OMR Overview for Medical

OMR Overview for Medical & Practice Assistants

CAREGROUP H E A L T H C A R E S Y S T E M

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OMR System Overview

The purpose of this presentation is to provide an overview of basic OMR functionality for medical & practice assistants.

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Topics Included

• What is OMR?

• Keystrokes & conventions

• Accessing OMR

• Accessing a patient’s record

• Patient information

• Recording vital signs & immunizations

• Entering notes

• Editing notes

• Establishing letter printing defaults

• Additional information & assistance

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Click on a topic to go directly to the topic information or click on Continue to review all topics sequentially.

What is OMR?

The Online Medical Record is a multi-featured ambulatory electronic patient record, available via the Clinical Computing system at the Medical Center and community health centers and practices.

OMR features include, but are not limited to Notes, Problem Lists, and Medication and Allergy Lists, Screening and Flow Sheets.

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OMR Keystrokes & Conventions

To move back one level Type an underscore (Shift hyphen) To exit Type a ^ (Shift 6) or

if in a word processor window press <ESC>

To view help Enter a ? or if in a word processor window press <F1>

To select a menu option Enter either the first letter of the item or

the number associated with the item

Default values At certain prompts, the system provides default values. Default values always follow // . To accept the default value, press <ENTER>.

To delete a previously Enter an * (Shift 8). filed entry without replacing the data

ContinueReturn to Table of Contents

Use these keystrokes & conventions when you work in OMR.For this overview, only mouse clicking is required.

Accessing OMR

Hospital and community practice computers provide direct access to OMR for authorized users.

Click on the CCC icon on your desktop OR click on CareWeb and then CCC Access via Metaframe.

To obtain a key to access OMR, contact the I.S. Support Center at (617) 754-8080.


To access OMR, sign onto CCC. Use the up & down arrow keys on your keyboard to select Online Medical Record.

SystemO

Appointments/SchedulingClinical InformationOnline Medical RecordOPD Reg (Outpatient Admitting)Online Medical Record

NextPage PrevPage DoneSelectSelect

Beth Israel DeaconessMedical Center

Clinical Computing – CCC System

Mary Smith Port: TS3.421


Accessing a Patient’s Record


CONTINUE WITH LAST ENTRY: FROG,KERMIT ? N //

When you sign into OMR, the system displays the name of the patient whose record you last accessed. Enter “ Y “ to open this patient’s record OR

Access another patient by entering one of the following: Last name, first name 7 digit CCC medical record number Social security number Room number for hospitalized patients Last name for patients currently or recently hospitalized or in ED

To access another OMR option, press <ENTER> to accept the default of “ N “.

Continue

There are several test patients in OMR to use for training.

They include: Kermit Frog, MRN 0901910 Kermit Frog, MRN 1213367

Return to Table of Contents

0901910

Patient Information Display


FROG, KERMIT 0901910 M41 Home: 781 555-1234Work: 617 555-1234

Online Medical Record Option Doctor: SANDS, DANIEL Z.Nurse: LEDERMAN,JOAN

1 Clinical Information OptionsNext: 05/07/01-RADIOLOGY

2 Display Summary 3 Lookup 4 Medication Sheet Allergy 5 Notes Doctor: SEIKH,JAVED 6 Order Entry 7 Problem List Hematology/Oncology 8 Screening, Flow Sheets and Forms Doctor: SCHNIPPER,LOWELL E. 9 To Do List 10 Vital Signs Rapid Entry 11 Utilities Infectious Disease

Doctor: BRODIE,SHARON

Online Medical Record Option:

(Edit or View More in Order Entry)

After selecting a patient, the OMR Display includes: Patient Demographics

Primary Care & Specialty Provider Names

To Edit Patient Phone Numbers or Provider Names select Order Entry.

Select Display Summary to view more Patient Information.


HCA PROBLEM LIST MEDICATION SHEET APPOINTMENTS

08/20/01 PODIATRY CLINIC07/11/01 LEXINGTON OCCUPA06/26/01 RADIOLOGY06/22/01 PODIATRY CLINIC06/19/01 RADIOLOGY06/06/01 LEX PSYCH05/23/01 HCA MEDICAL UNIT

HYDROCHLOROTHIAZIDIBUPROFEN

HYPERTENSIONLOW BACK PAINTOBACCO ABUSE

Problems/Meds/Screening/Flow/Appointments/Notes/To print/Quit : Q //

------------------------------------------- SUMMARY DISPLAY -----------------------------------------------

0901910 FROG,KERMIT M41 Drug Allergies: Last Entry 5/30/02No Healthcare Proxy info on file

View only Summary includes:

Primary care problem list

Medications

Appointments scheduled in CCC

Continue

To print a hard copy of the Display Summary: Enter “ T “ for To Print at the prompt.

