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Centers for Dialysis Care Electronic Medical Record Clarity: Physician & APN Training Module 1
Introduction Comments and Notes Table of Contents 2 Table of Contents ⏎
Introduction You may view the slides in order, or pick a topic by double clicking the box on the table of contents. Return to the Table of Contents by double clicking the box next to page #. The purpose of this presentation is to teach you 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 3 Login in at the CDC facility Login remotely over the Internet using the Citrix Server Basic navigation from the Clarity Home Page The Message and Task Application Signing Orders Documenting face to face rounding “Real-Time Charting (RTC)” Documenting an Office Visit (MD office visit – electronic) Documenting an Office Lab review (MD office lab review – electronic) Writing Progress Notes Problem Lists Medication Lists Writing Orders other than orders in the Physician Tab of Real-Time Charting The Clarity Reports Built in Clarity Help Functions Frequently asked Questions from CDC MD users Table of Contents ⏎
Notes You must have a CDC User ID and Password to use the CDC electronic medical record. If you are new to the CDC information systems, or if your current Di. Proton User ID and Password do not work in Clarity, please call or email the Help Desk to set up a user account at (216) 229 -6170 x 149. Clarity does NOT support any browser BUT Internet Explorer. The presentation assumes you know basic Windows and Internet Explorer navigation techniques. If these terms are foreign to you, please call the Help Desk for assistance. If you view this presentation on a computer connected to the Internet, clicking on the URL links (ex: www. cdcare. org) on the slides will take you to the actual site on the Internet. We will complete the roll out of Clarity to all of our facilities by the end of 2010. Some of the screens demonstrated in this presentation may be slightly different from the production application due to enhancements made as we go along. The essential functionality and navigation process will not change. Throughout this presentation the text “NP Organization E-Signature” denotes a path to take from the Navigation Pane through the sub-menus. In this case to get to the E-Signature screens from the Navigation Pane (NP). Clarity uses ‘drop down’ boxes for selection choices. Touching the down arrow reveals the choices. Scroll down and click your choice. Click ‘GO’ or ‘Search’ to finish. 4 Table of Contents ⏎
Note to Mac. Intosh (Apple) Users 1. While Clarity requires Internet Explorer, when you connect over the internet you are connected to CDC’s citrix server. When you launch the application you will be using the Internet Explorer application within CDC. 2. The Problem for most Mac users is to launch the Citrix client successfully. 3. When you connect to www. cdcare. org you will see the following window. If you try to start Clarity and you get a message about Citrix, download the “client” noted in the message window. Also, be sure you have the most recent version of Safari or Firefox. 5 Table of Contents ⏎
Table of Contents Introduction and Notes Patient Progress Notes Connecting to CDC EMR Using Checklists Navigating Clarity Medications & Allergies Signing Verbal Orders Problem Lists Writing Orders Reports Dialysis Rounds Help Functions cdc help desk 6 Table of Contents ⏎
Connecting To the CDC EMR Login at the Facility Login over the Internet 7 Table of Contents ⏎
General Comments about Login You may use Clarity from any computer in a CDC facility. You may use Clarity over the internet using the CDC Citrix Server. In either case, the process will take you to the same Clarity Login screen and Home Page. Clarity functions the same way irrespective of how you launch it. You Login to the Home Page (Welcome Screen). If you navigate to other Clarity sections you may be asked if you wish to continue the Login Session (just say yes). If you are timedout of the Login, you will not lose the work in your active window if you are doing a checklist or Real-Time Charting. 1. 2. 3. 4. 5. 8 Table of Contents ⏎
Login from CDC Facility Double click on Clarity Login 9 Table of Contents ⏎
Login from CDC Facility Note: Both User ID and Passwords fields are case sensitive Type in your User ID (Press TAB to go to password box) Type in your password Click the “I Accept” button or hit ENTER to complete login 10 Table of Contents ⏎
