Transcribe a New Document in MTM

Transcription

1 Get Started 1. From your AppBar, select the Transcription Entry icon. 2. From the Startup dialog box, select Open Document and click the button. 3. From the Open Assistant dialog box, select Document Explorer and click the button. The Document Explorer window opens. Document Explorer helps with the organization and filtering of transcribed documents in MTM. It allows you to: search for a patient, see previous documents transcribed for a patient, change the way in which documents display, look for documents using filters, and create new documents. 4. Click the Search a Patient icon to search and select the patient for whom the author has dictated the document. 5. In the Encounter Search dialog box that opens, fill in your search criteria, e.g., PIN, and then either press Enter on your keyboard or click the button. 6. Your search results are displayed. P a g e 1

2 It is VERY IMPORTANT to double-check that you are selecting the correct patient and the correct encounter (visit). Remember, it s not uncommon for a patient to have multiple visits during their health care journey. Remember, it is part of your responsibility to maintain an accurate electronic health record for the patient. 7. Select the correct encounter by either double-clicking it or by clicking it once and then clicking the button. 8. You are returned to the Document Explorer window, which may now display previously-transcribed documents for that patient (if any). 9. Click the button. 10. The Cerner Properties dialog box opens with the Patient Name field populated. P a g e 2

3 Change Cerner Properties the First Time You Login - Important The first time you login to MTM you need to set up the correct Cerner options for your transcribed documents. This means changing your Event Set to filter only document types that have been set up for London, as well as changing some other important parameters. 1. In order to access Cerner options, you must first close or cancel this Cerner Properties box. You ll come back to it later. 2. Notice that MTM uses MS Word 2007, which includes a Ribbon interface and associated tabs with commands. No more menu bar. You ll click the Cerner Transcription tab to see its commands. P a g e 3

4 3. Click the Cerner Options command. General Configuration Tab Under the Processing Options section: 1. Uncheck Save Productivity Statistics. 2. Uncheck Print Document on Submit if you do not wish to be prompted to print the document each time. Processing Parameters Tab 1. In the Event Set, Preferred Event Set section, replace the default ALL DOCUMENT SECTIONS with London MTM Transcribed Documents. This must be typed exactly. 2. In the Required Fields section, check Date of Dictation and Date of Service. 3. Click the button and then click the button. 4. You are returned to the transcription window; however, you do need to open the Cerner Properties dialog box to continue. It s best to return to the Home tab, which displays the most common commands in MTM and Word From the Home tab, click the Document Properties command. P a g e 4

5 Complete Cerner Properties Required fields display in yellow. 1. Document Type field. Click the button to select the type of document being dictated. You may also start typing the first few letters or words of the document and Cerner will auto complete it for you. 2. Author field. The primary physician for whom you work should automatically populate. However, if you need to change this or it does not appear, click the button to select the physician who dictated the document. 3. Date of dictation field. This field auto-populates with the current date and time, which may not necessarily be the date you transcribed the document. You need to manually adjust this field to ensure it reflects the date the author dictated the document. 4. Subject field. It is a free-text field and can be used to further clarify the document. 5. Date of service field. This field auto-populates with the current date and time. The Date of Service needs to reflect the date and time that the clinical event occurred. Manually adjust this field to ensure it reflects the date the clinical event occurred. Operative Report - change to date of surgery, Death Summary - change to date of death, Discharge Summary - change to date of discharge, Procedure Report - change to date of procedure. 6. Template field. We recommend using templates that have been created for all document types and include preset headings to reduce errors and make typing your document easier. Search for or type templates that start with LDN for London. 7. Co-Signer(s) field. If you are typing for a medical student or resident, they are the author but you must select the attending or MRP as the co-signer. 8. Reviewer(s) field. Add reviewers when the author has requested a copy be sent to another clinician or 3rd party, i.e., Ministry of Transportation. 9. For the Co-signer(s) and Reviewer(s) fields, you may type the last name or organization directly or click the buttons to open the Provider Lookup box. 10. The Personnel quick pick: section automatically lists all personnel who have accessed the patient s record and their relationship with the patient. 11. To choose a name from the Personnel quick pick: section, simple click the name and either click the Co-Signer(s) button or Reviewer(s) button to move them to the proper section. P a g e 5

