Admissions Class Manual - Office Administration
Contents
1. Function Keys MOX exercise Meditech Handouts MRI MRI Exercise Patient Search Types Standard Formats Outpatient Registration Routines Meditech Handouts Inpatient Registration Routines Screens Clinical Registration Edit Inpatient Registration Registration Exercises Registration Outpatient Types Review of Registration Types Interview Technique p NENNEN Test 3 Patient Registration Registration Inpatients and Related Routines Take Home Assignment Week Test 2 MOX SDC ER RCR Registration amp related routines Total Hours 24 Dates for Assignments and Tests will be discussed in class Final Mark out of 70 will be comprised of 50 from tests and assignments and 50 from the final exam The final mark from the OE CWS course will be out of 30 for a total course mark out of 100 Housekeeping Items 1 2 Attendance will be taken at all classes If absent arrange with a classmate for review Each class builds on the previous class You need to be here Test dates are set per handout Course content may vary in final 5 weeks paced by class No hotmail chat or internet during class You are here to learn Email is the best method to reach me with questions between classes Office Administration Hospital Info Systems Introductions Ralda Pearce Lakeridge Health Information Technology Department Applications Consultant formerly a Health Record Technician and Medica2. 2 Pre register yourself for a first visit on Apr 14 08 3 Be sure to choose the correct pre registration category for physio The location for physio is TP if using or Oshawa facility database Admit the Newborn for the baby from the patient Your first name O Brien Be sure to use the Newborn Registration routine O BRIEN BABY BOY or O BRIEN BABY GIRL Registration category Requested accommodation Service Entry Code should all be newborn Location is in the Nursery hint enter NU and press F9 lookup Edit the inpatient registration entered in the first scenario Add an allergy Aspirin Also change the address to 121 Simcoe St N Oshawa L1G 2B9 Discharge yourself and the baby to home OBRIEN YOURFIRSTNAME Part B Find the following information about the patients listed below 1 For unit 00000125 the patient s name is 2 For Daffy Duck DOB Oct 10 1910 the unit number is 3 For HCN 2633647074 what is the patients name 4 For Telephone number 905 985 4269 what is the patient s name 5 For patient Lois Leeman what are this patient s allergies 43 Complete Week 9 Homework assignment Office Administration Medical Homework Assignment Week 9 Registration Routines A patient can be in the system for a pending appointment out in the future When the patient arrives at the hospital they are if they are an inpatient or they are if they are an outpatient An inpatient can be moved to a new room or bed
3. continued see attached notes Q Practice Signon Viewing Screens in Meditech Terminology Mnemonic Dictionaries Unit unique number MRI and CPI Demographics Demo Recall Visit History Standard Format Menus and Routines Account Number och Pre and Registered Patient Status Patient Location Recurring Registration vs Revisits Customer Defined Screens and Queries Dictionaries MIS Dictionaries e Shared by many modules e Mnemonic with easy look up access e User Clinical Financial e Customer Defined Screens Examples of Clinical Location Room and Bed Provider Module Specific Dictionaries Contained within the specific module Supports using that module Mnemonics and easy look up access ADM specific examples religion account stack effective dates 15 Customer Defined Screens Used by many modules Provides the ability to collect data that is hospital site location or patient type specific Designed by the user Consists of queries put together in a screen that the user can answer the queries with text look ups Y N date number etc Can be required or not required Reports standard and NPR Standard Provided by the vendor Meditech e Fairly generic and usually requested by any client using the product e Cannot be edited or changed NPR Designed by the client usually an Applications Consultant in I T Response to a user request May be a list statistical o
4. follows the number separated by a dash e g 1231231231 Q if HCN not available and old 8 digit OHIP shown delete that number LHC MOH Health Care Number Release forms are used whenever there is a problem with a HCN eg invalid version code HCN not available etc and in Emerg the pt is given information with a phone number to call Ajax Registrations please inform patient to contact Business Office during office hours 50 SUBS INIT n a Leave blank if data exists here please linefeed out SUBS REL n a Leave blank if data exists here please linefeed out S I N required for WCB patients and those patients with insurance coverage entered as 123 456 789 all patients should be asked if their visit is WSIB related to ensure the hospital is collecting maximum revenue for that visit RELIGION enter the mnemonic as on the dictionary look up combined with the Affiliation the first 2 characters represent the religion eg AN Anglican not a required entry for pre registration or registration AJAX always fill in religion field only chose those religions that are recorded as other for affiliations eg ANOTH Anglican Other Ajax and Centenary religions are prefixed with V and Y respectively They are generic religions that don t get as specific with affiliation congregation as LHC does AFFILIATION n a leave blank EMPLOYER the employer field is not an optional field some employers have been entered
5. group which the patient visited on that date basis of statistical reports Menus Routines A menu is a user defined list of options available for registration of patients required for their job function Each individual option on the menu is called a routine Mnemonics Acode short form or abbreviation used to facilitate data entry and allow dictionary look up Patient Status e Defines the current status of the patient electronic registration i e a patient can be scheduled pre registered registered or discharged departed Patient lookup screens will display the patient status as well as the patient type i e REG ER is a patient registered in ER Recurring 6 Refers to a type of registration for patients who usually have a series of on going visits Registration Pre Registration Scheduled A patient is registered on the date when they are seen treated or admitted This involves entry of information specific to that visit The patient may have been pre registered where the same fields of information can be entered and then confirmed when the patient presents to be registered If the visit involves an actual appointment they may also have been scheduled Scheduled patients have minimal data entered Revisit e Choosing an existing patient registration and entering another visit date 12 Statement of Confidentiality System Information Access Agreement Interpretation Of Breach 6 Breach of confidentiality includes but
6. is not limited to accessing Health Information without authorization to do so without the need to know for direct patient care or performance of one s duties Breaches will result in deactivation of your password and discipline up to and including termination of employment or hospital privileges and or hospital affiliation Confidentiality Agreement e Without the authorization as outlined in policy and procedures the following access examples but not all inclusive are considered to be breaches of confidentiality Accessing the health record of Oneself A family member A neighbor friend A patient that you do not have a need to know for direct patient care or performance of one s duties Looking up address DOB on staff friends neighbors etc e Discussing patient and or situations in public areas eg Hallways cafeteria elevators even without mentioning names as patients can be identified by facts other than names Accessing personnel payroll or any financial information when not required for Direct Patient Care or Performance of one s duties System Information Access Agreement as undersigned acknowledge the receipt of my access password and understand that The code is equivalent to my signature and all reasonable steps necessary to safeguard my password from disclosure to others will be taken As physician office personnel use of my password will be strictly limited to accessing information
