Document Generator (EHR)

Transcription

1 Pulse Complete EHR Document Generator (EHR)

2 About This Reference Guide Functionality described within the document is intended for or newer versions of the Pulse Complete EHR software. The Pulse Complete EHR software is under constant development, and the reference materials are updated frequently. The most recent versions of all Pulse reference materials are always available online at: Acknowledgments Document Number: 01 Date: September 27, 2013 Pulse Systems Inc 3020 N. Cypress Suite 200 Wichita, KS

3 Table of Contents Document Generator within Pulse EHR... 4 Encounter Documents Window... 5 Encounter Documents Window: Overview of icons, menus and fields... 5 User Preferences Window User Preferences Window: Overview of icons, menus and fields Accessing Document Generator from the Point of Care module Accessing Document Generator from the Document Management module Understanding how appointment data is applied to newly created items within the Document Generator Non-Encounter Document Generator Accessing Document Generator from the Appointment List module Accessing Document Generator from the Patient Functions menu Accessing Document Generator from the enote module Accessing Document Generator from the echarge module Accessing Document Generator from the Orders module Accessing Document Generator from the OB Management module Appendix A Quick Phrases Daily Schedule Narrative of 32

4 Document Generator (EHR) Document Generator within Pulse EHR From various locations within the Pulse EHR, users can access the Document Generator to create transcription documents based on existing provider templates. The Document Generator is available within the following Pulse EHR locations: o Point of Care o echarge o enote o Orders o OB Management (through the Orders module control) o Document Management o Appointment List o Patient Functions Menu NOTE: For information on configuring templates, refer to the Document Generator Templates Admin enduser documentation. 4 of 32

5 Document Generator within Pulse EHR Encounter Documents Window Whenever Document Generator is accessed within the PulseEHR, the Encounter Documents window displays. Through this window, users can apply assigned templates for the selected users and then forward the created document to other users within the facility. Encounter Documents Window: Overview of icons, menus and fields Icon/Menu/Field Description Create Documents icon: Enables the user to generate transcription documents based on the selected template. 5 of 32

6 Document Generator (EHR) Icon/Menu/Field Description Action toolbar icon: Enables the user to perform the following actions for a saved document: Send for Review The Send for Review category of actions only contains one extended option, Send for Review & Task. Sign The Sign category of actions contains four extended options: Sign & Return to Sender; Sign & Route; Sign, Return, & Task; and Sign, Route & Task. Finalize The Finalize category of actions contains one extended option: Finalize & Task. Return to Sender The Return category of actions contains one extended options: Return to Sender & Task. NOTE: Refer to the Document Management enduser documentation for detailed information on the Action toolbar options. Load Provider Templates toolbar icon: Enables the user to perform the following actions: Change Provider Displays the Provider Lookup window, where users can locate, select and populate a specific provider s template list within the Template Selection field. Clear Provider Removes the current selected provider and populates all existing templates within the Template Selection field. Load Templates toolbar icon: Displays the selected item from the Template List within the Viewing Area. Type dropdown field: Enables the user to specify the document types displayed within the Narrative Templates panel. Find field: Enables the user to locate a template by specific title (complete or partial) within the selected template panel. Check All toolbar icon: Checks the box next to each item within the Documents panel. Uncheck All toolbar icon: Unchecks the box next to each item within the Documents panel Remove toolbar icon: Deletes the selected item(s) from the Documents panel 6 of 32

7 Document Generator within Pulse EHR Icon/Menu/Field Description Send Document to CC List toolbar icon: Enables the user to access the Clinic Notes CC List Manager window, where the template document can be send to specified CC recipients. View toolbar icon: Enables the user to select one of the following display options: o View Checked Documents Allows the user to select one or more to view. o View with Face Sheet Displays one or more documents with a face sheet as the first page in the viewing window. o View with Custom Face Sheet Allows the user to view one or more documents with a customized patient face sheet. o View Document History Displays the Document History window, allowing the user to view the signing history for a signed document signing. Settings icon: Enables access the User Preference window. Refer to section 2.2 User Preferences window for more information on how to configure and utilize the settings within the User Preference window. Print Routing icon: Enables the user to route all documents selected within the Documents panel through the Document Routing function. For detailed information about Document Routing, please refer to the Document Routing end-user documentation. Exit toolbar icon: Closes the Encounter Documents window Patient Information panel: Displays demographic, contact, Rx, allergy, alert, location, appointment, and chart note information for the selected patient. 7 of 32

