Chart Review. Topics. How do I access the patient s chart?

Transcription

1 Chart Review Topics How do I access the patient s chart? How do I use the Chart Review tabs? How do I view records in Chart Review? How do I use the Filter button? How do I use Flowsheets? How do I access Flowsheets through the Chart Review tab? How do I use Report Viewer? How do I access the patient s chart? A Chart includes all the data related to a patient and is organized much like a file cabinet and includes office visits, hospital stays, scanned documents, and laboratory reports. In Chart Review, individual tabs denote the various kinds of data in each file. You may open up a chart in two ways: either from a schedule or independent of a schedule. 1. From the Patient Care menu, choose Chart option. 2. Search for the patient s last, first name. 3. Click on the Chart Review activity. 1 Chart Review

2 How do I use the Chart Review tabs? The Chart Review Tabs displayed below appears when you initially access Chart Review. Which Chart Review Tab? Enc Notes Lab Cult Image Proc/Dx Tests Oth Ord Media Med Epis Ltr Out Docs Hlth Rpt Consent/Legal Misc Description of items Completely documented patient encounters, such as office visits, telephone calls, and med refills for the entire UW Health organization. Notes and transcriptions from a variety of encounter types. Individual lab results. Abnormal results will appear in red. Flowsheets and graphs can be generated here. Lab cultures will appear in the Lab tab and some lab cultures from some clinics will also appear in this tab isolated from the rest of the non-culture lab results. Imaging reports. Results of tests that are not lab or imaging tests, such as a Cardiac Stress Test, ECG/EKGs, etc. ECG/EKG results from clinics whose ECG testing is done through EpicCare will appear in this tab. Non-EpicCare ECG results may be found in the Other Ord tab. Also, diagnostic tests ordered and performed during an inpatient stay will be viewable here. Orders that are not lab, imaging, or medications, e.g, Consult/Transfer/Request orders, injections, supplies, etc. All the scans are here in one place in this tab. In many cases, these scans are accessible in other Chart Review tabs. This tab includes EKGs, Spirometer reports and Annotations besides scans. All medications, but Current Meds Only are displayed by default. Lists active and resolved Episodes (a group of encounters related to a particular health issue, such as anticoagulation applies to Phase 3 only). All letters generated through EpicCare. Scanned documents from non-uw Health entities. Labs, Images, and Diagnostic procedures NOT ordered by a UW provider will be found under this tab. This tab will only contain Scanned Health Report encounters. If a document needs to be scanned and it is NOT a result of any kind, nor a consent, nor an outside record, nor is it associated with a visit, HIM will create a Scanned-Health Report encounter to scan the paper to. Scanned information related to mail-order pharmacies or referrals, and Advanced Directive documents. Reports such as Immunization History and Clinical Summary (useful for an overview of the patient s health history). 2 Chart Review

3 How do I view records in Chart Review? To view single records, simply highlight and double click. To view multiple records, follow these steps: 1. Highlight the records you wish to view. 2. Click the Review Selected button. Use the scroll bar to view reports in succession. How do I use the Filter button? The Filters button is a way to narrow your search within Chart Review. 1. Use the Filters button to apply single or multiple filters in order to narrow your search. 2. Click the item you wish to filter, for example: Provider. 3. The results will display in the box below, including the number of encounters related to this match and their most recent date(s). 3 Chart Review

4 1. Click in the box next to the specific example of the parameter you originally used for the filter. In this case, we have selected Provider and we specifically want to see encounters with Dennis Breen. 2. Note that the number of encounters related to visits with clinic for example: Provider is nine and the most recent is dated 11/01/ The number of encounters and the most recent date matches the visits filtered for you to view. 4. If you want to re-use this filter for several patients, you can save it as a Quick Filter. Click on Save and name it (in this case office visits ). 5. You have created a button that will appear every time you open this tab of Chart Review on any patient. TIP: It is possible to apply multiple filters. For example, you could combine the specific provider name with a specific diagnosis. This could help you track the course of a patient s chronic health problem. 4 Chart Review

5 How do I use Flowsheets? Flowsheets allow you to combine and review data from different parts of the record. It is a way of combining data in either graph or table format. This facilitates data comparisons making it possible to view trends over time. There are two places Flowsheets can be accessed: From the Activity Tree From the Chart Review Tab 1. Click the Flowsheets tab on the Activity Tree. 2. A pop-up box will appear, allowing you to select the desired Flowsheet. You will be able to quickly view data which would typically be viewed over time. 3. Click Accept button. 5 Chart Review

6 How do I access Flowsheets through the Chart Review tab? In Chart Review, the following tabs include the Flowsheet button: Encounters Lab Episodes Notes/Trans Scanned Consent We will focus on using the Flowsheet functionality through the Lab tab because it is commonly used in clinics to view trends over time. It is also used to copy/paste into letters created in Health Link and it allows us to build on filtering skills. 1. Select Chart Review in the Activity Tree. 2. Select the Lab tab. 3. Click on the Filters button. 1. Select the lab tests you would like to view. 2. Click on the Lab Flowsheet button to display the lab result components. 6 Chart Review

7 1. If any results are abnormal, they will appear highlighted in yellow. 2. To select items to graph, click on the Component header to highlight all labs. 3. To create a Bar Graph or a Line Graph, click on the Region button. A Line Graph will appear by default. 1. Click on Bar Chart button to convert the graph into that format. 2. Click Print Graph button to print a copy. 3. Click Show Flowsheet button to return to the table of values. How do I use Report Viewer? The Report Viewer keeps a list of reports that have been viewed while you are in a section of Chart Review. Each time you view a report, linked report, scans, and other media, a link is added to the History Pane in chronological order, with the most recent listed first. To view the history, click the Report History button on the Report Viewer toolbar. This is available to you while you are viewing a report. 7 Chart Review

8 From the History Pane, you can select two reports, scans, or other linked media. Then you can view them in two different panes, which may facilitate a quick comparison between two reports. Previously, we had selected and viewed INR results from three different dates. 1. Because we had viewed three INR reports, these have been entered by Health Link into the Report History Pane. To see the Report History click the Report History button while in a report. 2. You can choose how to view the split panes: either Split Up/Down or Split Left/Right. In our example, we will choose the Up/Down version. 3. Using the Pane number buttons, assign a number to each lab report. (Click on the lab report, and then click on the number button.) 4. These numbers will show up in the History Pane. 5. Click on the Split Up/down button to arrange the panes in this format. 8 Chart Review

9 1. The Report History button toggles to show or hide the Report History pane. (In this view, the Report History pane is hidden. In the previous view it is not hidden.) 2. The report numbers correlate with the numbers assigned to the lab reports in the previous illustration. 3. To return to viewing a single Pane, you can click on View Pane 1 or View Pane 2 buttons. These buttons function as toggles that will allow you to move easily from one report to another. 4. Clicking the Detach Window button allows you to detach the Report Viewer screen from Hyperspace. The window can then be minimized, maximized, moved, or resized independently of Hyperspace. To reattach the window to Hyperspace, click Reattach Window or click the X in the upper right. 9 Chart Review