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GE Healthcare IT Centricity Practice Solution Flipbook PDF
3 Copyright 2011 General Electric Company. All rights reserved. Confidential and Proprietary Information How to Use This
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GE Healthcare IT
Centricity® Practice Solution CPS 10.0 Companion Guide Chart Module – Document Maintenance
Centricity® Services 1 Copyright 2011 General Electric Company. All rights reserved.
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Confidentiality and Proprietary Rights and Limitations and Conditions of Use This document is the confidential property of GE Healthcare, a division of General Electric Company (“GE Healthcare”) and is furnished to you, a current GE Healthcare customer, pursuant to an agreement between you and GE Healthcare. If you are not (i) a current GE Healthcare customer, and (ii) subject to a non disclosure obligations pursuant to an agreement with GE Healthcare, you are not authorized to access this document. No part of this document may be reproduced in any form, by photostat, microfilm, xerography, or any other means, or incorporated into any information retrieval system, electronic or mechanical, without the written permission of GE Healthcare. Contact your GE Healthcare representative with any inquiries regarding copying and/or using the materials contained in this document outside of the limited scope described herein. GE Healthcare reminds you that there may be legal, ethical, and moral obligations for medical care providers to protect sensitive patient information when dealing with vendors such as GE Healthcare. You should obtain explicit written consent from both the patient and GE Healthcare before you disclose sensitive patient information to GE Healthcare. Trademarks GE, the GE Monogram, and Centricity are trademarks of General Electric Company. All other product names and logos are trademarks or registered trademarks of their respective companies Copyright Notice Copyright 2011 General Electric Company. All rights reserved. Disclaimers Any information related to clinical functionality is intended for clinical professionals. Clinical professionals are expected to know the medical procedures, practices and terminology required to monitor patients. Operation of the product should neither circumvent nor take precedence over required patient care, nor should it impede the human intervention of attending nurses, physicians or other medical personnel in a manner that would have a negative impact on patient health. General Electric Company reserves the right to make changes in specifications and features shown herein, or discontinue the products described at any time without notice or obligation. This does not constitute a representation or warranty regarding the product or service featured. All illustrations or examples are provided for informational or reference purposes and/or as fictional examples only. Your product features and configuration may be different than those shown. GE Healthcare IT 540 West Northwest Highway Barrington, IL 60010 U.S.A. www.gehealthcare.com
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How to Use This Companion Guide: This Companion Guide is provided as an ancillary instructional guide to be used in conjunction with the CPS or EMR Computer Based Tutorials (CBT's), CPS or EMR Help Guides (F1), and CPS or EMR New Version Release Notes available to you with the purchase of the CPS product(s). Additionally, during your CPS or EMR Implementation or Upgrade, you will have GE Healthcare professionals available to assist you as designed by your purchase. For field-by-field explanation of the product or for point-and-click functionality explanation, please reference the CBTs, Help Guides, and/or New Version Release Notes. This Companion Guide is a compilation of “best practices” obtained from multiple healthcare practice workflows, which are combined with the functionality of CPS or EMR software, to provide the most commonly used workflows within an ambulatory physician office. The workflows described in this Companion Guide are recommendations ONLY and do not necessarily reflect mandatory setup/settings. The Companion Guide should be used as a reference in determining the best workflow designs for your specific medical practice needs. The Companion Guide is divided into sections that represent major functionality areas and/or workflows of the CPS or EMR product. Please note that topics affecting more than one area of functionality may be cross-referenced. Also, at the end of each section, you will find a Notes area available for your own customized notes. For more information on customer education services and tools concerning the CPS or EMR products, please visit the Centricity Customer Portal, http://centricityportal.gen21.com/knav/nav and/or the Customer Education website: www.cpstraining-gehc.com.
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Table of Contents Document Maintenance ............................................................................................................................. 5 Appending Documents ................................................................................................................................ 6 Discarding the Document ........................................................................................................................11 Filed in Error ....................................................................................................................................................12 Move and Remove .......................................................................................................................................13 Orders Completion Assistant ..................................................................................................................13 Notes ..................................................................................................................................................................15
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Document Maintenance
Scenario: As you create your day-to-day documentation for patient care, there will be opportunities where you will need to alter that documentation in a variety of ways. Document Maintenance reviews numerous opportunities to alter your patient documentation. Typical Staff Responsible for this Process?: Clinical Staff, Clinical Support Staff
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Appending Documents When a document is signed, you are unable to alter the information contained in that document. When there is a need to add to the information contained in a document, you do have an ability to Append. A simple append allows the user to add additional details to the original signed document that can no longer be edited. This simple append feature does not, however, allow the user to alter the Clinical Lists. To append, highlight the document by clicking on it and then clicking the Append icon.
