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activEHR Exams, User Guide - September 2011

1. J 7 Intermediate Exam Anterior Segment ee eee E Confrontation VF Options Pook Intermediate Exam Posterior Segment e ei onfrontatior W gi 0 Lens Insurance Billing Rule Sets mp pa M Patient Lifesty Y Gross visual fi E Pretest Exam Components Quadrant finger Y T z y Distance YA Kd Simultaneous fi Near 4 Y Facial amlser E Contact Lens VA vi Cover test Vi T A Manual lensomet H Dilation Y H Vital Signs Y General externa Vi Ishihara Y 55 Page
2. When the list it has more than one entry in it can be sorted by any criteria simply by clicking on the column header Once the list is sorted the column header it is sorted by will indic ate an arrow to let you know which orderit is in either ascending or descending To reverse the order simply click on the column header again The below two screenshots show sorting by Description once in ascending orderand once in descending order ICD9 Code 367 1 ICD9 Code 336 02 367 1 kb Description Migraine Myopia Posterior subcapular polar cataract Description Posterior subcapular polar cataract Myopia Migraine Updated Date 07 18 2011 07 18 2011 07 18 2011 Updated Date 07 18 2011 07 18 2011 07 18 2011 Entered Date 07 18 2011 07 18 2011 07 18 2011 Entered Date 07 18 2011 07 18 2011 07 18 2011 4 Page Procedure Code History Procedure Code History Search Procedure Codes 3201 Today 50201 OV HP PROBLEM FOCUSED Office Visit 92015 M REFRACTION 92012 OVINTERMEDIATE EXAM d OW COMPREHENSIVE EXAM Date Performed Eve Cek The Procedure Code History is divided like the Problem list into a list for Today and a Complete List On today s list add the procedure codes that apply to today s visit so that they can be billed to the patient account and paid for The search function here works exactly like the search function on the Problem List in that you can search for either
3. right or left Contact Lens Search Parameters Maximize Q Close OD Rx 0 00 0 00 x ofS 0 00 Spherical P Bifocal 2 Toric P Select OD Lens OS Rx 0 00 0 00 x op 0 00 2 Spherical 2 Bifocal P Toric D Select 05 Lens 73390580061 Lot Humber Bar Code Revenue Ke Search boxes for Lot Numbers the benefit is that you can easily perfom product recall searches in the event of a Recall Sphere Bifocal and Tonc lens search You can limit search results to a particular lens design because the catalog is split into spherical bifocal and tonc lenses This helps you find what you need when you need it 39 Page e Prescnbing Certified e Prescnbing is available for each provider and designated staff member at a practice orclinic that hasbeen registered with Rcopia DrFirst To do this please contact your account manager at Kowa EMRlogic as the registration with the e Prescnbing Company is done by usasa courtesy to you our customer Once registered the e Prescnbing segment will be installed to your activeHR 2011 1 x x This enables full two way functionality including Drug Drug Interactions Allergy Alerts Drug Formula ry information and Drug history foreach patient from other physicians To access the e Prescnbing section navigate to any exam page and click on the e Prescnbing tab on the top navigation bar as shown below Eye Health Exam Conft Billing An History Ex Pre Test E Refraction Contact L
4. Group ABB CONCISE Optical Group Clea sl Clea 7 X Manufacturer Ciba Vision Corporation ll Ciba Vision Corporation y Wearing Schedule Series Ai Optix Aqua 6pk y Ai Optix Aqua 6pk y sl CL Billing Codes COEUR Replacement Schedule SSP 32240 a ssp 32241 El 6 Wear Care Instructions and Print Rx At this point you can add wear and care instructions for this patient and or print the contact lens Rx Current Wear Care Instrutions Wearing modality daily wear replace monthly Solutions Opti free daily cleaner Cleaning protocol no rub Cleaning frequency daily New Wear Care Instrutions Wearing modality daily wear replace monthly Solutions Opti free daily cleaner Cleaning protocol no rub Cleaning frequency daily Contact Lens Action List o act Contact Lens Action List Click to view amy of the Following links a Add New Contact Lens _ Do Progress Evaluation 2 1 Do Trial 2 Fitting Fl Hide Progess Evaluations amp Trials a Print Selected Contact Lens Prescription DEMO 37 Page Contact Lens Search Page _ CL Search Page a ae Series Selection lt Contact Lens Search Parameters A la Available Series y Maximize Close OD Rx 0 00 4 0 00 x 0 0 00 J Spherical j Bifocal 2 Toric 2 Select OD Lens OS Rx 0 00 4 0 00 x 0 0 00 J Spherical J Bifocal 2 Toric P Select OS Lens ode Search Lot Number Bar Code Revenue v Sele
5. Information 4 Auto Refraction Subjective OD 4 25 1 00 X 074 1 50 0 50 BI 1 00 BU Auto OD 2 25 0 75 X 102 20 20 20 20 OS 3 25 1 00 X 002 1 50 0 50 BI 0 50 BU OD 0 00 0 75 X 102 OS 2 00 0 25 X 093 20 20 20 20 PD OS 0 75 0 25 X 093 Auto Keratometry OD 43 50 07 74 86 44 50 07 59 176 OS 43 50 07 77 97 44 50 07 58 007 The Contact Lens Exam process is well defined so it is important to follow best practices during this segment of the exam This provides you or your Contact Lens Technician with the ability to get what you need when you need it even dunng the CL Exam This is based on the choices you select in one hypenink or check box on the Documentation Data Entry Page and tells the software what to display next effectively guiding you through the exam and ensunng best practices are followed This is again in line with the philosophy of what you need when you need it 26 Page Documenting a Contact Lens Exam 1 Enter Reason for Visit Problems and or External Measurements Contact Le Lid Tear film Eye Health Exam Conii Billing An History Ex Pre Test E Refraction e Prescribing Imaging History gt Reason For Visit Problems Issues Current CLs Current Wear Care Instrutions New CL fit Patient has never previously worn lenses New Wear Care Instrutions General CL use history External Measurements Aa Pupils equal Size in low ill 5 mm
6. It could be the case that an office might not have auto equipment or pemaps an instrument might not be linkable In that case data can be entered manually as well This also serves as a redundancy in the event that an auto instrument breaks down then the office can continue patient care unintenupted Helpful Hint Please be aware that linking your equip ment eliminates a considerable amount of manual data entry thus enhancing accuracy and increasing efficiency If you have instruments that are not linked you will need to re open the Decision Manager window left side and click on the icon for the instrument you wish to use or place a check mark in the checkbox The instrument will then show on the Exam Information Manager window right side 17 Page o gt Eb Front Desk jx J Refraction O A Text or voice entry ke a OME Patient wants new glass S o OME RT Instrument Library O Refraction Exam Action yy o O E Current primary spectac CDI Manual Keratometry 2 o O H Exam Keratometry gl 3 Previous exam final Rx FS L Ta Previous Rx s D o OME Tonometry 3 z O Auto Lensometer O EA Lensometer Manual O A Manual Refraction e Main Office EME L pH Ki 5 e SR en rs 5 Activate Practice Management Tree View An Web Browser View acti VE HR Refraction 4 Refraction Exam Configurations RT Acquire RT 5100B Data In future releases of the EHR Charts we will be d
7. Selected Contact Lenses Manufacturer Series Type BC i Sphere Cylinder Class Enter the patient s current Rx Sph Cyl Axis Add into the right eye and select the type of lens this is either Sohencal Bifocal or Tonc 28 Page The Seres _ CL Search Page lt __ Favorite Series a e UN Avalable Series D day tawet JE ikay Aare 1 LIM Aanue 2 Gpk F Aave 2Colou L M Acuvue 2 Colou Selection area will show at the Contact Lens Search Parameters J Maximize ZX Close oDRx 1004 000 x ol 000 P Bifocal OSRx 0757 000 x OZ 000 P Spherical JP Bifocal Bar Code Search Lot Number Bar Code Revenue e Series Selection Bi A Available Series 1 day Acuvue Trueye 30pk l 1 day Acuvue Trueye 90pk Acuvue 2 6pk l Acuvue 2 Colour Enhancer l Acuvue 2 Colours Opaque Acuvue Dk l Acuvue Advance 6pk l Acuvue Advance Plus 24pk l Acuvue Advance Plus 6pk l F P i KR i P F P E Acuvue Oasys pk l F y left Toric Toric hand side mm A 7 Select OD Lens 7 Select OS Lens Once you select the senes the contact lenses available will be shown and the ones appropnate forthe Rx will be highlighted _ CL Search Page Series Selection lt IN Favorite Series N Available Series ON 1 day Aarue T FF 1 day Aanue T FF Acuvue 2 6pk CI Aawe 2 Colo 718 Acuvue Advanc la Acuvue Advance Di Aave Gasys LII Air Optix Aqua LI
8. and physiological findings You can also record fit characteristics and your assessment and plan for this patient s 31 Page lens lenses Each link will pop up a Data Entry screen for you to enter your specific findings Helpful Hint The Visual Acuity findings are recorded for both eyes simulta neously as frequently the VA s are similar post over refraction In the event that the VA s are different simply click on the appropriate hypenrlink in the other eye and fine tune the VA The Over Refraction and the resultant CL power calculation are performed independently undereach eye in the patient record Be sure to select and highlight the appropnate lens on the History Grid This is what tells the system which lens para meters you are documenting at the moment Progress Evaluation 1 Distance YA Distance YA Dist cCL OD 20 25 Dist cCL OD 20 25 Dist sc 20 50 Dist sc 20 50 Near YA Near YA Near cl OD 20 30 Near cl OD 20 50 Near cc 05 20 125 Near cc 05 20 25 Near sc 05 20 725 Near sc 05 20 25 Over Refraction 0 25 Over Refraction 0 00 Calculated Power 0 00 Calculated Power 0 00 Fit characteristics Fit characteristics Movement insufficient movement Movement insufficient movement Comfort significant edge awareness dry feeling Comfort significant edge awareness dry feeling Direction of rotation no rotation Direction of rotation no rotation Assessment Plan This is where you can document you
9. fomally the Exam Infomation Manager window managing not just exam data but exam infomation Infomation is data made meaningful Each time a new exam segment icon is selected you will see an exam form that has been populated with the appropnate sections required for that exa m segment asyou have chosen in the Exa m Type Selection see example above Horizontal Tabs Across the top of the exam form you will find a nbbon with each exam form already open The exam form you are currently working on will be moved to the left side of the nbbon And the segment of the exam you are working on is clearly labeled above the Tab Ribbon Name Sean Test Patient Sex Male acti E H FR History Exam Birthdate 07 10 1965 Age 45 Exam 07 10 2011 Provider Semmelweis Main Office Search y 4 History Exam Exam Configurations Billing And Coding Pre Test Exam Refraction Eye Health Exi p You can toggle between the tabs on this nbbon as often as needed with 1 touch and data entered will automatically save as you move through the vanous tabs Inturtiveness Rule of Thumb tf you wantto change something click on it Most titles topics or findings in the exam workspace are hyperlinked So for example if you want to enter a finding in Review of Systems click on the title This will take you automatically to a more detailed information page known asa Data Entry Page 5 Page actiVEUR History Exam 4 History Exam Exam Configu
