OE TRAINING MANUAL
ORDER ENTRY
How to sign on to the
MEDITECH System
Password
The Desktop
Special Function Keys
Toolbar
Care Area: Enter/Edit Pt Data
Process Orders
Color Coding
Canceling Orders
Process Location Activity
Color Coding
Acknowledge
Un-acknowledge
Overview of the Order Entry
Module
Enter Orders
Order Entry Screen
How to Identify a Patient
How to Identify a Physician
Priorities
Customer Defined Screens
Series Orders
Continuous Orders
Redundant Orders
Duplicate Orders
EnterRequisitions
Edit Requisitions
Canceling Requisitions
Reports
Patient Transfer
Transferring Patient
Patient Discharge
Order Sets
Patient Admission (ER
HUCs)
Review Orders
By Service Date
By Order Date
Canceling Orders
Patient Charges
EMR
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HOW TO SIGN ON TO THE MEDITECH SYSTEM
PURPOSE: To sign on to the MT system in
order to access routines and functions
1.Click the MT Icon from the desktop.
2. The MT sign on screen will appear, Enter your User Name and Password. The first time will require
a new password to be selected, this password needs to be at least 4 characters long (prefer more
than 6) with either alpha or numerical characters or preferably both. This password will expire every
90 days. A previous password can’t be used again for 6 months.
3. This will take you to the MT desktop. Based on your role you will have access to certain routines
and functions. Click on the Routine of Function that you want to use.
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THE DESKTOP
File
Exit
Help
Lookup
Print Preferences
Links
Menu
MenuButton
Button
Session Mgmt
Cut Copy Paste
Forward
Backward
Special Function
EMR Link
Shortcut
Toolbar
This is the MT desktop. You access it after signing onto the MT System. It contains menus and
shortcuts to your most frequently used routines and functions. Along the right hand side of the
desktop is your toolbar. Placing your mouse on one of the icons and holding it there will give you
access to a tool tip. The tool tip defines what function can be carried out when you click on that
particular icon.
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SPECIAL FUNCTION KEYS
Esc
F1
F5
Exit
Help
Get
SPECIAL
FUNCTION KEY
F6
F7
Next
Print
Section Pref
F8
Special
Functions
F9
F10
Lookup
Links
F11
F12
EMR
OK
Link File
FUNCTION
ESC
Clears the field in the routine or exit without filing
F1
Supplies on-line information about your present prompt
<shift> F1
Supplies on-line help for the current routine
F5
Allows you to retrieve text and data and insert it at the location of the
F6
Moves the cursor forward to the next grouping of prompts
<shift> F6
Moves the cursor back to the previous grouping of prompts
F7
Accesses the printing destination window and displays the current settings
F8
Performs specific functions as dictated by the routine or current application
you are in
<shift> F8
Performs specific functions as dictated by the application or routine you are
in
F9
Displays a list of valid responses for the prompt
F10
From a desktop, displays the most recent menu selections in the current
session. You can then double click on any screen on the list to go
immediately to that screen
F11
From a patient screen, opens the patient’s record in the EMR. From
anywhere else, opens the EMR and then you can choose the patient from a
lookup
F12
Allows you to approve the information on the screen and proceed with this
routine. If you are in a lookup window it allows you to select the highlighted
item, if you are in a data entry screen it files the information, if you are in a
report routine it allows you to print the report, and if you are in a view window
it allows you to exit from the routine
<shift> F12
Minimizes the current session. When you return to the session, a dialog box
requires you to re-enter your password before continuing.
cursor
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Overview of the Order Entry Module
You can use the Order Entry Module to quickly and accurately enter orders for patient tests and procedures,
diets and patient care interventions. These orders can be reviewed and edited using the Order Entry (OE)
Application.
From one screen you can enter orders for a single procedure, multiple procedures, order sets and series orders.
These can be entered from any number of categories.
The Order Entry Module can be used to request services, supplies and equipment from other Departments
within the organization. These may not be directly related to a specific patient.
Patient orders can be reviewed through the Order Entry Application. This will allow the end user to check on
the current status of the order and, depending upon access, allow the end user to make edits to the original
order.
