\n<\/p>\n
Quadramed – for the 9\/23 rollover affecting 9\/26 \u00a0<\/span><\/p>\n Meaningful Use<\/span><\/strong> \u00a0<\/span><\/strong><\/p>\n \u00b7 \u00b7 \u00b7 o o o o o \u00a7 \u00a7 \u00a7 \u00a7 \u00a7 o \u00b7 \u00a0<\/span><\/strong><\/p>\n FYI: \u00a0<\/span>Visit Summary \u00b7 \u00b7 \u00b7 o \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span><\/span><\/strong>5\/2\/11mammogram\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>normal<\/span><\/p>\n \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>6\/1\/11CBC\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>normal<\/span><\/p>\n \u00b7 \u00b7 \u00b7 \n Meaningful Use in \n Hospital required to use a federally certified version of \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>Problem \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>Medication \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>Diagnostic \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>Brief that requires \n v v v v v v \u00d8 \u00d8 v \n There will be a explanation and disclaimer at the bottom “This is a summary of your current visit only and any \n \u00b7 \u00b7 \u00b7 \u00b7 \u00b7 \n Pending: \u00a0<\/span>add Quadramed – for the 9\/23 rollover affecting 9\/26 ambulatory visits \u00a0 Meaningful Use (Accountable Care Act) requirements for patient visit summary which we must give to patients: \u00a0 \u00b7 Allergies, medication list & diagnostic tests will auto-populate. \u00b7 Problem list– enter all that were thought about\/discussed\/acted upon in any fashion by you, the provider, during….<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":826,"menu_order":0,"comment_status":"open","ping_status":"open","template":"","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"class_list":["post-836","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/836","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/comments?post=836"}],"version-history":[{"count":1,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/836\/revisions"}],"predecessor-version":[{"id":837,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/836\/revisions\/837"}],"up":[{"embeddable":true,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/826"}],"wp:attachment":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/media?parent=836"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}
\nambulatory visits<\/span><\/strong><\/p>\n
\n(Accountable Care Act) requirements for patient visit summary which we must
\ngive to patients:<\/span><\/p>\n
\n<\/span><\/span><\/span>Allergies,<\/strong>
\n<\/span>medication list & diagnostic tests will auto-populate.<\/span><\/p>\n
\n<\/span><\/span><\/span>Problem list<\/span><\/strong>–
\nenter all that were thought about\/discussed\/acted upon in any fashion by you,
\nthe provider, during this visit; old list will become view only.\u00a0 <\/span>Input problems with type and severity to make
\na new list which you must maintain with only active chronic and acute
\ndiagnoses.\u00a0 <\/span>Do Not input “routine
\nhealth visit.” Remove inactive\/redundant<\/span><\/p>\n
\n<\/span><\/span><\/span>\u00a0<\/span>Subjective,
\nassessment and plan \u00a0<\/span>(SAP)<\/span><\/strong><\/p>\n
\n<\/span><\/span><\/span>a new field in
\nGenmed z-out (after return visit choice) and visit note <\/span><\/p>\n
\n<\/span><\/span><\/span>Fill out only
\nonce, it will flow to the other field, doesn’t matter which one you fill<\/span><\/p>\n
\n<\/span><\/span><\/span>BRIEF, patient
\nfriendly, what they need to know from this visit<\/span><\/p>\n
\n<\/span><\/span><\/span>subjective,
\nproblem-oriented A\/P<\/span><\/p>\n
\n<\/span><\/span><\/span>Example:<\/span><\/p>\n
\n<\/span><\/span><\/span>today for diabetes
\nand 3 days cough<\/span><\/p>\n
\n<\/span><\/span><\/span>Cough because of
\ncold – Robitussin 2 teaspoons 4 times daily as needed, fluids<\/span><\/p>\n
\n<\/span><\/span><\/span>Diabetes
\nimproving – increase Lantus to 20 units at night, strict diet, check blood
\ntests 1 week before next appointment<\/span><\/p>\n
\n<\/span><\/span><\/span>Health
\nmaintenance-keep mammogram appointment<\/span><\/p>\n
\n<\/span><\/span><\/span>return
\nappointment – December<\/span><\/p>\n
\n<\/span><\/span><\/span>do not repeat everything else already on the summary<\/span><\/strong> (problem list, medication list, labs)<\/span><\/p>\n
\n<\/span><\/span><\/span>\u00a0<\/span>The visit summary will print out with Z.-out
\nand given to patient before they leave<\/span><\/p>\n
\ndetails<\/span><\/strong><\/p>\n
\n<\/span><\/span><\/span>problem list <\/span><\/strong>of
\nthe active diagnoses you choose on this visit: Chronic & acute<\/span><\/p>\n
\n<\/span><\/span><\/span>medication list<\/span><\/strong>-active
\ngoing back 3 months from current visit<\/span><\/p>\n
\n<\/span><\/span><\/span>Labs & diagnostic tests <\/span><\/strong>-going back from current visit to immediately previous
\nvisit summary \u00a0<\/span>only:<\/span><\/p>\n
\n<\/span><\/span><\/span>date\u00a0\u00a0\u00a0\u00a0 <\/span>study\/test name\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>normal\/abnormal<\/span><\/p>\n
\n<\/span><\/span><\/span>If you do the SAP
\nat Z.-out, it will flow to the visit note, you
\n<\/span>do not need to repeat it when you do your formal patient note if it
\ncontains everything you want to say, if not refer to and supplement it.<\/span><\/p>\n
\n<\/span><\/span><\/span>If you complete
\nyour documentation before the patient leaves the SAP will flow automatically to
\nthe visit summary for the patient<\/span><\/p>\n
\n<\/span><\/span><\/span>The visit summary
\nis intended for patients for the single visit. Any further information\/details
\ncan be obtained from Medical Records<\/span><\/p>\n
\n<\/p>\n
\nambulatory – 9\/24\/11<\/strong><\/p>\n
\nthe EMR piloted in Coney Island Hospital. Rollout 9\/23. Compliance is required
\nby 10\/1. This certified version is not changeable, but allows us to define
\nwhere we get the data. Many have worked to figure where we are already entering
\nthe relevant data and as well as patient flow.
