Difference between revisions of "CQM - record CMS69v10 (MU3)"

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=== Intervention Performed ===
=== Intervention Performed ===
==== Create/Find procedure order ====
* [[CQM - Intervention Performed (MU3)|example record entry for Intervention Performed]]
* Use the Administrative->Procedure Order Form
* Enter the Time Collected and select Intervention from the Default Procedure Type drop-down
* Search for the appropriate code from the Procedure Test find code popup, usually found in the CQM value set.
* Enter the attributed reason code for the test if there is one by clicking the asterix and use the find code popup to search for the code from the value set. 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


=== Physical Exam Performed ===
=== Physical Exam Performed ===

Revision as of 21:17, 30 May 2022

Encounter Performed

Medication Order

Intervention Order

Intervention Performed

Physical Exam Performed

Create/Find Observation form

  • Create an observation form under Clinical->Observation
Physical Exam Type
  • In an Observation form choose Physical Exam Performed for Type
  • Search for the appropriate code from the code popup for the exam
  • Enter the appropriate value for the result, like for BMI a value of 30
  • Select the 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

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

CQM c1 main page