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User Manual

1. Osteoporosis Anemia Glaucoma 1 1 1 1 1 1 1 1 LI 1 i i i i i i 1 3 5 3 A 1 1 a 1 1 1 1 1 1 1 m 1 1 1 1 1 42 1 1 42 1 1 1 1 1 ue 1 1 un 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 4 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 aN 1 1 1 1 1 1 m 1 1 m 1 i 2 o 18 15 B i 2 g 2 k e EET 1 Im 1 i D m 1 i i eee AIME HE ADEST C i i i aic HE os IR is 2 is H 4 E o a x j 5 i 1116 i ie i m 1 1 1 1 1 o T Re E ul o
2. ONUS GENS Exhibit 09 140 Cut If you wish to change the location of this block on the form template click the cut button The blue boundary around the block will turn red indicating that block is ready to be shifted Now click the yellow Add New Block Icon of the location where you want to relocate the block A small two button window opens with the Paste and Add buttons Click the Paste button The block will relocate to this position Delete The Delete button is in white color indicating that the block cannot be deleted altogether from the template Edit When you click the Edit button the following Edit window opens EE EMR NEXT User Manual lt gt There are currently 33 entries your Favorites List for this block You can always manage your favorite lists by visiting Lists Menus section under Primary Configuration tab above If you would like to add or delete items right now just click HERE and it will open the Allergies edit window for you on this very screen v Initially display in Opened state Exhibit 09 141 The window shows you how many entries you have in the Pick List for this block and how you could manage the list The only editing possible for this block is to either open it in activated state on a new chart or in de activated state To open it activated on new charts keep the c
3. EMR User Manual 4o gt To open the block in an activated state on a new chart keep the Initially display in opened state checkbox checked To open it in de activated state uncheck the checkbox Click the OK button Save the changes EMR User Manual lt gt 09 03 08 Editing the Master Problem List Block Back When you click the Edit Template Block Icon of the Master Problem List Block a small three button window opens as shown in Exhibit 09 156 The buttons include Cut Edit and Delete Master Problem List 1 Code Onset Nature x Desc Status Leas wm am am amma eee NE mm Exhibit 09 156 Cut If you wish to change the location of this block on the form template click the cut button The blue boundary around the block will turn red indicating that block is ready to be shifted Now click the yellow Add New Block Icon of the location where you want to relocate the bl
4. NERT the ultimate mobility experience Version 1 0 6 20 2013 Every effort has been made to make the manual as complete and accurate as possible but no warranty of any kind whatsoever is implied Table of Contents 01 What does this EMR system do for you 008 02 Definitions amp terminologies used in the manual 009 03 You Should Know 011 04 Getting Started 013 05 The Home Page 018 06 Patient Charts amp Encounter Forms 024 06 01 General Information Form 030 06 01 01 The Utility Block 033 06 01 02 Personal Information amp Patient Pharmacy Block 045 06 01 03 Contact Information Block 048 06 01 04 Work Information Block 050 06 01 05 Directives Block 051 06 01 06 General Information Block 053 06 01 07 Insurance Block 054 06 01 08 Secondary Insurance Block 058 06 01 09 Guarantor s Block 062 06 01 10 The Print Functionality 064 06 02 History Form 069 06 02 01 Past Medical History PMH Block 071 06 02 02 Past Surgical History PSH Block 072 06 02 03 Known Allergies ALG Block 073 06 02 04 Health Maintenance Block 076 06 02 05 Family History Block 079 06 02 06 Social History Block 081 06 02 07 Master Problem List Block 083 EMR NEXT User Manual 06 02 08 Master Medication List Block 087 06 02 09 The Print Functionality 092 06 02 09 01 History Note 094 06 02 09 02 Problem List 096 06 02 09 03 Medic
5. EMR NEXT User Manual 06 02 09 04 Allergy List Pack Exhibit 06 126 shows the Allergy List First Cardiology Clinic 1001 Parkway Drive Chester AL 23866 Tel 234 508 5580 Fax 234 567 8902 E Allergy List for Smith John DOE Feb 25 1943 n Erythromycin Type Keaction Status Active Dust Mite Type Reaction Status Active Fish or Crustacean Shellfish Type Reaction status Active Signed 5 Exhibit 06 126 1 Your Clinics Name Address Phone amp Fax Number 2 Name of Report along with patient Name and Date of Birth 3 List of Allergies from the History Form along with reaction type of the allergy and the status 4 Space for your signature 5 Date amp Time Stamp of when the report was generated ENT EMR NEXT User Manual lt gt lt gt gt 06 02 09 05 Health Maintenance Report Back Exhibit 06 127 shows the Health Maintenance Report First Cardiology Clinic P 1001 Parkway Drive Chester AL 23866 Tel 234 598 5580 Fax 234 567 8902 2 Health Maintenance for Smith John DOB Feb 25 1943 Influenza Vaccine 01 01 2013 250 mg 2 Signed 5 Exhibit 06 127 1 Your Clinic s Name Address Phone amp Fax Number 2 Name of the report along with patient name and Date of Birth 3 List of procedures administered to the patient along with the date of administration and in case of vaccines the size of the dose 4 Space for your signatu
6. 1 Quantity 30 Thirty Refills 3 Three Excuse Letter eee R Chromagen FA TAB GEQ Face Sheet X Quantity 10 Ten Refills 3 Three Face Label R Abilify 20 mg TAB GEQ Custom Report 1 x uantity 10 Ten Refills 3 Three Custom Report 2 q Total number of items 4 Exhibit 06 267 Print Fax Encounter Related Documents Smith John Referral Letter w s Prescription First Cardiology Clinic 1001 Parkway Drive Chester AL 23866 Laboratory Order Tel 234 598 5589 Fax 234 567 8902 O Radiology Order O General Order Apr 16 2013 PATIENT REFERRAL LETTER 9 Referral Letter First Hospital anaq sete KTZ Lane AL 123 ABC Drive Any City Any State Any ZIP Encounter Note Tel 123 456 789 Fax 123 456 789 Cd p o ESSERE CH DoB Feb 25 1943 Visit Superbill Dear Sir Excuse Letter Oo MONDO ODE CONSO This letter of referral introduces Smith John who is a patient of our practice He is being referred for consultation treatment of the following condition s Face Sheet O Patient Invoice Chest pain Face Label e We have the following information available for your use Chief Complaint Back svmptoms Past Medical History Nothing on record signature Stamp Past Surgical History Nothin
7. 09 15 am 09 30 am Smith John 10 00 am Confirmed 10 15 am 10 30 90 00004 Smith Tom 10 45 Completed 11 00 am 11 15 am 11 30 am 11 45 am Reminder Card 12 00 pm Reminder Letter 12 15 pm No Show Letter 12 30 pm 12 45 pm 90 00006 Smith Jack 111 222 333 01 00 pm Exhibit 08 020 Print Fax Reminder Card Smith John M SMITH JOHN HAS AN APPOINTMENT WITH Davis Richard MBBS FIRST CARDIOLOGY CLINIC 1001 Parkway Drive Chester AL 23866 Tel 234 598 5589 Fax 234 567 8902 ON Tue May 7 2013 at 09 00 AM THIS TIME IS RESERVED EXCLUSIVELY FOR YOU 24 HOUR NOTICE IS APPRECIATED IF YOU ARE UNABLE TO KEEP THIS APPOINTMENT Exhibit 08 021 EE EMR NEXT User Manual lt gt Print Fax Reminder Letter Smith John First Cardiology Clinic 1001 Parkway Drive Chester AL 23866 Tel 234 508 5580 Fax 234 567 8902 May 6 2013 Smith John 123 ABC Drive Any City Any State Any ZIP This is just to remind you that your appointment with me is scheduled on Tue May 7 2013 at 09 00 AM We look forward to seeing you on this date If you can t keep your appointment for any reason please contact our office as soon as possible so that we may reschedule your appointment You may call us at 234 598 5589 anytime during office hours Thank yo
8. EXHIBIT 06 275 1 Your clinic s name address and telephone amp Fax numbers 2 Title of the Report Requisition the same title is also used for Laboratory Order and Radiology Order 3 Name address and phone number of the Supplier This has to be typed manually in the report and cannot be called from the database EMR NEXT User Manual lt gt 4 This part shows the name date of birth of the patient for whom the services have been requested You have to type the nature of services in the report manually like hardware has been typed in this exhibit manually 5 This part shows the list of the General Services ordered They are picked from the Orders Requisitions block of the related encounter form 6 Space for your signature followed by your name and ID No 7 Date of the encounter form All fields in the darker shade are editable i e data called in from the original chart or encounter form may be edited added or deleted in these sections of the report EMR NEXT User Manual 06 03 16 02 05 Report 5 Referral Letter Pack Exhibit 06 276 shows the Referral Letter in the Print Fax Encounter Related Documents window e First Cardiology Clinic 1001 Parkway Drive Chester AL 23866 Tel 234 598 5589 Fax 234 567 8902 Apr 16 2013 PATIENT REFERRAL LETTER My First Hospital Q Smith John ABC Street XYZ Lane Any City AL 123 ABC Drive Any City Any
9. QGuaran Institution Relation Exhibit 06 067 Oct Relation Nov Name Dec DOB Exhibit 06 068 Male Ph Female Transgender Gender Exhibit 06 069 ENT EMR NEXT User Manual lt gt 06 01 10 The Print Functionality Back The Print Functionality on the General Information Form is identified at Item 16 of Exhibit 06 012 Only Patient Face Sheets and Face Labels can be printed from this form When you click the printer icon the Print Fax Demographics and Insurance Window opens Print Fax Demographics and Insurance Smith John Face Sheet O Face Label Exhibit 06 070 Two Radio Buttons are available in the left column under the patient s name Select the required radio button to call the report on the viewing pane Exhibit 06 071 amp Exhibit 06 073 The Print button is presently de activated When a report is called in the pane it will activate Clicking this button will take the user to the computer operating system for printer selection or for sending fax EMI EMR NEXT User Manual lt gt The Face Sheet Face Sheets are covering sheets for patient s physical folder When the Face Sheet Radio Button is clicked the face sheet appears in the viewing pane like this Print Fax Demographics and Insurance Smith John Face Sheet Face Sheet First Cardiology Clinic MINER 1001 Parkway Drive Chester
10. SSN Phone Last Name First Name Birth Date Visit Date Age amp Gender age is age is gt Import Expx Exhibit 07 010 Dashboard um Scheduler Ti Customize Total charts in database 14 11 charts found Find Charts Where LAST NAME FIRST NAME DOB AGE PHONE 55 02 25 1951 62 123 456 789 MRN Nicola Phone Jack 111 222 333 9 Last Name Albert First Name O Daniel O Birth Date Nicholas Visit Date Alexandar Aga amp Gender Hubert 03 20 1959 Adam starts with w starts with gt Import Export Import Scanned Files Export Superbills Exhibit 07 011 xm EMR NEXT User Manual lt gt Smith John Delete Chart Schedule Phone Notes Documents Refill Meds Exhibit 07 012 Open Chart Please enter at least 3 characters of Last Name to start the search Exhibit 07 013 3 Scanned Documents Images can be imported into the system through the Dashboard Images imported in the system must be attached to specific charts There is a set of folders available for each chart The images must be stored in appropriate folder Folders are discussed in Section 06 01 01 item 4 of the manual and are illustrated as Exhibit 06 027 Item 3 on Exhibit 07 001 is the button for importing files in the system It opens the Document Filer Exhibit 07 014 with the Select Image button activated When the button
11. gt 09 01 04 14 Past Social History PSH Phrases Back Past Social History Phrases are used in the Past Social History Block in the History Form Section 06 02 02 Exhibit 06 078 When you click on the block icon on the block the Past Surgical History Window shown in Exhibit 06 079 opens Entries in the Past Surgical History Block are managed from here in Customization Section When you click the Open button on the field identified as item 4n in Exhibit 09 002 the Add Delete PSH Phrases Window opens Add Delete PSH Phrases x Master List Your Favorites Appendectomy Appendectomy Carotid endarterectomy Carotid endarterectomy Cataract surgery Cataract surgery Cesarean section Cesarean section Cholecystectomy Cholecystectomy Colectomy Colectomy Coronary angioplasty Coronary angioplasty Coronary arteriography Coronary arteriography Coronary artery bypass graft Coronary artery bypass graft Episiotomy Episiotomy Gastric bypass surgery Gastric bypass surgery Hemorrhoidectomy Hemorrhoidectomy Hernia repair Hernia repair Hysterectomy Hysterectomy 999 9 05 aminertomuv Laminectomy Add Your Own PSH Phrases Mastectomy radical Mastectomy total Exhibit 09 089 b Sb Eb Eb Eb Eb Eb amp Ep Ep 1 The left side of the window is for the Master List of Past Surgical History Phrases The list has more than 20 entries None of these phrases will
12. gt 09 03 01 Adding New Blocks to the History Form Template Back When you click any of the yellow icons on the History Form Template the Add Blocks Window shown in Exhibit 09 106 opens Add Blacks Restorable Default Blocks None User Definable Blocks Block With Single Freetext Field Block With Multiple Freetext Fields Block With Multiple Freetext Fields Extensible Rows Block With Single Dropdown Block With Multiple Dropdowns Block With Multiple Picklists O Block With Large Freetext Area Block With Multiple Buttons Block With Multiple Checkboxes Exhibit 09 106 The Add Blocks Window has two sections The first one says Restore Default Blocks and the second says User Definable Blocks Restore Default Blocks Four of the eight editable blocks shown in Exhibit 09 104 can be deleted from the template altogether These are 1 Past Medical History 2 Past Surgical History 3 Family History 4 Social History If any of these blocks is deleted then the system retains the EMR NEXT User Manual format of the deleted block in this section of the window If you want to recreate the deleted block at its original location or any other new location open this window from the yellow icon of the desired location click the radio button of the block you want to restore and press the Continue button on the window to proceed To show you how the mechanism works
13. Ep Eb Sb Eb Ep Ep Eb Eb Eb Eb Eb Ep 2 Click this right arrow to move the Allergies Phrases to your list of favorites 3 If the phrase you are looking for is not included in the Master List you can write it yourself in this field EMR User Manual lt gt 4 This field is optional However if specify the code the next two fields will become mandatory and they will have to be specified too Type the code of the Allergy here 5 This field is to be left blank unless item 4 has been provided Specify the classification of the Allergy Code here Presently there are two classes of codes available in the USA SNOWMED CT and RxNorm 6 This field is to be left blank unless items 4 amp 5 have been provided Specify the type of Allergen here by selection from the dropdown list shown in Exhibit 09 092 Available options include drug food and others 7 Press this right arrow to include the Allergy in your list of favorites The Allergies you have added from this field will not be added in the Master List They will only be added to your favorites 8 This is the list of your favorites that you have prepared either by selection from the Master List or by writing the Allergies yourself or as a combination of both 9 If you want to delete the Allergy Phrase from your list of favorites click the corresponding trash can icon If the phrase was selected from the
14. First Field First Option Second Option x Second Field hmi x Clear Field Undo Last x i First Option Second Option A Third Option Past Surgical History Past Medical History Exhibit 09 126 EMR NEXT User Manual lt gt 09 03 01 07 Block with Large Free Text Area Pack When you click the seventh radio button in the User Definable Blocks section of the Add Blocks window Exhibit 09 106 and press the Continue Button the following Add window opens v Initially display in Opened state Exhibit 09 127 As the name suggests this block will have a single field with multiple rows Write the name of the block in the white field at the top If you want this block to initially appear in opened state on charts keep the checkbox checked If you want it to appear initially as de activated uncheck the checkbox Click Ok The Add window will close and the block will be created on the template Save the changes Now when you open a new chart the block will appear on the Form as shown in Exhibit 09 128 for simplicity and uniformity we have opened the new block as the first block on the chart It is named Seventh Block Please note that on the History Form the lines in the block will extend according to requirement EE EMR NEXT User Manual lt gt Add X Seventh Block v Initially display in Opened state Exhi
15. 10 If you want to include any block s from the Encounter Form or the History Form in the letter handout this is the place to specify which block s to include The block s included will appear in the template as bullet points If you at any time in future wish to delete the selected block from the template the delete button is right next to it 11 Click this button to select the History Form Encounter Form block to be included in the letter handout The window shown in Exhibit 09 015 will open listing all selectable blocks 12 This is the space for the closing text of the letter handout It may also spread over multiple paragraphs and may be as long as required EMR NEXT User Manual lt gt 13 The system name and the time stamp of the letter handout 14 Once you have drafted the template click Save to save and activate it 15 Before saving the template there was an Inactive sign here After saving it has converted into Active meaning that the template may now be selected for printing from the Print Fax Encounter Related Documents Window Exhibit 06 265 16 At any time if you wish to delete the template click this button The template will wash out and will be available for reuse Available Sections Chief Complaint Encounter Reason History of Present Illness Review of Systems Procedures Services Physical Examination Assessment Diagnosis Orders
16. Date Note Next x Sleep Habits Misc Screening Mammogram 7 aliii SEXE ss Master Problem List Misc 1 Code Onset Nature x gt Desc Status Screening Pap Smear Date Note Next x Misc Master Medication List h 1 Rx x Sig Status Exhibit 06 074 The History Form stores Patient s past and current medical history When you take in a new patient or when you start using this system you should load patient medical ENT EMR NEXT User Manual 4o gt history on this form Thereafter certain blocks of this form get updated from the encounter forms automatically The top section of the form is the common on all three forms and has been discussed in detail as items No 1 to 6 of Exhibit 06 012 Items in the lower section include EMR NEXT User Manual lt gt 06 02 01 Past Medical History PMH Block Back Past Medical History m Exhibit 06 075 The Past Medical History Block looks like this Its placement on the History Form is identified as item 1 on Exhibit 06 074 You can either write the past medical history manually or you may select PMH phrases from the list that opens when you click the square on the right of the block Exhibit 06 076 You may click as many PMH phrases as required they will add in the form one after another upon each click The system has 56 pre loaded PMH phrases but only your f
17. EMR NEXT User Manual lt gt For each system a suitable set of observations is provided When the checkbox is checked the corresponding system expands to show the available observations Exhibits 06 155 to 06 169 show the available observations for each system By default these observations are marked as negative Clicking the negative sign turns them positive as shown in Exhibit 06 170 Clicking a positive sign reverts the negative status Observations may be added or subtracted from the form according to the requirement of the practice Section 09 04 06 shows how this is done A checked checkbox is an indication that the system has been checked Therefore if you examine a system even if all findings are normal and none of the observations are marked positive the checkbox must remain checked General Fevers Chills Sweats Appetite loss Weight loss Fatigue Exhibit 06 155 Eyes Vision loss Double vision Blurred vision Eye irritation Eye pain Discharge Light sensitivity Exhibit 06 156 4 EMR NEXT User Manual lt gt lt gt ENMT Earache Ear discharge Ringing inthe ears Decreased hearing Frequent colds Nasal congestion Nosebleeds Bleeding gums Difficulty swallowing Hoarseness Sore throat Exhibit 06 157 Cardiovascular Difficulty breathing at night Chest pain or disc
18. Oxygen Mask Sling Wheel Chair Ice Box Prescription Benadryl Childrens Allergy Fastmelt TAB disintegrating Benadryl Cold 500 25 30 mg TAB Chromagen FA TAB Abilify 20 mg TAB Referral My First Hospital for Chest pain Yours sincerely B Davis Richard MBBS NPI BA 12345678 EXHIBIT 06 276 W EMR NEXT User Manual lt gt gt Referral Letter is printed when you are referring a patient to some other doctor This letter takes details from the General Form History Form and the concerned Encounter Form of the patient chart T 10 11 12 13 14 15 16 17 18 Your clinic s name address and telephone amp Fax numbers Date of Encounter Title of the Report Patient Referral Letter Name address and phone number of the doctor or the hospital to which the patient is being referred Patient Name Address Date of Birth and Sex Free Type Field for salutations Introductory remarks Complains for which the patient is being referred Chief Complaint the patient has Past Medical History Past Surgical History Known Allergies Family History Positive identified illness traits appear in red Social History Positive Identified high risk social traits appear in red Procedures amp Services prescribed Only those prescribed in the current encounter Physical Examination details Assessments amp Diagnosis Only those established in the curre
19. folder will appear in the blank space as shown in Exhibit 09 017 Name the folder and click the Update button to save it Now this folder will be available to all patients Any number of folders can be created this way To delete the folder click the Trash Can icon next to it If any patient has any documents in the deleted folders the documents will move to the default Others folder Customer letters handouts created in Section 09 01 02 04 may be mapped to custom folders First create the custom folder and then select it while specifying the folder type for the letter item 3 on Exhibit 09 014 While naming custom folders there should be no blank spaces An alert will appear as shown in Exhibit 09 018 Folder name cannot be left blank either An alert will appear as shown in Exhibit 09 019 if the name is left blank White spaces are not allowed in Folder names Exhibit 09 018 3 Please provide a Folder Name or delete the empty row Exhibit 09 019 EMR User Manual lt gt 09 01 02 06 Form Validation and other Rules Back Edit Forms Validation and Other Rules Allow signing of encounter even if it contains blank Chief Complaint block V Allow signing of encounters even if there are Dx with blank Status Nature fields Hide insurance and guarantor blocks on General form suitable for cash only practices Exhibit 09 020 The Edit Forms Vali
20. item 8 of Exhibit 09 007 but there the feature is for Prescriptions and Orders only Here it is for all other letters 13 If you wish to include any footnote on letters and notes specify the note here 14 Press the Update button to save the changes EI EMR NEXT User Manual 4o gt First Cardiology Clinic 1001 Parkway Drive Chester AL 23866 Tel 234 508 5589 Fax 234 567 8902 Encounter Note for Smith John on Apr 12 2013 DoB Feb 25 1951 Chief Complaint Back symptoms O Boils Past Medical History Abnormal PAP smear Past Surgical History Carotid endarterectomy Known Allergies Erythromycin Dust Mite Fish or Crustacean Shellfish Family History Diabetes Stroke Hypertension Heart Disease Cancer Asthma Hay Fever Arthritis Osteoporosis Anemia Migraine 2 Alzheimers Epilepsy Glaucoma Social History Alcohol Use Caffeine Use Tobacco Use Drugs Use Chm Exposure TB Exposure HIV Exposure Sex Relations Excersice Sleep Habits Procedures Services 10040 Acne surgery 85018 Blood count hemoglobin Hgb 84550 Uric acid blood Exhibit 09 010 lt First Cardiology Clinic 1001 Parkway Drive Chester AL 23866 Tel 234 598 5589 Fax 234 567 8902 Encounter Note for Smith John on Apr 12 2013 DoB Feb 25 1951 Chief Complaint Back symptoms Boils Past Medical
21. lt gt Default NOTE if any X Abdominal pain NOS This is a default note Exhibit 09 053 Your Favorites Note Abdominal pain NOS Abdominal pain epigastric Abnormal Stress Test Abnormal red blood cell Acne Alcoholic psychosis other Allergy NOS Ankle closed lateral malleolus Asthma NOS Back pain w radiation NOS Cannabis abuse NOS Cannabis abuse continuous Cannabis dependence episodic Chest pain NOS P 2 2 2 2 2 2 2 2 2 2 Depression major single episode partial remission Depression major single episode severe w Eb Ej Eb Eb Ej Ep Eb psychosis Exhibit 09 054 EMR User Manual lt gt You need to click SAVE button below to keep the changes you have made this favorite list Do you want to close this window without saving Exhibit 09 055 EE EMR NEXT User Manual lt gt 09 01 04 02 Pack Procedure Px Codes are used in the Procedures amp Services Block in the Encounter Form Section 06 03 08 These are the procedures or services offered by you to your patients Exhibit 06 210 shows the Procedures amp Services Block on the Encounter Form When you click the field icon on the block the Procedures amp Services Window shown in Exhibit 06 211 opens The Window lists your favorite Procedure Codes and th
22. 11 00 am 11 15 am 11 30 am 11 45 am 12 00 pm 12 15 pm 12 30 pm 12 45 pm 01 00 pm 01 15 pm 01 30 pm Exhibit 10 004 3 Dashboard J Scheduler CHART PATIENT S NAME 4 Scheduler Ti Customize Thu May 23 2013 VISIT REASON NOTES You are on the Schedule Screen Click on a topic to start 2 Booking an appointment 2 Locating an appropriate slot 7 Locating the next empty slot Booking special appointments 7 Searching booked appointments L Performing tasks on booked slots 2 Opening a patient s chart 2 Marking missed appointments 7 Rescheduling an appointment 2 Deleting an appointment Online User Manual T Customize r 2mzmo Chart ID 00002 Yellow Sticky Note Telephone Notes DOB General Notes Gender Scans Documents Marriage Pharmacy My First Pharmacy Siblings fnamazcoozm Other Info Race Contact Information Address 123 ABC Drive City Any City ZIP Code Country USA State Home Ph 123 456 789 Cell Ph Exhibit 10 005 EMR NEXT User Manual First Cardiology Clinic 123 45 6789 123 Feb 25 1951 Male Married Any ZIP Cd Any State 123 456 789 62 years You are on the Patient Chart Click on a topic to start 2 Adding patient s photograph 2 Viewing Attaching phone notes 2 Viewing Attaching general notes 7
23. Follow up Visi Join Work School This is free type field ui E M Code Code Basis Follow up Visit Join Work School after 2 weeks Exhibit 03 001 See the Join Work School field in the exhibit The field is identified with a down arrow at the end encircled in red All fields with this type of down arrow at the end are combo boxes In part 1 of the illustration free typing has been done in the field Then in part 2 the down arrow was clicked and the drop down list appeared for selection The cursor has been moved on the value after 2 weeks When the selected value is clicked the selection overwrites the initial inscription as can be seen in part 3 of the illustration The other type of combo box is shown in exhibit 03 002 sn EMR NEXT User Manual lt gt Medications Rx 1 Rx Benadryl Childrens Allergy Fastmelt TAB disintegrating GEQ X Sig Presently free type field Oty Ref 0 Medications Rx e a 1 Rx Benadryl Childrens Allergy Fastmelt TAB disintegrating GEQ X Se Qty Ref 0 Medications Rx T 1 Rx Benadryl Childrens Allergy Fastmelt TAB disintegrating GEQ X Qty Ref 0 Exhibit 03 002 The identification of such fields is that when you take the cursor over the name of the field the name gets highlighted in grey See the Sig field in part 2 of the exhibit The field is initially a free type field as you can see in part
24. Screening Pap Smear w Initially display in Opened state Exhibit 09 144 Colorectal Screening Date Note Next x Misc k am m m m m m mo m NES S HN aua m om m m m m m NES NO S S S Exhibit 09 145 EMR User Manual lt gt 09 03 06 Editing the Family History Block Back When you click the Edit Template Block Icon of the Family History Block a small three button window opens as shown in Exhibit 09 146 The buttons include Cut Edit and Delete cut Edit Delete EN a ee eee Family History Diabetes Stroke tt Exhibit 09 146 Cut If you wish to change the location of this block on the form template click the cut button The blue boundary around the block will turn red indicating that block is ready to be shifted Now click the yellow Add New Block Icon of the location where you want to relocate the block A small two button window opens with the Paste and Add buttons Click the Paste button The block will relocate to this position Delete If you wish to delete the block altogether click the Delete button The block will remove from the template Section 09 03 01 shows how to restore the block Edit When you click the Edit button the Edit Wind
25. Stroke Hypertension Heart Disease x Cancer Asthma Hay Fever Arthritis Osteoporosis Anemia Migraine Alzheimers Epilepsy Glaucoma Exhibit 06 092 This is the Family History Block Its placement on the History Form is identified as item 5 on Exhibit 06 074 Fourteen diseases are pre defined on the block but you may add or delete as many diseases as required according to the requirements of your practice Section 09 03 06 shows how to add or delete diseases from the block At the outset the values are set to negative indicating absence of family history for this disease Click the negative sign to turn it positive as shown in Exhibit 06 093 Now either enter data manually or select names of relatives from the given list Open the list window by clicking the square button at the end of the field as shown in Exhibit 06 094 The square button will appear only when you click the disease to positive Select as EMR NEXT User Manual lt gt many relations as required by clicking them and they will add to the field You can combine selection with manual inscriptions also The list window also allows you to clear the field or clear the last entry in the field Respective buttons are available at the top of the window The relations in the list in any of the diseases can also be added to or deleted Section 09 03 06 shows how to do this At the end of the Medical History block is a free
26. a L ee Marriage Country United States State AL Pharmacy Siblings Phone Facsimile Other Info Race Plan Expiry ID No Group No Contact Information Auth No Address Remarks City ZIP Code Relation Home Ph Country United States State AL Name Home Ph Cell Ph DOB Gender Email E Doe Flag x Exhibit 06 128 Item 2 on Exhibit 06 128 identifies the button which creates encounter forms When the button is clicked the encounter is created Item 3 on Exhibit 06 129 shows the encounter tab which will appear when the first encounter is opened for the patient EMR User Manual lt gt Item 4 shows the encounter counter After the first encounter is opened it reads 1 of 1 meaning that the first encounter form of a total of one encounter forms is open Dashboard Scheduler I Customize g First Cardiology Clinic 3 Photograph Chart ID 00014 Doe Smith oe jemmazcoozm VW 20 40 I N o 2mzmo Encounter 1 Date Apr 26 2013 Type Physical Examination Referred by C Constitutional Attended by Davis Richard MBBS BA 12345678 C Eyes ENMT Received Details g Neck Payment type L Billing not required Respiratory Note for Biller C Cardiovascular 1 Breasts Chief Complaint Encounter Reason astrointestina 1 of e TUAM SQ 1 Genitourinary Femal
27. button below the viewing pane activates as shown in item 13 marked on Exhibit 08 004 When this button is clicked the appointment books and the color of the entry turns blue as shown in Exhibit 08 005 Four icons now appear at the end of the entry which will be discussed in item 13 If the duration of the appointment had been selected as 90 minutes then a complete group of slots equaling 90 minutes would have been booked as can be seen in Exhibit 08 006 There are two bookings of 90 minutes each in Exhibit 08 006 Just for your information The viewing pane initially shows the time slots from the beginning to the end of the session in slot durations that you have defined Section 04 For example if you had defined the time slots for 10 minutes and your session began at 9 00 am and ended at 5 00 pm the slots available on your schedule will be 9 00 9 10 9 20 9 30 4 20 4 30 4 40 4 50 If you had defined two sessions for the day the time slots between the two sessions would appear deactivated please note that there will at least be one slot gap between the two sessions as a system requirement Both sessions cannot adjoin each other WE EMR NEXT User Manual lt gt 8 This is the calendar for browsing on the scheduler the top are the Month and the Year fields where values are selected from dropdown lists The day is selected by clicking the date tab on the month s calendar In the Exhibit 6
28. s country is different from your country 9 Specify the Hospital Clinic s State Province here Initially the State Province in which your company is based will come selected Change if the Hospital Clinic s State Province is different from yours 10 Specify the Hospital Clinic s telephone number here EMR NEXT User Manual 11 12 13 14 NPI EIN PIN PVN 33N TIN Specify the Hospital Clinic s fax number here Specify the Hospital Clinic s email address here If you want the Hospital Clinic s name to be included in the dropdown list only in the Encounter Statistics Block as a referring Hospital Clinic click the first radio button If you want its name to be included in the dropdown list only in the Referral Block as a Hospital Clinic to whom you refer the patient click the second radio block If you want the name to be included in both the blocks click the third radio button Click the Save button to save the Hospital Clinic s particulars DEA Champus DPS Medicare NSC Medicaid UPIN Medi Cal OSCAR License BCID Group BSID Other Exhibit 09 051 EMR NEXT User Manual 4o gt lt gt 09 01 04 01 Diagnosis Dx Codes Pack Diagnosis Codes are used in the Assessment amp Diagnosis Block on the Encounter Form Section 06 03 09 and in the Master Problem List in the History Form Section 06 02 07 In the Encounter Form there are two parts of the
29. 25 Once you have completed press this button to save the data If any mandatory field is left blank the system will raise an alert like that in item 13 Once all the requirements are met the data will save and the screen will close This screen appears on the system only at the time of initial setup If any data is required to be changed subsequently it can be done from the Customization Area Section 09 01 01 01 amp 09 01 01 02 EMR NEXT User Manual lt gt 05 Home Page Back Q Dashboard Scheduler Ti Customize J 2 3 4 5 6 7 EMR NEXT Electronic Medical Records System Navigation Guide the ultimate Mobility eXperience wre would you like to do Create a new patient chart Open an existing patient chart Open an existing chart that you recently viewed Search charts import documents or export bills Go to an already opened chart Do scheduling related tasks Customize program according to your specialty Open context sensitive help Do data backups or restore Exhibit 05 001 The Home Page operates from the dark grey tool bar on the top There are 8 iconic buttons on the tool bar each of which has a tool tip that appears when you take the mouse over them 1 Click this button to create a new chart The following window opens Q Last and First names are required to create a chart O JO Last First M o Create New Chart Open Existing Chart Qi Exhibit 05
30. E o to o 9 Bik 2 ica qa a X i 5 o E z z oc zimit o 5 my EN e e e o Desc ices tt Procedures Serv e e Exhibit 09 160 EMR NEXT User Manual lt gt Dashboard Scheduler I Customize n Encounter Form Template Unsaved First Cardiology Clinic Save when done Photograph Chart ID 00001 Click To Attach Respiratory Cardiovascular Breasts Details Gastrointestinal Billing not required Genitourinary Female Genitourinary Male Lymphatic Musculoskeletal 3 Save Changes Exhibit 09 161 EMR NEXT User Manual lt gt 09 04 01 Adding New Blocks to the Encounter Form Pack Template When you click any of the yellow icons on the History Form Template the Add Blocks Window shown in Exhibit 09 162 opens Add Blocks Restorable Default Blocks None User Definable Blocks Block With Single Freetext Field Block With Multiple Freetext Fields Block With Multiple Freetext Fields Extensible Rows Block With Single Dropdown Block With Multiple Dropdowns O Block With Multiple Picklists B
31. EMR User Manual lt gt gt Body Mass Index Blood Pressure Smith John Blood Pressure Trend Systolic mmHg 40 03 25 2101 10047047201 0047067201 0047067201 004117201 Stage Hypertension Stage Hypertension PreHypertensian 140 120 t 100 50 2 an L c z Show Growth Charts Exhibit 06 186 EMR User Manual lt gt gt Growth Charts Weight for Age Stature for Age PTT TTT TTT TT TT TT TT 4 eon dl PECL 55 41 CR ISP He EEE PR EEN PP T RRA 4 Exhibit 06 187 2 5 0 2 gt gt lt LLI 2 cc lt gt gt Growth Charts X BMI for Age Stature for Age Weight for Age T 190 MEN ae tature for rcentil LL LLEFTLTILLLLsm Stature for age percentiles Boys 2 to 20 years CAT ee s m TOT tO CCAS rm TLLLLLLLLLLLLLLLLLLLLYZ Y LM A ag aa d LLL EL LE dL LE ttt tt ee HPE ee epe eee I nu AZ PEER EEE a FAK LA Le eT EE EE EE EE EE TE 135 ALEEEEEE CS HHHH HHHH C
32. Edit When you click the Edit button the following Edit window opens EMR NEXT User Manual lt gt There currently 17 entries in your Favorites List for this block You can always manage your favorite lists by visiting Lists Menus section under Primary Configuration tab above If you would like to add or delete items right now just click HERE for the Lab Orders and HERE for the Radiology Orders edit window v Initially display in Opened state Exhibit 09 215 The window shows you how many entries you have in the Pick List for this block and how you could manage the list The only editing possible for this block is to either open it in Opened activated state on the Encounter Form or in de activated state To open it activated on new Encounter Forms keep the checkbox marked To open it de activated uncheck the checkbox and click the OK button Save the changes EMR NEXT User Manual lt gt 09 04 12 Editing the Medications Block Back When you click the Edit Template Block Icon of the Medications Block a small three button window opens as shown in Exhibit 09 216 The buttons include Cut Edit and Delete Cut Edit Delete 1 m Se Medications Rx Lee um am amo umu a Exhibit 09 216 Cut If you wish to change the location of this block on
33. Heated thermal gloves Protective covering Protective covering Rigid dressing Protective stocking Sling Rigid dressing Wheel Chair Silesian bandage Single ply socks Torque absorption pylon Waist belt Wool socks Add Your Own General Order Exhibit 09 073 1 The left side of the window is for the Master List of General Orders The list has twelve entries only as a sample None of these General Order items will appear in your list of favorites unless you make them favorite 2 Click this right arrow to move the General Order item to your list of favorites 3 If the General Order item you are looking for is not included in the Master List which will usually be the case as the master list is just a sample you can write it yourself in this field EMR User Manual lt gt 4 Press this right arrow to include it in your list of favorites The General Order items you have added from this field will not be added in the Master List They will only be added to your favorites 5 This is the list of your favorites that you have prepared either by selection from the Master List or by writing the General Order items yourself or as a combination of both 6 If you want to delete a General Order item from your list of favorites click the corresponding trash can icon If the item was selected from the Master List it will still be available for re selection the
34. REFILL REQUEST Name Smith John DoB Feb 25 1945 Sex M Add 123 ABC Drive Any City Any State Any ZIP Cd Abilify 20 mg m Mc pcne 10 Ten o 3 B Thuee o Ks 2 4 E Tem s MEM oc Three M Total number of items 2 b Signed Dated Apr 23 2013 4 50 inch x 7 50 inch 96 dpi Exhibit 06 258 Once the medicines to be refilled are selected and the Refill Selected Meds button item 5 Exhibit 06 257 is clicked the Refill Writer opens with the selected medicines showing therein 1 Your clinic s name address phone number and fax number 2 Title of the Report Refill Request 3 Patient s name Date of Birth Sex and Address EMR NEXT User Manual lt gt 4 Name of the selected medicine with a free type field under it to write any remarks 5 selection of GEQ Generic Equivalent DAW Dispense as Written indication 6 Quantity of medicine This field is editable and a dropdown list appears for selection of quantity when you click the field 7 Number of Refills This field is editable and a dropdown list appears for selection of number of refills when you click the field 8 The total number of medicines included in this refill is shown 9 Space for your signature 10 Print Date 11 Checkbox to add your electronic signature If your electronic signature is not available a message will appear See section 09 01 01 02 for adding
35. Viewing Filing scans or images 7 Going to Historical Data section 7 Going to Encounters section Bl Creating a new encounter Online User Manual Name DOB lt Dashboard 4 Scheduler Ti Customize reamzme Chart ID 00002 Encounter 12 Date May 04 2013 Type Office Visit New First Physician Attended by Davis Richard MBBS Received Details E N t 0 u N T E R s Note for Biller Chief Complaint Encounter Reason History of Present Illness Location Exhibit 10 006 EMR NEXT User Manual BA 12345678 Payment type L Billing not required First Cardiology Clinic 62 years You are on the Patient Chart Click on a topic to start 2 Accessing favorite lists Bl Doing Physical Examination 2 Writing a prescription Calculating Code Bl Locking an encounter 2 Addendums to an encounter 7 Deleting an encounter 2 viewing past encounters 7 Going to General section Bl Creating a new encounter Printine Faxing Online User Manual 7 Entering Assessment Diagnosis 2 Going to Historical Data section Musculoskeletal skin Neurologic lt lt gt 11 Creating and Restoring Backups Back It is important that you take backups of the system periodically preferably every day at the end of your working session If you so wish you
36. and the block will be created on the template Save the changes Now when you open a new chart the block will appear on the Form as shown in Exhibit 09 174 for simplicity and uniformity we have opened the new block as the first block on the chart It is named Fourth Block Whenever there is an entry in this block the Patient Invoice if Patient Invoice is issued and the Super Bill will both include the amount If the amount is to be recovered through the Super Bill then amend the amount in the Patient Invoice to Zero EMR NEXT User Manual Add Fourth Block First Option Second Option Third Option Fourth Option Fifth Option k wv Initially display in Opened state Billable Procedure Exhibit 09 173 Chart ID 00001 Doe John First Cardiology Clinic Photograph Click To Attach Fourth Block Fifth Option Encounter 5 Date First Option Referred by Fourth Option Attended by Davis 58014 Option Third Option Received Details Payment type Billing not required Note for Biller Chief Complaint Encounter Reason History of Present Illness Exhibit 09 174 E d Physical Examination Genitourinary Female Genitourinary Male Lymphatic Musculoskeletal C Skin E Neurologic Constitutional El Eyes Neck Respiratory Cardiovascular E Breasts Gastrointestinal EMR NEX
37. as can be seen in Exhibit 09 010 Allergies and positive factors are appearing in red in the exhibit If you wish to remove the distinction and show all factors in black check this checkbox EMR User Manual 4o gt 9 In default state the system starts the patient name with last name followed by first name If you wish to show the first name first check this checkbox This change will apply to all letters and reports including prescriptions and orders But it will not apply to the forms on the screen 10 On EMR Next you have option of three fonts Times Arial and Courier The default is set on Times To change the font select appropriate radio button The change will apply to all letters and reports including prescriptions and orders But it will not apply to forms on the screen 11 EMR Next has an option of three font sizes set at Smaller Medium and Larger Default is set on Medium Select appropriate radio button to change font size This change will apply only to those reports and letters which are printed on full size A4 size paper Reports printed on small paper will continue on system default 12 If you use pre printed letterheads you do not need EMR Next to print the name amp address of the clinic on the letters and reports Check this checkbox to prevent printing of header on the letters and reports This functionality is also included in the Edit Prescriptions Orders Settings Window
38. button opens the Refills Window shown in Exhibit 07 034 Upper section shows patient s allergies Next are all the Medicines in the Master Medication List for the patient There is a checkbox against each medicine Check the checkbox for the medicines required to be refilled Now the Refill Selected Meds button will activate Click the button to open the Refill Writer Exhibit 07 035 The functionality of the Refill Writer is discussed in detail in section 06 03 16 01 02 If you are unsure which medicine requires refilling a list of the last 5 Refill Requests for the patient appears in the lower section of the Window Click Open to open the required request Are You Sure You Want To Delete This Chart And All Its Related Documents Yes Delete Chart Exhibit 07 029 Exhibit 07 030 File was successfully deleted EMR User Manual lt gt 3 Scheduler Ti Customize E Sat May 4 2013 amp Sat May 4 2013 Smith John CHART PATIENT s NAME PHONE VISIT REASON NOTES 2 Last Name First Name Visit Reason Notes 00002 123 456 789 15 Phone Chart ID Len Sun Mon Tue Wed Thu Fri Sat zs z e s e Le JL Reset To Today Search Next Day Having Min Slot gt Exhibit 07 031 x Phone Notes x 00002 Smith John 1 4 26 2013 Patient This is a phone note Exhibit 07 032 E
39. button to save the changes mE EMR NEXT User Manual Assessment Diagnosis Ongoing Problems lt gt 1 Code 789 00 Onset Status x Desc Abdominal pain NOS Note New Assessments 1 Code 790 0 Onset Nature x Desc Abnormal red blood cell Note Exhibit 09 021 First Cardiology Clinic Chart ID 00005 Smith Nicola Yellow Sticky Note 55 Work Information Telephone Notes Tav ME Status DOB General Notes Employer Work Ph Gender Scans Documents Pharmacy Siblings General Information Other Info Race Contact Information Address City ZIP Code Country United States State AL Home Ph Cell Ph Directives Email Contact z Advance Info Release Exhibit 09 022 EMR NEXT User Manual 4o gt First Cardiology Clinic Photograph Click Chart ID 00014 Doe Smith Yellow Sticky Note e SSN Insurance 1 Telephone Notes r y Carrier n General Notes Address SN City ZIP Code Scans Documents T En Marriage z Country United States State AL Pharmacy Siblings Phone Facsimile Other Info Race 7 Plan ES Expiry ID No Group No Contact Information Copay Auth No Address Remarks City ZIP Code Relation Home Ph Country United States State AL Name Home Ph Cell Ph DOB Gender Email Insurance 2 Carrier ie Work Information Address Status gen City
40. encounter ea EMR NEXT User Manual lt gt 19 Medications prescribed for the patient Only those prescribed in the current encounter 20 Name of the clinic or hospital to which patient referred onwards 21 Space for your signature 22 Your name and ID All fields in the darker shade are editable i e data called in from the original chart or encounter form may be edited added or deleted in these sections of the report EMR User Manual lt gt 06 03 16 02 07 Report 7 Encounter Note Back Exhibit 06 278 shows the Consultation Note in the Print Fax Encounter Related Documents window D First Cardiology Clinic 1001 Parkway Drive Chester AL 23866 Tel 234 598 5589 Fax 234 567 8902 Encounter Note for Smith John on Apr 16 2013 DoB Feb 25 1943 Past Surgical History Nothing on record Known Allergies Dust Mite Eggs Milk or Lactose Intolerance Family History Diabetes Stroke Hypertension Heart Disease Cancer Asthma Hay Fever Arthritis Osteoporosis Anemia Migraine Alzheimers Epilepsy Glaucoma Social History Alcohol Use Caffeine Use Tobacco Use Drugs Use Chm Exposure TB Exposure HIV Exposure Sex Relations Excersice Sleep Habits Procedures Services 10040 Acne surgery 95115 Allergen immunotherapy single INT 85018 Blood count
41. office 75 80 min p Eb Eb Psychotherapy interactive office with 75 90815 min Exhibit 09 061 1 The left side of the window is for the Master List of Evaluation amp Management Codes and their descriptions The list has more than 100 entries The first column shows the codes while the second section shows the description None of these codes will appear in your list of favorites unless you make them favorite EMR NEXT User Manual lt gt gt 2 Click this right arrow to move the Evaluation amp Management Code to your list of favorites 3 If the Description of the Evaluation amp Management Code you are looking for is not included in the Master List you can write it yourself in this field 4 Write the Evaluation Management Code in this field 5 Press this right arrow to include it in your list of favorites The E M Code and Description you have added from this field will not be added in the Master List They will only be added to your favorites 6 This is the list of your favorites that you have prepared either by selection from the Master List or by writing the description and E M codes yourself or as a combination of both 7 Charges for the Evaluation Management Code are specified from here Click the pencil icon to open the window shown in Exhibit 09 062 Specify the charges and click the OK button The charges specifi
42. only positive factors are shown 2 If you uncheck this checkbox patient s Social Security Number will also appear on the encounter note as shown in Exhibit 09 012 3 f you check this checkbox Master Problem List will be included in the Referral Letters Consultation Notes and Encounter Notes This setting is not applicable on other letters 4 f you check this checkbox the Master Medication List will be included in the Referral Letters Consultation Notes and Encounter Notes This setting is not applicable on other letters 5 The difference between the two note styles is shown on Exhibits 09 010 and 09 013 In Exhibit 09 010 the first note style has been used The positive factors are indicated with a sign while the negative factors are indicated with a sign In Exhibit 09 013 the second note style has been used The positive factors are indicated by a Yes notation while the negative factors are indicated by a No notation 6 If this checkbox is unchecked then the chief complaints will appear in continuation in the same line In the default state where the checkbox is checked each complaint takes a new line 7 f this checkbox is unchecked then all plan note items will appear in continuation one after the other in the same line In the default state where this checkbox is checked each plan note item starts with a fresh line 8 In default state positive factors or factors of concern are shown in red
43. see Notes to item 6 in Section 08 7 Define change work time from here Dropdown lists on the field give you selectable options configured according to the standard time slots defined by you The start time for the first session has a 24 hour option But the end time can only be after the start time Different weekdays may start and end at different times There is no compulsion to have similar timings throughout the week 8 If your clinic practice runs in two sessions define change work time for the second session from here Dropdown lists on the field give you selectable options configured according to the standard time slots defined by you The second session can start only after the first session closes Likewise the second session can end after it has started It is possible to have only one session on some weekdays and two sessions on others Timings of the second session need not be consistent throughout the week 9 Add or change signature stamp on the system from here Click the Select button on the right to select the signature stamp The system will take you to the operating system Browse to the location where the signature stamp is available EMR User Manual lt gt and click to bring it the system The stamp size must be within 36 pixels in height and 168 pixels in width If the stamp size is larger an alert will appear Resize the image and import it To remove the stamp
44. 00 am 30 00002 Smith John 123 456 789 Add Slot Exhibit 08 025 EE EMR NEXT User Manual lt gt Scheduler Th Customize Thu May 9 2013 09 15 09 30 09 45 10 00 10 15 10 30 10 45 11 00 11 15 11 30 11 45 12 00 12 15 12 30 12 45 01 00 01 15 01 30 01 45 02 00 02 15 02 30 02 45 03 00 03 15 03 30 03 45 Specials EJETJEJESESESES s e s o belie 2 aaa frs 20 21 22 23 24 25 2 27 28 29 30 1 1 2 3 4 5 6 Exhibit 08 026 EMR NEXT User Manual lt gt 09 Customization Back EMR Next is a very flexible system You can re design the whole forms there are three forms General History and Encounter according to your clinic s practice s requirements This means 1 you can change the positioning of the blocks in the forms 2 you can remove blocks that you do not need permanently from the forms and you can add new blocks that you may need permanently in the form templates Within each block you can add or remove elements and sub elements elements within an element Within each element you can add or delete values permanently thereby changing the Lists of Values These values may either be items phrases auxiliary data for the values etc EMR Next also allows you to make your own Letter Report Templates for
45. 002 EMR NEXT User Manual lt gt a Select the right Radio Button to either create new chart or open an existing one The default selection is Open New Chart b Specify patient s Last Name First Name and Middle Name Initial here c If either the first name or Last Name is left Blank and the Create Chart button is pressed item e this message will appear d If you are not sure whether or not the patient already exists in your database this quick search is available on the Last Name where you can type up to 10 characters and a dropdown list appears with all patients with that Last Name Exhibit 05 003 e Click this button to create the chart f Click this button to abort the chart creation action Last First Create New Chart Open Existing Chart Last Name First Name DOB Home Phone Chart ID Smith Q Jahn 02 25 1943 1 123 456 789 00002 Srnith Tom 00004 Smith Nicola 00005 Smith 111 222 333 Exhibit 05 003 If a chart already exists with exactly the same first and last name the system will raise an alert and will drop down the list of all such charts EMR User Manual lt lt Exhibit 05 004 If you are sure that this is not the same patient click yes on the alert Otherwise click no and click on the name of the patient in the dropdown list To visit the existing chart press No on the alert windo
46. 008 h Age amp Gender This is a dual factor option Both gender and age has to be specified Options for gender are Male Female or Transgender Exhibit 07 009 and options for age are Equals To Greater Than or Less Than Exhibit 07 010 Select both and enter the age value in the value field aa EMR NEXT User Manual Find Charts Where starts with w starts with equals to Exhibit 07 002 Find Charts Where Exhibit 07 004 mu EMR NEXT User Manual Find Charts Where starts with 7 starts with equals to Exhibit 07 003 Find Charts Where starts with w starts with equals to Exhibit 07 005 4o gt Find Charts Where SSN Phone Last Name First Name Birth Date Visit Date Age amp Gender starts with w starts with equals to Exhibit 07 006 Find Charts Where SSN Phone Last Name First Name Birth Date Visit Date Age amp Gende Exhibit 07 008 Find Charts Where O SSM MRN Fhone Last Name First Name Birth Date Visit Date Age amp Gende Exhibit 07 007 Find Charts Where O SSN Phone Last Name First Name Birth Date Visit Date Age amp Gender males w ageis w males females transgenders Exhibit 07 009 mm EMR NEXT User Manual lt gt lt gt Find Charts Where
47. 06 Editing the Review of Systems Block Back When you click the Edit Template Block Icon of the Review of Systems Block a small three button window opens as shown in Exhibit 09 199 The buttons include Cut Edit and Delete Cut Edit Delete sss Seen erm gt Review of Systems HHH General Cardiovascular Respiratory Gastrointestinal Genitourinary Male Genitourinary Female HUN DS ER S DG T Musculoskeletal EE EN ENS DNO UU Exhibit 09 199 Cut If you wish to change the location of this block on the form template click the cut button The blue boundary around the block will turn red indicating that block is ready to be shifted Now click the yellow Add New Block Icon of the location where you want to relocate the block A small two button window opens with the Paste and Add buttons Click the Paste button The block will relocate to this position Delete If you wish to delete the block altogether click the Delete button The block will remove from the template Section 09 04 01 shows how to restore the block Edit When you click the Edit button the following Edit window opens EE EMR NEXT User Manual lt gt Review of Systems General Fevers Chills Sweats Appetite loss Weight los
48. 07 020 wu EMR NEXT User Manual 40 gt Export Superbills Batch 4 Yesterday s Encounters Other Date 2013 Batch C Include encounters even if there CPT codes or contain Billing not required flag Batch for Mar 25 2013 1 superbill out of 1 encounter First Cardiology Clinic 1001 Parkway Drive Chester AL 23866 Tel 234 598 5589 Fax 234 567 8902 Encounter Date Mar 25 2013 SUPER BILL Chart ID 00002 Ene Date Mar 25 2013 Superbill No S 00002 2 ID BA 1234567 Patient Details Address 123 ABC Drive Any City Any State Any ZIP Cd Cell 123 456 789 Work Status Marital Status Married Primary Insurance Camrier ABClmwaxeCo D O Jor O _ j Remarks Secondary Insurance _ Remarks Guarantor Remarks gt Exhibit 07 021 Export Superbills Batch x Yesterday s Encounters Other Date 2013 Batch C Include encounters even if there are no CPT codes or contain Billing not required flag Batch for Mar 25 2013 1 superbill out of 1 encounter First Cardiology Clinic 1001 Parkway Drive Chester AL 23866 Tel 234 598 5589 Fax 234 567 8902 Encounter Date Mar 25 2013 SUPER BILL Chart ID 00002 Encounter Type Office Visit Est Enc Date Mar 25 2013 Encounter No 2 Superbill No S 00002 2 Provider Details Name Davis Richard MBBS ID BA 12345678 Name Smith John DoB Feb 25
49. 1 of the exhibit there is an inscription saying Presently free type field In part 2 the cursor was brought over the name of the field and clicked Now the field has converted for selection and when you click in the field the dropdown list appears as can be seen in part 3 3 Only three patient charts can be opened at a time To open the next one one of the previously opened charts will have to be closed o EMR NEXT User Manual 04 Getting Started lt gt Back When you have downloaded the system from the Microsoft Store following EMR Next icon would be appearing on your desktop the EMR Next icon is pointed by the red arrow d Calendar Internet Explorer Store 21 SkyDrive Minneapolis Star Tribune Carmelo Anthony scores 36 points Knicks beat Celtics 85 78 in playoff opener Y T Exhibit 04 001 Click on the icon The homepage will open IE Dashboard E Scheduler EMR NEXT Electronic Medical Records System the ultimate Mobility eXperience ames sic Mu G Ti Customize Navigation Guide What would you like to do Create a new patient chart Open an existing patient chart Open an existing chart that you recently viewed Search charts import documents or export bills Go to an already opened chart Do scheduling related tasks Customize program according to your specialty Open context sensitive help Do data backups or restore B EMR NEXT
50. 1951 Sex Male Address 123 ABC Drive Any City Any State Any ZIP Cd Tel 123 456 789 Cell 123 456 789 Work Status Marital Status Married Primary Insurance Carrier ABC Insurance ID uth Address 11th Street Sea View Road Alabama AL Plan My First Plan Relation Name DoB el Remarks Secondary Insurance Carrier ID Address 2 Relation ame el Remarks Guaranter Remarks ee Exhibit 07 022 EET EMR NEXT User Manual lt gt Batch file successfully saved at the specified location Exhibit 07 023 5 Flagged charts and documents are retrieved from the dashboard Frequently you will be called away from the chart or the document you are working on You would want to complete what you were doing later on You can flag such charts or documents The flagging option is available from three points For charts there is a button at the bottom right corner on the chart screen See the flag button on the bottom black strip in Exhibit 06 131 For external documents that are being imported in the system there is a check box for flagging the document available on the Document Filer Item 7 Exhibit 07 015 For documents already saved in the system folders the flagging button is available at the bottom of the document viewer respectively Exhibit 07 025 To view flagged documents open the dashboard and click the flagged items bar at the bottom of the left co
