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Transcript of OMR Transcription Options & Features Click Mouse to Advance.
OMR Transcription Options & Features
CAREGROUP H E A L T H C A R E S Y S T E M
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OMR Transcription Overview
The purpose of this presentation is to provide an overview of basic OMR transcription functions.
Continue to View List of Contents
• Keystrokes & conventions
• Accessing OMR & Transcription options
• Entering a note in Transcription• Using free text• Using a template• Pasting from Word
• Saving a transcribed note & forwardingit for signature
• Editing a transcribed note • Printing unsigned notes
• Establishing margin & printing defaults
Topics Included
Click on a topic to go directly to the topic information or click on
Continue to review all topics sequentially. Continue
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 & Transcription Options
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Accessing OMR & Transcription Options
The Online Medical Record (OMR) is part of BIDMC’sClinical Computing System (CCC).
To obtain OMR access contact the IS Support Center at (617) 754-8080.
Hospital computers provide direct access to OMR for authorized users.
External transcription services can access OMR remotely.
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Continue
Users can access OMR remotely using one of the following methods:
• via the Meditech emulator program through a dial-up connection using a modem• via Metaframe using an Internet connection
To install the Meditech emulator use the following link:http://home.caregroup.org/portal.asp?category=emulator
To install Metaframe use the following link & follow the directions provided: http://home.caregroup.org/metaframe/
To obtain remote access help using any of these methods, contact the IS Support Center at (617) 754-8080.
Remote Access
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
Continue
You have OMR messages.
Transcription Option
1 Clinical Information options 2 Display/Edit Transcription 3 Enter Transcription 4 Hard Copies - Unsigned 5 Insert test enter/edit 6 Letter/Notes Defaults 7 OMR Messages (Notes for printing) 8 Online Medical Record 9 Providers’ Schedules10 Transcription Report11 Utilities
Transcription Option: 3
Continue
The Transcription Option menu includes options for:
• Displaying & editing transcriptions
Return to Table of Contents
• Entering transcriptions• Printing copies of unsigned notes• Establishing defaults
Entering a Transcription
ContinueReturn to Table of Contents
You have OMR messages.
Transcription Option
1 Clinical Information options 2 Display/Edit Transcription 3 Enter Transcription 4 Hard Copies - Unsigned 5 Insert test enter/edit 6 Letter/Notes Defaults 7 OMR Messages (Notes for printing) 8 Online Medical Record 9 Providers’ Schedules10 Transcription Report11 Utilities
Transcription Option: 3
Enter 3 at the Transcription Option prompt to enter a transcription.
Continue
At the Provider prompt, enter the provider’s name using the format Last Name, First Name. Enter the first few letters of the name & OMR will display matches.
OMR displays the provider’s default Service & Location. Press <ENTER> to accept this information or type in the Service & Location specified in the dictation.
PROVIDER: SMIT, MAR
1. SMITH, MARY 11- 111 PSYCHIATRY PAGE: 99999OK? Y / /
Service and Location: 1. Psychiatry, Beth Israel Hospital Outpatient DepartmentOk? Y / /
PATIENT: FROG,KERMIT
There are several test patients in OMR to use for training. They include: Kermit Frog, MRN 0901910 Kermit Frog, MRN 1213367
0901910123-12-1234
Continue
OMR displays matches to the name you entered. Press <ENTER> to accept the name displayed.
At the Patient prompt, you can identify the patient in a variety of ways: 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
After you enter the patient’s identifying information,OMR displays a list of patients to choose from.
NextPage PrevPage DoneSelectSelect
Choose Patient:
Frog,Kermit 41 M 000-00-0000 21 Sep 1959 OUTPT 0901910 123 Main Street Anywhere 12345Frogger Frogette Frogge
Frog,Kermit 79 M 000-00-0000 2 Feb 1922 OUTPT 0078199 (ACCESS RESTRICTED) Ziggy Phyllis Nancy
Frog, Kermit 36 M 000-00-0000 28 Jul 1964 OUTPT 1058295 (ACCESS RESTRICTED)Joseph Donna Fanny Frog
Frog,Kermit 25 M 000-00-0000 1 Jan 1976 OUTPT 1117257 11 Glendale St Everett 02149Richard Mary Linda
4
1
2
3
44 Frog,Kermit 25 M 000-00-0000 1 Jan 1976 OUTPT 1117257 11 Glendale St Everett 02149Richard Mary Linda
Use the up and down arrow keys on your keyboard tohighlight the correct patient and press <ENTER>.
