Objective:
Patient attended class. With Significant Other? No Yes
Any observed barriers to learning? No Yes
Concepts:
1. Location of batteries.
2. Using memory.
3. Coding machine.
4. Using glucose control. These expire 3 mo after opening.
5. Performing a blood glucose test.
A. Clean fingertip (only) with warm soap and water.
B. Use side of any or all fingertips unless there is sore or other damage present.
6. Proper care and storage of machine and strips.
7. Disposal of lancets in puncture-proof container. Label.
A: Knowledge deficit r/t Advantage SBGM
P: If no previous directions received, recommend 1-2 X day test and prn any signs low blood sugar.
RX:
1. Advantage glucose monitor kit (To pharmacy)
2. Advantage glucose control solutions. Disp 1 box Q 3 mo. Refill X3. (To pharmacy).
3.___No__Advantage Test Strips.Disp:__0___Boxes Q 3 mo. Refill X3.
___No____Monojector. Only one. No Refill.
___No______Lancets. #100 Q 3 mo. Refill X3.
Evidence of Learning: Patient coded, used glucose controls, and checked his own blood sugar during class. When mistakes were made, they were acknowledged by patient and corrective action stated.
Signed by: /es/ TIUPROVIDER,THREE
PGY3 MEDICAL RESIDENT 03/20/96 08:31
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Ward Print Progress Notes Example
This option is usually used by the night ward clerk. The output is in RM/BED order to facilitate filing. It prints all notes after the last time they were printed, and for ALL current inpatients on the ward, regardless of whether the location of the note is that ward, a nice feature for transferred patients or patients with outpatient clinic appointment notes.
This print option requires that you specify a printer; you can’t print to the screen.
Print by Ward is designed to support batch printing. It has the unique ability to determine when the last note was printed so that sites can now capture the infamous “orphan” note which was a problem under Progress Notes 2.5. A new page is started for each patient.
Print Progress Notes for ALL patients on WARD
----------------------------------------------------------------------
Select WARD Location: 6 1A
Print Notes Starting With (DATE/TIME): t-20 (MAY 23, 1997).........
...........
>> 32 notes found for WARD 1A
DEVICE: PRINTER
======================================================================
MEDICAL RECORD Progress Notes
======================================================================
NOTE DATED: 05/27/97 12:13 CLINICAL WARNING
ADMITTED: 04/20/97 15:58 1A
Mr. TIUPatient is becoming violent and self-destructive again. Will try a new
Prescription.
Signed by:/ es/ Ten TIUProvider, MD
05/27/97 12:14
05/28/98 09:45 Addendum
Mr. TIUPatient is more calm, and responding to counseling and medication
Signed by:/ es/ Ten TIUProvider, MD
05/28/97 10:14
NOTE DATED: 04/20/97 12:13 CLINICAL WARNING
ADMITTED: 04/20/97 15:58 1A
Mr. TIUPatient is violent and self-destructive again. Prescribed tranquilizer.
Signed by:/ es/ Ten TIUProvider, MD
04/20/97 01:20
TIUPATIENT,SEVEN REGION 5 Printed: 06/09/97 11:50
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Section 3: Managing TIU
Chapter 9: Introduction
Chapter 10: Menu Assignments
Chapter 11: Document Definition Set-up
Chapter 12: User Class Set-up
Chapter 13: Parameter Set-ups
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Chapter 9: Managing TIU: Introduction
TIU is managed through use of the following tools:
Menu assignments
Parameter set-ups
Document Definitions
User Class set-up
See the TIU Implementation Guide for more detailed instructions on performing these various set-ups.
TIU Maintenance Menu
Option Name
TIU PARAMETERS
MENU
TIUF DOCUMENT
DEFINITION
USR CLASS
MANAGEMENT
MENU
TIU IRM TEMPLATE
MGMT
TIUHL7 Message
Manager
Menu Text Description
TIU Parameters
Menu
Document
Definitions
User Class
Management
TIU Template
Mgmt Functions
TIUHL7 MSG
MGR
This option allows the Clinical Coordinator or IRMS Application Specialist to set up either the Basic or Upload Parameters for
TIU
Document Definitions menu, which includes:
Edit Document Definitions
Sort Document Definitions
Create Document Definitions
Create Objects
Menu of options for managing User Class
Definition and Membership
Menu options for managing pre-defined templates created by your medical center.
Utility for viewing message going in and out of the TIU Generic HL7 Interface.
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Legal Requirements
Patient Confidentiality
TIU works with patient records and documents. All users are reminded to be aware of the confidentiality of these records.
Electronic Signature
TIU uses a combination of menu access, User Classes, and Electronic Signature codes to maintain security and responsibility. Individuals in the system who have authority to approve actions, at whatever level, have an electronic signature code. Like the access and verify codes used when gaining access to the system, the electronic signature code is not visible on the screen. These codes are also encrypted so that they are unreadable to other users, even when viewed in the user file by those with the highest levels of access.
Electronic signature codes are required by TIU for every action that currently requires a signature on paper.
How to Change Your Electronic Signature Code
1. Select User’s Toolbox from the Mailman Menu.
2. Select Edit Electronic Signature Code from the User’s Toolbox menu.
Select Option: User's Toolbox
Display User Characteristics
Edit Electronic Signature code
Edit User Characteristics Menu Templates ...
Spooler Menu ...
TaskMan User
User Help
Select User's Toolbox Option: Edit Electronic Signature code
This option is designed to permit you to enter or change your Initials,
Signature Block Information and Office Phone number. In addition, you are permitted to enter a new Electronic Signature Code or to change an existing code.
3. Enter your initials.
4. At the “Signature Block Printed Name:” prompt, enter your name as you want it printed on forms that require your signature.
5. At the “Signature Block Title: prompt,” enter your job title as you want it printed on forms that require your signature.
6. Enter your office phone number.
Enter your signature code.
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Electronic Signature, cont’d
INITIAL: JG
SIGNATURE BLOCK PRINTED NAME: FIVE TIUPROVIDER
SIGNATURE BLOCK TITLE: Clinical Coordinator
OFFICE PHONE: (101)555-5736
Enter your Signature Code:xxxxxxx
Cosignature
Cosignature requirements are determined at local levels. Sites or departments can set
Cosignature requirements for certain kinds of documents through the Document
Parameter Edit option on the TIU Parameters Menu. Individual clinicians can designate a default cosigner on their Personal Preferences option.
Links and Relationships with Other Packages
TIU is closely linked to other applications and utilities — Authorization/Subscription
Utility (ASU) List Manager utility, the Computerized Patient Record System (CPRS),
Visit Tracking, etc. This linkage should remain transparent to users, but the IRM Service and Clinical Coordinators will need to coordinate the components.
Instructions will be provided (with a TIU patch) for setting up the interface with CPRS.
See the User and Technical Manuals of the above-listed packages for further instructions about interfaces.
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Chapter 10: Menus and Option Assignment
TIU menus and options are not exported on a single menu, but as individual menus intended for categories of users. These are described in earlier sections of this manual and also here. Sites may rearrange these as needed. Recommended assignments are also listed on the following pages. We’ve also included an example of a potential Clinical
Coordinator Menu.
Progress Notes(s)/Discharge Summary [TIU] ...
1 Progress Notes User Menu ...
1 Entry of Progress Note
2 Review Progress Notes by Patient
2b Review Progress Notes
3 All MY UNSIGNED Progress Notes
4 Show Progress Notes Across Patients
5 Progress Notes Print Options…
6 List Notes By Title
7 Search by Patient AND Title
8 Personal Preferences…
9 ALL Documents requiring my Additional Signature
2 Discharge Summary User Menu ...
1 Individual Patient Discharge Summary
2 All MY UNSIGNED Discharge Summaries
3 Multiple Patient Discharge Summaries
3 Integrated Document Management
1 Individual Patient Document
2 All MY UNSIGNED Documents
3 All MY UNDICTATED Documents
4 Multiple Patient Documents
5 Enter/edit Document
6 ALL Documents requiring my Additional Signature
4 Personal Preferences ...
1 Personal Preferences
2 Document List Management
Text Integration Utilities (MRT) ...
1 Individual Patient Document
2 Multiple Patient Documents
3 Review Upload Filing Events
4 Print Document Menu ...
1 Discharge Summary Print
2 Progress Note Print
3 Clinical Document Print
5 Released/Unverified Report
6 Search for Selected Documents
7 Unsigned/Uncosigned Report
8 Reassignment Document Report
9 Review unsigned additional signatures
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TIU Menus and Options cont’d
Text Integration Utilities (MIS Manager) ...
1 Individual Patient Document
2 Multiple Patient Documents
3 Print Document Menu ...
1 Discharge Summary Print
2 Progress Note Print
3 Clinical Document Print
4 Search for Selected Documents
5 Statistical Reports...
6 Unsigned/Uncosigned Report
7 Missing Text Report
8 Missing Text Cleanup
9 Signed/unsigned PN report and update
10 UNKNOWN Addenda Cleanup
11 Missing Expected Cosigner Report
12 Mark Document as 'Signed by Surrogate'
13 Mismatched ID Notes
14 TIU 215 ANALYSIS ...
15 Transcription Billing Verification Report
Text Integration Utilities (Transcriptionist) ...
1 Enter/Edit Discharge Summary
2 Enter/Edit Document
3 Upload Menu...
1 Upload Documents
2 Help for Upload Utility
4 List Documents for Transcription
5 Review/Edit Documents
6 Transcription Billing Verification Report
Text Integration Utilities (Remote User) ...
1 Individual Patient Document
2 Multiple Patient Documents
Progress Notes Print Options ...
PNPA Author- Print Progress Notes
PNPL Location- Print Progress Notes
PNPT Patient- Print Progress Notes
PNPW Ward- Print Progress Notes
Document Definitions (Clinician) ...
1 Edit Document Definitions
2 Sort Document Definitions
3 View Objects
MAS Options to Print Progress Notes...
Admission- Prints all PNs for Current Admission
Batch Print Outpt PNs by Division
Outpatient Location- Print Progress Notes
Ward- Print Progress Notes
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TIU Menus and Options cont’d
TIU Maintenance Menu...
