Difference between revisions of "CQM - record CMS122v10 (MU3)"

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=== Encounter Performed ===
=== [[CQM - Encounter Performed (MU3)|example record entry for Encounter Performed]] ===
==== [[CQM - Encounter Performed (MU3)|example record entry for Encounter Performed]] ====


=== Diagnosis ===
=== Diagnosis ===

Revision as of 20:53, 30 May 2022

example record entry for Encounter Performed

Diagnosis

  • Add a medical problem with the appropriate code and set the begin date and end date if valid and select Diagnosis as the Classification Type

Assessment Performed

  • In an Observation form choose Assessment for Type
  • Search for the appropriate code from the code popup
  • Select the date period by entering a date (start) and End Date.
  • If this an exception case click the asterix to choose the Negated reason and enter the appropriate code from the look up.
  • Save the form

Intervention Performed

  • Use the Administrative->Procedure Order Form
  • Choose Intervention from the Default Procedure Type
  • Search for the appropriate code from the Procedure Test find code popup
  • Enter the reason for the code for the test by clicking the asterix and use the find code popup to search for the code from the value set and choose pending or completed for the reason status. Otherwise if this an exception case choose negated and enter the appropriate code from the look up.
  • Save the order

Laboratory Test Performed

  • Configure a Procedure Group. Add a sub item Procedure Order, Test Type Laboratory Test. Add a sub item Discrete result.
  • From the encounter use Admin->Procedure Order to create the order.
  • Search and find the previously created order, choose Laboratory Test, and associate a diagnosis. Also set the collected time, select completed and save.
  • Go to Procedures->Pending Review and record the result.

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