Login from the Internet 1. 2. 3. Type http: //www. cdcare. org/ in your address bar in the browser Mouse Over either to “CDC Users” Double Click “CDC Citrix Login” 11 Table of Contents ⏎
Login from the Internet 1. Type your User name and Password as usual (case sensitive) 2. You can expedite this process by going directly to https: //citrix. cdcare. org/Citrix/Access. Platform 1/auth/login. aspx 3. You can also “drag” this URL from the address window to your desktop creating a Desktop Short Cut 12 Table of Contents ⏎
Login from the Internet Choose this Clarity icon (NOT the desktop icon) 13 Table of Contents ⏎
Navigating through Clarity Home Page Window Control 14 Table of Contents ⏎
Clarity Home Page YOUR NAME Physician USER You have 1 new message and 1 new task. . Your Name and system notices Navigation Pane Click for sub-menus Messages and Tasks Notification 15 Table of Contents ⏎ Welcome Screen and News area
Clarity Home Page, Messages and Tasks USER, Physician YOUR NAME Physician USER Clicking on the Message or Task Icon will open the indicated window in the Welcome Screen. Clicking on the date of the Task or Message will reveal the contents. Respond as you would to any email. CDC has not developed a procedure for these functions. Messages sent via this utility stay within Clarity. They do not go to the CDCare. org e-mail system. 16 Table of Contents ⏎
Navigation: “Select a Patient” All patient specific actions (write or review a note, checklist, order, or report) begin with the same patient selection screen shown on the next slide. You need only select clinic, patient, and status if you are looking for one patient. If you are looking for groups of patients you can add more filters from the drop down menus. If you get a “no record found” message, you may have chosen the wrong facility or status (choosing “All” under status will find patients currently in the hospital or pending transfer in). If you are switching from patient to patient in different facilities, the program may revert to your default clinic. A good way to find all your patients at a given facility is to specify the clinic, choose “All” in the status box, choose your name from the “Primary Nephrologist” drop down menu and click “Search. ” This action will list your patients. You can use the printing function on your browser to print the displayed page from “print preview. ” 17 Table of Contents ⏎
Navigation: “Select a Patient” YOUR NAME Click “search” to find the patient Choosing yourself from the Primary Nephrologist drop down list and not specifying a patient, will generate a list of all your patients in the selected clinic Choose “ALL” unless you are sure your patient is not in the hospital or “pending” If your search returns “No records found, ” check the Clinic choice, Status and spelling of name 18 Table of Contents ⏎
Navigating through Clarity YOUR NAME Physician USER 19 Table of Contents ⏎ From the Home Page choose “Patient” on the navigation pane. Choosing “Patient” will display a sub-menu of choices within the Patient specific applications. In this case “immunizations” were selected. Choosing any of the values in the Patient sub -menu will take you to a patient selection screen.
Notes On the Clarity Window Control 20 The page that shows the navigation pane and the Welcome message is the Home Page. When you open a file from the navigation pane, some will open in the area of the welcome message, some will open as utility on their own page. Those that open in their own page, will not have a navigation pane. In this case, the Home Page (Navigation Pane) may be in a window behind the new window. You can appreciate the sequence by toggling the window size button on the Internet Explorer Title bar. This perspective is demonstrated on the next few slides. You LOGOUT of the home page. You merely close the other types of pages. Table of Contents ⏎
Clarity Window Control Toggling this icon will close the page. If you close the home page, it will log you off Clarity. Closing pages without the navigation pane will not log you off clarity. YOUR NAME Clicking this icon minimizes the window and puts it down on the “start” bar on your desktop. Bring it back by clicking on the title 21 Table of Contents ⏎ Clicking this icon will toggle between a full screen and scalable window. In the full screen mode, the other windows will be behind (not lost or closed). See next slide.
