Practice Partner EMR Pre-Load/Scanning Document Version: EMR_v1.05 Software Version: 9.5.2 Date: 02/29/2012 1 2011 HealthPoint Medical Group and Practice Partner System
About This Document Confidentiality and Proprietary Rights This document is the confidential property of HealthPoint Medical Group. 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 HealthPoint Medical Group. Inquiries regarding copying and/or using the materials contained in this document outside of the limited scope described herein should be addressed to HealthPoint Medical Group. Copyright Notice Copyright 2011 HealthPoint Medical Group. All rights reserved. Special Symbols 2 2011 HealthPoint Medical Group and Practice Partner System
Introduction... 5 Objectives and Summaries... 5 Special Symbols... 5 Lesson One: Logging in/out of Practice... 6 Access Standards... 7 Logging in/out of Practice Partner... 8 Accessing Practice Partner:... 8 To Log in:... 9 Practice Partner Login:... 10 To Login:... 11 Lesson Two: Patient Lookup... 13 Patient Lookup... 14 Lesson Three: Chart Overview... 15 Patient Chart... 16 Lesson Four: Adding a Patient Photo... 17 Adding a Patient Photo... 18 Lesson Five: Loading Pharmacies... 21 Loading Pharmacies... 22 Lesson Six: Pre-Load... 24 Allergies and Intolerance... 25 Medications... 27 Problems... 29 Immunizations... 31 Pediatric Immunization... 34 Pediatric Height, Weight, and Head Circumference... 35 3 2011 HealthPoint Medical Group and Practice Partner System
Pre-loading same day visits:... 35 Lesson Seven: Scanning... 36 Zoom... 37 Appendix: Valid Prescription Take Drop Down List... 48 4 2011 HealthPoint Medical Group and Practice Partner System
Introduction As a clinical software system, McKesson Practice Partner manages a variety of information including patient demographics, clinical details, and production analysis. For more information on Practice Partner EMR visit our website http://emr.healthpointmedicalgroup.com Objectives and Summaries This manual contains objectives which provide you with overall goals that you will achieve by the end of this training. This manual contains a summary for your review at the end of each lesson. Special Symbols Throughout this manual symbols will highlight areas that require additional attention. NOTE Indicates guidance information that expounds upon the provided information. TIP Indicates supplemental help to the supplied information. STOP Indicates important information that can include specific instructions that are required. 5 2011 HealthPoint Medical Group and Practice Partner System
Lesson One: Logging in/out of Practice Objectives: By the completion of this chapter, you will be able to: Successfully log into Practice Partner Successfully log out of Practice Partner 6 2011 HealthPoint Medical Group and Practice Partner System
Access Standards HealthPoint Medical Group and all our members have a responsibility to safeguard the privacy of all patients and protect the confidentiality of their health information. In the course of employment or assignment you will come into contact with confidential patient information. The following access standards will be followed: Only authorized persons will be granted access. This access will be appropriate to the job role. Only authorized persons may enter and view data. Passwords and system IDs will not be shared. Practice Partner keeps an audit trail of all entries and can generate reports of a user's access and activity within the system. Physical security of the workstations and files will be maintained. 7 2011 HealthPoint Medical Group and Practice Partner System
Logging in/out of Practice Partner Accessing Practice Partner: To access Practice Partner, you must first login into HealthPoint EMR Citrix Portal by clicking on the HealthPoint EMR icon or by typing http://hpemr.baycare.org on the internet page. The Citrix screen will open to the HealthPoint access screen, click OK. 8 2011 HealthPoint Medical Group and Practice Partner System
To Log in: Enter your User ID and Password. This is the same user ID and password you use to log into the computer. Once the login process is completed, the HealthPoint EMR icon will be available to select. NOTE If prompted, follow instructions to download the Citrix upgrade. To access Practice Partner, click on the HealthPoint EMR icon. There are two icons to choose from. To access the Production click on the HealthPoint EMR icon, to access test click on the HealthPoint EMR Test icon. 9 2011 HealthPoint Medical Group and Practice Partner System
