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TABLE OF CONTENTS
Getting Started Gettin to the !o in "a e !o in $n %han in "asswords Main Screen & Na igation &avi ation ()idin *enu ,ree View -adio Buttons Setting "p #o$r Clinic /aci)ity 0dministration User 0dministration "ractice 0dministration 0ddress Boo3 Adding a Ne& 'atient "atient Demo raphics "atient 5istory Up)oadin Documents ")ing t*e Calendar (ettin Up (chedu)es *a3in 0ppointments 0ppointment (tatus Ne& Enco$nter) & Coding 7penin a &ew 8ncounter 8ncounter /orms Usin the /ee (heet 0ddin "rescriptions I))$e) & Imm$ni,ation) 0ddin $ssues 0ssociatin $ssues with 8ncounters $mmuni9ations 'atient Note) & Tran)action) "atient &otes ,ransactions -e:erra)s Basic ,ransactions Ba)ic Billing Bi))in -eports Generatin %)aims Generatin 5%/0 /orms Acco$nting & /ecei a0le) 8;p)anation o: Bene:its 8nterin "ayments "atient $nvoices and "ayments /eporting Genera) -eports 8;amp)es o: %ommon)y Used -eports Bi))in -eports "atient -eports pg 3 p # p # p # pg ! p ' p + p + p . pg % p 1 p 12 p 11 p 1' pg (% p 14 p 66 p 66 pg +! p 6' p 64 p #1 pg 33 p ## p #' p #+ p #1 pg -+ p 46 p 44 p 4+ pg -. p 41 p '1 p '6 p '# pg !p '4 p '' p '1 pg 1( p +1 p +6 p +4 pg 11 p ++ p ++ p .2 p .1
GETTING STA/TE2
Getting to t*e Login 'age $n your browser<s address bar you wi)) need to enter the )ocation o: your 7pen8*- insta))ation. /or most users this address wi)) consist o: the name o: your server :o))owed by a :orward )eanin s)ash= >openemr> and another :orward )eanin s)ash. ,his shou)d )oo3 )i3e this: http://*y(erver&ame/openemr/ Be sure to chec3 with your 0dministrator= as the )ocation o: your 7pen8*- insta))ation may be di::erent. 0s an e;amp)e the 7pen8*- )ive demo is )ocated at: http://opensourceemr.com:6122/openemr/ 7nce you have entered the correct address= you shou)d be presented with the )o in screen:
Logging In ,he )o in screen contains two input bo;es: <Username< and <"assword<. ,he :irst time you )o in to a :resh insta))ation o: 7pen8*- you wi)) need to )o in as >admin> with a password o: >pass>. ?our administrator may provide you with your own username and password. Note that the OpenEMR login is case-sensitive. ?ou wi)) a)so be presented with a drop-down )ist o: possib)e )an ua es in which you can view 7pen8*-. ,he de:au)t )an ua e @8n )ishA shou)d a)ready be se)ected. 7nce you have entered the correct username and password= simp)y c)ic3 the <!o in< button or press <8nter<. C*anging 'a))&ord) $: this is your :irst time )o in in to 7pen8*- it is recommended that you chan e your password to somethin more secure. ,o do this se)ect <*isce))aneous B "assword< :rom the navi ation )ist on the )e:t= or simp)y <"assword< in the -adio Button navi ation scheme. #
,his wi)) brin up the "assword %han e screen. 8nter your new password into the two input bo;es= ma3e sure you type the same thin into each bo;. 0nd remember that 7pen8*-<s username and passwords are case sensitive.
7nce you<ve done this= c)ic3 the <(ave %han es< button. ?ou wi)) then be required to )o in a ain with your new password. Note: If you are using the OpenEMR demo instance, please do NOT change the admin password!
Na igation 7pen8*- can be con:i ured with your choice o: three navi ation schemes. ()idin *enu= ,ree View= or -adio Buttons. ?ou can speci:y which scheme you wou)d )i3e to use by oin to <0dministration B G)oba)s< and se)ectin the desired navi ation scheme :rom the <!ayout (ty)e< drop down )ist.
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Sliding Men$
,he ()idin *enu option is the de:au)t navi ation scheme :or 7pen8*- 4.1. ,his e;pandin menu-sty)e navi ation scheme presents a hierarchica) )ist o: pa e )in3s on the )e:t side o: the screen which can be directed to )oad in either the top or bottom widow o: the main screen. ,he patient search :unction is )ocated be)ow the navi ation )ist on the )e:t hand side o: the screen= a)on with a )in3 to 7pen8*-<s support pa e on (ource:or e.net. Tree 3ie&
,he ,ree View navi ation scheme presents the same hierarchica) navi ation )ist as the ()idin *enu= but without the icons C menu-button sty)in .
/adio B$tton)
,he -adio Button navi ation scheme :unctions simi)ar to the ,ree View e;cept that the )in3s are presented as an unordered )ist= with a series o: radio buttons to the ri ht and )e:t o: each item. (e)ectin the )e:t radio button wi)) )oad the desired pa e in the top window= whi)e se)ectin the ri ht hand button wi)) )oad the pa e in the bottom window. ?ou can a)so disab)e the top or bottom window by c)ic3in on the appropriate chec3bo; at the top o: the navi ation menu @this :unction is avai)ab)e on a)) navi ation schemesA. /or the purpose o: this Users Guide we wi)) assume you are usin the ,ree View navi ation scheme. 0 comp)ete cross re:erence o: menu items :or both the -adio Button and the ,ree View/()idin *enu navi ation schemes can be :ound here.