Reports are available through the Order Entry Application. These include statistical reports, and several patient
order reports, just to name a few.
The patient Care Data Screen allows the organization to capture patient information such as Height, Weight,
Allergies, Code Status, and Isolation Status.
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Enter/Edit Patient Data (Standard Fields)
Click on the following button from the Meditech desktop and then click on
Patient Data and then Enter/Edit Patient Data.
On this screen, after the patient has been identified, the A/S, Loc, Rm/Bd, Admit date, admission status and
unit number come over from the Admissions Module. In addition the Visit Reason identified at the time of
Registration defaults in. None of these fields can be edited in Order Entry.
Temporary Location: Identify a temporary location to which the patient is being moved, such as the OR, Pt,
DI. This function then allows the receiving location to access the Patient’s Data and to allow Stat Broadcasting
of Lab Results. In addition, there is an audit trail that can be used to track a patient’s movement thruoughout the
organization on a given date or for a range of dates.
Return Date/Time: Identify an expected return date and time at this prompt. If you enter the date and time the
minutes will automatically calculate.
Mins: If you did not enter a date and time at the previous field, you can enter the anticipated number of minutes
you anticipate the patient will be at the temporary location. Once entered, the return date and time will
automatically fill in.
Hold Tray: Date/Meal/Release This option is used to hold a tray of a patient having a procedure when the
patient needs to be NPO. The date, meal to be held and release time needs to be input. This information will
print on the dietary meal list.
Condition: This area will not be populated.
Visitor’s Allowed: This area may not be used at ECMC.
Condition Comment: This area may not be used at ECMC.
Height: The information for height is mandatory and can be entered in either feet, and inches or metric units
and equivalent will be calculated in the other system of measurement.
Weight: The information for weight is mandatory and can be entered in pounds and ounces or kilograms and
the equivalent will be calculated in the other system of measurement.
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BSA: The Meditech system will automatically calculate the patient’s BSA using the height and weight
information entered.
Restore Orders: This option will not be used at ECMC.
Visit Diagnosis: This option will not be used at ECMC.
Allergies/Adverse Drug Reactions: A checkmark in the box indicates that Allergy/ADR information has been
entered on this patient and is available to be viewed by clicking on the Allergies/Adverse Reactions Tab.
Enter/Edit Patient Data (Custom Queries)
Enter/Edit Patient Data (Allergies/Adverse Reactions)
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Information regarding the Patient’s Allergies and Adverse Drug Reactions will be entered in this section of the
Patient Care Data Screen. This section is mandatory. This information will flow over to the Pharmacy Module,
Dietary and will be viewable in ITS (Radiology).
Allergies should be entered under the “Coded” Section. This allows the system to look to the allergy Dictionary
and perform an Interaction Check with Pharmacy.
Allergy or Adverse Reaction: Identify leading letters of the allergy you are attempting to enter and then
perform a lookup using the “F9” key or the binoculars along the toolbar. This will give you a list of items to
choose from. Drugs can be found either by their generic or trade names.
Type: Identify whether this is an “Allergy” or “AdvReac” (Adverse Reaction).
Sev: At this prompt you will identify the severity of the reaction. The choices are M(Mild), I(Intermediate),
S(Severe), and U(Unknown).
Date: The date the information was entered is recorded here.
Ver?; Pharmacy will verify all allergy/adverse reactions
Text?: Entering a “Y” at the Text Prompt brings up a pop up screen where additional comments can be added.
Blank Line Under Allergy: Allows you to choose from a group response “F9” and identify the specific
reaction.
If the allergy the patient has identified is not available in the “Coded” section it can be entered in the “Uncoded”
Section of the screen. However, it does not go through the Interaction Checks.
Once all the information has been entered file using “F12” or clicking on the checkmark along the toolbar.
Once the information has filed it passes to the Pharmacy Module where the information will be verified. This
will update the VER? To “Y”. Once an allergy is verified, no edits can be made to any of the information.
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HOW TO ENTER ORDERS
Purpose: To place orders for services, tests
or procedures from other Hospital Departments.
Click on the ICON “Enter
Orders”
The Enter Order Screen will
Appear
1.
2.
3.
4.
5.
6.