10. is populated from the selection in the Exam Type Selection tab If necessary you can add to this screen either by going through the Data Entry Hypenink Pop ups next to Review of Systems and PFSH or by opening the Decision Manager Window 16 Page Pre Test Exam acti VE HR Pre Test Exam 4 Pre Test Exam Exam Configurations Billing And Coding Distance YA Vital Signs Near YA Color vision Contact Lens YA Ishihara Stereapsis testing Stereo fly As with the History Exam the Pre Test Exam is pre populated with appropnate hyperlinks based on the selection made in the Exam Type Selection tab Simply click on each test to perform it and records your test findings Any tests done in preparation for the doctor s refraction and eye health exam are done in the Pre Test Exam segment This section may be performed by either a technician or the doctor Findings entered in the Pre Test Exam that impact the refraction will be automatically camed forward into the Refraction segment so that the doctor can pick up where the technician left off without having to jump between the two segments of the exam What you want when you want it what you need when you need it Generally pre test refractive equipment other than an auto phoropter is linked to this screen A linked instrument will show on the Exam Information Manager Window The exam forms are set up to transfer data from a linked piece of equipment into the appropnate exam segment
11. on the Add Text icon and the Custom Text Entry window will appear in the Exam Information Manager area on the nght side of your screen In some cases a plain Text Editor window will display which is accessed via the same icon 7 Text or Yoice Entry Font FontSize 4 B Z U see BB EI E Mi lx save Close A Close e Start typing your notes in the window and click on Save your work is saved but the custom text box remains open WR e Be sure to click on the Save Close icon Mee when you have completed typing the note Thisicon will both save the custom text and close the window saving additional clicks e The Close icon cate Chose will not save custom text already entered The benefit of this is that if you enter something in error you can delete the text and move on in one Click e If you right click you will see additional standard Windows Right Click Functionality 7 Text or voice entry Font FontSize Y B Y U He da i Custom Text Custom Text Custom Text Undo Cut Copy Paste Delete Send to OneNote Select all 11 Page Text Entry window This is the window that appears when the Add Text icon is clicked on forthe manual entry of numeric instrument readings or findings On the Custom Text Entry window you can enter infomation in the following ways e Use the sider bars which can be used by left clicking and dragging the handle barto the correct position e Place the cursor on the num
12. status field for the problem in question and choose for example resolved Once you do this the problem list will be separated into active problemsand resolved ones The sa me is true for problems in remission etc Problem List gt Search ICD9 Codes 4 Today Complete List Onset ICD9 Code Description Eye Entered Date Resolved Date Problem Type Ocular Risk System Care Type Status Code System active 2 06 24 2011 367 1 Myopia 06 24 2011 Diagnosis active 2 16 840 1 11 06 26 2011 346 Migraine 06 26 2011 06 26 2011 Diagnosis active 2 16 840 1 11 inactive in remission resolved Problem List gt Search ICD9 Codes d Today Complete List Onset ICD9 Code Description Eye Entered Date Resolved Date Problem Type Ocular Risk System Care Type Status El active 1 06 24 2011 367 1 Myopia 06 24 2011 Diagnosis active El resolved 1 06 26 2011 346 Migraine 06 26 2011 06 26 2011 Diagnosis resolved In the case of a resolved problem you can record the date on which the problem was resolved ormarked assuch underthe appropnate field 43 Page Problem List Search ICD9 Codes Today Complete List Onset ICA Code Description Entered Date Resolved Date Problem Type El active 1 06 24 2011 367 1 Myopia 06 24 2011 Diagnosis El resolved 1 06 26 2011 346 Migraine 06 26 2011 June 2011 E Mo Tu We Th Fr Sa 1141314 BI 6 9 110 11 13 14 15 16 17 AE 20121 22 23 24725 27 26 29 30
13. 1 00 2 00 X 175 Transfer to Final Rx Final Rx OD 1 00 2 00 X 180 OS 1 00 2 00 X 175 Transfer to Optical Specialty Rx Action List S e g Specialty Rx Action List Click to view any of the following links a Transfer Final Rx to SY Distance Rx Transfer Final Rx to SY Near Rx Transfer Final Rx to Computer Glasses Transfer Final Rx to Occupational Glasses Transfer Final Rx to Sunglasses Transfer Final Rx to Hobby Glasses a Transfer Final Rx to Sport Glasses a Transfer Final Rx to Specialty Rx 01 da Transfer Final Rx to Specialty Rx 02 DEMO 3 Transfer to Final Rx After the refraction is complete click the Transfer to Optical link 20 Page Lensometer Manual OD 1 00 2 00 190 OS 1 00 2 00 x 175 Transfer Manual Lensometer to Subjective Subjective OD 1 00 2 00 x 160 OS 1 00 2 00 175 Transfer to Final Rx Final Rx OD 1 00 2 00 180 OS 1 00 2 00 4175 Transfer to Optical Specialty Rx Action List You will be given a pop up confiming the transfer was successful then click OK Lensometer Manual OD 1 00 2 00 160 OS 1 00 200 4175 Transfer Manual Lensometer to Subjective Subjective gt 0D 1 00 200x180 OS 1 00 200 4 175 Transfer to Final Rx 7 Successfully executed Transfer Final Rx to Visions Rule Set Command Final Rx E OD 1 00 2 00 180 OS 1 00 2 00 x 175 Transfer to Optical Specialty Rx Action List E From here the Rx is transf
14. 367 1 Myopia 06 24 2011 Diagnosis active activEHR Charts offers an up to date problem list kept foreach patient The problem list is created and maintained from within the Billing Coding form You will notice that some problems have auto populated here when you open this form after completing an exam Some need to be added by searching forthem using the Search IC Do Codestool To search for an ICD9 Code you can type eitherthe code itself orthe problem it represents The search tool types as you type so if you are not sure of the digit past the decimal orof the spelling of the condition it will be displayed 42 Page Problem List Search 1CD9 Codes 344 Today c 346 Migraine oC 346 0 Migraine Onset ICDA Co wc 346 00 Migraine oe FAR TU Adie sin auras with intrthl Eire sarir Problem List Search ICD9 Codes mod Today O 346 migraine o gt 346 0 migraine DA CO SG 346 00 migraine If an item needs to be deleted from the Problem List because either it was populated there by the software and it should not have been orbecaus you accidentally chose the wrong item from the search results you can nght click on it and choose Delete 346 Migraine A Delete On the Complete List will be all of the problems that were so far recorded for this patient including today s This list can be maintained by marking problems that are active inactive in remission and or resolved Double click on the
15. Dose Unit Route DoseTiming Duratior StopDate Refills Status Allergies Add New OnsetDate Allergen Name Allergen Group Reaction Allergy Group Drug Generic Name Results Add New Filler Order Num Date of Observation Coding Code Name Result Units Reference Al Default Range Fl Orders KL Add New Filler Order Num Observation Coding Code Source Code Name Instructions Ordering Placer Order Specimen Source Diagnostic Status Default Provider No Serv Change The Billing Coding form is part of the Plan Management portion of activVEHR Charts lt is also your start and end point of every exam When you begin an exam with an existing patient whose last exam you recorded in activEHR Charts you would consult their previous Billing Coding form in the same way that you would read their paper chart prior to their exam To end an exam you would enter today s Exam into the Billing Coding form On the Billing Coding form you will find an E M Compliance counter that automatic ally counts the exam elements you did throughout this exam and remember that populating nomal does get counted here as having completed a specific exam element The Billing Coding form is broken down into a number of elements Elements Counter EM Compliance ICDS Codes Selected Coding Level History HPI 0 ROS 11 PFSH 3 Exam PE 2 Medical Decision Making Diagnosis And Management U Billing Coding offers
16. EI Problem List ER MEE Procedure Code History H OMS Medications H OTE Allergies H CIM Non Rx medications H OTE Assessment D OE Plan ER O Plan tor each diagnosis E Tests completed list for todays exam H OME Quality checklist E O Arpenged Text 2 Medications Ean Allergies E ID Signature jue Results e Orders You will be prompted to enter your usema me and password in omerto sign off on this exam Signature Za Print Qa Close certify that the findings herein are the findings prepared by myself and certify that the findings are accurate to the best of my understanding Jeffrey Allen User Name Password Sign The text as well as your name will appear under the Elements Counter on the Billing Coding segment EM Compliance Selected Coding Level History HPI 5 ROS 11 PFSH 2 Exam PE 2 Medical Decision Making Diagnosis And Management 4 signature certify that the findings herein are the findings prepared by myself and certify that the findings are accurate to the best of my understanding Jeffrey Allen 48 Page Any changes to the exam after it has been locked need to be done by using the Append Text box Thisis found in the Decision Manager window as well H O E Text or voice entry H MMS ICDS Codes H CMS Dx Codes Quick List ME Procedure Codes wl Et Compliance H CS Biling codes selected H MM Problem List H WITE Procedure Code History LIM Medica