8 Document Generator (EHR) Icon/Menu/Field Description Narrative Templates panel: Displays the user s or assigned provider s assigned templates. Users can select items from the Narrative Templates panel to customize and generate a document. NOTE: Display settings within the Narrative Templates panel are configurable within the User Preferences window. 8 of 32

9 Document Generator within Pulse EHR Icon/Menu/Field Description e-note Templates panel: Enables the user to utilize enote templates to customize and generate a document. Refer to the enote end-user documentation for more information on how utilize to generate a document from an enote template. 9 of 32

10 Document Generator (EHR) Icon/Menu/Field Description Documents panel: Displays all transcription documents created from the available template panels. File option: Enables users to access the following options: o Save Saves the template item within the Viewing Area as a document o Page Setup Allows configuration of the template page settings o Print Preview Displays a preview of the printed document o Print Prints the selected document 10 of 32

11 Document Generator within Pulse EHR Icon/Menu/Field Description Edit option: Enables users to perform the following actions within the document: o Undo o Redo o Cut o Copy o Paste o Select All o Find View option: Enables users to display the following within the document: o Page View Displays the document as a whole page o Normal Displays the document in its default view o Headers and Footers Displays the headers and footers within the document o Toolbar Enables/disables the Toolbar within the document o Button Bar Enables/disables the Button Bar within the document o Status Bar Enables/disables the Status Bar within the document o Horizontal Ruler Enables/disables the Horizontal Ruler within the document o Vertical Ruler Enables/disables the Vertical Ruler within the document Insert option: Enables the user to insert the following within the document: o Page Break o Image o Page Number o Quick Phrase NOTE: Refer to Appendix A - Quick Phrases for more information. Remove option: Enables the user to delete one of the following elements from the document: o Header/Footer o Page Number (Header/Footer) 11 of 32

12 Document Generator (EHR) Icon/Menu/Field Description Format option: Enables the user to perform the following actions within the document: o Character Allows configuration of font and character size within the document o Paragraph Allows for formatting of the document o Bullets and Numbering Inserts bullets and numbering of selected content within the document o Headers and Footers Allows the user to configure the header and footer for the document o Image Allows formatting of an inserted image o Tabs Allows for configuration of tabs within the document o Text Color Allows for selection of text color within the document o Text Background Color Allows for selection of text background color within the document Tools option: Enables users to perform the following: o Spell Check Completes a spell check for the selected document Table option: Enables users to perform the following: o Insert Places a columned table within the document o Delete Removes columns, rows from a table o Split Divides columns, rows within a table o Select Highlights a table, rows or columns o Grid Lines Enables/disables gridlines within a table o Properties Displays properties of a table Save toolbar icon (Viewing Area): Enables the user to save changes made to an existing document. 12 of 32

13 Document Generator within Pulse EHR Icon/Menu/Field Description Export toolbar icon: Enables the user to select one of the following export options for the document: Print This option is used to print the information needed to a selected printer. A printer dialog will appear for the user to select a printer. Fax This option is used to fax the viewed documents directly from the system to a specified fax number. The Pulse Fax Server must be running and communicating with the Pulse Patient Relationship Management system. This option is used to the viewed documents directly from the system to a specified address. NOTE: HIPAA does not recognize as a secure method of transmitting patient information (demographics or medical history). It is suggested to use this function only within your network. For the option to function, the Host Name, Port, and Address fields within the Transcript section of the Site File must be complete. Publish to Portal This option allows the user to submit the transcription document to the patient s corresponding Portal account. NOTE: Patients must have a Patient Portal account to utilize the Publish to Portal option. Print Preview This option is used to view the formatted transcription document prior to printing. View icon: Enables the user to display/hide the following within the document: Grid Lines Applies grid lines to the textbased tables displayed within the document viewing area. Styles Displays the Styles window, allowing users to create/configure style sheets. Style sheets can be applied to textbased items. Pulse Banner Enables the user to display/hide the standard Pulse header (containing basic appointment information) within the selected document Pulse Footer Enables the user to display/hide the standard Pulse footer within the selected document. Refresh Allows the user to fresh the document viewing area 13 of 32