Clarity Window Control Both of these windows are in the scalable mode. Toggling these boxes will bring them to the full screen mode putting the other window behind. In the scalable mode, you can resize the window by ‘click dragging’ this corner to change the vertical/horizontal dimensions. 22 Table of Contents ⏎
Signing Verbal Orders E-Signature 23 Table of Contents ⏎
Clarity E-Signature (NP Organization E-Signature) YOUR NAME Physician USER User You have 1 new message and 1 new task. . You sign your verbal orders via this path to the screens shown next. 24 Table of Contents ⏎
NP Organization E-Signature Select Clinic and Status Click Search Orders are displayed one page at a time Click reject if you did not give the order Clicking this box checks all the orders on the page, otherwise click one order at a time Navigate from page to page 1. 2. 3. 4. 5. 6. 7. Review all the orders. Check one at a time or all by checking the box on the first row. Type your User Name and Password. If you wish a copy of your signed orders, click Show Report. Click “Sign Selected” (everything you checked will be signed, or the whole page if you checked the first box. Go on to the next page and repeat the process. If you ‘reject’ a medication order, it is placed on hold. Other rejected orders are cancelled. The facility runs a ‘rejected order’ report. If you see numerous orders that you did not give or do not recognize, please notify the Facility Manager. 25 Table of Contents ⏎
Patient Progress Notes Reviewing Patient Notes Writing Patient Notes 26 Table of Contents ⏎
Clarity: Patient notes There are 2 ways to write a note in Clarity: 1. A ‘free text’ note (NP Patient Notes) A typed text note with a “TYPE” drop down choice list, a summary line and a text insertion window. Starts, as do all Patient choices at the “Select Patient” screen. 2. A ‘Check List’ (NP Patient Checklists) An “interactive” note that incorporates formatted text, current data from the dialysis and laboratory results and free text insertion windows. Once completed, it remains in its list form or can be printed as a report. While their content is different, they all work the same way. 3. 27 We will discuss the Office Lab Review, Office Visit, and Real Time Charting Physician Note in this presentation. Table of Contents ⏎
Clarity: Free text patient notes. 28 Table of Contents ⏎ You can review, print and write patient notes from NP Patient Notes. You can ‘import’ text notes from the computer clipboard into these notes. You can review notes written from checklists. Orders written from NP Patient Physician Orders are reviewable here. This path will take you to “Select a Patient” if you are not already working with a patient. The next slide shows index screen after you have selected a patient.
Clarity: Reviewing Patient Notes You can change patients by clicking here. By using “type” and/or “date” filters you can look at specific notes. In this case all the MD Office Lab Reviews for this patient are listed. Clicking “Notes Report” displays the content of all the progress notes in chronological order. Clicking on the column heading (in any table like this in Clarity) will sort the rows by that column. Review an individual note by clicking on the date. 29 Table of Contents ⏎
Clarity: Writing Patient Notes By clicking on “Add New” you can write a note on the patient listed at the top of the page. 30 Table of Contents ⏎
Clarity: Writing Progress Notes The note can be attached to a dialysis treatment by clicking here. Date and Time stamps are supplied. Choose a type from the drop down list. In this case “Hospital Progress Note” is chosen. ‘Grayed’ out fields are not active in the note writing screen. Type a summary of the note. Then type your note in the note entry box. When finished click “Add. ” 31 Table of Contents ⏎ Patient undergoing evaluation for GI bleeding …etc. Any text that is on the computer ‘s clipboard can be pasted [Ctrl-V] into this space such as discharge summaries, op notes, x-ray reports etc.
Problem Lists Multidisciplinary Problem and Diagnosis List 32 Table of Contents ⏎
Clarity: Problem List (NP Patient Problem List) 33 Table of Contents ⏎ Problems can be medical diagnoses, or active care plan issues. The completeness of this list will support co-morbidity documentation under the new bundled payment system. All disciplines can enter and modify problems. Problem List report: NP Patient Reports Problem List The problems are printed on the Problem List Report. The following slide shows how to add, modify (update), or delete a problem.