0 success:u) )o in brin s you to the appointment ca)endar. Be:ore you be in schedu)in appointments you<)) want to con:i ure some basic in:ormation :or your users. ,o start settin up your c)inic= se)ect <0dministration< :rom the navi ation )ist on the )e:t o: the screen. ,his wi)) brin up a )ist o: avai)ab)e administration pa es. %)ic3 </aci)ities< to brin up the /aci)ity 0dministration pa e. ,his is one o: severa) pa es within the 0dministration section o: 7pen8*-. 0dministration a)so inc)udes sections :or mana in your :aci)ity<s /orms= "ractice in:ormation= %a)endar cate ories= !ists= Database administration= and more. !in3s to these sections can be :ound in the )e:t hand navi ation )ist under <0dministration< @or at the top o: the pa e i: you<re usin the -adio Button navi ation schemeA.
Facilit4 Admini)tration
De<)) start by settin up your :aci)ity :or your users. ,here is a de:au)t c)inic a)ready bui)t in. $t wi)) need to be updated with the correct in:ormation :or your c)inic. ,o do this= simp)y c)ic3 on the name o: the c)inic= in this case E?our %)inic &ame 5ereF= to edit it<s detai)s. ,his pops up a )i htbo; containin a :orm :or editin your c)inic<s in:ormation.
8nter the correct name= address C contact in:ormation :or your c)inic. ,his in:ormation wi)) be used :or bi))in = so ma3e sure to inc)ude who to direct bi))in in:ormation to= and enter your :aci)ity<s &"$ and %!$0 number. $ndicate whether your :aci)ity is a bi))in and/or service )ocation by c)ic3in the chec3bo; ne;t to the appropriate option. $: your c)inic is a bi))in )ocation= you may a)so want to chec3 the <0ccepts 0ssi nment< bo;. Dhen you are :inished enterin your c)inic<s in:ormation c)ic3 the <(ave< button to update your c)inic and return to the /aci)ity 0dministration pa e.
?our c)inic may have additiona) :aci)ities in which care is iven= such as a hospita). ,o create a new :aci)ity= c)ic3 <0dd< and enter the re)evant data as you did :or the other c)inic. 7pen8*- a)so provides you with the option o: desi natin a co)or :or each o: your :aci)ities= which wi)) then be used in the ca)endar view to distin uish between appointments made at the di::erent :aci)ities. 8nter a he;adecima) code in the <%o)or< :ie)d= or c)ic3 <"ic3< to se)ect a co)or :rom the pop up menu. %)ic3 <(ave< when :inished.
")er Admini)tration %)ic3in <Users< in the navi ation )ist wi)) brin you to the User / Groups 0dministration pa e. ,his pa e contains a )ist o: your c)inic<s users. $: you have not yet added any users= then on)y >admin> wi)) be shown.
?ou can add a new user by c)ic3in the <0dd User< button= or you can modi:y an e;istin user by c)ic3in on their username. Both methods wi)) pop up a )i htbo; containin the user pro:i)e pa e. 5ere you can edit a user<s "assword= /aci)ity in:ormation and 0ccess %ontro)= as we)) as their authori9ation status. 0uthori9ed users are practitioners= and wi)) appear in the appointment ca)endar. ,hey can a)so be associated with encounters :or bi))in purposes= and are ab)e to authori9e encounter in:ormation entered by non-authori9ed users so that the encounter wi)) be bi))ab)e. 12
,o authori9e your practitioners be sure to c)ic3 the <"rovider< chec3 bo;. 7ther :aci)ity sta:: do not need to be authori9ed. "ractitioners wi)) a)so need their U"$& and /edera) ,a; $D entered :or correct bi))in = as we)) as their /edera) Dru $D :or prescription writin . 7nce your user<s in:ormation has been updated success:u))y c)ic3 <(ave< to return to the User / Groups 0dministration pa e. 'ractice Admini)tration &e;t you<)) need to enter the re)evant practice in:ormation :or your c)inic. ,his inc)udes pharmacy and insurance company in:ormation= as we)) as the types o: documents your c)inic accepts. %)ic3in the <"ractice< )in3 in the navi ation menu wi)) brin you to the "ractice 0dministration pa e where you wi)) be presented with a )ist o: )in3s :or editin your :aci)ities< in:ormation.
,he "ractice 0dministration pa e initia))y presents you with the )ist o: your c)inics pharmacies. %)ic3 the <0dd a "harmacy< button to enter the contact in:ormation :or your c)inic<s pharmacy. 0 drop down menu )ets you 11
se)ect the pre:erred method :or trans:errin prescription in:ormation. 7nce you<ve entered the correct in:ormation= c)ic3 <(ave< to add your new pharmacy.
Be:ore settin up any insurance companies= you<)) want to enter your G16 "artner in:ormation. ,hese are the c)earin houses or )ar e payers to whom you wi)) send e)ectronic bi))in . *ost practices wi)) probab)y Hust use a sin )e c)earin house. ,o add one o: these c)earin houses= c)ic3 on <G16 "artners< and then c)ic3 the <0dd &ew "artner< button.
,he $D numbers that you enter here wi)) need to be provided to you by the c)earin house/partner. ,he <Version< number re:ers to the version o: the G16 4#.p protoco) speci:ication used and shou)d probab)y not be chan ed. %)ic3 <(ave< to save the in:ormation you<ve entered. (e)ectin <$nsurance %ompanies< :rom the )in3s at the top o: the pa e brin s up a )ist o: companies that have been added to your c)inic. $: this is a new insta))ation o: 7pen8*-= this )ist wi)) be empty. ?ou can add a new 16
insurance company by c)ic3in <0dd a %ompany<. 7r= you can edit an e;istin company by c)ic3in on it<s name in the )ist.
7nce you have entered the correct in:ormation= c)ic3 <(ave< to save any chan es= or add the new company to the )ist.