7. is the Family Dr x She is requesting a semi private room she is diabetic and allergic to ASA xi She is assigned to room OPIN please choose a bed xii The reason for visit is cholecystectomy so the service will be General Surgery Record the account number and unit number assigned when the registration is filed Account Number Unit Number 2 Using the Account number to identify the patient change the attending Dr to Dr Wherrett File the change 3 Go to Inpatient Reports and do the Admit Register by Time for T print on the S creen Make sure that your patient appears on this list 4 Using the Unit number to identify this patient discharge the inpatient home today 5 Pre register this same patient for 30 03 08 using one of the following patient types PRE SDC to Location ODS with Dr Siomra PRE CLI to Location OCONS with Dr Doran PRE RCR to Location TP with Dr M Martin Or register this type REG ER to Location ER with Dr Paidra 35 Office Administration Medical Homework Assignment Week 7 The Patient field 1s the key field in patient registration In this field we should be recording the patient s name Ifa patient has a preferred name to be called it should be captured in the name field You may key in a patient s number in the Patient field to ensure you are selecting the correct patient from the MRI database This also makes the registration process as the system will not take yo
8. one another Whenever one goose falls out of formation it suddenly feels the drag and resistance of trying to go it alone It will quickly try to get back into formation to take advantage of the lifting power of the birds in front f we have as much sense as a goose we will stay in formation with those who are headed the same way we are going When the lead goose gets tired it rotates back in the wing and another goose takes over the point position t pays to take turns doing hard jobs The geese from behind honk constantly as you ve no doubt heard whenever a flock passes overhead They do this to encourage those up front to keep up their speed An encouraging word goes a long way Finally when a goose gets sick or is wounded by a gun shot and falls out of the formation two geese follow it down to stay with it and protect it They stay until it is either able to fly again or dies They then launch out on their own or with another formation to catch up with the group f we have the sense of a goose we will stand by each other Author Unknown 29 Registration Status ADM IN e Admitted Inpatient DIS IN e Discharged Inpatient PRE IN e Pre admitted Inpatient REG CLI e Registered Clinical PRE CLI Pre registered Clinical DEP CLI e Departed Clinical PRE ER Pre registered Emergency REG ER e Registered Emergency DEP ER e Departed Emergency PRE SDC Pre registered Surgical Day Care REG SDC e Registe
9. option to view more information before choosing a record if no record is chosen New defaults in at this prompt and a NEW unit number will be assigned further demographic information will be required if a record is chosen the existing unit defaults in with all existing information and you must then proceed to verify or update this data if patient ID fields eg name sex dob do not match the existing data in Medical records the user is prompted to U pdate ie update the pt information to what you have entered for the current registration you are doing information is stored in demo recall for any further registrations that will occur out in the future C opy ie accept the pt information as it had been collected on the patient s previous registration Or S earch again takes your cursor back to the Unit number prompt so that you can search further Guide to using the U or C option use U to update if the name you ve entered will improve the name use C if what was already on file for the patient was better f you have used U the patient s former name will automatically be added to the maiden other name field 49 At this point the cursor appears beside the Insurance data on the screen It is meant at this time for the user to confirm the data displayed on the registration summary eg Patient address Employer Next of Kin Person to Notify Guarantor Guarantor s Employer and list of Insurances Once
10. standard format if patient is a resident of Ontario and Postal Code is unknown enter 5 if the Postal Code is not known and pt is NOT from ONtario enter HOME PH enter the patient s home phone number with area code as NNNNNNNNNN It will automatically display as NNN NNN NNNN As of 26 Jun 01 the standard format is for the area code to be included for ALL phone numbers When registering patients if you notice a phone number without an area code please correct the number by adding the area code RESIDENCE CODE enter the 4 digit code from the Residency Code Manual Most Durham Region residence codes can by found easily in the lookup by entering 2431 and then press F9 Durham Region residence codes for the most part fall in the group of residence code numbers that will display Select the appropriate residence code from the list For details see Standard 2 MARITAL STATUS with the new privacy legislation the collection of Marital Status is optional for all patients with the exception of Mental Health patients We must collect Marital Status for mental health patients for submission on the TREAT RAI mental health abstract as it is a piece of required data that they must submit Marital Status field is a dictionary field with a F9 look up You may use U unknown only when applicable LANGUAGE enter the mnemonic see table F9 HCN Health Care Number Will only accept valid HCN s if a version code is on the card it
11. the ER account as having you being transferred to Sunnybrook Hospital 3 Pre register yourself for a series of visits to Physio Hint the location to use is TP if using the Oshawa database Your first visit is scheduled to be on April 1 of this year 4 Register yourself for a visit to the X ray department for yesterday Hint the location to be used is XR if using the Oshawa database 5 Register the account that you pre registered in question 4 for one week ago T 7 6 Enter a revisit for today for the physio account 7 Pre register an inpatient account for Dec 25 2008 for having a baby this is considered an obstetrical visit Dr Rowe will be your obstetrician 8 Edit the ER departure that you entered in question 2 and change the time to the current time 9 Use the Review patient activity to make sure that your ER account was registered departed and then had the departure edited 10 Enter a Day Surgery account for yourself for today for a D amp C Dr Hepburn will be performing the procedure 45 Week 11 1 Review Take Home Assignment 2 Practice Scenarios Practice Scenarios Week 11 1 You pre registered yourself last week for a visit to come and have a baby Register that account today to room 5A or 5AH 2 Enter a newborn registration for the baby You had a baby boy Be sure to use the correct registration routine 3 Discharge the baby home 4 Undo the discharge as you are not feeling
12. using the routine This routine is also useful to change the Or mid way through a patient s stay The routine is used if two patients will exchange rooms and beds Review patient activity 1s like a of all registration events that occurred to a patient account Each event 15 and stamped and includes the staff person s mnemonic that made the change Three examples of registration error correcting routines are some of these routines have provided to staff due to risk 1ssues for the hospital if used inappropriately To completely cancel an account the account must be at status The or routine discharges the patient in the system for the current episode of care Reprint admissions forms routine allows you to reprint a or labels A patient armband needs to be replaced if worn as clinical staff must have positive patient I D prior to the administration of medications taking laboratory or diagnostic imaging tests 44 Week 10 Hand in Week 9 homework assignment on Registration Routines Take up homework from Week 8 Demo of Patient Care Inquiry PCI Q Practice Exercises questions 1 10 in hard copy manual Take Home Assignment Practice Exercises Week 10 You have registered yourself in the Meditech system in a previous class Using your existing unit number perform the following registration exercises 1 Register yourself to the Emergency Department today to see Dr Paidra for your migraine headache 2 Depart
13. well and need to stay another day so the baby will stay with you 5 Enter a Day Surgery account for Unit who is going to have a cystoscopy with Dr Gibson this afternoon 6 Admit the patient from question 5 as she had complications and now has to stay Use the roll up of the Day Surgery account Admit the patient to a bed on Location 6M or 7M 7 Transfer yourself from question 1 to a bed on Location 4F 8 Discharge yourself and the baby 9 Edit the admission for Unit and add an allergy to codeine 10 Find out which patient has health card number 3726898889 The name of the patient is 46 Week 12 1 Final Exam written portion hands on registration portion 47 USER S MANUAL THE FIELDS IN OUTPATIENT REGISTRATION most are also seen in the Inpatient registration routine also Revision date NOVEMBER 2007 PRE REGISTRATION REGISTRATION Recurring Clinic ER Surg Day Care For all patients there are 6 screens of information required for either pre registration or registration These screens and fields will be explained individually Some registration types may also have Customer Defined Screens CDSs with hospital or location specific questions Some fields are required and others are optional entries are dictionary driven requiring a mnemonic to be entered and others are free format allowing more descriptive entry are optional at pre registration but required at the time of registration
