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Naval Medical Center Portsmouth, VA 
620 John Paul Jones Circle
Portsmouth, VA 23708-2197
Phone: 757-953-5000; DSN: 377-5000

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Naval Medical Center Portsmouth
  

AHLTA Nuggets

 

AHLTA

User Quick Reference 

and

“How To” Guide

 

 

 

  a.k.a.

 

 

AHLTA

-  NUGGETS   -

Prepared 10/12/06

General helpful hints for using AHLTA.. 4

Help. 4

Locking/Unlocking Your Workstation. 4

Navigating around the screen in AHLTA.. 4

Appointments. 6

Searching for a Patient 6

Check-in a Scheduled Appointment 6

Create a New Unscheduled Appointment 6

Cancel an Appointment 6

Undo Cancelled Appointments. 6

Transfer an appointment 7

Add a Provider to an Appointment 7

Add or Change a Comment in the “Comments” Field. 7

Changing what displays in the Appointments Module. 7

Encounters. 8

Changing what displays in each Encounter window. 8

Documenting an Encounter 8

Screening a Patient 8

Entering Patient Vital Signs. 9

Selecting an Template. 9

Documenting in the S/O Note. 10

Documenting the Assessment and Plan. 10

Completing the Disposition. 11

Signing the Encounter 11

Copying Lab or Rad Results Directly into a Note. 12

Add a Note to an Encounter 12

Importing an Image to an Encounter Note. 12

Edit Image Size. 13

Documenting a Telephone Encounter (Telcon) 13

Creating a New Telephone Consult: 13

To Make a New Appointment in the Telephone Consults module: 13

Cancelling a Telephone Consult 14

Transferring a Telephone Consult 14

Documenting a Telcon Encounter 14

S/O Templates. 15

Editing an S/O Template. 15

Merge S/O Templates. 15

Creating a “Free Text” Template. 15

Creating an Order Set 16

Editing an Order Set 16

Merging an Order Set with a Template. 17

Other Modules. 17

Alert Review.. 17

Co-Signs. 17

New Results. 18

List Management 19

Sign Orders. 19

Health History. 19

Adding Problems to the Master Problem List 20

Adding an OTC/Outside Medication to the Master Meds List 20

Adding an Allergy. 20

Patient Questionnaires. 21

Completing a Questionnaire in an Interview.. 21

Associate Questionnaire with an Encounter 21

Clinical Notes. 21

Previous Encounters. 22

To “Amend” or “Append” a Previous Encounter see the instructions under “Co-Signs” earlier in this document. 22

Copying a Previous Encounter into the Current Encounter 22
Fail-Over Mode Operation Overview Of Fail-Over Operations

 

 

General helpful hints for using AHLTA

 

Help

 

There are many ways to get help with the AHLTA application:

§                     AHLTA User Guide

§                     Online Help (located within AHLTA application) – On the keyboard, press F1 or, from the Help menu, click Help Topics, and then search by topic or keyword.

§                     AHLTA Technical Support Team:  (**DBA’s name here**), ext. ****

§                     AHLTA Sustainment Trainer:  (**Your name here**), ext. ****

§                     (***Your MTF***) General Computer Help Desk:  ext. ****

 

Note: The content of this document is designed to be generic; therefore, service-specific processes are not addressed. Follow the established procedure of your MTF at all times.

 

Locking/Unlocking Your Workstation

 

To maintain patient data integrity and protect patient privacy, it is important to lock the application when you are away from the system. A locked application prevents unauthorized users from accessing an open patient encounter.

 

To lock the application, press CTRL-Z on the keyboard or, from Tools on the Menu Bar, click Lock.

To unlock the application:

  1. Click on the AHLTA logo with your name next to it on taskbar (at the bottom of your screen).
  2. Enter your AHLTA password in the Password field.
  3. Click OK.

 

 

Navigating around the screen in AHLTA

 

The “Module” window:  This is where everything happens, just like in your email program or on most internet web pages, this is where you can view and manipulate information.  However, to get to the right page to view the info you need, you must choose the appropriate folder from the “Folder List” on the left side of the screen.  Then, if you need to “act on’ any of the information in that module, you will need to click on one of the icons in the “Action Bar” that is at the top of the screen, (hence the name).

The Folder List:  The Folder List is on the left hand side of the screen and shows you all of the administrative modules that affect you and all of the modules for the information that comprises the patients’ electronic medical record. 

Remember this rule of thumb for the Folder List:  If it is ABOVE the patients’ name, it is something that applies to YOU… if it is BELOW the patients’ name; it is part of their record and applies only to THEM.

Therefore, if you are looking for an appointment list… that is an administrative function so look at the top half of the list for the word Appointments and then click on it to call up the Appointments module.  IF… however, you need to see a specific lab for a patient, just click on the “Lab” icon that is in the lower half of the Folder List, (below their name) and their lab history will display in the main module window to the right.