1 TIU Parameters Menu...
1 Basic TIU Parameters
2 Modify Upload Parameters
3 Document Parameter Edit
4 Progress Notes Batch Print Locations
5 Division - Progress Notes Print Params
2 Document Definitions (Manager) ...
1 Edit Document Definitions
2 Sort Document Definitions/Objects
3 Create Document Definitions
4 Create Objects
5 Create TIU/Health Summary Objects
3 User Class Management ...
1 User Class Definition
2 List Membership by User
3 List Membership by Class
4 Manage Business Rules
4 TIU Template Mgmt Functions ...
1 Delete TIU templates for selected user.
2 Edit auto template cleanup parameter.
3 Delete templates for ALL terminated users.
5 TIU Alert Tools
6 Unsigned/Uncosigned Report
7 TIUHL7 Message Manager
TIU Conversion Clean-up Menu [GMRP TIU]
This menu comes with Patch GMRP*2.5*44 which is distributed prior to TIU to help clean up the Generic Progress Notes File (#121) and the Generic Progress Notes Title File
(121.2). It also contains options to assist in populating the TIU Document Definition File
(8925.1), which is roughly equivalent to file #121.2.
This menu is NOT exported on any existing menu. It should be assigned to the person responsible for getting the Progress Notes package ready for conversion to TIU. We suggest that this be limited to one person per site or several people working closely together on these clean-up exercises.
1 Calculate Number of PNs per TITLE
2 Number of Notes per TITLE - Report
3 DELETE a Progress Notes TITLE
4 MOVE Notes to Another TITLE
5 Edit TITLE - Enter/Edit Doc Class
6 TITLEs Sorted by Document Class - Report
7 CONVERT TITLEs (#121.2) to TIU (#8925.1)
PRT Title of Progress Note
UN List Unsigned Progress Notes by AUTHOR
DEL Delete a Signed Progress Note
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Suggested Clinical Coordinator Menu
TIU doesn’t export a Clinical Coordinator Menu. However, sites may wish to create one which includes most of the other menus and options, except possibly IRM options requiring programmer access.
Text Integration Utilities (Transcriptionist) ...
Text Integration Utilities (MRT) ...
Progress Notes(s)/Discharge Summary [TIU] ...
Text Integration Utilities (MIS Manager) ...
Text Integration Utilities (Remote User) ...
Progress Notes Print Options ...
MAS Options to Print Progress Notes…
Document Definitions ...
TIU Parameters Menu...
User Class Management ...
Upload Menu
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Menu Assignment
We recommend assigning menus as follows:
Option Name
TIU MAIN MENU
TRANSCRIP-TION
TIU MAIN MENU
MRT
TIU MAIN MENU
MGR
Menu Text Description
Text Integration
Utilities
(Transcriptionist)
Text Integration
Utilities (MRT)
Text Integration
Utilities (MIS
Manager)
Main Text Integration Utilities menu for transcriptionists.
Main Text Integration Utilities menu for Medical Records
Technicians.
Main Text Integration Utilities menu for MIS Managers.
TIU MAIN MENU
CLINICIAN
TIU MAIN MENU
REMOTE USER
Progress Notes(s)/
Discharge Summary
[TIU]
Text Integration
Utilities (Remote
User)
Main Text Integration Utilities menu for Clinicians.
TIU PRINT PN USER
MENU
TIU MAS PRINT PN
MENU
TIUF DOCUMENT
DEFINITION
TIU IRM
MAINTENANCE
MENU
GMRP TIU
Progress Notes Print
Options
MAS Options to
Print Progress Notes
Document
Definitions
IRM Maintenance
Menu
TIU Conversion
Clean-up Menu
Assign to:
Transcriptionists
Medical
Records
Technicians
MIS Managers.
Clinicians
This option allows remote users
(e.g., VBA RO personnel) to access only those documents that have been completed, to facilitate
VBA RO personnel, etc. processing of claims on a need-toknow basis.
Menu for printing Progress Notes. ADPACs, managers
Menu of options for printing
Progress Notes for specific locations, individually or by batch
MAS ADPACs
& supervisors
Document Definition
(Clinician)
Document Definition
(Manager)
Clinicians
Clinical
Coordinator,
IRM staff
This option allows IRM staff to set/modify the various parameters controlling the behavior of TIU, as well as the definition of TIU documents.
A menu of options for getting the
Progress Notes package ready for conversion to TIU
IRM, maybe
Clinical
Coordinators
(or some of the options on the menu.
ADPACs, IRM, or Clinical
Coordinators.
Limit to few.
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Chapter 11: Setting up TIU Parameters
TIU Parameters Menu
This menu contains options for Clinical Coordinators or IRM Application Specialists to set up the basic parameters (including Upload parameters) for TIU.
Menu Text Option Name Description
Basic TIU Parameters
TIU BASIC
PARAMETER EDIT
This option allows you to enter the basic or general parameters which govern the behavior of the Text
Integration Utilities
Modify Upload Parameters
TIU DOCUMENT
PARAMETER EDIT
Document Parameter Edit
TIU UPLOAD
PARAMETER EDIT
Division - Progress Notes
Print Params
Progress Notes Batch Print
Locations
TIU PRINT PN DIV
PARAM
TIU PRINT PN LOC
PARAMS
This option allows the definition and modification of parameters for the batch upload of documents into
V
IST
A.
This option lets you enter the parameters that apply to specific documents (i.e., Titles), or groups of documents (i.e., Classes, or
Document Classes).
These parameters are used by the
[TIU PRINT PN BATCH
INTERACTIVE] and [TIU PRINT
PN BATCH SCHEDULED] options.
If the site desires a header other than what is returned by $$SITE^ VASITE the .02 field of the 1st entry in this file will be used. For example, Waco-
Temple-Marlin can have the institution of their progress notes as
“CENTRAL TEXAS HCF.”
Option for entering hospital locations used for [TIU PRINT PN OUTPT
LOC] and [TIU PRINT PN WARD] options. If locations are not entered in this file they will not be selectable from these options.
NOTE: The TIU Implementation Guide and TIU Technical Manual contain instructions and examples for using these options.
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Chapter 12: Document Definitions
TIU uses a document storage database called the Document Definition hierarchy. This hierarchy provides the building blocks for Text Integration Utilities (TIU). It allows documents (Titles) to inherit characteristics of the higher levels, Class and Document
Class, such as signature requirements and print characteristics. This structure, while complex to set up, creates the capability for better integration, shared use of boilerplate text, components, and objects, and a more manageable organization of documents. End users (clinical, administrative, and MIS staff) need not be aware of the hierarchy. They work at the Title level with the actual documents.
Plan the Document Definition Hierarchy your site or service will use before installation of TIU and conversion of progress notes. This step is critical to the organization of existing and future documents in each site’s implementation of TIU. A worksheet is provided in Appendix A of the TIU Implementation Guide to help build the three basic levels.
Example of Document Definition Hierarchy
CLASS
Clinical
Documents
CLASSES
Progress
Notes
Discharge
Summary
Other
DOCUMEN
T CLASSES
Clinician
Notes
Nursing
Notes
Dietitian
Notes
Psychologist
Notes
TITLES
ICU
Nursing
Notes
Cardiology
Nursing
Notes
Eye Clinic
Nursing
Notes
Other
Notes
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Document Definition Options
Option
Text
Edit Document
Definitions
Option
Name
TIUFH EDIT
DDEFS
Create
Document
Definitions
Sort Document
Definitions
TIUFC
CREATE
DDEFS
TIUFA SORT
DDEFS
Create Objects
TIUFJ
CREATE
OBJECTS
MGR
View Objects
TIUFJ VIEW
OBJECTS
MGR
Description
This option lets you view and edit entries. Entries are presented in hierarchy order. Items of an entry are in sequence order, or if they have no sequence, in alphabetic order by menu text, and are indented below the entry. Since Objects don’t belong to the hierarchy, they can’t be viewed/edited using the Edit Options.
This option lets you create new entries of any type (Class,
Document Class, Title, Component) except Object, placing them where they belong in the hierarchy. Although entries can be created using the Edit and Sort options, the Create option streamlines the process. This option presents entries in hierarchy order, traversing ONE line of descent, starting with
Clinical Documents at the top.
The Create option permits you to view, edit, and create entries, but only from within the current line of descent. The
Create Option doesn’t let you copy an entry.
This option lets you view parts of the hierarchy by selected sort criteria. It displays the selected entries in alphabetic order by Name, rather than in hierarchy order. Depending on sort criteria, entries can include Objects. The Sort option lets you view and edit entries.
This option lets you create new objects or edit existing objects. First you select Start With and Go To values, and the existing Objects within those values are displayed in alphabetical order.
This option lets you look at or edit existing objects. First you select Start With and Go To values, and the existing Objects within those values are displayed in alphabetical order.
NOTE: For further information about using the Document Definition system, see the TIU/ASU Implementation Guide or the TIU
Technical Manual.
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Chapter 13: Defining User Classes
The Authorization/Subscription Utility (ASU), which is distributed with TIU, provides a mechanism for sites to associate users with User Classes, allowing them to specify the level of authorization needed to sign or order specific document types and orderables. It also allows privileges to be inherited, through its use of a hierarchical structure. A set of
Business Rules (which can be modified or added to by sites) further strengthens the
Utility’s ability to define roles and responsibilities for clinical documents.
See the ASU Clinical Coordinator Manual or the TIU/ASU Implementation Guide for more information about ASU, its relationship to TIU, and its implementation.
User Class Management Menu
Option Option Name Description
User Class Definition USR CLASS
DEFINITION
This option allows review, addition, editing, and removal of User Classes.
List Membership by
User
List Membership by
Class
Edit Business Rules
Manage Business
Rules
USR LIST
MEMBERSHIP BY
USER
USR LIST
MEMBERSHIP BY
CLASS
USR EDIT
BUSINESS RULES
USR BUSINESS
RULE
MANAGEMENT
This option allows review, addition, editing, and removal of individual members to and from User Classes.
This option allows review, addition, editing, and removal of individual members to and from User Classes.
This option allows the user to enter Business
Rules authorizing specific users or groups of users to perform specified actions on documents in particular statuses (e.g., an
UNSIGNED PROGRESS NOTE may be
EDITED by a PROVIDER who is also the
EXPECTED SIGNER of the note, etc.).
This option allows you to list the Business rules defined by ASU, and to add, edit, or delete them, as appropriate.
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Chapter 14: National Document Titles
Certain entries in the Document Definition file have been exported either with TIU and/or with various TIU patches. The operation of certain functions in VistA and CPRS depends on these entries being there. These entries include certain classes, document classes, and titles. Most exported Document Definitions are marked “National.” Local editing of
National Document Definitions is severely restricted.
Note: You must limit your editing of national Documents Definitions to actions permitted by the exported Document Definition options. Other editing will cause certain functions of VistA and
CPRS to not work properly.
National Classes
Classes are the most fundamental unit of organization in the Document Definition file.
CLINICAL DOCUMENTS is the root class for all other classes and document classes.
PROGRESS NOTES contains note titles that appear on the Notes tab of CPRS.
