ChartMaker® 2018.2 Software Release 6.5.7

Where can I find it?

Clinical: Template Editing – Note Section

What do I need to know?

In an effort to provide an alternative solution to help you comply with the requirements against Information Blocking as outlined in the 21st Century Cures Act (21CCA), the Note Section template control has been updated to allow you to tag sections of a chart note with C-CDA Section Labels which will then be used when exporting C-CDA information to the patient’s PatientPortal for the various Document Types when signing a note, manually exporting a note via the Send note to Patient Access option, or exporting a chart note via the Export Patient Data dialog.

The Section Label Management dialog, accessed when using the Note Section control, has been updated with two new radio buttons: Letter Section Labels and C-CDA Section Labels.

When the Letters Section Labels option is selected, the various section labels used for tagging section of the chart note to be used when generating referral letters will be listed. This functionality works in a similar manner as in previous versions.

When the C-CDA Section Labels option is selected, the various document sections will be listed allowing you to tag sections of a chart note as a particular type of data which will then be to be used to generate structured data for that note and saved to the database. This structured data will then be used when populating sections for the various Document Type files for the C-CDA export. These new sections labels work in a similar manner to the data types used to tag checklists via the Include As field.

In the Section Label Management dialog, you can copy section labels (for example, if there are two separate sections of the chart note that should be tagged as Assessment, you can copy the system generated Assessment section, and use the original system section in one area and use the copy in another area of the chart note), as each section label can only be used once in a chart template. A copied section label is automatically associated with the CCDA section of the label it was copied from, and the name of the copy is system generated. You can also delete a copied section label, if needed. However, system generated section labels, those with an asterisk, cannot be deleted. The Delete option will only be activated for copied labels.

Section labels can be added to a template by highlighting the section in the template that the section label should cover, then clicking the Note Section control option in the left menu, then selecting the CCDA Section Labels radio button, then highlighting the applicable section label, and then clicking the OK button; or, by placing the cursor in the location in the template, double-clicking the Note Section control option, then selecting the CCDA Section Labels radio button, then highlighting the applicable section label, and then clicking the OK button, and then clicking and dragging the start/end tag to desired location in the note. Different section labels can overlap and can be embedded in other section labels, if needed. Once a section label has been added to the template, it can be removed by deleting either the Start tag or the End tab for the section, deleting one will automatically delete the other.

How do I use it?

Upon upgrade, these options will be available as outlined above. You can edit  your chart templates and add the applicable CCDA Section Labels to those templates, as needed.

Where can I find it?

Clinical: Chart Notes

What do I need to know?

The system has been updated so that whenever a note section is added to chart template via the template editor (see the Template Editor – Note Section Updates  entry for further details), any text output, whether generated from a widget or free-text, between the start and end tag of that section label, will be saved to the database as structured data and will be included in any applicable CCDA exports for the corresponding document types. Do note, that any information that appears between the start and end tags of note sections from Grids, Signature (Topaz) widget, Embedded Objects/Files, Confidential button, Image for Markup Control, OLE Objects, Diagrams (or any images in general), and any formatting options that are used at bottom of note header will not be saved in the database as structured data or be included in the CCDA export.

How do I use it?

Upon upgrade, notes sections will appear for those subsequent chart notes whose templates have been updated with CCDA section labels. Simply enter applicable data and text between these section markers and upon saving the chart note, the text data will written to the database, and will be used to populate sections of any applicable CCDA exports for the corresponding document types.

Where can I find it?

Clinical: Chart Notes (Note Header) and Chart > Export > Patient Data

What do I need to know?

The system has been updated to populate the various Document Types for CCDA export with any outputted text data, whether generated from a widget or entered as free-text, included between the CCDA Section Label tags in chart notes. These document type files are generated for CCDA export manually via the Export Patient Data dialog, or when signing a chart note that has the Release to Patient option checked. The data from these note sections will appear in the corresponding sections of the CCDA export file.

Do note, that any information that appears between the start and end tags of note sections from Grids, Signature (Topaz) widget, Embedded Objects/Files, Confidential button, Image for Markup Control, OLE Objects, Diagrams, or any images in general, and any formatting options that are used at bottom of note header will not be saved in the database as structured data or be included in the CCDA export.