51. 323 09 01 04 10 History of Present Illness HPI Phrases 325 09 01 04 11 Reasons For Referral RFR Phrases 327 09 01 04 12 Plan Notes Phrases 329 09 01 04 13 Past Medical History PMH Phrases 331 09 01 04 14 Past Social History PSH Phrases 333 09 01 04 15 Allergies Phrases 335 09 02 General Form Template 338 09 03 History Form Template 344 jl EMR NEXT User Manual 09 03 01 Adding New Blocks to the History Form Template 346 09 03 01 01 Block with Single Free Text Field 349 09 03 01 02 Block with Multiple Free Text Fields 351 09 03 01 03 Block with Multiple Free Text Fields 355 extensible rows 09 03 01 04 Block with Single Dropdown 358 09 03 01 05 Block with Multiple Dropdowns 361 09 03 01 06 Block with Multiple Pick lists 365 09 03 01 07 Block with Large Free Text Area 369 09 03 01 08 Block with Multiple Buttons 371 09 03 01 09 Block with Multiple Checkboxes 374 09 03 02 Editing the Past Medical History Block 377 09 03 03 Editing the Past Surgical History Block 379 09 03 04 Editing the Known Allergies Block 381 09 03 05 Editing the Health Maintenance Block 383 09 03 06 Editing the Family History Block 386 09 03 07 Editing the Social History Block 391 09 03 08 Editing the Master Problem List Block 396 09 03 09 Editing the Master Medication List Block 398 09 04 Encounter Form Template 400 09 04 01 Adding New Blocks to the Encounter Form Temp
52. 567 8902 Total Charges Service Da Apr 16 20 Service Office Visit Ne AMOUNT Exhibit 06 032 LOCKED Saturday April 27 2013 7 45 00 AM Move Button Documents can also be moved from one folder to another Open the document in the Document Viewer and click the Move button A small window opens asking for the Chart ID to which you want to move the document and the type of folder to which you want to move it Exhibit 06 033 Provide the information choose folder type from dropdown list Exhibit 06 034 and click the move button on the small window The move will take place and the document viewer w ill go blank ID Exhibit 06 033 change Move Handouts Other ID Le Type Exhibit 06 034 change System generated documents cannot be moved to any other chart They may only be moved from one folder in the chart to another folder in the same chart Similarly a flagged document also cannot be moved out of the chart but it may be moved to any other folder within the chart A notation comes in red on the m EMR NEXT User Manual 40 gt small window that the document is flagged If you still want to move a flagged document to another chart provided it is not a system generated document remove the flagging and then move it Delete Button Any document whether system generated or imported can be deleted by selecting the respective documen
53. 586 5523 Plan 1215 123 458 6565 Expiry ID Group No Copay 250 Auth No Rema QD relation D Name DOB Exhibit 06 052 Qon Ph Gender 1 If you have already defined the patient s Insurance Company in the database Section 09 01 03 01 tells how it is done you may select the name from the dropdown list Exhibit 06 053 Otherwise write the name manually in the form If you have defined all required information of the Insurance Company in the EN EMR NEXT User Manual lt gt lt gt database section 09 01 03 01 the first eight fields of this block will be automatically populated when you select the Insurance Company 2 Address of the Insurance Company This will be populated upon selection of the insurance company if all data requirements have been completed while defining the insurance company in the database Otherwise write the address manually 3 The city the Insurance Company is located in This will be populated upon selection of the insurance company if all data requirements have been completed while defining the insurance company in the database Otherwise write the name of the city manually 4 Zip Code or the Postal Code of the Insurance Company If your clinic is located in USA the field seeks Zip Code For all other countries the field asks for Postal Code This will be populated upon selection of the insurance
54. AGE GENDER WEIGHT and HEIGHT are all required to plot growth charts Exhibit 06 191 EMR NEXT User Manual 06 03 07 Physical Examination Block Back Exhibit 06 192 shows the Physical Examination Block The location of the block on the Encounter Form is identified by item 7 on Exhibit 06 134 This block is a part of the Objective Section of the encounter under the Center for Medicare amp Medicaid Guidelines for taking patient history Physical Examination a Constitutional Fyes Neck Respiratory Cardiovascular Breasts Gastrointestinal Genitourinary Female Genitourinary Male Lymphatic Musculoskeletal Skin Neurologic Oooo ooo ooo oe CT Psychiatric Exhibit 06 192 15 systems are defined in this block but more systems can be added or removed according to requirement of your practice Section 09 04 08 shows how to do so EMR User Manual lt gt lt gt gt For each system suitable set of examinations is listed When the checkbox is checked the corresponding system expands to show the listed examinations Exhibits 06 193 to 06 207 show the list of examinations available for each system When you check the checkbox of the exam you perform it sets the exam result to negative and inserts a suitable negative result phrase in the field If the findings are positive click the negative sign It will turn positive the negative finding phrase will wi
55. Allergy NOS Inactive B Family History 706 1 Acne Inactive Diabetes Stroke Hypertension Heart Disease Cancer 789 00 Abdominal pain NOS Improving Asthma Hay Fever Arthritis Osteoporosis Anemia Migraine Alzheimers Epilepsy Glaucoma 403 90 Asthma NOS 724 4 Back pain w radiation NOS 786 50 Chest pain NOS Active Social History Alcohol Use Caffeine Use Tobacco Use Drugs Use Chm Exposure TB Exposure HIV Exposure Sex Relations Excersice Sleep Habits 1 V Include medical history Exhibit 06 284 Face Sheets may be required as covering information for patient s physical file Face Sheets do not save on the system and may be generated afresh as and when required 1 Your clinic s name address phone number and fax number EE EMR NEXT User Manual lt gt 2 Title of Report Patient Face Sheet 3 This section contains the patient s basic information which includes Name Date of Birth Social Security Number Gender Marital Status Race name of patient s Pharmacy and other information as typed in the general form items 3 amp 8 Exhibit 06 012 4 This section contains the patient s contact information which includes Address Home Phone Cell Phone Email and Emergency contact particulars 5 This section contains patient s work information which includes Work Status n
56. Bill will both include the amount If the amount is to be recovered through the Super Bill then amend the amount in the Patient Invoice to Zero EMR User Manual Second Block First Field Second Field Third Field Fourth Field Fifth Field Initially display in Opened state Billable Procedure Exhibit 09 167 First Cardiology Clinic John Photograph Click To lt gt Chart ID 00001 Doe Attach Second Block Physical Examination First Field Constitutional Second Field Eyes Third Field Fourth Field Neck Fifth Field Respiratory Cardiovascular Breasts Gastrointestinal Encounter Date May 22 2013 Type Genitourinary Female Referred by Genitourinary Male Attended by Davis Richard MBBS BA 12345678 _ Lymphatic Musculoskeletal Received Details skin Payment type Billing not required Neurologic Exhibit 09 168 EMR NEXT User Manual lt gt gt 09 04 01 03 Block with Multiple Free Text Fields Extensible Back Rows When you click the third radio button in the User Definable Blocks section of the Add Blocks window Exhibit 09 162 and press the Continue Button the following Add window opens v Initially display in Opened state X Billable Procedure Code Exhibit 09 169 The difference in this and the previous block is that in this bloc
57. Block First Field First Option 5econd Option Third Option Second Field Fourth Option Fifth Option Sixth Option b aud v Initially display in Opened state Billable Procedure Exhibit 09 176 First Cardiology Clinic Chart ID 00001 Doe John Photograph Click To Attach z Fifth Block First Field Second Field Encounter 6 Date May 22 2013 Type Referred by Attended by Davis Richard MBBS BA 12345678 Received Details Payment type Billing not required Note for Biller Chief Complaint Encounter Reason Exhibit 09 177 EMR User Manual Physical Examination Constitutional Eyes ENMT Neck Respiratory Cardiovascular Breasts A Gastrointestinal 5 Genitourinary Female Genitourinary Male Lymphatic Musculoskeletal E Skin Neurologic lt gt lt gt Fifth Block x First Field SEE Second Field m Fifth Option Fourth Option sixth Option Exhibit 09 178 EMR NEXT User Manual lt gt 09 04 01 06 Block with Multiple Pick lists Back When you click the sixth radio button in the User Definable Blocks section of the Add Blocks window Exhibit 09 162 and press the Continue Button the following Add window opens Add X v Initially display in Opened state X Billable Procedure Code Exhibit 09 179 As the
58. Click it again to re activate it Click the block icon twice to refresh the block EE EMR NEXT User Manual 06 03 09 Assessment Diagnosis Block Back Exhibit 06 212 shows the Assessment Diagnosis Block The location of the block on the Encounter Form is identified by item 9 on Exhibit 06 134 This block is a part of the Assessment Section of the encounter under the Center for Medicare amp Medicaid Guidelines for taking patient history Assessment Diagnosis Ongoing Problems New Assessments Exhibit 06 212 Exhibit 06 212 shows a blank Assessment Diagnosis block When entries are inserted in the block it looks as shown in Exhibit 06 213 Assessment Diagnosis Ongoing Problems 1 Code 780 00 Onset Status x Desc Abdominal pain NOS Note New Assessments 1 Code 790 0 Onset Nature x Desc Abnormal red blood cell Exhibit 06 213 EMR NEXT User Manual lt gt lt gt The upper section of the block is for Ongoing Problems Click the Ongoing Problems field icon to call the Past Problems window Exhibit 06 214 The upper section of the window shows the problems dealt with in the previous encounter while the lower section shows all other problems diagnosed for the patient earlier those recorded in the Master Problem List along with their status If the problems are repeating click on the problems in the window to bring them on to the current encounter fo
59. Configuration General Form Template History Form Template Encounter Form Template T Customize Chart ID 00001 First Cardiology Clinic Yellow Sticky Note Telephone Notes General Notes Gender Scans Documents Pharmacy Siblings Other info Insurance 1 Marriage Carrier Photograph Address t City Country United States Phone Plan i ID No Copay i Remarks 1 1 i Relation ZIP Code State Facsimile Expiry Group No Auth No Home Ph Gender Exhibit 09 101 Update Successful Any changes made in GENERAL or HISTORY sections will be reflected in new Charts whereas any changes in the ENCOUNTER section will be reflected in new Encounters Exhibit 09 102 EMR NEXT User Manual Save Changes lt gt lt gt 3 Dashboard Scheduler Ti Customize E First Cardiology Clinic N Photograph z Click To x Chart ID 00018 New Patient Attach AAA A i AA i ii iii i ia Pharm ey gy H 5 Facsimile 5 Other Info Race n Plan Expiry R Y ID No Group No y Auth No Remarks Relation Home Ph Name DOB Gender Insurance 2 Carrier Work Information DM Status City ZIP Code Employer Work Ph C
60. Cut If you wish to change the location of this block on the form template click the cut button The blue boundary around the block will turn red indicating that block is ready to be shifted Now click the yellow Add New Block Icon of the location where you want to relocate the block A small two button window opens with the Paste and Add buttons Click the Paste button The block will relocate to this position Delete If you wish to delete the block altogether click the Delete button The block will remove from the template Section 09 03 01 shows how to restore the block Edit When you click the Edit button the Edit Window shown in Exhibit 09 152 opens showing the ten default elements The exhibit is showing the first two elements but there is a scroll bar on the right which becomes visible when you take the mouse to it right inner edge of the window Scroll down for the remaining eight elements EMR NEXT User Manual lt gt Social History Alcohol Use Phrase for Normal Finding if any Phrases for Abnormal Findings Never Rarely Moderate Heavy Caffeine Use Phrase for Normal Finding if any Phrases for Abnormal Findings Never Rarely Moderate v Initially display in Opened state Exhibit 09 152 There is two tiered editing on this window In the first tier you can either add or remove elements from the list In the second tier you can add or
61. EMR User Manual lt gt 3 Edit your Professional ID from here In the second field edit the type of ID that it is Options are available in the dropdown list on the field If you wish to reproduce the ID on reports check the appropriate checkbox The first checkbox is for Prescriptions second for Laboratory Orders Radiology Orders and General Orders and the third for Notes EMR Next has provision to store up to three different IDs It is possible to use different IDs on different reports prescriptions laboratory orders radiology orders notes depending on how you check the checkbox 4 The Enable Scheduling checkbox would already be checked while making the initial configuration Section 4 Since it is a mandatory field you can t uncheck it i e amendments will not save if the field is unchecked 5 Change the standard slot duration from here Slots are available for 5 minutes 10 minutes and 15 minutes Once changed the time slots in the Scheduler will re configure according to the new standard If existing appointments do not fit in completely in the new schedule they will convert into irregular appointments see Notes to item 6 in Section 08 6 Change the clinic s workdays from here Checkmark days to add them as workdays and uncheck them to remove from the workweek If an existing workday is made a holiday the appointments scheduled for that day will convert into irregular appointments
62. Insurance Block of the Primary Configuration tab of the Customization Area like this Insurance Companies ABC Insurance E f My First Insurance Co tm My Second Insurance Co Exhibit 09 034 To edit the particulars click the first icon corresponding to the name of the Insurance Company To delete the Insurance Company from your list click the second trash can icon corresponding to the name of the Insurance Company To add a new Insurance Company to your list click the Add button on the block The Add Insurance Company Window will open as shown in Exhibit 09 035 cu EMR NEXT User Manual lt gt Add Insurance Company E comet Plans Add Plan Exhibit 09 035 1 Write the name of the insurance company here 2 Write the insurance company s ID number here 3 Specify the type of ID number by selection from the dropdown list on the field The types available in the dropdown list are illustrated in Exhibit 09 036 4 Write the name or designation of the contact person at the insurance company here 5 This field is for the insurance company s address 6 This field is for the insurance company s city county etc 7 Specify the insurance company s zip code postal code here 8 Specify the insurance company s country here Initially the country in which your practice is based will come selected Change if the insurance compan
63. John Gender Male Feb 25 1943 Phone 123 456 789 ess 123 ABC Drive Any City Any State Any ZIP Cd Phone Insurance ABC Insurance ID No Group No Insurance2 ID No Group No Exhibit 06 073 Face Labels include the following information of the patient in order Date on which the label is printed Patient s Social Security Number Name Gender Date of Birth Phone Number Address Guarantor s Name Guarantor s Phone Number d Insurance Company s Name Insurance Policy No amp Group No 27 Insurance Company s Name Insurance Policy No amp Group No EMT EMR NEXT User Manual lt gt 06 02 History Form Back First Cardiology Clinic Photograph Click Chart ID 00014 Doe Smith To Past Medical History Family History Diabetes Stroke e Hypertension Past Surgical History Heart Disease Cancer Asthma Hay Fever _ Known Allergies Arthritis 1 Allergen x Osteoporosis Reaction Status Anemia Migraine Alzheimers Epilepsy Glaucoma Health Maintenance Influenza Vaccine Date Note Next x Dose Lot MER C Social History Pneumococcal Vaccine Date Note Next x Alcohol Use Dose Lot MER Caffeine Use Tobacco Use ww Drugs Use Colorectal Screening Chm Exposure Date Note Next x TB Exposure Misc HIV Exposure m Sex Relations Prostate Screening Excersice
64. Mar Female Apr Transgender Exhibit 06 039 Exhibit 06 040 Marriage Married Race White Siblings Race Married White Divorced Black Separated Hispanic Widowed 7IP Code Asian Single state Other Exhibit 06 041 Exhibit 06 042 EMR NEXT User Manual lt gt Pharmacy My First Pharmacy Other Infa 2 41 My First Pharmacy Contact My Second Pharmacy Address My Third Pharmacy Exhibit 06 043 EMR NEXT User Manual lt gt 06 01 03 Contact Information Block Pack Contact Information Block on the General Information Form is identified at Item 9 of Exhibit 06 07 The Contact Information Block looks like this Contact Information Address Q 123 ABC Drive City Q City ZIP Code Any ZIP Cd Country 4 12 Q state Any State Home 1123 456 789 D Cell Ph 123 456 789 Email Eme vv nu Exhibit 06 044 1 Two lines are available for the address 2 City is to be entered manually No dropdown available 3 Zip Code field available if your clinic is US based Otherwise the Post Code field is available 4 Enterthe country manually here Be careful to avoid spelling mistakes 5 Enter the State Province etc here manually Again be careful to avoid spelling mistakes 6 This field is restricted for numeric input only Auto formatting applies according to US standards if your practice is based in USA 7 This field is restricted for numeric inp
65. Medical History Window are managed from here in the Customization Section When you click the Open button on the field identified as item 4m in Exhibit 09 002 the Add Delete PMH Phrases Window opens Add Delete PMH Phrases Xx Master List Your Favorites Abnormal mammogram Abnormal PAP smear Abnormal PAP smear Abnormal mammogram Anemia blood disorder Anemia blood disorder Angina Angina Arthritis joint disease Arthritis joint disease Asthma breathing problems Asthma breathing problems Back problems Back problems Bleeding trait Bleeding trait Cancer Cancer Chicken pox Chicken pox Chronic cough Chronic cough Chronic obstructive pulmonary disease Chronic obstructive pulmonary disease Congenital defect Congenital defect Depression Depression 0011107707 Denressive disarder Depressive disorder Add Your Own PMH Phrase 1 Diabetes Dizziness or fainting spells b Eb Bb Eb Eb Eb Ep Eb Ep Ear nose throat trouble Exhibit 09 087 1 The left side of the window is for the Master List of Past Medical History Phrases The list has more than 50 entries None of these phrases will appear in your list of favorites unless you make them favorite 2 Click this right arrow to move the Past Medical History Phrases to your list of favorites 3 If the phrase you are looking for is not included in the Master List you can write
66. SS Stroke d Third Field Hypertension Fourth Field Heart Disease Fifth Field Cancer Asthma Hay Fever Arthritis Past Surgical History HIH Osteoporosis Anemia Migraine Alzheimers Past Medical History EE Glaucoma Exhibit 09 112 EMR NEXT User Manual lt gt 09 03 01 03 Block with Multiple Free Text Fields Extensible Pack Rows When you click the third radio button in the User Definable Blocks section of the Add Blocks window Exhibit 09 106 and press the Continue Button the following Add window opens v Initially display in Opened state Exhibit 09 113 The difference in this and the previous block is that in this block on the actual form if you want to add multiple lines for any field they can be added and deleted In the previous form each field had only one line so limited writing space Write the name of the block in the white field on the top EMR User Manual lt gt Add as many rows as required by pressing the black down arrow under the first two fields If you have added extra fields they can be deleted by clicking the trash can icon at the end of the respective field Now write the names of the fields in the white space at the beginning of each field For example we created five fields and gave them the names First Field Second Field Third Field Fourth Field and Fifth Field as shown in
67. User Manual lt gt Exhibit 04 002 When you click any option on the home page for the first time the Initial Configuration Screen slides in from the right This is because the system requires some basic information before it can be used E Dashboard Schedul a GB hoe Pa aa Initial Configuration T The program needs some basic info about your clinical setup just two small forms you are set to go You will be able to edit this info later if needed E M R M X Your Location Country United States Unit State AL Electronic Medical Records System the ultimate Mobility eXperience Practice or Clinic Information TETTE 4 LEM Address Line 1 ZIP Code HE Telephone Facsimile Email Address 4 Specialization EE Please enter the name of your practice or clinic Exhibit 04 003 Exhibit 04 003 shows the Initial Configuration Screen The data on this screen will be used throughout the system Some information is mandatory Mandatory fields are identified by an asterisk after their prompts 1 Select the country you practice in from the dropdown list 2 Identify whether the next geographical unit is a State Province Territory County or Principality as the case may be If you operate in US the unit will automatically get identified as State 3 Type the name of the unit If you are in USA or Can
68. Where default notes are added to the diagnosis code the color of the pencil icon in the window turns blue as can be seen in the first entry in Exhibit 09 058 9 Specify the charges for the Procedures amp Services here Click the Rates icon to open the window shown in Exhibit 09 058 Specify the charges and click the OK button The charges specified here will be picked up in the Patient Invoice and the Super Bill directly whenever this Procedure or Service is prescribed 10 If you want to delete the Procedure Code from your list of favorites click the corresponding trash can icon If the code was selected from the Master List it will still be available for re selection there but if you had yourself defined the code and description they will be lost 11 Save the changes made to the list by clicking the Save button In Exhibit 09 056 the button is in white color because it is not activated yet It activates whenever a change is made in the window If you try to close the window without saving the changes the alert shown in Exhibit 09 060 will raise 12 The Reset button clears all unsaved changes In Exhibit 09 056 the button is in white color because it is not activated yet It activates whenever a change is made in the window WOII EMR NEXT User Manual lt Default NOTE if any X Acne surgery This is a default note Exhibit 09 057 Default CHARGE if any X Acne surgery 92 06 Exhibit 09 0
69. ZIP Code Employer Work Ph Country United States State AL Phone Facsimile Plan 8 Expiry Directives ID No Group No Contact Auth No Advance S Info Release b adl Remarks Relation Home Ph General Information a Name DOB Gender Guarantor Relation Home Ph Name DOB Gender Remarks Exhibit 09 023 EMR NEXT User Manual lt gt 09 01 02 07 Clinical Decision Support Rules Back Edit Clinical Decision Support Rules There are currently no rules added to the system Click ADD RULE button below to proceed Exhibit 09 024 Add CDS Rule x 90 Age Filter Sex Filter g Qs Exhibit 09 025 The Clinical Decision Support Rules Window shown in Exhibit 09 024 opens when you click the Edit button on item 2g in Exhibit 09 002 For the first time the window will be blank as it looks in the Exhibit When you add the rules they will display on the window To add a rule click the Add Rule button The Add CDS Rule Window shown in Exhibit 09 025 will open 1 Four Clinical Decision Support Rules can be implemented on EMR Next as listed in the dropdown list on this field Exhibit 09 026 a Care Suggestion b Drug Allergy Interaction EMR User Manual lt gt Drug Drug Interaction d Drug Formulary Check 2 If you want to system to prevent the action to be taken in case the conditions of the rule ar
70. a part of the Objective Section of the encounter under the Center for Medicare amp Medicaid Guidelines for taking patient history Procedures Services C o CL k D e Exhibit 06 210 Procedures Services Block registers the Procedures Performed by you or Services offered by you to the patient The block initially shows one set of entries The entry set includes 1 Code of the Procedure Service based on which the biller will make the bill 2 Modifier to the Procedure Service Code 3 Description of the Procedure Service 4 Any remarks you want to incorporate with regards to the service or the procedure performed Entries may either be written manually or selected from the Procedures Services Window Exhibit 06 211 which opens when the block icon is clicked The upper section of this window shows the Procedures services extended in the previous encounter If a procedure service is being repeated click on the item in the upper section of the window to copy it on the fresh encounter form New procedures services may be selected from the lower section of the window where your favorite procedures services are shown See Section 09 01 04 02 for how to create your favorites from over 100 procedures services and their CPT codes already available in the system database Click on the item to bring it on the encounter form along with the code and default note if any default not
71. amount in the Patient Invoice to Zero EP EMR NEXT User Manual Add Eighth Block First Factor Second Factor Third Factor Fourth Factor w w Initially display in Opened state Billable Procedure Exhibit 09 186 Chart ID 00001 Doe John First Cardiology Clinic Photograph Click To Attach Eighth Block Fourth Factor Second Factor Encounter 9 Date May 22 2013 Type Referred by Attended by Davis Richard MBBS Received Details Payment type Billing not required Note for Biller Chief Complaint Encounter Reason Exhibit 09 187 EMR User Manual Third Factor First Factor BA 12345678 LJ Physical Examination Constitutional Eyes ENMT Neck Respiratory Cardiovascular Breasts Gastrointestinal B Genitourinary Female Genitourinary Male Lymphatic Musculoskeletal g Skin Neurologic lt gt lt gt 09 04 01 09 Block with Multiple Checkboxes Back When you click the ninth radio button in the User Definable Blocks section of the Add Blocks window Exhibit 09 162 and press the Continue Button the following Add window opens v Initially display in Opened state X Billable Procedure Code Exhibit 09 188 This block is quite similar to the previous one with the exception that instead of toggle buttons the values will be in
72. appear in your list of favorites unless you make them favorite 2 Click this right arrow to move the Past Surgical History Phrases to your list of favorites 3 If the phrase you are looking for is not included in the Master List you can write it yourself in this field 4 Press this right arrow to include it in your list of favorites The Past Surgical History Phrases you have added from this field will not be added in the Master List They will only be added to your favorites EMR User Manual lt gt 5 This is the list of your favorites that you have prepared either by selection from the Master List or by writing the phrases yourself or as a combination of both 6 If you want to delete the Past Surgical History Phrase from your list of favorites click the corresponding trash can icon If the phrase was selected from the Master List it will still be available for re selection there but if you had yourself written it it will be lost 7 Save the changes made to the list by clicking the Save button In Exhibit 09 089 the button is in white color because it is not activated yet It activates whenever a change is made in the window If you try to close the window without saving the changes the alert shown in Exhibit 09 090 will raise 8 The Reset button clears all unsaved changes In Exhibit 09 089 the button is in white color because it is not activated yet It activates whenever a chan
73. arrow under the first two fields If you have added extra fields they can be deleted by clicking the trash can icon at the end of the respective field 407 EMR NEXT User Manual lt gt Now write the names of the fields the white space at the beginning of each field For example we created five fields and gave them the names First Field Second Field Third Field Fourth Field and Fifth Field as shown in Exhibit 09 167 If you want this block to initially appear in opened state on charts keep the checkbox checked If you want it to appear initially as de activated uncheck the checkbox If this block is billable i e you recover charges for the entry in this block then check the Billable Procedure checkbox The next three fields will activate Enter the billing code description and the amount to be filled in these fields Click Ok The Add window will close and the block will be created on the template Save the changes Now when you open a new chart the block will appear on the Form as shown in Exhibit 09 168 for simplicity and uniformity we have opened the new block as the first block on the chart It is named Second Block Please note that two additional full length fields also appear at the end of the block for any free type notes The lines will extend according to the length of the text Whenever there is an entry in this block the Patient Invoice if Patient Invoice is issued and the Super
74. can also take multiple backups for the same day This will help you restore your workings on the system in case of a system crash or in case your tablet laptop gets misplaced It is therefore important that you keep external copies of your backups also This means that the backup file should also be saved at a location outside your tablet laptop It could either be another computer an external hard drive or USB or even on your email address if the backup file is within the permissible size of your email service Item 8 on Exhibit 05 001 in Section 05 The Homepage is for taking backups and restoring them When you click on the icon this window will open Backup Restore Make a new backup Restore from a backup Exhibit 11 001 The first option is for making a backup and the second is for restoring it Making Backups When you click the first button on Exhibit 11 001 the system takes you to the operating System and asks you to open the folder in which you want to save your backup as shown in Exhibit 11 002 Browse to the desired folder location and click the Save Backup at this location button The backup folder will save with the following naming convention EMR NEXT User Manual lt gt EMR Backup day of the week date with time An alert will popup indicating that the backup has been saved Exhibit 11 003 Click OK to close the alert Files k Fere Disk C sort by name
75. click on the Remove button on the right 10 This button gives online help suiting this area Click the icon and inbuilt help as shown in Exhibit 09 004 will appear 11 After adding or changing the information data click Save to save the changes EMR NEXT User Manual 09 01 02 01 Pointer Targets amp Buttons Pack Normal Larger suitable for mouse stylus input suitable for touch input Swelling of hands or feet Swelling of hands or feet Ti IA NMATITAFAI DUCI VATIT A Tee ILU SEE DLE eR T Leg cramps with exertion Leg cramps with exertion CF Vertical gap between pointer targets Swelling of hands feet Swelling of hands or feet Shape of toggle buttons on chart forms Leg cramps with exertion Leg cramps with exertion Exhibit 09 006 The Edit Pointer Targets amp Buttons Window shown in Exhibit 09 006 opens when you click the Edit button on item 2a in Exhibit 09 002 This window performs two functions 1 It increases or decreases space between two fields on the form Since EMR Next is a touch enabled system it will sometimes be convenient for you to increase spacing between two lines to achieve touch accuracy or to decrease it to bring visual compactness While your requirement will come only in areas where lines are selected by touch like from dropdown lists or from field windows from where you select values the spacing difference wil
76. company if all data requirements have been completed while defining the insurance company in the database Otherwise write the Zip Code Postal Code manually 5 The country in which the Insurance Company is located This will be populated upon selection of the insurance company if all data requirements have been completed while defining the insurance company in the database Otherwise write the name of the country manually 6 The State Province of the Insurance Company If your clinic is located in USA the field requires the name of the State For all other countries name of the Province is sought This will be populated upon selection of the insurance company if all data requirements have been completed while defining the insurance company in the database Otherwise write the name of the State Province manually 7 The Insurance Company s telephone number This will be populated upon selection of the insurance company if all data requirements have been completed while defining the insurance company in the database Otherwise write the telephone number manually 8 The Insurance Company s fax number This will be populated upon selection of the insurance company if all data requirements have been completed while defining the insurance company in the database Otherwise write the fax number manually 9 Refers to the particular Insurance Plan of the Insurance Company The field is selectable from the list of plans already fed
77. electronic signature on the system 12 If you press the refresh button all editing that you have done to the refill request will undo and the report will revert to the state when the report was called in the Refill Writer 13 Once you are done save the Refill Request 14 Refill Request may be printed individually for each medicine or as a combined Request for all medicines in one letter This radio button gives you the option The default value of the radio button is combined and a combined report will print a EMR NEXT User Manual lt gt gt Refill Writer Refill for Smith John First Cardiology Clinic Combined 1001 Parkway Drive Chester AT 23866 73450955 734556 7_ 2 Tel 234 598 5589 Fax 234 567 890 9 Separate REFILL REQUEST Name Smith John Dob Feb 25 1943 Sex Add 123 ABC Drive Any City Any State Any ZIP Cd R Abilify 20 mg TAB Quantity 10 Ten Refills 3 Three Dated Apr 23 2013 1 Spelled Quantities and Micro Print Signature Line 5 Magnification First Cardiology Clinic 1001 Parkway Drive Chester AL 23866 Tel 234 595 5289 Fax 234 567 8902 Sign Stam REFILL REQUEST 4 50 inch x 3 25 inch 96 dpi Exhibit 06 259 15 If the radio button is changed to separate then separate requests will be generated for each medicine 16 You can see here that only one medicine appears in this report 17 And a counter appe
78. episodic 004000 Eb Eb mb Eb Eb Eb Eb Eb Ep Eh Abnormal glucose other 786 50 Chest pain NOS Depression major single episode partial Add Your Own Diagnosis Code 296 25 P na d remission Depression major single episode severe w psychosis Exhibit 09 052 1 The left side of the window is for the Master List of Diagnosis Codes and their descriptions The list has more than 1900 entries The first column shows the codes while the second section shows the description None of these codes will appear in your list of favorites unless you make them favorite EMR NEXT User Manual lt gt 2 This is the 3 10 character quick search for the description you are looking for Enter the search value and enter the right arrow icon next to it The cursor will jump to the first entry starting with the search value 3 Click this arrow to move the Diagnosis Code to your list of favorites 4 f the Description of the Diagnosis you are looking for is not included in the master list you can write it yourself in this field 5 Write the Diagnosis Code in this field 6 Press this right arrow to include it in your list of favorites The Diagnosis Code and Description you have added from this field will not be added in the Master List They will only be added to your favorites 7 This is the list of your favorites that you have prepared either by selection from the Mast
79. has been selected The scheduler will open for the selected date in the viewing pane and the date on the viewing pane item 12 will change to the selected date Please note that the date marked as item 2 will not change It will continue to show today s date 9 You can also navigate the months from the backward amp forward arrows Click the back arrow to go to a previous month and the forward arrow to go to a future month 10 If the scheduler is open on any other day and you want to come back to today the fast way is to click to this button which will bring you back without having to go through the hassle of selecting today s date on the calendar 11 If you have a busy schedule and you want to find the next vacant slot of particular time duration select the time duration here and click Go The scheduler will open on the next date on which a slot of this duration is available 12 This is the date on which the scheduler is open Available and booked time slots on the viewing pane pertain to this date 13 Once an appointment is booked these four columns will be filled by four icons Enlarged view of the icons is shown in Exhibit 08 007 Functionality of these icons will be discussed in the Notes to item 13 14 Marked as item 14 is a search for the past and upcoming appointments of the patient When the icon is clicked the search window shown in Exhibit 08 008 opens The first field has three options in its dropdown
80. has been referred by any other doctor or any other hospital clinic the name of the doctor or the hospital clinic If you have the name of the doctor hospital clinic in your database then select from dropdown list Exhibit 06 138 otherwise write manually Section 09 01 03 03 shows how to add the names of doctors to the database and Section 09 01 03 06 shows how to add name of hospitals clinics to database EMR NEXT User Manual lt gt gt 6 The referring doctor s ID If the ID has been stored along with the of the doctor in the database it will be picked upon selection of doctor in item 5 If the ID is not in the database write manually 7 Your name along with suffix 8 Your ID number Date Apr 11 2013 Typa avis Jan 5 Office Visit New Feb Office Visit Est Exhibit 06 136 Exhibit 06 137 Referred by E Attended by BA 123456078 First Physician Received 5 Payment typs My First Hospital Exhibit 06 138 EMR NEXT User Manual lt gt 06 03 02 Fee Recovery Block Back Exhibit 06 139 shows the Fee Recovery Block The location of the block on the Encounter Form is identified by item 2 on Exhibit 06 134 This block is for any fees that you may receive directly from the patient during encounter Cash Only practices will always be using this block o S Payment type not required Biller Exhibit 06 139 Receiv
81. hemoglobin Hgb 17003 Destroy Lesions 2 14 Physical Examination Eyes Conjunctivae Lids Conjunctivae clear no ptosis Assessment Diagnosis Ongoing problems taken into account 7244 Back pain w radiation NOS 493 90 Asthma NOS New problems added to the master list 786 50 Chest pain NOS Orders amp Requisitions Calcium Ionized Cancer Antigen 125 Cholesterol total Oxygen Mask Sling Wheel Chair Ice Box Prescription Benadryl Childrens Allergy Fastmelt TAB disintegrating Benadryl Cold 500 25 30 mg TAB Chromagen FA TAB Abilify 20 mg TAB Referral My First Hospital for Chest pain Davis Richard MBBS NPI BA 12345678 EXHIBIT 06 278 EMR NEXT User Manual lt gt Encounter Note is report of the encounter that you might wish to print and place on the patient s file This report takes details from the General Form History Form and the concerned Encounter Form of the patient chart 10 11 12 13 14 15 16 17 Your clinic s name address telephone amp Fax numbers Title of the Report Encounter Note along with the patient s name encounter date and Date of Birth Chief Complaint the patient has Past Medical History Past Surgical History Known Allergies Family History Positive identified illness traits appear in red Social History Positive Identified high risk social traits appe
82. is clicked system takes you to the operating system Navigate to the file location and select file The system supports only JPEG BMP PNG and GIF images and only one image can be selected at a time Upon file selection the system brings you back to the Document Filer in the state shown in Exhibit 07 015 with the selected file viewing on the viewing pane Select the Chart to which the document image is to be saved by using the search mechanism at item 1 of Exhibit 07 015 The dropdown list that opens when you use the search mechanism is shown as Exhibit 07 016 The Chart ID and the Patient Name of the selected patient will populate in items 2 amp 3 respectively The file name will carry over to item 4 as the name of the file on the system Edit file name if required Select folder to which the image is to be stored from dropdown field on item 5 Exhibit 07 017 If you want to insert the timestamp EMR NEXT User Manual lt gt the image check the Apply Sign checkbox identified as item 6 be careful while applying sign as such documents will become a permanent feature of the chart and cannot be deleted If you wish to flag the document flagging discussed at Item 5 below check the Also Flag This Document checkbox identified at item 7 Now click the Import Now button The document will save as desired and the notification shown in Exhibit 07 018 will appear to confirm the saving Exhibit
83. it yourself in this field EET EMR NEXT User Manual lt gt lt gt 4 Press this right arrow include it in your list of favorites The Past Medical History Phrases you have added from this field will not be added in the Master List They will only be added to your favorites 5 This is the list of your favorites that you have prepared either by selection from the Master List or by writing the phrases yourself or as a combination of both 6 If you want to delete the Past Medical History Phrase from your list of favorites click the corresponding trash can icon If the phrase was selected from the Master List it will still be available for re selection there but if you had yourself written it it will be lost 7 Save the changes made to the list by clicking the Save button In Exhibit 09 087 the button is in white color because it is not activated yet It activates whenever a change is made in the window If you try to close the window without saving the changes the alert shown in Exhibit 09 088 will raise 8 The Reset button clears all unsaved changes In Exhibit 09 087 the button is in white color because it is not activated yet It activates whenever a change is made in the window You need to click SAVE button below to keep the changes you have made to this favorite list Do you want to close this window without saving Exhibit 09 088 EMR User Manual lt
84. list as shown in Exhibit 08 009 After selecting the search option select the value on the basis of which search is to be applied Options include Last Name First Name Telephone No and Chart ID Exhibit 08 010 Then specify whether your search value will start with or equal to the given value Exhibit 08 011 Thereafter provide the value in the last field and press the Go button If you had opted for upcoming appointments the search results will appear as shown in Exhibit 08 012 If you had opted for past appointments search results will appear as in Exhibit 08 013 There was a third search option which said Display Appointment History If this option is selected and search is applied as in Exhibit 08 014 the Appointment History will display as shown in Exhibit 08 015 There are two blocks in the history The first shows Patient s Name Chart ID Telephone No Total Past Appointments Missed Appointments No of Upcoming Appointments and Next Appointment Date The second block shows the Patient s Name Social Security Number Medical Record Number Date of Birth Home Phone Cell Phone Chart EET EMR NEXT User Manual lt gt Created Date Total No of Encounters and the Last Encounter Date Important point to note is that the figure of Total Past Appointments Missed Appointments should equal the Total Encounters In this case total past appointments are 5 and missed appointments are 1 So
85. name suggests this block will have a multiple fields with Pick Lists Field Windows The advantage of this block over the previous block is that in the previous block only one value can be selected for each field on the History Form In this block multiple values can be selected for each field Write the name of the block in the top field EE EMR NEXT User Manual lt gt Add as many fields as required by clicking the black down arrow under the first field the black dropdown arrow on the left If you have added extra fields delete them by clicking the trash can icon at the left of the respective field For each field add as many rows as required for values in the pick list for the field by pressing the black down arrow under the first two rows of the respective field If you have added extra rows they can be deleted by clicking the trash can icon at the right of the respective row Write the name of each of the field Write the values of the pick lists of each field in the rows you have made available for each field For example we created two fields and gave them the names First Field and Second Field as shown in Exhibit 09 180 For each field we created three row values The values for the first field are First Option Second Option and Third Option For the second field the values are Fourth Option Fifth Option and Sixth Option If you want this block to initially appear in opened state on charts keep the check
86. not have a signature stamp a notification will pop up Exhibit 06 122 Exhibit 06 122 Reports called from this window can only be printed or faxed They are not stored in the database When the print button is clicked the system takes you to the operating system for Your signature image cannot be found in the database selection of printer fax WEB EMR NEXT User Manual lt gt lt gt 06 02 09 01 History Note Pack Exhibit 06 123 shows the complete History Note First Cardiology Clinic 1001 Parkway Drive Chester AL 23866 Tel 234 598 5589 Fax 234 567 8902 History Note for Smith John on Apr 30 2013 DoB Feb 25 1943 Past Medical History Abnormal PAP smear Past Surgical History Carotid endarterectomy Known Allergies Erythromycin Dust Mite Fish or Crustacean Shellfish Family History Diabetes Stroke Hypertension Heart Disease Cancer Asthma Hay Fever Arthritis Osteoporosis Anemia Migraine Alzheimers Epilepsy Glaucoma Social History Alcohol Use Caffeine Use Tobacco Use Drugs Use Chm Exposure TB Exposure HIV Exposure Sex Relations Excersice Sleep Habits e Master Medication List Abilify 20 mg TAB Active Benadryl Cold 500 25 30 mg TAB Active Benadryl Childrens Allergy Fastmelt TAB disintegrating Active Carmol 10 10 LOT Active Chromagen F
87. o a 1 1 1 5 gt x mI ESSO sH oe i lt o a O un un 1 1 1 i 1 4 k 4 k 4 k e e e e Past Medical History e Past Surgical History Status Known Allergies Reaction 1 Allergen E i x x x x x x i 1 i k c c t 1 p E o E a 1 rA RZ 4005 2 2 2 2 i tk o it 1 i Sike t8 o o val 2 2 19 1 Q E 1 bo o E 1 i 5 i ig o 5 5 i 1 4 gt o v s a 2 m bo MIN rt T 8 T T i i3 8 3 EC SE HB EE i 2 o o g vo o zz o i P eS 2 2 I o amp 2 A i LI a e e Exhibit 09 104 2 5 0 2 2 gt Lu 2 lt gt All the eight blocks the lower portion of the Template are encircled by blue dotted lines These lines indicate that the blocks are editable A blue circular icon is attached to the upper left corner of each of the encircled blocks It is the Edit Template Block Icon on clicking whic
88. opened an alert pops exhibit 06 132 asking if you want to open a blank encounter form or you want to copy the previous encounter form this may save you some writing if there are particulars on the previous encounter form that you might want to carry on the fresh form also Add Encounter Add Encounter Blank Encounter Form Blank Encounter Form Copy of Encounter 8 Copy of Last Encounter Copy of Last Encounter Exhibit 06 132 Exhibit 06 133 EMR NEXT User Manual lt gt If there is any particular encounter form you want to be copied then you must navigate to that encounter form and then create the new encounter Like in Exhibit 06 133 the patient had 12 encounters But the doctor wanted to copy encounter 8 on the fresh encounter form He she navigated to encounter 8 and then clicked the create new encounter button The popup window now asks if a blank encounter form needs to be created or encounter 8 should be copied or the last encounter 12 should be copied A click on the center button created a fresh encounter form 13 with contents of encounter 8 copied thereon Deletion of Encounter forms is discussed in section 06 03 16 01 01 The complete Encounter Form is shown in Exhibit 06 134 The top section is the same as that discussed in the General Form Encounter Form specific items are discussed section wise EMR NEXT User Manual Chart ID 00014 Doe Smith Firs
89. per appointment Although the third option of defining the SSD as 5 minutes and selecting six slots per appointment is also available but this will be too cumbersome Exercise your judgment while defining the SSD Check mark the days of the week on which your clinic operates Define the starting times and closing times for the first session for each weekday individually Time intervals in the dropdown list item 23 are constructed according to the SSD defined by you in item 19 Dropdown lists are managed in a manner that you cannot define the closing time earlier than the starting time It is not necessary to define the same starting and closing times for each weekday For e g Monday may start at 9 00 am Tuesday at 10 am and so on If your clinic runs in two sessions define the starting times and closing times for the second session here Again the dropdown list is managed in a manner that the second session cannot start before the close of the first session and neither can it close before the start time If the clinic operates in only one session leave this part blank Time slots in the dropdown list start from 12 am and go up to 12 pm in intervals equal to the SSD defined by you in item 19 For e g if you had selected the SSD of 15 minutes the second slot will start at 12 15 am the third at 12 30 am and so on so forth lt gt lt lt 24 If you want to move back to the earlier screen press this button
90. radiation NOS 493 90 Asthma NOS New problems added to the master list 786 50 Chest pain NOS If you need any additional information please advise Yours sincerely Davis Richard MBBS NPI BA 12345678 Exhibit 06 283 Patients require Excuse Letters to seek leave from job school on account of illness 1 Your clinic s name address telephone amp fax numbers 2 Date of encounter 3 Title of Report Medical Excuse Letter 4 Addressee s name designation and address lines will add as per requirement This has to be typed in the report Does not carry over from the encounter form n EMR NEXT User Manual lt gt lt gt 5 Patient s name address date of birth and sex 6 Salutations these have to be typed on the letter itself 7 Recommendation for leave The sentence has two editable portions Name of the patient and the recommended duration of leave both of which carry over from the encounter form duration of leaves carries from item 8 in exhibit 06 236 8 Details pertaining to patient s medical condition and treatment Includes list of Procedures Services applied in the encounter and Assessments diagnosis made 9 Space for your signature followed by your name and ID 10 Time stamp of when the Excuse Letter was printed 202 EMR NEXT User Manual lt gt 06 03 16 02 11 Report 11 Face Sheet Back Exhibit 06 284 shows the Fac
91. remove values for any of the element First Tier Editing To remove any of the ten elements in the Social History Block uncheck the checkbox to the left of the element The element will remove along with its values To add new elements in the Social History Block scroll down to the bottom of the window as shown in Exhibit 09 155 Click the black down arrow icon at the left of the window to create new fields as shown in the Exhibit Write the name of the elements in the fields You can create as many elements as required After creating an element add rows for values of the element by clicking the inner black down arrow icon of the respective element Add as many rows as required and specify their values If extra rows have been created delete them by clicking the corresponding trash can icon EMR NEXT User Manual 4o gt The Phrase for Normal Finding if any field next to the element name is for specifying a phrase like for example Trait Not Found which will appear in the form whenever the findings for this element are normal To specify the phrase click the square icon at the end of the field The field it will turn blue as shown in Exhibit 09 153 ready for inscription Second Tier Editing For each of the ten elements below the Normal Finding Phrase is a list of Abnormal Findings These are the intensities of misuse of the social element If you wish to remove any of these intensities from the list
92. respective Edit Template Block Icon EE EMR NEXT User Manual lt gt The seven editable blocks include 1 Contact Information Block 2 Work Information Block 3 Directives Block 4 General Information Block 5 Insurance 1 Block 6 Insurance 2 Block 7 Guarantor Block There is only one editable feature in these blocks which is either to keep them initially activated when a new chart is created or to keep them deactivated We have already mentioned in Section 06 01 while discussing these respective blocks that if you click the Block Title Icon on the block an alert will be raised saying Closing this block would also reset its fields to their default values Are you sure you want to close it If you click the No button on the alert the action will abort But if you click the Yes button on the alert all entries made in this block will clear and the block will be de activated To reactivate the block click the Block Title Icon again The activation or deactivation of the block can thus be done from the chart itself But if you do not need the blocks most of the time then rather than going through the hassle of deactivating them every time a new chart is created you can simply deactivate them on the template from here for once and all Then if you need to activate the blocks on a case to case basis you can do it on the chart To deactivate a block on the template click the Edit Template Block Icon
93. shape of checkboxes The block will have a single field with multiple checkboxes Write the name of the block in the white field at the top this will also be the name of the field EMR User Manual 40 gt Add as many checkboxes as required by clicking the black down arrow under the second row If you create more rows than required you can delete them by clicking the trash can icon at the end of the respective row Write the descriptions of the checkboxes in the respective rows created The default value of the checkboxes is unchecked If you want the default value to appear as checked check the checkboxes We added four rows for four checkboxes naming them First Checkbox Description Second Checkbox Description Third Checkbox Description and Fourth Checkbox Description and kept them initially unchecked as shown in Exhibit 09 189 If you want this block to initially appear in opened state on charts keep the checkbox checked If you want it to appear initially as de activated uncheck the checkbox If this block is billable i e you recover charges for the entry in this block then check the Billable Procedure checkbox The next three fields will activate Enter the billing code description and the amount to be filled in these fields Click Ok The Add window will close and the block will be created on the template Save the changes Now when you open a new chart the block will appear on
94. shown in Exhibit 06 022 To add a note click the Add Note button at the bottom right on the window The Add General Note window opens as in Exhibit 06 023 The window shows the name of the patient and has two fields In the first select the nature of the note from the drop down list Exhibit 06 024 The options are Addendum Clarification Information Instruction Other The second field is for the note itself When done click on the Save button to save the note The note will appear like shown in Exhibit 06 025 in the General Notes Window First is the serial number of the note then the date then the nature of the note in this case it is an information received and then the note You may add as many notes as you want which appear in serial order in the window To delete any note click on the Trash Can Icon on the right of the respective note The system raises an alert to confirm if you want to delete the note Exhibit 06 026 Click Delete Note to delete or Don t Delete to abort deletion action To print the notes click the Print button at the bottom left of the window The button is deactivated if there is no note WE EMR NEXT User Manual lt gt S General Notes x 00002 Smith John There is no data to display Add Note Exhibit 06 022 Add General Note gt 00002 Smith John NoteType Exhibit 06 023 Add General Note 00002 Smith John Note Type This is a
95. system Hospitals Clinics that have been recorded in the system will show in the Hospitals Block of the Primary Configuration tab of the Customization Area like this Hospitals Bi Tm My First Hospital BE Tm My Second Hospital BL My Third Hospital Exhibit 09 049 To edit the particulars click the first icon corresponding to the name of the Hospital Clinic To delete the Hospital Clinic from your list click the second trash can icon corresponding to the name of the Hospital Clinic To add a new Hospital Clinic to your list click the Add button on the block The Add Hospital Window will open as shown in Exhibit 09 050 EMR NEXT User Manual lt gt Add Hospital Hospital Name ID Number Street Address k Exhibit 09 050 1 Write the name ofthe Hospital Clinic here 2 Write the Hospital Clinic s ID number here 3 Specify the type of ID number by selection from the dropdown list on the field The types available in the dropdown list are illustrated in Exhibit 09 051 4 Write the name or designation of the contact person Hospital Clinic here 5 This field is for the Hospital Clinic s address 6 This field is for the Hospital Clinic s city county etc 7 Specify the Hospital Clinic s zip code postal code here 8 Specify the Hospital Clinic s country here Initially the country in which your practice is based will come selected Change if the Hospital Clinic
96. text area where you can write any general notes There is no restriction on the size of the note You can perpetually add to it or delete from it Diabetes Cb Stroke Hypertension m Exhibit 06 094 Diabetes Diabetes E BS Clear Field Undo Last Stroke Hypertension Heart Disease Exhibit 06 095 If you do not need the Family History Block click the square icon before the block title block icon to clear and de activate the block Click it again to re activate it Click the block icon twice to refresh the block EMR NEXT User Manual lt gt lt gt 06 02 06 Social History Block Pack Social History Alcohol Use Caffeine Use Tobacco Use Drugs Use Chm Exposure TB Exposure ES HIV Exposure Sex Relations Excersice Sleep Habits Exhibit 06 096 This is the Social History Block Its placement on the History Form is identified as item 6 on Exhibit 06 074 There are ten social factors habits amp exposures listed in the block but you may add to or delete any of them according to the requirements of your practice See section 09 03 07 for how to add to or delete social factors from this block At the outset the values are set to negative indicating absence of habit or exposure Click the negative sign to turn it positive as shown in Exhibit 06 097 Now either enter data manually or select observations from the given list Open the list
97. text field or as a combination of four dropdown values of Dosage Route Frequency and Duration While the character of the field can be changed on specific charts by clicking the name of the field if you wish that the field should initially appear as a free text field keep the radio buttons unchanged If you wish that the field should initially appear as a dropdown combination field change the radio button to the lower value EMR User Manual lt gt 2 Toopen the block in an activated state on a new chart keep the Initially display in opened state checkbox checked To open it in de activated state uncheck the checkbox Click the OK button Save the changes Initially show Sig as a free text data entry field Initially show Sig as a combination of dropdown menus There are currently 28 entries in your Favorites List for this block You can always manage your favorite lists by visiting Lists Menus section under Primary Configuration tab above If you would like to add or delete items right now just click HERE and it will open the Medications edit window for you on this very screen v Initially display in Opened state Exhibit 09 159 EMR User Manual lt gt gt 09 04 Encounter Form Template Pack When you click the fourth tab on the Customization Home Page identified as Item 4 on Exhibit 09 001 the History Form Template opens The template is s