DISCHARGE SUMMARY contains note titles that appear on the D/C Summ (Discharge
Summary) tab of CPRS.
LR LABORATORY REPORTS was released with patch TIU*1*137 in support of
Anatomic Pathology. You should not add any local document classes to this class.
CLINICAL PROCEDURES was released with patch TIU*1*109.
SURGICAL REPORTS was released with patch TIU*1*112 and is not used until the surgery patch SR*3*100 is installed.
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National Document Classes
Four of the national document classes are in support of CWAD (CRISIS NOTE,
CLINICAL WARNING, ADVERSE REACTION/ALLERGY, ADVANCE
DIRECTIVE). If these are changed, then CWAD will not function properly. The same is true for other document classes such as ADDENDUM, DISCHARGE SUMMARIES, and ASI-ADDICTION SEVERITY INDEX. The last of these contains notes pushed from the Psychiatry Package.
For the LR ANATOMIC PATHOLOGY document class, nine (9) business rules were exported by patch USR*1*23, the companion patch to TIU*1*137. These rules help to ensure that the Anatomic Pathology features of the Lab Package function properly. All access to the titles in this document class (creating, editing, signing, cosigning, and printing) except viewing takes place through the Lab Package. Local sites must not circumvent the rules by adding, modifying, or overriding the business rules. (A list of the exported business rules is in the TIU/ASU Implementation Guide, Exported Business
Rules section.)
Note: The TIU class, document class, user class, note titles, and business rules installed by patch TIU*1*137 and USR*1*23 must not be modified in any way or the Anatomic Pathology enhancements to the Lab Package will not work properly. An exception exists in the case of USR*1*31, which directed medical centers to change these rules to refer to CHIEF, MIS or CHIEF, HIM rather than the LR ANATOMIC
PATHOLOGY EMPTY CLASS. The VA Office of Inspector
General (OIG) determined that these rules are not in harmony with VHA Handbook 1907.1. See the section USR*1*31 Impact on Business Rules in the TIU Implementation Guide for details.
For document class PATIENT RECORD FLAG CAT I, a business rule was exported by patch USR*1*24, the companion patch to TIU*1*165, that limits the writing of notes in this document class to a select group. This select group is made up of members of the user class DGPF PATIENT RECORD FLAGS MGR. Circumventing this rule violates the intent of keeping the flag documentation process in the hands of qualified domain experts.
Patch TIU*1*171 installed document titles and objects to support Spinal Cord Injury. It also creates the Document Class SCI OUTCOMES. The objects are listed on the TIU
Web Page at http://vista.med.va.gov/tiu/html/objects.html
.
HISTORICAL PROCEDURES contains medicine procedures that were converted to TIU notes by TIU*1*182 in support of the Medicine Package Conversion patch MD*1*5.
This document class must be left with status INACTIVE.
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The complete list of national document classes is:
ADDENDUM
ADDICTION SEVERITY INDEX
ADVANCE DIRECTIVE
ADVERSE REACTION/ALLERGY
C & P EXAMINATION REPORTS
CLINICAL WARNING
CRISIS NOTE
DISCHARGE SUMMARIES
HISTORICAL PROCEDURES
LR ANATOMIC PATHOLOGY
PATIENT RECORD FLAG CAT I
PATIENT RECORD FLAG CAT II
OPERATION REPORTS
NURSE INTEROPERATIVE REPORTS
ANESTHESIA REPORTS
PROCEDURE REPORT (NON-O.R.)
SCI OUTCOMES
Note:
Although CONSULTS was not exported as “National,” the same cautions apply. If you make explicit changes to
CONSULTS, then the Consults tab of CPRS may not work properly.
TIU*1*169 supports patch DVBA*2.7*53 C & P WORKSHEET MODULE PHASE.
These patches together allow users to create C & P Examination documents and store them in TIU. The advantage to this is that providers are allowed to view the C & P exams in CPRS along with the rest of a patient’s medical record. C & P documents are entered through the C & P Worksheet Module using a title in the C & P EXAMINATION
REPORTS Document Class. Upon signing, the C & P Exams are retained in AMIE and stored in TIU.
Further information on this can be found in the AMIE Regional Office User Manual.
National Titles
The complete list of national note titles (in alphabetical order) is:
ADDENDUM
ADVANCE DIRECTIVE
ADVERSE REACTION/ALLERGY
ANESTHESIA REPORT
ASI-ADDICTION SEVERITY INDEX
CLINICAL WARNING
DISCLOSURE OF ADVERSE EVENT NOTE
CRISIS NOTE
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DISCHARGE SUMMARY
HISTORICAL CARDIAC CATHETERIZATION PROCEDURE
HISTORICAL ECHOCARDIOGRAM PROCEDURE
HISTORICAL ELECTROCARDIOGRAM PROCEDURE
HISTORICAL ELECTROPHYSIOLOGY PROCEDURE
HISTORICAL ENDOSCOPIC PROCEDURE
HISTORICAL EXERCISE TOLERANCE TEST PROCEDURE
HISTORICAL HEMATOLOGY PROCEDURE
HISTORICAL HOLTER PROCEDURE
HISTORICAL PACEMAKER IMPLANTATION PROCEDURE
HISTORICAL PRE/POST SURGERY RISK NOTE
HISTORICAL PULMONARY FUNCTION TEST PROCEDURE
HISTORICAL RHEUMATOLOGY PROCEDURE
LR AUTOPSY REPORT
LR CYTOPATHOLOGY REPORT
LR ELECTRON MICROSCOPY REPORT
LR SURGICAL PATHOLOGY REPORT
NURSE INTERPRETATIVE REPORT
OPERATION REPORTS
PATIENT RECORD FLAG CATEGORY I
RISK OF CJD
SCI CRAIG HANDICAP ASSESSMENT&REPORTING TECHNIQUE-SHORT FORM
SCI DIENER SATISFACTION WITH LIFE SCALE
SCI GENERAL NOTE
SCI FUNCTIONAL INDEPENDENCE MEASURE
WRIISC ASSESSMENT NOTE
PROCEDURE REPORT
Note: The HISTORICAL titles in document class HISTORICAL
PROCEDURES were created by patch TIU*1*182 with status
INACTIVE. The status of these titles MUST REMAIN inactive in order to prevent users from entering notes on these titles.
All notes on these titles are auto-generated by the Medicine
Conversion patch MD*1*5.
Note: The TIU document classes, user class, category I note title, and category I business rule installed by patches TIU*1*165 and
USR*1*24 must not be modified in any way or Patient Record
Flags may not work properly.
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Patch TIU*1*159 implements the War-Related Illness and Injury Study Centers
(WRIISC pronounced “risk”) note title and template. The associated note title is WRIISC
ASSESSMENT NOTE . This note is described in the memo Description of WRIISC
Programs and Associated Referral Process accompanying the patch. To get it to work properly a Clinical Coordinator authorized to edit shared templates must perform the following steps from the CPRS GUI:
1. Go to the Notes tab.
2. From the Options menu, select Edit Shared Templates.
3. In the Shared Templates pane highlight document Titles.
4. From the Tools menu select Import Template.
5. Select WRIISCASSESSMENT.TXML and press Open.
6. Highlight the WRIISC ASSESSMENT template.
7. In the Associated Title list box, select WRIISC ASSESSMENT NOTE.
8. Press OK.
Once these steps have been performed, the template and note title will work for all CPRS users. Further information about setting up shared templates is available in the
Computerized Patient Record System (CPRS) User Guide in the section on Creating
Personal Document Templates.
Patch TIU*1*261 permits an authorized user to rescind an Advance Directive document by changing the title to RESCINDED ADVANCE DIRECTIVE.
Patch TIU*1*261 supports Imaging patch MAG*3.0*121, which provides the ability to watermark images "RESCINDED".
Note: EXACT TITLE NAMES are REQUIRED
The title of the Advance Directive to be rescinded must be ADVANCE DIRECTIVE
The title it is changed to when it is being rescinded must be RESCINDED ADVANCE
DIRECTIVE
Both LOCAL and National Standard titles must be as above. Variations on either title will cause the Change Title action to fail to watermark images as rescinded.
These exact titles are required by policy. See the VHA HANDBOOK 1004.02 section on Advance Directives: http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=2042
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Chapter 15: TIU Alert Tools
Starting with patch TIU*1*158, there is a new option in the TIU Management Menu that allows refresh and manipulation of TIU alerts, especially with respect to signatures. These tools are designed to assist CACs, and other users with TIU management responsibilities, to help control the backlog of unsigned notes. It accomplishes this by providing flexible control over alert generation.
The following actions are available:
BROWSE DOCUMENT—If authorized, presents a read only view of a selected document.
CHANGE VIEW—Allows entry new search criteria.
COMBINATION ALERTS—Allows the sending of new alerts for single or multiple documents to the expected signers (AUTHOR/
DICTATOR, EXPECTED COSIGNER/ATTENDING
PHYSICIAN, and ADDITIONAL SIGNER(S)) and one or more third parties. RESEND rules outlined below apply for a document's expected signers.
DELETE ALERTS—Allows deletion of all the alerts for a single or multiple documents.
DETAILED DISPLAY—If authorized, allows the viewing of document details.
EDIT DOCUMENT—If authorized, allows the editing a selected TIU document.
IDENTIFY SIGNERS—If authorized, allows the editing of the expected signers of a TIU document and removal of additional signers.
RESEND ALERTS—Allows the regeneration of alerts for a single document or multiple documents; all alerts associated with each document are deleted before being resent. Previously sent 3rd Party Alerts would be deleted and need to be resent. Alerts are sent appropriate to the document's status and only to expected signers as follows:
The Author/Dictator & Expected Co-signer/Attending—only receive alerts if they have not signed.
Additional Signer(s)—will only receive alerts if the document has been signed.
THIRD PARTY ALERTS—Allows the sending of new alerts for a single document or multiple documents to one or more third parties regardless of the document's status.
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Business rules are checked and adhered to, so while anyone who has access to this option can use it, you may be blocked from certain functions such as viewing unsigned notes.
In the following example, TUI Alert Tools are accessed through the TIU Maintenance
Menu [TIU IRM MAINTENANCE MENU], a year of notes are checked for Dr. Snow, then alerts are resent for an unsigned note:
Select TIU Maintenance Menu Option: ?
1 TIU Parameters Menu ...
2 Document Definitions (Manager) ...
3 User Class Management ...
4 TIU Template Mgmt Functions ...
5 TIU Alert Tools
5 TIU Alert Tools [TIU ALERT TOOLS]
6 Active Title Cleanup Report [TIU ACTIVE TITLE CLEANUP]
7 TIUHL7 Message Manager
Enter ?? for more options, ??? for brief descriptions, ?OPTION for help text.