Clarity: Problem List Maintenance NP Patient Problem List • • • 34 Table of Contents ⏎ NP Patient Report Problem List “Add New” or Update (by clicking on) problem Choose (or change) the category (organ system) Indicate whether active or not Free text comment or explanation Put ICD 9 code (search via “Select” ICD-9). Text Automatically displayed. Indicate if you wish the problem displayed Place a start (or supply stop) date on reports ”Add, ” “Submit, ” or “Delete” Problem List Report Looks like this
Medications & Allergies Medication List Medication Report Patient Allergies 35 Table of Contents ⏎
Clarity: Medication List (NP Patient Medications) Staff enters orders for medication starts, stops, or changes at NP Patient Medications Either MD’s, or APN’s, or Staff can enter Medication Allergies (NP Patient Medication Allergies) are displayed both on the List and the Report MD’s and APN’s should place medication orders in NP Patient Physician Orders (or RTC orders) Once the staff enters the order, it will display on the Medication List Report (NP Reports Patient Reports Medications) 36 Table of Contents ⏎
Clarity: Medication List and Report NP Reports Patient Report Medications NP Patient Medications • • Displays Allergies Choices for Status of Medication Click on Med for order details and history Not formatted for printing and filing in office record. 37 Table of Contents ⏎ • • Printed version suitable to file in office chart Run for a defined date range Allergies and date of last med review displayed Dose history of meds given during dialysis listed (for date range)
Clarity: Medication Allergies • • Add or update a medication allergy Find medication in “Select Medication” Specify the type of reaction “Add” or “Submit” to display on medication list and report • Clicking “Update Allergy etc…” will return an “Access Denied” error message (don’t do it). 38 Table of Contents ⏎
Writing Notes Using Checklists Office Lab Review: Checklists: Office Visit 39 Table of Contents ⏎
Clarity: Checklist (NP Patient Checklists) 40 Table of Contents ⏎ From the Navigation Pane chose Patient From the Patient Sub Menu choose Patient Checklists On the next screen you will chose what checklist you wish to use
Clarity: Checklists, Office Lab Review 1. Choose “MD OFFICE LAB REVIEW (ELECTRONIC) & click “GO. ” 2. The next slide shows the OFFICE LAB REVIEW check list. 3. Note that the Check List opens in its own window. There is no Navigation Pane on this window. Clicking the “X” box in the upper right hand corner will close this window only. The Clarity navigation pane may be behind this window if you have not toggled the scalable option. 4. You can print this checklist to document your review in your office record. 5. YOU CANNOT PUT ORDERS ON THIS CHECKLIST. That functionality is in development. 6. To write orders you must go “NP Patient Physician Orders” 41 Table of Contents ⏎
Clarity: Checklists, Office Lab Review After you have signed the note, you can print it for your records. 1. 2. 3. 4. 5. Select the appropriate Clinic and Patient from the drop down boxes. Select your name from the Physician UPIN drop down box. Type month of the data reviewed. You may review previous notes by using the History drop down menu. Go through the list responding to the prompts. Clicking on text like “View BP trends report” will display the most recent BP data in a PDF page. Close the page after you review it. 6. 7. 8. 9. 10. Enter free text as you wish in the adjacent “Notes” column. Indicate whether the patient is stable or unstable (and the reason for the unstable status). Sign the note with your User Name and Password. If you wish to write orders, go to “NP Patient Physician Orders. ” Go on to the next patient by changing the Name and Clinic in the selection boxes. 42 Table of Contents ⏎
Clarity: Checklists, MD Office Visit From “NP Patient Checklists” Choose “MD Office Visit (electronic)” Choose the patient from the “Select Patient” screen. Complete the check list as noted in the next screen. 43 Table of Contents ⏎ 1. You may document your H & P on this check list. 2. You can review dialysis, BP, medications, and cumulative laboratory results. 3. You can print this report to place in your office record. 4. As of yet, you CANNOT write orders in this checklist. 5. You can write orders by “NP Patient Physician Orders.
Clarity: Checklists, MD Office Visit 1. 2. 3. 4. 5. 6. 7. 8. 9. 44 Table of Contents ⏎ Choose the Clinic and Patient. Choose your name from the MD list. Record the CC, PI etc. in either of the text entry boxes (Value or Notes). View the Linked Reports. Comment in the adjacent Notes column. Record your Exam by clicking the organ system and adding the observations in the adjacent Notes column. Complete your assessment and plans. Sign with your User Name and Password. Print the report for your office records. To write orders you must go “NP Patient Physician Orders
Writing Orders not Associated with Dialysis Real-Time Charting 45 Table of Contents ⏎
Clarity Writing Orders 46 Table of Contents ⏎ (NP Patient Physician Orders) From the navigation pane chose “Patient” From the Patient Sub. Menu chose “Physician Orders” Select Patient from the “Select Patient” screen The next screen is the physician order panel.