17. History Actions Renew Selected Select AN Select None Check Interactons for Selected DR oars No Quantity NR by EM Actions Renew P cyclobenzaprine Tablet 10 mg 1 tablet by mouth three times a day as needed for pain Disp 30 NR last 06 02 2010 by EMDo started on 06 02 2010 Actions Rene Prescobel op Copy To Patent Lipitor atorvastatin Tablet 10 ma 1 tablet by mouth every night with a glass of water Disp 10 NR last 06 01 2010 by EMDo started on 06 01 2010 Actions Renew Prescribe Stop Copy To Patient W Lipitor atorvastatin Tablet 10 mg 1 tablet by mouth every night with a glass of water Disp 10 NR last 06 01 2010 by EMDo started on 05 31 2010 Actions Renew Prescribe Sop Copy To Patient Tylenol acetaminophen Tablet 325 mg 1 tablet by mouth three tes a day Disp 20 RA 1 last 06 02 2010 by EMDo started on 06 01 2010 Actions Rene Prescribe Sion Copy To Patient j con uni pou 40 Page Plan amp Management Billing amp Coding Name Larry Test Patient acti EH R i Billing And Coding Birthdate 06 23 1919 Exam 06 23 2011 Search 4 Billing And Coding Exam Configurations History Exam Pre Test Exam Refraction EM Compliance ICDS Codes Selected Coding Level History HPI O ROS 11 PFSH 3 Exam PE 2 Medical Decision Making Diagnosis And Management O Problem List Procedure Code History Medications Add New Date Qty Unit Medication
18. IN Ar Optix Night l i Aquaflex Super LU Avara Gok Contact Lens Search Parameters J Maximize 3x Close OD Rx 100 0 00 gt x 015 0 00 gt 7 Bifocal OSRx 075 0 00 gt x OC 0 00 Spherical gt Bifocal Bar Code Search Lot Number Bar Code Revenue v Selected Contact Lenses Manufacturer Series Type BC Dia Sphere Cylinder Vistakon Acuvue 2 6pk SPH 8 30 14 1 25 0 00 Vistakon Acuvue 2 6pk SPH 8 30 14 1 00 0 00 Vistakon Acuvue 2 6pk SPH 8 30 14 0 75 0 00 Vistakon Acuvue 2 6pk SPH 8 70 14 1 25 0 00 Vistakon Acuvue 2 6pk SPH 8 70 14 1 00 0 00 Vistakon Acuvue 2 6pk SPH 8 70 14 0 75 0 00 O O O O O O F 4 Toric Toric 0 00 0 00 0 00 0 00 0 00 0 00 SE Select OD GN 7 Select OS Lens v Color Class Clear Revenue Clear Revenue Clear Revenue Clear Revenue Clear Revenue Clear Revenue 29 Page Selected Contact Lenses Manufacturer Series Yistakon Yistakon Wistakon Yistakon Yistakon Vistakon Acuvue 2 6pk Acuvue 2 6pk Acuvue 2 6pk Acuvue 2 6pk Acuvue 2 6pk Acuvue 2 6pk Axis Cylinder Sphere 0 75 1 00 1 25 0 75 1 00 1 25 0 00 U 0 00 0 0 00 0 0 00 0 0 00 U 0 00 U Class Revenue Revenue Revenue Revenue Revenue Revenue Chose the lens with the correct Base Curve and Diameterand click on Select Lens Contact Lens Search Parameters das OD Rx 1 0015 0 00 x 0 0 00 gt OS Rx 0 00 0 00 x 0 0 00 Bar Code Searcl ot Number Ba ode Revenue Sel
19. Page have been saved to this form automatically Le in the example above Review of Systems Review of Systems As Constitution fever Integumentary 6 Page Go Forward Anow Unlike with the Action Manager where you go forward on every individual task in the activEHR Charts you only use the Go Forward Arrow to end the exam and go back to the UserLevelon the Action Manager Note that at the end of an exam the icons on the Action Manager will not have changed color because dunng the exam you won t be opening each form through the icon on the Action Manager The only icon that will tum green or yellow if you are still in the middle of the exam is the Exam Configuration icon asthat isthe icon through which you entered the exa m forms Patient Messages Mot Started Exam Configurations Completed Billing 4nd Coding Mot Started Follow Up Esam Not Started History Exam Mot Started Practice Management Tree View Toggle Button The blue and pink button located to the nght of the Handler and Location drop down boxes allows you to hide or unhide the Practice Management Tree View which houses the Action Manageras well asthe Decision Management Window Exam d Seattle sl During the exam most of the time you won t need the Decision Manager window open so you might find it more efficient to work with a cleaner looking screen by minimizing it using the button shown above You can bring it back by clicking
20. Populate Normal This has a number of advantages Review of Systems La Neurological Endocrine Ears Nose Mouth Throat Respiratory Eyes Constitution Integumentary Gastrointestinal Vascular Cardiovascular Genitourinary Musculoskeletal Lymphatic Hematologic Immunologic Psychiatric Endocrine none none chronic cough asthma no problems none none none none none none none none none EM Compliance selected Coding Level History HPI O ROS 11 PFSH 2 1 The screen is not cluttered with nomal findings that you need to read through to find the place you need to enteran abnomal finding 2 Having the screen clear of the nomal findings prevents you from forgetting to record oroverlooking an item for which you need to record an abnomal finding 3 None Nomal are not yet checked and won t need to be unchecked in order to record an abnomal finding 13 Page Search Function There isa new Search box at the top nght of the Exam Information Manager Window To use this feature start by typing in a search term This is designed for rapid results similar to Google Search As you type the search engine starts responding immediately The more details you provide the more the search engine will dnll down to find exactly what you want There is also the ability to click on the magnifying glass icon at the far right of the search box Helpful Hint The search feature isspecific to the se
21. SP school age children exam o op A D VSP adult exam External measurements amp Descriptions Hi BEES sxem Baseline neurological amp functional tests Ga Ka Medicaid exam without dilation A E Confrontation YF H Medicaid exam with dilation O Er m Medicare exams bet o ilation E Medicare level 2 exam O General external exam y Medicare level 3 exam em e r Slit lamp exam OD Select v Medicare level 4 exam 7 A Slit lamp exam OS Select v Medicare level 5 exam Posterior pole exam OD Select v Follow up exam selection 7 Posterior pole exam OS Select Y Refractive surgery follow up exam Peripheral retina exam OD E Cataract extraction follow up exam SE Peripheral retina exam OS ti pecialty exams 15 Page Helpful Hint In this version only the Exam Types labelled in green are functional The Exam Typesin black font are under construction After you have made your selection i e Medicare level 4 exam you can start your exam by going to the tab that is relevant asa next step for your exam If this is a retuming patient and you have their previous exa m recorded in the Charts you might want to start with the Billing amp Coding Plan amp Management tab to review the case pror to this exam If this is a new patient or the pr
22. Size in normal ill 3 mm Size in high ill 2 mm Shape round Tear film OU Normal tear film Click on the Reason For Visit link to list any problems or issues the patient has with their current lenses The current wear instructions would display here if any were recorded ina previous exam You can enter any extemal measurements as well see screen shot above If there is a history of contact lenses that this patient has recorded through activEHR Charts it will be disolayed in the Contact Lens History Gnd You can tell which brands were wom if they were tnalsand the outcome of the tral fitting Contact Lens History Grid gt Contact Lens Action List E Today Complete List Prescribed or Workup Right Contact Lens Information Right Status Right Status Description Left Contact Lens Information Left Status Left Status Descripti itting Date AS Sideways Arows are present throughout the Contact Lens Exam form Click them to hide parts you either have finished or don t need to work with and therefore don t want to display The benefit is that the screen will always look as uncluttered as possible Rather than your patient record distracting you with information you don t need you have the option to hide that information until you need it This is consistent with the philosophy of What you need when you need it 2 Start the CL Exam Click on the Contact Lens Action List For this step you have two op
23. actiVE HR Maximizing Your Use of activEHR Charts EMR logic EMRlogic Systems Inc l Page Table of Contents EEGENEN EE 2 INTRODUCTION EE 4 BEFORE VOU START EE 4 NAVIGATING THE ACTIVER CHARTS A a ei elite 4 eet Ee eet ARR lient sia 4 D cision Manager e e EE 5 EXamn lnformotion Manager VIA oa 5 LE A PAG A1 EOI TODS sos A SAA AAA a a a 5 Intuitiveness Rule of Thumb If you want to change something click on it cecccccseeeccecesececeesececeeeeeesesecens 5 DOG ENUY PORN A A ni di ed de ne 6 BOCK TO BUTTON EEN 6 GO FOMW GIG AITO ER RENE dd data 7 Practice Management Tree View Toggle Button 7 COMMONLY USED TOOLS IN ACTIVEHR CHARTS sccsccssccsccssccsccsscnsccsccsscnsccsccsscnscssccsscnscescosscnscescossonscess 9 Common ICONS and SYMDOIS air 9 Hyperlink EP OPUS A AA ae inner donnee A 10 Ada TONE SY ege ET 11 TEX ele tee E 12 reene ANR le M ao 12 Populate Normalement einen in 13 Popu iote Normal Best ele de EE 13 A ON UON AAA PP aes aig a aoe na ee 14 How DoT Review Previous EXAM Recon ide 14 GETTING STARTED WITH AN EXAM EXAM TYPE SELECTION ccsccssccsccsscssccsccssccsccsscsscsscsscsscnscossonsoeses 15 HISTORY EXAM ME 16 PRE TESTEXA BE 17 REFRACTON ee 18 EVE HEALTH EA Miss 22 ACTIVER IMAGING aaa A one 24 CONTACT LENS E 26 DOCUMENTING a Contact Lens EXA aa aaa 27 E PRESCRIBUN LEE A0 PLAN amp MANAGEMENT BILLING amp CODING csccsccsscssccsccssccsccsscnsccsscsscnsccssc
24. an exam element counter to assist with medical billing It automatically counts the HPI ROS and PFSH elements of the History Exam and the PE elements of the Eye Health Exam The count can be changed manually if necessary by simply clicking on the element that needsto be changed 41 Page EHR tem Properties Use the controle on the property page below to set the data for each parameter Mame Selected Coding Level History HPI ROS FFSH Exam Physical Exam Medical Decision Ma Diagnosis And Man Risk Rememberthat populating nomal does count ascompleted elements in an exam Note Diagnosis and Management has to be entered by the provider as it is impossible to automate the thought process that takes place during an exam and the provider is the only one who knows at what level this exa m truly should be billed The level of the exam needs to be selected at the very beginning of the exam because that level i e Comprehensive is the goal or the expectation for this particular exam To reach that goal or expectation the necessary fields and tests are pre populated in every relevant exam form If it tums out that a particular exam won t meet the expected level those items that won t be needed can simply be skipped Problem List Problem List Search ICD9 Codes Today Complete List Onset ICD9 Code Description Eye Entered Date Resolved Date Problem Type Ocular Risk System Care Type Status 06 24 2011
