Copyright 2012 Pulse Systems, Inc. Page 1 of 51

Transcription

1 The PulsePro Transcription module provides a method of creating and storing patient transcription documents within the PulsePro database. First the Header information must be added, and then the selected template can be completed using the interface to Microsoft Word. The Header dialog contains the data to attach the document to the patient and provider. It also assigns the template format. Other information can be added to the document, such as date of service, referring physician and episode. Click anywhere to continue Copyright 2012 Pulse Systems, Inc. Page 1 of 51

2 To begin, it is assumed that you are logged in the PulsePro application with the appropriate security and permissions to complete this task. Click the Reports/Forms group button in the Navigation Pane. Copyright 2012 Pulse Systems, Inc. Page 2 of 51

3 Click the Transcripts icon in the Reports/Forms group. Copyright 2012 Pulse Systems, Inc. Page 3 of 51

4 The Transcription window is displayed consisting of a toolbar, a series of criteria fields, a list pane and a preview pane. To create a new document, click the Add button on the toolbar. Copyright 2012 Pulse Systems, Inc. Page 4 of 51

5 The document header window is displayed consisting of a toolbar. Some information has already been completed for you. Additional fields will automatically be populated as selections are made. Several buttons are available on the toolbar. Copyright 2012 Pulse Systems, Inc. Page 5 of 51

6 For each field provided, enter or select the applicable value using the Tab key to advance to the next field, keeping in mind that those fields with red titles are required. To locate a patient, type search criteria in one or more fields of the Patient Information group, then click the lookup button on the field. Copyright 2012 Pulse Systems, Inc. Page 6 of 51

7 Typing Animation Copyright 2012 Pulse Systems, Inc. Page 7 of 51

8 No Script Copyright 2012 Pulse Systems, Inc. Page 8 of 51

9 The Patient Lookup window opens with the patient s meeting the specified criteria displayed in the list pane. Click to select the appropriate patient record, and then click the Select button on the toolbar. Copyright 2012 Pulse Systems, Inc. Page 9 of 51

10 No Script Copyright 2012 Pulse Systems, Inc. Page 10 of 51

11 NOTE If using the patient s account number to merge the patient s information from the database into the document header, verify that you have entered the account number correctly and completely. Click anywhere to continue Copyright 2012 Pulse Systems, Inc. Page 11 of 51

12 The window is refreshed, with the patient demographics fields populated with the details for the selected patient. Verify that you have selected the correct patient record by comparing the patient s date of birth, Social Security number, sex, and chart number against your selected record. Copyright 2012 Pulse Systems, Inc. Page 12 of 51

13 The patient s current referring physician is populated into the Referring Physician field by default. If this was not the provider for this particular episode, use the Lookup button on the field to locate the physician in the usual manner by utilizing the Provider/Staff lookup window. Copyright 2012 Pulse Systems, Inc. Page 13 of 51

14 Next fill in the Date of Service field. Although the date of service can be typed into this field, it is recommended that the lookup button be used to locate an existing appointment. In doing so, the transcription document is tied to the appointment and becomes a part of the history for that appointment. Click the lookup button on the Date of Service field. Copyright 2012 Pulse Systems, Inc. Page 14 of 51

15 The Select Episode/Appointment dialog is displayed listing all of the appointments for the selected patient. If needed, use the criteria fields provided to filter the list. When located, click the appointment record in the list pane, then click the Select button. Copyright 2012 Pulse Systems, Inc. Page 15 of 51

16 No Script Copyright 2012 Pulse Systems, Inc. Page 16 of 51

17 Once an existing date of service is selected, the fields in the Dictating Provider group have also been automatically populated with the information from the original appointment. If needed, the lookup button on the provider fields can be used to select an alternate provider. Two additional fields are available which can associate this transcription document to an existing Order or Episode for this patient. Use the Lookup buttons on the fields provided to locate and select the appropriate items. Copyright 2012 Pulse Systems, Inc. Page 17 of 51

18 The information displayed in the Transcriber group is based on the current user s login account. The dictation date defaults to the current date and time. An alternate user account may be selected using the lookup button on the Name field if applicable. If the transcription document is being prepared by an outside provider, deselect the In House radio button. Copyright 2012 Pulse Systems, Inc. Page 18 of 51

19 ABOUT OUTSOURCED TRANSSRIPTION Typically, transcription services that have been outsourced will deliver a Microsoft Word based document. These are imported and assigned to the patient accounts using the procedure explained in the Importing Out-Sourced Transcription Documents lesson in this module. Click anywhere to continue Copyright 2012 Pulse Systems, Inc. Page 19 of 51

20 Next, we will select the document type and template which will be used. In the Document group, click the down arrow on the Type field, then select the Clinic Notes Type from the drop-down list. Copyright 2012 Pulse Systems, Inc. Page 20 of 51

21 No Script Copyright 2012 Pulse Systems, Inc. Page 21 of 51

22 NOTE: If you have associated the selected physician with a particular Note Types, only those Note Types will be displayed. Click anywhere to continue Copyright 2012 Pulse Systems, Inc. Page 22 of 51

23 Click the down arrow on the Template field to view the list of options. Copyright 2012 Pulse Systems, Inc. Page 23 of 51

24 The drop-down list is populated with the templates that were previously created in the system and were assigned to the selected Notes type. Select the appropriate option from the list. Copyright 2012 Pulse Systems, Inc. Page 24 of 51

