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ChartMaker® 2016 Software Release 6.2.4

Here are some of the main highlights in ChartMaker® Medical Suite 2016 (file version 6.2.4). To read a full list of enhancements, view the Release Notes.

Where can I find it?

Clinical: Facesheet – Health Alert

What do I need to know?

The Health Alert button in the Facesheet has been updated so that whenever button becomes active (highlighted), indicating that a procedure is due per the Flow Sheets, you can now click the Health Alert button to access a Health Alerts dialog that will display the Flow Sheet name, and underneath any procedures that are due for that flowsheet.

How do I use it?

Upon upgrade, the new functionality for Health Alerts will be available. When the Health Alert button becomes active, simply double-click it to access the Health Alerts dialog that will outline any procedures that are due.

Where can I find it?

Clinical: Chart > Infobutton & Alert Manager

What do I need to know?

A new Infobutton dialog has been created that allows you to research and retrieve diagnostic and therapeutic information concerning a patient via MedlinePlus. The Infobutton dialog is accessed through the Chart menu when in a patient’s chart (Chart > Infobutton), or via the  button located at the bottom-left of the decision support Alert Manager dialog.

After the Infobutton dialog has been accessed, you can then configure the various parameters to search, locate, save, and print applicable diagnostic and therapeutic information as needed. In the Patient Search Criteria section of the Infobutton dialog, you can refine you search by the patient’s Age, Birth Date, Birth Sex, Race, Ethnicity, Sexual Orientation, Gender Identity, as well as Diagnoses, Medications, Procedures, and Lab Results. When selecting diagnoses, medications, procedure, and lab results the corresponding drop-down lists will populate with information from the patient’s chart.

After the search criteria has been selected, you can click the Search button, and the system will retrieve any applicable information from MedlinePlus. You can then scroll through the information in the various tabs below, click the various links in the pages as needed, and then once the desired information has been located, you can save or print that information using the corresponding buttons. Any information saved will appear as a hyperlink in the Saved Information section. You can then access that information as needed by double-clicking the link, and the information will open in a tab below. When that information is no longer needed, you can delete it by highlighting the item in the Saved Information section, and then clicking the Delete button.

How do I use it?

Upon upgrading the ChartMaker Medical Suite, the various methods of accessing and searching for information via the Infobutton dialog as described above will be available. You can save, print, and maintain information as outlined.

Where can I find it?

Clinical: Chart > Medication History

What do I need to know?

The system has been updated with a Medication History dialog that allows you to import Medication History for a patient from the SureScripts Network into the patient’s chart, and then reconcile that information with any medications currently in the patient’s chart. The Medication History dialog is accessed through the Chart menu when in a patient’s chart (Chart > Medication History). The medication history information is also available through the Medication History button in the Prescribe Medication dialog, however, you are not able to import and reconcile medications when accessing via the Prescribe Medication dialog, it is view only from this area.

Do note, to access Medication History for a patient, the patient must have given medication history consent and it must be configured in the Consent dialog for that patient (i.e., in ID Tab > Consent or Medication History Consent button in Prescribe Medication dialog).

When accessing the Medication History dialog, you may first receive a series of dialogs indicating that the system is gathering the information, or that the Medication History is pending for the patient. Likewise, you may also receive dialogs that indicate that there is no history information available for the patient, or that history information could not be retrieved. See below for examples of these types of messages.

In the Medication History dialog, the patient basic demographic information will be listed, along with medication history for that patient. Beside the Medication History title, at the top of the dialog, the number of medication occurrences will appear in parentheses.

At the bottom of the dialog there is a Filter By section that allows you filter the medication history by Medication, Prescriber, and Last Fill Date. After the filter items are configured as desired, simply click the Filter button. You can then view the medication by scrolling through the Medication section, Reconcile the medications, or Print the medication history. When reconciling and printing, only those medications that are included in the filter criteria will be included.