Enter “ A “ to view more patient appointment information.


Enter “ M “ to view additional information about the patient’s medications

0901910 FROG,KERMIT M41

-----------------------------------------------APPOINTMENT HISTORY----------------------------------------------------

07/12/01 1:30 PM PODIATRY CLINIC PODIATRY,BASILE07/11/01 3:00 PM LEXINGTON OCCUPA OT, LEX06/26/01 3:00 PM RADIOLOGY LEX, RAD 106/22/01 8:30 AM PODIATRY CLINIC PODIATRY, LYONS CANCELLED06/19/01 2:00 PM RADIOLOGY LEX, RAD 106/06/01 11:00 AM LEX PSYCH STEVENS, LEX NO SHOW05/23/01 10:00 AM HCA MEDICAL UNIT DESAI, SAMEER HYPERTENSION

Press < Enter > to continue.

Continue

The Appointment History display shows the following for CCC appointments:

• Appointment date & time

• Service• Provider

• Cancel/No Show Status or Billing Diagnosis


Drug Allergies: Last Entry 5/30/02

No Healthcare Proxy info on file

FROG,KERMIT 0901910 09/21/59 Drug Allergies: Last entry 05/30/02-----------------------------------------------------------------------------------------------------------------------------------

1. HYDROCHLOROTHIAZID 25MG PO Tablet [ #30 R3 ] 03/30/2001 One by mouth every day [SMITH] 2. IBUPROFEN 400 MG PO Tablet [#30 R0] 03/30/2001 One by mouth every 8 hours for low back pain [SMITH]

History? N //

Continue

The Medication List displays all active medications & the last date an allergy was entered.

To see a history of changes made to the medication order enter “ Y “ at the prompt.

To return to the Display Summary without reviewing the history press <ENTER>.

Recording Vital Signs & Immunizations


FROG,KERMIT 0901910 M41 Home: 781 555-1234Work: 617 555-1234

Online Medical Record Option Doctor: SANDS, DANIEL Z.

1 Clinical Information Options Next: 05/07/01-RADIOLOGY 2 Display Summary 3 Lookup 4 Medication Sheet 5 Notes Doctor: SEIKH,JAVED 6 Order Entry 7 Problem List Hematology/Oncology 8 Screening, Flow Sheets and Forms Doctor: SCHNIPPER,LOWELL E. 9 To Do List 10 Vital Signs Rapid Entry 11 Utilities

Infectious DiseaseDoctor: BRODIE,SHARON



Nurse: LEDERMAN,JOAN

Allergy

Use the Lookup option to view patient lab results.

Select Vital Signs Rapid Entry to enter the patient’s vital signs

Continue Return to Table of Contents

FROG,KERMIT Vital Signs Rapid Entry------------------------------------------------------------------------------------------------------------------------------------------------

Continue

0901910 M41

DATE: 8/14/2002 //

BLOOD PRESSURERESULT:

HEART RATERESULT:

WEIGHT (IN LBS)RESULT:

TEMPERATURERESULT:

120/65

72

115

97.5


OMR displays today’s date. Press <ENTER> to accept the date or type in anotherDate and press <ENTER> to continue. Then enter values at each vital sign prompt.





Online Medical Record Option: 8



Allergy

Select Screening, Flow Sheets and Forms to enter immunization information.


FROG,KERMIT 0901910 41

Screening/Flow Sheets Option

1. Periodic Screening2. Health Education3. Health History4. Vital Signs5. Immunizations and PPD6. Flow Sheets7. Health care proxy8. Eye refractions9. Anticoagulation form10. Diabetes Labs11. Diabetes General

Screening/Flow Sheets Option:


Select Immunizations and PPD to enter immunization information.