$n practice= many insurance companies have mu)tip)e insurance p)ans with a separate bi))in address :or each p)an. 0t this time= you wi)) need to add each p)an as a separate insurance company. *any insurance companies a)so assi n their own doctor-speci:ic $D numbers= and these numbers must appear in your c)aims. %)ic3 on <$nsurance &umbers< to see a )ist o: your c)inic<s providers and their de:au)t $D numbers.
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%)ic3 on a provider<s name to brin up a )ist o: insurance companies and the correspondin $D numbers that have been entered :or that provider. (e)ectin <0dd &ew< presents a :orm :or addin this provider<s numbers :or another insurance company. /i)) in this in:ormation and c)ic3 the <(ave< button to add the new number. ?ou can a)so edit an e;istin set o: numbers by c)ic3in on the company name in the )ist.
&ote that one o: the se)ections in the drop down )ist o: insurance companies is >De:au)t>I you can use this to :i)) in de:au)t numbers :or insurance companies not otherwise entered. &e;t c)ic3 on <Documents< to see a )ist o: patient documents that have been up)oaded. %)ic3in the <8dit %ate ories< button disp)ays a hierarchy o: the di::erent types o: documents that you can attach to a patient. ,he de:au)t set is shown.
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,o add more cate ories c)ic3 on the desired parent :o)der<s name= :i)) in the name o: the new document type= and c)ic3 <0dd %ate ory<.
Addre)) Boo5 7pen8*- a)so contains a bui)t-in address boo3 :or storin use:u) contact in:ormation :or your sta:: as we)) as other doctors= c)inics= etc. that your o::ice may contact on a re u)ar basis. (e)ect <0ddr Boo3< @under <*isce))aneous<A :rom the navi ation menu to brin up your c)inic<s 0ddress Boo3.
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,his wi)) present you with a )ist o: a)) o: the contacts current)y contained in your 0ddress Boo3. %)ic3 on a person<s name to edit their contact in:ormation= or c)ic3 <0dd &ew< to enter a new contact into your address boo3.
$n the 0dd &ew "erson dia)o bo;= se)ect a type= and enter their name and address. $: you are addin a physician to your address boo3= be sure to inc)ude their U"$& and other $D numbers :or bi))in and re:erra)s. 8nterin a <(pecia)ty< wi)) a))ow you to narrow your search parameters when writin )etters to a particu)ar physician= etc. Dhen you are :inished enterin the new contact in:ormation= c)ic3 <(ave<. &ote that the new contact has been added to the )ist. 1+
?ou can search :or a particu)ar contact in the address boo3 by enterin their name and/or specia)ty at the top o: the pa e and c)ic3in <(earch<. ,his brin s up a )ist o: any contacts matchin your search parameters.
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$n the (earch or 0dd "atient pa e enter the patient<s name C birth date. $: you have an e;istin chart :or this patient= you may enter the chart number under <8;terna) $D<. $: you do not enter a number the system wi)) automatica))y assi n one that is equa) to its interna) patient $D. Dhen you are :inished c)ic3 <%reate &ew "atient<.
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NOTE: Clicking the calendar button next to the ' O!' "ield #ill pop up an eas$ to use date selection tool "ound throughout the OpenEMR progra%. &i%pl$ click the arro#s to the right or le"t o" 'Toda$' to advance the date "or#ard or back a single %onth or $ear' or hold an arro# do#n to select the %onth or $ear %anuall$. &electing the da$ o" the %onth #ill then "ill the selected date into it's respective "ield in the proper "or%at ())))-MM- * ?ou shou)d now be presented with the "atient (ummary "a e= which contains a summary o: the patient<s identi:yin in:ormation= inc)udin emp)oyment= insurance and provider in:ormation in sections that may be e;panded or co))apsed at wi)) by c)ic3in the )in3 to the ri ht o: the desired section. ,he pa e a)so inc)udes )in3s to the patient<s medica) history= documents= etc. at the top o: the screen= as we)) as a )ist o: EissuesF associated with that patient= and any appointments they may have schedu)ed in a co)umn a)on the ri hthand side.
&otice that additiona) patient re)ated pa es are now accessib)e via the navi ation menu to the )e:t. ,o continue enterin patient in:ormation c)ic3 <8dit< ne;t to the desired section. ,his wi)) brin up a series o: tabs containin inputs :or the various types o: patient data. %)ic3 on the tab :or the section you wou)d )i3e to wor3 with and :i)) in the desired :ie)ds. &ote that :ie)ds )abe)ed in red are required in order :or bi))in to wor3 proper)y. ,o enter a patient<s insurance in:ormation :or the :irst time c)ic3 <edit< ne;t to the Demo raphics section. ,he $nsurance in:ormation section can be :ound be)ow the Demo raphics tabs.
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(e)ect the patient<s insurance company :rom the drop-down )ist= or you can search :or it by c)ic3in <(earch/0dd<. Doin so brin s up a )i htbo; containin severa) :ie)ds which are searchab)e @)abe)ed in reenA. 8nterin a partia) va)ue into one or more :ie)ds and c)ic3in the <(earch< button presents you with a )ist o: a)) insurance companies matchin those parameters.
(e)ectin the desired name :rom the )ist wi)) automatica))y ma3e it the se)ection :or that patient.
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$: the desired insurance company is not yet entered= you can a)so add it here by comp)etin a)) the :ie)ds and c)ic3in <(ave as &ew<. ,his a)so se)ects the new)y added insurance company :or this patient. $: the patient is a)so the insured party= then se)ectin Ese):F :rom the drop-down )ist wi)) automatica))y popu)ate the <(ubscriber< section with the re)evant data :or you.