25. ascular Genitourinary Musculoskeletal Lymphatic Hematologic Immunologic Psychiatric Orientation status at time of exam oriented to person place amp time General observations Billing And Coding PESH As Past medical history Past ocular history Past personal medical history social history education hobbies driving tobacco use 8 Page Commonly Used Tools in actvEHR Charts As with the navigation of the exam segment there is consistency across the entire activEHR Charts module in terms of the functionality itself The tools that you will be using in order to record your exam findings etc are represented consistently by the sa me symbols and icons Common Icons and Symbols icon Description oo This Icon enables repeat use of the same descnptors e g to document the patient s complaint 1 complaint 2 complaint 3 etc Thisicon indicatesthat you are ata node in the tree structure and more information can be accessed by expanding the tree at this point This isthe symbol used for bullets It signifies a final node in this section no more content below AS Text or Voice entry d Clg vision O dla Ocular sensation appearance o E Existing ocular condition recommendations o Trauma in or around the eye 7 ie O dk Systemic Condition o L Significant family history CI e Refractive CI Other Clicking on an icon directly or placing a check mark in the check box to the l
26. cted Contact Lenses v Manufacturer Series Type BC Dia Sphere Cylinder Axis Add Color Class The CL Search Page is a tool for searching for lenses using our onboard continually updated contact lens catalog There are a number of features in this tool to make working with a large lenscatalog easer e Favorite Series In the CL Search page you can set up a favorite senes that make it easier for you to find the lenses you prescnbe more often than others Find the seres in the list and check mark those you wish to make as favontes Series Selection lt E a Available Series Acuvue 2 Colour Enhancer Acuvue 2 Colours Opaque Acuvue ass Apk wi 1 Air Optix Aqua 6pk Air Optix Night amp amp Day Aqua pk Aquarlex Sup rthin Avaira pk wi 1 Biofinity Ew 6pk Biomedics 38 Biomedics 55 w Biomedics 55 Premier Biomedics Mc Gpk larik Le 1 Ze Close the CLSearch page and re open it You will see a list of Favorites preceding the list of Available Senes 38 Page Series Selection Hi E Favorite Series wi 1 Air Optix Aqua 6pk wi 1 Biofinity Ew pk al ja Biomedics 55 Premier Bi ja Available Series It is just as easy to remove a senes from the list of favorites simply uncheck that senes then close and open the CLSearch page Search Boxes for Bar Codes Using a bar code scanner Trial and Revenue lenses boxes can be pulled out of inventory and scanned when the cursor is in the correct field i e
27. e Imaging Note In order for the e Prescnbing module to work correctly all the yellow highlighted demographic fields on the Patient Address View must be completed i e First Name Last Name Address 1 City 4p Postal State Province Phone Number and Sex For further details on the e prescnbing interface please refer to the Rcopia Dr First End User Guide A EMRiogic activEHR DEMO Web Browser Vie Er x Ae fie Edt Becord View Ecernat Jock Reports Video Window Settings Wizards Help BE a we el __ tot SAR Bee BG Da OW A ee BAB g Work Space Manager Name Joshua Garcia Sex Male acti HH R e Prescribing Birthdate 11 21 1959 Age 51 Exam 11 25 2010 Provider Roberts Canton Contact Lenses Reason For Visit History Exam e Preseribing Activ maging e Prescribe Messages e Prescribe Prescription Report Practice User EMRLog Doctor R Trial lene selection Patient Joshua Garcia DOB 11 21 1959 Phone 205 403 6106 Last Office Visit 04 27 2007 Visit Today W ee rase Pharmacy RITE AlD 2028 E ISAACS AVE 2028 EAST ISAACS AVENUE WALLA WALLA WA zi Vies Change Formulary None D y L ens RB Final lons dispensed eS New instructions CIS Base measurements BS Retractve ntermaton BS Hx of wear and compliance 0 sat Veo Pope Links Wi Select Medication for Prescription Name Find Category Search Favorites Choose a Favorte Use View Eda View Dotai Mini PEM Pharmacy
28. e acti EHR Output Documents 4 Output Doc Exam Conti Billing An History Ex Create Continuity of Care Document Create Public Health Surveillance Receive Continuity of Care Document Receive Continuity of Care Record Receive HL Lab Results At this time the Decision Manager Window can be collapsed again to not take up valuable real estate Growth Charts In order to comply with Meaningful Use requirements activEHR Charts offer Growth Charts that plot the growth in height overage aswell asthe weight gain lossoverage More information coming ata laterdate 51 Page actiVEH R Height in Growth Charts Weight Ib Growth Chart Weight vs Age 52 Page Maintaining Your actvEHR Charts Exam Forms Content vs Functionality With traditional software every so often the software company would release a version update to introduce new functionality and features This version update structure applies to the application itself and going forward will remain the same However the activEHR Charts themselves need to be kept up to date not only with version updates as the software does but also with updates just to the content itself rather than the functionality Content here refers to the information accessed by the exam forms from the underying database A version update cannot download new content This is done by a synchronization of data called an Active Sync descnb
29. ected Contact Lenses Manufacturer Series Type BC Vistakon Acuvue 2 6pk SPH 8 30 Yistakon Acuvue 2 6pk SPH 8 30 Yistakon Acuvue 2 6pk SPH 8 30 Vistakon Acuvue 2 6pk SPH 8 70 Yistakon Acuvue 2 6pk SPH 8 70 Vistakon Acuvue 2 6pk SPH 8 70 A Spherical P Bifocal P Toric Select OD Lens Spherical 7 Bifocal 7 Toric 7 Select OS Lens v v Dia Sphere Cylinder Axis Add Color Class 14 0 75 0 00 0 0 00 Clear Revenue 14 1 00 0 00 0 0 00 Clear Revenue 14 1 25 0 00 0 0 00 Clear Revenue 14 0 75 0 00 0 0 00 Clear Revenue 14 1 00 0 00 0 0 00 Clear Revenue 14 1 25 0 00 0 0 00 Clear Revenue Repeat for the left eye and close the screen You will see the lens parameters you ve chosen in the Contact Lens History grd Next to each lens are two columns where you can enter your notes as you go through such asif this lens is their current lens or a tnal or if this tnal failed or succeeded etc Simply double click on the field you wish to notate and a drop down window will appear Contact Lens Action List E Today Complete List Prescribed or Workup Right Contact Lens Information Fitting Date 06 23 2011 8 30 14 0 1 00 Acuvue 2 6pk Right Contact Lens Information 4 301 14 0 1 00 Acuvue 2 pk Right Status Right Status Description Left Contact Lens Information 8 80 14 2 1 00 Biomedics 55 Right Status Right Status Description Double click Active Inactive Failed trial Trial Fit Left Status Discc Date Left Statu
30. ed below Regulary Updating Content Every Monday and Thursday new content to the activEHR Charts may be downloaded using the Knowledgebase Management tool in activEHR Follow the below steps 1 In activEHR click on Wizards and choose Knowledgebase Management Wizards Security Help Add Insurance Payer Auto Pricing Setup Wizard Knowledgebase Management Wision web Record Maintenance Lens Coding Wizard 2 On the Knowledgebase Updates window that pops up choose Synchronize from Server No PMM It is important that you chose the option stating no PMM because otherwise you nsk changing your Action Manager workflows which were individually set up for your office at the time of implementation Knowledgebase Updates Ea Synchronization for Client Server Visions Synchronize Spectacle Lenses Synchronize Contact Lenses ActiveEHR Sync Cancel Synchronize from Server No PMM Synchronize from Server with Fedt 3 Hit Continue enterthe admin credentials and confirm that this is what you want to do 4 When the Active Sync iscomplete a window will appearto alert you of this 53 Page Appendix B Setting up Exam Configurations The pre populated fields and exams that are caused by the Exam Type Selection can be customized if you wish the normal findings to be renamed Le WNL instead of nomal etc Or forexample if your office does not do an Ishihara test for Color Visi
31. ed on the Exam Information Manager window this icon denotes a Data Entry Page popup which offers a list of data entry pages that were not part of the original selection that populated from the Exam Type Selection Scroll down to select a hyperlink from within the list in the pop up window This action will take you to the data entry page that corresponds to your selection SH la e Sprsu E Click to view any oF the following links da Past ocular history F Past personal medical history Date of procedure Date of Incident m Family history r Family list F Social history Add text This icon denotes an Action List popup which displays a list of actions that can be taken at this point in the exam Scroll down to select a hyperlink from within the list in the pop up window This action will populate the piece of the exam corresponding to the link you clicked and will also take you to the exam form area where that piece was populated E Trial 1 Action List Click to wiew any ofthe Following links CS Do Trial 1 CL Search using Subjective A Co Trial 1 CL Search on Selected CL E Select amp Order Final Contact Lens 10 Page Add Text symbol If you don t find the specific item you want to document for a patient in the exam forms or if there are notes you wish to leave on an exam you can use the Add Text or Text or Voice Entry links located throughout the Decision Information Manager window Single click
32. eft of an icon will place that item on the Exam Information Manager window at the nght Clicking on the symbol to the left of an item oron the text of an item itself will cause all items below that node to be displayed In the case ofa bullet orfinal node nothing will happen The item will not be selected and placed in the Exam Information Manager window Sig nifies an Information Data Entry Page Click on this symbol to open the information page and make your selections Signifiesan Add Custom Text tool Click on this symbol to open the Custom Text Entry or Text Editor windows and be guided through your selections There are two different types of Text Entry windows one with Siders and text entry boxes only and the other just forentenng plain text The window for entenng plain text is known asa Custom Text Editor window Both windowsare accessed via the Add Text icon 9 Page See more information on this b y clicking here This icon indicates an item that will display on the Exam Information Manager window with a hypenink pop up either an action list popup indicated by this icon ora Data Entry Page popup indicated by thisicon Le See the table below for more infora mtion on Hyperlink Pop Hypenink Pop ups It is easy to know when this roll over function is available as these headings are marked with the Data Entry Page icon to its nght Review of Systems Aa or Contact Lens Action List When locat
