Explorer Menu is being replaced with Discern Report Portal. Please review the following instructions to locate reports.
How to access reports using Discern Reporting Portal:
Select Discern Reporting Portal on the tool bar in PowerChart or add to your AppBar, see last page.
The reason this document was created is because we have many patients that receive their flu vaccine outside our system and we have not captured this information well in the past. The flu vaccine is a measure that is tracked. An example of the workflow,
During intake,
Ask the patient if they would like a flu shot. If yes then order and complete your normal workflow
If the patient states NO, please complete this new form in the intake section
If the patient had one outside our system document that through the immunization workflow (screenshot in attachment)
For Specialty areas that do not give the flu shot, we still need your help to capture flu vaccines that have been given outside the practice. Please ask your patients if they had the flu shot and if it is outside our system please document in the immunization workflow. If they state they are going to refuse the vaccine, you can chart this in the intake form as well.
Please contact the TTP Performance Improvement group for further questions.
Tutorial:
In order to aid the ambulatory locations in documenting and tracking influenza vaccines, a new section has been added to the ambulatory intake PowerForms.
The fields are not required, but it is an expectation that this section is addressed, especially during the influenza season.
There are two fields to fill out, if applicable; in the event the patient has not had the vaccine, whether it was because they declined it or the vaccine was not available.
Provided also is a field that displays the influenza vaccines previously documented in the Cerner PowerChart system.
Please make sure to adhere to your department’s policy regarding addressing the patient's need for the vaccine, ordering of vaccine, and documentation of the vaccine (historical or otherwise) in the Immunization Profile tool in PowerChart.
For you convenience: New leg length fields if needed. They do not calculate into the Hgt/Wgt/BMI measurments. For recording purposes only.
TTP CLINICAL NURSING UPDATE AND REFRESHER / September 2018
To report Patient Treatment of Notifiable Conditions to Lubbock Health Department, TTP Clinical Nursing Staff should follow these required guidelines to #1) document treatment and #2) complete notification process to the Lubbock Health Department:
Open patient chart on the correct clinical encounter.
Add a new power note. Select Notification Documentation as the note type.
Select the Communicable Disease Report Form Encounter pathway.
Fill out the custom note as required utilizing the smart templates (ST), bringing in all vital reportable information from the patient’s chart.
Option of: Faxed to Lubbock Health Department @ fax # 806 775 3184.**This is documentation purposes only ***
Sign the power note when finished, and request signature by provider as notification of reporting.
VERY VERY IMPORTANT: When signing your note, you MUST check the box at the bottom that states – PRINT FINAL DOCUMENT USING. THE MEDICAL RECORD REQUEST OPTION WILL AUTOMATICALLY DEFAULT. Now you may click SIGN and submit your note.
These steps are critical in telling the Cerner System how and where to fax your patient’s power note to the Lubbock Health Department.
One Time Set-up for Your Defaults:
#1) Template: This is automatically set to TTUHSC – CLINIC REFERRAL LETTER.
#2) Purpose: Select FURTHER MEDICAL CARE. This choice will now save as your default.
#3) Device: Type in LUBBOCK HEALTH DEPARTMENT, select this option.
The Remote Report Distribution Selection window will open……NO NOT CHANGE ANY INFORMATION. CLICK OK.
4) The Medical Record Request window will reopen….RIGHT CLICK ON THE LUBBOCK HEALTH DEPARTMENT UNDER THE DEVICE OPTION, AND SET LUBBOCK HEALTH DEPARTMENT AS YOUR DEFAULT (this is a one-time default set)
5) Click SEND.
6) Request Submitted window will open. Click OK. Process is completed.
The GAD-7 is available as an Ad Hoc form in Powerchart. This form is typically completed by the patient and then scanned into the chart. The information will now be transcribed to the electronic form and the results will display in the Results Flowsheets. These results can be populated in the Powernote by the provider similar to other results. The paper document can then be destroyed per your clinics guidelines and does not need to be scanned into the chart.
Ambulatory Fall Risk Assessment –
The Fall Risk Assessment will be added as a section to the all ambulatory intake forms. This form is based off the CDC STEADI Algorithm for Fall Risk Screening, Assessment, and Intervention and the Risk Recommendations field comes from the recommendations of the STEADI algorithm. This section is required for Annual Wellness Visits. Visit https://www.cdc.gov/steadi/index.html for more information.
