Meaningful Use Exam Protocol Stage 1

Transcription

1 Meaningful Use Exam Protocol Stage 1 During the attestation period there are a few steps to be conscious about while recording patient data. This guide will explain what to do on each screen and tab in order to comply with Meaningful use throughout the patients visit. Patient Profile Tab Satisfy Core Objectives: Core Objective #7 Record Demographics Core objective #9 Record Smoking Status Menu Objective #4 Patient Reminders The first step is properly documenting patient demographic s according to Meaningful Use standards. Record the following demographics: Preferred language Gender Race Ethnicity Date of birth Record Smoking Status. Recall Date to send recalls address to exchange information electronically 1 P age

2 Patient Demographics tab Menu Objective #7 Medication Reconciliation Counseling patients could be as simple as explaining how lack of physical activity or nutrition and smoking can affect their eyes. During the examination keep in mind patients who may be Diabetic or Glaucoma suspects. These patients will affect your Clinical Quality Measures. PFSH Tab If a patient is referred to your office, record this information in the Demographics Tab of the patient profile. Aid Clinical Quality Measures: NQF 0421 a. Adult Weight Screening NQF 0028 a. Preventative Care and Screening Measure Pair b. Tobacco Use Assessment and Tobacco Cessation Intervention Document when counseling for the following by checking off the boxes in Social History: Nutrition Physical Activity Tobacco Cessation 2 P age

3 Health Tab This tab is broken down into 10 sub-tabs. These tabs will satisfy or aid the following: Core Objectives #1-6, 8, 12, and 14 Menu Objective #1,5,6 and 8 Vital Signs Tab Core Objective #8 Record Vital Signs Aid Clinical Quality Measure: NQF 0013 Hypertension: Blood Pressure Measurement by recording: Blood pressure Arm Pulse Height Weight Problem List Tab Document a problem in the list or check off the No known problem checkbox. Core Objective #3 Maintain Problem list Aid Core Objectives: Core Objective #11 Clinical Decision Support Rules Menu Objective # 3 Patient lists Menu Objective #6 Patient-Specific Education Resources Aid Clinical Quality Measure: NQF 0086 Primary Open Angle Glaucoma NQF 0088 Diabetic Retinopathy NQF 0089 Diabetic Retinopathy NQF 0055 Diabetes: Eye exam NOTE: Certain objectives require for a specific diagnosis or problem to be documented in order for those objectives to be met. Medication Allergies Tab Document at least one medication allergy or check off the No known allergies box. Core Objective # 6 Medication Allergy list. 3 P age

4 Medication Tab Document at least one medication or check off the No known medication box. Core Objective #5 Active Medication List Aid Core Objective: Core Objective #1 CPOE for Medication Orders, Core Objective #2 Drug Interaction Checks, Core Objective #4 e-prescribing, Core Objective #11 Clinical Decision support rules, Menu Objective #1 Drug Formulary Checks, Menu Objective #3 Patient lists Menu Objective # 6 Patient-Specific Education Resources NOTE: When signed up with e-prescribe, this will enable Drug formulary checks as well as Drug interaction checks. Certain objectives require for a medication to be documented in order to aid in satisfying those objectives. HL7 CCD/CCR Tab These objectives may be satisfied by generating a CCD and exporting, ing or uploading the CCD to HealthVault. Aid Core Objective: Core objective #12 Electronic Copy of Health information Core Objective #14 Electronic Exchange of Clinical Information Aid Menu Objectives: Menu Objectives #5 Patient Electronic Access and Transition of Care Summary. 4 P age

5 Internal Tab Aid Clinical Quality Measures: NQF 0088 Diabetic Retinopathy NQF 0089 Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy. Document dilation with diabetic patients along with a diagnosis of diabetic retinopathy. Assessment Tab Satisfy Clinical Quality Measure: NQF 0088 NQF 0089 Aid Menu Objectives: Menu Objective #4 Patient Reminders Menu Objective #8 Transition of Care Summary This will also aid in additional problem list documentation, e-prescribing, and patient specific education. Setup a recall in the assessment tab. Setting up recalls will help ensure that certain Clinical Quality measures are met by sending the patient a reminder to return for their follow up on POAG or Diabetic eye exams. Satisfy Menu Objective: Menu Objective # 4 Patient Reminders When referring a patient out to another provider document this in the referred to and reason section of the assessment tab. Menu Objective # 8 Transition of Care Summary The assessment tab will be the last step in the examination. Ensure that all problems, medications, recalls, education and proper follow up plans are completed. 5 P age

6 Post Examination Satisfy Core Objectives: Core objective #12 Electronic Copy of Health Information Core Objective#13 Clinical Summaries Satisfy Menu Objectives: Menu Objective #5 Patient Electronic Access may be satisfied after an examination. If a patient requests a copy of their Health information or access to their records you may generate a CCD and upload to HealthVault in the Health tab of the patient profile or exam screen. After each examination print or an Exam Summary letter. Core objective # 13 Clinical Summaries. NOTE: Electronic Copy of Health Information, Clinical Summaries and Patient Electronic Access must be completed within 3 or 4 business days after the examination. 6 P age