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Cortex GOLD Audit Report Decoder Heather Sousa Cortex User Group 2011 New Orleans.

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Presentation on theme: "Cortex GOLD Audit Report Decoder Heather Sousa Cortex User Group 2011 New Orleans."— Presentation transcript:

1 Cortex GOLD Audit Report Decoder Heather Sousa Cortex User Group 2011 New Orleans

2 Reasons to Audit To Track who entered or deleted information on a Case or a Patient. To track what information was entered or deleted on a Case or Patient. CAP Lab General Checklist question: –GEN Data Input ID

3 CAP; Laboratory General Checklist Compliance There is an adequate system to identify all individuals who have entered and/or modified patient data or control files. NOTE: When individual tests from a single test order (e.g. multiple tests with same accession number) are performed by separate individuals and the test result is entered into the LIS, the system must provide an audit trail to document each person involved. For example, a single accession number having orders for electrolytes and a lipid panel may have testing done by two or more individuals. The laboratory should be able to identify the responsible personnel who performed each test and posted the data. This includes sequential corrections made to a single test result. If autoverification is used, then the audit trail should reflect that the result was verified automatically at a given time. With point-of-care testing, if the individual performing the test is different than the individual entering test data into the LIS, both should be uniquely identified by the system and retrievable by audit trail. REFERENCES 1) Jones JB. The importance of integrating POCT data into an organized database. Advance/Laboratory. 1999;8(9):8-10 2) Halpern NA, Brentjens T. Point of care testing informatics. The critical care-hospital interface. Crit Care Med. 1999;15: GEN.43800Data Input IDPhase II

4 Gold Archive Reports With Gold 2008 SP1 all Gold Users have AutoAudits set up in their system. Gold versions prior to this must have the AutoAudit scripts installed and running for these reports to produce results. The Audit_Archive_Reports are used if you have too much data audited, and want to store/archive it in these reports. This way when you run Audit_Report it won’t take so long, because you’ve archived, for example, all cases except the past 3 years.

5 AUDIT_REPORT by Accession Number Note: Even though you have a choice for Accession Range, Audit will use the “From” Accession number only. Tables Audited by this Report Cases Case_Screener Case_Diagnosis Case_SpecialStatus Case_Procedure PrintJob

6 AUDIT_REPORT_BY_ACTION_TYPE by Accession Number Note: You should only Audit one Accession number at a time, even though you get the choice to enter a range of Accession numbers. Tables Audited by this Report Cases Case_Screener Case_Diagnosis Case_SpecialStatus Case_Procedure PrintJob ACTION TYPE = Delete, Insert, View, Update

7 AUDIT_REPORT_FOR_PATIENT by Patient Number or Patient Name Enter Patient’s last name and choose from a list OR Enter the Patient Number Tables Audited by this Report PatientPayor Patient You may use this report to see who changed a Patient’s name or Insurance Information

8 AUDIT_REPORT_FOR_PATIENT_BY_ ACTION_TYPE by Patient Number or Patient Name Enter Patient’s last name and choose from a list OR Enter the Patient Number Tables Audited by this Report PatientPayor Patient You may use this report to see who changed a Patient’s name or Insurance Information ACTION TYPE = Delete, Insert, View, Update

9 See Power Point slide Table: Cases (Only Columns Listed Below are Audited in AUDIT_REPORT) 10IDInternal Case ID. Hover over Accession # in Case Management AccessionNoAccession Number 11ClinicianIDID number of Clinician on the case on Requisition Tab 12ClinlocationIDID number of Clinician Location on the case on Requisition Tab (not copies to) CompletedDateDate case was completed ElectronicallySignedFlag =Y when it goes to pathologist review (button) or N when it doesn’t LastUpdatedyByLast person who saved LastUpdatedDateLast time it was saved by this person 13StatusCode50006Completed/Locked 50008Final Print 50002Gross Entered 50004Gross Printed 50000Open 14PatientIDID number of the patient on the Case. Hover curser over patient name to see Patient ID number.

10 Cases.CaseID Hover over the Accession number on the case to get the CaseID

11 Cases.ClinicianID Clinician ID: See number to the right of the Clinician Name in Maintain Clinicians area.

12 Cases.ClinLocationID Clinician Location ID: See the number to the Right of the Location. In Maintain Clinician Locations area.