Dhen you are :inished= c)ic3 <(ave< at the top o: the pa e to save and return to the Demo raphics summary. ?ou can see that $nsurance now has it<s own section= and a)) o: the new patient data is now visib)e on the summary pa e.
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'atient 7i)tor4 &e;t se)ect <5istory< at the top o: the "atient (ummary pa e ,his brin s up a pa e containin in:ormation about the patient<s medica) history. %)ic3in <8dit< wi)) brin up a data entry pa e with tabbed sections= simi)ar to that o: the Demo raphics pa e.
0ccess the desired sections by c)ic3in on the appropriate tab and enter in the patient<s data as necessary= then c)ic3 <(ave<. %)ic3 <Bac3 ,o "atient< to return to the "atient (ummary pa e. "ploading 2oc$ment) (e)ect <Documents< at the top o: the patient (ummary pa e. 5ere you may up)oad :i)es that you have scanned 66
/irst= c)ic3 the appropriate Document %ate ory :or the :i)e you wish to up)oad= then c)ic3 <Browse<. ,his wi)) present you with the standard dia)o :or )ocatin the :i)e on your computer. 7nce the desired :i)e has been se)ected= c)ic3 <Up)oad< to save the :i)e in 7pen8*-.
7nce the :i)e is up)oaded= you wi)) be presented with a report= con:irmin the :i)e has been up)oaded success:u))y. ,o see the new :i)e= c)ic3 on the p)us si n ne;t to the appropriate document cate ory which disp)ays a )ist o: a)) the :i)es in that cate ory. %)ic3 on the name o: the new :i)e to view it.
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5ere you can a)so attach a note to the document= associate it with a particu)ar issue= or move it to a di::erent cate ory or patient.
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/or users who are not practitioners= such as someone who wor3s at the :ront des3= the %a)endar wi)) show the schedu)es o: a)) the practitioners at the c)inic by de:au)t. Dhen you :irst start usin 7pen8*- you wi)) need to set up schedu)es :or a)) o: your practitioners. ,o do this= se)ect :rom the <"roviders< )ist @on the bottom )e:t o: the ca)endar windowA the person who<s schedu)e you wish to set up. &e;t c)ic3 the time at which that provider is schedu)ed to enter the o::ice.
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,his wi)) present you with the <0dd &ew 8vent< dia)o bo;.
,he c)inic and provider name shou)d be automatica))y :i))ed in :or you= as we)) as the time that you se)ected. %)ic3 the <"rovider< tab and choose E$n 7::iceF :rom the <%ate ory< drop-down )ist. ?ou can a)so choose to ma3e this a repeatin event= which a))ows you to set up an event on)y once :or a iven period o: time. Do this by se)ectin the <-epeats< chec3bo;= and settin the appropriate :requency C duration. Dhen you are :inished c)ic3 <(ave< to update the ca)endar. &ow you wi)) see a b)oc3 o: avai)ab)e time s)ots :or that provider<s schedu)e. (cro)) down and c)ic3 on the time that the provider is schedu)ed to )eave the o::ice :or the day.
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?ou can a)so add a )unch brea3 in your practitioners< schedu)es. ,his is done the same way= with the e;ception o: the duration= which in this case is non-9ero.
&ow you can see your practitioner<s :u)) schedu)e )aid out on the %a)endar pa e. %ontinue settin up the %a)endar in this :ashion unti) a)) your practitioners< schedu)es have been entered.
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Ma5ing Appointment) &ow that the c)inic and a)) it<s practitioners are set up= you can be in schedu)in appointments :or your patients. ,o )ocate a patient in the system= enter a)) or part o: their name into the search :ie)d in the bottom )e:t corner o: the screen @be)ow the navi ation )istA and c)ic3 <&ame<. ,his wi)) brin up a )ist o: a)) the patients in your system matchin that name. $: you need to narrow the )ist= you can enter a )on er search term= such as their :u)) name @8 . Erour3= rodFA.
%)ic3 on the desired name to brin up the Demo raphics summary :or that patient. $: you have the patient on the phone= now wou)d be a ood time to con:irm that their contact and insurance in:ormation is up to date. $: the patient is not a)ready in the system= you can se)ect <&ew/(earch< :rom the menu to be in enterin their in:ormation.
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,he ri ht-hand side o: the "atient (ummary shows a )ist o: a)) current and :uture appointments :or that patient. %)ic3 <e;pand< ne;t to the 0ppointments section i: the )ist is not a)ready visib)e. %)ic3 <0dd< to schedu)e an o::ice visit. ,his wi)) present you with the same 0dd &ew 8vent dia)o used ear)ier. E7::ice VisitF is se)ected as the %ate ory by de:au)t. ?ou can chan e the cate ory to E&ew "atientF i: this is their :irst visit. $: a primary provider has been entered :or that patient= they wi)) be se)ected automatica))y.
%)ic3 </ind 0vai)ab)e< to see a )ist o: appointment times avai)ab)e :or that provider :or the ne;t . days. ?ou can chan e the start date or the number o: days shown and c)ic3 <(earch< to disp)ay a new )ist usin those parameters.
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7nce a date and time have been a reed upon= se)ectin that time :rom the )ist wi)) c)ose the window= and the se)ected time wi)) appear in the 0dd 8vent dia)o . *a3e sure to enter the correct duration :or the appointment and c)ic3 <(ave<.
-eturn to the ca)endar usin the navi ation menu on the )e:t. 0dvancin to the appropriate date= usin the arrows at the top o: the screen= shows the new appointment )isted in the provider<s schedu)e. *ousin over the patient<s name disp)ays a toot-tip with in:ormation about that patient= such as date o: birth.
