Import Patient Data

ChartMaker Clinical has the ability to import patient data from a Consolidated CDA (CCDA), a Healthcare Information Technology Panel CCD/C32, or an ASTM Continuity of Care Record (CCR) file. Information that can be imported includes basic demographic information (patient first and last name, address, date of birth, gender), diagnosis, allergies, medications, medical history, and immunization history. The imported data will then be contained in a Clinical Document that can be attached to an existing patient, or a new patient can be created and the Clinical Document will be attached to that new patient's chart. When allergies, diagnoses, and/or medications are included in a CCDA import, a Reconciliation, Allergy, and Prescribe button will appear below the imported information, along with a Diagnosis checklist, allowing you to reconcile the information in the patient's chart with the information in the imported file.

 

Use the following steps to import patient data.

 

 

  1. Click Chart > Import > Patient Data.
     

  2. In the Import Options section of the Import Document dialog, click the Import data to an existing patient chart radio button if you want to attach the Clinical Document to an exiting patient's chart, or click the Create new patient from imported data radio button if you would like to create a new patient and have the Clinical Document attached to that new patient.
     

  3. If you are importing an encrypted file, check the Decrypt Data option, then enter the applicable Password, and then Verify the Password in the corresponding fields.
     

  4. In the File field, click the button.



     

  5. In the Open dialog, browse to the location of the file you want to import, highlight the applicable file, and then click the Open button. The File field will now contain the path to the file you are importing.



     

  6. In the File format field, select Consolidated CDA (CCDA), Healthcare Information Technology Panel CCD/C32, or ASTM Continuity of Care Record (CCR).
     

  7. Check the This patient has been transferred or referred to provider, or has not yet seen the provider option at the bottom-left of the Import Document dialog to track whether the patient has been transferred, referred, or never seen the by provider. When this option is selected, it will be counted toward any applicable Meaningful Use and MIPS 2018 performance measures.
     

  8. In the Import Configuration section, click the Configure button to select the sections and the order those sections will appear in the chart note.  



     

  9. In the CDA Section User Preferences dialog you have the ability to select which sections you want to be displayed, as well as the order in which those sections should appear. Check the Display column for those sections you want to initially appear in the note. Uncheck the Display column for any of those sections you do not want to initially appear in the chart note.

    To change the order of a section, highlight the applicable section, and then use the Move Up and/or the Move Down buttons to modify that sections position.

    When the sections and order have been configured as desired, click the OK button.

    NOTE: Whenever a user modifies the preference settings in the CDA Section User Preferences dialog and saves those changes by clicking the OK button, the system will save these user-specific preferences, and the selected sections to display and order will default when importing subsequent documents for that user.


     

  10. Click the Next button. If you are Creating a new patient based on the imported data, skip to step 12.
     

  11. When importing patient data for an existing patient, the Import Document dialog will contain a summary of the patient information and the Select patient field will contain the patient's name. Verify that name is correct or modify the patient as needed. You can also check or uncheck the This patient has been transferred or referred to provider, or has not yet seen the provider option, if applicable. When this option is selected, it will be counted toward any applicable Meaningful Use and MIPS 2018 performance measures. When all of the information is correct, click the Finish button. The Clinical Document containing the imported information will then be created. Skip to step 13.



     

  12. When creating a new patient based on the imported data, the Import Document dialog will contain a summary of the patient information and a Chart Information section that allows you to Select the Practice and Chart Number for the patient, as needed. The Chart Number filed will contain the next available chart number so this only needs to be changed if an unique chart number is needed. You can also check or uncheck the This patient has been transferred or referred to provider, or has not yet seen the provider option, if applicable. When this option is selected, it will be counted toward any applicable Meaningful Use and MIPS 2018 performance measures. When all of the information has been configured as desired, click the Finish button. The system will then create a new patient and the Clinical Document containing the imported information will then be created.



     

  13. If the imported information is for an existing patient, their patient’s chart will open with the Clinical Document embedded in the note with a Clinical Document display widget. If the imported information is for a new patient, the new patient will be created, their new chart will open with the Clinical Document embedded in the note with a Clinical Document display widget.

    The display widget has a Configure display button and Print button at the top of the display widget that allows you to override the display configuration for this specific note, if desired, and print the information in the imported document per the display parameters selected. Click the Configure display button, or Print button as needed.

    When you click the Configure display button, a CDA Section User Preferences dialog will appear allowing you to select which sections you want to be displayed, as well as the order in which those sections should appear. Do note, only those sections contained within the imported document will be displayed as selectable options. Also, any modifications made in the CDA Section User Preferences, accessed via the display widget, will be for that specific note only and will not affect any default settings configured in the Import Document dialog.




     

  14. If the imported CCDA file contains an allergies, diagnoses, or medications, click the Reconciliation button.
     

  15. In the Clinical Information Reconciliation dialog you can view the various Medications, Diagnoses, and Allergies by clicking the corresponding tab. The allergies, diagnoses, and medications are broken into the patient’s Current Chart Allergies/Medications, Available Allergies/Medications from C-CDA Import for the patient, and a Final Merged List. Each list will show the available allergy (name, start and last modified dates, and reaction information) and medication (name, start and last modified dates, and sig information) detail.

    Allergies, Diagnoses, and Medications in the Available Allergies/Diagnoses/Medications from C-CDA Import 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. Allergies, diagnoses, and medications can be moved individually through by clicking the Add button, or in bulk using the Add All button. Each allergy/diagnosis/medication also includes a Skip checkbox that can be manually selected but will be turned on if the allergy/diagnosis/medication already exists, has an end date that has passed, or if there isn't enough information to import the allergy/diagnosis/medication. Allergies, diagnoses, and 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. This will open the prescribe dialog with as much of the available information found in the CDA pre-filled. The prescribe dialog will also show the original name, dates, and text from the import at the bottom.

    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 discontinue dialog will appear and then the medication will be marked as ended.




    New diagnoses added to the Final Merged List can be edited by using the Change button. This will open the Note Diagnosis dialog with as much of the available information found in the CDA pre-filled.

    An added diagnosis can be removed from the list and existing diagnoses can be resolved on either the final or current list. If a diagnosis is resolved, the End Diagnosis dialog will appear and then the diagnosis will be marked as resolved.




    New allergies added to the Final Merged List can be edited by using the Change button. This will open the Change Allergy dialog allowing you to modify the reaction text. Likewise, allergies in the final merged list will have a Reviewed checkbox so they can be marked as reviewed once confirmed. A Review All link is added at the bottom to quickly mark all items as reviewed.

    An allergy can be removed from the Current Chart Allergies list and the Final Merged List. If an allergy is removed, a Remove Allergy dialog will appear allowing you to enter a reason for the removing the allergy.




    No changes will be made to a patient's chart until the you click the Confirm button. If the Cancel button is clicked, no allergies will be removed or added to the chart, no medications will be discontinued or added to the chart, and no diagnoses will be resolved or added to the chart. When confirmed, Clinical will run through all actions and complete them. All output will appear by the allergy or the prescribe button, or in the diagnosis checklist, in the note.

    Once all allergies/diagnoses/medications are confirmed and moved into the patient's chart, drug interactions will be performed on all new allergies and medications. If a drug interaction happens, and no comment has been added, the Interactions Present screen will appear showing the interaction and the name of the drug in the title. You will have the option to add a comment and proceed, or discontinue the drug.
     

  16. You can then Add and Modify Allergy Information via the Allergy button, Add, Renew, or Discontinue Medications as needed via the Prescribe button, or Add and Modify Diagnosis Information via the Diagnosis List.
     

  17. When finished, click the Save button or close out of the chart.