Each icon used to access Practice Partner has its own separate database. For example: HealthPoint EMR - Is where the production database resides. This is where all our live patients are stored. HealthPoint EMR test - Is where training and testing will takes place. Practice Partner Login: Every Operator has an assigned user ID, password, and access level. This prevents unauthorized access to the system, protects critical patient information, and protects patient confidentiality. The password must be alphanumeric 8 characters, contain at least one uppercase, and one number. NOTE If you forget your password, contact the help desk to have your password reset. The help desk telephone number is (813) 636-2034, This is also located on your computer monitor. Logging On: 10 2011 HealthPoint Medical Group and Practice Partner System
To Login: Enter your assigned EMR User ID and Password. The password displays as asterisks (*) so it can t be seen. You may use the tab key or the mouse to advance the cursor from field to field. NOTE When logging in for the first time a temporary password will be given to you. Once you log in you will be prompted to change your password. This will occur at your initial login. NOTE You have 5 attempts to log into EMR, if you are not able to log in because either the user ID or password is incorrect; you will receive a pop up stating The system could not log you on. Make sure your User ID is correct, then type your password again. In the Provider ID field, select the appropriate provider by selecting the drop down arrow. If you know the providers code, you can type the code in the Provider ID field. After selecting the drop down arrow a Provider Select screen will open. To search by name select the radio button Name, type the last name of provider and click the Search button, highlight the name and click the OK. In the Practice ID field, select the drop down arrow then select the appropriate practice code. 11 2011 HealthPoint Medical Group and Practice Partner System
Provider Select After logging in, a disclaimer screen will appear in yellow. Please pay attention to the top of the screen where it states Practice Partner LIVE database. This is the only place in Practice Partner to notice if you are in the LIVE database or in the TEST database. It is very important to make sure you are logged into the correct database. Click the OK button and it will take you to Practice Partner s main screen. 12 2011 HealthPoint Medical Group and Practice Partner System
Lesson Two: Patient Lookup The purpose of this chapter is to give you an overview on how to look up a patient record. Objective By the completion of this chapter, you will: Have a complete understanding of the Lookup screen Have the ability to look up a patient using patient name, and patient ID 13 2011 HealthPoint Medical Group and Practice Partner System
Patient Lookup Patient Lookup In order to access a patient, you must go through the Patient Lookup Screen. You can locate patient lookup screen by doing the following: File/Open Chart on the Menu Bar, the Chart button on the tool bar, or the Patient button on the toolbar. You can locate a patient by selecting the radio button Patient Name, Patient ID, and Phone Number. When you have selected your search criteria, fill in the areas under Search for or Patient Name Search Filters. Click the Lookup button, locate your patient and click OK. This will bring you to the Patient Chart. Repeat the step if you are not able to locate the patient. 14 2011 HealthPoint Medical Group and Practice Partner System
Lesson Three: Chart Overview The purpose of the chapter is to give an overview of the patient chart. Objectives By the completion of this chapter, you will be able to: Navigate around the patient chart. 15 2011 HealthPoint Medical Group and McKesson Practice Partner
Patient Chart Chart Overview: The top portion of the patient chart will allow you to view Patient Name, Sex, Age, Next Appointment, ID, and DOB. The middle of the patient chart allows you to access, Chart Summary, Progress Note, Past Medical History, Social History, Family History, Hospital Records, Correspondence, Orders, Preventive Health, Flow Charts, Clinical Elements, Paper Chart Summary, Scanned documents, Problems List, Health Maintenance, Rx/Medications, Vital Signs, Laboratory Data, Images, Radiology, EKG, Pathology, Special Studies, Consults, Advance Directives, Level II, Prenatal (If female), and Patient Messages. Bottom left hand side of the patient chart displays demographics. Bottom right hand side of the patient chart allows you to free text any additional notes. 16 2011 HealthPoint Medical Group and Practice Partner System