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Appointment Stat$) 7pen8*-<s ca)endar system inc)udes a status indicator= a))owin doctors and sta:: to see at a )ance what is oin on with a)) appointments and the correspondin encounters :or the day. ,o chan e the status o: a iven appointment= doub)e-c)ic3 on the appointment b)oc3. ,his brin s up the 8dit 8vent window. %hoose the correct appointment status :rom the drop-down )ist. &otice each status has a unique symbo) associated with it.
?ou can a)so type a note into the <%omments< )ine i: more in:ormation is needed. %)ic3 <(ave< to update the status o: the appointment.
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?ou can see that the symbo) ne;t to the appointment time has chan ed to indicate it<s new status. 0ny comments are now a)so visib)e when mousin over the patient<s name on the appointment ca)endar.
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,he bottom window a)so shows any notes )e:t :or that provider about their patients. ,he %a)endar shows the appointments schedu)ed :or that day. "roviders can see the status o: any iven appointment= indicated by the symbo) shown between the appointment time and the patient<s name. ,he EJF symbo)= :or e;amp)e= indicates that the patient has arrived at the c)inic and is ready to be in their appointment. Opening a Ne& Enco$nter ,o be in the encounter= c)ic3 on the patients name in the 0ppointment %a)endar. ,his brin s you to the patient<s (ummary pa e= as we)) as the "ast 8ncounters C Documents pa e which )ists any previous encounters or :i)es that were up)oaded :or that patient.
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(e)ect <5istory< at the top o: the pa e to view a summary o: the patients *edica) 5istory and !i:esty)e in:ormation. %)ic3 <8dit< to enter any in:ormation that may be incomp)ete.
,he "atient 8ncounters C Documents pa e at the bottom o: the screen disp)ays a )ist o: a)) encounters that have been entered :or this patient. /or new patients= there may be no encounters )isted. By de:au)t= 7pen8*- is set to enerate an empty 8ncounter when a patient<s status has been set to E0rrivedF @JA. ,o open this encounter and be in enterin data= c)ic3 on the new entry in the 8ncounters )ist= then c)ic3 <8dit< ne;t to the provider<s name. $: your c)inic<s version o: 7pen8*- is con:i ured di::erent)y= you can be in a &ew 8ncounter manua))y by se)ectin <%reate Visit< :rom the navi ation )ist on the )e:t. Both methods wi)) brin you to the &ew 8ncounter /orm.
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5ere you can enter a brie: description o: the encounter and the date o: service. 8ncounters :or new patients wi)) not have any $ssues or Dia noses associated with them at this time= so c)ic3 <(ave< to continue with the encounter. Enco$nter Form) ,his wi)) brin you bac3 to the summary pa e :or this 8ncounter. Disp)ayed is a )ist o: a)) the :orms associated with this encounter. ?ou may c)ic3 <8dit< ne;t to any o: these :orms to edit its contents.
0t the top o: the pa e are drop-down )ists o: :orms that can be added to the encounter. 7pen8*- comes con:i ured with severa) common encounter :orms by de:au)t= but your c)inic may have their own customi9ed encounter :orms as we)). (e)ect E(70"F :rom the <%)inica)< drop-down )ist to add that :orm to the encounter. #'
,he (70" :orm wi)) contain a subHective C obHective record o: the patientKs vita) in:ormation= as we)) as any notes on the assessment o: the patient<s hea)th and su ested treatment p)ans. 8nter the appropriate in:ormation and c)ic3 <(ave /orm< to return to the 8ncounter summary pa e.
?ou<)) see that the (70" :orm has been added to the )ist o: :orms :or this encounter. 0)so shown is a summary o: its contents. ")ing t*e Fee S*eet &e;t se)ect the E/ee (heetF :rom the <0dministrative< drop-down )ist. ,he /ee (heet is di::erent :rom most other :orms in that it enters and modi:ies bi))in in:ormation that is stored e)sewhere in the systemI it is not rea))y an encounter :orm= and when used it wi)) not appear in the encounter<s )ist o: :orms.
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,he /ee (heet inc)udes severa) drop-down )ists o: the most common)y used bi))in codes. $t can and shou)d be customi9ed so that it<s most suitab)y adapted to your practice.
$nc)uded is a search :eature= where you can search :or and se)ect :rom the thousands o: bi))in codes in the database. 0nd be)ow that is a )ist o: a)) the bi))in codes= a)on with their char es and other re)ated in:ormation= that have been se)ected :or this encounter. /or e;amp)e= se)ectin EDetai)edF :rom the <8stab)ished "atient< drop-down adds the associated %", code to the )ist.
!oo3 :or an appropriate bi))in code by enterin a search term in the bo; to the )e:t o: the <(earch< button. *a3e sure the correct code type is se)ected and c)ic3 <(earch<.
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,he drop-down )ist above wi)) then be popu)ated with any bi))in codes that match your search parameters. (e)ectin the desired code :rom the )ist wi)) add it to the )ist o: codes :or this encounter.
,he /ee (heet a)so a))ows you to Husti:y the se)ected codes :or bi))in purposes. Lusti:ication is the association o: $%D1 codes with procedure codes. $nsurance companies require this :or bi))in = in order to >Husti:y> payin :or procedures. ,o do this= c)ic3 the drop-down menu under <Lusti:y< :or the desired %", code. (e)ect the appropriate $%D1 code :rom the )ist and c)ic3 <(ave<.
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,o see the /ee (heet has been associated with this encounter= c)ic3 <Visit 5istory< in the navi ation menu to o to the )ist o: encounters :or this patient. ?ou can see that the %", C $%D1 codes are )isted ne;t to the new encounter= as we)) as the (70" :orm that was added ear)ier.