After the Reconcile button has been clicked, a Clinical Information Reconciliation (CIR) dialog will appear that allows you to view and reconcile the various medications, broken into the patient’s Current Chart Medications, Available Medications from Surescripts Medication History, and a Final Merged List. Each list will show the available medication (name, start and last modified dates, last fill date, and sig information) detail.

Medications in the Available Medications from Surescripts Medication History list are color-coded to denote the level of medication information available and the ability of importation. You can click the Legend option for a complete listing. Medications can be moved individually by clicking the Add button, or in bulk using the Add All button. Each medication also includes a Skip checkbox that can be manually selected, but will be turned on if the medication already exists, has an end date that has passed, or if there isn’t enough information to import the medication. Medications that have been added will show in the Final Merged List and labels will be updated to show their status as added.

New medications added to the Final Merged List can be edited by using the Change button (except for controlled substances which cannot be changed during the import process). This will open the Prescribe Medication dialog with as much of the available information found in the Surescripts Medication History pre-filled. The Prescribe Medication dialog will also show the original name, dates, and text from the import at the bottom of the dialog for reference.

An added medication can be removed from the list and existing medications can be discontinued on either the final or current list. If a medication is discontinued, the End Medication dialog will appear and then the medication will be marked as ended.

After all the applicable medications have been reconciled, you can Confirm the import. The system will then import the medications in the Final Merged List, and after confirmation messages have been satisfied, you will return to the Clinical Information Reconciliation (CIR) dialog with the medication information updated. An Auto-generated drug log will be created listing the drug details for each medication imported. Likewise, the patient’s facesheet will be updated with the medications imported, and the medications will appear in the patient’s History tab.

How do I use it?

Upon upgrade, the Medication History functionality will be activated. When in a patient’s chart click Chart > Medication History to view, import, and reconcile medication information from the SureScripts Network for that patient. (Do note, the patient must have given medication history consent and it must be configured in the Consent dialog to access the medication history.) The work-flow will be similar to that described above.

Where can I find it?

Clnical: Chart Notes

What do I need to know?

A new Care Plan widget is available to add to chart note templates, via the Template Editor, that allows you to add Health Status, Impressions, Health Concerns, and Goals regarding a patient’s health care.

When the Care Plan widget is accessed, a Care Plan dialog will appear allowing you to add, edit, and delete care plan information for the patient.

The Health Status drop-down list will contain pre-configured status items along with the corresponding SNOMED codes. You can select an item or leave this field blank. When a health status is selected, it will appear in the History tab along with the SNOMED description and code.

The Impressions field allows you to enter any free-text impressions or assessments.

The Heath Concerns section allows you to add chart diagnoses that are of concern via the Add Diagnoses button, or additional health concerns in free-text format via the Add Additional Health Concerns button. When adding diagnoses, an Add Diagnoses as Health Concerns dialog will appear listing any active, inactive, or pre-existing diagnoses that are in the patient’s chart; you can simply check any diagnoses you want to include as health concerns. When adding additional health concerns, an Add Health Concern dialog will appear allowing you to add a free-text description of the concern. After diagnoses and additional health concerns have been added, you can edit and remove items by highlighting the applicable items, and using the Edit and Remove button.

The Goals section allows you to add, edit and remove health goals for the patient via the Add Goal, Edit, and Remove buttons. When adding and editing goals, the Add Goal dialog will appear allowing you to select from user-created list of common goals, or to enter or modify a free-text goal for the patient. Likewise, the Initiated By field allows you to associate who initiated the goal: Provider, Patient, or Both. Common goals can be maintained via the Goal Maintenance dialog accessed by Edit button. Goals added in the Goals Maintenance dialog can be shared with other users in the system, as desired. When a new goal is added, it will appear in the patient’s History tab with the text of the goal.

In addition, in the Note output field you can determine how this information is outputted to the note. You can choose to output the configured information in List format, Paragraph format, or No Output.