The following lists the various Document Types and note section data that will be included in the CCDA export for those document types:

• The Clinical Summary (accessed via the Note Selection field in the Export Patient Data dialog), Cardiology Report, and Unknown Note Summary (accessed when tagging a chart note via the Document Type button in the Note Header) have been updated to include any information included between the following note section tags: Results, Chief Complaint, Social History, Reason for Referral, Functional Status, Mental Status, Medical Equipment, Assessment, Health Concerns, and Plan of Treatment.
• The Consultation Note (accessed via the Note Selection field in the Export Patient Data dialog or when tagging a chart note via the Document Type button in the Note Header) has been updated to include any information included between the following note section tags: Assessment, Review of Systems, Chief Complaint, Reason for Visit, History of Present Illness, General Status, Plan of Treatment, Medical Equipment, Nutrition, Functional Status, Mental Status, Results, Past Medical History, Social History, and Advance Directives.
• The Discharge Summary (accessed via the Note Selection field in the Export Patient Data dialog or when tagging a chart note via the Document Type button in the Note Header) has been updated to include any information included between the following note section tags: Review of Systems, Chief Complaint, Reason for Visit, History of Present Illness, Hospital Course, Plan of Treatment, Nutrition, Functional Status, Past Medical History, and Social History.
• The History and Physical Note (accessed via the Note Selection field in the Export Patient Data dialog or when tagging a chart note via the Document Type button in the Note Header) has been updated to include any information included between the following note section tags: Assessment, Review of Systems, Chief Complaint, Reason for Visit, History of Present Illness, General Status, Plan of Treatment, Results, Past Medical History, Physical Exam, and Social History.
• The Imaging Narrative (accessed via the Note Selection field in the Export Patient Data dialog) and Radiology Report (accessed when tagging a chart note via the Document Type button in the Note Header) have been updated to include any information included between the following note section tag: Imaging Narrative.
• The Lab Report Narrative (accessed via the Note Selection field in the Export Patient Data dialog) has been updated to include any information included between the following note section tag: Lab Report Narrative.
• The Pathology Report Narrative (accessed via the Note Selection field in the Export Patient Data dialog) and Pathology Report (accessed when tagging a chart note via the Document Type button in the Note Header) have been updated to include any information included between the following note section tag: Pathology Report Narrative.
• The Procedure Note (accessed via the Note Selection field in the Export Patient Data dialog or when tagging a chart note via the Document Type button in the Note Header) has been updated to include any information included between the following note section tags: Assessment, Review of Systems, Chief Complaint, Reason for Visit, History of Present Illness, Procedure Description, Plan of Treatment, Procedure Indications, Anesthesia, Complications, Past Medical History, Procedure Findings, Physical Exam, and Social History.
• The Progress Note (accessed via the Note Selection field in the Export Patient Data dialog or when tagging a chart note via the Document Type button in the Note Header) has been updated to include any information included between the following note section tags: Assessment, Review of Systems, Chief Complaint, Objective, Subjective, Plan of Treatment, Nutrition, Instructions, Results, Physical Exam, and Interventions.
• The Referral Summary (accessed via the Note Selection field in the Export Patient Data dialog) and the Referral Note (accessed when tagging a chart note via the Document Type button in the Note Header) have been updated to include any information included between the following note section tags: Assessment, Review of Systems, History of Present Illness, General Status, Plan of Treatment, Medical Equipment, Nutrition, Functional Status, Reason for Referral, Mental Status, Results, Past Medical History, Physical Exam, Social History, and Advance Directives.

How do I use it?

Upon upgrade, these options will be available as outlined above. To manually export one of these document types, access the Export Patient Data dialog, check the document type in the Note Selection field, select the patient (if needed) and the applicable Options, and then click the Save or Print button. Document types associated with chart notes will be automatically exported when signing a note when the Release to Patient option is checked.

Where can I find it?

Clinical: Patient Chart > History tab > All / Results button

What do I need to know?

The All (General)  area of the History tab has been updated to display a Pulse Intensity, Pulse Rhythm, Blood Pressure Extremity, Blood Pressure Position, Blood Pressure Taken By, O2 Content, O2 Flow Rate, Stature for Age Percentile, Length for Age Percentile, Weight for Length Percentile, Weight for Age Percentile, Weight for Stature Percentile, BMI for Age Percentile, and/or a Head Circumference for Age Percentile entry whenever a value is configured, or percentile calculated, in the Vital Signs Entry dialog. Any LOINC and SNOMED Codes will also appear for these entries, if applicable.

The Results area of the History tab has been updated to display a Pulse Intensity, Pulse Rhythm, Blood Pressure Extremity, Blood Pressure Position, Blood Pressure Taken By, O2 Content, O2 Flow Rate, Stature for Age Percentile, Length for Age Percentile, Weight for Length Percentile, Weight for Age Percentile, Weight for Stature Percentile, BMI for Age Percentile, and/or a Head Circumference for Age Percentile entry whenever a value is configured, or percentile calculated, in the Vital Signs Entry dialog. Any LOINC and SNOMED Codes will also appear for these entries, if applicable.

How do I use it?

Upon upgrade, these options will be available as outlined above.

Where can I find it?

Practice Manager: Payment > Pending Payments

What do I need to know?

The system has been updated to easily allow you to decipher collection charges when posting pending payments. Whenever an open charge that is in collections is associated with a pending payment, the procedure code for that open collection charge will appear in red. Likewise, the bottom of the Pending Payments screen has been updated with a key indicating that Collection charges are in red.

How do I use it?

Upon upgrade, these options will be available and can be used as outlined above.