Adding 're)cription) ,o prescribe medication :or this patient c)ic3 <8dit< ne;t to the "rescriptions section in the "atient (ummary window= and c)ic3 <0dd<. ,his presents you with a :orm :or enterin prescription data= inc)udin dosa e= re:i))s= and whether or not eneric over-the-counter substitutions are a))owed :or this patient.
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,he "rescription :orm inc)udes a search :unction :or )oo3in up a particu)ar type o: medication. (e)ectin <@c)ic3 here to searchA< ne;t to the Dru :ie)d wi)) brin up a new :ie)d into which a search term may be entered. %)ic3in <(earch< disp)ays a drop-down )ist o: possib)e medications enerated by connectin to the web site www.r;)ist.com. (e)ectin the desired medication wi)) :i)) in the Dru :ie)d :or you.
(e)ectin <?es< ne;t to <0dd to *edication !ist< wi)) a))ow the prescription to be inc)uded in the $ssues )ist as a *edication as we)).
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8nter the correct data to comp)ete the :orm and c)ic3 <(ave<. ?ou are then presented with a :orm :or eneratin a "D/ o: the prescription in:ormation. $t may be printed or sent by emai) or :a;. %hoosin a pharmacy :rom the drop down )ist and c)ic3in <0uto (end< wi)) use whichever de:au)t method was se)ected when you set up that pharmacy.
%)ic3in <"rint @"D/A< wi)) enerate the :o))owin "D/ document to be saved or printed as necessary. ,he de:au)t temp)ate :or this :orm may a)so be customi9ed to your c)inic<s own speci:ications.
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?ou can see that the prescription added ear)ier has been )isted in the *edications section. %)ic3in <8dit< ne;t to one o: these sections wi)) present you with this patient<s issues )ist :or that cate ory. %)ic3 <0dd< to add a new medica) issue you want to 3ept trac3 o: :or this patient.
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/or each issue type there is a )ist o: common)y se)ected tit)es which are customi9ab)e :or your c)inic<s speci:ic needs. $: the desired tit)e is not inc)uded= it can be typed into the te;t bo; be)ow the )ist. 8nter the appropriate be innin and end dates= and se)ect the <7ccurrence< :rom the drop-down )ist provided. %)ic3in in the <Dia nosis< :ie)d wi)) present a search dia)o :or )ocatin the correct $%D1 code :or this issue. 8nter the appropriate search term and c)ic3 <(earch< to brin up a )ist o: possib)e $%D1 codes. (e)ectin the desired code wi)) c)ose the search window and enter the se)ected code in the te;t :ie)d.
0dditiona) issues are entered in the same mannerI c)ic3 <Bac3< to return to the "atient (ummary pa e and c)ic3 <0dd< ne;t to the appropriate issue type= or c)ic3 <$ssues< at the top o: the pa e to see a comp)ete )ist o: a)) issues :or this patient. &otice that the <0dd &ew $ssue< dia)o a)so uses the 7pen8*- date se)ection too) described ear)ier.
7nce the new issues have been added success:u))y you shou)d see an updated )ist o: a)) the issues that have been entered :or this patient. ?ou may c)ic3 on an issue in the )ist at any time to edit it.
A))ociating I))$e) &it* Enco$nter) ,he :ar ri ht co)umn in the $ssues )ist represents the number o: encounters associated with a iven issue. %)ic3 on the <2< ne;t to a new)y added issue to brin up the $ssues C 8ncounters dia)o .
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,his dia)o contains a )ist o: a)) the issues and encounters associated with this patient. $t is used to set @and viewA the re)ationships between issues and encounters. &ote that the issue that was Hust c)ic3ed on has been hi h)i hted.
(e)ect the appropriate encounter :rom the )ist on the ri ht to hi h)i ht it. %)ic3in <(ave< now )in3s the se)ected issue to the se)ected encounter.
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%ontinue associatin issues with encounters as necessary. -e:reshin the $ssues )ist shows the current in:ormation :or a)) issues.
Imm$ni,ation) %)ic3 <Bac3< to return to the "atient (ummary pa e. &ow c)ic3 <8dit< ne;t to the $mmuni9ations section. ,his pa e contains a :orm :or enterin in:ormation on any immuni9ations the patient has received.
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%)ic3 inside the <$mmuni9ation @%VG %odeA< :ie)d C se)ect the correct immuni9ation code usin the search dia)o provided.
8nter any data you may have= inc)udin the date o: the shot= and the name o: the provider who administered it. %)ic3 <(ave $mmuni9ation<. ,he new)y added immuni9ation now appears in the )ist at the bottom o: the screen.
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-eturn to the (ummary pa e via the navi ation menu on the )e:t. &otice that the ri ht side o: the "atient (ummary pa e now shows an updated )ist o: a)) active issues= immuni9ations and prescriptions.
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%)ic3 on the desired patient to brin up the "atient (ummary pa e. $: the user is not 0uthori9ed they wi)) be unab)e to see the patient<s medica) detai)s such as issues= immuni9ations and prescriptions.
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%)ic3 <8dit< ne;t to the &otes section to brin up the "atient &otes pa e= then c)ic3 <0dd<. ,his wi)) pop up a )i htbo; with a te;t :ie)d :or enterin the note= as we)) as drop-down )ists :or se)ectin the type o: note= and the person to whom the note is addressed.
,ype your note in the te;t bo; and c)ic3 <(ave as new note<.
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,he new note now appears in the )ist on the "atient &otes pa e. ,he chec3bo; is used to contro) whether the note is >activeF. %)ic3 the <(ent $tems< tab to view any patient notes that have been addressed to others. %)ic3 <View "atient< to return to the patient summary.