7.
Identify the Patient
Identify the Ordering Physician
Choose the Category in which the test is being ordered
Identify the procedure
Answer the Pri, Qty, Date and Time prompts as
appropriate
Answer any questions
File the procedure using the “F12” Key or the
“checkmark”
Enter Care Area Orders
The Order Entry Screen can be divided into three main sections.
• The first section contains demographic information about the patient for whom the orders are being
processed.
• The second section is where the actual order(s) will be entered.
• The third section contains questions or information regarding either the category from which the order is
being requested or the specific procedure that is being ordered.
SECTION 1: There are several screen prompts located in this section of the order entry screen.
•
User: When you sign on to Meditech and enter the Care Area Orders Screen, your user mnemonic and
name default in.
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•
Patient: At this prompt you will enter the name of the patient for whom the orders are to be processed.
Your can do this using one of the following options:
1.
Full name (Starting with last name)
Ex: Smith, John A
2. Partial Name (Starting with last name)
Ex: Smi, Jo
3. Account Number (EV123) You do not need to put in the extra 000’s
4. <SPACEBAR> Enter: pulls up last patient worked on.
Note: Once the appropriate patient has been chosen, the A/S (age and sex), Loc (Inpatient Location), RM
(Room#), BD (Bed Assignment), Admit (Admit Date), Status (Registration Status) and Unit # (Patient MR#)
will automatically fill in.
•
•
Attend DR: The name of the attending Physician will default in. This information comes from Admissions.
Order DR: The name of the Physician ordering the test or treatment is entered here using any of the
following methods:
1.
2.
3.
Mnemonic: The Physician’s user Mnemonic (abbreviation). This will be the
first 3 letters of their last name, followed by the first two letters of their first
name. Ex: KEPDE (Dr. Dennis Kepka)
Name: Enter N\ followed by a partial name then lookup.
Ex: N\KEP F9.
Enter “/X”, F9, A pop-up screen appears. Enter the appropriate information
into the fields. Enter “F12”. A list of physicians will appear. Choose the
appropriate one.
• Source: The source of the order needs to be typed in this area, whether it is written, telephone, or verbal.
•
SECTION 2: This section is where you will enter information regarding the tests, procedures, services or
interventions that are being requested.
The following screen prompts are located here:
•
Category: This is the department from which you are requesting a service. The Categories include:
LAB, RAD, CARDREHB, DIET, CARD, CS, CT, ECHO, EKG, ER, MRI, MRA, NM,
CONS, EEG, MAM, PHA, PT EVAL, REC, OSTEO, OT, ST, RT, RTL, SLEEP, US, VASC
If you know the mnemonic of the category you can enter it into the blank space. Otherwise, do a lookup
“F9”and search for the category.
Note: If you are uncertain which category the test or procedure might be in, you can enter a “?” followed by the
first few letters of the description, followed by “F9”. This will give you a list of options. You can highlight the
appropriate response and press “enter”.
•
Procedure: Enter the mnemonic of the procedure, test or service that is being requested. Ex: if you were
ordering a “potassium” level you would enter “K” at this prompt. If you do not know the mnemonic of the
test being ordered,, you can type in a “?” followed by several letters of the word such as “POT”. The
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system will do a string search and bring up a listing of several procedures that contain the word potassium
in it. You can then choose the appropriate procedure.
Note: To choose multiple procedures from the same category, click on the first test, hold down the control key
and scroll down to the next test, click and continue until all tests are chosen.
•
•
•
•
•
Procedure Name: The procedure name will automatically fill in once you have entered the mnemonic at
the previous prompt.
Pri: This is the priority of the service being requested. You have three options: “S” (Stat), “R” (Routine),
“U” (Urgent). “T” (Timed) will be added when the lab module goes live. Stat is used if needed
immediately, Urgent is used as the next priority followed by Routine.
Qty: Indicate how many of these tests or procedures are being requested. In some instances the cursor will
skip over the quantity
Date: You will enter the date the procedure is to be completed here. You can use the format “mmddyyyy”
or use the “T” convention where “T” would mean today, T+1 would be tomorrow etc.
