Prenatal Care Module - Indian Health Service

RESOURCE AND PATIENT MANAGEMENT SYSTEMPrenatal Care Module(BJPN)Supplement: EHR Optimization for Prenatal CareVersion 1.0March 2013Office of Information TechnologyDivision of Information Resource ManagementAlbuquerque, New Mexico

Prenatal Care Module (BJPN)Version 1.0Table of Contents1.0Introduction. 11.1EHR GUI Layout Examples . 11.1.1 Panel . 11.1.2 Chief Complaint, Measurements, and Reproductive Factors . 21.1.3 Lab Tab with Preconfigured Worksheet. 31.1.4 Enter POV and Patient Ed Using Pick Lists. 41.1.5 Prenatal Health Summary Button and Order Tab DisplayedConcurrently . 51.1.6 Quick Notes – Shortcut to Note Title/Template . 61.1.7 Sample Reminder Dialog Displayed . 82.0Vital Entry and Display Configuration . 102.1Vital Entry . 102.2Cover Sheet Vital Display . 123.0Lab Worksheet Configuration . 164.0Order Menu . 195.0Health Summary Tool Configuration . 215.1Creating Flowsheet in IHS Health Summary . 215.1.1 Example . 215.1.2 Instructions . 225.1.3 Viewing Flowsheets and Other Components in Adhoc Health Summary245.2Creating Health Summaries for 1st, 2nd, and 3rd Trimester . 265.2.1 Enabling VA Health Summary Components . 275.2.2 Instructions for Prenatal 1st Trimester Summary. 285.2.3 Instructions for Prenatal 2nd and 3rd Trimester summary . 335.2.4 Example . 366.0Create Health Summary Buttons on the EHR Panel . 396.1Find the IEN of the VA Health Summary . 396.2Configure the Health Summary Button . 397.0Creating a TIU Object from VA Health Summary Types . 438.0Quick Note. 468.1Access to quick note configuration . 468.2Adding Quick Note to EHR . 468.3Creating a Quick Note . 478.4Using Quick Note . 508.5Sample Reminder Dialog Template . 52Acronym List . 54Contact Information . 55Supplement: EHR Optimization for Prenatal CareMarch 2013iiTable of Contents

Prenatal Care Module (BJPN)Version 1.0Supplement: EHR Optimization for Prenatal CareMarch 2013iiiTable of Contents

Prenatal Care Module (BJPN)1.0Version 1.0IntroductionThis guide will provide the Clinical Applications Coordinator (CAC) tools tooptimize the Electronic Health Record (EHR) Graphical User Interface (GUI) forPrenatal Care. Optimizations include exposure of pregnancy-related measurements onthe vital entry and cover sheet vital display components, creation of Health Summaryflowsheets and Veterans Affairs (VA) Health Summary as Health Summary Buttons,Text Integration Utilities (TIU) Objects for ease of review, and documentation andconfiguration of Quick Notes.1.1EHR GUI Layout Examples1.1.1PanelFigure 1-1 shows a panel with: Shortcuts to customized health summaries Quick launch of obstetrics (OB) note with templateFigure 1-1: EHR panel displaying shortcutsSupplement: EHR Optimization for Prenatal CareMarch 20131Introduction

Prenatal Care Module (BJPN)1.1.2Version 1.0Chief Complaint, Measurements, and Reproductive FactorsFigure 1-2: Reproductive Factors and Chief ComplaintsSupplement: EHR Optimization for Prenatal CareMarch 20132Introduction

Prenatal Care Module (BJPN)1.1.3Version 1.0Lab Tab with Preconfigured WorksheetFigure 1-3: Sample Lab tabSupplement: EHR Optimization for Prenatal CareMarch 20133Introduction

Prenatal Care Module (BJPN)1.1.4Version 1.0Enter POV and Patient Ed Using Pick ListsFigure 1-4: Sample Pick ListsSupplement: EHR Optimization for Prenatal CareMarch 20134Introduction

Prenatal Care Module (BJPN)Version 1.0Figure 1-5: Sample OB Pick List1.1.5Prenatal Health Summary Button and Order Tab DisplayedConcurrentlyBecause the reports launched from the Health Summary buttons on the toolbaroverlay other page contents, the clinician may review this document while workingthrough the chart.Figure 1-6: Sample Prenatal flowsheetSupplement: EHR Optimization for Prenatal CareMarch 20135Introduction

Prenatal Care Module (BJPN)1.1.6Version 1.0Quick Notes – Shortcut to Note Title/TemplateFigure 1-7: Sample EHR Shortcut ButtonsClick the Quick Notes button then Double click the Quick Note Selection.Figure 1-8: Quick Note SelectorThis opens predefined Note Title and Template.Supplement: EHR Optimization for Prenatal CareMarch 20136Introduction

Prenatal Care Module (BJPN)Version 1.0Figure 1-9: Sample predefined Note Title and TemplateSupplement: EHR Optimization for Prenatal CareMarch 20137Introduction

Prenatal Care Module (BJPN)1.1.7Version 1.0Sample Reminder Dialog DisplayedFigure 1-10: Sample Reminder dialogBrief SOAPSupplement: EHR Optimization for Prenatal CareMarch 20138Introduction

Prenatal Care Module (BJPN)Version 1.0Figure 1-11:Order by weeks gestation.Supplement: EHR Optimization for Prenatal CareMarch 20139Introduction