The Action Bar:  The “Action Bar” is at the top of the screen it is where you can see what you are able to do with the info in the module that you are looking at.  For instance, if you want to create a new appointment for a patient, then first click on the Appointments module in the Folder List then, once it appears, look up at the Action Bar and you’ll see an icon called “New Appt.”… yes, that’s it, nothing more complicated than that…  in short:  If you need to do something with the information you are looking at… just look up at the Action Bar and there should be an icon there that will help you do it.   Again, this may seem obvious to you but if you take a second to actually look at the Action Bar at the top of each module page, most of your usage questions will be answered. 

The Patient Data Bar:  This is the bright green ribbon just below the Action Bar that tell you whose medical record you are currently looking at.  This may sound like an obvious statement but when you are moving around in the system, viewing several different records, it is important to get in the habit of looking up at the Patient Data Bar to make sure you are still viewing information on the correct patient.

The Options Button:  This button is on the far right side of the Patient Data Bar and it allows you to set the defaults for whatever module you are in.  This not only applies to the way the module appears but also the default information that it will display each time you open it.

A note on “Typing” in the system:  ALWAYS finish any typing that you do in AHLTA by hitting the enter key… this will either save the text you are typing or start the search for the term you are looking for… do not assume that simply closing a page will save your text

 

 

 


Appointments

 

Searching for a Patient

  1. In the Folder List on the left side of the screen, click Search.
  2. Enter the search criteria into the appropriate field, (searching by the patients’ full SSN will return the least number of names and do it the fastest).
  3. When the list appears, double-click on the correct patient to select them.

Check-in a Scheduled Appointment

  1. In the Folder List on the left side of the screen, click Appointments.
  2. Double-click the patients’ name.

Create a New Unscheduled Appointment

  1. In the Folder List on the left side of the screen, click Appointments.
  2. On Action Bar along the top of the screen, click the New Appt icon.
  3. Conduct a patient search, (as shown above).
  4. Verify that the “Assigned Clinic” and “Provider” are correct or select the correct entries from the pull-down menus;
  5. Select the appropriate “Appointment Type”.
  6. Type in the “Reason for Appointment” in the appropriate field.
  7. Click OK.

 

Note: Telcon Appointments are created in the Telephone Consult module. To create a telephone consult appointment, see the “Create New Telephone Consult” section later in this document

Cancel an Appointment

  1. In the Folder List on the left side of the screen, click Appointments. 
  2. Select appointment to cancel then on Action Bar, click the Cancel icon.
  3. In Reason for Cancellation section, select appropriate reason, click OK.

Undo Cancelled Appointments

  1. In the Folder List on the left side of the screen, click Appointments. 
  2. Select (highlight) the appointment you want to “un-cancel”.
  3. Click on the Undo Cancel icon on the Action Bar.
  4. Click Yes at the message prompt.

Transfer an appointment

  1. In the Folder List on the left side of the screen, click Appointments.
  2. Select (highlight) the appointment to transfer;
  3. Click the Transfer icon on Action Bar.
  4. Select the new Provider from drop-down list; click OK.

Add a Provider to an Appointment

  1. In the Folder List on the left side of the screen, click Appointments.
  2. Select (highlight) the appointment to add a provider to.
  3. Click the “Add Provider” icon on the Action Bar,
  4. Select the Provider you want to add to the appt. from drop-down list; click OK.

Add or Change a Comment in the “Comments” Field

  1. In the Folder List on the left side of the screen, click Appointments.
  2. Select (highlight) the appointment to add a comment to.
  3. Click the View Comments icon on the Action Bar.
  4. Type any comments into the window that appears then click OK to save.

Note:  The “Comments” field is the only field in the Appointments module that can be changed repeatedly from that screen so it can be used for communicating any type of clinic-specific or patient-specific information that may be needed for your particular processes and procedure.  However, remember that it is limited in size so it is best to either abbreviate or create a “code” for passing on the information.

Changing what displays in the Appointments Module

  1. In the Folder List on the left side of the screen, click Appointments.
  2. In Appointments screen, click either Change Selections or the Options buttons.
  3. Select the “Clinics”, “Providers”, “Dates”, and “Status Selection” criteria to display what you would like.
  4. Click the Set Selections as Default button.


Encounters

Changing what displays in each Encounter window.  (You should do this the first time you enter into the system

1.   In the Appointments screen double-click on any appointment.

2.   When an Encounter screen opens, click on the “Options” button in the upper right hand corner of screen.

3.   When the Encounter Summary Properties screen appears, revise the “Signature Block” section to most closely identify your title and location, if appropriate.

4.   Under the “Autocite Preferences” section, select check boxes for information you want to appear in the screen display for all encounters.

(Note:  It’s recommend that you only choose “Past Medical Problems” and “Allergies”.  “Meds” is also handy but can make some encounter docs very long and hard to navigate.)

5.   In A/P Active Order Default section, select check boxes for active orders to show in default display of these order tabs.  (This is normally NOT selected because it can slow down the time it takes to load the A/P section.)