33. egment e La Lens Insurance Billing Rule Sets Review of Syste Confrontation Y p cornea E Gastointestinal Gross visual fi y Normal cornea deep and quiet How to Customize Exam Components Repeat steps 1 4 above 5 Here you can alterthe tests that come up in specific exams Ishihara test with the HRR test so it comes up by default Forexample replace the Lu Web Browser View E r Configurable Exam Rule Sets Eve Heath Exam Initial Components History Exam Components Health Exam Initial Components E Master Exam Component Selection al E z Medicare Level 4 Exam Component Selection IABIN EE SS b VSP Adult Exam Component Selection Review of Syste Near VA Fl baw EyeMed Exam Component Selection Past ocular his Mear 44 hd nota gt SS 7 Medicare Level 5 Exam Component Selection Pazt personal m Contact Lens vA FP 7 Medicare Level 3 Exam Component Selection amp 4144 7 Medicaid Exam Without Dilation Family history IOF wi Medicare Level 2 Exam Component Selection gem ke a C Medicaid Exam with Dilation Social history External measur Vi z N Cataract Extraction Follow up Exam Orientation sta Baseline neural vi
34. eric field to manually type in the value via key stroke or use the up down arrowsthat appearwhen you click on the value All instrument linking dates hypenink will open this same tool and can be modified and fine tuned by the user This provides complete flexibility Append Text At the bottom of the Decision Manager window you will find a node called Append Text Notes added here will be date time stamped with login information so the user will know who what when and why the record was changed after the system has locked the record Records are locked after 24 hours 6 04 appended Text Appended Text Font FontSize B Z U 59 FEE t E Y El save Li Save Close X Close Appended text added Jun 30 2011 Patient called 24 hours after her visit to report that she is already feeling great relief of symptoms Thisishow the Appended note would appear in the medicalrecord Diagnosis And Management Patient called 2 symptoms Problem List to report that she is already feeling great relief of Search ICD9 Codes Today Complete List Onset ICD9 Code Description Eye Entered Date Re active 4 03 09 2011 648 8 Diabetes Gestational OD 03 09 2011 06 29 2011 362 07 Diabetic macular edema 06 29 2011 06 29 2011 371 41 Arcus senilis 06 29 2011 06 29 2011 371 57 Endothelial corneal dystre 06 29 2011 12 Page This is the equivalent to the doctor signing the paper record to signify that
35. erred to the Spectacle Order screen where by default the status comes up You will see the Rx in the Right and Left Lens fields The Status Description and Status fields will also show further details that were entered in the EHR Charts module Rx Order History 2 1 00 2 00 180 lia Record 1 21 Page Eye Health Exam acti EHR Eye Health Exam 4 Eye Health Exam Exam Configurations Billing And Coding History Exam Eye Health Exam Action List E Slitlamp exam OD Slitlamp exam OS Dilation lids lids Tonometry conjunctiva conjunctiva IOP sclera sclera 06232011 08 33AM Carmen comea External measurements amp Descriptions AC iris AC iris General external exam tear film tear film ant vitreous ant vitreous Functional A Baseline Neurological lens lens Baseline neurological amp functional tests Posterior pole exam OD Posterior pole exam 05 Confrontation VE optic nervehead optic nervehead Quadrant finger counting nerve fiber layer nerve fiber layer vasculature vasculature Cover test macula macula posterior retina posterior retina Vitreous exam OD Vitreous exam US Vitreous Vitreous Peripheral retina exam OD Peripheral retina exam OS Peripheral Retina Peripheral Retina The Eye Health Exam segment allows you to enter those findings pertaining to the Physical Exam The form itself is consistent with the entire activEHR Charts in that it follows the Touch N Go ph
36. esults Orders Results Add New Filler Order Num Date of Observation Coding Code Name Result Units Reference Abnormal Resp Default Range Flags Obse Le Orders Add New Filler Order Num Observation Coding Code Source Code Name Instructions Ordering Placer Order Specimen Source Diagnostic Status Collection Default Provider No Serv Change Quantity The Results area is used to receive and track lab results that you get back from other labs The Orders area shows the tests that you have ordered from a lab At this time both Results and Orders need to be added manually In the case of Results if the lab that is sending the results has certified EHRs as well then they may be able to transfer this data in HL7 HL7 isthe programming language that underlies all electronically transfered patient information such as Continuity of Care documents test results etc and is the language that allows practices using different EHRs to communicate to each other as part of the Meaningful Use requirements For more information on this please refer to the activEHR 2011 1 1 Training Package Signature Once the Billing Coding segment is finished open the Decision Manager window to the left and click on the icon next to signature 47 Page ER Biling And Coding E Initialization Rule Sets ER O CA Text or voice entry H ME ICD9 Codes H CIM Dx Codes Quick List ER MMS Procedure Codes ER MEE Ent Compliance H ba Billing codes selected H W
37. evious exam was not recorded in the Charts module start recording this patient s history in the History Exam tab Note Ignore the Exam Configuration tab to the left of the Exam Type Selection tab as well as the Back to Exam Configuration button Go straight to the tab representing the exam segment you wish to document History Exam actiVEHR were 4 History Exam Exam Configurations Billing And Coding Pre Test Exam Get Previous Histo Review of Systems As HE SH As Populate Normal Constitution Completed as part of history Integumentary Past medical history Patient Lifestyle Eyes Past ocular history Neurological Past personal medical history Endocrine Social history Ears Nose Mouth Throat education Respiratory hobbies Gastrointestinal driving Vascular Cardiovascular tobacco use Genitourinary Musculoskeletal Lymphatic Hematologic Immunologic Psychiatric Orientation status at time of exam oriented to person place amp time General observations The History Exam follows the general tools and functionality and is very easy to leam Begin by recording the HPI History of Present Illness then the abnormals in the Review of Systems each item one ata time top to bottom although thiscan be documented in any order of preference Next document the PFSH Past Family and Social History finishing with Populate Normal Remember that what you see on the History Exam when you first open that screen
38. gment of the exam you are in Example You are in the History Segment of the Exam and you want to get to migraine Simply start typing what you are interested in and the knowledge base is instantly at your fingertips Click on the search result you were looking for with the Touch n Go capability Name Annie Test Patient Sex Male History Exam Birthdate 06 15 1954 Age 57 Exam 06 21 2011 Provider Allen Raleigh Search migraine y Exam Configurations Billing And Coding Pre Test Exam Refra T History Exam a Review of Systems Review of Systems ba PFSH 45 a D Data entry page Constitution a 4 Review of Systems 1 Integumentary Past medical history a BS Neurological Eyes Past ocular history migraine headache Neurological Past personal medical history Endocrine Social history Ears Nose Mouth Throat education Respiratory hobbies Gastrointestinal driving Vascular Cardiovascular tobacco use Genitourinary Musculoskeletal Lymphatic Hematologic Immunologic Psychiatric Orientation status at time of exam oriented to person place amp time General observations How Do I Review Previous Exam Records If you want to display a previous exam record ensure that you are on the tab representing the exam segment you want to view then nght click on the tab nbbon All previously documented records will be available to choose from including today s Therefore it s easy to come backto t
39. ilosophy of If you want to change something click on it The Eye Health Exam can be perfomed at any time that suits you during the patient encounter The system is built to work for you not you working forthe system We suggest that you document the nght eye findings first following accepted documentation guidelines Since many physical exam findings are bilateral you have the option of copying all or some of the findings to the other eye using Touch N Go technology 1 Click from the Action List to Transfer only Slit Lamp findings from OD to OS Or 2 you can copy specific segments of the Physical Exam For example just the slit lamp exam the postenor pole exam etc Simply click on the Eye Health Exam Action List and make your choice 22 Page Eye Health Exam Action List e Eve Health Exam Action List Click to view any of the following links Get Previous Eye Health Exam Populate Normal Transfer All OD to OS Transfer Slit Lamp OD to OS Transfer Posterior Pole OD to OS Transfer Peripheral retina OD to OS Transfer Peripheral retina OD to OS By rolling over the Action List icon you can also import the previous Eye Health Exam findings for your reference making it more efficient for you to know what you need to know when you need to know it 23 Page activEHR Imaging The activEHR Imaging Tab is available on the chart exam nbbon at all times regardless of the choice made in the Exam Type Selectio
40. ing Imaging 0 image s aded successfully Helpful hint If you have multiple locations using the same image storage solution you can see imagesfrom any location using optional EyeSend Technology To view an existing image click on the thumbnail and you will navigate directly to the specific image Please review the activEHR Imaging user manual for further details The Touch n Go DRAW it feature allows for Touch N Go drawings and templates for easy yet sophisticated drawingsthat cover all areas of the eye Drawings are automatically saved 24 Page with all other images under the Dra w It column in the Imaging Browser page in the patients chart for easy reference Once complete in the imaging whether it be editing drawings or viewing new and or prior images or documents retum to the activEHR Imaging tab in activEHR Charts The thumbnails are refreshed with yourchangesand additions That s it 25 Page Contact Lens Exam Name Jane Black Sex Female acti VE H R j Contact Lenses Birthdate 02 23 1994 Age 17 Exam 07 28 2011 Provider Grue Main Office Search Contact Le Eye Health Exam Confi Billing An History Ex Pre Test E Refraction e Prescribing Imaging History gt Reason For Visit Problems Issues Current CLs Current Wear Care Instrutions External Measurements Aa General CL use history New Wear Care Instrutions Contact Lens History Grid gt Contact Len