Lesson Four: Adding a Patient Photo The purpose of the chapter is to upload a photo to a patient chart. Objectives By the completion of this chapter, you will be able to: Upload photos to a patient chart 17 2011 HealthPoint Medical Group and McKesson Practice Partner
Adding a Patient Photo 1. Receptionist will take the photo via a digital camera or webcam. 2. The photo will be saved, by the receptionist, to the following location as the patient s name: T:\ppart\Patient Photos\%dr. s name%\mickey Mouse Example : t:\ppart\patient Photos\Wray\Mickey Mouse 3. The receptionist will attach the patients photo to their chart 4. Open Chart 5. Click on Patient icon 6. Click Photo the Load Patient Photo screen will appear. 18 2011 HealthPoint Medical Group and Practice Partner System
7. Click Browse 8. Go to computer then to P:/Share Drive and select the scanning folder, locate your sites folder and then your name. 19 2011 HealthPoint Medical Group and McKesson Practice Partner
9. You should be able to see the list of photos available. Select the correct picture and click OK. Check the box labeled Delete Original File After Load? after you make sure you are loading the correct photo for the patient. 10. Once you click OK, you will be able to see the photo on the patient information screen. Click OK to close. If the patient refuses to take a picture use the sign below and take a picture of it with the webcam and upload in the patients chart. Declined Picture 20 2011 HealthPoint Medical Group and Practice Partner System
Lesson Five: Loading Pharmacies The purpose of the chapter is to upload a photo to a patient chart. Objectives By the completion of this chapter, you will be able to: Load pharmacies to the patient s chart 21 2011 HealthPoint Medical Group and McKesson Practice Partner
Loading Pharmacies From the Configuration tab you can associate pharmacies with the patient. From the Configuration tab click the New button to the right of the Patient Pharmacies section. In the Pharmacy ID box click the drop down arrow to select pharmacy. A screen called Pharmacy Select will appear. Click the drop down arrow to locate pharmacy. Locate the desired pharmacy. You can search by Pharmacy Name, Pharmacy ID, or Nickname. 22 2011 HealthPoint Medical Group and Practice Partner System
If this is a preferred pharmacy, click on the Preferred check box. Enter a Note if applicable. Click Ok when finished. 23 2011 HealthPoint Medical Group and McKesson Practice Partner
Lesson Six: Pre-Load The purpose of the chapter is to pre-load Allergies or Intolerance, Medication, Problems, and Immunization. Objectives By the completion of this chapter, you will be able to: Pre-load Allergies or Intolerance, Medication, Problems, and Immunization 24 2011 HealthPoint Medical Group and Practice Partner System
Each site will receive an abstract sheet to pre-load Medications, Allergies, Problems, and Immunizations. Each site MUST use this sheet to export information from the patient s chart onto the abstract sheet. Once the information has been abstracted and placed on the abstract sheet the information MUST be verified by a provider prior to entering the information into Practice Partner. The will prevent incorrect information being entered into the patient s record in Practice Partner. Allergies and Intolerance To Pre-load Allergies or Intolerance: From the patients chart click on the Rx/Medications tab, the Rx/Medication screen will display. To add an allergy click on the Allergy button Click on the Allergy button on the bottom of the screen, a new screen will display called Allergy. 25 2011 HealthPoint Medical Group and McKesson Practice Partner
