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Clinical Training Manual

                          

 

 

Welcome to Epitomax…..

 

Your Behavioral Health web-based system that integrates Patient Tracking, Scheduling, Service Activity, Billing, Clinical, and Accounts Receivable. This document includes a table of contents, step-by-step processes on how to perform functional activities, graphic screenshots illustrating program activities, notes, tips and special conditions. This document is meant to assist you in your use of the clinical functionality in Epitomax.

 

 

                                                                                                                                          

 

                                                               

 

 

                                              

                                   

 

Table Of Contents

 

Service Documentation.. 4

Client Management 8

Clinician Management 21

 

 

 

Service Documentation

 

Service Activity tracking in Epitomax is used to record all activities performed by Staff (both billable and non-billable activities). A day of Service Activity can be Completed after all activities have been resolved (i.e., Statuses set to something other than Pending) for that day. Once a day of activity is “Completed” for a Staff Person, then Charges for any billable services will be processed for billing purposes and the Completed day will be available for payroll processing.

To view incomplete Service Activity

The View Incomplete Service Activity function allows users to view a list of incomplete days of Service Activity for the selected staff person.

 

1.    Click on the Service Activity Entry menu item from the Service Activity menu

2.    Select the Staff Person from the Search box by using the Ellipsis

3.    Click Ok

4.    Click Submit

 

 

* The Incomplete Days summary screen is displayed.  This is the view screen for the list of Service Activity entries that have not been “Completed” or generated through Payroll in the system.

Clicking Update completes the day for any date having the Complete the Day With No Activity checkbox checked.

 The list of Incomplete Days includes all records for the chosen staff between the last day charges were generated and the current system date plus 21 days.  It may also include any Completed Days where Payroll and Charges have not been generated.

 The Complete The Day With No Activity checkbox only displays for days where the Total Hours column equals zero and the activity date is less than or equal to the current date.

 Another way to get to an activity and document it is using View Staff Activity on the Scheduling menu.  Clicking on the activity in the staff calendar is the same as doing step 6 below.  The rest of the lesson is the same from there.

 

5.    Click on an Activity Date to view or modify the activities for that day.

 

 

* The Staff Daily Activity Entry screen is displayed.

 

6.    Click on the Activity Status link to open the desired activity.

 

 

* The Staff Activity window opens.  This displays information about the activity, patients attending, and other staff that are associated with the activity.

 

7.    If the link to the right on the Associated Patients frame, says Add Form, a form has not yet been associated with this activity.  Click on the Add Form link.

 

 

* The Add Form To Activity window opens.  This allows you to select a Form Type from a list of all available.

 

8.    Enter the desired choice in the Select Form field.

9.    Click on the Add button.

10. The Add Form To Activity window closes and the selected form is displayed.

If the form has a narrative template associated with it, the Generate Narrative button is available at the bottom of the form.

If the form is a Progress Note, a list of Common Phrases buttons is displayed on the right of the form.  Clicking on a text field and then clicking on a Common Phrases button will insert the phrase into the text field.  If the text in the field is selected, clicking on a Common Phrases button will replace the text.  Use the arrow keys on your keyboard or click on the field a second time to deselect the text prior to clicking on a Common Phrases button.

If the form is a Multipart Progress Note three panes will be displayed to the left side of the Common Phrases.  See Multipart Progress Notes for more information.

 

11.  Fill in the fields on the form and click on the Update button to save your changes

12. Close the form by clicking on the Close button or the  button on the upper right of the window.

13. The link to the right of the Associated Client now says View Form.  Click on the View Form link to open the form again.

14. You will now sign the form.  Click on the Sign button.

 

 

15. Enter your User Name and Password.

16. Click on the Submit button.

 

  If your signature meets the conditions for required signatures, and it is the last required signature to be added, the form status will change from Pending to Completed.  The status can be seen on the Associated Clients frame.

 

17. Close the form by clicking on the Close button..

18. Close the Service Activity window by clicking on the Close button in the Staff Activity section or the  button on the upper right of the window..

 

Client Management

Epitomax allows users to view a client’s electronic documentation organized by client admission.  When services or activities are entered into Epitomax and forms are associated with those activities, those forms show up in the client’s Electronic Record.

Electronic Record

Clinical users can view and/or modify the client’s electronic record by navigating to the Clinical tab of the client’s admission episode.

 

1.    Click on the Case Load menu item from the Clinical menu.

 

 

* The Case Load screen is displayed.  This is the view screen for viewing the clients where the logged in user is an Internal Care Giver.  From this screen the user can easily navigate to the Client Record, Admission, and Add Activity screens for each client.