Clarity Writing Orders 1. You can review existing orders by clicking on the order’s date. 2. You can change patients by clicking the “Change” box to bring up the “Select Patient” screen. 3. You can add a new order for the patient listed by clicking “Add New” 4. Clicking “Add New” brings up the screen shown in the panel to the right. 47 Table of Contents ⏎ 1. 2. 3. 4. 5. 6. 7. (NP Patient Physician Orders) The date and time stamp are supplied Write a summary of the order in the “Summary” box. Write the order(s) in the text entry window. You may write as many orders as you wish. Please put each order on its own line. Please use the standard hospital order writing conventions. No abbreviations. “Increase Dry Weight to 68 KG” NOT “ dw to 68. ” 8. Click “Add”. If the “Add” button is not displayed, you cannot enter the order. You are likely in an some other user’s login. 9. These orders are checked twice a day. You should call the facility if the order you wrote is urgent or if it pertains to today’s dialysis.
Dialysis Rounds The Treatment Menu Rounding Physician Dashboard Real-Time Charting 48 Table of Contents ⏎
Clarity: The Treatment Menu RTC Status states the current status of dialyzing patients. Real-Time Charting (RTC) is where you do and document your face to face rounding. Table of Contents ⏎ Rounding Physician Dashboard (see next slide) lists your patients for that day. This is useful place to plan your rounds. 49 Treatment History lists an individual patient’s treatments. You can click on the date to see the treatment. These as table format reports. Clicking underlined text opens the treatment or patient dialysis RTC record.
Clarity: Rounding Physician Dashboard One, Patient Two, Patient Three, Patient 1. 2. 3. 4. 5. Pick your name and today’s date. “Search” will list all patients assigned to you. Clicking on the patient’s name will open their RTC record. The table lists the scheduled time and treatment station. Any requests from the RN staff are listed in the last two columns. You can get a list of your rounding patients by printing this table using the printer function of your browser through print preview. 6. There should be a list of your patients in your CDC mailbox. 50 Table of Contents ⏎
Clarity: Dialysis Rounds “Real-Time Charting” Dialysis, face to face rounding is done through a utility named “Real. Time Charting. ” You can review all the current dialysis data, nursing and tech documentation, and machine data through this application. Through the Physician “tab, ” you can review previous dialysis records, laboratory, BP and medication reports. You can write orders through this application. You can receive messages from the nursing staff about issues requiring your attention during rounds. You can document your participation in the Unstable Care Plan IDT meeting. 51 Table of Contents ⏎
Notes on Rounding at CDC We expect that notes are entered during or shortly after the visit. The computer stands can be lowered, allowing you to sit and talk to the patient while reviewing their data. If the system is down, there are down time forms for you to use. Hand Hygiene 52 You must wear disposable gloves when you use the chair-side computer terminals. You should do hand hygiene before and after using terminals at the center desk, though you do not need to wear gloves at the terminals away from the chair-side. Table of Contents ⏎
Clarity: Real Time Charting (RTC) From the “NP Treatments Real. Time Charting” If you use the terminals at the station, the utility will already be open. You need to choose the patient from the “Start” bar in the Windows desktop. Patient, Name 53 Table of Contents ⏎ You can review the dialysis prescription (though there is a more efficient way – see patient reports) The next slides go through the process of documenting face to face rounding.
