APA Accredited Internship in Clinical and Counseling Psychology

                              

EMR Overview

 

 

Welcome to the wonderful world of Electronic Medical Records (EMR) at the Cook Counseling Center. What follows is a brief introduction and overview to the most commonly performed tasks at our clinic. Please refer specific questions to your supervisor. For more information than you’d ever want to know about ethical record keeping, see APA’s guidelines: (http://www.apa.org/practice/recordkeeping.html).

 

Step 1: Logging In

 

1.      Click on the Medicat Icon on the computer’s desktop.

2.      Input User Name, Password, and make sure Clinic = “Counseling.”

3.      In the Medicat start-up screen, click on Appointments

a.      This is the main scheduling page for all CCC employees.

4.      To open the EMR section of Medicat, click on File > Open > EMR

a.      You now have both windows of Medicat open that you will need throughout the day (scheduling and electronic medical records).

b.     Alternatively, from the appointment screen, click on Home, which will take you to the Medicat start-up screen. Then click on EMR.  (Make sure you click only once on EMR. If you click multiple times, and EMR screen will open for each time you clicked, creating confusion for you and slowing down your computer. If this happens, just close all but one of the EMR screens.)

 

Step 2: Navigating and Using the Medicat Scheduling Screen

 

1.      Icons

a.      Home Icon: Takes you to the Medicat home screen (with the buttons for various features of Medicat).

b.     Appt Icon: Takes you back to the main scheduling screen if you have used another component of the scheduling screen.  If you’re on the Home screen, you can get to appointments by clicking this icon.

c.      Client Icon: Provides the client information that is in the Medicat database (address, phone, etc.)

d.     Ticket Icon: No longer used from appointments.  You will be doing tickets from EMR

e.      History Icon: Provides information about previous diagnosis used for client; however, this information is accessible from EMR as well so you probably won’t need to use this icon.

f.       Exit Icon: Closes Medicat Scheduling.

g.      Today Icon: Use if you have looked at the schedule for some day in the past or future and you want to quickly return to today’s schedule. Also, you can click on this icon to refresh your screen rather than waiting for the computer to refresh it automatically.

h.     Check-In Icon:  The front office will use this icon to check-in your client unless the student has done self check-in.  If the student does self check-in, the computer will automatically perform this function.

i.        Block Icon:  Used to put anything other than appointments on your schedule.

                                                              i.      Type: Block, Reservation, Group Reservation, Template

1.      Block – Used for everything other than client appointments

2.      Reservation used for appointments – support staff will schedule

3.      Group Reservation used for groups – support staff will schedule

4.      Template – not used

                                                            ii.      Block Reason – Reasons in the box change depending on the “type” choice above – We will only discuss Block reasons

1.      Most used reasons are as follows:

a.      CCAdmStf

b.     CCGroup

c.      CCHold

d.     CCOutreach

e.      CCResearch

f.       CCSupGrp

g.      CCSupInd

h.     CCTraining – Seminar block

i.        Lunch

j.        Off

2.      Many of the other codes you see under “Block Reason” are not counseling codes – use only codes beginning with CC except for lunch and off codes

                                                          iii.      Date Range

1.      Current – setting something for a single day only

2.      Permanent – Better not to use this code

3.      Expires – Set the date range for when the event expires.  If you set things over holidays and then try to set something else, you may or may not get a message saying there is a conflict. 

4.     Suggestion: It is better to set things for smaller periods of time and to specifically check dates before trying to use the permanent or expires date range to set something.  Sometimes Medicat allows certain codes to cover other codes without telling you that you have covered something up when you set the second block.

                                                         iv.      Time – Use to set the duration of the event.  If you have to go to another campus location of off campus, make sure you also block time to allow you to get there at the necessary time.  Suggestion: If you have to go to another campus location, allow yourself 15 minutes prior to and after the event for transit.  Put the time span of the event in the note section but block your schedule from 15 minutes earlier to 15 minutes following the conclusion of the event.

                                                            v.      Color – Defaults are set for different codes.  Looking at the All Provider view of the schedule, it is easier for other staff to read the schedule if you use the default color for the code you are using.

