User Guide
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- Using the Consults Package with TIU
- 1. From TIU, choose Integrated Document Management.
- 2. Select Enter/edit Document.
- 3. Enter the patient’s name.
- 5. Choose the consult to enter findings.
- 6. Enter and edit findings.
- 8. Repeat for other patients.
- Correcting Misdirected Results
Quick OrdersQuick Orders are a feature of CPRS that allow certain prompts to be automatically filled in by the computer. Your ADPAC can set them up (a subject that is discussed in the CPRS Setup Guide.) CPRS is shipped with a number of quick orders. Number 91, EKG, Portable on the screen pictured below is one of them. These quick orders do not have any of the fields filled in. They are only provided as place-holders and limited examples of what is possible. Add New Orders Feb 13, 1998 13:21:08 Page: 1 of 1 CPRSPATIENT,TWELVE 666-24-3779 1A/B-1 FEB 3,1923 (74) 0 ORDER SETS... 30 PATIENT CARE... 70 LABORATORY... 1 Patient Movement 31 Condom Catheter 71 Chem 7 2 Diagnosis 32 Guaiac Stools 72 T&S 3 Condition 33 Incentive Spirometer 73 Glucose 4 Allergies 34 Dressing Change 74 CBC w/Diff 75 PT
10 PARAMETERS... 40 DIETETICS... 76 PTT 11 TPR B/P 41 Regular Diet 77 CPK 12 Weight 42 Tubefeeding 78 CPK 13 I & O 43 NPO at Midnight 79 LDH 14 Call HO on 80 Urinalysis 50 IV FLUIDS... 81 Culture & Suscept 20 ACTIVITY... 51 OUTPATIENT MEDS... 21 Ad Lib 55 INPATIENT MEDS... 90 OTHER ORDERS... 23 Bed Rest / BRP 91 EKG: Portable 24 Ambulate TID 60 IMAGING ... 25 Up in Chair TID 61 Chest 2 views PA&LAT 99 Text Only Order Enter the number of each item you wish to order. >>> + Next Screen TD Set Delay ... Q Done Select Item(s): Done// Basically, quick orders supply stock answers to some of the prompts required to make an order. For example, if we filled in the values for the placeholder EKG, Portable, we might answer the following questions in the quick order template:
Category: Inpatient Place of Consult: Bedside
The other four prompts, Reason for the Request, Urgency, Attention, and Provisional Diagnosis, are all left blank in the quick order template. The answer to these questions change every time we place an order for a portable EKG. These four questions are the only ones asked when you place an order for “EKG, Portable.” Using the Consults Package with TIUDirect TIU InputOn page 26 are the directions for entering results from the Consult/ Result Tracking screen. You can also enter results directly from TIU. This may be preferable if you are doing large volumes of consults or it fits your office work flow. The basic steps to entering findings through TIU given here are. The interested user should look at the TIU Clinical Coordinator & User Manual for further information.
Example:
1 Progress Notes User Menu ... 2 Discharge Summary User Menu ... 3 Integrated Document Management ... 4 Personal Preferences ... Enter ?? for more options, ??? for brief descriptions, ?OPTION for help text. Select Progress Notes/Discharge Summary [TIU] Option: 3 Integrated Document Management --- Clinician's Menu --- Select Integrated Document Management Option: 2. Select Enter/edit Document.Example:
1 Individual Patient Document 2 All MY UNSIGNED Documents 3 Multiple Patient Documents 4 Enter/edit Document Enter ?? for more options, ??? for brief descriptions, ?OPTION for help text. Select Integrated Document Management Option: Enter/edit Document 3. Enter the patient’s name.Follow the usual VISTA conventions for selecting a patient. Example: Select PATIENT NAME: CPRSPATIENT,FIV 03-05-33 666332432 YES SC VETERAN A: Known allergies Select TITLE:
4. Select a document title.Using the standard help functions (? or ??), you can see a list of titles that are available to you. Consult your supervisor or ADPAC about which one is appropriate to your situation. Example: Select TITLE: ? Answer with TIU DOCUMENT DEFINITION NAME, or ABBREVIATION, or PRINT NAME Do you want the entire TIU DOCUMENT DEFINITION List? Y (Yes) Choose from: ADVANCE DIRECTIVE TITLE ADVERSE REACTION/ALLERGY TITLE ASI-ADDICTION SEVERITY INDEX TITLE BP TEST NOTE TITLE CLINICAL WARNING TITLE CRISIS NOTE TITLE DISCHARGE SUMMARY TITLE MEDICINE CONSULT TITLE Select TITLE: MEDICINE CONSULT TITLE
Patient Location: 2B Date/time of Admission: 05/10/96 10:17 Date/time of Note: NOW Author of Note: CPRSPROVIDER,SEVEN ...OK? YES// You must link your Result to a Consult Request...