98. the patients Section 09 01 04 12 shows how to add Plan Note phrases to database Multiple Plan Notes can be selected Plan Notes can also be added manually The Plan notes window has two edit buttons Clear Field for clearing all entries in the Plan Note block and Undo Last for deleting the last entry selected from the window If you do not need the Plan Notes Block click the square icon before the block title block icon to clear and de activate the block Click it again to re activate it Click the block icon twice to refresh the block EMR NEXT User Manual lt gt Exhibit 06 232 WE EMR NEXT User Manual lt gt 06 03 13 Encounter Checklist Block Back Exhibit 06 233 shows the Encounter Checklist Block The location of the block on the Encounter Form is identified by item 13 on Exhibit 06 134 wu mauum Reviewed Past Family and Social Histor Obtained old records summarized old records Discussed Reviewed tests dE interpreted tests data Exhibit 06 233 This is a confirmatory block to ensure that certain vital elements of the encounter which are not a part of the encounter form sequence have also been covered Five elements are included in the block 1 Reviewed the Past Family and Social PFS History The field icon opens the PFS History Consolidated View Window Exhibit 06 234 The window shows the Previous Encounter Fi
99. the Form as shown in Exhibit 09 190 for simplicity and uniformity we have opened the new block as the first block on the chart It is named Ninth Block All the checkboxes are appearing on the form with their initial values being Unchecked Whenever there is an entry in this block the Patient Invoice if Patient Invoice is issued and the Super Bill will both include the amount If the amount is to be recovered through the Super Bill then amend the amount in the Patient Invoice to Zero EET EMR NEXT User Manual Ninth Block First Checkbox Description Second Checkbox Description Third Checkbox Description Fourth Checkbox Description v Initially display in Opened state Billable Procedure Exhibit 09 189 First Cardiology Clinic Chart ID 00001 Ninth Block L Fourth Checkbox Description C Third Checkbox Description L Second Checkbox Description L First Checkbox Description Encounter 10 Date May 22 2013 Type Referred by Attended by Davis Richard MBBS BA 12345678 Received Details Payment type Billing not required Note for Biller Exhibit 09 190 EFI EMR NEXT User Manual Photograph Click To Attach Physical Examination Constitutional Eyes Neck mj Respiratory Cardiovascular E Breasts Gastrointestinal Genitourinary Female Genitourinary Male Lymphatic Musculoskeletal Skin Neurolo
100. the Medicine 2 Dispensation instructions which can either be Generic Equivalent GEQ or Dispense as Written DAW The field is selectable from the dropdown list on it Exhibit 06 224 3 The Signature field is a combo box Initially it is set for manual inscription But if the field title is clicked it breaks into four selectable sections for Dosage Route Frequency and Duration Exhibits 06 225 to 06 228 4 Quantity of medicine to be dispensed Numeric values are available from 1 to 540 in workable lots and thereafter one month dosage two months dosage and three months dosage quantities are specifiable Exhibit 06 229 5 Number of refills authorized Values are selectable from dropdown list on the field Exhibit 06 230 Medicines may either be written manually in the block or selected from the Medications Window that pops when you click the block window icon If medicines are being added manually add blank sets of entries by clicking the add field arrow at the bottom of the block and then fill them appropriately EMR User Manual lt gt Medications Window has 4 sections Exhibit 06 223 The top section lists known allergies The second section lists all medicines included in the Master Medication List The third section includes medicines prescribed in the previous encounter The fourth section is the list of your favorites The system has over 4500 medic
101. the form template click the cut button The blue boundary around the block will turn red indicating that block is ready to be shifted Now click the yellow Add New Block Icon of the location where you want to relocate the block A small two button window opens with the Paste and Add buttons Click the Paste button The block will relocate to this position Delete If you wish to delete the block altogether click the Delete button The block will remove from the template Section 09 04 01 shows how to restore the block Edit When you click the Edit button the following Edit window opens EFE EMR NEXT User Manual lt gt e Initially show Sig as free text data entry field C Initially show Sig as a combination of dropdown menus There are currently 28 entries in your Favorites List for this block You can always manage your favorite lists by visiting Lists Menus section under Primary Configuration tab above If you would like to add or delete items right now just click HERE and it will open the Medications edit window for you on this very screen v Initially display in Opened state Exhibit 09 217 The window shows you how many entries you have in the Pick List for this block and how you could manage the list Two kinds of editing are possible for this block 1 To initially show the Signature field as a free text field or to show it as a combination of Dosage Ro
102. the radio button is set to print yesterday s bills If any other day s bills are to be printed set the radio button to other date and select the date from the dropdown list Exhibit 07 020 Batches cannot be generated for multiple days together One date has to be selected at a time Normally such encounters where CPT codes are not specified or where Billing Not Required has been checked on the Encounter Form are not included in the Super Bill Batch If you desire them to be also included in the batch check the checkbox available on the window Now click the Generate Batch button The batch will be generated and the Super Bills will appear in the viewing pane on the window stacked one after the other Exhibit 07 021 Review them if desired and click the Save Button The batch will be saved and the Export and Print buttons will activate Exhibit 07 022 An alert will also be raised as shown in Exhibit 07 023 Every individual Super Bill will be saved in respective Patient s chart in the Billing folder Click the Export button to generate an electronic file or click Print button to take a hard print Electronic files can be generated either in HTML format or in CSV comma separated values format CSV files open in Excel Contents of the Super Bills are discussed at length in Section 06 03 16 02 08 Upon review if you find any errors in any Super Bill do not save the batch Go to the concerned Encounter Form and make th
103. titled Zip Code For all other countries it is titled Postal Code 9 Change your practice s phone number from here If you practice in USA or Canada the number will auto format according to the prevailing standard in USA or Canada For all other countries the there is no formatting The field accepts only numerical values 10 Change your practice s fax number from here If you practice in USA or Canada the number will auto format according to the prevailing standard in USA or Canada For all other countries the there is no formatting The field accepts only numerical 11 Change your clinic s ID number here 12 Select the type of ID that you have entered in item 11 above Several options are included in the dropdown list on the field If none is applicable select others 13 If your clinic has a second ID change the second ID here 14 Select the type of ID that you have entered in item 13 above Several options are available in the dropdown list on the field If none is applicable select others EMR User Manual 15 16 17 18 19 Change your clinic s practice s email address from here Change your clinic s practice s specialization from here Various options are available in the dropdown list on the field If none is applicable select others If your clinic practice has a logo add or change the logo from here Click the Select button on the right of the fi
104. to re activate it Click the block icon twice to refresh the block Assessment Diagnosis 2 Ongoing Problems Problems dealt with in the Previous visit 724 4 Back pain w radiation NOS 1 Code 724 4 Onset Status x Desc Back pain w radiation NOS Other past problems in Master Problem List Note 995 3 Allergy NOS Inactive 706 1 Acne Inactive 789 00 Abdominal pain NOS Improving New Assessments Exhibit 06 214 Your aibicidie f g j kil m New Assessments Favorites niloipigirisiti ui iviwixi yiz 1 Code 794 30 Onset Nature x 789 00 Abdominal pain NOS Desc Abnormal Stress Test 789 06 Abdominal pain epigastric Note 794 30 Abnormal Stress Test 790 0 Abnormal red blood cell Exhibit 06 215 Status x Mature Improving Minor m Stable 7 7 Self Limited Exhibit 06 216 Exhibit 06 217 EMR NEXT User Manual lt gt 06 03 10 Orders Requisitions Block Back Exhibit 06 218 shows the Orders Requisitions Block The location of the block on the Encounter Form is identified by item 10 on Exhibit 06 134 This block is a part of the Plan Section of the encounter under the Center for Medicare amp Medicaid Guidelines for taking patient history Orders Requisitions mauumum mun Exhibit 06 219 Orders Requisitions Block is for the tests prescribed for the patient Tests are classified in three categories in the system Laboratory Tests Radiology
105. uncheck the corresponding checkbox and the intensity will remove from the list of this element If you wish to add more intensities or any other applicable phrases click the black down arrow under the last row and more rows will be added as shown in Exhibit 09 154 Now specify the degree of intensity To remove a row created by you click the corresponding trash can icon Please note that changes made to one element are not automatically applicable to all elements Values of each element have to be changed individually Social History Alcohol Use Phrases for Abnormal Findings Never Rarely Moderate Heavy Caffeine Use Phrase for Normal Finding if any Phrases for Abnormal Findings Never Rarely Moderate v Initially display in Opened state Exhibit 09 153 EMR User Manual 4o gt Social History Alcohol Use Phrase for Normal Finding if any Phrases for Abnormal Findings Never Rarely Moderate Heavy V Caffeine Use Phrase for Normal Finding if any Phrases for Abnormal Findings Mever Rarely Moderate wv Initially display in Opened state Exhibit 09 154 Walks Runs Swims Sleep Habits Phrase for Normal Finding if any Phrases for Abnonnal Findings Less than 6 hours 6 to 8 hours More than 8 hours k Phrase for Normal Finding if any Phrases for Abnonmnal Findings w Initially display in Opened state Exhibit 09 155
106. v RHDSetup 11 23 2012 5 30 A Documentation sources 2 17 KB EMR Manual Update EMR Screenshots VisualStudio2012 PerfLogs Save Backup At This Location Exhibit 11 002 4 Backup successtully saved at your specified location Exhibit 11 003 Restoring Backups When you click the second button on Exhibit 11 001 an alert shown in Exhibit 11 004 will be raised cautioning that if you restore backup any existing data on the system will be lost If you wish to abort the restoration action click Don t Restore on the alert If you wish to continue click Yes Restore Now EMR NEXT User Manual lt gt EMR Next will then take you to the operating system for selection of the backup folder Please note that there are multiple files in the backup folder The entire folder must be selected and not individual files as shown in Exhibit 11 005 The first column in Exhibit 11 005 shows four backup folders When you select your desired backup folder the system will open the folder as shown in Exhibit 11 006 Now click the Select this backup button The backup will restore and the system will give a confirmatory alert as shown in Exhibit 11 007 Click the OK button and restart EMR Next to activate the restored backup Restoring from a backup would erase all of your current data Are you sure you want to proceed Yes Restore Now Exhibit 11 004 Fi les Screensho
107. value to show as positive click the negative sign of the respective factor It will turn positive We added four rows for four factors naming them First Factor Second Factor Third Factor and Fourth Factor and kept the initial values as negative as shown in Exhibit 09 131 If you want this block to initially appear in opened state on charts keep the checkbox checked If you want it to appear initially as de activated uncheck the checkbox Click Ok The Add window will close and the block will be created on the template Save the changes Now when you open a new chart the block will appear on the Form as shown in Exhibit 09 132 for simplicity and uniformity we have opened the new block as the first block on the chart It is named Eighth Block All the factors are appearing on the form with their initial values showing as negative 372 EMR NEXT User Manual lt dop gt Eighth Block First Factor Second Factor Third Factor Fourth Factor v Initially display in Opened state Exhibit 09 131 First Cardiology Clinic Photograph Click T Chart ID 00033 New 8 m amp Eighth Block Family History First Factor Second Factor Diabetes Third Factor Fourth Factor Stroke Hypertension Heart Disease Cancer Past Medical History Asthma Hay Fever Arthritis Osteoporosis Past Surgical History Anemia Migraine Alzheimers Epi
108. whenever this Service Type is selected If the point of service has been defined the pencil icon on the List of Favorites will turn blue as shown in the first entry in Exhibit 09 077 5 If you want to delete the Service Type from your list of favorites click the corresponding trash can icon The Service Type will still be re selectable from the Master List 6 Save the changes made to the list by clicking the Save button If you try to close the window without saving the changes the alert shown in Exhibit 09 078 will raise 7 The Reset button clears all unsaved changes Default POINT OF SERVICE code if any Office Visit New Exhibit 09 076 gm EMR NEXT User Manual lt gt gt Your Favorites POS Office Visit New Office Visit Est Preventive New Preventive Est Office Consultation Confirmatory Consult Inpatient Consult Initial Evaluation Hospital Initial Hospital Subsequent Hospital Discharge Emergency Services Critical Care Services Surgical Services Nursing Initial Nursing subsequent Nursing Discharge Nursing Annual Exhibit 09 077 e e amp amp e e amp amp amp amp amp h Ep Eb Sb Eb EP ED ER Ep Ej Ep Eb EP ED ED You need to click SAVE button below to keep the changes you have made to this favorite list Do you want to close this window without saving Exhibit 09 078 mem EMR NEXT U
109. window icon is clicked Exhibit 06 147 shows the Quality Window Selection from window may be mixed with manual noting In case multiple illnesses are selected in item 1 use of manual comments to identify the qualities of specific illnesses is recommended 4 Specify the Severity of the illness here Either specify manually or select from the Severity Window which pops when the field window icon is clicked Exhibit 06 148 shows the Severity Window Selection from window may be mixed with manual noting In case multiple illnesses are selected in item 1 use of manual comments to identify the severity of specific illnesses is recommended 5 Specify the Duration of the illness here Either specify manually or select from the Duration Window which pops when the field window icon is clicked Exhibit 06 149 shows the Duration Window Selection from window may be mixed with manual noting In case multiple illnesses are selected in item 1 use of manual comments to identify the duration of specific illnesses is recommended 6 Specify the Timing of the illness here Either specify manually or select from the Timing Window which pops when the field window icon is clicked Exhibit 06 150 shows the Timing Window Selection from window may be mixed with manual noting In case multiple illnesses are selected in item 1 use of manual comments to identify the timing of specific illnesses is recommended 7 Specify the Context of the i
110. window is discussed in Section 09 01 01 01 b Provider Information For changing your own particulars When you click the Edit Button on the field the Edit Provider Window opens The window is discussed in Section 09 01 01 02 2 Preferences This part covers seven features as discussed individually a Pointer Targets amp Buttons Field spacing and shape of toggle buttons can changed from here When you click the Edit Button on the field the Edit Pointer Targets amp Buttons Window opens The window is discussed in Section 09 01 02 01 EMR User Manual lt gt b Prescriptions amp Orders Print sizes and settings of Prescriptions and Orders can be changed from here When you click the Edit Button on the field Edit Prescriptions Orders Settings window opens This window is discussed in Section 09 01 02 02 Default Notes amp Letters Certain settings on letters and notes Consultation Notes Encounter Notes and Referral Letters can be changed from here When you click the Edit Button on the field the Edit Notes Letters Settings Window opens The window is discussed in section 09 01 02 03 Custom Letters amp Handouts You can design and save up to eight letter and handout templates from here When you click the Edit Button on the field the Edit Custom Letters Handouts Templates Window opens The window is discussed in Section 09 01 02 04 Document Folders Yo
111. 0 min Psychotherapy office 45 50 min Psychotherapy office with E M 45 50 min Psychotherapy office 75 80 min Psychotherapy office with E M 75 80 min Psychotherapy interactive office 20 30 min Psychotherapy interactive office with E M 20 90811 30 min 90812 Psychotherapy interactive office 45 50 min Psychotherapy interactive office with E M 45 20813 50 min 30814 Psychotherapy interactive office 75 80 min Psychotherapy interactive office with E M 75 y Y Y Eb EF Eb Ej Eh Eh El 90815 Ch audam Exhibit 09 063 EMR User Manual lt gt gt You need to click SAVE button below to keep the changes you have made to this favorite list Do you want to close this window without saving Exhibit 09 064 EMR User Manual lt gt 09 01 04 04 Medications Back Medicines are selected in the Medications Block in the Encounter Form Section 06 03 11 and in the Master Medication List in the History Form Section 06 02 08 These are the medicines that you prescribe to your patient and are printed in the Prescriptions Section 06 03 16 02 01 When you click the block icon in the Medications Block the list of medicines shown in Exhibit 06 223 opens This list shows your favorite Medicines that you construct from here in the Customization Section When you click the Open button on the fie
112. 007 Exhibit 05 007 2 mj EMR NEXT User Manual e Insert up to first ten characters of the patient s last name in the quick search f List of all patients with the same last name drops down for selection Select the required patient chart and click the Pull Chart button to pull the chart Click this button to open an existing chart directly from the homepage The functionality of this button is exactly the same as that of the first button with the exception that the default selection of the Radio Button is on Open Existing Chart instead of Create New Chart exhibit 05 008 lt lt Create New Chart e Open Existing Chart Chart ID 00002 Cancel Pull Chart Exhibit 05 008 8 The Recently Viewed Icon shows the 20 most recently viewed charts for quick access The bullets of charts opened in your current session appear in dark blue see the color of the bullet for Smith Albert in comparison with the color of the bullets for the other three patients in Exhibit 05 009 while those of charts opened in previous sessions in grey Click the desired chart to access it 00007 Smith Albert 00002 Smith John 00013 Smith Kerry 00003 Harry Exhibit 05 009 This icon opens the dashboard see Section 07 This icon opens the scheduler see Section 08 This icon opens the customization screens see Section 09 This icon opens screen sensitive help Section 10 This ico
113. 04 05 shows how to do it Each of the windows specified in items 2 9 has a Clear Field button to clear all inscriptions selections in the corresponding field They also have an Undo Last button to clear the last selection from the window If you do not need the History of Present Illness Block click the square icon before the block title block icon to clear and de activate the block Click it again to re activate it Click the block icon twice to refresh the block History of Present Illness First phrase for HPI Clear Field HPI Previous Encounter none Location Quality Severity Your Favorites Duration First phrase for HPI Onset Timing Second phrase for HPI Third phrase for HPI Cantavt Exhibit 06 145 Location x Clear Field Undo Last All over Ankle left Ankle right Arm left Arm right Back Back lower Back upper Chest Chest left cide EMR NEXT User Manual Exhibit 06 146 Clear Field Undo Last Burning Cramping Crushing Dull Fullness Pressure Pressure sensation Pulsating Radiating Exhibit 06 147 Clear Field Undo Last 1 on a scale of 1 5 2 scale of 1 5 3 scale of 1 5 4 on a scale of 1to 5 5 on a scale of 1to 5 Critical Disabling High severity Intolerable Exhibit 06 148 EMR User Manual lt gt lt gt Clear Field Undo Last Continuous Episodic Few days
114. 06 01 02 You may either feed the particulars manually for each patient or you may enter the particulars of the Pharmacy in the block marked as 3b on Exhibit 09 002 just once and whenever a patient with this pharmacy pays a visit simply select the pharmacy from the dropdown list on the corresponding field in the General Form All the pre fed particulars of the insurance company will be called wherever required on this selection Pharmacies that have been recorded in the system will show in the Pharmacies Block of the Primary Configuration tab of the Customization Area like this Pharmacies BE My First Pharmacy BL My Second Pharmacy BE My Third Pharmacy Exhibit 09 037 To edit the particulars click the first icon corresponding to the name of the Pharmacy To delete the Pharmacy from your list click the second trash can icon corresponding to the name of the Pharmacy To add a new Pharmacy to your list click the Add button on the block The Add Pharmacy Window will open as shown in Exhibit 09 038 EMR User Manual Add Pharmacy X JU Pharmacy Name j 4 E Address Exhibit 09 038 Write the name of the pharmacy company here Write the pharmacy s ID number here Specify the type of ID number by selection from the dropdown list on the field The types available in the dropdown list are illustrated in Exhibit 09 039 Write the name or designation of the con
115. 07 014 Document Filer Li H E R i File Details 4 6 5 Foder Apply Sign Also flag this document 8 Exhibit 07 015 mE EMR NEXT User Manual Last Name Smith Smith Smith Smith Exhibit 07 016 Folder Medication Also Laboratory Radiology Consultation Hospital Insurance Billing Directives Handouts Other Legacy Exhibit 07 017 First Name John Tom Nicola Jack lt gt DOB Home Phone 02 25 1951 123 456 789 111 222 333 Chart ID 00002 00004 00005 O00006 File successfully imported To import another file just click on the Select File button again and repeat the process Exhibit 07 018 4 Super Bills are prepared and printed exported from the dashboard Super Bills are your mandate to your billing agent for preparation of final bills for recovery from Insurance Companies amp other parties The bills are based on charted encounters those encounters which have been recorded in patient charts From the Dashboard the whole day s batch of Super Bills is generated Individual EE EMR NEXT User Manual lt gt Super Bills cannot be generated from here Generating individual Super Bills has been shown in Section 06 03 16 02 08 When you click the Export Super Bills button on the dashboard the Export Super Bills Batch Window opens Exhibit 07 019 By default
116. 08 discusses how the scheduler operates 7 Also specify by selecting from the dropdown list when the next visit is being scheduled as shown in Exhibit 06 246 This will be on an approximate basis here the actual appointment if made will be on the scheduler Manual comment is also allowed in this field 8 If the patient requires a doctor s certificate for joining school work fill in the time from when he she may resume in the Join Work School field or select appropriate phrase from the dropdown list When you print the excuse letter Section 06 03 16 02 10 the selected or inscribed phrase will appear in the letter Obtain 50806 Psychotherapy office 45 50 min Interp 90807 Psychotherapy office with E M 45 50 min E M Code Code Basis Exhibit 06 237 Code Basis Service Tima Exhibit 06 238 One or more fields required to complete this action are empty Please scroll through the form and fill in the fields highlighted to RED color Exhibit 06 239 WOI UTII EMR NEXT User Manual Encounter 7 Date 11 2013 Referred by Exhibit 06 240 Assessment Diagnosis 1 Code 724 4 Onset Desc Back pain w radiation NOS Note 1 Code 794 30 Onset Desc Abnormal Stress Test Exhibit 06 241 lt gt Ongoing Problems New Assessments EM Code Encounter 4 Service Based Time Based Exhibit 06 242 WOII I EMR NEXT User Manu
117. 081 the button is in white color because it is not activated yet It activates whenever a change is made in the window If you try to close the window without saving the changes the alert shown in Exhibit 09 082 will raise 7 The Reset button clears all unsaved changes In Exhibit 09 081 the button is in white color because it is not activated yet It activates whenever a change is made in the window You need to click SAVE button below to keep the changes you have made to this favorite list Do you want to close this window without saving Exhibit 09 082 EMR NEXT User Manual lt gt 09 01 04 11 Reasons For Referral RFR Phrases Back Reasons For Referral Phrases are used in the Referral Block on the Encounter Form Section 06 03 15 Item 4 on Exhibit 06 249 When you click on the field the dropdown list shown in Exhibit 06 252 opens for selection of reason The list is managed from here in the Customization Section When you click the Open button on the field identified as item 4k in Exhibit 09 002 the Add Delete Reasons for Referral Phrases Window opens Add Delete Referral For Phrases x Master List Abdominal pain Acquired foot deformities Acute sprains and strains Allergic rhinitis Anorectal condition Bursitis synovitis tenosynovitis Cardiac arrhythmia Cardiovascular signs and symptoms Cervical pain syndrome Chest pain Cholelithiasis cholecystitis D
118. 22 Secondary Insurance Cell Phone 123 456 789 Carrier Email Address Emergency Phone Fax Plan Work Information ID Number Group No Status Auth No Copay Institution Relation Phone Name DoB Phone Remarks Contact Info Release 10D Guarantor Information Relation General Information Name DoB Phone Remarks B MEDICAL HISTORY Known Allergies Master Medication List Dust Mite Eggs Milk or Lactose Intolerance Abilify 20 mg TAB Active Benadryl Cold 500 25 30 mg TAB Active Past Medical History Benadryl Childrens Allergy Fastmelt TAB disintegrating Active Nothing on record Carmol 10 10 LOT Active Chromagen FA TAB Active LE Past Surgical History Nothing on record Master Problem List 995 3 Allergy NOS Inactive 2 Family History 706 1 Acne Inactive Diabetes Stroke Hypertension Heart Disease Cancer 789 00 Abdominal pain NOS Improving Asthma Hay Fever Arthritis Osteoporosis Anemia 403 90 Asthma NOS Migraine Alzheimers Epilepsy Glaucoma 7244 Back pain w radiation NOS 786 50 Chest pain NOS Active B Social History Alcohol Use Caffeine Use Tobacco Use Drugs Use Chm Exposure TB Exposure HIV Exposure Sex Relations 7 Excersice Sleep Habits 1 V Include medical history Exhibit 06 072 Face Sheets may be used as covering sheets for patient folder
119. 30 whether age should be equal to less than or more than a certain value for the rule to activate 8 Provide the value of the age band here 9 Ifthe rule should be applied only to patients of a particular sex use the sex filter Select from the dropdown list Exhibit 09 031 which sex the Rule should apply to 10 Write in this field the text or the message that should appear on the Alert if the conditions of the Rule are met 11 After creating the Rule save it Saved Rules show in the Clinical Decision Support Rules Window as shown in Exhibit 09 032 EMR User Manual lt gt Exhibit 09 033 shows how the alert will raise upon activation of the Rule First test rule has been set as a Drug Allergy interaction Carmol has been specified as the triggering medicine and Dust Mite has been specified as the target Allergy Blocking mode has been selected In the Exhibit you may see the Allergy Dust Mite appearing in the Window and a medicine starting with Carmol being selected The Alert is a blocking alert with a red stop sign The precautionary alert has a green stop sign Use the Edit button corresponding the rule as shown in Exhibit 09 032 to edit the rule Use the Delete button corresponding the rule as shown in Exhibit 09 032 to delete the rule Rule Type Trigger Age Filter Care Suggestion Display Text Drug Allergy Interaction Drug Drug Interaction Drug Formulary Che
120. 500 25 30 mg TAB Cardura 2 mg TAB Carmol 10 10 LOT Carmol 10 shampoo Inderal LA 60 mg CAP ER Lamictal 25 mg TAB No Known Medications Exhibit 06 116 There are medications already listed in this block You must first delete them manually before the changing to No Known Medications status Exhibit 06 117 Are you sure you want to change the status of Master Medication List block Exhibit 06 118 Master Medication List mm No Known Medications EMR User Manual lt gt gt Exhibit 06 119 If you do not need the Master Medication List Block click the square icon before the block title block icon to clear and de activate the block Click it again to re activate it Click the block icon twice to refresh the block EMR NEXT User Manual lt gt 06 02 09 The Print Functionality Back The Print Functionality on the History Form is identified at Item 9 of Exhibit 06 074 When the print icon is clicked the Print Fax Historical Data Window opens Exhibit 06 120 Print Fax bHistorical Data x Smith John History Note Problem List Medication List Allergy List eee Health Maint Exhibit 06 120 As can be seen in the left column of the window five Reports may be printed from this window Data for all these reports comes from the History Form Individual Reports are discussed section wise Reports are called in the viewin
121. 58 Your Favorites Note Rate 10040 Acne surgery 95115 Allergen immunotherapy single INJ 85018 Blood count hemoglobin Hgb 1 003 Destroy Lesions 2 14 20526 Injection therapeutic carpal tunnel 92012 Oph Medical Xm amp Eval Intrm Est Pt 90732 Pneumococcal vaccine Adult IM 84425 Thiamine Vitamin B 1 Eb Ep EP Eb ED 84550 Uric acid blood Exhibit 09 059 EE EMR NEXT User Manual lt gt You need to click SAVE button below to keep the changes you have made to this favorite list Do you want to close this window without saving Exhibit 09 060 EE EMR NEXT User Manual lt gt 09 01 04 03 Evaluation amp Management EM Codes Pack Evaluation amp Management EM Codes are used in the Evaluation amp Management Code Block in the Encounter Form Section 06 03 14 Evaluation amp Management Codes are billing codes for patient encounters These charges are established by American Medical Association When you select the Evaluation amp Management code in the Block the charges are automatically picked by the Patient Invoice and the Super Bill The EM codes are selected from the dropdown list on the field identified as item 1 on Exhibit 06 236 This list shows your favorite Evaluation amp Management Codes that you construct from here in the Customization Section When you click the Open button on the field identified as item 4c on Exhibit 09 002 the A
122. A TAB Active Master Problem List 0953 Allergy NOS Inactive 706 1 Acne Inactive 789 00 Abdominal pain NOS Improving 40390 Asthma NOS Active 724 4 Back pain w radiation NOS Controlled 786 50 Chest pain NOS Active Signed o Exhibit 06 123 1 Your Clinic s Name Address Phone amp Fax Number 2 Title of the Report along with patient name date of birth and the date of the History Note 3 Past Medical History is called from the History Form 4 PastSurgical History is called from the History Form 5 Known Allergies are called from the History Form 6 Family History is called from the History Form Positive diseases are identified in red 7 Social History is called from the History Form Positive adverse social traits are identified in red EMI EMR NEXT User Manual lt gt 8 Master Medication list is called from the History Form and shows the name medicine and status 9 Master Problem List is called from the History Form and identifies the problem and its status 10 Space for your signature 11 Date and Time stamp of when the print was taken WEB EMR NEXT User Manual 06 02 09 02 Problem List Back Exhibit 06 124 shows the Problem List First Cardiology Clinic 1001 Parkway Drive Chester AL 23866 Tel 234 598 5589 Fax 234 567 8902 e Problem List for Smith John DOB Feb 25 1943 005 3 Allergy NOS 706 1 Acne 789 00 Abdom
123. AD M ELLE LLLI APA ABRE H FH HHHH LL M LZ AA ARR Ate 2 n 4 8 B F 8 10 11 12 13 14 Ts 18 17 18 18 290 yrs Exhibit 06 188 EMR User Manual lt gt gt Growth Charts Weight for Age Stature for Age BMI for Age Hr AH EE e LEE EP e lli 2 1111 IA CONCRETE a TR e HELLE HERCLE ERR LET ES HELLE TEE ELE PRSE TERRE ELE PELLE LEEPRLTPRCRELELEELELLELEE ELE ED LE ELE LE E ELEC TET RS jillu IIS ELLE ELLE ERR ERCTELELL HEEL BG LH E GL 7 LONGE NEEDED a HHT SSS TET SSN LLL LER HELLE EUEEH ELE ES EHE ELT HET EL STATS Hilli ff fd ef Inn HH HIE HELM AAA TTT E SE 21 EF 1 SA TNT SOT us NE BILAN INIHI Exhibit 06 189 between 2 and 20 years sage must be ET m Exhibit 06 190 75 2 gt 0 2 gt lt LLI 2 cc 2 lt gt gt A The patient s
124. AL 23866 e Tel 234 508 5589 Fax 234 567 8902 PATIENT FACE SHEET Basic Information Primary Insurance Name Smith John Carrier ABC Insurance Co DOB Feb 25 1943 Address llth Street Sea View Road Alabama AL SSN Phone 123 586 5523 Fax 123 458 6565 Gender Male Plan My First Plan Marriage Married ID Number Group No Race White Auth No Copay 250 Pharmacy My First Pharmacy Relation Other Info Name DoB Phone Contact Information Remarks Address 123 ABC Drive Any City Any State Any ZIP Cd Secondary Insurance Home Phone 123 456 789 Carrier Cell Phone 123 456 789 Address Email Phone Fax Emergency Plan ID Number Group No Work Information Auth No Status Relation C include medical history Exhibit 06 071 The full Face Sheet looks like this EMR NEXT User Manual lt gt First Cardiology Clinic 1001 Parkway Drive Chester AL 23866 Tel 234 598 5589 Fax 234 567 8902 B PATIENT FACE SHEET Basic Information Primary Insurance Name Smith John Carrier ABC Insurance Co DOB Feb 25 1943 Address 11th Street Sea View Road Alabama AL SSN Phone 123 586 5523 Fax 123 458 6565 Gender Male Plan AB 1215 Marriage Married ID Number Group No Race White Auth No Copay 250 Pharmacy Peter Pharmacy Relation Other Info Name DoB Phone Information Remarks Address 123 ABC Drive Any City Any State Any ZIP Cd Home Phone 123 456 789
125. Allergy Qty Ref s Genitou Benadryl Cold 500 25 30 m Y Cardura 2 mg TAB Carmol 10 1096 LOT 2 E Muscul _ of Carmol 10 shampoo Plan Notes Skin 2 Chromagen FA Neurolo Chromagen FA TAB Psychiat cyclocort 0 196 LOT L Endocrir Cyclogyl 0 596 SOL L Reviewed Past Family and Social History Hemato Cyclogyl 196 SOL eee Diuril 250 mg 5 mL SUS C Obtained old records Summarized old records 2 interpreted tests data Discussed Reviewed tests Exhibit 09 033 EMR NEXT User Manual lt gt 09 01 03 01 Insurance Companies Pack Particulars of the patient s Insurance Company are required for billing purposes These particulars are required in the General Form on the patient chart in the two Insurance Company Blocks discussed in Section 06 01 07 Exhibit 06 052 and Section 06 01 08 Exhibit 06 059 You may either feed the particulars manually for each patient or you may enter the particulars of the Insurance Company in the block marked as 3a on Exhibit 09 002 just once and whenever a patient with this insurance company pays a visit simply select the Insurance Company from the dropdown list on the corresponding field in the General Form If all the required particulars are fed here data in eight fields on the General Form will be called upon selection of the Insurance Company Insurance Companies that have been recorded in the system will show in the
126. Assessment amp Diagnosis Block one for Ongoing Problems and the other for New Assessments In the Ongoing Problems part Diagnosis Codes identified in previous encounters are shown and can be re selected In the New Assessments part new problems are identified This is where you need the list of Diagnosis Codes Exhibit 06 215 shows the New Problems Window The Window lists your favorite Diagnosis Codes and their descriptions You construct this list of favorites from this Section i e from the field identified as 4a in Exhibit 09 002 When you click the Open button on the field the Add Delete Diagnosis Codes Window opens Add Delete Diagnosis Codes x Master List e Search Master List Your Favorites Note Abdominal pain epigastric 789 00 Abdominal pain NOS Abdominal pain LLQ 789 06 Abdominal pain epigastric Abdominal pain NOS 794 30 Abnormal Stress Test 790 0 Abnormal red blood cell 706 1 Acne Abdominal pain RLQ Abdominal pain RUQ Abdominal pelvic mass LLQ 291 89 Alcoholic psychosis other Abdominal pelvic mass NOS 995 3 Allergy NOS Abdominal pelvic mass RLQ 824 2 Ankle closed lateral malleolus Abnormal blood chemistry other 493 90 Asthma NOS Abnormal coagulation profile 724 4 Back pain w radiation NOS Abnormal electrocardiogram 305 20 Cannabis abuse NOS Abnormal fasting glucose 305 21 Cannabis abuse continuous Abnormal glucose tolerance test 304 32 Cannabis dependence
127. Change radio button to second row if you want to enable the Referred by field only on consultation type Encounters and click the OK button Save the changes If the radio button is changed then the Referred by field on the Encounter Form will initially appear disabled When a consultation type encounter is selected in the type field this field will get enabled EFI EMR NEXT User Manual lt gt 09 04 03 Editing the Fee Recovery Block Back When you click the Edit Template Block Icon of the Fee Recovery Block a small two button window opens as shown in Exhibit 09 193 The buttons include Cut and Delete Cut 222000 re me Received Details Payment type Billing not required Note for Biller eee eee eee m m m eee m s m s Exhibit 09 193 Cut If you wish to change the location of this block on the form template click the cut button The blue boundary around the block will turn red indicating that block is ready to be shifted Now click the yellow Add New Block Icon of the location where you want to relocate the block A small two button window opens with the Paste and Add buttons Click the Paste button The block will relocate to this position Delete If you wish to delete the block altogether click the Delete button The block will remove from the template Section 09 04 01 sho
128. Complaint on a new line Ow Show every Plan Notes item on a new line Font Face Times C Arial Courier Font Size O Smaller Medium Larger 11 Exhibit 09 009 The Edit Notes Letters Settings Window shown in Exhibit 09 009 opens when you click the Edit button on item 2c in Exhibit 09 002 Notes in context of this window specifically mean Encounter Notes Section 06 03 16 02 07 and Consultation Notes Section 06 03 16 02 06 Letters includes Referral Letters Section 06 03 16 02 05 and all other letters generated by the system EMR User Manual lt gt lt gt 1 This setting is applicable only to Referral Letters Consultation Notes and Encounter Notes The difference between verbose content and concise content is explained with the help of Exhibits 09 010 and 09 011 which are extracts of an Encounter Note Compare the Family History and Social History sections of both the exhibits In Exhibit 09 010 all the factors included in the family history and social history appear in the note with the positive ones marked accordingly and shown in red and the negative ones marked accordingly and shown in black This is how the notes will appear if you select the verbose content radio button All factors covered in a checklist whether negative or positive are shown By contrast in Exhibit 09 011 where concise content has been selected
129. Delete to abort the cancellation action If the appointment is being cancelled prior to it s saving i e the entry is still in yellow color simply click the cross x at the end of the entry as can be seen in Exhibit 08 004 and it will be deleted without raising the alert The second icon is for rescheduling the appointment The existing appointment will be cancelled but the name of the patient and other particulars in the patient data block items 3 amp 4 on Exhibit 08 001 will be retained Book the new appointment and save The third icon is to mark the status of the appointment and to print certain reports When the icon is clicked the window shown in Exhibit 08 019 opens The first five buttons on the window mark the status and have color tags that transfer to the entry The statuses are EET EMR NEXT User Manual lt gt gt Status Color Tag Pending White Confirmed Yellow Arrived Green Completed Blue No show Brown Exhibit 08 020 shows how the yellow tag has transferred to the patient s entry when the Confirmed status was marked The last three buttons on the window shown in Exhibit 08 019 are for printing Reminder Cards Reminder Letters and No Show Letters When the buttons are clicked the card or letters open in the Print Fax Window The formats of the card and letters are shown in Exhibits 08 021 08 022 and 08 023 The fields in brown background are editable Click the print button on the window t
130. EG Extremities Exhibit 06 198 Breasts Breasts Inspection Breasts Palpation Exhibit 06 199 EMR NEXT User Manual lt gt Gastrointestinal Abdomen Exam Liver Spleen Hernia Anus Perineum Rectum TERI Stool Occult Exhibit 06 200 Genitourinary Female C Genitalia urethra C Bladder Cervix C Uterus Adnexa Exhibit 06 201 Genitourinary Male C Scrotum Penis Prostate Exhibit 06 202 Lymphatic Neck Nodes Axillae Nodes Groin Nodes Generalized EMR NEXT User Manual lt gt Exhibit 06 203 Musculoskeletal Gait Station Digits Nails Joints Bones Muscles Exhibit 06 204 Skin Skin Inspection Skin Palpation Exhibits 06 205 Neurologic Cranial Nerves Exam Sensory Exam Exhibit 06 206 Psychiatric Judgment Insight Orientation TPP Memory Mood Affect Exhibit 06 207 EMR NEXT User Manual lt gt Conjunctivae Lids Discharge present Clear Field Undo Last x Pupil Iris Exam L Optic Disc Exam Exhibit 06 208 Exhibit 06 209 EET EMR NEXT User Manual lt gt 06 03 08 Procedures Services Block Back Exhibit 06 210 shows the Procedures Services Block The location of the block on the Encounter Form is identified by item 8 on Exhibit 06 134 This block is
131. ET EMR NEXT User Manual lt gt Smith John FHC Medication Import Scanned File H Laboratory Radiology J Consultation 1 Hospital J Insurance HHJ Billing 1 J Directives Handouts J Other HHC Legacy Exhibit 07 033 EMR User Manual lt gt Refills 00002 x Make New Refill Master Medication List Abilify 20 mg TAB Benadryl Cold 500 25 30 mg TAB Carmol 10 10 LOT Chromagen FA TAB Meds prescribed in the last encounter cb none Last 5 Refills Friday April 26 2013 4 21 33 AM Tuesday April 23 2013 4 19 54 AM Thursday April 18 2013 5 53 42 AM Tuesday April 16 2013 6 23 57 AM Exhibit 07 034 Ex EMR NEXT User Manual lt gt Refill Writer X Refill for Smith John First Cardiology Clinic Combined 1001 Parkway Drive Chester AL 23866 B ART Tel 234 508 5389 Fax 234 567 8902 REFILL REQUEST Name Smith John DoB Feb 25 2015 Sex Add 123 ABC Drive Any City Any State Any ZIP Cd Total number of items 2 Sign Stamp 4 50 inch x 7 50 inch 96 dpi Exhibit 07 035 EET EMR NEXT User Manual lt gt 08 The Scheduler Pack You have already defined session times for all seven days of the week on the Provider Information page of the Initial Configuration Screen when you log
132. Exhibit 09 114 If you want this block to initially appear in opened state on charts keep the checkbox checked If you want it to appear initially as de activated uncheck the checkbox Click Ok The Add window will close and the block will be created on the template Save the changes Now when you open a new chart the block will appear on the Form as shown in Exhibit 09 115 for simplicity and uniformity we have opened the new block as the first block on the chart It is named Third Block Please note on the form in Exhibit 09 115 that e Two additional full length fields also appear at the end of the block for any free type notes The lines will extend according to the length of the text e There is a black down arrow Add Line icon below each field to add lines There is also a cross shaped Delete Line icon at the end of each line to delete line EMR User Manual Third Block First Field Second Field Third Field Fourth Field Fifth Field w Initially display in Opened state Exhibit 09 114 Chart ID 00022 New 3 First Cardiology Clinic Photograph Click To Attach Third Block First Field Second Field Third Field Fourth Field Fifth Field WwW Exhibit 09 115 EMR User Manual Diabetes Stroke Hypertension Heart Disease Cancer Asthma Hay Fever Arthritis Osteoporosis Anemia Migraine Alzheimers Epileps
133. Few hours Few minutes Few months Seasonal Since last 2 days Exhibit 06 149 Clear Field Undo Last Abrupt After meals After standing for a while At night At rest Daily Diurnal Exhibit 06 150 EMR NEXT User Manual lt gt gt Clear Field Undo Last At rest At work High altitude In crowds In the car On exertion Exhibit 06 151 Clear Field Undo Last Abates on its own Abates with meds Abates with OTC meds Aggravates on changing position Aggravates on coughing Exhibit 06 152 Clear Field Undo Last Abdominal pain Achiness Anxiety Back stiffness Exhibit 06 153 EMR User Manual 06 03 05 Review of Systems ROS Block Back Exhibit 06 154 shows the Review of Systems Block The location of the block on the Encounter Form is identified by item 5 on Exhibit 06 134 This block is a part of the Subjective Section of the encounter under the Center for Medicare amp Medicaid Guidelines for taking patient history Review of Systems d General Eyes Cardiovascular Respiratory Gastrointestinal Genitourinary Male Genitourinary Female Musculoskeletal Skin Neurologic Psychiatric ee P Endocrine EJ Hematologic Lymphatic Allergic lmmunologic Exhibit 06 154 15 systems are defined in this block but more systems can be added or removed according to requirement of your practice Section 09 04 06 shows how to do so
134. History Abnormal PAP smear Past Surgical History Carotid endarterectomy Known Allergies Ervthromycin Dust Mite Fish or Crustacean Shellfish Family History Diabetes Social History Alcohol Use Procedures Services 10040 Acne surgery 85018 Blood count hemoglobin Hgb 84550 Uric acid blood Physical Examination Vitals BP 130 100 Weight Exhibit 09 011 EMR NEXT User Manual 4o gt First Cardiology Clinic 1001 Parkway Drive Chester AL 23866 Tel 234 598 5589 Fax 234 567 8902 Encounter Note for Smith John on Apr 12 2013 SSN 123 45 6789 DoB Feb 25 1951 Exhibit 09 012 First Cardiology Clinic 1001 Parkway Drive Chester AL 23866 Tel 234 598 5589 Fax 234 567 8902 Encounter Note for Smith John on Apr 12 2013 DoB Feb 25 1951 Chief Complaint Back symptoms Boils Past Medical History Abnormal PAP smear Past Surgical History Carotid endarterectomy Known Allergies Erythromycin Dust Mite Fish or Crustacean Shellfish Family History Diabetes Yes Stroke No Hypertension No Heart Disease No Cancer No Asthma No Hay Fever No Arthritis No Osteoporosis No Anemia No Migraine No Alzheimers No Epilepsy No Glaucoma No Social History Alcohol Use Yes Caffeine Use No Tobacco Use No Drugs Use No Chm Exposure No TB Exposure No HIV Exposure No Sex Relations No Excersice No Sleep Habits
135. History Nothing on record Known Allergies Dust Mite Eggs Milk or Lactose Intolerance Family History Diabetes Stroke Hypertension Heart Disease Cancer Asthma Hay Fever Arthritis Osteoporosis Anemia Migraine Alzheimers Epilepsy Glaucoma Migrain Social History Alcohol Use Caffeine Use Tobacco Use Drugs Use Chm Exposure TB Exposure HIV Exposure Sex Relations Excersice Sleep Habits Procedures Services 10040 Acne surgery 95115 Allergen immunotherapy single INT 85018 Blood count hemoglobin Hgb 17003 Destroy Lesions 2 14 Physical Examination Eyes Conjunctivae Lids Conjunctivae clear no ptosis Assessment Diagnosis Ongoing problems taken into account 7244 Back pain w radiation NOS 493 90 Asthma NOS New problems added to the master list 786 50 Chest pain NOS Orders amp Requisitions Calcium Ionized Cancer Antigen 125 Cholesterol total MRI Ankles both Crutches Oxygen Mask Sling Wheel Chair Ice Box Prescription Benadryl Childrens Allergy Fastmelt TAB disintegrating Benadryl Cold 500 25 30 mg TAB Chromagen FA TAB Abilify 20 mg TAB Referral My First Hospital for Chest pain Again thank you for allowing us to participate in the care of your patient If you have questions or concerns about any related aspect of the care pleas
136. ID equals to Exhibit 08 009 Exhibit 08 010 Exhibit 08 011 EMR NEXT User Manual lt gt Chart ID Last Name First Name Visit Reason Exhibit 08 012 Search Last Appointment Where starts with w Last Name First Name Visit Reason Chart ID Exhibit 08 013 Exhibit 08 014 X Appointment History Chart Status 00005 Open Chart Exhibit 08 015 EMR NEXT User Manual lt gt Quick Notes Exhibit 08 016 B APESTA Scheduler Mon May 6 2013 Month of May 2013 MITIWIT F S S M T W T IF S S IMIT IW T F 6 7 8 9 20 11 12 13 14 15 16 17 38 19 20 21 22 23 24 25 26 27 28 22 30 31 Sun Mon Tue Wed Thu Fri Sat 20 v 2 T8 E4 BRB un f s e 8 19 20 21 22 24 25 2e 27 28 29 o 9 212 1 5 16 18 Exhibit 08 017 EMR NEXT User Manual lt gt gt you sure you want to delete the appointment of Smith John permanently Yes Delete It Exhibit 08 018 Smith John X Pending Confirmed Arrived Completed Wo Show Reminder Card Reminder Letter No Show Letter Exhibit 08 019 WE EMR NEXT User Manual lt gt 7 2013 5 CHART PHONE VISIT REASON NOTES 09 00 15 00002 Smith John 123 456 789
137. If user created blocks are deleted they cannot be restored User Definable Blocks In the second part of the window there are nine radio buttons These are the nine formats in which you can create the new block But one block can use only one format EPI EMR NEXT User Manual lt gt lt gt 09 04 01 01 Block with Single Free Text Field Back When you click the first radio button in the User Definable Blocks section of the Add Blocks window Exhibit 09 162 and press the Continue Button the following Add window opens v Initially display in Opened state Billable Procedure Exhibit 09 164 Write the name of the block or the prompt of the field in the white space on the window If you want this block to initially appear in opened state on charts keep the checkbox checked If you want it to appear initially as de activated uncheck the checkbox If this block is billable i e you recover charges for the entry in this block then check the Billable Procedure checkbox The next three fields will activate Enter the billing code description and the amount to be filled in these fields Click Ok The Add window will close and the block will be created on the template Save the changes Now when you open a new chart the block will appear as this on the Form for simplicity and uniformity we have opened the new block as the first block on the chart It is named Fir
138. John 12948789 ge Visit Reason Notes 00002 123 456 789 Chart ID Phone Len Sun Mon Tue Wed Thu Fri Sat 25 25 so E3 2 3 4 5 e s ibe 26 2728 29 30 3 2 4 5 Search Next Day Having Min Slot 13 Book Appointment H Exhibit 08 004 Scheduler 6 2013 T Customize 7 2013 CHART PATIENT S NAME PHONE VISIT REASON NOTES Last Name First Name MI am 15 00002 Smith John 123 456 789 CREE Sun Mon Tue Wed Thu Fri Sat B5 Lelle Es Le 7 8 Search Next Day Having Min Slot Exhibit 08 005 EMR NEXT User Manual lt gt lt gt Scheduler Customize Midas see S Thu May 9 2013 CHART PATIENT S NAME PHONE VISIT REASON NOTES p Last Name First Name MI Visit Reason Notes NENNEN NN EJ Chart ID Phone Len ps ps EET ununi m 90 00005 Smith Nicola Reset To Today Search Next Day Having Min Slot m 90 00001 Doe John gt Exhibit 08 006 Exhibit 08 007 Search Upcoming Appointment w Where starts with w Exhibit 08 008 Last Name Search Upcoming Appointment w Last Name Search Upcoming Appointment First Name starts with w Search Last Appointment Telephone starts with Display Appointment History Chart
139. Lab Order you are looking for is not included in the Master List you can write it yourself in this field EMR User Manual lt gt 4 Press this right arrow to include it in your list of favorites The Lab Orders you have added from this field will not be added in the Master List They will only be added to your favorites 5 This is the list of your favorites that you have prepared either by selection from the Master List or by writing the Lab Orders yourself or as a combination of both 6 If you want to delete a Lab Order from your list of favorites click the corresponding trash can icon If the Lab Order was selected from the Master List it will still be available for re selection there but if you had yourself written it it will be lost 7 Save the changes made to the list by clicking the Save button In Exhibit 09 069 the button is in white color because it is not activated yet It activates whenever a change is made in the window If you try to close the window without saving the changes the alert shown in Exhibit 09 070 will raise 8 The Reset button clears all unsaved changes In Exhibit 09 069 the button is in white color because it is not activated yet It activates whenever a change is made in the window You need to click SAVE button below to keep the changes you have made to this favorite list Do you want to close this window without saving Exhibit 09 070 WI EMR NEX
140. Master List it will still be available for re selection there but if you had yourself written it it will be lost 10 Save the changes made to the list by clicking the Save button In Exhibit 09 091 the button is in white color because it is not activated yet It activates whenever a change is made in the window If you try to close the window without saving the changes the alert shown in Exhibit 09 093 will raise 11 The Reset button clears all unsaved changes In Exhibit 09 091 the button is in white color because it is not activated yet It activates whenever a change is made in the window ase Type Exhibit 09 092 EMR User Manual lt gt You need to click SAVE button below to keep the changes you have made to this favorite list Do you want to close this window without saving Exhibit 09 093 EMR NEXT User Manual lt gt 09 02 General Form Template Back The tab marked as Item 2 on Exhibit 09 001 opens the General Form Template shown in Exhibit 09 094 First Cardiology Clinic Photograph Click To er SS Attach 1 Yellow Sticky Note SSN e Insurance 1 Telephone Notes Carrier Tay General Notes DOB i i Address Gender n Scans Documents Tm i mae E Zr Code arriage Country United States State AL i Pharmacy Siblings i Phone Facsimile Other info Race i
141. No Procedures Services 10040 Acne surgery 85018 Blood count hemoglobin Hgb 84550 Uric acid blood Exhibit 09 013 EMR NEXT User Manual lt gt 09 01 02 04 Custom Letters and Handouts Back Edit Custom Letters Handouts Templates X O91 02 Os O4 Os 06 2 Z z Cras Header W Date Patient Sig Line ACTIVE 4 7 15 First Cardiology Clinic 1001 Parkway Drive Chester AL 23866 Tel 234 598 5589 Fax 234 567 8902 05 08 2013 2 RE John Doe Jr 1000 Riverside Drive Chester VA 12345 6789 9 LUP Content from the encounter or history form if any Q Medications Rx Delete rae Signed Smith John MD ID 123456789 EN Qs Exhibit 09 014 The Edit Custom Letters Handouts Templates Window shown in Exhibit 09 014 opens when you click the Edit button on item 2d in Exhibit 09 002 EMR Next allows you to design up to eight letters or handouts that may be needed in your practice Once designed these templates will be available for all patients 1 The eight radio buttons on the top of the window are for each letter handout respectively Blank templates are available for each radio button Select the template you want to prepare edit EMR NEXT User Manual lt gt 2 Specify the of the report as would appear the system This is the name of the template in the Print Fax Enc
142. Now this encounter can also be deleted You may keep repeating this action and delete all the encounters one by one EMR User Manual 06 03 16 01 02 Refilling Medications Back Clicking the Refill Medications button item 2 Exhibit 06 257 pops the Refills window Refills 00002 Make New Refill BAIT Alaster Medication List Abilify 20 mg TAB Benadryl Cold 500 25 30 mg TAB Benadryl Childrens Allergy Fastmelt TAB disintegrating Vj Carmol 10 10 LOT Chromagen FA TAB eds prescribed in this encounter Abilify 20 mg TAB Chromagen FA TAB Benadryl Cold 500 25 30 mg TAB Thursday April 18 2013 5 53 42 AM Tuesday April 16 2013 6 23 57 AM EXHIBIT 06 257 1 Patient s allergies are shown at the top 2 This part shows the Master Medication List 3 This part shows the Medicines prescribed in this encounter EMR NEXT User Manual lt gt lt gt gt 4 Check the checkboxes of the medicines you want to re fill 5 Click the refill selected meds button to open the Refill Writer Exhibit 06 258 6 This section shows the last five refills of this patient on this encounter form 7 Press the Open button to see the concerned refill report The Refill Writer Refill Writer X lt Refill for Smith John First Cardiology Clinic combined 1001 Parkway Drive Chester AL 23866 Tel 234 595 5589 Fax 234 367 8902
143. Office Visit New Insurance LHJ Billing Visit Superbil Visit Superbil 2 MEN Patient Invoic DESCRIPTION AMOUNT J Directives J Handouts H Other J Legacy Services Professional services rendered on Apr 16 2013 0074T Online Consultation 10040 Acne surgery 95115 Allergen immunotherapy single INJ 85018 Blood count hemoglobin Hgb 17003 Destroy Lesions 2 14 Total Charges Exhibit 06 037 Flagged Documents cannot be moved to any other patient until the flagging has been removed But it may be moved to any other folder of the same patient Print Button Documents can be printed from the Document Viewer Open the document in the viewer and click the Print button at the bottom left The system takes you to the operating system for printer selection and print execution EMR User Manual lt gt 06 01 02 Personal Information amp Patient Pharmacy Block Back Placement of the Personal Information amp Patient Pharmacy Block on the General Information Form is identified at Item 8 of Exhibit 06 07 The Personal Information amp Patient Pharmacy Block looks like this SSN 123 vos Feb 25 1943 k Gender Male Marriage Married aa Pharmacy My First Pharmacy Siblings Race White 9 Other Info Exhibit 06 038 This block requires following information 1 If y
144. PI EIN PIN PVN SSN TIN Exhibit 09 045 EMR NEXT User Manual DEA DPS NSC UPIN OSCAR BCID BSID Champus Medicare Medicaid Medi Cal License Group Other lt gt lt gt 09 01 03 05 Radiology Clinics Pack You need to specify the name and particulars of the Radiology Clinic on Radiology Orders Radiology Orders are discussed in Section 06 03 16 02 03 You have option to either type the name and particulars of the Radiology Clinic manually for each Radiology Order you issue or to feed the particulars of the Radiology Clinic in the block marked as 3e on Exhibit 09 002 just once and whenever a Radiology Order is issued click the icon marked as item 4 on Exhibit 06 273 to call the list of Radiology Clinics on your database and select the name amp particulars Radiology Clinics that have been recorded in the system will show in the Radiology Clinics Block of the Primary Configuration tab of the Customization Area like this Radiology Clinics Bi Tu My First Radiology Clinic BE uj My Second Radiology Clinic Bi My Third Radiology Clinic Exhibit 09 046 To edit the particulars click the first icon corresponding to the name of the Radiology Clinic To delete the Radiology Clinic from your list click the second trash can icon corresponding to the name of the Radiology Clinic To add a new Radiology Clinic to your list click the Add button on the blo
145. Print Separately Radiology Order PRESCRIPTION General Order Name Smith John DoB Feb 25 1043 Sex M Add 123 ABC Drive Any City Any State Any ZIP Cd Referral Letter Consultation Note R Benadryl Childrens Allergy Fastmelt TAB disintegrating DAW Encounter Note Quantity 30 Thirty Refills 3 Three Visit Superbill R Benadryl Cold 500 25 30 mg TAB GEQ Quantity 30 Thirty Refills 3 Three O Patient Invoice O Excuse Letter CE UM E E R Chromagen FA TAB GEQ Face Sheet 2 Quantity 10 Ten Refills 3 Three Face Label e sa R Abilify 20 mg TAB GEQ Custom Report 1 Quantity 10 Ten Refills 3 Three OO Custom Report 2 Total number of items 4 Signature Stamp eve Exhibit 06 266 EMR NEXT User Manual 4o gt Print Fax Encounter Related Documents x Smith John Prescription Prescription First Cardiology Clinic MF T 1001 Parkway Drive Chester AL 23866 Laboratory Order Tel 234 598 5589 Fax 234 567 8902 H Radiology Order PRESCRIPTION General Order Name Smith John DoB Feb 25 1943 Sex M u Add 123 ABC Drive Any City Any State Any ZIP Cd Referral Letter Consultation Note Benadryl Childrens Allergy Fastmelt TAB disintegrating DAW Encounter Note Quantity 30 Thirty Refills 3 Three Visit Superbill Benadryl Cold 500 25 30 mg TAB GEQ Patient Invoice