Continue
At the Date of Service prompt, enter the date using the formatMM/DD/YY or enter T-X. For example for yesterday, enter T-1.
There are 4 dictation types: initial note, letter, progress note, telephonecontact. Enter the type of dictation you want to create.
You can enter a dictation even if the patient did not have a visit recorded in the system on the date of service entered.
DATE OF SERVICE:
Continue
T-1
Initial note Letter Progress note Telephone contact
WHICH TYPE OF DICTATION?: PROGRESS NOTE
No visit recorded for FROG,KERMITWith SANDS,DANIEL Z. on 07/22/01Enter dictation anyway? N / / Y
--------------------------- ----------------------------- -------------------------- -------------------------Medications before July 22, 2001
PROZAC 20MG—One by mouth at bedtime
No medications DC’d on July 22, 2001.
No medications prescribed on July 22, 2001.--------------------------- ----------------------------- -------------------------- -------------------------
For help info press <F1> To exit press <ESC>
111-72-57 FROG,KERMIT M25
Provider: Smith, MaryDate: July 22, 2001 Type of dictation: Progress note
OMR includes the patient’s medications as established by the clinician’sdefault settings.
Continue to View HelpFor HELP press <F1>
To escape the notes screen: Press <ESC> at any time.
--------------------------- ----------------------------- -------------------------- -------------------------Medications before July 22, 2001
PROZAC 20MG—One by mouth at bedtime
No medications DC’d on July 22, 2001.
No medications prescribed on July 22, 2001.--------------------------- ----------------------------- -------------------------- -------------------------
For help info press <F1> To exit press <ESC>
111-72-57 FROG,KERMIT M25
Provider: Smith, Mary Date: July 22, 2001
Top of Document F9
Additional Help F1Select Text F2Paste F3Delete Word F4 & Shift F4Text Inserts F6Set Up Search F7Search F8Top of Document F9End of Document F9Page Up Shift Up Arrow Page Down Shift Down ArrowWord Back Shift Left ArrowWord Forward Shift Right ArrowExit <ESC>
Top of Document F9
OMR Help: Use the up & down arrow keys on your keyboard to highlight a Help option.
To Exit Help: Press <ESC>.Continue
: Progress Note
Options for Creating Notes
• Type in freeform text
• Use a personal text insert • Use a public text insert
When you create any note type you can:
Continue
• Combine freeform text & text inserts in a single note
• Paste in text from a word processing file
Transcription with Text from a Word Processing File
ContinueReturn to Table of Contents
To Paste Text into OMR
• Create the note in Word or other word processing software program
• Highlight or select the text and click on Copy
• Initiate note or letter in OMR
• Click on Edit
• Click on Paste
• OMR pastes the Word text into the OMR note
MEDITECH Remote WorkstationOptions Edit HelpEdit
Copy Alt+C Paste Alt+V Paste Alt+V
111-72-57 FROG,KERMIT M25
ContinueReturn to Table of Contents
Transcription with Freeform Text
ContinueReturn to Table of Contents
--------------------------- ----------------------------- -------------------------- -------------------------Medications before July 22, 2001
PROZAC 20MG—One by mouth at bedtime
No medications DC’d on July 22, 2001.
No medications prescribed on July 22, 2001.--------------------------- ----------------------------- -------------------------- -------------------------
For help info press <F1> To exit press <ESC>
111-72-57 FROG,KERMIT M25
Provider: Smith, MaryDate: July 22, 2001 Type of dictation: Progress note
Type in freeform text.
You can combine freeform text with insert text in a single note.
Press <F6> to access text inserts.
Continue
25 year old male with history of depression
Return to Table of Contents
Transcription with a Template
ContinueReturn to Table of Contents
----------------------------------------------------------------------------------------------------------------
Medi
Pro
No m
No m---------------------------------------------------------------------------------------------------------------
Select Topic
NameExamNorm{Antepartu{Complianc{Dermatolo{Discharge{Endocrine{HCA}{Psychia
GENERAL: Well appearing in no distress***(Index Term)******(Index Term)******(Index Term)******(Index Term)******(Index Term)******(Index Term)******(Index Term)***
NextPage PrevPage Done
111-72-57 FROG.KERMIT M25
Provider: Smith, MaryDate: July 22, 2001 Type of dictation: Progress note
For help info press <F1> To exit press <ESC>
SelectSelect
{Psychiatr
{Psychia *** (Index Term)****
When you press <F6>, OMR displays personal text inserts first, followed by public text inserts organized by service. You can use any service’s text inserts. Use the arrow keysto select the Service from the list or enter the first few letters of the Service name. Press <ENTER>.