41. ion The idea is that on this screen you will select which kind of exam you are doing for this patient Based on your selection the releva nt sections and tests that should be conducted will populate throughout the entirety of the exam forms from the History Exam to the Eye Health Exam This concept permeates the activEHR Charts and it isa key piece to remember This User Guide will touch on the Exam Type Selection again asthe vanous exam segments are explained Navigating the activEHR Charts Action Manager Each patient encounter is broken down into a senes of exam segments which asa whole are accessed via the Action Manager more specifically via the Exam icon on the practice level of the Action Manager Optical Mot Started Mot Started 4 Page While each segment has its own particular purpose and while there are tools and functions that are specific to each forn the exam forms offer a great level of consistency when it comesto the navigation and the use of the varous forms themselves Decision Manager Window Once an exam workflow icon has been selected e g History Exam the left side window known as the Decision Manager reveals the tree that matches with the selected exam segment Please note that it is only necessary to use the Decision Manager window when you need to add additional documentation to this section of the exam that was not orginally populated from your Exam Type Selection
42. isplaying the non linked instruments your practice uses in the Exam Information Manager window to eliminate having to go to the Decision Manager window forthem Refraction On the Refraction form you would finish the refraction with the information that was forwarded to this exam segment from the Pre Test exam If you go to this page without having completed the Pre Test segment or even started it the Exam Information Manager screen will open empty However you will be able to find anything you need on the Decision Manager window to the left The screenshot below illustrates how the Refraction cames over the Visual Acuity findings as well asthe manually entered Lensometer findings 4 Pre Test Exam Distance VA Dist cc OD 20 25 Dist cc OS 20 30 Dist sc OD 20 30 Dist sc 05 20 40 Near VA Near cc OD 40 245 Near cc 05 20 30 Near sc OD 20 30 Near sc 05 20 40 Contact Lens YA Lensometer Manual OD 1 00 2 00 4 180 OS 1 00 2 00 41775 4 Refraction Distance YA Dist cc OD 20 25 Dist cc OS 20 50 Dist sc OD 20 50 Dist sc OS 20 40 Near YA Near cc OD 20 25 Near cc 05 20 SU Near sc OD 20 0 Near sc 05 20 40 Contact Lens YA l ensometer Manual OD 1 00 2 00 4 180 OS 1 00 400 4775 Transfer Manual Lensometer to Subjective 18 Page Within the Refraction transfer links lead you through the process of the refraction Le Transfer Manual Lensometer t
43. ks Add Mew Contact Lens Do Progress Evaluation 1 Do Trial 2 Fitting Hide Progess Evaluations amp Trials Print Selected Contact Lens Prescription The appropnate hyperinks will show below the Refraction Information you will want to refer to Clicking on the arrow to the right of the hypenink will allow you to toggle to either hide or unhide and display the Thal fitting procedure This keeps your patient record from appearng too busy and cluttered 34 Page Trial Fitting 1 Right Trial Fitting 1 Left Trial Fitting 1 CL OD 1 6 70 14 0 1 25 Acuvue 2 Diagnostic Distance VA Distance VA Near VA Near VA Over Retraction 0 00 Over Refraction 0 00 Calculated Power 0 00 Calculated Power 0 00 Fit description Assessment Plan Fit description Assessment Plan Special instructions Special instructions Specialty lens parameters Specialty lens parameters Trial 1 Action List Document your findings using the easy Touch N Go method You can perform up to five 5 trial fittings and 5 progress evaluations perencounter with activEHR Once you decide that a satisfactory tral fitting has been attained you can order the exact revenue Non Tnal lenses and you can ordera supply of lenses for this patient 5 Order Contact Lenses Click on the Tnal 1 Action List and choose Select amp Order Final Contact Lens Tr Wi CR Trial 1 Action List Click bo wiew any of the following links ES Do T
44. luation 1 Action List o Progress Evaluation 41 Action List Click to wiew any of the Following links Select amp Order Contact Lens With or Without Change EN Select amp Order Contact Lens and include Ower Refraction DEMO The CLSearch Page will come up with the Rx Brand and Options pre populated CL Search Page WER Series Selection lt Contact Lens Search Parameters A _J F Favorite Series Maximize X Close e Available Series m 1 day A 1 OD Rx 1 00 000 x 0 0 00 Spherical 7 Bifocal 7 Toric 7 Select OD Lens LI y a weg OSRx 175 000 x ol 0 00 7 Spherical P Bifocal Toric Select OS Lens E a 2 Col Bar Code Search Lot Number Bar Code Revenue H farue 2 Colou LJ y Acuvue 6pk Selected Contact Lenses v Aam Advanc 7 B Aave Advanc Manufacturer Series Type BC Dia Sphere Cylinder Axis Add Color Class ViISslonNuil ALUVUE AM gt vVpayuc writ 0 JU AT UV Za U UU V V VU wyatt wey nevoiuc A e Vistakon Acuvue 2 6pk SPH 8 70 14 1 25 0 00 0 0 00 Clear Revenue wl Acuvue Oasys t E Vistakon Acuvue 2 Colour Enhancer SPH 8 70 14 1 25 0 00 0 0 00 Ocean Blue Revenue m FF Air Oplix Aqua Vistakon Acuvue 2 Colour Enhancer SPH 8 70 14 1 25 0 00 0 0 00 Emerald Greer Revenue ln Air Optix Night Vistakon Acuvue 2 Colour Enhancer SPH 8 70 14 1 25 0 00 0 0 00 Aquamarine Revenue la Aquaflex Super Vistakon Acuvue 2 6pk SPH 8 70 14 1 00 0 00 0 0 00 Clear Revenue L z Avara Gpk Vistakon Acuvue 2 C
45. n Medicaid Exam vith Dilation Cataract Extraction Follow up Exam Intermediate Exam Anterior Segment Intermediate Exam Posterior Segment H a Lens Insurance Billing Rule Sets 4 Here you can change the way that normal findings are displayed next to each finding FA lu Web Browser Yiew a d Configurable Exam Rule Sets History Exam Components i D Master Exam Component Selection Eye Health Exam Initial Components Review of Syste O Distance VA O lids pu D Medicare Level 4 Exam Component Selection VSP Adult Exam Component Selection Constitution NC none Near YA Normal lids H EyeMed Exam Component Selection Integumentary N none Near VA M nota conjunctiva Medicare Level 5 Exam Component Selection 1 Medicaid Exam Without Dilation i Medicare Level 2 Exam Component Selection TT Medicaid Exam With Dilation E p Cataract Extraction Follow up Exam B D D je A Medicare Level 3 Exam Component Selection D D i D Intermediate Exam Anterior Segment Eyes NC Neurological NC Endocrine NC no problems none none Contact Lens YA Hp IOP Normal conjunct sclera Q H External measur Normal sclear Ears Nose Mou none Respiratory NC Baseline neurol Confrontation VF Options tear film within normal limits p 1 Normal tear fil none normal appearance Ze Intermediate Exam Posterior S
46. n This has been done because you never know when you will need to referto images or drawings during your exam routines I Name Vanessa Deluna Sex Female a ct E H FR v SE ng Birthdate 02 26 1981 Age 30 Se Exam 08 05 2011 Provider Grue Main Office Search History Ex Exam Conft Billing An Pre Test E Refraction Eye Health Contact Le e Prescribing Imaging Image Capture Draw IT 19 image s loaded successfully Drawing Fundus Color Fundus FA HRT OCT Report Slit Lamp 03 02 08 05 2011 20 48 33 08 02 2011 13 06 03 2011 14 00 53 08 02 2011 10 10 07 03 02 2011 10 01 07 08 02 2011 22 53 36 08 02 2011 10 37 3 Eutesnal Eso OS 01 04 OD RS nn DS FA 2 2011 10 37 3 E P 2011 13 06 03 Once you load this segment by clicking on the Imaging tab you will see actual thumbnails of all previously acquired images and drawings displayed and categonzed by image or document type in vertical columns They are automatically date and time stamped and saved with the most recent images showing at the top of the column Image thumbnails only appear if images were acquired dunng previous patient encounters In the case of a patient record with no images only image capture and draw it hyperlinks are displayed with a zero Image count Name Jane Black Sex Female acti E H FR g Imaging Birthdate 02 23 1994 Age 17 Exam 07 28 2011 Provider Grue Main Office Search Eye Health e Prescrib
47. ns Action List Today Complete List Prescribed or Workup Right Contact Lens Information Right Status Right Status Description Left Contact Lens Information Left Status Left Status Description Fitting Date 06 23 2011 Trial Fitting 1 Order 8 60 14 2 1 75 Air Optix Aqua 6pk 8 60 14 2 1 25 Air Optix Aqua 6pk 06 23 2011 Progress Eval 1 8 30 14 0 1 00 Acuvue 2 6pk Active 8 80 14 2 1 00 Biomedics 55 Active Now you can change the previously active pair of lenses to Inactive by double clicking in the field and changing the status This wa y you have a complete record of every lens your office has tried for every patient You can also add a reason as to why and date stamp every step of the process Right Contact Lens Information Right Status Right Status Description Discontinued Date 6 60 14 21 1 75 Air Optix Aqua 6pk 6 50 14 0 1 00 Acuvue 2 6pk Inactive insufficient movement 06 23 2011 Enter the appropriate notes into the new contact lenses to be ordered and enter an expiration date forthe Rx Right Contact Lens Information Right Status Right Status Description Expiration Date 8 601 14 21 1 75 Air Optix Agua 6pk Active primary contact lens pair 06 23 2011 36 Page Order History Revenue Trials RX Right Eye Left Eye Hi Hi Da besse R d Seenen ue 12 b 733905800061 le 765563154941 Right Contact Lens Left Contact Lens Contact Lens Reason Supplier ABB CONCISE Optical
48. nscnscesccnscnscescosscnscessosscnscess 41 TEE Cle ebe 41 PEON CTT EE 42 Procedure Code TE ict ea te eects age An ae A ds dd ee 45 Ee Dages 47 REPORT da dan Or DEE 47 SONO A A AA AS A E ladies intl Mesa aliae 47 EXAM REPORTS EE 50 OUTPUT DOCUMENTS ies 50 Create COnUNUILY OF Care Document sem ee 50 Create PUDIICHEGIEN SUIVEIN ANGE EE 50 2 Page Receive Continuity Of Care DOCUMENT EE 50 Receive CONTINUILY OF Care RECOIG EE 50 h celve ALT EOD RESUS ieee E e de eee ee San eh de a ce i a e ea TTA 50 GROWTH CHARTS SSSR ERI A annee terne caida 51 MAINTAINING YOUR ACTIVEHR CHARTS EXAM FORMS cccccecceccccccccccccccccccccsccccccccccccccccccccccccccceccecees 53 CONTENT VS EUNGTIONALIRY EE 53 REGULARLY UPDATING CONTENT tas 53 APPENDIX B SETTING UP EXAM CONFIGURATIONS cccccccccccccccccccccccccccccccccccccccccccccccccccccccccsccccecccceccece 54 PLEASE Ten EE 54 HOW TO CHANGE NORMAL DESCRIPTIONS scescsceccecccececcecececcuccecuceecuceecscesceceseecsseecuseecnceecscaecscuecscsescuseecesascssaecs 54 HOW TO CUSTOMIZE EXAM COMPONENTS aaa 55 3 Page Introduction activEHR introduces an industry first approach to EHRs a knowledgebas dnven Clinical Documentation methodology we call activEHR Charts Throughout this User Guide we will explain and guide you through the functions and principles that undenie this technology Before You Start The activEHR Charts 2011 1 1 are based on the Exam Type Select