1. JUL 16, 1997@06:08 278 PULMONARY CHOOSE 1-1:
TIU lists one or more active consults for the patient. Select the one you have findings for. Example:
1. JUL 16, 1997@06:08 278 PULMONARY CHOOSE 1-1: 1 278
1>
TIU enters the editor specified in your VISTA personal preferences. There are a number of alternate ways to enter findings in TIU. Consult the TIU Clinical Coordinator & User Manual for details.
1> No significant findings. Suggest respiratory therapy. 2> EDIT Option: Saving MEDICINE CONSULT with changes... Enter your Current Signature Code: 7. Sign the findings.At the prompt, enter your signature code. If you do not sign the document at this time, VISTA generates an alert to remind you to sign it at a later time. There is a detailed discussion of electronic signatures under step 2, Sign the Consult.
E Enter your Current Signature Code: SIGNATURE VERIFIED.. You may enter another CLINICAL DOCUMENT. Press RETURN to exit. Select PATIENT NAME: Note: If your site supports the dictation and transcription of Consult results, you may also use the batch upload facility of TIU to support single-point transfer of Consult results in mixed batches (with Discharge Summaries, Progress Notes, etc.) for either in-house or contract transcription services. Correcting Misdirected ResultsOccasionally a consult result is linked to the wrong consult. If this is detected prior to signature, it is possible for the author of a consult result to re-direct the record to a different consult request by any of several methods, as illustrated in the examples below:
Following signature, such corrections can only be made by those persons who are granted permission to do so under the Authorization/ Subscription Utility (ASU). Information on how to make this kind of correction is contained in the Consult/Request Tracking Technical Manual. Examples: You may redirect a consult result through the Link to Request action, when processing the alert for the unsigned consult result: --- Clinician's Menu --- 1 Progress Notes User Menu ... 2 Discharge Summary User Menu ... 3 Integrated Document Management ... 4 Personal Preferences ... Select Progress Notes/Discharge Summary [TIU] Option: VA View Alerts 1. CPRSPATIE (C0167P): PULMONARY CONSULT available for signature. 2. ARTPATIEN (A1414): New order(s) placed. 3. ARTPATIEN (A1414): New consult PLM (Routine) 4. CPRSPATIE (C2432): New consult CAR (Routine) Select from 1 to 4 or enter ?, A I, F, P, M, R, or ^ to exit: 1 Opening PULMONARY CONSULT record for review... (Continued on the next page.) Browse Document Jan 26, 1998 16:49:32 Page: 1 of 1 PULMONARY CONSULT CPRSPATIENT,T 666-01-0167P PULMONARY CLINIC Visit Date: 01/26/98@16:37 DATE OF NOTE: JAN 26, 1998@16:37:34 ENTRY DATE: JAN 26, 1998@16:37:34 AUTHOR: TIUPROVIDER,THREE