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| === Encounter Performed === | | == CMS69v10 == |
| ==== Find/Create encounter ====
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| * Use past encounters or create a new encounter
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| * Under Visit Details select the appropriate option from the Type Drop-down that corresponds to the code in Lists->Encounter Types.
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| === Create/Find Care Plan form === | | === Intervention Order === |
| * Create a care plan under Clinical->Care Plan | | * [[CQM - Intervention Order (MU3)|example record entry for Intervention Order]] |
| ==== Medication Order ====
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| * In the Care Plan form add an entry with Planned Medication Act for Type
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| * Search for the appropriate code from the code popup
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| * Select the date
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| * If this an exception case click the asterix to choose the Negated reason and enter the appropriate code from the look up.
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| * Save the form
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| === Create/Find procedure order ===
| | === Intervention Performed === |
| * Create a procedure order under Admin->Procedure Order
| | * [[CQM - Intervention Performed (MU3)|example record entry for Intervention Performed]] |
| ==== Intervention Order/Performed ====
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| * Use the Administrative->Procedure Order Form | |
| * Choose Intervention from the Default Procedure Type
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| * Search for the appropriate code from the Procedure Test find code popup
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| * Enter the Reason 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.
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| * Save the order
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| === Create/Find Observation form === | | === Medication Order === |
| * Create an observation form under Clinical->Observation | | * [[CQM - Medication Order (MU3)|example record entry for Medication Order]] |
| ==== Physical Exam Performed ====
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| * In an Observation form choose Physical Exam Performed for Type | | === Physical Exam Performed === |
| * Search for the appropriate code from the code popup | | * [[CQM - Physical Exam Performed (MU3)|example record entry for Physical Exam Performed]] |
| * Select the date
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| * If this an exception case click the asterix to choose the Negated reason and enter the appropriate code from the look up. | | === Patient Characteristic Race === |
| * Save the form
| | * [[CQM - record prelim config (MU3)|preliminary setup for measures]] |
| ==== 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 | | === Diagnosis === |
| | * [[CQM - Diagnosis (MU3)|example record entry for Diagnosis]] |
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| | === Patient Characteristic Payer === |
| | * [[CQM - record prelim config (MU3)|preliminary setup for measures]] |
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| | === Back to CQM c1 main page === |
| | * [[OpenEMR_Certification_Stage_III_Meaningful_Use#Clinical_Quality_Measures_.28170.315.28c.29.29|CQM c1 main page]] |