                                                          vi.      Automatic Deletion: Leave as “no”

                                                        vii.      Notes: Freetext – Add whatever information you need to help you remember what this specific event is.

j.        Arrange Icon: The arrangement on this page is set so no one can use this icon to change the arrangement.  If one person changed something, it would change it on other’s screen as well.

k.      Templates Icon: This icon will not be needed.

l.         Refresh Icon: Used if you want to refresh your screen rather than waiting for the computer to do this automatically (it’s done automatically every minute).

 

2.      Drop Down Menus you can change

a.      View: You can change the view to a Week, Month or to All Providers.  Use the Week or Month view if you are looking at a single person’s schedule.  If you are looking at multiple schedules, this has to be set on All Providers.

b.     Clinic: You will probably leave this on Counseling.

c.      Provider: This drop down menu is used with the Week of Month choice of view.  You can look at any member of the Counseling Staffs’ schedule a week at a time by setting the View to Week or Month and then setting the Provider to the person whose schedule you wish to view.

d.     Date: You can use the calendar to move to any date in the past or future.  To return to today, just click on the Today Icon in the top toolbar.

 

3.      Setting terminology preferences for your computer (patient v. client): Go to Tools > Preferences > General > check box “use Counseling terminology” near bottom of screen > Ok.  Preferences will change when you reboot Medicat.

 

Step 3: Setting Up EMR with your Preferences

 

1.      General Tab

a.      *Current User: Your name

b.     Billing Clinic: Counseling

c.      *Billing Provider: Your name

d.     Billing Facility: Counseling

e.      Chart Request Reason: CnsltClin

f.       Date Format: Your choice

g.      Time Format: Your choice

h.     Orders: Leave as settings are set

i.        Unread Results: uncheck all

j.        Task List: Check In-Progress Notes, Uncharted Appointments, and Canceled Appointments.

 

2.     Clinical Notes Tab

a.      Check Show in-progress notes box

b.     Group Notes: By appointment

c.      Sort Notes: Descending

d.     Default Note View: Edit

e.      SOAP Notes

1.      Allow structured notes: Leave all boxes unchecked

2.      Check automatically create or update ticket

3.      Leave show intake section unchecked

4.      Note header setting: Check first five choices.  The others are optional.

f.       Phone Number Verification: Your Choice

Note: Sections E and F above only affect SOAP notes.

 

3.     Client Summary Tab

a.      Place a check mark beside those items in the left column you would like to appear on your Summary Tab.  Suggested items: Diagnosis, [Current Medications], [Educational Bulletins], ccTesting, CCC Referrals, [Freetext Summary].

b.     In the right column, you can arrange the order of appearance for the items you checked in the left column.  They will be arranged approximately in a right to left order, although the computer will make the best use of space on this page and so sometimes 2 or 3 items may be to the right of a long item on the left or vice versa.

c.      Set color for each section as it appears on your summary tab.  Color won’t appear until an item appears in this section.

d.     Click okay after you have set all of these choices

 

4.     Today’s Visit Tab

a.      Orders: For all three, click on radio button for ticket.  The Default should be Counseling.  Uncheck the two boxes under each of the three items.

b.     Uncheck detailed diagnosis linking

c.      Number of values returned: Suggest that this be set to 25

d.     SOAP Data Entry: Check List for both

 

Step 4: Using EMR

 

This is your “HOME” screen. The top half of this screen will show all appointments scheduled for you today at CCC (if not, be sure to check the correct username is being recognized by EMR – click on the OPTIONS button on the top toolbar to assess). The bottom half of this screen will show you various “tasks” related to your clients – such as open notes, notes that have been started and saved, uncharted appointments, etc. Therefore, the names of your client(s) for the day will be listed on the top of the “HOME” screen and bottom half once they have arrived and checked in (under the Uncharted Notes tab).

 

When you want to open a client’s file, especially when you will make notes or entries in that file, it is best to click on the client’s name from the bottom, Uncharted Notes tab (this ensures that your file entry will be acknowledged by EMR and that client/file will not remain as Uncharted after your entry).

 

Once you double-click on a client’s name, EMR will take you into their record.