FROG,KERMIT------------------------------------------------------------------------------------------------------------------------------------------------

Continue

0901910 M411. INFLUENZA 12/18/20012. PNEUMOCOCCAL3. TETANUS (Q 10 YRS) 02/02/1990 TD4. HFLU (ONCE)5. HEPATITIS A6. HEPATITIS B7. MENINGOCOCCAL8. MMR9. MEASLES10. MUMPS11. PPD (5 TU) + CTRL12. POLIO (INACTIVE)13. RUBELLA14. VARICELLA15. YELLOW FEVER16. TYPHOID17. LYME VACCINE

Add / Edit / Delete / Rapid entry / Full display / Quit: Q //


“ R “ to enter several immunizations.

“ D “ to delete an immunization entry.

“ E “ to edit an existing immunization entry.

Enter “ A “ to add a new immunization.

A

From the options listed select: “ F “ to display all information for each immunization.

OMR displays the patient’s most recent immunization information

FROG,KERMIT------------------------------------------------------------------------------------------------------------------------------------------------

Continue

0901910 M41 ADD

PNEUMOCOCCAL VAX

DATE: 08/14/2002 //

COMMENT:

FOOTNOTE ( CO./LOT # …) :

RT DELTOID

#431-929 / Exp 12/03


OMR displays today’s date. Press <ENTER> to accept the date or type in another date. Press <ENTER> to continue and enter values at each prompt.

OK TO FILE ON SCREENING SHEET? Y //

At the final prompt press < ENTER > to file the immunization information.

FROG,KERMIT------------------------------------------------------------------------------------------------------------------------------------------------

Continue

0901910 M41

1. INFLUENZA 12/18/20012. PNEUMOCOCCAL3. TETANUS (Q 10 YRS) 02/02/1990 TD4. HFLU (ONCE)5. HEPATITIS A6. HEPATITIS B7. MENINGOCOCCAL8. MMR9. MEASLES10. MUMPS11. PPD (5 TU) + CTRL12. POLIO (INACTIVE)13. RUBELLA14. VARICELLA15. YELLOW FEVER16. TYPHOID17. LYME VACCINE

Add / Edit / Delete / Rapid entry / Full display / Quit: Q //

08/14/2002 RT DELTOID # LOT #431-929


Press < ENTER > to accept the default of “ Q “ and return to the main OMR menu

After filing, OMR updates the display with the new immunization information.

OMR Notes

Return to Table of Contents Continue to Create New Note








Allergy

Select Notes to view, edit or create a new note.

Continue to NotesReturn to Table of Contents

FROG,KERMIT 0901910 M41 NOTES------------------------------------------------------------------------------------------------------------------------------------------------

1. 07/12/01 2. 07/11/01 3. 07/11/01 4. 06/06/01 5. 05/23/01

INITIALLETTERINITIALINITIALINITIAL

BASILEKECKKECKBIRNBAUMDESAI

Mr. Desai

(POD)(RHAB)(RHAB)(PSYC)(MED)

New/Edit/View/Review/Cosign/Print/Forward/Delete/Monitor/Quit:

Continue to View Note

Notes Summary Display includes: Note date, type, author, status/title & service.

To view any note, enter the number associated with the note on the list.

1



Date: 07/12/01 Signed on: 07/12/01

------------------------------------------------------------------------------------------------------------------------------------------------

Medications before July 12, 2001:

HYDORCHLOROTHIAZIDE 25MG—One by mouth every dayIBUPROFEN 400MG—One by mouth every 8 hours as needed for low back pain

No medications DC’d on July 12, 2001.

No medications prescribed on July 12, 2001

------------------------------------------------------------------------------------------------------------------------------------------------

Continue / Back up / Quit : Q

Patient seen for fungal toe nail infection. Treatment options discussed. Patient will consider options and call with a decision regarding which he prefers.

Return to Notes List

Enter “ Q “ to return to the Notes List.



1. 07/12/01 2. 07/11/01 3. 07/11/01 4. 06/06/01 5. 05/23/01

INITIALLETTERINITIALINITIALINITIAL

BASILEKECKKECKBIRNBAUMDESAI

Mr. Desai

(POD)(RHAB)(RHAB)(PSYC)(MED)

New/Edit/View/Review/Cosign/Print/Forward/Delete/Monitor/Quit: N

Continue

Enter “ N “ to create a new note.


Service and Location:1. General Medicine/Primary Care at APG Sharon

Ok? Y / /Copy a noteInitial noteLetterProgress noteTelephone contact

Which type of note?: TELEPHONE CONTACTDATE OF CONTACT: 08/14/2002 / /

When you create a new note the system prompts for:

Service/Location – Press <ENTER> to accept your default service/location.