14. you have mail at the bottom right corner of your MOX menu i e MAIL 12 indicates you have 12 messages indicates new messages 21 How to read messages Choose 1 For You type 1 and press enter The options are on the line to the right of where the cursor is flashing Delete Transfer Print View Send Forward Acknowledge Exit Delete deletes the message that you have highlighted but msg can be retrieved within 5 days from the Mail You Have Deleted screen Transfer transfers your message to a filing cabinet which you create Print prints your message to the printer device View opens your message if it is longer than the space on the Screen e Send send a message to individual s or to a distribution group e Forward returns the msg to the sender and allows you to add a reply Hint when forwarding a msg Press spacebar then press enter at recipient rather than typing in the sender s name this will automatically enter the sender s name Acknowledge if you receive a msg That has Please Acknowledge at the bottom of the screen you must acknowledge before deleting How to send a new message Choose 6 Send Message from the main menu e The cursor will be flashing under the heading Recipient In upper case type the LASTNAME FIRSTNAME leaving no spaces of the person s name to whom you are sending the message IB e Tips V Can send message to a printer by entering a and th
15. Hone Ph Hork Ph Rel To Pt Employer Postal Code Person To Notifyu Postal Code ect Charter smplate ppt D depart ti lookup doc PA cumentation New Fea Lal Test OR Manager 18 My Documents mA WMH1 7 51 1 3 1 TEST J 2 MIS B 321 Options Edit Help Inpatient Admission Edit Patient po HAY 2002 INFECTION CONTROL QUESTIONS HAS PATIENT BEEN My Network yect Charter DIAGNOSED EXPOSED TO HULTI RESISTANT ORGANISM HRSR URE ESBL disais If Y pt needs ISOLATION and MRO cultures MRO1 x omn IN A HOSPITAL IN OR OUT OF CANADA IN THE PAST THO YEARS depart ti IF SO WHERE e If V pt needs MRO cultures MRO2 zh aria RESIDED RECEIVED TREATMT IN NRSG HOME LTC RETIREMENT CHEMO peas BOARDING DIALYSIS OR INSTITUTIONAL SETTING IN PAST 2 YRS LE IF SO WHERE Miet s If V patient needs MRO cultures HRO3 New Fea COMMENTS FOR INFEC CONTROL FOR INFECTION CONTROL Exclude patient from MRO screening A Lal Test OR Manager WMH176113 1 TES E ap Homework Complete terminology crossword puzzle 19 Criss Cross Puzzle Office Admin Terminology Assignment RAcrassm e uam result in termination of enplcowvmt 3 a place a patient wialta 4 individual cptlon on manu B group of acceptable responie ll central patient index l sendz infa from system ta zystemn 13 abbrewiatlorn ld programming language nada by HBHadlta
16. NONE RESIDENCE CODE e Enter 4 digit number from Residence Code Manual for current year 26 SHORT FORMS e For next of kin and related e SP same as patient e SPIN Same as Person to Notify e SNOK Same as Next of Kin e SG Same as Guarantor SOCIAL INSURANCE NUMBER 9 digits eg 123 456 789 with hyphens Patient Types IP Inpatient can be Acute Rehab Complex Continuing Care Chronic Mental Health Outpatient can be SDC Surgical Day Care CLI Clinical ER Emergency RCR Recurring REF Referred 27 Week 5 P R I D E Outpatient Registration Routines Screens see attached notes Inpatient Registration Routines Screens Q Clinical CLI Registration Clinical CLI Registration Edit MOX exercise Can You Multitask P R LD E PERSONAL RESPONSIBILITY FOR INDIVIDUAL DAILY EFFORT 28 Goose Story Next fall when you see geese heading south for the winter flying in their familiar V formation you might be interested in knowing why they fly that way Science has learned that as each bird flaps its wings it creates uplift for the bird immediately behind it By flying in a V formation the flock together gains over 70 more flying range than if each bird flew on its own Like the geese people who share a common direction and a sense of community can get where they are going quicker and easier because they are traveling on the thrust of
17. Office Administration Option Medical Hospital Info Systems Year 2 Semester 2 Sequence Of Instruction Registration MOX Component WEEK 1 WEEK 2 WEEK 3 WEEK 4 WEEK 5 WEEK 6 WEEK 7 WEEK 8 WEEK 9 WEEK 10 WEEK 11 WEEK 12 Learning Outcomes Housekeeping Items Intro to HIS Terminology Security and Confidentiality Password Forms Terminology Practice Sign On Viewing Registration Screens Test 1 Terminology MOX Interactive MOX Practice Review Test Function Keys MOX exercise Demo Recall Patient Searches Standard Formats Patient Types Outpatient Registration Routines Screens Clinical Registration Edit MOX exercise Test 2 MOX Surgical Day Care Registration ER and RCR Review MOX test Inpatient Registration Related Routines Exercises Interview Techniques Review Outpatients Exercises Test 3 Patient Registration Review Inpatient Registration and Routines Practice Exercises Review of Registration Test Demo PCI Practice Exercises Take Home Assignment Review Take Home Assignment Practice Scenarios Final Exam WEEK 1 Review of Learning Outcome and Course Outline Housekeeping Items Introduction to HIS see attached notes Terminology see attached notes Security and Confidentiality see attached note Password Forms hand out in class SEQUENCE OF INSTRUCTION Registration Component Password Forms Terminology continued Viewing ocreens Test 1 Terminology
18. agic vs Client Server Q Access Security and Confidentiality Access beyond the walls home Drs offices Nursing homes Durham Access To Care Terms Commonly Encountered Account Number A system assigned number fiscal year to indicate all visits included with a specific patient encounter Eg Al01234 06 for acute inpatient registered e Eg PI00004 06 for acute inpatient pre registered CDS Customer Defined Screen A series of prompts or questions defined by the users to collect information or statistical data not included in the standard product Q CPI Central Patient Index 11 A computerized listing of all patients with additional demographic information and cross linking to a listing of all hospital visits Assignment of unit numbers automatically occurs and is maintained in the CPI Demographics e Patient information that usually does not change from visit to visit i e name date of birth family physician Demo Recall Any fields that are part of the patient demographics are stored and recalled on every subsequent visit These fields help to identify that you have chosen the correct patient from a previous visit but still need to be confirmed and updated if required Dictionaries A group of acceptable responses built in the system to provide the user with a lookup at the prompt built and maintained by the Information Technology Department Location A mnemonic indicating a place or
19. all insurances if the patient is from another province or outside Canada Other Canadian provinces start with PP and Federal plans such as RCMP and Armed Forces start with FG Federal Government Note specific detailed notes re non residents out of Country can be found in this MOX Library CABINET NAME ACCESS OWNER Non resident procedure READ ONLY VELLA LISA V 2 refers to extra insurance for semi private or private coverage Most general insurances start with letters GI 3 n a for recurring but do not erase existing info 51 Note when you are changing insurance 1 from OHIP to WCB please enter N at the question Retain policy holder information from OHIP so that you won t need to remove the HCN which defaults to the WCB Policy field GUARANTOR the guarantor is always the patient if 19 years of age or over entering SP will cause the data to default in for age 18 and under it is the custodial parent SNOK or it could be the Children s Aid or Family Services for Foster Children it is the Children s Aid Depending upon the circumstances the name of the Power of Attorney may be the name seen in this field B AR statements are sent to the name shown here this is why we are to show the name of the person responsible for payment of the account If itis NOT the name of the person who holds Insurance 2 covering semi You will be able to specify the holder of Ins 2 when completing fields in Guarantor s Emp
