cityMD
When sending prescription electronically, what do you deselect?
-Controlled Medications (Sent by providers only) - Administered Medications (In-Office) - Labs - Diagnostic Imaging
How to send referrals/consults?
1. After adding a diagnosis into the "Assessment" section of the Progress Note, please check off the box under the "PL" column to add the diagnosis to the Problem List. 2. From the right chart panel, click on the adjacent to the ".Consults / Referrals - Par8o ONLY" to expand the order set options. Open the appropriate order set for the applicable referral type by clicking on Referral Types: ▪ List - No appointment made by CityMD; extra resource for the patient printed out and given by PCR ▪ Concierge / Routine - Appointment made by CityMD Aftercare within 7 business days ▪ Urgent - Appointment made within 2 business days - initiated by PCR and taken over by CityMD Aftercare ▪ STAT - Appointment made by on-site PCR - for soonest appointment 3. The Problem List window will pop-up. Check off the appropriate diagnosis from the Problem List. The Referral will now automatically be linked to this assessment. ▪ If multiple diagnoses are present, please make the most appropriate selection for outgoing referral (i.e. Shoulder Pain dx for an Orthopedic referral, Elevated Blood Pressure for a Primary Care Physician referral, etc). 4. Select the desired referral once in the Order Set window. If there are no other desired referrals, click "Order" ONLY from top of the window to apply. 5. From the Progress Note, click on the purple link for the ordered referral to open the referral window. 6. Required for the PCR & Aftercare: Specify in the "Reason" field the reason for the referral. 7. Ensure that the "Ref From" and "Facility From" are correct and reflect the provider assessing the patient during the current visit and CityMD site patient is visiting. 8. In the "Ref To" section Click on the "Ellipsis (...)" adjacent to Provider. 9. Search for "Par8o" inside the search field. 10. Select "Par8o, Referrals", then return to the previous referral window. 11. Within the referral window, within the "Specialty" field, use the drop-down menu to scroll and find the specialty of the referral. 12. Ensure there are (3) attachments in the "Attachments" ▪ The "Medical Summary", "CCR/CCD" and "Progress Notes" are automatically attached. 13. Click "Send Referral", then click "Send Anyway", then uncheck the box for "Send reminder fax," and click "Send". 14. Click the "OK" button to exit.
Order Linking Steps
1. At the very top of the Progress Note, click on the "Orders" tab. 2. Click on the "Order Details" button. A. Click on "CPT-ICD Association" tab and link all the CPT codes to the applicable Assessment ICD Codes. B. Click on "ICD-Order Mapping" tab and link all the orders to the applicable Assessment ICD Codes. 3. Select the "Save" button and return to the Progress Note.
Can a scribe add prescribed medicaiton?
1. Can be added by the scribe, but MUST be sent electronically by the Provider. 2. Pre-made scripts can be found in the right chart panel 3. All controlled substances require documentation from PMP (Prescription Monitoring Program) with a reference number. a. "PMP" Template is merged from the Right Chart Panel.