146. Requisitions Medications Rx Plan Notes Past Medical History Past Surgical History Known Allergies Family History Social History Master Problem List Master Medication List Exhibit 09 015 EMR NEXT User Manual lt gt 09 01 02 05 Document Folders Back Edit Folders x Edit Folders X Medication Medication Laboratory Laboratory Radiology Radiology Consultation Consultation Hospital Hospital Insurance Insurance Billing Billing Directives Directives Handauts BG Handouts Other Legacy Other E Legacy Add Add Exhibit 09 016 Exhibit 09 017 The Edit Folders Window shown in Exhibit 09 016 opens when you click the Edit button on item 2e in Exhibit 09 002 EMR Next has eleven default folders as shown in Exhibit 09 016 These folders are available for all patients Access to these folders is available from the Utility Block on the General Form See Section 06 01 01 Item 4 on Exhibit 06 014 They appear in the Document Viewer as shown in Exhibit 06 027 The documents mapped to these folders are listed in Section 06 01 01 The default folders can neither be deleted nor edited However you may create additional folders edit their names at will and delete them if you do not need them any further EMR User Manual lt gt To add folder click the Add button on the Window
147. S BA 12345678 Received Details Payment type Billing not required Note for Biller Chief Complaint Encounter Reason Exhibit 09 184 Photograph Click To Attach Physical Examination Constitutional E Eyes ENMT E Neck Respiratory Cardiovascular Breasts Gastrointestinal Genitourinary Female Genitourinary Male Lymphatic Musculoskeletal skin Neurologic EMR User Manual lt gt lt gt 09 04 01 08 Block with Multiple Buttons Back When you click the eighth radio button in the User Definable Blocks section of the Add Blocks window Exhibit 09 162 and press the Continue Button the following Add window opens v Initially display in Opened state wv Billable Procedure Code Exhibit 09 185 This block will have a single field with multiple factors The factors can be marked positive or negative by clicking the appropriate value of the respective or button for the factor on the History Form Write the name of the block in the white field at the top this will also be the name of the field EMR NEXT User Manual lt gt Add as many factors as required by clicking the black down arrow under the second row If you create more rows than required you can delete them by clicking the trash can icon at the end of the respective row Write th
148. Second Option and Third Option For the second field the values are Fourth Option Fifth Option and Sixth Option If you want this block to initially appear in opened state on charts keep the checkbox checked If you want it to appear initially as de activated uncheck the checkbox If this block is billable i e you recover charges for the entry in this block then check the Billable Procedure checkbox The next three fields will activate Enter the billing code description and the amount to be filled in these fields Click Ok The Add window will close and the block will be created on the template Save the changes Now when you open a new chart the block will appear on the Form as shown in Exhibit 09 177 for simplicity and uniformity we have opened the new block as the first block on the chart It is named Fifth Block In Exhibit 09 178 the dropdown list on the Second Field is open Please note that on the form the field values will arrange alphabetically Please note that two additional full length fields also appear at the end of the block for any free type notes The lines will extend according to the length of the text Whenever there is an entry in this block the Patient Invoice if Patient Invoice is issued and the Super Bill will both include the amount If the amount is to be recovered through the Super Bill then amend the amount in the Patient Invoice to Zero NL EMR NEXT User Manual Fifth
149. State Any ZIP Tel 123 456 789 Fax 123 456 789 Cd DB Feb 25 1943 Dear Sir This letter of referral introduces Smith John who is a patient of our practice He is being referred for consultation treatment of the following condition s Chest pain We have the following information available for your use hief Complaint Back symptoms Past Medical History Nothing on record Past Surgical History Nothing on record Known Allergies Dust Mite Eggs Milk or Lactose Intolerance Family History Diabetes Stroke Hypertension Heart Disease Cancer Asthma Hay Fever Arthritis Osteoporosis Anemia Migraine Alzheimers Epilepsy Glaucoma Social History Alcohol Use Caffeine Use Tobacco Use Drugs Use Chm Exposure TB Exposure HIV Exposure Sex Relations Excersice Sleep Habits Procedures Services 10040 Acne surgery 95115 Allergen immunotherapy single INT 85018 Blood count hemoglobin Hgb 17003 Destroy Lesions 2 14 Physical Examination Eyes Conjunctivae Lids Conjunctivae clear no ptosis Assessment Diagnosis Ongoing problems taken into account 7244 Back pain w radiation NOS 493 90 Asthma NOS New problems added to the master list 786 50 Chest pain NOS Orders amp Requisitions Calcium Ionized Cancer Antigen 125 Cholesterol total MRI Ankles both Crutches
150. T User Manual lt gt lt gt gt 09 04 01 05 Block with Multiple Dropdowns Back When you click the fifth radio button in the User Definable Blocks section of the Add Blocks window Exhibit 09 162 and press the Continue Button the following Add window opens v Initially display in Opened state X Gillable Procedure Code Exhibit 09 175 As the name suggests this block will have a multiple fields with dropdown lists Write the name of the block in the top field EMR NEXT User Manual lt gt Add as many fields as required by clicking the black down arrow under the first field the black dropdown arrow on the left If you have added extra fields delete them by clicking the trash can icon at the left of the respective field For each field add as many rows as required for values in the dropdown list of the field by pressing the black down arrow under the first two rows of the respective field If you have added extra rows they can be deleted by clicking the trash can icon at the right of the respective row Write the name of each of the field Write the values of the dropdown lists of each field in the rows you have made available for each field For example we created two fields and gave them the names First Field and Second Field as shown in Exhibit 09 176 For each field we created three row values The values for the first field are First Option
151. T User Manual lt gt 09 01 04 06 Radiology Orders Back Radiology Orders are selected in the Orders Requisitions Block on the Encounter Form Section 06 03 10 These are the Radiology tests you prescribe for your patients Based on the Radiology Orders the Radiology Order Report shown in Section 06 03 16 02 03 is prepared When you click the Block Icon on the Orders Requisitions Block the Orders Requisitions Window shown in Exhibit 06 221 opens The second part of this window holds the list of Radiology Orders The list is managed from here in the Customization Section When you click the Open button on the field identified as item 4f on Exhibit 09 002 the Add Delete Radiology Orders Window opens Add Delete Radiology Orders x Master Your Favorites CAT Abdomen amp Pelvis with and without contrast CAT Facial Region CAT Abdomen amp Pelvis with contrast CAT Head and Neck CAT Abdomen amp Pelvis without contrast MRI Ankles both CAT Abdomen with contrast MRI Long Bone extremity CAT Abdomen without contrast Ultrasound Abdomen CAT Chest High Resolution Ultrasound Abdomen Complete with Pelvis CAT Chest with amp without contrast Ultrasound Bladder CAT Chest with contrast X Ray Abdomen CAT Chest without contrast X Ray Acromioclavicular Joint Bilateral Eb Eb Eb Eb amp Ep CAT Extremeties X Ray Facial Bones CAT Facial Region CAT Head and Neck CA
152. T Head Plain amp RAI CAT Head with and without contrast CAT Head with rantract Add Your Own Radiology Order cd Exhibit 09 071 1 The left side of the window is for the Master List of Radiology Orders The list has more than 200 entries None of these Radiology Orders will appear in your list of favorites unless you make them favorite 2 Click this right arrow to move the Radiology Order to your list of favorites 3 If the Radiology Order you are looking for is not included in the Master List you can write it yourself in this field EE EMR NEXT User Manual lt gt 4 Press this right arrow to include it in your list of favorites The Radiology Orders you have added from this field will not be added in the Master List They will only be added to your favorites 5 This is the list of your favorites that you have prepared either by selection from the Master List or by writing the Radiology Orders yourself or as a combination of both 6 If you want to delete a Radiology Order from your list of favorites click the corresponding trash can icon If the Radiology Order was selected from the Master List it will still be available for re selection there but if you had yourself written it it will be lost 7 Save the changes made to the list by clicking the Save button In Exhibit 09 071 the button is in white color because
153. Tests and General Orders The Orders Requisitions Window is accordingly divided into three sections Exhibit 06 221 Click the Block Window Icon to call the Orders Requisitions Window Exhibit 06 220 The window includes your favorite Orders Requisitions which you have identified from over 250 Laboratory Orders and 200 Radiology Orders available in the system s database or which you have added yourself to the system Sections 09 01 04 05 for Lab Orders 09 01 04 06 for Radiology Orders and 09 01 04 07 for General Orders show how to select favorites from the pre loaded Orders Requisitions and how to add new Orders Requisitions to the database For General Orders there are just a few pre loaded items as a sample You have to develop your own database for them Click the required Orders in the Orders Requisitions Window to bring them on to the encounter form They will come along with their category If you are not using the Orders Requisitions Window for selecting orders requisitions and are typing them in the block manually first click the add field icon at the bottom of the block to add a new set of entries and then fill it appropriately Category is selectable from the dropdown list on the field Add suitable description of the item There is no space limitation for the description Lines will add as per text requirement Incorrect entries can be deleted by clicking the delete field icon towards the end of the field Eac
154. Where SSN MRN May 4 2013 6 12 25 AM Smith John 00002 Xray on 4th April 2013 Imported File March 27 2013 6 12 35 AM Smith Nicola 00005 3575 Imported File March 26 2013 7 16 05 AM Smith Tom 00004 Visit Superbill Encounter 1 Visit Superbill Phone March 23 2013 12 17 37 AM Smith Jack 00006 Patient Chart Chart Last Name March 20 2013 6 14 40 AM Doe John 00001 Patient Chart Chart Birth Date O First Name O Visit Date Age amp Gender ssh Import Export Import Scanned Files Export Superbills b A Exhibit 07 027 EMR NEXT User Manual lt gt 7 7 on Exhibit 07 001 is the counter for the number of charts found as search result When the pane is in flagging mode the same counter shows the number of flagged documents as in Exhibit 07 027 Smith John Delete Chart Schedule Phone Notes Documents Refill Meds Open Chart Exhibit 07 028 The last button on Exhibit 07 028 was discussed in item 2 of this section and was shown as Exhibit 07 012 The remaining five buttons will be discussed here It is implied in case of each button that you have selected the required chart from the search results and clicked the Execution Button listed as item 1 of Exhibit 07 011 Delete Chart Click this button if you want to delete the patient s chart from the system Extreme care should be taken as a chart once deleted cannot be re
155. X Previous Encounter 04 10 2013 Vitals Problems 724 4 Back pain w radiation NOS Orders None Followup None Past Medical History Abnormal PAP smear Past Surgical History Carotid endarterectomy Family History Diabetes Social History Alcohol Use Allergies Erythromycin Dust Mite Fish or Crustacean Shellfish Master Medication List s Ability 20 mg TAB Benadryl Cold 500 25 30 mg TAB Carmol 10 10 LOT s Chromagen FA TAB Carmol 10 shampoo Abilify 10 mg TAB OK Have Reviewed EMR NEXT User Manual lt gt Exhibit 06 234 Document Viewer X Most recently filed external documents Laboratory xrays May 1 2013 5 12 57 AM Open xrays Smith John Exhibit 06 235 EMR NEXT User Manual lt gt 06 03 14 Evaluation amp Management Code Block Back Exhibit 06 236 shows the Evaluation amp Management Code Block The location of the block on the Encounter Form is identified by item 14 on Exhibit 06 134 IM Code Code Basis Join Work School nn Exhibit 06 236 This block serves three purposes a identification of the evaluation amp management code for your service charges for the encounter b scheduling of next visit and c specifying time by which the patient may join work school this is required for Excuse Note 1 If you know the Evaluation amp Management Co
156. able Procedure Code Exhibit 09 183 As the name suggests this block will have a single field with multiple rows Write the name of the block in the white field at the top If you want this block to initially appear in opened state on charts keep the checkbox checked If you want it to appear initially as de activated uncheck the checkbox If this block is billable i e you recover charges for the entry in this block then check the Billable Procedure checkbox The next three fields will activate Enter the billing code description and the amount to be filled in these fields Click Ok The Add window will close and the block will be created on the template Save the changes Now when you open a new chart the block will appear on the Form as shown in Exhibit 09 184 for simplicity and uniformity we have opened the new block as the first block on the chart It is named Seventh Block 424 EMR NEXT User Manual Please note that on the History Form the lines in the block will extend according to requirement Whenever there is an entry in this block the Patient Invoice if Patient Invoice is issued and the Super Bill will both include the amount If the amount is to be recovered through the Super Bill then amend the amount in the Patient Invoice to Zero First Cardiology Clinic Chart ID 00001 Doe John Seventh Block Encounter 8 Date May 22 2013 Type Referred by Attended by Davis Richard MBB
157. aboratory Orders are selected in the Orders Requisitions Block on the Encounter Form Section 06 03 10 These are the laboratory tests you prescribe for your patients Based on the Lab Orders the Lab Order Report shown in Section 06 03 16 02 02 is prepared When you click the Block Icon on the Orders Requisitions Block the Orders Requisitions Window shown in Exhibit 06 221 opens The first part of this window holds the list of Laboratory Orders The list is managed from here in the Customization Section When you click the Open button on the field identified as item 4e on Exhibit 09 002 the Add Delete Lab Orders Window opens Add Delete Lab Orders x Master ist Q Your Favorites A 1 Antitrypsin Calcium lonized AB SCR RFX ID Titer Cancer Antigen 125 ABO Group amp RH Type ACTH Test Cholesterol total Drug Screen 10 50 AFP Tumor Hemoglobin B Albumin Potassium K Aldolase Urinalysis Culture IF IN Aldosterone Alkaline Phosphatase Alkaline Phosphatase Isoenzymes ALT Test Ammonia serum Amylase ANA w RFX 4000000000000 Ancintensin converting enzume Add Your Own Lab Order J Exhibit 09 069 1 The left side of the window is for the Master List of Lab Orders The list has more than 250 entries None of these Lab Orders will appear in your list of favorites unless you make them favorite 2 Click this right arrow to move the Lab Order to your list of favorites 3 If the
158. ack When you click the fourth radio button in the User Definable Blocks section of the Add Blocks window Exhibit 09 162 and press the Continue Button the following Add window opens Add v Initially display in Opened state X Billable Procedure Code Exhibit 09 172 As the name suggests this block will have a single field with a dropdown list Write the name of the block which is also the prompt of the field in the white field on the left side Add as many rows as required for values in the dropdown list by pressing the black down arrow under the first two rows If you have added extra rows they can be deleted by clicking the trash can icon at the end of the respective row EMR User Manual lt gt Now write the values of the dropdown list in the fields For example we created five fields and gave them the names First Option Second Option Third Option Fourth Option and Fifth Option as shown in Exhibit 09 173 If you want this block to initially appear in opened state on charts keep the checkbox checked If you want it to appear initially as de activated uncheck the checkbox If this block is billable i e you recover charges for the entry in this block then check the Billable Procedure checkbox The next three fields will activate Enter the billing code description and the amount to be filled in these fields Click Ok The Add window will close
159. ada the list of states provinces will drop down for your selection For other countries or for other units enter the State Province manually 4 Write the name of your practice here 5 Write the address of your practice here os EMR NEXT User Manual lt gt gt 6 Write the City in which your practice is located here 7 Provide your Zip Code or postal code etc as applicable in your country 8 Give your main telephone number here For USA and Canada this field will be auto formatted with hyphens included in the appropriate places For all other countries only numerical values will be accepted 9 Give your main facsimile number here For USA and Canada this field will be auto formatted with hyphens included in the appropriate places For all other countries only numerical values will be accepted 10 Your practice s official email address 11 Select your specialization from the dropdown list If your specialization is not listed in the dropdown select other 12 Once all information is entered click Next to move on 13 If any mandatory field is not completed the system will raise this alert identifying the first blank field Complete the field and press Next again When all the mandatory fields have been completed the next screen will open Dashboard Schedul me acu 9 Initial Configuration rau Provider Information EMR MX Electro
160. ailable in the dropdown list Any available physician or Any Available hospital You must add to the list of doctors and hospitals to the database Sections 09 01 03 03 and 09 01 03 06 show how to do this 4 Specify the reason for the referral either by selecting suitable phrase from the dropdown list Exhibit 06 252 or by writing the reason manually in the available field Section 09 01 04 11 shows how more referral phrases may be added to the database When you print the Referral Letter Section 06 03 16 02 05 your selection comments in this field will be picked in appropriate section of the letter If you uncheck the Refer this patient checkbox at the beginning of the block further details selected typed in this block will clear EMR User Manual lt gt No Urgency Routine Next Available Need js Exhibit 06 250 E M Code Any available physician Follow First Physician Join Work Sc Any available hospital Referthi3 My First Hospital Referral To Exhibit 06 251 Cholelithiasis cholecystitis Deafness hearing loss Refer thi Degenerative joint disease Referral To For Reason ET Exhibit 06 252 EMR NEXT User Manual lt gt 06 03 16 Utility Buttons Block Back Exhibit 06 253 Exhibit 06 253 shows how the utility buttons block looks on the Encounter Form Item 16 on Exhibit 06 134 identifies the location of
161. al lt gt X EM Code Encounter Service Based Time Based Counseling time greater than 50 Total time spent v Mext Exhibit 06 243 Total time spent Exhibit 06 244 EM Code Encounter gt On the basis of your documentation input the following E M Code seems to be appropriate for this encounter 99201 Office Visit New patient level 1 Exhibit 06 245 Interpreted tests after 5 days after 6 days E M Code Follow up Visit ug Exhibit 06 246 a EMR NEXT User Manual lt gt Se ee after 1 week after 2 weeks after 3 weeks Exhibit 06 247 EMR NEXT User Manual lt gt 06 03 15 Referral Block Back Exhibit 06 248 shows Referral Block The location of the block on the Encounter Form is identified by item 15 on Exhibit 06 134 Refer this patient Exhibit 06 248 9 Refer this patient Need is Referral To For Reason um Exhibit 06 249 1 If the patient needs to be referred to another doctor check the checkbox in the Referral block Exhibit 06 249 2 Specify the urgency of the need here by selecting appropriate phrase from the drop down list Exhibit 06 250 3 Specify the doctor or the hospital to which the patient is being referred to by selection from the dropdown list Exhibit 06 251 Only two default entries are av
162. al 01 What does this EMR system do for you Back EMR NEXT is a complete electronic medical records system for ambulatory care physicians and healthcare providers It is an industry compliant EMR with a wide range of features and unparalleled customization capability Regardless of your specialty or work setting you will find EMR NEXT more than sufficient for your clinical documentation and workflow needs At the very least 1 It maintains provider s appointment schedule 2 It provides complete patient charting capability 3 It allows documenting patient visits in universal SOAP format 4 t provides complete prescription and refills management capability 5 It generates laboratory radiology and general orders 6 It generates encounter notes referral letters and consultation notes 7 It prepares visit super bills and patient invoices 8 It generates excuse letters patient face sheets and labels 9 It allows setting up clinical reminders and custom documents 10 It calculates BMI and supports blood pressure trending 11 It allows importing and organizing external image files such as scanned insurance cards consents and laboratory reports 12 It provides multiple data input methods including touch mouse keyboard and stylus 13 It provides extensive point and click lists and drop down menus to minimize data entry time and effort 14 It includes customization wizards to allow customizing chart forms accord
163. ame of Institution and work phone number 6 This section contains the emergency contact directives given by the patient and contact instructions in case of emergency whether or not information be released to third parties 7 This section contains the general information provided on the patient chart 8 This section contains the Primary Insurance Details and if the patient is not the principal insured then also particulars of the Principal Insured 9 This section contains the Secondary Insurance Details and if the patient is not the principal insured then also particulars of the Principal Insured 10 This section contains the guarantor s information and includes the relationship of the guarantor with the patient the guarantor s name date of birth phone number and remarks 11 The Face Sheet will end here unless this check mark is checked in which case the medical history will also be included in the face sheet 12 The Medical History section appears when the check mark identified in item 11 is checked 13 Known Allergies are listed 14 Past Medical History is listed 15 Past Surgical History is listed 16 Family History of illnesses is listed items identified appear in red with a positive prefix Other items are in black with a negative prefix EMR NEXT User Manual 4o gt 17 Social History of adverse traits is listed adverse traits appear in red suffixed with a positive sign while un
164. anual lt gt 06 03 16 02 03 Report 3 Radiology Order Pack Exhibit 06 273 shows the Radiology Order in the Print Fax Encounter Related Documents window O First Cardiology Clinic 1001 Parkway Drive Chester AL 23566 Tel 234 598 5589 Fax 234 567 8902 REQUISITION 3 My First Radiology ut 2 First Drive AL USA EE I I S I Tel 1 23 456 789 d Far 123456 6 189 This is a request for radiology services for KP MRI Long Bone extremity 00 s xb o ooo o d do n 789 00 Abdominal pain NOS po sima NOS f9 Signed Quir 12 2013 Davis Richard MBBS NPI BA 12345678 EXHIBIT 06 273 1 Your clinic s name address and telephone amp Fax numbers 2 Title of the Report Requisition the same title is also used for Laboratory Order and General Order 3 Name address and phone number of the Radiology Clinic that you either typed in the report manually or selected from the button EMR NEXT User Manual lt gt 4 This is the button clicking which the window opens with the names of the Radiology Clinics in your database Exhibit 06 274 shows how the window with the names of the laboratories appears on the screen See section 09 01 03 05 for how to add Radiology Clinics to the database 5 This part shows the name and date of birth of the patient for whom the radiology services have bee
165. aph The photograph should be available on the computer s operating system or on an external drive connected to it Double click the photo to bring it on the chart The photo should not exceed 500KB in size To replace or remove photo click on the saved photo The system raises an alert Exhibit 06 013 asking whether you want to remove or replace the photo Click the appropriate button to complete the action or click cancel to abort the replacement removal action h O Ed This chart already has a photograph attached Do you want to remove it or just replace it with another photograph Cancel Remove Replace Exhibit 06 013 7 The utility block is discussed in section 06 01 01 8 The personal information and patient pharmacy block is discussed in section 06 01 02 9 The contact information block is discussed in section 06 01 03 EMR NEXT User Manual 10 11 12 13 14 15 16 lt gt The work information block is discussed in section 06 01 04 The Directives Block is discussed in section 06 01 05 The General Information Block is discussed in section 06 01 06 The Principal Insurer s Block is discussed in section 06 01 07 The Secondary Insurer s Block is discussed in section 06 01 08 The Guarantor s Block is discussed in section 06 01 09 The Print Functionality on this page is discussed in section 06 01 10 EMR NEXT User Manual lt gt 06 01 01 The Utility Bloc
166. ar in red Procedures amp Services prescribed Only those prescribed in the current encounter Physical Examination details Assessments amp Diagnosis Only those established in the current encounter Orders amp Requisitions made for the patient Only those made from the current encounter Medications prescribed for the patient Only those prescribed in the current encounter Name of the clinic or hospital to which patient is referred Space for your signature Your name and ID Timestamp of when the Encounter Note was printed All fields in the darker shade are editable i e data called in from the original chart or encounter form may be edited added or deleted in these sections of the report EMR NEXT User Manual lt gt 06 03 16 02 08 Report 8 Visit Super Bill Pack Exhibit 06 270 shows the Visit Super Bill in the Print Fax Encounter Related Documents window First Cardiology Clinic 1001 Parkway Drive Chester AL 23866 Tel 234 598 5589 Fax 234 567 8902 Encounter Date Apr 16 2013 SUPER BILL Chart ID 00002 gif Encounter Details Encounter Type Office Visit New Enc Date Apr 16 2013 Encounter No 9 Superbill No S 00002 9 JP Provider Details Da Address 123 ABC Drive Any City Any State Any ZIP Cd Tel 123 456 789 Cell 123 456 789 2 Primary Insurance ABC Insurance Co 6 Gp ts JP Secondary Insuran
167. ars under the date the second medicine will have the counter number 2 18 And here starts the header for the second request The request continues and if you could scroll down you would have seen it Doux EMR NEXT User Manual lt gt Refill Waiter X Refill for Smith John First Cardiology Clinic 1001 Parkway Drive Chester AL 23866 Tel 234 598 5589 Fax 234 567 8902 Remarks REFILL REQUEST Name Smith John DoB Feb 25 1943 Sex M Add 123 ABC Drive Any City Any State Any ZIP Cd R Abilify 20 mg TAB GEQ Quantity 10 Ten Refills 3 Three R Chromagen FA TAB GEQ Quantity 10 Ten Refills 3 Three Total number of 1tems 2 Options Exhibit 06 260 Upon saving the Refill Request the following buttons are activated on the Refill Writer 19 Edit This button opens the Request in edit mode After making required changes save again 20 This button allows deletion of saved Request or adding remarks to it Clicking the button pops the Options window Exhibit 06 261 21 You may lock the refill request from here Once locked the refill request can neither be deleted nor amended But remarks may still be added Before locking the Request system will raise an alert Exhibit 06 262 Click Don t Lock on the alert to abort locking action click Lock Refill to lock the Request 22 This button enables you to print the report When the button is clicked the sy
168. at on the form the field values will arrange alphabetically Please note that two additional full length fields also appear at the end of the block for any free type notes The lines will extend according to the length of the text EMR User Manual lt gt Fifth Block First Field Second Option Third Option Second Field Fifth Option Sixth Option v Initially display in Opened state Exhibit 09 120 EMR NEXT User Manual lt gt First Cardiology Clinic Photograph Chart ID 00024 New 5 T Fifth Block Family History First Field HI Diabetes Second Field de Hypertension Heart Disease Past Surgical History EH Asthma Hay Fever Arthritis Osteoporosis Past Medical History Anemia Migraine Alzheimers Epilepsy Glaucoma Known Allergies Exhibit 09 121 Fifth Block Second Field um Fifth Option Fourth Option Rm Sixth Option Exhibit 09 122 EMR User Manual lt gt 09 03 01 06 Block with Multiple Pick lists Back When you click the sixth radio button in the User Definable Blocks section of the Add Blocks window Exhibit 09 106 and press the Continue Button the following Add window opens v Initially display in Opened state Exhibit 09 123 As the name suggests this block will have a multiple fields with Pick L
169. ation List 097 06 02 09 04 Allergy List 098 06 02 09 05 Health Maintenance Report 099 06 03 Encounter Form 100 06 03 01 Encounter Statistics 105 06 03 02 Fee Recovery Block 107 06 03 03 Chief Complain Encounter Reason Block 108 06 03 04 History of Present Illness HPI Block 109 06 03 05 Review of Systems ROS Block 115 06 03 06 Vital Signs Block 123 06 03 07 Physical Examination Block 135 06 03 08 Procedures Services Block 142 06 03 09 Assessment Diagnosis Block 144 06 03 10 Orders Requisitions Block 147 06 03 11 Medications Block 150 06 03 12 Plan Notes Block 154 06 03 13 Encounter Checklist Block 156 06 03 14 Evaluation amp Management E M Code Block 159 06 03 15 Referral Block 164 06 03 16 Utility Buttons Block 166 06 03 16 01 The first button on the Utility Buttons Block 167 06 03 16 01 01 Deleting Encounter Forms 168 EMR NEXT User Manual 06 03 16 01 02 Refilling Medications 169 06 03 16 02 The second button on the Utility Buttons Block 176 06 03 16 02 01 Report 1 Prescription 179 06 03 16 02 02 Report 2 Laboratory Order 182 06 03 16 02 03 Report 3 Radiology Order 184 06 03 16 02 04 Report 4 General Order 186 06 03 16 02 05 Report 5 Referral Letter 188 06 03 16 02 06 Report 6 Consultation Note 191 06 03 16 02 07 Report 7 Encounter Note 194 06 03 16 02 08 Repor
170. ations pre loaded in the database and you can either define your favorites from them or add new ones to the database Section 09 01 04 04 shows how it is done Click medicines either from the master medication list section previous encounter section or your favorites section to add to the medications in this encounter If a medicine is selected from previous encounter or from master medication section of the window all entries will carry to the new form from the most recent encounter including the dispensation instructions signature quantity and number of refills But the fields may be edited But if the medicine is freshly selected then only the dispensation instructions and signature will carry down Signature will carry down only if a signature phrase has been defined while selecting the medicine in the list of favorites Otherwise only dispensation instructions will carry down Quantity and number of refills will have to be specified The Medications Window has a search utility in case your list of favorite medicines is too long Enter a 3 10 character phrase included in the name of the medicine and the system will find all entries with the search phrase Alternatively click the alphabet with which the name of the medicine starts and the cursor will move to the first entry Starting with that alphabet Incorrect entries can be deleted by clicking the delete field icon towards the end of the field If you do not need the M
171. avorites appear in the window You can also make your own PMH phrases and add them to the favorites see section 09 01 04 13 for how to add PMH phrases to the favorites list and how to make your own PMH phrases Past Medical History Abnormal PAP smear Clear Field Undo Last Abnormal PAP smear Abnormal mammogram Anemia blood disorder Exhibit 06 076 The PMH Phrase Window has a Clear Field button clicking which will clear all entries made in the PMH Block so far The Undo Last button will only clear the last insertion in the block Click the square icon before the block title block icon to clear and de activate the block Click it again to re activate it Click the block icon twice to refresh the block EMR User Manual lt gt 06 02 02 Past Surgical History PSH Block Pack Past Surgical History d Exhibit 06 078 The Past Surgical History Block looks like this Its placement on the History Form is identified as item 2 on Exhibit 06 074 You can either write the past surgical history manually or you may select PSH phrases from the list that opens when you click the square on the right of the block Exhibit 06 079 You may click as many PSH phrases as required they will add in the form one after another upon each click The system has 24 pre loaded PSH phrases but only your favorites appear in the window You can also make your own PSH phrases and add them to the favorites se
172. bit 06 181 Vital signs may be recorded according to the British Unit System or the Metric System Select the system suiting your practice from the customization area section 09 04 07 Exhibits 06 173 to 06 181 show the values according to metric system The block icon towards the top right of the block opens the Vital Signs Window This window shows the Body Mass Index BMI Blood Pressure Chart and Growth Charts The window opens up on the BMI Chart but there is a set of radio buttons on the top of the window to toggle between the BMI Chart and the BP Chart For Growth Charts click the Show Growth Chart button at the bottom of the window The window changes name to Growth Charts Three Growth Charts are available BMI for Age Stature for Age and Weight for Age Click appropriate radio button for the required chart Exhibit 06 182 and Exhibit 06 183 show sample BMI charts The structure of the BMI chart for young patients 2 20years and older patients over 20 years is different according to prevailing guidelines For young patients 5 percentile 507 percentile and 95 percentile values are charted year wise for boys and girls and the patient s readings appear as a red dot on the chart for comparison For older patients The BMI chart is divided into four weight classes underweight Healthy Overweight and Obese The patient s weight appears as a dot in its respective class Appearance and structure of BMI Chart fo
173. bit 09 128 First Cardiology Clinic Photograph Click T Chart ID 00027 New 7 Seventh Block Family History Diabetes Stroke Hypertension Heart Disease Past Medical History ENS Asthma Hay Fever Arthritis Past Surgical History Osteoporosis Anemia Migraine Alzheimers Known Allergies Epilepsy 1 Allergen x Glaucoma Exhibit 09 129 EMR NEXT User Manual lt gt 09 03 01 08 Block with Multiple Buttons Back When you click the eighth radio button in the User Definable Blocks section of the Add Blocks window Exhibit 09 106 and press the Continue Button the following Add window opens v Initially display in Opened state Exhibit 09 130 This block will have a single field with multiple factors The factors can be marked positive or negative by clicking the appropriate value of the respective or button for the factor on the History Form Write the name of the block in the white field at the top this will also be the name of the field O EMR NEXT User Manual lt gt Add as many factors as required by clicking the black down arrow under the second row If you create more rows than required you can delete them by clicking the trash can icon at the end of the respective row Write the name of the factor in each of the row created The default value of the factors shows as negative If you want the default
174. black down arrow icon of the respective element Add as many rows as required and specify their values If extra rows have been created delete them by clicking the corresponding trash can icon EMR User Manual lt gt If you want the element to show the Encounter Form in expanded state click the radio button called Extended Otherwise the element will appear contracted and will expand upon clicking Second Tier Editing For each of the fifteen elements there is a list of descriptive values for the element Nature of the values is according to the nature of the parent element If you wish to remove any of the values from any element uncheck the corresponding checkbox and the value will remove from the list for this element along with its own tertiary list of values If you wish to add more values click the black down arrow under the last row of the concerned element and more rows will be added as shown in Exhibit 09 208 Now specify the values of the newly created rows To remove extra rows created by you click the corresponding trash can icon Third Tier Editing For each of the second tier values there is a tertiary tier of values which shows the abnormal findings of the secondary values If you want to remove any of the tertiary values for a secondary value uncheck the respective checkbox If you want to add extra tertiary values for secondary values click the black down arrow icon of the
175. box checked If you want it to appear initially as de activated uncheck the checkbox If this block is billable i e you recover charges for the entry in this block then check the Billable Procedure checkbox The next three fields will activate Enter the billing code description and the amount to be filled in these fields Click Ok The Add window will close and the block will be created on the template Save the changes Now when you open a new chart the block will appear on the Form as shown in Exhibit 09 181 for simplicity and uniformity we have opened the new block as the first block on the chart It is named Sixth Block In Exhibit 09 182 the pick list on the First Field is open Please note that on the form the field values will arrange alphabetically Please note that two additional full length fields also appear at the end of the block for any free type notes The lines will extend according to the length of the text Whenever there is an entry in this block the Patient Invoice if Patient Invoice is issued and the Super Bill will both include the amount If the amount is to be recovered through the Super Bill then amend the amount in the Patient Invoice to Zero EMR User Manual Sixth Block First Field First Option Second Option Third Option k mi Second Field Fourth Option Fifth Option Sixth Option wumununananuananananananananananananannunananunannaunannananunaaananaunananunana
176. ce Carie O Address jh Ee 10 A Referral Details Name FusPhyscim BS 12 Received 150 00 in Cash May be allowed concession MEN Notes for Biller Biling required Yes Note Recover the balance S O K U WICDs for this encounter PD Description _ 1 7244 Back pain w radiation NOS EH 4427 for this encounter PoS CPTCode PT escription Charge 1 11 047 Online Consultation 2000 2 11 100 0 50 3 11 95115 Allergen immunotherapy single INT 340 4 11 8018 Bloodcount hemoglobin Hgb 20 5 11 1708 24 2 y 756 Exhibit 06 279 Super Bill is the billing details you send to your billing agent for raising the bills on insurance companies or other third parties 1 Your clinic s name address telephone number and fax number 2 Encounter Date 3 Title of Report Super Bill EMR User Manual lt gt 4 Patient Chart ID 5 Encounter Details Includes Encounter Type Encounter Date Encounter No i e this patient s encounter no at your clinic and Super Bill No this is a combination of the Patient Chart ID and the Encounter NO 6 Provider Details Includes your name and ID 7 Patient Details Includes Patient Name Social Security No Date of Birth Sex Address Telephone amp C
177. changes you have made to this favorite list Do you want to close this window without saving Exhibit 09 080 EMR User Manual lt gt 09 01 04 10 History of Present Illness HPI Phrases Back History of Present Illness Phrases are used in the History of Present Illness Block in the Encounter Form Section 06 03 04 item 1 on Exhibit 06 144 When you click the block icon the History of Present Illness Window shown in Exhibit 06 145 opens When you click the Open button on the field identified as item 4j in Exhibit 09 002 the Add Delete HPI Phrases Window opens Add Delete HPI Phrases X Master List Your Favorites First phrase for HPI Second phrase for HPI Third phrase for HPI Add Your Own HPI Phrases Exhibit 09 081 1 The Master List of History of Present Illness Phrases has no entries You have to develop your own list of History of Present Illness Phrases 2 Specify the HPI Phrase in this field 3 Press this right arrow to include it in your list of favorites 4 This is the list of your favorites EMR User Manual lt gt 5 If you want to delete the History of Present Illness Phrase from your list of favorites click the corresponding trash can icon The phrase will be lost forever and you will have to re write it if you wish to use it again 6 Save the changes made to the list by clicking the Save button In Exhibit 09
178. ck Exhibit 09 026 Rule Mode Target Sex Filter Blocking Non Blocking Exhibit 09 027 mw EMR NEXT User Manual lt gt Age Filter Display Text ICD name starting ICD code starting MED name starting MED code starting Exhibit 09 028 Sex Filter ICD name starting ICD code starting MED name starting MED code starting ALG name starting ALG code starting LAB name starting LAB code starting 1 Exhibit 09 029 Age Filter Display Text Exhibit 09 030 EMR NEXT User Manual lt gt Male Female Transgender Exhibit 09 031 Edit Clinical Decision Support Rules Drug Allergy Interactions 1 This is the first test rule Edit Delete 2 This is the second test rule Edit Delete 3 This is the third test rule Edit Delete Exhibit 09 032 EMR User Manual lt gt Dashboard Scheduler Ti Customize r gt x mzma Master Medication List Abilify 20 mg TAB Review Previous Encounter s Prescription General Abilify 20 mg TAB 2O0 0 r Eyes Your Favorite 8 b f ENMT Medicines n o Drug Allergy Interaction Abilify 10 mg TAB Respirat Abilify 20 mg TAB This is the first test rule e mazcoozm N Gastroin Benadryl Childrens
179. ck Click it again to re activate it Click the block icon twice to refresh the block EMR NEXT User Manual lt NN lt lt NN 44 lt gt 06 03 06 Vital Signs Block Pack Exhibit 06 172 shows the Vital Signs Block The location of the block on the Encounter Form is identified by item 6 on Exhibit 06 134 This block is a part of the Objective Section of the encounter under the Center for Medicare amp Medicaid Guidelines for taking patient history Vital Signs HEH BP PR bpm Ht cms Waist cms sE RR cpm Wt kgs SpO2 Exhibit 06 172 This block lists the eight commonly observed vital signs 1 Blood Pressure BP 2 Pulse Rate PR 3 Height 4 Waist or Head if the patient s age is less than 2 years 5 Temperature Tp 6 Respiratory Rate RR 7 Weight Wt and 8 Oxygen Saturation Rate SpO2 Permissible values for all vital signs are available in the dropdown lists for each sign Manual entry is not permissible Exhibits 06 173 to 06 181 show the upper section of the dropdown lists for each sign BP BP PR Dpm Tp RR pm 30 10 40 11 zl of 54 Revie E 15 41 Exhibit 06 173 Exhibit 06 174 Exhibit 06 175 Ht cms Waist cms Tp Wi kgs SpO2 34 ic f Sy 41 34 1 Exhibit 06 176 Exhibit 06 177 Exhibit 06 178 EMR NEXT User Manual lt gt gt RR cpm Wt kgs 5 02 2 1 10 15 3 1 2 11 Exhibit 06 179 Exhibit 06 180 Exhi
180. ck The Add Radiology Window will open as shown in Exhibit 09 047 EMR NEXT User Manual lt gt Add Radiology X JJ Clinic o o Street Address 095 Femail Address Exhibit 09 047 1 Write the name of the Radiology Clinic here 2 Write the Radiology Clinic s ID number here 3 Specify the type of ID number by selection from the dropdown list on the field The types available in the dropdown list are illustrated in Exhibit 09 048 4 Write the name or designation of the contact person at the Radiology Clinic here 5 This field is for the Radiology Clinic s address 6 This field is for the Radiology Clinic s city county etc 7 Specify the Radiology Clinic s zip code postal code here 8 Specify the Radiology Clinic s country here Initially the country in which your practice is based will come selected Change if the Radiology Clinic s country is different from your country 9 Specify the Radiology Clinic s State Province here Initially the State Province in which your company is based will come selected Change if the Radiology Clinic s State Province is different from yours 10 Specify the Radiology Clinic s telephone number here 11 Specify the Radiology Clinic s fax number here EMR NEXT User Manual 12 Specify the Radiology Clinic s email address here 13 Click the Save button to save the Radiology Clinic s particu
181. click the Delete button The block will remove from the template Section 09 04 01 shows how to restore the block EE EMR NEXT User Manual lt gt Edit When you click the Edit button the following Edit window opens Physical Examination W Constitutional Vj General Appearance NAD well nourished amp hydrated O Extended Phrases for Abnormal Findings Acutely distressed Anxious Crying Confused Dehydrated Distressed Drowsy Fatigued Flat affect Ill appearing Malnourished ne eee a NB Ie YEN eer e dE T e J U I u v Initially display in Opened state Exhibit 09 206 There is three tiered editing on this window In the first tier you can either add or remove elements from the list In the second tier you can add or remove values for any of the element First Tier Editing To remove any of the fifteen elements in the Physical Examination Block uncheck the checkbox to the left of the element The element will remove along with its values To add new elements in the Physical Examination Block scroll down to the bottom of the window as shown in Exhibit 09 209 Click the black down arrow icon at the left of the window to create new fields as shown in the Exhibit Write the name of the elements in the fields You can create as many elements as required After creating an element add rows for values of the element by clicking the inner
182. cne surgery 95115 Allergen immunotherapy single INJ 85018 Blood count hemoglobin Hgb 17003 Destroy Lesions 2 14 Total Charges Exhibit 06 028 When the document is selected the buttons at the bottom activate These include Delete Move Flag and Print buttons and a Lock Icon for locking documents The Import Scanned File button was already activated The functionality of the five buttons is as follows Import Scanned File button Imported documents can be saved in any folder All imported documents must be in images either in JPG BMP PNG or GIF format Click on Import Scanned File button The following window opens Add to Chart 00002 Smith John Select File Upload Now File Exhibit 06 029 Now click the Select File button You will be taken to the operating system Click on the required file and the file will be brought on the window with its image EMR NEXT User Manual lt gt displayed the image slot on the left The file name will appear as the default document title Edit the title if required and select the folder Exhibit 06 030 to which the document is to be saved Click the Upload Now button and the file will get uploaded Chart 00002 Smith John File Select File Medication Laboratory Radiology Consultation Hospital Insurance Exhibit 06 030 Lock Document You may lock a d
183. d Scheduler Customize v 1 gt 4 4 Clinic Provider Insurance Companies Laboratories Lists Menus r Bi Clinic Information ABC Insurance Co Bi My First Laboratory Dx Codes L Provider Information Ej m My First Insurance Co My Second Laboratory Px Codes My Second Insurance Co Bi My Third Laboratory 92 EM Codes 3 Ib 6 E B Lab Orders Preferences Pharmacies Radiology Clinics lt f Rad Orders Pointer Targets amp Buttons My First Pharmacy i My First Radiology Clinic g Gen Orders Prescriptions and Orders m My Second Pharmacy h Visit Types Default Notes and Letters My Third Pharmacy CC Phrases Custom Letters amp Handouts h Add HPI Phrases Document Folders 3 1 G Physicians Hospitals k RFR Phrases Forms Validation amp Other Rules First Physician B My First Hospital Plan Notes Clinical Decision Support Rules oe 11 PMH Phrases 9 PSH Phrases ALG Phrases Exhibit 09 002 The Primary Configuration covers four types of customizations as marked in Exhibit 09 002 1 Clinic Provider Information This part contains the data that you entered initially when you set up the system discussed in Section 04 There are two screens a Clinic Information For changing your clinic s information When you click the Edit Button on the field the Edit Clinic Window opens The
184. d you may generate these reports from the Print Fax Encounter Related Documents window and edit them as required Only one Custom Report of each type can be saved for one encounter on the system EF EMR NEXT User Manual lt gt 06 03 16 03 The third button on the Utility Buttons Block Back The third button on the utility buttons block item 3 Exhibit 06 253 is for locking the encounter form Once an encounter form is locked it can neither be deleted nor edited Open the encounter form that you want to lock and click on the button The system raises the following alert Please note that locking an encounter makes it uneditable Do you still want to proceed 5 Yes Lock It Exhibit 06 286 Click Don t lock to abort locking action or Yes Lock it to lock the encounter form EMR User Manual lt gt 07 The Dashboard Back B Dashboard Th Customize P Total charts in database 14 esults to display Find Charts Where e LAST NAME FIRST NAME AGE PHONE e SSN MRN Phone Last Name First Name Birth Date Visit Date Age amp Gender J 9 Import Export ort Scanned Files Export Superbills 4 1 Exhibit 07 001 The fourth icon on the grey toolbar Item a on Exhibit 07 001 on the Home Page is for the Dashboard In Exhibit 07 001 the Dashboard has b
185. d Third Block Please note on the form in Exhibit 09 171 that e Two additional full length fields also appear at the end of the block for any free type notes The lines will extend according to the length of the text e There is a black down arrow Add Line icon below each field to add lines There is also a cross shaped Delete Line icon at the end of each line to delete line Whenever there is an entry in this block the Patient Invoice if Patient Invoice is issued and the Super Bill will both include the amount If the amount is to be recovered through the Super Bill then amend the amount in the Patient Invoice to Zero oan EMR NEXT User Manual Third Block First Field Second Field Third Field Fourth Field Fifth Field w Initially display in Opened state Billable Procedure Exhibit 09 170 Chart ID 00001 Doe First Cardiology Clinic Photograph Click To Attach Third Block First Field Second Field Third Field Fourth Field Fifth Field Exhibit 09 171 Physical Examination Constitutional Eyes Neck Respiratory Cardiovascular Breasts Gastrointestinal Genitourinary Female Genitourinary Male Lymphatic Musculoskeletal EE skin Neurologic 4 EMR NEXT User Manual lt gt lt gt gt 09 04 01 04 Block with Single Dropdown P
186. d while defining the insurance company in the database Otherwise write the fax number manually 9 Refers to the particular Insurance Plan of the Secondary Insurance Company The field is selectable from the list of plans already fed in by you in the database ENT EMR NEXT User Manual Exhibit 06 061 as shown in section 09 01 03 01 Otherwise type in the plan particulars manually 10 Expiry date of the Patient s Policy with reference to the Secondary Insurance Company This is selectable from dropdown list Exhibit 06 062 11 Patient s specific Policy No with reference to the Secondary Insurance Company 12 Group Number if any 13 The amount or percentage to be paid by the patient as specified in the secondary insurance company s plan 14 Authorization Code if any sought for the encounter 15 For any remarks pertaining to the insurance plan or secondary insurance company The field is restricted to 80 characters After these fields there is a sub block to be filled if the patient does not have his her own insurance policy and is using someone else s policy like father s mother s etc The sub block has following fields 16 The relationship of the insured with the patient The field is selectable from the dropdown list Exhibit 06 063 17 The Principal Insured s Home Phone Field is restricted to numerical values only If your clinic is located in USA or Canada the phone number will auto format acc
187. dation and Other Rules Window shown in Exhibit 09 020 opens when you click the Edit button on item 2f in Exhibit 09 002 The system has certain Form Validation Rules which if not met the Encounter Form is not saved 1 If the Chief Complaint Block in the Encounter Form is left blank it does not save But if you wish the system to override the deficiency check the checkbox The system will then allow saving of Encounter Forms without any entry in the Chief Complaint Block 2 By default the system allows you to save Encounter Forms even if the status of Ongoing Problems and the Nature of New Assessments is not mentioned in the Assessment Diagnosis Block of the Encounter Form For ready reference the Assessment Diagnosis Block of the Encounter Form is produced here as Exhibit 09 021 If you wish the system not to save the Encounter if these two fields are not completed uncheck the checkbox 3 If you are running a Cash Only Practice you will not need the Insurance Secondary Insurance and Guarantor Blocks on the General Form It will be convenient for you to remove them from the form Check this checkbox to remove these blocks from the form A comparison of how the form looks like with these blocks in and with these blocks out is available in Exhibits 09 022 and 09 023 Exhibit 09 22 shows the form without the three blocks and Exhibit 09 023 shows it with the blocks in 4 Click the Update
188. dd Delete Evaluation amp Management Codes Window opens Add Delete Evaluation amp Management Codes x i Your Favorites Rate Online Consultation 0074T Online Consultation Psychiatric Diagnostic Interview examination 90801 Psychiatric Diagnostic Interview examination Psychiatric Diagnostic Interview exam interactive Psychiatric Diagnostic Interview exam 90802 Psychotherapy office 20 30 min interactive Psychotherapy office with E M 20 30 min 90804 Psychotherapy office 20 30 min 90805 Psychotherapy office with E M 20 30 min 90806 Psychotherapy office 45 50 min Psychotherapy office 45 50 min Psychotherapy office with E M 45 50 min 90807 Psychotherapy office with E M 45 50 min 90808 Psychotherapy office 75 80 min 90809 Psychotherapy office with E M 75 80 min Psychotherapy office 75 80 min Psychotherapy office with E M 75 80 min Psychotherapy interactive office 20 30 min Psychotherapy interactive office with E M 20 30 min 90810 Psychotherapy interactive office 20 30 min Psychotherapy interactive office with E M 20 90811 30 min Psychotherapy interactive office 45 50 min Psychotherapy interactive office with E M 45 50 min c E c Psychotherapy interactive office 75 80 min 90812 Psychotherapy interactive office 45 50 min Psychotherapy interactive office with E M 45 Add Your Own EM Code 90813 50 min 90814 Psychotherapy interactive
189. de for the encounter select it from the dropdown list on this field Exhibit 06 237 Manual entry is not allowed If the E M Code is not available in the dropdown list first add it to the database and then select it Section 09 01 04 03 shows how to add E M codes to the database 2 Modifier to the E M Code 3 E M charges can either be service based or time based Select appropriate basis from the dropdown list Exhibit 06 238 4 If charges are time based specify the time here in minutes max 99 minutes 5 f you are unsure of the E M Code for the encounter the system has an E M Code Calculator that will suggest appropriate E M Code Click the field icon to open the E M Code Calculator Since the E M Code calculator works on the data entered in the encounter form if any data is not available it will show an alert Exhibit 06 239 and mark the required field in red Exhibits 06 240 amp 06 241 Once the required data is provided the calculator will seek whether the charges are service based or time based Exhibits 06 242 amp 06 243 For time based charges the time must also be selected from the dropdown list Exhibit 06 244 Click the Next button and the calculator now suggests suitable E M Code Exhibit 06 245 Click the Insert button to insert the code in the field EMR NEXT User Manual lt gt 6 Click this button to open the scheduler for scheduling the patient s next visit Section
190. discussed in Section 06 03 01 in the field identified as item 5 in Exhibit 06 135 The names of the doctors to whom you refer the patient are recorded in the Referral Block discussed in Section 06 03 15 in the field identified as item 3 on Exhibit 06 249 You may either feed the names and particulars of the doctors in the encounter forms each time patients are referred to you by them or you refer patients to them or you may enter their particulars in the block marked as 3c on Exhibit 09 002 just once and whenever this doctor refers a patient to you or you refer a patient to him her simply select the doctor s name from the dropdown list on the corresponding fields in either block in the Encounter Form All pre fed particulars of the doctor will be called wherever needed in the system Doctors that have been recorded in the system will show in the Physicians Block of the Primary Configuration tab of the Customization Area like this Physicians BE My First Physician Bi Tm My Second Physician BL My Third Physician Exhibit 09 040 To edit the particulars click the first icon corresponding to the name of the doctor To delete the doctor from your list click the second trash can icon corresponding to the name of the doctor To add a new doctor to your list click the Add button on the block The Add Physician Window will open as shown in Exhibit 09 041 2 EMR NEXT User Manual lt gt Add Ph
191. dress Service Type 123 ABC Drive Any City Any State Any ZIP Cd Office Visit New DESCRIPTION Services Professional services rendered on Apr 16 2013 0074T Online Consultation 10040 Acne surgery 95115 Allergen immunotherapy single INJ 85018 Blood count hemoglobin Hgb 17003 Destroy Lesions 2 14 Total Charges osis 724 4 Back pain w radiation NOS 493 90 Asthma NOS 786 50 Chest pain NOS Exhibit 06 282 EMR NEXT User Manual 06 03 16 02 10 Report 10 Excuse Letter Pack Exhibit 06 283 shows the Excuse Letter in the Print Fax Encounter Related Documents window First Cardiology Clinic 1001 Parkway Drive Chester AL 23866 Tel 234 508 5589 Fax 234 567 8902 Apr 16 2013 MEDICAL EXCUSE LETTER To The Administrator 123 ABC Drive Any City Any State Any ZIP ABC Company Ltd Cd Dear Sir or Madam The patient Smith John is currently under my care As his care provider it is my recommendation that he return to work school after 2 weeks This should be considered an excused absence due to the medical needs of the patient Following are some details relating to the patient s medical condition treatment Procedures Services 10040 Acne surgery 05115 Allergen immunotherapy single INT 85018 Blood count hemoglobin Hgb 17003 Destroy Lesions 2 14 Assessment Diagnosis Ongoing probiems taken into account 7244 Back pain w
192. e Open button on the field identified as item 4l in Exhibit 09 002 the Add Delete Plan Notes Phrases Window opens Add Delete Plan Notes Phrases x Master List e Your Favorites Avoid citrus fruits Begin light jogging Avoid dairy products Drink plenty of water Avoid outdoors when it is too cold hot or humid Have meals at the same time and amount Avoid strenuous workouts Begin light jogging Discontinue medications on noticing adverse reaction Drink plenty of water Eat high fiber food often Followup sooner on increased fevers or chills Followup sooner on increased pain Gargle with salt water Have meals at the same time and amount Keep food diary Maintain contact and schedule appointments as needed ZA a 99999002 Reduce fat consiimntion Add Your Own Plan Notes Phrases Exhibit 09 085 1 The left side of the window is for the Master List of Plan Notes Phrases The list has more than 20 entries None of these phrases will appear in your list of favorites unless you make them favorite 2 Click this right arrow to move the Plan Notes Phrases to your list of favorites 3 If the phrase you are looking for is not included in the Master List you can write it yourself in this field WE EMR NEXT User Manual lt gt 4 Press this right arrow to include it in your list of favorites The Plan Notes Phrases you have added from this field will not be added in the Maste
193. e 1 C Genitourinary Male Lymphatic History of Present Illness Museuloskeletal _ skin Neurologic 5 z Location 7 Flag Exhibit 06 129 Dashboard J Scheduler Customize First Cardiology Clinic Photograph Chart ID 00014 Doe Smith pd amp ezm 2zcoozm N gt 2 Encounter 2 Date Apr 26 2013 Type Physical Examination Referred by Constitutional Attended by Davis Richard MBBS BA 12345678 Eyes ENMT Received Details Neck Payment type L Billing not required C Respiratory C Cardiovascular m Breasts Chief Complaint Encounter Reason 2 ar Genitourinary Female Genitourinary Male Lymphatic History of Present Illness CEDE EE C Skin Neurologic 7 Location Doe Exhibit 06 130 Exhibit 06 130 shows the state where three encounter forms have been created Item 5 shows the counter reading 2 of 3 meaning that currently the second encounter EMR NEXT User Manual lt gt form out of a total of 3 encounter forms is open You may navigate to an earlier encounter by clicking the left pointing double arrow above the encounter counter and to a more recent encounter by clicking the right poi