EXP COSIGNER: URGENCY: STATUS: UNSIGNED DEMOGRAPHICS: CPRSPATIENT,TWO 666-01-0167P 31 JAN 1,1967 His disposition is good. + Next Screen - Prev Screen ?? More actions >>> Find Make Addendum Identify Signers Print Sign/Cosign Delete Edit Copy Link ... Quit Select Action: Quit// L Link ... Problem(s) Patient/Visit Link with Request Specify Linkage: L Link with Request You must link your Result to a Consult Request... The following CONSULT REQUEST(S) are available: 1> JAN 23, 1998@11:14 759 PULMONARY 2> JAN 23, 1998@11:14 760 PULMONARY CHOOSE 1-2: 2 760
PULMONARY CONSULT CPRSPATIENT,T 666-01-0167P PULMONARY CLINIC Visit Date: 01/26/98@16:37 DATE OF NOTE: JAN 26, 1998@16:37:34 ENTRY DATE: JAN 26, 1998@16:37:34 AUTHOR: TIUPROVIDER,THREE EXP COSIGNER: URGENCY: STATUS: UNSIGNED DEMOGRAPHICS: CPRSPATIENT,TWO 666-01-0167P 31 JAN 1,1967 His disposition is good. + Next Screen - Prev Screen ?? More actions >>> Find Make Addendum Identify Signers Print Sign/Cosign Delete Edit Copy Link ... Quit Select Action: Quit// (Continued on the next page.) 1. CPRSPATIE (C2342): New order(s) placed. 2. TIUPATIEN (T0167P): PULMONARY CONSULT available for signature. 3. ARTPATIEN (A1414): New order(s) placed. 4. ARTPATIEN (A1414): New consult PLM (Routine) 5. CPRSPATIE (C2432): New consult CAR (Routine) Select from 1 to 5 or enter ?, A I, F, P, M, R, or ^ to exit: 2. Through the Individual Patient Document option as shown here (which is identical to the Browse action, accessible by a number of familiar paths from TIU Clinician's options, or through the CPRS LM Chart): --- Clinician's Menu --- 1 Progress Notes User Menu ... 2 Discharge Summary User Menu ... 3 Integrated Document Management ... 4 Personal Preferences ... Select Progress Notes/Discharge Summary [TIU] Option: INtegrated Document Management --- Clinician's Menu --- 1 Individual Patient Document 2 All MY UNSIGNED Documents 3 Multiple Patient Documents 4 Enter/edit Document Select Integrated Document Management Option: INdividual Patient Document Select PATIENT NAME: CPRSPATIENT,TWO 01-01-67 666010167P ACTIVE DUTY A: Known allergies
List documents Beginning: 06/13/91// T-1 (JAN 25, 1998) Thru: 01/26/98// Visit: 01/26/98 One document found within date range... Opening PULMONARY CONSULT record for review... (Continued on the next page.) Browse Document Jan 26, 1998 16:49:32 Page: 1 of 1 PULMONARY CONSULT CPRSPATIENT,T 666-01-0167P PULMONARY CLINIC Visit Date: 01/26/98@16:37 DATE OF NOTE: JAN 26, 1998@16:37:34 ENTRY DATE: JAN 26, 1998@16:37:34 AUTHOR: TIUPROVIDER,THREE EXP COSIGNER: URGENCY: STATUS: UNSIGNED DEMOGRAPHICS: CPRSPATIENT,TWO 666-01-0167P 31 JAN 1,1967 His disposition is good. + Next Screen - Prev Screen ?? More actions >>> Find Make Addendum Identify Signers Print Sign/Cosign Delete Edit Copy Link ... Quit Select Action: Quit// L Link ... Problem(s) Patient/Visit Link with Request Specify Linkage: L Link with Request You must link your Result to a Consult Request... The following CONSULT REQUEST(S) are available: 1> JAN 23, 1998@11:14 759 PULMONARY 2> JAN 23, 1998@11:14 760 PULMONARY CHOOSE 1-2: 2 760