Therapeutic injections
1. Click on "Therapeutic Injections" link in the Progress Note to open the "Immunizations/Therapeutic Injections" window. 2. When the window opens, click on "Add" from the bottom panel adjacent to "Therapeutic Injections". 3. Select the appropriate Therapeutic Injection from the left-hand panel. 4. The following Therapeutic Injection details must be filled out: A. Dose (amount with units based on the provider's specifications) B. Dose Number (the dosage number in the series) C. Lot Number (retrieved from the medication vial) D. Route E. Location (Anatomical location) F. Expiration Date (Exp. Date) (retrieved from the medication vial) G. Status (Change from "Pending" to "Administered") H. Given By (Document the provider's name by clicking the "...") I. Assessment (check off the appropriate assessment for this medication) 5. Click "OK" once all therapeutic injections have been documented, or if there are additional therapeutic injections administered, then click on "Save and New" to repeat steps 3-5. 6. Click "X" in the top right corner to return to the Progress Not
Immunization
1. Click on the "Immunizations" link in the Progress Note to open the "Immunizations/Therapeutic Injections" window. 2. When the window opens, click on "Add" from the top panel adjacent to "Immunizations". 3. Select the appropriate Immunization from the left-hand panel. The vaccine dosage will automatically populate into the dose field. 4. The following Immunization details must be filled out: A. Dose Number (the dosage number in the series) B. Lot Number (retrieved from the vaccine vial) C. Route D. Location (Anatomical location) E. Expiration Date (Exp. Date) (retrieved from the vaccine vial) F. VIS Given Date (the Vaccine Information Statement given date) G. Status (Change from "Pending" to "Administered") H. Given By (Document the provider's name by clicking the "...") I. Assessment (check off the appropriate assessment for this vaccine) 5. Click "OK" once all immunizations have been documented, or if there are additional immunizations administered, then click on "Save and New" to repeat steps 3-5. 6. Once all immunizations have been documented, check off the "Immunizations Verified" check box. 7. Click the "X" in the top right corner to return to the Progress Note.
Preventive Medicine - Discharge instruction
1. Click on the "Preventive Medicine" link from the Progress Note. 2. Ensure "**Discharge Instructions" folder is selected on the left-hand panel before documenting any instructions. 3. When applicable, select appropriate preset macros by clicking on adjacent green arrows to merge into the Notes field. 4. Free text any provider-specific or visit-specific instructions into the "Notes" text box at the bottom. Ability to free-text provider-dictated instructions can be done at any time in the "Notes" section before the patient visit ends. 5. Select the "Browse..." button to open the menu for uploaded CityMD-specific discharge instructions (i.e. diagnosis-specific instructions). 6. Click in the "Find" bar and begin searching for instructions by typing a "." then the specific diagnosis. ● Ex: ".Pharyngitis " or ".Influenza". 7. Click on the relevant diagnosis-specific instructions and it will merge into the text box on the right-hand panel. 8. Click the "OK" button to apply the selected discharge instructions and close the "Preventive Medicine" window
How to proceed with Point of Care (POC) Testing and Procedures?
1. Click on the "Templates" tab from the right chart panel of the Progress Note for any tests performed and procedures. 2. Use the search box to search for the desired input for the appropriate POC test template. 3. Click on the left arrow to merge the POC test or procedure template into the Progress Note. 4. From the Progress Note, you can click on the green link to document the results and name of the employee who performed the test on the patient. 5. Open each green link to complete documentation by filling in each row. 6. Click "OK" when complete. Repeat the same steps to document who performed the test. ****Same for nebulizer and all inhouse procedures*****
How to document Rapid Strep test?
1. Click on the "Templates" tab from the right chart panel of the chart for any tests performed and procedures. 2. Use the search box to search for the Rapid Strep test template. 3. Click on the left arrow to merge ".POC - Rapid Strep" test or procedure template into the Progress Note. 4. From the Progress Note, you can click on the purple "Lab: Rapid Test for Streptococcal A" link under "Lab Reports". 5. Enter the results in the highlighted bar with the following: a. Test Result - Positive / Negative b. Control Result - Positive c. Performed By (Full Name) 6. Select that the Results have been "Received" (located on the LEFT of the middle of the screen). 7. Select that the Results have been "Reviewed" (located on the TOP of the middle of the screen). 8. Click "OK" when complete.