14 Document Generator (EHR) Icon/Menu/Field Description Header/Footer controls: Enables users to perform the following: o Switch between header and footer o Go to First Page header o Go to Normal header o Remove Header/Footer Zoom field: Enables users to configure the View Settings Print Routing icon: Enables the user to route the document currently displayed within the viewing area of the Document Generator window through the Document Routing function. For detailed information on Document Routing, please refer to the Document Routing end-user documentation. Page controls: Enables users to view any applicable pages Paragraph Font field: Enables users to select the paragraph font for the document Font field: Enables users to select the font text for the document Font Size field: Enables users to select font size for the document Format options: Enables users to format the text for the document Page Orientation options: Enables users to select the page justification for the document List Settings options: Enables users to apply a bullet or list to the document Formatting options: Enables users to view the formatting for the document Viewing Area: Displays the selected template with attached patient s information populated within. 14 of 32

15 Document Generator within Pulse EHR User Preferences Window Accessible through the Settings toolbar icon, the User Preferences window enables the user to configure various settings within the Document Generator window. User Preferences Window: Overview of icons, menus and fields Icon/Menu/Field Description Save icon: Enables the user to save changes made within the User Preferences window Refresh icon: Enables the user to reload the User Preference window Exit icon: Enables the user to exit the User Preference window Type field: Enables the user to specify the document types available within the Document Generator 15 of 32

16 Document Generator (EHR) Icon/Menu/Field Description Load Templates by Provider field: Enables the user to load the following templates within the Document Generator by default: Me Loads the user s templates only Appt Provider Loads templates by an item s attached appointment provider only All Loads the user s and appointment provider View field: Enables the user to specify the document viewing area to either Page View or Normal. Zoom field: Enables the user to adjust the default focus of an item within the document viewer by percentage. Preferred type field: Enables the user to generated documents as either a document or PDF file. Pulse Banner field: Enables the user to insert the Pulse Banner within the document. Pulse Footer field: Enables the user to insert the Pulse Footer within the document. Patient Info field: Enables the user to Show and/or Expand the Patient Info panel within the Document Generator. Split Distance field: Enables the user to specify the percentage of the Document Generator window designated to the List and Viewer panels. Screen Orientation field: Enables the user to display the List and Viewer panels vertically or horizontally within the Document Generator. enote Replace Carriage field: Enables the user to specify the range in which the program will automatically find and replace carriage returns within a generated enote document. 16 of 32

17 Document Generator within Pulse EHR Accessing Document Generator from the Point of Care module Accessible through the Document Generator toolbar icon under the Narrative tab of the Point of Care module, the Document Generator can be used to apply a template to patient encounter information. 17 of 32

18 Document Generator (EHR) Accessing Document Generator from the Document Management module Users can access the Document Generator through a Document Generator toolbar icon within the Document Management module. Appointment data associated with a selected Document Management item is carried over to the Document Generator and utilized as the date of service for newly created items. Understanding how appointment data is applied to newly created items within the Document Generator The Appt field located in the lower left section of the Patient Information panel within the Document Management module and the Document Generator window displays a selected item s associated appointment date and time. The appointment date and time under the Appt field within the Patient Information panel for the selected item is the data that will be associated with the new document when created within the Document Generator window. Accordingly, the Document Generator applies the selected Document Management item s associated appointment date and time as the date of service for the newly created item. 18 of 32

19 Document Generator within Pulse EHR The appointment date and time for selected Document Management items is viewable under the Appt field within the Patient Information panel under the Document Management module and the Document Generator window If the item in the list within Document Management is not associated to an appointment, then the Date of Service will not pass through and the newly created Document Generator document will have the current date as the Date of Service. If an appointment is not associated with the selected Document Management item, the Appt field will be blank under the Patient Information panel within the Document Management module and Document Generator window 19 of 32