6.   In the “Disposition Follow-up Discussed with Default” field, select the appropriate default.  (This is normally only changed to “Parent” for Pediatricians, otherwise it is rarely changed from the default of “Patient”.)

7.   Select the “Auto-Print check box, as needed. (This is normally NOT selected.)

8.   Select the “Auto-Save check box and enter number of minutes for auto saving (Recommended 2 minutes).

9.   Click OK.

 

 

Documenting an Encounter

All of the following occur in an open Encounter window (SF600) unless otherwise noted:

Screening a Patient

1.      Click on one of the “Screening” buttons.  (You can use either the grey button on the Encounter screen, the icon on the Action Bar or the icon in the lower left hand side of the screen in the Folder List; ANY of these will take you to the “Screening” page.)

2.   Select the “Reason for Visit” from either “Patient Problem List”, “Clinic Favorites List” or just search for the stated reason for the visit; then click the “Add button.

3.   On the Action Bar, click “Verify Allergy”.

4.   In the Allergy Module, select the appropriate check box(s) and update the allergy list as needed.  Then close the allergy module to return to Screening.

6.   To update work status, click on “Spec Work Status” and select the appropriate check box(s) and radio buttons(s) and then lick “OK”.

8.   When the screening is complete, clickOK” to go back to the main Encounter screen.

Entering Patient Vital Signs

1.      Click on one of the “Vitals” buttons (You can use either the grey button on the Encounter screen, the icon on the Action Bar or the icon in the lower left hand side of the screen in the Folder List, ANY of these will take you to the Vitals screen.)

2.      In the upper left part of the screen, select orthostatic or standard vitals entry.

3.      Where available, click ellipsis buttons for selection of modifiers.

4.      In the “Pain Severity section, select appropriate radio button and enter pain location.

5.      Select appropriate check boxes for additional entry fields.

Note:  Once you hit the “OK” button at the bottom of the screen, the vitals are considered “done” and if you choose to change them later, a “Change History” tag will be placed at the bottom of the encounter saying when they were changed and who changed them.

Selecting an Template

1.      Click on the one of the “S/O” buttons (You can use either the grey button on the Encounter screen, the icon on the Action Bar or the icon in the lower left hand side of the screen in the Folder List, ANY of these will take you to the S/O screen.)

2.      Use the pull-down menu to select from your favorite templates (This is just below the patients’ SSN on the green data bar.) 

Use these features for documentation:

1.      To Free Text under a given term:

  • Highlight the term you want to place free text under.
  • In the white box just above the list of terms, type your free text.
  • When done typing, HIT ENTER or the text will not save to the note.
  • Another way to enter free text is to use the “Notepad” icon in the top right corner of MEDCIN pane, (this will allow you to enter free text without labeling it with a specific term from the MEDCIN tree).

2.      For the HPI and ROS tabs, use:

  • Find Term – To find a specific term in the MEDCIN© tree, click the “Find Term” icon on the Action Bar and then enter the term in the box that appears.
  • Prompt – To find related terms, highlight a term in the tree, and then click on the “Prompt” button on the dashboard, (the row of buttons just below the green patient data bar).
  • Dx Prompt – To find terms related to a diagnosis, click on the “Dx Prompt” icon on the Action Bar and enter a diagnosis in search box that appears.
  • ROS/HPI – To flip ROS terms to HPI and vice versa, highlight the term and then click the “ROS/HPI” button on the dashboard.

3.      For the PMH tab, use:

  • History and FamHist – To change terms from patient history to family history, highlight the desired term and then click the appropriate dashboard button.

4.      For PE tab, use:

  • Browse From Here – To find a term by browsing the tree, highlight the nearest anatomical term available and click Browse From Here on the Action Bar.

5.      For the Test tab:

  • The “Test” tab is used for entering pertinent test results into the S/O note, not for ordering tests (that is done in the A/P section).  Since Lab and Rad results can be copied into the note directly from those modules, this tab is rarely used.

 

Documenting in the S/O Note

1.      In the Encounter window, click S/O.

2.      If no template is loaded, select one from the template dropdown list (just below the persons’ SSN on the patient data bar), or… if you can’t find the template you need in your favorites list, click the “Template Mgt” icon on the Action Bar and locate a template or AIM form using the search window.

3.      Once you have a template selected and loaded into the encounter, click the large plus signs to document positive or abnormal findings or the large minus signs for normal (or negative) findings.  If you need to have more specific options, click on the small plus sign next to the heading that you are interested in and more “specifiers” will appear in a tree format.

4.      If you prefer to check every condition listed in HPI, ROS, and PE sections, select abnormal conditions first, then click on the “AutoNeg” button next to the template dropdown list (just below the patient data bar) to quickly document normal findings.

(Note: Using AutoNeg can create a very “wordy” note that is harder for other providers to easily read, therefore, it is only recommended for use with short, precise templates.)

5.      When finished documenting S/O note, click “Close” on the Action Bar, or “A/P’ to continue on to the next step in the documentation process.