Select TIU Maintenance Menu Option: 5 TIU Alert Tools
Select DOCUMENT STATUS: UNSIGNED// ?
1 undictated 5 unsigned 9 purged
2 untranscribed 6 uncosigned 10 deleted
3 unreleased 7 completed 11 retracted
4 unverified 8 amended
Enter selection(s) by typing the name(s), number(s), or abbreviation(s).
Select STATUS: UNSIGNED// ALL undictated untranscribed unreleased
unverified unsigned uncosigned completed
amended purged deleted retracted
Select SEARCH CATEGORY: AUTHOR// ?
1 Author 3 Expected Cosigner 5 Additional Signer
2 Dictator 4 Attending Physician
Enter selection(s) by typing the name(s), number(s), or abbreviation(s).
Select SEARCH CATEGORY: AUTHOR// ALL Author Dictator Expected Cosigner
Attending Physician
Additional Signer
Select NEW PERSON: TIUPROVIDER,SEVEN CRS PHYSICIAN
Start Reference Date [Time]: T-7//t-365 (JUN 04, 2002)
Ending Reference Date [Time]: Jun 04, 2003// <Enter> (JUN 04, 2003)
Searching for the documents.... TIU Alert Tools Jun 04,
2003@14:01:48 Page: 1 of 1.
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Clinical Documents 5 Documents
by (ADD'L SIGNER,AUTHOR,DICTATOR,EXPECTED COSIGNER,ATTENDING PHYSICIAN)
for (TIUPROVIDER,SEVEN) from 06/04/02 to 06/04/03
Patient Document Ref Date Status .
1 TIUPATIENT,FO (T8832) OT ASSESSMENT NOTE 09/09/02 completed
2 TIUPATIENT,FO (T8832) Cardiology Note 09/23/02 unsigned
3 TIUPATIENT,FI (T0150) ONE-PER-VISIT NOTE 12/18/02 completed
4 TIUPATIENT,SI (T3323) Discharge Summary 02/27/03 unreleased
5 TIUPATIENT,SE (T6351) H&P GENERAL MEDICINE 02/27/03 completed
Enter ?? for more actions >>>
Browse Edit
Change View Identify Signers
Combo Alert(s) Resend Alert(s)
Delete Alert(s) Third Party Alert(s)
Detailed Display
Select Action:Quit// R Resend Alert(s)
Select Document(s): (1-5) 2
Resend Alerts for the following documents:
2 TIUPATIENT,FOUR (T8832) Cardiology Note 09/23/02 unsigned
Send these alerts as OVERDUE? NO// Y YES
Is this correct? YES// <Enter>
Sending Alerts....
Finished.
Enter RETURN to continue or '^' to exit:
Alert Tools FAQ
Q. My search results by an ADDITIONAL SIGNER and UNSIGNED documents aren't showing any matches but I know they exist. What's wrong?
A. Additional signers are usually added AFTER a document has been signed or co-signed. Add UNCOSIGNED and COMPLETED documents to your search criteria.
Q. I want to regenerate alerts for an UNCOSIGNED document, but I don't want the AUTHOR to get alerted. Should I just send a 3rd Party Alert to the
EXPECTED COSIGNER?
A. You could, but if you select RESEND ALERTS, the regenerated alerts are context sensitive and sent only to individuals that have NOT signed the document; in this case, only the EXPECTED COSIGNER and any
ADDITIONAL SIGNERS that have not signed will be alerted.
Q. I selected RESEND ALERTS and my 3rd Party Alerts disappeared! What happened?
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A. A document's alerts are deleted before being regenerated so that they remain accurate regarding the document's status; 3rd Party Alerts are deleted as well and must be resent since they are not officially part of the document's record and cannot be automatically regenerated.
Q. I changed the ADDITIONAL SIGNER for a document using IDENTIFY
SIGNERS, but it didn't update in the display. Why not?
A. Because there can be more than one ADDITIONAL SIGNER, unless the
ADDITIONAL SIGNER matches the search criteria, it won't be displayed.
Q. I added an ADDITIONAL SIGNER for a document using IDENTIFY
SIGNERS, but it didn't update in the display. Why not?
A. Because there can be more than one ADDITIONAL SIGNER, unless the
ADDITIONAL SIGNER matches the search criteria, it won't be displayed.
Q. The AUTHOR of several documents (requiring co-signature) is gone and I want to regenerate the alerts for the EXPECTED COSIGNER so they can
SIGN and COSIGN these UNSIGNED documents. Should I use RESEND?
A. It depends. Default alert behavior would be to send the alert AFTER the author has signed and in this case, the EXPECTED COSIGNER would have never received the alerts initially or even after using RESEND.
However, with TIU*1*151, a new document parameter was added that could be set so that the EXPECTED COSIGNER could receive the alert
IMMEDIATELY; even if the AUTHOR has not signed.
This parameter is shown below:
------
SEND COSIGNATURE ALERT: After Author has SIGNED// ?
Specify when the alert for cosignature should be sent
Choose from:
0 After Author has SIGNED
1 Immediately
------
If you have NOT specifically set this parameter or have it set to "After Author has SIGNED", you'll need to use a 3rd Party Alert to the EXPECTED
COSIGNER or change the parameter's setting to "Immediately" before using
RESEND.
If you HAVE set this parameter to "Immediately", you can use RESEND.
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Q. I used RESEND ALERT and the EXPECTED COSIGNER didn't get alerted! Why?
A. Two possible reasons. The first, please see the question just before this one.
The second, the EXPECTED COSIGNER may be inactivated or DIUSER'd.
Currently, kernel does not alert these individuals who are inactive or terminated.
TIU*1.0*158 will inform the user that an individual entered as a 3rd Party
Alert recipient is inactive/DIUSER'd. However, it does not verify every individual attached to a document since this would be too system intensive and time consuming on a batch send of alerts.
Q. I used RESEND ALERT and no alerts were resent to anyone, even though it appeared that alerts were being re-generated. Why?
A. While TIU may create and attempt to regenerate the alerts (this will always happen if TIU Alerts attempts to fulfill a user's request), it has no way of actually confirming whether or not kernel will send an alert to an individual associated with a document (See #7).
The important rule to remember is that kernel will not actually send alerts to inactivated or terminated users.
Additionally, TIU sends alerts based on the current status of the document and whether or not the recipient still needs to sign the document. If an individual has already signed, they should not receive an alert. However, if a user associated with a document has already signed and they are sent a 3RD
PARTY ALERT, they will receive another alert.
Q. I sent the AUTHOR (who has already signed) a 3RD PARTY ALERT and now they can't process it! What should I do?
Just RESEND ALERTs for that document. All alerts will be deleted and regenerated; 3RD PARTY ALERTS that had been manually generated will have to be re-entered (See #3).
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Chapter 16: HL7 Generic Interface
The purpose of the HL7 Generic Interface is to create a Health Level Seven (HL7) line to
Text Integration Utilities (TIU) that will support the upload of a wide-range of textual documents from Commercial-Off-the-Shelf (COTS) applications in use now and in the future at Veteran Administration (VA) Medical Centers. Projects that may work with the interface are the Remote Order Entry System (ROES) software used by the Denver
Distribution Center (DDC), the Precision Data Solutions Transcription Service software, and the VA Home Telehealth software.
The project creates a single COTS/application interface specification to allow textual documents to be uploaded and displayed in CPRS. This allows clinicians to view information from the COTS package without leaving the patient’s electronic medical record.
Generic HL7 will not work with external software unless it is specifically set up to do so.
The details of how to do this are contained in the Text Integration Utilities (TIU) Generic
HL7 Handbook. This handbook describes the HL7 fields required for each document types and gives additional information on system features and vendor guidelines. To retrieve this document go to the VistA Document Library at ( http://www.va.gov/vdl/ ), then click on CPRS: Text Integration Utility (TIU).
Message Manager
The only place where the Generic HL7 Interface is visible is in the TIU Maintenance
Menu. The TIUHL7 Message Manager has been added to this menu to assist medical center in setting up the interface.
If an error message is returned, it will be contained in clear text explaining the error.
The following is an example of using the HL7 message Manager to check an error message:
Select TIU Maintenance Menu Option: ?
1 TIU Parameters Menu ...
2 Document Definitions (Manager) ...
3 User Class Management ...
4 TIU Template Mgmt Functions ...
5 TIU Alert Tools
6 Active Title Cleanup Report
7 TIUHL7 Message Manager
Select TIU Maintenance Menu Option: 7 TIUHL7 Message Manager
Searching for messages.....
Refresh Message List
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TIUHL7 Received Messages
Receiving Sending Message
Message ID Date/Time Processed Application Application Status
1 99953044 Jul 31, 2006@11:24:53 TIUHL7 HTAPPL Rejected
2 99953046 Jul 31, 2006@11:27:14 TIUHL7 HTAPPL Rejected
3 99953048 Jul 31, 2006@11:28:44 TIUHL7 HTAPPL Accepted
4 200T40029200608 Aug 02, 2006@11:35:11 TIUHL7 HTAPPL Accepted
5 200T40003200608 Aug 02, 2006@14:28:14 TIUHL7 HTAPPL Accepted
6 99953050 Aug 02, 2006@15:45:41 TIUHL7 HTAPPL Accepted
Enter ?? for more actions
View Message Delete Message(s)
Refresh Message List
Select Action: Quit// 2
Note Error message.
TIUHL7 Message Viewer Aug 04, 2006@15:47:22 Page: 1 of 1
MSA^AR^99953046^TIUHL7^HTAPPL
ERR^PV1^44^^0000.00~Could not find a visit for Jul 31, 2006@16:21.
MSH^~|\&^HTAPPL^00T5~VAWW.VITERION.CC.MED.VA.GOV~DNS^TIUHL7^689~ANONYMOUS.MED.V
A.GOV~DNS^20060731092708-0700^^MDM~T02~MDM_T02^99953046^T^2.4^^^AL^AL^USA
EVN^T02
PID^^^~~~USVHA~NI|~~~USSSA~SS|290~~~USVHA~PI||^^TIUPATIENT~FIVE
PV1^^^GI WALK-IN^^^^^^^^^^^^NEW^^^^^^^^^^^^^^^^^^^^^^^^^20040626011903
TXA^^^TEXT^200607311621^^^^^33271~TIUPROVIDER~THREE~~~~~USVHA^~^^~USVHA^^^^PROGR
E
SS NOTE^^^^^^~~~~~~~~~~~~~~~~~~~~~~~~~~~~
OBX^1^TX^SUBJECT~This is the subject ^^NEW TEST TODAY NEW Location NEW TEST n ew REF date for GI WALK-IN .