20 Document Generator (EHR) Non-Encounter Document Generator Users can launch the Document Generator window without an associated appointment by simply selecting the launch option from the dropdown next to the Document Generator icon, labeled Non- Encounter Document Generator. Through the Non-Encounter Document Generator function, users can create a document template not attached to an existing appointment within the Document Generator window (current date is utilized as the date of service.) The Non-Encounter Document Generator icon is available under Document Management panels configured under both the User and Patient Dashboard. Consequently, the function that previously existed within the Document Generator icon on the Document Management toolbar has been moved to the dropdown menu next to the Document Generator icon. 20 of 32

21 Document Generator within Pulse EHR Accessing Document Generator from the Appointment List module The Document Generator is accessible through the right-click menu within the Appointment List module. 21 of 32

22 Document Generator (EHR) Accessing Document Generator from the Patient Functions menu With a patient pinned, users can access the Document Generator through the Document Generator option under the Patient Functions menu. 22 of 32

23 Accessing Document Generator from the enote module Document Generator within Pulse EHR Users can access the Document Generator through the enote module. Create Patient Handouts icon within the NOTE: Documents from the enotes module must be validated or finalized in order to generate a document from the Document Generator window. Refer to the enotes end-user documentation for more information. 23 of 32

24 Document Generator (EHR) Accessing Document Generator from the echarge module Users can access the Document Generator through the echarge module. Document Generator icon within the 24 of 32

25 Document Generator within Pulse EHR Accessing Document Generator from the Orders module Users can access the Document Generator within the Orders module by selecting an item and clicking the Document Generator icon. 25 of 32

26 Document Generator (EHR) Accessing Document Generator from the OB Management module Users can access the Document Generator within the OB Management module by selecting an item under the To Do Orders panel and clicking the Document Generator icon. 26 of 32

27 Appendix A Quick Phrases Appendix A Quick Phrases Quick Phrases is a function designed to streamline communication within clinics. By utilizing existing messages, Quick Phrases allows users to choose appropriate responses to common clinical requests conveniently. Wording provided in the Quick Phrases database is created and defined by users within each clinic. This ensures that terminology found via Quick Phrases is unique and specific to each clinic. Daily Schedule Perform the following to access the Quick Phrases function from the Daily Schedule: On the Schedule tab, right-click on a displayed patient and select Document Generator. On the Encounter Documents window, select a template from preview pane. The selected template displays in the document preview pane of the Encounter Documents window Click Insert from the toolbar section and select Quick Phrases 27 of 32

28 Document Generator (EHR) Selecting an existing Quick Phrase On the Quick Phrases window, select My QP or All QP to display the corresponding Quick Phrases in the List Panel. Select an applicable Quick Phrase from the displayed results The exact verbiage for the selected item displays on the Expanded Phrase section of the Quick Phrase window Click Select to transfer the selected Quick Phrase message to the Encounter Documents window 28 of 32

29 Appendix A Quick Phrases The Quick Phrase verbiage displays within the Encounter Document window Click Save Transcription to attach the Quick Phrase permanently to the document. Narrative Perform the following to access the Quick Phrases function from the Narrative tab: On the Clinical Dashboard, select a patient from the Schedule tab. Right-click the highlighted patient and select Point of Care The Point of Care window appears Click the Narrative tab On the Encounter Narrative tab, double-click on a group header. 29 of 32

30 Document Generator (EHR) The Narrative Notes and Attachments window appears. Quick Phrase icons are located within the toolbar section. Click the toolbar icon to access the Quick Phrase window 30 of 32

31 Appendix A Quick Phrases Selecting an existing Quick Phrase On the Quick Phrases window, select My QP or All QP to display the corresponding Quick Phrases in the List panel Select an applicable Quick Phrase from the displayed results The exact verbiage for the selected item displays on the Expanded Phrase section of the Quick Phrases window Click Select to transfer the selected Quick Phrase message to the Narrative Notes and Attachments window The Quick Phrase verbiage displays on the specified task section 31 of 32

32 Document Generator (EHR) Click Save to attach the message to the selected document 32 of 32