20. ame not the name they preferred to be called by o eg SMITH WILLIAM is the legal name SMITH BILL is the name the patient prefers to be called by Therefore the correct name to use in the Patient name field is SMITH WILLIAM You may enter SMITH BILL in the patient s other name field By doing so the system will search for both SMITH WILLIAM and SMITH BILL the next time the patient presents himself as SMITH BILL donot use quotation marks in the patient s name as the quotation marks will trip interfaces to other modules and prevent data from crossing to other applications a list of recent accounts at the hospital will appear on the screen for any patient s with this name Also any existing pre registration for the patient will appear with an option to select those accounts Please check locations carefully so as not to select a pre registration for another department 48 If no pre registration exists or is chosen press return When the cursor is at the name prompt verify the proper spelling If this is the most recent visit for the patient YOU have the ability to update the patient s name on the database REG CAT REGISTRATION CATEGORY enter the appropriate REG CAT press F9 look up key to view read the descriptions carefully to choose the correct one ACCT NUMBER defaults in an automatically assigned number or NEW will appear if you are registering a pre registered patient and the account number stack is the same for bo
21. are entered at the policy number line group SIZ policy etc Liberty Health must have the policy number on the policy line and the group number entered at Company number PAGE SCREEN 5 ACCIDENT OCCUR INFORMATION This screen is infrequently used often bypassed unless required by a specific registration location Should a patient present with a police officer it is a good idea to record police badge number in the police involvement field ADMISSION SOURCE use the F9 key to view the list of mnemonics ACCIDENT OCCURRENCE use the F9 key to view the list of mnemonics The remainder of the fields on this page are free format entry and are used by the hospital mainly for WCB patients These may be filled in or left blank as appropriate PAGE SCREEN 6 DOCTOR amp LOCATION INFORMATION PRIM CARE PHYS do not enter a physician mnemonic here this field used in US for managed care and not currently used by the Durham Region hospitals ATTEND PHY must be entered using a mnemonic from the dictionary F9 at this prompt enter the doctor or therapist or group responsible for this patient therapist mnemonics begin with Z followed by the first 3 letters of the therapist s group s last name in the case of 2 identical surnames the first initial of the first name has been added To view this list enter Z at the prompt then press F9 Note At any doctor prompt if you enter three characters of surname then X and press the lo
22. ation enter edit demographics employer next of kin and person to notify ocreen 3 Guarantor and insurances ocreen 4 Accident Occurrence Screen Screen 5 Doctor Location Information Inpatient Registration Screens ocreen 1 Registration Summary Identify Patient MRI search Verify some demographics Screen 2 Demographic Information Enter edit demographics employer next of kin and person to notify Screen 3 Guarantor and Insurances Screen 4 Accident Occurrence Screen ocreen 5 Infection Control Questions CDS Screen 6 Doctor Room Service Information Screen 7 ADM INPT CDS 2 En My Documents 2 WMH176113 1 TEST 5 5 MIS B 32 My Network Recycle Bin f e Internet Options Edit Help Patient Patient s Information Street Street City Province Hone Ph Other Ph Res Code Language Subscr Init Soc Ins Religion Affi l Email Use Email Postal Code Har Status Health Care subscr Relat Next Of Kin Nane Street street City Province Hone Ph Hork Ph Rel To Pt Postal Code What Are Standard fields Customer defined screens and prompts Standard formats eg Name age Mnemonics and Dictionary Lookups Free format and Free text fields Date field conventions On line documentation Standard and custom Required fields and optional fields Name Street Street City Province Emp Phone Pt Occup Emp Status Nane Street street City Province
23. ch 16 where HMeditech s bhaadquarteras3 are 17 astern used to laakn jB number assigned by system per visit 19 another visit dats Cour Patient info that stays are avery patient s l gal right USt Ger dafined JSF ayztuan Used ta ragiater real patients 9 an sxanple of a patient type 10 Eype af registration 14 user defined List af options awallabls 15 hospltal information syetan CIM ZU of wondr re dee iip fw Sarre Created by Puzzlesniker at Diseoveryehool com Page of 1 20 Week 3 Test 1 Terminology Take Up Crossword Puzzle Review module short forms definitions MOX Training Interactive Module Q Practice in Meditech MOX see attached notes Module Short Forms Definitions ADM Admissions MRI Medical Records Index ABS Abstracting CWS Community Wide Scheduling MOX Majic Office OE Order Entry ITS Imaging Therapeutic System B AR Billing and Accounts Receivable NUR Nursing LAB Laboratory PCI Patient Care Inquiry PHA Pharmacy EDM Emergency Department Module AP Accounts Payable MM Materials Management FA Fixed Assets PP Payroll amp Personnel CA Cost Accounting MIS Management Information System NPR No Problem Reporting OPS Operations Basic Instructions For Using MOX How to access MOX e Select the number beside MOX on your menu or enter the letter M when you are in PCI You will be notified that
24. d of list document F10 line feed to clear field key F11 exit F12 file save send Shift F8 online help F9 lookup 3l Study for Test Next Week 22 Week 6 MOX Test Surgical Day Care SDC Registration Emergency ER Registration and related routines Recurring RCR Registration and related routines 33 Week 7 Review of MOX Test Review Surgical Day Care SDC registration from last week Inpatient Registration Inpatient Registration related routines Inpatient Registration Exercises Homework assignment Important Points Patient s legal name should be recorded in the patient name field The correct postal code must be recorded for the patient s address and guarantor s address do not use 5 Patient s preferred name to be called should be recorded in the other name field We can only legally request a patient s social insurance number when the visit is WSIB related WSIB visits pay the hospital more money for a visit or procedure than if it were not a work related injury visit Collecting Employer information is not optional for any patient e STUDENT CHILD HOMEMAKER UNEMPLOYED RETIRED are just a few of the other non employers in the Employer Dictionary Provincial Health Insurances can be found in the insurance field by typing PP provincial plan and pressing F9 to look up the applicable one e Each have a Customer Defined screen defining the applicable insurance expiry date format Secondary in
25. en keying in the Meditech printer name eg WMH MISL3 e Can key in a persons telephone extension in the recipient field instead of typing in their LASTNAME FIRSTNAME eg keying in 4494 brings up PEARCE RALDA To choose one of the above options you would enter the highlighted letter at the beginning of the word i e to Delete enter D and press enter Your messages are listed below the Options line The highlight bar will appear on your most recent message and the actual message will appear below the line which indicates the date time and the sender s name You may type one or more names in the Recipient column Once you have entered the person s name then press the enter key until the cursor is flashing in the upper left lower block on the page Now type in your message When finished press the F12 function key A red box will appear with the message SEND Enter the letter Y 22 24 Doctors Address Phone Number e 24 on your MOX menu will provide you with Physicians Office addresses phone numbers and fax numbers Instructions on how to use this feature are on the screen Please inform us if you encounter any incorrect information 23 Week 4 Review of Terminology Test Function keys see attached note MOX exercise Demo Recall Review Demo Recall Exercises Patient Searches Standard Formats see attached notes Patient Types Important Keyboard Functions The MAGIC Office Module was written in two differen
26. ew notes and registration exercises Q Practice in Meditech TEST system Complete homework assignment 40 Office Administration Week 8 Homework Assignment Patient Interview Techniques results Health Card response incorrect WSIB semi private correct current risk ward blood products S IN bill database claim follow up breech of confidentiality drivers revenue masked By having a patient present their to you this will help in the selection of the patient from our When interviewing a patient it is important to ask questions in such a way that a patient gives you a detailed This ensures you obtain the most information and not just accepting information that is old and outdated If a patient s family doctor 1s incorrect in our system clinical will be sent to the doctor This 1s not only a but also the patient may not get appropriate care This is a issue for the hospital If a patient 1s unable to or having difficulty answering questions regarding their current address you may ask for their license to obtain this information All patients should be asked 1f their visit 1s related If yes we require the patient s This ensures the hospital can obtain maximum from the visit but also will ensure the patient s can be processed appropriately If a patient is unsure if they have coverage they should be placed in a room until they confirm 1f they are covered This will ensure the patient will not get an unexpected A reas