 

2.    Click on the Program link for one of the clients.

 

* The Episode screen is displayed.  This screen the view screen for all information pertaining to the open admission..

 

3.    Click on the Clinical tab.

 

 

 The Clinical tab is where the electronic documentation for the client admission is kept.  The set of tabs under the Clinical tab organize that documentation by Form Type.

 Progress Notes (as well as any other form) can be added from here.  However, adding a form from one of the tabs under the Clinical tab will not generate billing.  To document a service and generate billing from that service, see the section on Service Documentation.

There could be more forms under the tab than can fit on the screen at one time.  Use the Page Next button to see the next page of forms.

 

4.    Click on the Signatures link next to a form.

 

*      The Signatures List window opens.  The lists all signatures associated with the form.

Required signatures that have been fulfilled have their Role populated in the list.  Users that have signed who do not meet the required signatures criteria for the given form are listed without a Role.

 

5.    Close the Signatures List window by clicking Close button or the  button on the upper right of the window .

6.    Click on the Print link next to a form.

Clicking on the Print link opens the printed version of the form.

 

7.    Close the Print window by clicking on the  button on the upper right of the window.

 

Progress Notes

Forms associated with this client admission with a Form Type of Progress Note are listed under the Progress Notes tab. 

 

8.    The Progress Notes List can be filtered by Progress Note Form Types that are associated with the Episode, and sorted according to Activity Date, Activity Status, or Note Status..

9.    Click on the Activity Status link for one of the Progress Notes.

Activities can be viewed and edited from here.

 

10. Close the activity by clicking on the Close button in the Staff Activity section or the  button on the upper right of the window.

11. Click on the Edit link next to a Progress Note.

Clicking on the Edit link opens the Progress Note for editing.

Once a Progress Note with a Note Status of Pending is open for Edit, you have the ability to Update, Sign, Print, and view the Progress Note History Navigator.

 

12. You have already seen how to Update, and Sign a form.  Click on the History button.

 

 

* The Progress Note History Navigator window opens.  This is a filtered, chronological listing of similar Progress Notes associated with the Episode.  Although primarily intended for reference, all Progress Note Editing functionality, except the History button, is available to you from here.

 

By default, the Progress Note which is of the same type, and from the activity just prior to the one that was being edited when the History button was clicked, will be displayed first when the Progress Note History Navigator is opened (i.e. In the image above, the Progress Note associated with the activity that occurred on April 19, 2007 is being displayed.  So the Progress Note History Navigator would have been opened via the History button on the Progress Note associated with the activity on May 5, 2007).

 

13. Close the Progress Note History Navigatory by clicking on the Close button or the  button on the upper right of the window.

14. Close the form by clicking on the Close button or the  button on the upper right of the window.

15. Close the Progress Note window by clicking on the Close button or the  button on the upper right of the window.

 

Multipart Progress Notes

Forms associated with a client admission with a Form Type of Progress Note, and a page name prefaced by “multipart:” will have all the properties of Progress Notes.  The Progress Note window will additionally contain two additional sections; one for the Summary List and one for the Prescription Pad.

 

  1. Click on the Edit link for a Progress Note that has been defined as multipart.

 

 

*A Multipart Progress Note will initially open the sections on the left at reduced size.  Each section can be minimized, reduced, or maximized.

 

*The top section is the Summary List, the middle section is the Prescription Pad, and the bottom section is the Progress Note itself.

 

  1.  Click on the Summary List’s  button to maximize the Summary List section.

 

 

This view screen displays data, which can also be entered from the Diagnosis Tab on the Episode, with a header that has information pertaining to the activity, and fields that have information pertaining to the client’s medical record for the Episode. 

 

The other sections of the Progress Note are minimized when the Summary List is maximized.

 

  1. Enter new information or modify existing data.  Scroll to the bottom of the Summary List section, and Click the Update button to update the client’s Summary List for this Episode.

 

 

  1.  Click the Print button to open the Print window for the Summary List.

 

If the Summary List has been modified and you click Print without first updating, the Summary List will be updated before the Print window is opened.

 

  1.  Close the Print window by clicking on the  button in the upper right corner of the window.
  2. Click the History button to generate a Report of modifications made the Summary List associated with this Episode.

 

 

  1. Close the Summary List Report window by clicking on the  button in the upper right corner of the window.
  2. Click on the Prescription Pad’s  button to maximize the Prescription Pad.

 

 

*The Prescription Pad is a combination of the Prescription and Medication Tabs from the Client’s record.  All functions that can be performed from either of those tabs (Add Medication/Prescription, Print Medication/Prescription, Discontinue Medication/Prescription, etc.) can be performed from this section.