Enter ?? for more actions
Delete Message Reprocess Message
Select Item(s): Quit//
The messages displayed by the Message Manager are from the XTEMP Global, which is set to delete messages after seven (7) days. In other words, VistA discards HL7 messages that are more than seven (7) days old.
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Chapter 17: Helpful Hints/Troubleshooting
FAQs (Frequently Asked Questions)
NOTE: Most of these questions were received from TIU/ASU test sites. Thanks to
everyone who contributed!
Q: We just entered all of our Providers into the Person Class file (when the Ambulatory
Care Reporting Project came out). Do we have to do this all over again for the User Class file in ASU? Why can’t TIU and ASU just use the Person Class?
A: The Provider Class in ASU fulfills a different function, and therefore its database design is a different kind of hierarchy.
A patch to ASU in the near future will help assure that your efforts in populating the Person Class Membership at your site are not lost, or repeated. We are developing a mapping between a subset of the exported User Classes and the Person Class File (i.e., for each Person Class, there will be a corresponding User Class), which will help you
“autopopulate” User Class Membership, assure that future changes to an individual’s
Person Class Membership are reflected automatically in his User Class Membership, and allow resolution of privileges for inter-facility access to data. We recommend that you initially implement TIU and ASU by populating only the most essential User Classes (i.e.,
Provider; MRT; Chief, MIS; and Transcriptionist), and use the forthcoming patch to assist you in autopopulating more specific User Classes when you have become acquainted with the two products.
Q: We’ve heard that implementation of TIU is very complex and time-consuming. How long does is take?
A: TIU implementation is complex, but the amount of time it takes to implement has to do with the complexity of the site how many users; how big the database is; how extensive the hierarchy is; the level of users; how dependent the site is on the package
(obviously a site that is totally electronic has very different issues than a site where participation is optional. It took a test site with a million+ notes about 2.5 weeks to run their Progress Notes conversion.
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FAQs cont’d
Q: Will the Discharge Summary and Progress Notes packages be gone once files are converted to TIU?
A: Discharge Summary V. 1.0 and Progress Notes V. 2.5 should be made "Out of Order" once the conversions have been run, staff trained, and the cut-over started. The data in files 121 and 128 will remain until your site decides to purge these files. We suggest that they remain intact until you're sure the conversions have run correctly and the implementation is going smoothly.
Q: Can TIU be used without converting the Discharge Summaries until much later?
A: TIU can be used without converting Discharge Summary, but we strongly recommend that Progress Notes and Discharge Summary both be converted to TIU at the same time, to avoid complications.
NOTE: You cannot run dual implementations of Discharge Summary; that is,
Discharge Summary 1.0 and Discharge Summary through TIU.
Q: Is it possible to load ASU in production and start populating the groups before we load TIU?
A: Yes you can. The Business Rules will not be functional because they are tied to the
Document Definition File, but you will be able to populate the Class memberships.
Q: Do we have to delete or sign unsigned notes before we can convert them?
A: No, you don’t have to delete or sign the unsigned notes. The conversion will move them as is. However, you probably don’t want to be moving old, irrelevant notes from one package to the other. By the way, notes for test patients are NOT moved; they are ignored.
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FAQs cont’d
Q: Can we require a Cosignature for a particular note?
A. Yes, you can set Cosignature requirements for document classes or titles. Use the option Document Parameter Edit, as described in the TIU Implementation Guide.
Individual clinicians can designate an expected Cosigner through their Personal
Preferences option (described on page 64 of this manual).
Q Why do we have to enter Visits and encounter data for Progress Notes? What are
“Historical Visits”?
A: Visit data is now required for every outpatient encounter. The vast majority of
Progress Notes are already linked to an admission and don’t require additional visit information to be added.
A historical visit or encounter is a visit that occurred at some time in the past or at some other location (possibly non-VA). Although these are not used for workload credit, they can be used for setting up the PCE reminder maintenance system, or for other non-workload-related reasons.
NOTE: If month or day aren’t known, historical encounters will appear on encounter screens or reports with zeroes for the missing dates; for example, 01/00/95 or 00/00/94.
Q: Are there any terminal settings that we need to be aware of for TIU? On the VT400 setting in Smart Term, the bottom half of the Create Document Definitions screen was not scrolling properly. It was writing over previous lines and got very confusing!
A: Various terminal emulators can affect applications using the List Manager interface.
The VT220 and 320 work very well with List Manager.
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FAQs cont’d
Q: I have gotten my 600 clinic and ward locations set up, but when I try to print by ward I am only allowed to print to a printer. This is not true under the Print by Hospital Location, where I can print to the screen. What is the difference?
A: Print by Ward is designed to support batch printing. It has the unique ability to determine when the last note was printed so that sites can now capture the infamous “orphan” note which was a problem under Progress Notes 2.5. You might consider adding a message on entry into the option to inform users that they can only print to a printer (not on screen).
Q: Can we share business rules with other sites.
A: It isn’t yet known how appropriate or desirable it is to share business rules amongst sites. The package is exported with all the business rules needed to run the standard package. The differences are usually on a medical center basis.
For example, one site wants all users to be able to see all UNSIGNED notes. ON the flip side, another site doesn’t want any users to be able to print or view UNCOSIGNED notes until the cosigner has signed. Two very different views. Just because you are in the same
VISN doesn’t mean you would view these issues in the same light. Another example is the hospital that wants to restrict the entering/viewing/ printing of every Progress Note by
TITLE. You can do this, but it is not something we would recommend.
We strongly recommend that you work with the exported business rules for awhile before making any changes.
Q: When I read my Discharge Summaries after they come back from the transcriptionist, there are dashes (or other funny characters) sprinkled throughout; what do these mean and what am I supposed to do?
A: These characters (your site determines whether they will be dashes, hyphens or some other character) indicate words or phrases that the transcriptionist was unable to understand. You need to replace these with the intended word or phrase before you’ll be able to sign the document.
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FAQs cont’d
Q: What is the best editing/word-processing program and how can I learn how to use it?
A: This is partly a matter of personal preference and partly a matter of what’s available at your site. Commercial word-processors are available at some sites.
The FileMan line editor and Screen Editor are available at all sites. Of these two, most Discharge Summary users prefer the Screen Editor. Your IRM office or ADPACs can help you get set up with the appropriate editor and provide training. The Clinician Quick Reference Card summarizes the
FileMan Screen Editor functions.
Q: Why should a site require “release from transcription”?
A: Release from transcription is required to prevent a discharge summary from becoming visible to other users before the person entering the summary has completed the entry. For example, if a transcriptionist needed to leave the terminal, the summary would not be available for anyone else to look at until the summary is “released from transcription.”
Q: Why can’t we use extended ASCII characters (e.g., °, ≥, ∆, etc.) in our documents to be uploaded?
A: These alternate character sets are not standardized across operating systems and your MUMPS system may not be set up to store them.
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Questions about Reports and Upload
Q: At present we put all discharges in the Discharge Summary package. We do allow
Spinal Cord Injury to put “interim” summaries in on their patients every 6 months or annually. These reports stack up under the admission date and are all under that one date upon discharge.
When patients are transferred to the Intensive Care Units, they may have a very long/complicated summary to describe the care while in the unit. This should be an interward transfer note, but some of our physicians feel that due to the complexity of care delivered in the unit, this should be included in their Discharge Summary, BUT should have its own date (episode of care). I realize that the interward transfer note is a progress note and very few of our physicians are using progress notes. Our physicians seem to want to have that interward transfer information in these complex cases attached to the
Discharge Summary.
My question is will TIU offer us anything different that will satisfy our physicians? I still do not have a mental picture of what it will look like when I go to look up a DCS or PN from the TIU package. Will the documents be intermingled and arranged by date? I am a firm believer in calling things what they are and putting them where they belong when it comes to organizing our electronic record. I hate to see the DSC and interward transfers go together now in the DCS package as it does create a problem when the patient is actually discharged and Incomplete Record Tracking (IRT) thinks he was discharged when the interim was written. Does anyone have any thoughts and can someone show me how it looks when I get TIU and look up documents on a patient?
A: From: TIU Developer
Interim Summaries may be easily defined in TIU, and linked with the corresponding IRT deficiency. Parameters determining their processing requirements, as well as the format of a header for uploading them in mixed batches with Discharge
Summaries, Operative Reports, C&P exams, and Progress Notes can all be defined without modifying any code. A patch will be necessary to link them to a specific transfer movement, and to introduce a chart copy of the appropriate Standard Form. This involves a modest programming effort, but will have to be prioritized along with a number of other requests.
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FAQs cont’d
We need the help of the user community to try to sort out the relative priorities of each of these tasks, along with your patience, as we work to deliver as many of them as possible, as timely as possible...
A: From a user/coordinator:
A possible solution to the problem of rotating residents is to set up your summary package with the author not needing to sign the summary. This allows the attending physician to sign the report. While the residents may rotate in and out, the attending usually remains the same through the course of the patients stay.
Q. What are sites doing with C&Ps, & op notes?
It is my understanding that C&Ps are a type of discharge summary.
I’ve tried creating “C&P EXAM” as a title underneath the “DISCHARGE
SUMMARY” document class. I get TYPE errors when uploading test documents. The document parameters are defined for the upload fields.
A: From a user/coordinator: OP reports and C&P exams reside in their appropriate packages. You can use the TIU upload utility to put them there.
As for OP notes, we have several titles (i.e. Surgeon’s Post-OP note). file?
Do you have TIU in the APPLICATION GROUP field of the Surgery and C&P
Our FILE File has this for our Surgery file:
NUMBER: 130 NAME: SURGERY
APPLICATION GROUP: GMRD
APPLICATION GROUP: TIU
Q: Can we do batch upload of Progress Notes by vendor through TIU?
A: Yes, you may now batch upload Progress Notes through TIU. See instructions earlier in this manual (under Setting Parameters) or in the TIU Technical Manual.
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Q: Currently our Radiology reports are uploaded by the vendor. Can this functionality be built into TIU?
A: You may upload Radiology Reports, but it will be necessary to write a LOOKUP
METHOD to store several identifying fields in the Radiology Patient File. The remainder are stored in the Radiology Reports File, along with the Impression and Report Text. (The
TIU and Radiology development teams will work together on a lookup method, as development priorities allow.)
Q: We have hundreds of entries in files 128.1 and 128.5 to be cleaned up, because many duplicate discharge summaries were mistakenly uploaded by the transcriptionists of our vendor. How can we clean up these files?
A: You can use the Individual Patient Document option on the GMRD MAIN MENU
MGR menu, along with VA FileMan, to clean up the Discharge Summary files.