13 Cases.StatusCode The status of the case as it is signed out Completed/Locked 50008Final Print 50002Gross Entered 50004Gross Printed 50000Open

14 Cases.PatientID Patient ID: Hover with your curser over the Patient Name Or look at the bottom right corner of Case Management screen

15 See Power Point slide Table: Case_Diagnosis (All Columns are Audited in AUDIT_REPORT) 16AreaCodeDiagnosis Area Code. Identical to AreaCode column in Diagnosis Table GYN Comments40000 Diagnosis Hormonal40001 Inflammation Maturation Index40006 Other Quality NON GYN45004 Comments45000 Diagnosis Quality 17CaseIDInternal Case ID. Hover over Accession # in Case Management 18DiagnosisCodeThe Internal Code ID (only gyn and hybrid non gyn because they are code based) 19PrimaryFlagPrimary screener is marked “Y”, all others are marked “N” CYTOLOGY: Order of precedence highest to lowest: Pathologist/QC2/QC1/Cytotechnologist HISTOLOGY: Order of precedence highest to lowest: Pathologist Diagnosis/Pathologist Frozen/Pathologist Microscopic/Pathologist Gross 20ScreenerTypeScreener Type and StaffTypeCode are the same thing. SequenceThe order diagnosis codes should display on the case. This is also the order the rows were saved and should be retrieved. Per case. Allows system to order multiple codes. Organization tool that SQL uses.

16 Case_Diagnosis.AreaCode GYN –40004 Comments –40000 Diagnosis –40002 Hormonal –40001 Inflammation –40005 Maturation Index –40006 Other –40003 Quality NON GYN –45004 Comments –45000 Diagnosis –45003 Quality The codes entered for a case are broken down into the Groups below. Each group has a numerical code that is reference in the Audit. Codes are used with Hybrid version of Non Gyns.

17 Case_Diagnosis.CaseID Hover over the Accession number on the case to get the CaseID

18 Case_Diagnosis.DiagnosisCode Internal code for each Diagnosis on the case. See your Maintain Diagnosis area for your Lab’s specific codes.

19 Case_Diagnosis.PrimaryFlag The primary screener is marked “Y”, and all other screeners are marked “N”. Primary Screener = the highest ranked person signing out the case. –CYTOLOGY ranking from highest to lowest: Pathologist/QC2/QC1/Cytotechnologist –HISTOLOGY ranking from highest to lowest: PathDiagnosis/PathFrozen/PathMicroscopic/PathGross Case_Screener.PrimaryFlag = Case_Diagnosis.PrimaryFlag

20 Case_Diagnosis.ScreenerType StaffTypeCode is in the Case_Screener table ScreenerType is in the Case_Diagnosis table Cytotechnologist = 1 Pathologist = 2 (for all case types) StaffTypeCode and ScreenerType are the same animal.

21 See Power Point slide Table: Case_Screener (Only Columns Listed Below are Audited in AUDIT_REPORT) 22 CaseIDInternal Case ID. Hover over Accession # in Case Management 23 ControlNumberColumn number: Histology Only: 2 = Gross, 4 = Microscopic, 6 = Diagnosis, 8 = Frozen Cytology Only: All are set to 1 24 DateDate diagnosis was entered in the grid - for this screener 25 PrimaryFlagPrimary screener is marked “Y”, all others are marked “N” CYTOLOGY: Order of precedence highest to lowest: Pathologist/QC2/QC1/Cytotechnologist HISTOLOGY: Order of precedence highest to lowest: Pathologist Diagnosis/Pathologist Frozen/Pathologist Microscopic/Pathologist Gross QCCommentNon-Printing Comments per screener in the grid. Diagnosis Tab in Case Management SequenceInternal spreadsheet grid row number for this screener in Diagnosis tab. GYN sequence: 2= Cytotech, 3=Pathologist, 4=QC1, 5=QC2 This information may not be useful in an audit. Use StaffTypeCode instead. 26, 27 StaffIDInternal Staff ID Number for this screener 28 StaffTypeCode