194. e Paste and Add buttons Click the Paste button The block will relocate to this position Delete If you wish to delete the block altogether click the Delete button The block will remove from the template Section 09 04 01 shows how to restore the block EPI EMR NEXT User Manual lt gt 09 04 16 Editing the Referral Block Back When you click the Edit Template Block Icon of the Referral Block a small two button window opens as shown in Exhibit 09 222 The buttons include Cut and Delete _ ea CE EE Refer this patient EM ONUS GENS Exhibit 09 222 Cut If you wish to change the location of this block on the form template click the cut button The blue boundary around the block will turn red indicating that block is ready to be shifted Now click the yellow Add New Block Icon of the location where you want to relocate the block A small two button window opens with the Paste and Add buttons Click the Paste button The block will relocate to this position Delete If you wish to delete th
195. e Sheet in the Print Fax Encounter Related Documents window First Cardiology Clinic 1001 Parkway Drive Chester AL 23866 Tel 234 598 5589 Fax 234 567 8902 PATIENT FACE SHEET 2 Basic Information ae Primary Insurance 4 Name Smith John Carrier ABC Insurance Co DOB Feb 25 1943 Address 11th Street Sea View Road Alabama AL SSN Phone 123 586 5523 Fax 123 458 6565 Gender Male Plan AB 1215 Marriage Married ID Number Group No Race White Auth No Copay 250 Pharmacy Peter Pharmacy Relation Other Info Name DoB Phone 23 Contact Information Remarks Address 123 ABC Drive Any City Any State Any ZIP Cd Home Phone 123 456 789 EI Secondary Insurance Cell Phone 123 456 789 Carrier Email Address Emergency Phone Fax Plan Work Information ID Number Group No Status Auth No Copay Institution Relation Phone Name DoB Phone Remarks Contact Info Release 10D Guarantor Information Relation General Information Name DoB Phone Remarks MEDICAL HISTOR Y Known Allergies Master Medication List Dust Mite Eggs Milk or Lactose Intolerance Abilify 20 mg TAB Active Benadryl Cold 500 25 30 mg TAB Active Benadryl Childrens Allergy Fastmelt TAB disintegrating Active Carmol 10 10 LOT Active Chromagen FA TAB Active IL Past Medical History Nothing on record Past Surgical History Nothing on record Master Problem List 095 3
196. e block altogether click the Delete button The block will remove from the template Section 09 04 01 shows how to restore the block EFI EMR NEXT User Manual 10 Screen Sensitive Help Back EMR Next provides you with a facility of Screen Sensitive Help There is a help Icon Question Mark shaped on the Homepage marked as Item 7 on Exhibit 05 001 in Section 05 When you click this icon screen sensitive help will open as shown in Exhibit 10 001 Help X You are on the Home 5creen Click on a topic to start 7 Creating a new chart Opening an existing chart 7 Searching database for charts Revisiting an opened chart 7 Scheduling and related tasks 2 Settings and Customization Data Backups and Restore Online User Manual Exhibit 10 001 Some examples of how the help opens on various different locations on the system are shown in Exhibits 10 002 to 10 006 Apart from the main help icon on the homepage various screens and windows also have the help icons question mark shaped If you click those icons help will open focusing on that particular point WO III EMR NEXT User Manual lt gt lt gt Dashboard Scheduler Th Customize EMR NEXT You are on the Home Screen Electronic Medical Records System CBoc Un a ODE Dot the ultimate Mobility eXperience P Creating a new chart 7 Opening an existing chart Bl Searching database for charts 2 R
197. e do not hesitate to contact us Yours sincerely Davis Richard MBBS NPI BA 12345678 EXHIBIT 06 277 EMR NEXT User Manual lt gt gt lt gt Consultation Note is printed when the patient is referred to by some other doctor and you want to send the findings of your encounter with the patient to the referring doctor This letter takes details from the General Form History Form and the concerned Encounter Form of the patient chart 10 11 12 13 14 15 16 17 18 Your clinic s name address and telephone amp Fax numbers Date of Encounter Title of the Report Consultation Note Name address and phone number of the doctor or the hospital which referred the patient to you Patient Name Address Date of Birth and Sex Free Type Field for salutations Introductory remarks Free type field to enter final impression or conclusive remarks if any Chief Complaint the patient has Past Medical History Past Surgical History Known Allergies Family History Positive identified illness traits appear in red Social History Positive Identified high risk social traits appear in red Procedures amp Services prescribed Only those prescribed in the current encounter Physical Examination details Assessments amp Diagnosis Only those established in the current encounter Orders amp Requisitions made for the patient Only those made from the current
198. e is also created while selecting favorites in Section 09 01 04 02 If the default note is not appropriate for this patient it may be edited on the encounter form EMR NEXT User Manual lt gt If you are not using the block window and adding the procedures services offered manually first click the down arrow to add blank sets of entries and then fill them appropriately Every set of entry has a delete item icon at the right end Entries may be deleted by clicking the delete item icon for the particular item If your list of favorites in the Procedures Services window is long you can utilize the quick search available on the window Enter a 3 10 character phrase included in the Procedure Service and the system will find all entries with the search phrase Click the alphabet with which the description of the Procedure Service starts and the cursor will move to the first entry starting with that alphabet Procedures Services Previous Encounter none 1 Code 95115 Desc Allergen immunotherapy single INJ x Note rue 1 1 1 2 Code 10040 Desc Acne surgery x Favorites nloipigqirisiti ui iviwixiyiz Note 10040 Acne surgery 95115 Allergen immunotherapy single INJ 85018 Blood count hemoglobin Hgb Exhibit 06 211 If you do not need the Procedures Services Block click the square icon before the block title block icon to clear and de activate the block
199. e met then select Blocking from the dropdown list on this field Exhibit 09 027 But if you want just a cautionary alert be raised without stopping the action select Non Blocking 3 Trigger is the factor that will activate the rule The four rules covered in this window require either the ICD name or ICD Code or the Medicine Name or Medicine Code to invoke the rule Thus only these four values are mentioned in the dropdown list on this field Exhibit 09 028 4 Give the value of the triggering factor in this field For example if you selected Medicine Name starting with in the previous field then specify the name of the medicine in this field 5 f the rule activates upon interaction of one factor with another the second factor is called the target It is not necessary that every rule has a target Where Rules are activated on the basis of a single factor the target field should be left blank The target field has eight values in the dropdown list as shown in Exhibit 09 029 In addition to the four values in the trigger field Allergy Name Allergy Code Manufacturer s Laboratory s Name and Manufacturer s Laboratory s Code are also included 6 Give the value of the target factor here For example if Allergy Name was selected in the previous field specify the name of the Allergy here 7 Ifthe Rule should apply only on patients of certain age use the age filter Specify by selection from the dropdown list Exhibit 09 0
200. e name of the factor in each of the row created The default value of the factors shows as negative If you want the default value to show as positive click the negative sign of the respective factor It will turn positive We added four rows for four factors naming them First Factor Second Factor Third Factor and Fourth Factor and kept the initial values as negative as shown in Exhibit 09 186 If you want this block to initially appear in opened state on charts keep the checkbox checked If you want it to appear initially as de activated uncheck the checkbox If this block is billable i e you recover charges for the entry in this block then check the Billable Procedure checkbox The next three fields will activate Enter the billing code description and the amount to be filled in these fields Click Ok The Add window will close and the block will be created on the template Save the changes Now when you open a new chart the block will appear on the Form as shown in Exhibit 09 187 for simplicity and uniformity we have opened the new block as the first block on the chart It is named Eighth Block All the factors are appearing on the form with their initial values showing as negative Whenever there is an entry in this block the Patient Invoice if Patient Invoice is issued and the Super Bill will both include the amount If the amount is to be recovered through the Super Bill then amend the
201. e necessary corrections and generate the batch again If a Super Bill Batch has been generated and saved and another batch is generated for the day the earlier Super Bill for the day will be overwritten The system retains only one Super Bill for a day Similarly if a Super Bill had been generated for an individual patient earlier on and thereafter the batch is generated the earlier Super Bill will be overwritten and vice versa It is recommended that Super Bills are generated either after the clinic closure for the day or on the next working day The reason is that if there is any new encounter after the bills have been generated it might be skipped from billing if the Super Bill batch is not generated again Re generated bills will have a different time stamp and if you have already used the earlier Super Bill explanations may be warranted So to avoid these complications it is best to generate the Super Bill batch after you are sure that there will be no further encounters for the day wm EMR NEXT User Manual lt gt Export Superbills Batch 4 Yesterday s Encounters O Other Date Include encounters even if there no CPT codes or contain Billing not required flag Exhibit 07 019 Export Superbills Batch gt Yesterday s Encounters Other Date Y v Generate Batch _ Include encounters even if there are no CPT codes or contain Billing not required flag Exhibit
202. e patients demographic and insurance information is stored History Form Template Tab This tab deals with the template for the second form where patients historical data is stored The history form is highly customizable through the template on this tab You can edit or delete default blocks present on the form add your own blocks of various types and move blocks whereever you like to change the layout of the form to suit your needs Encounter Form Template Tab This last tab deals with the template for the third form of charts where patients visits are documented Just like the history form before the encounter form is fully customizable and you can easily modify it to suit your clinical workflow needs NOTE The organization of data within a chart is straightforward Every chart contains three forms one for demographic insurance information called the General form one for historical medical data called the History form and one for patient visit data called the Encounter form There is always one copy of General and History form associated with a chart whereas Encounters can be unlimited each corresponding to a patient visit When a new chart is added to the system it contains General and History form but no Encounters are appended to it The encounters are added to a chart as and when needed Exhibit 09 001 EE EMR NEXT User Manual lt gt The four tabs on the Cover Page segregate the customization area fou
203. e section 09 01 04 14 for how to add PSH phrases to the favorites list and how to make your own PSH phrases Hypertension Past Surgical History Carotid endarterectomy Clear Field Undo Last Appendectomy Carotid endarterectomy Cataract surgery Exhibit 06 079 The PSH Phrase Window has a Clear Field button clicking which will clear all entries made in the PMS Block so far The Undo Last button will only clear the last insertion in the block Click the square icon before the block title block icon to clear and de activate the block Click it again to re activate it Click the block icon twice to refresh the block xx EMR NEXT User Manual lt gt 06 02 03 Known Allergies ALG Block Pack Known Allergies ae 1 Allergen x Reaction Status Exhibit 06 080 The Known Allergies ALG Block looks like this Its placement on the History Form is identified as item 3 on Exhibit 06 074 Exhibit 06 080 shows one set of entries but by clicking the down arrow at the bottom left of the set any number of sets can be added The cross icon on the right deletes the set Each set consists of the name of the Allergen the Reaction that it causes and the status of the allergy The names of the Allergen may either be written manually or may be selected from your list of favorite allergen from the database see section 09 01 04 15 for how to create your list of favorite allergen Reaction
204. e the Metric Measurement System change the radio button to the lower row 2 To either open it in Opened activated state on the Encounter Form or in de activated state To open it activated on new Encounter Forms keep the checkbox marked To open it de activated uncheck the checkbox After editing click the OK button and Save the changes EP EMR NEXT User Manual lt gt 09 04 08 Editing the Physical Examination Block Back When you click the Edit Template Block Icon of the Physical Examination Block a small three button window opens as shown in Exhibit 09 205 The buttons include Cut Edit and Delete Cut Edit Delete p Physical Examination a Constitutional Eves Neck Respiratory Cardiovascular Breasts Gastrointestinal Genitourinary Female Genitourinary Male Lymphatic Musculoskeletal OD oo oo EE ERIT Exhibit 09 205 Cut If you wish to change the location of this block on the form template click the cut button The blue boundary around the block will turn red indicating that block is ready to be shifted Now click the yellow Add New Block Icon of the location where you want to relocate the block A small two button window opens with the Paste and Add buttons Click the Paste button The block will relocate to this position Delete If you wish to delete the block altogether
205. e top of the window which marks all systems as checked and all examinations therein as performed with normal findings This button should be clicked only if all items are checked and all exams are performed with normal findings If the button has been clicked by mistake click the block title icon to refresh the block There is a free text space available at the end of the block for any observations There is no space restriction Lines will add according to the length of the text If you do not need the Review of Systems Block click the square icon before the block title block icon to clear and de activate the block Click it again to re activate it Click the block icon twice to refresh the block EMR NEXT User Manual lt gt Constitutional General Appearance Exhibit 06 193 Eyes Conjunctivae Lids Conjunctivae clear no ptosis Pupil Iris Exam Optic Disc Exam Exhibit 06 194 ENMT External Ears Nose Canals TM Exam Hearing Assessment Mucosa Sept Turb Lips Teeth Gums Oropharynx Exam Exhibit 06 195 Neck Neck Exam Thyroid Exam Exhibit 06 196 EMR NEXT User Manual lt gt Respiratory Respiratory Effort Chest Percussion Chest Palpation Lungs Auscultation Exhibit 06 197 Cardiovascular Heart Palpation Heart Auscultation Carotid Arteries Abdominal Aorta Femoral Arteries Pedal Pulses E EH
206. eafness hearing loss Degenerative joint disease Depression anxiety neurosis Dermatitis eczema Add Your Own Referral For Phrases l Exhibit 09 083 707 Your Favorites Abdominal pain Acquired foot deformities Acute sprains and strains Allergic rhinitis Anorectal condition Bursitis synovitis tenosynovitis Cardiac arrhythmia Cardiovascular signs and symptoms Cervical pain syndrome Chest pain Cholelithiasis cholecystitis Deafness hearing loss Degenerative joint disease Depression anxiety neurosis Dermatitis eczema Diabetes mellitus External abdominal hernias hydroceles Fracture b Eb Eb Eb Ep Eb amp 1 The left side of the window is for the Master List of Reasons For Referral Phrases The list has more than 30 entries None of these phrases will appear in your list of favorites unless you make them favorite 2 Click this right arrow to move the Reason For Referral Phrases to your list of favorites 3 If the phrase you are looking for is not included in the Master List you can write it yourself in this field EMR NEXT User Manual lt gt 4 Press this right arrow to include it your list of favorites The Reason For Referral Phrases you have added from this field will not be added in the Master List They will only be added to your favorites 5 This is the list of your fa
207. ed 1 Write the amount recovered from the patient here 2 Mode of Payment is selectable from the dropdown list Options are Cash Card or Check Exhibit 06 140 3 This is a free type field in which you may want to write particulars like card number check number etc This field accepts up to 30 characters 4 Payment type is selectable from dropdown list Options include Copayment Coinsurance Part Payment amp Full Payment Exhibit 06 141 5 If full amount has been recovered and further billing is not required check this box The system will mark No Billing Required on the Super Bill accordingly 6 Any note that you might want to write for your biller The field accepts up to 80 characters Fayment type Received 5 Mote for Biller Copayment Payment type Note for Biller in Cash Chief Comp Coinsurance via Card Part payment Chief Complaint via Check Full payment Exhibit 06 140 Exhibit 06 141 Dom EMR NEXT User Manual lt gt 06 03 03 Chief Complain Encounter Reason Block Back Exhibit 06 142 shows the Chief Complain Encounter Reason Block The location of the block on the Encounter Form is identified by item 3 on Exhibit 06 134 This block is a part of the Subjective Section of the encounter under the Center for Medicare amp Medicaid Guidelines for taking patient history Chief Complaint Encounter Reason Hu Exhibit 06 142 This block records pati
208. ed extra fields they can be deleted by clicking the trash can icon at the end of the respective field EET EMR NEXT User Manual lt gt Now write the names of the fields the white space at the beginning of each field For example we created five fields and gave them the names First Field Second Field Third Field Fourth Field and Fifth Field as shown in Exhibit 09 111 If you want this block to initially appear in opened state on charts keep the checkbox checked If you want it to appear initially as de activated uncheck the checkbox Click Ok The Add window will close and the block will be created on the template Save the changes Now when you open a new chart the block will appear on the Form as shown in Exhibit 09 112 for simplicity and uniformity we have opened the new block as the first block on the chart It is named Second Block Please note that two additional full length fields also appear at the end of the block for any free type notes The lines will extend according to the length of the text EMR User Manual 4o gt Add Second Block First Field Second Field Third Field Fourth Field Fifth Field w v Initially display in Opened state Exhibit 09 111 EET EMR NEXT User Manual 40 gt First Cardiology Clinic Photograph Click T Chart ID 00021 New 2 poodles Second Block Family History First Field Diabetes Second Field
209. ed here will be picked up in the Patient Invoice and the Super Bill directly whenever this E M Code is selected Where rates have been specified for the E M Code the pencil icon turns blue as shown in the first entry in Exhibit 09 063 8 If you want to delete the Evaluation Management Code from your list of favorites click the corresponding trash can icon If the code was selected from the Master List it will still be available for re selection there but if you had yourself defined the code description and rate they will be lost 9 Save the changes made to the list by clicking the Save button In Exhibit 09 061 the button is in white color because it is not activated yet It activates whenever a change is made in the window If you try to close the window without saving the changes the alert shown in Exhibit 09 064 will raise 10 The Reset button clears all unsaved changes In Exhibit 09 061 the button is in white color because it is not activated yet It activates whenever a change is made in the window EMR User Manual lt gt gt Default CHARGE if X Online Consultation Exhibit 09 062 Your Favorites Rate OD 74T 90801 90802 90804 90805 90806 90807 90808 90809 90810 Online Consultation Psychiatric Diagnostic Interview examination Psychiatric Diagnostic Interview exam interactive Psychotherapy office 20 30 min Psychotherapy office with E M 20 3
210. edications Block click the square icon before the block title block icon to clear and de activate the block Click it again to re activate it Click the block icon twice to refresh the block EMR NEXT User Manual lt gt Allergies Erythromycin Dust Mite Fish or Crustacean Shellfish Exhibit 06 223 GO E Mi chew 1 SEQ Rx Chew 1 2 DAW Sig Exhibit 06 224 Exhibit 06 225 Exhibit 06 226 EMR User Manual Master Medication Master Medication List Rx Rx Sig Sig Exhibit 06 227 Exhibit 06 228 Qty 10 Ri Ref 3 1 2 1 2 Exhibit 06 229 Exhibit 06 230 lt gt 9 days 10 days 12 days 1 week EMR User Manual lt gt 06 03 12 Plan Notes Block Back Exhibit 06 231 shows the Plan Notes Block The location of the block on the Encounter Form is identified by item 12 on Exhibit 06 134 This block is a part of the Plan Section of the encounter under the Center for Medicare amp Medicaid Guidelines for taking patient history Plan Notes Exhibit 06 231 The Plan Notes Block is for any instructions to the patient with regards to the illness Click on the block icon to call the Plan Notes Window Exhibit 06 232 The upper section of the window shows the Plan Notes from the previous encounter if any and the lower section shows your favorite phrases with regards to special instructions to
211. een opened when the icon is clicked The dashboard performs five functions 1 On the top left corner it shows the total number of charts in the database 2 The block marked as item 2 on Exhibit 07 001 is the detailed search mechanism There are eight factors on which you can perform the search which will be discussed individually The dropdown list marked b on Exhibit 07 001 gives the search options for each factor Values in this dropdown list change according to the factors Enter the search value in the value field identified as item c and press the go button The search values will populate in the Viewing pane as can be seen in Exhibit 07 012 Press the execution button at the end of the desired entry item 1 on Exhibit 07 012 and an options window will appear with six options Press the last button Open Chart to open the chart Other options will be discussed later in this section a Social Security Number The search options are Starts with and Equals to Exhibit 07 002 If you know the complete SSN select Equals to and enter the SSN in the value field Otherwise enter at least first EMR NEXT User Manual lt gt gt three starting numbers If less than three characters are entered as search value an alert will appear as shown in Exhibit 07 013 with appropriate wording b Medical Record Number This is your clinic s own serial number if you maintain a
212. eir descriptions You construct this list of favorites from this Section i e from the field identified as 4b in Exhibit 09 002 When you click the Open button on the field the Add Delete Procedure Codes Window opens Add Delete Procedure Codes X Master List e Search Master List Your Favorites R 10040 Acne surgery 10040 Acne surgery 17360 Acne chemical exfoliation 95115 Allergen immunotherapy single INJ 17340 Acne Cryotherapy CO2 slush liquid N2 85018 Blood count hemoglobin Hgb 95117 Allergen immunotherapy 2 INJ 17003 Destroy Lesions 2 14 95115 Allergen immunotherapy single INJ 20526 Injection therapeutic carpal tunnel 97032 Application of modality 1 or areas 92012 Oph Medical Xm amp Eval Intrm Est Pt 97035 Application of ultrasound each 15 min 90732 Pneumococcal vaccine Adult IM 84590 Assay of Vitamin A 84425 Thiamine Vitamin B 1 Eb Bb Eb 84597 Assay of Vitamin K 84550 Uric acid blood 80048 Basic metabolic panel 85027 Blood count complete automated 85018 Blood count hemoglobin Hgb 85032 Blood count manual cell count 85049 Blood count platelet automated Add Your Own Procedure Cod e Exhibit 09 056 1 The left side of the window is for the Master List of Procedure Codes and their descriptions The list has more than 100 entries The first column shows the codes while the second sect
213. eld to select the logo The system will take you to the operating system Browse to the location where the logo is available and click the file to bring the logo in the field The size of the logo must be within 36 pixels in height and 58 pixels in width If the logo size is larger an alert will appear Resize the image and import again To remove the logo click on the Remove button on the right of the field This button will give the inbuilt help suiting this area Click on the icon will open online help as shown in Exhibit 09 004 After adding or changing the information data click Save to save the changes 4o gt Help X You are on the Customization Screen Click on a topic to start 2 Editing clinic information 7 Editing provider information Setting Preferences 7 Pointer Targets amp Buttons Prescriptions and Orders 7 Default Notes and Letters 2 Custom Letters amp Handouts 7 Document Folders Forms Validation amp Other Rules 7 Clinical Decision Support Rules Adding editing Ancillaries 7 Adding editing List Menu items Other Related Topics Online User Manual Exhibit 09 004 Note that if you will upload a logo image it would appear beside the clinics name on every printed document such as prescriptions orders or encounter notes Furthermore only JPG GIF PNG and BMP formats are supported and the image must be 36 pixels or less in heigh
214. ell Nos Work Status and Marital Status 8 Primary Insurance Particulars of the patient s insurance company Includes Carrier Name ID Policy No Group No of a group plan Authorization Code Carrier s Address Plan No under which policy has been issued Expiry of the policy Following particulars are of the principal insured PI if the patient is not the PI These include Relationship of the patient to the PI Name Date of Birth Telephone No and Remarks 9 Secondary Insurance Particulars of the secondary insurance company Includes Carrier Name ID Policy No Group No of a group plan Authorization Code Carrier s Address Plan No under which policy has been issued Expiry of the policy Following particulars are of the principal insured PI if the patient is not the These include Relationship of the patient to the PI Name Date of Birth Telephone No and Remarks if any 10 Particulars of the patient s guarantor They include Relationship of patient with guarantor Name Date of Birth Telephone No and Remarks 11 Name and ID of the doctor hospital clinic which referred the patient to you 12 Shows amount recovered by you directly from the patient along with the Details entered by you in the Encounter Form and the Payment Type selected for the amount recovered 13 Instructions for the biller whether or not to raise bill and Notes for the Biller 14 The ICD codes and descriptions o
215. em List s placement on the History Form is identified as item 7 on Exhibit 06 074 It is the history of all problems identified for the patient Initially you may record the problems of a new patient in this block directly but subsequently the list will update automatically from the encounter forms Entries may either be made manually or may be selected from your list of favorite problems Exhibit 06 100 Section 09 01 04 01 shows how to make your list of favorites from the collection of over 1900 preloaded problems in the system Master Problem List Your a lb c dje f g hjij j k l m 1 Code 789 00 Onset Nature x Favorites niloipigirisiti uj viwixiviz Desc Abdominal pain NOS Status Active 789 00 Abdominal pain NOS 789 06 Abdominal pain epigastric Exhibit 06 100 If you are adding problems manually create a fresh set of entries by pressing the down arrow icon under the last set of entries and fill in the data For selection from the database click the block window icon to call the list of favorites Each set of entries in the problem list include the following 1 DX code of the problem 2 The onset time 3 Nature of the problem 4 Description of the problem and 5 Status If you select the problem from your list of favorites the DX code description of the problem and the status would be called in from the selection Only the Onset time and the Nature of problem have to be specified individually T
216. en done click on the Save button to save the note The note will appear like shown in Exhibit 06 020 in the Phone Notes Window First is the serial number of the note then the date then the nature of the caller in this case the patient himself called and then the note You may add as many notes as you want which appear in serial order in the window To delete any note click on the Trash Can Icon on the right of the respective note The system raises an alert to confirm if you want to delete the note Exhibit 06 021 Click Delete Note to delete or Don t Delete to abort deletion action To print the notes click the Print button at the bottom left of the window The button is deactivated if there is no note EMR User Manual lt gt gt Phone Notes 00002 Smith John There is no data to display Add Note Exhibit 06 017 Add Phone Note 00002 Smith John Exhibit 06 018 Add Phone Note 00002 Smith John Caller ow Pharmacy This is a phone note Patient Farent Exhibit 06 019 EMR User Manual lt gt zx Phone Notes x 00002 Smith John 1 4 26 2013 Patient This is a phone note Exhibit 06 020 Are you sure you want to delete this note from database Delete Note Exhibit 06 021 3 General Notes Click the icon to open the General Notes window and view existing notes At the outset it will be blank as
217. ent s complaints You may either record the complaint manually or select your favorite complains from the Chief Complaint Encounter Reason window that pops when you click the block window icon at the top right of the block Section 09 01 04 09 shows how to add complaint phrases to the database Chief Complaint Encounter Reason Clear Field Undo Last Abdominal pain CC Previous Encounter none Your Favorites Abdominal pain A Abnormal appearance of eyes Exhibit 06 143 Exhibit 06 143 shows the open Chief Complaint Encounter Reason window The upper section shows the complaints selected in the previous encounter The lower section holds favorite phrases from which you may select as many as required The selection may be mixed with manual entry The Clear Field button in the window clears the field altogether The Undo Last button on the window clears the last of the multiple selections made from the window If you do not need the Chief Complain Encounter Reason Block click the square icon before the block title block icon to clear and de activate the block Click it again to re activate it Click the block icon twice to refresh the block EMR User Manual lt gt 06 03 04 History of Present Illness HPI Block Pack Exhibit 06 144 shows the History of Present Illness Block The location of the block on the Encounter Form is identified by item 4 on Exhibi
218. er List or by writing the description and codes of the Diagnoses yourself or as a combination of both 8 If you want to add a note to the Diagnosis Click the corresponding pencil icon The window shown in Exhibit 09 053 will open Write your note and click the ok button When the changes are finally saved by clicking item 10 on Exhibit 09 052 the note will always appear in the field for Notes Exhibit 06 213 in the Assessment Diagnosis Block when this diagnosis is selected Where default notes are added to the diagnosis code the color of the pencil icon in the window turns blue as can be seen in the first entry in Exhibit 09 054 9 If you want to delete the Diagnosis Code from your list of favorites click the corresponding trash can icon If the code was selected from the Master List it will still be available for re selection there but if you had yourself defined the code and description they will be lost 10 Save the changes made to the list by clicking the Save button In Exhibit 09 052 the button is in white color because it is not activated yet It activates whenever a change is made in the window If you try to close the window without saving the changes the alert shown in Exhibit 09 055 will raise 11 The Reset button clears all unsaved changes In Exhibit 09 052 the button is in white color because it is not activated yet It activates whenever a change is made in the window EE EMR NEXT User Manual
219. er and fax number 2 Name of the patient and his her address EMR NEXT User Manual 10 11 12 13 14 15 16 EMR NEXT User Manual Encounter Date and Service Type Name of the Report Invoice The Amount received from the patient during the encounter List of the CPT codes their description and charges applied in this encounter They may not necessarily equal the charges recovered by you Usually if the on spot recovery does not cover the full amount Super Bill is raised for the balance Total Charges raised as per the CPTs applied Any adjustments concessions you may make for the patient Adjustments can only be made directly in the report and do not carry forward from the encounter form Since this adjustment is incorporated directly in the invoice it does not carry through to the Super Bill You must show this adjustment in the Note for the biller item 6 of exhibit 06 139 for the final bill and the super bill to account for the adjustment The amount recovered from the patient directly during the encounter item 5 The net balance recoverable Net result of the total CPT charges less adjustments less this invoice amount If you do not want to show any billing details to the patient and show only the charges recovered from him directly press this button The patient will get only the directly recovered charges amount and the list of services rendered Exhibit 06 281 shows how t
220. es are seen as procedures Data requirement for vaccines include the following fields Date Note this is a free text field with a 20 character limit Next due date Dose ml or mg suffix is selectable Exhibit 06 088 Lot Number and Manufacturer Data requirement for procedures include the following fields Date Note this is a free text field with a 20 character limit Next due date and Miscellaneous this is also a free text field with a 40 character limit Dates in both the data sets are selectable from a dropdown list on the field Exhibit 06 089 amp 06 090 and the name of the manufacturer is also selectable from dropdown Exhibit 06 091 Dose Next Date MER Dose neumococcal Vac san Jan Date Pnewm DEI reine Exhibit 06 088 Exhibit 06 089 Exhibit 06 090 EMR NEXT User Manual 4o gt lt gt Abbott Adams Exhibit 06 091 After the Health Maintenance elements there is a free text area for any notes relating to health maintenance There is no limitation on the size of the note You may perpetually add to it or delete from it If you do not need the Health Maintenance Block click the square icon before the block title block icon to clear and de activate the block Click it again to re activate it Click the block icon twice to refresh the block wl EMR NEXT User Manual 06 02 05 Family History Block Back Family History Diabetes
221. es selectable from dropdown lists To show it as a free text field keep the radio button on the first value To show it as a fixed format date field change the radio button to the second value 2 To either open it in Opened activated state on the Encounter Form or in de activated state To open it activated on new Encounter Forms keep the checkbox marked To open it de activated uncheck the checkbox After editing click the OK button and Save the changes WU IZIZIUII EMR NEXT User Manual lt gt 09 04 11 Editing the Orders Requisitions Block Back When you click the Edit Template Block Icon of the Orders Requisitions Block a small three button window opens as shown in Exhibit 09 214 The buttons include Cut Edit and Delete BENE i S PD 5 Orders Requisitions m Exhibit 09 214 Cut If you wish to change the location of this block on the form template click the cut button The blue boundary around the block will turn red indicating that block is ready to be shifted Now click the yellow Add New Block Icon of the location where you want to relocate the block A small two button window opens with the Paste and Add buttons Click the Paste button The block will relocate to this position Delete If you wish to delete the block altogether click the Delete button The block will remove from the template Section 09 04 01 shows how to restore the block
222. ests E Code Basis lt gt gt lt gt 06 03 01 Encounter Statistics Back Exhibit 06 135 shows the Encounter Statistics Block The location of the block on the Encounter Form is identified by item 1 on Exhibit 06 134 Encounter 7 11 2013 9 Referred by Attended by Davis Richard MBBS 12345678 Exhibit 06 135 1 This is the encounter number In this case it is the seventh encounter of the patient 2 Date of encounter selected from dropdown list Exhibit 06 136 When creating an encounter future dates up to thirty days may be defined in case you want to prepare the form ahead of the appointed time The system will not allow creation of encounters more than 30 days ahead 3 Encounter type is selectable from the dropdown list Exhibit 06 137 Manual entry is not permitted 32 options are available in the dropdown Many have been picked from the billing regulations others have been devised from general experience of the industry You can manage your list of favorite Service Types in Section 09 01 04 08 4 This field is for the Point of Service Code for the encounters Codes have been pre inserted with the encounter types specified in the billing regulations For others field is presently blank Insert the code if one exists for the encounter type you select otherwise leave blank The Point of Service Codes are also managed from Section 09 01 04 08 5 If the patient
223. evisiting an opened chart 7 Scheduling and related tasks 2 Settings and Customization 2 Data Backups and Restore Online User Manual Exhibit 10 002 Dashboard T Customize Total charts in database 14 No results to display Find Charts Where LAST NAME FIRST NAME MI SFX DOB AGE PHONE SSN aa You are on the Dashboard Screen p Phone Click on a topic to start Last Name 7 Searching database for charts First Name Performing tasks on search results 2 Opening a chart 2 Refilling prescription Visit Date 2 Viewing filed documents e o m Attaching a phone note 2 Booking an appointment 2 Deleting a chart Other tasks from this screen 2 Filing a scan or document 2 Exporting superbills for billing Import Export 7 Accessing flagged documents Import Scanned Files s Online User Manual Export Superbills Exhibit 10 003 EMR NEXT User Manual Dashboard amp Thu May 23 2013 2 Last Name First Name MI s Visit Reason Notes 09 00 am 09 15 am 09 30 am 09 45 am 10 00 am 10 15 am CREE Sun Mon Tue Wed Thu Fri Sat 2629 so E3 2 3 4 BRR 12 5 a s e mr 6 20 21 22 23 24 25 25 zr 28 29 fo 1 Le lle 1 1 lel Search Next Day Having Min Slot 10 30 am 10 45 am
224. f diseases identified in this encounter 15 The CPT codes description of the procedures applied in the encounter and their charges totaling up to the final amount of the Super Bill 16 Report Generation Date EMR User Manual lt gt 06 03 16 02 09 Report 9 Patient Invoice Pack Exhibit 06 280 shows the Patient Invoice in the Print Fax Encounter Related Documents window e First Cardiology Clinic 1001 Parkway Drive Chester AL 23866 Tel 234 598 5589 Fax 234 567 8902 Service Date Apr 16 2013 Service Type 123 ABC Drive Any City Any State Any ZIP Cd Office Visit New DESCRIPTION Services Professional services rendered on Apr 16 2013 150 00 6277 0074T Online Consultation Q 200 00 10040 Acne surgery 55 00 95115 Allergen immunotherapy single INJ 34 00 85018 Blood count hemoglobin Hgb 25 00 17003 Destroy Lesions 2 14 75 00 Total Charges Adjustments This Invoice Total Balance Diagnosis 724 4 Back pain w radiation NOS 493 90 Asthma NOS 786 50 Chest pain NOS Copayment LJ Coinsurance Part Payment O Full Payment Total 150 00 paidinCash DO paidviaCard O paid via Check May be allowed concession Exhibit 06 280 This is the invoice you issue directly to the patient if you recover any payment from him her during the encounter 1 Your clinic s name address telephone numb
225. f the ROS in the previous encounter Exhibit 06 171 The Set All Systems To Normal button on the window will check the checkbox for all systems and leave the findings negative Care must be exercised to use this function only when all the systems have been reviewed To copy the findings of any specific system to the new encounter form click the system in the popup window If the previous findings of all the systems are to be brought on the new encounter form click the Insert All Previous Items button at the bottom of the window EMR NEXT User Manual Review of Systems ROS Previous Encounter General Fevers sweats Weightloss Eyes Vision loss Blurred vision Eye pain Genitourinary Male Frequent urination Foul urinary discharge Genital rashes or sores Exhibit 06 171 Chills Appetite loss Fatigue Double vision Eye irritation F gt Discharge Light sensitivity Blood in urine Kidney pain Cr Urinary urgency Trouble starting urinary stream Inability to empty bladder Burning or pain on urination Testicular pain or masses At the bottom of the block free type space is available for remarks Initially two lines are available but lines will add according to the length of the text If you do not need the Review of Systems Block click the square icon before the block title block icon to clear and de activate the blo
226. facility then you may wish to transfer the prescription thereon expeditiously If you check this checkbox and provide the url of the facility in this window every time you make a prescription and EMR NEXT User Manual lt gt press the print button the webpage of the facility will open and you will be position to type or copy paste the medicines from the system to the external facility 11 When you check the checkbox for accessing external e prescription website item 10 this field activates for the url of the webpage 12 Click the Update button to save the changes On Radio Buttons system default setting is marked with an asterisk On checkboxes system default is unchecked except on Enable Tamper Resistance on Rx checkbox item 7 where the system default is checked The help icons on the window open inbuilt help on the respective item EMR NEXT User Manual 09 01 02 03 Default Notes amp Letters Pack Edit Notes Letters Settings Note Content verbose includes all negative amp positive findings C Concise includes only positives and pertinent negatives Do not include 55 on encounter notes Include master problem list on notes and letters Include master medication list on notes and letters 2 Note Style Fatigue Lightheadedness Fatigue Yes Lightheadedness No Ow Show every Chief
227. favorite 2 Click this right arrow to move the Chief Complaint Phrases to your list of favorites 3 Ifthe phrase you are looking for is not included in the Master List you can write it yourself in this field 4 Press this right arrow to include it in your list of favorites The Chief Complaint Phrases you have added from this field will not be added in the Master List They will only be added to your favorites EMR User Manual lt gt 5 This is the list of your favorites that you have prepared either by selection from the Master List or by writing the phrases yourself or as a combination of both 6 If you want to delete the Chief Complaint Phrase from your list of favorites click the corresponding trash can icon If the phrase was selected from the Master List it will still be available for re selection there but if you had yourself written it it will be lost 7 Save the changes made to the list by clicking the Save button In Exhibit 09 079 the button is in white color because it is not activated yet It activates whenever a change is made in the window If you try to close the window without saving the changes the alert shown in Exhibit 09 080 will raise 8 The Reset button clears all unsaved changes In Exhibit 09 079 the button is in white color because it is not activated yet It activates whenever a change is made in the window You need to click SAVE button below to keep the
228. g on record Exhibit 06 268 1 The left column shows the patient s name on the top and 12 printable reports beneath it The asterisk after the report name like that on the first 10 reports in the exhibit means that a printable report of this category exists for this patient on this encounter The reports or the draft text opens when the radio button is selected Under the 12 system generated reports two Custom Reports are shown in the exhibit The system allows you to format up to 8 custom NE EMR NEXT User Manual 4o gt reports aS per you practice s requirement Section 09 01 02 04 shows how to format the custom reports 2 This is the document viewing pane Documents open in the pane when the corresponding Radio Button is selected 3 After opening the report editing is allowed therein only in fields which appear in a darker shade The refresh button removes all the editing done in the report and brings it back to the original shape 4 f you have a signature stamp in the setup see Section 09 01 01 02 checking this button will insert your signature in the document 5 The first four reports Prescription Laboratory Order Radiology Order and General Order have an option either to be printed as a combined single report or as a Separate report for each entry Click the appropriate radio button to print either separate reports of a combined report 6 Save the report after generating editing it 7 Thi
229. g pane by selecting the Radio Buttons When a report is called the print button and the signature stamp activates Exhibit 06 121 4 EMR NEXT User Manual Print Fax Historical Data x Smith John History Note Problem List Medication List Allergy List eee Health Maint L Signature Stamp Exhibit 06 121 History Note First Cardiology Clinic 1001 Parkway Drive Chester AL 23866 Tel 234 598 5589 Fax 234 567 8902 History Note for Smith John on Apr 30 2013 DoB Feb 25 1943 Past Medical History Abnormal PAP smear Past Surgical History Carotid endarterectomy Known Allergies Erythromycin Dust Mite Fish or Crustacean Shellfish Family History Diabetes Stroke Hypertension Heart Disease Cancer Asthma Hay Fever Arthritis Osteoporosis Anemia Migraine Alzheimers Epilepsy Glaucoma Social History Alcohol Use Caffeine Use Tobacco Use Drugs Use Chm Exposure TB Exposure HIV Exposure Sex Relations Excersice Sleep Habits Master Medication List Abilify 20 mg TAB Active Benadryl Cold 500 25 30 mg TAB Active Benadryl Childrens Allergy Fastmelt TAB disintegrating Active Carmol 10 10 LOT Active Chromagen FA TAB Active The signature stamp is used for applying your signature on the report See section 09 01 01 02 for adding your signature stamp to the system If you do
230. g to the entry Finally EMR NEXT User Manual lt gt when entry of the last name is complete the search window will show all patients with this last name if any You may review the list to determine if the patient already exists in your database If the patient is included in the list click the entry in the list The Patient Name Chart ID and Phone Number will get copied in respective fields on the Scheduler 4 Write the reason for the appointment 5 This is the duration of appointment By default the standard duration defined by you in the Initial Configuration Screen item 19 Exhibit 04 004 appears here But there is a dropdown list on this field from where you can change the duration of the appointment Exhibit 08 003 6 Click on the icon at the beginning of the viewing pane for the desired appointment starting time For example in Exhibit 08 004 the appointment is being sought for 15 minutes from 9 00 am Make sure that the slot is available at the desired time available slots appear in white Booked slots appear in blue In Exhibit 08 001 all slots are available on that day Although it is possible to book multiple appointments for the same slot This is discussed in notes to item 6 7 This is the viewing pane Once the icon marked at item 6 is clicked the patient s particulars fed in items 3 amp 4 will appear here highlighted in yellow as shown in Exhibit 08 004 Also the Book Appointment
231. ge is made in the window You need to click SAVE button below to keep the changes you have made to this favorite list Do you want to close this window without saving Exhibit 09 090 EMR NEXT User Manual lt gt 09 01 04 15 Allergies Phrases Back Allergy Phrases are used in the Known Allergies Block in the History Form Section 06 02 03 Exhibit 06 080 When you click the block icon on the block the Known Allergies Window shown in Exhibit 06 082 opens Entries in this window are managed from here in the Customization Section When you click the Open button on the field identified as item 4o in Exhibit 09 002 the Add Delete Allergies Phrases Window opens Add Delete Allergies Phrases x Master List Amoxil Ampicillin Aspirin Bactrim Ceftin Cefzil Codeine Depakene Dilantin Dust Mite Eggs Erythromycin Fish or Crustacean Shellfish 4400000000000 Fur or Dander Add Your Own Allergies Phrase Exhibit 09 091 1 The left side of the window is for the Master List of Allergies Phrases The list has more than 30 entries None of these phrases will appear in your list of favorites unless you make them favorite Your Favorites Amoxil Ampicillin Aspirin Bactrim Ceftin Cefzil Codeine Depakene Dilantin Dust Mite Eggs Erythromycin Fish or Crustacean Shellfish Fur or Dander Insulin Keflex Lamictal Milk or Lactose Intolerance b Eb
232. ged in the system the first time Section 04 You also defined the slot durations there three options were available 05 minutes 10 minutes and 15 minutes If you want to change any of this information it can be done from the customization screens This will be discussed in Section 09 Item 5 on Exhibit 05 001 identifies the icon for the Scheduler on the Home Page When the icon is clicked the scheduler opens for today s date FEM Scheduler Th Customize Mon May 6 2013 CHART PATIENT s NAME PHONE VISIT REASON NOTES 41 ww 8 Qi 5 6 Sun Mon Tue Wed Thu Fri Sat 19 20 26 27 28 29 so 1 2 3 4 5 6 Qe Next Day Having 15 Min Slot Exhibit 08 001 1 The Scheduler opens on the Day View The grey bar identified as item 1 is showing a yellow margin which indicates that the day view is active 2 The current date displays here 3 The first row in this block is for patient name Start with entering the patient s Last Name There is a search on this field As soon as you enter the first alphabet of the last name a window will open showing all last names starting with the alphabet Exhibit 08 002 The window lists the Last Name First Name Middle Name Initial Date of Birth Home Phone and Chart ID As you go on entering further alphabets the search will keep narrowing accordin
233. general note Addendum Clarification Infarmation Exhibit 06 024 7 EMR User Manual lt gt 3 X 00002 Smith John 1 4 26 2013 Information This is a general note Exhibit 06 025 Are you sure you want to delete this note from database Delete Mote Exhibit 06 026 4 Document Viewer Every chart has a set of folders attached to it These folders contain patient documents prepared by the system and documents imported by you in the system There are 11 pre defined folders in the system These are Medication Laboratory Radiology Consultation Hospital Insurance Billing Directives Handouts Legacy and Other You can also create your own folders in the system Procedure to create your own folders is discussed in Section 09 01 02 05 But any additional folders created will be available for all charts and not for selective charts only EJ EMR NEXT User Manual lt gt System generated documents go in following folders Name of Document Folder Prescriptions Medication Laboratory Orders Laboratory Radiology Orders Radiology General Orders Other Referral Letters Consultation Consultation Notes Consultation Encounter Notes Consultation Visit Super Bills Billing Patient Invoices Billing Excuse Letters Other Face Sheets Face Labels No Show Letters and Reminder Letters are not saved in the system When you click the scans docu
234. gic lt gt lt gt 09 04 02 Editing the Encounter Statistics Block Back When you click the Edit Template Block Icon of the Encounter Statistics Block a small three button window opens as shown in Exhibit 09 191 The buttons include Cut Edit and Delete Edit Delete Attended by Exhibit 09 191 Cut If you wish to change the location of this block on the form template click the cut button The blue boundary around the block will turn red indicating that block is ready to be shifted Now click the yellow Add New Block Icon of the location where you want to relocate the block A small two button window opens with the Paste and Add buttons Click the Paste button The block will relocate to this position Delete If you wish to delete the block altogether click the Delete button The block will remove from the template Section 09 04 01 shows how to restore the block Edit When you click the Edit button the following Edit window opens EMR NEXT User Manual lt gt e Enable Referred by field on all encounter types allow blank C Enable Referred by field only on consultation type encounters Exhibit 09 192 The only editing possible for this block is to either enable the Referred by field only on those type of Encounters where the Encounter is of a consultation type or to enable it on all encounters
235. h section of the Orders Requisitions Window has quick finder alphabet tabs If your list of favorites is long click the alphabet with which the description of the item EMR User Manual 4o gt starts in the respective section and the cursor will move to the first entry starting with that alphabet Calcium lonized Exhibit 06 220 Exhibit 06 221 EMR NEXT User Manual lt gt If you do not need the Orders Requisitions Block click the square icon before the block title block icon to clear and de activate the block Click it again to re activate it Click the block icon twice to refresh the block EMR NEXT User Manual lt gt 06 03 11 Medications Block Back Exhibit 06 222 shows the Medications Block The location of the block on the Encounter Form is identified by item 11 on Exhibit 06 134 This block is a part of the Plan Section of the encounter under the Center for Medicare amp Medicaid Guidelines for taking patient history Medications Rx TT Exhibit 06 222 Medications Section is for the medicines prescribed to the patient in this encounter Medications prescribed in an encounter automatically add up in the Master Medication List in the History Form The Master Medication List has an extra field for status which can only be manipulated from the history form A set of entries in the block includes the following 1 Name of
236. h the Edit Window of the respective block opens The edit functionality of each block will be discussed separately Before and after each block is a yellow circular icon This is the Add New Block Icon It allows you to add a block in the position of the icon By this mechanism you can add blocks virtually anywhere in the template There is no space limitation as the template stretches according to requirement Before proceeding further two important points to be remembered 1 Changes made to the template must be saved Unsaved changes will be lost Whenever you make a change in the template a red alert will appear at the top left corner of the screen reminding you to save the changes Save the changes by clicking the button at the bottom right corner of the screen Exhibit 09 105 shows both the alert and the Save button 2 Changes made to the template will be effective only on charts created after the changes Previous charts will remain unchanged Dashboard Scheduler T Customize g History Form Template Encounter Form Template First Cardiology Clinic Photograph Diabetes I Stroke i Hypertension Heart Disease Cancer Asthma 1 i Hay Fever 1 Arthritis Osteoporosis gt Anemia i Migraine LI 1 1 Alzheimers Exhibit 09 105 EMR NEXT User Manual lt
237. haped icon X at the end of corresponding field clicking which will delete the item e Free type field A field in which you are free to type anything you want e Alert A precautionary or informative elongated narrow window the function of which is to bring attention either to a requirement which is not being met or make you aware of consequences of the action being attempted or simply to inform you about a situation If it is an informative alert it will just have an OK button When you click the button the alert will get dismissed If it is a precautionary alert it will have two buttons one to continue with the desired action and the other to abort the invoked action Sometimes an alert will also have three buttons according to the requirement of the situation e Chart A set of forms representing a patient in the EMR system These include the General Form the History Form and the Encounter Forms There is always a one copy of General and History forms within a chart whereas the Encounters can be unlimited EMR NEXT User Manual lt gt e Encounter A meeting with the patient either within your clinic or elsewhere e Displaced Appointments An appointment that was initially booked for one or more complete timeslots but later on due to changing the normal slot duration from the customization screen the appointment is not fitting completely in the available timeslots due to which the las
238. has to be recorded manually Status can either be Active or Inactive by selection Exhibit 06 081 The default Status is Active To select from your favorite Allergen click the square icon at the right top of the block The Known Allergies Window opens up for selection Exhibit 06 082 Only one allergen may be selected in one set of entries although manually you may record more than one allergen in one block but this is not recommended Status Active Active Status Inactive Exhibit 06 081 If there are no known allergies the status of the block must be changed to Known Allergies To do so open the Known Allergies Window There is a No known Allergies button at the bottom of the window Exhibit 06 083 Click it to change the status If any allergies have been selected in the block the status will not change An alert will rise asking for the selected allergies to be deleted for changing the status to No Known Allergies Exhibit 06 084 Delete the allergies and then click the button in the window EMR NEXT User Manual lt gt gt again Another alert will rise confirming that the status is being changed Exhibit 06 085 If you click Yes on the alert the status will change and now the block will look like that in Exhibit 06 086 Known Allergies Your Favorites 1 Allergen Bactrim x u Amoxil Reaction Sta
239. he Onset field is initially a free type field but if you click on the field name it converts into a dropdown list for selection of date Exhibit 06 101 Nature of problem can be defined only by selection from the following selectable values Minor Self Limited Time Limited Acute Chronic Intermittent Recurrent Condition Symptom Finding amp Limitation Exhibit 06 102 The ENT EMR NEXT User Manual lt gt default status is set to Active Eight other statuses are available for selection as appropriate Improving Stable Controlled Worsening Uncontrolled Resolved Ruled out amp Inactive Exhibit 06 103 Mature Worsening Onset Status Uncontrolled Minor Resolved Jan Self Limited Nature Ruled Out Feb Time Limited Status Exhibit 06 101 Exhibit 06 102 Exhibit 06 103 Manually inserted values may be edited but values populated by selection may not be edited Entries in the Master Problem List may be deleted by pressing the cross x at the end of the list This option is recommended to be used only if an incorrect entry has been made For problems that have resolved the Status should be changed to Inactive and not deleted If a de activated problem is re diagnosed in a subsequent encounter the Status will change to active If your list of favorite Problems is very long and you cannot locate the problem in the list readily there is a 3 10 character search available here on the l
240. he Vital Signs Block a small three button window opens as shown in Exhibit 09 203 The buttons include Cut Edit and Delete l Vital Signs Lu s LL C EE P a 5 Ca ES ca Leas um cms ums Exhibit 09 203 Cut If you wish to change the location of this block on the form template click the cut button The blue boundary around the block will turn red indicating that block is ready to be shifted Now click the yellow Add New Block Icon of the location where you want to relocate the block A small two button window opens with the Paste and Add buttons Click the Paste button The block will relocate to this position Delete If you wish to delete the block altogether click the Delete button The block will remove from the template Section 09 04 01 shows how to restore the block Edit When you click the Edit button the following Edit window opens OE EMR NEXT User Manual lt gt Use English units for vital signs Use Metric units for vital signs v Initially display in Opened state Exhibit 09 204 Two kinds of editing are possible for this block 1 You can either use British Measurement System for Vital Signs or Metric Measurement System If you use British Measurement System let the radio button remain on the first row If you us