6 12. If the person is not found in the Personnel quick pick: section, use the Personnel lookup: section to search. Enter the last name. If you do not wish to only filter for physicians, uncheck Physicians only. 13. If the system finds more than one match, ALWAYS confirm that you have the correct provider by first clicking the binoculars icon to see the search results. 14. Next click the physician s name and then click the button to view more information, i.e., address, phone number, etc. NOTE: For Ministry of Transportation, type only ministry to select the correct office from a list. Alternatively, typing Ministry Of Transportation, London gives you an exact match. 15. When all fields in the Cerner Properties box are completed, click the button to return to the transcription entry window. Type Your Document The blue shaded areas of the transcription window are protected sections and include information interfaced from Cerner, e.g., demographic information, signature line. You cannot click and type in a protected section. If you find an error in a protected section, e.g., the wrong reviewer, you must click the Document Properties command on the Ribbon to display the Cerner Properties box to make your change. 1. By default the transcription window opens in Draft view. This is problematic because it is not a true representation of how the document looks when printed. P a g e 6

7 2. Switch to Print Layout view using the view icons at the bottom right of the window. 3. If you selected a template, preset headings display in the body of the document. 4. The headings with an underscore represent jump codes, which allow you to jump to different sections within the document. Most templates have jump codes built into them. Some contain many jump codes, i.e., Operative Note. 5. Press ALT+J to move the cursor forward through the alterable fields in a template (quickest), or click the Next Jump Code command on the Ribbon. If you didn t select a template, please remember to type (in bold) the kind of document you are transcribing at the top of your document, e.g., Discharge Summary. 6. Type the body of your document. Bulleted and Numbered Lists in MTM The bullets and numbering commands in the Paragraph group of the Ribbon are disabled in MTM. Create a Numbered List or Bulleted List as You Type 1. Type 1. to start a numbered list. 2. Type * (the asterisk character) to start a bulleted list. P a g e 7

8 3. Press the SPACEBAR key. 4. Type your text, and then press the ENTER key. 5. Word automatically inserts the next number or bullet at the beginning of the line. 6. Repeat step 4 to create additional list items. 7. To finish the list, press ENTER twice. You may also type your bulleted or numbered list in Word 2010 and then copy and paste into your MTM document. Remember to use Arial font for print quality. Spell Check and Submit Your Document Once the transcribed document is complete, you need to submit it electronically to the author for review and electronic signature. 1. To spell check your document prior to submitting, press F7. You may also right-click over the red-underlined words and choose a suggestion from Word s dictionary.) 2. Click the Submit command (or Ctrl+M), and the application automatically spell checks and grammar checks the document before submitting. (MTM uses Stedman s medical dictionary.) Please note that, at this, time you are unable to add entries to the dictionary. Print Assistant After you submit the document, it has been submitted to PowerChart as a preliminary report. 1. When setting up your Cerner options, if you set the option to Print Document on Submit, the Print Assistant window opens. 2. Choose one of the following options: a. Draft Print prints a draft print of the transcription. Site-specific identification will not print on draft copies. b. Manual Expedite prints the transcribed document on the final chart form. You are prompted to identify the output device (printer, fax) and the chart format. You can manually print/fax a copy to someone requesting a copy. c. Cancel you do not wish a printed copy. d. We do not use Routing. P a g e 8

9 3. Once you click the button or button, the document is automatically closed and sent to PowerChart, to the author and to the reviewer(s) electronically. 4. You are returned to the Startup box where you could begin your next document or exit the MTM application. Transcribe For a Resident or Medical Student The only difference when you are transcribing a document for a medical student or resident is that he or she is the author but you must select the attending physician or MRP as the co-signer in the Cerner Properties box. P a g e 9