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OMR Transcription Options & Features Click Mouse to Advance.

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Presentation on theme: "OMR Transcription Options & Features Click Mouse to Advance."— Presentation transcript:

1 OMR Transcription Options & Features Click Mouse to Advance

2 OMR Transcription Overview The purpose of this presentation is to provide an overview of basic OMR transcription functions. Continue to View List of Contents

3 Keystrokes & conventions Accessing OMR & Transcription options Entering a note in Transcription Using free text Using a template Pasting from Word Saving a transcribed note & forwarding it 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

4 OMR Keystrokes & Conventions To move back one level Type an underscore (Shift hyphen) To exitType a ^ (Shift 6) or if in a word processor window press To view helpEnter a ? or if in a word processor window press 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. To delete a previouslyEnter an * (Shift 8). filed entry without replacing the data Continue Return to Table of Contents Use these keystrokes & conventions when you work in OMR. For this overview, only mouse clicking is required.

5 Accessing OMR & Transcription Options Continue Return to Table of Contents

6 Accessing OMR & Transcription Options The Online Medical Record (OMR) is part of BIDMC’s Clinical Computing System (CCC). To obtain OMR access contact the IS Support Center at (617) Hospital computers provide direct access to OMR for authorized users. External transcription services can access OMR remotely. Continue

7 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: To install Metaframe use the following link & follow the directions provided:http://home.caregroup.org/metaframe/http://home.caregroup.org/metaframe/ To obtain remote access help using any of these methods, contact the IS Support Center at (617) Remote Access

8 To access OMR, sign onto CCC. Use the up & down arrow keys on your keyboard to select Online Medical Record. System O Appointments/Scheduling Clinical Information Online Medical Record OPD Reg (Outpatient Admitting) Online Medical Record NextPagePrevPageDone Select Beth Israel Deaconess Medical Center Clinical Computing – CCC System Mary Smith Port: TS3.421 Continue

9 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’ Schedules 10 Transcription Report 11 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

10 Entering a Transcription Continue Return to Table of Contents

11 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’ Schedules 10 Transcription Report 11 Utilities Transcription Option: 3 Enter 3 at the Transcription Option prompt to enter a transcription. Continue

12 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 to accept this information or type in the Service & Location specified in the dictation. PROVIDER: SMIT, MAR 1. SMITH, MARY PSYCHIATRY PAGE: OK? Y / / Service and Location: 1. Psychiatry, Beth Israel Hospital Outpatient Department Ok? Y / / PATIENT: FROG,KERMIT There are several test patients in OMR to use for training. They include: Kermit Frog, MRN Kermit Frog, MRN Continue OMR displays matches to the name you entered. Press 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

13 After you enter the patient’s identifying information, OMR displays a list of patients to choose from. NextPagePrevPageDone Select Choose Patient: Frog,Kermit 41 M Sep 1959 OUTPT Main Street Anywhere Frogger Frogette Frogge Frog,Kermit 79 M Feb 1922 OUTPT (ACCESS RESTRICTED) Ziggy Phyllis Nancy Frog, Kermit 36 M Jul 1964 OUTPT (ACCESS RESTRICTED) Joseph Donna Fanny Frog Frog,Kermit 25 M Jan 1976 OUTPT Glendale St Everett Richard Mary Linda Frog,Kermit 25 M Jan 1976 OUTPT Glendale St Everett Richard Mary Linda Use the up and down arrow keys on your keyboard to highlight the correct patient and press. Continue

14 At the Date of Service prompt, enter the date using the format MM/DD/YY or enter T-X. For example for yesterday, enter T-1. There are 4 dictation types: initial note, letter, progress note, telephone contact. 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,KERMIT With SANDS,DANIEL Z. on 07/22/01 Enter dictation anyway? N / / Y

15 Medications before July 22, 2001 PROZAC 20MG—One by mouth at bedtime No medications DC’d on July 22, No medications prescribed on July 22, For help info press To exit press FROG,KERMIT M25 Provider: Smith, Mary Date: July 22, 2001 Type of dictation: Progress note OMR includes the patient’s medications as established by the clinician’s default settings. Continue to View Help For HELP press To escape the notes screen: Press at any time.

16 Medications before July 22, 2001 PROZAC 20MG—One by mouth at bedtime No medications DC’d on July 22, No medications prescribed on July 22, For help info press To exit press FROG,KERMIT M25 Provider: Smith, Mary Date: July 22, 2001 Top of Document F9 Additional Help F1 Select Text F2 Paste F3 Delete Word F4 & Shift F4 Text Inserts F6 Set Up Search F7 Search F8 Top of Document F9 End of Document F9 Page Up Shift Up Arrow Page Down Shift Down Arrow Word Back Shift Left Arrow Word Forward Shift Right Arrow Exit Top of Document F9 OMR Help: Use the up & down arrow keys on your keyboard to highlight a Help option. To Exit Help: Press. Continue : Progress Note

17 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

18 Transcription with Text from a Word Processing File Continue Return to Table of Contents

19 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 Workstation Options Edit Help Edit Copy Alt+C Paste Alt+V FROG,KERMIT M25 Continue Return to Table of Contents

20 Transcription with Freeform Text Continue Return to Table of Contents

21 Medications before July 22, 2001 PROZAC 20MG—One by mouth at bedtime No medications DC’d on July 22, No medications prescribed on July 22, For help info press To exit press FROG,KERMIT M25 Provider: Smith, Mary Date: 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 to access text inserts. Continue 25 year old male with history of depression Return to Table of Contents