22 Case_Screener.CaseID Hover over the Accession number on the case to get the CaseID

23 Case_Screener.ControlNumber Control number lets you know where you are (which column) in the diagnosis grid, and whether you are in Cytology or Histology GYN HISTO 1 Cytology control number is always = 1 Histology is Pathologist type dependent: Gross=2, Micro=4, Diagnosis=6, Frozen=8

24 Case_Screener.Date Date the diagnosis was entered into the grid GYN HISTO

25 Case_Screener.PrimaryFlag The primary screener is marked “Y”, and all other screeners are marked “N”. Primary Screener = the highest ranked person signing out the case. –CYTOLOGY ranking from highest to lowest: Pathologist/QC2/QC1/Cytotechnologist –HISTOLOGY ranking from highest to lowest: PathDiagnosis/PathFrozen/PathMicroscopic/PathGross Case_Screener.PrimaryFlag = Case_Diagnosis.PrimaryFlag

26 Case_Screener.StaffID Internal Staff identification code for this screener. Find this in the Maintain Staff area in the Restricted Files

27 Case_Screener.StaffID Internal Staff identification code for this screener.

28 Case_Screener.StaffTypeCode StaffTypeCode is in the Case_Screener table ScreenerType is in the Case_Diagnosis table Cytotechnologist = 1 Pathologist = 2 (for all case types) QC1, Transcriptionist = 3 QC2, Consultant 1 = 4 (see chart for other StaffTypeCodes) StaffTypeCode and ScreenerType are the same animal.

29 See Power Point slide Table: Case_SpecialStatus (All Columns Audited in AUDIT_REPORT) 30 CaseIDInternal Case ID. Hover over Accession # in Case Management 31 EnteredDateDate the Special Status code was entered in Case Management (Coding Tab) 32 OnsetDateSecond Date next to the Special Status Code in Case Management (Coding Tab) 33 SequenceOrganizes multiple special status codes entered on the case for data retrieval 34 SpecialStatusCodeCode number assigned to the Special Status codes you use in your lab.

30 Case_SpecialStatus.CaseID Hover over the Accession number on the case to get the CaseID

31 Case_SpecialStatus.EnteredDate

32 Case_SpecialStatus.OnsetDate

33 Case_SpecialStatus.Sequence The sequence = which row the Special Status codes were entered into. 1212

34 Case_SpecialStatus.SpecialStatusCode

35 See Power Point slide Table: PrintJob (Columns Audited in AUDIT_REPORT) 37 CaseID Internal Case ID. Hover over Accession # in Case Management 38 ClinLocationNumber Is the same as ClinLocationID. Located to the right of the Clinician Location in Maintain ClinLocations. 39 ClinicianNumber Is the same as ClinicianID. Located to the right of the Clinician Name in Maintain Clinicians area. DestinationTitle This field changes depending upon how your are printing. ErrorDescription Reasons a case did not print. Status Message in red in Print Job Viewer. For example: “possible Pre-conversion case” 40 FinalPrint When you press the fax/print button from Case Management. Default to send to Final Print is unchecked = N. Final Print checked = Y ID Not important for auditing 41 NumberOfCopies The audit will pull “Number of Copies” from wherever the print job was sent to. For example, if the case is printed via the default printer then it’s the number of copies associated with this Report Location “default printer”. 42 PrintServerWorkstationName Shows Print Server that is processing Print Job. Can see this in print job viewer, scroll to the right. Priority Internal setting to determine print order, set to PrintJob.ID at this time. 44 ReportLocationDestination In Print Job viewer this is “Device/Fax#”. Detailed version of Rpt. Location Name 43 ReportLocationName Set up for each user as they log into GOLD. In Print Job viewer “Location” 45 RequestedByStaffNumber Staff number found in Maintain staff files, name in tracking tab. 46 ScheduleTime For each Report Location set up in ClinLocation, or at Designator level. The audit will show whatever your lab has Schedule Time setup as. PRINT JOB TABLE CONTINUED ON NEXT PAGE

36 See Power Point slide Table: PrintJobCONTINUED (Columns Audited in AUDIT_REPORT) 47 SystemCodeSource ClinLocation Designator Rule ClinLocation Rule Interface Copies To One-Off Designator 48 SystemCodeStatus Deleting Error Paused Processing Ready 49 SystemCodeType Default Fax Default Printer Fax Interface Printer SaveToFile Secure Delivery System 50 SystemCodePrintFileType Adobe PDF Post Script Word Doc Word Docx 51 SystemCodePrintFileSchema AccessionNumber and Clinician and Location Accession Number and Time Stamp Accession Number Only

37 PrintJob.CaseID Hover over the Accession number on the case to get the CaseID

38 PrintJob.ClinLocationNumber Clinician Location ID: See the number to the Right of the Location. In Maintain Clinician Locations area.