Time: Indicate the time the procedure is to be completed. You will enter the time using the military format
(0700= 7AM, 1900=7PM etc.) If requesting the test for now you can enter “N”. The system recognizes “N”
as the time you signed on to the session for this patient. Once you file and move on to the next patient, it
recompiles and calculates the new time. This field can be left blank except for certain LAB orders. If the
answer to the question “Collected by Nursing” is “Y” you are required to enter a time at the time prompt.
For Diets, “B” (Breakfast), “L” (Lunch) and “D” (Dinner) identify the time.
SECTION 3: If there are any questions or comments relevant to the category or procedure, they would be found
in section three of the enter order screen. Ex: order as written, mode of transportation, IV, O2, Pregnant etc.
You can continue entering all orders, regardless of the Category. When entering a second and all subsequent
orders from the same Category, you can press the “/” at the Category prompt and it will recall the last category
entered.
After all orders have been entered you will press the “F12” key or use the mouse to click on the “checkmark”
located along the right side of the Order Entry Screen. A pop-up box will appear asking you to confirm that you
want to file these orders. Click on “yes”. This will file and send the orders to the appropriate departments.
Note: If you realize that you have entered orders for the wrong patient and have not filed the orders, move the
cursor to the “Order Dr” field, press the “shift” and “tab” keys. A pop-up window appears to allow you to
identify another patient, using any of the patient identification methods.
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If you realize that you have entered orders by mistake, you can press the “Esc” key or the X on the toolbar. A
pop-up box will appear asking whether or not you want to Exit. Click on the “yes”. This will delete all orders
entered and return you to a blank screen.
Series Orders
Series Orders: Orders for procedures that are typically performed several times on a regularly scheduled basis
can be ordered as a series. Ex: CBC daily for the next three days. To enter a series order, at the Procedure
prompt, enter a “/” followed by the procedure mnemonic. Ex: “/CBC”.
Once you have identified the series order, the full procedure name appears on the screen. Complete the
remaining information as described for a single procedure. Four additional prompts appear in section 3 of the
Enter Order Screen.
Series Order Prompts
Standard System Formats for Directions: To complete the Directions prompt you can use any of the following
standard system formats:
Format Description
QnnD (every nn days)
Example
Q2D
QnnH (every nn hours)
Q3H
QnnM
Multiple times entries separated by
a comma
A sequence of two letter
abbreviations for days of the week,
no spacing between
A combination of the above
formats joined with the @ symbol
Q30M
08,10,12,14
Meaning
Beginning at the specified start
date and every 2 days thereafter
Beginning at the specified start
time and every three hours
thereafter
Every thirty minutes
0800,1000,1200,1400
MoWeFr
Monday, Wednesday, Friday
MoWe Fr@08,10,12
Every Monday, Wednesday and
Friday at 0800,1000,1200
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After completing the directions, enter the stop date and time for the series order. The count will automatically
calculate.
Continuous Orders
Entering a Continuous Order:
A Continuous order is different from a series order because it doesn’t have a stop time. Ex: CBC every day.
When entering a continuous order, at the procedure prompt precede the mnemonic with “/”. Ex: “/CBC”. The
screen will display the four additional prompts as seen in the Series order. At the Stop Date prompt, enter “C”.
The cursor skips the Stop Time field. The “Count Date” displays the number of procedures due to be performed
by midnight today, so in the above case it would be 1.
Processing a Continuous Order:
Edits can be made to a continuous order using the Process Continuous Order Routine. This can be found in the
“Review Order” and Process Order” routines. Once you sign onto the routine and identify a patient, the verb
strip buttons will activate allowing you to process the order as necessary.
Note:
Your ability to access the different functions in the continuous order routine is based on the requirements of
your job functions within the organization and defined in the Access Dictionary.
Once you have identified the patient for whom you are processing the continuous order(s), the remainder of the
fields automatically fills in. If there were more than one continuous order for this patient, they would all be
listed on the screen.
Use one of the buttons at the top you can:
• Stop an order
• Print a report of the continuous order
• Print an audit of the continuous order
Stop
Print
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The arrow preceding the “Ord
Dt $ Tm” Column indicates
there is additional information
regarding this order.
Click on the arrow along the
toolbar.