Continue
---------------------------------------------------------------------------------------------------------------------------
Medi
PR
No m
No m---------------------------------------------------------------------------------------------------------------------------
Select Topic
Name
ED/AdmitHMFP evalHMFP groupHMFP noteHMFP termHMFP treatNEURO dataNEURO evalOPD eval
BETH ISRAEL DEACONESS MEDICAL CENTERAMBULATORY SERVICES – HMFP PRACTICE GROUAMBULATORY SERVICES – HMFP PRACTICE GROUAMBULATORY SERVICES – HMFP GROUP PRACTICAMBULATORY SERVICES – HMFP PRACTICE GROUAMBULATORY SERVICES – HMFP PRACTICE GROUCONFIDENTIAL – NEUROPSYCHOLOGICAL DATA SCONFIDENTIAL NEUROPSYCHOLOGICAL CONSULTAMBULATORY SERVICES – RESIDENCY TRAINING
NextPage PrevPage Done
111-72-57 FROG.KERMIT M 25
Provider: Smith, MaryDate: July 21, 2001 Type of dictation: Progress note
For help info press <F1> To exit press <ESC>
Select
HMFP treat AMBULATORY SERVICES – HMFP PRACTICE GROU
HMFP treat
Select
A list of departmental text inserts appears.
Use the arrow keys to select the template.
Continue to Use a Text Insert
0901910 FROG.KERMIT M41
Provider: Smith, MaryDate: July 21, 2001 Type of dictation: Progress note
DSM-IV Diagnosis Codes & Diagnosis DescriptionAxis I [ ] Axis II [ ]Axis III [ ]Axis IV [ ]Axis V: [ ]
TYPE OF TREATMENT: Include relevant modality, frequency and duration of treatment; using the examples below.
Modality: [ ] Psychopharmacology
Frequency: [ ] Weekly [ ] Twice per month [ ] Monthly [ ] Quarterly [ ] Other, please specify:Duration: [ ] Within UR Protocol [ ] Out of Protocol[ ] Long term maintenance [ ] Other, please specify:For help info press <F1> To exit press <ESC>
296.33 Severe Depression
x
xx
Type the appropriate information into the text insert.
After the note is complete, press <ESC>.
Continue to Save NoteReturn to Table of Contents
Save Transcription
ContinueReturn to Table of Contents
111-72-57 FROG.KERMIT M25
Provider: Smith, MaryDate: July 21, 2001 Type of dictation: Progress note
Note:DSM-IV Diagnosis Codes & Diagnosis DescriptionAxis I [296.33] Severe DepressionAxis II [Axis III [Axis IV [Axis V: [
TYPE OF TREATMENT: In y, frequency andDuration of treatment; using the examples below.
Modality: [x] Psychopharmacology
Frequency: [ ] Weekly [x] Twice per month [ ] Monthly [ ] Quarterly [ ] Other, please specify:Duration: [x] Within UR Protocol [ ] Out of Protocol[ ] Long term maintenance [ ] Other, please specify:
For help info press <F1> To exit press <ESC>
Save and Exit
Select Choice
Discard and Exit Save and Exit
S
Save and Exit
When you complete data entry, press <ESC>, OMR prompts you to saveor discard your work.
You can save unfinished work & return to it later.Continue
When you choose to Save & File a note, OMR provides options to:
Review the text you entered
Enter a note title
File the note
Notify the provider that the note is ready to sign
If you press <ENTER> to accept the default of Yes, OMR sendsthe note to the provider’s online list of notes requiring signature.
Enter “ N “ if you wish to return later to complete additional work onthe note before you forward it to the provider for signature.
Review the note? N / /Title (I.e. SUMMARY):OK to file this note? Y / /Notify provider to sign note? Y / /
ContinueReturn to Table of Contents
Display/Edit Transcription
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Editing Transcribed Notes
Unsigned notes• Transcriptionists can edit any unsigned noteentered via transcription for services for which they authorized
Signed notes• Transcriptionists can not edit signed notes.• Once a note has been signed, OMR permitsproviders to make edits during the 3 hours following signing. After that, providers can add addendumsat any time.
Continue to Display/Edit Transcription
You can display or edit any unsigned note entered via theTranscription Option for services you are authorized to access.
Enter “ 2 “ at the Transcription Option prompt todisplay or edit an unsigned note.