241. he invoice looks like in this mode If you want to only hide the details of adjustments from the patient press this button The invoice will show up to the total charges for the CPTs applied but will not show any adjustments and how much balance is recoverable through the biller Exhibit 06 282 shows how the invoice looks like in this mode List of diagnoses made in the encounter A free type field for any remarks you may want to add in the invoice Lines will add according to text requirement Payment type as selected in the encounter form Mode of payment as specified in the encounter form next to the amount received lt gt lt gt 17 Shows the Details mentioned the encounter form Item 6 Exhibit 06 139 18 Net Amount received from the patient 19 Your identification and timestamp on the documents First Cardiology Clinic 1001 Parkway Drive Chester AL 23866 Tel 234 598 5589 Fax 234 567 8902 Service Date Apr 16 2013 Service Type 123 ABC Drive Any City Any State Any ZIP Cd Office Visit New DESCRIPTION Services Professional services rendered on Apr 16 2013 0074T Online Consultation 10040 Acne surgery 95115 Allergen immunotherapy single INJ 85018 Blood count hemoglobin Hgb 17003 Destroy Lesions 2 14 osis 7244 Back pain w radiation NOS AQ DO A Exhibit 06 281 Name Service Date Smith John Apr 16 2013 Ad
242. he only editing possible for this block is to either open it in activated state on a new chart or in de activated state To open it activated on new charts keep the checkbox marked To open it de activated uncheck the checkbox and click the OK button Save the changes EEZI EMR NEXT User Manual lt gt 09 03 03 Editing the Past Surgical History Block Back When you click the Edit Template Block Icon of the Past Surgical History Block a small three button window opens as shown in Exhibit 09 138 The buttons include Cut Edit and Delete Cut Edit Delete EET aS NEN TEE es Past Surgical History Bagi Exhibit 09 138 Cut If you wish to change the location of this block on the form template click the cut button The blue boundary around the block will turn red indicating that block is ready to be shifted Now click the yellow Add New Block Icon of the location where you want to relocate the block A small two button window opens with the Paste and Add buttons Click the Paste button The block will relocate to this position Delete If you wish to delete the block altogether click the Delete button The block will remove from the template Section 09 03 01 shows how to restore the block Edit When you click the Edit button the following Edit window opens EMR User Manual lt gt Past Surgical History The
243. heckbox marked To open it de activated uncheck the checkbox and click the OK button Save the changes WOI I EMR NEXT User Manual lt gt 09 03 05 Editing the Health Maintenance Block Back When you click the Edit Template Block Icon of the Health Maintenance Block a small three button window opens as shown in Exhibit 09 142 The buttons include Cut Edit and Delete Health Maintenance Influenza Vaccine Date Mote Next x Dose Lot MEFR k Exhibit 09 142 Cut If you wish to change the location of this block on the form template click the cut button The blue boundary around the block will turn red indicating that block is ready to be shifted Now click the yellow Add New Block Icon of the location where you want to relocate the block A small two button window opens with the Paste and Add buttons Click the Paste button The block will relocate to this position Delete The Delete button is in white color indicating that the block cannot be deleted altogether from the template Edit When you click the Edit button the following Edit window opens EMR User Manual lt gt Health Maintenance Item Name Description CVX Code if any Influenza Vaccine 15 Pneumococcal Vaccine 33 Colorectal Screening Prostate Screening Screening Mammogram screening Pap Smear k v Initially display i
244. hown in Exhibit 09 160 All the fifteen blocks in the lower portion of the Template are encircled by blue dotted lines These lines indicate that the blocks are editable A blue circular icon is attached to the upper left corner of each of the encircled blocks It is the Edit Template Block Icon on clicking which the Edit Window of the respective block opens The edit functionality of each block will be discussed separately Before and after each block is a yellow circular icon This is the Add New Block Icon It allows you to add a block in the position of the icon By this mechanism you can add blocks virtually anywhere in the template There is no space limitation as the template stretches according to requirement Before proceeding further two important points to be remembered 3 Changes made to the template must be saved Unsaved changes will be lost Whenever you make a change in the template a red alert will appear at the top left corner of the screen reminding you to save the changes Save the changes by clicking the button at the bottom right corner of the screen Exhibit 09 161 shows both the alert and the Save button 4 Changes made to the template will be effective only on charts created after the changes Previous charts will remain unchanged EI EMR NEXT User Manual lt gt Photograph Attach Click To First Cardiology Clinic Chart ID 00001 Physical Examination C Constitu
245. i Plan Expiry i n aaa 1 1 1 1 1 alae SEINE I AA EN a eae ar ert TPT ID No Group No I Contact Information i Copay Auth No 1 ss H Address Remarks 1 I City ZIP Code Relation Home Ph 1 in 1 1 Country United States State AL I rr 1 Home Ph Cell Ph DOB Gender a ARI i IC T I ili iX S ii iii iii Ie ea P Emergency e Insurance 2 ee eg a en D RU T et ITI lic eh ee Carrier 1 Work Information i 2 Status City ZIP Code x Employer Work Ph Country United States State AL cec o DP II DI UPS Facsimile AXE RS a E LET Expiry Directives i ID No Group No 1 Contact Copay Auth No 1 Advance Info Release Remarks 1 i E S ae pay eae ee ee ene eee a Relation Home Ph General Information i Name i m DOB Gender Guarantor Relation Home Ph Name eiie DOB Gender Remarks Exhibit 09 094 The General Form Template shows seven blocks encircled by dotted blue lines These encircled blocks are editable blocks on the template Blue icons which are attached to the upper left corners of the blocks are Edit Template Block Icons The blocks can be edited by clicking the
246. ially appear in opened state on charts keep the checkbox checked If you want it to appear initially as de activated uncheck the checkbox Click Ok The Add window will close and the block will be created on the template Save the changes Now when you open a new chart the block will appear on the Form as shown in Exhibit 09 135 for simplicity and uniformity we have opened the new block as the first block on the chart It is named Ninth Block All the checkboxes are appearing on the form with their initial values being Unchecked WEZ EMR NEXT User Manual Add X Minth Block First Checkbox Description Second Checkbox Description Third Checkbox Description Fourth Checkbox Description w Initially display in Opened state Exhibit 09 134 First Cardiology Clinic Photograph Chart ID 00034 New 9 Click To Attach Ninth Block Family History L First Checkbox Description Diabetes L Second Checkbox Description Stroke L Third Checkbox Description Hypertension Fourth Checkbox Description Heart Disease Cancer Asthma Hay Fever Arthritis Past Medical History Osteoporosis Anemia Migraine Alzheimers Past Surgical History Epilepsy Glaucoma Exhibit 09 135 EMR User Manual lt 4 gt lt gt 09 03 02 Editing the Past Medical History Block Back When you click the Edit Template Block Icon of the Past Medical History Bloc
247. identified traits appear in blacked suffixed with a negative sign 18 The Master Medication List 19 The Master Problem List 20 Date and time stamp when the face sheet was printed EE EMR NEXT User Manual lt gt 06 03 16 02 12 Report 12 Face Label Back Exhibit 06 285 shows the Face Label in the Print Fax Encounter Related Documents window Apr 19 2013 SaN Smith John Gender Male Feb 25 1943 Phone 123 456 789 123 ABC Drive Any City Any State Any ZIP Cd Phone ABC Insurance Co Group No Group Na Exhibit 06 285 Face Labels are small sticker that may be printed for miscellaneous purposes Face Labels do not save on the system and may be generated afresh as and when required Face Labels include the following information of the patient in order Date on which the label is printed Patient s Social Security Number Name Gender Date of Birth Phone Number Address Guarantor s Name Guarantor s Phone Number Insurance Company s Name Insurance Policy No amp Group No 2 Insurance Company s Name Insurance Policy No amp Group No EFI EMR NEXT User Manual lt gt 06 03 16 02 13 Reports 13 20 Custom Reports Back The system allows you to draft up to eight Custom Reports suiting the requirements of your practice Section 09 01 02 04 of the Manual shows how to design and name templates for Custom Reports Once designed amp name
248. in by you in the database Exhibit 06 054 as shown in section 09 01 03 01 Otherwise type in the plan particulars manually ENT EMR NEXT User Manual 10 Expiry date of the Patient s Policy This is selectable from dropdown list Exhibit 06 055 11 Patient s specific Policy No 12 Group Number if any 13 The amount or percentage to be paid by the patient as specified in the plan 14 Authorization Code if any sought for the encounter 15 For any remarks pertaining to insurance plan or insurance company The field is restricted to 80 characters After these fields there is a sub block to be filled if the patient does not have his her own insurance policy and is using someone else s policy like father s mother s etc The sub block has following fields 16 The relationship of the insured with the patient The field is selectable from the dropdown list Exhibit 06 056 17 The Principal Insured s Home Phone Field is restricted to numerical values only If your clinic is located in USA or Canada the phone number will auto format according to US Canadian specifications 18 Write the Last Name First Name and Middle Name Initial of the Principal Insured here 19 Date of Birth of the principal insured DOB is selectable from dropdown list Exhibit 06 057 20 The Principal Insured s Gender selectable from dropdown list Options include Male Female Transgender Exhibit 06 058 If you click the Bloc
249. inal pain NOS 493 90 Asthma NOS 724 4 Back pain w radiation NOS 786 50 Chest pain NOS Signed 5 Exhibit 06 124 Onset Status Inactive Onset Status Inactive Onset Status Improving Onset Status Active Onset Status Controlled Onset Status Active 1 Your Clinic s Name Address Phone amp Fax Number 2 Name of report along with patient s name and date of birth 3 List of problems from the Master Problem List along with the DD codes the onset dates and the status 4 Space for your signature 5 Date amp Time Stamp of when the list was printed WEB EMR NEXT User Manual lt gt lt gt 06 02 09 03 Medication List Pack Exhibit 06 125 shows the Medication List First Cardiology Clinic 1001 Parkway Drive Chester AL 23866 Tel 234 598 5589 Fax 234 567 8902 e Medication List for Smith John Feb 25 1943 9 Abilify 20 mg TAB Status Active Benadryl Cold 500 25 30 mg TAB Status Active Benadryl Childrens Allergy Fastmelt TAB disintegrating Status Active Carmol 10 10 LOT Status Active Chromagen FA TAB Status Active signed 7 Exhibit 06 125 1 Your Clinic s Name Address Phone amp Fax Number 2 Name of the Report along with patient name and Date of Birth 3 List of medicines from the Master Medication List along with status 4 Space for your signature 5 Date amp Time Stamp of when the list was generated
250. ing to the specific needs of the specialty This guide provides step by step instructions for working with charts and a host of other options mentioned above found within the EMR NEXT application ow EMR NEXT User Manual 4o gt lt gt 02 Definitions amp terminologies used the manual Back e Combo box The input field in which you can either write freely or select from its dropdown list Section 3 item 2 e Block Window Icon The icon which appears on the top right corner of any to the block in which it appears e Field Window Icon The icon that appears at the end of any field within a block The icon is also a light grey dotted square of this shape This icon is specific to the field at the end of which it appears e Field check box The square checkbox that appears at the beginning of any field Clicking a blank field check box checks it Clicking a checked field check box un checks it Depending on the nature of the field checking the field checkbox expands the field to show detailed elements within e Block Title icon this is the icon at the left of the title of the block in this shape Clicking this bullet de activates the block Re clicking the bullet re activates the block in refreshed state e Add item icon This is a triangular icon lt at the bottom of the block clicking which adds a blank item to the block e Delete item icon This is a cross s
251. input only Auto formatting applies according to US standards if your practice is based in USA If you click the Block Title Icon on the block an alert will be raised saying Closing this block would also reset its fields to their default values Are you sure you want to close it If you click the No button on the alert the action will abort But if you click the Yes button on the alert all entries made in this block will clear and the block will be de activated To reactivate the block click the Block Title Icon again status En Employer Employed In Employed Directiv Retired Exhibit 06 046 ENT EMR NEXT User Manual lt gt 06 01 05 Directives Block Back Work Directives Block on the General Information Form is identified at Item 11 of Exhibit 06 07 The Directives Block concerns patient s instructions regarding communication with family release of information to family and third party and advance instructions for procedures prohibited in case of emergencies Directives Block looks like this Directives Contact Gn I Advance Info Release QI Eu Exhibit 06 047 1 The Contact field has a dropdown selection of restrictions with regards to communicating with the patient at home Exhibit 06 048 Only one option can be selected from the dropdown but if multiple restrictions apply the remaining may be added manually Manual entry is permitted in this field 2 Adva
252. ion shows the description None of these codes will appear in your list of favorites unless you make them favorite 2 This is the 3 10 character quick search for the description you are looking for Enter the search value and enter the right arrow icon next to it The cursor will jump to the first entry starting with the search value 3 Click this arrow to move the Procedure Code to your list of favorites EMR User Manual lt gt 4 f the Description of the Procedure you are looking for is not included in the master list you can write it yourself in this field 5 Write the Procedure Code in this field 6 Press this right arrow to include it in your list of favorites The Procedure Code and Description you have added from this field will not be added in the Master List They will only be added to your favorites 7 This is the list of your favorites that you have prepared either by selection from the Master List or by writing the description and codes of the Procedures yourself or as a combination of both 8 If you want to add a note to the Procedure Click the corresponding pencil icon The window shown in Exhibit 09 057 will open Write your note and click the ok button When the changes are finally saved by clicking item 11 on Exhibit 09 056 the note will always appear in the field for Notes Item No 4 in Exhibit 06 210 in the Procedures amp Services Block when this procedure is selected
253. ired after test results are received Add new addendum up to 500 characters cannot be deleted once added O Ada now Exhibit 06 264 1 Your name suffix and the date and time the addendum was added is shown as the title of the addendum 2 The actual text of the addendum 3 Add anew addendum of up 500 characters here 4 When writing is complete click this button to add the addendum Be careful Once added the addendum cannot be deleted EET EMR NEXT User Manual lt gt 06 03 16 02 The second button the Utility Buttons Block Back The second button on the utility buttons block item 2 exhibit 06 253 is for printing reports When clicked Print Fax Encounter Related Documents window opens Print Fax Encounter Related Documents Smith John e Prescription B Laboratory Order Radiology Order O General Order Referral Letter O Consultation Note Encounter Note Visit Superbill Patient Invoice Excuse Letter Face Sheet O Face Label Custom Report 1 Custom Report 2 Exhibit 06 265 Print Fax Encounter Related Documents Smith John _ Prescription Prescription First Cardiology Clinic Pri i J Print Combined eran een RN SUN 1001 Parkway Drive Chester AL 23866 4 508_5 234 7 2 Laboratory Order Tel 234 598 5589 Fax 234 567 8902 O
254. is 298 0 Depressive psychosis 111 9 Dermatomycosis NOS No Known Problems Exhibit 06 104 There are problems already listed in this block You must first delete them manually before the changing to Mo Known Problems status Exhibit 06 105 Are you sure you want to change the status of Master Problem List block Exhibit 06 106 EN EMR NEXT User Manual lt gt Master Problem List T No Known Problems Exhibit 06 107 If you do not need the Master Problem List Block click the square icon before the block title block icon to clear and de activate the block Click it again to re activate it Click the block icon twice to refresh the block ENT EMR NEXT User Manual lt gt 06 02 08 Master Medication List Block Back Master Medication List SIE Status Exhibit 06 108 Master Medication List s placement on the History Form is identified as item 8 on Exhibit 06 074 This is the history of all medication prescribed to the patient For a new patient you may fill in the previously prescribed medication in this block manually but for all medications prescribed by you in encounters the list will update automatically from the respective encounter forms For each medicine the set of entries includes the name of the medicine Rx Dispensation Instructions Dosage Sig and Status You may either write each medicine manually by adding blank sets of entries by c
255. is initially a free type field But you may convert it to a selectable field by clicking at the field title The selectable field is broken into four subfields for Dosage Route Frequency and Duration Exhibits 06 112 06 113 06 114 amp 06 115 Status can either be Active Inactive Completed Discontinued Erroneous amp Not covered Exhibit 06 111 If a medicine has been prescribed by error or entered in the system by error you may either change the status to Erroneous or you may delete the medicine by clicking the cross x icon at the right of the medicine Master Medication Rx Exhibit 06 112 Exhibit 06 113 Exhibit 06 114 x 9 days x 10 days Master Medication List x 12 days Rx x 1 week Exhibit 06 115 ENT EMR NEXT User Manual lt gt Manually inserted entries may be edited but if the medicine has been selected from the list favorites the name is not editable Entries in the Master Medication List may be deleted by pressing the cross x at the end of the list This option is recommended to be used only if an incorrect entry has been made For discontinued medicines the Status should be changed as applicable rather than deleting the medicine from the list If a discontinued medicine is re introduced ina subsequent encounter the status will change appropriately If your list of favorite Medicines very long and you cannot locate the medicine in the list readil
256. iscussed Reviewed tests Exhibit 09 220 Cut If you wish to change the location of this block on the form template click the cut button The blue boundary around the block will turn red indicating that block is ready to be shifted Now click the yellow Add New Block Icon of the location where you want to relocate the block A small two button window opens with the Paste and Add buttons Click the Paste button The block will relocate to this position Delete If you wish to delete the block altogether click the Delete button The block will remove from the template Section 09 04 01 shows how to restore the block EMR NEXT User Manual lt gt 09 04 15 Editing the Evaluation amp Management Code Block Back When you click the Edit Template Block Icon of the Evaluation amp Management Code Block a small two button window opens as shown in Exhibit 09 221 The buttons include Cut and Delete Cut _____ es es es eee UIN a eae a iM Code Code Basis i Join Work School BPO Exhibit 09 221 Cut If you wish to change the location of this block on the form template click the cut button The blue boundary around the block will turn red indicating that block is ready to be shifted Now click the yellow Add New Block Icon of the location where you want to relocate the block A small two button window opens with th
257. ist Type the key word and the system will take you to all entries with the key word Exhibit 06 104 For fast location from a long list of problems in the favorites press the alphabet with which the problem starts and the system will take you to the first entry starting with the alphabet Exhibit 06 104 If there are no known problems the status of the block must be changed to No Known Problems To do so open the Master Problem List Window There is a No known Problems button at the bottom of the window Exhibit 06 104 Click it to change the status If any problems have been selected in the block the status will not change An alert will rise asking for the selected problems to be deleted for changing the status to No Known Problems Exhibit 06 105 Delete the problems and then click the button in the window again Another alert will rise confirming that the status is being changed Exhibit 06 106 If you click Yes on the alert the status will change and now the block will look like that in Exhibit 06 107 WE EMR NEXT User Manual lt gt Your ailb icidie i igihiiiljik li m Favorites niojpiqiris tiujviw x viz 789 00 Abdominal pain NOS 789 06 Abdominal pain epigastric 794 30 Abnormal Stress Test 790 0 Abnormal red blood cell 706 1 Acne 786 50 Chest pain NOS 296 25 Depression major single episode partial remission 296 24 Depression major single episode severe w psychos
258. ists Field Windows The advantage of this block over the previous block is that in the previous block only one value can be selected for each field on the History Form In this block multiple values can be selected for each field Write the name of the block in the top field EMR User Manual lt gt Add as many fields as required by clicking the black down arrow under the first field the black dropdown arrow on the left If you have added extra fields delete them by clicking the trash can icon at the left of the respective field For each field add as many rows as required for values in the pick list for the field by pressing the black down arrow under the first two rows of the respective field If you have added extra rows they can be deleted by clicking the trash can icon at the right of the respective row Write the name of each of the field Write the values of the pick lists of each field in the rows you have made available for each field For example we created two fields and gave them the names First Field and Second Field as shown in Exhibit 09 124 For each field we created three row values The values for the first field are First Option Second Option and Third Option For the second field the values are Fourth Option Fifth Option and Sixth Option If you want this block to initially appear in opened state on charts keep the checkbox checked If you want it to appear initially as de act
259. it is not activated yet It activates whenever a change is made in the window If you try to close the window without saving the changes the alert shown in Exhibit 09 072 will raise 8 The Reset button clears all unsaved changes In Exhibit 09 071 the button is in white color because it is not activated yet It activates whenever a change is made in the window You need to click SAVE button below to keep the changes you have made to this favorite list Do you want to close this window without saving Exhibit 09 072 5m EMR NEXT User Manual lt gt 09 01 04 07 General Orders Back General Orders are selected in the Orders Requisitions Block on the Encounter Form Section 06 03 10 These are the General Items like slings gloves etc that you prescribe for your patients Based on the General Orders the General Order Report shown in Section 06 03 16 02 04 is prepared When you click the Block Icon on the Orders Requisitions Block the Orders Requisitions Window shown in Exhibit 06 221 opens The third part of this window holds the list of General Orders The list is managed from here in the Customization Section When you click the Open button on the field identified as item 4g on Exhibit 09 002 the Add Delete General Orders Window opens Add Delete General Orders x Master List Your Favorites Gel socks Crutches Heat therapy wrap Ice Box Heated thermal balaclava Oxygen Mask
260. ital Initial Hospital Subsequent Hospital Discharge Emergency Services Critical Care Services Surgical Services Nursing Initial Nursing subsequent Nursing Discharge Nursing Annual Exhibit 09 075 c gt Office Visit New Office Visit Est Preventive Mew Preventive Est Office Consultation Confirmatory Consult Inpatient Consult Initial Evaluation Hospital Initial Hospital Subsequent Hospital Discharge Emergency Services Critical Care Services Surgical Services Nursing Initial Nursing Subsequent Nursing Discharge Nursing Annual 10 Y S S S S s s h EP EP Eb EF EP EP EP Eb Eb 1 The left side of the window is for the Master List of Visit Types The list has more than 35 entries None of these codes will appear in your list of favorites unless you make them favorite 320 EMR NEXT User Manual lt gt lt gt gt 2 Click this right arrow to move the Visit your list of favorites 3 This is the list of your favorites which you have prepared by selection from the Master List 4 Specify the Point of Service Code for the Service Type here Click the pencil icon to open the window shown in Exhibit 09 076 Specify the code and click the OK button The code will be picked up in the Patient Invoice and Super Bill
261. ity BI x Severity E 1 x Duration x Onset Timing B x Context ooo BE x Modifying Factors UBI x Signs Symptoms BE Exhibit 09 196 Cut If you wish to change the location of this block on the form template click the cut button The blue boundary around the block will turn red indicating that block is ready to be shifted Now click the yellow Add New Block Icon of the location where you want to relocate the block A small two button window opens with the Paste and Add buttons Click the Paste button The block will relocate to this position Delete If you wish to delete the block altogether click the Delete button The block will remove from the template Section 09 04 01 shows how to restore the block Edit EP EMR NEXT User Manual When you click the Edit button the following Edit window opens History of Present Illness Location All over Ankle left Ankle right Arm left Arm right Back Back lower Back upper Chest Chest right side Chest left side Elbow left Elbow right v Initially display in Opened state Exhibit 09 197 There is two tiered editing on this window In the first tier you can either add or remove elements from the list In the second tier you can add or remove values for any of the element First Tier Editing To remove any of the eight elements in the History of Present Illness Block uncheck the checkbox to the left of the element The eleme
262. ity Detected Phrases for Abnormal Findings v Initially display in Opened state Exhibit 09 208 EE EMR NEXT User Manual lt gt W Mood Affect No mood disorders calm affect Phrases for Abnormal Findings Agitation present Anhedonia present Anxiety present Anxiousness present Depression present Suicidal ideation noted No Abnormality Detected Phrases for Abnormal Findings Initially display in Opened state Exhibit 09 209 EET EMR NEXT User Manual lt gt 09 04 09 Editing the Procedures Services Block Back When you click the Edit Template Block Icon of the Procedures Services Block a small three button window opens as shown in Exhibit 09 210 The buttons include Cut Edit and Delete Cut Edit Delete ee NRI MUR RUE l E z Procedures Services HEI 1 Code Desc x Exhibit 09 210 Cut If you wish to change the location of this block on the form template click the cut button The blue boundary around the block will turn red indicating that block is ready to be shifted Now click the yellow Add New Block Icon of the location where you want to relocate the block A small two button window opens with the Paste and Add buttons Click the Paste button The block will relocate to this position Delete If you wish to delete the block altogether click the Delete button The block will remove from the template Secti
263. ivated uncheck the checkbox Click Ok The Add window will close and the block will be created on the template Save the changes Now when you open a new chart the block will appear on the Form as shown in Exhibit 09 125 for simplicity and uniformity we have opened the new block as the first block on the chart It is named Sixth Block In Exhibit 09 122 the pick list on the First Field is open Please note that on the form the field values will arrange alphabetically Please note that two additional full length fields also appear at the end of the block for any free type notes The lines will extend according to the length of the text EMR User Manual lt dop gt Sixth Block First Field First Option Second Option Third Option Second Field Fourth Option Fifth Option Sixth Option mumumununauanuananananananananananaanununaunanaunaanaaunannanaunanuanmana wuumun u v Initially display in Opened state Exhibit 09 124 EE EMR NEXT User Manual lt gt gt First Cardiology Clinic Photograph Click T Chart ID 00025 New 6 n Sixth Block Family History First Field gt gt Diabetes Second Field __ UB Stroke Hypertension Heart Disease Cancer Past Surgical History HE Asthma Hay Fever Arthritis Osteoporosis ipi Past Medical History 2 enema Migraine Alzheimers Epilepsy Known Allergies us Glaucoma Exhibit 09 125
264. k V Neck Exam D lt gt upple full ROM no JVD noted No thyromegaly or tenderness V Thyroid Exam NMothyromegaly or tenderness Respiratory Neck V Neck Exam Neck x Clear Field Undo Last Thyroid Exam Asymmetrical Respirato a a p ry Brudzinski sign present y Cardiovascular Exhibit 06 009 Asymmetrical thyromegaly or tenderness 7 EMR User Manual lt gt E There may be down arrow icons at the bottom of certain blocks like the one encircled in Exhibit 06 010 When you click these the full set of fields in the block is duplicated for additional entries Any number of sets may be added like this Procedures Services 1 Code 20526 Desc Injection therapeutic carpal tunnel x Note 2 Code 85018 Desc Blood count hemoglobin Hgh x Note 3 Code 10040 Desc Acne surgery x Note 4 Code Desc x Note Exhibit 06 010 F Asmall cross appearing at the end a field or set of fields like the one encircled in Exhibit 06 011 is for deleting the field You may delete all but the last entry in the block The last entry will get cleared on the click but will not be deleted xw EMR NEXT User Manual lt gt Procedures Services HHH 1 Code 20526 Desc Injection therapeutic carpal tunnel x Note 2 Code 85018 Desc Blood count hemoglobin Hgb x Note 3 Code 10040 Desc Acne su
265. k a small three button window opens as shown in Exhibit 09 136 The buttons include Cut Edit and Delete EN I M V LLL L z Past Medical History Exhibit 09 136 Cut If you wish to change the location of this block on the form template click the cut button The blue boundary around the block will turn red indicating that block is ready to be shifted Now click the yellow Add New Block Icon of the location where you want to relocate the block A small two button window opens with the Paste and Add buttons Click the Paste button The block will relocate to this position Delete If you wish to delete the block altogether click the Delete button The block will remove from the template Section 09 03 01 shows how to restore the block Edit When you click the Edit button the following Edit window opens 5x EMR NEXT User Manual lt gt Past Medical History There are currently 56 entries in your Favorites List for this block You can always manage your favorite lists by visiting Lists Menus section under Primary Configuration tab above If you would like to add or delete items right now just click HERE and it will open the PMH edit window for you on this very screen v Initially display in Opened state Exhibit 09 137 The window shows you how many entries you have in the Pick List for this block and how you could manage the list T
266. k on the actual form if you want to add multiple lines for any field they can be added and deleted In the previous form each field had only one line so limited writing space Write the name of the block in the white field on the top EMR NEXT User Manual lt gt as many rows as required by pressing the black down arrow under the first two fields If you have added extra fields they can be deleted by clicking the trash can icon at the end of the respective field Now write the names of the fields in the white space at the beginning of each field For example we created five fields and gave them the names First Field Second Field Third Field Fourth Field and Fifth Field as shown in Exhibit 09 170 If you want this block to initially appear in opened state on charts keep the checkbox checked If you want it to appear initially as de activated uncheck the checkbox If this block is billable i e you recover charges for the entry in this block then check the Billable Procedure checkbox The next three fields will activate Enter the billing code description and the amount to be filled in these fields Click Ok The Add window will close and the block will be created on the template Save the changes Now when you open a new chart the block will appear on the Form as shown in Exhibit 09 171 for simplicity and uniformity we have opened the new block as the first block on the chart It is name
267. k Back Placement of the Utility Block on the General Information Form is identified at Item 7 of Exhibit 06 07 The Utility Block looks like this Yellow Sticky Note 1 Telephone Notes o u x General Notes Scans Documents Exhibit 06 014 It has four utilities Yellow Sticky Notes Telephone Notes General Notes and a document viewer 1 Yellow Sticky Note Click on the icon to open the notepad Exhibit 06 015 Write your notes and press Done to save it Close by clicking the X icon on the top right The icon turns yellow to indicate that a note exists Exhibit 06 016 Open the note again add to it delete from it and press Done to save If you want to remove everything press the clear button on the bottom left and click Done EJ EMR NEXT User Manual lt gt Exhibit 06 015 Yellow Sticky Note e Telephone Notes General Notes Scans Documents Exhibit 06 016 2 Phone Notes Click the icon to open the Phone Notes window At the outset it will be blank like that shown in Exhibit 06 017 To add a note click the Add Note button at the bottom right on the window The Add Phone Note window opens as in Exhibit 06 018 The window shows the name of the patient and has two fields In the first select the nature of caller from the drop down list Exhibit 06 019 The options are Pharmacy Patient Spouse Patient Guardian Other The second field is for the note itself Wh
268. k Title Icon on the block an alert will be raised saying Closing this block would also reset its fields to their default values Are you sure you want to close it If you click the No button on the alert the action will abort But if you click the Yes button on the alert all entries made in this block will clear and the block will be de activated To reactivate the block click the Block Title Icon again WEB EMR NEXT User Manual lt gt lt gt gt ABC Insurance Address City ABC Insurance Co Country My First Insurance Co Exhibit 06 053 Plan My First Plan ID No My First Plan Copay My Second Plan Exhibit 06 054 Relation Name DOB Self Spouse Parent Exhibit 06 056 Gender Male Female Transgender Exhibit06 058 Expiry Group No Auth No Jan Feb Exhibit 06 055 DOB Jan Insuran Feb Exhibit 06 057 EMR NEXT User Manual 06 01 08 Secondary Insurance Block Back The Secondary Insurance Block on the General Information Form is identified at Item 14 of Exhibit 06 07 Some practitioners operate a Cash Only practice If yours is such a practice you will not need this block and you may remove it altogether from the form Section 09 01 02 06 shows how to remove the Insurance Blocks from the form The Secondary Insurance Block looks like this Insurance 2 Carrier ABC Insurance Co
269. l apply across the forms But that should not bother you The space increase is quite limited but it improves touch functionality Select appropriate radio button to increase or decrease spacing Please note that the EMR Next inherently detects whether or not your device is touch enabled and for touch enabled devices it automatically increases the spacing But once you adjust the spacing through this window the automated space adjustment feature will lapse and thereafter space adjustment will only be possible from this window 2 Some blocks in Patient Charts have toggle buttons for positive and negative findings By default these buttons are oval shaped Positive findings are encircled in red ovals while negative findings are encircled in light grey ovals If you wish to change the shape of these buttons to square like those shown on the right side in Exhibit 09 006 click the EMR NEXT User Manual lt gt lt gt radio button the right To revert ovals click the radio button on the left Changes in the settings will become effective only if the Update button on the window is clicked after making the changes EMR User Manual 09 01 02 02 Prescriptions amp Orders Back Edit Prescriptions Orders Settings xX Initial Print Mode Meds Combined all items on one page 7 Separate each item on a new page Orders Combined all items one page O Separa
270. l be covered in the same time EMR NEXT User Manual lt gt gt The third appointment is for 5 pm which is after the normal working hours and so it is also being shown below the normal schedule You can also book an appointment for an off day For example Exhibit 08 025 shows the schedule for a Sunday which is off for the clinic All normal appointment slots are grayed off Click the Add Slot button towards the bottom A slot will appear Define the appointment start time which in this case is 11 am and book the appointment like a normal appointment Such irregular appointments appear as a numeric indication in the month planner For example in Exhibit 08 026 the three irregular appointments booked for 11 May are appearing as a numeric value of 3 and the one appointment booked for Sunday May 12 is appearing as a numeric value of 1 item d on the Exhibit indicating the number of irregular appointments for the respective days Sometimes an appointment booked normally will also become irregular later on This can happen in two situations 1 the time for which the appointment was booked does not remain a part of the normal working time of the clinic any more and 2 the standard appointment slot duration changes after booking the appointment and the appointment is no more fitting in the slot of group of slots completely The maximum appointment duration on the system is for 90 minutes If you want to bo
271. lars NPI EIN PIN PVN SSN TIN Exhibit 09 048 EMR NEXT User Manual DEA DPS NSC UPIN OSCAR BCID BSID Champus Medicare Medicaid Medi Cal License Group Other lt gt lt gt 09 01 03 06 Hospitals Pack Patients will frequently be referred to you by Hospitals Clinics and you will also be referring them to Hospitals Clinics The names of the referring Hospitals Clinics or the Hospitals Clinics to which you refer the patients need to be recorded in Encounter Forms The names of referring Hospitals Clinics are recorded in the Encounter Statistics Block discussed in Section 06 03 01 in the field identified as item 5 in Exhibit 06 135 The names of the Hospitals Clinics to whom you refer the patient are recorded in the Referral Block discussed in Section 06 03 15 in the field identified as item 3 on Exhibit 06 249 You may either feed the names and particulars of the Hospitals Clinics in the encounter forms each time patients are referred to you by them or you refer patients to them or you may enter their particulars in the block marked as 3f on Exhibit 09 002 just once and whenever this Hospitals Clinics refers a patient to you or you refer a patient to it simply select the Hospital s Clinic s name from the dropdown list on the corresponding fields in either block in the Encounter Form All pre fed particulars of the Hospital Clinic will be called wherever needed in the
272. late 403 09 04 01 01 Block with Single Free Text Field 405 09 04 01 02 Block with Multiple Free Text Fields 407 09 04 01 03 Block with Multiple Free Text Fields 410 Extensible Rows 09 04 01 04 Block with Single Dropdown 413 L EMR NEXT User Manual 09 04 01 05 Block with Multiple Dropdowns 416 09 04 01 06 Block with Multiple Pick lists 420 09 04 01 07 Block with Large Free Text Area 424 09 04 01 08 Block with Multiple Buttons 426 09 04 01 09 Block with Multiple Checkboxes 429 09 04 02 Editing the Encounter Statistics Block 432 09 04 03 Editing the Fee Recovery Block 434 09 04 04 Editing the Chief Complaint Encounter Reason Block 435 09 04 05 Editing the History of Present Illness Block 437 09 04 06 Editing the Review of Systems Block 440 09 04 07 Editing the Vital Signs Block 444 09 04 08 Editing the Physical Examination Block 446 09 04 09 Editing the Procedures Services Block 451 09 04 10 Editing the Assessments Diagnosis Block 453 09 04 11 Editing the Orders Requisitions Block 455 09 04 12 Editing the Medications Block 457 09 04 13 Editing the Plan Notes Block 459 09 04 14 Editing the Encounter Checklist Block 461 09 04 15 Editing the Evaluation amp Management Code Block 462 09 04 16 Editing the Referral Block 463 10 Screen Sensitive Help 464 11 Creating and Restoring Backups 468 12 Navigation Guide 472 EMR NEXT User Manu
273. ld identified as item 4d on Exhibit 09 002 the Add Delete Medications Window opens Add Delete Medications Master List D Abilify 1 mg mL SOL Abilify 10 mg TAB Abilify 15 mg TAB e Search Master List Your Favorites 62 SIG Abilify 10 mg TAB Abilify 20 mg TAB Benadry Childrens Allergy Fastmelt TAB disintegrating Benadryl Cold 500 25 30 mg TAB Cardura 2 mg TAB Abilify 20 mg TAB Abilify 30 mg TAB Abilify 5 mg TAB Carmol 10 10 LOT Accolate 10 mg TAB Carmol 1096 shampoo Accolate 20 mg TAB Chromagen FA CAP AccuHist DM Pediatric DRP Chromagen FA TAB AccuHist DM Pediatric SYR Cyclocort 0 196 LOT AccuHist Drops 1 12 5 mg mL LIQ Cyclogyl 0 596 SOL AccuHist LA TAB ER Cyclogyl 196 SOL AccuHist PDX Drops 1 3 12 5 mg mL LIQ Diuril 250 mg 5 mL SUS 9 AccuHist PDX Syrup 2 5 50 5 mg 5 mL LIQ Eligard 7 5 mg kit Erythromycin Stearate stearate 250 mg TAB Add Your Own Medication Fluorabon 1 mg TAB chewable Inderal LA 60 mg CAP ER cde mg Ta b Eb Eb Eb Ep Eb Eb Eb Eb Eb Eb Ep ED Exhibit 09 065 1 The left side of the window is for the Master List of Medicines The list has more than 4500 entries None of these medicines will appear in your list of favorites unless you make them favorite 2 This is the 3 10 character quick search for the description you are looking for Enter the search value and enter the right ar
274. lepsy Known Allergies Ila Exhibit 09 132 EMR NEXT User Manual lt gt gt 09 03 01 09 Block with Multiple Checkboxes Back When you click the ninth radio button in the User Definable Blocks section of the Add Blocks window Exhibit 09 106 and press the Continue Button the following Add window opens v Initially display in Opened state Exhibit 09 133 This block is quite similar to the previous one with the exception that instead of toggle buttons the values will be in shape of checkboxes The block will have a single field with multiple checkboxes Write the name of the block in the white field at the top this will also be the name of the field EMR NEXT User Manual lt gt as many checkboxes as required by clicking the black down arrow under the second row If you create more rows than required you can delete them by clicking the trash can icon at the end of the respective row Write the descriptions of the checkboxes in the respective rows created The default value of the checkboxes is unchecked If you want the default value to appear as checked check the checkboxes We added four rows for four checkboxes naming them the First Checkbox Description Second Checkbox Description Third Checkbox Description and Fourth Checkbox Description and kept them initially unchecked as shown in Exhibit 09 134 If you want this block to init
275. licking the down arrow at the bottom of the last set of entries or you may select the medicines from your list of favorites by clicking on the block window icon Exhibit 06 109 Section 09 01 04 04 shows how to make your list of favorite medicines from the over 4500 preloaded medicines in the database and how to add more medicines to the database Master Medication List Yom 4 1 1 1 1 Rx Abilify 20 mg TAB GEQ x Favorites rip Pp ee ri 2 SS Sig Status Abilify 10 mg TAB x Abilify 20 mg TAB Benadryl Childrens Allergy Fastmelt TAB disintegrating Exhibit 06 109 When you select the medicine from your favorites the name and the signature will be called from the selection i e if a signature phrase has been added to the medicine in the favorites as explained in Section 09 01 04 04 while the dispensation instructions and the status will have to be individually specified If the signature phrase is not applicable in any specific instance it may be edited Selectable values for dispensation instructions are GEQ amp DAW Exhibit 06 110 while selectable values for Status include Active Inactive Completed Discontinued Erroneous amp Not Covered Exhibit 06 111 EMR NEXT User Manual lt gt Completed Discontinued Status Erroneous Not Covered Status Exhibit 06 110 Exhibit 06 111 If you are entering data manually the signature field
276. llness here Either specify manually or select from the Context Window which pops when the field window icon is clicked Exhibit 06 151 shows the Context Window Selection from window may be mixed with manual noting In case multiple illnesses are selected in item 1 use of manual comments to specify the context of each illness separately is recommended 8 Specify the Modifying Factors of the illness here Either specify manually or select from the Modifying Factors Window which pops when the field window icon is clicked Exhibit 06 152 shows the Modifying Factors Window Selection from window may be mixed with manual noting In case multiple illnesses are selected in item 1 use of manual comments to identify the Modifying Factors of specific illnesses is recommended 9 Specify the Signs Symptoms of the illness here Either specify manually or select from the Signs Symptoms Window which pops when the field window icon is clicked Exhibit 06 153 shows the Signs Symptoms Window Selection from window may be mixed with manual noting In case multiple illnesses are selected in item 1 use of manual comments to identify the signs symptoms of specific illnesses is recommended EMR User Manual lt gt The system has built in phrases for the illness qualifiers specified in items no 2 9 above You may add to or subtract from the built in phrases The qualifiers themselves can also be removed Section 09
277. lness Phrases is discussed in Section 09 01 04 10 EE EMR NEXT User Manual 4o k RFR Phrases or Reasons for Referral Phrases Maintenance of list of Reasons for Referral Phrases is discussed in Section 09 01 04 11 l Plan Notes Phrases Maintenance of list of Plan Notes Phrases is discussed in Section 09 01 04 12 m PMH Phrases or Past Medical History Phrases Maintenance of Past Medical History Phrases list is discussed in Section 09 01 04 13 n PSH Phrases or Past Surgical History Phrases Maintenance of Past Surgical History Phrases list is discussed in Section 09 01 04 14 ALG Phrases or Allergies Phrases Maintenance of list of Allergies Phrases is discussed in Section 09 01 04 15 EET EMR NEXT User Manual lt gt 09 01 01 01 Clinic Information Back Edit Clinic ad Your Location 2 9 Clinic Practice Information First Cardiology Clinic 6 Address Line 1 1001 Parkway Drive irseonone 023415955529 Facsimile 234 567 890 Email Address doc cardio com ie Specialization Other m greg indi Remove Select A JPG GIF or BMP image 36 pixel 3 8 inch OR LESS in height and 58 pixel 3 5 inch OR LESS in width Exhibit 09 003 The Edit Clinic Window shown in Exhibit 09 003 opens when you click the Edit button on item 1a in Exhibit 09 002 You may change the particulars of your practice clinic f
278. lock With Large Freetext Area Block With Multiple Buttons Block With Multiple Checkboxes Exhibit 09 162 The Add Blocks Window has two sections The first one says Restore Default Blocks and the second says User Definable Blocks Restore Default Blocks All the fifteen blocks shown in Exhibit 09 160 can be deleted from the template altogether When any of these blocks is deleted then the system retains the format of E EMR NEXT User Manual the deleted block in this section of the window If you want to recreate the deleted block at its original location or any other new location open this window from the yellow icon of the desired location click the radio button of the block you want to restore and press the Continue button on the window to proceed To show you how the mechanism works we deleted the Vital Signs and Chief Complaint Encounter Reason Blocks from the template Now the window looks as shown in Exhibit 09 163 Add Blocks gt Vital Signs Chief Complaint Encounter Reason Block With Single Freetext Field Block With Multiple Freetext Fields Block With Multiple Freetext Fields Extensible Rows Block With Single Dropdown Block With Multiple Dropdowns Block With Multiple Picklists Block With Large Freetext Area Block With Multiple Buttons Block With Multiple Checkboxes Exhibit 09 163 Only Default Blocks can be restored in this manner
279. lumn Item 5 Exhibit 07 001 All flagged items will appear in the display pane Exhibit 07 024 Once you have completed your work on the flagged documents you can remove the flagging by clicking on the flagging button Same button is used for flagging and de flagging An un flagged document is flagged and a flagged document is de flagged with the click of the same button EET EMR NEXT User Manual lt gt B Dashboard 1711 Customize Total charts in database 14 5 flagged documents Find Charts Where FLAG DATE PATIENT NAME CHART DOCUMENT TITLE DOCUMENT TYPE O SSN May 4 2013 6 12 25 AM Smith John 00002 Xray on 4th April 2013 Imported File O MRN March 27 2013 6 12 35 AM Smith Nicola 00005 IMG_3575 Imported File 22 March 26 2013 7 16 05 Smith Tom 00004 Visit Superbill Encounter 1 Visit Superbill March 23 2013 12 17 37 AM Smith Jack 00006 Patient Chart Chart 9 Last Name March 20 2013 6 14 40 AM Doe John 00001 Patient Chart Chart First Name Birth Date Visit Date amp Gender sa Import Export Import Scanned Files Export Superbills gt Exhibit 07 024 Document Viewer x Visit Superbill Encounter 1 Smith Tom First Cardiology Clinic 1001 Parkway Drive Chester AL 23866 Tel 234 598 5589 Fax 234 567 8902 Encounter Date Mar 26 2013 SUPER BILL Chart ID 00004 ID BA 12345678 Patient Details Name Smith Tom 8 e k Work Sta
280. ments Window it will be added in the Ongoing Problems section and not the New Assessments Section If you are not using the New Problems Window for selecting the problems and typing them manually first add a blank set of entry by clicking the add field icon at the bottom of the New Assessments section For deleting incorrect entries use the delete field icon the end of the corresponding set of entries If your list of favorites in the New Problems window is long you can utilize the quick search available on the window Enter a 3 10 character phrase included in the Problem and the system will find all entries with the search phrase Alternatively click the alphabet with which the description of the Problem starts and the cursor will move to the first entry starting with that alphabet All problems added in the New Assessments Section will add up in the Master Problem List in the History form along with all particulars Any subsequent changes made in the Onset Status and Notes field in the original encounter form will be updated in the EMR NEXT User Manual lt gt gt Master Problem List But any changes made these fields the Master Problem List itself will not be updated in the original encounter form If you do not need the Assessment Diagnosis Block click the square icon before the block title block icon to clear and de activate the block Click it again
281. ments icon item 4 Exhibit 06 014 the Document Viewer opens Document Viewer x H Medication H Laboratory 1 1 Radiology 1 Consultation 1 Hospital J Insurance H Billing Directives Handouts Other _ 88 Legacy Exhibit 06 027 At the outset all buttons are de activated other than Import Scanned File button on the top The folders are in the left section and the viewing pane is on the right In the Exhibit the nodes of the Medication Laboratory Billing and EMR NEXT User Manual lt gt gt Others folders show that there are documents therein Expand the node and select the required document to view it in the viewing pane Exhibit 06 028 Document Viewer x Smith John Patient Invoice Encounter 9 9 9 Medication First Cardiology Clinic al Pasa 1001 Parkway Drive Chester AL 23866 H Laboratory Tel 234 598 5589 Fax 234 567 8902 Radiology Consultation Name Service Date _ Hospital Smith John Apr 16 2013 Address Service Type 123 ABC Drive Any City Any State Any ZIP Cd Office Visit New C Insurance HKJ Billing Visit Superbil Visit Superbil Patient Invoice DESCRIPTION AMOUNT 1 J Directives Handouts H Other Legacy Services Professional services rendered on Apr 16 2013 0074T Online Consultation 10040 A
282. n Default is set not to print SSN or MRN on prescriptions and orders 6 Total number of medicines in the prescription is shown towards the end on combined prescriptions If you do not wish the total number of medicines to be shown check this box 7 There is a micro text line under the signature amp ID the words of which are visible only on magnification This text is proof that the document is an original If the document is photocopied the text will be copied as a continuous line and will show as a line on magnification thereby indicating that the document is not an original If you wish this tamper resistant text not to be printed on prescriptions and orders uncheck the checkbox 8 If you use pre printed stationery with your clinic s name and address printed on it you do not need the header which will only duplicate and overlap the pre printed title Check the checkbox to remove the header from the print 9 If you use pre printed stationery for prescriptions and orders then you need EMR Next just to print the name of the medicine or the item on the paper All other particulars will be covered in your pre printed stationery If this is the case check this checkbox But this setting will work only if you have selected the separate printing mode in item 1 above If you have selected the combined printing mode default setting will apply even if this checkbox is checked 10 If you use any e prescription software
283. n Opened state Exhibit 09 143 The window shows the six Health Maintenance elements included in the block If you want to remove any of these elements from the template uncheck the corresponding checkbox The element will be removed from the block on the template and the form If you want to add elements to the list add a row by clicking the black down arrow below the sixth element A new row will be added as shown in Exhibit 09 144 Write the name of the element in the description field If it is a vaccine write the CVX code in the next field A system differentiates between a vaccine and a procedure solely on the basis of the CVX code If CVX code is given it is treated as a vaccine If CVX code is not given it is treated as a procedure The set of fields created for a vaccine are shown in Exhibit 09 142 The set of fields created for a procedure are shown in Exhibit 09 145 To remove a user created row from the block click the trash can icon of the corresponding user created row EMR User Manual lt gt To open the block an activated state new chart keep the Initially display in opened state checkbox checked To open it in de activated state uncheck the checkbox Click the OK button Save the changes Health Maintenance Item Description CVX Code if any Influenza Vaccine 15 Pneumococcal Vaccine 33 Colorectal Screening Prostate Screening Screening Mammosram
284. n is for taking or restoring backups Section 11 EMR NEXT User Manual lt gt lt gt 06 Patient Charts amp Encounter Forms Back How to create or open an existing Patient Chart has been shown in Section 05 item 1 Exhibit 05 001 Every patient chart is spread over three tabular pages The first tab is the General form on which the patients demographic insurance and other miscellaneous information is stored The second tab called History is for documenting the patient s medical history including master problem and medication lists The third tab called Encounters is where the specific encounter details are documented There is always a one copy of General and History forms within a chart whereas the Encounters can be unlimited Each of these three forms is discussed separately further down this manual But there is some functionality common to all the three forms that is discussed below A Each of the three forms is composed of several blocks There is a small black square to the left of the name of the block exhibit 06 001 Clicking this square will disable the block and any data written in the block will be deleted But the system will raise an alert before disabling the block exhibit 06 002 Click Yes to continue disabling click No to abort Next time the chart is opened again this block will appear disabled exhibit 06 003 To re enable it click on the same Square again insu
285. n requested 6 This part shows the list of the Radiology services ordered They are picked from the Orders Requisitions block of the related encounter form 7 This section shows the ICDs noted in the concerned encounter form 8 Space for your signature followed by your name and ID No 9 Date of the encounter form All fields in the darker shade are editable i e data called in from the original chart or encounter form may be edited added or deleted in these sections of the report First Cardiology Clinic 1001 Parkway Drive Chester AL 23866 Tel 234 598 5589 Fax 234 567 8902 REQUISITION My First Radiology Clinic SIL FCD S3 15 HH MRI Ankles both ICDs 7244 Back pain v wi radiation NOS 49390 Asthma NOS Hf d d 786 50 Chest pain NOS cdd EIE EXHIBIT 06 274 EMR NEXT User Manual lt gt 06 03 16 02 04 Report 4 General Order Back Exhibit 06 275 shows the General Order in the Print Fax Encounter Related Documents window First Cardiology Clinic 1001 Parkway Drive Chester AL 23866 Tel 234 298 5589 Fax 234 567 8902 REQUISITION ABC Medical Store This is a request for uo p services for Smith John aa aaa ee ekon kibar ci o Ice Box E pis p EE E E B E E E E B E x E E B E E Thank you Signed Q Apr 16 2013 Davis Richard MBBS NPLBA 234568
286. n which you want to Other fields can remain blank The upper part of the form containing items 1 6 remains common for all three forms and the location remains fixed i e this portion does not scroll up when you scroll the form EMR User Manual lt gt lt gt 1 Chart ID chart number is system generated and will appear whenever new chart is created 2 Titles available on this system include Mr Ms Mrs amp Dr and are selectable from a dropdown list on the field 3 Three separate fields are available for the patient s Last Name First Name and initial of Middle Name The name populates from the name entered by you while creating this chart But it may be edited here 4 Suffixes available on the system include Sr Jr Il Ill amp IV and are selectable from a dropdown list on the field 5 Age is selectable from the dropdown list on the field The list starts from newborn and carries on a monthly basis to 23 months and then from 2 years onwards to 105 years However when you will enter the date of birth down below third field item 8 the age will correct itself according to the date of birth if there is a disparity between the two So it is recommended not to enter the age here and let the system populate it when you enter the date of birth 6 When you click the slot for the picture the system takes you to the operating system for selecting the photogr