The View Order Screen will
appear and allow you to see
details about this order.
When stopping a continuous
order, a pop-up screen will
appear.
Enter the date and time this
order is to be discontinued.
When printing a
continuous order
report, a pop-up screen
will appear. Enter the
category and the
service date you want
information for.
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Order Sets
An order set is a group of tests and/or procedures that are commonly ordered together. Ex: Cardiac Routine
Orders.
To place orders using an Order Set, at the Category prompt, enter a slash “/” followed by the mnemonic for the
Order Set. Press “F9” or the binoculars along the toolbar for a list of available order sets.
Once you select an order set, all orders in the set appear on the screen and:
• An arrow appears to the left of the first order in the set
• The cursor appears in the Category field for that order
• The customer defined queries for that Category and procedure appear in the lower section.
Default responses for all the fields in the order set may have been preset. It is important that you review each of
those fields for accuracy before filing. You may change any of the default responses necessary. If you need to
cancel any of the orders in the set you can do this by placing the cursor in the Category field, deleting the text
and then pressing enter.
If there are additional orders to be placed you can enter them as well.
Once you have verified the accuracy of the information you can press the “F12” key or click on the
“checkmark” along the toolbar.
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How to Review Orders- by Order Date
PURPOSE: To review the status of an order placed on a specific date.
Click on the following button
from the main menu
The Review Orders Screen will appear
1.
2.
3.
4.
Choose the Category in which
you want to review orders. If
you want to review all the orders
for a given date regardless of
Category, skip this prompt.
Identify the patient
Enter the order date of the orders
to be reviewed
Press “Enter”
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How to Review Orders by Service Date
PURPOSE: To review the status of an order scheduled on a specific date.
Click on the following button
from the main menu
The Review Orders Screen will appear
1.
2.
3.
4.
Choose the Category in which to
review orders. If you want to review
all the orders for a given date
regardless of Category, skip this
prompt
Identify the patient
Enter the service date of the orders to
be reviewed
Press “Enter”
Review Orders
There are two options for Reviewing Orders in Meditech.
• To review and/or edit all orders entered for a specific patient on a specific date based on when the test was
ordered (Order Date)
• To review and/or edit all orders for a specific patient on a specific date, based on when the test is to be
performed (Service Date)
• Category: In the review order screen(s) you can choose to review orders in a specific category. Or leave
the field blank to see all orders in all categories.
• Patient: Identify the patient for whom you are reviewing orders. (Use one of the several options previously
learned for identifying a patient). Once the patient is identified, the remainder of the fields will
automatically fill.
Once the date is entered, all appropriate orders for the date under review will appear.
Note: To choose the order you are interested in reviewing, use the up and down arrows to move the highlight
bar. To review several adjacent orders, hold down the shift key while moving the highlight bar. To review
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several orders that are not adjacent to each other, hold down the Ctrl key while moving the highlight bar and
then click when the appropriate order(s) are highlighted.
In both the Review Orders by Service Date and the Review Orders by Order Date routines, you can view the
• Category and Procedure Name
• Order Number, Status, Priority & Quantity
• Date and time of the order’s Service Date or Order Date
• Ordering Doctor
• Order Source
The boxes at the upper right corner
of the review order screens indicate
the number of orders highlighted
and the total number of orders
available for review.
The last column indicates:
The Order Source:
W(Written), P (Phone), F(Faxed),
V(Verbal) and if an order is
C(Continuous), R(Series), S(part of
an Order Set) or D(Duplicate)
The following table indicates what edits can be made to orders, depending upon whether that order is placed to
an interfacing application or exists within OE
Function
Cancel
Cancellation Request
CDS
Interfaced Module
Cannot cancel an order in an
interfaces module
All statuses except Com & CNC
Ver
OE Categories
All statuses except VER & Com
N/A
TRN, IPR, LOG
Note: The functions available on the Review Orders Screen are dependent upon the access group to which you
belong.
“E” button takes you directly to the Enter Orders Screen
“A” button will not be used at ECMC
“X” button allows you to cancel an order. Your ability to do so is dependent upon whether or not the order
meets certain criteria. If the order meets those criteria a message box appears asking the reason for cancellation.