Documenting the Assessment and Plan

 

1.   In the Encounter window click the “A/P” button; (You can use either the grey button on the Encounter screen, the icon on the Action Bar or the icon in the lower left hand side of the screen in the Folder List, ANY of these will take you to the A/P module).

2.   The “Diagnosis” tab will come up first, when it does, select a diagnosis from encounter template list that appears, the “Problem list” or your “Favorites list”, or by doing a search for the diagnosis you need in the search window to the right.  Then either double-click on the correct diagnosis(s) or hit the Add to Encounter button. (Note: Use may use the “Comment” section under each diagnosis to enter information about that diagnosis.)

3.   If an order set is available under the “Order Sets” tab, select from the available orders, and click the “Submit” button at the bottom of the screen.  If orders are not available, search for orders, highlight the diagnosis to associate the orders with, and submit or save to queue.

4.   Under the “Procedure” and “Other Therapies” tabs, select from the template list or search results, highlight the diagnosis to associate them with, and add the selections to the encounter.      

      (Note: To delete a diagnosis (or procedure or order, etc.) from the encounter, highlight the item and click the “Delete” icon on the Action Bar. To associate or disassociate an item from a specific diagnosis, use the < > button.)

6.   When finished documenting in the A/P section, click “Close” on the Action Bar, or the “Disposition” icon to continue on to the next step in the documentation process.

     

 

Completing the Disposition

1.   In the Encounter window click the “Disposition” button; (You can use either the grey button on the Encounter screen, the icon on the Action Bar or the icon in the lower left hand side of the screen in the Folder List, ANY of these will take you to the Disposition module).

2.   In the “Disposition” module, make the appropriate selections.

3.   If visit is work-related, complete Injury/Illness section. (Note: Marking an encounter as being related to an injury requires that at least one of the diagnoses be an “E” code)

4.   Complete the appropriate fields in the “Follow Up” and “Discussed” sections.

5.   When done with the Disposition module, click the “Sign” icon on the Action Bar.

 

 

Signing the Encounter

1.   On Action Bar, click Sign.

2.   Enter your AHLTA password.

3.   If a cosigner is required, select “Cosigner Required” check box and search for and select an appropriate cosigner.

4.   Select Auto-Print check box to print the encounter only if you need to have a hard copy of the encounter, (check your clinic policies and procedures to verify this, you probably do not have to print out an encounter except in special circumstances).

5.   If encounter contains sensitive information, select the “Sensitive” check box.

6.   Click Sign

  

Copying Lab or Rad Results Directly into a Note

1.   With an encounter open, click on the Lab or Radiology folder in “Folder List” on the left had side of the screen.

2.   Click on the Lab or Rad that you want to copy, then, by holding down the left mouse button, drag (highlight) the portion you wish to be copied.

3.   Right-click in the highlighted area and then select “Copy to Note”.

      (Note:  Click “Copy to Note” only once.  Multiple entries will appear on SF600 if it is clicked more than once.)

4.   Close the module to view the copied results.

 

Add a Note to an Encounter

A “Note” can be any type of electronic file that is already on your computer (i.e. – A photograph, a scanned document, a transcribed document, a Word file, etc.)

1.   In the Encounter window click the gray “Add Note” button.

2.   In the Select Note screen that appears, click “New Note”.

3.   On the Encounter Note screen, You may enter text in the “Note Category” and “Note Title” fields if you choose to, but the actual note that will appear needs to be written in the large field, below.

(Note:  To add a separate document file, see “Importing an Image to an Encounter”  Note”, below.)

4.   When you have finished the note, save it by clicking “Note Complete”, if you hit “Save Draft” instead, it will not allow you to sign the encounter until you have “completed” it by hitting the “Note Complete” button.

 

Importing an Image to an Encounter Note

The encounter note file supports only images saved to Windows Bitmap or Tagged Image Format files that are under 500K in size. See “Edit Image Size”, below for instructions to convert image files to one of the supported formats.

1.   In the Encounter window, click the “Add Note” button.

2.   On the Select Note screen, click “New Note”.

3.   On the Encounter Note screen, You may enter text in the “Note Category” and “Note Title” fields if you choose to, but the actual note (or image or file) that will appear in on the SF600 needs to be pasted into the large field, below.

4.   Click on the “Load File” button and search for the file as you would normally in your computer.  Be aware that not all file formats are currently accepted so you may need to convert a file before you can to save it to the “Add Note” section of the encounter.

5.   In the “Files of type:” field, select “All Files”

6.   Select file from its currently saved location and double click on it or click “Open”.

7.   If a “Preview” window comes up, then review it and click “Select” to load the image into the note.  (The image will only “Preview” if it is an image, a document will just load directly into the add note window.)

8.   When you have finished, save it by clicking “Note Complete”, if you hit “Save Draft” it will not allow you to sign the encounter until you have “completed” it by hitting the “Note Complete” button.

 

Edit Image Size

Sizing adjustments must be done before importing image to encounter note.