287. nananananunananananananananananananaunanannnunnannununanunnunnanannunanaannnananmanananananananananan v Initially display in Opened state Billable Procedure Exhibit 09 180 EMR NEXT User Manual 0 0 0 lt gt gt Chart ID 00001 Doe Sixth Block First Field Second Field Encounter 7 Date May 22 2013 Referred by Attended by Davis Richard MBBS Received Payment type Note for Biller Chief Complaint Encounter Reason Exhibit 09 181 Sixth Block First Field Second Field x Note for Biller Exhibit 09 182 EMR User Manual First Cardiology Clinic John Type BA 12345678 Details C Billing not required Physical Examination Constitutional Eyes ENMT Neck Respiratory l ilgi Cardiovascular C Breasts Gastrointestinal E Genitourinary Female E Genitourinary Male C Lymphatic E Musculoskeletal _ skin E Neurologic ub Clear Field First Option Second Option Third Option Photograph Click To Attach Undo Last lt gt lt gt gt 09 04 01 07 Block with Large Free Text Area Pack When you click the seventh radio button in the User Definable Blocks section of the Add Blocks window Exhibit 09 162 and press the Continue Button the following Add window opens Add X v Initially display in Opened state X Bill
288. nce Directives are prohibitions from the patient s side in case of emergencies Exhibit 06 049 Again only one option can be selected from the dropdown but if multiple prohibitions apply others may be added manually Manual entry is permitted in this field 3 This field records whether or not information may be divulged to third parties in case of need One selection is allowed other information may be added manually Exhibit 06 050 Manual Entry is permitted in this field If you click the Block Title Icon on the block an alert will be raised saying Closing this block would also reset its fields to their default values Are you sure you want to close it If you click the No button on the alert the action will abort But if you click the Yes button on the alert all entries made in this block will clear and the block will be de activated To reactivate the block click the Block Title Icon again sn EMR NEXT User Manual lt gt Contact I Advance Do not call regarding care on the home number um Do not call regarding care on the cell number Exhibit 06 048 Advance E Info Release Appointee will make decisions General Discussed No decision made No artificial life sustaining treatment Exhibit 06 049 Info Release a Yes Yes signature on file Yes signature on scan Do not release Exhibit 06 050 S EMR NEXT User Manual lt gt gt 06 01 06 General Info
289. nd if the patient is not the principal insured then also particulars of the Principal Insured 10 This section contains the guarantor s information and includes the relationship of the guarantor with the patient the guarantor s name date of birth phone number and remarks 11 The Face Sheet will end here unless this check mark is checked in which case the medical history will also be included in the face sheet 12 The Medical History section appears when the check mark identified in item 11 is checked 13 Known Allergies are listed 14 Past Medical History is listed 15 Past Surgical History is listed 16 Family History of illnesses is listed items identified appear in red with a positive prefix Other items are in black with a negative prefix EMR User Manual lt gt gt 17 Social History of adverse traits is listed adverse traits appear red suffixed with a positive sign while unidentified traits appear in blacked suffixed with a negative sign 18 The Master Medication List 19 The Master Problem List 20 Date and time stamp when the face sheet was printed Face Labels Face Labels are sticker style labels with the patient information When the Face Label Radio Button is selected the Face Labels call in the viewing pane like this Print Fax Demographics and Insurance Smith John Label O Face Sheet Face Label Apr 27 2013 SSN Smith
290. nd comprehensive as possible Still if you have more questions or need further clarification on any aspect of the system you can always contact us at support emrnext com and submit your queries The usual response time is within 8 hours UnisonCare Corporation assumes no liability or responsibility to any person or company for direct or indirect damages resulting from the use of any information contained in this user manual EMR NEXT User Manual
291. nd uniformity we have opened the new block as the first block on the chart It is named Fourth Block Fourth Block First Option Second Option Third Option Fourth Option Fifth Option k v Initially display in Opened state Exhibit 09 117 EMR NEXT User Manual lt lt First Cardiology Clinic Photograph Click To Chart ID 00032 New 4 Attach Fourth Block D Family History Fifth Option Diabetes First Option Past Medical Histo P Stroke Fourth Option Hypertension Second Option Heart Disease Third Option Cancer Past Surgical History HHI Asthma Hay Fever Arthritis Osteoporosis Known Allergies Migraine 1 Allergen x a Alzheimers Reaction Status Epilepsy Glaucoma Exhibit 09 118 EMR NEXT User Manual lt gt 09 03 01 05 Block with Multiple Dropdowns Back When you click the fifth radio button in the User Definable Blocks section of the Add Blocks window Exhibit 09 106 and press the Continue Button the following Add window opens v Initially display in Opened state Exhibit 09 119 As the name suggests this block will have a multiple fields with dropdown lists Write the name of the block in the top field Add as many fields as required by clicking the black down arrow under the first field the black dropdown arrow on the left If you have added extra field
292. ndings Vitals Problems Orders and Follow ups Past Medical History Past Surgical History Family History Social History Allergies and Master Medication List After reviewing all sections click on the OK have Reviewed button at the bottom of the window and the item on the encounter form will be check marked You may also check mark the item without opening the view if you have reviewed all factors from the history form 2 Obtained old records Here you certify by check marking the field that you have obtained the patient s old records if any that are not in your possession 3 Summarized old records Here you certify by check marking the field that you have reviewed the old records and extracted all pertinent information from the old records for future use 4 Interpreted test data here you certify by check marking the field that you have studied and interpreted all test data for the tests that were ordered for the patient 5 Discussed Reviewed tests here you certify by check marking the field that you have discussed and reviewed all tests with the patient For convenience the field icon will open document viewer in which you can review the three most recently imported documents into the system for this patient Exhibit 06 234 EMR NEXT User Manual lt gt Select the document in the upper section of the viewer and click the open button to view it PFS History Consolidated View
293. ne prescription Likewise you may either print each item of an order as a separate order or combine them on one order The first section of this window sets the default mode for combined or separate prints of prescriptions orders Initially the default is set at Combined Change the radio buttons for item wise printing Setting default still allows you to print reports in the other mode by selecting the appropriate radio button on the encounter form Item 14 Exhibit 06 258 amp Item 5 Exhibit 06 266 EMR NEXT User Manual lt gt lt gt 2 Set the print area width from here Many doctors use a smaller size paper for printing prescriptions and orders While paper width may not exactly match the available settings select the paper width which most appropriately fits the paper size you use Ideally print area width should be slightly less than the actual paper width 3 Set the print area height from here If you are using continuous roll then height is not an issue you may set any suitable height But if you are using perforated rolls or cut paper then set height in the same manner as the width keeping the print area height slightly smaller than the paper size 4 Set print alignment from here Two options are available left aligned and center aligned 5 If you wish to print the patient s Social Security Number or Medical Record Number on prescriptions and orders select appropriate radio butto
294. nic Medical Records System Enabie scheduting stot uration 1s min the ultimate Mobility eXperience py Days Gb session v Sun Mon Tue wed 06 15 06 30 am 06 45 am 07 00 am 07 15 am 07 30 am 23 07 45 am Exhibit 04 004 EMR NEXT User Manual Exhibit 04 004 shows the second page of the initial configuration screen Fields included here are 14 15 16 17 18 19 20 21 22 23 4 EMR User Manual Enter your last first and middle name initial here Enter the suffix you would like to use such as MD MD FACC APRN MBBS Enter your Professional ID here Identify the type of the Professional ID from the dropdown list Check the Enable Scheduling checkbox to schedule your workday The table will enable only after you check the box These are the radio buttons for defining the time slots for one appointment and they become visible after you have checked the box in item 18 3 options are available 5 minutes 10 minutes and 15 minutes Don t worry if your standard appointment slot SSD is of greater time Define appropriate slot here and use a combination in the scheduler For example say your SSD is 30 minutes You may either define the SSD as 15 minutes and use two slots per appointment or you may define it as 10 minutes and use three slots
295. nt encounter Orders amp Requisitions made for the patient Only those made from the current encounter EMR NEXT User Manual lt gt 4o gt 19 Medications prescribed for the patient Only those prescribed in the current encounter 20 Name of the clinic or hospital to which referred same as that which appears in item 4 21 Space for your signature 22 Your name and ID 23 Time stamp of when the referral letter was printed All fields in the darker shade are editable i e data called in from the original chart or encounter form may be edited added or deleted in these sections of the report EMR User Manual 06 03 16 02 06 Report 6 Consultation Note Pack Exhibit 06 277 shows the Consultation Note in the Print Fax Encounter Related Documents window First Cardiology Clinic 1001 Parkway Drive Chester AL 23866 Tel 234 598 5589 Fax 234 567 8902 Apr 16 2013 CONSULTATION NOTE First Physician Sud Roh KVE 123 Lane Any CI AL 123 ABC Drive Any City Any State Any ZIP Tel 123 456 789 Fax 123 456 789 Cd DoB Feb 25 1943 Dear Sir Madam Thank you for referring your patient Smith John to our office for consultation treatment Below are some relevant details of the office note which is a part of our electronic medical record for your patient Chief Complaint Back symptoms Past Medical History Nothing on record Past Surgical
296. nt will remove along with its values Second Tier Editing For each of the eight elements there is a list of values for the element Nature of the values is according to the nature of the parent element If you wish to remove any of the values from any element uncheck the corresponding checkbox and the value will remove from the list for this element If you wish to add more values click the black EMR NEXT User Manual lt gt lt gt down arrow under the last row of the concerned element more rows will be added as shown in Exhibit 09 198 Now specify the values of the newly created rows To remove extra rows created by you click the corresponding trash can icon Please note that changes made for one element are not automatically applicable to all elements Values of each element have to be changed individually You can either open the block in Opened activated state on the Encounter Form or in de activated state To open it activated on new Encounter Forms keep the checkbox marked To open it de activated uncheck the checkbox After making the changes to the block click the OK button and save the changes fixed generalized localized migratary unilateral Quality Burning Cramping Crushing Dull Fullness Pressure Pressure sensation Pulsating v Initially display in Opened state Exhibit 09 198 EMR NEXT User Manual lt gt 09 04
297. nting double arrow below the encounter counter The patient chart opens on the General Form If any encounter exists on the chart the encounters tab is visible but the encounter counter is not visible Exhibit 06 131 The encounter counter will become visible when the encounter tab is clicked and the counter will show the most recent encounter Dashboard J Scheduler Ti Customize G a ee 1 E First Cardiology Clinic z A Chart ID 00002 Smith John 70 years 5 T Yellow Sticky Note SSN Insurance 1 R MRN 123 J Telephone Notes Carrier ABC Insurance Co 4 DOB Feb 25 1943 General Notes Address 11th Street Sea View Road N Gender Male EDT A LUE 5 Scans Documents PE a DE amd 008 E Country United States State AL T Pharmacy My First Pharmacy Siblings E Phone 123 586 5523 Facsimile 123 458 6565 LS Other Info Race White Plan My First Plan Expiry ID No Group No Contact Information Copay 250 Auth No Address 123 ABC Drive Romane City Any City ZIP Code Any ZIP Cd Relation Home Ph Country USA State Any State Name Home Ph 123 456 789 Cell Ph 123 456 789 DOB Gender Email E Exhibit 06 131 When a new encounter is
298. ny Search options are Starts with and Equals to Exhibit 07 003 If you know the complete MRN select Equals to and enter the MRN in the value field Otherwise enter at least first three starting numbers If less than three characters are entered as search value an alert will appear as shown in Exhibit 07 013 with appropriate wording c Phone Search options are Home Cell and Work Exhibit 07 004 Select the appropriate option and enter the phone number and click Go Full value is required d Last Name Search options are Starts with and Equals to Exhibit 07 005 If you know the complete Last Name select Equals to and enter the name in the value field Otherwise enter at least first three characters of the Last Name If less than three characters are entered as search value an alert will appear as shown in Exhibit 07 013 e First Name Search options are Starts with and Equals to Exhibit 07 006 If you know the complete First Name select Equals to and enter the name in the value field Otherwise enter at least first three characters of the First Name If less than three characters are entered as search value an alert will appear as shown in Exhibit 07 013 with appropriate wording f Birth Date Date selection is available in Month Day and Year from dropdown lists Exhibit 07 007 g Visit Date Date selection is available in Month Day and Year from dropdown lists Exhibit 07
299. o print them These cards or letters do not save in the database The fourth icon is for opening the patient s chart Notes on Item 6 The system allows certain deviations for booking appointments It is possible to book short duration appointments overlapping appointments or appointments outside the normal working hours etc Such appointments will appear at the bottom of the day s schedule after the last normal working slot For example see Exhibit 08 024 The normal working hours of the clinic end at 4 pm Accordingly the last normal slot is for 3 45 pm the doctor has a 15 minute standard appointment slot Three appointments are appearing after the last normal slot The first is at 9 30 am second is at 2 15 pm and third at 5 pm The first appointment is a short duration appointment The appointment is being booked for 10 minutes whereas the standard appointment duration is 15 minutes So this appointment is appearing after the normal work schedule The second appointment is within normal working hours but this is a duplicate appointment i e an appointment already exists for the 2 15 slot as can be seen in the normal slot for that time This is the second appointment being booked for the same time You can book any number of parallel appointments like this for the same time You may want to do so if 1 you think that some patients will not turn up 2 you think that the appointments will be brief and two or more appointments wil
300. ock A small two button window opens with the Paste and Add buttons Click the Paste button The block will relocate to this position Delete The Delete button is in white color indicating that the block cannot be deleted altogether from the template Edit When you click the Edit button the Edit window shown in Exhibit 09 157 opens Two editings are possible in this block 1 The Onset Field in the Master Problem List can initially either appear as a free text field or as a date field in which dates are selectable from dropdown lists While the character of the field can be changed on specific charts by clicking the name of the fields if you wish that the field should initially appear as a free text field keep the radio buttons unchanged If you wish that the field should initially appear as a date field change the radio button to the lower value EMR User Manual lt gt 2 Toopen the block in an activated state on new chart keep the Initially display in opened state checkbox checked To open it in de activated state uncheck the checkbox Click the OK button Save the changes e Initially show Onset as a free text data entry field C Initially show Onset as a fixed format date field There are currently 19 entries in your Favorites List for this block You can always manage your favorite lists by visiting Lists Menus section under Primary Configura
301. ocument to protect it from deletion To lock document click the lock icon on the Document Viewer System will raise an alert warning that a locked document cannot be deleted Exhibit 06 031 Click Lock Document on the alert to lock the document or Don t Lock to abort the locking action A locked document cannot be deleted Are you sure you want to proceed Exhibit 06 031 An unlocked document is identified by the lock icon when the document is opened in the document viewer Exhibit 06 028 while a locked document is identified by the Locked notation with locking date and time in the place of the lock icon Exhibit 06 032 EMR User Manual lt gt Document Viewer x Smith John Patient Invoice Encounter 9 H Medication 1 Laboratory Radiology 71 Consultation Name _ Hospital Smith John Insurance Address CHA Billing r Visit Superbil Visit Superbil 71 Directives Handouts H Other Legacy Services 0074T 10040 95115 85018 17003 123 ABC Drive Any City Any State Any ZIP Cd Professional services rendered on Apr 16 2013 Online Consultation Acne surgery Allergen immunotherapy single INJ Blood count hemoglobin Hgb Destroy Lesions 2 14 First Cardiology Clinic 1001 Parkway Drive Chester AL 23866 Tel 234 598 5589 Fax 234
302. of the respective block The Edit window will pop The edit windows of each of the seven blocks are shown in Exhibits 09 095 to 09 100 Exhibit 09 099 is common for Insurance 1 Block and Insurance 2 Block as the windows are the same Uncheck the checkbox on the concerned window and click the OK button Then save the changes made to the template by clicking the Save Changes Button shown in Exhibit 09 101 An alert will appear as shown in Exhibit 09 102 saying that the changes will apply only to future charts and not to previously opened charts EMR User Manual lt gt As an example we have deactivated the contact information block in Exhibit 09 103 to show the appearance of a deactivated block when a fresh chart is created CONTACT INFORMATION v Initially display in Opened state Exhibit 09 095 WORK INFORMATION v Initially display in Opened state Exhibit 09 096 DIRECTIVES v Initially display Opened state Exhibit 09 097 WE EMR NEXT User Manual lt gt GENERAL INFORMATION v Initially display in Opened state Exhibit 09 098 There are currently 3 entries for Insurance Companies Go to Ancillaries Menus tab to add delete or edit the list v Initially display in Opened state Exhibit 09 099 GUARANTOR v Initially display in Opened state Exhibit 09 100 EE EMR NEXT User Manual n 8 Dashboard Scheduler Primary
303. ogy Clinic 1001 Parkway Drive Chester AL 23866 Tel 234 598 5589 Fax 234 567 8902 PRESCRIPTION Name Smith John DoB Feb 25 1943 Sex M Add 123 ABC Drive Any City Any State Any ZIP Cd R Benadryl Childrens Allergy Fastmelt TAB disintegratng DAW Quantity 30 Thirty Refills 3 Three R Benadryl Cold 500 25 30 mg TAB GEQ Quantity 30 Thirty Kefills 3 Three R Chromagen FA TAB GEQ Quantity 10 Ten Refills 3 Three R Abilify 20 mg TAB GEQ Quantity 10 Ten Refills 3 Three Total number of items 2 D EXHIBIT 06 270 o EMR NEXT User Manual lt gt 06 03 16 02 02 Report 2 Laboratory Order Back Exhibit 06 271 shows the Laboratory Order in the Print Fax Encounter Related Documents window First Cardiology Clinic 1001 Parkway Drive Chester AL 23866 Tel 234 598 5589 Fax 234 567 8902 REQUISITION My First Laboratory E uss E ons ans EEE EERE EERE ans E ass sz E EEE EEE Sheet Tel 123 456 789 Fax 123 456 789 This is a request for laboratory services for BSmith John DOB Feb 25 1943 tM 0 0 010 S 5 789 00 Abdominal pain NOS 493 90 Asthm pu Thank vou Signed Apr 12 2013 Davis Richard MBBS NPI BA 12345678 EXHIBIT 06 271 1 Your clinic s name address and telephone amp Fax numbers 2 Title of
304. ok an appointment for 120 minutes you can book two concurrent appointments say first one for 90 minutes and the second one for 30 minutes or in any other combination There are many possibilities to work out your required appointment duration For e g to book a 35 minute appointment when the standard slot duration is 15 minutes you may book a 30 minute appointment and a 5 minute appointment But in this case since the 5 minute appointment is a short duration appointment it will show with irregular appointments Other places on the system from where the Scheduler can be opened Scheduler can be opened from two other points in the system 1 When you execute a search on the dashboard and click the execution button on the search findings an action window opens Exhibit 07 012 the second button on which is to open the scheduler 2 When you check the checkbox for scheduling the next follow up visit on an encounter form the scheduler opens EMR User Manual Last Name Smith Smith Smith Smith Exhibit 08 003 lt gt gt CHART PATIE First Name Home Phone Chart ID John 02 25 1951 123 45 89 00002 Tom OOoO004 Nicola 00005 111 222 333 EE EMR NEXT User Manual Scheduler Ii Customize Mon May 6 2013 amp Tue May 7 2013 Smith John CHART PATIENT S NAME PHONE VISIT REASON NOTES 2 cT cm 09 00 15 00002 smith
305. omfort irregular heart beats Fatigue Lightheadedness Shortness of breath with exertion Palpitations Swelling of hands or feet Difficulty breathing while lying down Leg cramps with exertion Discoloration of lips or nails Recent weight gain Exhibit 06 158 Respiratory Sleep disturbances due to breathing Cough Coughing up blood Shortness of breath Chest discomfort Wheezing Excessive sputum Excessive snoring EMR NEXT User Manual Exhibit 06 159 Gastrointestinal Change in appetite Heartburn vomiting Abdominal pain Hemorrhoids Change in bowel habits Black or tarry stools Exhibit 06 160 Genitourinary Male Frequent urination Foul urinary discharge Genital rashes or sores Exhibit 06 161 Genitourinary Female Unusual urinary color Excessively heavy periods Exhibit 06 162 o EMR NEXT User Manual Indigestion Nausea Excessive gas Abdominal bloating Diarrhea Constipation Bloody stools Blood in urine Kidney pain Urinary urgency Trouble starting urinary stream Inability to empty bladder Burning or pain on urination Testicular pain or masses Inability to contral bladder Missed periods Lumps or sores Pelvic pain lt gt Musculoskeletal Back or neck pain Muscle weakness Exhibit 06 163 Skin Suspicious lesions Excessive perspiration Dr
306. on 1 i 2 2 H 1 v I 2 e H a a lt z 1 i z LI 1 1 1 1 1 oO 9 1g o o0 1 LI 1 gt 5 gu get sus ss LI i s LI 1 LI LI 1 1 1 1 1 1 LI LI 1 LI LI LI 1 1 1 1 1 1 1 1 1 LI 1 LI e REI ME bo wo d d E Lu E c E EI ME aie eer ha nhi er aD mel S NIME S EE QS EIUS BD a3 24 ien 1 idm o o e Orders Requisitions 1 e Waist SpO2 ins ibs Ht Wt i dz a o u o 20 c gt n Medications Rx e 9 Review of Systems n Cardiovascular Respiratory Gastrointestinal Genitourinary Male Plan Notes Es Genitourinary Female L Musculoskeletal C Neurologic Psychiatric C Summarized old records C Discussed Reviewed tests C Reviewed Past Family and Social History Interpreted tests data C Obtained old records o 1 Hematologic Lymphatic Allergic Immunologic 88 Endocrine E Code Basis
307. on 09 04 01 shows how to restore the block Edit When you click the Edit button the following Edit window opens EMR NEXT User Manual lt gt There currently 9 entries in your Favorites List for this block You can always manage your favorite lists by visiting Lists Menus section under Primary Configuration tab above If you would like to add or delete items right now just click HERE and it will open the Procedure Codes edit window for you on this very screen v Initially display in Opened state Exhibit 09 211 The window shows you how many entries you have in the Pick List for this block and how you could manage the list The only editing possible for this block is to either open it in Opened activated state on the Encounter Form or in de activated state To open it activated on new Encounter Forms keep the checkbox marked To open it de activated uncheck the checkbox and click the OK button Save the changes EMR NEXT User Manual lt gt 09 04 10 Editing the Assessments Diagnosis Block Back When you click the Edit Template Block Icon of the Assessment Diagnosis Block a small three button window opens as shown in Exhibit 09 212 The buttons include Cut Edit and Delete cut Edit Delete Assessment Diagnosis New Assessments 4 Exhibit 09 212 Cut If you wish to change the location of thi
308. ording to US Canadian specifications 18 Write the Last Name First Name and Middle Name Initial of the Principal Insured here 19 Date of Birth of the principal insured DOB is selectable from dropdown list Exhibit 06 064 20 The Principal Insured s Gender selectable from dropdown list Options include Male Female Transgender Exhibit 06 065 If you click the Block Title Icon on the block an alert will be raised saying Closing this block would also reset its fields to their default values Are you sure you want to close it If you click the No button on the alert the action will abort But if you click the Yes button on the alert all entries made in this block will clear and the block will be de activated To reactivate the block click the Block Title Icon again WE EMR NEXT User Manual lt lt lt lt Carrier ABC Insurance Co Address City ABC Insurance Co Country My First Insurance Co Exhibit 06 060 Plan My First Plan ID No My First Plan Copay My Second Plan Exhibit 06 061 Relation Name DOB Self Spouse Parent Exhibit 06 063 Gender Male Female Transgender Exhibit 06 065 Expiry Group No Auth No Jan Feb Exhibit 06 062 DOB Jan Insuran Feb Exhibit 06 064 EMR NEXT User Manual lt gt 06 01 09 Guarantor s Block Back The Guarantor s Block on the General Information Form is identified at I
309. ounter Related Documents Window Exhibit 06 265 and the file name in the patient folder 3 Select from the dropdown list the folder in which this letter handout should save 4 The checkbox identified as item 4 on Exhibit 09 014 is to display your clinic s practice s header on the letter The header itself on the letter handout is also identified as item 4 If you use pre printed stationery with the clinic s letterhead printed on it check this checkbox off 5 The checkbox identified as item 5 on Exhibit 09 014 is for the date on the report handout If this checkbox is checked the date on which the letter is generated will appear automatically in the position identified as item 5 6 The checkbox identified as item 6 on Exhibit 09 014 is for the patient s name and address to appear automatically on the letter handout The name and address will appear in the position also marked as item 6 7 f the checkbox identified as item 7 is checked which by default is checked the signature line with your name and ID will also appear automatically at the end of the letter handout The signature block is also identified on the template as item 7 8 This is the title of the letter handout as it would be read from the document This may or may not be the same as the name specified in item 2 9 This is the space for the opening text of the letter handout It may spread over multiple paragraphs and may be as long as required
310. ountry United States State AL Phone Facsimile 3 Exhibit 09 103 There is another kind of editing of the General Information Block also If you run a Cash Only Practice then you can remove the Insurance 1 Insurance 2 and the Guarantor Blocks from the template altogether Please note that all three blocks can be removed or retained as a set It is not possible to delete only one or two of these three blocks The procedure to do this has been explained in detail in Section 09 01 02 06 and the appearance of the General Information Form before and after removal of the three blocks has been shown in Exhibits 09 022 and 09 023 EMR User Manual lt gt Back 09 03 History Form Template When you click the third tab on the Customization Home Page identified as Item 3 on Exhibit 09 001 the History Form Template opens The template looks like th IS A U gt 9 6 i Chart ID 00001 CQ0000000c00c00200200000c00c00000c0000000000000000200000200000000000000002000002002000002002000000000020020000020020 wmm 2 ula m au 1 C 92 2 S p LE 8 5 amp E rom d
311. our practice is located in US Social Security Number SSN is required For practitioners in Canada Health Card No HCN appears For all other countries Patient ID is required 2 Medical Record Number MRN is your own series of patient number if you maintain one for your clinic 3 Date of Birth comes by selection in the month day and year field The range is from 1908 to the current year Exhibit 06 039 4 Gender also comes by selection from a dropdown list Three options available Male Female amp Transgender Exhibit 06 040 5 Marital Status is also selected from a dropdown list Options include Married Divorced Separated Widowed Single Separated Co habiting amp Others Exhibit 06 041 6 Sibling details must be entered manually No selection available from the system EP EMR NEXT User Manual lt gt 7 Race comes by selection from dropdown list Options include White Black Hispanic Asian amp Other Exhibit 06 042 8 Specify the name of the Patient s pharmacy here If you have defined the pharmacy in your database Section 09 01 03 02 shows how to you may select it from the dropdown list Otherwise write the name of the pharmacy manually in the form 9 This is a 20 character field for any other information you may want to add concerning the fields in this block DOB Feb 25 1943 Gender Male Gender Marriage Jan Marriage Siblings Feb siblings Male Race
312. ow shown in Exhibit 09 147 opens showing the fourteen default elements The exhibit is showing the first element but there is a scroll bar on the right which becomes visible when you take the mouse to it right inner edge of the window Scroll down for the remaining thirteen elements EMR User Manual lt gt Family History Diabetes Phrase for Normal Finding if any Phrases for Abnormal Findings Aunt Brother Children Father Grand Father Grand Mother Mother sister spouse v Initially display in Opened state Exhibit 09 147 There is two tiered editing on this window In the first tier you can either add or remove elements from the list In the second tier you can add or remove values for any of the element First Tier Editing To remove any of the fourteen elements in the Family History Block uncheck the checkbox to the left of the element The element will remove along with its values To add new elements in the Family History Block scroll down to the bottom of the window as shown in Exhibit 09 150 Click the black down arrow icon at the left of the window to create new fields as shown in the Exhibit Write the name of the elements in the fields You can create as many elements as required After creating an element add rows for values of the element by clicking the inner black down arrow icon of the respective element Add as many rows as required and specify their values If ex
313. pe off and a field icon will appear at the end of the field Now either write the result manually or select appropriate phrase from the corresponding exam result window which pops when the field icon is clicked Exhibit 06 208 Multiple selections are allowed Each exam result window has a Clear Field button to clear all insertions in the field There is also an Undo Last button to clear the last selection from the field The result phrases in the exam result window can be added or removed or edited according to the requirement of your practice Even the negative finding phrase can be edited Section 09 04 08 shows how to do it The block icon opens Physical Examination window showing the Physical Examination results of the previous encounter Exhibit 06 209 It shows the systems checked the examinations performed and the findings Positive results are shown in red while normal findings appear in black To copy findings of any system from this window to the current encounter form click on the system in the window and the observations will be copied down on the new encounter overwriting any freshly written data in the item After copying the data may be edited further To copy the results of all the systems checked in the previous encounter to the fresh encounter form click the Insert All Previous Items button at the bottom of the window There is also a set all systems to normal button at th
314. pened state Exhibit 09 148 EMR User Manual lt gt Diabetes Phrase for Normal Finding if any Phrases for Abnonnal Findings Aunt Brother Children Father Grand Father Grand Mother Mother Sister Spouse Uncle V Stroke Phrase for Normal Finding if any w Initially display in Opened state Exhibit 09 149 Brother Children Father Grand Father Grand Mother Mother sister Spouse Uncle Phrase for Normal Finding if any Phrases for Abnormal Findings wv Initially display in Opened state Exhibit 09 150 EE EMR NEXT User Manual lt gt To open the block an activated state new chart keep the Initially display in opened state checkbox checked To open it in de activated state uncheck the checkbox Click the OK button Save the changes EMR User Manual lt gt 09 03 07 Editing the Social History Block Back When you click the Edit Template Block Icon of the Social History Block a small three button window opens as shown in Exhibit 09 151 The buttons include Cut Edit and Delete cut Edit Delete L ee Social History Alcohol Use Caffeine Use D Tobacco Use Exhibit 09 151
315. r List They will only be added to your favorites 5 This is the list of your favorites that you have prepared either by selection from the Master List or by writing the phrases yourself or as a combination of both 6 If you want to delete the Plan Notes Phrase from your list of favorites click the corresponding trash can icon If the phrase was selected from the Master List it will still be available for re selection there but if you had yourself written it it will be lost 7 Save the changes made to the list by clicking the Save button In Exhibit 09 085 the button is in white color because it is not activated yet It activates whenever a change is made in the window If you try to close the window without saving the changes the alert shown in Exhibit 09 086 will raise 8 The Reset button clears all unsaved changes In Exhibit 09 085 the button is in white color because it is not activated yet It activates whenever a change is made in the window You need to click SAVE button below to keep the changes you have made to this favorite list Do you want to close this window without saving Exhibit 09 086 EMR User Manual 09 01 04 13 Past Medical History PMH Phrases Pack Past Medical History Phrases are used in the Past Medical History Block in the History Form When you click the block icon on the block the Past Medical History Window shown in Exhibit 06 076 opens Entries in the Past
316. r parts 1 Primary Configuration This part covers your clinic s basic information general system wide settings and the management of lists and menus that are used by various elements on the chart forms These will be discussed in Section 09 01 of the Manual 2 General Form Template This part covers the formatting placement and editing of the blocks in the General Form Template These will be discussed in Section 09 02 of the Manual Changes made in the General Form template will apply only to the charts created after the change Previous charts will remain unchanged 3 History Form Template This part covers the formatting placement and editing of the blocks in the History Form Template These will be discussed in Section 09 03 of the Manual Changes made in the History Form template will apply only to the charts created after the change Previous charts will remain unchanged 4 Encounter Form Template This part covers the formatting placement and editing of the blocks in the Encounter Form Template These will be discussed in Section 09 04 of the Manual Changes made in the Encounter Form template will apply only to the Encounter Forms created after the change Previous Encounter Forms will remain unchanged Thus a patient chart may contain Encounter Forms of different formats EE EMR NEXT User Manual 09 01 Primary Configuration Back 3 Dashboar
317. r patients between 2 20 years is different from that for older patients Exhibit 06 184 shows the BMI chart for a patient between 2 20 years If the patient is under 2 years there will be no BMI chart A message will appear on the chart window as shown in Exhibit 06 184 BMI calculations require weight and height data If weight or height data is not available in the chart a message will appear on the chart asking for the data to be provided Exhibit 06 185 Exhibit 06 186 shows the Blood Pressure Chart The BP chart shows the trend of the systolic and diastolic readings for the past six encounters Separate charts are shown for systolic readings and diastolic readings The readings appear as blue dots on the chart connected by a blue line to show the trend Dates of encounters show on the x axis of the graph while readings show on the y axis If readings have not been taken in any encounter dots will not appear for that encounter EMR NEXT User Manual lt gt gt Exhibits 06 187 06 188 and 06 189 show the BMI for Age Stature for Age and Weight for Age growth charts On each of the three growth charts the 57 10 25 507 751 also 85 in BMI only 90 and 95 percentile values have been charted according to age The patient s readings appear on the chart as a red dot For growth chart calculations the patient must be within 2 20 years of age If the patient does not fall within this age group an ale
318. rance 1 Carrier ABC Insurance Co ur Address 11th Street 5ea View Road Exhibit 06 001 HE Closing this block would also reset its fields to their default values Are you sure you want to close it Insurance 1 Exhibit 06 002 L EMR NEXT User Manual Exhibit 06 003 B Many fields have a down arrow icon towards the end exhibit 06 004 This means that a dropdown list is available for selecting the data which opens when this arrow is clicked exhibit 06 005 But you can make manual entries or combine the selection with manual additions and deletions also wunununun Carrier ABC Insurance Co Address City ABC Insurance Co Country My First Insurance Co Phone My Second Insurance Co Exhibit 06 005 C Many fields have a square icon towards the end Exhibit 06 006 When you click this icon a separate window with feeding options opens as can be seen in Exhibit 06 006 the blue Chief Complaint Encounter Reason window opened when the square icon encircled in red was clicked Multiple entries may be selected from such windows and the selected entries may be edited manually EMR NEXT User Manual lt gt First Ca Clear Field Undo Last Chart ID 00002 Smith John CC Previous Encounter none Encounter 7 Date Apr 11 2013 Type Your Favorites Referred by Abdominal pain Attended by Davis Richard MBBS BA 12345678 Abnormal appearance of eyes Allergy symptom
319. ratory to your list click the Add button on the block The Add Laboratory Company Window will open as shown in Exhibit 09 044 EE EMR NEXT User Manual lt gt Add Laboratory ad IU Laboratory Name e o ID Number Contact 2 Femail Address Exhibit 09 044 1 Write the name of the Laboratory here 2 Write the Laboratory s ID number here 3 Specify the type of ID number by selection from the dropdown list on the field The types available in the dropdown list are illustrated in Exhibit 09 045 4 Write the name or designation of the contact person at the Laboratory here 5 This field is for the Laboratory s address 6 This field is for the Laboratory s city county etc 7 Specify the Laboratory s zip code postal code here 8 Specify the Laboratory s country here Initially the country in which your practice is based will come selected Change if the Laboratory s country is different from your country 9 Specify the Laboratory s State Province here Initially the State Province in which your company is based will come selected Change if the Laboratory s State Province is different from yours 10 Specify the Laboratory s telephone number here 11 Specify the Laboratory s fax number here co EMR NEXT User Manual 12 Specify the Laboratory s email address here 13 Click the Save button to save the Laboratory s particulars N
320. re 5 Date amp Time Stamp of when the report was generated ENT EMR NEXT User Manual lt gt 06 03 Encounter Form Back Every time a patient visits you you must record the encounter The encounter may either result from a scheduled appointment or may be created directly on the patient chart if the visit is unscheduled There is no limit on how many encounters are opened for a patient Over the years the number of encounters for most patients is expected to run in hundreds For your convenience the system will open to the most recent encounter when you open the chart and click on the encounters tab Section 08 Notes to Item 13 shows how an encounter is opened from a scheduled appointment on the scheduler In this section opening an encounter directly on the patient chart is explained When you create a new chart only two tabs appear on the left the General Form and the History Form as can be seen in Exhibit 06 128 The space marked as 1 on the Exhibit is the place where the Encounter tab will appear once an encounter is created x m Dashboard Scheduler Customize S First Cardiology Clinic N Photograph Click To Chart ID 00014 Doe Smith Attach 5 T Yellow Sticky Note SSN Insurance 1 T R Telephone Notes MRN Carrier DOB General Notes Address Gender E e Scans Documents
321. re but if you had yourself written it it will be lost 7 Save the changes made to the list by clicking the Save button In Exhibit 09 073 the button is in white color because it is not activated yet It activates whenever a change is made in the window If you try to close the window without saving the changes the alert shown in Exhibit 09 074 will raise 8 The Reset button clears all unsaved changes In Exhibit 09 074 the button is in white color because it is not activated yet It activates whenever a change is made in the window You need to click SAVE button below to keep the changes you have made to this favorite list Do you want to close this window without saving Exhibit 09 074 EE EMR NEXT User Manual 09 01 04 08 Visit Types Pack Visit Types are defined in the Encounter Statistics Block in the Encounter Form in the field named Type Section 06 03 01 Item 3 Exhibit 06 135 When you click the field a dropdown list appears with the various Service Types as shown in Exhibit 06 137 This list is managed from here in the Customization Section When you click the Open button on the field identified as item 4h on Exhibit 09 002 the Add Delete Visit Types Window opens Add Delete Visit Types X Master List O Your Favorites POS Office Visit New Office Visit Est Preventive New Preventive Est Office Consultation Confirmatory Consult Inpatient Consult Initial Evaluation Hosp
322. re are currently 24 entries in your Favorites List for this block You can always manage your favorite lists by visiting Lists Menus section under Primary Configuration tab above If you would like to add or delete items right now just click HERE and it will open the PSH edit window for you on this very screen v Initially display in Opened state Exhibit 09 139 The window shows you how many entries you have in the Pick List for this block and how you could manage the list The only editing possible for this block is to either open it in activated state on a new chart or in de activated state To open it activated on new charts keep the checkbox marked To open it de activated uncheck the checkbox and click the OK button Save the changes EET EMR NEXT User Manual lt gt 09 03 04 Editing the Known Allergies Block Back When you click the Edit Template Block Icon of the Known Allergies Block a small three button window opens as shown in Exhibit 09 140 The buttons include Cut Edit and Delete Known Allergies x 1 Allergen x Reaction Status
323. respective set of tertiary values and extra rows will be created as shown in Exhibit 09 207 Now specify the values for these extra rows If extra rows are created delete them by clicking the trash can icon corresponding to the rows The first row in the tertiary set of values is for the normal finding phrase The default phrase used in the system is No Adverse Finding If you want to change the wording of the phrase click the square icon to the right of the field The field will go blank and turn blue ready for inscription Now write the changed wording Please note that changes made for one element are not automatically applicable to all elements Values of each element have to be changed individually You can either open the block in Opened activated state on the Encounter Form or in de activated state To open it activated on new Encounter Forms keep the checkbox marked To open it de activated uncheck the checkbox After making changes to the block click the OK button and save the changes 17 EMR NEXT User Manual lt gt Malnourished Pale complexion Sarcastic Teartul Uncomfortable Uncooperative Unkempt Withdrawn Conjunctivae clear no ptosis Phrases for Abnormal Findings Chalazion present Discharge present v Initially display in Opened state Exhibit 09 207 Malnourished Pale complexion Sarcastic Tearful Uncomfortable Uncooperative Unkempt Withdrawn wr No Abnormal
324. restore the block Edit When you click the Edit button the following Edit window opens EMR NEXT User Manual lt gt Plan Notes There are currently 3 entries in your Favorites List for this block You can always manage your favorite lists by visiting Lists Menus section under Primary Configuration tab above If you would like to add or delete items right now just click HERE and it will open the Plan Motes edit window for you on this very screen v Initially display in Opened state Exhibit 09 219 The window shows you how many entries you have in the Pick List for this block and how you could manage the list The only editing possible for this block is to either open it in Opened activated state on the Encounter Form or in de activated state To open it activated on new Encounter Forms keep the checkbox marked To open it de activated uncheck the checkbox and click the OK button Save the changes EET EMR NEXT User Manual lt gt 09 04 14 Editing the Encounter Checklist Block Back When you click the Edit Template Block Icon of the Encounter Checklist Block a small two button window opens as shown in Exhibit 09 220 The buttons include Cut and Delete Cut ieee EY SEE NE EEO IE PSTD TERS ERED SS e Reviewed Past Family and Social History Obtained old records Summarized old records Interpreted tests data D
325. rgery x Note 4 Code Desc Note Exhibit 06 011 Now let us move on to each of the specific forms on the chart EMR NEXT User Manual 06 01 General Information Form Back amp First Cardiglogy Clinic Photograph ChartID 00014 Doe Smith as Yellow Sticky Note 55 Insurance 1 Telephone Notes General Notes Address City ZIP Code Scans Documents 2 zi Marriage Country United States State AL Pharmacy Siblings 5 Facsimile Other Info Race ss Plan Expiry ID No Group No Contact Information Auth No Finale Remarks City ZIP Code Relation Home Ph Country United States State AL Name Home Ph Cell Ph DOB Gender Email ya a S Insurance 2 Work Information Address Status City ZIP Code Employer Work Ph Country United States State AL 2 Facsimile e Plan Expiry Directives ID No Group No Contact SSS 25 Copay Auth No Advance Info Release Remarks BEEN Relation Home Ph General Information st Name DOB Gender Guarantor Relation Home Ph Name DOB Gender Remarks Exhibit 06 012 If you see too much data requirement on the General Page don t be worried All fields are optional You need fill in only that informatio
326. ries is discussed detail in Section 09 01 03 04 e Radiology Clinics Maintenance of list of Radiology Clinics is discussed in detail in Section 09 01 03 05 f Hospitals Maintenance of list of Hospitals amp Clinics is discussed in detail in Section 09 01 03 05 4 This part maintains lists of various other elements that you will need while maintaining patient charts on EMR Next a Dx Codes or Diagnosis Codes Maintenance of list of Dx Codes is discussed in Section 09 01 04 01 b Px Codes or Procedural Codes Maintenance of list of Procedural Codes is discussed in Section 09 01 04 02 c EM Codes or Evaluation amp Management Codes Maintenance of list of Evaluation amp Management Codes is discussed in Section 09 01 04 03 d Medications Maintenance of list of Medications is discussed in Section 09 01 04 04 e Lab Orders Maintenance of list of Lab Orders is discussed in Section 09 01 04 05 f Radiology Orders Maintenance of list of Radiology Orders is discussed in Section 09 01 04 06 g General Orders Maintenance of list of General Orders is discussed in Section 09 01 04 07 h Visit Types Maintenance of list of Visit Types is discussed in Section 09 01 04 08 i CC Phrases or Chief Complaint Phrases Maintenance of list of Chief Complaint Phrases is discussed in Section 09 01 04 09 j HPI Phrases or History of Present Illness Phrases Maintenance of list of History of Present Il
327. rm All fields will be carried down from the originating encounter except the Status field which must be re selected as appropriate from the dropdown list exhibit 06 216 The Notes and the Onset field are editable The onset field is a combo box Initially it is a free text field but if you click on the field name it becomes a dropdown list for selection of date Freshly Assessed Problems are added in the New Assessments section Click the New Assessments field icon to call the New Problems Window Exhibit 06 215 The window lists your favorite problems along with their ICD codes The system has over 1900 pre inserted problems with ICD codes from which you identify your favorites or add new problems Section 09 01 04 01 shows how it is done After selecting the problems from the window fill in the onset Nature and Notes if any The onset field is a combo box Initially it is set for free text typing A click on the field name makes it a dropdown list for date selection The Nature field is a dropdown list Exhibit 06 217 with two sets of options The first set includes Minor Self Limited Time Limited Acute Chronic Intermittent amp Recurrent The second set includes Condition Symptom Finding amp Limitation Only one value can be selected in the field The Notes Field is free text with no limitation Lines will add as per text requirement If you select an ongoing problem from the New Assess
328. rmation Block Back General Information Block on the General Information Form is identified at Item 12 of Exhibit 06 07 The General Information Block is a free entry block for any and as much information you want to store There is no space restriction Lines will add automatically if the text exceeds the initially available space General Information Block looks like this General Information Exhibit 06 051 If you click the Block Title Icon on the block an alert will be raised saying Closing this block would also reset its fields to their default values Are you sure you want to close it If you click the No button on the alert the action will abort But if you click the Yes button on the alert all entries made in this block will clear and the block will be de activated reactivate the block click the Block Title Icon again ENT EMR NEXT User Manual 06 01 07 Insurance Block Back The Insurance Block on the General Information Form is identified at Item 13 of Exhibit 06 07 Some practitioners operate a Cash Only practice If yours is such a practice you will not need this block and you may remove it altogether from the form Section 09 01 02 06 shows how to remove the Insurance Block from the form The Insurance Block looks like this insurance 1 Carrier ABC Insurance Co ur Address 6 11th Street Sea View Road City 9 Alabama country United States AL Phone 123
329. rom here Fields marked with asterisk require mandatory input and cannot be left blank 1 Change the country of your practice from the dropdown list available on the field 2 Change by selection from the dropdown list on the field whether the next geographical segment is a State Province Territory County Principality or some other division If your country of practice is USA only State can be EMR NEXT User Manual lt gt selected here If your country of practice is Canada only Province can be selected here For all other countries selection is unrestricted 3 Change the name of the segment defined in item 2 above If your country of practice is USA then the State can only be selected from the dropdown list on this field If your country of practice is Canada then the Province can only be selected from the dropdown list on this field For all other countries the name of the segment has to be entered 4 Change the name of your practice from here 5 Add or change the Sub Title of your practice clinic from here Subtitle appears under the practice clinic name on all documents 6 Change the address of your practice from here Two lines are available for the address 7 Change the city of your practice from here Cities have to be entered manually No dropdown list is available 8 Change the Zip Code or Postal Code of your area from here If your country of practice is USA the field is
330. rom the list for this element If you wish to add more values click the black down arrow under the last row of the concerned element and more rows will be added as shown in Exhibit 09 201 Now specify the values of the newly created rows To remove extra rows created by you click the corresponding trash can icon Please note that changes made for one element are not automatically applicable to all elements Values of each element have to be changed individually You can either open the block in Opened activated state on the Encounter Form or in de activated state To open it activated on new Encounter Forms keep the checkbox marked To open it de activated uncheck the checkbox After making the changes to the block click the OK button and save the changes Review of Systems General Fevers Chills Sweats Appetite loss Weight loss Fatigue w Vision loss Double vision Blurred vision Eye irritation Eye pain v Initially display in Opened state EE EMR NEXT User Manual lt gt Exhibit 09 201 V Hematologic Lympl skin discoloration Bleeding Enlarged lymph nodes Fevers Abnormal bruising w V Allergic Immunolog Seasonal allergies Hives or rash Persistent infections HIV exposure v Initially display in Opened state Exhibit 09 202 EMR NEXT User Manual lt gt 09 04 07 Editing the Vital Signs Block Back When you click the Edit Template Block Icon of t
331. rom the template Section 09 04 01 shows how to restore the block Edit When you click the Edit button the following Edit window opens EF EMR NEXT User Manual lt gt chief Complaint Encounter Reason There are currently 74 entries in your Favorites List for this block You can always manage your favorite lists by visiting Lists Menus section under Primary Configuration tab above If you would like to add or delete items right now just click HERE and it will apen the CC edit window for you on this very screen v Initially display in Opened state Exhibit 09 195 The window shows you how many entries you have in the Pick List for this block and how you could manage the list The only editing possible for this block is to either open it in Opened activated state on the Encounter Form or in de activated state To open it activated on new Encounter Forms keep the checkbox marked To open it de activated uncheck the checkbox and click the OK button Save the changes EFI EMR NEXT User Manual lt gt 09 04 05 Editing the History of Present Illness Block Back When you click the Edit Template Block Icon of the History of Present Illness Block a small three button window opens as shown in Exhibit 09 196 The buttons include Cut Edit and Delete Cut Edit Delete L rm UP ee eee eer NDS History of Present Illness Location BE x Qual
332. row icon next to it The cursor will jump to the first entry starting with the search value 3 Click this right arrow to move the Medicine to your list of favorites EMR User Manual lt gt 4 f the Medicine you are looking for is not included in the Master List you can write it yourself in this field 5 Write the Code of the medicine in this field 6 Press this right arrow to include it in your list of favorites The name and the code of the medicine you have added from this field will not be added in the Master List They will only be added to your favorites 7 This is the list of your favorites that you have prepared either by selection from the Master List or by writing the name and code of the medicine yourself or as a combination of both 8 If you want to add a default signature phrase for the medicine it is done from here Click the pencil icon and the window shown in Exhibit 09 066 will open Write the phrase and click the OK button Now the signature phrase will appear in the signature field in the medicines block identified as item 3 on Exhibit 06 222 whenever this medicine is selected However the phrase can be edited on the encounter form if required The pencil icon of the medicines on which a signature phrase has been entered turns blue as is shown in the first and the seventh entry on Exhibit 09 067 9 If you want to delete the medicine from your list of favorites click the co
333. rral Block as a doctor to whom you refer the patient click the second radio block If you want the name to be included in both the blocks click the third radio button Click the Save button to save the doctor s particulars DEA Champus DPS Medicare NSC Medicaid UPIN Medi Cal OSCAR License BCID Group BSID Other Exhibit 09 042 EE EMR NEXT User Manual lt gt 09 01 03 04 Laboratories Back You need to specify the name and particulars of the Laboratory on Laboratory Orders Laboratory Orders are discussed in Section 06 03 16 02 02 Either you type the name and particulars of the Laboratory manually for each Laboratory Order you issue or you feed the particulars in the block marked as 3d on Exhibit 09 002 just once and whenever a Laboratory Order is issued click the icon marked as item 4 on Exhibit 06 271 to call the list of Laboratories on your database and select the name amp particulars Laboratories that have been recorded in the system will show in the Laboratories Block of the Primary Configuration tab of the Customization Area like this Laboratories E My First Laboratory E m My Second Laboratory E fw My Third Laboratory Exhibit 09 043 To edit the particulars click the first icon corresponding to the name of the Laboratory To delete the Laboratory from your list click the second trash can icon corresponding to the name of the Laboratory To add a new Labo
334. rresponding trash can icon If the medicine was selected from the Master List it will still be available for re selection there but if you had yourself written the name and the code they will be lost 10 Save the changes made to the list by clicking the Save button If you try to close the window without saving the changes the alert shown in Exhibit 09 068 will raise 11 The Reset button clears all unsaved changes Default 516 for this drug if any Abilify 10 mg TAB This is a default SIG Exhibit 09 066 e EMR NEXT User Manual lt gt Your Favorites 516 Abilify 10 mg TAB Abilify 20 mg TAB Benadryl Childrens Allergy Fastmelt TAB disintegrating Benadryl Cold 500 25 30 mg TAB Cardura 2 mg TAB Carmol 10 10 LOT Carmal 10 shampoo Chromagen FA CAP Chromagen FA TAB Cyclocort 0 1 LOT Cyclogyl 0 5 SOL Cyclogyl 196 SOL Diuril 250 mg 5 mL SUS Eligard 7 5 mg kit Erythromycin Stearate stearate 250 mg TAB Fluorabon 1 mg TAB chewable Inderal LA 60 mg CAP ER XQ S S YQ S S S OY S Y oW Y Y S b Eb Eb Eb E Lamictal 25 TAB Exhibit 09 067 You need to click SAVE button below to keep the changes you have made to this favorite list Do you want to close this window without saving Exhibit 09 068 EMR User Manual 4o gt 09 01 04 05 Laboratory Orders Back L
335. rt will raise as shown in exhibit 06 190 Growth chart calculations also require weight and height They also require sex identification If either of the three is missing an alert will raise as shown in exhibit 06 191 To print the BMI Charts Blood Pressure Charts and Growth Charts click the print icon on Vital Signs Window or the Growth Chart Window mj EMR NEXT User Manual lt gt Body Mass Index Blood Pressure rh Smith John Height cm 18 5 25 30 197 5 50 60 70 e 90 100 110 120 Weight kilograms Show Growth Charts Exhibit 06 182 EMR NEXT User Manual lt gt Body Mass Index C Blood Pressure BMI for Age IT TA liii er m oe NM LL E LL zd Ee 2 m E TL 2 mN PLI 2 3 4 5 6 7 B 9 10 4 12 13 14 15 46 1 Age years zl m ceo a Show Growth Charts Exhibit 06 183 17 EMR User Manual lt gt BMI calculations not applicable to children less than 2 years of age Show Growth Charts Beert guai Exhibit 06 184 EMR NEXT User Manual lt gt Patient s weight and height are needed to calculate value Please select applicable values in the Vital Signs block Show Growth Charts MIOW Growin 1 Exhibit 06 185
