Step-By-Step Guide to ICANotes and Meaningful Use

Which Buttons Do I Push?

A Step-by-Step Guide to Achieving Meaningful Use

(More detailed information about how to use ICANotes to achieve meaningful use is contained in the document "Meaningful Use and ICANotes" which is on our blog entry for February 1st

First, lets make a Complete Psychiatric Evaluation and make sure to use the features that help achieve Meaningful Use.

1. Demographics: Be sure to include the following demographics. They are all on the main demographic page:

Ethnicity, Race and Preferred Language

You need to record these demographic items for 80% of your patients.

2. Medical History: Tobacco Use: In the Medical History use the button "Health and Behavior" and the second Column button "Tobacco." Record the patient's smoking habits.

You need to record this information for 50% of patients who are 18 or older.

3. Medical History: Drug Allergy: In the Medical History section use the button "Adverse Drug Reaction" and record the patient's drug allergy history, even if negative.

You need to record this information for 80% of your patients.

4. Mental Status Exam: Vital Signs. In the MSE use the button "Constitutional/Vital Signs. Record, at minimum, the patient's blood pressure, height, and weight. The program will automatically calculate the BMI and these numbers are stored in the Log area, where they are also graphed.

You need to record this information for 50% of your patients.

5. Finish Initial: Problem List: The problem list is your diagnoses. So, make a diagnosis in the Finish Initial Screen.

You need to make a diagnosis for 80% of your patients.

6. Finish Initial: Active Medication List: Order a medication, or indicate "No Medication Ordered"

You need to enter something in the medication fields for 80% of your patients.

7. Finish Initial: Medication Reconciliation: You can access the Medication Reconciliation form from the Finish Initial screen.

You need to use the Medication Reconciliation form for 50% of your patients.

8. Finish Initial: Electronic Prescribing: To use electronic prescribing, you need to sign up for this service. If you are signed up there will be a button on the Finish Initial so you can access and use Electronic Prescribing.

You need to prescribe 40% of your prescriptions using Electronic prescribing.

9. Finish Initial: Patient Education Forms: When you compile your note you may be offered patient education information.

You need to print 10% on these forms and make them available to your patients.

10. Preview Page: Clinical Summary: On the preview screen push the button "Create Clinical Summary".

Clinical Summaries are used to meet a number of meaningful use measures.

You need to make a clinical summary electronically available within three days to 50% of patients who request them. You can indicate that the patient requested a summary and when it was sent electronically on the Preview screen.

You need to make a clinical summary electronically available within four days to 10% of your patients, whether they request them or not. The date the summary was sent to the patient should be recorded on the Preview screen.

You need to give a clinical summary to your patients for 50% of their office visits. This does not have to be electronically transmitted, so you can print the clinical summary for the patient and give it to them during their visit. Again, when the record was made available to the patient can be recorded on the Preview screen.

Now, lets make a Progress Note and make sure to use the features that will help achieve meaningful use.

In Progress Note Part One: Many of the features that were used in the Initial Assessment can also be used in Progress Note Part One. These include:

1. Medication Allergy: An adverse drug reaction can be documented using the Drug Reactions button on the top of column two.

2. Smoking Status: This can be recorded in the "Behavior" portion of the program.

3. Vital Signs: These can be recorded using the button, "Vital Signs" in column two.

4. Incorporate lab results: Enter lab results using the button, "Test Results" in column one.

In Progress Note Part Two: Here too many of the features that were used in the Initial Assessment can also be used in Progress Note Part two. These include:

1. Problem List: If you didn't make a diagnosis previously, you can make one here in PN 2.

2. Medication List: If you haven't already, you can order medications here in PN 2.

3. Incorporate Lab Results: Lab tests can be ordered from PN2, section 2, using the button, "Lab Requisitions".

4. Medication Reconciliation: The button to reach this section of the program is on PN 2, upper right.

5. Patient Summary Record for Referrals: Make a referral or request a consult using the "Referral" button on PN2, section 2.

6. E Prescription: As noted in the Initial Evaluation section above, to use electronic prescribing, you need to sign up for this service. If you are signed up there will be a button on the PN2 so you can access and use Electronic Prescribing.

7. Clinical Summaries: A Clinical Summary can be made by using the button, "Compile this Note" at the bottom right of PN2 and then, on the Preview Screen, using the button, "Create Clinical Summary".

Again, the Clinical Summary is used to meet a number of Meaningful Use measures, as follows:

You need to make a clinical summary electronically available within three days to 50% of patients who request them. You can indicate that the patient requested a summary and when it was sent electronically on the Preview screen.

You need to make a clinical summary electronically available within four days to 10% of your patients, whether they request them or not. The date the summary was sent to the patient should be recorded on the Preview screen.

You need to give a clinical summary to your patients for 50% of their office visits. This does not have to be electronically transmitted, so you can print the clinical summary for the patient and give it to them during their visit. Again, when the record was made available to the patient can be recorded on the Preview screen.

Chart Face: Patient Reminders: Patient Reminders: To create a patient reminder, use the "Set or See Reminder" button on the chart face. Use the "New" button to set a reminder and indicate that it is a patient reminder. Set the date of the reminder, who it is to be sent to and why.

Once the reminder to the patient has been made, the ICANotes program must be informed. Do that by returning to "Set or See Reminder", opening the reminder in question by clicking on it, and indicating in the appropriate fields that the reminder was done and