On the Date/Time identified enter the date the allergy was identified (onset date). If there is no date documented, add the date the problem was written in patients chart. Type in the allergy in the Medication/Allergy Name field, if you re not able to spell the medication or allergy correctly a screen will display called Select Drug Name, this will allow you to locate the correct spelling of the medication or allergy. If you do not see the correct spelling click on Next or Prior until you locate it. Locate the correct spelling then Click Drug Ok. Click Ok once you have located the correct spelling, this will display in the Medication/Allergy Name field. If the drug you type in is the correct one and the Select Drug Name displays click Drug OK. This will keep the name you originally typed in. Identify the Allergy Type by clicking the drop down arrow, the list included Drug Allergy, Drug Intolerance, Miscellaneous (add environmental in this area), and Food Allergy. Click the drop down arrow to choose the Reaction. When finished click OK. 26 2011 HealthPoint Medical Group and Practice Partner System
Medications Pre-Load Medications: From the patients chart click on Rx/Medications tab. Click the New button on the bottom of the screen, a new screen will display called Prescriptions. To locate a prescription select Template code or by indication, then click Lookup. The Rx Template Code allows you to lookup a prescription by Template Code. NOTE If you know the code you can directly input the code into the box. 27 2011 HealthPoint Medical Group and McKesson Practice Partner
Locate prescription and click OK. Select the desired medication and click OK, this will default the information in the Medication box. You can also manually type the medication in the Medication box along with the Size, Take, Frequency, Route, Duration, Amount, and Refills. NOTE If you choose to type in the take field you must specify how it will be taken. i.e. 1 Tab, 1 Cap etc. See Appendix for abbreviations that can be used in the Take field. In the Date box, add the date the medication was last prescribed in mm/dd/yy format. In the Duration box, if you do not place a duration the prescription will remain on the Current medication tab of the RX/Medications. If you place the Duration the prescription will move to the Historical tab after the duration days expire. It is recommended if the provider uses Allscripts print the medication list from Allscripts and then transfer the current medication information from Allscripts to Practice Partner. This information includes dose, duration, quantity, date medication was prescribe etc,. 28 2011 HealthPoint Medical Group and Practice Partner System
NOTE If a medication is in the current medication tab and an electronic refill request comes in it will duplicate the medication in the current medication tab. To avoid this from happening, the appropriate Date, Duration and amount of Refills must be entered during pre-load so the medication will move to historical. If the provider wants the medications to remain on the Current Tab do not put a Duration but when an electronic Rx Refill comes in it will duplicate the medication. In the Print box, click on the down arrow and click Do not print. Add the provider code in the Prov: box, or if medication was prescribed by an outside provider check the box Outside. When finished click OK. Problems To Pre-Load a Problem: NOTE Only Chronic problems will be pre-loaded. Adding a Major Problem: To enter a Major Problem, this is any chronic problem a patient may have, click on the Problem List tab from the patient s chart. A screen called Problems/Procedures will display. 29 2011 HealthPoint Medical Group and McKesson Practice Partner
Select correct tab and click NEW. Click on New button, a screen will display called Major Problem. Click on the Lookup button, you can either type in the ICD-9 Code, or type in the description then click Search. Click OK, when finished. Click Lookup screen to locate ICD-9 code. Once you have located the problem click OK. Under Provider, if you know the provider who diagnosed the problem add, the provider if not leave blank. Select Active or Inactive by clicking on the drop down arrow in Active/Inactive box. Under Date, add the Onset Date. Under Date Resolved, add the Stop Date. Click OK when finished. 30 2011 HealthPoint Medical Group and Practice Partner System
Immunizations To Pre-Load Immunizations: From the patient chart click on the Health Maintenance tab, a screen will display called Health Maintenance Summary. Click the New Button on the bottom of the screen, a screen called Health Maintenance Procedure will display. Right Click on Status box. Click on the More button to add more information. 31 2011 HealthPoint Medical Group and McKesson Practice Partner