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The standard reasons for canceling of an order include: AMA, Duplicate, Date/time wrong, order
placed in error, equipment not available, patient expired, other, Dr. canceled, change in patient condition,
patient discharged, patient refused.
•
After a cancellation reason is entered, the status of the order changes to CNC. If the order is from an
interfacing category, a cancellation request is sent to that application and the status will change to “CNC?”
If the cancellation request was sent after the order had been processed, a “Cancellation Request Denied”
requisition prints at the ordering location.
“P” button allows several Print options. You can print a copy of an order’s detail, an audit trail detailing every
event that has occurred with the order, print an audit trail of a continuous order or reprint the original
requisition.
“D” button allows direct access to the Patient Data Screen where you can edit or view patient information. The
Dietary data screen is also viewable.
“C” button gives access to the Continuous Order Routine.
“R” button is the Recompile button and allow you to refresh your screen and gain access to any new
information that may have been filed since signing on to the routine.
Note: When reviewing Series Orders in the Review Order routine by order date you will see all the projected
orders in the series. Ex: CBC ordered for today, tomorrow, and the following day, all three orders would appear
on the review order screen. However, if there is a Continuous order for the CBC, only today’s order would
appear.
When canceling a series or a continuous order, a pop-up screen will appear. You will have an option to cancel
the entire series or orders or just the one highlighted.
“V” button is to verify orders, all orders at ECMC will be placed at the verified status
“M” button is a miscellaneous area. This button allows the user to “Edit source” for how a test was ordered, and
“Process Continuous Orders”, which allows the user to cancel a continuous order.
How to Process Orders
Purpose: To Review orders for individual
patients or all patients at a particular location.
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1.
2.
3.
4.
The Process Order Screen appears in the background and the
Selection Profile in the foreground.
Identify a patient or choose the location for which you want to
review orders.
Select the criteria for those orders you want to review.
File
This takes you to the Process
Order Screen where
information will appear based
on the criteria chosen
The Process Orders Function allows you to review orders for individual patients or all patients at a specific
location. It allows for orders across multiple categories, procedures, statuses, services dates, priorities,
physicians and ordering users. The information can be sorted by choosing from a list of options. If the sort
criteria are left blank, the orders are sorted by service date and time and order date and time.
The information contained within the screen is color coded
with following definitions:
Red- cancel
Cyanide- cancel request
Dark Violet- ITS(Imaging and Therapeutic Services
Green – Lab
Dark Blue- PCS (Patient Care System)
Black- PHA (Pharmacy)
Process Location Activity
The process location activity routine allows you to obtain information regarding order activity for all patients at
a specific location. After identifying the location choose how to sort the information, define the date and time to
review orders.
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Process Location Activity
Sort Choices
Cat/Proc
Newest First
Oldest First
Room-Bed
The information on the Location
Activity Screen is is color-coded:
Black- Entered
Red-Cancelled
Red- Cancellation Request
Blue- Completed
Dk Green- Resulted
Dk Violet- status Changed
Dk Cyanide- Signed
Using the “F8” function of using the
Along the toolbar will bring
you to a popup box that
identifies the key for the colors
“A” button allows you to Acknowledge the orders being reviewed. To do this, highlight the order(s) to be
acknowledged and click on the “A” button.
“U” button allows an order(s) to be unacknowledged. Highlight the appropriate order(s) and click on the “U”
button.
“R” button is the recompile button. This allows the screen to be refreshed and gain access to any new
information that may have been filed since signing on to the routine. The recompile option will also refresh
automatically every 60 seconds.
The Location Activity Routine allows you to see the activity surrounding the orders in your department. Once
POM (physician order management) is in place, it will be the mechanism by which you will be able to
acknowledge orders that have been electronically entered by the physicians.
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When using any of the functions in the Location Activity Routine, you will be prompted to enter your user
mnemonic and password.
Note: To view the patient name and additional data about a particular order highlight the order and press the
right arrow key from the keyboard. A pop-up screen will display the additional information.
The Review Order, Process Order and Location Activity Routines can be utilized to complete any chart checks
that might routinely be done at the end of a shift or at the end of a 24 hour period of time.