Clarity: Real-Time Charting If you enter your note after the treatment is signed off by the RN, it will not appear in this list. 1. There are 6 tabs. You will document only in “Phy Rounding. ” 2. Make the appropriate clinic and patient selection choices. 3. You may review previous notes by the History drop down choice. (Be sure to return to today’s date before writing a note). 4. The record and types of notes (RP monthly assessment or Rounding Visit) are listed. 5. The record of hospitalizations is listed. 54 Table of Contents ⏎
Clarity: Real-Time Charting 1. A series of links to current data reports can be opened and reviewed. 2. You may make your comments in the Notes column adjacent to the value column. 3. Do not put orders in the Notes column. 55 Table of Contents ⏎
Clarity: Real-Time Charting Select the Level of Visit (mandatory field). If you are doing an “RP Monthly Assessment, ” check the box. Add comments as appropriate to the adjacent Notes column. 56 Table of Contents ⏎
Clarity: Real-Time Charting Document your H & P as indicated. Respond to the “Physician Request” if one is present. If no response needed, *NONE* will appear in this space. Review the listed Dialysis and Laboratory data. Indicate if your rounds are part of an IDT unstable care conference. You may write orders on this check list. Tell the charge nurse about any STAT orders. Sign with User Name and Password. Change to the next patient from the selection box at the top of the form. 57 Table of Contents ⏎
Clarity: Real-Time Charting If you make a comment in the Notes column and there a series of ‘radio’ buttons in the values column, be sure to check one of them. If you miss a required field, you will not be able to sign off the note until that field is completed. You will get an error message in red identifying the missing information. Correct the omission and re-sign the note. You cannot change to the next patient until you have signed off the current patient. As you round, you will inevitably think of things that we can add, change or make better. Please e-mail your suggestions to the help desk. We do want this application to serve your needs. We will work with the physician users to enhance this program. 58 Table of Contents ⏎
Running Reports Patient Specific Reports Batch Reports using “Advanced Mode” 59 Table of Contents ⏎
Clarity: Patient Specific Reports (NP Reports Patients) 60 Table of Contents ⏎ From NP Reports Patient Reports To a “Select Patient” screen if you are not already working with a specific patient. To a report selection drop down menu if you are already working with a patient.
Run for current patient or Select a new patient Select a date range Select Output Type then Run Report 61 Choose a report type
Clarity: Regularly Useful Reports NP Reports Patient Reports
Clarity: Combining Patient Reports with the “advanced mode” to create and save a batch A useful way to review your patients each month, is to run key reports that help you to interpret dialysis and laboratory data. By combining BP, Treatment Time, HGB & trends, in to a single report run for all your patients at a given facility, you can save the time of opening each of these. Run them to a. pdf file that you keep open on your desktop and you can review each patient quickly as you complete the check list. The next few slides demonstrate this method. 63 Table of Contents ⏎
Clarity: Batch Reporting ✓ 64 Table of Contents ⏎ Report Patient Report Choose a patient Choose the first report Click “Advanced Mode” “Add” additional reports Select a date range Click “Next”
Clarity: Batch Reporting Select yourself from the “care provider” box. “Run” the report. The report will open in a PDF file. You can “find” the patients in the file by putting their name in search box at the top of the file. pdf reader tool bar 65 Table of Contents ⏎
Help With Clarity Built in Help Functions CDC Frequently Asked Questions The CDC IT Help Desk 66 Table of Contents ⏎
Clarity: Help Functions 67 Table of Contents ⏎ There a number of useful built in help functions. Additionally, as shown on the following slide, there a screen and report specific help functions.
Clarity: Help Functions 68 Table of Contents ⏎ Page Specific help is seen in the upper right hand corner of many screens. Clicking it will open a help window. Reports list the content and source of data in the “More Info” link. Checking these does not alter your report or login status. All of these functions are ‘read only. ’ Feel free to explore, you cannot hurt the data base (or break the internet).
Frequently Asked CDC MD Questions I am in the hospital, at home, or in my office, how do I connect to the CDC EMR? From any Internet Explorer web browser type http: //www. cdcare. org follow the instructions in this slide set here. Internet Login I am in the hospital, how do I get dialysis orders and treatment summaries? NP Report Patient Reports
Frequently Asked CDC MD Questions con’t I want to add a new event/diagnosis to co-morbidities where do I add this? I want to write an order for a new medication, where to I write it? NP Patient Physician Orders free text orders How do I sign off verbal orders? NP Patient Problem List
Contacting CDC Help Desk 8 am to 5 pm, Monday thru Friday (216) 229 -6170 x 149 [email protected] org 71 Table of Contents ⏎
Clarity Quiz Please take quiz and fax to Education Department (216) 229 -2692 Table of Contents ⏎