MR-005 Content of the Legal Electronic Medical/Mental Health Record

Attachment A-Patient/Client Index in Open Chart

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Access in PnC depends on assigned permissions, roles, and responsibilities

Patient Index-Open Chart
Summary: Is a brief summary of the patients/clients EHR to include such things as demographics, insurance, allergies, alerts, last medical visit, PCP, problem list, medications, Counseling synopsis, Advanced Directives. The Summary List is not considered part of the EHR and is NOT copied for ROI/subpoena requests (it is a collection of information in the EHR).
Registration: The registration history of the patient/client (eligibility, SHIP coverage, other insurance, Admin Alerts and notes, destroyed charts, 4D reference, etc.
Reminders: This screen shows past and future reminders about this patient.
Appointments: This is a list of all past and future appointment dates and times. Includes who the provider was, and the status of each of those visits, no show, canceled, completed, and checked out.
All Results: This is a listing of all lab and x-ray results, the date done, when and who acknowledged and how the result was acknowledged.
Problem List: Information can flow from a visit note by provider request or can be entered outside of a note.
Health/Disease Tracker: Based on a specific problem on the patient/clients problem list
Immunization: All immunizations given at SHCS are done through a template which auto fills this screen. RN’s have the option of adding in any immunization documentation the patient brings in to a visit. Incoming immunization documentation is scanned into record.
Diagnoses: This is a list of all diagnoses for each patient/client encounter. Providers can click on any of the diagnoses and it will take them to that visit encounter. A provider can go to this screen and “Remove Diagnosis” if appropriate.
Allergies: This area stores all Allergy information identified in a clinic visit. A new allergy can be added in this screen outside a visit.
Medications: This screen houses the active and historical listing of the patient’s/client’s medications given at SHCS. Providers have the ability to Renew/Review, Add a medication, Edit a Medication, D/C a medication and screen a medication for drug alerts.
This screen shows the medication type, date ordered, dose/sign/duration.
When providers click on a medication it will show the Prescription on the bottom of the page with the ability to click on the visit date and go right into the note.
If the provider makes an error on a prescription and signs their note, they can then
Call the pharmacy to change the medication error, and then go to this screen and modify or D/C the medication.
Procedures: This is a listing of all procedures that were ‘completed’ on a patient/client.
Labs/Cross Tabs: Tabular data and Textural Data. This allows providers to compare lab values over a range of time.
Vitals: Vitals are performed at each medical visit. Can view all vitals done on a patient/client in this one area. Providers can graph each individual value by clicking on the icon next to the description. Providers also are able to go directly to the note associated with that set of vitals by clicking on the date.
Radiology: All scanned radiology results, associated with an order, are available here.
EKG/PFT: Awaiting interfaces, at this time EKG’s are scanned into the Documents folder under SHCS Diagnostics.
Compliance Forms: HIPAA compliance is now being tracked in PNC. (Will evaluate the ability to track entrance requirements for vets and FNP’s from this screen in the future.)
Lab Specimens: A listing of all patient’s lab orders, the status of that order, and the result. This is where the lab gets accessioned, an order can be canceled, and also where results are scanned.
Referrals: This is a listing of all the patient’s/client’s internal and external referrals. It shows the status of each referral.
Outside Care: (Not used at this time.)
DOCUMENTS: Any document scanned into the EHR will show up in a scanned folder. Documents honor security divisions.
Admin/Legal Antigen Folder
Clearance Forms/Physical Exams Immunizations
Clinical History Photographs
Consents Patient Letters
Lab Paper Chart
Logs and Questionnaires Clearance forms/physical exams
Outside Provider Referral Documents
MH Admin/legal Radiology Reports/Imaging
MH Testing
MH Outside Records
MH Clinical
MH Client Generated Records
SHCS Diagnostics
Messages: This is a list of secure messages related to a patient/client. Messages within a division, are viewable to staff who have access to messages in that Division. This area would also include any internal open communicator message from provider to provider with the patient/client attached. It shows the date sent, from whom, to whom, the read date, the subject, the status (resolved, unresolved, read), reply date and replied by. Messages ‘can’ cross divisions.
Letters: All letters that are produced in PNC will show up in this area, i.e. no-show letters, referral letters, letters to patients/clients regarding lab results, medical excuse letters, etc.
Orders: All signed orders on a patient/client will show up here - with the current status. When you select the order, you will see the complete order at the bottom of the page.
Flow Sheets: Flow sheets are initiated from within an encounter note.
Encounter Note:
08/01/07: SHS started documenting their notes in PnC. Brief psychiatry notes were also documented at this time.
07/01/11: CAPS began documenting their visit notes in PnC. MH and psychotherapy notes are under the Psychiatry and Counseling Divisions viewable by permissions.

08/07, 02/09, 07/11, 02/13