Enter Departmental Charges
The Enter Departmental Charge routine allows you to enter single and multiple charges for a single patient.
Category: Identify the Category to which the procedure(s) is associated.
Default Service Date: Identify the date the charges occurred.
Patient: Identify the patient using any of the following methods.
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Account Number (Vnnn)
Medical Record Number (U#Mnnn)
Full Name (Starting with last name)
Partial Name (Starting with last name)
Ex: Smith,JohnA
Ex: Smi,Jo
Location (Enter: L, space, Location mnemonic
Location (Enter: L, Space, Location mnemonic, enter)
then “F9”)
The name of the patient located in the first room and
A list of Patients at that location, sorted by room and
bed at that location will appear. Press the “F6” key
be number will appear. Choose the appropriate
and the next person at the location will appear.
patient. After entering orders and filling, the name of
Continue until you locate the patient you are looking
the next patient at the location will appear at the
for. (Shift “F6” moves you backwards)
patient prompt.
The A/S, Loc, RM, BD, Admit Date, Patient Admission Status and Medical Record Number automatically
default in. These fields cannot be edited.
Attend Dr: The attending Physician’s name defaults in, coming over from the Admissions Module.
Ordering Dr: You will need to identify the ordering physician for the procedure(s) being charged. This is a
required field. Use one of the following methods to identify a physician:
•
•
•
Mnemonic: The Physician’s user Mnemonic (abbreviation). This will be the first 3 letters of the last name,
followed by the first two letters of the first name. For Example: COORA (Dr. Randy Cook)
Name: Enter N\ followed by a partial name then “F9”. For Example: N\COO F9.
Enter “/X’, <F9> A pop-up screen appears. Enter the appropriate information into the fields and enter
“F12”. A list of physicians will appear. Choose the appropriate one.
Ask the Performing Dr: Answer Y/N If you would like to associate a particular physician with the
performance of this procedure(s). If you enter “N” here the cursor will skip the next field.
Default Performing Dr: If you enter “Y” at the previous prompt you can identify the physician you would like
to associate with this procedure(s) here. Use any of the methods learned earlier to identify the physician’s
name.
Default Technologist: The mnemonic and name of the user signed on to this routine will automatically default
in at this prompt. You can change the mnemonic or leave the field blank.
Procedure: Identify the procedure being charged for. You can access a list of those procedures by using the
“F9” key or the binoculars along the toolbar. To narrow the search you can begin with leading letters of the
mnemonic for the procedure and then complete the lookup. For Example; Enter “CARDNI” and the “F9” to
start a search for a Cardiopulmonary Stress Test.
NOTE: If there is a timed procedure with incremental charges associated with it, a pop-up screen appears.
Complete the start date and time and Stop date and time fields. The elapsed time will automatically calculate as
well as the Initial and additional fees.
Date: The date identified at the “Default Service Date” prompt will default in. You can change the date using
the “T” convention or “mmddyyyy”.
Per Dr: If you entered “N” at the “Ask Performing Dr” prompt the system will skip this prompt. If you
entered “Y” and entered the name of a physician at the “Default Performing Dr” prompt, the name of that
physician will default in. You can change the name of that physician here.
Tech: The mnemonic of the “Default Technologist: will default in. You can enter the mnemonic of another
technologist here.
Qty: If the procedure allows for multiples you would stop at this prompt and enter in the number. Otherwise,
“1” defaults in and the cursor will skip this field.
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Amount: If this is a procedure where you have the ability to edit the amount charged the cursor would stop
here and you would enter the ppropriate amount.
B/AR Comment: If these are timed or charge editable procedures the cursor stops here. You have the ability
to indicate to the billing department anything unusual about these charges. For example: you might want to
explain the reason why the patient is being charged twice or explain miscellaneous charges. Thes comments
pass to the B/AR module and may appear on the patient’s bill.
Note: Queries in the Patient Care Data Screen may have been identified as “Y: in the “Warnings at the order
time: field. If those quesitons have not been answered an administrative warning sign may appear when you
file charges on that patient. You will be able to file the charges.