Visit Code (E&M Code)
1. Click on the "Visit Code" link in the Progress Notes to open the "Billing" window and verify that the correct diagnosis codes are present in the "Assessment" section. If not, click the "Add" button to do so. 2. Verify that the correct diagnosis code is made as "Primary" with an "X" in the box left of the Diagnosis. 3. Click on the "Add E&M" button to load the "Visit Code" pop up window. (Refer to E&M Coding Compliance Guide for more info). A. If the patient is new, select the 9920X code. i. 99201 - Rarely Used ii. 99202 - Simple / Asymptomatic iii. 99203 - Low Complexity iv. 99204 - Moderate Complexity v. 99205 - Severe / High Complexity B. If the patient is established, select the 9921X code. i. 99211 - Rarely Used ii. 99212 - Simple / Asymptomatic iii. 99213 - Very Low Complexity iv. 99214 - Low and Moderate Complexity v. 99215 - Severe / High Complexity C. Examples when E&M code NOT required: i. Influenza Vaccine ONLY ii. DOT physicals iii. PPD Placement & read (UNINSURED) 4. Click the "OK" button to return to the "Billing" window. 5. Document in the "Billing Notes" section to communicate with the Patient Care Representatives for any of the following: ▪ School/Work Notes ▪ Waived Co-Pays etc. 6. Follow Up: MUST have an option selected. If no follow up is specified, ensure that "Follow up N/A" is selected. If follow up IS specified, uncheck "Follow up N/A" and select the appropriate follow up time frame. 7. Click "Done" to proceed to discharge process (next page), or "Close" in order to return to the Progress Notes for any changes to be made on the chart.
How to change status for fasting/non-fasting for blood work?
1. Click on the, "Lab Reports" link in the Progress Note. 2. Fasting Status a. Fasting - Patient did not eat or drink anything besides water in the last 8-12 hours. i. Select the check box under the "F" (Fasting) section if the patient has been fasting. b. Non-Fasting - Patient consumed any meals or fluids besides water in the last 8-12 hours. i. Leave the box under the "F" (Fasting) section blank.
What are the 6 things we verify before provider leaves?
1. Dx 2. Rx 3. Interactions. 4. Services Ordered 5. Provider Specific Instructions 6. Visit Code
Sending prescriptions
1. Everything in this window MUST be UNCHECKED except for medications that need to be sent to the pharmacy. You must uncheck controlled medications labeled with a . 2. Check off the Medications (non-controlled) to be ePrescribed to the pharmacy and change the mode to ePrescribe. 3. Select the appropriate pharmacy by clicking on "Click here to Select Pharmacy". 4. Check off "Show All". 5. Click the drop-down menu to toggle between searching methods. 6. Search for the pharmacy in the "Lookup Pharmacy" text box. 7. Select the pharmacy of choice. 8. Click the "OK" button. 9. Click on the Green "Send" button on the bottom right corner of the window to transmit the medications selected. Close the window and return to the Progress Note for the patient
Diagnostic Imaging Order Requirements
1. From the Progress Note, click on the purple link for the Advanced Diagnostic Imaging order to open the order specifications window. 2. Click "Add Notes" button above the "Notes" section. 3. Document the following in the "Notes" section (Do not use the Internal Notes section): i. STAT CT / MRI Orders: ● (STAT) (CT/MRI of Location) (Type of Contrast or No Contrast) (Wet Read Required) (PE Finding) (Evaluate For) ii. STAT US Orders: ● (STAT) (US of Location) (Wet Read Required) (PE Finding) (Evaluate For) iii. Routine CT / MRI Orders: ● (Routine) (CT/MRI of Location) (Type of Contrast or No Contrast) (PE Finding) (Evaluate For) iv. Routine US Orders: ● (Routine) (US of Location) (PE Finding) (Evaluate For) 4. Click the "OK" button to exit the "Add Notes" window. i. Note: Once you click "OK" and exit the "Notes" section, the information entered into this section is saved and unable to be edited. 5. Click "OK" once all information has been entered.