22 Transcription with a Template Continue Return to Table of Contents

23 Medi Pro No m Select Topic Name ExamNorm {Antepartu {Complianc {Dermatolo {Discharge {Endocrine {HCA} {Psychia GENERAL: Well appearing in no distress ***(Index Term)*** NextPagePrevPageDone FROG.KERMITM25 Provider: Smith, Mary Date: July 22, 2001 Type of dictation: Progress note For help info press To exit press Select {Psychiatr {Psychia*** (Index Term)**** When you press, 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 keys to select the Service from the list or enter the first few letters of the Service name. Press. Continue

24 Medi PR No m Select Topic Name ED/Admit HMFP eval HMFP group HMFP note HMFP term HMFP treat NEURO data NEURO eval OPD eval BETH ISRAEL DEACONESS MEDICAL CENTER AMBULATORY SERVICES – HMFP PRACTICE GROU AMBULATORY SERVICES – HMFP GROUP PRACTIC AMBULATORY SERVICES – HMFP PRACTICE GROU CONFIDENTIAL – NEUROPSYCHOLOGICAL DATA S CONFIDENTIAL NEUROPSYCHOLOGICAL CONSULT AMBULATORY SERVICES – RESIDENCY TRAINING NextPagePrevPageDone FROG.KERMITM 25 Provider: Smith, Mary Date: July 21, 2001 Type of dictation: Progress note For help info press To exit press 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

25 FROG.KERMITM41 Provider: Smith, Mary Date: July 21, 2001 Type of dictation: Progress note DSM-IV Diagnosis Codes & Diagnosis Description Axis 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 To exit press Severe Depression x x x Type the appropriate information into the text insert. After the note is complete, press. Continue to Save Note Return to Table of Contents

26 Save Transcription Continue Return to Table of Contents

27 FROG.KERMITM25 Provider: Smith, Mary Date: July 21, 2001 Type of dictation: Progress note Note: DSM-IV Diagnosis Codes & Diagnosis Description Axis I [296.33] Severe Depression Axis II [ Axis III [ Axis IV [ Axis V: [ TYPE OF TREATMENT: In y, frequency and Duration 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 To exit press Save and Exit Select Choice Discard and Exit Save and Exit S When you complete data entry, press, OMR prompts you to save or discard your work. You can save unfinished work & return to it later. Continue

28 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 to accept the default of Yes, OMR sends the note to the provider’s online list of notes requiring signature. Enter “ N “ if you wish to return later to complete additional work on the 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 / / Continue Return to Table of Contents

29 Display/Edit Transcription Continue Return to Table of Contents

30 Editing Transcribed Notes Unsigned notes Transcriptionists can edit any unsigned note entered via transcription for services for which they authorized Signed notes Transcriptionists can not edit signed notes. Once a note has been signed, OMR permits providers to make edits during the 3 hours following signing. After that, providers can add addendums at any time. Continue to Display/Edit Transcription

31 You can display or edit any unsigned note entered via the Transcription Option for services you are authorized to access. Enter “ 2 “ at the Transcription Option prompt to display 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’ Schedules 10 Transcription Report 11 Utilities Transcription Option: 2 Continue

32 You can display or edit notes using: Transcription date Patient ID Enter the name of the provider whose notes you want to display or edit. TRANSCRIPTION DATE OR PATIENT ID: T Continue PROVIDER: 1. SMITH, MARY PSYCHIATRY PAGE: SMITH, MARY

33 U 1. FROG,KERMIT 2. FROG,KERMIT U 3. FROG,KERMIT PROGRESS NOTE VISIT DATE: 07/24/01 MVW VISIT DATE: 07/22/01 MVW VISIT DATE: 07/23/01 MVW PROVIDER: SMITH, MARY Choose from above list to edit or press to continue displaying CHOOSE: 1 Continue At the prompt, enter the number associated with the note you wish to display 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.

34 PROVIDER: SMITH, MARY / / Service and Location: 1. Psychiatry, Beth Israel Outpatient Department Ok? 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 at each prompt. Provider name Service & location Patient name Date of service Type of dictation

35 Patient called to discuss test results. For help info press To exit press FROG,KERMIT M36 Provider: Smith, Mary Date: July 24, 2001 Type of dictation: Telephone contact Continue Asked patient to schedule follow-up appointment. Press to exit and file edits. Edit existing text or enter new text. Return to Table of Contents

36 Printing Unsigned Notes Return to Table of Contents Continue

37 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’ Schedules 10 Transcription Report 11 Utilities Transcription Option: 4 Hard Copies – Unsigned PROVIDER: Continue Select one of the following, or press for all: Initial note Letter Progress note Telephone contact WHICH 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 PSYCHIATRY PAGE OK? 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. Return to Table of Contents

38 Establishing Margin & Printing Defaults Return to Table of Contents Continue

39 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’ Schedules 10 Transcription Report 11 Utilities Transcription Option: 6 Continue To establish margin & printing defaults, enter “ 6 “ for Letter/Notes Defaults at the Transcription Option prompt.

40 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.

41 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. L MB PS 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

42 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: Continue Return 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

43 For Additional Information Continue to Additional Information about OMR

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

45 Click on CCC/OMR Help for OMR Documentation topics. Continue

46 OMR documentation topics include: General Information, Medications, Notes, Problem Lists, Management Options, and Transcription Information. Continue

47 Questions or Problems For computer & printer problems Call the IS Support Center x48080 For questions about how to use OMR Receive a response within 1 business day Continue

48 …And OMR Overview Training is Complete Click Here to Return to CCC/OMR Help OR Click Here to Return to the CareGroup Portal


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