Duplicate Charges: If you enter a duplicate charge on a patient you will be warned with a pop-up screen that
the charge is a duplicate. this to happen. You can choose whether or not you want to When you file (F12) the
order, a pop-up screen will appear asking you to identify the reason for duplication. This is a required field.
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Enter Departmental Charges (Batch)
The Enter Departmental Charges Batch routine allows you to enter single or multiple charges for a group of
patients. Use this routine to enter charges for several patients who receive exactly the same procedures.
Note: If charges for procedures are timed charges, each patient must have received the test for the same length
of time. You cannot vary the charge. In addition, the system handles the charges for timed procedures
differently in this routine. When you identify a timed procedure, the system supplies the charge3 for the initial
time block only.
Category: Identify the Category to which these charges will be posted.
Service Date: Identify the Service date of the tests or procedures being charged.
Performing Dr: If there is a physician that you want to associate with all these charges for all these patients,
identify that physician here. You can leave this field blank.
Default Technologist: The mnemonic of the end-user entering these charges defaults in at this prompt. If you
leave the field blank here you will be required to answer it in section three of this screen.
Default Ordering Doctor to Attending Doctor?: If you want to have the attending Dr. default in as the
ordering Dr, enter “Y”. Otherwise enter “N”.
Procedure: Identify the Procedure being charged for. This procedure will be the exact same procedure for
every patient listed in section three of this screen.
Tech: If you had identified a Default Technologist earlier, that mnemonic would default in here. You can enter
the mnemonic of another user. This is not a required field.
Qty: If the procedure is set up so that you can charge for multiples, the cursor would stop here and you would
indicate the appropriate quantity. Otherwise the cursor skips this field.
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Amount: If the procedure has been set up to be editable, the cursor would stop here and you would identify a
dollar amount. Otherwise, the cursor skips this field.
B/AR Comment: If the procedure is a charge editable or timed procedure, the cursor would stop here and you
would be able to send a comment to the billing department regarding this charge. The comment may appear on
the patient’s bill.
Patient: Identify the name of the patient using any of the methods learned earlier.
Order Dr: Identify the mnemonic of the Physician who ordered this procedure. If you had answered “Y” to
the “Default Ordering Doctor to Attending Doctor?” prompt, mnemonic of the attending physician would
default in here. You can edit that response using any of the methods learned earlier (How to identify a
physician). This is a required field.
Order Dr. Name: The Physician’s name will automatically default in after the mnemonic has been entered at
the previous prompt.
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Enter Charge/Credit
The Enter Charge/Credit Routine allows you to enter new information on a previous charge. In this routine you
can:
• Change the quantity
• Enter a new amount for the charge (if the procedure is defined as editable)
• Enter a credit for the charge
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Category: Identify the Category in which this charge will be posted, such as Cardiology, Non-Invas.
Order: you will need to enter the identification number of the order for which you are making adjustments.
The first four numbers of the ID contains the month and the day of the order and the last four numbers of the ID
indicate what sequence that order was placed on that day. For Example, the third EKG ordered on April 7
would have an ID number of 0407-001. If you do not know the order number but know the order date you can
enter the first four numbers and then press “F9”. The system will begin a string search from that date forward.
If you enter the first four numbers and then press “enter” you will only see a list of the orders placed that day.
Highlight the order you are interested in and press “enter”.
If the order you have chosen has not reached the status established for this procedure, a pop-up screen
will appear indicating that the order has not passed its “BILL ON STATUS”. You will not be able to go
any further. Click on the “OK”. This takes you back to the previous screen and you will need to exit or
choose another order.
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Once you have chosen the appropriate order, the Patient, Attending Dr., A/S, Loc, RM, BD, Admit Date,
Status, Unit # and order information from the procedure dictionary as well as billing information from
previous transactions default in. This is not editable.
The cursor stops to the left of the ”Act Date”.
Press “enter” and the cursor will move to the Qty field next to “Hosp Txn”. Enter in the appropriate
quantity of the adjustment, if appropriate. The system will automatically calculate an amount. If the charge
is editable you will be able to edit the amount.
B/AR Comment: This area will not be used.
If a credit is needed after the charges have gone to BAR, a credit slip will need to filled out and sent to
accounting.
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