Locate the immunization, right click your mouse on the Status box, it will turn from yellow to white. Click Done, the X will display in the box. Click on the More button this will allow more information to display. You can add Dose, Route, Given By, Dose Number Location, Facility, Lot, Expiration Date, Manufacture, Device, and VFC Status. Click OK when finished. NOTE Health Maintenance templates are based on age, sex, and problems. If an immunization is not displayed follow the steps below. To add a new immunization not listed in the predefined Health Maintenance for the patient: From the patient chart click on the Health Maintenance tab, a screen will display called Health Maintenance Summary. Click the Historical button on the bottom of the screen. Click Historical to add a new immunization not listed in the HM template. 32 2011 HealthPoint Medical Group and Practice Partner System
Click on the New Item button, a screen will display called Health Maintenance Procedures. To add new immunization click the New Item button. Type the immunization in the white box and click Search. Type the name of the immunization and click Search. Highlight the immunization and click OK when finished, the immunization will display in the Health Maintenance Procedure screen. Right click your mouse on the Status box; it will turn from yellow to white. Click Done, the X will display in the box. Click on the More button this will allow more information to display. You can add Dose, Route, Given By, Dose Number Location, Facility, Lot, Expiration Date, Manufacture, Device, and VFC Status. Click OK when finished, the add immunization will display in the Health Maintenance Summary screen. 33 2011 HealthPoint Medical Group and McKesson Practice Partner
Pediatric Immunization The templates for the Health Maintenance tabs or pediatrics are as followed: Newborn to 2 years and 11 months of age will display the recommended immunizations. 3 years to 10 years and 11 months the template will include the recommended immunizations for this age group, plus the 0-2 years old immunizations. 11 years to 17 years and 11 months included the recommended immunization for the age group, plus 0-2 and 3-10 immunizations. If the patient needs the immunization form immediately they must upload the immunizations in the Health Maintenance tab the upload the in Florida Shots to print the form. NOTE If you are scanning any Health Maintenance such as Mammograms, Colonoscopy s remember update Health Maintenance for the patient. 34 2011 HealthPoint Medical Group and Practice Partner System
Pediatric Height, Weight, and Head Circumference For pediatric patients you will pre-load the last 5 years of the patients height, weight, and head circumference. Click on the Vitals tab, once the tab is open click on the New button on the bottom of the screen. The vital screen will open, add the height, weight, and head circumference. Note: the OFC in vitals is for head circumference. Pre-loading same day visits: NOTE Pre loading for same day sick patients seen on EMR, if your provider chooses to see same day sick patients on the EMR it is not mandatory that the chart be totally pre-loaded that day. You have 3visits/2years to get the chart fully pre-loaded. You must pre-load the meaningful use elements such as vitals, Rx and meds. If the site choose to do this then make sure that all items are documented accordingly.(emr/paper chart and in IDX) the patient is EMR but pre-load is to be done. Once the patient has a scheduled appointment the chart will be preloaded at that time. 35 2011 HealthPoint Medical Group and McKesson Practice Partner
Lesson Seven: Scanning The purpose of the chapter is to understand how to scan documents using Zoom. Objectives By the completion of this chapter, you will be able to: Scan documents and place them into the correct categories in the patients chart. 36 2011 HealthPoint Medical Group and Practice Partner System