27. g a comment about where you want your placement to be at the end of this semester Delete the messages that you have received so far oend a message to the instructor that will not be received until 1 week from today and in the text of the message explain that this is a message using the special handling feature Demo Recall Exercise From your admissions module go to routine 55 Demo Recall Using the routine to View Demo Recall find out the following information Unit number 000156 patient s name is Patient SARRO ERIN patient s DOB is Patient PATTERSON KRISTA patient s HCN is Unit number 001010 patient s allergies Unit number 001010 medical alerts Patient AFFLECK BEN next of kin is otandard Formats Summary NAME LASTNAME FIRSTNAME MIDDLENAME No space between comma and firstname no apostrophes no periods no quotes e MCDONALD not MC DONALD ORILEY not ORILEY e Except SMITH JONES valid hyphenated names amp OBS pts ST AMANT not ST AMANT or STAMANT Note REV or DR or JR or SR etc follow the first name after a space eg CASEY BENJAMIN DR SAINT names enter with a space not a period and not joined together Eg ST PIERRE not STPIERRE or ST PIERRE Otherwise as has happened the patient s name may not be found on the unit number search and a new unit number is issued AGE e Newborns will show as age 0 until discharge An infants age will show as mont
28. have on line assistance where you can press the docum key to view without having to refer to this manual The computer does not allow advancement past required fields but provides assistance through dictionary look up where mnemonics are required PAGE SCREEN 1 Registration Summary PATIENT the key field in patient registration REG N SEARCHES FINDING PTS then Picking the Lakeridge patient There are various ways to find the patient but positive identification is faster and more accurate if you have either the Unit unique number or the HCN for the patient enter U followed by the 8 digit unit CPI UNIQUE number if known at LHO this can be a 6 or 8 digit unit number Leading zeros do not need to be entered enter followed by the Ontario Health Card number if known If there is a version code put a hyphen after the HCN then the version code eg 1234567890 XX Note this is becoming the preferred method for identifying patients but keep in mind that if the patient isn t found by the 10 digit root HCN the patient may still be in the MRI database eg with old OHIP enter the telephone number T 9055791111 this will display all the patients registered with that phone number There may be several family members listed please choose the correct one if there If you have neither the Unit or HCN at this prompt enter the patient s name in standard format LASTNAME FIRSTNAME should be the patient s true legal n
29. hs and days up to 5M 29D and children s ages as years and months up to 5Y 11M 25 UNIQUE 6 AO or 8 digit number also referred to now as a UNIT e n the ADM programs it is necessary to prefix the unique by U e LHO U s are numbers only other hospital records are alpha prefixed E Bowmanville N Port Perry DATE DDMMYY slashes will automatically be inserted 6 Eg 020189 02 01 89 2 JAN 1989 e OR e Enter T for today or T 1 for yesterday etc TIME Enter 24 hour format from 0000 to 2359 CITY e ifin Canada enter city only e If outside Canada enter CITY COUNTRY or State then at province USE LOOKUP PROVINCE e Please enter codes as used by Canada Post BC AB SK MB ON QU NB NS PEI NL NT LB YT use Look up key F9 to see options e For B C Alberta Saskatchewan Manitoba Ontario Quebec New Brunswick Nova Scotia P E I Newfoundland Northwest Territories Labrador Yukon Territory POSTAL CODE ANA NAN f you see it entered incorrectly please correct e f unknown or not available and pt is a resident of ON enter 5 otherwise enter for Canadian addresses Use 12 for NOT AVAIL RESIDENT OF U S A and 13 for OTHER COUNTRY OTHER THAN USA TELEPHONE e Enter NNN NNN NNNN 10 consecutive numbers that will display as NNN NNN NNNN Area code now required for ALL phone numbers 26 June 01 If unknown enter NK If pt has no phone enter
30. into the employer dictionary check lookup using the F9 key Entries such as CHILD and UNEMPLOYED and DECLINED are available if an employer is entered that does not exist on the current list all information re address and phone must be entered Note if you have to enter certain employers frequently ask your B AR rep I T Applications analyst or site Key User to set up the employer in this dictionary PT OCCUPATION free format entry may be used to indicate employed unemployed NEXT OF KIN enter the name in standard format If the address is the same as the patient enter SP and the address and phone number will default in otherwise enter the data as requested at the Relation prompt a list of mnemonics is available using F9 a CDS screen may be attached for additional contact number PERSON TO NOTIFY complete this section if clinical staff should be contacting an alternate person regarding issues relating to the patient if Person To Notify is same as Next of Kin leave blank and it will be assumed that PTN SNOK see Registration Standards 1 for further details if this information is different enter the data at each prompt as required a second person is usually collected for inpatients only but once collected is stored in demo recall a CDS screen may be attached for additional contact number PAGE SCREEN 3 INSURANCES amp GUARANTOR INSURANCE 1 usually OHIP use F9 to view the list of
31. k 1 Review of Learning Outcome and Course Outline Class defined expectations for our learning environment Housekeeping Items Introduction to HIS see attached notes Terminology see attached notes Security and Confidentiality see attached note Password Forms hand out in class Learning Outcome amp Course Outline Total hours 24 Dates for Assignments and Tests will be discussed in class Final Mark out of 70 will be comprised of 50 from tests and assignments and 50 from the final exam The final mark from the OE CWS course will be out of 30 for a total course mark out of 100 Class Website http dcadmissions tripod com This site will contain each weekly lecture homework assignments extra reading and contact info This is your site If you would like something added just ask Office Administration 1 Introduction to HIS Hospital Information System Hospital structure and process Meditech Structure and Terminology Password Forms Confidentiality Agreement Introduction What is an HIS What is Meditech HIS modules and how they interrelate Live vs Test database Hospital Structure and Funding Patient Types Access Security and Confidentiality What is an HIS Hospital Information System Technology to integrate clinical administrative and financial data Provides statistical data for Decision Support Meets Ministry Reporting Requirements May be 1 or multiple interfaced syste
32. l Transcriptionist Attended Durham College as part time student for 10 years Presently maintain ADM MRI modules Corporate Intranet OR Software and other applications Cathy Houthuys Lakeridge Health Port Perry Admitting Department Admissions Module key user Health Record Technician Elaine Schembri Rouge Valley Health System Applications Analyst Presently maintain ADM MRI SCH modules and other applications Now It s Your Turn Sequence Of Instruction Registration MOX Component Week 1 Learning Outcomes Housekeeping Items Intro to HIS Terminology oecurity and Confidentiality Password Forms Week 2 Terminology Practice Sign on Viewing Registration Screens Week 3 Test 1 Terminology MOX Interactive MOX Practice Week 4 Review test Function Keys MOX exercise Demo Recall Patient Searches Standard Formats Patient Types Week 5 Outpatient Registration Routines Screens Clinical Registration Edit MOX exercise Week 6 Test 2 MOX Surgical Day Care Registration ER and RCR Week 7 Review MOX test Inpatient Registration related routines Exercises Week 8 Interview techniques Review outpatients Exercises Week 9 Test 3 Patient Registration Review Inpatient Registration and Routines Practice Exercises Week 10 Review of Registration Test Demo PCI Practice Exercises Take Home Assignment Week 11 Review Take Home Assignment Practice Scenarios Week 12 Final Exam Wee