Transcription Option
1 Clinical Information options 2 Display/Edit Transcription 3 Enter Transcription 4 Hard Copies - Unsigned 5 Insert test enter/edit 6 Letter/Notes Defaults 7 OMR Messages (Notes for printing) 8 Online Medical Record 9 Providers’ Schedules10 Transcription Report11 Utilities
Transcription Option: 2
Continue
You can display or edit notes using: Transcription date
Patient ID
Enter the name of the provider whose notesyou want to display or edit.
TRANSCRIPTION DATE OR PATIENT ID: T
Continue
PROVIDER:
1. SMITH, MARY 11-111 PSYCHIATRY PAGE: 99999
SMITH, MARY
U 1. FROG,KERMIT 2. FROG,KERMITU 3. FROG,KERMIT
105829511172571316942
PROGRESS NOTEPROGRESS NOTEPROGRESS NOTE
VISIT DATE: 07/24/01 MVWVISIT DATE: 07/22/01 MVWVISIT DATE: 07/23/01 MVW
PROVIDER: SMITH, MARY
Choose from above list to editor press <ENTER> to continue displaying
CHOOSE: 1
Continue
At the prompt, enter the number associated with the note you wish todisplay or edit.
When you choose to display/edit transcriptions by transcription date& enter the provider whose notes you wish to display/edit, OMR Lists all notes entered via transcription for the transcription date specified.
OMR labels all unsigned Notes with a “ U “. Only the text of unsigned notes can be displayed or edited.
OMR also includes the system initials of the transcriptionist who entered the note.
PROVIDER: SMITH, MARY / /Service and Location: 1. Psychiatry, Beth Israel Outpatient DepartmentOk? Y / /PATIENT: FROG,KERMIT / /DATE OF SERVICE: 07/21/2001 / / Initial note Letter Progress note Telephone contact
WHICH TYPE OF DICTATION?: PROGRESS NOTE / /
Continue
The edit option allows you to make changes to unsigned notes entered using the transcription option. By typing the new information in at the appropriate prompt you can make edits to the following :
To retain the existing information, press <ENTER> at each prompt.
• Provider name• Service & location• Patient name• Date of service• Type of dictation
Patient called to discuss test results.
For help info press <F1> To exit press <ESC>
105-82-95 FROG,KERMIT M36
Provider: Smith, MaryDate: July 24, 2001 Type of dictation: Telephone contact
Continue
Asked patient to schedule follow-up appointment.
Press <ESC> to exit and file edits.
Edit existing text or enter new text.
Return to Table of Contents
Printing Unsigned Notes
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Transcription Option 1 Clinical Information options 2 Display/Edit Transcription 3 Enter Transcription 4 Hard Copies - Unsigned 5 Insert test enter/edit 6 Letter/Notes Defaults 7 OMR Messages (Notes for printing) 8 Online Medical Record 9 Providers’ Schedules10 Transcription Report11 UtilitiesTranscription Option: 4 Hard Copies – UnsignedPROVIDER:
Continue
Select one of the following, or press <Enter> for all: Initial note Letter Progress note Telephone contactWHICH TYPE OF DICTATION?:
To print out copies of unsigned notes for review or manual editing, enter “ 4 “ at the Transcription Option prompt.
SMITH, MARY 1. SMITH, MARY 11-111 PSYCHIATRY PAGE 99999OK? Y / /
Enter the name of the provider whose unsigned notes you wish to print.
Enter the type of unsigned note you wish to print. To print all types, press <ENTER>.
Return to Table of Contents
Establishing Margin & Printing Defaults
Return to Table of Contents Continue
Transcription Option
1 Clinical Information options 2 Display/Edit Transcription 3 Enter Transcription 4 Hard Copies - Unsigned 5 Insert test enter/edit 6 Letter/Notes Defaults 7 OMR Messages (Notes for printing) 8 Online Medical Record 9 Providers’ Schedules10 Transcription Report11 Utilities
Transcription Option: 6
Continue
To establish margin & printing defaults, enter “ 6 “ for Letter/Notes Defaultsat the Transcription Option prompt.
Default option
1 Letter printing 2 Notes printing
Default option: 1
Continue
To establish margin defaults, enter “ 1 “ for Letter Printing at the
Default Option prompt.
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:
ContinueReturn to Table of Contents
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
Continue to Additional Information about OMR
Click on HELP on the CareGroup portal for detailed CCC/OMR help.
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Click on CCC/OMR Help for OMR Documentation topics.
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OMR documentation topics include: General Information, Medications, Notes, Problem Lists, Management Options, and Transcription Information. Continue
Questions or Problems
For computer & printer problems
• Call the IS Support Center x48080
For questions about how to use OMR
• Email [email protected]• Receive a response within 1 business day
Continue
…And OMR Overview Training is Complete
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