(Continued on the next page.) Browse Document Jan 26, 1998 16:49:32 Page: 1 of 1 PULMONARY CONSULT CPRSPATIENT,T 666-01-0167P PULMONARY CLINIC Visit Date: 01/26/98@16:37 DATE OF NOTE: JAN 26, 1998@16:37:34 ENTRY DATE: JAN 26, 1998@16:37:34 AUTHOR: TIUPROVIDER,THREE EXP COSIGNER: URGENCY: STATUS: UNSIGNED DEMOGRAPHICS: CPRSPATIENT,THREE 666-01-0167P 31 JAN 1,1967 His disposition is good. + Next Screen - Prev Screen ?? More actions >>> Find Make Addendum Identify Signers Print Sign/Cosign Delete Edit Copy Link ... Quit Select Action: Quit// Select PATIENT NAME: Nothing selected. 3. You may choose the Link action from the All My Unsigned Documents Option, as shown below: --- Clinician's Menu --- 1 Individual Patient Document 2 All MY UNSIGNED Documents 3 Multiple Patient Documents 4 Enter/edit Document Select Integrated Document Management Option: All MY UNSIGNED Documents Searching for the documents..... MY UNSIGNED Documents Jan 26, 1998 16:51:18 Page: 1 of 3 by AUTHOR (TIUPROVIDER,THREE) or EXPECTED COSIGNER 40 documents Patient Document Ref Date Status 1 CPRSPATIENT,T (C0167) PULMONARY CONSULT 01/26/98 unsigned 2 ARTPATIENT,TW (A4321) Adverse React/Allergy 01/22/98 unsigned 3 CPRSPATIENT,O (C8796) Reparatory Therapy Note 01/20/98 uncosigned 4 CPRSPATIENT,F (R1350) Reparatory Therapy Note 01/16/98 uncosigned 5 CPRSPATIENT,T (C9999) Reparatory Therapy Note 01/16/98 uncosigned 6 CPRSPATIENT,T (C1350) Reparatory Therapy Note 01/15/98 uncosigned 7 TIUPATIENT,EI (T1239) Reparatory Therapy Note 01/15/98 uncosigned 8 CPRSPATIENT,T (C1563) Reparatory Therapy Note 01/14/98 uncosigned 9 CPRSPATIENT,T (C1563) Reparatory Therapy Note 01/14/98 uncosigned 10 PNPATIENT,FIV (P1350) Reparatory Therapy Note 01/14/98 uncosigned 11 DSPATIENT,TEN (D6572) Reparatory Therapy Note 01/14/98 uncosigned 12 HSPATIENT,ONE (H2591) Reparatory Therapy Note 01/14/98 uncosigned 13 TIUPATIENT,EI (T1239) Reparatory Therapy Note 01/14/98 uncosigned 14 TIUPATIENT,EI (T1239) Reparatory Therapy Note 01/14/98 uncosigned + + Next Screen - Prev Screen ?? More Actions >>> Find Sign/Cosign Change View Add Document Detailed Display Copy Edit Browse Delete Document Make Addendum Print Quit Link ... Identify Signers Select Action: Next Screen// L Link ... Problems Patient/Visit Link with Request Specify Linkage: L Link with Request Select Document(s): (1-14): 1 You must link your Result to a Consult Request... The following CONSULT REQUEST(S) are available: 1> JAN 