Type of Note – Type the first letter of the option which best suits your note: Copy, Initial, Letter, Progress, or Telephone Contact.

Date of Contact - System defaults in today’s date. Enter mm/dd/yy or T +/- n for another date. For three days ago, enter “ T – 3 “.


Date: August 14, 2002Note type: Telephone Contact

Author: Mary Smith

Note:

For help info press <F1> To exit press <ESC>

FROG,KERMIT0901910 M41

To escape the notes screen: Press <ESC> at any time.

For HELP press <F1>



Author: Mary Smith

Note:


FROG,KERMIT0901910 M41

Additional Help F1Select Text F2Paste F3Delete Word F4 & Shift F4Text Inserts F6Set Up Search F7Top of Document F8End of Document F9Page Up Shift Up ArrowPage Down Shift Down ArrowWord Back Shift Left ArrowWord Forward Shift Right ArrowExit <Esc>

Continue

OMR Help: Use the up & down arrow keys on your keyboard to select a Help option.

To Exit Help: Press <ESC>.


Options for Creating Notes

• Type in freeform text

• Use text insert

When you create any note type you can:

Continue

• Combine freeform text & text inserts in a single note• Copy & edit text from an existing note

To learn more about text inserts and copyingexisting notes, click on HELP on the CareGroupwebsite, then click on CCC/OMR help and selectOMR Notes Documentation.


090-19-10 FROG.KERMIT M41


Author: Mary Smith

Note:


Patient called for last date of MRI for comparison.Gave date of 1/2

Type in freeform text.


0901910 FROG.KERMIT M41


Author: Mary Smith

Note:Patient called for last date of MRI for comparison.Gave date of 1/2


Save and Exit

Select Choice

Discard and Exit Save and Exit

S

Save and Exit

Enter “ S “ to save and exit.


PROGRESS NOTE for FROG,KERMIT1. Exit2. Forward3. Monitor4. Print5. Sign

Choice: 5 / /

Monitor: Use this option if you wish the system to notify you when any clinician views your note for this patient. This feature is note specific and must be turned on for each note you wish to monitor.

Forward: Use this option to forward a copy of this note to the patient’sPCP, referring MD, or other provider.


PROGRESS NOTE for FROG,KERMIT1. Exit2. Forward3. Monitor4. Print5. Sign

Choice: 5 / / 5

FROG,KERMIT 0901910 M41 NOTES-------------------------------------------------------------------------------------------------------------------

KEY:

Select “ 5 “ to sign your note.

Enter your CCC key to complete the signing process.

Continue

Select an affiliation to indicate in which record this note/letter belongs. 1. BIDMC 2. HMFP Practice 3. APG Practice 4. Other Private PracticeAffiliation:

Save APG Practice as your default affiliation ? Y //

3

Enter the number associated with the affiliation for the note

Press <ENTER> to save the affiliation as a default for all your notes/letters.


Editing Notes

Unsigned notes• Editable at any time

Signed notes• Editable for 3 hours after signing• Users can add an addendum at any time



1. 8/14/02 2. 07/11/01 3. 07/11/01 4. 06/06/01 5. 05/23/01

PHONLETTERINITIALINITIALINITIAL

SMITHKECKKECKBIRNBAUMDESAI

Mr. Desai

(MED)(RHAB)(RHAB)(PSYC)(MED)

New/Edit/View/Review/Cosign/Print/Forward/Delete/Monitor/Quit: E

Continue

Enter “ E “ to edit the unsigned note. Then specify the number associated withthe note you wish to edit.

UNSIGNED


FROG, KERMIT 0901910 M41 TELEPHONE CONTACT

----------------------------------------------------------------------------------------------------------------------------------

Date of Contact Display Title08/14/02 PHONE SMITH UNSIGNED (MED)

Edit:1. Display title2. Note3. Date of contact

Select: 2

Continue

Enter “ 2 “ to edit the note text.



Date: May 4, 2001Note type: Telephone Contact

Author: Mary Smith

Note:Patient called for last date of MRI for comparison.Gave date of 1/2

For help info press <F1> To exit press <ESC>Edit existing text or enter new text.

Press <ESC> to exit and file edits.