,he new note is now )isted on the (ummary pa e. Tran)action) (e)ect <,ransactions< at the top o: the "atient (ummary to o to the "atient ,ransactions pa e. ,he ,ransactions pa e contains two basic :orm types. 0 simp)e :orm :or interna) transactions such as patient requests or bi))in transactions= and a re:erra) :orm.
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/eferral) %)ic3 <0dd< and se)ect E-e:erra)F :rom the drop-down )ist to be in a new -e:erra) transaction.
(e)ect the re:errin physician= ris3 )eve)= etc.= :rom the drop-down )ists provided and enter a reason :or the re:erra). 0nother drop-down contains a )ist o: physicians and c)inics :rom the 0ddress Boo3 to which you can re:er your patient. %)ic3 <(ave<. ,he re:erra) is now in the "atient ,ransactions )ist.
%)ic3 <"rint< ne;t to the transaction to enerate a printab)e version o: the -e:erra) :orm. Dependin on your system<s con:i uration= you may be as3ed to save the :i)e= or it may be printed '6
automatica))y.
Dhen you are :inished return to the ,ransaction )ist and c)ic3 <0dd<. Ba)ic Tran)action) 7ther transaction types use the simp)e transaction :orm. (e)ect the desired type :rom the )ist and enter the transaction detai)s in the te;t bo; provided. %)ic3 <(ave< when :inished.
,he new transaction has now been added to the )ist a)on with the re:erra). %)ic3 <8dit< ne;t to a transaction to edit its contents.
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BASIC BILLING
7n)y the 0dministrator= authori9ed users= and those with 0ccess %ontro) desi nated as E0ccountin F in their user pro:i)e can access 7pen8*-<s Bi))in system.
(e)ect </ees B Bi))in < :rom the navi ation menu on the )e:t. ,his brin s you to the main Bi))in screen. ,his wi)) present you with options to enerate a variety o: printab)e and e)ectronic c)aims and reports. Billing /eport) ,he Bi))in -eport pa e wi)) automatica))y disp)ay any bi))ab)e encounters that were enerated today. ?ou may use the bi))in search too) to choose :rom a variety o: criteria with which to search the avai)ab)e encounters. '4
/or instance= to view bi))ab)es :rom a di::erent time period se)ect EDate o: (erviceF :rom the <%hoose %riteria< section= choose the desired date ran e :rom the drop-down )ist= and c)ic3 <Update !ist< in the top ri ht corner o: the screen.
,he )ist shou)d now disp)ay a)) bi))ab)es :rom the se)ected date ran e.
Generating Claim) %)ic3in the chec3bo; to the ri ht o: the desired encounter wi)) enab)e a set o: buttons :or eneratin c)aims. ?our system shou)d be con:i ured with the appropriate set o: :orms :or the insurance companies and c)earin houses used by your c)inic. (e)ectin mu)tip)e encounters wi)) a))ow you to enerate batch :i)es :or many c)aims at once.
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%)ic3 <Generate G16< to create a c)aim :i)e that is suitab)e :or sendin to the c)earin house. 7pen8*- wi)) present you with a con:irmation popup= remindin you to chec3 the )o :i)e a:ter you have :inished eneratin your c)aims.
%)ic3in <7M< wi)) mar3 this item as c)eared= indicatin that bi))in has been comp)eted :or this encounter. ,he standard (ave /i)e dia)o shou)d appear ne;t= a))owin you to save the enerated batch :i)e to your computer.
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7nce the :i)e has been saved= c)ic3 <View !o < to chec3 whether the c)aims were enerated success:u))y.
$: there were any errors in the c)aim eneration process= they wi)) be disp)ayed here. 7therwise you wi)) see a note indicatin that the :i)e was enerated success:u))y.
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,he down)oaded c)aim :i)e shou)d contain the necessary encounter in:ormation= :ormatted :or bi))in . ,his is what wi)) be sent to the c)earin house= by whatever method has been speci:ied.
(e)ect EBi))in (tatus N Unbi))edF in the <%urrent %riteria< )ist and c)ic3 the red G to remove it :rom the )ist= or se)ect EBi))in (tatusF under <%hoose %riteria< and se)ect E0))F. %)ic3 <Update !ist< to re:resh the bi))in )ist and see the updated status o: the encounter.
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Generating 7CFA Form) $n 7pen8*- mu)tip)e :orms may be enerated :or each c)aim. /or e;amp)e= re-enter the desired date ran e= be sure that <Bi))in (tatus< is set to E0))F and c)ic3 <Update !ist< a ain to show the current status o: the c)aim. ?ou can see that the c)aim has been E*ar3ed as c)eared.F
%hec3 the bo; to the ri ht o: the encounter and c)ic3 <Generate %*( 1'22 "D/<. 7pen8*- wi)) now enerate a "D/ o: the 5%/0 c)aim= based on the standard 5%/0 :orm temp)ate. ,he new :orm can be viewed usin a "D/ viewer= or printed automatica))y on a pre-printed 5%/0 1'22 :orm= dependin on your system<s con:i uration.
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-eturnin to the Bi))in -eport and c)ic3in <Update !ist<= you can see that the status o: the bi))ab)e encounter has been updated.
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0t the top you may enter a source @ 8 . chec3 number A= pay date and chec3 amount. ,he <0mount< :ie)d wi)) be automatica))y decremented as payments are entered into the associated invoices. Dhen a)) invoices have been comp)eted this va)ue shou)d be 9ero.
,he search :ie)ds= with the b)ue bac3 round= are :or )ocatin a speci:ic invoice @or invoicesA. 8nter the +1
appropriate parameters= such as the date o: service= and c)ic3 <(earch< to brin up a )ist o: a)) invoices @c)aimsA matchin the requested parameters.