Questions about Document Definition
(Classes, Document Classes, Titles, Boilerplate text,
Objects)
Q: After the initial document definition hierarchy is built and used, can we modify the hierarchy structure if we feel it is incorrectly built? How flexible is this file?
A: Once entries in the hierarchy are in use, you can’t move them around. It would be wise to think your hierarchy through before installation. Don’t rush the process. If necessary, create new classes, document classes, and titles (the Copy function streamlines creating new titles), and deactivate the old ones. The users won’t be aware of the change if the
Print Name is the same, but the .01 Name is new.
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FAQs cont’d
Q: Who creates titles and boilerplates at a site?
A: Many test sites restrict the creation of titles and boilerplates as much as possible. At one site, users submit a request for a title or boilerplate. IRMS or the clinical coordinator create the boilerplate and/or title and forward it to the Chairman of the Medical Records
Committee for approval. Once approved it is made available for use. Titles are namespaced by service and the use of titles is restricted by user class. With the ability to search by title, keeping the number of titles small and their use specific can be very useful;.e.g. patient medication education is documented on an electronic progress note and can be reviewed easily.
Some of the other sites allow the ADPACs to create boilerplates without going through such a formal review process. Another site restricts this function to the Clinical
Coordinator. It was designed so that sites can do whatever they are most comfortable with.
Q: The root Class supplied with the package is CLINICAL DOCUMENTS. Can a peer class level be made using our configuration options? Ex: ADMINISTRATIVE
DOCUMENTS
A: You cannot enter a class on the same level as Clinical Documents.
In TIU Version 1.0, entries can only be created under Clinical
Documents.
Q: I’ve changed the technical and print names for a Document Class, but it doesn’t seem to have changed when I select documents across patients. What am I doing wrong?
A: When you select documents across patients, you are presented with a three-column menu. The entries in this menu are from the Menu Text subfield of the Item Multiple. To make a consistent change, you must update Menu Text as well as Print Name when you change a Document Definition name.
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Q: How can I print when I’m in Document Definitions options?
A: All Document Definitions printing is done using the hidden actions Print Screen and
Print List. First, locate the data to be printed so that it shows on the screen and then select either the action PS or PL. To locate the appropriate data use the Edit, Sort, or Create option to list appropriate entries.
To print a list, select the PS or PL action at this point. To print information on a single given entry, first locate the entry in one of the above lists, then select either the
Detailed Display action or the Edit Items action. Edit View shows all available information for a given entry. Edit Items shows the items of a given entry. Then select PS or PL. Enter PS for Print Screen to print the current display screen. It only prints what is currently visible on the screen, ignoring information that can be moved to horizontally or vertically (pages), so you should move left/right and up/down to the desired information before printing.
Enter PL for Print List to print more than one visible screen of information. Print List prints the entire vertical list of entries and information, including entries and information not currently visible but which are displayed when you move up or down. If the action is selected from the leftmost position of the screen, you’re asked whether to print ALL columns or only those columns visible on the current leftmost position of the screen. If you select the action after scrolling to the right, only the currently visible left/right columns are printed.
Q: Is it possible for sites to share objects they create locally?
A: As sites develop their own Objects, they can be shared with other sites through a mailbox entitled TIU OBJECTS in SHOP,ALL (reached via FORUM).
NOTE: Object routines used from SHOP,ALL are not supported by the CIO Field
Offices (formerly known as ISCs or IRMFOs). Use at your own risk!
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Helpful Hints/Troubleshooting, cont’d
Q:
Is there any way to change the Title of a Progress Note? For example, if I want to change one of my CWAD notes to a Nursing Psychology note, is that possible?
A:
Yes. Use the “hidden” action Change Title.
Q: Is there a way to access progress notes that have been linked to a problem? I can’t seem to find how this is done.
A: Assuming that notes are being linked to problems, you can use the Show
Progress Notes Across Patients option to search for notes by Problem. When prompted to Select SEARCH CATEGORIES:, enter Problem.
Select Progress Notes User Menu Option: Show Progress Notes Across
Patients
Select Status: COMPLETED// ALL undictated untranscribed unreleased unverified unsigned uncosigned completed, amended purged deleted
Select Progress Notes Type(s): ALL Advance Directive, Adv React/Allergy Crisis Note
Clinical Warning Historical Titles
Select SEARCH CATEGORIES: AUTHOR// PROB Problem
Select PROBLEM: ANGINA PECTORIS, UNS
2 matches found
1 Angina pectoris, unstable
2 Other and unspecified angina pectoris
Type “^” to STOP or Select 1-2: 1
Start Reference Date [Time]: T-2// T-9999 (JAN 20, 1970)
Ending Reference Date [Time]: NOW// <Enter> (JUN 06,1997@09:00))
Searching for the documents.
Of course, this query has several limitations:
Only one problem may be selected at a time (i.e., you can’t select ANGINA PECTORIS OR AIHD as a search criterion)
Problems can’t be “grouped” or expressed ambiguously (e.g., a search for ANGINA PECTORIS, rather than ANGINA PECTORIS, UNSTABLE, would not have found this record), and
The only way for this benefit to be exercised at all is for the clinicians at your facility to be actively using Problem List.
Still, if you’re interested in a focused search for all notes about a specific problem, and if your facility has committed to the use of the Problem List package, this can be a powerful asset for retrospective research, utilization review, and epidemiological studies. With the
Preventive Measures for certain chronic diseases being made part of the Director’s performance appraisal, being able to easily pull notes that document what was done for those problems is of HIGH importance.
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Facts & Helpful information
Action abbreviations on List Manager screens
The TIU and ASU packages don’t use mnemonics (abbreviations or numbers) for actions
(protocols) on List Manager screens, partly because it’s difficult to make them consistent with other packages and what users expect. Sites, however, can feel free to add whatever their users would like to have (e.g., $ for Sign).
Shortcuts
At any “Select Action” prompt, you can type the action abbreviation, then the = sign and the entry number (e.g., E=4).
Jump to Document Def in the Edit Document Definition option takes you directly to a document definition (Class, Document Class, or Title) if you know the name.
When reviewing several notes, the up-arrow (^) entry takes you to the next note. To exit from the review, enter two up-arrows (^^).
Visit Information
When you enter a Progress Note for an outpatient, this Progress Note now needs to be associated with a “visit.” For the majority of Progress Notes, this visit association is done in the background, based on Scheduling or Encounter Form data. If a visit has already been recorded for the date your Progress Note refers to, but the Progress Notes wasn’t linked (e.g., for standalone visits such as telephone or walk-in visits), you can select a visit from the choices presented to you during the PN dialogue. If no visit has been recorded, you must create a new visit. See the example below.
Example: Entry of Progress Note which needs Visit Information
Select PATIENT NAME: TIUPATIENT,FIVE TIUPATIENT,FIVE 4-9-46 666668829
YES SC VETERAN
(7 notes) D: 07/11/00 08:41
A: Known allergies
Enter RETURN to continue or '^' to exit: <Enter>
Enrollment Priority: GROUP 3 Category: IN PROCESS End Date:
Available notes: 11/25/1998 thru 07/13/2000 (71)
Do you wish to see any of these notes? NO// <Enter>
TITLE: ADVERSE 11/12 ADVERSE REACTION/ALLERGY TITLE
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Example: Entry of Progress Note, cont’d
This patient is not currently admitted to the facility...
Is this note for INPATIENT or OUTPATIENT care? OUTPATIENT// <Enter>
The following SCHEDULED VISITS are available:
1> JUN 29, 1999@08:00 ONCOLOGY
2> JUN 24, 1999@11:00 NO ACTION TAKEN ONCOLOGY
3> JUN 24, 1999@10:00 NO ACTION TAKEN ONCOLOGY
4> JUN 24, 1999@09:00 NO ACTION TAKEN CARDIOLOGY
5> JUN 24, 1999@08:00 GENERAL MEDICINE
CHOOSE 1-5, or
<U>NSCHEDULED VISITS, <F>UTURE VISITS, or <N>EW VISIT
<RETURN> TO CONTINUE
OR '^' TO QUIT: N
PATIENT LOCATION: GENERAL MEDICINE// <Enter>
Enter Visit Date/Time: NOW// <Enter> (JUL 13, 2000@09:21:24)
TYPE OF VISIT: AMBULATORY// <Enter> (WALK-IN) AMBULATORY (WALK-IN)
Enter/Edit PROGRESS NOTE...
Patient Location: GENERAL MEDICINE
Date/time of Visit: 07/13/00 09:21
Date/time of Note: NOW
Author of Note: TIUPROVIDER,SEVEN
...OK? YES//<Enter>
Calling text editor, please wait...
1>Treatment for allergic reaction to injury.
2><Enter>
EDIT Option: <Enter>
Saving Adverse React/Allergy with changes...
Is this Adverse React/Allergy ready to release from DRAFT? YES// <Enter>
Adverse React/Allergy Released.
Enter your Current Signature Code: <Enter Signature> SIGNATURE VERIFIED..
Select PRIMARY PROVIDER: TIUPROVIDER,SEVEN // <Enter> TIUPROVIDER,SEVEN
CRS PHYSICIAN
Please Indicate the Diagnoses for which TIUPATIENT,FOUR was Seen:
18 Ascites 34 Shoulder
1 Abdominal Pain 19 ASHD MISC (2)
2 Abnormal EKG 20 Asthma 35 DIETARY SURVEIL/COUN
3 Abrasion 21 Atrial Fibrillation 36 Cataract(s)
A list of diagnoses
5 Adverse Drug Reactio 23 Avulsion, Fingernail 38 Cardia Arrthythmia
relating to the clinic, as
6 AIDS/ARC BITE: 39 Cerebral Concussion
defined using the AICS
8 Alcoholism, Chronic 25 Insect Bite 41 Chest Pain
package, is presented
9 Allergic Reaction MISC 42 Chest Wall Pain
for you to choose from.
ANGINA: 27 Blurred Vision 44 Cholecystitis
11 Stable 28 BPH 45 Cirrhosis
12 Unstable 29 Bronchitis, acute 46 Conjunctivitis
13 Anorexia BURN: 47 Constipation
14 Appendicitis, Acute 30 First Degree 48 Contusion
15 Arthralgia 31 Second Degree 49 COPD
ARTHRITIS 32 Third Degree 50 Costochodritis
16 Osteo BURSITIS: 51 CVA
17 Rheumatoid 33 Elbow 52 Cyst, Pilonidal
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Example: Entry of Progress Note, cont’d
A list of procedures
Please Indicate the Procedure(s) Performed on TIUPATIENT,EIGHT
defined using the AICS package, is presented for you to choose from.