49. o Subjective This reduces the amount of data entry needed dunng the subjective as all you need to do Is refine the Subjective Rx according to which elements of the RX have changed Lensometer Manual OD 1 00 2 00 180 OS 1 00 2 00 175 Transfer Manual Lensometer to Subjective Lensometer Manual OD 1 00 2 00 X 180 OS 1 00 2 00 X 175 Transfer Manual Lensometer to Subjective Subjective OD 1 00 2 00 X 180 OS 1 00 2 00 X 175 Transfer to Final Rx Lensometer Manual OD 1 00 2 00 180 OS 1 00 200x175 Transfer Manual Lensometer to Subjective Subjective OD 1 00 2 00 x 180 OS 1 00 2 00 175 Transfer to Final Rx Final Rx OD 1 00 2 00 4 190 OS 1 00 200 41775 Transfer to Optical Specialty Rx Action List From here you can either 1 Send the Final Rxto the optical screen Lensometer Manual OD 1 00 2 00 x 160 OS 1 00 2 00 4 175 Transfer Manual Lensometer to Subjective Subjective gt 0D 1 00 200x180 OS 1 00 2 00 x 175 Transfer to Final Rx Successfully executed Transfer Final Rx to Visions Rule Set Command Final Rx OD 1 00 2 00 180 OS 1 00 2 00 x 175 Transfer to Optical Specialty Rx Action List 19 Page Rx Order History Fa Right Eye MA Record 1 2 Work with the Specialty Rx Lensometer Manual OD 1 00 2 00 X 180 OS 1 00 2 00 X 175 Transfer Manual Lensometer to Subjective Subjective OD 1 00 2 00 X 180 OS
50. oday s exam r r i 4 History Exam Y History Exam 06 21 2011 Get Previous History u E POI Populate Normal story Exam 06 15 2011 Completed as part of history History Exam 06 20 2011 14 Page Getting Started With an Exam Exam Type Selection Once you click on the Exam icon on the Action Manager you will be presented with a series of icons each representing the individual exam forms with the first being Patient Messages then Exam Configuration Billing Coding and so forth Current Tasks Test Patient Albert Patient Messages Hot Started Exam Configurations Mot Started Billing 4nd Coding Mot Started Click on Exam Configuration to get started with an exam This will tigger exam segments and tests to populate throughout the entire Exam module to ensure the corect documentation and Billing and Coding compliance has been met Exam Conflaurations Exam Ty e Name Benjamin Test Patient Sex Ma acti EH R vi i ti p Birthdate 06 18 1923 Age 88 election Exam 06 19 2011 Provider Alle Search DR Exam Configurations Exam Type Selection Billing And Coding History Exam Pre Test Exam Refraction 8 E Back to Exam Configurations Exam Type Selection Select exam components EyeMed exam Text entry HE EyeMed exam O Distance YA O VSP exam Near YA snellen O YSP infants and toddlers exam O Near VA M notation FA YSP preschool children exam O Contact Lens VA FR Y
51. olour Enhancer SPH 8 70 14 1 00 0 00 0 0 00 Ocean Blue Revenue L la Biofinity Ew Gpk Vistakon Acuvue 2 Colour Enhancer SPH 8 70 14 1 00 0 00 0 0 00 Emerald Greer Revenue 1 Biomedic 55Pre vistakon Acuvue 2 Colour Enhancer SPH 8 70 14 1 00 0 00 0 0 00 Aquamarine Revenue 4 TT p ct P wm o l gt 33 Page Progress Evaluation Contact Lens History Grid tr Contact Lens Action List CG Today Complete List Prescribed or Workup Right Contact Lens Information Right Status Right Status Description Left Contact Lens Information Left Status Fitting Date 08 07 2011 Progress Eval 1 Order 8 70 14 0 1 00 Acuvue 2 6pk Active lenses fit previously this office 8 70 14 0 1 75 Acuvue 2 6pk CL Order History Revenue Eedi Active Right Contact Lens Left Contact Lens Colors Contact Lens Reason Supplier ABB CONCISE Optical Group e ABB CONCISE Optical Group e Clear Clear ze Manufacturer Vistakon T Vistakon T Extras RES schedule Seres Acuvue 2 Bpk kd Acuyue 2 Bpk e ze CL Codes CL Codes H ne 3 Billing Billing Replacement Schedule SSP 30006 SSP 30005 fe Once the contact lens order is displayed on the Contact Lens History Grid and the status for each eye is set to Active it will be transfered automatically to the Contact Lens Order Screen 4 CL Fitting New or Refit Go to the Contact Lens Action List and choose Do Thal 1 Fitting Contact Lens Action List Click to view any of the following lin
52. on but an HRR test instead Please Note The defaults were set so that when an exam level is chosen the regulated and required fields and tests come up to achieve E M Compliance If you need to alter which test comes up as the default ensure that the Billing Coding level does not get altered by your choice Only replace like with like How to Change Nomal Descnptions 1 In activEHR go to Tools and choose User Configuration Pages Tools Reports Video Window Settings al Transaction Processing View Electronic Submission File i Process Electronic Remittance Back Office Payment Posting General Ledger Posting Web Browser User Configuration Pages FHR Web Farms 2 A Web Browser View will open here expand the Configurable Exam Rule Sets by clicking on the plus sign to the left of it k Web Browser Yiew ER Configurable Exam Rule Sets Ei Lens Insurance Billing Rule Sets 3 You will find a Master Exam Component Selection page and each Exam Type that can be chosen in the Exam Type Selection when you startan exam Clickon Master Exam Component Selection 54 Page Configurable Exam Rule Sets Master Exam Component Selection Medicare Level 4 Exam Component Selection SP Adult Exam Component Selection EveMed Exam Component Selection Medicare Level 5 Exam Component Selection Medicare Level 3 Exam Component Selection Medicaid Exam Without Dilation Medicare Level 2 Exam Component Selectio
53. r decisions on the status of the fit and next steps just as you do in your old paper charting methods If you decide that a different lens is necessary see both screenshots below you can then begin Tnal 1 Click here to skip to step 4 How to do Tnal 1 Back to Contact Lenses Assessment Plan acceptable fit try a different lens unacceptable fit Renew current CL Rx without change fit description Modify power and Rx as current primary C good fit Modify power and Rx as current supplemen oOo oo ea marginal fit Order supply of lenses NO insufficient movement Text entry excessive movement Expiration date uncomfortable 6 months decenters 1 year Text entry 2 years Status for CL history grid Justification of expiration date unacceptable trial lens Text entry current primary CL Rx Hext progress check current supplemental CL Rx 1 week previous primary CL Rx 2 weeks previous supplemental CL Rx 1 month III MN non current CL Rx 3 months 4 months 6 months 32 Page Assessment Plan Assessment Plan Assessment unacceptable frt Assessment unacceptable tit Status for CL history grid Status for CL history grid previous primary CL Rx previous primary CL Rx Plan try 3 different lens Plan try 3 different lens No Change Indicated Order another supply of these lenses from here Click on the Progress Evaluation 1 Action List and choose the appropnate option Progress Eva
54. rations Billing And Coding Get Previous Histo Review of Systems ds PESH La Populate Normal Constitution Completed as part of history Integumentary Past medical history Patient Lifestyle Eyes Past ocular history Neurological Past personal medical history Endocrine Social history Ears Nose Mouth Throat education Respiratory hobbies Data Entry Page This is where you may select from among the visible options and oradd explanatory custom text This is consistent throughout the charts if you want to change something click on it The exam screen you need to retum to will always be available on the top left horizontal ta b inside the exam workspace If you are unsure if a heading is a hypenink or not hover your mouse over it if the cursorhaschanged from an arrow to a hand symbol it isa hypenink actiVEUR History Exam Review of Systems 1 AE Review of Systems 1 Exam Configurations Back to History Exam Constitution none no problems fever shingles affect malaise atyes l chalazi weight loss double vizion DOOM O weight gain amblyopia Select Back To Button After completing your selections on a Data Entry Page it is possible to navigate back to the main chart segment i e History Exam by clicking on the Back to button which is displayed at the top left of the workspace area Back to Once back to the main exam segment you will notice that the findings you entered in the Data Entry
55. rial 1 CL Search using Subjective A Do Trial 41 CL Search on Selected CL SES Select amp Order Final Contact Lens Highlight the parameters of the final contact lens you wish to order in the CL Search Page Select OD Lens Select OS Lens and click Then repeatand click 35 Page _ CL Search Page 0 Series Selection lt Contact Lens Search Parameters A e al Available Series y Maximize Close 1 day Acuvue T A n EES OD Rx 1 7514 0 00 x 1 uz 0 00 7 Spherical 7 Bifocal 7 Toric 7 Select OD Lens Acuvue 2 6pk OS Rx 125 0 0014 x 0 0 00 Spherical 7 Bifocal Toric 7 Select OS Lens Acuvue 2 Coloul Bar Code Search Lot Number Bar Ci Acuvue 2 Colour e Revenue v Acuvue 6pk KKK Acuvue Advanc Selected Contact Lenses Acuvue Adyanc Aa Sa Manufacturer Series Type BC i Sphere Cylinder Axis Class Acuvue dvanc Acuvue Oasys Ciba Vision Corporation Air Optix Aqua 6pk SPH 8 60 1 50 0 00 0 Revenue Acuvue One Da Ciba Vision Corporation Air Optix Aqua 6pk SPH 38 60 1 75 0 00 0 Revenue Air Optix Aqua Ciba Vision Corporation Air Optix Aqua 6pk SPH 8 60 2 00 0 00 0 Revenue Air Optix Night Aquaflex Supert A d Avaira 6pk Biofinity Ew 6pk Biomedics 55 Biomedics 55 Pr v 1744 i Once you close the CL Search Page the contact lenses you have ordered are automatically added to the Contact Lens History Gnd Contact Lens History Grid gt Contact Le
56. s Action List E Today Complete List Prescribed or Workup Right Contact Lens Information Right Status Right Status Description Left Contact Lens Information Left Status Left Status Description Discontinued Expire Fitting Date Date Refractive Information gt Refractive Information 3 Auto Lensometer Refractive Information 4 Auto Refraction Subjective OD 4 25 1 00 X 074 1 50 0 50 BI 1 00 BU Auto OD 2 25 0 75 X 102 20 20 20 20 OS 3 25 1 00 X 002 1 50 0 50 BI 0 50 BU OD 0 00 0 75 X 102 OS 2 00 0 25 X 093 20 20 20 20 PD OS 0 75 0 25 X 093 Auto Keratometry OD 43 50 07 74 86 44 50 07 59 176 OS 43 50 07 77 97 44 50 07 58 007 a ei Activity Ja S We Rmwee M Patient Addr 18 Insurance 1 If a refraction was perforned prior to starting the Contact Lens Exam the Subjective Rx and Auto or Manual K s automatically display in the CL Exam so there is no need to change views to obtain the information you want This is part of our what you need when you need it technology The benefit is that you don t have to click back and forth between the Refraction form and the Contact Lens forn to view refractive information acti VE HR Contact Lenses Contact Le Eye Health Exam Conft Billing An History Ex Pre Test E Refraction e Prescribing Imaging History Contact Lens History Grid Refractive Information gt Refractive Information 3 Auto Lensometer Refractive