39 PrintJob.ClinicianNumber Clinician ID: See number to the right of the Clinician Name in Maintain Clinicians area.

40 PrintJob.FinalPrint For example: From Case Management, press Print/Fax button On your Audit Final print button checked = Y Final print button not checked = N

41 PrintJob.NumberOfCopies The audit will pull “Number of Copies” from wherever the print job was sent to. For example, if the case is printed via the default printer then it’s the number of copies associated with this Report Location “default printer”.

42 PrintJob.PrintServerWorkStationName Scroll to the right when in print job viewer Used to indicate that a job is in processing. Whenever a Print Server grabs a group of jobs to process, the first thing it does is stamp them with the name of the PrintServer that is processing them. It does this for single Printserver systems as well as multiple.

43 PrintJob.ReportLocationName Default Can be set up when you first log into GOLD One-offs Can be chosen when you Print from Case Management (drop down) Where your patient reports are printing

44 PrintJob.ReportLocationDestination In Print Job viewer this is “Device/Fax#”. Detailed version of Rpt. Location Name BizHub 451 is specific Report Printer Individual Fax number is specific to Fax to Brooks- office

45 PrintJob.RequestedByStaffNumber Staff name can be found on Tracking tab on case, but the Audit_Report lists that persons “StaffNumber” found in “Maintain Staff Codes” in Restricted Files area.

46 PrintJob.ScheduleTime The audit shows the Scheduled Time that is in the Print Job Viewer. Therefore it audits the time dependent upon how your lab has this set up. Scheduled Time can be set up in ClinLocation or at the Designator level

47 PrintJob.SystemCodeSource Internal Codes audited: ClinLocation ClinLocation Rule Copies To Designator Designator Rule Interface One-Off

48 PrintJob.SystemCodeStatus Internal Codes Audited: Deleting, Error Paused, Processing, Ready

49 PrintJob.SystemCodeType Internal Codes Audited: Default Fax, Default Printer, Fax Interface, Printer SaveToFile Secure Delivery System = Report Location Types

50 PrintJob.SystemCodePrintFileType Internal Codes Audited Adobe PDF Post Script Word Doc Word Docx

51 PrintJob.SystemCodePrintFileSchema Internal Codes Audited AccessionNumber and Clinician and Location Accession Number and Time Stamp Accession Number Only = Print Naming Schema

52 See Power Point slide Table: Case_Procedure (All Columns are Audited in AUDIT_REPORT) 53 AuthorizationNumberRarely used, but when a service requires an authorization to bill 54 BilledDateAuto filled when case is generated across to Soloman. 55CaseIDInternal Case ID. Hover over Accession # in Case Management 56 ICD1PSMG uses codes in Coding tab for more flexibility. 56 ICD2 56 ICD3 56 ICD4 57 InjuryDate InjuryDate should flow from the Case_Procedure into the Service.InjuryDate 58 Modifier1Specific to your lab. Gives insurance co an added code to procedure codes. Ex. Have an S case and an N case with same procedure code, use modifier to explain to the ins. Co this is NOT a duplicate charge. 58 Modifier2 58 Modifier3 PayorNumberNumber associated with the patient’s insurance company in your system 59 ProcedureCodeInternal Code associated with procedures on the case on Requisition tab. QuantityThe Quantity of each procedure code to be billed SequenceOrganizes multiple procedure codes in the Procedure grid in Case Management 60 WherePerformedScroll to the right in the Procedure grid, press F3 for a drop down list. For laboratories with multiple sites. NOTE: Not all laboratories use the extra fields in the Procedures Grid in Gold.