A simple Append adding text to the patient’s previously documented Plan:
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When the simple addition of text is not enough, and the Clinical Lists need to be altered, you must click the Click here to do a Full Update icon. This will give you access to the needed Encounter Types to appropriately alter your documentation.
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Although all Encounter Types, and their associated Forms, are available to use during a Full Update Append, it is most common to utilize a Clinical Lists Update. Utilizing a Clinical Lists Update ensures that you have access to all the Clinical Lists and that your documentation will contain a text translation of your charting. But if needed, using other Encounter Types with associated Forms is fine. Always remember: The Forms dictate the text translation. You want to be certain that the Encounter Type you select has the Forms containing the appropriate text translation for your additions.
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Once inside the Append document, you have access to all the usual tools and functionality of updating the patient’s chart. At this point, you’re engaging in the same functionality as creating any new document in the patient’s chart. Notice the grayed field at the top. This represents the original documentation that you can easily review as you are creating your additions.
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Upon signature, the Append Document links itself to the original Document in the patient’s chart. You’ll notice the gold + icon, along with the gold A icon. Even though there are technically two separate Documents in the patient’s chart, you can view the information seamlessly from the original Document into the Append Document.
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Discarding the Document You are able to Discard the Document you are working on if there are no signatures contained in the Document. If there are signatures, CPS will prevent you from utilizing the Discard Document feature. This feature is used when the creation of the new document was in error and should be completely discarded. Discarding the document leaves no evidence that the document ever existed.
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Filed in Error Filed in Error is utilized on Signed Documents when a portion, or the entire document is incorrect, and the entire document needs to be eliminated from the patient’s chart. Filed in Error works with the whole document, not portions of the document. There is no functionality to File in Error a portion of the document and leave the rest intact. After highlighting the document you wish to "File in Error" by going to "Actions" - "Document" - "File in Error", you'll receive the following window which shows the Clinical List data that will be eliminated from the patient's record once the action is complete.
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Move and Remove Move and Remove are functions that are only allowable to Documents that have a document status of Unsigned. For example, Lab Reports prior to being signed have a status of Unsigned. Office Visits, however, never have a status of Unsigned and are not subject to this functionality. Move allows the user to move a document with the status of Unsigned to another patient’s chart. For example, if a Lab Report inappropriately was indexed into the wrong patient’s chart, this functionality could easily move it to the right patient’s chart. You can accomplish this by using the Action menu in your upper toolbar. Remove allows the user to remove a document with the status of Unsigned from the patient’s chart. For example, this function could be used if a Lab Report came through your lab interface but was inappropriate and needed to be removed (e.g., lab report on a patient that you do not see in your practice, but bears a similar name to an actual patient in your practice). You can accomplish this by using the Action menu in your upper toolbar.
Orders Completion Assistant The Orders Completion Assistant allows for an automated workflow in the completing of an Order once the end documentation has been received. Documents with a status of Unsigned appear on the clinician’s Desktop needing review and signature. For example, a Lab Report comes in from the interface with the lab vendor.
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When the clinician attempts to Sign the document, a window appears illustrating all the incomplete Orders that have matched the data represented on the unsigned document. The window allows the user to Complete the necessary Orders as the signing workflow occurs.
Considerations: Each user has a Preference of the desired Document Types that will be subject to the matching of the Orders Completion Assistant. For example, a user may want Lab Report documents to be matched to outstanding Orders, but he may not want Consultation Report documents to be matched. Due to the nature of the results and the incoming document, a user may decide not to Complete a specific Order because of additional workflow that needs to take place. The user always has the ability to leave an Order incomplete, even though the incoming document has been signed. The Orders Completion Assistant does not force the user to complete. It merely suggests. In addition to the Orders Completion Assistant, the user still has the ability to manually Complete any Order at the appropriate time.
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