57. s Description 30 Page In the case of a current contact lens you would document active as this is what the patient is actively using now If following your exam you determine that a new CL Rx is indicated you will change the Status from active to inactive There are two tabs one to show today s activities only and a second tab to display the complete history of lenses this patient has been wearing Contact Lens Action List Today Complete List Performing a Progress Evaluation 1 Go to the Contact Lens Action List and choose Do Progress Evaluation 1 Contact Lens Action List E CH Contact Lens Action List Click to view any of the following links Add New Contact Lens Do Progress Evaluation 1 a Do Trial 1 Fitting A Print Selected Contact Lens Prescription DEMO The standard progress evaluation hyperiinks will display below the Refractive Information area See inside the Red Box in the screen shot below Refractive Information Refractive Information 3 Lensometer Manual Subjective OD 1 00 OD 1 00 OS 1 00 Os 1 00 Auto Heratometry Progress Evaluation 1 gt Distance YA Distance YA Near YA Near YA Over Refraction 0 00 Over Refraction 0 00 Calculated Power 0 00 Calculated Power U 00 Fit characteristics Fit characteristics Assessment Plan Assessment Plan Progress Evaluation 1 Action List ag Click on each hypenink to record your physical optical
58. s orthe activEHR Training Package 45 Page Procedure Code History Search Procedure Codes Today Complete List Date Performed Eye Code Description ICD9 Code 1 ICD9 Code 2 ICD9 Code 3 GetAssociatedEvent Error There is no Record of Insurance where Service For ts set to Exam or All Services for encounter date 07 18 2011 Once you have entered all of the procedure codes and linked the relevant diagnoses you can transfer this information directly to the patient s account by clicking on the Bill Plan Management Procedure Codes above the Problem List Bill Plan amp Management Procedure Codes Problem List Search 1CD9 Codes You will see a confimation message when the procedure codes have been successfully transferred Message from webpage You will notice that the procedure code was billed with the associated diagnosis code as well asthe price forthe procedure as it is set up in the relevant Fee Schedule New Invoice 07 18 2011 Inv 0197150 0 00 46 Page Medications Allergies Medications Add New Date Qty Unit Medication Dose Unit Route DoseTiming Duratior StopDate Refills Status Allergies Add New OnsetDate Allergen Name Allergen Group Reaction Allergy Group Drug Generic Name Both the Medications and Allergies list are populated from the e Prescnbing segment However if necessary you can add a medication or allergy here manually as well R
59. the procedure code itself or the descnption and that it also engages with the first couple of keystrokes As you type more the search results will narow down to display only what you are looking for as shown in the above screenshot Once you have entered the diagnoses in the Problem List you can associate their ICD9 codes with the procedure in the Procedure Code History You can associate up to fourICD9 codes with any procedure code Click on the field below ICD9 Code 1 All of the diagnoses from the Problem List toda y s and complete will be shown here to associate with the procedure code Repeat for ICD9 Code 2 3 and 4 if necessary You can also enter a date when the patient is eligible again for a certain procedure Procedure Code History Search Procedure Codes Today Complete List Date Performed Eye Code Description 1CD9 Code 1 ICD9 Code 2 ICD9 Code 3 ICD9 Code 4 Date Eligible 07 18 2011 92014 OV COMPREHENSIVE EXAM OG o 367 1 Myopia e 346 0 Migraine TCDS Code 1 Helpful Hint If you are trying to entera procedure code fora patient that does not have an insurance set up but in the Exam Configuration you chose an exam with insurance billing then you will see the below error alerting you It will prevent you from entering the procedure code until the insurance has been set up on the Primary Insurance screen For more information on how to enter insurance information successfully please refer to our online video
60. the record had been amended afterthe chart wasfinalized Populate Normal The user will first fill out portions of the chart with abnomal findings Populating Normal will fill in the remaining items The link for Populate Normal is located in the top left comer of the Exam Information Manager Window workspace at the right 4 History Exam Get Previous History Populate Normal Normal findings are displayed in black font whereas abnormal findings are displayed in blue font Review of Systems La Neurological Endocrine none Ears Hose Mouth Throat none chronic cough Respiratory Eyes asthma no problems An item marked as abnomal does count in the Billing Coding section of the Plan Management form For example if you Populate Normal without entenng any abnomal findings fora patient in the Review of Systems all 11 elements will be counted just as if some of those 11 elements where normal and some abnomal Review of Systems Aa Constitution none Integumentary hone Eyes no problems Neurological none Endocrine Ears Nose Mouth Throat none Respiratory none Gastrointestinal none Vascular Cardiovascular none Genitourinary none Musculoskeletal none Lymphatic Hematologic none Immunologic none Psychiatric none Endocrine EM Compliance selected Coding Level History HPI O ROS 11 PFSH 2 Populate Normal Best Practices First record all of the abnomal findings Then
61. the same button when you need to accessit 7 Page ma be Hd spode 3 Se eg El History Exam O Text or Voice Entry OF Hospital release pendir OE Emergency Callin OE Eyewear use history l d OE Patient Complaints HPI i CA Patient Complaints HPI M Review of Systems w PFSH 7 db Orientation status at time o Mos General observations OE Medications OE Non Rx meds CIR Allergies ba Completed as part of hi O dla Symptom tracking for c OE Charts Cl s Eye Medical Exam history Wis Patient Lifestyle CID Appended Text ajnpayos E BIN EA EI asmoJa acti EHR 4 History Exam Get Previous History Populate Normal Completed as part of history Patient Lifestyle actiVEH R 4 History Exam Get Previous History Populate Normal Completed as part of history Patient Lifestyle History Exam Exam Configurations Review of Systems As Constitution Integumentary Eyes Neurological Endocrine Ears Nose Mouth Throat Respiratory Gastrointestinal Vascular Cardiovascular Genitourinary Musculoskeletal Lymphatic Hematologic Immunologic Psychiatric Orientation status at time of exam oriented to person place amp time General observations History Exam Exam Configurations Review of Systems La Constitution Integumentary Eyes Neurological Endocrine Ears Nose Mouth Throat Respiratory Gastrointestinal Vascular Cardiov
62. tions H CMS Allergies H CIM Non Rx medications H CMS Assessment H CMS Plan i CIS Plan for each diagnosis o E Tests completed list for todays exam CMS Quality checklist d ee Appended Text wl Medications Allergies i A signature Results Orders The text editor will open and you ll notice it is time stamped with your entry The text editor hasthe same basic functionality as a Windows text processor Appended Text Font FontSize 4 B Z U ae Ee ES 7 We ha Save Close A close Appended text added Jul 41 2011 Appended text will appear on the Billing Coding segment below the signature indicating that ithasbeen added afterthe exam form was signed 49 Page Exam Reports After you have finished documenting your exam hit the Go Forward Arrow gt at the top of the exam forms like you would after any task This will mark the Exam Configuration icon green Current Tasks TestFatient Mathilda Esam Configurations Completed Re por te Mot Started In the 2011 1 1 Enhanced release two categones of reports will be available Output Documentsand Growth Charts Output Documents Mot Started Growth Charts Not Started Output Doc uments Under Output Documents you will find the following reports Create Continuity of Care Document Create Public Health Surveillance Receive Continuity of Care Document Receive Continuity of Care Record Receive HL7 Lab Results 50 Pag
63. tions depending on the reason for visit If the patient is an existing contact lens wearer you can begin by doing a Progress Evaluation based on the contact lenses they already wear In addition if you know the parameters of their existing contacts you can Add New Contact Lens and add this to the Contact Lens History Table so a complete history is always one click away 27 Page Choose Do Thal 1 Fitting from the Contact Lens Action List when you begin the Tnal Fitting process Contact Lens Action List E a Contact Lens Action List Click to view any of the following links ES Add Hew Contact Lens 2 Do Progress Evaluation 1 o Do Trial 1 Fitting Print Selected Contact Lens Prescription DEMO Whichever action hyperink you choose the relevant hypeninks will open below the Contact Lens History grid If your patient isa new contact lens wearer and does not have any lenses yet skip to step 4 by clicking here To record a patient s current Contact Lens Rxand or parameters to the history grid click on the Add New Contact Lens hypenink on the Contact Lens Action List see screen shot above CL Search Page Series Selection Contact Lens Search Parameters FF Available Series y Maximize Close OD Rx 0 004 0 00 x 0 0 004 JP Spherical gt Bifocal P Toric P Select OD Lens OS Rx 0 004 0 0017 x Do 0 004 P Spherical P Bifocal P Toric P Select OS Lens Bar Code Search Lot Number Bar Code Revenue v
64. xl x History Exam Mathilda Test E Text or Voice Entry bad name Patient ER ba Hospital release pending release interview S acti E E R w H istory Exa m Birthdate 06 20 1921 H MS Emergency Call in 2 Eyewear use history desire 7 Exam 06 21 2011 H OMA Patient Complaints HPI Patient Complaints HPI D Search H M Ay Review of Systems Wi PFSH 4 History Exam Exam Configurations Billing And Coding ape Orientation status at time of exam ES Get Previous Histo Ress Sons ds PESH As M Aa General observations TD Review of systems A CIE Mediceti H Populate Normal Constitution o gue ES Completed as part of history Integumentary Past medical history E Ha Alerces Patient Lifestyle Eyes Past ocular history LJ D is D H VIAJ Completed as part of history E Neurological Past personal medical history e 1431 Symptom tracking for outcomes Re Endocrine Social history o Ea Chaite Ears Nose Mouth Throat education R a as 5 TO H CAA Eye Medical Exam history Respiratory Pere Mg Patient Lifestyle Gastrointestinal ning M Appended Text og Vascular Cardiovascular tobacco use Genitourinary Musculoskeletal Ge Lymphatic Hematologic Immunologic Psychiatric gt Orientation status at time of exam i oriented to person place amp time General observations 2 Exam Information Manager Window The main workspace window now becomes the exam workspace or more

activEHR Exams, User Guide - September 2011

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