53 Case_Procedure.AuthorizationNumber

54 Case_Procedure.BilledDate Go to Procedures and scroll to the right

55 Case_Procedure.CaseID Hover over the Accession number on the case to get the CaseID

56 Case_Procedure.ICD1, Case_Procedure.ICD2, Case_Procedure.ICD3, Case_Procedure.ICD4, Go to Procedures and scroll to the right

57 Case_Procedure.InjuryDate Workers Comp information, should generate across

58 Case_Procedure.Modifier1, Case_Procedure.Modifier2, Case_Procedure.Modifier3 Specific to your lab. Gives insurance co an added code to procedure codes. Ex. Have an S case and an N case with same procedure code, use modifier to explain to the ins. Co this is NOT a duplicate charge

59 Case_Procedure.ProcedureCode

60 Case_Procedure.WherePerformed For labs with multiple laboratory sites Press F3 to get a drop down list of locations

61 Power Point Slide Table: PatientPayor (Only Columns Listed Below are Audited in AUDIT_REPORT_FOR_PATIENT) 62 CommentBilling Data Tab in Patient Demographics area. 62 SignatureSourceCodeBilling Data Tab in Patient Demographics area. p “signature generated by provider because….” ??? Get exact wording 62 RelatedPayorNumberBilling Data Tab in Patient Demographics area. – secondary insurance 62 GroupNumberBilling Data Tab in Patient Demographics area. 62 AuthorizationBilling Data Tab in Patient Demographics area.? same as AuthorizationNumber in Case_Procedure? 62 SubscriberNameBilling Data Tab in Patient Demographics area. 62, 63 SubscriberSocSecNoBilling Data Tab in Patient Demographics area. 62 SubscriberBirthDateBilling Data Tab in Patient Demographics area. 63 SubscriberSexDemographics tab in Patient Demographics area. 63 PatientNumberHover over patient name or find it on the Demographics tab in Patient Demographics area. 62 PayorNumberBilling Data Tab in Patient Demographics area.

62 1.PatientPayor.PayorNumber 2. PatientPayor.SubscriberName 3. PatientPayor.Comment 8. PatientPayor. SubscriberBirthDate 9. PatientPayor.SubscriberSocSecNo 4. PatientPayor.RelatedPayorNumber 5. PatientPayor.GroupNumber 6. PatientPayor. Authorization 7. PatientPayor.SignatureSourceCode Most of the PatientPayor table is found in the Billing Data Tab in Patient Demographics

63 PatientPayor.PatientNumber, PatientPayor.SubscriberSex, PatientPayor.SubscriberSocSecNo These 3 items from the Patient Payor Table are found on the Demographics Tab in the Patient Demographics area

64 Power Point Slide Table: Patient (Only Columns Listed Below are Audited in AUDIT_REPORT_FOR_PATIENT) 65AddressLine1Demographics tab in the Patient Demographics area 65AddressLine2Demographics tab in the Patient Demographics area BillingStatusCodeBilling Status Codes: Y “Suspend All Billing” S “Suspend Billing Statements” C “Suspend Billing Claims” 65CityDemographics tab in the Patient Demographics area CreditStatusCodeCredit Status Codes: 0None6 Sent To Collections 2On Pre-Collection Report7 Account Written Off 3Pre-Collection Letter Sent10 On Contract Payment Schedule 5On Collection Report LastUpdatedBySaved by whom LastUpdatedDateWhen it was saved 65MedicalRecordNoDemographics tab in the Patient Demographics area 65NameDemographics tab in the Patient Demographics area 65SocialSecurityNoDemographics tab in the Patient Demographics area 65StateDemographics tab in the Patient Demographics area 65ZipCodeDemographics tab in the Patient Demographics area

65 1.Patient.Name 2.Patient.SocialSecurityNo 3.Patient.MedicalRecordNo 4.Patient.Address1 5.Patient.Address2 6.Patient.City 7.Patient.State 8.Patient.Zip Most of the Patient Table can be found on the Demographics tab in the Patient Demographics area. Press the … button to get to Pt. Demographics!