1.   Open the image file outside AHLTA in a separate application, for example, Microsoft Paint.

2.   In Paint, or similar application, adjust the size.

3.   Save it in a supported format (BMP, TIFF, etc.).

 

Documenting a Telephone Encounter (Telcon)

 

Creating a New Telephone Consult:

Telcon Appointments can be created from either the Appointments module or the “Telephone Consults” module, but are accessible only from the “Telephone Consults” module.

To Make a New Appointment in the Telephone Consults module:

  1. In the Folder List on the left side of the screen, click “Telephone Consults”.
  2. On the Action Bar, click the “New Telcon” icon.
  3. Conduct a patient search, if required.
  4. Verify the default information and change it, if needed. (i.e.- clinic, doctor, etc.)
  5. Complete the “Reason for Telephone Consult” field and click OK.
  6. If you are just assigning it to a provider then you are done at this point.  If you are doing the Telcon yourself, fill out the sections in the Telcon Quick Entry screen as appropriate for the encounter type then close and sign it per the instructions on the screen . 

 

Cancelling a Telephone Consult

  1. In the Folder Lis on the left side of the screen, click “Telephone Consults”.
  2. Select the Telcon to cancel and right-click the mouse.
  3. Click the “Cancel Telcon” option and select reason for cancellation.
  4. Click OK.

 

Transferring a Telephone Consult

  1. In the Folder List on the left side of the screen, click “Telephone Consults”.
  2. Select the Telcon to transfer and right-click the mouse.
  3. Click the “Transfer Telcon” option.
  4. Select a Provider from the list and click OK.

 

Documenting a Telcon Encounter

1.   In the Folder List on the left side of the screen, click “Telephone Consults”.

2.   From “Telephone Consults” screen, open an appointment by double clicking on it.

3.   In the “Telcon Quick Entry” screen, enter a Provider note, if appropriate. (think of this section as a “Mini S/O Note” to briefly describe what the call is about and what the patient said during the call.

4.   Add a diagnosis by either choosing it from one patients’ problems list, your favorites list or by selecting a diagnosis using the Search results.

5.   Select appropriate E&M code. (whether it was a short, average or long call)

6.   Select appropriate radio button and click “OK”.  (You can simply sign and exit the encounter, go to the A/P section to order Labs, Rads or Meds or you can open the full SF600 to enter extensive encounter data.)


S/O Templates

Naming conventions for templates vary so please follow your clinics’ directives.

 

Editing an S/O Template

1.   Create and open an appointment for a test patient (a “QQQ” patient).

2.   Click on the S/O button and then, on the Action Bar, click the Template Mgt. icon.

3.   From the lists that are displayed or from search results, single-click to select a template and then, on Action Bar, click the Edit icon and then, when the Template edit mode window appears…

4.   To remove a term from template, select the term you want to remove from the pane on the right side of the screen, when it appear in the pane on the left, deselect it by clicking on the red plus sign till it goes white… you will see it disappear from the right hand pane.

5.   To add a term to a template, use the Find Term, Prompt, Dx Prompt, or Browse from Here icons to locate a term or group of terms.

6.   From the search results that appear in the pane on the left, click the plus beside terms you want to add and it will appear in the appropriate area on the right side of the screen.

7.   To save the edited template as a new template, click the Save As icon on the Action Bar at the top of the screen and enter a new name for the template in Template Name field then press the Save button.

 

Merge S/O Templates

1.   Open an appointment for a test patient (a “QQQ” patient).

2.   Click on the S/O button and then, on the Action Bar, click the Template Mgt. icon.

3.   From the lists that are displayed or from search results, Press and hold the Ctrl key on your keyboard while selecting each template that is to be merged.

4.   On the Action Bar, click the Save As icon and enter the name of new template.

5    Click the Save button.

      (Note: “AMEDD” encounter templates can be found in the Enterprise folder. The owner is listed as (Department of Defense). When saving a modified AMEDD template, remove the “AMEDD” name.)

 

Creating a “Free Text” Template

This template is found on the PE tab and is sometimes referred to as a “procedure”  template.

1.   From the S/O screen, click on the Find Term icon on the Action Bar.

2.   Search on the term “Free Text” and hit OK.

3.   A list of “terms” associated with free text entry will populate each of the tabs (HPI, PMH, ROS and PE).  Choose the one with the most appropriate heading for the free text that you will be entering.

4.   Enter the free text in the white field above the pane on the left hand side of the screen and make sure to click ENTER when you are done typing or the free text will not be saved.

5.   When you have entered the desired free text, click the Save As icon on the Action Bar and name the template as appropriate.

 

Creating an Order Set

1.   In the Encounter creen, click the A/P button.

2.   Order all Labs, Rads or Meds that you want to include in the order set as you normally would order them but in place of hitting the “Submit” button after each one , click on the “Save to Queue” button, instead.   

3.   Click on the Order Sets tab to review the orders, and then click on Save as Order Set and enter name of order set in Template Name field.