25 Several options are now available for selection using the checkboxes under the Template field. These options coincide with the available options that are configured when setting up clinic note types and will override the default options selected at that time. The Signature Required field should be selected if the document requires the dictating provider to sign the document. Copyright 2012 Pulse Systems, Inc. Page 25 of 51

26 To indicate that an envelope is to be printed with the document, select the Correspondence box. Copyright 2012 Pulse Systems, Inc. Page 26 of 51

27 The CC Required indicates that additional copies of the document will need to be sent to the interested parties for this patient. Copyright 2012 Pulse Systems, Inc. Page 27 of 51

28 The Use Template checkbox indicates to the system that the template selected above will be used and opened automatically in Microsoft Word once this header information is saved. If deselected, a blank document will be created. Copyright 2012 Pulse Systems, Inc. Page 28 of 51

29 Select the Desired Priority to be displayed in the Document Management Module. Copyright 2012 Pulse Systems, Inc. Page 29 of 51

30 If your system has been set up for these features, the Import File or Sound File fields can be used to look up and associate documentation or recorded transcription files for this document. Once attached, the Speaker button can be used to play the original recorded transcription file. Copyright 2012 Pulse Systems, Inc. Page 30 of 51

31 Finally, the description and Comment fields can be used to type any additional helpful information regarding this document. Copyright 2012 Pulse Systems, Inc. Page 31 of 51

32 Prior to opening the document, let s review the additional buttons available on the toolbar. The OK button will be used to save this document header. The Clear All button will clear all fields in the window in situations where you may need a clean window to start over. Copyright 2012 Pulse Systems, Inc. Page 32 of 51

33 The Clear Patient and Clear Provider buttons are used to clear patient demographics and Dictating Provider fields respectively. Copyright 2012 Pulse Systems, Inc. Page 33 of 51

34 The Send to will open the CC List Manager and will be covered in the Configuring a CC List lesson. The Patient Information button opens the Patient Summary window. The Admin Patient button can be used to access the Patient Registration window in PulsePro. Copyright 2012 Pulse Systems, Inc. Page 34 of 51

35 When all pertinent fields have been completed, save the document header and launch the template in Microsoft Word, click the OK button on the toolbar. Copyright 2012 Pulse Systems, Inc. Page 35 of 51

36 The new template document opens in a new window using Microsoft Word. The merge fields configured for this template are resolved using the information provided in the document header and patient record. This information varies depending on the template selected. Copyright 2012 Pulse Systems, Inc. Page 36 of 51

37 The document will now need to be completed using the Microsoft Word interface. Notice that several of the buttons on the Word toolbar are grayed out and an additional toolbar appears at the top of the window. This toolbar was created specifically for use with PulsePro and overrides some of the basic Word functions. Copyright 2012 Pulse Systems, Inc. Page 37 of 51

38 The New button can be used to discard the current document and start fresh with a new one. Click the Save button so save the current document and return to the Header window in PulsePro. Copyright 2012 Pulse Systems, Inc. Page 38 of 51

39 The Insert button can be used to display and then insert additional patient information into the document at the current cursor location. Copyright 2012 Pulse Systems, Inc. Page 39 of 51

40 The next three buttons can be used to return to PulsePro and view information. The Header button returns to the header window for the current document. Click the Info button to view a summary of all aspects of a patient s account. Click the Patient button to open the Patient Registration window and view or edit information about the selected patient. Copyright 2012 Pulse Systems, Inc. Page 40 of 51

41 The To button is used to display the Send To list of correspondents and insert the names or addresses into your document. Copyright 2012 Pulse Systems, Inc. Page 41 of 51

42 The Update button is used to periodically save the document while it is IN process. It is strongly recommended that this button be used while the document is being created. Copyright 2012 Pulse Systems, Inc. Page 42 of 51

43 The Finalize button will sign and finalize the document by inserting the signature of the Dictating Provider at the Signature merge field and locks the document to ensure changes cannot be made without unlocking the document. Copyright 2012 Pulse Systems, Inc. Page 43 of 51

44 The Draft button inserts a watermark on the document indicating that this version of the report is a draft and is not intended for use or distribution. Copyright 2012 Pulse Systems, Inc. Page 44 of 51

45 This button works as a toggle. Once a document is finalized, click the button again to remove the watermark. Copyright 2012 Pulse Systems, Inc. Page 45 of 51

46 The CC button provides access to the CC List as previously created in the system and can be used to address carbon copies to the selected interested parties. Copyright 2012 Pulse Systems, Inc. Page 46 of 51

47 ABOUT CARBON COPY RECIPIENT For more information regarding Carbon Copy recipients, please view the Configuring the CC List lesson in this module. Click anywhere to continue Copyright 2012 Pulse Systems, Inc. Page 47 of 51

48 When the document is complete, click the Exit button on the toolbar to close Microsoft Word and return to the Transcription module of PulsePro. Copyright 2012 Pulse Systems, Inc. Page 48 of 51

49 If the document has not been saved prior to exiting, a dialog box appears confirming whether any changes will be saved. Click Yes to continue. Copyright 2012 Pulse Systems, Inc. Page 49 of 51

50 The newly created document now appears in the list pane of the Transcription window and can be viewed using the preview pane. Continue to create additional transcription documents as needed. When finished, click the Exit button on the toolbar to return to the PulsePro dashboard. Copyright 2012 Pulse Systems, Inc. Page 50 of 51

51 You are now familiar with Creating a New Transcription Document in PulsePro. Copyright 2012 Pulse Systems, Inc. Page 51 of 51