Concluding the Visit Note. e-MDs Solution Series 8.0

Laboratory Order Forms and Radiology Order Forms follow e-MDs format, and this format cannot be altered.

Concluding the Visit Note

When note documentation is complete, click the Note Conclusion button (the yellow clipboard with the green check mark located on the toolbar above the note). Normally, this action will open the Note

Conclusion window, allowing you to choose which items to print (or fax) and permits sign-off of the note.

However, you can choose to have two pop-up reminder windows appear prior to the Note Conclusion window.

Setting User Preferences for Pop-Up Reminders

The first window allows verification of the diagnosis properties (severity, course, chronicity), which is important for accurate E&M code calculation.

The second window is a reminder to select an E&M code. This window appears only if an E&M code has not already been added to the note. It displays the automatically calculated code, allowing the user to accept that code or make changes.

Whether or not these windows appear is a user preference. Each user must choose to show these windows under his or her user preference options.

To set user preferences:

The provider must first be logged into e-MDs Chart

. This login links the preferences to the correct provider.

2. In the e-MDs Chart Options window, click the Visit Notes or Order Notes tab.

3. In the lower-left corner of the e-MDs Chart Options window, click either or both of the check boxes next to Automatically show: Diagnosis Properties and/or Automatically show: EM

Coder.

Verifying Diagnosis Properties

For accurate E&M coding, it is very important that the diagnosis properties (severity, course, and chronicity) be recorded. This can be done at any time from the Assessment section of the note. However, because the physician may frequently forget to address this, it is recommended that user preferences be set to allow a pop-up reminder at the time of note conclusion.

If the user preference is activated, when the provider clicks Conclude Visit Note, the All Visit ICDs window opens. This window lists every diagnosis from the note, by ICD code and description. Columns display the Severity, Progress, and Course of each diagnosis.

• Choices for Severity include Mild, Moderate, or Severe. All problems will default to Moderate.

(Except if a follow-up diagnosis was selected; in that case, the last recorded Severity for that problem will be displayed.)

To change the Severity,

click the radio button next to the desired severity choice.

• Choices for Progress include Improving, Stable, or Worsening. All problems will default to Stable.

(Except if a follow-up diagnosis was selected; in that case, the last recorded Progress for that problem will be displayed.)

To change the Progress

, click the radio button next to the desired progress choice.

• Choices for Course include Acute or Chronic. All ICDs in the database have been set to either

Acute or Chronic by e-MDs, and the diagnosis will display that default setting

. (Except if a followup diagnosis was selected; in that case, the last recorded Course will be displayed.) e-MDs Solution Series Chart User Guide 8.0 R01

103

To change the Course,

click the radio button next to the desired course choice.

• When all diagnosis properties have been set correctly, click Save.

Selecting the E&M Code

At any point during documentation of the Visit or Order Note, you can either manually select an E&M code or view the progress of the automated code calculation in the E&M Coder.

However, if no E&M code has been added to the note (and preferences have been set to be prompted for an E&M code), when you click Conclude Visit Note, the E&M Coder window will open. (Depending on your preferences, the window used to verify diagnosis properties may open first, and then the E&M Coder window.)

In the e-MDs E&M Coder window, view the calculated E&M code displayed in blue text in the lower left corner. Depending on whether structured templates were used to collect data (versus free text typing), this data may or may not be accurate. At this point, the user can manually change the data in any of the seven data collection fields (the boxes located to the left of the arrows).

Overriding any of the three Summary fields (to the right of the arrows) will turn the calculated code red, indicating that the code may be incorrect. It is better to instead correct any of the check boxes in the 7 data collection fields, allowing the E&M Coder to then recalculate the summary.

If the Calculated Code is deemed to be accurate, click Accept to add this E&M code to the note. It will automatically be tied to the primary (first) diagnosis.

Click Reset to clear all the data fields.

Click Cancel to close the E&M Coder without adding the E&M code to the note.

Note:

There are inherent difficulties in automating the determination of the E&M Code. This includes

(but is not limited to) the amount of time that may be spent in counseling and coordination of care and the subjective nature of determining the level of risk in "Medical Decision Making" section. Therefore, e-MDs does not warrant the validity of any calculated E&M code. The calculated code is meant to merely be a guide, and the physician must use his or her best judgment in adjusting that code, if necessary.

Using Automated Preventive Care E&M Coding

Preventive Care E&M codes are automatically dropped into the Visit and Order Notes when the appropriate ICD is added. For example, when V20.2 is added to a Well Child visit, the patient’s age will be assessed along with whether they are new or established and then the appropriate preventive E&M will automatically drop into the note without any intervention from the user. The preventive code will also be available in the E&M wizard IF the Type of Encounter for the note is set to Preventive Medicine

Services.