4.   Click Save.

 

Editing an Order Set

 Editing order sets must be done from within an encounter.

1.   Open an appointment for a test patient (a “QQQ” patient).

2.   From the Encounter screen, click on the A/P button.

3.   Click on the Order Sets tab and to choose the order set that you want to add to or edit from the pull-down menu.

4.   If you are simply editing an order set, select or de-select the items you want to change by using the check boxes next to each order.  Then click Save as Order Set and save template with same name or assign a different name if you want to save it as a new order set.

5.   If you want to add anything to the existing order set then order any Labs, Rads or Meds as you normally would order them but in place of hitting the “Submit” button after each one , click on the “Save to Queue” button, instead.

6.   Then, under the Order Sets tab, select the check boxes for each order to be included in new edited order set.

7.   Click on the Save as Order Set button and enter a name for the new order set in the Template Name field.

 

 

Merging an Order Set with a Template

An open encounter is not required to complete this function.

1.   In the “Tool” folder in the Folder List on the left side of the screen, click the Template Management icon.

2.   On the Action Bar, click the Search icon and follow the prompts to search for and select each template that you want to merge.

      (Note: If additional searches are required, at the bottom of the Template Search screen, select the Add to Search Results radio button.)

3.   Press and hold the Crtl key on your keyboard and then click to select the template(s) to merge.

4.   On the Action Bar, click on the Merge icon.

5.   Review the results in Template Details page that then appears.

6.   Click Save As on the Action Bar then enter a new template name and click Save.

 

Other Modules

Alert Review

 

Alert Review is the module where anything that you need to “do something with” will show up, this includes orders to sign, encounters to co-signs and new lab and rad results that need to be reviewed.

1.   In the Folder List on the left side of the screen, click on Alert Review.

2.   Double-click on the alert category you want to review.

5.   Review the alerts in the module that opens and process them as needed.

      (Note: Look on the Action Bar to see what options are available for resolving each type of alert.)

 

Co-Signs

When co-signing an encounter the difference between “Amending” and “Appending” is small but critical.  Amending an encounter will rewrite the encounter itself and can only be done by the original signer or the co-signer of the encounter.  Appending an encounter will place a statement at the end of the encounter and can be done by anyone with access to that patients’ record.  It also does not have the same legal equivalency as an amendment done by the attending provider(s).  Both amending and appending an encounter will create a “Change History” notice at the very bottom of the encounter that will state what was changed, when it was changed, who did it and a copy of what was removed.

1.   In the Folder List on the left side of the screen, click on Co-signs.

2.   Click on an encounter to select it for review.

3.   To amend the encounter, select it and, on Action Bar, click Amend Encounter.

Notes: 

  • As a co-signer, you can “Amend” any portion of the note. Amendments appear in the section that is amended and also in a “Change History” notification at the bottom of the encounter to indicate that a change was made after the initial signing of the encounter and what it was.
  • If amending the S/O note, when the Encounters S/O Notes screen appears, click the appropriate button (New Note, Edit Note, Delete Note). Once the S/O section is amended, the old S/O note is replaced by the amended note and the entire old note appears below in the Change History section.
  • You can load an encounter or S/O template to assist you in amending the encounter.

4.   When you have finished amending the note, click the Sign icon on the Action Bar.

5.   In the Co-Sign Encounter screen, click Sign to co-sign the note.

      Note:  If you amended the S/O note, you may be asked to review the A/P and Disposition, accordingly. Once you have done this, click Sign on the Action Bar and, sign as usual.

6.   To append a note to an encounter, select the encounter from the list and then click on the Append Narrative icon on the Action Bar.

7.   When the Encounter Note screen appears, complete the Note Category and Note Title Fields as appropriate.

8.   Enter any narrative to append (add) to the encounter in the large field on the lower half of the window, or… you may also load a file into the note by hitting the “Load File” button. (See “Import an Image to an Encounter Note” earlier in this document.)

9.   Once you are done, click Save and Sign.

10. On the Sign Appended Note screen, review narrative, enter password, and click Sign to sign appended narrative.

 

 

New Results

Results can be “forwarded” or “discarded” without being viewed but will have no electronic signature to indicate it was viewed.  However, if a result is “tossed” it will indicate in the patient records that it was viewed, when it was viewed and by whom.

1.   In the Folder List on the left side of the screen, click on New Results.

2.   Open the result, review, and close.

3.   Use the Action Bar icons to Forward, Discard, Save, or Toss the result.

4.   To forward, click Provider Search, select Provider, and click Forward.

 

List Management

List Management is where you can manage the list of your favorite diagnoses and procedures that show up when you click on the various “Favorites List” buttons that appear throughout the encounter.  If you have the permissions, you can also manage the lists of diagnosis and procedures for clinic-wide viewing.

1.   In the Folder List on the left side of the screen, click on Tools and then select List Management from the drop down list that appears.

