ChartMaker® 2018.2 Software Release 6.5.2
Here are some of the main highlights in ChartMaker® Medical Suite 2018.2 (file version 6.5.2). To read a full list of enhancements, view the Release Notes.
Where can I find it?
Clinical: Chart > Export > Patient Data
What do I need to know?
The Note Selection field of the Export Patient dialog has been updated with a drop-down list that contains new Consultation Note, Discharge Summary Note, History and Physical Note, Imagining Narrative, Lab Report Narrative, Pathology Report Narrative, Procedure Note, and Progress Note document types, in addition to the previous Clinical Summary document type, for the implementation of the USCDI (United States Core Data for Interoperability) standards that are required as part of the 21st Century Cures Act (21CCA). These new document types can be used in a similar manner as the Clinical Summary, using the similar functionality when saving, printing, and naming, as well as getting an exclusion dialog that contains applicable fields that can be excluded from the export, as needed.
The Consultation Note will contain the following sections in the export: History of Present Illness (information in a checklist that was tagged as HPI), Allergies and Intolerances, Problem/ Problems Addressed During This Encounter, Chief Complaint, Medications, Vital Signs, Procedures, and Results.
The Discharge Summary Note will contain the following sections in the export: Hospital Course (information in a checklist that was tagged as Hospital Course), Allergies and Intolerances, Plan of Treatment (containing instructions from a checklist tagged as Clinical Instructions, as well as future appointments), and Discharge Diagnosis (diagnoses that were interacted with in the selected note).
The History and Physical Note will contain the following sections in the export: Review of Systems (containing information in a checklist tagged as Review of System), General Status (containing information in a checklist tagged as General Status), Medications, Results, Past Medical History (containing information in a checklist tagged as Past Medical History), Vitals, Physical Exam (containing information in a checklist tagged as Physical Examination), Social History, Family History, Allergies and Intolerances, and Problems.
The Imaging Narrative will contain the following section in the export: Findings Section (containing information in a checklist tagged as Imaging Narrative).
The Lab Report Narrative will contain the following section in the export: Lab Report Narrative (containing information in a checklist tagged as Lab Report Narrative).
The Pathology Report Narrative will contain the following section in the export: Pathology Report Narrative (containing information in a checklist tagged as Pathology Report Narrative).
The Procedure Note will contain the following sections in the export: Complications (containing information in a checklist tagged as Complications), Procedure Description (containing information in a checklist tagged as Procedure Description), Procedure Indications (containing information in a checklist tagged as Procedure Indications), Post procedure Diagnosis (includes diagnoses that were interacted with in the selected note), Allergies and Intolerances, and Medications.
The Progress Note will contain the following sections in the export: Assessment and Plan (containing information in a checklist tagged as Assessment and Plan), Chief Complaint, Medications, Results, Vital Signs, Problems, and Allergies.
How do I use it?
Upon upgrade, these options will be available as outlined above. To export one of these document types, simply check the corresponding type, select the patient (if needed) and the applicable Options, and then click the Save or Print button.
Where can I find it?
Clinical: Reports > Meaningful Use > Dashboard
What do I need to know?
The Meaningful Use Dashboard has been updated for the 2021 reporting period, and the Stage field has been updated with a Stage 3 2021 option.
Likewise, all the Quality Measures for Meaningful Use Stage 3 2021 in the Meaningful Use Dashboard have been updated to the 2020 version for the 2021 reporting period, allowing you to select and run queries specific to the changes reflected in this stage for 2021, and provide accurate statistics for applicable attestation requirements.
Do note that, for Stage 3 2021, this year (and every year) CMS has made changes to the requirements for the majority of the CQMs. Please be sure to check the CQMs you are reporting to determine if changes were made that may affect your reporting and adjust accordingly.
How do I use it?
Upon upgrade, these options will be available and can be used as outlined above.
Where can I find it?
Clinical: Prescribe Medication and Confirm Prescription dialogs
What do I need to know?
The system has been updated to use the latest, NCPDP 2017071 schema, format for electronic prior authorization messages. Along with updating to the latest NCPDP standards, this change allows the Prior Authorization flag that checks if a medication needs ePA to no longer be dependent on the old Formulary data. Instead, the system will use a combination of the Surescripts Real Time Prescription Benefit and/or Real Time Formulary data that is obtained during the prescription process. This updated process allows for faster and more accurate notification of prior authorization, while also alleviating the majority false positives. Likewise, there have been some further minor enhancements to provide more efficient workflow and ease of use. See the medication entries below for further information regarding the changes made to Clinical system as it relates to the NCPDO 2017101 schema format update for ePA.
The Prescribe Medication screen has been updated so that the ePA indicator (ePA is required or ePA is not required), below the Pharmacy field, will now use a combination of the Surescripts Real Time Prescription Benefit and/or Real Time Formulary data to determine whether prior authorization is required for the medication being prescribed, allowing for faster and more accurate notification of prior authorization. In addition, the Override link has been removed from the Prescribe Medication screen and has been relocated to the Confirm Medication screen.
The Prescription section of the Confirm Prescription screen has been updated with an Override link that allows you to forgo the ePA workflow when the system determines that ePA is required for the medication being prescribed or allows you to activate the ePA workflow when the system determines that ePA is not required. The Override functionality works in a similar manner as it worked when it was in the Prescribe Medication screen in previous versions. Additionally, a new Expedite ePA checkbox that becomes active when the ePA workflow is required or user-requested, and when checked will send a priority indicator with the ePA request message.
How do I use it?
Upon upgrade, these options will be available and can be used as outlined above.
Where can I find it?
Clinical: Template Editing > Checklist > Find Check List Properties
What do I need to know?
The Include as drop-down list in the Finding Check List Properties dialog has been updated to include a Complications and a General Status option. When the Complications option is selected for a checklist, any data entered in the checklist will be pulled into any CCDA document type that has a Complications section. When the General Status option is selected for a checklist, any data entered in the checklist will be pulled into any CCDA document type that has a General Status section.
The Include as drop-down list in the Finding Check List Properties dialog has also been updated to include a Hospital Course, Imaging Narrative, Lab Report Narrative, Past Medical History, Pathology Report Narrative, Physical Examination, Procedure Description, Procedure Indications, and Review of Systems option.
When the Hospital Course option is selected for a checklist, any data entered in the checklist will be pulled into any CCDA document type that has a Hospital Course section. When the Imaging Narrative option is selected for a checklist, any data entered in the checklist will be pulled into any CCDA document type that has a Findings Section. When the Lab Report Narrative option is selected for a checklist, any data entered in the checklist will be pulled into any CCDA document type that has a Lab Report Narrative section. When the Past Medical History option is selected for a checklist, any data entered in the checklist will be pulled into any CCDA document type that has a Past Medical History section. When the Pathology Report Narrative option is selected for a checklist, any data entered in the checklist will be pulled into any CCDA document type that has a Pathology Report Narrative section. When the Physical Examination option is selected for a checklist, any data entered in the checklist will be pulled into any CCDA document type that has a Physical Examination section. When the Procedure Description option is selected for a checklist, any data entered in the checklist will be pulled into any CCDA document type that has a Procedure Description section. When the Procedure Indications option is selected for a checklist, any data entered in the checklist will be pulled into any CCDA document type that has a Procedure Indications section. When the Review of Systems option is selected for a checklist, any data entered in the checklist will be pulled into any CCDA document type that has a Review of Systems section.
How do I use it?
Upon upgrade, these options will be available as outlined above. To use one of these options for a checklist, simply select the applicable option, and then click the OK button.