NextGen Training EHR Manual RADIOLOGY For Coastal Health & Wellness Use Only. Rights Reserved.
TABLE OF CONTENTS
O GETTING STARTED WITH EHR
A. How to Access, Login and Exit the NextGen Application Pg I. Accessing NextGen 1 II. Logging In 2 III. Logging Out/Closing the NextGen Application 3
B. Common NextGen EHR Elements I. Shortcuts 5 II. EHR Desktop 6 III. EHR Toolbar and Icons 7
C. Changing Your Password in EHR I. Changing your Password 8
D. How to Access Patient Charts in EHR I. Selecting the Location 9 II Selecting the Provider 9 III Patient Icon 10 IV Patient Information Bar 11 V History Icon 12 VI History Toolbar 12 o Patient History Tab 12 Encounter Icons 13 History Toolbar Icons 13 o Categories Tab 14
O RADIOLOGIST RESPONSIBILITY WITHIN EHR
I. Accessing the Patient’s Encounter 15 II. Selecting a Template 15 III. Completing Orders 17
Getting Started With NEXTGEN HOW TO ACCESS, LOGIN AND EXIT THE NEXTGEN APPLICATION
I. ACCESSING NEXTGEN 1. Double left click on the NextGen 5 icon located on either the desktop or through RDS.
The NextGen Application Launcher will display.
2. Left click once on Electronic Health Record (EHR). The NextGen login window will display. The database name will display on the top banner.
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Getting Started With NEXTGEN HOW TO ACCESS, LOGIN AND EXIT THE NEXTGEN APPLICATION
II. LOGGING IN 3. Left click once in the User field and enter your user name. (First time logging in, user name will be provided by IT)
4. Left click once in the Password field and enter your password (First time logging in, a password will be provided by IT)
5. Confirm the following fields display “Coastal Health & Wellness” Enterprise Practice
6. Left click once on Logon, the appropriate database desktop will display EHR
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Getting Started With NEXTGEN HOW TO ACCESS, LOGIN AND EXIT THE NEXTGEN APPLICATION
III. LOGGING OUT/CLOSING THE NEXTGEN APPLICATION 7. Left click once on File, then Logout or Exit
EHR
A NextGen alert will display, Are you sure you want to Exit? Left click once on Yes
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Getting Started With EHR COMMON NEXTGEN EHR ELEMENTS
In NextGen the Electronic Medical Records (EHR) is a computerized and secured manner to store electronic medical records created to have the ability to access in a timely manner. Users may also do some of the following:
Capture encounter (visit) information Submit superbills for services provided Generate standard and customized reports Generate customized letters to send to patients
I. SHORTCUT MENUS Mouse and Keyboard Throughout the EHR application there are short-cut menus. Users can access short-cut menus by right-clicking in the appropriate area. Users can usually complete a task by clicking on an icon from the toolbar menu located across each desktop or by right clicking on an item and selecting the option from the shortcut menu.
Mouse Usage: Use the left mouse button to select and click items. Use the right mouse button to display a shortcut menu of options.
Minimize:
Click on the Minimize button on the title bar of the active window. The program window will minimize to the Windows taskbar.
Maximize/Restore: On the Windows taskbar, click the Icon of the database to restore.
NextGen Application Launcher
EHR
On the EHR title bar, select the Maximize button to change the sizing of the user screen or restore to normal size
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Getting Started With EHR COMMON NEXTGEN EHR ELEMENTS II. DESKTOP
When you log into the EHR application, the EHR’s main window will display. All EHR functions are performed inside this window or desktop.
Title Bar: Displays NextGen’s Tool Bar: Contains a row of icons name and current patient’s Full Menu Bar: Contains several shortcut that allows access to functions and Name, DOB, Age, Sex, and menus. When you click on an item in the modules. Along with the current MRN menu bar, the short cut menu display location and Provider’s name
Status Bar: Displays the current Practice name status of EHR.N Most common Current Logged in User status “Ready” Caps, Number, and Scroll Locks;
Date
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Getting Started With EHR COMMON NEXTGEN EHR ELEMENTS III. TOOLBAR AND ICONS The Top toolbar is located directly under the NextGen EHR main menu. It consists of icon buttons, a location list and a provider list.