2.   To add a term, highlight the appropriate heading (Diagnosis, Procedure, etc.) and then click the Add icon on the Action Bar.

3.   Using the Search window that appears, select the term you want to add and then click the OK button to add it to the list that you have highlighted.

4.   To delete a term, select the term to delete and click the Delete icon on the Action Bar, to remove it from the list.

 

Sign Orders

1.   In the Folder List on the left side of the screen, click on Sign Orders.

2.   To review details, click plus sign next to order or click Expand/Collapse to view details of all orders.

3.   To cancel orders, select check box next to be cancelled, click Cancel Selected Order, and click Yes.

4.   To sign orders select check box next to orders to be signed and click Sign Selected Orders.

5.   To sign all orders shown, click Sign Selected Orders.

 

Health History

The Health History module is a convenient way to get a personalized “snapshot” of information that is in the patients’ medical record.  It saves you from having to open up each module to view specific information that you find pertinent to doing your job.  It can be configured in any form that you find easiest to view (i.e. - Current Problems list on top followed by current meds or labs or rads, etc.).  This can be done simply by opening up the module and then clicking on the “Options” button in the upper right corner of the screen. This is a great dashboard view to see a snapshot of the patient’s care. You should consider opening it at the start of every encounter.

 

Adding Problems to the Master Problem List

The Master Problem list is a list of the most recent diagnoses that the patient has been documented as having along with all of the encounters, procedures, labs and consults that are associated with that particular diagnosis.  The list is automatically updated from the A/P section each time an encounter is signed.  It can also be updated manually if the provider chooses to use a different diagnosis code than what has already been entered via a previous encounter, or if the patient has a condition that has not been diagnosed or treated at a military treatment facility and therefore not entered into AHLTA.  This is the same for “Family History” entries, which are also managed from this screen.

1.   In the Folder List on the left side of the screen, click on Problems.

2.   On the Problem List screen, highlight either Problem List, or Family History.

3.   Click the Add icon on the Action Bar,.

3.      In the Select Diagnosis or Select Procedure areas at the bottom of the screen, select a diagnosis or procedure from the Search, Clinic List, or User List tabs.

4.      Click OK.

5.      In New Problem, New Procedure, or New Family History section, complete relevant fields.

6.      Click Save.

 

Adding an OTC/Outside Medication to the Master Meds List

1.   In the Folder List on the left side of the screen, click on Meds.

2.   On the Meds screen, set the search filter to Outpatient Current.

3.   Click the Add icon on the Action Bar.

4.   Click Record OTC/Outside Medication.

5.   When the New OTC/Outside Medication section appears at the bottom of the screen, click on the Medications… button and search for the desired med or supplement.

6.    Complete the relevant fields and click OK.

 

Adding an Allergy

1.   In the Folder List on the left side of the screen, click on Allergy.

2.   On Action Bar for Allergy screen, click Add.

3.   In the New Allergy section that appears at the bottom of the screen, select an allergen from the drop-down list or click Allergen to search for an allergen using the Healthcare Data Dictionary that appears.

4.   In the  New Allergy section, select a reaction from drop-down list or click Reaction to search for a reaction using the Healthcare Data Dictionary that appears.

      (Note:  You can search for multiple reactions.)

5.   Complete by entering additional information in the remaining fields, as needed.

6.   Click Save.

Patient Questionnaires

 

Completing a Questionnaire in an Interview

1.   From within an open encounter, in the Folder List on the left side of the screen, click on Patient Questionnaires.

      (Note: When completed from within an open encounter, the questionnaire is automatically associated with that encounter.)

2.   Click the Interview icon on the Action Bar and Select an appropriate questionnaire from the lists that appear.

3.   Complete interview and record answers.

4.   To add comments, click the Add Comment link next to the appropriate question.

5.   When you have completed the interview, click Done on Action Bar, and close the module.

 

Associate Questionnaire with an Encounter

1.   Open the encounter or simply remain in the encounter that you are in if that is the correct one.

2.   In the Folder List on the left side of the screen, click on Patient Questionnaires and select the questionnaire that you want associated with that specific encounter.

3.   Click the Encounter icon on the Action Bar, select the current encounter and click OK.

5.   Close the Questionnaires module

      (Note:  To view questionnaires in the S/O notes, you need to set your options to do so.  To do this, open up an encounter, click on the Options button in the upper right corner of the screen, and in the AutoCite prefences section of the window that appears, select the Questionnaires checkbox and click OK to save it as a default. When you are back at the Encounter screen, you may need to click AutoCite again to refresh.

 

Clinical Notes

Even though both Clinical Notes and the “Add Notes” section within an encounter will each let you enter free text or photographs or other files into them in nearly the same way, they differ in the basic theory of their usage.  The “Add Notes” section is for information that applies to that specific encounter, whereas Clinical Notes is where you enter information that should go into the patients’ medical record but was not gathered during or that applies to a specific encounter, (i.e. – outside consults, police reports, etc.).