Note:

If a well visit diagnosis is added to a note the preventive E&M will be added automatically whether the Type of Encounter in the visit details is set to Preventive Medicine Services or not. For example even for a visit marked as Office/Outpatient Visit if a well diagnosis is added to the note the preventive E&M will be dropped in automatically.

An feature related to the Preventive E&M code is that if there is a “sick” diagnosis code in the note as well as a “well visit” diagnosis then an additional window will pop up at Note Conclusion (in lieu of the E&M

Wizard) prompting the user to add a second E&M code (along with a 25 modifier) to the note, if desired

(see screenshot below for an example). This new screen is similar to the E&M wizard in that it provides codes based on whether the patient is a New or Established patient. e-MDs will not try to calculate an

E&M level for the sick visit. The decision for picking an appropriate sick visit code is left up to the user. e-MDs Solution Series Chart User Guide 8.0 R01

104

Printing or Faxing Visit-Related Items

To print and fax visit related items:

1. At the conclusion of a Visit or Order Note, click the Conclude Note button, located on the Chart toolbar (clipboard with a green check mark button).

2. The Note Conclusion window contains two columns labeled Print and Fax with check boxes in each column corresponding to each report type that can be printed or faxed (E

XAMPLE

: Visit

Notes, Patient Ed, Superbill, etc.).

3. To print or fax a report, click the check boxes in the Print column next to those items to be printed

AND/OR in the Fax column for those items to be faxed. Anything not checked will not be printed

(or faxed).

Important!

The exception to the Print and Fax column check boxes is the Prescription report.

It only has one check box which is under the Print column. This check box represents that the prescriptions will be PROCESSED (either printed or faxed depending on the way prescriptions were designated when they were created). It is important that this check box ALWAYS be checked; otherwise the prescriptions will not be printed or faxed.

4. If the item is to be faxed, click the Edit button (pencil icon) in the Edit column to the right of the report name

5. A compact version of the Fax Monitor will open and you can enter information such as Title, To,

From and the Phone (Fax) number.

6. After the information is entered, click the OK button to save the information into the Note

Conclusion window.

7. If the item is to be printed, each report type (i.e. Visit Note, Order Note, Prescriptions, etc.) can be routed to any printer. This is typically set up in advance in Print Options, but can be changed on the fly by clicking the Print Options button in the Note Conclusion window OR by clicking the

Printer Icon in the Options column. The Printer Icon in the Options column provides for faster access to the print options of the specific report chosen.

8. After all print and fax issues have been dealt with, address the Conclude Note portion of this window. See “To sign off a Visit or Order Note” below for details. e-MDs Solution Series Chart User Guide 8.0 R01

105

Successive messages will appear on screen as each report is routed as a print job to the appropriate printer(s).

Signing Off the Note

To sign off a Visit or Order Note:

1. At the conclusion of a Visit or Order Note, click the Conclude Note button, located on the Chart toolbar (yellow clipboard with a green check mark button).

2. Address the Print Options in the top half of the Note Conclusion window. (See the

To print and fax visit related items

procedure for details.)

3. Decide whether the documentation is complete or needs editing at a later point in time.

○ If incomplete, check Close Note/Edit Later. This enables printing or faxing of reports (such as

Prescriptions and Patient Education), while permitting later editing of the note.

○ If the note is finished, check Close Note/Permanent Sign Off. Enter your application password. Permanent sign off requires that the note’s author: 1.) be logged in, 2.) be designated as the Healthcare Provider in the Visit Details section of the Note, and 3.) use his/her password as a signature.

Note: After a note is permanently signed, it cannot be edited with out un-signing it. However, a time-stamped addendum can be added to the bottom of the note. See "Add an Addendum to

a Signed Off Note" for details. See the "Un-sign Note Feature" section for details on un-

signing a note.

4. Choose whether or not to flag the note as Ready to Bill.

○ If a note is permanently signed, it is considered "ready to bill." Because the note cannot be edited, it is assumed that no further billing charges will be added. So, if the Close

Note/Permanent Sign Off option is selected, the Ready to Bill check box is disabled.

○ On the other hand, a common scenario is that the note documentation is not complete, but all of the billing codes have been added. In this case, select Close Note/Edit Later and put a check mark next to Ready to Bill. If this is done, e-MDs Bill will display the visit in red text to identify the fact that the note is unsigned, and a check mark will appear in the Ready to Bill? column, informing billing personnel that the final invoice can be built.