Ordering X-rays
1. From the right chart panel click on the adjacent to the "*X-Ray (In-House)" to expand the order set options. 2. Open the appropriate anatomical order set for the requested X-Ray by clicking on. 3. Check off the requested X-Ray order and click the "Order" button ONLY from the top of the window. 4. From the Progress Note, click on the "Diagnostic Imaging" link to open the "Diagnostic Imaging" window. ---Blue color---- 5. Within the "Diagnostic Imaging" window, click on the "Quick Transmit" button on the bottom left corner to open the "Transmit Diagnostic Imaging Orders" window. 6. From within the "Transmit Diagnostic Imaging Orders" window, select the X-Rays orders to be transmitted. a. Note: i. If multiple X-Rays were ordered with different clinical information, only select one X-Ray order at a time to transmit and complete steps 7 and 8. Then, repeat steps 4-8 for the additional X-Ray orders. ii. If only one X-Ray was ordered, or multiple X-Rays were ordered with the same clinical information, you may select all the X-Ray orders and complete steps 7 and 8. 7. At the bottom of the window, within the "Clinical Information" section type in the following information: a. (Relevant) PE: Physical Examination findings for x-ray b. EVALUATE FOR: What is being determined? 8. Click on the "Transmit" button to send the X-Ray order to the X-Ray machine. Additionally, a window will pop-up to select a printer destination to print the X-Ray requisition form. 9. Obtain the X-Ray requisition form from the printer, write the Room Number on it, and provide it to the X-Ray technologist performing the imaging study.
".Magic Mouthwash and Prednisone Rx
1. Search for the ".Magic Mouthwash and Prednisone Rx" in the "Templates" section. 2. Expand the template order set options by clicking adjacent to ".Magic Mouthwash and Prednisone Rx". 3. Click on adjacent to the appropriate order set category for Magic Mouthwash Rx or the Prednisone - Tapers to open the order set. 4. Select the requested medication by the Provider. 5. Click "Order" to order the prescription.
how to add medication for peds?
1. Search for the ".Pediatric Rx and Labs" in the "Templates" section. 2. Expand the template order set options by clicking adjacent to ".Pediatric Rx and Labs". 3. Click on the "OS" next to the appropriate weight of the child. 4. Select the requested medication by the Provider. 5. Click "Order" to order the prescription(s).
How to add first dose medication?
1. Search for the medication being ADMINISTERED from the "Templates" from the right chart panel of the Progress Note. 2. Click on the left arrow to merge the medication into the chart.
How to add wait and see?
1.Click on the "Treatment" link from inside of the Progress Note to review medications already added or to add new medications. 2. Add "Wait and See" in the "Comments" sections for the Pharmacy 3. Add "Wait and See" in the "Notes" section for the Pharmacy and Aftercare:
Completion of X-RAY Documentation
After the X-Ray is performed, the Provider will interpret the results. To document the results, follow these steps: 1. From the Progress Note, click on the purple link for the X-Ray order to open specifications window. 2. In the middle of this pop-up window, document within the "Result" field the following details: ▪ Provider's read / results followed by "..." and their initials. o Ex: "No infiltrates, cardiomegaly, or pneumothorax...SW" ▪ DO NOT use the drop-down menu for any results. 3. Click "OK" to save and exit the window and return to the Progress Note.
When should you send prescriptions?
After visit code
Where do you add school/work notes?
Billing Notes at the bottom of visit code
Before documenting HPI, make sure to...
Click in the "c/o" cell to the left of the appropriate symptom
If pt presents with a cough, what should you ask them next?
Fever, body aces, or chills? Yes Okay... run flu test
When you have an established pt. what should you do in drug history?
For an established patient or a patient seen at CityMD at least once in the past: a) Verbally review all medications listed. b) Delete any medications the patient is no longer taking/has discontinued. Select the red STOP (-) button to the left of the medication name.
If a minor what should you add in social history for tobaccoo?
Is there anyone in the house that uses tobacco?
What should you never do in drug allergies section?
NEVER free type
Can you click on the purple lab on the left?
NEVER. it will freeze computer
Do pts under the age of 18 require BP screening?
No they do not.
When doing the Healthy lifestyle, do you actually click print?
No. Once the Print screen appears, hit "cancel", because the printout is already at the front desk. Click "ok" to add a note in Treatment to document that the education material was given.
How do we link all prescriptions, orders, and procedures to a diagnosis?
Order Linking
When adding referrals, the provider is....