When creating a note with a Care Plan button, if the patient already has a Care Plan from a previous note, all the previously entered information will automatically be pulled into the new note. When opening the Care Plan dialog, you can view, edit, and remove items done previously. A patient will only have one active care plan at any time, and this information will be included when generating Transition of Care documents for the patient.

How do I use it?

Upon getting the upgrade, a Care Plan option will be available in the Template Editor to add the Care Plan widget to applicable chart note templates. Once the widget has been added to a template, simply click the Care Plan button from inside a chart note to access the Care Plan dialog.  Then select and enter the applicable information and options as needed, and then click the OK button once finished.

Where can I find it?

Mobile App: Charge Capture

What do I need to know?

The Charge Capture functionality has been updated with a new Charge History screen that is appears once a patient has been accessed via the Patient Search screen, and allows you to add a new charge, view the details of previously sent charges, or to copy a charge that had been previously sent from ChartMaker® Mobile. When entering the Charge History screen the patient name will appear at the top, a New Charge link will then appear, and then a Sent Charges section that will contain any previously sent charges from ChartMaker® Mobile. In the Sent Charge section you can either view the charge details for a previously sent charge, and/or copy a previously sent charge.

If you click the New Charge option, you will enter the Charge Capture screen and you can enter the charge capture information as in previous versions.

If you want to copy a previously sent charge, simply tap the  icon next to the corresponding charge in the Sent Charges section. Do note, that if the patient does not previously sent charges a message will appear in this section indicating that no mobile charges have been entered for this patient.

To view the details of a previously sent charge, tap the applicable charge and the Charge Details screen will appear displaying the charge details for that charge capture. In the Charge Details screen you can add a new charge by tapping the  icon, or copy the currently selected charge by tapping the  icon. Likewise, a Copy Charge link and a New Charge link will appear below the charge details information.

         

When copying charges from wither the Charge History or Charge Details dialog, after tapping the  icon, you will then enter the Charge Capture screen where the procedure and the diagnoses from the previous charge will be populated in the corresponding fields. The provider will default to the user logged in, if that user is a provider. If the user logged in is not a provider, and has previously sent charges, the provider from the previous charge will be populated. If the user logged in is not a provider, and has not previously sent charges, the Provider field will be blank and will need to be configured. The Service Date for the copied charge will default to today’s date, and the Practice will default based on user access and preference. Comments will not be copied. You can add and modify the charge information as needed.

          

How do I use it?

Upon upgrading the ChartMaker Medical Suite (requires version 6.2.4.325 or higher), as well as the Mobile App, these changes do not require intervention on the user’s part in order for them to be displayed. You do, however, need to be enrolled for the Mobile App. If you are not yet enrolled, you can enroll here.

Where can I find it?

Mobile App: Rounds

What do I need to know?

A new Rounds option is available that allows access to a Rounding List where you can view a hospital rounds patient list for each separate facility, and/or hospital, outside of your office, that you see patients. The hospital rounding list is based on information added in the Patient Hospitalization dialog in Practice Manager (accessed via the Hospitalization button in the Patient screen). Any patient with an open hospitalization record (where a Discharge Date has not been entered in the Patient Hospitalization dialog), will be displayed for each applicable facility. The Rounding List will display the patient’s name, date of birth, admission date, and room number, as well as giving you the option to copy a previous charge, add a new charge, or access to a Rounding Details screen where you indicate that a patient has been Skipped (for those patients where a charge has not been entered for the current day), view visit details, and view any charges that have been sent for visit.

The Rounds option can be accessed via the Home screen in ChartMaker Mobile or via the Mobile menu accessed by tapping the  icon located in the top left the screen.

                     

After the Rounds option has been tapped, a Census screen will appear displaying each facility, the total number of patients within each facility, and the number of patients seen and/or skipped out of that patient total for each facility. To access the Rounding List for a facility, simply tap the applicable facility in the Census screen.