Use the toolbar to access various EHR functions quickly
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Getting Started With EHR CHANGING YOUR PASSWORD 1. Complete “Getting Started with NextGen - How to Access, Login and Exit the NextGen Application” process
2. Understand “Getting Started with EHR - Common NextGen EHR Elements”
I. CHANGING YOUR PASSWORD IN EHR 3. Left click once on Admin on the menu bar
4. Left click once on User Password, the Change Nextgen Account Password screen displays
5. Left click once in the Old Password field and enter your current password
6. Left click once on the New Password field and enter your new password
7. Left click once on the Confirm New Password field and re-enter your new password
8. Left click once on OK.
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Getting Started with EHR HOW TO ACCESS PATIENT’S CHART IN EHR
1. Complete “Getting Started with NextGen - How to Access, Login and Exit the NextGen Application” process
2. Understand “Getting Started with EHR - Common NextGen EHR Elements”
I. SELECTING THE LOCATION Once the EHR database is logged in, the Select Location screen will display after a user accesses EHR
3. Left click once on the location in which patients are receiving services from o TC Coastal Health & Wellness (Texas City site) o Gal Coastal Health & Wellness (Galveston site)
. Lab users also have access to other locations for special unique projects
4. Left click once on OK, the location will display in the toolbar of the EHR
II. SELECTING THE PROVIDER The Select Provider screen displays O Even if you are not assigned a provider, select a resource, Nurse Only; Walk-In Provider. etc…
5. Left click once the provider in which services are being provided by, this includes documentation of any type of communication or encounter with a patient.
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Getting Started with EHR HOW TO ACCESS PATIENT’S CHART IN EHR
6. Left click once on OK, the provider name will display in the toolbar of the EHR
III. PATIENT ICON
7. Left click once on the Patient Icon located on the toolbar to access the patient lookup screen, to search for a patient’s chart. . Most users performing day to day tasks will mainly access patient charts through the Inbox icon. See “WorkFlow” documentation
8. Left click once in the Last (name) field and enter the person’s last name
9. Left click once in the Birth Date field and enter the person’s date of birth
10. Left click once on the Find button to display a search result of Matching Records of all persons with the same last name and date of birth NOTE: The less search criteria the user enters, the more person search result will display. If person is not listed based on search ALWAYS perform a double search by removing data from a field. Ex: Only enter a last name without a DOB or enter a DOB without a last name. Review each result in the matching records list and determine if the person is listed
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Getting Started with EHR HOW TO ACCESS PATIENT’S CHART IN EHR
11. Left click once on the patient’s name to highlight the patient
12. Left lick once on Open to open the patient’s chart
IV. PATIENT INFORMATION BAR
The patient information bar displays: o Patient name, DOB, address, and contact information . additional phone numbers and email address can be accessed by clicking on contact
o Insurance/Payer Name (if patient has coverage) o Preferred Language o Patient Portal Enrollment
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Getting Started with EHR HOW TO ACCESS PATIENT’S CHART IN EHR o Alerts, Allergies, Problems, Diagnoses, Medications and Appointments, Badges/Hyperlink: Badges with numbers attached, indicate number of items. “?” indicates unknown
V. HISTORY ICON
Left click once on History icon to easily access the patient’s history toolbar, if a patient has not been selected the patient lookup screen will display first If a patient chart is opened, Patient icon will need to be used to look up a patient. The history icon will always open the history toolbar on the right side of the desktop, displaying patient’s history of encounters and templates.