336. ryl Cold 500 25 30 mg TAB GEQ O Quantity 30 Thirty QD Refills 3 Three R GEQ Quantity 10 D Refills 3 Three 74 Abilify 20 mg TAB cro Quantity 10 Ten Refills 3 Three Total number of items 4 EXHIBIT 06 269 1 Your clinic s name address and telephone amp Fax numbers 2 Title of the Report Prescription 3 Patient s Name 4 Patient s Date of Birth 5 Patient s Sex EMR User Manual lt gt 6 Patient s Address 7 The Medication Symbol If you wish that any particular medicine or medicines do not appear in the print click on this symbol for respective medicine s The item s will be highlighted If you take the print in this state these items will not appear in the print Exhibit 06 270 shows highlighted entries on the report 8 The name of the medicine 9 Specification whether the medicine may be dispensed as Generic Equivalent GEQ or as Dispense as Written DAW 10 Quantity of medicine s 11 Number of Refills 12 Total Number of items in the print 13 The highlighted medicines item 7 will not be included in the print 14 They are even omitted from the medicine count All fields in the darker shade are editable i e data called in from the original chart or encounter form may be edited added or deleted in these sections of the report EMR User Manual lt gt First Cardiol
337. s Face Sheets do not save on the system and may be generated afresh as and when required All information on the Face Sheet is called from the General Information Form and the History Form History Form is the next section in this manual Fields in the Face Sheet include 1 Your clinic s name address phone number and fax number 2 Title of Report Patient Face Sheet ENT EMR NEXT User Manual lt gt 3 This section contains the patient s basic information which includes Name Date of Birth Social Security Number Gender Marital Status Race name of patient s Pharmacy and other information as typed in the general form items 1 3 4 5 7 8 amp 9 in Exhibit 06 038 4 This section contains the patient s contact information which includes Address Home Phone Cell Phone Email and Emergency contact particulars 5 This section contains patient s work information which includes Work Status name of Institution and work phone number 6 This section contains the emergency contact directives given by the patient and contact instructions in case of emergency whether or not information be released to third parties 7 This section contains the general information provided on the patient chart 8 This section contains the Primary Insurance Details and if the patient is not the principal insured then also particulars of the Principal Insured 9 This section contains the Secondary Insurance Details a
338. s Fatigue w Vision loss Double vision Blurred vision Eye irritation Eye pain Discharge v Initially display in Opened state Exhibit 09 200 There is two tiered editing on this window In the first tier you can either add or remove elements from the list In the second tier you can add or remove values for any of the element First Tier Editing To remove any of the fifteen elements in the Review of Systems Block uncheck the checkbox to the left of the element The element will remove along with its values To add new elements in the Review of Systems Block scroll down to the bottom of the window as shown in Exhibit 09 202 Click the black down arrow icon at the left of the window to create new fields as shown in the Exhibit Write the name of the elements in the fields You can create as many elements as required After creating an element add rows for values of the element by clicking the inner black down arrow icon of the respective element Add as many rows as required and specify their values If extra rows have been created delete them by clicking the corresponding trash can icon EE EMR NEXT User Manual lt gt Second Tier Editing For each of the fifteen elements there is a list of values for the element Nature of the values is according to the nature of the parent element If you wish to remove any of the values from any element uncheck the corresponding checkbox and the value will remove f
339. s Received Details Ankle symptoms Payment type Billing not required Anxiety nervousness Note for Biller Back symptoms Bedwetting Chief Complaint Encounter Reason Q Bite animal Bite insect Blisters Blood pressure test Boils History of Present Illness Burn scald Chest pain Common cold flu Canstinatinn Exhibit 06 006 D Many fields are preceded by a negative sign enclosed in an oval enclosure like the two shown in Exhibit 06 007 When you click it the sign changes to positive and a square icon appears at the end to call the popup window with predefined values as can be seen in Exhibit 06 008 This toggle feature shows absence or presence of any factor When the field is negative the default inscription for negative findings will appear in the field and editing is not permitted When it is clicked to positive the default inscription disappears and the field is ready for insertion You may either write your own finding or select pre defined values from the popup window that will appear at the click of the square icon at the end of the field The popup window is shown in Exhibit 06 009 identified by the red arrow WEB EMR NEXT User Manual lt gt gt Physical Examination Constitutional Eyes lt m Neck V Thyroid Exam Respiratory Exhibit 06 007 Physical Examination Constitutional Eyes Nec
340. s delete them by clicking the trash can icon at the left of the respective field EMR NEXT User Manual lt gt For each field as many rows as required for values in the dropdown list of the field by pressing the black down arrow under the first two rows of the respective field If you have added extra rows they can be deleted by clicking the trash can icon at the right of the respective row Write the name of each of the field Write the values of the dropdown lists of each field in the rows you have made available for each field For example we created two fields and gave them the names First Field and Second Field as shown in Exhibit 09 120 For each field we created three row values The values for the first field are First Option Second Option and Third Option For the second field the values are Fourth Option Fifth Option and Sixth Option If you want this block to initially appear in opened state on charts keep the checkbox checked If you want it to appear initially as de activated uncheck the checkbox Click Ok The Add window will close and the block will be created on the template Save the changes Now when you open a new chart the block will appear on the Form as shown in Exhibit 09 121 for simplicity and uniformity we have opened the new block as the first block on the chart It is named Fifth Block In Exhibit 09 122 the dropdown list on the Second Field is open Please note th
341. s block on the form template click the cut button The blue boundary around the block will turn red indicating that block is ready to be shifted Now click the yellow Add New Block Icon of the location where you want to relocate the block A small two button window opens with the Paste and Add buttons Click the Paste button The block will relocate to this position Delete If you wish to delete the block altogether click the Delete button The block will remove from the template Section 09 04 01 shows how to restore the block Edit When you click the Edit button the following Edit window opens EPI EMR NEXT User Manual lt gt e Initially show Onset as a free text data entry field C Initially show Onset as a fixed format date field There are currently 19 entries in your Favorites List for this block You can always manage your favorite lists by visiting Lists Menus section under Primary Configuration tab above If you would like to add or delete items right now just click HERE and it will open the Diagnosis Codes edit window for you on this very screen v Initially display in Opened state Exhibit 09 213 The window shows you how many entries you have in the Pick List for this block and how you could manage the list Two kinds of editing are possible for this block 1 To initially show the Onset field as a free text field or to show it as a fixed format date field with dat
342. s button allows saved reports to be opened in edit mode Save them again after editing 8 To print or fax the report click this button 9 This formatting toolbar is available on Referral Letter Consultation Note Encounter Note Excuse Letter and the Custom Reports In any report the editable portions appear in a slightly darker shade while un editable portions appear on the background yellow canvas Only those reports pertinent to the encounter form from which the Print Fax Encounter Related Documents window has been opened can be viewed or printed To print a report created from some other encounter form open the Print Fax Encounter Related Documents window from that encounter form But all documents created from any encounter form may be viewed or printed from the Document Viewer available on the General Form of the patient chart Section 06 01 01 Item 4 on Exhibit 06 014 EMR NEXT User Manual lt gt 06 03 16 02 01 Report 1 Prescription Back Exhibit 06 269 shows the Prescription Report in the Print Fax Encounter Related Documents window First Cardiology Clinic 1001 Parkway Drive Chester AL 23866 Tel 234 598 5589 Fax 234 567 8902 PRESCRIPTION Name Smith John f DoB Feb 25 1943 Sex Add 125 ABC Drive Any City Any State Any ZIP Cd R 0 Childrens Allergy Fastmelt TAB disintegrating Quantity 30 Thirty D QD 3 Three 8 R Senad
343. ser Manual lt gt 09 01 04 09 Chief Complaint CC Phrases Back The Chief Complaints are used in the Chief Complaints Block in the Encounter Form Section 06 03 03 Exhibit 06 142 When you click the block icon on the block the Chief Complain Encounter Reason Window shown in Exhibit 06 143 opens The complaints listed in the window are managed from here in the Customization Area When you click the Open button on the field identified as item 4i in Exhibit 09 002 the Add Delete CC Phrases Window opens Add Delete CC Phrases x Master usc Qu Your Favorites Abdominal pain Abdominal pain Abnormal appearance of eyes Abnormal appearance of eyes Allergy symptoms Allergy symptoms Ankle symptoms Ankle symptoms Anxiety nervousness Anxiety nervousness Back symptoms Back symptoms Bedwetting Bedwetting Bite animal Bite animal Bite insect Bite insect Blisters Blisters Blood pressure test Blood pressure test Boils Boils Burn scald Burn scald Chest pain Chest pain 9999 00900 Commnn cold flu Common cold flu Add Your Own CC Phrases Constipation Cough 01 Cough barking Exhibit 09 079 b Eb Eb Eb Eb Eb Eb amp Ep Eb Ep 1 The left side of the window is for the Master List of Chief Complain Phrases The list has more than 70 entries None of these phrases will appear in your list of favorites unless you make them
344. st Block EP EMR NEXT User Manual First Cardiology Clinic Chart ID 00001 Doe John First Block Encounter 2 Date May 22 2013 Type Referred by Attended by Davis Richard MBBS BA 12345678 Received Details Payment type Billing not required Note for Biller Chief Complaint Encounter Reason History of Present Illness Exhibit 09 165 Photograph Click To Attach Physical Examination a Constitutional 2 Eyes Neck Respiratory Cardiovascular Breasts Gastrointestinal Genitourinary Female Genitourinary Male Lymphatic Musculoskeletal Skin Neurologic Whenever there is an entry in this block the Patient Invoice if Patient Invoice is issued and the Super Bill will both include the amount If the amount is to be recovered through the Super Bill then amend the amount in the Patient Invoice to Zero EMR NEXT User Manual lt gt lt gt 09 04 01 02 Block with Multiple Free Text Fields Back When you click the second radio button in the User Definable Blocks section of the Add Blocks window Exhibit 09 162 and press the Continue Button the following Add window opens v Initially display in Opened state X Billable Procedure Code Exhibit 09 166 Write the name of the block in the white field on the top Add as many rows as required by pressing the black down
345. stem will take you to the printer options on the computer laptop tablet operating system 23 The remarks that are added from the options are show here wa EMR NEXT User Manual lt gt Options Delete this Refill Exhibit 06 261 Clicking the options button on the Refill Writer item 20 Exhibit 06 260 pops the Options window 24 To delete the Refill Request select this radio button and press OK item 26 An alert will raise Exhibit 06 263 before deleting the Request Press Yes Delete It to delete press Don t Delete to abort deletion action 25 To add remarks to the Refill Request select this radio button write the text of the remarks in the provided field and press OK item 26 A locked refill cannot be deleted or further edited Are you sure you want to lock it Lock Refill Exhibit 06 262 you sure you want to delete this refill from database u Yes Delete It Exhibit 06 263 3 View Add Addendums This button also activates when the form is locked When clicked the Addendums to Encounter window pops The window has two sections Upper pane for existing addendums and lower narrower pane for the new text EVI EMR NEXT User Manual lt gt Addendums to Encounter 9 Existing addendums B Davis Richard MBBS Monday April 22 2013 7 12 19 results are expected after one month Re call if requ
346. surance Company If your clinic is located in USA the field seeks Zip Code For all other countries the field asks for Postal Code This will be populated upon selection of the insurance company if all data requirements have been completed while defining the insurance company in the database Otherwise write the Zip Code Postal Code manually 5 The country in which the Secondary Insurance Company is located This will be populated upon selection of the insurance company if all data requirements have been completed while defining the insurance company in the database Otherwise write the name of the country manually 6 The State Province of the Secondary Insurance Company If your clinic is located in USA the field requires the name of the State For all other countries name of the Province is sought This will be populated upon selection of the insurance company if all data requirements have been completed while defining the insurance company in the database Otherwise write the name of the State Province manually 7 The Secondary Insurance Company s telephone number This will be populated upon selection of the insurance company if all data requirements have been completed while defining the insurance company in the database Otherwise write the telephone number manually 8 The Secondary Insurance Company s fax number This will be populated upon selection of the insurance company if all data requirements have been complete
347. t and clicking on the Delete button at the bottom left of the Document Viewer The system will raise an alert confirming whether the file is to be deleted or not Exhibit 06 035 Click Yes to delete and No to abort deletion action Signed Document Delete this File Delete this File Exhibit 06 035 Exhibit 06 036 But if the document is locked it cannot be deleted and when the Yes button is clicked to delete the document the red notation of Signed Document appears on the window as shown in Exhibit 06 036 In this case click No to exit Flag Document If you need to review or work on a document later on you may as a reminder flag it Flagged documents are viewable from the Dashboard Section 07 Item 5 discusses this aspect in detail To flag a document open it in the Document Viewer and click the Flag Button Whenever a flagged document is opened a red asterisk appears on the Flag button Exhibit 06 037 To remove flagging click the Flag button again EE EMR NEXT User Manual lt gt Document Viewer x Smith John Patient Invoice Encounter 9 First Cardiology Clinic Medication L 1001 Parkway Drive Chester AL 23866 H Laboratory Tel 234 598 5589 Fax 234 567 8902 Radiology Consultation 3 Name Service Date CJ Hospital Smith John Apr 16 2013 Address Service Type 123 ABC Drive Any City Any State Any ZIP Cd
348. t x Misc _ Prostate Screening Date Hote Next x Misc Screening Mammogram Date Note Next x Misc Screening Pap Smear Date Note Next x Misc k Exhibit 06 087 EMR NEXT User Manual The Health Maintenance Block records the procedures performed on the patient Its placement on the History Form is identified as item 4 on Exhibit 06 074 The system has six pre installed procedures in this block Influenza Vaccine Pneumococcal Vaccine Colorectal Screening Prostrate Screening Screening Mammogram and Screening Pap Smear Other procedures and vaccines may be added to the form or any of these deleted suiting your practice Section 09 03 05 shows how to add or delete procedures from the Health Maintenance Block The exhibit shows one set of entry for each element You can add as many sets of entries as required for any element by clicking the down arrow at the end of the element You may delete the added entries by clicking the cross x icon at the right of each set of entry but the original set cannot be deleted It will be cleared As you can see in Exhibit 06 087 the data requirement of the first two elements is different from that of the last four This is because the first two elements are vaccines while the other four are procedures The system recognizes a vaccine by the CVX code defined for it see section 09 03 05 for defining elements and their CVX codes All elements without CVX cod
349. t 06 134 This block is a part of the Subjective Section of the encounter under the Center for Medicare amp Medicaid Guidelines for taking patient history History of Present Illness Location pr quality x severity Duration Q Em Onset Timing sontes 9 5 Modifying Factors Signs Symptoms Exhibit 06 144 1 Define the present illness either manually or by selection from the History of Present Illness Window that pops when you click the block window icon on the top right of the block The upper section of the HPI window shows the illnesses recorded in the previous encounter The lower section lists you favorite HPI phrases that you have defined in the database Section 09 01 04 10 shows how to define favorite HPI phrases Multiple entries may be selected Selections may be integrated with manual comments 2 Specify the location of the illness here Either specify manually or select from the Location Window which pops when the field window icon is clicked Exhibit 06 146 shows the Location Window Selection from window may be mixed with manual noting In case multiple illnesses are selected in item 1 use of manual comments to identify the location of specific illnesses is recommended EMR User Manual lt gt Specify the Quality of the illness here Either specify manually or select from the Quality Window which pops when the field
350. t 8 Visit Super Bill 196 06 03 16 02 09 Report 9 Patient Invoice 198 06 03 16 02 10 Report 10 Excuse Letter 201 06 03 16 02 11 Report 11 Face Sheet 203 06 03 16 02 12 Report 12 Face Label 206 06 03 16 02 13 Reports 13 to 20 Custom Reports 207 06 03 16 03 The third button on the Utility Buttons Block 208 07 The Dashboard 209 08 The Scheduler 229 09 Customization 245 09 01 Primary Configuration 247 09 01 01 01 Clinic Information 251 09 01 01 02 Provider Information 254 09 01 02 01 Pointer Targets amp Buttons 257 09 01 02 02 Prescriptions amp Orders 259 09 01 02 03 Default Notes amp Letters 262 09 01 02 04 Custom Letters and Handouts 267 m EMR NEXT User Manual 09 01 02 05 Document Folders 270 09 01 02 06 Form Validation and other Rules 272 09 01 02 07 Clinical Decision Support Rules 275 09 01 03 01 Insurance Companies 281 09 01 03 02 Pharmacies 284 09 01 03 03 Physicians 287 09 01 03 04 Laboratories 290 09 01 03 05 Radiology Clinics 293 09 01 03 06 Hospitals 296 09 01 04 01 Diagnosis Dx Codes 299 09 01 04 02 Procedure Px Codes 303 09 01 04 03 Evaluation amp Management EM Codes 307 09 01 04 04 Medications 311 09 01 04 05 Laboratory Orders 314 09 01 04 06 Radiology Orders 316 09 01 04 07 General Orders 318 09 01 04 08 Visit Types 320 09 01 04 09 Chief Complaint CC Phrases
351. t Cardiology Clinic Photograph Click To Attach Encounter 1 Date Apr 26 Type Reviewed Past Family and Social History Physical Examination Referred by _ Constitutional Attended by Davis Richard MBBS BA 12345678 C Eyes ENMT Received Details Payment type Billing not required j C Respiratory Note for Biller E per o Breasts Chief Complaint Encounter Re E Genitourinary Female C Genitourinary Male E Lymphatic History of Present Illness skin Neurologic E Psychiatric Quality Severity Duration Onset Timing Context Assessment Diagnosis Modifying Factors Signs Symptoms Vital Signs BP PR bpm Ht cms Waist cms Tp ms RR cpm Wt kgs 5 2 Review of Systems Orders Requisitions E General 1 Eyes ENMT Cardiovascular Medications Rx E Respiratory 1 Rx Gastrointestinal Sig E Genitourinary Male Genitourinary Female A Musculoskeletal skin 7 A Neurologic Psychiatric C Endocrine Hematologic Lymphatic i C Obtained old records E Allergic Immunologic C Interpreted tests data E M Code e Follow up Visit Procedures Services Join Work School 1 Code Desc x WES C Refer this patient Exhibit 06 134 EMR NEXT User Manual Ongoing Problems New Assessments Qty Ref L Summarized old records L Discussed Reviewed t
352. t and 58 pixels or less in width with white or transparent background As such in case of a scanned image you may need to avail services of someone with expertise in graphics to edit and ar resize it Once you have the image of correct size on your hard drive just choose the file using Select button and the image would show up in the display area EMR NEXT User Manual lt gt 09 01 01 02 Provider Information Back Edit Provider 4 Provider Information ps sue woos Ee Ear in 4 Enable Scheduling Duration 05 min 10 15 min Q Q session c Rxs Orders Notes Rxs Orders Notes Rxs Orders Notes Optional JPG GIF or BMP image 36 pixel 3 8 inch OR LESS in height and 168 pixel 1 3 4 inch OR LESS in width Exhibit 09 005 The Edit Provider Window shown in Exhibit 09 005 opens when you click the Edit button on item 1b in Exhibit 09 002 You may change the particulars of your practice clinic from here Fields marked with asterisk require mandatory input and cannot be left blank 1 Your name as the practitioner can be changed from here Start with Last Name then First Name and then the Middle Name Initial 2 Edit your suffix from here Options include MD MD FACC APRN MBBS selectable from the dropdown list on the field
353. t timeslot is partially booked For example a 40 min appointment booked when the normal slot duration was 10 min will become stale if the normal slot duration is changed to 15 min as the third last slot will only be partially filled 15 15 10 Displaced appointments are also called stale appointments e Stale Appointments An appointment that was initially booked for one or more complete timeslots but later on due to changing the normal slot duration from the customization screen the appointment is not fitting completely in the available timeslots due to which the last timeslot is partially booked For example a 40 min appointment booked when the normal slot duration was 10 min will become stale if the normal slot duration is changed to 15 min as the third last slot will only be partially filled 15 15 10 Stale appointments are also called displaced appointments EMR User Manual lt gt 03 You Should Know Back 1 Many fields have dropdown lists associated with them If there is a dropdown list on a field it will open when you click in the writing space of the field Free writing is not allowed in such fields unless and until they are combo boxes a combination of free type and dropdown list 2 There are two types of combo boxes Exhibit 03 001 shows the first type E M Code Code Basis Join Work School This is free type field after 2 weeks E M Code after 3 weeks
354. tact person at the pharmacy here This field is for the pharmacy s address This field is for the pharmacy s city county etc Specify the pharmacy s zip code postal code here Specify the insurance company s country here Initially the country in which your practice is based will come selected Change if the pharmacy s country is different from your country though this is highly unlikely Specify the pharmacy s State Province here Initially the State Province in which your company is based will come selected Change if the pharmacy s State Province is different from yours 10 Specify the pharmacy s telephone number here 11 Specify the pharmacy s fax number here EMR User Manual lt gt 12 Specify the pharmacy s email address here 13 Click the Save button to save the insurance company s particulars NPI EIN PIN PVN SSN TIN Exhibit 09 039 EFI EMR NEXT User Manual DEA DPS NSC UPIN OSCAR BCID BSID Champus Medicare Medicaid Medi Cal License Group Other lt gt lt gt 09 01 03 03 Physicians Pack Patients will frequently be referred to you by other doctors and you will also be referring them to other doctors The names of the referring doctors or the doctors to whom you refer the patients need to be recorded in Encounter Forms The names of referring doctors are recorded in the Encounter Statistics Block
355. te each item on a new page Print Area width 3 25 inch 4 00 inch 4 50 inch Page width Print Area Height When printing all items on one page amp 4 50 inch 5 50 inch 7 50 inch Page height When printing each item on a new page 3 25 inch O 4 50 inch 5 50 inch 7 50 inch Print Area Alignment Left side of the page 7 Center of the page entire block shifts CO Include SSN on Rx orders CO Include MRN on Rx orders Do not include S5N MRN Do not show Item on Rx V Enable tamper resistance on Rx D Do not insert page header for use with preprinted stationery Use Prescription Blank format when printing each med new page Enable access to an external e prescription website from within the program 2 Exhibit 09 007 V Enable access an external e prescription website from within the program 2 website LIRL 2 2220 example https eprescribe allscripts com Exhibit 09 008 The Edit Prescriptions Orders Settings Window shown in Exhibit 09 007 opens when you click the Edit button on item 2b in Exhibit 09 002 Settings of this window are limited to Prescriptions and Laboratory Orders Radiology Orders and General Orders referred simply as Orders in the remaining part of this section The window performs following functions 1 On EMR Next you may either print each medicine as a separate prescription or combine them on o
356. tem 15 of Exhibit 06 07 The block contains information of the patient s guarantor if any The block looks like this Guarantor Relation MOD Q Ph Name DOB 2 Gender Remarks Exhibit 06 066 1 Select the relationship of the guarantor with the patient from the dropdown list Exhibit 06 067 Options include Self Spouse Parent Child Other Institution 2 Guarantor s Home Phone Number Field is restricted to numerical values only If your clinic is located in USA or Canada the phone number auto formats to country standards 3 Specify Guarantor s Last Name First Name and Middle Name Initial 4 Guarantor s Date of Birth is selectable from dropdown list Exhibit 06 068 5 Select Guarantor s Gender from dropdown list Exhibit 06 069 Options include Male Female Transgender 6 You may write any remarks here pertaining to the guarantor here The field is restricted to 80 characters If you click the Block Title Icon on the block an alert will be raised saying Closing this block would also reset its fields to their default values Are you sure you want to close it If you click the No button on the alert the action will abort But if you click the 62 EMR NEXT User Manual lt gt Yes button on the alert all entries made this block will clear the block will be de activated To reactivate the block click the Block Title Icon again
357. the Report Requisition the same title is also used for Radiology Order and General Order 3 Name address and phone number of the Laboratory that you either typed in the report manually or selected from the button EMR User Manual 4o gt 4 This is the button on clicking which the window opens with the names of the Laboratories in your database Exhibit 06 272 shows how the window with the names of the laboratories appears on the screen See Section 09 01 03 04 for how to add Laboratories to your database 5 This part shows the name and date of birth of the patient for whom the laboratory services have been requested 6 This part shows the list of the laboratory services ordered They are picked from the Orders Requisitions block of the related encounter form 7 This section shows the ICDs noted in the concerned encounter form 8 Space for your signature followed by your name and ID No 9 Date of the encounter form All fields in the darker shade are editable i e data called in from the original chart or encounter form may be edited added or deleted in these sections of the report First Cardiology Clinic 1001 Parkway Drive Chester AL 23866 Tel 234 398 5589 Fax 234 567 8902 REQUISITION My First Laboratory My Second Laboratory My Third Laboratory ICDs 789 00 Abdominal pain NOS 403 90 Asthma NOS 724 4 Back pain w radiation NOS EXHIBIT 06 272 EMR NEXT User M
358. the block in the Encounter Form The block has three buttons EMR NEXT User Manual lt gt 06 03 16 01 The first button on the Utility Buttons Block Back When you click the first button the following window pops up Encounter10 Encounter 10 ad Refill Medications View Add Addendums Exhibit 06 254 Exhibit 06 255 The window opens in the Exhibit 06 254 state if the encounter form has not been locked The first button is active and the second and third are de activated see section 06 03 16 03 for locking The window opens in the Exhibit 06 255 state if the encounter form is locked The first button is de activated and the second and third are active see section 06 03 16 03 for locking EMR NEXT User Manual lt gt 06 03 16 01 01 Deleting Encounter Forms Back When you click the Delete this encounter button the system raises this alert Are You Sure You Want To Delete Encounter 10 Of Patient 00002 Yes Delete Encounter EXHIBIT 06 256 Click Don t Delete to abort deletion action click Yes Delete Encounter to delete the encounter form Only the last encounter form may be deleted First open the last encounter form and then go for deletion If you have opened any earlier encounter form you will be unable to delete the encounter Once the last encounter form has been deleted the second last encounter becomes the last encounter
359. the total encounters should be 4 but instead only 1 is being shown This shows that the scheduler has not been managed correctly There were three more missed appointments which were not marked accordingly marking missed appointments is discussed in notes to item 13 as No Show appointments 15 This icon is for the Scheduler s Note Pad Clicking this icon opens the Note Pad Exhibit 08 016 The Note Pad is not specific to any chart Notes may be written and deleted on an ongoing basis Notes are saved by clicking the Save button on the right To clear the entire notepad press the clear button and then the save button When the notepad is clear the icon is transparent When notes are written the icon turns yellow 16 If you want to see the Monthly Planner click this button The monthly plan will open as in Exhibit 08 017 Booked slots are shown in Blue as in item a on the Exhibit Holidays non working days are shown in grey as in item b on the Exhibit If you want to take a print of the monthly plan click the print icon marked as item c To go back to the daily schedule click Day View Notes to Item 13 The functionality of the four icons on the viewing pane as mentioned in item 13 and shown in Exhibit 08 007 is as follows The first icon is for canceling the appointment An alert pops to confirm that you want to cancel the appointment Exhibit 08 018 Click Yes Delete it to cancel the appointment and Don t
360. tion tab above If you would like to add or delete items right now just click HERE and it will apen the Diagnosis Codes edit window for you on this very screen v Initially display in Opened state Exhibit 09 157 EMR NEXT User Manual lt gt 09 03 09 Editing the Master Medication List Block Pack When you click the Edit Template Block Icon of the Master Medication List Block a small three button window opens as shown in Exhibit 09 158 The buttons include Cut Edit and Delete Master Medication List i SIE Status Leas am mmm Exhibit 09 158 Cut If you wish to change the location of this block on the form template click the cut button The blue boundary around the block will turn red indicating that block is ready to be shifted Now click the yellow Add New Block Icon of the location where you want to relocate the block A small two button window opens with the Paste and Add buttons Click the Paste button The block will relocate to this position Delete The Delete button is in white color indicating that the block cannot be deleted altogether from the template Edit When you click the Edit button the Edit window shown in Exhibit 09 159 opens Two editings are possible in this block 1 The Signature Field in the Master Medication List can initially either appear as a free
361. tional Eyes A Genitourinary Male Musculoskeletal E Neurologic 1 Psychiatric Genitourinary Female o Lymphatic Gastrointestinal E Respiratory Cardiovascular LI i 1 1 LI LI LI LI LI LI LI LI 1 1 1 LI LI 1 LI LI LI LI LI LI i i i i i I Ps E EEE I mali i E bo 1 1 1 1 2 1 0 1 I i28 m i i i mimi i i pum i amp i i i lz i as i 18 1 1 YW Q i i E 1 1 1 W 1 ts i gt i i 0 E 1 LI LI LI LI LI LI BLUE s jg s B ig B Bi io DE m i 1 1 i o ere Si 4 2 07 O i Im 3 gt OD 1 1 1 1 Ci o E 1 10 TI 8 2 i i o iG 2 i 12 2 21 i MI i Ul 4 a LI 4 LI Locati
362. tra rows have been created delete them by clicking the corresponding trash can icon WOIZ I amp EMR NEXT User Manual lt gt The Phrase for Normal Finding if any field next to the element name is for specifying a phrase like for example No Family History which will appear in the form whenever the findings for this element are normal To specify the phrase click the square icon at the end of the field The field it will turn blue as shown in Exhibit 09 148 ready for inscription Second Tier Editing For each of the fourteen elements below the Normal Finding Phrase is a list of Abnormal Findings These are the relationships in which the disease prevails prevailed If you wish to remove any of these relationships from the list uncheck the corresponding checkbox and the relationship will remove from the list of this element If you wish to add more relationships click the black down arrow under the last row and more rows will be added as shown in Exhibit 09 149 Now specify the name of the relationship To remove a row created by you click the corresponding trash can icon Please note that changes made to one element are not automatically applicable to all elements Values of each element have to be changed individually Family History V Diabetes Phrases far Abnormal Findings Aunt Brother Children Father Grand Father Grand Mother Mother Sister Spouse wv Initially display in O
363. trieved unless a previous backup is installed See Section 11 and all record of the patient will be lost When the button is clicked the system will raise an alert Exhibit 07 029 Click Yes Delete Chart to delete or click Don t Delete to abort deletion action After deletion system will raise an informative alert to show action has been completed Exhibit 07 030 Schedule This button is clicked if you want to schedule an appointment for the patient The scheduler will open with the patient s name chart ID and Phone Number called in relevant fields of the scheduler Exhibit 07 031 The scheduler will open on the current date Navigate to desired date to make the appointment Scheduler is discussed at length in Section 08 Phone Notes If you want a phone note to the patient s chart click this button The Phone Notes Window will open showing existing notes Exhibit 07 032 Click the ves EMR NEXT User Manual lt gt Add Note button to add the note Detailed functionality is discussed at Item 2 Section 06 01 01 Documents If you want to view patient s documents or import a new one click this button The Document Viewer will open as shown in Exhibit 07 033 View the documents or import them as the case is Document import function has been discussed in detail in Item 4 Section 06 01 01 Refill Meds This button enables you to make Medicine Refill Requests Clicking this
364. ts t by name v EMR Backup Monday May 6 2013 6 23 EMR Backup Thursday April 18 2013 7 5 EMR Backup Thursday May 23 2013 5 1 EMR Backup Thursday May 23 2013 7 0 Select This Backup Exhibit 11 005 EMR NEXT User Manual lt gt Files emp Backup Thursday May 23 2013 7 00 55 AM 000010 000031 000081 222 KB 9 9 KB 3 71 KB 36 4 KB 000011 000061 000090 5 2 3 2013 5 11 26 12 7 7 3 27 2013 6 26 AN 2 26 2013 222 KB 31 5 KB 3 88 KB 31 3 KB 000020 000041 000070 000091 5 20 2013 3 22 A 3 26 20 3 23 2013 4 34 Al 3 26 2013 013 6 30 AM 377 KB 31 5 KB 3 87 KB 31 3 KB 000021 000050 000100 5 21 2013 6 21 AN 5 18 2013 4 54 AM 22 2013 11 53 PM 3 22 2013 6 35 A 377 KB 65 2 KB 3 67 KB 3 66 KB 000030 000051 000080 3 22 2013 6 24 AM 5 18 2013 5 41 AM 4 3 2013 6 43 AN 000101 66 KB 65 3 KB 36 4 KB 3 68 KB Select This Backup Exhibit 11 006 Restore successtully completed You need to restart the EMR program to apply changes Click the below button to close it down After closing please restart it manually as you noramlly do Exhibit 11 007 4 EMR User Manual lt lt 12 Navigation Guide Back Item 9 on Exhibit 05 001 on the Homepage Section 05 is the Navigational Guide or the menu in descriptive form It operates in the same manner as the iconic menu FURTHER SUPPORT Every effort has been made to make this guide as complete a
365. tus Active ee Ampicillin 2 Allergen Aspirin x Aspirin Reaction Status Active Bactrim a Ceftin Cefzil Exhibit 06 082 Your Favorites Amoxil Ampicillin Aspirin Bactrim Ceftin Cefzil Codeine Insulin Keflex Larnictal Milk or Lactose Intolerance Peanuts Known Allergies Exhibit 06 083 There are allergies already listed in this block You must first delete them manually before the changing to No Known Allergies status EMR NEXT User Manual lt Exhibit 06 084 Are you sure you want to change the status of Known Allergies block Exhibit 06 085 Known Allergies i Mo Known Allergies Exhibit 06 086 If you do not need the Known Allergies block click the square icon before the block title block icon to clear and de activate the block Click it again to re activate it Click the block icon twice to refresh the block As already said in the last sentence of the first paragraph of this section the cross icon at the right of the set of entries deletes the corresponding set All but the last sets may be deleted The last set will be cleared but will not delete EMR NEXT User Manual lt gt gt 06 02 04 Health Maintenance Block Back Health Maintenance Influenza Vaccine Date Note Next x Dose Lot _ Pneumococcal Vaccine Date Note Next x Dose Lot MER Colorectal Screening Date Note Nex
366. tus Marital Status Camie es Address AL JPlar Secondary Insurance Cami es Ath Address __ Pla Ep Remarks Guarantor Name Remarks Referral Details Name Received 75 00 in Cash Payment Type Copayment Notes for Biller Billing required Yes Note Ignore Exhibit 07 025 6 Item 6 on Exhibit 07 001 is the viewing pane The pane has a dual functionality It is used also for the findings of Search Results as well as for List of Flagged Items EMR User Manual lt gt A small yellow margin the Search Results Bar or the Flagged Items shows the mode in which the viewing pane is currently Item a on Exhibit 07 026 shows that the viewing pane is currently in the search mode while Item b on Exhibit 07 027 shows that the viewing pane is currently in the flagged documents mode 3 Dashboard I Customize Total charts in database 14 No results to display Find Charts Where e SSN MRN LAST NAME FIRST NAME AGE PHONE Phone Last Name Birth Date O O First Name O Visit Date Age amp Gender 1e Import Export Import Scanned Files Export Superbills Exhibit 07 026 3 Dashboard Scheduler Ti Customize Total charts in database 14 5 flagged documents FLAG DATE PATIENT NAME CHART DOCUMENT TITLE DOCUMENT TYPE Find Charts
367. u can create additional folders on EMR Next and edit their names from here When you click the Edit Button on the field the Edit Folders Window opens The window is discussed in Section 09 01 02 05 Forms Validation amp Other Rules There are certain Form Validation Rules which are applied when the Encounter Forms are saved These rules may be enforced or waived from here When you click the Edit Button on the field the Edit Forms Validation amp Other Rules Window opens The window is discussed in Section 09 01 02 06 Clinical Decision Support Rules If certain medicines react with other medicines or if certain medicines cause allergies etc you may wish to avoid using such medicines etc Such rules can be made from here When you click the Edit Button on the field the Edit Clinical Decision Support Rules Window opens The window is discussed in Section 09 01 02 07 3 This part maintains lists of institutions and individuals which you will need in your day to day work on the system These include EE EMR NEXT User Manual Insurance Companies Maintenance of list of Insurance Companies is discussed in detail in Section 09 01 03 01 Pharmacies Maintenance of list of Pharmacies is discussed in detail in Section 09 01 03 02 Physicians Maintenance of list of doctors is discussed in detail in Section 09 01 03 03 lt gt lt 4 gt gt Laboratories Maintenance of list of Laborato
368. u for providing the opportunity to serve you Sincerely Davis Richard MBBS Signature Stamp Exhibit 08 022 Print Fax No Show Letter x Smith John First Cardiology Clinic 1001 Parkway Drive Chester AL 23866 Tel 234 598 5589 Fax 234 567 8902 May 6 2013 Smith John 123 ABC Drive Any City Any State Any ZIP Cd Dear Patient This is just a reminder to inform you that you have missed your appointment with me scheduled on Tue May 7 2013 at 09 00 AM We have tried to contact you by phone without success Please call us at 234 598 5589 to schedule another appointment Thank you for providing the opportunity to serve you Sincerely Davis Richard MBBS C Signature Stamp Exhibit 08 023 EMR NEXT User Manual lt gt Scheduler Customize Thu May 9 2013 s Smith Jack 111 222 333 Sun Mon Tue Wed Thu Fri Sat 26 27 ze 29 so Office Hours end at 04 00 pm 2 3 4 5 6 7 8 Reset To Today 09 30 am 10 00002 Smith John 123 456 789 Search Next Day Having Min Slot 02 15 pm 15 00014 Doe Smith 05 00 pm 15 00008 Smith Daniel 3 Exhibit 08 024 j Scheduler 9 2013 Customize z z s Hoon Fe se s oe e z gt aser as ss o n ps es Der o Search Next Day Having Min Slot 11
369. ug Address e 11th Street 5ea View Road City Alabama ZIF Code country D United States state AL Phone 123 586 5523 Qe 123 458 6565 Plan My First Plan SE ID No 6 Group 250 Auth Remark relation Name DOB Exhibit 06 059 Q Home Ph Gender 1 If you have already defined the patient s Secondary Insurance Company in the database Section 09 01 03 01 tells how it is done you may select the name from the dropdown list Exhibit 06 060 Otherwise write the name manually in the form If you have defined all required information of the Insurance Company ENT EMR NEXT User Manual lt gt lt gt in the database section 09 01 03 01 the first eight fields of this block will be automatically populated when you select the Secondary Insurance Company 2 Address of the Secondary Insurance Company This will be populated upon selection of the secondary insurance company if all data requirements have been completed while defining the insurance company in the database Otherwise write the address manually 3 The city the Secondary Insurance Company is located in This will be populated upon selection of the insurance company if all data requirements have been completed while defining the insurance company in the database Otherwise write the name of the city manually 4 Zip Code or the Postal Code of the Secondary In
370. use in a variety of situations All the above functions and changes in the system s parameters are carried out from the Customization area Location of the Customization Icon on the homepage is identified as item 6 on Exhibit 05 001 When this icon is clicked for the first time during a session the Customization Cover Page opens Q Dashboard Scheduler Customize 1 1 2 3 4 Primary Configuration General Form Template History Form Template Encounter Form Template Welcome to the EMR NEXT customizations Here you would be able to configure various aspects of your clinic and customize chart forms The customization area has been divided into 4 separate sections each corresponding to a tab at the top of the screen Below is a brief overview of these sections and tasks that can be performed therein Primary Configuration Tab You edit all information regarding your practice through this section including your own credentials and schedule etc Furthermore all auxillaries such as insurance companies laboratories and pharmacies associated with your practice are managed from this tab You also customize most of the lists and menus from here that are used at various places in the system And finally you can also set various preferences on this screen General Form Template Tab A patient s chart is comprised of three forms please see the NOTE below This tab encompasses the template for the first form of charts wher
371. ut only Auto formatting applies according to US standards if your practice is based in USA EMR User Manual lt gt 8 Save the patient s email address here 9 Free typing field for saving patient s emergency contact name amp address If you click the Block Title Icon on the block an alert will be raised saying Closing this block would also reset its fields to their default values Are you sure you want to close it If you click the No button on the alert the action will abort But if you click the Yes button on the alert all entries made in this block will clear and the block will be de activated To reactivate the block click the Block Title Icon again EMR User Manual lt gt gt 06 01 04 Work Information Block Back Work Information Block on the General Information Form is identified at Item 10 of Exhibit 06 07 Work Information Block looks like this Work Information Status D gr Em oloyer gt Work Ph Exhibit 06 045 1 Work Status can either be selected from the dropdown list or may be inserted manually Selectable options include Employed Unemployed Retired Full time student Part time student Exhibit 06 046 2 Write the name of the employer in this field Field accepts up to 40 characters so if the name is longer try to abbreviate shorten wherever possible 3 Work Phone The field is restricted for numeric
372. ute Frequency and Duration values selectable from dropdown lists To show it as a free text field keep the radio button on the first value To show it as a combination of values field change the radio button to the second value 2 To either open it in Opened activated state on a Encounter Form or in de activated state To open it activated on new Encounter Forms keep the checkbox marked To open it de activated uncheck the checkbox After editing click the OK button and Save the changes EMR NEXT User Manual lt gt 09 04 13 Editing the Plan Notes Block Back When you click the Edit Template Block Icon of the Plan Notes Block a small three button window opens as shown in Exhibit 09 218 The buttons include Cut Edit and Delete cut Edit Delete NNNM Plan Notes Exhibit 09 218 Cut If you wish to change the location of this block on the form template click the cut button The blue boundary around the block will turn red indicating that block is ready to be shifted Now click the yellow Add New Block Icon of the location where you want to relocate the block A small two button window opens with the Paste and Add buttons Click the Paste button The block will relocate to this position Delete If you wish to delete the block altogether click the Delete button The block will remove from the template Section 09 04 01 shows how to
373. vorites that you have prepared either by selection from the Master List or by writing the phrases yourself or as a combination of both 6 If you want to delete the Reason For Referral Phrase from your list of favorites click the corresponding trash can icon If the phrase was selected from the Master List it will still be available for re selection there but if you had yourself written it it will be lost 7 Save the changes made to the list by clicking the Save button In Exhibit 09 083 the button is in white color because it is not activated yet It activates whenever a change is made in the window If you try to close the window without saving the changes the alert shown in Exhibit 09 084 will raise 8 The Reset button clears all unsaved changes In Exhibit 09 083 the button is in white color because it is not activated yet It activates whenever a change is made in the window You need to click SAVE button below to keep the changes you have made to this favorite list Do you want to close this window without saving Exhibit 09 084 EMR NEXT User Manual 4o gt 09 01 04 12 Plan Notes Phrases Back Plan Notes Phrases are used in the Plan Notes Block in the Encounter Form Section 06 03 12 Exhibit 06 231 When you click the block icon on the block the Plan Notes Window shown in Exhibit 06 232 opens Entries in this window are managed from here in the Customization Section When you click th
374. w The alert will close Now click on the name of the patient in the dropdown list The Pull Chart Window will open with the Chart ID mentioned in the Chart ID slot Exhibit 05 005 Click Pull Chart to call the Chart X ET fee Lag 1 At least 1 chart with the name Smith John already exist Are you sure you want to create a new chart with this name Cancel Create Chart Last Name First Name Home Phone Chart ID Exhibit 05 004 Create New Chart Open Existing Chart Chart ID 00002 Cancel Pull Chart Exhibit 05 005 EMR User Manual lt lt If you want to open existing chart from here select the Open Existing Chart button item a Exhibit 05 002 The appearance of the window slightly changes from that shown in Exhibit 05 002 Create New Chart Open Existing Chart Cancel Pull Chart Exhibit 05 006 a The Radio Button has been changed to Open Existing Chart b Chart Id field activates Insert Chart ID c Click Pull Chart to pull the chart d Click Cancel to abort chart pulling action If you do not remember the Chart ID use the quick search on the Last Name EMR NEXT User Manual C Create New Chart Open Existing Chart Chart ID Last Name First Name M DOB Home Phone Chart ID Smith e John 00002 smith smith Smith Smith Tom 00004 Nicola 00005 Jack 00006 Albert O00
375. we deleted the Past Medical History and Past Surgical History Blocks from the template Now the window looks as shown in Exhibit 09 107 Add Blocks X Past Medical History Past Surgical History Block With Single Freetext Field Block With Multiple Freetext Fields Block With Multiple Freetext Fields Extensible Rows Block with Single Dropdown Block with Multiple Dropdowns Block with Multiple Picklists Block With Large Freetext Area Block With Multiple Buttons O O O O O O O O O O O Block With Multiple Checkboxes Exhibit 09 107 Only Default Blocks can be restored in this manner If user created blocks are deleted they cannot be restored User Definable Blocks EMR NEXT User Manual lt gt lt gt In the second part of the window there are nine radio buttons These are the nine formats in which you can create the new block But one block can use only one format EMR User Manual lt gt 09 03 01 01 Block with Single Free Text Field Back When you click the first radio button in the User Definable Blocks section of the Add Blocks window Exhibit 09 106 and press the Continue Button the following Add window opens Initially display in Opened state Exhibit 09 108 Write the name of the block or the prompt of the field in the white space on the window If you want this block to initiall
376. window by clicking the square button at the end of the field as shown in Exhibit 06 098 The square button will appear only when you click the habit exposure to positive Select as many observations as required by clicking them and they will add to the field You can combine selection with manual inscriptions also The list window also allows you to clear the field or clear the last entry in the field Respective buttons are available at the top of the window Observations for any habit exposure can also be added to or deleted from the customization area see section 09 03 07 At the end of the Social History 4 EMR User Manual block is a free text area where you can write any general notes There is no restriction on the size of the note You can perpetually add to it or delete from it Alcohol Use Go mn Caffeine Use Tobacco Use Exhibit 06 097 Alcohol Use Alcohol Use Go BS Clear Field Undo Last Caffeine Use Heavy Tobacco Use Moderate Drugs Use Exhibit 06 098 If you do not need the Social History Block click the square icon before the block title block icon to clear and de activate the block Click it again to re activate it Click the block icon twice to refresh the block EMR NEXT User Manual lt gt lt gt 06 02 07 Master Problem List Block Pack Master Problem List m 1 Code Onset Nature x Desc Status Exhibit 06 099 Master Probl
377. ws how to restore the block EFI EMR NEXT User Manual lt gt 09 04 04 Editing the Chief Complaint Encounter Reason Pack Block When you click the Edit Template Block Icon of the Chief Complaint Encounter Reason Block a small three button window opens as shown in Exhibit 09 194 The buttons include Cut Edit and Delete EN IM LL Chief Complaint Encounter Reason um D Exhibit 09 194 Cut If you wish to change the location of this block on the form template click the cut button The blue boundary around the block will turn red indicating that block is ready to be shifted Now click the yellow Add New Block Icon of the location where you want to relocate the block A small two button window opens with the Paste and Add buttons Click the Paste button The block will relocate to this position Delete If you wish to delete the block altogether click the Delete button The block will remove f
378. y Glaucoma Family History lt gt lt gt 09 03 01 04 Block with Single Dropdown Pack When you click the fourth radio button in the User Definable Blocks section of the Add Blocks window Exhibit 09 106 and press the Continue Button the following Add window opens v Initially display in Opened state Exhibit 09 116 As the name suggests this block will have a single field with a dropdown list Write the name of the block which is also the prompt of the field in the white field on the left side Add as many rows as required for values in the dropdown list by pressing the black down arrow under the first two rows If you have added extra rows they can be deleted by clicking the trash can icon at the end of the respective row EET EMR NEXT User Manual lt gt Now write the values of the dropdown list in the fields For example we created five fields and gave them the names First Option Second Option Third Option Fourth Option and Fifth Option as shown in Exhibit 09 117 If you want this block to initially appear in opened state on charts keep the checkbox checked If you want it to appear initially as de activated uncheck the checkbox Click Ok The Add window will close and the block will be created on the template Save the changes Now when you open a new chart the block will appear on the Form as shown in Exhibit 09 118 for simplicity a
379. y s country is different from your country EMR NEXT User Manual lt gt 9 Specify the insurance company s State Province here Initially the State Province in which your company is based will come selected Change if the insurance company s State Province is different from yours 10 Specify the insurance company s telephone number here 11 Specify the insurance company s fax number here 12 Specify the insurance company s email address here 13 This section is for the insurance company s insurance plans The company may have several insurance plans You can feed as many insurance plans as required To delete the plan click the trash can icon before the plan 14 Specify the name of the plan here 15 Specify the amount which is co payable by the patient under the plan 16 To add more plans click the Add button 17 Click the Save button to save the insurance company s particulars DEA Champus DPS Medicare EIN NSC Medicaid PIN UPIN Medi Cal PVN OSCAR License SSN BCID Group TIN BSID Other Exhibit 09 036 EMR NEXT User Manual lt gt 09 01 03 02 Pharmacies Back Particulars of the patient s Pharmacy are required for issuance of prescriptions These particulars are required in the General Form on the patient chart in the Personal Information amp Patient Pharmacy Block in the field marked as item 8 on Exhibit 06 038 in Section
380. y there is a 3 10 character search available here on the list Exhibit 06 116 Type the key word and the system will take you to all entries with the key word For fast location from a long list of favorite medicines press the alphabet with which the problem starts and the system will take you to the first entry starting with the alphabet Exhibit 06 116 If an inactive medicine is prescribed again in a subsequent encounter the status will change to active If there are no known medications the status of the block must be changed to No Known Medications To do so open the Master Medication List Window There is a No known Problems button at the bottom of the window Exhibit 06 116 Click it to change the status If any medicines have been selected in the block the status will not change An alert will rise asking for the selected medicines to be deleted for changing the status to No Known Medications Exhibit 06 117 Delete the medicines and then click the button in the window again Another alert will rise confirming that the status is being changed Exhibit 06 118 If you click Yes on the alert the status will change and now the block will look like that in Exhibit 06 119 ENT EMR NEXT User Manual 4o gt Your a cou e gihjijrjgj jk il m Favorites nioilpiairisi tiul lviwi izxi iviz Abilify 10 mg TAB Abilify 20 mg TAB Benadryl Childrens Allergy Fastmelt TAB disintegrating Benadryl Cold
381. y appear in opened state on charts keep the checkbox checked If you want it to appear initially as de activated uncheck the checkbox Click Ok The Add window will close and the block will be created on the template Save the changes Now when you open a new chart the block will appear as this on the Form for simplicity and uniformity we have opened the new block as the first block on the chart It is named First Block EMR User Manual lt gt gt First Cardiology Clinic Photograph Click T Chart ID 00020 New 1 E First Block Family History Diabetes Past Surgical History ES Stroke Hypertension Heart Disease Cancer Past Medical History Hay Fever Arthritis Osteoporosis Known Allergies Hd Anemia _ Migraine 1 Allergen x MM Alzheimers Reaction Status Epilepsy Glaucoma Exhibit 09 109 EMR NEXT User Manual lt gt 09 03 01 02 Block with Multiple Free Text Fields Back When you click the second radio button in the User Definable Blocks section of the Add Blocks window Exhibit 09 106 and press the Continue Button the following Add window opens v Initially display in Opened state Exhibit 09 110 Write the name of the block in the white field on the top Add as many rows as required by pressing the black down arrow under the first two fields If you have add
382. yness Rasn Changes in hair or nails Exhibit 06 164 Neurologic Headaches Weakness or numbness Tingling Faints or blackouts Tremors Memory loss Exhibit 06 165 EMR NEXT User Manual Joint pain Jaint stiffness or swelling Muscle cramps Muscle aches Loss of strength Night sweats Poor wound healing ltching Flushing Changes in color of skin Poor balance Difficulty with speaking Difficulty with concentration Disturbances in coordination Brief paralysis Visual disturbances seizures Sensation of room spinning Excessive daytime sleeping lt gt Psychiatric Anxiety Nervousness Depression Memory change Frightening visions or sounds Thoughts of suicide or violence Exhibit 06 166 Endocrine Heat or cold intolerance Weight change Excessive thirst or hunger Excessive sweating or urination Exhibit 06 167 Hematologic Lymphatic Skin discoloration Bleeding Enlarged lymph nodes Fevers Abnormal bruising Exhibit 06 168 Allergic lmmunologic Seasonal allergies Hives orrash Persistent infections HIY exposure Exhibit 06 169 WOIIIIII EMR NEXT User Manual lt gt General Fevers Chills Sweats CD Appetite loss Weight loss Fatigue Exhibit 06 170 The block icon on the top right of the block pops the Review of Systems Window which shows the details o
383. ysician 4 1 Physician Name E 4 6 City County ZIP Code Femail Address Telephone 11 Fax aid Exhibit 09 041 1 Write the name of the doctor here 2 Write the doctor s ID number here 3 Specify the type of ID number by selection from the dropdown list on the field The types available in the dropdown list are illustrated in Exhibit 09 042 4 Write the doctor s Salutation Like MD MBBS etc here 5 This field is for the doctor s address 6 This field is for the doctor s city county etc 7 Specify the doctor s zip code postal code here 8 Specify the doctor s country here Initially the country in which your practice is based will come selected Change if the doctor s country is different from your country 9 Specify the doctor s State Province here Initially the State Province in which your company is based will come selected Change if the doctor s State Province is different from yours 10 Specify the doctor s telephone number here EMR User Manual 11 12 13 14 EIN PIN PVN 55N TIN lt gt gt Specify the doctor s fax number here Specify the doctor s email address here If you want the doctor s name to be included in the dropdown list only in the Encounter Statistics Block as a referring doctor click the first radio button If you want his her name to be included in the dropdown list only in the Refe

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