33. ld e g 1234567890 will assist you in selecting the correct patient from our database Ensure you word your questions to the patient in order for them to give you a detailed reply back e E g Don t ask Is your address is still 123 Wherever Street Instead ask the patient What is your current address e By doing so it increases the likelihood that you will get the most current information as patient can not just answer yes yes yes repeatedly to your questions Don t ask the patient if their family doctor is still e g Dr Pedretti e Instead ask the patient Who is your family doctor e This again ensures the most up to date information is gathered If a patient is having difficulty answering questions ask them if they have a driver s license e Much of a patients demographic information appears on their driver s license including their postal code Person To Notify should only be collected if it is different than the Next of Kin All patient s should be asked if their visit is WSIB related if yes S I N is required If a patient is unsure if they have semi private coverage they must be assigned a ward room e Instruct patient or Next of Kin to confirm if the patient will be covered Once they confirm and sign for the coverage the patient can be moved to a semi private room This ensures the patient will not get a bill for the additional charges if not covered Asking a patient s religion can sometimes pose some difficultie
34. loyer Note Do not change the guarantor name and or address by entering SP at the name prompt if there is data shown in the Guarantor Employer fields unless you know that this is the patient s guarantor Instead just linefeed the name field then enter the revised name Otherwise the patient s employer and not the employer of the person who holds the secondary insurance will be entered into the Guarantor Employer section If an address change is needed then YES you can enter SP in the address field GUARANTOR S EMPLOYER See Standard 6 for more details although this field must be collected for INPTS for OUTPT registration this field is less applicable collect if possible usually patient s employer will default from previous registration for adults or it will be entered if you enter SP for same as patient if semi private insurance coverage is covered by someone other than the patient i e parent husband etc you must enter that person s employer here You will be able to indicate the name relationship when completing screen 2 of the Ins 2 information PAGE SCREEN 4 INSURANCE INFORMATION INSURANCE COMPANY name will default in from page 3 POLICY If Insurance 1 is OHIP Policy shows the HCN entered on Page 2 but the cursor bypasses this field if a HCN change is needed it has to be done on screen 2 if the HCN is unavailable the query lines at the bottom of this screen allow explanati
35. ms What is Meditech The vendor chosen by Lakeridge Health for the HIS An integrated single vendor solution Provides administrative clinical and financial applications that talk to each other Head office Boston with other sites across North America and Great Brittan Meditech Modules Include Abstracting Admissions Medical Records Billing amp Accounts Receivable Cost Accounting General Ledger Materials Management Fixed Assets Payroll and Personnel Order Entry Nursing PCI Patient Care Inquiry Community Wide Scheduling ITS Lab Pharmacy Emergency Department Module MOX MIS NPR Operations Many others exist that have not yet been implemented at Lakeridge Health Other Interfaced External Applications What is Interfaced Software Necessary data elements sent via HL7 interface or NPR report from Meditech to other vendor software Why is it used e To fill a void that Meditech at present time does not deliver or deliver as well as another software vendor One way vs two way interface e Meditech to other vendor software e Meditech to other vendor other vendor back to Meditech Other Software Vendors Lakeridge Health has MSM MedSurg MedDiet MedQual Upgrading to PICIS OR Manager Smart Track Medisolution MediHR Lanier dictation transcription 3M Coding Abstracting software Budman HiNext Treat for Mental Health Blue Chip archiving scanned images Hospital Structure F
36. ok up key you will be able to see the phone number and some other information for the doctors providers whose surname starts with the letters you have entered eg enter as SMI X then press the look up key FAMILY PHY also entered as mnemonic see F9 not a required entry Enter the mnemonic if you know it or enter 2 3 characters of their surname and do a look up and select the name if it is shown f the name is not on the dictionary enter the surname initial and town city if known in free format e g CASEY B UXBRIDGE f the patient does not have a family physician or does not know the name of the family physician do not enter eg NONE or SCARBORO or LIST GIVEN eg entries at this field generate copies to reports in other modules If you see an entry preceded with a delete or correct It used to indicate that the doctor was not on staff at OGH OTHER PHYS for entry of a consultant or other attending physician any doctors looking after patient should be entered here as well so that the patient record is available to them in the PCI module 53 not a required field REASON FOR VISIT free format entry enter the medical surgical reason why the patient is here try to be as clinical and consistent as possible Reports are generated from the data entered into this field Think about how many reasons for visits could be used for the visit of a stroke TIA dizziness left sided weakness CVA stroke e
37. on of how this info will be obtained you may see the HCN listed in the query lines as prior to 1 Jul 91 staff at OGH recorded this information here for the OHIP insurance please enter the name exactly as it appears on the Health Card at the Subcriber prompt The remainder of the prompts on this page are not necessary unless you are aware of eg an expiry date shown on the card Press F12 to quickly reach the bottom of the page For other primary insurances such as other province or out of country follow the insurance queries They will prompt you with the required information If Insurance 1 is WCB for WSIB 22 Enter the Claim number if known but leave BLANK for new cases such as in Emerg where a Claim number will not yet have been assigned by WSIB Reminder when you are changing insurance 1 from OHIP to WCB please enter N at the question Retain policy holder information from OHIP so that you won t need to remove the HCN which defaults to the WCB Policy field If secondary insurances are entered please enter relevant data as requested in the pop up screen seen after you press return at the Query screen for that particular insurance This is seen for GS Green Shield QUERY SCREEN ZA00010 and shows FORMAT 000000 00 or ABC 000000000 00 EMPLOYER FOR THIS COVERAGE GOES UNDER GUARANTOR EMPLOYER PEREGRINE EMPLOYEES WERE GM GET NEW POLICY With the exception of Liberty Health all policy numbers
38. on the patients of the physician s for whom work and only on the basis of a Need to know for Direct Patient Care or Performance of One s duties will not attempt to access any unauthorized information As a student allied health care personnel use of my password will be strictly limited to accessing information on patients for who provide service care and only on the basis of a Need to know for Direct Patient Care or Performance of One s duties understand that information contained in the regional database is confidential in nature and can not be disclosed or used by any individual for purposes other than to which the information is intended e fl have reason to believe that the confidentiality of the password has been violated will contact the Information Technology Department immediately for reassignment of a new password acknowledge and agree that the password is and will remain the exclusive property of the Lakeridge Health Corporation Information System 13 e understand that if print any part of the record such hard copy will be treated with the same confidentiality as all other records Security and destruction of copies will be in compliance with each facilities policies acknowledge that as a safeguard to confidentiality random audits will be conducted understand that will be accountable for documented access to patient personnel payroll or any financial information 14 Week 2 Terminology
39. on why we ask a patient their religion 1s that some religions prohibit the use of All patient s who present to hospital in the Emergency Department or to be admitted will be screened appropriately for infection control purposes Ifa patient 1s febrile and showing signs of an infection they should be to prevent the spread of infection to other patients staff or their families 4 Week 9 Hand in Week 8 homework assignment on Patient Interview Techniques Q Patient Registration Test test 3 Take up homework from Week 7 Q Review of Inpatient Registration and Related Routines Practice Exercises see page amp __ of manual Registration Routines Pre Register e Routine used to pre register a patient to hospital for a pending visit out in the future Register Admit e Routines used to register a patient e Register for outpatients e Admit for inpatients Transfer e Inpatient routine used to transfer patient to a different room and bed during a patient s stay Also used to change a patient s requested accommodation mid stay their patient service or their attending physician Swap Used if two patients will literally swap rooms beds Done in one step as opposed to 3 steps if transfer routine was used View Patient e Can view entire completed registration for each account number Review Patient Activity e Audit Trail of what events occurred with a patient account the date and time the event occurred along with