66 “Actions” Insert View Delete Update

67 At PSMG the Internal Procedure Code for = 1003 Items audited when a case is first created.

68 AUDIT_REPORT: Run by Accession number Created a new case for this patient. Look at your Cases & Case_Procedure Table Audit Decoder

69 Coding tab: Diagnosis tab: Cytotech Adds Diagnosis Code, Quality Code and initials in the grid Special Status code added

70 Control Number is always 1 for Cytology Cytotech entering dx in the grid Added Special Status code # 27 = “HPV Test Ordered” Whoever Modifies the case will be tracked in this column (This is a test case, so Hsousa is the only person modifying data ) Date and time case saved after modification Cytotech’s Staff ID = 0009 (Deryl) StaffTypeCode = 1 (cytotech) Dx area code for “Quality” = Dx Code for “Satisfactory for Eval” = 148 Cytotech is the highest ranked screener, therefore PrimayFlag = Y Dx area code for “Diagnosis” = Dx Code for Low Grade = 173 Cytotech is the highest ranked screener, therefore PrimayFlag = Y View: Tracks cases that have just been Opened

71 Diagnosis Tab 2 nd Procedure Code added :Physicians interpretation (auto inserted see Lab Pref) Requisition Tab Pathologist Dx and initials in the grid, completed date, saved

72 Old Value New Value Old Values are re-Inserted Except Cytotech is no longer highest ranking screener (Primary Flag=N) Pathologist = ScreenerType 2 Path argreed with Cytotech, see Diagnosis Codes are unchanged (148, 173) Must Delete Old Values first New Information is also Inserted (Pathologist’s dx in the grid) Pathologist is the Primary Screener=Y Case was completed, and the Status Code changed from “50000” = Open to “500006” = Completed/Locked. Case_Diagnosis Table

73 Old Value New Value Case_Screener Table Must Delete Old Values first Old Values are re- Inserted Except Cytotech is no longer highest ranking screener (Primary Flag=N) New Information is also Inserted (Pathologist’s dx in the grid) Pathologist is the Primary Screener=Y Cytotech StaffID Path StaffID Must Delete Old Values first Case_Procedure Table Old Values are re- Inserted 2 nd Procedure code is added: 1023 = Physicians Interpretation code. Case viewed by new Staff “lmcomber”, StaffID “0026”

74 Print Case and go to Print Job Viewer Scroll to the right to get these audited fields Displayed in GoldAudited as Schedule Time Report SourceSystem Source Code Report Clinician NameClinician Number Report ClinLocation NameClinLocation Number Final PrintFinal Print (Y or N) Requested ByRequested By Staff NumberDisplayed in GoldAudited as AccessionAccession number CopiesNumber of Copies LocationReport Location Name TitleDestination Title StatusSystem Code Status Device/Fax#Report Location Destination Print Server WorkstationPrint Server Workstation Name

75 Notes on the Print Job Table Think of it as a “holding bin”. There are many ways from many screens to print a report in Gold. The AUDIT_REPORT takes a “snap shot” of how the report is printed but this information is not necessarily available to see in the case. Pay attention to the Modified Time…everything is done at once. The best way to Track printing is to use the Tracking/Files Tab in Case Management. See Print Tracking below.

76 Printed Case (pg 1) Status is changed from Locked: to Final Print: Print Job has been printed by PSMG Print server Update using Print server from system Status Code “270004=Ready” to “ = Processing” Old Value New Value PrintJob Table Print Job billed by llaman. Delete old values

77 Printed Case (pg 2) System Code Source = ClinLocation: System Code Status = Ready: (Shown out of order. Here Ready “270004” is inserted, on the prior page it was Updated from Ready “270004” to Processing “270001”, and then once the print job was finished Processing “270001” was Deleted.) System Code Type = Printer: Final Print = Y (The box was checked to go to Final Print status. And you saw on the last slide that the case went to Final Print because the Case.StatusCode changed from Locked to Final Print) New Value Old Value PrintJob Table Insert New Values

78 AUDIT_REPORT_FOR_PATIENT by Patient Number or Patient Name Enter Patient’s last name and choose from a list OR Enter the Patient Number Tables Audited by this Report PatientPayor Patient You may use this report to see who changed a Patient’s name or Insurance Information

79 Audit_Report_By_Patient PatientPayor. PolicyNumber is updated And it was done by L Briggs Old Value New Value


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