Continue

/2001



Date: May 4, 2001Note type: Telephone Contact

Author: Mary Smith

Note:


Save and Exit

Select Choice

Discard and Exit Save and Exit

S

Save and Exit

Enter “ S “ to save and exit.

Continue

Patient called for last date of MRI for comparison.

Gave date of 1/2/2001


Continue

TELEPHONE CONTACT for FROG,KERMIT1. Exit2. Forward3. Monitor4. Print5. Sign

Choice: 5 / / 5

Select “ 5 “ to sign your note.

KEY:

Enter your CCC key to complete the signing process.

Select an affiliation to indicate in which record this note/letter belongs. 1. BIDMC 2. HMFP Practice 3. APG Practice 4. Other Private PracticeAffiliation: 3

Enter the number associated with the affiliation for the note

Save APG Practice as your default affiliation ? Y //

Press <ENTER> to save the affiliation as a default for all your notes/letters.


Letter Printing Default Settings


You have NOTES.

Online Medical Record Option

1 Alerts, Notes, and Attestations2 Clinical Information Options3 Management Options and Reports4 Patient Selection –OMR 5 Utilities

Online Medical Record Option

Default settings allow users to establish margins used for letter printing andthe number of copies printed.

Continue

3

To access Defaults, enter “ 3 “ for Management Options and Reports.


Management/Report Option

1 Notes reprint 2 Prescriptions reprint 3 To Do List Personal Entries Display 4 Anticoagulation lists 5 Defaults 6 Insert text 7 Access notification list 8 To change access reason 9 OMR Support Options10 Copy Reminders (Alerts/Notes/Attestations)

Management/Report Option: 5

Continue

Enter “ 5 “ for Defaults.


Default option

1 Access notification 2 Medication printing 3 Notes/Letters 4 Show open appointments

Default option: 3

Continue

To establish margin and printing defaults, enter “ 3 “ for Notes/Letters.


Notes default setting

1 Forward automatically 2 Medications into progress/initial notes 3 Printing 4 Service/Location 5 Sign-off

Notes default setting: 2

Continue

Enter “ 3 “ for Printing to establish margins and other printing defaults.


LETTER PRINTING

L LETTERHEAD: Beth Israel Hospital (2 inch top margin) / /LS SECOND PAGE LETTERHEAD:M MARGINS: Two (2) inch left margin / /B BOTTOM MARGIN: Increased margin (1.25 inch) / /W WINDOWS PAGE BREAK OFF?:PS PRINT SINGLE COPY OF LETTER (ON STATIONARY)?: Y / /ESFL PRINT “ELECTRONIC SIGNATURE ON FILE” ON LETTERS

EDIT:

If you print letters for providers, you can use the Letter Printing Default options to establish margins for provider letters.

Enter “ M “ at the prompt to establish the left margin.

Enter “ B “ at the prompt to establish the bottom margin.

Enter “ PS “ at the prompt to control how many copies OMR prints of each letter.

LMBPS

Continue

Enter “ L “ at the prompt to establish the top margin.

Enter “ ESFL “ at the prompt if you wish “ Electronic Signature on File “ to print on each letter.

ESFL


Default option

1 Letter printing 2 Notes printing

Default option: 2 Notes printing

NOTE PRINTING

PU PRINT UNSIGNED NOTES DOUBLE SPACED?:ESFN PRINT “ELECTRONIC SIGNATURE ON FILE” ON NOTES?:

EDIT:


Enter “ PU “ at the prompt to print all unsigned notes double spaced.

Enter “ ESFN “ at the prompt if you wish to have “ Electronic Signature on File “ printed on all notes.

PUESFN

For Additional Information


Click on HELP on the CareGroup portal for detailed CCC/OMR help.


Click on CCC/OMR Help for OMR Documentation topics.


OMR documentation topics include: General Information, Medications, Notes, Problem Lists, Management Options, and Transcription Information. ContinueReturn to Table of Contents

Questions or Problems

For computer & printer problems

• Call the IS Support Center (617) 754-8080

For questions about how to use OMR

• Email [email protected]• Receive a response within 1 business day


mailto:[email protected]

…And OMR Overview Training is Complete

Click Here to Return to CCC/OMR Help

OR

Click Here to Return to the CareGroup Portal


http://home/portal.asp?category=CCC%20help

http://www.home.caregroup.org/

OMR Overview for Medical

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