VI. HISTORY TOOLBAR The History Toolbar is the most important tool for working with patients' files. The History Toolbar provides users access to virtually every single component of the patient’s medical record allowing easy access to the Modules within the EHR.
o PATIENT HISTORY TAB
Each folder displayed in the Contents window of the History Toolbar represents one Encounter. Folders preceded by a plus sign contain additional information, (e.g. a Template, a Document, a Procedure, etc...) To display all of the contents of a particular Encounter, left click once on the Expand button (+ plus sign) The icons within the folder represent the following: o Templates (blue chart icone) . Progress Note
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Getting Started with EHR HOW TO ACCESS PATIENT’S CHART IN EHR . Intake . Histories o Documents . Letters or addendums o Procedures . Charges associated to the visit o Problems . Diagnosis o Allergies o Medications o Orders . Lab and X-Ray orders
ENCOUNTER ICONS
Icon Allows you Create a new encounter. Allows you to create a new clinical encounter to New document telephone calls, etc… Lock an encounter. If accessible with rights, allows to lock an encounter, Lock no data can be added or removed from a template once an encounter has been locked. o A red lock means – an encounter was once locked but is now unlocked o A blue lock means the encounter is locked and only addendums can be added Search for a specific Allows you to search for a specific encounter by Search encounter. provider, location, diagnosis, and date range within the current patient
HISTORY TOOLBAR ICONS
Icon Opens Allows you Select Template dialog. Access to all available templates. Templates Generate a Document dialog. Access to all available documents. Documents
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Getting Started with EHR HOW TO ACCESS PATIENT’S CHART IN EHR Open Image File dialog. Open and modify images to illustrate patient's Images status. Procedure Summary window. View and/or add any charges to the selected Procedures patient. Problems Summary window. View and/or add any diagnosis to the selected Problems patient. Allergies Summary window. View and/or add any allergies to the selected Allergies patient. Medications Summary View and/or add all prescriptions for the selected Medications Window. patient. Labs Module Access the Lab Module Orders
O CATEGORIES TAB In this tab all “categorized” templates, documents, and scanned paper records will be stored. O Scanned documents are dated
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NEXTGEN EHR Radiologist RADIOLOGIST RESPONSIBILITIES
Purpose: The Radiologist will be responsible for correctly reviewing and documenting patient data within the electronic health records.
1. Complete “Getting Started with NextGen - How to Access, Login and Exit the NextGen Application” process
2. Understand “Getting Started with EHR - Common NextGen EHR Elements”
3. Understanding “Getting Started with EHR - How to Access Patient Charts in EHR”
I. ACCESSING THE PATIENT’S ENCOUNTER
5. At this time users will ALWAYS perform a FOUR POINT CHECK, this is required at the start of every encounter workflow. It consists of selecting the Patient, Location, Provider, and the Encounter Date and Time. The four-point check insures that the information captured during the encounter is accurate for the selected patient.
6. Left click once to highlight the encounter date, within the History Toolbar, to select the encounter to review or document patient information
II. SELECTING A TEMPLATE
7. Left click once on the Templates Icon, the “Select Template” screen displays
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NEXTGEN EHR Radiologist RADIOLOGIST RESPONSIBILITIES
Radiology Report
8. Left click once on “Radiology Report” template
9. Left click once on OK, the “Radiology Report” template will display
Follow process for dictation Highlight the documented findings and do a right click and copy
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NEXTGEN EHR Radiologist RADIOLOGIST RESPONSIBILITIES III. COMPLETING ORDERS 10. Left click once on the Order to complete dictation
11. Left click once in the Report Text field to activate the curser to paste the findings
12. Perform a “ctrl” and “V” shortcut command on the keyboard to paste the findings
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NEXTGEN EHR Radiologist RADIOLOGIST RESPONSIBILITIES
13. Left click once on the Chart Note button, located on the upper right of the report text field. This will generate the report as a document, electronically sign the document and the report is sent to the ordering provider for their review and signature
14. Left click once on the blue check mark located on the upper right corner of the generated document
15. Left click once on the “X” on the document tab to close out the report. The screen returns to the radiology report template.
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NEXTGEN EHR Radiologist RADIOLOGIST RESPONSIBILITIES
16. Left click once on File in the menu bar, to display the shortcut menu
17. Left click on “Close Patient” to close the current patient’s chart
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