 

1.      Icons

a.      New: Drop down menu appears for various notes or to add to your “to do” list

b.     File: Only active on the Procedure/Diagnosis tab – use to view attachments

c.      Home: Takes you to the EMR Home Screen

d.     Client/Patient: Use to open a client file that doesn’t appear on your screen that day.

e.      To Do: Can create a “to do” list for yourself

f.       Results: Will not use as this is for labs primarily

g.      Options: Set the options to determine the appearance of your screen in EMR

h.     Refresh: Click on this after you have completed an action and want your screen to update right away. 

 

Step 5: Charting Client Notes and Contacts

 

When a chart is opened, six tabs will appear under the client’s identifying information (* = the two most-often used by clinicians). A summary is given for each tab below.

·        “Patient/Client Summary”

o       The default listings under this tab include: Allergies, CCTesting, Lab, and Recalls and Referrals (the 2nd and 4th are especially useful for us). For example, this is where you and others can see that you referred a client for testing or to another program/agency.

·        “Clinical Notes” *

o       All electronic medical record history will be listed here (i.e. triages, intakes, progress notes). It is useful to access client’s previous session(s) before their next visit.

·        “Patient/Client Results”

o       Not frequently used by clinicians; psychiatry may use this space.

·        “Proc / Dx History”

o       Chronological history of procedures and diagnoses.

·        “Appt History”

o       Chronological history of appointments listed, for example, by provider.

·        “Today’s Visit” *

o       This is where we record our interactions with a client. Three items must be completed – here is our suggested format.

1.      Record the Dx; select from the “Diagnosis Grouping” to help narrow your search. Double click on your desired dx until it appears in the box to the right. Clicking the red X on the left-hand column of this box will help you erase mistakes.

2.      Record the “Proc” (procedure); most of our usual procedures can be found within the “Counseling” subset of “Procedure Sets” (search if you’d like to find others). At this point, Click “Save” on the bottom toolbar to save the dx and procedure. Medicat will confirm that Today’s Visit has been saved.

3.      Clicking on “Notes” on the left-hand margin will give you four options: Structured Note, FreeText Note, SOAP Note, and Message. All of our services can be documented using the first two choices: Structured Note & FreeText Note. You may use the SOAP Note format if you like and if instructed by your supervisor; doing so could combine steps 1 & 2 above into the SOAP Note format but will not be outlined here. Below is an overview of the different types of notes and forms to use.

 

Step 6: Using the CCC Forms and Writing Progress Notes

 

For interns, practicum students, and post-docs, you will have to make sure that each form has the correct “Provider” listed before you complete the form. In your case, this provider should be your supervisor. Selecting your supervisor in the “Provider” box will ensure that s/he will be sent the form once you have saved or signed the document.

 

Selecting the “Structured Note” will give you access to the following forms:

  • Assessment Referral Form
  • Case Closing Summary
  • Intake Summary
  • Psychiatric Referral
  • SHC (Shiffert Health Center) Referral Form
  • Triage

 

For each of these forms, you must click SUBMIT on the bottom of the form to properly save. Then, EMR will generate a print preview of the completed form, be sure to SAVE or SIGN the form at this point (Your supervisor will discuss with you whether they’d prefer you to SAVE or SIGN your first couple of forms. SAVE allows one to go back and edit the form; SIGN only allows adding new information via an “addendum” with no deletion possible). Again, be sure that your supervisor is listed as the “Provider” so the form will be sent to them.

 

Selecting the “FreeText Note” will give you access to the following forms (under “Template”):

·        “(Note)”: used for the clinician to make a general note on a client.

·        Group Note

·        Individual Note

·        Consultation Note

 

Once you have selected the note to use under Template (i.e. Group or Individual), be sure to complete the “Provider” (your supervisor), “DOS” (Date of Service), and “Summary” (i.e. “Session 1”) sections. Next, place the cursor in the form itself to complete the progress note. Again, speak with your supervisor about whether to SAVE or SIGN the form.

 

Conclusion and Practice:

 

This concludes our overview of basic record keeping procedures within Medicat’s EMR. In general, feel free to practice and try out different areas of the Medicat system with your supervisor (use members of the fictional Duck family for this purpose: Daisy, Huey, Dewey, Louie, or Donald Duck – all SSN’s begin with 8 zeros). For example, click on the different tabs on the top toolbar to see what they mean and where they will take you.