Amb Cardiopulmonary Arrest Report
A new form for documenting emergent situations that occur in the clinic that require a patient to be transported. The form is has 1 required field (Clinic Name/Location). A freetext summary is included at the bottom of the form. Clinic policy should dictate the information required when such an event occurs. The completed form can be found in Clinical Notes > Clinic Office > Cardiopulmonary Arrest Report.
Several passive updates were installed with the latest code upgrade. Listed below are two extras that were noted.
Medication PowerForm with Task List Charting:
1. The Lot Number and Manufacturer fields rotated positions
2. The OBGYN PowerChart Maternity Prenatal Cards have moved from "diabled from modifying existing card" (mpages 6.2 in December, 2016) to "disabled from back-charting on a previous date card" (mpages 6.3+ in July, 2017).
This translates to making sure you are charting on the prenatal card on the date of service. The secondary workflow of modifying/late charting through iNet still exists.
The 'standing delegation' communication type has been added to the Nurse and Psych Nurse Office Clinic positions. The default is verbal/read. If the nurse is placing a standing delegation order, they will need to select the applicable option. Please see screenshot below.
Please inform the clinics/nursing staff accordingly.
To assist with compliance in the documentation needs for Combest, some additions and modifications are being made to nursing intake PowerForms. Some of these additions are viewable in the main stream intake forms as well.
New sections are being added to the intakes as well as located outside of them, should you wish to document that specific data without having to fill out the entire intake form.
To document the Early Entry into Pregnancy Care, there is a new section being added to the OB intake PowerForm. It has no required fields, it is not mandatory to fill out. This is for the purpose of documenting when a pregnant female entered the health care system for pregnancy care. Was it with us? Or was the first visit with someone else?
The new Sexuality History section combines some existing fields from the Female Reproductive History, and pulls them into the new section that can be used for any gender. New fields added to this section include expanded Sexual Orientation, the new Gender Identification, as well as the new Sex at Birth.
For those that need to track medication authorizations, there is now a new form available to you! If you would like this added to your departments adhoc folder, just let us know.
For those who were unaware, there is a PowerForm for the documentation of outside Hemoglobin A1Cs if ever needed for ambulatory use. Due to CAP regulatory requirements, they need to know the locaiton of the outside laboratory that performed the test. Therefore, in the near future, the field for the location will be made "required" (yellow). This existing field is a freetext field for your convenience.
For a further Meaningful Use, Quality requirments, a new mandatory field has been added to catch "smokeless" tobacco data and education.
You can expect this to be turned on by September 23rd. Please educate all nursing staff accordingly.
TUG Test (Timed Up & Go)
PHQ-9 (Patient Health Questionnaire - Adult)
Two new powerforms are available for provider/mid-level/nurse documentation. Currently, the powerform is nested (when saved) in "form browser" and "clinical notes". Hopefully at a later date it will also live in the flowsheet as well, but this has not yet been approved and their is not estimated date.
The forms can be found for ad hoc documentation within the "Additional Assessments" folder.
* In Ad Hoc, click on the 'Workers Compensation' tab
* Once the form opens, populate the following fields:
1. Date of Injury
2. Injured at Work
3. Employer (if needed)
4. Injury Side
5. Injury Site
* Once a form is completed, use the check mark to sign it
* A charge will need to be dropped by the provider or nurse for the visit
* The date of injury will flow through the interface into TES for the coders and billing staff to
add to claims
*The coders will still have to populate the remaining fields in TES
Updated Pain Assessment for the Cognitively Impaired
To stay in accordance with current evidence based practice, UMC has updated their inpatient nursing documentation of the cognitively impaired patient. This will have small changes to outpatient pain documentation as well. No changes will be noticible unless you select that option for cognitively impaired while doing your pain documentation. You will then be taken to the newly updated subscreen to continue as usual.
The new cognitively impaired pain assessment tool will go in to effect later today and should cause minimal workflow change.
A side note to point out is that each field has reference text associated to it that can assist staff with how to score a particular field if they get stuck.
‘Unknown History’ has been added to the Transfusion History DTA:
For your convenience, a new diabetic foot exam with diagram if you should ever need/want to document specific foot assessments. Enjoy!
FOLDERS:
Case Management
Ambulatory Procedures
TTU Family Medicine
TTU Internal Medicine
TTU Student Health
TTU Combest
TTU Pediatrics
Ambulatory Intake/History
A new section has been added to document healthcare agents or decision makers for the patient. The fields are not mandatory, so feel free to use them as you need to. Enjoy!