Zoom Zoom allows you to scan your images directly into Practice Partner via the TWAIN interface, or directly select pre-scanned or any other viewable files. Once in the Zoom interface, these files can be linked to a note in any part of the patient s chart and sent to a provider for review. You can also add text or comments to the note. The links appear in the note as a permanent hyperlink otherwise known as a PLINK. Unlike the LINK label marker, permanent hyperlinks are not removed when you save notes. Setting up scanning devices for Practice Partner Zoom 1. Log into Practice Partner Zoom 2. From the scanner, Fujitsu Model, click on the scan button. A screen will display giving you the option to select a program to open the scanner. Select Microsoft Scanner and Wizard. 3. Check the box that states always use this program, then click OK. 4. A new screen will display Welcome to Scanner and Camera Wizard. Click the Next button on the bottom of the screen. 37 2011 HealthPoint Medical Group and McKesson Practice Partner
5. From the Scanner and Camera Wizard, choose the Black and white pictures radio button then, click Next. 6. On the first box type the name of the file you want to create (ie: Groupcast account number/type of document) for this group of documents that you are scanning. 7. Under Select a file format, click on the drop down arrow choose TIF. 38 2011 HealthPoint Medical Group and Practice Partner System
8. Under Chose a place to save this group of picture, click on Browse. Go to Computer/P: drive/scanning/site Folder Name/User Name, and then click Next. (ie: P:/Scanning/ApolloBeach/April) should display, click Next. 9. From the Scanning and Camera Wizard, leave the default radio button set to Nothing I m finished working with these pictures and then click Next. Your document will scan at this time. 10. Continued as normal when indexing patient information from Zoom 39 2011 HealthPoint Medical Group and McKesson Practice Partner
To scan: To access Zoom, select the Scan option from the Task menu. This displays the Practice Partner Zoom screen. Verify your personal folder is attached if it is not then you must attach your folder to each computer you use. From Zoom go to File on the Menu bar go down to Configuration Click on the Folders & Files tab Under Default Scan Settings click on the Browse button Go to Computer and the Share Drive (P:) Locate the Scanning folder and then locate your sites folded I.e. Hampton Lakes Under each sites folder each user will have their own folder, if the user is a PSA then there will be PSA 1 and PSA 2 folders that can be attached. Select the appropriate folder and click it The folder will default to the Scan Folder box Under File Prefix highlight the information and delete it Under Loaded File Handling click on the Archive loaded file radio button Go to Archive Folder and click the Browse button Go to Computer and the Share Drive (P:) Locate the Scanning folder and then locate your sites folded I.e. Hampton Lakes Under each sites folder each user will have their own folder, if the user is a PSA then there will be PSA 1 and PSA 2 folders that can be attached Click on the folder and select the Archive folder that has been created, this will drop the archive folder in the Archive Folder box Under Archive Prefix highlight the information displayed and delete it Click OK when finished, this will attach your folders to the computer in use 40 2011 HealthPoint Medical Group and Practice Partner System
Next click the Scan button on your scanning machine, the document will scan through. The Practice Partner Zoom screen is broken down into 4 sections, which include File, Image(s), Document tabs, and Note. To select your documents from a folder: Click the Browse button to open the Browse for Folder screen. Navigate to the folder where your documents are stored. Select the folder and click OK. The selected folder will be displayed in the Folder field. To select your documents from a file: Click the Browse button to open the Choose File screen. Navigate to the file you wish to link. Select the file and click Open. The selected file will be displayed in the File field. 41 2011 HealthPoint Medical Group and McKesson Practice Partner
If there are multiple files in the folder, you can use the up and down arrows located in the File field to scroll through the files/documents. Each of the selected files/documents will be displayed in the Image(s) section of the screen. Important: The system does not allow you to scan a batch of documents at one time then sort them individual. If you are scanning with a desktop scanner (the small scanners) and need to rotate your document you can manually rotate your document in the browse section of Zoom. Highlight the scanned document and right click. Select Edit this will open the document. Click on Image on the menu bar. Select Flip/Rotate chose the correct rotations for your document. Once you have selected your document(s), you can select where you want to attach the document(s). Chart Note: Click this tab to link files to a note in any part of the patient s chart. Patient Photo: Click this tab to link a patient photo to the Patient screen. Patient Attachment: Click this tab to attach file(s) to the Patient screen. 42 2011 HealthPoint Medical Group and Practice Partner System
