User Guide


Using the Consults Package with Clinical Procedures



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Using the Consults Package with Clinical Procedures

Individual consult types can be designated to be resulted with the Clinical Procedures package. If this is the case, then Consults expects clinical procedures results to be attached to the consult. This attachment is usually accomplished with the CPUser program.


If the instrument in question has not yet been connected to Clinical Procedures, then the consult may be completed in the usual way by an authorized provider. (Authorized providers being clinicians whom the CAC has set up as an interpreter for the appropriate service.) In this case Consults will filter the note titles available and only allow you to use Clinical Procedures titles.
When the clinical procedure results are present, Consults changes the status to PR (partial results). This means that, at least, at stub of a TIU document has been attached to the consult. It could also mean that one or more images and/or instrument reports created by a clinical device are also attached to the consult. Additionally, the interpretation of the clinical device image(s) or text may have been uploaded and is ready for signature.

The minimum required by the consults package to complete a clinical procedures consult is the interpretation of the clinical device output. If this is not supplied via upload, then it must be entered by the consulting clinician. When this interpretation is entered, the following fields are required and are prompted for (if not already present):






Windows Quick Start




Introduction 58

Windows Flow of Information 59

Starting Consults in Windows 59
Order New Consult 62
Print Form 64
Forward Request 65
Receive Request 66
Comment 67
Complete a Consult (From the Consults Tab) 69
Complete a Consult (From the Notes Tab) 71
Complete a Consult (From Medicine Results) 73

Other Windows Topics 75

Cancel Request 75
Detailed Display 77
Discontinue Order 76
Make Addendum 83
New Date Range 85
Results Display 88
Select Consult 89
Select New Patient 90
Select Service 91
View by Status 92

Key

1. Steps are numbered and bolded:











Introduction

1. Before each process, select the consult:





Windows Flow of Information

Starting Consults in Windows

1. Start CPRS for Windows:





2. Select the connection:

Note: Depending on the way CPRS is installed on your machine, you may not see this step



3. Log-on to your system:








4. Select a patient:














5. Click the Consults Tab:




Order New Consult

1. Select New Consult:



2. Fill out the Order a Consult dialog:









Print Form 513

1. Select Print from the File Menu:




2. Select the Printer Device:







Forward Request

1. Select Forward:









2. Fill in the Forward Consult dialog:




Receive Request

1. Select Receive:




2. Click OK.







Comment

1. Select Add Comment:








2. Fill in the Add Comment to Consult Dialog:




3. Select the People to Receive the Alert:




Note: If this were an Inter-Facility Consult, individuals from the other facility involved would not be on this list. In this case, the Notification System decides who to notify at the other facility by referring to Consults files.

4. Select OK:



Complete a Consult (From the Consults Tab)

1. Select Complete/Update Results:



2. Select the Title of the Note:




3. Type in the text of the results:










4. Save the note:






Complete a Consults (From the Notes Tab)


Before starting, from the CPRS Windows program, select the correct patient and click the Notes tab.
1. Click New Note:


2. Select the Title of the Note:







3. Select the consult:

4. Type in the text of the results:




5. Save the note:




Complete a Consult (From the Medicine Results)

1. Select Attach Medicine Results:



2. Select the medicine result.





3. No signature is necessary at this time.

Undo Medicine Results

Select Remove Medicine
Results

2. Select the medicine result to be removed.






Other Windows Topics

Cancel (Deny) Request



This is a consult receiver’s action. If you are the consult originator, use the Discontinue Order action.


1. Select Cancel:




2. Consult dialog:







A notification is automatically sent to the consult originator so that the consult can be edited and resubmitted.

Discontinue Order



This is a consult originator’s action. If you are the consult receiver, use the Cancel (Deny) action.


1. Select Discontinue:





2. Fill out the Discontinue Consult dialog:





A notification is automatically sent to the originator of the consult with information about the discontinuation of the order.

Detailed Display


Consults in Windows always show the detailed display of whatever consult is selected.