40. r combination May contain data from one or multiple applications MRI Search Databases Registration Screens Overview Outpatient and Inpatient Standard Screens and CDS s Terminology CR C MRI Medical Record Index CPI Central Patient Index 1 facility vs multi facility 1 database shared MRI Multi database ADM linking records What about Rouge Valley What about Ross Memorial Lindsay ISE TOM Oshawa Emerg U 00521478 Port Perry Day Surgery U N0061318 Bowmanville Inpatient U E0012854 At each site there will be a paper folder chart for this patient in Health Records Electronically there are 3 unit numbers but they are linked so that in MRI one record exists Can be identified by any one of the 3 numbers 16 Visits to more than 1 Site My Documents c LG SITES SIERRA L po Options Edit Help PRE SDC plit Hail 8 hed d Record le ve LOS Location Attending Doctor Principal Diagnosis Reason for Visit ae pA cumentation New Fea LOS Location Attending Doctor Principal Diagnosis Reason for Visit Patient Registration Q Series of screens and prompts Collection of demographic and visit specific data Must first determine patient type to select correct routines and screens Q Basis of electronic health record Outpatient Registration Screens ocreen 1 Registration summary Identify Patient MRI Search Verify some demographics ocreen 2 Demographic inform
41. red Surgical Day Care DEP SDC e Departed Surgical Day Care PRE RCR Pre registered Recurring REG RCR Registered Recurring DIS RCR e Discharged Recurring SCH SDC e Scheduled Surgical Day Care SCH CLI e Scheduled Clinical Outpatient Registration Routines Clinical Emergency Surgical Day Care Recurring Inpatient Registration Routines Screens Pre register Register Discharge 30 MOX Exercise 2 Send a certified message to your instructor saying what your plans are for Reading week Set the message so that it will not be received until the next day Q Send a message to the class saying if you feel you are ready for the test next week have sent you a message about the importance of attending every class Please reply to me with your comments Send a message using bold italics and underline Q Delete all the messages in your mailbox Short Cuts SP e Same as Patient SNOK e Same as Next of Kin T e lodays date T 5 e Todays date five days T 1 e Yesterday s date N Now time in 24 hour clock Space Bar Enter e MOX reply to sender without typing in their name Space Bar Enter Enter e MOX reply to all recipients of original MOX message Blind Carbon Copy LASTNAME FIRSTNAME MOX To Printer e WMH MISL3 eg of printer Recipient shortcut e Key in phone extension in recipient field Function Keys F6 previous field F7 top of list document F8 en
42. s A good reply back to the patient is we ask this question for all patients as some religions have food restrictions or restrictions on blood products being administered If a patients Health Card is returned with a denied or a stolen status simply instruct the patient to stop by the billing office as their seems to be a problem with their Health Card In rare instances a patient or their next of kin may become violent Contact security immediately should this occur Patients who present with febrile illnesses should be properly screened and masked if appropriate to help prevent the spread of infection This is for the protection of other patients staff and staff member s families 37 Patient Types Inpatient IP can be any one of the following Acute e Rehab getting patients mobile again e Complex Continuing Care Chronic e Mental Health Q Outpatient can be any one of the following SDC Surgical Day Care CLI Clinical ER Emergency RCR Recurring REF Referred 38 Class Exercise Outpatient Types 1 Patient with unit number is scheduled to have surgery on April 21 2008 with Dr Valiulis for an endoscopic Cholecystectomy She is not planning to stay over night Her new address is RR Concession Road 6 Oshawa Ontario L1G8A7 Pre register this patient using the correct outpatient type Use location ODS 2 Patient with Health Care Number is sent to the X ray department for a Chest X ray by hi
43. s being entered remember that the face sheet will needed to be reprinted or the additions noted on that page and initialled as the caregivers are referring to this information for the current visit LOCATION entered as a mnemonic see F9 very important for statistics In a pre registration the next prompt will be SERVICE DATE please enter the expected date of the first visit if unknown generally the convention has been to enter 25 12 of the current year unless the month is December and visit is not expected in that month or 31 03 of next fiscal year if visit is not expected in the current fiscal year RESERVATION TAKEN AT TIME will default in as the current date and time COMMENT a free format field for extra information may be used to record medications or a prompt to registration staff about checking particular information when the patient arrives In a registration the next prompt will be DATE TIME these default in as the current date and time but may be linefeed out to enter a previous date or time eg needed for areas doing registration after pt arrival or for newborns to show date time of birth future times and dates may not be entered COMMENT as above 54
44. s her Family Doctor Register this patient for today The patient tells you he she is allergic to IVP dye Be careful to think about what outpatient type this is Use Location XR 3 Using the routine Visit History for the patient June Abba tell me the type and location of her visit on this date March 1 2007 4 Pre register yourself for Speech Therapy for the date of April 15 2008 Use location TSA Now register this account for T 6 Then enter a revisit for T 4 and another visit for T Think about the patient type she is coming for a series of visits Using the edit delete revisit routine remove the visit for T 4 Using the Review Patient Activity routine display the events for this patient on the screen and have your instructor review 5 Using the same unit number from question 1 this patient has now arrived in the Emergency department by ambulance with acute chest pain Register the patient Dr Vandersluis is the ER doctor today The patient has a new allergy to Morphine Use Location ER 6 The above patient is seen by Dr P Morra and he now decides that she needs to be admitted Admit the patient from room ERM She has requested a Semi Private room 7 Transfer the patient to CCU or CCUH CRITCAREME or CRITCARESU for the Oshawa site 8 The patient is now being sent to Sunnybrook Discharge the patient and be sure to use the correct Discharge Disposition 39 Test Next Week Patient Registration Revi
45. surances in general can be found by typing GI general insurance and pressing F9 look up All patients should be asked if their visit is WSIB related Self Pay SP Day Surgery procedures need to be paid in advance of the surgery Patients who present who are Self Pay must provide credit card information upon registration The correct physician mnemonics must be entered for each patient visit attending admitting most responsible family doctor emergency doctor or other If the wrong physician mnemonic is chosen the negative impacts are e Dictated reports results get sent to wrong physician therefore appropriate follow up can not be done e We breech patient confidentiality as the patient has not authorized the hospital to share their medical information with that Physician e Should a legal case arise the wrong physician s is associated with a patient chart Dr s access in PCI is limited to those patients who their physician mnemonic is associated Drs may miss seeing their patients in hospital patients may not be followed up appropriately 34 Class Exercise Inpatient Registration 1 Register this patient as an inpatient i DURHAM YOURFIRSTNAME li Your Date of Birth ii Lives at 32 Rossland Rd E Oshawa ON L1G 8A7 iv Speaks English attends Northminster United Church v HON vi Works at GMC vii Next of Kin is her husband DURHAM ROBERT who lives with her viii Dr Valiulis is the admitting and attending Dr IX Dr Brankston
46. t MEDITECH programming technologies NPR and T The word processing features are in NPR while the database and spreadsheet features are in T Therefore depending upon which feature you are using some keys have different functions The keys listed below are the ones you will be using most often in this quick start You will learn more about the differences in the keys functionality later in the training Lookup Lists all possible responses to a prompt Help Provides on line documentation for explanations on how to use system Exit Exits any routine Does not save data Delete Deletes one character at a time OK or ESC These keys bring up the same utility menu which allows you to File and Exit File Exit Print Delete Line Deletes entire line beginning at the cursor position Enter Press this key at the end of each entry This signals the computer that the entry is complete Or in the word processor it indicates an end of a line and beginning of a new one Up Left Right Down Arrows Moves the cursor backward and forward one space at a time and up and down one line at a time 24 MOX Exercise Send a message to your instructor describing your experience using the MOX tutorial used last week Send a message to the whole class telling them your birthday and how you would like to spend the day You have a message from your instructor please reply to this message Edit the message you sent in question 1 addin