Par80,Referrals
Where do you add discharge instructions?
Preventive Medicine - Discharge Instruction
In the ROS, what should I try to do first?
Quickly input the chief complaint. Eg, if pt has a cough go to ENT and type (+) cough
For ALL STATs, ONLY use the...
STAT order set or category *
How to remove problems list from the pt's Progress Notes
The first method is: 1. Uncheck the "PL" checkbox. 2. Click on the "Problem List" button in "Assessment". 3. The Problem List window will open. Select all assessments to be removed. 4. Click on "Remove" on the top right corner. 5. A pop-up window will open. Click the "Remove" button. The problem list is now successfully cleared. 6. Click the "OK" button on the bottom right corner to exit.
When documenting dx in assessment, where will you be typing in the dx?
Type in box should already be active in bottom left
When taking the history, make sure to do what at the end of each history?
Verified Box
When adding prescription drugs in history, make sure to check....
Verified box and Rx Name Only box
How to order Advanced Diagnostic Imaging - CT/MRI/ULTRASOUNDS?
When the Provider is ordering Advanced Diagnostic Imaging, follow the steps below: 1. From the right chart panel, search for ".CT / MRI / Ultrasound". 2. Click on adjacent to ".CT / MRI / Ultrasound" to expand the order set options. 3. Open the appropriate anatomical order set for the applicable Advanced Diagnostic Imaging type by clicking on . 4. Check off the requested Advanced Diagnostic Imaging order. 5. Click the "Order" button ONLY from the top of the window
Ordering Labs
When the Provider is ordering a Lab, follow the steps below: 1. From the "Templates" tab within the Right Chart Panel, locate the appropriate labs order set desired based on location by searching for .Lab (NEW JERSEY ONLY) or .Labs. 2. Select the to show a drop-down menu, in which you can search via a desired category of labs and open the appropriate order set by clicking on adjacent to the appropriate lab order set. a. New Jersey locations (Except CityMD Wall): Search .Lab (NEW JERSEY ONLY) b. All other locations: Search .Labs 3. Select the desired labs ordered by the Provider. 4. Click "Order" button to proceed to the "Order Sets" window. These labs will appear under "Lab Reports
If pt. is a current smoker, what do you do in social history?
Yes for counseling Date
Order Sets are commonly identified on the Right Cabinet as....
[+] signs. Order Sets usually require an order being sent out of the office.
All PT pt's require...
a "Custom Rx" paper prescription along with a referral in Par8o. The patient needs to take this paper prescription to the referred Physical Therapy facility.
When should you do the visit code
after order lining
If the Provider orders STAT labs, what should you do...?
always notify the Medical Assistant (MA) and Manage
After adding a diagnosis into the "Assessment" section, what is the next CRITICAL step?
check off the box under the "PL" column to add the diagnosis to the Problem List
With all labs and advanced imaging, once ordered, what is the next step?
merge the Labs/Advanced Imaging Template from the right chart panel. This is done to indicate that additional work-up is being performed for the patient.
What are some pertinent information that can be included in HPI?
o OTC or RX meds and better/worse o Sick contacts +/- o Travel +/- o History of similar episodes +/- o Pertinent medical issues specific to the CC (i.e. asthma for cough) o History of tobacco use/products +/-
After adding a diagnosis into the "Assessment" section of the Progress Note, please check off the box under?
the "PL" column to add the diagnosis to the Problem List.
What are order sets on the right hand side?
● Order Sets ● Set of Orders usually sent out of the office ○ .Labs ○ *X-Ray (In-House) - Done in office but also sent out to a Radiologist for review ○ .Consults / Referrals - Par8o System ○ .CT / MRI / Ultrasounds
What are templates on the right hand side?
● Services usually performed in office ○ Point of Care Testing (POC) ○ Procedures ○ First Dose Medications
The template is not required for the lab orders listed below:
● Urine culture ● Throat culture ● Labs for Routine Physicals ● Labs for OccMed Cases ● Labs for CityMD EHS