NOTE Insurance Card in the Title field please put Year and then Insurance Card. Example: 2011 Insurance Card Carrier Attachment: Click this tab to attach file(s) to Carrier Maintenance. If you are linking files to the patient's chart pay attention to the or next to each section. To select a patient type the patients ID in the ID field, or click Lookup. NOTE Before indexing the scanned document into the patients records verify you have the correct document. Verify the patient s name on the document to the patient you have selected on the Lookup button. This will help eliminate scanned documents indexed in the wrong patients chart. Under the Note section, click the drop down arrow and select the category you wish to display the scanned document in. NOTE Verify you have the correct category before indexing the document into the patient s record. This will help eliminate scanned documents indexed in the wrong chart tab. Select the Date of the scanned document not the day you scanned it. Under Title select the title from the drop down arrow, add the prefix PL for Preload. This will allow the provider to determine which scanned documents are pre-loaded documents. If there is no title in the drop down arrow box to chose from type PL - and create a title. You must have a title in order to move on. 43 2011 HealthPoint Medical Group and McKesson Practice Partner
Select Provider. Once all items have been selected the Red will display to a Green. If you want to add additional notation, type in the Note Text. Click the Save button when finished. Under the Image(s) you can zoom the image, move from page to page. When finish click the Close button to take you out of Zoom. 44 2011 HealthPoint Medical Group and Practice Partner System
Scanning Confidential Documents: If confidential lab results come back such as HIV or any STD the user will scan the confidential result into the Level II tab. If there are also other results attached the user will then black out the confidential results using a black sharpie and scan the results to the Lab Miscellaneous section through Zoom. Important: If you scanned a document into the wrong patient s chart or wrong chart tab, contact your Site Manager or Practice Manager to correct the issue. To delete a scanned document from a patients chart: NOTE Site Managers and Practice Managers do not have access to delete from the Progress Note tab, if a document has been scanned incorrectly to the progress note tab you must contact help desk for removal. This can only be done by Site Managers and Practice Managers. Open the correct patient s records. Select the tab that the incorrect scanned document resides in. Verify the document is the correct document you want to delete, once you delete the scanned document there is no way to retrieve the document back. Go to Edit on the Menu bar. Click on the Delete Note, the system will ask to confirm delete click OK. This will remove the scanned document from the tab. The site manager or practice manager will notify the staff member who scanned the wrong document to rescan the document back into the correct record or chart tab. 45 2011 HealthPoint Medical Group and McKesson Practice Partner
NOTE Please see scanning matrix for items to be pre-loaded. Items will be highlighted in in gray and bolded. Document Type Tabs to Preload Comments scan into Radiology Radiology Y Last mammogram, colonoscopy, X-Ray etc. EKG EKG Y Last EKG Level II Level II Y Physical Questionnaire Level II highly confidential Biographic Data Patient Attachment Living will, custody, consent (nonclinical) HIPAA, INS Card. Advance Directives Advance Y Last updated Advance Directives Directives Preventive Health Preventive Health Y Growth Chart / Immunization Records The provider can chose up to 10 items/max 20 pages to be scanned into the patients chart. The office will have access