47. tc if there are multiple reasons for visit type them with a comma separator and then a space before the next reason for visit MEDICAL ALERTS ALLERGIES these are 15 character free format fields There are two such fields for Medical Alerts and four fields for Allergies If you see infection control type information in the Medical Alert field do not adjust it may read something similar to MRSA EXP ISOL amp SCREEN ON ADMIT AJAX registration staff are to just enter yes or no if these fields are not already with recorded entries Please do not remove any existing entries or refer to your key user if you have any questions These fields are shared with the other hospitals in Durham Region and entries such as PALLIATIVE CARE and TT GUSTO 10 11 97 may have special significance in patient care Universal Precautions are in place throughout Lakeridge Health Corporation do not record text related to HIV AIDS etc The Allergy Fields will print on most Face Sheets and the Emerg form If the patient has a LATEX allergy Latex should always be entered in one of the fields If the patient has multiple drug allergies and all cannot be entered in the existing allergy fields Multiple Drugs should be entered in one field This will promote care givers to question the patient directly or refer to a complete list through another chart source Note if the face sheet for the pts visit was printed PRIOR to additional Alerts and Allergie
48. th categories you will see the pre assigned number default into this field BIRTHDATE enter in standard format DD MM YY itis not necessary to enter slashes but 2 digits must be entered for day and month Jan 5 1965 is entered 050165 shown as 05 01 65 for some older patients it will be necessary to enter the format DDMMYYYY without the slashes eg 01011897 AGE calculates from date of birth and defaults in if no date of birth is known please enter an approximate age SEX enter M F or U MAIDEN OTHER NAME enter in standard format as patient may already have records under a former name Multiple maiden other names can be entered Do not use this field for reasons other than the maiden other name MOTHER S FIRST NAME not frequently used useful for people with common names e g Mary Smith two may have the same date of birth but not likely the same mother s name or babies with same last name and sex etc Defaults in if you have already identified the patient by U or HCN and information had been previously collected Is automatically added when newborns are registered in the Newborn Registration routine UNIT for those patients not already identified by U or HCN at this prompt the computer will automatically do an MRI search for an existing record of this patient 8 levels of search will occur searching all records with similar names sex date of birth range and maiden name these records are listed with an
49. the staff person s mnemonic who performed that event Undo 6 Used to undo a registration event Error correcting routine Cancel Error correcting routine To completely cancel an admissions account Account must be at pre registered status to cancel Outstanding clinical issues must be moved to another account if they exist or they will be completely wiped out from the system Limited access provided to staff for this routine Fix Admission Error correcting routine To fix original admit date and time of admission Discharge or Depart e Discharges patient from current episode of care Discharge Edit e Allows correction of discharge date and time Reprint Admissions Forms Allows you to re print a face sheet patient labels or wristband 42 Class Assignment Part A Register this Inpatient 1 Your first name O Brien your date of birth your address your next of kin is Patrick O Brien 2 You are being admitted today and have a baby 3 Your insurance is OHIP the number is 1818181818 AC 4 You are covered for Sandard Ward accommodation 5 Dr Rowe is your admitting and attending Doctor Enter your own family Doctor 6 You have Diabetes and are allergic to Ampicillin and ASA 7 You are admitted to Room 5A Choose a vacant bed 8 Enter the reason for visit as OBS Pre Register this Outpatient choose the correct outpatient type 1 You need a series of physio treatments for L tennis elbow
50. the user presses the return key a menu box appears listing the screens and their content in order From the summary screen the user can decide which fields need entry or editing and proceed directly to that screen NOTE There will always be required data entry on screen 6 prior to F iling Remember to check for correct spelling of all demographic information listed previously as well as all new information you enter on a patient PAGE SCREEN 2 DEMOGRAPHIC DATA includes all data formerly entered on page 1 and 2 of the registration screens STREET enter as much information as possible on the FIRST line free format Many report formats do not refer to the second street field Do not use the sign eg RR 1 as the 7 sign causes problems with interfaces to other modules Follow standard format cheat sheet note for proper format of address for apartments it is entered as the apartment number street number eg Apt 121 35 Simcoe St S would be entered as 121 35 Simcoe St S For Nursing Home Nursing Home name should go into street address 1 field with the nursing home street address being entered into line 2 CITY if from outside Canada also enter the state and or country TIP if you know the postal code enter the postal code into city prompt and the city province postal code AND residence code will default to those fields PROVINCE enter the 2 digit code according to Canada Post see standard formats POSTAL CODE as per
51. u through the 9 soundex search levels The correct format to enter a patient s Social Insurance Number is SIN s should only be asked if the visit 1s related Collecting a patient s is not optional For patient s who do not work you can enter things like Or All patients should be asked if their visit is related It is important for two reasons First if it 1s not asked it could affect a patient s claim Secondly these types of visits the hospital more for that visit or procedure For Provincial Health insurance outside of Ontario it is very important to collect the insurance date 1n the correct date Format information is defined on each insurance s Elective procedures must be paid for in advance of a patient s Day Surgery Patient s who present to hospital in Emergency or for an acute admission who are Self Pay must provide upon registration It is important to collect the correct physician information during the registration process Otherwise negative impacts could include These are just two of several negative impacts that exist 36 Week 8 Hand in homework assignment from Week 7 Interview Techniques Review of Outpatient Types Review of Registration Types Outpatient Registration Exercise see pg of manual Homework Assignment Handout on Patient Interview Techniques Due Next Week Interview Techniques All patients should present their Health Card e Keying in a patient s Health Card into the Patient name fie
52. unding Lakeridge Health Bowmanville LHB Oshawa Whitby LHO Port Perry LHP Active Hospital Chronic Hospital Rehab Hospital Acute Inpatients Inpatients Only LHO only Outpatients Inpatients Only Patient Types Inpatients Active Chronic Rehab Mental Health Outpatients Clinical Recurring Emergency Surgical Day Care Referred 10 NEM NEN My Documents 2 WMH176113 1 TEST 5 5 MIS B 447 Options Edit Help pE My Computer _ MEDITECH Adwissions Module Nain Menu p B Sign Dff My Hetwork Places 10 11 20 21 22 Internet Explorer j Inpatients Inpatients Inpatient Reports Dutpatients Clinical Emergency Room Referred Recurring 24 29 26 t surgical Day Care Provider Office Visit Provider Practice Record Check In Patient Information Data Processing Housekeeping statistics Deno Recall Aa Bon pictures arepoink E ject Charter smplate ppt p depart Fi a lo m ku P i d oc All Patients Other Henus Additional Patient Routines Non MAGIC Interface al Dictionaries cumentation Me Fea 30 Observation Patients BHH RJP TEST Mail 8 7 d Test OR Manager Inbox Microsoft Ou EE Fw Information Up USE MEMORY E Ft PowerPoin ct WMH176113 1 TES lt 5 10 PM Other Concepts for discussion Test vs Live databases M
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