,he )ist shows the patient and invoice number= as we)) as the current ba)ance to be paid. ,he number with a E-F in the <"rv< co)umn indicates the number o: insurance companies :or which this invoice is awaitin payment. Entering 'a4ment) %)ic3in the invoice number you wish to wor3 with opens the 87B $nvoice window. &otice that the source and pay date :rom the previous window have been copied overI this saves time in the common case where a sin )e chec3 :rom the insurance company pays :or mu)tip)e c)aims.
,he 87B $nvoice pa e contains a detai)ed )ist o: payments made on this invoice so :ar. 8nter the payment amount ne;t to the remainin ba)ance= and chec3 <&eeds secondary bi))in <. ,his wi)) a))ow the c)aim to be rebi))ed to the secondary insurance. (e)ect <Done with $ns1< above to indicate that the primary insurance 87B has been posted. Dhen you are :inished= c)ic3 <(ave<.
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7nce payment has been bi))ed and received :rom secondary insurance= it can be entered in the same way. 8nter the source and pay date= etc. and )ocate the appropriate invoice@sA usin the search :unction. "ayment amounts are now shown a)on with the remainin ba)ance. ,he number in the <"rv< co)umn has a)so decreased. (e)ect the invoice number to brin up the 87B $nvoice window a ain.
8nter the payment amount and se)ect <$ns6< to indicate that the secondary insurance 87B has been posted. $nvoice adHustments may a)so be made here. 8nter the adHustment amount @or c)ic3 <D< to waive the entire remainin ba)anceA= and se)ect a reason :or the adHustment :rom the drop-down )ist provided. %)ic3 <(ave< when :inished.
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'atient In oice) and 'a4ment) 7nce payments :rom the insurance companies have been received and entered= you can use 7pen8*-<s 87B pa e to enerate invoices :or bi))in patients the remainin amounts.
(e)ect <Due "t< :rom the drop-down )ist and c)ic3 <(earch< to disp)ay a )ist o: a)) invoices that are awaitin payment :rom patients. $nvoices sti)) awaitin payments :rom insurance companies wi)) not be shown.
%hec3 the bo; ne;t to the desired invoice and c)ic3 <"rint (e)ected (tatements< to enerate an invoice :or that patient usin a customi9ab)e temp)ate. Dependin on your c)inic<s 7pen8*- con:i uration= the invoice may be printed automatica))y.
0 <1< in the <"rv< co)umn now indicates that the patient has been bi))ed once :or this c)aim. ,his number wi)) +4
increment every time a new invoice is printed :or this encounter. ,his is use:u) when printin so that second and )ater notices may be worded di::erent)y :rom the initia) statement. ?ou can a)so c)ic3 on the patient<s name in the invoice )ist to create a bi))in note :or that patient. 8nter your note into the te;t :ie)d and c)ic3 <(ave<.
7nce payment has been received= it can be entered into the invoice in the same manner as the insurance payments. $n the <&ow postin :or< )ist be sure to se)ect E"atientF. 8nter the payment amount as be:ore and c)ic3 <(ave<.
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/E'O/TING
Dithin 7pen8*- there are a wide array o: reports you can enerate which may be use:u) :or your practice. ,hese inc)ude enera) reports such as appointment and encounter reports= bi))in reports= and patient speci:ic reportin . General /eport) *ost enera) reportin too)s can be :ound by se)ectin <-eports< :rom the navi ation menu at )e:t. $n the ,ree View scheme= the )ist o: avai)ab)e reports is divided into a hierarchica) )ist within the navi ation menu.
E9ample) of Commonl4 ")ed /eport) %)ic3in <-eports B Visits B (uperbi))< brin s up the (uperbi)) -eport pa e. ,his presents you with a dia)o :or se)ectin a date ran e.
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%)ic3in <(ubmit< produces a report :or each encounter in the date ran e= and shows patient demo raphics and insurance in:ormation= as we)) as the bi))in codes and amounts.
,he 0ppointments -eport @<-eports B Visits B 0ppointments<A ives you a )ist o: appointments :or a iven provider= or :or a)) providers= in a speci:ied date ran e. $t can be sorted by c)ic3in on any o: the :our co)umn headin s.
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,he 0ppointments and 8ncounters -eport @ <-eports B Visits B 0ppt-8nc< A ives you a use:u) cross-re:erence o: appointments with their correspondin encounters. ,his a))ows you to easi)y spot many types o: errors= such as appointments with missin encounters= encounters with missin appointments= missin char es= and authori9ations or Husti:ications that are required but not done.
,he $nsurance Distribution report @)isted under <-eports B $nsurance<A shows you how many patients seen over a iven time period use each 3ind o: insurance.
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,he $ndi ent "atients report )ists a)) encounters :or patients that were seen without insurance. @&one shown here.A
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Billing /eport)
/rom the main Bi))in pa e c)ic3 <-eports<= or se)ect <-eports B /inancia) B %ash -ec< :rom the navi ation menu.
,his is the %ash -eceipts report. $t brea3s down ross income by provider :or a iven time period. ,he user can a)so e)ect to see a detai)ed brea3down o: cash receipts= itemi9in each procedure :or which a char e was made.
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'atient /eport)
Dhen a patient is active within the system= the user has the option o: eneratin a report :or that speci:ic patient. ,o do so= c)ic3 on <-eport< at the top o: the "atient (ummary pa e.
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,he user can choose to inc)ude or omit a wide variety o: patient in:ormation. Dhen satis:ied with your se)ections= c)ic3 <Generate -eport<. ,his produces a report inc)udin a)) the speci:ied patient in:ormation.
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