\n<\/span>Applies to primary and subspecialty
\ncare practices.<\/strong> Patients\u00a0 <\/span>will
\nreceive a visit summary at the end of each ambulatory encounter containing:\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>Medication
\nAllergies<\/p>\n
\nlist<\/p>\n
\nlist<\/p>\n
\nand lab studies<\/p>\n
\nNote<\/p>\n
\ncompletion of the note before exiting the patient<\/strong>, replaces medication list
\nat Z-out. In brief:<\/p>\n
\n<\/span><\/span><\/span>Medication Allergies – pulled from Quadramed<\/p>\n
\n<\/span><\/span><\/span>Problem List: will have to enter a new problem
\nlist with severity and type of problem and maintain it, old problem list will
\nbecome “view only” create
\nstandard work to keep this up to date <\/strong><\/p>\n
\n<\/span><\/span><\/span>“Problem list”\u00a0 <\/span>for this summary will be from the diagnoses
\nchosen for the current visit (note or Z.-out), therefore must enter every
\ndiagnosis that is touched, required consideration, education, assessment,
\nintervention. Pull these from problem list that will pop up.<\/p>\n
\n<\/span><\/span><\/span>Medication list will be the list of active
\nmedications from past 3-6 months. maintain
\nmedication list.<\/strong><\/p>\n
\n<\/span><\/span><\/span>Diagnostic and lab studies (blood work,
\npathology, cardiology, PFTs, radiology etc.) occurring in the interval from the
\nprevious visit to current visit, the date, name of the examination and whether
\nor not it was normal or abnormal by the laboratory reference values or
\ndetermined by the interpreter. There is a possibility that the patient may
\nvisit a subspecialty practice and primary care testing will display on their
\nsummary before they see primary care and vice versa.<\/p>\n
\n<\/span><\/span><\/span>Brief note will be pulled from a new field
\n“assessment and plan” that follows the old “note.” I will
\ntry to add subjective<\/p>\n
\n<\/span><\/span><\/span>keep brief and simple, is going to the patient<\/p>\n
\n<\/span><\/span><\/span>assessment\/plan from the problem list, including
\nhealth maintenance<\/p>\n
\n<\/span><\/span><\/span>The old “visit note” field will be
\nchanged to PMHx, Data, physical examination and can continue all the
\nruminations and documentation that will not be given to the patient<\/p>\n
\nstating something approximating:<\/p>\n
\nquestions about its contents should be discussed with your provider. Additional
\ninformation available upon request from HIM.”<\/p>\n
\n<\/span><\/span><\/span>residents require orientation, will request 5
\nminutes before noon conference for a few days in the beginning of each rotation
\nfor the next several months until we catch everyone<\/p>\n
\n<\/span><\/span><\/span>Review and reinforce during ambulatory team
\nmeetings<\/p>\n
\n<\/span><\/span><\/span>Review and reinforce during precepting<\/p>\n
\n<\/span><\/span><\/span>Give feedback when signing notes<\/p>\n
\n<\/span><\/span><\/span>Please audit for compliance, look at the notes
\nfrom encounter, can use residents during block time for peer reviewing quality
\nimprovement (ACGME requirement)<\/p>\n
\nsubjective to A\/P,\u00a0 <\/span>delete DME (alcohol
\npads, lancets etc.) from the medication list.<\/p>\n","protected":false},"excerpt":{"rendered":"