1.   In the Folder List on the left side of the screen, click on Clinical Notes.

2.   On Action Bar, click the New icon to create a new clinical note, (or Edit to edit an existing clinical note).

3.   From the Note Types drop-down list, select a note type.

4.   In the POC field, select a facility from the drop-down list.

5.   Enter note text and save. (If you would like to load a photograph or some other file type into the note follow the instructions listed under “Importing an Image to an Encounter Note” which is covered earlier in this document.)

 

 

Previous Encounters

 

To “Amend” or “Append” a Previous Encounter see the instructions under “Co-Signs” earlier in this document.

 

Copying a Previous Encounter into the Current Encounter

1.   In an open encounter, click on Previous Encounters in the Folder List.

2.   Right-click on the previous encounter to be copied forward into the current encounter and then click Copy Forward.

3.   Open the S/O section in the in current encounter.

      (Note: Terms copied from the previous encounter appear in yellow.)

4.   If the current findings reflect little or no change from visit copied, modify terms as needed and click AutoEnter for rapid documentation. Continue to document variances.

Fail-Over Mode Operation Overview of Fail Over Operations
Prior to the release of 838, AHLTA architecture utilized a central database, the Clinical Data Repository (CDR). Because of this architectural design, AHLTA was dependent on its ability to access the CDR. AHLTA clinical team members could not conduct basic patient services when the CDR was down or inaccessible due to a Wide Area Network (WAN) issue.
With the release of 838, AHLTA will implement a Local Cache architecture. The purpose of the Local Cache architecture is to provide AHLTA clinical team members with the ability to electronically document patient encounters in the event of a WAN or application outage between the CHCS host site and the CDR. A local cache server will be added at each host site that includes the Local Cache Database (LCD). During the documentation of an encounter, all data will be saved to the LCD. Once an encounter is signed, the encounter data are synced with the CDR.
Local Cache implementation consists of two main system modes: "normal mode" and "failover mode." If the CDR, LCD, and CHCS are available, the system is in normal mode. If the CDR is unavailable, but the LCD and CHCS are available, the system is in failover mode.
During failover mode, the AHLTA client presents data from the LCD and CHCS, instead of the CDR. The change in the architecture allows clinical team members to continue to document existing encounters, as well as to create new encounters in a failover mode. Upon completion of the encounters in failover mode, the encounters will be queued for later submission to the CDR. Once connectivity has been restored, the completed encounters will be synced with the CDR automatically.
To ensure that the LCD contains pertinent clinical data in the case of failover, a nightly push occurs from the CDR to the LCD. The data in this push includes:

  • Application Data
  • Patient Data
  • User Settings
  • Immunization data

Some modules are not supported in failover mode and will be unavailable. During failover mode, all modules that support failover mode will write their data to the LCD and/or CHCS.

Supported Fail-Over Functionality

Patient Encounter modules write their data to the LCD regardless of whether AHLTA is in normal or failover operations. After an encounter is signed, the data will be synced with the CDR. If the encounter is not signed, the data will continue to reside on the LCD and will not write to the CDR. During failover operations, signed encounters will be queued for later submission to the CDR when connectivity has been restored.
Patient Encounter module functionality is not affected by failover operations, with the noted exceptions.
Patient Encounter modules:

  • Current Encounter Summary (SF600)
  • Screening & Vitals
  • S/O and A/P
  • Drawing
  • Disposition
  • Co-Signs

Ancillary patient data modules will have limited functionality in failover mode. In normal operations, the ancillary patient data modules read/write their data to and from the CDR directly. During failover operations, the ancillary patient data modules read/write their information from/to the LCD and/or CHCS instead of the CDR.
Ancillary patient data modules:

  • Allergy
  • Appointments
  • Demographics
  • Health History
  • Immunizations
  • Lab Results
  • List Management
  • Medications
  • Patient Search
  • Previous Encounters
  • Problems
  • Rad Results
  • Tasking
  • Telephone Consults
  • Template Management

Unsupported Fail-Over Functionality

During transition to failover mode, modules that are not supported during failover operations close without saving. Any data that had been written to unsupported modules since the last save are lost and the module is removed from the Toolbar, Shortcuts list, and Folders list. The user will be unable to access any unsupported modules in failover mode. To minimize the potential impact, users are encouraged to save their work and close modules that are not being used.
The following modules are not supported in failover mode:

    • Army Readiness
    • Clinic Configuration Management
    • Clinical Data Capture
    • Clinical Notes
    • Consult Log
    • DD2766
    • DFI
    • Documents Inbox
    • Eforms
    • Flowsheets
    • Immunizations Admin
    • List Management
    • New Results
    • Notifications
    • OB Summary
    • Patient List
    • Patient Questionnaires
    • Patient Registries
    • PKC Couplers
    • Questionnaire Setup
    • Readiness
    • Registry Setup
    • Reminder Mapping
    • Reports
    • Rx Alternatives
    • Scan/Import
    • Screening Notification
    • Vital Signs (Review)
    • Wellness

     

     

 
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