23, 1998@11:14 759 PULMONARY 2> JAN 23, 1998@11:14 760 PULMONARY CHOOSE 1-2: 2 760 (Continued on next page.) MY UNSIGNED Documents Jan 26, 1998 16:51:32 Page: 1 of 3 by AUTHOR (TIUPATIENT,THREE) or EXPECTED COSIGNER 40 documents Patient Document Ref Date Status 1 CPRSPATIENT,T (C0167) PULMONARY CONSULT 01/26/98 unsigned 2 ARTPATIENT,TW (A4321) Adverse React/Allergy 01/22/98 unsigned 3 CPRSPATIENT,O (C8796) Reparatory Therapy Note 01/20/98 uncosigned 4 CPRSPATIENT,F (R1350) Reparatory Therapy Note 01/16/98 uncosigned 5 CPRSPATIENT,T (C9999) Reparatory Therapy Note 01/16/98 uncosigned 6 CPRSPATIENT,T (C1350) Reparatory Therapy Note 01/15/98 uncosigned 7 TIUPATIENT,EI (T1239) Reparatory Therapy Note 01/15/98 uncosigned 8 CPRSPATIENT,T (C1563) Reparatory Therapy Note 01/14/98 uncosigned 9 CPRSPATIENT,T (C1563) Reparatory Therapy Note 01/14/98 uncosigned 10 PNPATIENT,FIV (P1350) Reparatory Therapy Note 01/14/98 uncosigned 11 DSPATIENT,TEN (D6572) Reparatory Therapy Note 01/14/98 uncosigned 12 HSPATIENT,ONE (H2591) Reparatory Therapy Note 01/14/98 uncosigned 13 TIUPATIENT,EI (T1239) Reparatory Therapy Note 01/14/98 uncosigned 14 TIUPATIENT,EI (T1239) Reparatory Therapy Note 01/14/98 uncosigned + ** Item 1 Reassigned. ** >>> Find Sign/Cosign Change View Add Document Detailed Display Copy Edit Browse Delete Document Make Addendum Print Quit Link ... Identify Signers Select Action: Next Screen// Q Quit
2 All MY UNSIGNED Documents 3 Multiple Patient Documents 4 Enter/edit Document Select Integrated Document Management Option: 4. From the CPRS Chart, the dialog looks like this (NOTE: If CONSULTS is defined as a CLASS under CLINICAL DOCUMENTS, this approach is not yet available): OE CPRS Clinician Menu RR Results Reporting Menu AD Add New Orders RO Act On Existing Orders PP Personal Preferences ...
Current patient: ** No patient selected ** Patient Name ID DOB Appointment Date No patients found. Enter the number of the patient chart to be opened + Next Screen CV Change View ... FD Find Patient - Previous Screen SV Save as Default List Q Close Select Patient: Change View// WINCHESTER,CHARLES EMERSON III 01-01-67 107010167P ACTIVE DUTY A: Known allergies Searching the patient's chart ... (Continued on the next page.) Cover Sheet Jan 27, 1998 15:20:40 Page: 1 of 1 CPRSPATIENT,TWO 666-01-0167P1A JAN 1,1967 (31) Item Entered Allergies/Adverse Reactions | 1 DUST | 10/07/97 | Patient Postings | | Recent Vitals | No data available | | Immunizations | No immunizations found. | | Eligibility | Not Service Connected | | Enter the numbers of the items you wish to act on. >>> NW Enter New Allergy/ADR CV (Change View ...) SP Select New Patient AD Add New Orders CC Chart Contents ... Q Close Patient Chart Select: Chart Contents// CC;N Chart Contents ...