In the Rounding List screen the facility and each applicable patient will be listed along with their date of birth, admission date, and room number for the date range listed in below the facility name. You can tap the From and To date to modify the date range as needed. Likewise, you can tap the  icon to order the patients by Admitted Date, Name, or Room Number, as well as filter by Practice and/or Provider. The number of patients for the date range and filtered patients will appear above the  icon.

Any patient that has an  icon next to their name have been skipped, and any patient that has an  icon next to their name has had a charged entered for the current date for the selected facility and is considered to have been seen. Patients without an icon next to their name have been neither skipped, nor had a charge entered, and therefore are considered not seen.

In the Rounding List you can copy a previously sent charge for a patient by tapping the  icon, enter a new charge for the patient by tapping the  icon, or accessing the Rounding Details screen for the patient by tapping the  icon.

          

When copying a charge, a Copy a sent charge screen will be displayed with a list the five (5) most recent charges sent from ChartMaker® Mobile. You can then tap the  icon next to the charge you want to copy. You will then enter the Charge Capture screen where the procedure and the diagnoses from the previous charge will be populated in the corresponding fields. The provider will default to the user logged in, if that user is a provider. If the user logged in is not a provider, and has previously sent charges, the provider from the previous charge will be populated. If the user logged in is not a provider, and has not previously sent charges, the Provider field will be blank and will need to be configured. The Service Date for the copied charge will default to today’s date, and the Practice will default based on user access and preference. Comments will not be copied. You can add and modify the charge information as needed.

When adding a charge, you will access the Charge Capture screen and the Provider field will default as described when copying a charge, the Facility field will default to the facility from the Rounding List, and the Service Date will default to today’s date. You can add and modify the charge information as needed.

When accessing the Rounding Details screen, the patients name will appear at the top of the screen, if you tap their name the drop-down will display their Account Number, Date of Birth, and Birth Sex. The next section will display a Skipped option that you can turn on or off by using the corresponding slider. Or, if a charge has been sent for this patient for today’s date, this section will state Charges sent, and the Skipped option will not be available. The Visit Details and any Sent Charges will then be listed. If any charges have been sent, you can copy any of the charges if needed.

          

 

How do I use it?

Upon upgrading the ChartMaker Medical Suite (requires version 6.2.4.325 or higher), as well as the Mobile App, these changes do not require intervention on the user’s part in order for them to be displayed. You do, however, need to be enrolled for the Mobile App. If you are not yet enrolled, you can enroll here.

Where can I find it?

Mobile App: Patient Search

What do I need to know?

The Patient Search screen, accessed via Charge Capture or Patient, has been updated with an Add Patient button, that allows you to add a new patient in ChartMaker® Mobile.

After the  button has been tapped, a New Patient screen will appear allowing you to enter the patient’s name, date of birth, birth sex, and the practice they are associated with. The First Name, Last Name, Date of Birth, Birth Sex, and Practice information is required when adding a new patient.

         

After the applicable information is entered for the patient, you can tap the Next button. The system will check for any duplicate patients, and if there are similar patients, an Existing Patients Found message will appear displaying the similar patients. You can then tap Continue to continue adding the patient as entered, or tap Cancel to go back to the New Patient screen and modify the patient’s information, or go back to the Patient Search screen to access the correct patient.

          

After the Continue button has been tapped, the configured patient information will appear for confirmation. If everything is correct, you can tap the Confirm button to add the patient. The patient will then be created, and you will then be able to enter a charge, add another patient, or search for a patient by tapping the appropriate link below. See Figure 6. Do note, that when new patients are added through ChartMaker® Mobile, they are given a status of NPI (New Patient Incomplete Information), and their status will need to be activated in Practice Manager prior to processing any pending charges.

          

How do I use it?

Upon upgrading the ChartMaker Medical Suite (requires version 6.2.4.325 or higher), as well as the Mobile App, these changes do not require intervention on the user’s part in order for them to be displayed. You do, however, need to be enrolled for the Mobile App. If you are not yet enrolled, you can enroll here.

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