Family Medicine Progress Notes Templates - PowerPoint by ayj58676

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Family Medicine Progress Notes Templates document sample

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                  Electronic Medical Record Update
                            October 2004

MUSC EMR Update                  1                   October 2004
                            Clinical System Initiatives

•    PMSI/Practice Partner Overview and Status
•    Other Clinical System Initiatives
•    Information Technology Governance Structure

    MUSC EMR Update                     2                 October 2004
                        PMSI/Practice Partner Features

•    Goal: Paperless outpatient chart.
•    Types of entry functions:
      – Vitals, problem list, allergies
      – Phone requests documented
      – Meds/prescription (and re-fill) writer
      – Clinic notes (can be transcribed or entered via ‘point and click’
      – Scanning capability (referring or lose documents)
•    Other types of data available
      – Lab and radiology results
      – Hospital transcription such as Discharge Summaries and Operative

    MUSC EMR Update                   3                  October 2004
                      Practice Partner Implementation Objectives

•    Enhance patient safety (e.g., PP has a prescription writing tool that has drug
     interaction and allergy checking features).
•    Improve documentation quality in order to better address regulatory, legal,
     and MUSC guidelines.
•    Improve coordination of care via secure electronic storage of clinical
     documentation such as vital signs, clinic notes, medications, problem lists,
     allergies, and phone calls.
•    Enhance revenue by improved workflow efficiencies, decreased turnaround
     time for documentation and availability of clinical documentation for billing
•    Reduce the costs of medical records storage, filing space, transcription costs
     and records management.
•    Decrease time spent with call backs from patients and pharmacies.

    MUSC EMR Update                       4                    October 2004
                          Practice Partner – Transcription Options

1. Dictation options:
    A. Transcriptionist can type directly into PP, after selecting the patient in PP. The Word
        processing function within PP* has spell check and allows for templates to be built (e.g.,
        standard headings, sections, etc.). This PP tool also allows for easy import of meds lists
        and other data into the note that is available within PP (and vice-versa).

     B. Transcriptionist types in MS/Word (with some required standard codes at the top of the
        Word document) - and then imports these documents into PP and selecting a note import
        function. This import can be done in ‘batches.’

2. Physician direct entry options:
    A. Physician types directly into PP* using the word processing function as described in 1A

     B. Physician enters notes via pre-formatted templates that are typically developed for the
        type of diagnosis or type of visit. Each specialty usually creates/refines these templates
        over time.

*Note: PP does not currently have bold, italics, etc. capabilities in the current version, but a new
    version that has these features will be implemented by the end of 2004.

  MUSC EMR Update                                5                        October 2004
                       PMSI’s Practice Partner (PP) system

•    Goal: 330 ‘attending’ physicians on PP by end of 2005*.
      *For each physician, there are many additional users that are activated
        (e.g., nurses, COM staff, billing personnel).
      – Approx. 120 physicians currently using PP.
      – Approx. 50 in process (beginning with nurses) thru 12/31/2004.
      – Remaining 160 physicians to be implemented in 2005.
•    Two Oracle data bases to be merged into one (November)
•    System/server redundancy planned for December.
•    Supported by Ambulatory IS team led by Jim Smith (5 FTEs).

    MUSC EMR Update                    6                     October 2004
                         Practice Partner Current Status

Currently Utilizing Practice Partner
Family Medicine             23
Endocrinology               18
Internal Medicine (partial) 27
Neurosurgery                 5
OB/GYN                      27
General Pediatrics          10
Pediatrics (others)         10
Plastic Surgery               4
In Process
Neurology                            13
Rheumatology                 8
Ortho – adult               11
Pulmonary                   13
Peds surgery                 2

  MUSC EMR Update                         7                October 2004
                             Practice Partner Rollout Plan

2005 Rollout (yet to be scheduled)
Cardiology                    22
Dermatology                    6
HemOnc                        14
Infectious Diseases            6
ENT                           19
Nephrology                    15
Ophthalmology                 17
Peds Adolescent Med            2
Peds Cardiology               11
Peds HemOnc                    4
Peds Nephrology                2
Peds Neonatology              11
Peds Pulmonary                 4
Surgery                       22
Urology                        6
    Total 2005               161

  MUSC EMR Update                         8                  October 2004
                           Other Clinical System Initiatives

•    Advanced Point of Care Clinical System (RFP…)
•    OR system replacement
      – Reinitiated in July (i.e., vendor selection to replace SurgiServe).
      – Site visits in progress.
•    Transplant system
      – Reinitiated in May (RFP process...).
      – Intent to award to be announced this week.
•    ‘C3’ project (Oacis)
      – Computerized Clinical Charting (C3).
      – Pilot for inpatient nursing documentation on wireless (laptop!?) LYNX DAL
          COWs – scheduled for mid November.
      – Web front-end to Oacis in early 2005.

    MUSC EMR Update                       9                    October 2004
                                     IT Governance Committees

                                                                                                  Revised: 9/30/2004
                                               Information Technology
                                             GOVERNANCE STRUCTURE

                                                  President's Council
                                                    Chair: Dr. Ray

                                                Information Management                               Medical Executive
                                                                                                     Chair: Dr. David
                                                 Chair: Dr. Frank Clark

                                                   Financial & Admin                                 Physician
   Infrastructure     Academic & Research                                   Interdisciplinary
                                                  Information Council                           Information Council
Information Council    Information Council                                Information Council
                                                     Chair: Patrick                              Chair: Dr. David
Chair: Kurt Nendorf    Chair: Valerie West                                   Chair: Marilyn
                                                       Wamsley                                        Soper

 MUSC EMR Update                                         10                                October 2004
                                          OCIO Team

                                                                                                 Revised: 5/1/2004
                                           Office of the CIO
                                        ORGANIZATION CHART

                                           Dr. Ray Greenberg

                                         Chief Information Officer
                                               Frank Clark

Director of Academic     Director of     Director of Finance
                                                                     Director of Clinical        Controller
   and Research        Infrastructure    and Administrative
                                                                          Systems            Support Services
      Systems             Systems             Systems
                                                                      Dave Northrup          Melissa Forinash
       Vacant          Kurt Nendorf          John Dell

    MUSC EMR Update                               11                                  October 2004

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