2 Limited Exam 18 Pericardiocentesis 30 Elbow
3 Intermediate Exam 19 Thoracotomy 31 Nasal
4 Extended Exam ENT 32 Phalanx
5 Comprehensive Exam 20 Removal Impacted Cer 33 Radial Head
ESTABLISHED PATIENT NASAL CAUTERING AND 34 Shoulder
6 Brief Exam 21 Anterior, Simple 35 Temporomandibular
7 Limited Exam 22 Anterior, complex 36 Finger Splint
8 Intermediate Exam 23 Posterior 37 Forearm Splint
9 Extended Exam EYE 38 Injection Tendon She
10 Comprehensive Exam 24 Foreign Body Removal LIGAMENT/TRIGGER
CONSULTATIONS -26 PROFESSIONAL C PULMONARY
11 Brief Visit -32 MANDATED SERVI 39 Admin Oxygen
12 Limited Visit 25 Air ambulance servic 40 Inhalation Therapy
13 Intermediate Visit 26 PET follow SPECT 41 Peak Flow Spirometry
14 Extended Visit ORTHOPEDIC UROLOGY
15 Comprehensive Visit ARTHROCENTESIS 42 Foley Catherter
27 Intermediate MISCELLANEOUS
CARDIOVASCULAR 28 Major Joint (shoulde I&D
Select Procedures (<RETURN> to see next page of choices): (1-42): 24
43 Abcess
SIMPLE REPAIR, WOUND
44 Less than 2.5 cm
45 2.6 - 7.5 cm
46 Greater than 7.5 cm
SOFT TISSUE:
47 Burns 1 * Local Trea
48 Dressings Medium
49 Dressings Small
50 Transfusion
51 Venipuncture
52 OTHER Procedure
Select Procedures: (1-52): 48
FOREIGN BODY REMOVAL W/ MOD W/ MOD X 2:
How many times was the procedure performed? 1// <Enter>
Current CPT Modifiers:
-26 PROFESSIONAL COMPONENT
-32 MANDATED SERVICES
Select another CPT MODIFIER: ??
Choose from:
22 UNUSUAL PROCEDURAL SERVICES
23 UNUSUAL ANESTHESIA
26 PROFESSIONAL COMPONENT
32 MANDATED SERVICES
47 ANESTHESIA BY SURGEON
50 BILATERAL PROCEDURE
51 MULTIPLE PROCEDURES
52 REDUCED SERVICES
53 DISCONTINUED PROCEDURE
54 SURGICAL CARE ONLY
55 POSTOPERATIVE MANAGEMENT ONLY
56 PREOPERATIVE MANAGEMENT ONLY
57 DECISION FOR SURGERY
A list of CPT Modifiers can be printed out by entering two question marks (??) at the prompt.
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Example: Entry of Progress Note, cont’d
58 STAGED OR RELATED PROC BY SAME PHYS DURING POSTOP PERIOD
59 DISTINCT PROCEDURAL SERVICE
62 TWO SURGEONS
66 SURGICAL TEAM
73 DISC O/P HOSP/AMB SURG CENTER (ASC) PROC PRIOR ADMIN-ANESTH
74 DISC O/P HOSP/AMB SURG CENTER (ASC) PROC AFTER ADMIN-ANESTH
76 REPEAT PROCEDURE BY SAME PHYSICIAN
77 REPEAT PROCEDURE BY ANOTHER PHYSICIAN
78 RETURN TO OP ROOM FOR RELATED PROC DURING POSTOP PERIOD
79 UNRELATED PROC OR SERVICE BY SAME PHYS DURING POSTOP PERIOD
80 ASSISTANT SURGEON
81 MINIMUM ASSISTANT SURGEON
82 ASSISTANT SURGEON (WHEN QUAL RES SURGEON NOT AVAIL)
90 REFERENCE (OUTSIDE) LABORATORY
99 MULTIPLE MODIFIERS
AA ANESTHESIA PERF BY ANESGST
AS PA,NP,CN ASSIST-SURG
QX CRNA SVC W/ MD MED DIRECTION
QZ CRNA SVC W/O MED DIR BY MD
SG ASC FACILITY SERVICE
TC TECHNICAL COMPONENT
Select another CPT MODIFIER: 47 ANESTHESIA BY SURGEON
Select another CPT MODIFIER: <Enter>
DRESSINGS MEDIUM:
How many times was the procedure performed? 1// <Enter>
Select CPT MODIFIER: <Enter>
Was this encounter related to any of the following:
Service Connected Condition? Y YES
You have indicated the following data apply to this visit:
DIAGNOSES:
995.3 Allergic Reaction <<< PRIMARY
PROCEDURES:
65205 Foreign Body Removal W/ Mod w/ mod x 2
CPT Modifier(s):
-26 PROFESSIONAL COMPONENT
-32 MANDATED SERVICES
-47 ANESTHESIA BY SURGEON
16015 Dressings Medium
SERVICE CONNECTION:
Service Connected? YES
...OK? YES// <Enter>
Posting Workload Credit...Done.
Print this note? No// <Enter> NO
You may enter another Progress Note. Press RETURN to exit.
Select PATIENT NAME:
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Visit Orientation
Why associate Progress Notes with Visits?
Database design: An event (clinical or otherwise) may be fully described by five key attributes or parameters: Who, what, when, where, and why. Three of these (i.e., who, when, and where), are all encoded in the Visit File entry itself. The remaining two parameters (what, and why), are generally included in the content of the document.
The VHA Operations Manual, M-1, Chapter 5 requires that every ambulatory visit have at least one Progress Note. Deficiencies with respect to this requirement can only be identified if Progress Notes are associated with their corresponding Visits.
Inter-facility data transfer requires identification of the Facility from which the data originated. Because the Facility is an attribute of the Visit file entry, it is not necessary to maintain a reference to the facility with every clinical document.
Workload Capture, particularly for telephone and standalone encounters, where the only record of the encounter is frequently a Progress Note, can be easily accommodated, provided that notes are associated with visits.
“Roll-up” of documentation by Care Episode. To allow access to all information pertaining to a given episode of care (e.g., for close-out of a hospitalization), a visit orientation is essential.
Integration with PCE, Ambulatory Care Data Capture, and CIRN. The visit orientation provides a useful associative entity for interfaces with other clinical data repositories that allow query and report generation based on the existence of a variety of coded data elements. For example, a search of PCE to identify all patients with AIHD who were discharged without a prescription for aspirin prophylaxis might identify a cohort of patients for further evaluation. The ability to call for all the cardiology notes entered during the corresponding care episodes could revolutionize retrospective chart review).
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Glossary
ASU
238
Action
Boilerplate Text
Business Rule
Class
Clinician
Component
Authorization/Subscription Utility, an application that allows sites to associate users with user classes, allowing them to specify the level of authorization needed to sign or order specific document types and orderables. ASU is distributed with TIU in this version; eventually it will probably become independent, to be used by many V
IST
A packages.
A functional process that a clinician or clerk uses in the TIU computer program. For example, “Edit” and “Search” are actions. Protocol is another name for Action.
A pre-defined TIU template that can be filled in for
Titles, speeding up the entry process. TIU exports several Titles with boilerplate text which can be modified to meet specific needs; sites can also create their own.
Part of ASU, Business Rules authorize specific users or groups of users to perform specified actions on documents in particular statuses (e.g, an unsigned progress note may be edited by a provider who is also the expected signer of the note).
Part of Document Definitions, Classes group documents. For example, “Progress Notes” is a class with many kinds of progress notes under it.
Classes may be subdivided into other Classes or
Document Classes. Besides grouping documents,
Classes also store behavior which is then inherited by lower level entries.
A doctor or other provider in the medical center who is authorized to provide patient care.
Components are “sections” or “pieces” of documents, such as Subjective, Objective,
Assessment, and Plan in a SOAP Progress Note.
Components may have (sub)Compon-ents as items.
They may have Boilerplate Text. Components may be designated as “Shared.”
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CPRS
CWAD
Discharge Summary
Document Class
Document Definition
Glossary, cont’d
Computerized Patient Record System. A comprehensive V
IST
A program, which allows clinicians and others to enter and view orders,
Progress Notes and Discharge Summaries (through a link with TIU), Problem List, view results, reports
(including health summaries), etc.
Cautions, Warnings, Adverse Reactions, Directives; a type of Progress Note.
Discharge summaries are summaries of a patient’s medical care during a single hospitalization, including the pertinent diagnostic and therapeutic tests and procedures as well as the conclusions generated by those tests. They are required for all discharges and transfers from a VA medical center, domiciliary, or nursing home care. The automated
Discharge Summary module of TIU provides an efficient and immediate mechanism for clinicians to capture transcribed patient discharge summaries online, where they’re available for review, signing, adding addendum, etc.
Document Classes are categories that group documents (Titles) with similar characteristics together. For example, Nursing Progress Notes might be a Document Class, with Nursing Dialysis
Progress Notes, Nursing psychology Progress
Notes, etc. as Titles under it. Or maybe the
Document Class would be Psychology Notes, with
Psychology Nursing Notes, Psychology Social
Worker Notes, Psychology Patient Education Notes, etc. under that Document Class..
Document Definition is a subset of TIU that provides the building blocks for TIU, by organizing the elements of documents into a hierarchy structure. This structure allows documents (Titles) to inherit characteristics (such as signature requirements and print characteristics) of the higher levels, Class and Document Class. It also allows the creation and use of boilerplate text and embedded objects.
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Glossary, cont’d
HIMS
IRT
Interdisciplinary Note
MIS
MIS Manager
MRT
Hospital Information Management System, common abbreviation/synonym used at VA site facilities; also known as MIS (see below).
Incomplete Record Tracking, a package TIU can interface with to transmit incomplete progress notes and discharge summaries.
A new feature of Text Integration Utilities (TIU) for expressing notes from different care givers as a single episode of care. They always start with a single note by the initial contact person (e.g., triage nurse, case manager, attending) and continue with separate notes created and signed by other providers, then attached to the original note.
Common abbreviation/synonym used at VA site facilities for the Medical Information Section of
Medical Administration Service. May be called
HIMS (Health Information Management Section).
Manager of the Medical Information Section of
Medical Administration Service at the site facility who has ultimate responsibility to see that MRTs complete their duties.
Medical Record Technician in the Medical
Information Section of Medical Administration
Service at the site facility who completes the tasks of assuring that all discharge summaries placed in a patient’s medical record have been verified for accuracy and completion and that a permanent chart copy has been placed in a patient’s medical record for each separate admission to the hospital.