Note:

In order to identify all unsigned patient notes that have been designated as “ready to bill,” you can select that filter in the “Unsigned Notes (Crystal Reports Version)” in e-MDs Reports

User Guide

.

5. When finished, click OK, or click Cancel to close this window and return to the note.

Customizing, Printing, or Exporting the Clinical (Visit) Summary

During each patient visit, information about that visit is automatically compiled to create a summary document that can be printed or exported for the patient. This summary includes, among other things:

• Reason(s) for the visit

• Instructions based on clinical discussions that took place during the visit

• Information on immunizations and medications administered during the visit

• Time and location of next appointment, testing, or recommended appointment schedule

You can access the summary document by selecting it for printing or electronic transmission (exporting) on the Note Conclusion screen that is displayed during the Visit and Order Note sign off process. e-MDs Solution Series Chart User Guide 8.0 R01

106

Users have the option of excluding certain sections of the summary from the Note Conclusion screen.

(HIPAA requirements allow healthcare providers to exclude patient information the provider deems as harmful for the patient.)

To select sections to include or exclude in the Clinical (Visit) Summary:

1. Select (click) the check box in the Print or Elec column for the Clinical (Visit) Summary. The pencil icon in the Edit column will become active. the

Summary Options window.

3. Click the check box before each section you want to include, or deselect sections to be excluded if sections are already checked.

4. To keep these settings for all future patients, click the check box before the Save as Default

Settings option at the top of the screen. When this window opens in the future, your saved settings will be preselected. If you do not check this option, you will need to select and/or deselect sections for each patient.

Note:

If you save these options as your default settings, they will affect only your Clinical (Visit)

Summary output. Other users will need to set their own default settings when logged in under their own login names. These are not global defaults for your facility.

Printing and Saving a Clinical (Visit) Summary

If Print is selected on the Note Conclusion screen, the summary will print on the default printer. If Elec

(electronic transmission) is selected, a Save CCD file check box will be displayed to allow you to save the

Clinical (Visit) Summary as a C-CDA (XML) file. See e-MDs Solution Series Utilities Guide for information about C-CDA files.

• If the patient is a Portal user, a pop-up window will be displayed, and you will have the option to send the Clinical (Visit) Summary to the patient's account on the Portal. (The patient would then be able to view the summary, save the summary to a location outside the Portal, or send the summary to another provider using Direct messaging.) Click Yes to add the summary document to the patient's Portal account. Click No to skip this step. e-MDs Solution Series Chart User Guide 8.0 R01

107

• After the Visit or Order Note is concluded (by selecting Close Note/Edit Later or Close

Note/Permanent Sign Off), the Clinical (Visit) Summary is automatically saved to the Visit Notes folder in DocMan for future reference, as needed.

Note: The Clinical (Visit) Summary C-CDA can be viewed in a browser window. If your browser is

Internet Explorer version 9, the browser Security Setting “Access data sources across domains” must be selected in order to view the C-CDA in human readable format.

• To print the Clinical (Visit) Summary from DocMan, locate the summary in the Visit Notes folder, right-click the summary, and select Print.

See e-MDs Solution Series Utilities Guide for more information on printing documents from DocMan.

• A record of the Clinical (Visit) Summary creation and distribution will be tracked and listed on the

Chart Audits report. See e-MDs Reports User Guide for information on how to list and view this logged information.

Generating and Exporting a Transition of Care file (Chart Summary)

When you need to export a summary of the information documented in all Visit Notes (this would essentially be the information in the Health Summary), you can use the Export Transition of Care (C-

CDA) option that is available when you click the CCD icon in the patient-specific toolbar in Chart. This export option is available in the Chart and DocMan modules.

See e-MDs Solution Series Utilities Guide for instructions on importing and exporting Transition of Care

(C-CDA) files.

Using the Un-Sign Note Feature

This feature allows users to un-sign a note. This feature allows the provider that signed a note off (and

only

that provider) to un-sign the note and make changes before re-signing it. Notes can only be un-

signed within 24 hours

of when the note was originally signed. The feature was added to allow users to make simple changes within 24 hours of the end of a visit. This can be for items such as adding additional orders or prescriptions that may have been forgotten or overlooked during the visit.

To un-sign a note:

1. Go to Chart View and select the note to be edited. pop-up menu.

If the choice is not available, then it has been more than 24 hours since the note was signed off.

Reopening a Previous Note

To reopen an unsigned note for editing:

1. First, select the patient. (On either the main e-MDs Chart or Tracking Board toolbar, click File and then select the Open Patient Chart menu option. Or, click the yellow folder icon near the upper left corner of either application. Either method will open the Find Patient window.) e-MDs Solution Series Chart User Guide 8.0 R01

108