 

*The number of prescriptions and medications listed depends on the size of the Prescription Pad section.  It will list as many as possible per screen, with prescriptions first, and in descending order by Prescription Date.

 

*Clicking on Print Multiple will only allow one to print multiple prescriptions, not medications.

 

The rows are color coded according to Prescription Date, Rewrite Date, Discontinue Date, and the current Date.  Future prescriptions are blue, rewritten are green, discontinued are red, and current are black.

 

  1.  Click the Summary List’s  button to change the sizes of all sections to reduced.
  2. Close the Multipart Progress Note window by clicking the  button in the upper right corner of the window, or scrolling to the bottom of the Summary List or Progress Note sections and clicking the Close button.

 

Assessments / Evals

Forms associated with this client admission with a Form Type of Assessment are listed under the Assessments / Evals tab.  The same steps and functionality described above for Progress Notes is used on the Assessments / Evals tab.

 

26. Click on the Assessments / Evals tab.

 

 

Treatment Plans

The Treatment Plans tab shows the current or history of treatment plan forms for the client admission.

 

27. Click on the Treatment Plans tab.

 

 

28. Click on the Add button.

If a Treatment Plan already exists for this client admission, you would not normally create another one.

 

 

29. Enter the desired form in the Select Form field.

30. Click on the Add button.

31. Click on the Edit link next to the Treatment Plan.

 

 

32. Enter some data in the form.

33. Scroll to the bottom of the form.

34. Click on the Update button to save your changes.

35. Close the form by clicking on the Close button or the  button on the upper right of the window.

36. Click on the Print link next to the Treatment Plan.

37. Close the print window by clicking on the  button on the upper right of the window.

Misc. Forms

Forms associated with this client admission with a Form Type of Miscellaneous are listed under the Misc. Forms tab.  The same steps and functionality described above for Progress Notes is used on the Misc. Forms tab.

 

38. Click on the Misc. Forms tab.

 

 

Discharge Summary

The Discharge Summary tab allows the user to generate a discharge summary for the client admission in narrative form.  Generating the discharge summary involves selecting a template form or source form, filling in any missing data on the form, generating the narrative, reviewing the narrative to make any desired edits, and electronically signing the discharge summary.

 

39. Click on the Discharge Summary tab.

 

 

40. Enter a Template Name.

41. Click on the Update button.

 

 

42. Click on the Edit Discharge Summary link.

 

Much of the data on the Discharge Summary Input form should be populated for you already.

 

43. Enter any missing data as desired.

44. Scroll to the bottom of the form.

 

 

45. Click on the Update button to save your changes.

46. Scroll to the bottom of the form.

47. Click on the Generate Narrative button.

48. Review the generated text and make any desired changes.

 

 

49. Click on the Update button to save your changes.

 

 

Clinician Management

 

Epitomax offers tools that enable clinical users to manage electronic documentation efficiently.  In this section, you will learn about some of those tools.

Clinician Dash Board

The Clinician Dash Board is a place where clinicians who complete electronic documentation should go frequently.  The main section on this screen is the Documentation Due section in the middle.  This section shows documentation that the logged in user is responsible for completing including: services with missing documentation, documentation the user has not yet signed, and documentation requiring an update.

 

1.    Click on the Clinician Dash Board menu item from the Clinical menu.

 

 

The Clinician Dash Board screen has 3 sections: Important Client Events, Documentation Due, and Today’s Schedule.

Sections can be closed and opened up by clicking on the section heading.

Forms can be signed electronically by Editing and Signing, or by viewing the Signatures List and Adding one..

 

2.    Click on the words ‘Important Client Events’ above the top section.  Notice how the section closes giving more space on the screen for the other sections.

3.    Click on the words ‘Documentation Due’ above the middle section.  Now the majority of the screen is available to display the Today’s Schedule section.

4.    Click on the words ‘Documentation Due’ again.  Notice how the section opens up again.

5.    Click on the Due Date to open the activity.

6.    Close the window by clicking on the  button on the upper right corner of the window.

7.    Click on one of the Edit links.

8.    Close the form by clicking on the Close button or the  button on the upper right of the window.

 

Incomplete Documentation Report

The Incomplete Documentation Report shows incomplete documentation by Clinician or for all clinicians with a given Staff Manager.

 

1.    Click on the Incomplete Documentation Report menu item from the Clinical menu.

 

 

 

2.    Enter criteria for the report and click on the Submit button.

 

 

* The Incomplete Documentation Report is generated and displayed for the given criteria.