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Object
Progress Notes
TIU
Title
User Class
Glossary, cont’d
Objects are a device to extract data from other
V
IST
A packages to insert into boilerplate text of progress notes or discharge summaries. This is done by having a placeholder name embedded in the predefined boilerplate text of Titles, such as:
“PATIENT AGE.” The creator of the Object types the placeholder name into the boilerplate text of a
Title, enclosed by '|'s. If a Title has the following boilerplate text:
“Patient is a healthy |PATIENT AGE| year old male
...”
Then a user who enters such a note for a 56 year old patient would be presented with the text:
“Patient is a healthy 56 year old male ...” where the age for this specific patient is pulled from the patient database.
The Progress Notes module of TIU is used by health care givers to enter and sign online patient progress notes and by transcriptionists to enter notes to be signed by caregivers at a later date. Caregivers may review progress notes online or print progress notes in chart format for filing in the patient’s record.
Text Integration Utilities
Titles are definitions for documents. They store the behavior of the documents which use them.
User Classes are the basic components of the User
Class hierarchy of ASU (Authorization/
Subscription Utility) which allows sites to designate who is authorized to do what to documents or other clinical entities.
Rev. January 2012 Text Integration Utilities V. 1.0
Clinical Coordinator & User Manual
241
Index
<Enter>
121.2
8925
8925.1
Action
Action abbreviations
Actions
13
202
170
202
237
232
16, 50, 65
Add Document
Additional Signature
50, 65
75, 200
Additional Signatures 108
Admission- Prints all PNs for Current Admission 184
Alert Tools
Alert Tools FAQ
214
216
ALL Documents requiring my Additional Signature 66
All MY UNSIGNED Discharge Summaries 62
All MY UNSIGNED Documents
All MY UNSIGNED Progress Notes
66, 69
43 allow edit
Ambulatory Care Data Capture
Amended
18
236
49, 64
ANATOMIC PATHOLOGY (AP)
ASCII
ASCII characters
ASCII file transfer
ASCII Protocol Upload
ASU
ATTENDING
Author( Print Progress Notes
Batch printing
Batch upload
Batch upload of Progress Notes
Batch Upload Reports
Benefits
Boilerplate
Boilerplate Text
Boilerplates
Business Rule
Business Rules
C&P EXAM
210
10
225
167
167, 168
208, 237
161
45, 183
195, 224
227
227
166
10, 11
11
237
229
237
222, 224
227
C&P exams
Captioned headers
Care Episode
Change Title
Change View
CHIEF, HIM
CHIEF, MIS
CIRN
Class
Clean up the Discharge Summary file
Clinical Coordinator Menu
Clinical data repositories
Clinical Document Print
CLINICAL DOCUMENTS
Clinical Procedures
Upload
Clinician
226
173
236
50, 231
50, 65
49, 64
49, 64
236
206, 237
228
203
236
100, 122
229
171
237
242
Clinicians
Completed
Component
Computerized Patient Record System
22
49, 64
237
23
Consults
Upload
Conversion Clean-up Menu
Copy
Correcting Documents
Cosigning privilege
COTS
171
202
50, 65
125
62
219
CPRS
Create Document Definitions
23, 28, 39, 199, 219, 238
207
CWAD
CWAD components
Data repositorie
Defaults
Defining User Classes
Delete Document
Deleted
238
85
236
14
208
50, 65
49, 64
Detailed Display
Diagnosis
Discharge Summaries
Discharge Summary
Upload
Discharge Summary Menu
41, 50, 65
33
18
58, 238
170
58
Discharge Summary Print
Discharge Summary Statuses and Actions
Discharge Summary User Menu
Discharge Summary V. 1.0
94, 116
64
22
222
Display Upload Help 173 division 87, 92, 103, 106, 134, 143, 144, 145, 146,
147, 148, 166, 167
Division
Document Class
Document Definition
Document Definition File
Document Definition Hierarchy
Document Definition Options
184
206, 238
238
202
11, 81, 206, 228
207
Document Definitions
Document Definitions (Clinician)
Document Definitions printing
Document List Management
Documents Requiring Additional Signature
Edit
206
81
230
78
75
65
Edit Cosigner [EC]
Edit Document Definitions
Electronic Signature Code
Enter/Edit Discharge Summary
Enter/edit Document
Enter/Edit Document
Entered in Error
Correcting
Entry of Progress Note error code error message
18
81, 82, 207
198
160, 161
66
73, 160, 163
125
30
219
219
Text Integration Utilities V. 1.0
Clinical Coordinator & User Manual
Rev. January 2012
Exit
Expected Cosigner
FAQs
File transfer
FILING ERROR
Find
Find Patient
Frequently Asked Questions
Generic Progress Notes Title File
Glossary
GMRP TIU
Graphic Conventions
Header
Health Information Management Section
Health Summary
Health Summary component
Help for Upload Utility hidden action menu
Hidden actions
HIMS
HISTORICAL PROCEDURES
Historical Visits
HL7 Generic Interface
HL7 Troubleshooting
Identify Signers
Individual Patient Discharge Summary
210, 211, 212
223
219
219
65
59
Individual Patient Document 66, 67, 87, 88, 114, 176
Integrated Document Management 22, 66
Interdisciplinary Notes
Inter-facility data transfer
51
236
Interim Summaries
Interward transfer note
Intranet
226
226
12
Introduction
Introduction to the TIU User Manual
Introduction to TIU
Introduction, Managing TIU
IRT
IRT deficiency
Legal Requirements
Line Count
Line Count Statistics by AUTHOR
Line Count Statistics by SERVICE
Line editors
Link
198
113, 155
132
133
225
50, 65
9
12
10
197
239
226
Linkages
Links and Relationships with Other Packages
List area
List Documents for Transcription
List Manager utility
List Notes by Title
LM Considerations
Interdisciplinary Notes
Location( Print Progress Notes
LOOKUP METHOD
Maintenance Menu
Make Addendum
Managing TIU
Manual organization
MAS Options to Print Progress Notes
Meaning of Icons
Medical Record Technicians
232
143
221
166
93
50, 65
23
221
202
237
202
13
226
112
85
85
165
17
17
112, 239
11
199
15
160
15
46
55
45, 183
228
197
50, 65
196
12
184
54
87
Rev. January 2012 Text Integration Utilities V. 1.0
Clinical Coordinator & User Manual
Medicine Conversion
Menu Actions
Interdisciplinary Notes
Menus and Option Assignment
Message window
Minus (-) sign
MIS
MIS Manager
MIS Manager’s Menu
Mismatched ID Notes
Missing Expected Cosigner Report
Missing Text Cleanup
Missing Text Report
Mnemonics modify the Expected Cosigner
Modify the hierarchy
MRT
MRT Menu
MRTs
Multiple Patient Discharge Summaries
210, 212
Multiple Patient Documents 66, 71, 72, 87, 89, 90,
115, 178, 179, 180 national document titles
New Note
Object
209
50
240
Objects
OE/RR 2.5
Online Help
OP reports
81, 84
23, 39
14
227
Outpatient Location- Print Progress Notes
Outpatient note
Parameters
Parameters Menu
Parentless Addenda
Patch GMTS*2.7*12
Patient( Print Progress Notes
184
32
205
205
139
85
45, 183
53
200
15
15
239
239
112
146
143
137
135
232
18
228
239
87
86, 87
63
PCE
Person Class file
Personal Preferences
Plus (+) sign prevents editing
Print actions
Print by Ward
Print Document Menu
Print Document Menu ...
Print Options
Printed Discharge Summary
PRIVACY ACT OFFICER
Problem
Procedure
Progress Note Print
Progress Notes
Upload
Progress Notes Menu
Progress Notes Print Menu
Progress Notes Print Options
Progress Notes Statuses
Progress Notes User Menu
Progress Notes V. 2.5
231
34
97, 119
29, 240
170
29
183
45, 181
49
22
222
236
221
22, 76
15
73
65
182
195, 224
94, 116
87
181, 182
60
49, 64
243
Progress Notes/Discharge Summary [TIU] Menu 22,
23 prohibits editing
Provider Class
73
221
Purpose of Text Integration Utilities
Quit
Radiology reports
10
50, 65
228
Reassign action
Reassignment Document Report
Reassignment Document Report
Release from transcription
Released/Unverified Report
Remote User Menu
Remote Users
Reports and Upload resend alerts
Resolution Status
Review Progress Notes
Review Progress Notes by Patient
Review unsigned additional signatures
125
87, 107
200
225
87, 103
175
174
226
215, 216
92
39
36
88, 113
Review Upload Filing Events
Review/Edit Document
Reviewing Notes
Rotating residents
Router/filer
Screen Display
Screen Editor
Scrolling region
Search
Search by Patient AND Title
Search categories
Search for notes by Problem
Search for Selected Documents
87
160
23
227
165
15, 17
225
15
28, 42
48
63, 71, 231
231
87, 104, 112, 123
Share objects
SHOP,ALL
Shortcut
Shortcuts
Show Progress Notes Across Patients
Sign/Cosign
230
230
16
232
44
50, 65 signatures signing privilege
SOAP
Sort Document Definitions
214
62
237
81, 207
Special Instructions for the First Time Computer User
12
Standardized user interface
Statistical Reports
Statuses
Template
Terminal settings
Title
10
130
64
237
223
240
Titles
TIU and VISTA Conventions
TIU Conversion Clean-up Menu
TIU for Clinicians
TIU for MIS/HIIMS Managers
TIU Maintenance Menu
TIU SET-UP MENU
TIU*1*158
TIUF
TIUHL7
Transcription Billing Verification Report
Transcription Billing Verification Report
TRANSCRIPTIONIST Line Count Statistics
Transcriptionist Menu
Transcriptionists
Troubleshooting
Uncosigned
Undictated
Unreleased
Unresolved Errors
206, 229
14
202
21
111
202
197
214
207
197
160
155
131
160
159
221
49, 64
49, 64
49, 64
92
49
64, 69
105, 134
49, 64
49, 64
29, 37, 232
165 unsigned
Unsigned
Unsigned/Uncosigned Report
Untranscribed
Unverified
Up-arrow (^)
Upload Documents
Upload errors
Avoiding
Correcting
Upload Filing Events
Upload Menu
User Class
User Class file
User Class Management Menu
User responses
Using TIU
VBA RO
VBC Line Count
Verify action
View Objects
Visit Information
Visit Orientation
Visit Tracking
Ward( Print Progress Notes
170
168
92, 93
160, 165
240
221
208
13
19
175
113, 155
91
81, 84
232
236
199
45, 183
Ward—Print Progress Notes
Word-processing program
Word-processors
Workload Capture
WRIISC
XTEMP Global
184
225
173
236
212, 213
220
244 Text Integration Utilities V. 1.0
Clinical Coordinator & User Manual
Rev. January 2012
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