Changes made by Patch 73 for ICD-10 Remediation


ICD Diagnosis Code Display
ICD Diagnoses will be displayed on the user-selected Consults or Procedures.

If an existing consult (for which ICD-10 diagnosis was entered) is selected for display or the action Display Details is used, the ICD-10-CM diagnosis code and full description/definition will be displayed.




If the user selects an existing consult to display or uses the action Display Details and the Provisional Diagnosis was entered using free text data entry, the CRT package will not designate the diagnosis as ICD-9 or ICD-10.

The CRT package will display ICD Diagnosis on the display details of Consults/Procedures orders.



  • If the user selects an order to display details and the Provisional Diagnosis was entered as an ICD-9 diagnosis using the Lexicon, the ICD-9 diagnosis code and description/definition will be displayed.

  • If the user selects an order to display details and the Provisional Diagnosis was entered as an ICD-10 diagnosis using the Lexicon, the ICD-10-CM diagnosis code and full description/definition will be displayed.

  • If the user selects an order to display and the Provisional Diagnosis was entered using free text data entry, then Consults will not designate the diagnosis as ICD-9 or ICD-10.

  • If the user selects an existing consult to display and the Provisional Diagnosis was entered using the Lexicon then Consults will designate the particular diagnosis as ICD-9 or ICD-10.





  • ICD Diagnosis on the Display SF 513 action will be displayed for a particular Consults or Procedure.

    • If the user performs the action Display SF 513 for a consult or procedure for which ICD-10 diagnosis was entered, Consults will display the ICD-10-CM diagnosis code and full description/definition.

    • If the user performs the action Display SF 513 for a consult or procedure and the Provisional Diagnosis was entered using free text data entry, then Consults will not designate the diagnosis as ICD-9 or ICD-10.

    • If the user performs the action Display SF 513 for a consult or procedure and the Provisional Diagnosis was entered using the Lexicon, then Consults will designate the particular diagnosis as ICD-9 or ICD-10.

ICD Diagnosis Search

Consults will provide the ability to search on ICD-10-CM diagnosis full (expanded) text descriptions and codes.




  • Consults will display ICD Diagnosis on the Display SF 513 action for a particular Consults or Procedure.

    • If the user performs the action Display SF 513 for a consult or procedure for which ICD-10 diagnosis was entered, Consults will display the ICD-10-CM diagnosis code and full description/definition.

    • If the user performs the action Display SF 513 for a consult or procedure and the Provisional Diagnosis was entered using free text data entry, Consults will not designate the diagnosis as ICD-9 or ICD-10.

    • If the user performs the action Display SF 513 for a consult or procedure and the Provisional Diagnosis was entered using the Lexicon, then Consults will designate the particular diagnosis as ICD-9 or ICD-10.

Make Addendum



An Addendum is a medical statement by a patient care professional about a specific Note. It differs from a Comment in that it is about medical matters, where Comments, which can be written by anyone, should contain information needed to administer the consult.


1. Select the Consult and the Note
2. Select Make Addendum





3. Type the addendum:







4. Save the note:






New Date Range

1. Select Consults by Date Range:





2. Fill in the List Consults by Date Range Dialog:







3. Select OK:


Quit









Or you can press the Alt and F4 keys at the same time (Alt+F4).

Results Display





Note: If this were an Inter-Facility Consult, CPRS’s Remote Data Views would retrieve the results over the VA Intranet. This may take slightly longer.



Select Consult








Select New Patient

1. Choose Select New Patient from the File Menu:



2. Use the Patient Selection Dialog:








Select Service

1. Select Consults by Service from the View Menu:





2. Select the service you want:


View by Status

1. Select Consults by Status from the View Menu:







2. Select the status you want from the list:








Hold down the Ctrl key when selecting to select more than one status.

Custom List

1. Select Custom View from the View Menu:


3. Select the view you want.

Do one or more of the following:




3.Click OK.


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