Prenatal Care Module (BJPN)2.0Version 1.0Vital Entry and Display ConfigurationVital entry and display can be configured at the System, Division, Location, Service,Class, and User locations. Consider where and when obstetrical measurements will beentered and where they should be viewed. It may be appropriate to add someobstetrical measurements for data entry to some but not all locations but display allfor the system level. This will be site specific.The following measurements are available for pregnancy (in additional to all othermeasurements):2.1 Abdominal girth (pregnancy) Cervical dilatation Edema Effacement Estimated Gestational Age Fetal Heart Tones Fundal Height Presentation StationVital EntryResource and Patient Management System (RPMS) Mast Configuration menu VIT TPLThis option will configure the vital entry dialog that is displayed for the user. This isnot cumulative so you must add each measurement you want to display as this willoverride the higher level settings (i.e. System).Tip:Only expose the obstetrical measurements on the vital entrytemplate to the clinicians who perform these measurements.This will reduce clutter for the majority of users. Considermaking a TIU User Class of “OB Clinicians” and place theindividuals into this class and configure the User ClassLevel.Data Entry TemplatesVital Measurement Input Template may100 UserUSR[choose200 ClassCLS[choose300 ServiceSRV[chooseSupplement: EHR Optimization for Prenatal CareMarch 201310be set for the following:from NEW PERSON]from USR CLASS]from SERVICE/SECTION]Vital Entry and Display Configuration

Prenatal Care Module (BJPN)400 Location500 Division900 SystemVersion 1.0LOCDIVSYS[choose from HOSPITAL LOCATION][choose from INSTITUTION][YAKIMA-HC.PRT.IHS.GOV]Enter selection: 200 LocationUSER CLASSSelect HOSPITAL LOCATION NAME: OB CLINICIANS----- Setting Vital Measurement Input Template for User Class: OBCLINICIANS ----Select Sequence: 5Are you adding 5 as a new Sequence? Yes//YESSequence: 5//5Measurement: HT Select Sequence: 10Are you adding 10 as a new Sequence? Yes//YESSequence: 10//10Measurement: WTSelect Sequence: 15Are you adding 15 as a new Sequence? Yes//YESSequence: 15//15Measurement: BP1BP2BPFCHOOSE 1-2: 1 BLOOD PRESSURESelect Sequence: 20Are you adding 20 as a new Sequence? Yes//YESSequence: 20//20Measurement: PUSelect Sequence: 25Are you adding 25 as a new Sequence? Yes//YESSequence: 25//25Measurement: RESPIRATIONSSelect Sequence: 30Are you adding 30 as a new Sequence? Yes//YESSequence: 30//30Measurement: PASelect Sequence: 35Are you adding 35 as a new Sequence? Yes//YESSequence: 35//35Measurement: O21O22O2CHOOSE 1-2: 1 02 SATURATIONSelect Sequence: 40Are you adding 40 as a new Sequence? Yes//YESSequence: 40//40Measurement: PFSelect Sequence: 45Are you adding 45 as a new Sequence? Yes//YESSequence: 45//45Measurement: FHSelect Sequence: 50Are you adding 50 as a new Sequence? Yes//YESSupplement: EHR Optimization for Prenatal CareMarch 201311Vital Entry and Display Configuration

Prenatal Care Module (BJPN)Version 1.0Sequence: 50//50Measurement: FETAL HEART TONESSelect Sequence: 55Are you adding 55 as a new Sequence? Yes//Sequence: 55//Measurement: EDSelect Sequence:YES55Check your work in the General Parameters menu (XPAR) using the List Valuesoption.Values for BEHOVM -----USER CLASS: OB CLINICIAN5HEIGHTUSER CLASS: OB CLINICIAN10WEIGHTUSER CLASS: OB CLINICIAN15BLOOD PRESSUREUSER CLASS: OB CLINICIAN20PULSEUSER CLASS: OB CLINICIAN25RESPIRATIONSUSER CLASS: OB CLINICIAN30PAINUSER CLASS: OB CLINICIAN3502 SATURATIONUSER CLASS: OB CLINICIAN40PEAK FLOWUSER CLASS: OB CLINICIAN45ESTIMATED GESTATIONALAGEUSER CLASS: OB CLINICIAN50FUNDAL HEIGHTUSER CLASS: OB CLINICIAN55FETAL HEART TONESUSER CLASS: OB CLINICIAN60EDEMA2.2Cover Sheet Vital DisplayRPMS Master Configuration menu VIT CVRThis option will configure the cover sheet measurement list that is displayed for theuser. This is not cumulative; add each measurement to display as this will overridethe higher level settings. Recommend displaying all measurements for system level inmost cases. Only the most recent will display and if male, the patient would neverhave an obstetrical measurement.Tip:Display the obstetrical measurements at the system level(or whatever level is set for your sheet display for yourclinical users). This information is valuable to more thanjust obstetrical providers.Measurement Listed on Cover SheetVital signs list for cover sheet may be set for the following:100 User200 Class300 ServiceUSRCLSSRV[choose from NEW PERSON][choose from USR CLASS][choose from SERVICE/SECTION]Supplement: EHR Optimization for Prenatal CareMarch 201312Vital Entry and Display Configuration

Prenatal Care Module (BJPN)400 Location500 Division900

the vital entry and cover sheet vital display components, creation of Health Summary flowsheets and Veterans Affairs (VA) Health Summary as Health Summary Buttons, Text Integration Utilities (TIU) Objects for ease of review, and documentation and configuration of Quick Notes. 1.1 EHR GUI Layout Examples . 1.1.1 Panel . Figure 1-1. shows a panel .