to the paper chart for 3 visits or 18 months (whichever comes first) before the chart is stored off site. NOTE NOTE If the document in the patient s chart is found unsigned then the unsigned document needs to be brought to the site manager s attention. The site manager will share with the appropriate provider for the provider to review and sign. Once the document has been signed the document will be given back to the pre-loader to scan in the patient s record in EMR using the PL prefix in the title. No document will be scanned until the provider has reviewed and signed it. If a provider chooses lab results to be pre-loaded manually add PL-QC performed by and the name of the person who performed the test. This is only for in-house labs, out source labs you would add PL - performed by. Example: PL- Labcorp KJ This will also inform the provider these lab results entered were pre-loaded results. 46 2011 HealthPoint Medical Group and Practice Partner System
Pre-load stamps Each office starting pre-load will need to order the pre-load stamp. This stamp will allow you to track the progress of the chart during pre-load. See below: As each item has been completed a date will need to be displayed. For every time the chart has been pulled a date will need to be entered. When the chart is fully completed a date will need to be displayed and the chart will be stored off site. 47 2011 HealthPoint Medical Group and McKesson Practice Partner
Appendix: Valid Prescription Take Drop Down List Aer Aerosol Film Film Aer Powd Aerosol Powder Flakes Flakes Aer Sol Aerosol Solution Foam Foam Aer Spr Aerosol Spray Fm w/app Foam with applicator Aer w/ad Aerosol with adapter Garg Gargle Bar Bar Gel Gel Subl Tab Buccal or Sublingual Tablet Gel soln Gel forming solution Cap Capsule Gel w/app Gel with applicator Cap Unsp Capsule Unspecified Gran Granule Chew Chewable Tablet Gran recon Granule for reconstitution Chew Bar Chewable (candy) Bar GTT Drops Chew Tab Chewable Tablet GTTS Drops Chew Gum Chewing Gum Gum Gum Comb Form Combination Forms HHN Nebulize Solution Conc Concentrate Imp Implant Contr Dev Contraceptive Devices Impl Implant Contr Spg Contraceptive Sponge INH Inhalant Crm w/app Cream with applicator Inh Ref Inhalant (Refill Canister Only) Crm Cream INJ Injection Crystal Crystal INJ IM Injection Dent Rns Dental Mouth Rinse INJ IV Injection Dent Prod Dental Product INJ ML Injection Dev Devices INJ SQ Injection Inj Ly Pwd Injectable Lyophilized Dosepak Dosepak Powder Douche Douche Inj Unsp Injectable Unspecified Drsg Dressing or Bandage Insert Insert Band Dressing or Bandage Int Pwd Internal Powder Drop Drops Irr Irrigant Elix Elixir Kit Kit Emul Emulsion Leaves Leaves Enema Enema Liq Liquid EC Cap Enteric Coated Capsule Lollipop Lollipop EC Tab Enteric Coated Tablet Lotion Lotion Ext Crm External Cream Loz Lozenge Ext Liq External Liquid Loz or Tr Lozenge or Troche Ext Oint External Ointment ml susp Suspension Ext Pwd External Powder ml sol Solution Extract Extract Nasal Nasal 48 2011 HealthPoint Medical Group and Practice Partner System
Neb Sol Nebulize Solution Oil Oil Oint Ointment Oint w/app Ointment w/applicator Oph Liq Co Ophthalmic Liquid (Compliance Cap) Oph Liq Ophthalmic Liquid Oph/Otic Ophthalmic or Otic Oral Oral Otic Otic Pad Pad Paste Paste Patch Patch or Disc Patch/Disc Patch or Disc Ped Liq Pediatric Liquid Pellet Pellet Pwd Powder Pwd Eff Powder Effervescent Inj Pwd Powder for injection Pwd rec Powder for reconstitution PUFF Inhalant Rect Crm Rectal Cream or Ointment Rect Oint Rectal Cream or Ointment Rect Supp Rectal Suppository Ring Ring Shampoo Shampoo Soap Soap Sol Tab Soluable Tablet Sol Solution Spirit Spirit Sponge Sponge Spray Spray Stick Stick Strip Strip Sup Suppository(ies) Sus Suspension SR Cap Sustained Release Capsule SR Inj Sustained Release Injection SR Tab Sustained Release Tablet SR Tabs Sustained Release Tablet Swabs Swabs Syp Syrup Tab Tablet TAB PV Vaginal Tablet Tab D Sup Tablet Day Supply Tab Unsp Tablet Unspecified Tampon Tampon Tape Tape Tar Tar Test Test Test Kits Test Kits Thr Spray Throat Spray and Swabs Thr Spr Throat Spray and Swabs Tinc Tincture Troche Troche TSP Sus Suspension Ur Supp Urethral Suppository Vag Crm Vaginal Cream Vag Fm Vaginal Foam Vag Oint Vaginal Ointment Vag Supp Vaginal Suppository Vag Tab Vaginal Tablet Wafer Wafer Wax Wax 49 2011 HealthPoint Medical Group and McKesson Practice Partner