CPRSPATIENT,TWO 666-01-0167P1A JAN 1,1967 (31) Currently viewing 17 notes Title Written Author SigSt 1 PULMONARY CONSULT | 01/26 16:37 RUSSELL,J compl 2 Respiratory Therapy Note | 12/11 16:59 RUSSELL,J uncos 3 General Note | 10/16 /91 NO,D compl 4 General Note | 06/17 /91 BUECHLER,M compl 5 General Note | 06/13 /91 MCCLENAH,M compl Enter the numbers of the items you wish to act on. >>> NW Write New Note CV Change View ... SP Select New Patient AD Add New Orders CC Chart Contents ... Q Close Patient Chart Select: Chart Contents// CV Change View ... (Continued on the next page.) Signed Notes Jan 27, 1998 15:20:46 Page: 1 of 1 CPRSPATIENT,TWO 666-01-0167P1A JAN 1,1967 (31) Currently viewing 17 notes
1 PULMONARY CONSULT | 01/26 16:37 RUSSELL,J compl 2 Joel's Test Note | 12/11 16:59 RUSSELL,J uncos 3 General Note | 10/16 /91 NO,D compl 4 General Note | 06/17 /91 BUECHLER,M compl 5 General Note | 06/13 /91 MCCLENAH,M compl Enter the numbers of the items you wish to act on. >>> 1 all signed 4 signed/author Save as Preferred View 2 my unsigned 5 signed/dates Remove Preferred View 3 my uncosigned Select context: 2 my unsigned
CPRSPATIENT,TWO 666-01-0167P1A JAN 1,1967 (31) Currently viewing all unsigned notes
1 PULMONARY CONSULT | 01/27 15:19 RUSSELL,J unsig Enter the numbers of the items you wish to act on. >>> NW Write New Note CV Change View ... SP Select New Patient AD Add New Orders CC Chart Contents ... Q Close Patient Chart Select: Chart Contents// 1 (Continued on the next page.)
CPRSPATIENT,TWO 666-01-0167P1A JAN 1,1967 (31) Currently viewing all unsigned notes
1 PULMONARY CONSULT | 01/26 16:37 RUSSELL,J unsig Enter the numbers of the items you wish to act on. >>> Edit Detailed Display Identify signers Make Addendum Browse Copy Sign Print Delete Select Action: BR Browse Browse Document Jan 26, 1998 16:49:32 Page: 1 of 1 PULMONARY CONSULT CPRSPATIENT,T 666-01-0167P PULMONARY CLINIC Visit Date: 01/26/98@16:37 DATE OF NOTE: JAN 26, 1998@16:37:34 ENTRY DATE: JAN 26, 1998@16:37:34 AUTHOR: TIUPROVIDER,THREE EXP COSIGNER: URGENCY: STATUS: UNSIGNED DEMOGRAPHICS: CPRSPATIENT,TWO 666-01-0167P 31 JAN 1,1967 His disposition is good. + Next Screen - Prev Screen ?? More actions >>> Find Make Addendum Identify Signers Print Sign/Cosign Delete Edit Copy Link ... Quit Select Action: Quit// L Link ... Problem(s) Patient/Visit Link with Request Specify Linkage: L Link with Request You must link your Result to a Consult Request... The following CONSULT REQUEST(S) are available: 1> JAN 23, 1998@11:14 759 PULMONARY 2> JAN 23, 1998@11:14 760 PULMONARY CHOOSE 1-2: 2 760
(Continued on next page.) Browse Document Jan 26, 1998 16:49:32 Page: 1 of 1 PULMONARY CONSULT CPRSPATIENT,T 666-01-0167P PULMONARY CLINIC Visit Date: 01/26/98@16:37 DATE OF NOTE: JAN 26, 1998@16:37:34 ENTRY DATE: JAN 26, 1998@16:37:34 AUTHOR: TIUPROVIDER,THREE EXP COSIGNER: URGENCY: STATUS: UNSIGNED DEMOGRAPHICS: CPRSPATIENT,TWO 666-01-0167P 31 JAN 1,1967 His disposition is good. + Next Screen - Prev Screen ?? More actions >>> Find Make Addendum Identify Signers Print Sign/Cosign Delete Edit Copy Link ... Quit Select Action: Quit// Unsigned Notes Jan 27, 1998 15:20:55 Page: 1 of 1 CPRSPATIENT,TWO 666-01-0167P1A JAN 1,1967 (31) Currently viewing all unsigned notes
1 PULMONARY CONSULT | 01/27 15:19 RUSSELL,J unsig Enter the numbers of the items you wish to act on. >>> NW Write New Note CV Change View ... SP Select New Patient AD Add New Orders CC Chart Contents ... Q Close Patient Chart Select: Chart Contents// Q Close Patient Chart Yüklə 0,82 Mb. Dostları ilə paylaş:
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